i radiological images fracture bilateral parietal bones with acute subdural hematoma in right fronto-parietal region ii right submandibular gland pleomorphic adenoma covid -19 pneumonia iii hepatocellular carcinoma placenta previa grade iv with placenta accreta contributed by: department of radiology dr. akbar niazi teaching hospital, islamabad i histopathology images endometrial stromal sarcoma figure 1: gross presentation of endometrial stromal sarcoma. intact bicornuate uterus appears heart shaped. figure 3: microscopic view of endometrial stromal sarcoma with marked pleomorphic nuclei and marked mitosis (arrow) (h&e, 400x). figure 2: endometrial stromal sarcoma. cut surface of uterus shows large necrotic mass obliterating the endometrial cavity and reaching up to isthmus. figure 4: microscopic view of high grade endometrial stromal sarcoma infiltrating the bundle of myometrium (arrow) (h&e, 100x). ii metaplastic carcinoma of breast figure 1: gross appearance of mastectomy specimen with large prominent lump. figure 3: microscopic examination reveals pure squamous cell carcinoma–metaplastic carcinoma of breast (h&e, 100x). figure 2: cut surface of mastectomy specimen showin g large necrotic mass with hemorrhagic areas. figure 4: metaplastic carcinoma of breast showing nests of squamous cells infiltrating the stroma (h&e, 100x). contributed by: department of pathology dr. akbar niazi teaching hospital, islamabad journal of journal of islamabad medical & dental college (jimdc); 2016:5(3):131-133 131 original article diagnostic value of combined: creactive protein, total leukocyte count and platelet count in neonatal sepsis abstract objective: this study was designed to evaluate the diagnostic value of combination of total leukocyte count, platelet count and c reactive protein for the diagnosis of neonatal sepsis. patients and methods this cross-sectional study was conducted at department of pediatrics, dhq hospital, sargodha. blood samples for sepsis work-up including c-reactive protein (crp), platelet count, tlc and blood culture collected were before the initiation of antibiotic therapy. the complete blood count was done on the automated hematology analyzer; crp level estimation was done by latex agglutination method. patient having abnormal values of tlc, crp and platelet count were followed by report of blood culture which was used as gold standard for the diagnosis of neonatal sepsis. results: there were 98(38%) male and 162(62%) female patients with mean age of 1.8 ± 1.6 days. c-reactive protein, total leukocytes counts and platelet count collectively, were abnormal in 132(50.7%) suspected neonates with sepsis. blood culture was found positive in 166(63.8%) neonates. the sensitivity, specificity, positive and negative predictive value of combined abnormal crp, total leukocyte counts and platelet count was 75.3%, 92.5%, 94.6% and 67.9% respectively. conclusion: the diagnostic value of combined abnormal tests (crp, tlc and platelet count) was found significant and can be used for the early diagnosis of neonatal sepsis when boold culture results are awaited. keywords: c reactive protein, neonatal sepsis, total leukocyte count, platelet count. introduction neonatal sepsis is defined as a clinical syndrome of bacteremia characterized by signs and symptoms of infection in the first four weeks of life. 1 it encompasses various systemic infections of the newborn such as septicemia, meningitis, pneumonia and urinary tract infections. neonatal sepsis is one of the major causes of neonatal mortality in the developing countries contributing to 12% of all neonatal deaths, 2 and it continues to be a major cause of morbidity and mortality in pakistan. 3 blood culture is still considered to be the ‘gold standard’ for diagnosis of neonatal sepsis. the yield of a positive blood culture ranges from 8-73% as shown in various studies. 4 7 however, the technique of blood culture is time consuming and demands a well-equipped laboratory which is not available in most of the community hospitals. 5 therefore, there is need for a test that is cheap and can be easily performed with quick availability of reports. 6 an ideal diagnostic test for neonatal sepsis should have maximum sensitivity and specificity. 7 there are other tests which may support diagnosis in such cases. cbc with the absolute neutrophil count and crp are amongst the most frequently used. 8 combination of abnormal total leukocyte count, platelet count and c reactive protein have been used to evaluate infants with sepsis or with probable sepsis in different studies. 9 in one study, the positive predictive value for combination (tlc, platelet count, crp) was 79.24%. 10 the rationale of this study was to evaluate the diagnostic value for combination (tlc, platelet count and crp) for evaluation of patients with neonatal sepsis. patients and methods this cross-sectional study was carried out at department of pediatrics, dhq hospital, sargodha from march to august 2014. non-probability sampling technique was used and neonates suspected to have early neonatal sepsis were included. neonatal sepsis was clinically suspected if a neonate presented within first 7 days after birth with two or more of these; temperature instability < 35 or > 38.5c, tachypnea > 60/min, tachycardia > 200/min or capillary refill > 3 sec. 11 neonate who received antibiotics before admission or having major congenital abnormalities were excluded. approval was taken from hospital ethical committee and informed consent was obtained from parents. each neonate was examined by a pediatric resident and blood samples were collected before the initiation of corresponding author: dr mohsin butt e mail: proudpakistani65@hotmail.com received: aug 22, 2016; accepted: oct 16, 2016 mailto:proudpakistani65@hotmail.com 270 j i m d c 2 0 1 7 270 op e n ac c e ss c a s e r e p o r t surgical scar breast carcinoma: a rare entity ateeque ahmed khan 1, sasui memon 2 1 professor, chairperson and head of radiology department, dow university of health sciences 2 resident radiology department, dow university of health sciences (dow university of health sciences / civil hospital karachi) a b s t r a c t breast carcinoma is common having many predisposing and genetic causes, however, breast carcinoma of surgical scar is very rare entity. carcinomatous changes can occur at the site of burns scar, chronic ulcers, fistulous tracts, chronic infections and surgical scars. here we report the case of 44 years old female patient who underwent surgical excision of fibroadenoma of left breast and developed mass at the site of previous surgical scar 7 years later, which proved to be carcinoma on radiological imaging and biopsy reports. key words: breast carcinoma, scar carcinoma, surgical scar carcinoma address of correspondence sasui memon email: sassuimemon290@gmail.com article info. received: august 24, 2017 accepted: september 12, 2017 cite this case report: khan a.a, memon s. surgical scar breast carcinoma. 2017; 6(4) funding source: nil conflict of interest: nil i n t r o d u c t i o n breast cancer is the most common female malignancy and most common cause of death in women aged 40-50 years.1 chronic inflammation, surgical scars and burns can give rise to cancer, however very few cases have been reported where malignancy arises from surgical scars.2 traumatic tissue behaves as an oncogene, and scar tissue as functional layer plays major role in development of cacinoma.3 the unstable scar tissues cannot withstand against tumifective particle and can undergo carcinomatous changes.4 we report a rare case of breast carcinoma developing on previous surgical scar of benign etiology. c a s e r e p o r t s a 44-year-old female presented to radiology department civil hospital karachi for mammography. she had a complaint of palpable mass in left breast in upper outer quadrant for three months. mass was firm in consistency, non-movable and about 3-4cm in size. it was not adherent to overlying skin, not associated with pain. overlying skin was normal, no redness or discharge was present. patient had history of excision of fibroadenoma at the same site seven years back. she was afebrile and family history of breast carcinoma was negative. mammography showed heterogeneously dense parenchyma, which reduced the sensitivity of mammogram. ultrasound breast was done which showed an irregular spiculated hypoechoic mass with posterior acoustic shadowing at 1-2 o clock position (previous site of surgery) with positive color doppler flow along with adjacent satellite nodule (figure 1a, 1b). figure 1a: ultrasound left breast showing an irregular spiculated hypoechoic mass with posterior acoustic shadowing at 1-2 o clock position c a s e r e p o r t 271 j i m d c 2 0 1 7 271 figure 1b: satellite nodule with positive color doppler flow. on the basis of ultrasound, birads v was given and biopsy was done which proved to be carcinoma. contrast enhanced ct scan (cect) chest and abdomen were advised for metastatic workup which came out to be negative, and did not show any visible significant mass (figure 2). figure 2: coronal and axial images of cect showing no mass lesion in left breast (arrow). d i s c u s s i o n chronic ulcers, fistulous tracts, surgical scars and burn scar can give rise to dysplasia and carcinoma.3 trauma and scar tissue play a vital role in malignant transformation. several criteria are proposed by freund et al for surgical scar breast cancer identification: 1) previous history of surgery at the site of carcinoma 2) normal breast before surgery 3) healed surgical scar 4) similarity between surgical scar and tumor site and 5) appropriate time between tumor and previous surgery.2 scar tissue heal slowly because of low vascularity and is more prone to infections. it undergoes continuous reparative process and has no lymphatics so that it can undergo dysplasia but can grow in isolation.4,5 ultrasound is useful in detecting small breast cancers and is useful in women with dense breasts where mammography has low sensitivity,6 (as in our case where mass was very clear on ultrasound however mammography and cect did not show any significant mass). ultrasound characteristics of malignant mass include an irregular shape hypoechoic mass with indistinct margins, taller than wider, and posterior acoustic shadowing.7 c o n c l u s i o n scar carcinoma of breast is rare form of carcinoma seen at the site of previous surgery. thin scar tissue, low vascularity of scar, increased susceptibility to infection in scar tissue and instability of scar tissue to withstand carcinogens, increases the chances of carcinoma at the surgical site. rarity of the disease enabled us to report this case r e f e r e n c e s 1. mcpherson k, steeelc, and dixonj. breast cancerepidemiology, risk factors, and genetics. bmj 2000; 321(7261): 624–28. 2. kim m, kim e, lee j, youk j, park b, kim h, oh k, breast cancer from the excisional scar of a benign mass. korean j radiol. 2007; 8(3): 254–57. 3. freund h, biran s, laufer n, eyal z. breast cancer arising in surgical scar. j surg oncol 1976; 8(6):477-80. 4. saaiq m, ashraf b. marjolin’s ulcers in the post-burned lesions and scars. world j clin cases 2014; 2(10): 507– 14. 5. bowers rf young jm. carcinoma arising in scars, osteomyelitis, and fistulae. arch surg.1960; 80(4):564-70. 6. gokhale s. ultrasound characterization of breast masses. ind j radiol. 2009; 19(3): 242–47. 7. raza s, goldkamp a, chikarmane s, birdwell r. us of breast masses categorized as bi-rads 3, 4, and 5: pictorial review of factors influencing clinical management. radiographics. 2010;30(5):1 199-213. 119 j i m d c 2 0 1 7 119 address of correspondence: dr usman hassan email: drusmanhassan256@gmail.com role of molecular biology in histopathology usman hassan consultant histopathologist, shaukat khanum cancer hospital and research center, lahore pathology has evolved significantly in the past 50 years. even i can feel lot of changes in last 10 years of my histopathology practice starting from my residency days till the present day and things are now developing even at a greater pace. it is very difficult to keep up the pace with these ever-changing and developing diagnostic modalities. light microscopy was the sole examination technique at first and pathology was comparatively simple. however, with increasing tumor diagnosis and tumor burden across the globe, a strong need was felt to strengthen the classification systems so that diseases could be put into specific categories and hence treated in a more specified and accurate manner. this need gave birth to the technique of immunohistochemistry, which was based on the principle of antigen retrieval and binding of specific antibodies designed for a particular antigen. nowadays well-developed histopathology departments use hundreds of antibodies in order to diagnose different kinds of diseases particularly several kinds of neoplastic diseases including benign and malignant tumors. we can very confidently classify tumors broadly into categories of carcinoma, lymphoma, sarcoma, neuroendocrine tumor, melanoma, perivascular epithelioid cell tumor, metastatic tumor etc. each of these broad groups can be further classified into specific categories based on histological and immunohistochemical features. this has revolutionized the treatment options for patients. however, every technique has a limitation. after immense and colossal research in the field of immunohistochemistry, it is now very much known that immunohistochemistry has got its own limitations. despite, for example, cytokeratins which are meant to stain carcinomas can also be expressed in sarcomas. likewise, melanocytic markers which are known to diagnose melanoma can also show positivity in perivascular epithelioid cell tumors. cd99 initially considered a very specific marker for ewing’s sarcoma is now known to show expression in osteosarcoma (small cell variant), lymphoblastic lymphoma and synovial sarcoma. cd56 also shows its positivity in a number of tumors including carcinomas, lymphomas, and sarcomas. therefore, we cannot overemphasize the fact that a single technique is not enough to diagnose a particular disease. it is the combination of clinical features, radiological features, histological findings and immunohistochemical results that is important for an accurate diagnosis. researchers long ago started feeling that even classifying tumors based on histology and immunohistochemistry was not enough. the reason was the observation that patients having same age, gender, type, and stage of disease behaved differently. for instance, patients having lung adenocarcinoma, breast carcinoma, malignant melanoma, colorectal adenocarcinoma, thyroid carcinoma, sarcomas, gastrointestinal stromal tumor (gist), ovarian carcinoma, lymphoma behaved very much differently even if they belonged to the same group of disease and shared similar demographic details and same type and stage of the disease. these findings led and compelled investigation, exploration, analysis, testing, and experimentation of genetics of disease. i can assure you that in future genetics will be the part and parcel of every field related to diagnostics, especially pathology. at this point of time, fluorescence in situ hybridization (fish), pcr, next-generation sequencing (ngs) and tissue microarrays are the genetic techniques used in combination with histology and immunohistochemistry for diagnosing and classifying malignancies. now it is established that malignancies having similar histological e d i t o r i a l 120 j i m d c 2 0 1 7 120 and immunohistochemical features and belonging to the same group can behave differently on account of their different genetic phenotypes. using this fact, scientists are working very hard to develop targeted therapies against different types of genetic aberrations e.g. identification of many oncogenes and tumor suppressor genes. ngs has particularly helped a lot in understanding the genetics of a large number of diseases and malignancies as it has the capability of sequencing and analyzing millions of dna molecules at reduced rates. some of the genetic aberrations are of prognostic and other are of therapeutic interest. with the help of ngs, mutations of interest are studied for their prognostic and therapeutic values and few are selected to develop targeted therapies. ngs is not available routinely in pakistan and very rarely used for research purposes at very few centers. i would like to give you few examples of the role of genetic studies in finding out molecules of treatment and prognostic significance. lung adenocarcinomas can look alike histologically but have different genetic makeups. few genes of interest in lung adenocarcinoma are egfr, alk and ros1 against which targeted therapies have been developed e.g. erlotinib against egfr mutation and crizotinib in alk and ros1 mutated adenocarcinomas. gist having kit and pdgfra mutations can benefit from imatinib or sunitinib therapy whereas sdh deficient gists do not benefit from this therapy and require second line drug regime. colorectal carcinomas having kras mutations behave and respond to therapy differently than colorectal carcinomas having microsatellite instability (msi). breast carcinomas which are er and pr positive are given different therapy than those which are triple negative for er, pr and her-2/neu or which are only her-2/neu positive. these are very few basic examples of very common tumors like a drop in the ocean. unfortunately, the discovery of genetic aberrations has outpaced the development of targeted therapies. pcr technique is cheaper and very much simpler than ngs. the particular gene of interest can be tested in tumor tissue and treatment can be based on the results. of course, only limited number of genes can be studied as compared to ngs in which millions of molecules can be assessed. the ability of the molecular department to run pcr tests on formalin fixed tumor tissue is a big advantage for the pathologists and treating oncologists and every effort should be made to acquire this expertise. fish technique is another very useful and very simple technique which works on the principle of binding of the fluorescent probe to a complementary antigen of interest. we use quite a few fish tests in our department. we use her-2/neu amplification studies in breast carcinomas, fish break apart probes for ewing’ sarcoma (ewsr1 gene rearrangement), synovial sarcoma (x;18) and alveolar rhabdomyosarcoma (foxo1 gene rearrangement), n-myc and mdm2 amplifications studies for neuroblastoma and liposarcoma respectively, break apart probe for alk gene rearrangement in lung adenocarcinoma and 1p and 19q co-deletion studies in oligodendrogliomas. some of these results have therapeutic and some have prognostic value for the patient. every institute can tailor these techniques according to their own needs. pathologists should assess the tumor burden and tumor types being diagnosed in their institutes and discuss the need to develop different molecular techniques with oncologists and molecular biologists. this not only helps to diagnose tumors with accuracy but also help oncologists to assess prognosis and treatment plan of different tumors. i think we have entered the era in our lives where genetics has gained an utmost importance in diagnostics and therapeutics of diseases and nobody can deny the importance of genetics. therefore, in spite of avoiding the understanding of genetics, every university and college should make genetics a compulsory part of their curriculum as it has already been included in the curriculum of undergraduate and postgraduate students in the developed world so that doctors have the basic knowledge of genetic techniques by the time they become qualified pathologists. j islamabad med dental coll 2019 54 op e n ac c e ss sudden maternal death from suspected amniotic fluid embolism and a dead baby delivered with natal teeth faiza kamran ali 1, feriha fatima khidri 2, kamran ali shahani 3, rafia shah 4 1 postgraduate trainee, department of gynaecology and obstetrics, isra university hospital, hyderabad 2 lecturer, biochemistry department, liaquat university of medical and health sciences, jamshoro 3 head, department of pediatrics, khairpur medical college 4 lecturer, prosthetic dentistry, liaquat university of medical and health sciences, jamshoro a b s t r a c t amniotic fluid embolism (afe) is a rare presentation in obstetric emergencies that carries great risk for the life of both mother and fetus. it is usually characterized by sudden cardiovascular collapse, respiratory distress and disseminated intravascular coagulation. here we present a case of sudden death of a pregnant woman due to suspected afe. we also present a rare finding of natal teeth in her deceased baby, which along with reported afe in the mother, is an unlikely event in the medical literature. key words: amniotic fluid embolism, natal teeth, pregnancy correspondence: feriha fatima email: ferihafatima@yahoo.com article info: received: november 9, 2018 accepted: november 22, 2018 cite this case report: ali fk, khidri ff, shahani ka, shah r. sudden maternal death from suspected amniotic fluid embolism and a dead baby delivered with natal teeth. j islamabad med dental coll. 2019; 8(1):54-56 funding source: nil conflict of interest: nil i n t r o d u c t i o n amniotic fluid embolism (afe) is a rare and unpredictable obstetric emergency, and an important cause of maternal mortality in the developed countries. it is characterised by a triad of sudden cardiovascular collapse, respiratory distress and disseminated intravascular coagulation.1 it is clinically diagnosed early during labour with ruptured membranes and occurs consequently due to the entry of amniotic fluid, fetal skin cells, hair or debris into the maternal circulation. it has a reported incidence of 1: 15,200 to 1: 53, 800 among pregnancies.2 the presence of tooth/teeth in a child at birth is an uncommon condition of the oral cavity and is referred to as ‘natal teeth’.3 the lower primary central incisors are most commonly erupted natal teeth, however eruption of multiple natal teeth (> 2) is an extremely rare occurrence.4 c a s e r e p o r t a 35-year-old gravida 6 para 5 was received in emergency of gynaecology and obstetrics department, isra university hospital hyderabad, with a history of sudden death. the attendants gave history that the patient experienced sudden uterine contractions and rupture of membranes about six hours ago. on her way to the hospital, she suddenly developed shortness of breath with a cough and collapsed in the vehicle within 5-10 minutes. she had completed her 41 weeks of gestation and was previously healthy. all her previous pregnancies were un-eventful and normal vaginal deliveries. she did not have a history of diabetes mellitus, chronic hypertension, preeclampsia/eclampsia, bleeding disorder, gestational hypertension, antepartum haemorrhage, fever or trauma. her death was confirmed on arrival at the hospital, however, fetal heart sounds were audible on fetoscope. immediate peri-mortem emergency caesarean section (c-section) was performed. after giving incision in the uterus, surgeons observed abnormally excessive uterine bleeding and suspected defective coagulation. the likely clinical diagnosis was amniotic fluid embolism, a rare pregnancy complication causing sudden cardiac arrest to multiple organ damage with or without coagulopathy. a dead male baby weighing 3.2 kg was delivered. placenta appeared normal on gross examination. general physical and systemic examination c a s e r e p o r t j islamabad med dental coll 2019 55 of the neonate revealed no abnormality. on oral examination, lips, tongue, palate and the floor of the mouth were normal in appearance. however, the baby had 4 natal teeth (2 maxillary and 2 mandibular), which is an extremely rare finding. teeth were whitish opaque in colour, mature and immobile. the size of the crown and gingival appearance were normal. the face of the baby was symmetrical and no morphological abnormality was seen (figure 1). the cause of the afe could not be determined due to the refusal of post-mortem by the patient’s family. figure 1: a new-born male baby with natal teeth in anterior maxillary area. *(photograph was taken after permission from the attendants) d i s c u s s i o n the presented case describes the sudden death of a woman in labour with no identified known risk factors. the afe diagnosis was made according to the criteria presented by fitzpatrick et al.1. lewis 5 reported that, 11 out of the 17 parturient women with experience of afe presented with prodromal symptoms such as shortness of breath, pain in chest, agitation, pin pricking sensations, nausea and vomiting. the time period between prodromal symptoms to collapse ranged from minutes to four hours. in the present case report, the parturient woman experienced dyspnea accompanied with a cough; however, it lasted only for a few minutes followed by collapse with no other specific symptoms. afe was diagnosed on the basis of sudden cardiac arrest, dyspnea, severe clinical bleeding observed during perimortem emergency c-section, and occurrence of the event during labour with no explanation for the clinical findings. unfortunately, no pharmacological or other therapies presently have been able to prevent or treat afe. it is managed with multidisciplinary approach using supportive treatment and managing shock simultaneously.6 table i: diagnostic criteria for afe in the absence of any other identified cause: either (i) acute maternal collapse presented with one or more of the following features: sudden cardiac arrest acute fetal compromise heart arrhythmias coagulation disorders decreased blood pressure maternal haemorrhage warning symptoms such as agitation, restlessness, numbness and tingling seizure dyspnea (ii) exclusion of women presenting with maternal haemorrhage without evidence of early coagulation disorder or cardio‐respiratory compromise or diagnosis confirmed at post-mortem examination due to the presence of fetal squamous cells or hair in the maternal lungs another aspect found in the present case was a dead fetus born with multiple natal teeth. previously, natal teeth have been classified as mature teeth showing complete development with moderately good prognosis or immature showing incomplete formation and poor prognosis.7 other classifications have categorized natal teeth into four classes: (i) shell shaped crown with poor attachment to the alveolus by gingival tissue and the lack of a root; (ii) solid crown with poor attachment to the alveolus by gingival tissue and small or absent root; (iii) incisal margin of the crown erupted through gingival tissue and (iv) unerupted with edematous gingival tissue but palpable tooth.8 according to these criteria, the baby had mature, firmly fixed, normal primary dentition and true normal j islamabad med dental coll 2019 56 eruption. the mesio-distal width and inciso-gingival length of the crowns were comparatively similar to the well erupted mature deciduous incisors. on palpation, 2 upper and 2 lower dentitions was felt, which was an unusual finding than earlier reported cases which usually have reported few natal teeth.7 the occurrence of natal teeth was regarded as a bad omen in chinese history, however, they were considered as a sign of luck in england, france and italy. the mechanism behind natal teeth, although is not well defined, however, certain factors, such as superficial site of the germ, infections, malnutrition, febrile incidents, hormones, hereditary or unusual osteoblastic activity may confer risk. its management to either extract or to retain, is usually decided by the dentition after assessing mobility and degree of maturity.7 c o n c l u s i o n this case report diagnosed a case of amniotic fluid embolism on the basis of clinical criteria, which if undiagnosed poses a serious threat for both mother and baby. it also highlighted the unusual finding of multiple natal teeth in a new born baby. in the present case, it was an unfortunate event to receive a mother after death occurrence followed by delivery of a dead baby, therefore further management was not possible; though it provides awareness to clinicians about two rare events in the same case. r e f e r e n c e s 1. fitzpatrick ke, tuffnell d, kurinczuk jj, knight m. incidence, risk factors, management and outcomes of amniotic‐fluid embolism: a population‐based cohort and nested case–control study. bjog: an international journal of obstetrics & gynaecology. 2016;123(1):100-9. 2. rezai s, hughes ac, larsen tb, fuller pn, henderson ce. atypical amniotic fluid embolism managed with a novel therapeutic regimen. case rep obstet gynecol 2017; id 8458375 3. malki ga, al-badawi ea, dahlan ma. natal teeth: a case report and reappraisal. case rep dent. 2015:21(40)4. 4. leung ak, robson wlm. natal teeth: a review. j natl med assoc. 2006;98(2):226. 5. lewis g. the confidential enquiry into maternal and child health (cemach) the seventh report on confidential enquiries into maternal deaths in the united kingdom. london: cemach. 2007. 6. moore j, baldisseri mr. amniotic fluid embolism. crit care med 2005;33(10):s279-s85. 7. cunha rf, boer fac, torriani dd, frossard wtg. natal and neonatal teeth: review of the literature. pediatr dent. 2001;23(2):158-62. 8. hebling j, zuanon a, vianna d. dente natal—a case of natal teeth. odontol clin. 1997;7:37-40. summary journal of islamabad medical & dental college (jimdc); 2016:5(4):192-194 192 original article effect of pre-operative education on level of anxiety in patients undergoing cataract surgery azra parveen1, rehana ellahi2, saima sultana3, muhammad tahir4 ,tahira khatoon5 1nursing instructor mayo hospital lahore 2director, shaukat khanum hospital, lahore 3nursing instructor, pakistan institute of medical sciences, islamabad 4nursing instructor, pakistan institute of medical sciences, islamabad 5nursing instructor, postgraduate college of nursing, lahore abstract objective: to determine the effects of preoperative education on the level of anxiety in patients undergoing cataract surgery by comparing the anxiety level among interventional and control group. study design: experimental post-test design patients and method: this cross-sectional study was conducted at ophthalmic department of mayo hospital lahore. a total of 100 cataract patients were selected from by purposive nonprobability sampling technique and divided into two groups (control & interventional) by dividing the days. data was analyzed by using hospital anxiety and depression scale (hads). result: out of total 100 patients, 50 were included in control group and 50 were in interventional group. in control group there were 26(52%) male and 24(48%) females and in interventional group 25(50%) were male and 25(50%) were females. among controls, there was no patient with normal score of anxiety level, 8 (16%) patients were with mild score, 38(76%) patients were with moderate score and 4(8%) patients were with severe score. in interventional group, there were 38(76%) patients with normal score, 11(22%) patients were with mild score, only 1(2%) patient was with moderate score and no patient was with severe score. conclusion: a good relationship was found between preoperative education and reduction of anxiety level in patients undergoing cataract surgery. key words: anxiety, cataract, patient education, preoperative, surgery introduction cataract remains the leading cause of blindness globally. according to the latest assessment, 51% of blindness occurs due to cataract, which represents about 20 million people. this is a very serious issue as cataract is easily curable through a simple surgery, which is today available in the whole world.1-5 many improvements in the development and use of microsurgical instruments and surgical techniques were made in recent years. phacoemulsification is one of those improvements which become a procedure of choice for all routine cataract surgeries.6-8,1 presently over 85% of all cataract surgeries in the world are performed using phacoemulsification with topical/local anaesthesia. that is performed with a small corneal incision and requires no sutures. these techniques enable the surgeon to perform this procedure in 30 minutes or less and with no pain, having immediate visual improvement.9-11 it is well documented that hospitalization for surgery is associated with increased anxiety.12,13 perioperative anxiety is a known entity and highly acknowledged.14,15 for most people, anxiety is an unpleasant emotion and can be a reason of avoidance or refusal of operation.16,17 it can adversely affect anaesthetic induction and patient recovery as well as decrease patient satisfaction, and perceived quality of care. in order to reduce anxiety of patients various interventions can be used such as preoperative patient’s education and reassurance, relaxation techniques, touch therapy, mild sedation and music therapy etc.2,3,18,13,19 present study was planned to see if providing information and giving education to patients about their treatment can reduce anxiety and aid recovery. patients and method a sample of 100 cataract patients were selected from the ophthalmic department of mayo hospital lahore by using purposive nonprobability sampling technique and divided into two groups (control & interventional) by dividing the corresponding author: saima sultana e mail: saimapims@yahoo.com received: may 25,2016; accepted: december 19, 2016 mailto:saimapims@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):192-194 193 days. data was collected by using hospital anxiety and depression scale (hads).17 the data was entered and analyzed by spss version ibm-20 and was representated in the form of figures, tables and percentages. mean with standard deviation was calculated for quantitative variables and percentages and frequencies were computed for categorical variables. chi-square and student t-test was used to compare the effect of preoperative education on level of anxiety in patients undergoing cataract surgery. a p-value of ≤ 0.05 was considered as statistically significant. result among controls there was no patient with normal score of anxiety level, 8(16%) patients were with mild score, 38(76%) patients were with moderate score and 4(8%) patients were with severe score. in interventional group there were 38(76%) patients with normal score, 11(22%) patients with mild score, only 1(2%) patient with moderate score and no patient was with severe score (table 1). table 1: final outcome of hospital anxiety depression scale in studygroups study group p-value control (n=50) no (%) interventional (n=50) no (%) s c o ri n g normal 0(0%) 38(76%) 0.000 mild 8(16%) 11(22%) moderate 38(76%) 1(2%) severe 4(8%) 0(0%) table 2: hospital anxiety depression scale in study groups control n=50 interventional group n=50 p-value mean + sd 12.30 +1.95 6.28 +2.27 0.000 according to had scale, in interventional group mean score was lower as compared to control group patients (table 2). discussion a current experimental study has explored the effect of preoperative education on level of anxiety of patients undergoing cataract surgery. it has provided strong evidence, that pre-operative education has a positive effect on decreasing anxiety of patients during surgery. other studies also have also shown that pre-operative information provides beneficial health results and also helps in avoiding post-operative complications.1,9,10,13,16 there were 100 patients included in our study in which 50 were control and 50 were from interventional group. the male to female ratio was same in interventional and in control group. most of the patients recruited in our study were old, as the mean age of the controls was sixty-five years and that of interventional group. in another study told mean age was above fifty years that was quite similar to this study as well as female gender was; contrary to our results; found to be more prone to cataract.1 other studies support the same, and define the implication of this knowledge in our setting.9,11,15,16 the pre-operative patient’s guidelines that was used in current study, should be given to cataractsurgery-patients before surgery, it may help them to understand the surgical procedure and ultimately reduction of their anxiety level. it is thus strongly suggested that there is a relationship between pre-operative education and reduction of anxiety level in patients undergoing cataract surgery. pre-operative information helped the interventional group to be less anxious, less frightened from the procedure, avoiding worrying thoughts and fear of mis-happenings. most of the patients strongly agreed that preo-perative education is helpful against anxiety and beneficial for patient’s outcomes. they also strongly agreed that providing pre-operative education in pakistan is imperative for all cataract patients. patients in interventional group experienced less anxiety, short hospital stay and higher satisfaction regarding surgical procedure they underwent and less intra-operative complications. conclusion a good relationship was found between pre-operative education and reduction of anxiety level in patients undergoing cataract surgery. conflict of interest this study has no conflict of interest as declared by any author references 1. dua hs, singh ad. prevalence of cataract surgery in pakistan. br.j ophthalmol. 2007;91(10):1267-73. 2. brumfield vc, kee cc, johnson jy. preoperative patient teaching in ambulatory surgery settings. aorn j. 1996 ;64(6):941-52. 3. bhowmik sr. pre-operative orientation programme on pre and post-operative anxiety. sinhgad j nurs. 2012;1(2):1214. 4. world health organization. strategies for preventing of blindness & visual impairment. international council of ophthalmology 2013;who. 5. asthury n. a hand to hold: communication during cataract surgery. eye.2004; 18:115-116. doi:10.1038/sj. eye.6700569 6. nijkamp md, kenens ca, dijker aj, ruiter ra, hiddema f, nuijts rm. determinants of surgery related anxiety in journal of islamabad medical & dental college (jimdc); 2016:5(4):192-194 194 cataract patients. british journal of ophthalmology. 2004;88(10):1310-4. 7. foggitt ps. anxiety in cataract surgery: pilot study. journal of cataract & refractive surgery. 2001;27(10):1651-5. 8. morrell g. effect of structured preoperative teaching on anxiety levels of patients scheduled for cataract surgery. insight-the journal of the american society of ophthalmic registered nurses. 2001;26(1):4-9. 9. nijkamp md, ruiter ra, roeling m, van den borne b, hiddema f, hendrikse f, et.al. factors related to fear in patients undergoing cataract surgery: a qualitative study focusing on factors associated with fear and reassurance among patients who need to undergo cataract surgery. patient education and counseling. 2002 ;47(3):265-72. 10. caumo w, schmidt ap, schneider cn, bergmann j, iwamoto cw, bandeira d, ferreira mb. risk factors for preoperative anxiety in adults. acta anaesthesiologica scandinavica. 2001;45(3):298-307. 11. pager ck. randomised controlled trial of preoperative information to improve satisfaction with cataract surgery. british journal of ophthalmology. 2005;89(1):10-3. 12. rizvi z, rehman t, malik s, qureshi a, paul l, qureshi k, memon s, rafi s, ali a. an evaluation of topical and local anesthesia in phacoemulsification. jpma. the journal of the pakistan medical association. 2003;53(4):167-70. 13. sørlie t, busund r, sexton j, sexton h, sørlie d. video information combined with individualized information sessions: effects upon emotional well-being following coronary artery bypass surgery—a randomized trial. patient education and counseling. 2007 ;65(2):180-8. 14. snaith rp. the hospital anxiety and depression scale. health and quality of life outcomes. 2003;1(1):29 doi: 10.1186/1477-7525-1-29 15. cupples sa. effects of timing and reinforcement of preoperative education on knowledge and recovery of patients having coronary artery bypass graft surgery. heart & lung: the journal of critical care. 1991;20(6):654-60. 16. haugen as, eide ge, olsen mv, haukeland b, remme år, wahl ak. anxiety in the operating theatre: a study of frequency and environmental impact in patients having local, plexus or regional anaesthesia. journal of clinical nursing. 2009 ;18(16):2301-10. authorship contribution: author 1: conception, synthesis and planning of the research author 2,4,5: active participation in active methodology author 3 interpretation, analysis and discussion https://dx.doi.org/10.1186/1477-7525-1-29 j islamabad med dental coll 2021 62 ope n acce ss a case of calvarial tuberculosis in an elderly male patient miqdad haider1, aijaz zeeshan khan chachar2, nabeel shafqat3, waqar zaheer4 1registrar department of medicine, fatima memorial hospital, lahore pakistan 2senior registrar department of medicine, fatima memorial hospital, lahore pakistan 3postgraduate resident, dhq gujranwala pakistan 4medical officer, social security hospital, islamabad pakistan a b s t r a c t tuberculosis (tb) is still endemic in developing countries like pakistan. tuberculosis affecting bones account for 1% of all tb infections. calvarial tuberculosis, a rare manifestation of extra-pulmonary tb, accounts for 0.2%-1.3% of all cases of skeletal tb. even in developing countries where tb is endemic, cases with this type of tb are not commonly seen. the most commonly involved sites are the frontal and parietal bones, with destruction of both the inner and outer table. proper diagnosis and timely management help in improving prognosis. h ere we describe the case of a 70 -year-old male patient with pulmonary and extrapulmonary (calvarial) tuberculosis. the diagnosis was established on histopathological examination with demonstration of acid-fast bacilli (afb) and typical features seen on computed tomography (ct) scan. key words: calvarial tb, pulmonary tuberculosis, scalp swelling correspondence: miqdad haider email: miqdad14@yahoo.com article info: received: october 21, 2020 accepted: october 27, 2020 cite this case report: haider m, chachar azk, shafqat n, zaheer w. a case of calvarial tuberculosis in an elderly male patient. j islamabad med dental coll. 2021; 10(1): 62-65. doi: 10.35787/jimdc.v10i1.624 funding source: nil conflict of interest: nil i n t r o d u c t i o n infection with mycobacterium tuberculosis is still a common entity in our part of the world. there has been resurgence in even developed countries with increase in prevalence of human immunodeficiency virus (hiv) infection.1 mycobacterium can infect any organ of the body, although pulmonary manifestation is the most common one.2 extrapulmonary involvement is seen in pericardium, meninges, kidneys, adrenal glands and bones, etc.3 calvarial tuberculosis involving the skull bones is a rare extra-pulmonary manifestation of tb.4 approximately 1% of all patients with tuberculosis1 have bone involvement and of these only 0.2% -1.3% are diagnosed as having tb of calvarium.2 a possible reason for this low incidence might be scarcity of lymphatics in the skull bone. majority of the diagnosed patients are of young age (first two decades of life).5 the incidence of tb of skull although low at the moment, is on the rise in countries with poor socioeconomic status, prevalent malnutrition and also due to various immunodeficiency states. perforating tuberculosis of the skull is a term used by volkmann6 to describe small punched-out lesions with granulation tissue covering both the inner and outer tables of the calvaria. awasthy et al. 6 described that it has low tendency to spread and is c a s e r e p or t j islamabad med dental coll 2021 63 not linked with a periosteal reaction. these lesions are commonly known as circumscribed lytic lesions. the most frequently seen clinical presentation of calvarial tb is a scalp swelling with discharge. frontal and parietal bones are usually involved. 5 computed tomography (ct) scan may show a lytic lesion and histopathological evidence is required for a definite diagnosis. our patient was a 70-year-old male who presented with a scalp swelling which was fluctuant on palpation. c a s e r e p o r t a 70-year-old male presented to the outpatient department (opd) of medicine, fatima memorial hospital, lahore, with complaints of cough for two months, fever (undocumented) since one month, shortness of breath on exertion and weight loss of about 5 kg over a period of three months. patient was a non-smoker and belonged to lower income class. on examination, he was an old ill looking man, afebrile with blood pressure of 130/90 mmhg and regular pulse of 84 beats/minutes. chest auscultation revealed bronchial breath sounds in right upper lobe of the lung along with coarse crackles and decreased breath sounds in right lung base. further examination revealed a painless swelling in the scalp, with no visible discharge. it was 3x3 cm in diameter, non-tender, soft and fluctuant on palpation. he was admitted in the hospital for further workup and management. investigations showed hemoglobin level of 9.8 mg/dl, total leucocyte count 8500/mm3, differential leucocyte count with 60% polymorphs, 35% lymphocytes and erythrocyte sedimentation rate of 88 mm/hr. serum creatinine level was 0.9 mg/dl and random blood sugar level was 136 mg/dl. urine examination showed 1-2 pus cells, and no glucose. serum potassium (4.4 mmol/l), serum sodium (139 mmol/l) and serum magnesium (1.7 mg/dl) were within the normal range. chest x-ray revealed right upper lobe cavitating lesion and blunting of right costophrenic angles. high resolution computed tomography (hrct) of chest confirmed findings of the chest x-ray, demonstrating wedge shaped cavity in right upper lobe with bilateral pleural effusions, confirmed by the consultant radiologist of the hospital. for the scalp swelling, x-ray of skull was done which showed erosion of the underlying bone. necrotic debris was obtained on fine needle aspiration cytology (fnac). computed tomography (ct) scan was advised, which showed a subperiosteal abscess with punched out lytic lesion and extradural abscess (figure 1). for a definitive diagnosis of this lesion, surgical intervention was performed. tissue was excised, debridement done and the curettings were sent to the histopathology laboratory. the report revealed presence of caseous granulomas. ziehl-neelsen (zn) staining of the sample showed acid fast bacilli (afb), hence confirming the diagnosis of tuberculosis of this region. the patient was diagnosed as having pulmonary and extrapulmonary (calvarial) tuberculosis infection. anti-tuberculous therapy (att) was started. att along with timely surgical intervention helped in improvement of the patient’s condition. patient was discharged after observation and was advised to follow up in the medical opd. figure 1: ct brain plain showing punched-out lytic lesion (arrows) in the parietal bone. j islamabad med dental coll 2021 64 d i s c u s s i o n calvarial tuberculosis is a very rare disease even in countries where tb is endemic. a primary source of tb (like pulmonary tb) may exist followed by spread through the hematogenous route.3,7 calvarial tb as a single diagnosis is seen very rarely. about 75-90% patients with calvarial tb are under 20 years of age. 2,5 it has been observed to affect both sexes equally with no sex predilection. early in the course of the disease the diagnosis can be easily missed because of lack of typical clinical signs. the appearance of a painless fluctuant scalp swelling is the most common presentation and usually the first symptom, as was seen in our patient.3,7 the scalp swelling is usually associated with erosion of the underlying bone.7 the most common sites for calvarial tb are the frontal and parietal bones and rarely in the occipital bone.5 our patient also had involvement of the parietal bone of the skull. the clinical findings depicting intracranial involvement such as seizures, meningitis and venous sinus thrombosis is rarely observed in calvarial tb. our patient presented with scalp swelling with no discharge and pulmonary manifestations of tb but no evidence of neurological findings. mantoux test and raised erythrocyte sedimentation rate (esr) are good markers for the diagnosis of tb along with other confirmatory tests. mantoux test may be negative in 10% tb patients, while the esr may be normal in 10% of patients.8 findings of calvarial tb on x-ray skull are variable and nonspecific, as seen in our patient who showed some erosion of the underlying bone. x-ray findings can only be suggestive but not diagnostic in case of calvarial tb.9 ct scan and magnetic resonance imaging (mri) are strongly recommended to assess extent of bone involvement, scalp swelling and the amount of intracranial extension. in our case, ct showed punched-out lytic lesion with subperiosteal abscess. demonstration of acid-fast bacilli (afb) in the smears or biopsy specimen is diagnostic, but due to severe necrosis in some specimens’ afb may not be demonstrable.10 in our patient, surgical debridement was done. on histopathology caseous necrosis was seen. ziehl neelsen (zn) stain of the sample showed afb, confirming the diagnosis of tuberculosis of this region. management of this condition include antitubercular therapy (att) and surgery. surgical management by debridement and curettage was the sole modality of treatment which showed very good results before the start of att.2 as in our case both att along with surgery were used for treatment with a good outcome, as the patient improved and was discharged home. recent studies suggest that combination therapy (att with surgery) is far better as more areas of involved bone , will be the source of releasing tubercle bacilli, if surgery is delayed. 10,11 prognosis solely relies on the associated tuberculous lesion and local extent of the disease. our case had a good prognosis as there was limited local invasion of the disease. c o n c l u s i o n calvarial tb can present in an elderly patient as a scalp swelling without a discharging sinus. typical features on ct brain and fnac with afb staining help in the definitive diagnosis. timely surgical intervention followed by initiation of anti-tubercular therapy are associated with good prognosis. r e f e r e n c e s 1. datta sgs, bhatnagar v, pan s, mehta r, sharma c. primary calvarial tuberculosis: a report of three cases. br j neurosurg. 2019; 33(2): 196 -201. doi: 10.1080/02688697.2017.1409879. j islamabad med dental coll 2021 65 2. sridharan s, balasubramanian d. primary calvarial tuberculosis. surg neurol int. 2017; 8: 126. doi: 10.4103/sni.sni_495_16. 3. ravikanth r, mathew s, selvam rp. calvarial tuberculosis presenting as multiple osteolytic soft tissue lesions. chrismed j health and res. 2017; 4(4): 278-9. doi: 10.4103/cjhr.cjhr_36_17. 4. homagain s, shrestha s, sah s, sedain g. calvarial tuberculosis: a diagnostic quandary: a case report. jnma j nepal med assoc. 2019; 57: 198 -201. pmid: 31477963. 5. bhoi sk, naik s, jha m, pradhan n. skull base and calvarial tuberculosis presenting as chronic meningitis. ijtb. 2020; 67(3): 411 -3. doi: 10.1016/j.ijtb.2020.01.011. 6. awasthy n, chand k, singh a. calvarial tuberculosis: review of six cases. ann indian acad neurol. 2006; 9(4): 227-29. doi: 10.4103/0972-2327.29205 7. akpınar a, erdoğan u, koçyiğit m. primary calvarial tuberculosis presenting with scalp swelling and lytic bone lesion: a case report. med bull haseki. 2018; 56(3): 240-3. doi: 10.4274/haseki.3532. 8. mackowiak pa, yalamanchili m, ada s, bradstreet p. a 27-year-old man with soft-tissue swelling on the scalp and hypochondrium. clin infect dis. 2002; 35(6): 763-4. 9. choo y-h, seo y, choi j. calvarial tuberculosis presenting with skin defect in an elderly patient. world neurosurg. 2020; 140: 267 -70. doi: 10.1016/j.wneu.2020.05.076. 10. da silva martins ams, fanjul f, rosselló aac, jaume mr. calvarial tuberculosis: an unusual presentation of disseminated tuberculosis. bmj case rep. 2019; 12(4): e226967. doi: 10.1136/bcr -2018-226967. 11. sant’anna cc, perinei pl, pessôa ac, goudouris e, frota ac. calvarial tuberculosis: two cases in children. rev inst med trop s paulo. 2020; 62. doi: 10.1590/s1678-9946202062068. j islamabad med dental coll 2021 140 o p e n a c c e s s frequency of isolation of coagulase negative staphylococcus from blood cultures and its antibiogram nadia aslam1, nazma kiran2, naima mehdi3 1professor, department of pathology, rai medical college, sargodha 2associate professor, department of pathology, rai medical college, sargodha. 3assistant professor, department of pediatric microbiology, the children’s hospital and university of child health sciences, lahore a b s t r a c t background: coagulase-negative staphylococci are members of stable skin inhabitants. they are frequent contaminants in blood cultures and can lead to unnecessary exposure of patients to antimicrobial drugs and excess hospital costs. this study aims to estimate the frequency of coagulase-negative staphylococci in blood cultures and their antibiograms. materials and methods: this cross-sectional study was performed in a tertiary care hospital over one year from april 2018 to march 2019. blood cultures received in the laboratory were processed to isolate coagulase-negative staphylococci. susceptibility to various antimicrobial drugs was detected by disc diffusion method and e-strips. results: a total of 13802 blood cultures were processed in one year. 1750 blood cultures yielded bacterial growth and 374 blood cultures were positive for staphylococci. out of these 374 blood cultures, 97 were categorized as staphylococcus aureus and 277 were coagulase-negative staphylococci. out of 13802 total blood cultures performed during study period, 277 blood cultures positive with coagulase negative staphylococcus means contamination rate of 2% out of total blood cultures. 277 coagulase negative staphylococcus positive cultures out of 1750 positive blood cultures means contamination rate of 15.8% out of positive blood cultures. among coagulase-negative staphylococci, 68.2% isolates were resistant to cefoxitin, 95.3% to penicillin, 85.1% to erythromycin, 37.5% to ciprofloxacin, 59.6% to gentamicin, 68.6% to fusidic acid, 3.6% to teichoplanin, and 1.4% to linezolid. all isolates were sensitive to vancomycin. conclusion: the rate of blood culture contamination was 2% out of total blood cultures and 15.8% out of positive blood cultures. keywords: antibiogram, bacteremia, blood culture, drug resistance authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: nadia aslam email: drnadia76@yahoo.com article info: received: december 4, 2019 accepted: september 2, 2021 cite this article. aslam n, kiran n, mehdi n. frequency of isolation of coagulase negative staphylococcus from blood cultures and its antibiogram. j islamabad med dental coll. 2021; 10(3): 140-144. doi: 10.35787/jimdc.v10i3.468 funding source: nil conflict of interest: nil i n t r o d u c t i o n coagulase-negative staphylococci (cons) are members of the normal flora of the skin.1,2 there are more than 40 species of cons. they are members of the genus staphylococcus but they are unable to produce coagulase and they are less virulent and pathogenic than staphylococcus aureus.2 these organisms rarely cause disease in a healthy population. cons being multidrug-resistant may get selected due to excessive use of antimicrobials in hospitals and their ability to form biofilms can lead o r i g i n a l a r t i c l e https://www.sciencedirect.com/topics/medicine-and-dentistry/staphylococcus-aureus j islamabad med dental coll 2021 141 to foreign body-related or device-associated healthcare infections.2 blood cultures are of crucial importance in diagnosing septicemia in critically ill patients.3 blood culture contamination/pseudo bacteremia may occur when cultures get contaminated with microbial flora of skin due to ineffective or inappropriate sterile technique being practiced while drawing blood specimen or processing of cultures. blood cultures give falsepositive results with organisms that were not present in the bloodstream.4 blood culture contamination is quite a common issue encountered in microbiology laboratories. cons are frequent isolates from microbiological culture and are considered as culture contaminants.3-5 cons being opportunistic pathogens can cause nosocomial infections and are multi-drug resistant.2 therefore, it is of utmost importance to differentiate between blood culture contamination and true bacteremia to avoid prolonged hospital stays, excessive costs and unneeded exposure of patients to antimicrobial drugs in a hospital setting which can ultimately select for drug-resistant organisms such as vancomycin-resistant enterococci.5 several guidelines are available to differentiate blood culture contaminants from pathogens but the true “gold standard” is yet not determined.3,5 if only one blood culture out of a set of two is positive it is presumed to be blood culture contamination and if both bottles yield organism that is considered as true bacteremia.5 cons considered as true contaminants of blood culture in past are more recently reported as a cause of true bacteremia in some patients.5 blood culture contamination with cons being a member of skin flora may result from the faulty technique. false-positive blood cultures may lead to a prolonged hospital stay and unnecessary treatment with anti-staphylococcal drugs leading to additional costs. this study was conducted to estimate the frequency and percentage of cons isolation from blood cultures and their antimicrobial drug resistance pattern. m a t e r i a l s a n d m e t h o d s this cross-sectional study was carried out at the microbiology laboratory of a tertiary care hospital, from april 2018 to march 2019. all blood culture samples received in the microbiology laboratory during the period of study were processed to isolate cons. one positive blood culture out of a set of two was presumed to be blood culture contamination. repeat samples from the same patients were excluded. the total blood cultures (13802) received in the pathology laboratory over the period of one year were processed to isolate members of genus staphylococcus. blood culture bottles were processed after 48 hours of incubation, subculture was done on solid media (chocolate and macconkey’s agar). identification was done based on colonial morphology and gram stain. after overnight incubation at 35°c, each distinctive colony morph type was selected and gram stain was performed. gram positive cocci arranged in clusters were selected and catalase test was performed. gram-positive, catalase-positive cocci were labeled as staphylococci. tube coagulase and deoxyribonuclease (dnase) tests were performed to differentiate among staphylococcus aureus and coagulase negative staphylococci. the organisms with coagulase and dnase-test negative were labelled coagulase-negative staphylococci. the frequency of cons in blood cultures was calculated and recorded. antimicrobial drug susceptibility test was performed. organisms were suspended in mueller-hinton broth to the turbidity of a 0.5 mcfarland standard and then plated on muellerhinton agar. susceptibility of cons to various drugs like penicillin (10 u), cefoxitin (30 μg), gentamicin (10 μg), ciprofloxacin (5 μg), erythromycin (15 μg), fusidic acid (10 μg), linezolid (10 μg), vancomycin (30 μg) and teichoplanin (30 μg) was detected by j islamabad med dental coll 2021 142 using disc diffusion technique and e strips according to clinical and laboratory standards institute (clsi) recommendations.6 susceptibility of isolates to various drugs was detected and was reported as frequency and percentages. r e s u l t s a total of 13802 blood cultures were processed in one year. 1750 (12.7%) blood cultures yielded bacterial growth. the most frequent isolated from blood cultures were gram-negative bacteria followed by staphylococci and enterococci. out of 1750 blood cultures, 1130 (64.5%) blood cultures yielded gram negative bacteria, 374 (21.4%) blood cultures were positive for staphylococci. out of these 374 blood cultures, 97(25.9%) were categorized as s. aureus and 277 (74.1%) were cons. frequency of cons was 2% (277/13802) out of total blood cultures while frequency of cons was 15.8% (277/1750) out of positive blood cultures. antimicrobial drug susceptibility was performed and drug resistance pattern in cons has been shown in graph 1. graph 1: frequency of drug resistance in coagulasenegative staphylococci (n=277) d i s c u s s i o n blood culture contamination with commensal skin flora leads to increased costs, prolonged hospital stays, and patient morbidity. unnecessary and prolonged hospitalization and antimicrobial drug use can lead to healthcare-associated infections.7 this study was conducted to determine the rate of blood culture contamination. in this study, the frequency of cons was 2% out of total blood cultures and 15.8% out of positive blood cultures. a study conducted by khan f et al reported cons were isolated in 10.6% of positive blood cultures.8 a study by malik s et al reported 18% contamination rate of the blood culture9. while according to gupta s et al, rate of blood culture contamination by cons was 17.4% of positive cultures.10 the rate of blood culture contamination should be calculated and monitored to devise appropriate measures and interventions to keep the rate low as 2–3%.7,9,11 studies have documented that implementing aseptic techniques and better skin antisepsis significantly reduces the blood culture contamination rate.12 a study by geisler bp et al demonstrated that dedicated and trained phlebotomists can play a positive role in decreasing the rate of blood culture contamination and this can lead to decreased health care costs and unnecessary use of antimicrobial drugs.13 even by implementing simple informational intervention aiming at increasing basic knowledge and skill of phlebotomists can be effective in decreasing blood culture contamination significantly.14 drug susceptibility pattern revealed 95.3% of cons were resistant to penicillin, 68.2% to cefoxitin, 85.1% to erythromycin, 59.6% to gentamicin, and 68.6% to fusidic acid. the majority of cons are drugresistant especially to cefoxitin and methicillin.2 contamination of blood cultures with an organism that is not present in the bloodstream can lead to unnecessary prolongation of hospital stay, excess http://www.tjmrjournal.org/searchresult.asp?search=&author=shilpi+gupta&journal=y&but_search=search&entries=10&pg=1&s=0 j islamabad med dental coll 2021 143 costs and exposure to undesired effects of broadspectrum antibiotics.15 studies have reported that approximately more than 59% of the patients with blood culture contamination with cons received antimicrobial therapy especially vancomycin.16 in this study teichoplanin resistance was found in 3.6% and linezolid resistance in 1.4% of cons. teicoplanin resistance in cons is reported by several studies.17 another study by gu b reported linezolid resistance in 1.4% of cons.18 inappropriate use of antimicrobials especially vancomycin, teicoplanin and linezolid for false-positive blood cultures can lead to the selection of resistant strains and this can pose a threat to the spread and survival of resistant strains in hospitals thus leading to nosocomial infections. cons may serve as a reservoir of drug resistance genes and it can transfer those genes to other more virulent true pathogens especially s. aureus.2 the strength of the study is that it depicts the rate of blood culture contamination in a particular hospital and setting, this study highlights the urgent need for devising strategies to reduce the rate of blood culture contamination. the limitations of this study are that in the absence of a true gold standard for determining blood culture contamination some cases of true bacteremia may be reported as blood culture contaminants. c o n c l u s i o n the rate of blood culture contamination was 2% out of total blood cultures and 15.8% out of positive blood cultures. r e c o m m e n d a t i o n s cons can contaminate blood cultures and are usually multidrug-resistant. therefore, interventions should be devised and implemented directed towards better skin antisepsis, improving the knowledge and skill of phlebotomists to reduce the rate of blood culture contamination. the rate of blood culture contamination should be monitored in health care facilities in preand post-intervention periods to monitor the effect of those interventions. r e f e r e n c e s 1. argemi x, hansmann y, prola k, prévost g. coagulasenegative staphylococci pathogenomics. int j mol sci. 2019; 20(5): 1215. doi: 10.3390/ijms20051215 2. becker k, heilmann c, peters g. coagulase-negative staphylococci. clin microbiol rev. 2014; 27(1-2): 870–926. doi: 10.1128%2fcmr.00109-13 3. sidhu sk, malhotra s, devi p, tuli ak. significance of coagulase-negative staphylococcus from blood cultures: persisting problems and partial progress in resource-constrained settings. iran j microbiol. 2016; 8(6) :366–71. pmc 5420390 4. laupland kb, church dl. population-based epidemiology and microbiology of community onset bloodstream infections. clin microbiol rev. 2014; 27(4): 647–64. doi:10.1128/cmr.00002-14 5. elzi l, babouee b, vögeli n, laffer r, dangel m, frei r, et al. how to discriminate contamination from bloodstream infection due to coagulase-negative staphylococci: a prospective study with 654 patients. clin microbiol infect. 2012; 18(9): e355–61. doi: 10.1111/j.14690691.2012. 03964.x 6. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing. 28th ed. clsi supplement m100 2018. 7. alnami ay, aljasser aa, almousa rm, torchyan aa, bin saeed aa, al-hazmi am, et al. rate of blood culture contamination in a teaching hospital: a single center study. j taibah univ med sci 2015; 10(4): 4326. doi: 10.1016/j.jtumed.2015.08.002 8. khan f, kirmani s, siddiqui n, sultan a, sami h, mahtab md, et al. cons in blood culture: contaminants or pathogens? int j curr microbiol app sci 2015; 1: 88-94. 9. malik s, ravishekhar k. significance of coagulase negative staphylococcus species in blood culture. j clin diagn res 2012; 6(4): 632-35. 10. gupta s, kashyap b. bacteriological profile and antibiogram of blood culture isolates from a tertiary care hospital of north india. trop j med res 2016; 1992): 94-9. doi: 10.4103/1119-0388.185426 11. bentley j, thakore s, muir l, baird a, lee j. a change of culture: reducing blood culture contamination rates in an emergency department. bmj qual improv rep. 2016; 5(1): u206760.w2754. doi:10.1136/bmjquality.u206760.w2754 j islamabad med dental coll 2021 144 12. marlowe l, mistry rd, coffin s, leckerman kh, mcgowan kl, dai d, et al. blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. infect control hosp epidemiol. 2010; 31(2): 171-6. doi: 10.1086/650201 13. geisler bp, jilg n, patton rg, pietzsch jb. model to evaluate the impact of hospital-based interventions targeting false-positive blood cultures on economic and clinical outcomes. j hosp infect. 2019; 102(4): 438-44. doi: 10.1016/j.jhin.2019.03.012 14. roth a, wiklund ae, palsson as, melander ez, wullt m, cronqvist j, et al. reducing blood culture contamination by a simple informational intervention. j clin microbiol. 2010; 48(12): 4552–8. doi: 10.1128/jcm.00877-10 15. hughes ja, cabilan cj, williams j, ray m, coyer f. the effectiveness of interventions to reduce peripheral blood culture contamination in acute care: a systematic review protocol. syst rev. 2018; 7(1): 216.doi: 10.1186/s13643-018-0877-4 16. dempsey c, skoglund e, muldrew kl, garey kw. economic health care costs of blood culture contamination: a systematic review. am j infect control.2019;47(8):9637. doi:10.1016/j.ajic.2018.12.020. 17. cremniter j, slassi a, quincampoix jc, sivadon-tardy v, bauer t, porcher r, et al. decreased susceptibility to teicoplanin and vancomycin in coagulasenegative staphylococci isolated from orthopedicdevice-associated infections. j clin microbiol. 2010; 48(4): 1428–31. doi: 10.1128/jcm.02608-12 18. gu b, kelesidis t, tsiodras s, hindler j, humphries rm. the emerging problem of linezolid-resistant staphylococcus. j antimicrob chemother. 2013; 68(1): 4-11. doi: 10.1093/jac/dks354 j islamabad med dental coll 2021 105 open access post-procedural drainage versus no drainage in laparoscopic cholecystectomy at dhq hospital charsadda, pakistan muhammad bilal1, viqar aslam2, zaheer ud din3, waqas jan4, inamullah5, shehzad khan3, ali hasnain malik3 1district surgeon, district headquarter hospital, charsadda, khyber pakhtunkhwa-pakistan 2associate professor, department of surgery, lady reading hospital, peshawar khyber pakhtunkhwa-pakistan 3medical officer, district headquarter hospital, charsadda, khyber pakhtunkhwa-pakistan 4general surgeon, district headquarter hospital, charsadda, khyber pakhtunkhwa-pakistan 5senior medical officer, district headquarter hospital, charsadda, khyber pakhtunkhwa-pakistan a b s t r a c t background: laparoscopic cholecystectomy (lc) is the treatment of choice for symptomatic gall stones but controversy regarding the routine use of drainage after elective lc still exists. the objective of this study was to determine the efficacy of post-procedural drainage versus no drainage after simple laparoscopic cholecystectomy. the postoperative complications were also evaluated in both groups after the lc procedure. material and methods: this randomized controlled trial (rct) was conducted in patients who underwent laparoscopic cholecystectomy according to a pre-set inclusion criterion. ninety-three patients were randomly assigned into group a (with drainage tube) and group b (without drainage tube) using sealed opaque envelopes containing computer‐ generated random numbers. primary (like duration of hospital stay, postoperative pain) and secondary outcomes (like postoperative complications) were noted in both groups. chi-square, fischer exact test and mann witney u test were applied as appropriate and statistical significance was established at p < .05. results: the number of patients with hospital stay exceeding two days were more in group a (n=23; 51.1%) than b (n=13; 28.8%) (p < .05). group a presented with more postoperative complications but differences between the two groups were statistically non-significant. both groups experienced a high level of pain at six hours of surgery followed by progressive decrease in severity at 24 and 48 hours, respectively (p=.06). conclusions: post-procedural drain placement after laparoscopic cholecystectomy has no advantages as there is no significant difference in post-operative complications and duration of hospital stay in drainage versus no drainage groups. key words: complications, laparoscopic cholecystectomy, pain severity, postoperative drain. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2-5 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad bilal email: bilalsurg@gmail.com article info: received: may 15, 2020 accepted: june 22, 2021 cite this article. bilal m, aslam v, din z u, jan w, inamullah, khan s, et al. post-procedural drainage versus no drainage in laparoscopic cholecystectomy at dhq hospital charsadda, pakistan. j islamabad med dental coll. 2021; 10(2): 105-109. doi: 10.35787/jimdc.v10i2.554 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 106 i n t r o d u c t i o n stones in the duct of the gallbladder, that result in blockage is amongst the most common illness related to the gastrointestinal tract. laparoscopic cholecystectomy (lc) is used in the treatment of over 80% of cholelithiasis cases across the world. lc provides a safe and effective treatment for most patients with symptomatic gallstones and has become the treatment of choice. this procedure proves to be less invasive management of gallstones than open cholecystectomy, thus leading to faster recovery and few postoperative complications.1-5 to prevent bile or blood collection that might become infected, post-operative drains have been routinely placed by many surgeons to avoid any further interventional procedures. another reason for drainage is to allow carbon dioxide used for insufflation during laparoscopy, leave via drain site leading to decreased shoulder pain and postoperative nausea and vomiting.3-6 however, some surgeons believe that the use of drains only increases the wound infection rate by 2%.3 in a randomized controlled trial, tzovaras and colleagues also assessed the usefulness of drains in elective lc, so this issue is still generating a significant debate.7 this clinical study was designed to find out whether the placement of post-operative drain was valuable or not with regards to post-operative outcomes and complications. so, the efficacy of placement of drains versus no drain placement in lc was assessed. the complications were evaluated in both groups after the lc procedure. m a t e r i a l a n d m e t h o d s this rct was conducted in the surgical unit of district headquarter hospital (dhq), charsadda, khyber pakhtunkhwa, pakistan from february till december 2018. approval for the study was obtained from the ethics committee of the hospital. a sample size of 90 patients was calculated using the who calculator.7 after fulfilling the eligibility criteria and dropouts, 90 patients were recruited for this study (figure 1). patients with symptomatic gall stones confirmed on ultrasonography, hematological and biochemical tests were included in the study while patients with cholangitis and pancreatitis were excluded. they were randomly assigned into two groups (a & b), (n=45 for each group) using sealed opaque envelopes containing computer‐generated random numbers. in group a, a drain made of polyethylene was placed in each patient at the end of the lc through the trocar (5 mm) at the anterior axillary line for 48 hours.12 group b patients were without postprocedural drains. the study was conducted after proper evaluation of patients undergoing lc procedures. standard surgical protocols were followed for the procedure. all patients received one dose of ceftriaxone (1 gm) during the induction of general anesthesia (ga). protocols regarding pre and post-operative placement of drains and induction of analgesia were the same for both groups. patients were operated by the same surgeon and his team using similar protocols. primary outcomes including duration of hospital stay, post-operative pain, and secondary outcome like post-operative complications were noted in both groups. data was collected on a structured proforma. pain as a significant finding was evaluated by using numerical rating scale (nrs) in which a numbering from 0 to 10 was given to the patient on a ruler. patients chose their level of pain according to the numbers. number ‘0’ on the scale represented ‘no pain at all’ while ‘10’ on the scale indicated ‘unbearable pain’. j islamabad med dental coll 2021 107 figure 1: flow chart depicting randomization in the trial protocol. the recordings were taken after 06, 24, and 48 hours of surgery. both groups received 75 mg of diclofenac sodium intramuscularly every eight hours, postoperatively and from the next day oral combination of ibuprofen and paracetamol was started. data were analyzed through statistical package for social science (spss) version 23. frequencies (percentage) and median (range) were calculated. chi-square, fischer exact test and mann witney u test were applied as appropriate and statistical significance was established at p < .05. r e s u l t s in group a there were 10 males and 35 females while in group b, 9 males and 36 females were included. the mean age of patients in group a was 38.5 ± 5.28 years and for group b it was 39.12 ±5.07 years. the number of patients with hospital stay exceeding two days were more in group a (n=23; 51.1%) than b (n=13; 28.8%) (p < .05). group a presented with more postoperative complications but differences were statistically non-significant (table i). no hernia, reoperation, or death was reported in both groups. table i: list of postoperative complications in both groups complications group a (with drain) group b (without drain) *pvalue pain in right shoulder 6 (13.3%) 5 (11.1%) 0.17 infection (surgical site) 3 (6.6%) 1 (2.2%) 0.18 infection (respiratory) 1 (2.2%) 0 0.71 nausea 22 (48.8%) 11 (24.4%) 0.32 vomiting 15 (33.3%) 9 (20%) 0.19 *p-value <.05 was taken as statistically significant j islamabad med dental coll 2021 108 both groups experienced a high level of pain at six hours of surgery followed by progressive decrease in severity at 24 and 48 hours, respectively (table ii). there was no significant difference in pain analyzed in both groups (p=.06). table ii: postoperative pain score (median and range) postoperative hours group a (with drain) group b (without drain) 6 6 (0-9) 5 (0-9) 24 4 (0-9) 3 (0-7) 48 2 (0-7) 2 (0-7) *p-value was > .05 d i s c u s s i o n laparoscopic surgery has many advantages as it is more reliable, precise and cause less damage as compared to conventional surgery. the routine placement of drain has become a part of the operation, because of fear of collection of blood or bile for a long period or to allow the escape of carbon dioxide accumulated during the procedure. however, controversies have surrounded this practice.8,9 mean hospital stay of patients in the group without drainage was less in our study, which is similar to the studies conducted by gurusamy et al.10 and satinsky et al.11 patients complain of postoperative shoulder pain, nausea and vomiting, due to use of a shortterm drain postoperatively based on the theory that high-pressure co2 insufflation during the operation and the accumulation of gas in the right subphrenic area leads to these complaints.3-6 the results showed no significant differences in postoperative complications in the two groups (with and without drain) i.e., wound infections, mortality, respiratory infection and/or nausea. this is in accordance with the observations of gurusamy et al. and valappil et al.8,10 however many studies have revealed that the use of drain is associated with increased morbidity.8,12-15 according to literature, drainage prevent complications as it allows co2 used for insufflation during laparoscopy procedure leave via the drain site, while according to others drain is a source of infection.16-20 nrs score in this study revealed that every patient experienced different level of pain, though there was no significant difference in pain scores in both groups. group a experienced a high level of pain at 24-48 hours of surgery. uchiyama et al.15 and tzovaraset et al.7 also suggested that drain placement was linked with increased pain.8 the results of this study showed that laparoscopic cholecystectomy without drainage has more advantages over lc with drainage, as well as reduced hospital stay. these results are in accordance with the studies done by sharma and lucarelli.12,13 therefore, it proves that laparoscopic cholecystectomy without drainage is safest and should be considered as the option of choice for uncomplicated cholecystitis. if a drain is used, it should be removed within 24 to 48 hours, as recommended by other authors.12,14 the major limitation of this clinical trial was that it was a single center study on a limited number of patients. a multi-center clinical trial enrolling large number of patients should be carried out to authenticate findings of our study. c o n c l u s i o n we conclude that post-procedural drain placement after laparoscopic cholecystectomy has no advantages as there is no significant difference in post-operative complications and duration of hospital stay in drainage versus no drainage groups. j islamabad med dental coll 2021 109 r e f e r e n c e s 1. strasberg sm. tokyo guidelines for the diagnosis of acute cholecystitis. j am coll surg. 2018; 227(6): 624. doi: 10.1016/j.jamcollsurg.2018.09.005. 2. kapoor t, wrenn sm, callas pw, abu-jaish w. cost analysis and supply utilization of laparoscopic cholecystectomy. minim invasive surg. 2018; 7838103. doi: 10.1155/2018/7838103. 3. feng jw, yang xh, liu cw, wu bq, sun dl, chen xm, et al. comparison of laparoscopic and open approach in treating gallbladder. cancer j surg res. 2019; 234: 269-76. doi: 10.1155/2018/7838103. 4. jeans pl. murphy's sign. med j aust. 2017; 206(3): 115-16. doi: 10.5694/mja16.00768. 5. kose sh, grice k, orsi wd, ballal m, coolen mjl. metagenomics of pigmented and cholesterol gallstones: the putative role of bacteria. sci rep. 2018; 8(1): 11218. doi: 10.1038/s41598-018-295718. 6. sarawagi r, sundar s, raghuvanshi s, gupta sk, jayaraman g. common and uncommon anatomical variants of intrahepatic bile ducts in magnetic resonance cholangiopancreatography and its clinical implication. pol j radiol. 2016; 81: 250-5. doi: 10.12659/pjr.895827. 7. tzovaras g, liakou p, fafoulakis f, hatzitheofilou c. is there a role for drain use in elective laparoscopic cholecystectomy? a controlled randomized trial. am j surg. 2009; 197: 759-63. doi: 10.1016/j.amjsurg. 2008.05.011. 8. valappil mv, gulati s, chhabra m, mandal a, de bakshi s, bhattacharyya a, et al. drain in laparoscopic cholecystectomy in acute calculous cholecystitis: a randomized controlled study. postgrad med j. 2020; 96: 606-9. doi: 10.1136/postgradmedj-2019-136828. 9. gurer a, dumlu eg, dikili e, kiyak g, ozlem n. is a drain required after laparoscopic cholecystectomy? eurasian j med. 2013; 45(3): 181-4. doi: 10.5152/eajm.2013.37. 10. gurusamy ks, samraj k, mullerat p, davidson br. routine abdominal drainage for uncomplicated open cholecystectomy. cochrane database syst rev. 2007; 4: cd006004. doi: 10.1002/14651858.cd006003. 11. satinsky i, mittak m, foltys a. subhepatic drainage in laparoscopic cholecystectomy-a necessity or an overused tradition? rozhl chir. 2003; 82: 427-31. pmid: 14619087. 12. sharma a, gupta sn. drainage versus no drainage after elective laparoscopic cholecystectomy. kathmandu univ med j. 2016; 14(53): 69-72. pmid: 27892445. 13. lucarelli p, picchio m, martellucci j, de angelis f, di filippo a, stipa f, spaziani e. drain after laparoscopic cholecystectomy for acute calculous cholecystitis. a pilot randomized study. indian j of surg. 2015; 77(2): 288-92. doi: 10.1007/s12262-012-0797-9. 14. mandrioli m, inaba k, piccinini a, biscardi a, sartelli m, agresta f, et al. advances in laparoscopy for acute care surgery and trauma. world j gastroenterol. 2016; 22(2): 668. doi: 10.3748/wjg.v22.i2.668. 15. uchiyama k, tani m, kawai m, terasawa h, hama t, yamaue h. clinical significance of drainage tube insertion in laparoscopic cholecystectomy: a prospective randomized controlled trial. j hepatobiliary pancreatic surg. 2007; 14(6): 551-6. doi: 10.1007/s00534-007-1221-x. 16. cm t. sabiston textbook of surgery. noida. elsevier (18 ed). 2009; 2: 1556. 17. hawasli a, brown e. the effect of drains in laparoscopic cholecystectomy. j laparoendosc surg. 1994; 4(6): 393-8. doi: 10.1089/lps.1994.4.393. 18. hawasli a. to drain or not to drain in laparoscopic cholecystectomy: rationale and technique. surg laparosc endosc. 1992; 2(2): 128-30. pmid: 1341518. 19. jorgensen jo, gillies rb, hunt dr, caplehorn jr, lumley t. a simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy. aust nz j surg. 1995; 65(7): 466-9. doi. 10.1111/j.1445-2197.1995.tb01787.x. 20. abbott j, hawe j, srivastava p, hunter d, garry r. intraperitoneal gas drain to reduce pain after laparoscopy: randomized masked trial. obstet gynecol. 2001; 98(1): 97-100. doi: 10.1016/s00297844(01)01383-7. journal of islamabad medical & dental college (jimdc); 2012(2):-69-71 69 original article spectrum of bone lesions at pakistan institute of medical sciences muhammad rafiq* and ashok kumar tanwani** * postgraduate resident, department of pathology, pakistan institute of medical sciences, islamabad ** professor, department of pathology, pakistan institute of medical sciences, islamabad abstract objective: to study demographic details of bone lesions diagnosed at pakistan institute of medical sciences (pims), islamabad patients and methods: a retrospective analysis of histopathology reports of 222 patients diagnosed to have various types of bone lesion, in the department of pathology at pakistan institute of medical sciences, islamabad during a period of five years (july 2005june 2010) was conducted. these biopsies were evaluated on hematoxylin and eosin (h&e) stained sections from paraffin embedded tissue blocks. special stains performed whenever required. results: pyogenic osteomyelitis comprised 43.6% of all bone pathologies, followed by granulomatous most probably tuberculous osteomyelitis in 7.6%. chronic osteomyelitis was more commonly observed in 20-30 years of age group and males were affected more as compared to females. the commonest age group for benign lesion was 11-20 years. primary malignant tumors were noted in 4.9% cases and metastatic tumors were seen in 14.4%. the commonest age group for metastatic tumors was more than 50 years of age. males were affected more as compared to females in overall bone lesions. femur was the commonest site in primary bone lesions. jaw bones and scalp were more commonly involved metastatic tumors. conclusions: metastatic tumors were more common than primary malignancies. scalp and mandible involvement was seen in metastatic tumors and bones of lower limbs were more commonly involved in primary bone lesions. males were more commonly affected than females in this study. key words: primary bone tumors, metastatic tumors, tumor like lesions. introduction bone infections, tumor like lesions and neoplasms are not common lesions and pathologists generally lack clinical experience with these lesions. histopathologist requires clinical and radiological details for final diagnosis. benign, malignant and non-neoplastic bony lesions occur at typical sites and certain age groups. non-specific osteomyelitis can be diagnosed in younger age group and clinically presents as acute, chronic or granulomatous inflammation.1 although acute osteomyelitis seems to be less prevalent, the timely diagnosis and management in cases of osteomyelitis is a major challenge. staphylococcus aureus accounts for 4080% of infections followed by group a beta-haemolytic streptococcus.2 in usa the wide spread use of hemophilus influenzae vaccine has virtually eliminated acute osteomyelitis caused by this organism.3 the world health organization (who) has estimated that one third of the global population is infected with mycobacterium tuberculosis (mtb). tuberculosis has been reported in all bones of the body.4 the positive yield of mtb by different available methods is reported less frequently. therefore clinical correlation with other supportive tests in combination may be helpful for diagnosis and management. bone tumors in comparison to the myriad of other tumors are relatively uncommon, constituting only 0.5% of all types of cancer.5 bone tumors remain a daunting challenge to the orthopedic surgeons and the pathologists. the majority of primary bone tumors present during childhood and late adolescence, coinciding with the growth spurt and time of maximum constructive activity of bone. they frequently affect long bones and tend to occur at the ends of bones where growth is maximum. osteosarcoma is the most common primary malignant bone tumor in children followed by ewing’s sarcoma and lymphoma.6 tumor like bone lesions include various non-neoplastic lesions originating from or affecting the bone as solitary or some times multiple lesions. these include simple bone cyst, aneurysmal bone cyst, intra-osseous ganglion, epidermal cyst and subchondral cyst.7, 8 this study was designed to study demographic details of bone lesions diagnosed at pims. materials and methods a retrospective study was performed at the department of pathology, pims, from july 2005 to june 2010. the histopathological reports, slides and request forms were retrieved from records of department. total number of bone specimens received during the study period was 270. out of these, 48 specimens were excluded due to nonrepresentative tissue for diagnosis. the remaining 222 biopsy specimens of bone lesions with appropriate diagnosis were included in the study. results were entered on spss version 15. mean and standard deviation were calculated for quantitative variables e.g. age. frequencies and percentages journal of islamabad medical & dental college (jimdc); 2012(2):-69-71 70 were calculated for qualitative variables like histological diagnosis, gender, site of involvement etc. results frequencies of various histological diagnoses, gender, age and site distribution are summarized in table 1 and 2. among 222 cases, a total of 114 (51.2%) cases of osteomyelitis were diagnosed. out of these 92 were of chronic osteomyelitis, 5 were acute and 17 were tuberculous osteomyelitis. eighty one were males and 33 were females. sixty six cases were in the age range of 11-30 years of age group. sites of involvement were lower limbs in 86, upper limbs in 10, and scalp in 6 cases. in the remaining 12 cases site was not known. bone tumors were diagnosed in 108 (48.8%) cases. benign tumors and tumor like lesions were diagnosed in 65 (29.3%) cases. these included 15 (6.7%) cases of osteochondroma, 12 (5.4%) of aneurysmal bone cyst, 8 (3.6%) of fibrous dysplasia, 6 (2.7%) of giant cell tumor, 4 (1.8%) of osteoma, and 3 (1.4%) of chondroma. the lower limb was affected in most cases (table 1). males were 41 and remaining were females. most of the lesions were in the age group of 11-20 years (table 2). primary malignant tumors were seen in 11 (4.9%) cases. among these 7 cases were of osteosarcoma and 4 cases were of ewing’s sarcoma. in 9 cases lower limb was involved. males were affected in 6 cases and females in 5 cases. ewing’s sarcoma was most frequently seen in first decade and osteosarcoma in second decade. metastatic cancers were seen in 32 (14.4%) cases. among them squamous cell carcinoma was seen in 14 (6.3%) cases and metastatic malignant neoplasm in 5.0%. the remaining patients had small cell carcinoma, meningioma, adenocarcinoma, renal cell carcinoma and follicular cell carcinoma of thyroid. the mean age was more than 51 years in most cases. out of 32 cases of metastatic tumors, 22 were males and 10 were females. in majority of squamous cell carcinoma patients, mandible was involved. discussion pattern of bone lesions is reported less frequently. osteomyelitis is common in 10 to 30 years of age group and potentially serious disease.9 this disease is less common in developed countries but constitutes most of the bone pathology lesions in developing countries. majority of the cases are located in lower limbs followed by upper limbs in this study. the similar findings also reported by hanif et al and rasool et al.10, 11 tuberculous osteomyelitis has been reported in all bones of body.12 in addition, the spine is the most frequently involved site in adults whereas it is rare in children, as reported in our study. bone tumors are more common in adolescence age group. osteosarcoma is the second commonest cause of death due to cancer in children. it is most frequently seen in young people in the second and early third decades of life as over 60% of diagnosis are made between 10-20 years of age group. table 1: frequency of bone lesions according to site (n=222) diagnosis u p p er li m b l o w er l im b f a ce / s ca lp s p in e u n k n o w n t o ta l (% ) osteomyelitis tb osteomyelitis osteochondroma chondroma osteoma osteomalacia osteoid osteoma bone cyst fibrous dysplasia giant cell tumor osteosarcoma ewing’s sarcoma metastatic cancer others 7 3 7 3 0 0 0 1 0 4 0 0 0 2 74 8 7 0 1 2 1 9 5 1 6 2 8 4 0 0 0 0 3 0 0 1 3 0 0 0 20 4 0 4 0 0 0 0 0 1 0 0 0 0 0 0 16 2 1 0 0 0 0 2 1 1 1 2 4 1 97 (43.7) 17 (7.6) 15 (6.7) 3 (1.4) 4 (1.8) 2 (0.9) 1 (0.5) 14 (6.3) 9 (4.1) 6 (2.7) 7 (3.1) 4 (1.8) 32 (14.4) 11 (5.0) the similar findings were observed in this study. it usually occurs in metaphyses of long bones most frequently in order of distal femur, proximal tibia, proximal humerus and proximal femur.13 in contrast to osteosarcoma, ewing’s sarcoma tends to occur at much younger age group. ewing’s sarcoma is comparatively rare but highly malignant neoplasm. it not only affects long bones but also spine, pelvis and ribs.14 this is in contrast to our findings that 2 out of 4 cases were diagnosed in lower limbs. ewing’s sarcoma was equally distributed in both sex and first decade of life in the present study, which is in contrast to cotteril et al, who analyzed 975 cases of ewing’s sarcoma and found age range of 8 months to 47 years with a higher incidence in males under 15 years of age.15 another study carried out by muzaffar et al on frequency of bone cancer at agha khan university hospital found that osteosarcoma was the most common primary bone malignant tumor followed by ewing’s sarcoma. they also found that bone tumors are relatively more prevalent in males.16 the metastatic tumors are common in old age group and uncommon in pediatric age group. these findings also observed by tsukushi et al.17 tumor like bone lesions include various bone cysts, ganglion cyst etc. we found 12 (5.4%) cases of aneurysmal bone cyst in males and females 2:1, majority of the cases journal of islamabad medical & dental college (jimdc); 2012(2):-69-71 71 were in 10-20 years of age group and lower limb was commonly involved. table 2: frequency of bone lesions according to age & sex (n=222) diagnosis age (yrs) male female osteomyelitis tb osteomyelitis osteochondroma chondroma osteoma osteomalacia osteoid osteoma bone cyst fibrous dysplasia giant cell tumor osteosarcoma ewing’s sarcoma metastatic cancer others 3-75 7-64 14-41 20-23 24-64 19-65 18 8-23 10-71 14-51 13-40 8-23 21-70 11-40 71 10 12 0 0 2 1 10 4 4 4 2 22 6 26 7 3 3 4 0 0 4 5 2 3 2 10 5 spence et al also observed the same findings.18 metastatic tumors were observed in 11.1% cases by jain et al19 and common sites for metastatic tumors were femur with pelvis, spine and humerus with ribs. in contrast our study revealed jaw bones were the commonest site for metastatic tumors. conclusion osteomyelitis is the most frequent bone pathology. among the malignant bone tumors osteosarcoma is more prevalent in males than females followed by ewing’s sarcoma. in the majority of primary bone lesions, lower extremity is the most frequent site of involvement. metastatic tumors are more common in elderly age group. references 1. urso s, pacciani e, fariello g, colajacomo m, fassari fm, randisi f et al. nonspecific osteomyelitis in childhood and adolescence. the contribution of imaging diagnosis. radiol med. 1995;90(30):212-18. 2. ibia eo, imoisili m and pikis a. group a b-hemolytic streptococcal osteomyelitis in children. pediatrics 2003;112(1):22-8. 3. lazzarini l, mader jt and calhoun jh. osteomyelitis in long bones. j bone joint surg am. 2004;86:2305 18. 4. watts, hugh g, lifeso, robert m. current concepts reviewtuberculosis of bones and joints. j bone joint surg 1996;78(2):288-99. 5. mohammad a, sani ma, hezekiah ia and enoch aa. primary bone tumors and tumor like lesions in children in zaria, nigeria. afr j paediatr surg. 2010;7:16-8. 6. o’donnell p. evaluation of focal bone lesions. basic principles & clinical scenarios. imaging 2003;15: 298 7. marina n, gebhardt m, teot l, gorlick r. biology and therapeutic advances for pediatric osteosarcoma. the oncologist 2004; 9 (4): 422-41. 8. eth ek, ojaimi j, kitagawa y, choong pfm. out come of patients with osteosarcoma over 40 years of age: is angiogenesis is a marker of survival? international seminars in surgical oncology 2006;3(7):1-12. 9. uhl m, adier cp, herget gw. tumor like lesions. radiologe 2004; 44 (10): 1013-22. 10. hanif g, zaman s, hussain m, mahmood n, shahid a and ghazal a. clinico-morphological pattern of bone lesions in children. biomedica. 2009;25:59-62. 11. rasool mn. primary subacute hematogenous osteomyelitis in children. british editorial society of bone and joint surgery. 2001; 83-b(1):93-8. 12. davies pdo, humphries mj, yfield spb, nunn aj, darbyshire jh, citron km et al. bone and joint tuberculosis. a survey of notifications in england and wales. j bone joint surg 1984; 66-b (3): 326-30. 13. berg vdh, kroon hm, slear a and hogendoom p. incidence of biopsy proven bone tumors in children. a report based on the dutch pathology registration “palga”. j pediat ortho. 2008; 28 (1):29-35. 14. pritchard d, dahlin d, dauphine r, taylor wf, beabout jw, rochester et al. ewing’s sarcoma. a clinicopathological and statistical analysis of patients surviving five years or longer. j bone joint surg am. 1975;57:10-16. 15. cotteril sj, ahrens s, paulussen m, jurgens hf, vou’te pa, gadner h et al. prognostic factors in ewing’s tumor of bone: analysis of 975 patients fron the european intergroup cooperative ewing’s sarcoma study group. j clin oncol. 2000;18(17):3108-14. 16. muzzafar s, soomro i, pervez s, hassan s. clinicomorphological pattern and frequency of bone cancer. j pak med assoc 1999;49(5):110-2. 17. 14 tsukushi s, katagiri h, kataoka t, nishida y and ishiguro n. serum tumor markers in skeletal metastasis. jpn j clin oncol. 2006;36(7):439-44. 18. spence kf, sell kw and brown rh. solitary bone cyst. treatment with freeze-dried cancellous bone allograft: a study of one hundred seventy-seven cases. j bone joint surg am. 1969;51:87-96. 19. jain k, sunila, ravishankar r, mruthyunjaya, et al bone tumors in a tertiary care hospital of south india: a review 117 cases. indian j med & pediat oncol. 2011;32(2):82-5. 244 j i m d c 2 0 1 7 244 open access f u l l l e n g t h a r t i c l e the relationship of tinnitus with cognitive impairment in normal hearing individuals sadaf raffat mustafa 1, kashmala munawar 2 1 assistant professor, department of ent, railway hospital, rawalpindi 2 audiologist, lecturer audiology, pirs, isra university, islamabad a b s t r a c t objective: to determine the impact of tinnitus on cognitive impairment in normal hearing individuals. patients and methods: this cross-sectional study was conducted at the ent department of railway hospital, rawalpindi from 1st march 2016 to 1st january 2017. a total of sixty (n=60) patients of both gender between age 18 to 50 years, who had normal hearing (clinically examined by tuning fork test and later on confirmed by pure tone audiometry) with history of unilateral or bilateral tinnitus of more than 3 months’ duration were included in the study. mini mental state examination scale was used to assess cognition. results: there were 42% (25/60) males and 58% (35/60) females in the study sample. a total of 53.33% (n= 32) patients were identified with impaired cognition, of which 65.62% (n=21/32) patients were found with mild cognition while 34.38% (n=11/32) patients were found to have severe cognitive impairment. moreover, it was also observed that the cognitive impairment was more prevalent in people of younger age group (p<0.05), office workers (p<0.05) and people living in urban area (p<0.05). conclusion: a significant percentage of patients with tinnitus of more than 3 months’ duration were found to have impaired cognition and was more prevalent in people of younger age group, office workers and people living in urban areas. key words: examination, impaired cognition, mini mental state, tinnitus. author`s contribution 1, 2 conception, synthesis, planning of research and manuscript writing interpretation and discussion data analysis, interpretation, manuscript writing and active participation in data collection address of correspondence sadaf raffat mustafa email: drsadafrafat@yahoo.com article info. received: september 21, 2017 accepted: november 3, 2017 cite this article. mustafa s.r, munawar k. the relationship of tinnitus with cognitive impairment in normal hearing individuals. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n tinnitus, defined as the perception of sound in the absence of corresponding auditory stimulation, is a widespread phenomenon. estimates of the incidence of tinnitus in the general population vary widely.1 in one of the local study conducted, it was reported that most patients of tinnitus were seen between age of 40 to 60 years and 76.6% patients were male. hearing loss accompanied tinnitus in 90% patients and 53% patients had tinnitus of moderate intensity.2 tinnitus sufferers frequently struggle with difficulty in sleeping, irritability, and cognitive deficits.3 tinnitus patients also show cognitive bias in the way they handle information. such information processing style suggests either depressive functioning, or anxious vigilance, or both.4,5 some experimental research has appeared in the last few years that have confirmed effects of tinnitus on aspects of selective or divided attention and working or long-term memory.6,7 in a recent study muhammad n et al described that tinnitus impairs working memory, executive attention and selective attention. they also concluded that tinnitus does interfere with working memory and reduces cognition that needed to perform tasks that require o r i g i n a l a r t i c l e 245 j i m d c 2 0 1 7 245 voluntary, effortful or strategic control.8 the mini-mental state examination (mmse) is the most frequently used brief cognitive instrument to track individuals at risk for, or affected by, disorders that impair cognition.9,10 despite significant limitations, the mini mental state exam remains the most frequently used cognitive screening instrument. its best value in the community and primary care appears to be for the purpose of ruling out a diagnosis of cognitive disorder.11 it is quite evident that the emotional and cognitive effects of tinnitus have a significant impact on patients, their families and their job and merit thorough investigation. present study was designed to investigate the effects of tinnitus on cognitive functions among our local population. the primary aim of present study was to determine the impact of tinnitus on cognition impairment in normal hearing individuals. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at the ent department of railway hospital, rawalpindi from 1st march 2016 to 1st january 2017. sample size was calculated through who calculator by taking prevalence of tinnitus in general population 17.5%, confidence interval 95% and absolute precision 10%.12 calculated sample size was 56 individuals. a total of 60 patients were inducted to exclude the possibility of dropouts. patients of both gender between ages 18 to 50 years, who had normal hearing (clinically examined by tuning fork test and later on confirmed by pure tone audiometry) with history of unilateral or bilateral tinnitus of more than 3 months’ duration were included in the study. tuning fork test was done on these subjects in a silent room to evaluate the hearing of each ear to confirm the normal hearing of study participants. mentally handicapped patients were excluded from the study. mini mental state examination scale was used to assess cognition. selected patients were interviewed after explaining the study and taking their consent. mini mental state examination (mmse) questionnaire used to perform this task. mmse is an 11-question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. each assessment area had score to award. the maximum score is 30. a score of ≥24 showed no cognitive impairment. a collective score <24 and ≥18 is indicative of mild cognitive impairment while a score less than 18 is indicative of severe cognitive impairment. all the demographic data and questionnaire results noted on the predesigned preformed and statistical analysis of data was performed using spss-version 22. results were stratified according to demographic profile like age, gender, occupation etc. chi-square and fisher exact test (where single cell frequency was <5) were applied to assess the significance of difference. p≤0.05 was considered statistically significant. r e s u l t s among 60 patients, 42% (25) were males and 58% (35) were females. total of 53.33% (n= 32) patients were identified with impaired cognition, out of which 65.62% (n=21/32) patients presented with mild cognition while 34.38% (n=11/32) patients were found to have severe cognitive impairment. demographic detail of participants is presented in table 1. table 1: demographic characteristics of participants (n=60) characteristics frequency percentage age (years) 18-36 37-50 41 19 68.3 31.7 gender male female 25 35 42 58 occupation office worker factory worker miscellaneous 18 12 30 30 20 50 residence rural urban 18 42 30 70 as shown in table 2, age, gender and residence had shown significant effect on the level of cognition in respondents. (p value <0.05). d i s c u s s i o n the field of cognitive neuroscience has expanded rapidly, investigating the neural underpinnings of human cognitive activity. until recently, the role of cognitive functioning has been neglected to a large extent in tinnitus research. people with tinnitus report subjective difficulties in mental concentration and psychological treatments for tinnitus 246 j i m d c 2 0 1 7 246 usually emphasize on concentration difficulties and how to manage them.9,13 it is likely that tinnitus disrupts the processing of information and memory system, that monitors the process of interpretation.14, 15 research is ongoing to explore causal relationship between cognition and tinnitus. table 2: cognition level among different classes of respondents (n=32) variables mild impairment n (%) severe impairment n (%) p-value age (years) 18-37 37-50 16 (76.2) 05 (23.8) 05 (45.5) 06 (54.6) <0.05 gender male female 10 (47.6) 11 (52.4) 05 (45.5) 06 (54.5) <0.05 occupation office worker factory worker miscellaneous 11 (52.4) 02 (09.3) 08 (14.3) 01 (09.1) 03 (27.3) 07 (36.4) <0.05 residence rural urban 09 (42.9) 12 (57.1) 01 (09.1) 10 (90.9) <0.05 results of present study showed that a total of 53.33% (n= 32) patients were identified with impaired cognition, of which 65.62% (n=21/32) patients were with mild cognition while 34.38% (n=11/32) patients were found to have severe cognitive impairment. moreover, it was also observed that the cognitive impairment was more prevalent in people with younger age group (p<0.05), office workers (p<0.05) and people living in urban area (p<0.05). our results are comparable with the recent researches on the subject. in a recent systematic review on experimental outcomes of studies exploring the impact of tinnitus upon cognitive function and their implications for clinical management of invasive tinnitus, authors reported that tinnitus impairs cognitive function by way of impact upon executive control of attention. authors emphasized that clinical management of patients reporting tinnitus and cognitive difficulties requires an understanding of the reciprocal relationship between tinnitus and cognitive function, with additive effects of other psychiatric and somatic disorders.16 in studies on reaction time, it is assumed that shorter reaction times to tinnitus related sounds reflect preferential processing of the tinnitus signal.17 hallam et al. used a range of neuropsychological tests, and added complexity by presenting them under single and dual task conditions. the authors concluded that cognitive inefficiency in tinnitus patients is related to control of intentional processes, in line with the habituation model.3 in contrast. waechter s found no differences in terms of cognitive performances between individuals with tinnitus compared to individuals without tinnitus. they concluded that hearing impairment might be the possible confounder in previous studies on hearing-impaired subjects with tinnitus.18 in another study aimed to investigate the possible impact of tinnitus on the performance of challenging cognitive tasks reported that tinnitus sufferers were no more depressed nor anxious than controls, but they performed less well on both cognitive tasks.19 andersson g et al investigated cognitive interference caused by tinnitus, by means of a modified version of the stroop color-word test. the performances of tinnitus patients and healthy controls with normal hearing were compared on three versions of the stroop test: the original version, a modified version including physical-threat words, and a tinnitus version for which tinnitus words (descriptors of tinnitus; e.g., peep) were derived empirically. results showed that tinnitus patients performed significantly slower on all test conditions. in conclusion, the results indicate that tinnitus patients have impaired overall cognitive performance.20 it has been reported in a recent systematic reviews that cognitive behavioral therapy which uses relaxation, cognitive restructuring of the thoughts and exposure to exacerbating situations resulted in a significant improvement in depression score in six studies and quality of life (decrease of global tinnitus severity) in another five studies.21,22 in a very recent study ahmed b, et al investigated the moderating role of gender between perception of tinnitus and psychological adjustments in pakistani tinnitus patients and reported that females were more prone to anxiety than males. depression is also perceived more by female tinnitus patients.23 the limitation of our study is relatively smaller sample size, limited availability of time and resources etc. that will 247 j i m d c 2 0 1 7 247 be overcome in next upcoming researches. we recommend further case control or cohort studies are required in order to establish a definite causal relationship between tinnitus and cognition in normal hearing individuals as well as further studies with larger population are needed to evaluate pathophysiology of cognitive functions and to know that why these functions impair due to tinnitus. in summary, based on present study results and based on the literature review on the subject the evidence is convincing that tinnitus impairs cognitive function likely by way of impact upon executive control of attention. clinical management of patients reporting tinnitus and cognitive difficulties requires an understanding of the reciprocal relationship between tinnitus and cognitive function, with additive effects of anxiety, depression, and somatic cognitive bias. cognitive behavioral therapy reported to have a positive impact on overall quality of life. we recommend further studies to establish the impact of advancing age, hearing loss, anxiety, depression, tinnitus duration and distress upon cognitive function in people with invasive tinnitus. c o n c l u s i o n a significant percentage of patients with tinnitus of more than 3 months’ duration were found to have impaired cognition, which was more prevalent in people of younger age group, office workers and people living in urban areas. outcomes of the study do serve as an understanding of cognitive ailments among tinnitus patients in our local population and will further help the clinicians to recognize and treat them at an earlier stage. r e f e r e n c e s 1. shargorodsky j, curhan gc, farwell wr. prevalence and characteristics of tinnitus among us adults. am j med. 2010; 123(8):711-8. 2. malik kz, rashid d. khan z, altaf c. tinnitus matching. pafmj. 2009; 59(1):90-4. 3. hallam rs, mckenna l, shurlock l. tinnitus impairs cognitive efficiency. int j audiol. 2004; 43(4):218–26. 4. andersson g. the role of cognition in tinnitus. j acta otolaryngol. 2006; 126(556):39-43. 5. stevens c, walker g, boyer m, gallagher m. severe tinnitus and its effect on selective and divided attention. int j audiol. 2007; 46(5):208–16. 6. andersson g, ingerholt c, jansson m. autobiographical memory in patients with tinnitus. psychol health. 2003; 18(5):667–75. 7. das sk, wineland a, kallogjeri d, piccirillo jf. cognitive speed as an objective measure of tinnitus. laryngoscope. 2012;122(11):2533-8. 8. mohamad n, hoare dj, hall da. the consequences of tinnitus and tinnitus severity on cognition: a review of the behavioral evidence. hear res. 2016; 332:199-209 9. mitchell aj. a meta-analysis of the accuracy of the minimental state examination in the detection of dementia and mild cognitive impairment. j psychiatr res. 2009;43(4):411–31. 10. gluhm s, goldstein j, loc k, colt a, van liew c, coreybloom j. cognitive performance on the mini-mental state examination and the montreal cognitive assessment across the healthy adult lifespan. cogn behav neurol. 2013;26(1):1-5. 11. ismail z, rajji tk, shulman ki. brief cognitive screening instruments: an update. int j geriatr psychiatry. 2010;25(2):111–20. 12. møller a.r. epidemiology of tinnitus in adults. in: møller a.r., langguth b., de ridder d., kleinjung t. (eds) textbook of tinnitus. springer, new york, ny, 2011, p-2937. 13. henry ja, dennis kc, schechter ma. general review of tinnitus: prevalence, mechanisms, effects, and management. j speech lang hear res. 2005;48(5):1204– 35. 14. andersson g, baguley dm, mckenna l, mcferran dj. tinnitus: a multidisciplinary approach. london: whurr; 2005. 15. mirz f, pedersen cb, ishizu k, johannsen p, ovesen t, sødkilde-jørgensen h, et al. positron emission tomography of cortical centres of tinnitus. hear res. 1999;134(1):133-44. 16. tegg-quinn s, bennett rj, eikelboom rh, baguley dm. the impact of tinnitus upon cognition in adults: a systematic review. int j audiol. 2016; 55(10):533-40. 17. jacobson gp, calder ja, newman cw, peterson el, wharton ja, ahmad bk. electrophysiological indices of selective auditory attention in subjects with and without tinnitus. hear res. 1996; 97(1):66-74. 18. waechter s, brännström kj. the impact of tinnitus on cognitive performance in normal-hearing individuals. int j audiol. 2015;54(11):845-51. 19. jackson jg, coyne ij, clough pj. a preliminary investigation of potential cognitive performance decrements in non-help-seeking tinnitus sufferers. int j audiol. 2014; 53(2):88-93. http://www.tandfonline.com/toc/ioto20/current http://www.tandfonline.com/toc/ioto20/current 248 j i m d c 2 0 1 7 248 20. andersson g, eriksson j, lundh lg, lyttkens l. tinnitus and cognitive interference: a stroop paradigm study. j speech lang hear res. 2000; 43(5):1168-73. 21. grewal r, spielmann pm, jones se, hussain ss. clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review. j laryngol otol. 2014; 128(12):102833. 22. martinez-devesa p, perera r, theodoulou m, waddell a. cognitive behavioural therapy for tinnitus. cochrane database syst rev. 2001; 1. 23. ahmed b, ahmed a, aqeel m, akhtar t, salim s. impact of tinnitus perception on psychological distress in male and female tinnitus patients. foundation uni j psychol. 2017; 1(1):56-77. summary journal of islamabad medical & dental college (jimdc); 2016:5(4):168-171 168 original article correlation of duration of hepatitis c infection with triglycerides and total cholesterol muhammad imran khan almani1, ahsan kazmi2, imtiaz haider3, tariq afzal3, muhammad ammar khan4, rahat farwa5, aziz bangish6, and imran haider7 1 blood unit, benazir bhutto hospital rawalpindi. 2 ,3&7department of pathology rawalpindi medical college rawalpindi. 4.department of pathology sargodha medical college sargodha. 5. department of medicine nishtar medical college multan. 6. shaheed zulfiqar ali bhutto medical university, pims g-8 islamabad abstract objective: to study the correlation of duration of chronic hcv infection with total cholesterol and triglycerides. patients & methods: in this cross-sectional observational study we recruited 37 hcv infected patients who were diagnosed at least 6 months ago. seven patients were excluded due to hyperglycemia. patients suffering from metabolic disorders affecting total cholesterol and triglycerides were also excluded. serum triglycerides, total cholesterol, and plasma glucose were measured by enzymatic method. data was entered on spss version 16. mean, standard deviation was calculated for numerical data. pearson correlation was used to find association of duration of hcv with total cholesterol and triglycerides. results: mean age of 30 subjects was 39.9±9.5 years, duration of hcv infection was 4.1±3.4 years and mean fasting plasma glucose was 81.7±6.4mg/dl. total cholesterol and triglycerides were 107±30mg/dl and 72.3±23.5mg/dl respectively. triglycerides showed a significant correlation with duration of hcv infection (p=0.024) and total cholesterol (p=0.001). conclusion: there is a significant correlation of triglycerides with duration of hcv infection (p=0.024) and total cholesterol (p=0.001). key words: chronic hepatitis c, total cholesterol, triglycerides and correlation introduction hepatitis c virus (hcv) was identified and was named as non-a non-b hepatitis in 1970 and as hcv in 1989. 1, 2 chronic hepatitis c virus (chcv) infection is an important cause of hepatitis causing liver cirrhosis and end stage liver disease.3 prevalence rate of hcv infection ranged from 0.1% to 12%, in different populations.1 globally estimated carrier state rate has been reported 3% (175 millions).1 about 200 million people (3.3% of the world’s population) were infected with hcv worldwide in 2009.2 in one study, about 10 million people (5% of worldwide hcv infected patients) have been reported in pakistan.2 in developing countries overuse and unsafe injection practices causes 2 to 5 million hepatitis c virus infections and these infections lead to high burden of chronicity, disability and death.4 liver is a vital organ and plays a key role in metabolism and synthesis of serum lipoproteins.5 impaired lipid metabolism is closely associated with chronic liver disease which result in low levels of total cholesterol (tc) and low density lipoprotein cholesterol (ldl) regardless of degree of fibrosis.5 several mechanisms have been proposed to alter cholesterol homeostasis in hcv infected patients. one of the proposed mechanism is through its interference with the mevalonate pathway, resulting in decreased cholesterol synthesis. this diminished synthesis may then subsequently upregulate ldl-receptor expression, ultimately lowering ldl levels.6-8 hepatitis c viral proteins have also been shown to directly activate the pi3-k/akt sign align pathway, resulting in activation of the master regulator sterol response element binding protein (srebp), which plays a critical role in activation of genes essential to fatty acid and cholesterol biosynthesis.9-12 additionally, infection with hcv is associated with reduced microsomal triglyceride transfer protein (mttp), an enzyme critical for vldl synthesis, and whose inhibition results in decreased circulating ldl and cholesterol levels.13hypolipidemias have thus been found associated with chcv infection through several mechanisms.14 very few studies have been conducted in our setup, on the correlation of metabolic variables like total cholesterol and triglycerides in chcv patients. present study was planned corresponding author: muhammad imran khan almani email: imran_almani@yahoo.com. received: may 28, 2016; accepted: dec 29,2016 mailto:imran_almani@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):168-171 169 to study the correlation between duration of chcv infection and serum total cholesterol and triglycerides. patients and methods this cross-sectional study was conducted at pathology department holy family hospital. about 37 anti-hcv antibodies positive patients of both genders and all ages, who were in fasting state were enrolled in the study. sampling was done by non-probability convenience sampling. only diagnosed cases of hcv with at least 6 months’ post-diagnosis were included. patients with known hyperlipidemias, dyslipidemia, diabetes mellitus or hyperglycemia, endocrine disorders affecting lipid metabolism and myocardial infarction were excluded from this study.out of 37 patients 7 were excluded due to fasting hyperglycemia. informed consent was obtained from each patient prior to enrolment in this study. fasting venous blood sample collected in a gel tube for total cholesterol and triglycerides and into sodium fluoride tube for plasma glucose measurement. samples were centrifuged after about half an hour. we analyzed these samples for serum triglycerides (tg), serum total cholesterol (tc) and fasting plasma glucose (fpg). tc, tg and glucose were measured by enzymatic method. statistical package for social sciences (spss) version 16 was used for statistical analysis. mean, standard deviation (sd), variance and skewness of, duration of hcv infection after diagnosis, with t.c, and tg were measured. duration of hcv (dhcv) infection was considered by the time when the patient came to know about his infection first time after that the patient got advise to screen himself for viral hepatitis and was declared reactive for anti hcv antibodies by either immunochrmatography, enzyme linked immunosorbent assay (elisa), or polymerase chain reaction (pcr). pearson’s correlation was applied to see the correlation between duration of hcv infection, triglycerides, and total cholesterol. p. value less than 0.05 was considered significant. results baseline characteristics of total 30 patients are presented below in table 1.age of these patients ranged from 22-60 years with mean of 38.90 years+9.488sd. mean duration of hcv infection was 4.13 years+3.431 sd. mean fasting plasma glucose was 81.7mg/dl±6.4 sd. total cholesterol and triglycerides were 107±30 mg/dl and 72.3±23.5mg/dl respectively. as shown in table 2, tg showed a significant correlation with duration of hcv infection (p=0.024), however correlation of cholesterol with duration of hcv was not significant (p value.606) the correlation between tg and tc was also significant (p=0.001). table 1: statistical analysis of biographic and biochemical variables (n=30) variable mean sd age (in years) 38.90 9.488 duration of hcv (in years) 4.13 3.431 fbs (mg/dl) 81.70 6.439 total cholesterol(mg/dl) 107.30 30.268 triglycerides (mg/dl) 72.30 23.511 table 2: correlations different variables with duration of hepatitis c infection (n=30) pearson correlation p value total cholesterol (tc) 0.098 0.606 triglycerides (tg) 0.412 0.024 tc vs tg 0.581 0.001 correlation is significant < 0.05. discussion lipoproteins are closely connected to the process of hepatitis c virus (hcv) infection. in our study triglycerides were low in majority of the patients and showed a significant correlation with duration of hcv infection (p=0.024).our results are comparable with findings of the perlemuter, et al, who also reported that the levels of triglycerides in hcv infected patients were moderately low.15 in 2006, d. siagriset al. reported serum tc (p < 0.0005), hdl-c (p < 0.0005) and ldl-c (p < 0.0005) were lower in chronic hepatitis c patients compared with controls. they also reported that this finding is more pronounced in patients infected with hcv genotype 3a. patients with hcv genotype 3a had significantly lower levels of tc, hdl-c, ldl-c, higher viral load and higher frequency of hepatic steatosis than those with other genotypes. they proposed that further studies are needed to define the pathophysiology of the relationship between lipid metabolism and hcv infection.16 in a study done by corey ke et al, it was observed hepatitis c is associated with decreased cholesterol and ldl levels. this hypolipidemia resolves with successful hepatitis c treatment but persists in nonresponders.08other studies have also reported that hepatitis c virus infected patients with hcv viremia have significantly low serum tg and cholesterol levels.17,18 single nucleotide polymorphism in interleukin 28b gene have been found and reported in journal of islamabad medical & dental college (jimdc); 2016:5(4):168-171 170 hcv positive patients with lower levels of triglycerides.19 skowroński et al observed that there was a significant correlation of duration of hcv infection with total cholesterol which is in agreement with our study. 20 in the same study skowroński et al. found that there was no significant correlation of duration of hcv infection with triglycerides,20 while in our study we observed that there is significant correlation of duration of hcv infection with triglycerides. circulating lipid levels are altered in patients with hcv, regardless of the duration of infection. in a cohort of patients with acute hcv, early infection was associated with reduction in ldl and total cholesterol levels and following successful anti-hcv treatment, the lipids of these patients returned to pre-infection levels.7patients with chc also have also demonstrated reduced levels of circulating ldl, apolipoprotein b100 (apob) and total cholesterol, compared to healthy controls and seem to resolve after successful clearance of chc, supporting the hypothesis that hcv has a direct cytopathic effect upon host lipid metabolism. the presence and degree of hypocholesterolemia carries important prognostic implications for patients with chc. elevated ldl and high-density lipoprotein (hdl) levels have thus been associated with improved rates of sustained virologic response.6 conclusion serum triglycerides have a significant correlation with the duration of hcv infection. chronic hcv infection is associated with hypotriglyceridemia. limitations and recommendations this was a small sample sized study and included only triglycerides and total cholesterol as target variables in our study. it is thus suggested that studies may be conducted with large sample size and other variables of lipid profile like very low-density lipoprotein (vldl), low-density lipoprotein (ldl) and high-density lipoprotein cholesterol (hdl). moreover it is suggested that studies are conducted to find out various mechanisms leading to hypolipidemias, association with genotypes and effect of their treatment response. conflict of interest this study has no conflict of interest as declared by any author. references 1. houghton,m. the long and winding road leading to the identification of the hepatitis c virus. journal of hepatology. 2009;5: 939–948. 2. waheed, y., shafi, t., safi, s.z. and qadri, i. hepatitis c virus in pakistan: a systematic review of prevalence, genotypes and risk factors. world j gastroenterol. 2009;15:5647-5653. 3. kumar, .v, abbas, a.k., fausto, n, mitchell, r.n. 2007. liver, gallbladder and biliary tract. in: robin basic pathology, 8th ed. delhi: elsevier india private limited 643644. 4. bosan, a., qureshi,h., bile, k.m., ahmad, i. and hafiz,r. a review of hepatitis viral infections in pakistan. j pak med assoc. 2010;60(12):1045-1058. 5. guindy, a.e., emein, a.a. and ghoraba, h. serum lipid, steatosis and fibrosis in patients with chronic hepatitis c genotype 4. tanatamediical science journal.2007; 2(2):90-97. 6. lambert je, bain vg, ryan ea, thomson ab, clandinin mt. elevated lipogenesis and diminished cholesterol synthesis in patients with hepatitis c viral infection compared to healthy humans. hepatology. 2013;57:1697–704. 7. corey ke, mendez-navarro j, barlow ll, patwardhan v, zheng h, kim ay, et al. acute hepatitis c infection lowers serum lipid levels. j viral hepat. 2011;18:e366–71. 8. corey ke, kane e, munroe c, barlow ll, zheng h, chung rt. hepatitis c virus infection and its clearance alter circulating lipids: implications for long-term follow-up. hepatology. 2009;50:1030–7. 9. kim ss, peng lf, lin w, choe wh, sakamoto n, kato n, et al. a cell-based, high-throughput screen for small molecule regulators of hepatitis c virus replication. gastroenterology. 2007;132:311–20. 10. oem jk, jackel-cram c, li yp, zhou y, zhong j, shimano h, et al. activation of sterol regulatory element-binding protein 1c and fatty acid synthase transcription by hepatitis c virus non-structural protein 2. j gen virol. 2008;89:1225–30. 11. su ai, pezacki jp, wodicka l, brideau ad, supekova l, thimme r, et al. genomic analysis of the host response to hepatitis c virus infection. proc natl acadsci u s a. 2002;99:15669–74. 12. schaefer ea, chung rt. hcv and host lipids: an intimate connection. semin liver dis. 2013;33:358–68. 13. mirandola s, realdon s, iqbal j, gerotto m, dal pf, bortoletto g, et al. liver microsomal triglyceride transfer protein is involved in hepatitis c liver steatosis. gastroenterology. 2006;130:1661–9. 14. nashaat, e.h. lipid profile among chronic hepatitis c egyptian patients and its levels pre and post treatment. nature and science. 2010; 8(7):83-89. 15. perlemuter, g., sabile, a., letteron, p., vona, g., topilco, a., tien, y.c., koike, k., pessayre, d., chapman, j., barba, g. and brechot, c. 2002. hepatitis c virus core protein inhibits microsomal triglyceride transfer protein activity and very low-density lipoprotein secretion: a model of viral-related steatosis. the faseb journal, 16: 185-194. 16. siagris, d., christofidou, m., theocharis, g. j., pagoni, n., papadimitriou, c., lekkou, a., thomopoulos, k., starakis, i., tsamandas, a. c. and labropoulou-karatza, c. 2006. serum lipid pattern in chronic hepatitis c: histological and virological correlations. journal of viral hepatitis. 2006, 13: 56-61. 17. dai, c.y., chuang, w.l., ho, c.k., hsieh, m.y., huang, j.f., lee, l.p., hou, n.j., lin, z.y., chen, s.c., hsieh, m.y., wang, l.y., tsai, j.f., chang, w.y. and yu m.l. 2008. associations between hepatitis c viremia and low serum triglyceride and cholesterol levels: a community-based study. journal of hepatology 49 (2008) 9-16. journal of islamabad medical & dental college (jimdc); 2016:5(4):168-171 171 18. simon, t.g. and butt, a.a. 2015. lipid dysregulation in hepatitis c virus, and impact of statin therapy upon clinical outcomes. world j gastroenterol. 2015; 21(27): 8293-8303. 19. li jh, lao xq, tillmann hl, rowell j, patel k, thompson a, suchindran s, muir aj, guyton jr, gardner sd, mchutchison jg, mccarthy jj. interferon-lambda genotype and low serum low-density lipoprotein cholesterol levels in patients with chronic hepatitis c infection. hepatology 2010; 51: 1904-1911 [pmid: 20235331 doi: 10.1002/hep.23592] 20. skowroński, m., ziółkiewicz, d.z., juszczyk, j. and wysocka, b.w. 2009. intermediate clinical manifestation of diabetes in patients with hepatitis c virus infection. e&c hepatology, 5: 34-39. .. authorship contribution: author 1: conception, synthesis and planning of the research, active participation in active methodology interpretation, analysis and discussion author 2: conception, synthesis and planning of the research, active participation in active methodology interpretation, analysis and discussion author 3: conception, synthesis and planning of the research, interpretation, analysis and discussion author 4,5,6: active participation in active methodology, interpretation, analysis and discussion 259 j i m d c 2 0 1 7 259 open access f u l l l e n g t h a r t i c l e estimation of serum ferritin level to detect iron deficiency anemia in children less than 5 years of age ahsan kazmi 1, rubina mansoor 2, muhammad imran khan almani 3, humaira zafar 4 1 professor chemical pathology, pathology department, al nafees medical college, islamabad 2 assistant professor, rawalpindi medical university, rawalpindi 4 research assistant, bsc (hon) mlt, rawalpindi medical university, rawalpindi 3 associate professor, pathology department, al nafees medical college, islamabad a b s t r a c t objective: to evaluate serum ferritin levels in children less than five years as screening measure for iron deficiency anemia (ida). subjects and methods: a cross-sectional study was conducted at benazir bhutto hospital rawalpindi from 1st march 2010 to 31st jan 2011. a simple random sampling technique was adopted for study proceedings. fifty children of less than five (5) years of age were enrolled in the study. the study population included children, aged less than five presenting at pediatrics outpatient department. the children with known hematological abnormality, infection, inflammation were excluded from the study. blood complete picture for hemoglobin and serum ferritin level estimation were the diagnostic tools used and correlated afterwards. data were collected and entered in statistical package for social sciences (spss, version 16) for analysis. descriptive statistics were calculated. chi-square test was applied for evaluation and calculation of significance in each of the characteristics of the population at p ≤ 0.05. results: a total of 50 children with age range of 3-60 months, were recruited for the study. the study population was categorized into three groups; infants (3-12 months), toddlers (13-23 months) and preschool-age (24-60 months) groups. the mean hematocrit of the study population was 33.5 (2.8%) and the mean serum ferritin level was 52.4 ng/ml with a range value of 0.2-353.0 ng/ml. thirty-eight (38) patients of the study population were iron-deficient, with serum ferritin levels of less than 12 ng/ml. conclusion: serum ferritin level is a good screening test for detection of iron deficiency in children key words: children less than five years, iron deficiency anemia, serum ferritin levels. author`s contribution 1, conception, synthesis, planning of research and manuscript writing 2,3 interpretation and discussion data analysis, 3, interpretation, manuscript writing and active participation in data collection address of correspondence ahsan kazmi email: kazmi4ahsan@yahoo.com. article info. received: december 10, 2017 accepted: december 21, 2017 cite this article. kazmi a, mansoor r, almani mik, zafar h. estimation of serum ferritin level to detect iron deficiency anemia in children less than 5years of age. jimdc.2017;6(4): funding source: nil. conflict of interest: nil i n t r o d u c t i o n iron deficiency anemia (ida) is one of the most prevalent nutritional deficiency and accounts for almost one-half of anemia cases. it is more prevalent in the developing countries. in most cases, this deficiency disorder may be diagnosed through complete blood count and low levels of serum ferritin.1 it is the commonest cause of nutritional anemia in infancy and childhood.2 children aged 0–5 years, women of childbearing age, and pregnant women are particularly at risk.3 about 1.2 billion people worldwide show varying levels of iron deficiency. prevalence rates vary among countries. in pakistan 33.2% under five children are suffering from nutritional anemia.4 a thorough o r i g i n a l a r t i c l e 260 j i m d c 2 0 1 7 260 review of current literature reveals that iron deficiency (id) and iron deficiency anemia (ida) widely persist in pakistan and necessitate immediate remedial actions.5 several lab tests of iron homeostasis like total iron binding capacity, serum iron level, serum ferritin level, serum transferrin, and bone marrow iron staining have been used. these tests are used either single or in combination to assess iron stores in patients. major form in which iron is stored in the body is serum ferritin. it can detect early changes in body iron store. many authors recommend it as the most important blood test for the diagnosis of iron deficiency.6-8 it causes little patient discomfort as compared to bone marrow iron studies. in this study, we used serum ferritin level to assess the level of iron storage in the children less than five years of age. we used serum ferritin level below 12 ng/ml to diagnose iron deficiency state, according to who recommendations. iron stores are depleted below this value.9 the poor school performance due to cognitive dysfunction and behavioral deficit is associated with iron deficiency anemia.10 hence, primary prevention by way of screening for iron deficiency in apparently non-anemic individuals especially children is very important. s u b j e c t s a n d m e t h o d s this prospective study was carried out at the benazir bhutto hospital, rawalpindi. this is a tertiary care teaching hospital, affiliated with rawalpindi medical university, rawalpindi. the study population included fifty (50) children, aged less than five presenting at pediatrics outpatient department. the children with known hematological abnormality, infection, inflammation were excluded from the study. for ethical considerations, the study was approved by ethical committee of benazir bhutto hospital, rawalpindi. informed consent was obtained from parents of all the participant children. personal data of the recruited children was recorded in a performa. five milliliters of blood were drawn from these children and divided into two halves one for cbc other was centrifuged to separate the serum for ferritin level estimation. the serum samples were stored in the deep freezer and ferritin analysis was carried out in batches. serum ferritin was assayed by sandwich enzyme link immunosorbid assay (elisa) technique. cbc was performed on sysmax® hematology analyzer. data were collected and entered in statistical package for social sciences (spss, version 16) for analysis. the study population was categorized into three groups; infants (3-12 months), toddlers (13-23 months) and preschool-age (24-60 months) groups. descriptive statistics were calculated. chi-square test was applied for evaluation and calculation of significance in each of the characteristics of the population at p ≤ 0.05. r e s u l t s a total of 50 children with age range of 3-60 months, were recruited for the study. table 1 shows the age groups of the study population. table 1: the study population by age groups ages (months) frequency percentage chi square x2 pvalue infants (3-12) 14 28 0.06 ≤ 0.88 toddlers (13-24) 24 48 preschoolage (25-60) 12 24 total 50 100 mean serum ferritin level of the study population was 52.4 ng/ml with a range value of 0.2-353.0 ng/ml (figure 1). figure 1: scatter-gram of the serum ferritin levels of the study population thirty-eight (38) patients of the study population were iron-deficient, with serum ferritin levels of less than 12 ng/ml. the mean hematocrit of the study population was 33.5 (2.8%). table 2 below shows the prevalence of irondeficiency among various age groups. 261 j i m d c 2 0 1 7 261 table 2: frequency of iron deficiency among age groups age categories n iron deficient (%) non-iron deficient (%) chi square (x2) pvalue infants 14 10 4 0.60 ≤ 0.62 toddlers 24 17 7 preschoolage 12 11 1 total 50 38 12 d i s c u s s i o n the serum ferritin was found less than 12ng/ml in anemic children of the study population. serum ferritin level is a very useful clinical tool to assess iron deficiency anemia in adults. but in children less than 5 years more efforts are needed in our own population to find out its relationship with ida. in india, a study conducted by deeksha kapur et al concluded that ferritin is more sensitive indicator of ida as compared to hemoglobin.11 paiva et al. documented that plasma ferritin levels decrease when there is a deficiency of iron that is not complicated by another concomitant disease.12 according to the report presented by abdullah et al, under the aegis of canadian pediatrics surveillance program ―for infants of 12 months of age, several tests of iron status are available, but each has limitations. a serum ferritin of less than 10 µg/l has been suggested as a cut-off for children indicating depletion of iron stores; however, as it is an acute phase reactant, the committee on nutrition recommends simultaneous measurement of c-reactive protein (crp)‖.13 sukanya linpisarn et al, in a study carried out in thailand in 1996, recognized that serum ferritin accurately reflects total body iron stores after 6 months of age and is only depressed in iron deficiency. as revealed by the response to oral iron, serum ferritin was the only confirmatory test and was quite accurate in their population.14 serum ferritin concentration is an early indicator of the status of iron stores and is the most specific indicator available of depleted iron stores, especially when used in conjunction with other tests to assess iron status. under normal conditions, a direct relationship exists between serum ferritin concentration and the amount of iron stored in the body, such that 1 µg/l of serum ferritin concentration is equivalent to approximately 10 mg of stored iron. however, measured ferritin levels have some limitation, acute and chronic inflammation can increase serum ferritin levels and the assessment of iron status but is not a cause iron deficiency.15 abdus sattar khan et al reported in his local study conducted in 2006 that serum ferritin is the only reliable and sensitive parameter for diagnosis of iron deficiency anemia and estimation of iron stores in normal and anemic individuals. it is more precise and sensitive as compared to serum iron, tibc and transferrin saturation for detection of iron stores in normal and iron deficient subject, which was less than normal value of 15 ng/ml in all iron deficient children.16 according to a clinical report of american academy of pediatrics, ―in establishing the definitive iron status of an individual, it is desirable to use the fewest tests that will accurately reflect iron status. any battery of tests must include hemoglobin concentration, because it determines the adequacy of the circulating red cell mass and whether anemia is present. one or more tests must be added to the determination of hb concentration if id or ida is to be diagnosed.17 in a study conducted in india by chithambaram ns et al. concluded that, if evaluation of iron status is done only by testing number of rbc’s, hb and hematocrit, early signs of iron depletion can go undetected and also those tests were not specific to detect iron deficiency state. by monitoring the status of storage iron (ferritin), we can detect iron deficiency state earlier and initiate appropriate treatment to prevent ida.18 magnus domello¨f et al. recommended that age-specific cutoffs for iron status indicators, including hemoglobin and ferritin, should be used for young children.19 while characterizing a simple, easily accessible, cost effective and commonly used diagnostic test for iron deficiency anemia in developing countries and especially at primary care level, it is suggested that serum ferritin assay has been considered the best single test for the diagnosis of iron deficiency anemia. serum ferritin at a very low level (<14 ng/ml) gives very high likelihood ratio (lr+42) and is the most powerful test with an area under the roc curve of 0.95. c o n c l u s i o n serum ferritin level is a good screening test for early detection of iron deficiency anemia in children less than 5 years of age. 262 j i m d c 2 0 1 7 262 s u g g e s t i o n s iron deficiency is an important public health problem in developing countries. prompt screening for iron deficiency, especially under-five years of age, presenting at a health facility should be encouraged. l i m i t a t i o n s 1. small sample size 2. crp, which would have strengthened the study, was not done, due to financial restraints. a c k n o w l e d g m e n t s the authors are thankful to the head of department, prof dr asghar rai, medical and nursing staff of the pediatrics department, benazir bhutto hospital rawalpindi, pakistan, for their invaluable help in sample and data collection. we are also thankful to our lab staff and participants of this study for their cooperation. r e f e r e n c e 1. aldallal s. iron deficiency anemia: a short review. j immunooncol. 2016; 2(1): 106. 2. who. assesing the iron status of populations: ferritin. [last accessed 12.01.2018]. available from: www.who.int/nutrition/publications/micronutrients/.../97892 41596107_annex2.pdf 3. lopez a, cacoub p, macdougall ic, peyrin-biroulet l. iron deficiency anaemia. the lancet. 2016; 387(10021):90716. 4. habib ma, black k, soofi sb, hussain i, bhatti z, bhutta za, raynes-greenow c. prevalence and predictors of iron deficiency anemia in children under five years of age in pakistan, a secondary analysis of national nutrition survey data 2011–2012. plos one. 2016; 11(5): e0155051. 5. saeed akhtar, anwaar ahmed, asif ahmad, zulfiqar ali, muhammad riaz, tariq ismail. iron status of the pakistani population-current issues and strategies. asia pac j clin nutr 2013; 22 (3):340-347. 6. ong kh, tan hl, lai hc, kuperan p. accuracy of various iron parameters in the prediction of iron deficiency in an acute care hospital. ann acad med singapore. 2005; 34(7):437–40. 7. jeremiah za, buseri fi, uko ek. iron deficiency anaemia and evaluation of the utility of iron deficiency indicators among healthy nigerian children. hematology. 2007;12(3): 249–53. 8. de benoist b. geneva: who; 2008. [last accessed on 2013, jan 27]. world prevalence of anaemia 1993-2005. who global data base on anaemia. online. available from: http://www.who.int/vminis/publications/anaemia_prevalenc e/en/index.html. 9. who i. nutritional anemias: tools for effective prevention and control. 2017. available from: apps.who.int/iris/bitstream/10665/259425/1/978924151306 7-eng.pdf 637k. 10. grantham-mcgregor s, ani c. a review of studies on the effect of iron deficiency on cognitive development in children. j nutr. 2001; 131(2): 649–68. 11. deeksha kapur, kailash nath agarwal, sushma sharma. detecting iron deficiency anemia among children (9-36 months of age) by implementing a screening program in an urban slum. indian pediatrics 2002; 39(7):671-676 12. paiva aa, rondó phc, guerra-shinohara em. parameters for the assessment of iron status. revista de saúde pública. 2000; 34(4): 421-6. 13. abdullah k, zlotkin s, parkin p, grenier d. iron-deficiency anemia in children. ottawa: canadian pediatric surveillance program, canadian pediatric society. retrieved may. 2011; 21:2013. 14. sukanya linpisarn, prasong tienboon, nongkran promtet, pachern putsyainunt, sappaporn santawanpat and george j fuch. iron deficiency and anaemia in children with a high prevalence of haemoglobinopathies: implications for screening. international journal of epidemiology. 1996; 25(6):1262-66. 15. jacobs, f. miller, m. worwood, m. r. beamish, c. a. wardrop. ferritin in the serum of normal subjects and patients with iron deficiency and iron overload. british medical journal, 1972; 4(5834): 206-208. 16. abdus sattar khan, said alam shah. iron deficient children and significance of serum ferritin. j pak med assoc. 2005; 55(10): 420-23 17. clinical report—diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). from the american academy of pediatrics. pediatrics. november 2010;126(5)1040: 50. 18. chithambaram ns, reddy rs. clinical and biochemical profile of iron deficiency state in preanemic under 5 children in a tertiary care hospital. int j contemp pediatr. 2017; 4(2):530-3. 19. magnus domello¨f, et al. iron requirements of infants and toddlers. jpgn.2014; 58(1):119-129. 20. jm alquaiz1, hm abdulghani, ra khawaja, s shaffiahamed. accuracy of various iron parameters in the prediction of iron deficiency anemia among healthy women of child bearing age, saudi arabia. iranian red crescent medical journal. 2012; 14(7):397-401. j islamabad med dental coll 2021 4 open access seasonal trends of influenza in islamabad, pakistan s ania raza1, muhammad usman2, imran ahmad3 1associate consultant, pathology laboratory, shifa international hospital, islamabad pakistan 2consultant, pathology laboratory, shifa international hospital, islamabad pakistan 3chief pathologist, pathology laboratory, shifa international hospital , islamabad pakistan a b s t r a c t background: viral outbreaks have always been a challenging task for clinicians and influenza virus has been on top of the list. the history of influenza epidemic reveals its devastating effects in the form of multiple deaths and economic burden. hence this study was planned to recognize the peak activity time span of influ enza infection and its frequency in our set-up at shifa international hospital, islamabad pakistan. material and methods: a cross sectional study was performed in pathology laboratory, shifa international hospital islamabad from april 2016 to march 2019. nasopharyngeal swabs were collected from patients of all age groups, with clinically suspected influenza infection throughout the year, irrespective of gender, according to hospital’s standard policy. samples were analysed on genexpert kit (xpert flu assay) . data collected was entered and then analysed in spss version 17. results: of the total 591 samples included in study, 233 (39.4%) were positive for influenza (flu a or flu b), while 358 (60.6%) showed negative results. total 172 (73.8%) were positive for flu a while 61 (26.1%) were positive for flu b. among flu a cases, 107 (62.2%) were positive for h1n1. most of the positive cases (n=206; 88.4%) were reported in the months of january and february during the three -year period (2016-2019) of this study. conclusions: influenza virus has peak activity in the months of january and february. both influenza a and b are circulating in the environment but flu a is predominant and h1n1 is more prevalent . key words: h1n1 stain, influenza, seasonal flu trend. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: sania raza email: drsanraza@gmail.com article info: received: may 11, 2020 accepted: february 24, 2021 cite this article. raza s, usman m, ahmad l. seasonal trends of influenza in islamabad, pakistan. j islamabad med dental coll. 2021; 10(1): 4-8. doi: 10.35787/jimdc.v10i1.549 funding source: nil conflict of interest: nil i n t r o d u c t i o n year 2018 marks a century to 1918 influenza pandemic1 and we are almost still in the same boat as far as influenza spread is concerned. influenza virus is one of the causes of global epidemics and affects up to 20% of the population in a season with significant morbidity and mortality.2 it results in almost 3 to 5 million cases of severe illness, and 290,000 to 650,000 deaths globally each year.3 people at higher risk are pregnant, elderly, children and chronically ill patients.4 influenza is a contagious infection, viral in origin and infects the respiratory system. it develops suddenly and patient feels symptoms of cough, sore throat, fever, chills, runny nose, body aches or fatigue. mostly recovery occurs within a few days, but sometimes high-risk patients develop complications which may lead to secondary or i gi n a l a r ti c le j islamabad med dental coll 2021 5 bacterial infections like myocarditis, asthma, myositis, sepsis or even death. 5 severe influenza infection is treatable with antivirals, if treatment is started earlier. timely treatment (within 48 hours of onset) with antivirals helps decreasing the severity of disease by reducing duration of illness and complications and may also reduce mortality, specifically among high-risk population.6,7 influenza virus escapes our immune system by the process of antigenic shift and drift. there are four main genera of influenza viruses; a, b, c and d. 2 the major cause of influenza pandemic is antigenic shift in influenza a virus.8 the emergence of new viral subtypes occurs due to two types of surface proteins; hemagglutinin (h) and the neuraminidase (n). there are 18 hemagglutinin and 11 neuraminidase subtypes circulating in wild birds.9 but in mammals, few of these cause infections. major pandemics were reported in 1918 (h1n1), 1957 (h2n2), 1968 (h3n2) and 2009 (h1n1).10 seasonal epidemic is caused by human influenza a and b viruses. it occurs mainly due to antigenic drift and an individual can experience multiple episodes of influenza throughout life, due to this antigenic drift. the history of influenza epidemic shows that it can be devastating and can lead to multiple deaths and economic burden. hence, this study was planned to recognize the peak activity time span of influenza infection, its frequency in our set-up and prevalence of h1n1 strain. this was important because there is lack of literature regarding influenza in this part of the world. this information will be useful for clinicians in defining influenza management program and will help in prevention of spread of this deadly infection. defining the time span of peak influenza activity in our set up can also contribute to determine the timings of implementation of influenza vaccine . m a t e r i a l a n d m e t h o d s a cross sectional study was performed in the pathology laboratory, shifa international hospital islamabad, pakistan from april 2016 to march 2019. permission for the study was obtained from the institutional review board and ethical committee of shifa international hospital, shifa tameer-e-millat university, islamabad pakistan. nasopharyngeal swabs were collected from patients of all age groups (both genders) with clinically suspected influenza infection according to the hospital’s standard policy. duplicate samples from the same patient were excluded from the study. nasopharyngeal swabs were transported immediately to the laboratory in universal transport medium (utm) and stored at 28°c (up to 72 hours) till further processing. specimen was checked for influenza positivity by cepheid xpert flu assay (automated multiplex real-time rtpcr) according to manufacturer's guidelines. sample was mixed by inverting utm five times and then transferred to cartridge through transfer pipette. cartridge lid was opened. 300 ul of specimen, diluted in transport medium was transferred to cartridge. cartridge lid was closed. after bar coding, typing of patient and sample id, xpert flu assay was scanned and test started. sample processing control was run along with test. results were interpreted automatically by genexpert instrument system from measured fluorescent signals and embedded calculation algorithms. data collected was entered and then analysers in spss 17.0. r e s u l t s in the three-year study time period (april 2016 to march 2019), overall, 591 samples of clinically suspected patients from both inpatient and outpatient departments of shifa international hospital were collected and tested by xpert flu assay. out of those, 233 (39.4%) were positive for j islamabad med dental coll 2021 6 tab l e i: yearly distribution of influenza positive cases to tal number of samples tes ted to tal positive (%) f l u a (%) f l u b (%) april 2016march 2017 31 11 (35.4) 7 (63.6) 4 (36.3) april 2017march 2018 234 93 (39.7) 81 (87) 12 (13) april 2018march 2019 326 129 (39.5) 84 (65.1) 45 (34.8) total 591 233 (39.4) 172 (73.8) 61 (26.1) flu a or flu b while 358 (60.6%) showed negative results (table i). most of the positive cases (88.4 %) were reported in the months of january and february (figure 1). total 172 (73.8%) were positive for flu a while 61 (26.1%) were positive for flu b. out of positive flu a cases during the three-year period, 107 (62.2%) were positive for h1n1 (table ii). figure 1: monthly distribution of influenza positive cases tab l e ii: h1n1 positive cas es a mong f lu a positive y ear f l u a pos itive h 1 n1 positive (%) april 2016march 2017 7 0 april 2017march 2018 81 42 (51.8) april 2018march 2019 84 65 (77.3) total 172 107 (62.2) d i s c u s s i o n data obtained through this study provides evidence that peak activity time period of influenza was in the months of january and february (88.4%). a surveillance study was done to determine the seasonal activity of influenza from 2011-2016 in six who regions. it indicated 6.1-month activity period of influenza in south east asia region. 11 pakistan was not included in this study and there was no consistent peak activity observed in india, bangladesh, bhutan and indonesia. nepal and thailand had two peak activity; march-april and july-august for nepal and february-march and julynovember for thailand, respectively. 11 in a study conducted in indonesia from 2013-2016, 19% of patients with severe acute respiratory infection were positive for influenza. 12 in another study by mudhigeti et al. carried out in india from 2017-2018, 40% of influenza-suspected cases were positive for influenza.13 these findings are similar to our data, as we had 39.4% cases positive for influenza among suspected cases. in our study, samples were analysed through cepheid xpert flu assay which is a robust automated nucleic acid amplification based diagnostic test.14 the sensitivity of the test is greater than culture techniques while its performance is comparable to that of molecular reference standards.10 cultures can be helpful for public health purposes but cannot provide timely result to help in patient management.15 rapid influenza diagnostic tests are also available but their sensitivity is low as compared to the molecular pcr-based techniques.16 a surveillance study done at national influenza center in islamabad pakistan in collaboration with all provinces from 2008-2011, revealed 24% positive influenza cases among suspected cases. 17 they reported that influenza a cases were predominant (72%) with h1n1 as the most common subtype (82%). we also reported 73% influenza a cases with 62% h1n1 strain in our study. interestingly most cases were from the federal capital (islamabad) j islamabad med dental coll 2021 7 (53%). the study also stressed upon the need for continuous surveillance of influenza.17 it is a frequent practice to treat flu-like symptoms without laboratory diagnosis, however confirming the diagnosis aids in decreasing overall hospital stay, treatment cost, unnecessary antibiotics, morbidity and mortality related to infection and better chance of getting prompt treatment and implementation of infection control measures.18 it also helps hospital to get prepared for seasonal infection. in 1918 pandemic, there was little knowledge about influenza but now we have reached the era when we have diagnostic facilities, antivirals drugs and influenza vaccines available.19 in the light of this study, the peak activity time span of influenza in islamabad was documented. knowing the epidemic strain and season of its prevalence in our set-up can help in starting vaccine campaigns before the peak season, giving information to drug manufacturers for upcoming increased requirement in supply and providing awareness to public regarding its spread and implementation of control measures on an individual basis.20 we can try to minimize the spread of infection and can help in reducing death rates due to influenza. the main limitation of this study was that data was obtained from a single center in islamabad, therefore, these findings cannot be generalized. collection of data from different laboratories of pakistan will help in recognising trends in the whole country. further, enhanced surveillance in different regions of pakistan can also help in optimising efforts for management of the infection. c o n c l u s i o n influenza virus places a substantial burden on health management in our set up with the peak activity in the months of january and february. both influenza a and b are circulating in the environment, but flu a is predominant and h1n1 is prevalent. r e c o m m e n d a t i o n it is needful to minimize the impact of this inevitable epidemic by available means. timely diagnosis and knowing frequency, duration and peak season helps in defining influenza management program. continuous surveillance from all regions of the country is required for optimal management of influenza infection. r e f e r e n c e s 1. short kr, kedzierska k, sandt ce. back to the future: lessons learned from the 1918 influenza pandemic. front cell infect microbiol. 2018; 8: 343. doi: 10.3389/fcimb.2018.00343 . 2. thompson ww, shay dk, weintraub e et al mortality associated with influenza and respiratory syncytial virus in the united states. jama. 2003; 289(2): 179 – 86. doi: 10.1001/jama.289.2.179 . 3. iuliano ad, roguski km, chang hh, muscatello dj, palekar r, tempia s, et al. estimates of global seasonal influenza-associated respiratory mortality : a modelling study. lancet. 2018; 391(10127): 12851300. doi: 10.1016/s0140-6736(17)33293-2. 4. taubenberger jk and morens dm. the pathology of influenza virus infections. annu rev pathol. 2008; 3:499-522. doi: 10.1146/annurev.pathmechdis.3. 121806.154316. 5. sellers sa, hagan rs, hayden fg, fischer wa. the hidden burden of influenza: a review of the extrapulmonary complications of influenza infection. influenza other respir viruses. 2017; 11(5): 372 –93. doi: 10.1111/irv.12470. 6. davidson s. treating influenza infection from now and into the future. front immunol. 2018; 9: 1946. doi: 10.3389/fimmu.2018.01946. 7. uyeki tm, bernstein hh, bradley js, englund ja, file tm, fry am, et al. clinical practice guidelines by the infectious diseases society of america: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenza. clin infect dis. 2019; 68(6): 1 -47. doi: 10.1093/cid/ciy866. 8. webster rg, govorkova ea. continuing challenges in influenza. ann n y acad sci. 2014; 1323(1):115 -39. doi: 10.1111/nyas.12462. j islamabad med dental coll 2021 8 9. sleman ss. how influenza a virus causes ‘‘epidemics’’ and ‘‘pandemics’’ among the populations? j infect dis ther. 2017; 5: 319. doi: 10.4172/2332-0877.1000319. 10. cohen dm, kline j, may ls, hamett ge, gibson j, liang sy, et al. accurate pcr detection of influenza a/b and respiratory syncytial viruses by use of cepheid xpert flu+rsv xpress assay in point-of-care settings: comparison to prodesse proflu. j clin microbiol. 2018; 56(2): e1237 -17. doi: 10.1128/jcm.01237-17. 11. newman lp, bhat n, fleming ja, neuzil km. global influenza seasonality to inform country-level vaccine programs: an analysis of who flunet influenza surveillance data between 2011 and 2016. plos one. 2018; 13(2): e0193263. doi: 10.1371/journal.pone.0193263. 12. susilarini nk, haryanto e, praptiningsih cy, mangiri a, kipuw n, taraya i et al. estimated incidence of influenza-associated severe acute respiratory infections in indonesia, 2013-2016. influenza other respir viruses. 2018; 12(1): 81 –7. doi: 10.1111/irv.12496. 13. mudhigeti n, racherla rg, mahalakshmi pa, pamireddy m l, nallapireddy u, kante m et al. a study of influenza 2017–2018 outbreak in andhra pradesh, india. indian j med microbiol. 2018; 36(4): 526-31. doi: 10.4103/ijmm.ijmm_18_272. 14. haglund s, quttineh m, nilsson ba, matussek a, henningsson aj. xpert flu as a rapid diagnostic test for respiratory tract viral infection: evaluation and implementation as a 24/7 service. infect dis. 2018; 50(2): 140-4. doi: 10.1080/23744235.2017.1380841. 15. merckx j, wali r, schiller i, caya c, gore gc, chartrand c, et al. diagnostic accuracy of novel and traditional rapid tests for influenza infection compared with reverse transcriptase polymerase chain reaction: a systematic review and metaanalysis. ann intern med. 2017; 167(6): 394 -409. doi: 10.7326/m17-0848. 16. influenza (seasonal) [internet]. available from: https://www.who.int/news-roo m/factsheets/detail/influenza-%28seasonal%29 [cited september 2019] 17. badar n, aamir ub, mehmood mr, nasir n, alam mm, kazi bm, et al. influenza virus surveillance in pakistan during 2008-2011. plos one. 2013; 8(11): e79959. doi: 10.1371/journal.pone.0079959. 18. weekely smn, marlowe em, poulter m, dwyer d, speers d, rawlinson w, et al. evaluation of the cepheid xpert flu assay for rapid identification and differentiation of influenza a, influenza a 2009 h1n1, and influenza b viruses. j clin microbiol. 2012; 50(5): 1704–10. doi: 10.1128/jcm.06520-11. 19. taubenberger jk and morens dm. 1918 influenza: the mother of all pandemics. emerg infect dis. 2006; 12(1): 15–22. doi: 10.3201/eid1201.050979. 20. grohskopf la, sokolow lz, broder kr, walter eb, bresee js, fry am, et al. prevention and control of seasonal influenza with vaccines: recommendation s of the advisory committee on immunizati o n practices---united states, 2017–18 influenza season. mmwr recomm rep. 2017; 66(2): 1 -20. doi: 10.15585/mmwr.rr6602a1. j islamabad med dental coll 2021 89 open access evaluation of clinicopathological findings and postoperative outcomes of modified radical mastectomy in a tertiary care center in lahore, pakistan usman ali rahman1, khalil ahmad2, umair nazir3, shabbar hussain changazi4, ayesha choudary4, qamar ashfaq ahmad5 1associate professor, department of surgery, al-aleem medical college, lahore, punjab pakistan 2professor, department of surgery, al-aleem medical college, lahore, punjab pakistan 3operation theatre technologist, gulab devi hospital, lahore, punjab pakistan 4assistant professor, department of surgery, services institute of medical sciences, lahore, punjab pakistan 5associate professor, department of surgery, services institute of medical sciences, lahore, punjab pakistan a b s t r a c t background: modified radical mastectomy (mrm) remains the mainstay of breast cancer surgery in under-developed countries like pakistan as it reduces the morbidity and mortality associated with radical surgery. this study aims to delineate the clinicopathological findings and postoperative outcomes of patients undergoing modified radical mastectomy for breast carcinoma in a local setting. material and methods: this cross-sectional study was conducted in gulab devi hospital lahore, punjab pakistan, from january 2016 to december 2019. patients (n=70) with carcinoma breast planned for modified radical mastectomy were included in the study. two suction drains were placed (in the axilla and under the flap) and removed when drainage was less than 30 cc in 24 hours. the patients were followed-up weekly for one month and then at monthly intervals for up to one year. independent t-test and chi-square test were used to study associations between different variables. a pvalue less than .05 was considered statistically significant. results: the mean age of the patients was 48.43 ± 12.3 years. most of the patients (42.86%) had stage-ii, grade-i carcinoma (50%) with invasive ductal carcinoma as the most frequent histological variety (80%). majority of the patients (n=60; 85.57%) were er/pr positive. mean duration of surgery was 124.8 ± 20.33 minutes, the mean duration of placement of drains was 3.5±4.5 days, and the mean length of hospital stay was 4.67 ± 1.07 days. most common complications of mastectomy were wound infection (23.57%) and seroma formation (20%). six patients (8.57%) developed recurrence of disease in one year follow-up. neoadjuvant chemotherapy increased the mean duration of surgery and drains placement (p<.05) but had no effect on mean hospital stay and complications associated with surgery (p>.05). conclusions: grade-i invasive ductal carcinoma with er/pr positive receptor status was the most frequent variety of breast carcinoma. neoadjuvant chemotherapy was associated with increased operative time and increased duration of drain placement. key words: breast carcinoma, complications, modified radical mastectomy, neoadjuvant chemotherapy. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5 data analysis; manuscript editing. correspondence: shabbar hussain changazi email: shabbarchangazi246@gmail.com article info: received: november 18, 2020 accepted: june 14, 2021 cite this article. rahman u a, ahmad k, nazir u, changazi s h, choudary a, ahmad q a. evaluation of clinicopathological findings and postoperative outcomes of modified radical mastectomy in a tertiary care center in lahore, pakistan. j islamabad med dental coll. 2021; 10(2): 89-94. doi: 10.35787/jimdc.v10i2.634 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 90 i n t r o d u c t i o n the mainstay for the treatment of breast carcinoma is mastectomy. initially, radical mastectomy that removes pectoralis major muscle along with breast tissue is regarded as the standard management of breast carcinoma.1 however, this operation is associated with high morbidity and poor cosmesis. modified radical mastectomy (mrm) was devised to address these issues. in this technique, pectoralis major muscle is left intact while breast tissue and the associated axillary lymph nodes are removed. this technique gained popularity as it was as efficacious as radical surgery, and morbidity was markedly decreased in mrm.2 with further advancement in breast surgery, breast-conserving therapy showed similar results in terms of morbidity and disfigurement. however, there are certain limitations for breast conservation therapy such as locally advanced disease and contraindications for radiotherapy, etc.3-6 mrm usually follows an uneventful recovery. complications after mrm can be minimized with proper preoperative assessment, meticulous dissection, absolute hemostasis, and tension-free wound closure. in addition to the standard oncologic evaluation, preoperative evaluation includes an assessment of the patient’s overall physiologic status, with specific consideration on the tolerability of anesthesia, uncontrolled diabetes, hypertension, anemia, or coagulopathy. complications of modified radical mastectomy include seroma formation, wound infection and dehiscence, skin flap necrosis, hematoma formation, paresthesia of the arm along its medial aspect and lymphedema (late complication).7-9 mrm remains the mainstay of breast cancer surgery in under-developed countries like pakistan. this is attributed to several reasons including the advanced stage at presentation, the lack of timely access to high-quality investigations, unaffordable cancer treatment, limited access to radiotherapy, and the lack of training in breast conservation surgery.10,11 the goal of this study was to evaluate the different stages, grades, and histological types of breast cancer and complications and outcomes of mastectomy with axillary clearance performed in a four-year period, in a local setting. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted from january 2016 to december 2019 in gulab devi hospital lahore, punjab pakistan. approval was obtained from the institutional review board of alaleem medical college/ gulab devi hospital lahore, punjab pakistan. a sample size of 70 patients was calculated with who calculator at 80% confidence level, 5% margin of error, using 12% expected percentage of breast cancer.12 patients presenting with carcinoma breast and planned for modified radical mastectomy were included in the study through non-probability consecutive sampling method. informed consent was taken. patients with metastatic disease, uncontrolled diabetes mellitus, and uncompensated liver disease were excluded from the study. for diagnosis of disease, core needle biopsy of breast mass was done. staging tests included ultrasound abdomen, ct scan of the chest and bone scan. patients with locally advanced breast cancer (stage-iii) underwent neoadjuvant chemotherapy before surgery. all patients having breast carcinoma underwent modified radical mastectomy with axillary clearance up to level ii. two suction drains were placed: one in the axilla and the other under the flap. hemostasis was secured by diathermy and sutures. suction drains were removed when drainage was less than 30 cc in 24 hours. the patients were advised to follow up j islamabad med dental coll 2021 91 weekly for one month and then at monthly intervals for up to one year. data was statistically analyzed using spss v.21. categorical variables like the stage of the disease, grade of disease, histological type, complications of the surgery, and recurrence of disease were presented as frequencies and percentages. continuous variables including age, time of surgery, duration of the drain, and hospital stay were analyzed as mean with standard deviation. association of neoadjuvant chemotherapy with duration of surgery, duration of the drain, and hospital stay was analyzed using independent t-test. the association of neoadjuvant chemotherapy with surgical complications was compared using chisquare test. a p-value of less than .05 was considered statistically significant. r e s u l t s out of 70 patients, 66 (94.29%) were married with a mean age of 48.43 ± 12.3 years. most of the patients had stage-ii disease (42.86%). highly differentiated carcinoma was most prevalent (50%) and invasive ductal carcinoma was most frequent histological variety (80%) of carcinoma. majority of patients with breast carcinoma had er/pr positive (85.71%) receptor status (table i). twenty-one (30%) patients had neoadjuvant chemotherapy. the mean duration of surgery was 124.8 ± 20.33 minutes. suction drains were left in the axilla and under the flap for a mean duration of 3.5 ± 4.5 days ranging from 3 to 6 days. wound infection was the most frequent complication of surgery (28.75%) followed by seroma formation (20%). only 6 (8.57%) patients developed recurrence of disease in oneyear follow-up (table ii). the mean hospital stay of all patients was 4.67 ± 1.07 days. we did not report any death during the 30-days follow-up. table i: characteristics of patients presenting with breast carcinoma (n=70) variables n (%) stage stage-tis 1 (1.43) stage-i 18 (25.71) stage-ii 30 (42.86) stage-iii 21 (30) grade grade-i 35 (50) grade-ii 20 (28.57) grade-iii 15 (21.43) histological type ductal carcinoma in situ 1 (1.43) invasive ductal carcinoma 56 (80) invasive lobular carcinoma 10 (14.28) medullary carcinoma 2 (2.85) mucinous carcinoma 1 (1.43) receptor status er 60 (85.71) pr 60 (85.71) her2/neu 20 (28.57) table ii: complications and outcomes of mastectomy (n=70) variables n (%) seroma 14 (20) wound infection 20 (28.57) flap necrosis 3 (4.28) respiratory tract infection 2 (2.85) recurrence 6 (8.57) only 21/70 (30%) patients received neoadjuvant chemotherapy. mean duration of surgery was significantly decreased in patients receiving neoadjuvant chemotherapy with an increase in mean duration of drain(s) placement (p<.001). however neoadjuvant chemotherapy had no effect on mean hospital stay (table iii). the association of neoadjuvant chemotherapy with surgical complications was statistically insignificant (table iv). j islamabad med dental coll 2021 92 table iii: association of neoadjuvant chemotherapy with mean duration of surgery, duration of the drain and hospital stay mean duration neoadjuvant chemotherapy pvalue* yes (n=21) no (n=49) surgery (minutes) 100.30±12.20 149.32±25.46 .001 drain placement (days) 4.43±0.87 3.59±0.93 .001 hospital stay (days) 4.71±1.08 4.57±1.07 .143 *p <.05 was considered as statistically significant table iv: association of neoadjuvant chemotherapy with surgical complications (n=70) complications neoadjuvant chemotherapy p-value* yes (n=21) no (n=49) seroma yes 3 11 .529 no 18 38 wound infection yes 7 13 .564 no 14 36 flap necrosis yes 2 1 .432 no 19 48 respiratory infection yes 1 1 .732 no 20 48 *p <.05 was considered as statistically significant d i s c u s s i o n modified radical mastectomy with axillary clearance is the most common surgical procedure performed for cancer of the breast. in this study, the mean age of patients was significantly lower than other studies.13,14 this is an alarming sign and depicts the early occurrence of breast carcinoma in the local population. we report a mean duration of 3.67 days for drain placement and 4.67 days for hospital stay, respectively. however, a study conducted by karwasra et al.14 showed increased mean durations for drain (9.22 days) and hospital stay (9.22 days). okada et al.15 reported mean hospital stay of 7days. these results had higher mean duration of drain and mean hospital stay as compared to the present study. this may due to more meticulous dissection and heavy patient load leading to refinement of operative skills. in this study 14(20%) patients developed seroma and 20 (20.87%) patients developed wound infection. karwasra and colleagues14 conducted a study in rohtak, india with a sample of seventy-five patients and documented that 11 (14.67%) patients developed wound infection, which is higher as compared to our study. similarly, dahri and colleagues16 conducted a study in nawab shah, sindh pakistan on 150 patients. according to their study wound infection was seen in 15 (10%) patients, seroma formation in 50 (33.3%) and wound dehiscence in 2 (1.3%) patients, respectively. decreased rate of postoperative complications, especially seroma formation and wound infection were due to improved surgical techniques i.e., proper skin flap harvesting, absolute hemostasis, obliteration of dead space, tensionless skin closure, early physiotherapy of arm on operative side, and removal of the drain after it had remained empty for 24 hours. our study demonstrated that neoadjuvant chemotherapy significantly increased the mean duration of surgery and the mean duration of the drain placement. these findings are in concordance with studies conducted by gümüş et al.17 and uslukaya et al.18 both these studies reported increased mean duration of surgery and mean duration of drain in patients who underwent neoadjuvant chemotherapy. they also reported increased length of hospital stay with neoadjuvant chemotherapy. in our study neoadjuvant chemotherapy had no effect on mean hospital stay and complications associated with surgery. this may be because patients were discharged and sent home with the drain. patients were advised to come to the outpatient department, once there was minimal addition in the drain. finally, this study depicted that j islamabad med dental coll 2021 93 neoadjuvant chemotherapy was not associated with an increased risk of postoperative complications. similar results were also shown by studies conducted by adamson et al.19 and decker et al.20 irrespective of the chemotherapeutic drugs used for treatment. c o n c l u s i o n grade-i invasive ductal carcinoma with er/pr positive receptor status was the most frequent variety of breast carcinoma. neoadjuvant chemotherapy was associated with increased operative time and increased duration of drain placement. r e f e r e n c e s 1. freeman md, gopman jm, salzberg ca. the evolution of mastectomy surgical technique: from mutilation to medicine. gland surg. 2018; 7(3): 308. doi: 10.21037/gs.2017.09.07. 2. lumachi f, brandes aa, burelli p, basso sm, iacobone m, ermani m. seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study. j eur surg oncol. 2004; 30(5): 526-30. doi: 10.1016/j.ejso.2004.03.003. 3. arndt v, stegmaier c, ziegler h, brenner h. quality of life over 5 years in women with breast cancer after breast-conserving therapy versus mastectomy: a population-based study. j cancer res clin oncol. 2008; 134(12): 1311. doi: 10.1007/s00432-008-0418y. 4. vrouwe sq, somogyi rb, snell l, mcmillan c, vesprini d, lipa je. patient-reported outcomes following breast conservation therapy and barriers to referral for partial breast reconstruction. plast reconstr surg. 2018; 141(1): 1-9. doi: 10.1097/prs.0000000000003914. 5. thiessen fe, tjalma wa, tondu t. breast reconstruction after breast conservation therapy for breast cancer. eur j obstet gynecol reprod biol. 2018; 230: 233-8. doi: 10.1016/j.ejogrb.2018.03.049. 6. fang m, zhang x, zhang h, wu k, yu y, sheng y. local control of breast conservation therapy versus mastectomy in multifocal or multicentric breast cancer: a systematic review and meta-analysis. breast care. 2019; 14(4): 188-93. doi: 10.1159/000499439. 7. shaikh bf, memon aa, kumar m, memon z, soomro e. complications of modified radical mastectomy in carcinoma breast patients. med channel. 2014; 20(1). 8. rana am, ahmed su, alam f, joardar ai, chowdhury ak, bari ma, et al. electrosurgery dissection versus sharp dissection: effect on early postoperative wound complications in modified radical mastectomy. mmj. 2019; 28(3): 634-40. pmid: 31391437. 9. abass mo, gismalla md, alsheikh aa, elhassan mm. axillary lymph node dissection for breast cancer: efficacy and complication in developing countries. j glob oncol. 2018; 4: 1-8. doi: 10.1200/jgo.18.00080. 10. cleary j., gelband h., wagner j. cancer: disease control priorities. 3rd ed. washington, dc: world bank; 2015; p. 320-63. 11. barton mb, frommer m, shafiq j. role of radiotherapy in cancer control in low-income and middle-income countries. lancet oncol. 2006; 7(7): 584-95. doi: 10.1016/s1470-2045(06)70759-8. 12. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: cancer j clin. 2018; 68(6): 394-424. doi: 10.3322/caac.21492. 13. menhas r, umer s. breast cancer among pakistani women. iran j public health. 2015: 586-7. pmid: 26056679. 14. karwasra rk, srivastava s, parshad s, tripathi m, arora b. a prospective randomized study on management of suction drains in patients undergoing modified radical mastectomy. ijermdc. 2015; 2(11): 9-19. issn: 2349-1590 15. okada n, narita y, takada m, kato h, ambo y, nakamura f, et al. early removal of drains and the incidence of seroma after breast surgery. breast cancer. 2015; 22(1): 79-83. doi: 10.1007/s12282013-0457-3. 16. dahri fj, awan ms, qazi ar, khaskheli nm, soomro ia. early wound complications following modified radical mastectomy with axillary clearance. j surg pak. 2011; 16:4. 17. gümüş m, satıcı ö, ülger bv, oğuz a, taşkesen f, girgin s. factors affecting the postsurgical length of hospital stay in patients with breast cancer. j breast health. 2015; 11(3): 128. doi: 10.5152/tjbh.2015.2546. 18. uslukaya ö, türkoğlu a, gümüş m, bozdağ z, yılmaz a, gümüş h, et al. factors that affect drain indwelling time after breast cancer surgery. j breast health. 2016; 12(3): 102. doi: 10.5152/tjbh.2016.3070. j islamabad med dental coll 2021 94 19. adamson k, chavez-macgregor m, caudle a, smith b, baumann d, liu j, et al. neoadjuvant hemotherapy does not increase complications in oncoplastic breast-conserving surgery. annals surg oncol. 2019; 26(9): 2730-7. doi: 10.1245/s10434-019-07408-6. 20. decker mr, greenblatt dy, havlena j, wilke lg, greenberg cc, neuman hb. impact of neoadjuvant chemotherapy on wound complications after breast surgery. surgery. 2012; 152(3): 382-8. doi: 10.1016/j.surg.2012.05.001. j islamabad med dental coll 2019 8 open access commonly occurring bacteria in diabetic foot infections and their sensitivity to various antibiotics muneeb-ullah 1, awais saeed abbasi 2, seemab niaz 3, wajiha mahjbeen 4 1, 2 registrar, accident and emergency department, dr. akbar niazi teaching hospital (danth), islamabad. 3post graduate trainee, pims hospital, islamabad. 4associate professor, chemical pathology, danth, islamabad a b s t r a c t background: diabetic foot infections are a common cause of morbidity in type 1 & 2 diabetes mellitus. the selection of appropriate empirical treatment is thus essential while treating such patients. the main objective of this study was to find out most prevalent bacteria and their sensitivity to various antibiotics in patients with diabetic foot infections. material and methods: this cross-sectional study was conducted in the department of surgery, pakistan institute of medical sciences (pims), islamabad from january 2017 to december 2017. a total 118 patients were included through consecutive sampling technique. samples were collected in the form of swab, pus or tissue material and were cultured on blood agar and microorganisms were identified using standard microbiological methods. antimicrobial sensitivity was also checked. statistical package for social sciences (spss) version 22 was used to analyze data. results: out of 118 patients, 72% (n=85) were males while 28% (n=33) were females. cultures of 105 patients were positive and most common organisms isolated were s. aureus (32.4%; n=34), e. coli (17.1%; n=18), p. aeruginosa (14.3%; n=15), polymicrobials (14.3%; n=15) and k. pneumoniae (7.6%; n=8). antibiotics to which organisms were most sensitive included piperacillin/tazobactam (69.5%; n=73), imipenem (55.2%; n=58), amikacin (43.8%; n=46), vancomycin (40%; n=42) and levofloxacin (38.1%; n=40). conclusion: most common organisms causing diabetic foot infections in our study were s. aureus, e. coli, p. aeruginosa, polymicrobial and klebsiella. overall most sensitive antibiotics to these organisms included piperacillin/tazobactam, imipenem, amikacin, vancomycin and levofloxacin. key words: antibiotics, diabetic foot infections, escherichia coli, pseudomonas aeruginosa, piperacillin/tazobactam, staphylococcus aureus authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3 interpretation, discussion, active participation in data collection 4 data analysis. correspondence: muneebullah email: muneebullah@gmail.com article info: received: march 24, 2018 accepted: january 10, 2019 cite this article. muneeb-ullah, abbasi as, niaz s, mahjbeen w. commonly occurring bacteria in diabetic foot infections and their sensitivity to various antibiotics. j islamabad med dental coll.2019; 8(1):8-12 funding source: nil conflict of interest: nil i n t r o d u c t i o n the average worldwide prevalence of type 2 diabetes mellitus in adults is 6.4 %. it ranges from 3.8 to 10.2% among different regions of pakistan. rates of undiagnosed diabetes may be as high as 50% in some areas.1 incidence of type 1 diabetes mellitus also vary worldwide with highest reported incidence in finland and sardinia (3765 per 100,000) and lowest in china and venezuela (0.1-1.9 per 100,000).2,3 foot related problems are an important cause of morbidity in patients with diabetes mellitus. lifetime risk of foot ulcers for diabetic patients (type 1 or 2) may be as high as 25%.4 neuropathy, peripheral vascular disease (pvd) and poor glycemic control are among the important risk factors responsible for development of diabetic foot infection.5 o r i g i n a l a r t i c l e j islamabad med dental coll 2019 9 sensory neuropathy causes diminished perception of pain and temperature that leads to poor recognition of injury to the feet. autonomic neuropathy causes reduced sweat secretion resulting in dry, cracked skin that facilitates the entry of microorganisms. motor neuropathy leads to foot deformities leading to pressure induced soft tissue damage. most of the diabetic foot infections are polymicrobial and are variable depending on the extent of involvement.5 host defense and neutrophil functions are impaired by hyperglycemia. trauma in patients with one or more of these risk factors precipitate development of wounds that are slow to heal and predispose to secondary infection. three key steps involved in evaluation of a patient with diabetic foot infection are: 1) identification of risk factors, 2) determination of extent and severity of infection and 3) assessment of microbial etiology.5 for preventive and monitoring strategies, certain risk categorization systems can be used. one such system is developed by international working group on the diabetic foot that stratifies patients as follows:6 0) no evidence of neuropathy, 1) neuropathy present but no evidence of foot deformity or pvd, 2) neuropathy with evidence of deformity or pvd, 3) history of foot ulceration or lower extremity amputation. at least 2 of the following i.e. erythema, warmth, tenderness or swelling should be present to make a presumptive diagnosis of diabetic foot infection. osteomyelitis is likely to be present if bone can be seen at the floor of deep ulcer.7 aerobic gram-positive cocci which include staphylococcus aureus (s. aureus), streptococcus agalactiae (s. agalactiae), streptococcus pyogenes (s. pyogenes) and coagulase negative staphylococci are mostly responsible for superficial diabetic foot infections (cellulitis and infected ulcers in antibiotic-naive patients).8 deep and chronically infected ulcers and those that are previously treated with antibiotics, are more likely to be polymicrobial and in addition to above mentioned microorganisms; involve enterococci, enterobacteriaceae, pseudomonas aeruginosa (p. aeruginosa), and anaerobes.8 wounds with extensive local inflammation, necrosis, malodorous drainage, necrosis, or gangrene with signs of systemic toxicity should be presumed to have anaerobic organisms in addition to the above pathogens.8 microbiological spectrum also differs by geographic location; with gram-negative pathogens predominating in the sub-tropical climates of africa and asia, in contrast to gram-positive organisms in the western parts of the world.9 current study is aimed at identifying the common pathogens involved in diabetic foot infections in our set-up and their susceptibility to commonly used antimicrobial therapy that may guide in selection of effective empiric treatment. m a t e r i a l a n d m e t h o d s this was a cross sectional study, conducted in the department of surgery, pakistan institute of medical sciences (pims), islamabad. duration of study was one year, from january 2017 to december 2017. patients, presenting in the outpatient department, emergency or ward, qualifying the criteria of pedis (perfusion, extent, depth, infection and sensation) system of diabetic foot classification were included in the study.10 this study was approved by the ethics committee of the hospital and written informed consent was obtained from all the patients prior to enrolment in this study. a total of 118 patients presenting with signs and symptoms suggestive of diabetic foot infection were included in this study through consecutive sampling technique. sample size was calculated through who sample size calculator by using 95% confidence interval, 80% power of study and 7.4% prevalence of diabetic foot ulcer in pakistan.11 calculated sample size was 106 diabetic patients. in order to overcome the possibility of dropouts, total 118 patients were included in the study. collected samples included swabs, pus and tissue material after cleansing with non-antimicrobial substance. at the time of sample collection, no patient was on antimicrobial therapy. samples were sent promptly to microbiology laboratory where they were cultured on blood agar and macconkey agar plates. organisms were further identified using respective biochemical tests according to standard microbiological protocols. bacteria that were cultured included s. aureus, e. coli, p. aeruginosa, proteus, klebsiella pneumoniae, methicillin resistant s. aureus, staphylococcus epidermidis, acinetobacter, s. viridans and enterobacter. a polymicrobial group was added when culture was positive for two or more j islamabad med dental coll 2019 10 organisms. isolates were tested for susceptibility to commonly used antimicrobial therapy. antibiotics that were included in culture sensitivity included piperacillin/tazobactam, linezolid, ceftriaxone, vancomycin, imipenem, meropenem, levofloxacin, coamoxiclav, cefoperazone /sulbactam, amikacin, clindamycin, ceftazidime, ciprofloxacin, tigecycline, chloremphenicol, tobramycin and cefoxitin. statistical package for social sciences (spss) version 22 was used to analyze data. the categorical data is presented in frequencies and percentages i.e. gender frequency, most common organisms and most sensitive antibiotics. r e s u l t s a total of 118 patients were included in this study with a mean age of 53 ± 9.8 years. out of 118 patients, 85 were males (72%), and 33 were females (28%). about 105 patients (89%) tested positive for bacterial growth, while 13 patients (11%) had no organism growth on culture. of the culture positive patients, 71.4% were males and 28.6% were females. cultured organisms were divided into 11 groups. first five organisms isolated in 105 culture positive patients in descending order were, s. aureus (32.4%; n=34), e. coli (17.1%; n=18), p. aeruginosa (14.3%; n=15), polymicrobial (14.3%; n=15) and k. pneumoniae (7.6%; n=8) (table i). top five antibiotics to which organisms were sensitive in descending order were piperacillin/tazobactam (69.5%), imipenem (55.2%), amikacin (43.8%), vancomycin (40%) and levofloxacin (38.1%) (table ii). table i: frequency and percentage of organisms isolated in culture positive patients (n=105) sr. no organism frequency percentage 1 staphylococcus aureus 34 32.4% 2 escherchia coli 18 17.1% 3 pseudomonas aeruginosa 15 14.3% 4 polymicrobial 15 14.3% 5 klebsiella pneumoniae 8 7.6% 6 proteus 5 4.8% 7 methicillin resistant staphylococcus aureus 3 2.9% 8 staphylococcus epidermidis 3 2.9% 9 acinitobacter 2 1.9% 10 streptococcus viridans 1 1% 11 enterobacter 1 1% on an individual basis, s. aureus (n=34) was most sensitive to vancomycin (61.8%; n=21), e. coli (n=18) was most sensitive to piperacillin/tazobactam (88.9%; n=16), p. aeruginosa (n=15) was most sensitive to piperacillin/tazobactam (100%; n=15), polymicrobial (n=15) was most sensitive to piperacillin/tazobactam and amikacin (60%; n=9) and k. pneumoniae (n=8) was most sensitive to piperacillin/tazobactam (75%; n=6) (table iii). table ii: frequency and percentage of antibiotic sensitivity against organisms isolated (n=105) sr no antibiotic frequency percentage 1 piperacillin/tazobactam 73 69.5% 2 imipenem 58 55.2% 3 amikacin 46 43.8% 4 vancomycin 42 40% 5 levoflaxacin 40 38.1% 6 cefoperazone/sulbactam 34 32.4% 7 co-amoxiclav 33 31.4% 8 ceftriaxone 22 21% 9 linezolid 16 15.3% 10 meropenem 16 15.3% 11 tobramycin 13 12.4% 12 ciprofloxacin 6 5.7% 13 tigecycline 5 4.8% 14 clindamycin 4 3.8% 15 chloremphenicol 4 3.8% 16 ceftazidime 2 1.8% 17 cefoxitin 1 1% d i s c u s s i o n our study shows that there is a male predominance in patients of diabetic foot with male to female ratio of 2.5:1. other studies carried out in pakistan either show higher male predominance of 4:1 for diabetic patients at nishtar hospital, multan 12 and cmh peshawar,13 or comparable ratio of 2.3:1.14 male predominance can be due to males working outdoors exposed to contaminated surroundings compared to females performing household chores. moreover, females in general are more concerned about their health and adopt preventive strategies. our study shows mean age of 53 ± 9.8 years, which is in agreement to a study done on 73 patients in karachi with a mean age of 52.7 ± 9.4 years.15 according to another study carried out in nishtar hospital multan, the most commonly affected age group was also 50 to 60 years.12 the logical explanation for affecting older individuals is that diabetes is usually diagnosed at a later age with multiple j islamabad med dental coll 2019 11 table iii: top five common organisms and their sensitivity to different antibiotics sr no antibiotic sensitivity s. aureus (n=34) e. coli (n=18) pseudomonas (n=15) polymicrobial (n=15) klebsiella (n=8) 1 piperacillin/ tazobactam 55.9% (n=19) 88.9% (n=16) 100% (n=15) 60% (n=9) 75% (n=6) 2 imipenem 52.9% (n=18) 66.7% (n=12) 80% (n=12) 40% (n=6) 37.5% (n=3) 3 amikacin 26.5% (n=9) 44.4% (n=8) 40% (n=6) 60% (n=9) 75% (n=6) 4 vancomycin 61.8% (n=21) 22.2% (n=4) 33.3% (n=5) 26.7% (n=4) 12.5% (n=1) 5 levoflaxacin 50% (n=17) 27.8% (n=5) 46.7% (n=7) 6.7% (n=1) 12.5% (n=1) co-morbidities, poor diabetic control and nutritional deficiencies. the most common groups of organisms identified in this study are s. aureus, e. coli, p. aeruginosa and polymicrobial. this was also seen in a study done in khyber pakhtunkhwa where s. aureus and e. coli were the most common organisms in diabetic foot patients.16 in another study staphylococcus aureus was the most prevalent organism constituting 23.16% of the organisms isolated followed by escherichia coli (17.89%) and klebsiella (12.63%).15 proteus, s. aureus, klebsiella and p. aeruginosa were the most widely recognized microorganisms of diabetic foot infections.17 another study showed s. aureus being the most commonly isolated organism.18,19 our findings are comparable with other studies conducted in this region. in our study, organisms are most sensitive to piperacillin/tazobactam, imipenem, amikacin, vancomycin and levofloxacin. in a study on diabetic foot ulcers in jinnah postgraduate medical center, karachi organisms were most sensitive to meropenem, effective in 95% patients.15 the specific antibiotic given against culture sensitive organisms helps in prevention of drug resistance, more accurate management and speedy recovery rather than empirical therapy. so, each organism being more sensitive to specific antibiotic should be treated with antibiotic of choice accordingly. culture sensitivity should be done regularly to identify the organism and start proper antibiotic regimen. hospital based studies can also help in maintaining an antibiogram, which should be periodically updated for devising antibiotic protocols for effective treatment of bacterial infections. c o n c l u s i o n diabetic foot infections are common in older age group with male predominance. most common infecting organisms included s. aureus, e. coli, p. aeruginosa, polymicrobial and klebsiella with piperacillin/ tazobactam, imepenem, amikacin, vancomycin and levofloxacin emerging as the most sensitive antibiotics in our diabetic patients. r e f e r e n c e s 1. ali a, abbasi as, mushtaq s, azim s, jamil m. a comparative study of waist circumference, waisthip ratio and bmi in diabetics and non-diabetics. ann. pak. inst. med. sci. 2017:13(1):27-34. 2. harjutsalo v, sund r, knip m, groop ph. incidence of type 1 diabetes in finland. jama 2013; 310(4):427-428. 3. weng j, zhou z, guo l, zhu d, ji l, luo x, et al. incidence of type 1 diabetes in china, 2010-13: population-based study. bmj 2018; 360: j5295. 4. boulton a, armstrong d, albert s, frykberg r, hellman r, kirkman m, et al. comprehensive foot examination and risk assessment. endocrine practice. 2008 ;14(5):576-83. 5. lipsky ba, berendt ar, deery hg, embil jm, joseph ws, karchmer aw, et al. diagnosis and treatment of diabetic foot infections. clin infect dis 2004; 39(7):885. 6. bus sa, van netten jj, lavery la, monteiro-soares m, rasmussen a, jubiz y, et al. iwgdf guidance on the prevention of foot ulcers in at-risk patients with diabetes. diabetes metab res rev 2016; 32(1):16. 7. grayson ml, gibbons gw, balogh k, levin e, karchmer aw. probing to bone in infected pedal ulcers. a clinical sign of underlying osteomyelitis in diabetic patients. jama 1995; 273(9):721-3. 8. zubair m, malik a, ahmad j. clinico-microbiological study and antimicrobial drug resistance profile of j islamabad med dental coll 2019 12 diabetic foot infections in north india. foot (edinb) 2011; 21(1):6-14. 9. hatipoglu m, mutluoglu m, uzun g, karabacak e, turhan v, lipsky ba. the microbiologic profile of diabetic foot infections in turkey: a 20-year systematic review: diabetic foot infections in turkey. eur j clinmicrobiol infect dis 2014; 33(6):871-8. 10. schaper nc. diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. diabetes metab res rev 2004; 20(1): s90. 11. zhang p, lu j, jing y, tang s, zhu d, bi y. global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. ann med. 2017 feb 17;49(2):106-16. 12. khan abgm, bhatti a, qureshi kh. diabetic foot; surgical management. professional med j.2012;19(1):06-10. 13. mishwani ah, kiyani ka. surgical management of diabetic foot and role of ut (university of texas) classification.pak armed forces med j. 2011;61(3):367-71. 14. imran m, mahmood z, nadeem m, tahir ch, tashah. pattern of diabetic foot lesions and surgical procedures for management. pak j med health sci.2011;5(1):81-4. 15. nageen a. the most prevalent organism in diabetic foot ulcers and its drug sensitivity and resistance to different standard antibiotics.j coll physicians surg pak. 2016;26(4):293-6. 16. ayub r, raza ss, shafiullah, ahsan j, hussain ak, nadeem md. bacterial culture isolates from infected diabetic foot tissue specimens and their sensitivity to antimicrobial agents. j med sci. 2016;24(4):2734. 17. rahimoon ag, alam mt, talpur ms. diabetic foot infection; frequency of microbes and antimicrobial sensitivity pattern attertiary care hospital, karachi. professional med j. 2015;22(11):1415-22. 18. lipsky ba, berendt ar, cornia pb, pile jc, peters ej, armstrong dg, et al. infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. clin infect dis; 2012: e132–e173. 19. roberts ad, simon gl. diabetic foot infections: the role of microbiology and antibiotic treatment. seminvasc surg. 2012; 25(2):75–81. 83 j i m d c 2 0 1 7 83 op e n ac c e ss f u l l l e n g t h a r t i c l e endoscopic diagnosis in patients with acute upper gastrointestinal bleeding ghulam mujtaba shah1, anwar ali jamali2, riaz ahmad khokhar3, shohabudin rind4 1 demonstrator physiology (fcps-gastroenterology), pumhs, lakhyari endoscopic suit, nawabshah 2 assistant professor medicine, pmch, nawabshah 3 ,4 post graduate resident in gastroenterology, isra university of medical sciences, hyderabad a b s t r a c t objective: to determine the causes of acute upper gastrointestinal bleeding using upper gastrointestinal endoscopy. patients and method: this cross-sectional study was conducted at peoples university of medical and health sciences (pumhs), lakyari endoscopic suit, nawabshah from jan 2015 to march 2016. patients presenting with acute upper gastrointestinal bleeding were inducted in the study. after stabilizing the patients, upper gastrointestinal endoscopy was performed. data was entered and analyzed by statistical software package spss version 10.0. mean ± sd was calculated for quantitative variables and qualitative variables like gender and endoscopic findings were expressed as frequencies and percentages. results: out of 208 patients, 139 (67%) were males and 69 (33%) were females. mean age of the patients was 52.77±14.5 sd years. haematemesis was the main presenting complaint followed by melena. bleeding related to portal hypertension was present in 112 (53.84%) patients, followed by peptic ulcer disease in 74 (35.57%) patients. malignant lesions were present in 11(5.28%) patients while miscellaneous lesions were found in 11(5.28%) patients. conclusion: gastro esophageal variceal bleeding was the leading cause of upper gi bleeding followed by ulcerative disease. keywords: endoscopy, esophageal varices, peptic ulcer disease, upper gastrointestinal bleeding author`s contribution 1conception, synthesis and planning of the research-2-4active participation in active methodology interpretation and discussion, analysis . address of correspondence dr. ghulam mujtaba shah mian.scientist@yahoo.com article info. received: april 3, 2017 accepted: may 29, 2017 cite this article: shah gm, jamali aa, khokhar ra, rind s, endoscopic diagnosis in patients with acute upper gastrointestinal bleeding. jimdc. 2017; 6(2):83-86. funding source: nil conflict of interest: nil i n t r o d u c t i o n acute upper gastrointestinal bleeding is defined as bleeding from a source proximal to the ligament of treitz. it is a common medical emergency and remains a major cause of morbidity and mortality. upper gastrointestinal bleeding (ugib) remains to be the commonest cause of critical care hospital admissions, accounting for 6-13% mortality. the incidence of ugib is 2-fold greater in males than in females, in every age group, although the death rate is comparable in the both genders. the ugib has been observed by an increasing frequency in older people, with a concurrent relationship with significant comorbidities that augment mortality. mortality amplify with older age (>60 years). over the past 10-30 years there has been a minimal to no change in mortality rates.2 in an international study, there has been a decrease in mortality from 11% to 7% in france, however no decrease in mortality was found in greece.3 according to the american society for gastrointestinal endoscopy (asge) and a large multicenter study, increasing mortality of 14.4% has been found in elderly population with increased male preponderance.4,5 in a study from spain, ugib was six times more common than lower gi bleeding.6 o r i g i n a l a r t i c l e 84 j i m d c 2 0 1 7 84 upper gastrointestinal endoscopy remains to be an initial recommended procedure in early diagnosis and management of ugib. it reduces duration of hospitalization, recurrence rate of bleeding, number of transfusions, reduced resources and need of surgical intervention. the diagnosis becomes easier when the patient present with hematemesis. even in the absence of hematemesis, 40 to 50% of patients in the emergency room with gi bleeding have an upper gi source.7-9 the main causes of bleeding are usually the peptic ulcers (50.6%; gastric ulcer in 24.4%, duodenal ulcer in 20.6%, and combined gastroduodenal ulcer in 5.6%), congestive gastropathy (2.5%), mallory–wiess tears (11.3%), druginduced mucosal damage (1.9%).10 in different studies, variceal bleeding is also a common cause with nearly 20% of patients presenting with acute ugib.11-13 the common complication among patients with acute ugib is a risk of re-bleeding (1.9%), and mortality may thus reach up to 13.8%.6 sung et al, in a large randomized controlled trial found re-bleeding in 5.9% of the patients receiving treatment for acute bleeding than placebo 10.3%.14 p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at department of medicine pumhs, lakyari endoscopic unit nawabshah from january 2015 to march 2016. permission was taken from hospital ethical committee. sample size of 208 patients was calculated by 95% confidence level with 7% confidence interval, using creative research system sample size calculator. non-probability, convenient sampling technique was used. all patients presenting with upper gastrointestinal hemorrhage in emergency department were inducted in the study. patients having history of bleeding disorders or who refused to give consent were excluded from study. the wwritten consent of patients /attendants was taken. history, examination and routine investigations were carried out. blood was arranged after grouping and cross match. gastric lavage with levine tube was done and blood was replaced whenever required. after stabilizing the patient, upper gastrointestinal endoscopy was performed within 24 hours after pre-medications. pre-medications included, combination of narcotic and benzodiazepine and were administered by the expert gastroenterologist. the instrument used for the endoscopy was standard forward viewing conventional fiber-optic flexible endoscope (gif 130, gif 140) olympus japan with a large bore dual channel, one for water lavage and other for suction. the procedure of endoscopy was performed by experienced gastroenterologist and researcher. after the procedure, patients were followed for re-bleeding and for other complications up to second day of hospital stay. strict instruction to patients and their relatives were given for proper opd follow up after first week and second week. patients requiring surgical treatment for ugib were referred to respective unit after endoscopy. data was analyzed by statistical software package spss version 10.0. descriptive statistics including patient’s age, gender, and admission number were entered. mean ± sd was calculated for age and frequency of qualitative variables like gender and endoscopic findings was expressed as frequencies and percentages. r e s u l t s out of 208 patients, 139 (67%) were males and 69 (33%) were females with male to female ratio of 2.01:1. mean age of the patients was 52.77 ±14.5 sd years and age range of 15 -90 years. mean hemoglobin of the patients was 8.43 gms/dl ± 1.47 sd (table 1). table 1: baseline information of the patients in the study group (n=208) variables result age (years) mean±sd 52.77 ±14.5 hemoglobin (g/dl) mean±sd 8.43 ± 1.47 male number (%) 139 (67) female number (%) 69(33) regarding presenting complaint, hematemesis was the most common presentation followed by melena and mixed presentation (table 2). table 2: presenting complaints of patients in the study group (n=208) presenting complaints frequency n (%) hematemesis 142(68) melena 62(30) mixed 4(2) pattern of acute upper gastrointestinal bleeding in patients is presented in table 3. as shown in the table, the most common cause of gi bleeding was portal hypertension seen in 53.85% patients, followed by 85 j i m d c 2 0 1 7 85 ulcerative lesions seen in 35.57% patients and malignant lesions seen in 5.29% cases. table 3: causes of bleeding in the participants of study (n=208) cause frequency n (%) portal hypertension esophageal varices fundal varices portal hypertensive gastropathy 112(53.85) 96(46.15) 14(6.73) 2(0.96) ulcerative disease duodenal ulcers gastric erosions gastric ulcers mixed lesions 74(35.57) 31(14.90) 16(7.70) 16(7.70) 11(5.28) malignant lesions esophageal growth gastric growth duodenal growth 11(5.29) 2(0.96) 8(3.85) 1(0.48) dielufoey lesion 3(1.44) miscellaneous lesions 8(3.85) d i s c u s s i o n upper gastrointestinal bleeding (ugib) is the most frequent complication occurring in gastroenterology with mortality rate from 4-15%.15-16 nearly more than 300,000 hospital admissions and about 30,000 deaths per annum in america have a source from upper gastrointestinal tract.17 in our study upper gastrointestinal bleeding was one of the most common cause of emergency admissions. upper gastrointestinal endoscopy is the urgent primary diagnostic and therapeutic tool for the patients presenting with hematemesis.18-20 it precisely describes the bleeding site, ascertains the specific cause and also provides information that will assist in predicting the outcome. it also specifically accedes to treatments to stop bleeding and reduces the risk of re-bleeding. in clinical trials, also these endoscopic parameters were used to determine the efficacy of treatment.13 in our study, endoscopy was done to determine the cause of bleeding and also for endoscopic and other management. in this study, the most common cause of upper gastrointestinal bleeding was portal hypertension related varices and gastropathy seen in 53.84% cases and 46.1% cases of esophageal varices. elwakil et al have found variceal bleeding to be the most common presentation in emergency room reported in 70.1% cases,21 these patients presented with hematemesis and melena. whereas ahmed et al reported 43 % cases of bleeding caused by esophageal varices.12 this variation from elwakil et al study was because the study was conducted in egypt where the chronic liver disease has different prevalence from our region. however, the results of study conducted by ahmed et al study are comparable with our results. najam un nasir et al in their study from mayo hospital lahore also found esophageal varices to be the commonest (54%) cause of acute upper gi bleed.22 the second commonest cause was peptic ulcer disease as in our study which was observed in 74 (35.57%) cases. bhutta et al has found 34% cases of peptic ulcer disease with upper gi bleeding.23 different studies have reported peptic ulcer disease being more common than esophageal varices.23,24 in different studies the reported incidence of peptic ulcer disease is 31-67%.25-28 these endoscopic findings are comparable with our study. other causes of ugib included 8 cases (3.84%) of reflux esophagitis, mallory weiss tears, one case of gastric tumor and three cases (1.44%) of dieulafoys lesion. bhutta et al found 18.4% cases of deudenitis, gastric erosions and erosive gastritis.22,23 this high number is due to inclusion of gastric erosions which has been mentioned separately in our study. ahmed et al in his study also found reflux esophagitis in 9 % cases.12 in our study gi neoplasms as a cause of bleeding was present in 11(5.28%) patients. sohail bhutta et al reported carcinoma stomach, carcinoma esophagus, ampullary carcinoma in 2.8% cases.23 a nepalian study conducted by dewan kr et al reported malignancy in 3.3% cases as the cause of upper gi bleed.28 in our study, the main presentation of patients was hematemesis observed in 68.2%, followed by melena in 29.8% cases and both hematemesis and melena in 2% cases and various international data also supported our finding.29 c o n c l u s i o n portal hypertension including portal gastropathy, esophageal varices and fundal varices remained the most common causes of upper gastrointestinal bleeding on endoscopy followed by peptic ulcer disease. 86 j i m d c 2 0 1 7 86 acknowledgement: authors acknowledge the support of mr. rana shakil ahmad, clinical research executive from medical affair, pv and clinical research department of getz pharma in review of the manuscript. r e f e r e n c e s 1. holster il, kuipers ej. management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives.world j gastroenterol. 2012; 18(11):1202-7. 2. acute upper gi bleeding, nice clinical guideline (june 2012). 3. lanas a, perez-aisa ma, feu f, ponce j, saperas e, santolaria s, et al. a nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. am j gastroenterol. 2005; 100(8):1685-93. 4. cerulli ma. upper gastrointestinal bleeding. e-medicine updated: 2013. 5. pilotto a, maggi s, noale m, franceschi m, parisi g, crepaldi g. development and validation of a new questionnaire for the evaluation of upper gastrointestinal symptoms in the elderly population: a multicenter study. j gerontol a biolsci med sci. 2010;65(2):174-8. 6. alatise oi, aderibigbe as, adisa ao, adekanle o, agbakwuru ae, arigbabu ao. management of overt upper gastrointestinal bleeding in a low resource setting: a real world report from nigeria. bmc gastroenterology. 2014;14(1):210. 7. sostres c, gargallo cj, lanas a. nonsteroidal antiinflammatory drugs and upper and lower gastrointestinal mucosal damage. arthritis research & therapy. 2013; 15(3):s3. 8. witting md, magder l, heins ae, mattu a, granja ca, baumgarten m. ed predictors of upper gastrointestinal tract bleeding in patients without hematemesis. am j emerg med. 2006;24(3):280–5. 9. witting md, magder l, heins ae, mattu a, granja ca, baumgarten m. usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis. ann emerg med. 2004;43 (4): 525–32. 10. gonzález-gonzález ja, garcía-compean d, vázquezelizondo g, garza-galindo a, jáquez-quintana jo, maldonado-garza h. nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. clinical features, outcomes and predictors of in-hospital mortality. a prospective study. ann hepatol. 2011; 10(3):287-95. 11. morales uc, sierra ss, hernández ha, arango da, lopez ga. upper gastrointestinal bleeding: risk factors for mortality in two urban centres in latin america. revista espanola de enfermedades digestivas: organo oficial de la sociedad espanola de patologia digestiva. 2011; 103(1):20-4. 12. ahmad i, atif ma, mustafa g. upper gastrointestinal endoscopy: indications and outcome experience at sheikh zayed hospital rahim yar khan. j sheikh zayed med coll .2010;1(1):27-29. 13. abbasi a, bhutto ar, butt n, munir sm, dhillo ak. frequency of portal hypertensive gastropathy and its relationship with biochemical, haematological and endoscopic features in cirrhosis. j coll physicians surg pak. 2011; 21(12):723-6. 14. sung jj, barkun a, kuipers ej, et al.; peptic ulcer bleed study group. intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. ann intern med. 2009;150(7):455–64. 15. laine l. upper gastrointestinal bleeding. clinical update american society of gastrointestinal endoscopy. 2007; 14(3):1-4. 16. marmo r, koch m, cipolletta l, capurso l, pera a, bianco ma, et al. predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study. am j gastroenterol 2008; 103(7): 1639-47. 17. cappell ms, friedel d. initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. med clin north am. 2008; 92(3):491-509. 18. ahmad si, atif ma. upper gi endoscopy a review of 500 cases at sheikh zayed medical college/hospital rahim yar khan. pak j med health sci .2007; 1(4):137-9. 19. mumtaz k, majid s, shah h, hameed k, ahmed a, hamid s, jafri w. prevalence of gastric varices and results of sclerotherapy with n-butyl 2 cyanoacrylate for controlling acute gastric varicealbleeding.world j gastroenterol. 2007; 13(8):1247-51. 20. cappell ms. therapeutic endoscopy for acute upper gastrointestinal bleeding. nat rev gastroenterol hepatol. 2010; 7(4):214-29. 21. elwakil r, reda ma, abdelhakam sm, ghoraba dm, ibrahim wa. causes and outcome of upper gastrointestinal bleeding in emergency endoscopy unit of ain shams university hospital. j egypt socparasitol. 2011;41(2):455-67 22. nasir nu, nadeem ma, imran m, hussain i. oesophageal varices vs peptic ulcer: a study of 100 patients. pak j gastroeneterol. 1998; 12 (1-2):53-56. 23. bhutta s, jamil m, aziz k, uddin w. an etiological study of upper gastrointestinal bleeding. j rawal med coll .2012; 16(1):31-3. 24. chung ik, lee dh, kim hu, sung ik, kim jh; korean college of helicobacter and upper gastrointestinal research;guidelines of treatment for bleeding peptic ulcer disease. korean association of gastroenterology.korean j gastroenterol. 2009; 54(5):298-308. 25. holster il, kuipers ej. management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. world j gastroenterol. 2012; 18(11):1202-7. 26. theocharis gj, thomopoulos kc, sakellaropoulos g, katsakoulis e, nikolopoulou v. changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in greece. j clingastroenterol. 2008; 42(2):128-33. 27. hearnshaw sa, logan rf, lowe d, travis sp, murphy mf, palmer kr. use of endoscopy for management of acute upper gastrointestinal bleeding in the uk: results of a nationwide audit. gut. 2010; 59(8):1022-9. 28. sarwar s, dilshad a, khan aa, alam a, butt ak, tariq s,et al. predictive value of rockall score for rebleeding and mortality in patients with variceal bleeding. j coll physicians surg pak. 2007; 17(5):253-6. 29. dewan kr, patowary bs, bhattarai s. a study of clinical and endoscopic profile of acute upper gastrointestinal bleeding. kathmandu univ med j. 2015; 12(1):21-25. http://www.ncbi.nlm.nih.gov/pubmed?term=holster%20il%5bauthor%5d&cauthor=true&cauthor_uid=22468083 http://www.ncbi.nlm.nih.gov/pubmed?term=kuipers%20ej%5bauthor%5d&cauthor=true&cauthor_uid=22468083 http://www.ncbi.nlm.nih.gov/pubmed/22468083?dopt=abstract http://www.pakmedinet.com/author/irfan+ahmad http://www.pakmedinet.com/author/moazzam+ali+atif http://www.pakmedinet.com/author/ghulam+mustafa http://www.pakmedinet.com/jszmc http://www.pakmedinet.com/jszmc j islamabad med dental coll 2022 8 o p e n a c c e s s impact of resveratrol in attenuating cisplatin induced testicular toxicity in male adult rats shahnaz bano memon1, sajjad ali almani2, muhammad saqib baloch3, samreen ali4, tanveer ahmed talpur5, harender kumar6 1assistant professor, department of pharmacology, isra university, hyderabad 2assistant professor, department of anatomy, dow university of health & science 3assistant professor, department of anatomy, muhammad medical college, mirpurkhas 4assistant professor, department of pharmacology, suleman roshan medical college 5,6final year medical student, isra university, hyderabad a b s t r a c t background: resveratrol is a poly-hydroxy phenol plant toxin that reduces oxidative stress and prevents tissue damage by increasing endogenous antioxidant levels. the study aimed to investigate the protective effects of resveratrol by histochemical, ultrastructural and biochemical methods in testicular toxicity induced by the cisplatin in wistar albino rats. methodology: the quasi-experimental study was carried out at the department of pharmacology, anatomy and postgraduate laboratory of isra university hyderabad from october 2020 to march 2021. twenty-four male, healthy wistar albino rats of age from 8-10 weeks and having body weight 250-300 grams, were included in the study. rats were divided into three groups; each group have same number (n=08) of rats. group-a (control), group-b (experimental group or cisplatin group), group-c (experimental group or cisplatin + resveratrol combination group). preand postexperimental body weight of all animals was measured, blood samples were collected for the biochemical analysis for the oxidative markers, semen parameters, and histo-morphology. data was analyzed using spss version 24.0. results: statistically significant decline in the bodyweight and testicular weight in group b and c respectively (p<0.05). while group-b had lower sperm count, motility, and viability when compared to group-c (p<0.05). group-b also had significantly lower levels of oxidative markers than group-c (p<0.05). groupb's testicular histology significantly differed from group-c's (p<0.05). seminiferous tubules in group-b were irregular, regressive, and atrophic. conclusion: resveratrol is a powerful antioxidant shows potential in reducing cisplatin-induced oxidative stress and, eventually, testicular toxicity in mice models. keywords: cisplatin, oxidative stress, resveratrol, toxicity authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing.5,6 correspondence: shahnaz bano memon email: dr.memonshahnaz@gmail.com article info: received: may 10, 2021 accepted: march 31, 2022 cite this article. memon sb, almani sa, baloch ms, ali s, talpur ta, kumarh. impact of resveratrol in attenuating cisplatin induced testicular toxicity in male adult rats. j islamabad med dental coll. 2022; 11(1):8-13. doi: 10.35787/jimdc.v11i1.716 funding source: nil conflict of interest: nil i n t r o d u c t i o n cisplatin is one of the most commonly used agents for chemotherapy owing to its action on a wide array of cancers.(1) the use of cisplatin, however, is limited due to an extensive list of side effects including the likes of nephrotoxicity, neurotoxicity, testicular toxicity, etc.(2, 3) the deleterious effects of cisplatin have been highlighted in numerous studies.(4-6) reactive oxygen species (ros) induced oxidative stress has been deemed to be the underlying culprit in the production of testicular toxicity by cisplatin. (5, 6) o r i g i n a l a r t i c l e j islamabad med dental coll 2022 9 these ros, produced in the testicular tissue, disrupts the normal function of leydig cells as well as causes disruption in steroidogenesis, leading eventually to infertility.(7) based on this, various antioxidants including extract of cinnamon, ginger, and ginkgo biolba have been designated to provide protection against testicular toxicity prompted by cisplatin administration.(4-6) resveratrol, (trans-3,4',5-trihydroxystilbene) (rsv), is found in over 70 species of edible plants and different foods like cranberries, grapes (skin and seeds), peanuts, dark chocolates, pistachios, etc.(7) it has a potential to fight against pathogens, anticancer properties and possess a potent antioxidant potential. the positive effects of rsv usage for the treatment of numerous disease states has been documented in different studies.(8) the antioxidant effects of rsv are exerted by its ability to reduce lipid peroxidation and its ability to increase the levels of different endogenous antioxidants. (9) the objective of the study was to investigate the protective effects of resveratrol in testicular toxicity induced by cisplatin in wistar albino rats. m e t h o d o l o g y quasi-experimental study was performed at the department of physiology and postgraduate laboratory of isra university hyderabad from october 2020 to march 2021. twenty-four male, healthy wistar albino rats of age from 8-10 weeks and having body weight 250-300 grams, were included in the study. the study animals were procured from the sindh agriculture university, tando jam, sindh. selection of rats was done by nonrandom purposive sampling technique while the standard method of power analysis for animal studies was used for the sample size calculation.(10) the ethical approval for the study was sought from the ethical review board of isra university, hyderabad, which is completely furnished to give permission for animal studies. the procured wistar rats were placed in plastic cages at wellequipped and hygienic setting of postgraduate laboratory in isra university, hyderabad. the animals were kept in a for ten days acclimatization period at the optimal temperature of 24-26℃ in a day-night (12/12) hours cycle. each cage was having nozzles of stainless steel bedded with sawdust along with feed containers to avoid any harm to the study animals. while rats were provided with chow diet and clean water ad libitum during this period. after the period of acclimatization, rats were divided into three groups, each group have same number (n=08) of rats. group 1 was the control group, in which rats were given a normal chow diet and clean water ad libitum only, group 2 was the experimental group, in which rats were given (single dose of cisplatin (7mg/kg) through intra-peritoneal route with normal diet). (11), and group 3 (single dose of cisplatin (7mg/kg) through intra-peritoneal route followed by (10 mg/kg) of oral resveratrol for 21 days. (8, 11) bodyweight of all rats was measured and recorded before initiation of the experiment. while on conclusion of the period of experiment, the body weight of all animals was measured again using electronic precision measuring balance. later, all rats were sacrificed by cervical dislocation after given anesthesia. blood samples were collected by cardiac puncture for the biochemical analysis. testes of all experimental animals were cleanly removed and weighed after proper dissection through midline incision. for estimating the structural framework and motility, the epididymal content was suspended by extracting the cauda epididymis of one testis, which was afterward macerated with scissors in a petri dish containing normal saline (3ml). likewise, the spermcount was achieved by removing the cauda epididymis of the other testis, which was then macerated by scissors in a petri dish containing 0.9ml of 10% formalin. j islamabad med dental coll 2022 10 the testicular tissue was fixed in the bouin's solution and then sliced into longitudinal sections. the tissues were then circulated through water after being properly arranged in labelled cassettes. the sliced tissues were placed in lithium carbonate solution in 70% alcohol for removing any excess fixative. after passing these samples through a series of alcohol concentrations ranging from 70% to 100%, tissue blocks were created and embedded in paraffin wax. tissues were sliced in cut sections of 5µm thick-were obtained through rotary microtome and then stained with hematoxylin and eosin (h&e) for examination. serum sod, gpx and cat levels were analyzed at the research and diagnostic laboratory of isra university, hyderabad. the collected data was entered and analyzed in spss ver. 24.0. the descriptive findings were expressed as mean±sd. one-way anova with post hoc tukey’s analysis was applied for the statistical analysis. significance level of p-value ≤ .05 was considered as significant. r e s u l t s mean body weight of all three groups (a, b and c) prior to the experiment group was 238.4±6.10 gm., 240.6±7.81 gm., and 230.5±6.8 gm. respectively. significant difference in mean before and afterexperimental body weight of rats of all groups. while a statistically significant (p<0.05) decline in body weight of rats in both experimental groups (group b and c) (table 1). a statistically significant difference (p<0.05) in mean testicular weight was also observed in all three groups. (table 1). moreover, the sperm count, its motility, and viability was reduced significantly in cisplatin treated group b (table 1). *: statistically significant difference (p<0.05) between group b and c as compared with the group a ᴥ: statistically significant difference (p<0.05) between group b and c a statistically significant difference (p<0.05) in levels of sod, gpx, and cat was observed in all study groups. while the post hoc tukey test disclosed a significant decrease in gpx, sod, and cat levels in group b when compared to controls. in comparison to group b, group c had significantly higher levels of antioxidants (p<0.05). apart from that, group iii and group i didn’t show any statistical difference in antioxidant levels. (table 2) table 1. post-hoc analysis of weight (testicular and body), sperm count, motility and viability between all groups study groups a b c testis weight (g) 1.53 ± 0.36 1.03 ± 0.20* 1.40 ± 0.65 ᴥ body weight (g) 247.1 ± 6.41 196.7 ± 9.29* ᴥ 210.0 ± 6.48 ᴥ sperm count (x106/ml) 72.84 ± 4.65 30.46 ± 3.18* ᴥ 62.44 ± 5.74 ᴥ motility (%) 71.84 ± 5.25 27.79 ± 3.66* ᴥ 66.74 ± 4.56 ᴥ viability (%) 80.33 ± 2.86 51.86 ± 3.36* ᴥ 68.11 ± 2.26 ᴥ table 2. post-hoc analysis of serological markers between all study groups study groups a b c glutathione peroxidase (umol/mg protein) 9.90±1.51 4.29±0.78* ᴥ 8.13±0.51 ᴥ superoxide dismutase (u/mg protein) 13.20±0.50 5.90±0.15* ᴥ 11.38±0.79 ᴥ catalase (u/mg protein) 19.42±1.04 12.70±0.67* ᴥ 17.68±1.58 ᴥ j islamabad med dental coll 2022 11 *: statistically significant difference (p<0.05) between group b and c as compared with the group a ᴥ: statistically significant difference (p<0.05) between group b and c figure 1. testicular cross-sections photographed under a microscope (h&e 400) the testicular architecture of the experimental animals in group a was normal, with regular seminiferous tubules. cisplatin-treated rats (group b) had their normal testicular architecture disrupted but uneven small seminiferous tubules without any spermatogenesis. atrophic, degenerative as well as regressive tubules were also detected. the testicular architecture of rsv-treated rats (group c) was nearly normal, with most of the seminiferous tubules showing regular morphology identical to group a. furthermore, the seminiferous tubules atrophied and degenerated were greatly reduced. d i s c u s s i o n the optimal functioning of the reproductive system is critically threatened by the presence of ros prompted oxidative stress. spermatogenesis, as well as other important processes within the testicular tissue, are hampered by injuries caused by ros.(12) ros also causes occlusion of arteries, which compromises the blood supply making the tissue prone to oxidative stress due to increased oxygen demands and consumption. (12) the current study demonstrated the actions of resveratrol in protecting the testicular tissue against cisplatin induced toxicity. it was found that cisplatin, in addition to causing histological discrepancies, led to oxidative stress which was ameliorated by rsv administration. although being beneficial against a wide variety of cancers, cisplatin administration is accompanied with a long list of complications, all of which are attributed to the inherent capability of cisplatin to generate ros. (8, 13) in the current study, the body weight as well as the semen parameters of the experimental animals were reduced post cisplatin administration. additionally, the testicular histological architecture was also compromised. these findings are in accordance with those reported by hamza et al. who reported that cisplatin exerts a toxic effect on not only on testicular histology but on testicular function as well. (14) in the current study, the levels of endogenous antioxidants were also markedly decreased. these findings are also in agreement to the findings of albader et al. and madhu et al. which also j islamabad med dental coll 2022 13 demonstrated a decline in the total antioxidant status (tas) of the cisplatin treated rats. (15, 16) being a polyphenolic phytoalexin, the beneficial role of resveratrol in preventing the manifestation of toxicity in testicular tissue caused by the administration of various toxins has been reported by several studies. (17) (18) (19) (20) observations of this current study are consistent with these findings as rsv was able to prevent testicular toxicity post cisplatin administration which was evident from the comparatively higher semen parameters as well as serum antioxidant levels in the rsv receiving group. the studies by nagehan et al. and reddy et al. reported findings consistent with the current study. according to their studies, rsv administration was able to amend the toxic effects produced by cisplatin. this was evident by improved semen parameters, and an elevated level of plasma antioxidants. additionally, rsv therapy also barred the cisplatin prompted discrepancies in the histological architecture. these findings are in support of the current study.(7, 21) owing to limited availability of time and monetary resources, other parameters such as inflammatory as well as hormonal markers could not be explored. therefore, further studies are recommended to investigate the effects of rsv, both individually as well as in combination with other antioxidants. c o n c l u s i o n resveratrol is a potent protective agent with promising results in attenuating cisplatin-induced oxidative stress and eventually the testicular toxicity in mice models. r e f e r e n c e s 1. cao x, xiong s, zhou y, wu z, ding l, zhu y, et al. renal protective effect of hydrogen sulfide in cisplatininduced nephrotoxicity. antioxid redox signal. 2018;29(5):455-70. doi: 10.1089/ars.2017.7157 2. gómez-sierra t, eugenio-pérez d, sánchezchinchillas a, pedraza-chaverri j. role of foodderived antioxidants against cisplatin inducednephrotoxicity. food chem toxicol. 2018;120:23042. doi: 10.1016/j.fct.2018.07.018. 3. sarafraz z, ahmadi a, daneshi a. transtympanic injections of n-acetylcysteine and dexamethasone for prevention of cisplatin-induced ototoxicity: double blind randomized clinical trial. int tinnitus j. 2018;22(1):40-5. doi: 10.5935/0946-5448.20180007 4. elshiekh aa, elkolaly hr, tawfeek nm, mohamed aa, mohamed aa. possible protective effect of ginger extract and beetroot juice against cisplatin induced testicular and cytogenetic toxicity in adult male albino rats. ejhm. 2019;76(5):4046-54. doi: 10.21608/ejhm.2019.42298 5. okdah ya, kandil eh. potential therapeutic effect of cinnamon against cisplatin-induced testicular toxicity and oxidative stress in rats. transylvanian review. 2018;1(12). 6. tutuncu m, kiray m, yonguc n, bagriyanik ha, editors. the protective effects of fucoidan on cisplatin induced testicular cytotoxicity in rats. multidisciplinary digital publishing institute proceedings; 2018:2(25), 1554; doi: 10.3390/proceedings2251554 7. özyilmaz yay n, şener g, ercan f. resveratrol treatment reduces apoptosis and morphological alterations in cisplatin induced testis damage. j res pharm. 2019;23(4). doi:10.12991/jrp.2019.170 8. meghji ka, talpur ra, uqaili aa, nizammani ym, kazi n, nizammani gs. resveratrol attenuates oxidative stress in chemotherapy induced acute kidney injury: an experimental rat model. kmuj. 2019;11(2). doi: 10.35845/kmuj.2019.19114 9. truong vl, jun m, jeong ws. role of resveratrol in regulation of cellular defense systems against oxidative stress. biofactors. 2018;44(1):36-49. doi: 10.1002/biof.1399 10. meghji ka, memon tf, ahmed i, memon sg, noor n, abbas a. nephroprotective effects of l-arginine against chemotherapy induced acute kidney injury in wistar rats. jimdc. 2020;9(4):249-55. doi: 10.35787/jimdc.v9i4.535 11. köroğlu km, çevik ö, şener g, ercan f. apocynin alleviates cisplatin‐induced testicular cytotoxicity by regulating oxidative stress and apoptosis in rats. andrologia.2019;51(1):e13227.doi:10.1111/and.13 227 12. asadi n, bahmani m, kheradmand a, rafieian-kopaei m. the impact of oxidative stress on testicular function and the role of antioxidants in improving it: a review. j clin diagn res. 2017;11(5):ie01-ie05. doi: 10.7860/jcdr/2017/23927.9886. 13. boroja t, katanić j, rosić g, selaković d, joksimović j, mišić d, et al. summer savory (satureja hortensis l.) extract: phytochemical profile and modulation of cisplatin-induced liver, renal and testicular toxicity. j islamabad med dental coll 2022 13 food chem toxicol. 2018;118:252-63. doi: 10.1016/j.fct.2018.05.001 14. hamza a, elwy h, badawi a. fenugreek seed extract attenuates cisplatin‐induced testicular damage in w istar rats. andrologia. 2016;48(2):211-21. doi: 10.1111/and.12435 15. al-bader m, kilarkaje n. effects of bleomycin, etoposide and cisplatin treatment on leydig cell structure and transcription of steroidogenic enzymes in rat testis. eur j pharmacol. 2015;747:150-9. doi: 10.1016/j.ejphar.2014.12.006 16. madhu p, reddy kp, reddy ps. role of melatonin in mitigating chemotherapy-induced testicular dysfunction in wistar rats. drug chem toxicol. 2016;39(2):137-46. doi: 10.3109/01480545.2015.1055359 17. türedi s, yuluğ e, alver a, kutlu ö, kahraman c. effects of resveratrol on doxorubicin induced testicular damage in rats. exp toxicol pathol. 2015;67(3):229-35. doi: 10.1016/j.etp.2014.12.002 18. el-fattah aaa, fahim at, sadik nah, ali bm. resveratrol and curcumin ameliorate di-(2ethylhexyl) phthalate induced testicular injury in rats. general and comparative endocrinology. 2016;225:45-54. 19. yuluğ e, türedi s, alver a, türedi s, kahraman c. effects of resveratrol on methotrexate-induced testicular damage in rats. the scientific world journal. 2013;2013. doi:10.1155/2013/489659 20. meydanli eg, gumusel a, ozkan s, tanriverdi g, balci mc, develi is s, et al. effects of resveratrol on highfructose-induced testis injury in rats. ultrastruct pathol. 2018;42(1):65-73. doi: 10.1080/01913123.2017.1397075 21. reddy kp, madhu p, reddy ps. protective effects of resveratrol against cisplatin-induced testicular and epididymal toxicity in rats. food chem toxicol. 2016;91:65-72. doi: 10.1016/j.fct.2016.02.017. j islamabad med dental coll 2021 159 open access assessment of agility in elderly population of islamabad maheen khan1, sana bashir1, humaira hussian1, tayyaba saman1, rida fatima1, hina shafi2 1student, doctors in physical therapy, foundation university institute of rehabilitation sciences, islamabad 2assistant professor, foundation university institute of rehabilitation sciences, islamabad a b s t r a c t background: agility is considered as one of the important components of physical fitness. in older adults, it is of utmost importance in response to any stimulus. the objective of this study was to determine normative values of agility in elderly population of islamabad. methods: a cross-sectional survey was conducted in community settings of islamabad from february–july 2019 after approval by the ethical review committee of foundation university islamabad. the calculated sample size was found to be 267, but due to missing data, analysis was done on 250(100 females and 150 males). participants were selected by convenient sampling. physically independent participants were included and diseased population (severe musculoskeletal, neurological, and cardiopulmonary disorders), decreased functional status affecting hearing, vision, memory recall was excluded from the study. par-q was utilized in uncovering any possible health risks linked to exercise. for evaluation of agility, the american alliance for health, physical education, recreation, and dance (aahperd) agility test was performed. agility scoring is based on time in seconds, with higher score representing less agility, and agility score of less than 62 represents good agility. data were analyzed through spss version 21. results: the mean age, bmi and agility score of participants were 60.7±5.81 years, 26±4.30 kg/m² and 22.42±5.2 respectively. there was significant difference (p<0.001) in agility between males and females, with the mean agility score higher in females as compared to males. similarly, agility score was significantly high in females as compared to males in bmi range of 18.5 to >30 and all age categories. conclusion: elderly population of pakistan has good agility score keywords: agility, older adults, physical fitness authors’ contribution: 1-2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: hina shafi email: hina.shafi@fui.edu.com article info: received: august 19, 2020 accepted: august 30, 2021 cite this article. khan m, bashir s, hussain h, saman t, fatima r, shafi h. “assessment of agility in elderly population of islamabad”. j islamabad med dental coll. 2021; 10(3): 159-163. doi: 10.35787/jimdc.v10i3.588 funding source: nil conflict of interest: nil i n t r o d u c t i o n aging results in a continuous decline in functional capacity, demonstrated by reduced strength of lower limbs, impaired balance and agility. such alterations may influence a person’s everyday activities such as climbing and descending stairs or sitting and standing up from a chair, apart from decreasing capability of the older adults to quickly react to external stimulus, such as slipping and staggering and to regain balance.1 maintaining physical activity and fitness is of utmost importance in the geriatrics health care system to make elderly population live independently. work has been done to assess and maintain the functional independence level in elderly population which is essential for their daily activities. this can only be o r i g i n a l a r t i c l e j islamabad med dental coll 2021 160 achieved by improving measures of functional fitness including specific motor abilities such as agility, balance and coordination. 2 physical fitness comprises of two categories, health related and skill related fitness. skill related fitness includes several fitness components such as agility, reaction time, balance, coordination, power and speed. 3 functional independences in older population can be achieved by improving the variables (comorbidities, body composition, physical activity, agility and walking).4 agility has been, indeed, defined as a rapid wholebody movement with change of velocity or direction in response to a “stimulus”.5 available evidence suggests that a lack of effectively integrating neuromuscular and cognitive function during difficult tasks might be an underlying reason for falls in seniors.6 it is supported by literature that agility declines with increase in age.7 one reason behind this may be that elderly people usually don’t get health benefits associated with an active lifestyle.8 human evolutionary process advocates that the standard for health is related to physical activity. contrary to this, inactivity has deleterious effect on health throughout life. 9 physical function in elderly can be conserved or enhanced through agility training.10 deterioration in health as well as fitness can be efficiently alleviated through exercise. the proposed conventional training for older adults usually focuses on components of physiological robustness separately such as strength, endurance, balance and flexibility. so, a more comprehensive framework is a requisite for functional drills. there are several agility training perceptions that are collectively addressing strength, balance, spatial orientation and stop and go.11 there is no such study done in pakistan where norms of agility in older adults have been found. more work is done on other components of physical fitness and agility remained a left-out component. so, the purpose of our study is to provide baseline values and current level of agility in elderly population. m a t e r i a l a n d m e t h o d s cross-sectional survey was conducted in community settings of islamabad from february–july 2019 after approval by the ethical review committee of foundation university islamabad. raosoft was used for sample size calculation with a margin of error 5%, confidence level 90%, and 50% response distribution with population size of 20,000 and found as 267. data analysis was done on 250 participants instead of 267 due to the factor of missing information. study participants were selected by convenient sampling; inclusion criteria were the physically independent elderly population of >51 years of both genders (males and females) whereas diseased population (i.e., elderly adults with certain severe musculoskeletal, neurological, and cardiopulmonary disorders) were excluded from the study. after written informed consent; an aneroid sphygmomanometer was used to measure the blood pressure of participants, a weight machine, and measuring tape to measure the weight and height of participants. people who were at risk with increased physical activity were identified by the physical activity readiness questionnaire (par-q.) which consist of seven questions to find out the readiness of the participants to participate in physical activity as well as some questions regarding basic information (age, gender, height, bodyweight. etc). the elderly who answered “no” to all the 7 questions of parq were made part of the study and allowed to perform american alliance for health, physical education, recreation, and dance (aahperd) agility test. firstly, participants were educated about the aahperd agility test which was used to assess the value of agility in seconds and then asked to perform it. where agility scoring is based on time in seconds, normative values are >99 =very weak, 75-95.15= weak, 63-74 = regular, 43-62 = good, <42 = very good (7). the heart rate and blood pressure of every participant were recorded before the performance of the test. the setting of the test j islamabad med dental coll 2021 161 included two cones and a chair (the total span of the setting was approximately 31 ft. the subject was asked to get up from the chair as the time started and walk towards (with a usual walking speed) and move around the cone on the right side of the chair then return to the chair (to seated position) then get up again from the chair and walk towards (with a usual speed of walking) and move around a cone on left of the chair (both right and left-sided cones were placed at a same distance from the chair). the procedure of the test was demonstrated by the researcher followed by the performance of the test by the participants. the time duration of the second trial was recorded in which the participants completed the whole course. the total test duration was approx. 10-15 minutes for each participant (including, explanation of the purpose of study, attainment of consent, screening, demonstration of the test by researcher, and performance of test by participants). data was analyzed using spss 21. data was presented in the form of mean and standard deviation. for comparison of gender, independent t-test was used. for comparison of age and weight categories, one way anova was used. the level of significance was set at < 0.05. r e s u l t s agility was assessed within a sample of 250 elderly adults (>51 years age) living in islamabad, out of which 100 were females (40%) and 150 were males (60%). there was significant difference (p<0.001) in agility score between male and females, with the mean agility score higher in females as compared to males. similarly, agility score was significantly high in females as compared to males in bmi range of 18.5 to >30 and all age categories (table ii). table i: demographic data variables mean ± s.d agility (sec) 22.42±5.2 age (years) 60.7 ± 5.81 height(cm) 164.51±10.7 weight(kg) 70 ± 11 bmi (kg/m²) 26 ± 4.3 heart rate(bpm) 77.2 ± 11.2 systolic blood pressure(mmhg) 127.4 ± 12 diastolic blood pressure(mmhg) 82.2 ± 10.13 table ii: agility score in age categories and its relationship with gender variables categories male no. (mean ±sd) female no. (mean ±sd) p-value agility (seconds) 20.24 ± 3.93 25.70 ± 5.06 <0.0001* bmi (kg/m2) under weight (<18.5) 6 (20.33 ± 5.53) 2 (22 ± 5.65) 0.726 normal weight (18.524.9) 55 (20.35 ± 3.95) 31 (24.97 ± 4.58) <0.0001* overweight (25-29) 69 (20.22 ± 3.99) 49 (25.94 ± 5.42) <0.0001* obese (>30) 20 (20 ± 3.43) 18 (26.72 ± 4.86) <0.0001* age (number of participant, mean ±sd) 51 to 55 year 21 (18.67 ± 3.95) 30 (24.97 ± 5.56) <0.0001* 56 to 60 year 57 (20.56 ± 3.92) 44 (24.75 ± 3.71) <0.0001* 61 to 65 year 39 (20.26 ± 3.89) 16 (27.69 ± 6.54) <0.0001* 66 to 70 year 19 (21.63 ± 3.53) 6 (29 ± 4.52) <0.0001* 70 to 75 year 11 (19.18 ± 4.19) 2 (26.50 ± 2.12) 0.038* >75 year 3 (20 ± 6.24) 2 (31 ± 7.01) 0.162 *significant difference with p-value of <0.05 j islamabad med dental coll 2021 162 d i s c u s s i o n this study mainly focused on agility normative scores base line data of older adults of islamabad. according to our study, the mean score of agility is greater in females as compared to males, hijan et al also reported that physical attributes are the cause behind these differences in scores. difficulty in personal care and functional ailments during diseased states are usually experienced by elderly females as compared to males of the same age. 14 the literature supports the decrease in scores of agilities with increasing age and the most likely reason behind this is reduced physical activity. countering this, our study has found a distinct pattern. holistically, there are a number of reasons for a compromise in physical activity in advanced age. the built of a person, particularly, the weight and height of the body have a key role in motor wellness stature. contrary to the results of our study which reveals no significant relationship between agility and weight that might be because of some confounding features including ethnicity, occupation, and daily lifestyle differences, j. thakur (2016) inferred that a considerable relationship exists between agility and weight.16 another research was conducted by jd liu and his colleagues, regarding senior fitness tests and it concluded that irrespective of body weight stature, every older adult reacted to the components of the test in the same way. the importance of every element of functional fitness was also the same for the participants, having dissimilar bodyweight statures. 18 pak-kwong chang et al conducted a study regarding elements of functional fitness in a community of elderly people in hong kong. the study concluded that age-related decline was detected in every element under examination, particularly in agility, flexibility, and balance. 17 unlike the results of our study, the results of previous studies exhibit that considerable relation exists between agility and weight and greater body mass index linked with decreased performance abilities, inhibiting the development of appropriate motor skills ultimately influencing agility. 19,20 results of another study conducted by t.rohilla showed that a significant and positive correlation is there between functional walking capacity and muscle strength of the lower body in older adults. in contrast to our study, it is evident from this research that in older age muscle wasting affects muscle strength which further casts impact on the functional walking capacity and this keeps on going with growing age. 19 our study provides normative values of agility in older adults which can be taken as a reference for future studies but there are few limitations that should be considered while conducting any similar study such as there was a lack of cooperation from females to participate that might be due to apprehension, related to the test performance. the study sample size was small with a low confidence level. resources were not enough to approach multiple people over large geographical areas. as physical fitness including all of its components, especially agility may vary depending on the living environment of older adults, so people belonging to different setups can be a confounding factor. c o n c l u s i o n elderly population of islamabad has good agility scores r e c o m m e n d a t i o n s studies must be conducted among different cities in pakistan and the results should be compared. further studies should be done focusing on the effects of agility training in older adults and then compare pre and post agility training results in order to investigate the effects of agility training on the risk of falls in the elderly population. j islamabad med dental coll 2021 163 r e f e r e n c e s 1. elam c, aagaard p, slinde f, svantesson u, hulthén l, magnusson ps, bunketorp-käll l. the effects of ageing on functional capacity and stretch-shortening cycle muscle power. j phys ther sci. 2021;33(3):25060. doi: 10.1589/jpts.33.250 2. varela s, ayán c, cancela jm. batteries assessing health related fitness in the elderly: a brief review. eur rev aging phys act. 2008;5(2):97-105. doi 10.1007/s11556-008-0037-2 3. thompson cr, editor. prevention practice: a physical therapist's guide to health, fitness, and wellness. slack incorporated; 2007. 4. pereira c, fernandes j, raimundo a, biehl-printes c, marmeleira j, tomas-carus p. increased physical activity and fitness above the 50th percentile avoid the threat of older adults becoming institutionalized: a cross-sectional pilot study. rejuvenation research. 2016;19(1):13-20. doi: 10.1089/rej.2015.1669 5. chaalali a, rouissi m, chtara m, owen a, bragazzi nl, moalla w, chaouachi a, amri m, chamari k. agility training in young elite soccer players: promising results compared to change of direction drills. biology of sport. 2016;33(4):345. doi: 10.5604/20831862.1217924 6. lichtenstein e, faude o, zubler a, roth r, zahner l, rössler r, hinrichs t, van dieën jh, donath l. validity and reliability of a novel integrative motor performance testing course for seniors: the “agility challenge for the elderly (ace)”. front physiol. 2019;10:44. doi: 10.3389/fphys.2019.00044 7. chhabra r, desai m, kumar a. determination of agility in elderly using assistive device by 8 foot up and go test. j indian acad geriatrics. 2018; 14(1). 8. hambrook r, middleton g, bishop d, crust l, broom d. time to speed up, not slow down: a narrative review on the importance of community-based physical activity among older people. j health soc sci. 2020;5(1):91-102. doi: 10.19204/2019/tmts7 9. harridge sd, lazarus nr. physical activity, aging, and physiological function. physiology. 2017;32(2):15261. doi: 10.1152/physiol.00029.2016 10. de lima vc, castaño laa, boas vv, uchida mc. a training program using an agility ladder for community-dwelling older adults. jove (journal of visualized experiments). 2020(157):e60468. doi: 10.3791/60468 11. morat m, faude o, hanssen h, ludyga s, zacher j, eibl a, et al. agility training to integratively promote neuromuscular, cognitive, cardiovascular and psychosocial function in healthy older adults: a study protocol of a one-year randomized-controlled trial. int j environ res public health. 2020;17(6):1853. doi: 10.3390/ijerph17061853 12. benedetti trb, mazo gz, gonçalves lht. adaptation of the aahperd test battery for institutionalized older adults. rev bras cineantropom desempenho hum. 2014;16(1):1-14. doi: 10.5007/19800037.2014v16n1p1 13. kazoglu m, yuruk zo. comparison of the physical fitness levels in nursing home residents and community-dwelling older adults. arch gerontol geriatr. 2020; 89:104106. doi: 10.1016/j.archger.2020.104106 14. hajian-tilaki k, heidari b, hajian-tilaki a. are gender differences in health-related quality of life attributable to sociodemographic characteristics and chronic disease conditions in elderly people?. int j prev med. 2017;8(1):95; doi: 10.4103/ijpvm.ijpvm_197_16 15. keadle sk, mckinnon r, graubard bi, troiano rp. prevalence and trends in physical activity among older adults in the united states: a comparison across three national surveys. preventive medicine. 2016;89:37-43. doi: 10.1016/j.ypmed.2016.05.009 16. thakur js. association of obesity with agility and speed of university level kabaddi players. ijpesh. 2016;3(2):254-6. e-issn: 2394-1693 17. chung pk, zhao y, liu jd, quach b. functional fitness norms for community-dwelling older adults in hong kong. arch gerontol geriatr. 2016;65:54-62. doi: 10.1016/j.archger.2016.03.006 18. liu jd, quach b, chung pk. further understanding of the senior fitness test: evidence from communitydwelling high function older adults in hong kong. arch gerontol geriatr. 2019;82:286-92. doi: 10.1016/j.archger.2019.02.011 19. rohilla t, tiwari s. lower body muscular strength affects the agility and functional walking capacity in later age. journal of human kinetics. 2014;2(3): 4044. 20. ceschia a, giacomini s, santarossa s, rugo m, salvadego d, da ponte a, et al. deleterious effects of obesity on physical fitness in pre-pubertal children. eur j sport sci. 2016;16(2):271-8. doi: 10.1080/17461391.2015.103045 j islamabad med dental coll 2019 166 ope n ac cess diagnostic value of immature-to-total neutrophil ratio in neonatal sepsis husnain ali1, ejaz hussain2, imran mahmood khan3, iqtada haider shirazi4, muhammad imran5, bilal ahmad6 1 senior registrar, department of pediatrics, islamabad medical & dental college, islamabad 2 senior registrar, women medical & dental college, abbottabad 3 associate professor, department of pediatrics, islamabad medical & dental college, islamabad 4 professor, neonatology department, pakistan institute of medical sciences, islamabad 5 senior registrar, department of pediatrics, shifa college of medicine, islamabad 6 assistant professor, department of pediatrics, islamic international medical college, rawalpindi a b s t r a c t background: neonatal sepsis is the third most common reason of neonatal mortality in pakistan. blood culture, the gold standard test for diagnosis of neonatal sepsis (ns), is time consuming. therefore, rapid diagnostic tests with good specificity and sensitivity is needed for accurate and early diagnosis of this condition. the objective of this study was to determine the diagnostic value of abnormal (≥ 0.2) immature-to-total-neutrophil ratio in neonatal sepsis. material and methods: this cross-sectional study was carried out on 288 neonates, aged 0-28 days, admitted with suspected sepsis. detailed history of the neonates was recorded including gender, age, birth weight, maternal age, gestational age and clinical features. blood culture and peripheral blood films were done in each case. differential leucocyte counts, total polymorphoneutrophil count (pmn), immature neutrophil count, mature neutrophil count and calculation of i/t ratio was carried out in the pathology department of pims, islamabad. the study outcome was divided into three groups on the basis of positive or negative blood culture and i/t ratio as normal, probable sepsis and proven sepsis group. data was analyzed by spss version 21.0. diagnostic value of i/t ratio was determined in ns by calculating values of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) by considering the blood culture as the gold standard test of ns. results: the mean age and weight of the neonates at the time of admission was 1.1 (± 0.6) days and 2.51 (± 0.40) kg, respectively. about 60% of the neonates were males and 118(41%) neonates had i/t ratio of ≥ 0.2. on the basis of positive or negative blood culture and i/t ratio, 82 (28.5%) neonates were diagnosed as proven sepsis, 43 (14.9%) neonates had probable sepsis and remaining 163 (56.6%) neonates were declared as normal. out of 82 neonates with positive blood cultures, 75 (91.5%) had i/t ratio ≥ 0.2, while 7 (8.5%) had i/t ratio ≤ 0.2. the sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of abnormal i/t ratio to diagnose neonatal sepsis was 91%, 79%, 64%, 96% and 83%, respectively. conclusions: due to substantially high diagnostic accuracy of i/t ratio ≥ 0.2, we recommend it as a useful, rapid and cost-effective tool in accurate diagnosis of neonatal sepsis. key words: diagnostic value, immature-to-total neutrophil ratio, neonatal sepsis authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3,4 active participations in data collection 5,6 data analysis. correspondence: imran mahmood khan email: lifesaverforu@yahoo.com article info: received: january 4, 2019 accepted: november 2, 2019 cite this article. ali h, hussain e, khan im, shirazi ih, imran m, ahmad b. diagnostic valu e o f immature-to-total neutrophil ratio in neonatal sepsis. j islamabad med dental coll.2019; 8(4): 166-170. doi: 10.35787/jimdc.v8i4.475 funding source: nil conflict of interest: nil i n t r o d u c t i o n neonatal sepsis (ns) is defined as “a clinical syndrome o f systemic illness accompanied by bacteremia occurring in the first month of life”.1 up to 25% of children in intensive care units have sepsis.2 according to unicef statistics o f 2015, neonatal mortality rate in pakistan is 46 deaths per 1,000 live births.3 in pakistan, ns is the third most or i gi n a l a r ti c le j islamabad med dental coll 2019 167 common cause of neonatal mortality after prematurity and birth asphyxia, resulting in 17.2% of neonatal deaths.3 however developed countries have very low inciden ce o f ns i.e. 1/1000 in term neonates and 4/1000 in preterm neonates.4 early diagnosis of ns is primarily based on clinical presentation, while laboratory diagnosis mainly depends on blood cultures. the definitive diagnosis of ns on the basis of blood cultures takes at least 36 hours, which is quiet time consuming.5 on the other hand, the standard hematological investigations in terms of white blood cell (wbc), neutrophils and platelet counts are all simple tests which are easily available, time saving and cost effective compared to blood cultures.6 it should also be noted that negative blood culture cannot always rule out ns. on the other hand, blood culture can become positive due to contamination from skin or asymptomatic bacteremia.7 therefore, hematological parameter should be considered for quick diagnosis of bacterial infections in neonates a n d ruling out neonatal sepsis to prevent over-usage of antibiotics and concomitant emergence of antibiotic resistant strains. timely and effective management of neonatal sepsis can significantly reduce neonatal mortality. band cells are defined as “neutrophils that ha ve not reached full maturation. they are characterized by absence of complete separation of the lobes, which gi ve s the nucleus a characteristic horse-shoe shape with a uniform thickness”. on stimulation by pro-inflammatory cytokines, the bone marrow releases these cells into the circulation.8,9 raised immature neutrophil count in blood is usually considered as an indicator of sepsis. in 2005, the international consensus conference on pediatric sepsis rephrased the definition of ns by including “the presence of immature neutrophils >10% ”.10 however the diagnosti c accuracy of immature neutrophil count in sepsis has become debatable, as it is affected by many causes othe r than infection including perinatal asphyxia, maternal hypertension, hemorrhage, hemolysis, corticosteroids, parenteral nutrition and surgery, etc.11,12 this study was planned to assess the diagnostic accuracy of abnormal (≥ 0.2) immature-to-total neutrophil (i/t) ratio in neonatal sepsis at our clinical setting. m a t e r i a l a n d m e t h o d s after seeking permission from institutional ethics review board of pakistan institute of medical sciences (pims), islamabad, this cross-sectional study was carried out at neonatology department of pims from 1st november, 2014 till 30th april, 2015. this study included 288 neonates between 0-28 days admitted in neonatal icu with suspicion of sepsis. neonates of diabetic mothers and those with severe neonatal jaundice resulting from blood group incompatibilities and congenital anomalies were excluded from the study. the sample size was calculated with who sample size calculator with following values of calculations; 95% confidence interval, 5 % margin of error and 75% true prediction of neonatal sepsis by i/t ratio ≥ 0.2.13 neonates between 0-28 days admitted in the nicu with suspected sepsis were screened for enrollment. those who fulfilled the above-mentioned inclusion criteria were registered in the study after informed consent of parents/ caretaker of the neonates. once enrolled, a careful history was taken from the parents/caretakers of each enrolled neonate regarding gender, age, birth weight, maternal age, gestational age and clinical features and recorded i n a preset structured proforma. once the information was obtained, necessary investigations were done within 24 hours of admission. the skin was cleaned with a spirit swab and blood sample was taken after skin became dry. about 1 ml of blood sample was collected in tubes containing edta and sent to laboratory for blood cultures. beckman coulter hmx automated hematology analyzer (usa) was used to obtain values of total wbcs and platelets. peripheral blood films were stained by leishman staining method. differential leucocyte counts, total polymorphoneutrophil count (pmn), immature neutrophil count, mature neutrophil count and calculation of i/t ratio was carried out in the pathology department of pims, islamabad. the study outcome was divided into three groups: 1. normal group – both blood culture and i/t ratio were negative, 2. probable sepsis group – blood culture was negative but the i/t ratio was ≥ 0.2 along with clinical features of ns, 3. proven sepsis group – blood culture was positive along with clinical features of ns with or j islamabad med dental coll 2019 168 without i/t ratio ≥ 0.2. data was recorded on a structured proforma and analyzed by spss version 21.0. mean and standard deviation were calculated for quantitative variables such as age of neonate, maternal age, gestational age, wbcs, pmn and platelet count. frequencies and percentages were calculated for qualitative variables like gender, clinical signs, prematurity and neonatal sepsis. moreover, diagnostic value of i/t ratio was determined in ns by calculating values of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) by considering the blood culture as the gold standard test of ns. r e s u l t s in this study, 288 neonates with clinical features of ns were enrolled. the mean age was 1.1 (± 0.6) days (table i). out of 288, 173 (60% ) neonates were males while 1 1 5 (40% ) were females with a male-to-female ratio of 1.5:1. the mean birth weight was 2.51 (± 0.40) kg with 21 (7.3% ) neonates having a birth weight less than 2 kg and 111 (38.5% ) having birth weight between 2.0 and 2.5 kg. the mean maternal age of the neonates was 25.8 (±5.3) years and the mean gestational age of neonates was 36.9 (± 1.8) weeks. about 91 (31.6% ) neonates were premature while 197 (68.4% ) were full term neonates. regarding clinical symptoms, 108 (37.5% ) had `tachypnea, 89 (30.9% ) lethargy, 88 (30.6% ) reduced sucking, and 119 (41.3% ) had vomiting during their stay in the hospital. the mean wbc count was 6905 (± 221.7) mm3 with 39 (13.5% ) neonates having a wbc count more than 10,000 mm3. the mean pmn count was 4833 (± 155.2) mm3 and the mean platelet count was 216972 (± 2566.1) mm3. the diagnostic value of i/t ratio in ns was determined b y calculating its sensitivity, specificity, ppv and npv by considering blood culture as gold standard. out of 82 neonates with positive blood cultures, 75 (91.5% ) had i/t ratio ≥ 0.2, while only 7 (8.5% ) neonates had i/t ratio ≤ 0.2. therefore, the sensitivity of i/t ratio to diagnose neonatal sepsis was 91% , specificity was 79% , ppv was 64% , npv was 96% and diagnostic accuracy was 83% . out of 82 neonates with proven sepsis, 49 (60% ) neonates were males. while, out of 43 neonates with probable sepsis, 26 (60% ) were males. table i: descriptive statistics of neonates characteristics mean ± sd age (days) 1.1 ± 0.6 maternal age (years) 25.8 ± 5.3 birth weight (kg) 2.51 ± 0.40 gestational age (weeks) 36.9 ± 1.8 white blood cells (mm3) 6905 ± 221.7 neutrophils (mm3) 4833 ± 155.2 platelets (mm3) 216972 ± 2566.1 characteristics n (%) gender male 173 (60%) female 115 (40%) gestational age premature 91 (31.6%) full time 197 (68.4%) i/t ratio ≤ 20% 170 (59%) ≥ 20% 118 (41%) blood culture positive 82 (28.5%) i/t ratio ≤ 0.2 7 (8.5%) i/t ratio ≥ 0.2 75 (91.5%) negative 206 (71.5%) i/t ratio ≤ 0.2 163 (79.1%) i/t ratio ≥ 0.2 43 (20.9%) d i s c u s s i o n neonatal sepsis is still one of the most common reasons of neonatal mortality and morbidity despite the great advancements in neonatal care. clinical features of neonatal sepsis are often confused with those of noninfectious and metabolic diseases. in such cases, often empirical antibiotics are started early to avoid neonatal mortality which can result in adverse effects a n d emergence of resistant strains. in order to prevent these complications and timely management of neonatal sepsis, rapid, cost effective and accurate diagnostic test is needed.14 in our study, out of 288 neonates, 82 (28.5% ) were diagnosed as proven sepsis, 43 (14.9% ) neonates had probable sepsis and remaining 163 (56.6% ) neonates were normal. out of 82 neonates with positive blood cultures, 75 (91.5% ) neonates also had i/t ratio ≥ 0.2, while 7 (8.5% ) had i/t ratio ≤ 0.2. therefore, the sensitivity of i/t ratio to diagnose neonatal sepsis was 91% , specificity was 79% , ppv was 64% , npv was 96% j islamabad med dental coll 2019 169 and diagnostic accuracy was 83% . our findings are comparable with those of other studies done in different parts of the world. an egyptian study on 285 neonates showed that 65.6% of patients had abnormal i/t ratio with sensitivity, specificity, ppv and npv of 82.4% , 81.3% , 92.5% and 62.2% , respectively.15 this study also showed that i/t ratio of more than 0.3 was associated with increased odds of mortality, suggesting a prognostic role of i/t ratio in predicting the patients outcome.15 sensitivity and specificity of this study can be compared to our study but ppv and npv are quite different. similarly, a retrospective study on 125 newborns by bernhard and colleagues in austria found that an abnormal i/t ratio ≥ 0.2 was a more common finding th a n an abnormal wbc count in early onset sepsis.16 a study conducted in india by annam and colleagues analyzed cord blood for various hematological parameters and found that an abnormal i/t ratio is the most sensitive parameter for early onset neonatal sepsis.17 makkar and coworkers from india also evaluated the importance of hematological scoring system in the early diagnosis of ns. this study revealed that i/t ratio of ≥ 0.2 had a high sensitivity (94% ), high specificity (94% ) and npv (94% ) but low ppv (8% ) for the diagnosis of neonatal sepsis. these values were the highest among all other hematological parameters.18 a retrospective study in united states by hornik and colleagues on a large co h o rt of neonates (n=166,092) from 1996 to 2009 observed that i/t ratio ≥ 0.2 was significantly associated with ns with a sensitivity of 54.6% and specificity of 73.7% .13 specificity of this study is comparable to that of our study but sensitivity is much lower than that of our study. murphy and wiener also conducted a retrospective study on neonates who were assessed for ns within the first 2 4 hours of life. of the 3,154 included neonates, 1,539 (49% ) had two normal (≤ 0.2) i/t ratios and a negative blood culture at 24 hours. none of these neonates with normal i/t ratios were subsequently diagnosed with ns (npv 100% ).19 the results are similar to those of our study. yet in another study conducted in usa on 163 infants, bhandari and colleagues found very low sensitivity (33% ), specificity (1% ), ppv (1% ) and npv (66% ) of i/t ratio (≥ 0.2) for the diagnosis of ns. the findings of this study are quiet different as compared to our study mainly due to smaller sample size used in this study.20 another prospective study from bangladesh conducted on 80 neonates also showed low sensitivity and specificity of i/t ratio ≥ 0.2 lower than those of our study mainly due to low sample size.21 c o n c l u s i o n we recommend i/t ratio > 0.2 as very useful, rapid and cost-effective investigation in early detection of ns. it can save life of many neonates by early administration of antibiotics in cases of ns and unnecessary use of antibiotics in those with no sepsis thus preventing antibiotics resistance and adverse effects. r e f e r e n c e s 1. gomella t, cunningham d, eyal f. neonatology. 7th ed. tricia lacy gomella, editor. new york: mc graw hill; 2013. 665 p 2. wynn j, cornell tt, wong hr, shanley tp, wheeler ds. the host response to sepsis and developmental impact. pediatrics. 2010; 125(5): 1031–41. doi: 10.1542/peds.2009-3301 3. unicef. maternal and newborn health disparities: pakistan. 2017 4. lopez e, guiral e, soto s. neonatal sepsis by bacteria: a big problem for children. clin microbiol. 2013; 2(06): 125. doi: 10.4172/2327-5073.1000125 5. haque kn. neonatal sepsis in the very low birth weight preterm infants: part 2: review of definition, diagnosis and management. j med sci. 2010; 3(1): 11-27 6. ghosh s, mittal m, jaganathan g. early diagnosis of neonatal sepsis using a hematological scoring system. indian j med sci. 2001; 55(9): 495–500. 7. clark r, powers r, white r, bloom b, sanchez p, benjamin dk. prevention and treatment of nosocomial sepsis in the nicu. j perinatol. 2004; 24(7): 446–53. doi: 10.1038/sj.jp.7211125 8. cavallazzi r, bennin c-l, hirani a, gilbert c, marik pe. review of a large clinical series: is the band count useful in the diagnosis of infection? an accuracy study in critically ill patients. j intensive care med. 2010; 25(6): 353–7. doi: 10.1177/0885066610377980 j islamabad med dental coll 2019 170 9. newman tb, draper d, puopolo km, wi s, escobar gj. combining immature and total neutrophil counts to predict early onset sepsis in term and late preterm newborns: use of the i/t2. pediatr infect dis j. 2014; 33(8): 798–802. doi: 10.1097/inf.0000000000000297 10. goldstein b, giroir b, randolph a. international consensus conference on pediatric sepsis. international pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. pediatr crit care med. 2005; 6(1): 2–8. doi: 10.1097/01.pcc.0000149131.72248.e6 11. shah ba, padbury jf. neonatal sepsis. virulence. 2014; 5(1): 170–8. doi: 10.4161/viru.26906 12. seebach jd, morant r, rüegg r, seifer t b, fehr j. the diagnostic value of the neutrophil left shift in predicting inflammatory and infectious disease. am j clin pathol. 1997; 107(5): 582–91. doi: 10.1093/ajcp/107.5.582 13. hornik cp, benjamin dk, becker kc, benjamin dk, li j, clark rh, et al. use of the complete blood cell count in early-onset neonatal sepsis. pediatr infect dis j. 2012; 31(8): 799–802. doi: 10.1097/inf.0b013e318256905c 14. saleem m, israr shah k, mukhtar cheema s, azam m. hematological scoring system for early diagnosis of neonatal sepsis. jrmc. 2014; 18(1): 68-72 15. saied da. can we rely on the neutrophil left shift for the diagnosis of neonatal sepsis? need for reevaluation. egypt pediatr assoc gaz. 2018; 66(1): 22–7. doi: 10.1016/j.epag.2017.12.002 16. bernhard r, renoldner b, hofer n. comparison between pathogen associated laboratory and clinical parameters in early-onset sepsis of the newborn. open microbiol j. 2016; 10(1): 133–9. doi: 10.2174/1874285801610010133 17. annam v, medarametla v, chakkirala n. evaluation of cord blood haematological scoring system as an early predictive screening method for the detection of early onset neonatal sepsis. j clin diagnostic res. 2015; 9(9): sc04-sc06 10.7860/jcdr/2015/11621.6493 18. makkar m, gupta c, pathak r, garg s, mahajan nc. performance evaluation of hematologic scoring system in early diagnosis of neonatal sepsis. j clin neonatol. 2013; 2(1): 25–9. doi: 10.4103/22494847.109243 19. murphy k, weiner j. use of leukocyte counts in evaluation of early-onset neonatal sepsis. pediatr infect dis j. 2012; 31(1): 16–9. doi: 10.1097/inf.0b013e31822ffc17 20. bhandari v, wang c, rinder c, rinder h. hematologic profile of sepsis in neonates: neutrophil cd64 as a diagnostic marker. pediatrics. 2008; 121(1): 129–34. doi: 10.1542/peds.2007-1308 21. walliullah sm, islam mn, siddika m, hossain ma, chowdhury ak. role of micro-esr and i/t ratio in the early diagnosis of neonatal sepsis. mymensingh med j. 2009; 18(1): 56–61. pmid: 19182751 j islamabad med dental coll 2021 228 o p e n a c c e s s internet use and its addiction among medical students in hyderabad, pakistan tariq feroz memon1, ghulam hussain baloch2, muhammad talha khan3, ferrukh zehravi4, munawar hussain soomro5, jehanzaib motlani6 1assistant professor, department of community medicine, liaquat university of medical & health sciences, jamshoro 2assistant professor, department of community medicine, isra university, hyderabad 3,4senior lecturer, department of community health sciences, bahria university medical & dental college, karachi 5associate professor, department of community medicine, shaheed mohtarma benazir bhutto medical university, sindh 6student, final year mbbs, isra university, hyderabad a b s t r a c t background: with the advances in information and technology, internet addiction appears as a serious obsessive condition that has various negative consequences on human physical and mental wellbeing. the objective of the study was to determine the use of internet and its level of addiction among medical undergraduate students studying at isra university, hyderabad. methods: this cross-sectional study was carried out at the isra university, hyderabad between august and december 2019. undergraduate medical (mbbs) students of either gender were invited to participate in the study. stratified sampling technique was applied for the selection of participants. a structured 5-point likert scale questionnaire for the internet addiction test was adopted from dr. kimberly young and used for the measurement of participant’s internet addiction level. results: a total of 263 students were included in the study. over half (54.37%) of them were male while 51.71% were from the age group 21-22 years. internet addiction was found prevalent in 85.17% of participants. of these, 54.37% were mild or minimal internet addicts while 10.27% were severely addicted. a statistically significant difference (p<0.05) was observed between gender, age groups, year of study, and current residential status of participants. conclusion: students between the age group (19-20) years, hostlers, in 2nd year of study and males were mainly addicted to internet. keywords: internet addiction, medical students, technology authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3,4 critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: tariq feroz memon email: drtariqferoz@gmail.com article info: received: june 2, 2021 accepted: december 3, 2021 cite this article. memon tf, baloch gh, khan mt, zehravi f, soomro h, motlani j. internet use and its addiction among medical students in hyderabad, pakistan. j islamabad med dental coll. 2021; 10(4): 228-233. doi:10.35787/jimdc.v10i4.724 funding source: nil conflict of interest: nil i n t r o d u c t i o n the world has remodeled over recent years within the field of technology. in this remolding, the internet is one of the conducive factors to the current milestone. (1) globally, the number of internet users have surged exponentially by one thousand-fold in last one and half decade. the recent report on internet users also indicated that over half of the world’s population (approximately 4 billion people) have internet access. while in 2017 alone, about quarter a billion new internet users o r i g i n a l a r t i c l e j islamabad med dental coll 2021 232 were recorded. (1) inflated consumer demand has initiated competition among electronic suppliers. as a result, there is a fall in the prices of gadgets like laptops, desktop computers, pads, and mobile phones. (2) after these advancements, the use of the internet has risen sharply, not just for communication, but as a tool for seeking information and marketing. furthermore, an increase in internet coverage, especially among developing countries and rural areas, has made the internet a source of entertainment. subsequently. it is rapidly becoming a part of daily life. (3) the use of the net has brought many benefits within the education field. the ample provision of e-books, dictionaries, and encyclopedias made the pursuit of information faster and accessible. moreover, simulation videos, powerpoint presentations, and online slides provide a more precise, clear, and elaborate view of the topic under study (4) despite the many benefits of the web mentioned above, various adverse consequences are also becoming apparent. the array of the consequences involves excess money spent on web subscriptions and wastage of time while surfing on the net. in addition, issues related to mental health are raising like depression, ruined relationships, and job loss. (5) arguably, the most concerning manifestation of this are pathological internet addiction. specifically, internet addiction can be defined as the use of internet devices for 7 hours or more per day, which predisposes one to dependence and mental health problems. (6) moreover, it leads to disturbance of sleep, pain in the neck, strained eyes, traffic accidents, etc. worldwide, mental disorders because of internet addiction are a novel health concern. the pathological internet addiction presents with compulsive behavior, poor performance in academia, and neglect of social and occupational responsibilities. (7) furthermore, excessive internet use results in craving social media like facebook, instagram, twitter, snapchat, and whatsapp. in addition, various other activities cause web addiction. for example, online gaming, listening to music, watching films, online shopping, and gambling. (8) internet addiction can be diagnosed by asking eight diagnostic questions. the answer to these questions can ascertain a specific type of internet addiction. (9) however, pathological form of web addiction is common in college and university students. in addition, several studies have found an association between internet addiction and anxiety. likewise, the high prevalence of internet addiction among medical students has become a serious concern. (6, 10) limited information is available regarding internet addiction among the students. no study has been conducted on internet addiction among undergraduate medical students in hyderabad so far. this study will help to get an insight into this issue that can help policy makers in devising strategies for its prevention and control. m e t h o d o l o g y this cross-sectional study was carried out at the isra university, hyderabad between august and december 2019. stratified sampling technique was applied for the selection of participants. the sample size of 237 was calculated, using the formula for anticipated population proportion (raosoft). the confidence level of 95%, 5% margin of error and 19% anticipated proportion were used in the formula (11)(12) a total of 263 participants were included by applying calculation for design effect; to reduce the possibility of non-responsiveness. all medical students from 1st to final year mbbs, who gave consent to participate were included. incentives such as medical textbooks and/or dictionaries were provided to the students. the study was ethically approved by the ethical review board of isra university, hyderabad while written informed consent was also sought from all the participants. socio-demographic details of all students (age, gender, marital status, ethnicity, religion and year of study, etc.) were gleaned, followed by a structured questionnaire consisting of 5-point likert scale j islamabad med dental coll 2021 232 questions adopted from dr. kimberly young, as a tool for internet addiction test (iat).(9, 13) the iat is a valid inventory that is used to measure the severity of self-reported compulsive use of the internet. the scores of internet addiction were categorized according to the responses of total 20 items of iat, the maximum score 100 was considered as the extreme usage/severe addiction. while the iat scores less than 30 meant normal internet users, 3149 mild addiction, 50-79 represented moderate addiction and 80-100 showed severe addiction. the questionnaires were circulated to the study participants soon after their morning lectures. spss-23 was used for both the descriptive and inferential statistical analysis of data. qualitative data was presented as numbers and percentages. quantitative variables were measured as mean and standard deviation and analyzed using student ttests or one-way anova, based on the classification of data available. r e s u l t s the age range of the respondents was from 19 to 24 years with the mean age of 21.26 ± 3.44 years. the majority of respondents were from 2nd-year mbbs while most of the respondents were day scholars (table i). table i: socio-demographic details of study participants (n=263) variables n (%) gender male female 143 (54.37) 120 (45.63) age group 19-20 years 21-22 years 23-24 years 104 (39.54) 136 (51.71) 23 (8.74) year of study 1st year 2nd year 3rd year 4th year 5th year 63 (23.96) 81 (30.79) 67 (25.47) 31 (11.78) 21 (8.00) present residence hostler day scholar 79 (30.03) 184 (69.97) platform participant spend the most time on the internet online games movies/videos social media learning websites 23 (8.74) 75 (28.52) 152 (57.80) 13 (4.94) the majority of study participants (n=224) scored between 31 and 100 in iat and were found to be addicted to the internet (figure 1). figure 1: status of internet addiction among medical students (n=263) out of the 224 addicted respondents, the majority of them were mild or minimal internet addicts (table ii). table ii: distribution of participant’s level of internet addiction (n=263) level of internet addiction frequency (%) total score range no addiction 39 (14.83) < 30 mild 143 (54.37) 31-49 moderate 54 (20.53) 50-79 severe 27 (10.27) 80-100 total 196 (74.5%) participants strongly agreed that they often stay online longer than envisioned. while, 103 (39.16%) respondents reported that they prefer the internet excitement to intimacy with their friends or family. moreover, 105 (39.92%) reported that they feel moody, nervous, or depressed after they become offline while this feeling disappears once they get back online. j islamabad med dental coll 2021 232 a statistically significant (p<0.05) difference was found between the internet addiction scores of both genders. male medical students that were found to be more addicted to the internet compared with their counterparts. the mean internet addiction score was statistically highest among the age group 19-20 while lowest in the 23-24 years group. moreover, the mean internet addiction score was statistically highest in 2nd-year mbbs students while lowest in 5th-year medical students. statistically significant difference was found in internet addiction level between hostlers and day scholars (table iii). table iii: comparative analysis of mean internet addiction scores with the demographic variables (n=263) variable internet addiction score mean (± s.d) p-value gender male female 52.77 (±14.67) 39.28 (±13.38) 0.001* age group 19-20 21-22 23-24 57.30 (±14.42) 55.75 (±14.59) 48.52 (±14.40) 0.033** year of study 1st year 2nd year 3rd year 4th year 5th year 48.69 (±16.66) 52.39 (±16.03) 46.62(±16.96) 45.19 (±16.52) 37.33 (±16.45) 0.007** present residence hostel day scholar 55.75(±17.55) 48.82 (±17.89) 0.004* * student’s t-tests for gender and present residence ** anova for age group and year of study d i s c u s s i o n despite many advantages of internet usage, there are several adverse effects of its consumption which are evident. adolescents especially students at all levels are more likely to become victim to internet addiction. keeping in view these harmful effects, this study was planned to estimate the magnitude of internet addiction among medical students. the response rate in the study was 87.66% which was encouraging. this could be attributable to the students' incentives along with a thorough explanation of the study objectives. in the present study, 85.17% of participants are internet-addicted which is a large number. ali et al reported 85% of their participants to be internet addicts. these findings are consistent with our study.(14) this high number is quite alarming and this could be because medical students of isra university have easy access to an internet facility and internet utilization by students is not regulated. the results of the present study have revealed that only 14.83% of the respondents were regular internet users. as the number is very low, it indicates that internet addiction is rampant in the cohort of this study. similar findings are also reported by ali et al. and ahmer et al. in their study (14, 15) while these findings are inconsistent with the findings of nduanya et al who reported higher prevalence than our study.(16) our study discovered that 12.05% of respondents were severely addicted to the internet, many of the studies have reported the lower prevalence of severe internet addiction. (16-18) moreover, our study revealed that 63.84% of the respondents were mild or minimal and 24.11% were moderate internet addicts. these findings are comparable with studies by ahmer et al., chaudhari et al., and haque et al.(1, 15, 19) findings of the current study revealed that male medical students are more addicted to the internet compared with their counterparts. our study findings are comparable to those reported by javaeed et al., imani et al, and upadhayay et al. (9, 18, 20) in addition, a systematic review by shao et al also revealed that male students were more internet addicted than females students.(21) these findings are in contrast with the findings of ahmer et al where internet addiction among females was found to be more as compared to males.(15) however, ranganatha et al. haven’t observed any variation in the mean internet addiction scores between both genders.(22) j islamabad med dental coll 2021 232 in this study, the internet addiction was found to be more prevalent among participants between age group 19-20 years, while this prevalence of internet addiction was declined in 23-24 years of age participants. this is possibly because with advancing age and maturity, medical students engage and focus more on other important responsibilities and trend of internet surfing decreases. these findings are consistent with the findings of earlier studies that reported a similar pattern.(1, 14, 15) lastly, it has been found that students residing in the hostel had the highest mean internet addiction score compared with day scholars. these findings are consistent with the findings of qadir et al.(23) this can also be explained as students residing in hostels, being alone, get bored and spend longer duration using the internet for change of mind. the study has certain limitations. foremost, it was conducted in only one public sector medical university. the information gathered from participants was only regarding the internet usage while data related to determinants of excess usage of the internet, time spent on the particular website or social media, the impact of internet addiction on mental health, etc. was not collected. further studies are recommended in the future to address this issue more extensively. c o n c l u s i o n students between the age group (19-20) years, hostlers, in 2nd year of study and males were mainly addicted to the internet. this rising burden of internet addiction predicts a probable increase in the number of severely internet addicts in the near future. r e f e r e n c e s 1. haque m, abubakar ar, naina-mohamed i, saidin nb, azhar nik. internet addiction a global concern: a cross-sectional appraisal amongst imminent medical doctors of national defence university of malaysia. j pharm pract community med. 2019;5(4), 75-79. doi:10.5530/jppcm.2019.4.19 2. anandi bs, gududur a. technology addiction and associated health problems among medical students in kalaburagi district. nat j comm med. 2018;9(4):294-9. issn 2229 6816 3. tsimtsiou z, haidich a-b, spachos d, kokkali s, bamidis p, dardavesis t, et al. internet addiction in greek medical students: an online survey. academic psychiatry. 2015;39(3):300-4. doi:10.1007/s40596014-0273-x 4. hashim r, hameed s, ayyub a, ali s, raza g. internet use: disruptive or enhancing towards learning? views & perceptions of undergraduate medical students. pafmj. 2016;66(1):157-61. issn : 2411-8842 5. chupradit s, leewattana a, chupradit pw. the correlation analysis of internet usage and depression among undergraduate university students in thailand: cross-sectional study. j adv res dyn control syst.2020;12:825-37. doi:10.5373/jardcs/v12sp6/sp20201100 6. d’souza l, manish s, raj s. relationship between academic stress and internet addiction among college students. int j indian psychol. 2018;6(2):1008. doi: 10.25215/0602.010 7. ambad sna, kalimin km, yusof kmaak. the effect of internet addiction on students’emotional and academic performance. e-academia journal. 2017;6(1). issn 2289-6589 8. asrese k, muche h. online activities as risk factors for problematic internet use among students in bahir dar university, north west ethiopia: a hierarchical regression model. plos one. 2020;15(9):e0238804. doi: 10.1371/journal.pone.0238804 9. upadhayay n, guragain s. internet use and its addiction level in medical students. adv med educ pract. 2017;8:641-47. doi: 10.2147/amep.s142199 10. mostafa a, hoque r, chakraborty r, haque m, munna ms. internet use and addiction: a crosssectional study to ascertain internet utilization level for academic & non-academic purpose among medical and university students of bangladesh. konuralp medical journal. 2019;11(3):404-15. doi: 10.18521/ktd.522996 11. chathoth v, kodavanji b, arunkumar n, pai sr. internet behaviour pattern in undergraduate medical students in mangalore. ijirset. 2013;2(6):2133-6. issn: 2319-8753 12. raosoft i. sample size calculator. 2004. available from: ww raosoft com/samplesize. 2016. 13. young k. internet addiction test (iat): stoelting; 2016. 14. ali r, mohammed n, aly h. internet addiction among medical students of sohag university, egypt. j egypt j islamabad med dental coll 2021 233 public health assoc. 2017;92(2):86-95. doi: 10.21608/epx.2018.8946 15. ahmer z, tanzil s. internet addiction among social networking sites users: emerging mental health concern among medical undergraduates of karachi. pjms. 2018;34(6):1473. doi: 10.12669/pjms.346.15809 16. nduanya cu, okwaraji fe, onyebueke gc, obiechina ki. a cross sectional study on internet addiction, locus of control and psychological distress in a sample of nigerian undergraduates. j med res. 2018;4(3):14650. issn: 2395-7565 17. thakur a, peepre k, vaswani a, gupta k, verma a, singh d, et al. internet addiction, behavioral aspects and health-related problems associated with it: a cross-sectional study among engineering students of jabalpur district. int j res med sci. 2018;6(1):253-8. doi:10.18203/2320-6012.ijrms20175729 18. javaeed a, bint zafar m, iqbal m, ghauri sk. correlation between internet addiction, depression, anxiety and stress among undergraduate medical students in azad kashmir. pjms. 2019;35(2):506. doi: 10.12669/pjms.35.2.169 19. chaudhari b, menon p, saldanha d, tewari a, bhattacharya l. internet addiction and its determinants among medical students. ind psychiatry j. 2015;24(2):158. doi: 10.4103/09726748.181729 20. imani a, esmaeeli s, golestani m, ghoddoosi-nejad d, baghban baghestan e, arab-zozani m. relation between internet addiction and educational burnout among students in faculty of health management and medical informatics of tabriz university of medical sciences: a cross-sectional study. mod care j. 2018;15(2). doi: 10.5812/modernc.66027. 21. shao y-j, zheng t, wang y-q, liu l, chen y, yao y-s. internet addiction detection rate among college students in the people’s republic of china: a metaanalysis. child adolesc psychiatry ment health. 2018;12(1):1-10. doi: 10.1186/s13034-018-0231-6 22. ranganatha s, usha s. prevalence and pattern of internet addiction among medical students, bengaluru. int j commun med pub health. 2017;4(12):4680-4. doi:10.18203/23946040.ijcmph20175350 23. qadir s, naeem a, akhtar mn. internet use behavior: emerging student mental health problem. gomal j med sci. 2018;16(2):39-42. doi:10.46903/gjms/16.02.1920 j islamabad med dental coll 2021 83 open access changing antimicrobial susceptibility and resistance pattern of acinetobacter species over the last eight years in a tertiary care hospital in lahore, pakistan fareeha imran1, muna malik1, amina asif1, gulnaz akhtar2, sidra zaman3, aasma noveen ajmal4 1assistant professor, department of pathology, ameer-ud-din medical college/pgmi/lgh, lahore, punjab pakistan 2associate professor, department of pathology, ameer-ud-din medical college/pgmi/lgh, lahore, punjab pakistan 3demonstrator, department of pathology, avicenna medical college, lahore, punjab pakistan 4senior demonstrator, department of pathology, ameer-ud-din medical college/pgmi/lgh, lahore, punjab pakistan a b s t r a c t background: acinetobacter spp. is a highly resistant nosocomial pathogen that leads to a broad range of human infections resulting in high morbidity and mortality. due to unpredictable mdr patterns of acinetobacter spp., it is imperative to know the institutional prevalent susceptibility profiles of these residing pathogens. the objective of this study was to determine the antimicrobial susceptibility pattern of acinetobacter species over the last 8 years in a tertiary care hospital in lahore, pakistan. material and methods: a retrospective study was carried out in lahore general hospital, a tertiary care hospital in lahore, pakistan. eight-year data was gathered from january 2012 to december 2019. all specimens were handled according to standard operating procedures in the microbiology laboratory of the pathology department of lahore general hospital. the acinetobacter spp. were identified in the laboratory by gram staining, oxidase test, catalase test and triple sugar iron fermentation and their antibiotic sensitivity pattern was noted. results: the highest yield of acinetobacter spp. from the clinical specimen was isolated from pus followed by tracheal secretion, blood, and urine in the last three years (from 2017 to 2019). most of the isolates were multi-drug resistant (mdr). there was a progressive increase in resistance of acinetobacter spp. the highest progression in resistance was observed among the cephalosporin and quinolone group of antibiotics. conclusions: increased resistance to commonly used antimicrobials against acinetobacter species has been observed with the highest resistance to quinolones and cephalosporins. key words: acinetobacter, antibiotic stewardship, multidrug resistance, nosocomial infections. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6 data analysis; manuscript editing. correspondence: fareeha imran email: fareehaimran536@hotmail.com article info: received: october 5,2020 accepted: june 15, 2021 cite this article. imran f, malik m, asif a, akhtar g, zaman s, ajmal a n. changing antimicrobial susceptibility and resistance pattern of acinetobacter species over the last eight years in a tertiary care hospital in lahore, pakistan. j islamabad med dental coll. 2021; 10(2): 83-88. doi: 10.35787/jimdc.v10i2.615 funding source: nil conflict of interest: nil i n t r o d u c t i o n acinetobacter species is one of the most important opportunistic non-fermenting bacteria associated with hospital-acquired infections with almost 20% of infections occurring in intensive care units.1 it is a o r i g i n a l a r t i c l e j islamabad med dental coll 2021 84 major cause of urinary tract infection, surgical site infection, septicemia, pneumonia, and ventilatorassociated pneumonia. in the past, they were considered contaminants but now they are an important cause of healthcare-associated infections.2 hospital-acquired infections are the sixth leading cause of death in the usa.3 invasive procedures and misuse of broad-spectrum antibiotics are the major risk factors for the acquisition of infection with acinetobacter species. increased resistance leads to treatment failure, prolonged hospital stays, financial burden and increased mortality.4,5 multidrug efflux pumps, target modification, permeability defects, and enzymatic degradation of drugs are important mechanisms of acquired resistance against a wide range of antibiotics.6 acinetobacter species have been declared by who as one of the most serious organisms among eskape pathogens (enterococcus faecium, staphylococcus aureus, klebsiella pneumoniae, acinetobacter species, pseudomonas aeruginosa, and enterobacter species).6 it is very difficult to eradicate acinetobacter from the environment due to its ability to survive on dry surfaces for a longer period and resistance to most of the disinfectants.7 about 48-85% of the clinical isolates have shown multidrug resistance.1 acinetobacter spp. are emerging as one the most resistant pathogens in pakistan as well as globally and are a great burden to human health.8,9 increased incidence of mdr strains of acinetobacter species is due to a lack of compliance with basic infection control measures.8 due to unpredictable mdr patterns of acinetobacter spp., it is imperative to know the institutional prevalent susceptibility profiles of these residing pathogens. hence, this study was conducted to observe the antibiogram of the last eight years of various clinical samples from which acinetobacter spp. was isolated by a simplified phenotypic identification protocol and to determine the changing antibiotic susceptibility pattern of these isolates. this is essential for proper antimicrobial stewardship, which is the key to effective control of infections. m a t e r i a l a n d m e t h o d s this retrospective study was carried out in lahore general hospital, lahore, a tertiary care hospital. approval was obtained from the ethical review committee of postgraduate medical institute/ ameer-ud-din medical college/ lahore general hospital, lahore, pakistan. this study comprised of eight-year data from january 2012 to december 2019. samples from both indoor and outdoor patients were collected and processed according to standard protocols of the microbiology laboratory of the pathology department, lahore general hospital, lahore, pakistan. these samples included blood, csf, pus, wound swabs, tips, tracheal secretion, fluid, sputum, bronchial wash, pleural tap, tissue/biopsy, and urine. all acinetobacter spp. isolated and identified after biochemical tests were included in this study. clinical samples from patients already taking antibiotics and repeat isolates from the same patient were excluded. all clinical specimens were initially inoculated on a blood agar and macconkey agar, while the urine specimens were inoculated on cystine lactose electrolyte deficient (cled) medium. the inoculated plates were incubated aerobically at 37°c and checked for bacterial growth after 24 hours. the morphology of bacterial colonies was examined with a hand lens. the bacteria were identified first by gram staining, catalase test, oxidase tests, and hanging drop method for motility. the acinetobacter spp. were identified as gramnegative or gram variable coccobacilli, oxidase j islamabad med dental coll 2021 85 negative and catalase positive. each strain was inoculated on the triple sugar iron (tsi) slant for the identification of its ability to ferment sugars. the antimicrobial susceptibility pattern was evaluated by the kirby-bauer disc diffusion method according to respective clsi guidelines.10 a bacterial suspension of 0.5 mcfarland turbidity standard was made and inoculated on muller hinton agar plate for each acinetobacter spp. isolate. aminoglycosides, carbapenem, quinolones, cephalosporins. ampicillin / sulbactam, cotrimoxazole, piperacillin / tazobactam, and doxycycline discs were inoculated on plates and incubated for further 24 hours of aerobic incubation at 37°c. atcc 19606 strain of acinetobacter species was used as a quality control strain in all standard operating procedures.11 frequencies and percentages were calculated for the qualitative variables like acinetobacter species isolated from clinical samples and percentage resistance pattern to various antibiotics. r e s u l t s the results were tabulated according to each year. a total number of clinical samples were tabulated from which acinetobacter species were isolated according to the specimen. the highest yield of acinetobacter spp. from the clinical specimen was isolated from pus followed by tracheal secretion, blood, and urine in the last three years from 2017 to 2019 (table i). figure 1 is showing the eight years resistance pattern in our settings with a progressive increase in resistance of acinetobacter spp. the highest progression in resistance was observed among the cephalosporin and quinolone groups of antibiotics d i s c u s s i o n despite rigorous endeavors, nosocomial multi-drug resistant (mdr) acinetobacter spp. is still a major problem owing to its great capability to propagate and colonize human and environmental reservoirs. acinetobacter spp. is a highly resistant nosocomial pathogen that leads to a broad range of human infections resulting in high morbidity and mortality rates.12 over the years acinetobacter species are increasingly being isolated from a broad array of clinical specimens. it is the need of the day to periodically analyze the antimicrobial susceptibility and resistance pattern of this common pathogen so that appropriate antibiotic policy can be formulated for empirical as well as a targeted treatment. the variations in the antibiogram of acinetobacter spp. demands periodic surveillance of these pathogens for an appropriate selection of therapy.13 acinetobacter species has attained a foothold in the icu settings, causing nosocomial pneumonia which accounts for around 36% of hospital-acquired pneumonia in asian countries.14,15 this is in concordance with this study, which shows acinetobacter species infections on the rise over the past eight years, especially in the icus. this is an imminent threat for the spillover of this organism in the general wards, highlighting the importance of keeping a strict eye over its prevalence and antimicrobial susceptibility and resistance pattern. analysis of antibiograms of acinetobacter species over the last eight years in our hospital has unveiled some interesting findings. an increased pattern of antimicrobial resistance has been reported in a tertiary care hospital in nepal with 100% resistance to cephalosporins.16 these observations indicated that cephalosporins are no more a drug of choice for effective treatment of acinetobacter infections.17 this is an alarming situation as our study also shows cephalosporin resistance on the rise over the last j islamabad med dental coll 2021 86 table i: yearly distribution of growth of acinetobacter spp. isolated from different clinical specimens specimen 2012 2013 2014 2015 2016 2017 2018 2019 n blood 28 22 29 38 32 152 161 257 719 csf 7 31 27 30 42 61 98 187 483 pus 44 48 54 57 56 198 390 407 1245 tracheal secretion -2 1 17 32 207 312 478 1049 sputum -7 3 -4 30 37 42 123 wound swab -5 2 28 24 69 85 76 289 bronchial wash - --8 8 7 5 28 fluid ---9 8 19 13 25 74 tips -4 2 17 48 76 95 76 218 pleural tap -----2 4 7 13 urine 11 6 15 38 92 143 170 206 681 tissue/ biopsy ----2 21 30 56 109 total organisms isolated 90 126 133 234 348 986 1438 1822 5140 n-total number of specimens; csf-cerebrospinal fluid * 0% values show the antibiotic discs were not available in these years figure 1: eight-year percentage resistance pattern of different groups of antibiotics to acinetobacter spp. eight years with resistance reaching up to almost 100%. the carbapenems are considered salvage therapy for most multidrug-resistant organisms. however, the emergence of carbapenemase enzymes is a worldwide phenomenon narrowing the available spectrum of antimicrobials for the treatment of mdr acinetobacter species.18 the present study showed approximately 60% resistance to carbapenems which are also very alarming for clinically isolated acinetobacter spp. in the tertiary care hospital. another alarming finding is the rise of antimicrobial resistance to quinolones reaching up to 90% in the j islamabad med dental coll 2021 87 year 2019. elshahat et al. and roy et al. commented in their recent studies on quinolones resistance in clinical isolates of acinetobacter spp. according to them, quinolones resistance is more than 90% among acinetobacter isolates, which is consistent with the present study.19,20 an interesting finding of our study is a revival of antimicrobial susceptibility to doxycycline. sadhu et al. reported that doxycycline has good efficacy against mdr acinetobacter spp., and its use can be considered as an alternative therapy to downregulate the pressure on other groups of antibiotics.21 therefore, the sensitive pattern of doxycycline in our hospital settings would be a good sign for treating nosocomial infections. this may be due to the phenomenon of antibiotic holidays and holds a promising perspective for other antibiotics as well. this can contribute to the appropriate institution of antimicrobial stewardship which involves giving the right antibiotic, at the right time, in the right dose, and for an appropriate period. observing antibiotic holidays stepwise for other groups of antibiotics may lead to a revival of their susceptibility and hence clinical effectiveness. the progressively increasing trend of antimicrobial resistance in acinetobacter species to major groups of antibiotics over the last eight years is an eyeopener for our hospital as well as for antibiotic policymaking. it is high time that all tertiary care hospitals maintain and publish yearly antibiograms, as this is an essential component of antimicrobial stewardship. c o n c l u s i o n the current antibiogram of acinetobacter species revealed the progressively increasing resistance of this hospital bug which is now posing a great threat to patients in hospital settings. judicial use of antibiotics by clinicians should be ensured to maintain an antibiotics stewardship program. r e c o m m e n d a t i o n s we recommend every tertiary care hospital maintain its hospital antibiograms. this will help to maintain antibiotic stewardship in their hospital settings according to their local trend of antibiotic resistance. we also recommend following strict infection prevention and control programs to overcome antibiotic resistance among local hospital nosocomial bacteria. a c k n o w l e d g e m e n t s we acknowledge dr. iffat javed, professor of pathology, for guiding us in the making of antibiograms r e f e r e n c e s 1. fayyaz m, khan iu, hussain a, mirza ia, ali s, akbar n. frequency and antimicrobial susceptibility pattern of acinetobacter species isolated from pus and pus swab specimens. j coll physicians surg pak. 2015; 25(5): 346-9. pmid: 26008660. 2. sarkar m, jena j, pattnaik d, mallick b. prevalence of nonfermentative gram-negative bacilli and their antimicrobial susceptibility profiles in a tertiary hospital of eastern india. int j advances med. 2018; 5(2): 366-70. doi: 10.18203/23493933.ijam20181070. 3. begum s, hasan f, hussain s, shah aa. prevalence of multi drug resistant acinetobacter baumannii in the clinical samples from tertiary care hospital in islamabad, pakistan. pak j med sci. 2013; 29(5): 1253-58. doi: 10.12669/pjms.295.3695. 4. vaja k, kavathia gu, goswami ys, chouhan s. a prevalence study of acinetobacter species and their sensitivity patter in a tertiary care hospital rajkot city of gujrat (india): a hospital based study. iosr j dent med sci. 2016; 15(7): 54-8. doi:10.9790/0853150765458. 5. odsbu i, khedkar s, khedkar u, nerkar ss, tamhankar aj, stålsby lundborg c. high proportions of multidrug-resistant acinetobacter spp. isolates in a district in western india: a four-year antibiotic susceptibility study of clinical isolates. int j environ res public health. 2018; 15(1): 153. doi: 10.3390/ijerph15010153. 6. lee cr, lee jh, park m, park ks, bae ik, kim yb, et al. biology of acinetobacter baumannii: pathogenesis, antibiotic resistance mechanisms, and prospective j islamabad med dental coll 2021 88 treatment options. front cell infect microbiol. 2017; 7: 55. doi: 10.3389/fcimb.2017.00055. 7. chandra p, mittal v, chaturvedi r. isolation, characterization and antibacterial susceptibility test of acinetobacter species obtained from tertiary care hospital. int j curr microbiol app sci. 2017; 6(2): 1279-86. doi: 10.20546/ijcmas.2017.602.144. 8. chatterjee n, dam s. epidemiological study of acinetobacter baumannii and its resistance pattern in clinical isolates from a private hospital in kolkata, eastern india. int j curr res life sci. 2018; 7(05): 2001-3. 9. juyal d, prakash r, shanakarnarayan sa, sharma m, negi v, sharma n. prevalence of non-fermenting gram negative bacilli and their in vitro susceptibility pattern in a tertiary care hospital of uttarakhand: a study from foothills of himalayas. saudi j health sci. 2013; 2(2): 108-12. doi: 10.4103/2278-0521.117915. 10. national committee for clinical laboratory standards. performance standards for antimicrobial susceptibility testing. clinical and laboratory standards institute; 2017. 11. lob sh, hoban dj, sahm df, badal re. regional differences and trends in antimicrobial susceptibility of acinetobacter baumannii. int j antimicrob agents. 2016; 47(4): 317-23. doi: 10.1016/j.ijantimicag.2016.01.015. 12. qi l, li h, zhang c, liang b, li j, wang l, et al. relationship between antibiotic resistance, biofilm formation, and biofilm-specific resistance in acinetobacter baumannii. front microbiol. 2016; 7: 483. doi: 10.3389/fmicb.2016.00483. 13. sahu r, pradhan cs, swain b, panigrahy r, sahu mc. surveillance of acinetobacter spp. and drug sensitivity pattern in an indian tertiary care teaching hospital. int j pharm sci rev res. 2016; 39(1): 203-7. 14. garnacho-montero j, timsit jf. managing acinetobacter baumannii infections. curr opin infect dis. 2019; 32(1): 69-76. doi: 10.1097/qco.0000000000000518. 15. chung dr, song jh, kim sh, thamlikitkul v, huang sg, wang h, et al., asian network for surveillance of resistant pathogens study group. high prevalence of multidrug-resistant nonfermenters in hospitalacquired pneumonia in asia. am j respir crit care med 2011; 184(12): 1409–17. doi: 10.1164/rccm.201102-0349oc. 16. joshi pr, acharya m, kakshapati t, leungtongkam u, thummeepak r sitthisak s. co-existence of blaoxa23 and blandm-1 genes of acinetobacter baumannii isolated from nepal: antimicrobial resistance and clinical significance. antimicrob res infect control. 2017; 6(21): 0107. doi: 10.1186/s13756-017-01805. 17. manchanda v, sanchaita s, singh np. multidrug resistant acinetobacter. j glob infect dis. 2010; 2(3): 291-304. doi: 10.4103/0974-777x.68538. 18. khanal br, wagle s, tiwari br. biofilm formation and colistin susceptibility of clinical isolates of acinetobacter species in a tertiary care hospital of nepal. national j lab med. 2019; 8(1): 12-5. doi: 10.7860/njlm/2019/38143:2335. 19. elshahat m, aboelized e, abd el rahman r, nabil m, yassin a. association between mutations in gyr a/b and par c/e genes of acinetobacter baumannii clinical isolates and fluoroquinolones resistance. microbes and infectious diseases. 2021; 2(2): 343-51. doi: 10.21608/mid.2021.64414.1127. 20. roy s, chatterjee s, bhattacharjee a, chatterjee p, saha b, dutta s, et al. overexpression of efflux pumps, mutations in the pumps’ regulators, chromosomal mutations and aac6’ib-cr are associated with fluoroquinolone resistance in diverse sequence types (sts) of neonatal septicaemic acinetobacter baumannii: a 7-year single centre study. front microbiol. 2021; 12: 602724. doi: 10.3389/fmicb.2021.602724. 21. sandhu r, dahiya s, sayal p. evaluation of multiple antibiotic resistance (mar) index and doxycycline susceptibility of acinetobacter species among inpatients. indian j microbiol res. 2016; 3(3): 299304. j islamabad med dental coll 2020 291 open access a cadaveric morphometric study of lumbar vertebrae in zimbabwean adult males maimoona khan1, basira delland zvikomborero1 1department of anatomy, college of health sciences, university of zimbabwe, harare zimbabwe a b s t r a c t background: transpedicular screw fixation has been widely used for spinal reconstruction because of its good fusion results. however, pedicle walls can be damaged during fixation if diameter of the screw is too large or screw is misplaced. knowledge of the morphometric dimensions of the pedicle is thus important for effective fixation and to avoid complications. the main objective of this study was to measure the pedicle transverse diameter (ptd), pedicle vertical diameter (pvd) and chord length of male adult cadavers from zimbabwean population. material and methods: it was a descriptive cross-sectional study carried out at the department of anatomy, university of zimbabwe college of health sciences, harare zimbabwe, from june 2019 to december 2019. the lumbar vertebrae from 15 adult male cadavers were dissected out and pedicle transverse diameter (ptd), pedicle vertical diameter (pvd) and chord length was measured and compared (on right and left sides), using a vernier caliper. the statistical analysis was done using spss version 20.0., with data expressed as means, standard deviation and ranges. student’s t-test was used to estimate the difference in pedicle dimensions of the right and left sides of the lumbar vertebrae. results: there was an insignificant difference between pedicle dimensions (ptd and pvd) of the right and left sides (p > .05). ptd steadily increased from vertebral level l1 to l5 followed by an abrupt increase at l5. pvd gradually decreased from l1 to l5 level. the chord length increased from a minimum at l1 to reach a maximum at l3 and then again decreased to l5 level. conclusions: pedicle dimensions of the zimbabwean population differ from those reported in previous studies for other population groups and can be useful while performing pedicle screw fixation for lumbar vertebral fractures. a screw length of 40-45 mm should be used for lumbar transpedicular screw fixation with minimal risk of implant failure in zimbabwean population. key words: chord length, lumbar vertebrae, pedicle transverse diameter, pedicle vertical diameter authors’ contribution: 1-2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: maimoona khan email: maimoonakhan@hotmail.com article info: received: december 25, 2019 accepted: december 22, 2020 cite this article. khan m, zvikomborero bd. a cadaveric morphometric study of lumbar vertebrae in zimbabwean adult males. j islamabad med dental coll. 2020; 9(4): 291-297. doi: 10.35787/jimdc.v9i4.479 funding source: nil conflict of interest: nil i n t r o d u c t i o n the lumbar vertebral column consists of five vertebrae numbered from l1 to l5, articulating at inter-vertebral joints.1 these vertebrae have a large kidney-shaped body for support and weight bearing. during weight transmission, lumbar vertebrae support much of the weight of the upper body and o r i g i n a l a r t i c l e j islamabad med dental coll 2020 292 are thus more prone to degenerative changes with advancing age. therefore, surgical interventions are most commonly performed in this region to alleviate symptoms of backache caused by arthritic changes, deformities and fractures.2 the pedicles of a lumbar vertebrae arise near the upper border of the posterolateral aspect of the body. they are large, stout and strong, consisting almost entirely of cortical bone with a small core of cancellous bone.3 research in an indian population has shown that pedicle width increases from l1 level and reaches maximum at l5, whereas pedicle height is maximum in the l1 and l2 vertebrae, then decreases from l3 down to l5.4 transpedicular screw fixation of the lumbar vertebrae is performed surgically in patients with thoraco lumbar vertebral fractures, spondylolisthesis, kyphosis, posterolateral synostosis, vertebral collapse and canal stenosis.5 these screws are commonly used for posterior fixation in spinal instability, but their insertion remains challenging. there is a misplacement rate of up to 11% even with navigation techniques. the diameter of the screw is determined by the horizontal diameter of the pedicle.6 successful fixation depends on detailed knowledge of the size and dimensions of the pedicles. the minimum width of the pedicle is an important factor to consider during screw selection. a screw of larger diameter can damage the pedicle and may end up causing injuries,7 like dural tears, leakage of cerebrospinal fluid and damage to spinal nerve roots.8 multiple researches have reported variations in pedicle morphometry between different ethnic groups.9 imaging techniques such as c-arm fluoroscopy can be employed to enhance accuracy during pedicle screw placement. however, this exposes both patient and surgeon to radiations along with increased cost and operative time.10 a detailed study of dimensions of the pedicles of lumbar vertebrae is thus essential for proper fixation without complications. therefore, the main objective of this study was to measure the pedicle transverse diameter (ptd), pedicle vertical diameter (pvd) and cord length of male adult cadavers from zimbabwean population. m a t e r i a l a n d m e t h o d s this descriptive cross-sectional study was carried out in the department of anatomy, university of zimbabwe college of health sciences harare, zimbabwe. the duration of the study was 6 months, from june 2019 to december 2019. the sample consisted of 15 adult black zimbabwean male cadavers.11 non probability convenience sampling was used, where cadavers were selected according to their accessibility and proximity to the researcher. approval of joint research ethics committee of the university of zimbabwe was taken before carrying out the study. adult black male cadavers, between the age group of 24 to 40 years with no obvious vertebral deformities were included in the study. male cadavers with scoliosis or other gross vertebral malformations, injuries of lumbar vertebrae, caucasians, females and children were excluded from this study. osteoporotic changes were not ruled out, since only male cadavers, aged between 25 to 40 years were considered in this study. embalmed human cadavers were dissected using posterior approach to the lumbar spine. with the cadaver in prone position, the postaxial musculature was retracted as far as the tips of the transverse processes with scalpels and retractors. the lumbar vertebrae were then removed by cutting through intervertebral joints. after removal, the vertebrae were heated in a macerating tank for 36 hours at a constant temperature of 700c. the remaining soft tissues were removed by manual dissection12 and the vertebrae were air dried. the pedicle width (transverse diameter), pedicle height (vertical diameter) and chord length were measured on both j islamabad med dental coll 2020 293 sides of the lumbar vertebrae by using a sliding vernier caliper13 (figures 1a and b). pedicle height was measured at two sites; mid pedicle and at root of the pedicle (junction of pedicle with the vertebral body).13 chord length was measured from the posterior cortical entry point of the pedicle to the anterior vertebral cortex along the axis of the pedicle.13 statistical analysis was done by ibm-spss version 20.0. means, standard deviations and ranges were calculated. student’s t-test was used to estimate the difference in pedicle dimensions of the right and left sides. r e s u l t s the mean ptd (width) and the mean pvd (height) for all lumbar vertebrae levels was 11.17 ± 4.11 mm (table i) and 15.52 ± 1.31 mm (table ii), respectively. using the student’s t-test, it was established that there was no significant difference in ptd and pvd between the right and left sides of the lumbar vertebrae (p > .05). the mean chord length was 47.36 ± 1.32 mm (table iii). similarly, student’s t-test showed no significant difference in the chord length of the right and left sides (p > .05). no effect of weight was envisaged on the chord length. table i: comparison of the mean pedicle transverse diameter of the right and left sides of the lumbar vertebrae vertebral level values left pedicle transverse diameter (mm) right pedicle transverse diameter (mm) p-value* pooled mean l1 mean 8.08 8.04 .766 8.06 sd 1.45 1.32 1.36 range 5-9.8 5.6-9.8 5-9.08 l2 mean 8.22 8.13 .673 8.18 sd 1.14 1.28 1.19 range 6.25-9.6 5.25-9.65 5.25-9.65 l3 mean 9.78 9.75 .877 9.81 sd 1.05 1.32 1.17 range 7.6-11.4 6.85-12 6.85-12 l4 mean 11.49 11.34 .535 11.41 sd 1.37 1.26 1.29 range 9.8-13.6 8.7-13.1 8.7-13.6 l5 mean 18.36 18.45 .807 18.41 sd 2.13 2.46 2.25 range 13.7-21 13.2-22.15 13.2-22.15 *p-value < .05 was considered statistically significant figure 1: photograph of lumbar vertebra showing pedicle measurement using sliding vernier caliper. a: pedicle transverse diameter, b: pedicle vertical diameter. j islamabad med dental coll 2020 294 table ii: comparison of the mean pedicle vertical diameter of the right and left sides of the lumbar vertebrae vertebral level values left pedicle vertical diameter (mm) right pedicle vertical diameter (mm) p-value* pooled mean l1 mean 16.28 16.57 .137 16.42 sd 1.46 1.37 1.40 range 14.6-19.9 14.5-19.3 14.5-19.9 l2 mean 15.54 15.85 .172 15.69 sd 1.2 1.04 1.11 range 14-18.6 14.4-18.5 14-18.6 l3 mean 15.36 15.54 .415 15.45 sd 1.07 1.09 1.07 range 14.1-18.5 13.1-18.2 13.1-18.5 l4 mean 14.99 15.18 .45 15.09 sd 1.15 0.98 1.06 range 13.5-17.7 13.6-17 13.5-17.7 l5 mean 14.68 15.21 .173 14.94 sd 1.32 1.52 1.42 range 12.4-16.8 12.4-18.8 12.40-18.8 *p-value < .05 was considered statistically significant table iii: comparison of the mean chord length of the right and left sides of the lumbar vertebrae vertebral level values left chord length (mm) right chord length (mm) p-value* pooled mean l1 mean 46.29 46.34 .682 46.31 sd 1.18 0.97 1.06 range 43.7-48.2 44.3-47.5 43.7-50 l2 mean 46.91 47.86 .731 47.39 sd 0.87 1.2 1.14 range 45.4-48.4 45.8-50 45.4-50 l3 mean 48.33 48.63 .891 48.48 sd 1.07 1 1.03 range 46.4-50 46.8-50.3 46.4-50.3 l4 mean 47.89 47.17 .632 47.53 sd 0.95 1.27 1.16 range 46.0-49.2 44.6-48.9 44.6-48.9 l5 mean 47.36 46.85 .415 47.1 sd 1.19 1.29 1.24 range 44.7-49.4 44.5-49.3 44.5-49.4 *p-value < .05 was considered statistically significant d i s c u s s i o n lumbar region of the vertebral column plays an essential role in weight transmission and also permits a wide range of movement. pedicles of the posterior arch of the vertebra are important in transmission of force between anterior and posterior elements of the vertebrae.14 any deformity of the pedicles can affect the weight transmission dynamics and can also compress neural structure. pedicle screw fixation is a successful method of spine stabilization and has shown promising fusion results. the insertion of the screws remains challenging due to variations in width and height of pedicles and the proximity of the spinal nerve roots. ptd is an important factor that j islamabad med dental coll 2020 295 determines the diameter of the screw used. variations in pedicle morphometry has been reported in people of different ethnic groups.12 the present study showed that there is a steady increase in the pedicle transverse diameter from l1 to l4 followed by an abrupt increase at l5 level. this is consistent with the findings in studies done on korean, american, and indian populations.15-17 a study done in the saudi population showed a higher ptd between l1 and l4 and a smaller diameter of l5 as compared to other populations. although there is a general increase in ptd, there is no abrupt increase in ptd at l5 level.18 in the present study, the ptd is smaller than that found in american, indian and saudi populations.16-18 in two studies conducted in an indian population,19,20 there was a general increase in ptd from l1 to l5 except at l2 level where minimum increase was seen. in cross-section, ptd is the minimum thickness of the pedicle and hence dictates the maximum pedicle screw diameter. a study conducted in usa showed that ptd in the upper and lower lumbar vertebral levels was greater than 5 mm and 7 mm, thus pedicle screws of diameter 5 mm and 7 mm could be used in these regions respectively.21 based on the results obtained in the present study, where mean pedicle width is greater than 7 mm and 9 mm in the upper and lower lumbar regions respectively, it can be concluded that the maximum diameter of pedicle screw instrumented in the lumbar regions should be 7 mm and 9 mm in the respective vertebral segments. the maximum pvd was obtained at l1 level and there was a steady decrease down to l5. this trend is similar to the ones found by the other researchers.16,17,21 however, data of saudi population showed minimum pvd at vertebral level l2 and a maximum at l5.18 in cross section, the vertebral pedicle is oval in shape. it has been established that the pedicle vertical diameter is significantly greater than the transverse diameter.22 therefore, from a practical point of view, pvd carries lesser significance in selecting the pedicle screw diameter than ptd, and our study conforms to this theory. in the present study, maximum chord length was recorded at l3 level and the minimum at l1. in a turkish study, the longest chord length was obtained at level l1 and the shortest was at vertebral level l5, lower than those obtained in the current study.22 chord length determines the maximum length of any screw that can be safely used for pedicular screw fixation without anterior cortex violation.23 three other studies (american and indian) reported that the longest chord length was at l2 while the shortest was at vertebral level l5.16,24,25 the screw length should include 50% of the vertebral body in order to minimize instrument failure while allowing for effective screw fixation. a significantly longer screw can perforate the anterior cortex of the vertebral body causing damage to visceral organs and major blood vessels.16 currently, 40-43 mm screw length is used in zimbabwe, but the results of present study showed that a screw length of 40-45 mm can be used in the lumbar region for effective fixation with minimal risk of implant failure. the main limitation of the study is that it is a single center study with a limited sample size and hence the study may not reflect the morphometric characteristics of lumbar vertebrae pedicles of the entire male adult zimbabwean population. c o n c l u s i o n morphometric studies of pedicles of lumbar vertebrae shows variations in different ethnic groups and their detailed knowledge is crucial for successful pedicle screw fixation. a screw length of 40-45 mm should be used for lumbar transpedicular j islamabad med dental coll 2020 296 screw fixation with minimal risk of implant failure in zimbabwean population. r e f e r e n c e s 1. ayodeji sa, deborah sa, allen sa. x-raying of the lumbar spine. ijnpt. 2016; 2(4): 24-38. doi: 10.11648/j.ijnpt.20160204.11 2. ukunda un, lukhele mm. the posterior-only surgical approach in the treatment of tuberculosis of the spine: outcomes using cortical bone allografts. bone joint j. 2018; 100(9): 1208-13. doi: 10.1302/0301620x.100b9.bjj-2017-1326.r2 3. chaturvedi a, klionsky nb, nadarajah u, chaturvedi a, meyers sp. malformed vertebrae: a clinical and imaging review. insights imaging. 2018; 9(3): 343-55. doi: 10.1007/s13244-018-0598-1 4. mohanty sp, kanhangad mp, bhat sn, chawla s. morphometry of the lower thoracic and lumbar pedicles and its relevance in pedicle fixation. musculoskelet surg. 2018; 102(3): 299-305. doi: 10.1007/s12306-018-0534-z 5. scarone p, vincenzo g, distefano d, del grande f, cianfoni a, presilla s, et al. use of the airo mobile intraoperative ct system versus the o-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients. j neurosurg: spine. 2018; 29(4): 397-406. doi: 10.3171/2018.1.spine17927 6. o'halloran d, suh s, inventors; globus medical inc, assignee. methods and apparatus for treating vertebral fractures. united states patent us 10,537,368. 2020 jan 21. 7. macke jj, woo r, varich l. accuracy of robot-assisted pedicle screw placement for adolescent idiopathic scoliosis in the pediatric population. j robot surg. 2016; 10(2): 145-50. doi: 10.1007/s11701-016-05877 8. dayani f, chen yr, johnson e, deb s, wu y, pham l, et al. minimally invasive lumbar pedicle screw fixation using cortical bone trajectory–screw accuracy, complications, and learning curve in 100 screw placements. j clin neurosci. 2019; 61: 106-11. doi: 10.1016/j.jocn.2018.10.131 9. abbas j, peled n, hershkovitz i, hamoud k. pedicle morphometry variations in individuals with degenerative lumbar spinal stenosis. biomed res int. 2020; 2020: 7125914. doi: 10.1155/2020/7125914 10. esfandiari h, newell r, anglin c, street j, hodgson aj. a deep learning framework for segmentation and pose estimation of pedicle screw implants based on c-arm fluoroscopy. int j comput assist radiol surg. 2018; 13(8): 1269-82. doi: 10.1007/s11548-0181776-9 11. gupta kk, attri jp, singh a, kaur h, kaur g. basic concepts for sample size calculation: critical step for any clinical trials! saudi j anaesth. 2016; 10(3): 32831. doi: 10.4103/1658-354x.174918 12. lopopolo rb. cunningham’s manual of practical anatomy: thorax and abdomen. 2017; 2: 135–37. oup oxford 13. singh r, srivastva sk, prasath cs, rohilla rk, siwach r, magu nk. morphometric measurements of cadaveric thoracic spine in indian population and its clinical applications. asian spine j. 2011; 5(1): 20-34. doi: 10.4184/asj.2011.5.1.20 14. munusamy t, thien a, anthony mg, bakthavachalam r, dinesh sk. computed tomographic morphometric analysis of cervical pedicles in a multi-ethnic asian population and relevance to subaxial cervical pedicle screw fixation. european spine j. 2015; 24(1): 120-6. doi: 10.1007/s00586-014-3526-1 15. bordes sj, tubbs rs. lumbar vertebrae. in surgical anatomy of the lateral transpsoas approach to the lumbar spine 2020: (pp. 83-89). elsevier. 16. kim nh, lee hm, chung ih, kim hj, kim sj. morphometric study of the pedicles of thoracic and lumbar vertebrae in koreans. spine. 1994; 19(12): 1390-4. doi: 10.1097/00007632-199406000-00014 17. zindrick mr, wiltse ll, doornik a, widell eh, knight gw, patwardhan ag, et al. analysis of the morphometric characteristics of the thoracic and lumbar pedicles. spine. 1987; 12(2): 160-6. doi: 10.1097/00007632-198703000-00012 18. singel tc, patel mm, gohil dv. a study of width and height of lumbar pedicles in saurashtra region. j anat soc india. 2004; 53(1): 4-9. 19. amonoo-kuofi hs. age-related variations in the horizontal and vertical diameters of the pedicles of the lumbar spine. j anat. 1995; 186(pt 2): 321. pmid: 7649830 20. tyagi s, chhabra s, narayan rk. morphometric study of width and height of lumbar pedicles in population of haryana. int j appl dent sci. 2017; 3(4): 78-81. 21. krag mh, weaver dl, beynnon bd, haugh ld. morphometry of the thoracic and lumbar spine related to transpedicular screw placement for surgical spinal fixation. spine. 1988; 13(1): 27-32. doi: 10.1097/00007632-198801000-00007 22. lien sb, liou nh, wu ss. analysis of anatomic morphometry of the pedicles and the safe zone for through-pedicle procedures in the thoracic and lumbar spine. eur spine j. 2007; 16(8): 1215-22. doi: 10.1007/s00586-006-0245-2 23. kadioglu hh, takci e, levent a, arik m, aydin ih. measurements of the lumbar pedicles in the eastern j islamabad med dental coll 2020 297 anatolian population. surg radiol anat. 2003; 25(2): 120-6. doi: 10.1007/s00276-003-0109-y 24. kumar v, mittal m. morphometric study of pedicles of dried human lumbar vertebrae. ijhcr. 2020; 3(8): 30-4. 25. gosal gs, boparai a. a prospective study to assess the morphology of pedicles of lower thoracic and lumbar vertebrae using computerized tomography scan measurements in north-indian population. int j sci res. 2015; 4(5): 2935-6. j islamabad med dental coll 2021 95 open access response of hepatitis b vaccine in children with celiac disease – an experience at ayub teaching hospital, abbottabad pakistan bibi aliaa1, syed sajid hussain shah2 1assistant professor, department of pediatrics, lady reading hospital peshawar, khyber pakhtunkhwa, pakistan 2assistant professor, department of pediatrics, ayub medical college abbottabad, khyber pakhtunkhwa, pakistan a b s t r a c t background: celiac disease (cd), characterized by chronic small intestinal inflammation, is an immune-mediated disorder, with a strong family history and association with dq2 hla haplotype. it has been postulated that children with cd show less response to hepatitis b vaccine due to overexpression of hla-dq2 haplotype. this study was done to determine the response of hepatitis b vaccine in children with cd in our tertiary care setting in the hazara region of eastern khyber pakhtunkhwa, pakistan. material and methods: this cross-sectional study was conducted in the pediatrics outpatient department (opd) of ayub teaching hospital, abbottabad pakistan from april 2018 till march 2020. children with cd (n=38) aged 1-14 years with completed hbv vaccination, anti-tissue transglutaminase iga antibody (ttg-iga) >150 iu/ml and/or typical histological findings of cd on small-bowel biopsy, were included in the study. hepatitis b surface antibody (hbsab) titer of ≥10 miu/ml was taken as antibody positive, while hbsab levels < 10 miu/ml were considered as vaccine non-responsive. data was analyzed using spss version 20.0. chi square test was applied for comparison with p-value < .05 taken as significant. results: out of 38 diagnosed cases of cd, 15 (39.5%) were males and 23 (60.5%) were females. mean age of children was 8.32±3.26 years with an age range of 3-14 years. hbsab levels ranged from 0.10 to 62.7 miu/ml with a mean of 11.2+17.42 miu/ml. hbsab levels were less than 10.0 iu/ml in 73.7% of children with cd. small intestinal biopsy was performed in 11 (28.9%) patients. there was a significant relationship between anti ttg-iga levels and histopathology findings with p-value of .001. conclusions: in children having celiac disease, there was low rate of protective antibody response to hepatitis b vaccine. key words: antibody response, celiac disease, hepatitis b vaccine, hbsab levels. authors’ contribution: 1-2 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: syed sajid hussain shah email: syed_sajid20@yahoo.com article info: received: july 15, 2020 accepted: june 4, 2021 cite this article. aliaa b, shah ssh. response of hepatitis b vaccine in children with celiac disease – an experience at ayub teaching hospital, abbottabad pakistan. j islamabad med dental coll. 2021; 10(2): 95-100. doi: 10.35787/jimdc.v10i2.565 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 96 i n t r o d u c t i o n celiac disease (cd) is an immune mediated-disorder with a strong genetic predisposition. it is characterized by chronic small intestinal inflammation induced by ingestion of gluten moiety in the diet. worldwide the estimated prevalence of cd in children is about 1%.1 in 2010, 2.2 million children under five years of age were diagnosed with celiac disease. it has an immunological basis as evidenced by a strong family history and association with the dq2 hla haplotype. individuals lacking the dq2 haplotype are generally positive for dq8.2-4 hepatitis b virus (hbv) vaccine was introduced in the early 1980s for use in individuals at high risk for acquiring hbv infection. in pakistan, it is currently administered to all infants as part of the epi (expanded programme on immunization) program. it is also administered to previously unvaccinated adults at high-risk, in an attempt to achieve universal protection against hbv infection. a course of three doses of hepatitis b vaccine can be administered in a variety of schedules: such as at birth, 1and 6months schedule, the 6-, 10and 14-weeks doses and the 2-, 4and 6-months schedule. all schedules induce protective levels of antibody to hepatitis b surface antigen (hbsag) in majority of healthy infants and children.5 about 90% of adult population respond to hbv vaccination.6 non-responders are often found to carry specific human leukocyte antigen (hla) haplotype, including dr7, dr3, and dq2.7 since the hla-dq2 haplotype is over-represented in celiac population, it seems reasonable to hypothesize that patients with celiac disease are less able to respond to hbv vaccine than the general population, whose frequency of hla haplotype b8, dr3, and dq2 are much lower. it has been postulated that this genetic profile may play a crucial role in predisposing celiac patients to a lower grade of immunization to hepatitis b vaccine.8 cd is not an uncommon disease. there is scarcity of data regarding exact prevalence of cd and response of children with cd to hepatitis b vaccination.9 the problem of chronic hbv infection and its associated complications like liver carcinoma remains a major public health problem. children with cd who are non-responsive to hbv vaccination could be considered as a large reservoir of hbv-susceptible individuals who will persist as healthy carriers, leading to spread of the disease in healthy subjects. this study was therefore carried out to determine the response of hepatitis b vaccine in children with cd presenting in the outpatient department (opd) of pediatrics at ayub teaching hospital, abbottabad, pakistan. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in the pediatrics opd of ayub teaching hospital, abbottabad in hazara division, kpk, pakistan from april, 2018 till march, 2020. approval was sought from the ethics committee of ayub medical institutions, abbottabad pakistan. informed consent was taken from parents prior to the conduct of research. sample size (n=27) was calculated with openepi sample size calculator for cross-sectional studies, taking prevalence of cd in children as 1%1 and confidence interval of 95%. a total of 38 patients were included in the study using purposive sampling technique. the study population included both new and old cases of celiac disease diagnosed during the study period. children aged 1 to 14 years, diagnosed with cd on the basis of a thorough history were included. laboratory diagnosis of cd was done on standard clinical criteria including abnormal serological marker, anti-tissue transglutaminase iga j islamabad med dental coll 2021 97 antibody (ttg-iga) >150 iu/ml and/or small-bowel biopsy histological findings such as villous atrophy with crypt hyperplasia and increased intraepithelial lymphocytes. biopsy was not done in patients with anti ttg-iga level >150 iu/ml. other inclusion criterion was that patient must have completed three full doses of recombinant hbv vaccination as evidenced by epi/vaccination card. children with chronic hepatitis b infection, immunodeficiency or on immunosuppressant drugs and chronic diarrhea due to other causes were excluded. clinical data was compiled for each subject from a review of previous medical and vaccination records. age, sex, immunization status especially hbv vaccination (including timing of immunizations), age of diagnosis for cd, results of celiac panel if it was done within 2 months before the antibody testing (as a reflection of adherence to gluten-free diet in cd group), medication (current and past), coexisting medical condition and family history were recorded. patients diagnosed with cd were tested for hepatitis b surface antibody (hbsab). samples with antibody titers of ≥10 miu/ml were taken as positive. hbsab levels less than 10 miu/ml were considered a vaccine non-responsive. these children were given one extra shot of hbv vaccine. data was entered on specific proforma which included chronological age, age at diagnosis, sex, weight, height, presenting complaint, co-morbid condition (diabetes mellitus, hypothyroidism, epilepsy, dermatitis herpetiformis) anti ttg-iga level, histopathology (if biopsy done), hbsab level along with both mother and father education. data was analyzed using spss version 20.0. chi square test was used for comparison of different variables with p-value less than .05 considered as statistically significant. r e s u l t s out of 38 diagnosed cases of cd, 39.5% (n=15) were male and 60.5% (n=23) were female. mean age of children was 8.32±3.26 years with an age range of 314 years. mean values of age at diagnosis, height, weight, anti ttg-iga and hbsab levels are given in table i. the most common presenting complaint for which patient visited the opd was chronic diarrhea (n=21; 55.3%) followed by pallor (n=10; 26.3%) (table ii). regarding age at diagnosis, almost half of the children (n=20; 52.6%) were diagnosed in >5 years to 10 years age group followed by <5 years (n=11; 28.9%) and >10 years age group (n=7; 18.4%). table i: baseline characteristics of children with celiac disease characteristics min max mean + sd age (years) 3.00 14.00 8.32 + 3.26 weight (kg) 6.90 42.00 19.18 + 8.15 height (cm) 70.00 157.90 113.46 + 21.52 age at diagnosis (years) 2.00 14.00 7.51 + 3.57 anti ttg-iga (iu/ml) 11.90 800.00 242.02 + 173.09 hbsab level (miu/ml) 0.10 62.71 11.21 + 17.42 most of the mothers (71.1%) were educated up to tenth grade (secondary school/high school level) while most of the fathers (71.1%) had higher level of education (eleventh grade/intermediate or higher). most of the children with cd (n=32; 84%) had higher levels of anti ttga-iga than the cut-off value of 150 iu/ml. small bowel biopsy was done in all patients with anti ttg-iga levels <150 iu/ml, except one patient. in majority of patients with anti ttg-iga levels >150 iu/ml, small bowel biopsy was not done. histopathology of small bowel showed increased epithelial lymphocytes along with villous atrophy. j islamabad med dental coll 2021 98 there was significant relationship between anti ttgiga levels and histopathology findings (p=.001). hbsab levels were less than 10.0 iu/ml in majority of patients, with 28 (73.7%) patients having antibody less than protective levels and only 10 (26.3%) patients having levels in the protective range. in children with anti ttg-iga level more than 150 iu/ml, majority of patients (71.87%) were having anti hbsab levels less than 10 miu/ml (p=.559). d i s c u s s i o n in this study we report lower levels of hbsab (<10.0 iu/ml) in 73.7% of cd children (n=38) with a mean age of 8 years in our tertiary care set-up at abbottabad, pakistan. some of the affected children can present with involvement of endocrine, neural, liver, heart, and skin as atypical presentation of cd. autoimmune diseases are more prevalent in children with cd as compared to normal healthy children.10 hepatitis b viral infection in very much prevalent in our part of the country and children with less levels of protective hbsab are prone to infection despite completing the series of hbv vaccination. inclusion of hbv vaccine in national immunization program has led to a decrease in chronic hbv carriers and liver cancer associated with it.11,12 sparks et al.13 studied children with cd recorded in the institutional registry and developed a celiac care index. the common presentation was iron deficiency (41%) in their study. we reported history of progressive pallor in 26.3% of the patients. non immunity to hbv in their study was comparable to our findings (70% versus 73.7%). another study by walkiewicz-jedrzejczak et al.14 included children with cd who had completed primary hbv vaccination. more than half of the children (58%) in this study did not have protective antibody levels in response to hbv vaccine. ertekin et al.15 also compared response to standard hbv vaccine in cd and healthy children. male and female distribution of celiac disease was comparable to our study. hbv vaccine non-responders were 38.5% as compared to 73.7% in our study. snyder et al.16 in their expertinformed recommendations for management of cd in children endorsed routine screening for hb immunization status. most of the studies have shown that 30-70% of children with cd are nonresponsive to hbv vaccine.16 zifman et al.17 retrospectively evaluated cd children for the effect of gluten free diet on hbsab response. they found no relation of gluten free diet on preand post hbsab levels. urganci and kalyoncu18 studied hepatitis a and hepatitis b vaccine response in children with cd. children who got hbv vaccine, the overall response rate in protective range was 70%. this is in sharp contrast to our reported figure of 26.3%. though the exact reason for this difference in response is not known, genetic factors may be responsible and should be explored. in a study by filippelli et al.19 patients were grouped according to age. majority (48.9%) of their patients were in age category of 0 to 5.5 years at diagnosis while in our study majority (52.6%) of patients were between 5.1 to 10 years of age. this may be due to lack of education of parents specifically mothers, as most of them were educated up to high school level (10th grade) or even less. in our setup most of the children are brought to hospital by mothers. in filippelli et al.19 study the overall response rate of hbv vaccine in all three age groups was 69.37%, while in our study group it was only 26.3%. in study by leonardi et al.20 50% of patients did not show response to table ii: presenting complaints of patients with celiac disease complaints frequency n (%) pallor 10 (26.3) failure to thrive 1 (2.6) diarrhea 21 (55.3) constipation 3 (7.9) abdominal distension 1 (2.6) short stature 2 (5.3) total 38 (100) j islamabad med dental coll 2021 99 hbv vaccine. in our study, 73.7% patients were not having hbsab in protective range. this difference can also be attributed to genetic differences between the two populations. rousseff et al.21 included 133 children with celiac disease in their study with 35% affected males and 55% were nonresponsive to hbv vaccine. rousseff et al. gave booster shot of hbv and the non-response rate reduced from 55% to 23%. anania et al.22 recommended practical guidelines for vaccination of children with cd as hbv vaccine response in children with cd is less and it may be related to hla or gluten exposure at the time of vaccination. vitaliti and colleagues23 in their mini review highlighted the possible factors in nonresponsiveness of cd children to hbv vaccine and emphasized for the alternate schedule of hbv vaccine. heshin-bekenstein et al.24 compared pre-s vaccine with standard hbv vaccine in children who were known cases of cd. pre-s vaccine is recombinant hepatitis b vaccine, containing major s protein and minor pre-s1 and pre-s2 proteins of hbv coat. these children completed their primary immunization course and their hbsab were not in the protective range. the response to standard hbv vaccine was 87% after one month as compared to pre-s vaccine, whose response rate was 98%. in our study, we gave one extra shot of standard hbv vaccine. a major limitation of our study was checking hbsab level only once due to high cost of the test. so, it is not clear if our population is responsive to the extra shot of hepatitis b vaccine. another limitation in this study was that we only included children with cd and no comparison was done with healthy population. therefore, we cannot comment on the actual difference of response between diseased and non-diseased children. due to rare availability and high cost, hla dq2 test was not done. this study gave insight in to the prevalence of nonresponsiveness to hepatitis b vaccine in children with cd who are prone to be infected with hepatitis b virus in our population. c o n c l u s i o n children with celiac disease are less responsive to hepatitis b vaccine. these children should be tested for hbsab levels, apart from monitoring adherence to gluten free diet and surveillance for other autoimmune diseases. r e f e r e n c e s 1. hashmi ma, hussain t, masood n, younas m, ashghar rm, shafi ms. accuracy of anti-tissue transglutaminase iga antibody in the diagnosis of paediatric celiac disease. j coll physicians surg pak. 2016; 26: 263-6. 2. bingham sm, bates md. pediatric celiac disease: a review for non-gastroenterologists. curr probl pediatr adolesc health care. 2020; 50(5): 1-4. doi: 10.1016/j.cppeds.2020.100786. 3. özgenel şm, temel t, üsküdar teke h, yıldız p, korkmaz h, özakyol a. hla-dq2/dq8 frequency in adult patients with celiac disease, their first-degree relatives, and normal population in turkey. turk j gastroenterol. 2019; 30(4): 321-5. doi: 10.5152/tjg.2019.18255. 4. cabrera cm, godoy ls, lópez vmn. is the double gene dose of dq2.5 or dq2.5/dq2.2 an involved factor in the clinical features of celiac disease? scand j gastroenterol. 2019; 54(8): 960-4. doi: 10.1080/00365521.2019.1647283 5. posuwan n, wanlapakorn, vongpunsawad s, sintusek p, leuridan e, damme pv, et al. comparison of hepatitis b surface antibody levels induced by the pentavalent dtwp-hb-hib versus the hexavalent dtap-hb-hib-ipv vaccine, administered to infants at 2, 4, 6, and 18 months of age, following monovalent hepatitis b vaccination at birth. vaccine. 2020; 38(7): 1643-51. doi: 10.1016/j.vaccine.2019.12.065. 6. 6.kayar y, dertli r. factors affecting hepatitis b immunization in celiac disease. ann med res. 2019; 26(8): 1478-83. doi: 10.5455/annalsmedres.2019. 05.296. 7. passanisi s, dipasquale v, romano c. vaccinations and immune response in celiac disease. vaccines. 2020; 8(2): 278. doi: 10.3390/vaccines8020278. 8. noh kw, poland ga, murray ja. hepatitis b vaccine nonresponse and celiac disease. am j gastroenterol. j islamabad med dental coll 2021 100 2003; 98: 2289–92. doi: 10.1111/j.1572-0241.2003. 07701.x. 9. rashid m, rashid h.j pak med assoc 2019;69(12):1883-8.doi: 10.5455/jpma.286805. 10. ahishali e, boztas g, akyuz f, ibrisim d, poturoglu s, pinarbasi b, et al. response to hepatitis b vaccination in patients with celiac disease. dig dis sci. 2008; 53(8): 2156-9. doi: 10.1007/s10620-007-0128-3. 11. liang x, bi s, yang w, wang l, cui g, cui f, et al. evaluation of the impact of hepatitis b vaccination among children born during 1992–2005 in china. j infect dis. 2009; 200: 39-47. doi: 10.1086/599332. 12. mcmahon bj, bulkow lr, singleton rj, williams j, snowball m, homan c, et al. elimination of hepatocellular carcinoma and acute hepatitis b in children 25 years after a hepatitis b newborn and catch-up immunization program. hepatology. 2011; 54: 801-7. doi: 10.1002/hep.24442. 13. sparks b, salman s, shull m, trout a, kiel a, hill i, et al. a celiac care index improves care of pediatric patients newly diagnosed with celiac disease. j pediatr. 2020; 216: 32-6. doi: 10.1016/j.jpeds. 2019.09.071. 14. walkiewicz-jedrzejczak d, egberg m,nelson c, eickoff j. evaluation of the response to vaccination with hepatitis b vaccine in pediatric patients diagnosed with celiac disease. sage open med. 2014; 2: 1-5. doi: 10.1177/2050312114563346. 15. ertekin v, tosun ms, selimoglu ma. is there need for a new hepatitıs b vaccine schedule for children with celiac disease? hepat mon. 2011; 11(8): 634-7. doi: 10.5812/kowsar.1735143x.715. 16. snyder j, butzner jd, de felice ar, fasano a, guandalini s, liu e, et al. evidence-informed expert recommendations for the management of celiac disease in children. pediatrics. 2016; 138(3): e20153147.1-17. doi: 10.1542/peds.2015-3147. 17. zifman e, zevit n, heshin-bekenstein m, turner d, shamir r, silbermintz a. effect of a gluten free diet on hepatitis b surface antibody concentration in previously immunized pediatric celiac patients. pediatr gastroenterol hepatol nutr. 2020; 23(2): 132-6. doi: 10.5223/pghn.2020.23.2.132. 18. urganci n, kalyoncu d. response to hepatitis a and b vaccination in pediatric patients with celiac disease. j pediatr gastroenterol nutr. 2013; 56: 408-11. doi: 10.1097/mpg.0b013e31827af200. 19. filippelli m, garozzo mt, capizzi a, spina m, manti s, tardinol, salpietro c, leonardi s. immune response to hepatitis b virus vaccine in celiac subjects at diagnosis. world j hepatol. 2016; 8(26): 1105-9. doi: 10.4254/wjh.v8.i26.1105. 20. leonardi s, spina m, spicuzza l, rotolo n, rosa ml. hepatitis b vaccination failure in celiac disease: is there a need to reassess current immunization strategies? vaccine. 2009; 27(43): 6030-3. doi: 10.1016/j.vaccine.2009.07.099. 21. rousseff t, claeys t, vande vijver e, moes n, vande velde s, schelstraete p, et al. hepatitis b virus vaccination and revaccination response in children diagnosed with coeliac disease: a multicenter prospective study. acta gastroenterol belg. 2019; 82(1): 27-30. 22. anania c, olivero f, spagnolo a, chiesa c, pacifico l. immune response to vaccines in children with celiac disease. world j gastroenterol. 2017; 23(18): 320513. doi: 10.3748/wjg.v23.i18.3205. 23. vitaliti g, praticò ad, cimino c, di dio g, lionetti e, la rosa m, leonardi s. hepatitis b vaccine in celiac disease: yesterday, today and tomorrow. world j gastroenterol. 2013; 19(6): 838-45. doi: 10.3748/wjg.v19.i6.838. 24. heshin-bekenstein m, turner d, shamir r, bar-meir m, dagan r, zevit n, et al. hepatitis b virus revaccination with standard versus pre-s vaccine in previously immunized patients with celiac disease. j pediatr gastroenterol nutr. 2015; 61: 400-3. doi: 10.1097/mpg.0000000000000856. j islamabad med dental coll 2021 169 o p e n a c c e s s audiometric characteristics of presbycusis: a hospital-based study ghulam saqulain1, gul-e-zahra2, nazia mumtaz3 1head of department, otorhinolaryngology, capital hospital pgmi, islamabad 2audiologist, yusra general hospital, islamabad 3head of department, speech language pathology, riphah international university, lahore a b s t r a c t background: presbycusis is related to degenerative changes of aging resulting from deficient cochlear microcirculation. it is characterized by bilateral, symmetrical, sensorineural hearing loss (snhl) in which recruitment and speech discrimination is affected in the absence of noise exposure. the objective of this study was to analyze the pure tone audiogram characteristics in presbycusis. methods: this descriptive study recruited n=192 cases of presbycusis of both genders, aged 50 to 80 years with convenience sampling technique. the study was conducted at yusra general hospital and the national institute of rehabilitation medicine, islamabad from1st july 2017 to 30th september 2017. pure tone audiometry was used to collect audiometric data. spss-24 was used for data analysis. chi-square and pearson’s correlation were used to determine association between variables with p < 0.05 taken as significant. results: pure tone audiometry revealed 58 (30.2%) right and 65 (33.9%) left ears with high frequency gently sloping audiogram, while the second commonest configuration being high frequency steeply sloping curve in 51(26.6%) right and 52(27.1%) left ears. there was a significant correlation between the configuration of the audiogram and age with p=0.000, while no significant correlation with gender (p=0.71). the majority,77 (40.10%) right and 71(36.98%) of left ears had moderately severe hearing loss, while severe hearing loss was second commonest with 60(31.25%) right and 70(36.46%) left ears affected. the severity of hearing loss had a significant (p=0.000) positive correlation with age but no significant relationship with gender. conclusion: high frequency gently sloping audiogram was the commonest configuration followed by high frequency steeply sloping curve. moderately severe hearing loss was most commonly seen followed by severe hearing loss. key words: audiogram, aging, hearing loss, presbycusis. authors’ contribution: 3conception; 1literature research; manuscript design and drafting; 3 critical analysis and manuscript review; 2data analysis; manuscript editing. correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: april 30, 2020 accepted: september 10, 2021 cite this article. saqulain g, gul-e-zahra, mumtaz n. audiometric characteristics of presbycusis: a hospital-based study. j islamabad med dental coll. 2021; 10(3): 169-175. doi: 10.35787/jimdc.v10i3.543 funding source: nil conflict of interest: nil i n t r o d u c t i o n presbycusis is the general term applied to age related hearing loss. it is characterized by reduced hearing sensitivity, little understanding of speech in noisy environments, delayed central processing of acoustic information and impaired localization of sound sources. the risk factors are noise exposure, hypertension, family history, smoking and medication among many others. hearing thresholds over 25 db in both ears is said to be hearing loss and can be classified as mild, moderate, severe, or profound.1 it is related to degenerative changes of aging occurring in the cochlear hair cells and central o r i g i n a l a r t i c l e j islamabad med dental coll 2021 170 auditory connections resulting from deficient cochlear microcirculation.2 it is characterized by bilateral, symmetrical, sensorineural hearing loss (snhl) in which recruitment and speech discrimination is affected in the absence of noise exposure. with presbycusis, the chances of hearing loss (hl) increase by 9% with each year of advancing age.3 though etiology is a simple degenerative process of cochlear aging, however, environmental factors may also contribute to it. presbycusis weakens communication which affects quality of life in many ways, causing personal frustration, relationship problems, anxiety, depression and other negative emotions.4 presbycusis is also related to lack of physical activity, certain nutrients, exposure to noise, genetic predisposition and other comorbidities. 5 presbycusis is divided into four main types with specific characteristic audiometric curves including sensory (high frequency steeply sloping curve), neural (moderate down sloping curve towards high frequency with severely reduced speech discrimination), strial or metabolic (flat curve) & cochlear conductive or mechanical (high frequency gently sloping).6 downward sloping audiogram is associated with degenerative changes involving hair cells, spiral ganglion and stria vascularis.7 presbycusis affects the individuals’ quality of life in daily social and communicational interactions being prevalent in the aging population.8 hussain b et al in a local study noted that with already high prevalence of presbycusis and increase in ageing population in coming decades, it is expected to rise significantly and can become a critical issue for the elderly community.9 with a dearth of research on presbycusis in pakistan and an increasing population with longevity as a universal trend along with a lack of organized screening, preventive and management options for the aging population, it might become a burden for the economy by increasing the less productive and partially disabled population. hence, this study was conducted with the objective to analyze the pure tone characteristics of presbycusis and may act as a local reference and foundation for further research to plan rehabilitative strategies. m a t e r i a l & m e t h o d s this was a descriptive cross-sectional study employing 192 cases of presbycusis using convenience sampling technique. the study was conducted at audiology clinics of yusra general hospital and national institute of rehabilitation medicine, islamabad, pakistan over three months from 1st july 2017 to 30th september 2017. a sample size of 196 was calculated taking a population proportion (p) of 0.15 10 and effect size (deff) of 1 with 5% absolute precision (d) and the two-sided level of significance (α) of 95% using the formula: cases with incomplete data were excluded from the study leaving behind a valid sample population of 192 cases. the sample included both genders aged 50 to 80 years and excluded those with infective and obstructive pathologies of the outer and middle ear, tympanosclerosis, otosclerosis, ototoxicity, meniere's disease and acoustic neuroma. pure tone audiometry (pta) was done for data collection. a medical history sheet and otoscope were used to rule out outer and middle ear pathologies. the study was conducted after obtaining approval of the irb of isra institute of rehabilitation sciences, isra university with registration number 1502-m phil hs002 dated 18th april 2017 and informed consent from the patients. pta was performed using pure tone audiometer model “maico ma 51” and both ears were tested with headphones by giving continuous pure tone signals to determine air conduction through the j islamabad med dental coll 2021 171 descending to ascending order. also, bone pta was performed using pure tone audiometer model “maico ma 51” and both ears were tested with headphones by giving continuous pure tone signals to determine air conduction through the descending to ascending order. also, bone conduction procedure was performed using a bone conductor. these tests were performed in a sound proof room by single audiologist to avoid any impact of noise and any inter-examiner difference. spss 24 was used for data analysis. age was presented by mean and standard deviation while categorical variables were presented by frequencies and percentages. pearson’s correlation and chi-square test were used to determine the association between different variables and a p-value of <0.05 taken as statistically significant. r e s u l t s the current study sample (n=192) comprised a predominantly male population of 129(67.19%) and 63(32.81%) females with male to female ratio of 2.05:1 and a mean age of 65.85 ± 7.36 years. the pattern of hearing loss among the subjects is shown with high frequency gently sloping curve (mechanical, cochlear conductive) on an audiogram in 58 (30.2%) and 65 (33.9%) right and left ears respectively. the second commonest configuration was a high frequency steeply sloping curve (sensory) in 51(26.6%) and 52(27.1%) right and left ears respectively. (table i) a statistically significant difference (p<0.001) was present between age group and configuration of audiogram with high frequency gently sloping audiogram predominantly seen at age group 56-60 and 61-65 in the right ear and 56-60, 61-65 & 6670 in the left ear, while high frequency steeply sloping audiogram predominantly seen at age group 66-70 and 71-75 in the right ear and 71-75 years age group for the left ear. pearson’s r correlation was positive. there was dominancy of male gender in the pattern of high frequency gently sloping hearing loss, possibly due to predominance of male population in the sample, however, the difference was not statistically significant (p=0.716) with a negative pearson r correlations among gender and configuration of hearing loss. table i: age group & gender * configuration of hearing loss (pure tone threshold curve): cross tabulation (n=192) ear age group (years) & gender configuration of hearing loss curve (puretone) total (n, %) correlations flat high frequency steeply sloping (metabolic , strial) high frequency gently sloping (mechanical, cochlear conductive) precipit ous fragment ary chisquare pearso n's r right 50 to 55 4 4 6 4 0 18 (9.37%) value: 49.233 p-value: 0.000 value: 0.080 56 to 60 4 6 18 6 0 34 (17.71%) 61 to 65 9 11 13 7 0 40 (20.83%) 66 to 70 12 14 13 8 2 49 (25.52%) 71 to 75 5 10 5 4 8 32 (16.67%) 76 to 80 4 6 3 0 6 19 (9.90%) total n (%) 38 (19.8) 51 (26.6) 58 (30.2) 29 15.1) 16 (8.3) 192 (100%) j islamabad med dental coll 2021 172 left 50 to 55 6 4 5 3 0 18 (9.37%) value: 59.195 p-value: 0.000 value: 0.092 56 to 60 4 6 22 2 0 34 (17.71%) 61 to 65 9 11 12 8 0 40 (20.83%) 66 to 70 12 14 16 6 1 49 (25.53%) 71 to 75 4 11 6 2 9 32 (16.67%) 76 to 80 5 6 4 0 4 19 (9.89%) total n (%) 40 (20.8) 52 (27.1) 65 (33.9) 21 (10.9) 14 (7.3) 192/ 100% right m 23 37 37 21 11 129 (67.19) value: 2.110 p-value: 0.716 value: .040 f 15 14 21 8 5 63 (32.81) total n (%) 38 (19.8) 51 (26.6) 58 (30.2) 29 (15.1) 16 (8.33) 192 (100) left m 23 39 42 15 10 129 (67.19) value: 3.623 p-value: 0.459 value: .056 f 17 13 23 6 4 63 (32.81) total n (%) 40 (20.8) 52 (27.1) 65 (33.8) 21(10.9) 14 (7.29) 192 (100) as far as the severity of hearing loss is concerned (table ii), the majority, 77 (40.10%) and 71 (36.98%) of right and left ears respectively had moderately severe hl, while severe hl was second commonest with 60 (31.25%) and 70(36.46%) of right and left ears affected respectively. profound hl was interestingly uncommon with 14(7.29%) and 15(7.81%) of right and left ears affected. table ii: age group & gender * degree/ severity of hearing loss: cross tabulation (n=192) ear age group (years) & gender degree/ severity of hearing loss total n (%) correlations mild moderate moderately severe severe profound chi-square pearson's r right 50 to 55 2 8 7 1 0 18(9.37) value: 145.36 p-value: 0.000 value: 0.699 56 to 60 1 21 11 1 0 34(17.71) 61 to 65 0 7 25 8 0 40(20.83) 66 to 70 0 1 27 19 2 49(25.52) 71 to 75 0 1 5 21 5 32(16.67) 76 to 80 0 0 2 10 7 19(9.89) total n (%) 3 (1.56) 38 (19.79) 77 (40.10) 60 (31.25) 14 (7.29) 192 (100) left 50 to 55 2 9 5 2 0 18(9.37) value: 146.483 p-value: 0.000 value: 0.670 56 to 60 0 17 13 4 0 34(17.71) 61 to 65 0 4 26 10 0 40(20.83) 66 to 70 0 3 22 23 1 49(25.52) 71 to 75 0 1 3 22 6 32(16.67) 76 to 80 0 0 2 9 8 19(9.89) total n (%) 2 (1.04) 34 (17.71) 71 (36.98) 70 (36.46) 15 (7.81) 192(100) j islamabad med dental coll 2021 173 right m 2 23 58 37 9 129(67.19) value: 3.961 value: 0.411 value: 0.019 f 1 15 19 23 5 63(32.81) total n (%) 3 (1.56) 38 (19.79) 77 (40.10) 60 (31.25) 14 (7.29) 192 (100) left m 2 23 51 42 11 129(67.19) value: 3.572 p-value: 0.467 value: 0.058 f 0 11 20 28 4 63(32.81) total n (%) 2 (1.04) 34 (17.70) 71 (36.98) 70 (36.46) 15 (7.81) 192(100) there was increase in hl with advancing age. the relationship was significant with a p-value of <0.001 with a positive relationship on pearson’s r correlation among age and severity of hearing loss in both ears. along with male predominance, there was also a predominance of a moderately severe degree in both genders with 58 and 51 males having a moderately severe degree of hl in right and left ears respectively. on the other hand, there were 19 and 20 females with a moderately severe degree of hearing loss in right and left ears respectively. however, the difference was not statistically significant with a p-value of 0.411 and 0.467 in right and left ear respectively with a positive pearson’s r correlation among gender and severity of hearing loss in both ears. figure 1 shows a positive liner relationship between age and frequency of hl. figure 1: scatter plot showing linear positive relationship between age and hearing threshold (n=192) d i s c u s s i o n in this study, with 67.19% males and 32.81% female population and a mean age of 65.85±7.0, high frequency gently sloping curve (mechanical, cochlear conductive) was the commonest presentation, while the second commonest configuration was high frequency steeply sloping curve (sensory). literature search revealed varying audiometric configurations like sarafraz m et al revealed predominance (64.29%) of the sensory pattern on audiogram followed by neural (16.25%), conductive (9.54%), metabolic (2.68%) and sensoryneural (7.16%) in decreasing order of frequency which is in contrast to this study.11 wang & puel noted sharply sloping curve in high frequency in males compared to gradual slope in females. 12 a study by wasana k et al reported slow age-related decline with an audiogram showing deterioration at j islamabad med dental coll 2021 174 1, 2 and 4 khz with a typical moderately sloping curve (mechanical cochlear conductive)13 which was the most predominant curve in this study as well. in a nigerian study published in 2013, sogebi oa et al reported a predominance of serial pattern with a flat loss involving both speech and higher frequencies.14 moreover, demeester k et al in a belgian study in 2009 reported a predominance of the flat curve (37%) followed by high frequency, gently sloping curve (35%) and high frequency steeply sloping curve (27%). also, low frequency ascending curve, mid-frequency u-shape and reverse u-shape curves were seen in less than 1% of the subjects.15 as far as the severity of hl is concerned, the present study revealed that the majority of right and left ears suffered moderately severe hl, while severe hl was second commonest and profound hl was interestingly uncommon. this finding may be due to the fact that our sample population had a mean age of 65.85 ± 7.36 years being a hospital-based study and very old adults in which severe and profound presbycusis could have been noted, were not included. a somewhat similar pattern was noted in a study by fei j which revealed normal hearing in 29.5%, mild to moderately severe hl in 59.5% and severe & profound hl in 11% with conductive element noted in 5.45%.16 in the current study, a statistically significant difference was noted between age and configuration of the audiogram (p-value of 0.000) with a positive correlation for both ears, due to progress of hl in aging population due to presbycusis. while the predominance of male gender was observed in the pattern of high frequency gently sloping hearing loss, however, the difference was not statistically significant (p=0.716). in contrast to our results, a study by demeester k et al found that in females, a flat curve was significantly more common, while in males, high frequency steeply sloping curves were more frequently encountered and noise and solvent exposure did not affect this pattern. 15 wu pz et al noted that though level of hl is quite predictable from hair cell amount degenerated, however as strial tissue is lost, cell death becomes intense and audiogram slope is not diagnostic for strial degeneration. 17 as far as the severity of hl is concerned, in the present study, increase in age revealed an increase in the severity of hl, the difference being statistically significant (p=0.000) with positive correlation. this difference is due to the degenerative changes occurring in the organ of corti with increasing age.1 similarly, in a study by rigters sc et al., an increase in hl of 0.29 to 1.35 db per year for low and high frequencies respectively was reported in aging population. 18 with regard to severity/ degree of hearing loss in the current study, gender-wise, the difference was not statistically significant with a p-value of 0.411 and 0.467 in right and left ears respectively with a positive correlation among gender and severity of hearing loss in both ears. in contrast, study by demeester k et al revealed more hearing loss in females compared to males, with a flat curve of the audiogram,15 while wasano k et al did not report any significant gender difference in youngest and oldest age groups.13 audiogram findings are critical in predicting inner ear degeneration and hence current study is of significant importance. 17 c o n c l u s i o n high frequency gently sloping audiogram was the commonest configuration followed by high frequency steeply sloping curve. severity wise moderately severe hearing loss was the commonest followed by severe hearing loss. disclaimer this research is part of the main research of m phil (speech-language pathology) thesis project. r e f e r e n c e s 1. shen y, ye b, chen p, wang q, fan c, shu y, et al. cognitive decline, dementia, alzheimer’s disease and presbycusis: examination of the possible molecular mechanism. frontiers in neuroscience. 2018 jun 8;12: 394. doi:10.3389/fnins.2018.00394 https://doi.org/10.3389/fnins.2018.00394 j islamabad med dental coll 2021 175 2. kurata n, schachner pa, paparella mm, cureoglu s. histopathologic evaluation of vascular findings in the cochlea in patients with presbycusis. jama otolaryngol head neck surg. 2016; 142(2):173–178. doi:10.1001/jamaoto.2015.3163 3. haider hf, flook m, aparicio m, ribeiro d, antunes m, szczepek aj, et al. biomarkers of presbycusis and tinnitus in a portuguese older population. front. aging neurosci. 2017; 9: 346. doi: 10.3389/fnagi.2017.00346 4. el-mahdy hm, abdallah es, ramadan en, abdelmordy ma. quality of life among elderly hearing impairment (presbycusis) at benha city. journal of nursing science benha university. 2020 jan 1;1(1):1-8. 5. puga am, pajares ma, varela-moreiras g, partearroyo t. interplay between nutrition and hearing loss: state of art. nutrients 2019; 11(1): 35. doi: 10.3390/nu11010035 6. opatwattana c, utoomprurkporn n. age-related hearing loss (presbycusis). chula med j. 2018; 62(2):175-85. 7. cheslock m, de jesus o. presbycusis. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2021. available from: https://www.ncbi.nlm.nih.gov/books/nbk559220/. 8. homans nc, metselaar rm, dingemanse jg, vander schroff mp, brocaar mp, wieringa m.h, et al. prevalence of age-related hearing loss, including sex differences, in older adults in a large cohort study. laryngoscope. 2017; 127(3):725-30. 9. hussain b, ali m, qasim m, masoud ms, khan l. hearing impairments, presbycusis and the possible therapeutic interventions. biomed. res. 2017;4(4):1228-12445. 10. garcia jv, rovira jmv. descriptive study on the prevalence of presbycusis among a population in the industrial belt of barcelona by exploring a random sample of primary healthcare center users. european j investiga. 2018;8(2):79-90. doi: 10.30552/ejihpe.v8i2.246 11. sarafraz m, saki n, nikakhlagh s, maleki m, jonaky r.s. distribution of audiometric findings in patients with presbycusis. biomed pharmacol j. 2015;8 (march spl edition). 12. wang j, puel jl. presbycusis: an update on cochlear mechanisms and therapies. j clin med. 2020 jan 14;9(1):2018. doi: 10.3390/jcm9010218. 13. wasano k, kaga k, ogawa k. patterns of hearing changes in women and men from denarians to nonagenarians. 2021; 9:100131. doi: 10.1016/j.lanwpc.2021.100131 14. sogebi oa, olusoga-peters oo, oluwapelumi o. clinical and audiometric features of presbycusis in nigerians. afr. health sci. 2013;13(4):886-892. 15. demeester k, van wieringen a, hendrickx jj, topsakal v, fransen e,van laer l, et al. audiometric shape and presbycusis. int j audiol. 2009;48(4):22232. doi: 10.1080/14992020802441799 16. fei j, lei l, su-ping z, ke-fang l, qi-you z, shi-ming y. an investigation into hearing loss among patients of 50 years or older. j otol. 2011;6(1):44-49. 17. wu pz, o'malley jt, de gruttola v, liberman mc. age-related hearing loss is dominated by damage to inner ear sensory cells, not the cellular battery that powers them. j neurosci. 2020 aug 12;40(33):63576366. doi: 10.1523/jneurosci.0937-20.2020 18. rigters sc, van der schroeff mp, papageorgiou g, baatenburg de jong rj, geodegebure a. progression of hearing loss in the aging population: repeated auditory measurements in the rotterdam study. audiol neurotol 2018; 23:290–297 j islamabad med dental coll 2019 34 open access comparison of caralluma tuberculata with metformin for antidiabetic activity: an animal study muhammad saleh faisal 1, waqar hayat 2, asad inayat 3, muhammad sohaib 4, waheed iqbal 5 1 assistant professor, department of pharmacology khyber medical college, peshawar 2 trainee medical officer, department of medicine khyber teaching hospital, peshawar 3 trainee medical officer, department of medicine khyber teaching hospital, peshawar 4 research assistant, khyber medical university, peshawar 5 chemist, department of pharmacology, khyber medical college, peshawar a b s t r a c t background: caralluma tuberculata, is a wild herb, which grows in the hills of balochistan and has been known to have medicinal and nutritional properties since antiquity. this experimental research was designed to study the hypoglycemic properties of caralluma tuberculata and to compare them with metformin. material and methods: this was a laboratory-based animal experimental study. it was conducted in the pharmacology laboratory of khyber medical university, peshawar from february 2016 to august 2016. two types of extracts of caralluma tuberculata [crude extract and carbon tetrachloride (ccl4) extract] were prepared and administered to normal and alloxan treated diabetic rabbits. to study anti-diabetic activity, eighty-four rabbits were divided into two main groups. group i (normal/non-diabetic rabbits; n= 21) and group ii (diabetic/alloxanized rabbits; n=63). each group was further divided into sub-groups (7 rabbits in each). effect of caralluma tuberculata, metformin and 2% gum tragacanth on blood glucose levels were checked at 0, 2, 4, 6, 8, 12 and 24 hours of drug administration. the extracts were given in capsule form and in cooking oil. data analysis was done using spss version 16. for calculation and comparison of the hypoglycemic effects at various doses and different time intervals, analysis of variance (anova) and tukey’s post hoc test were applied. results: the crude extract, 200mg/kg body weight of caralluma tuberculata showed significant decrease (p<0.001) in mean blood glucose levels from 2-hour till12 hours. whereas, highly significant reduction of blood glucose was seen from 2 hours after treatment till 24 hours, when carbon tetrachloride (ccl4) fraction of caralluma (100mg/kg body weight) in capsule form was administered. metformin 500mg/kg body weight was given to compare its effects with plant crude extract and it was found that metformin appeared to be less effective in comparison with caralluma tuberculata. conclusion: caralluma tuberculata lowered the blood glucose level and turned out to be more significant in developing hypoglycemia when taken with cooking oil. more work is essential to provide stronger evidence for the use of this natural agent in the management of diabetes mellites. key words: anti-diabetic, caralluma tuberculata, hypoglycaemic authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3-5 interpretation, discussion, data analysis, active participation in data collection. correspondence: waheed iqbal email: waheediqbal22@gmail.com article info: received: july 22, 2018 accepted: november 10, 2018 cite this article: faisal ms, hayat w, inayat a, sohaib m, iqbal w. comparison of caralluma tuberculata with metformin for anti-diabetic activity: an animal study. j islamabad med dental coll.2019; 8(1):34-39 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus is one of the most common metabolic disorders which occur either due to insufficient insulin release (type 1 diabetes) or tissue resistance to insulin (type 2 diabetes). there were around 382 million diabetic patients in the year 2013, and it is estimated that this figure is going to flare up to 592 million by 2035. most of o r i g i n a l a r t i c l e j islamabad med dental coll 2019 35 the diabetic patients reside in lower to middle developed countries.1 prevalence of diabetes in rural areas of pakistan constitutes 7% and 2.5% for men and women respectively, while in urban areas this figure is about 6% for men and 3% for women. according to another study, the glucose intolerance in urban areas is 14.2% for women and 6.3% for men versus 10.9% for women and 6.9% for men in rural areas.2 there are many plants which have been reported due to their traditional use as anti-diabetic agents, like momordica charantia, citrullus colocynthis, allium sativum, opuntia, aloe and artemisia.3,4 in many indian traditional approaches like ayurveda, about 800 different medicinal plants have been identified to have hypoglycemic activity, but very few of them got scientific scrutiny.5 valuable information is available about phytochemical components responsible for hypoglycemic effect. the isolation of glycans from plant families such as, granmineae, ranunculaceae and extraction of glycosides from scrophulariaceae, rhamnaceae, caesalpiniaceae and papaveraceae are good examples of this. moreover, some triterpenes from ranunculaceae, saponins of malvaceae and alkaloids of apocyanaceae have been reported for their hypoglycemic effect.6,7 however, the search for newer plants with anti-diabetic activity is still in progress. caralluma tuberculata, which belongs to family asclepiadaceae is a wild herb, grows in most of the hilly areas of balochistan and is used as a vegetable since centuries. caralluma species have been used by humans as tonic, carminative, anti-helminthic and anti-tumor agent.8 caralluma is reported to be effective in rheumatism and also known to have hypotensive effect.9,10 the phytochemical constituents include volatile alkaloids, cardiac glycosides, flavonoids, saponins, sterols and tannins.11 adnanet al reported that caralluma when hydrolyzed under mild conditions gives cymarose, sarmentose, oleandrose or digitoxose as sugar component while work of bashir et al identified its various nutritional aspects and composition.12, 13 this study was an attempt first to evaluate the hypoglycemic activity of crude and carbon tetrachloride (ccl4) extracts of caralluma tuberculata and then to compare this hypoglycemic activity with metformin. m a t e r i a l a n d m e t h o d s this experimental study was carried out at the department of pharmacology, khyber medical university, peshawar from february 2016 to august 2016. institutional approval was obtained and all the ethical issues pertaining to animal pain and distress, feeding, caging etc. were addressed according to standard protocols for animal studies. healthy male rabbits weighing 1 kg to 1.5 kg of oryctologus cunniculus species were selected and kept in animal house for one week under strict observation where they were fed upon clean water and fresh fodder. to induce diabetes in normal rabbits, alloxan monohydrate was injected in a dose of 150 mg/kg body weight using tuberculin syringe. a week later, blood levels of glucose were determined by glucose oxidase method and only those rabbits were included in the study whose blood glucose level was in the range 300-500mg/100ml.14,15 to study anti-diabetic activity, eighty-four rabbits were divided into two main groups. group i (normal/non-diabetic rabbits; n= 21) and group ii (diabetic/alloxanized rabbits; n=63). each group was further divided into sub-groups (7 rabbits in each, as the minimum number in each group is 6 in already established protocols).15 group 1 (n=21) was further subdivided into following 3 subgroups: subgroup a1: treated with crude extract of caralluma tuberculata 200 mg/kg body weight. subgroup b1: treated with metformin 500 mg/kg body weight. subgroup c1: serving as control receiving 20 ml 2% gum tragacanth solution. group ii (n=63) was further divided into following 9 subgroups: subgroup a2: treated with crude extract of caralluma tuberculata 200 mg/kg body weight (capsule form). subgroup b2: treated with metformin 500 mg/kg body weight. subgroup c2: serving as control receiving 20 ml 2% gum tragacanth solution. subgroup a3: treated with ccl4 of caralluma tuberculata 100 mg/kg body weight (capsule form). subgroup b3: treated with metformin 500 mg/kg body weight. j islamabad med dental coll 2019 36 subgroup c3: serving as control receiving 20 ml 2% gum tragacanth solution. subgroup a4: treated with ccl4 of caralluma tuberculata 100 mg/kg body weight (in cooking oil). subgroup b4: treated with metformin 500 mg/kg body weight. subgroup c4: serving as control receiving 20 ml soy bean cooking oil. the aerial part of the plant was washed and air dried. the dried material was grinded, passed through a mesh and put in distilled water at room temperature for several days, followed by squeezing in a muslin cloth. this procedure was repeated thrice, which as a result produced green syrupy residue. fractionation of crude extract of caralluma tuberculata was carried out by suspending the crude extract in water, partitioned with carbon tetrachloride (ccl4) by vigorous shaking in a separating funnel. the ccl4 layer was separated and evaporated under reduced pressure in rotary evaporator. the resultant residue was then treated with methanol. the methanol soluble fraction was separated from the insoluble (water soluble) material and evaporated in rotary evaporator. effect of caralluma tuberculata, metformin and 2% gum tragacanth on blood glucose levels were checked at 0, 2, 4, 6, 8, 12 and 24 hours of drug administration. data analysis was done using spss version 16 and expressed as mean ± sd. for calculation and comparison of the hypoglycemic effects at various doses & different time intervals, analysis of variance (anova) and tukey’s post hoc test were applied. r e s u l t s in non-diabetic group, treatment with crude extract of caralluma produced significant reduction in mean blood glucose levels at 2 hours (p<0.001), 4 hours (p<0.001) 8 hours (p<0.001) and 12 hours, but gradual increase in blood glucose levels was seen at 24 hours as compared to that at 12 hours interval (p<0.001). however, with metformin, the blood glucose levels decreased after 2 and 4-hours interval but they started increasing from 8 to 24 hours interval after treatment. this increase was significantly high as compared to that at 12 hours interval (p<0.01). oral administration of 20 ml 2% gum tragacanth suspension did not produce any appreciable decrease in blood glucose level (table i). when capsule form of caralluma crude extract was given, significant reduction in blood glucose levels were observed at 2, 4, 8, 12and 24-hours interval (p<0.001) as compared to that at zero hour (p>0.1) (table ii). compared to 2 hours interval, there was no significant decrease in blood glucose levels at 4 hours interval (p=0.2) and 8 hours interval (p=0.2). there was significant decrease in blood glucose levels at 12 hours interval compared to that at 8 hours interval (p<0.05) and highly significant increase at 24 hours interval compared to that at 12 hours interval (p<0.001). table i: blood glucose levels after oral administration of crude extract of caralluma tuberculata, metformin and 2% gum tragacanth in non-diabetic rabbits (n=21) time interval crude extract 200mg/kg body weight 500 mg/kg body weight 20 ml (hours) caralluma tuberculate a1; (n=07) metformin b1; (n=07) 2% gum tragacanth c1; (n=07) blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd 0 104.33  1.33 92.16±0.83 94.17±0.60 2 79.67 ± 2.96 82.00±0.96 94.00±0.58 4 73.17 ± 2.64 72.50±1.31 94.33±0.81 8 80.33 ± 2.23 79.66±1.76 93.50±0.67 12 72.50 ± 0.88 87.16±0.75 91.67±0.50 24 99.50 ± 1.61 92.00±0.57 92.50±1.05 table ii: blood glucose levels after oral administration of crude extract of caralluma tuberculata (capsule form), metformin and 2% gum tragacanth in diabetic rabbits (n=21) time interval crude extract 200mg/kg body weight (capsule form) 500 mg/kg body weight 20 ml (hours) caralluma tuberculate a2;(n=07) metformin b2;(n=07) 2% gum tragacanth c2;(n=07) blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd 0 318.16 ± 2.05 335.16 ± 3.04 309.00 ± 1.62 2 268.00 ± 2.61 318.50 ± 2.96 309.66 ± 1.78 4 263.00 ± 1.24 306.50 ± 1.65 309.00 ± 0.89 8 269.33 ± 1.97 322.66 ± 3.08 309.16 ± 3.25 12 260.33 ± 1.50 327.00 ± 2.50 312.00 ± 2.85 24 287.83 ± 3.52 340.80 ± 3.63 310.33 ± 2.50 j islamabad med dental coll 2019 37 in comparison with metformin, capsule form of caralluma crude extract showed significantly low mean blood glucose levels at 2 hours interval (p<0.001), 4 hours interval (p<0.001), 8 hours interval (p<0.001), 12 hours interval (p<0.001) and 24 hours interval (p<0.001). oral administration of 2% gum tragacanth did not produce any appreciable decrease in blood glucose levels. after oral administration of ccl4 fraction of caralluma in capsule, blood glucose levels dropped markedly at 2 hours interval as compared to zero hour (p<0.001). but increase in mean blood glucose levels was observed at 8, 12 and 24 hours. in comparison with metformin and 2% gum tragacanth, ccl4 fraction of caralluma significantly lowered the blood glucose levels at 2 hours interval (p<0.001); 4 hours interval (p<0.001); 8 hours intervals (p<0.001); 12 hours intervals (p<0.001) and 24 hours intervals (p<0.001) (table iii). table iv shows that ccl4 fraction of caralluma in soy bean cooking oil caused significant reduction in blood glucose levels at 2, 4, 8, 12and 24-hours intervals (p<0.001). there was significant difference in blood glucose levels in all groups at 4 hours interval compared to that at 2 hours interval (p<0.05). no significant increase in comparison at 4 hours vs. 8 hours (p=0.2); 8 hours vs 12 hours (p=0.2) and 12 hours vs 24 hours (p=0.2) was observed in groups a4, b4 and c4. after treatment with 20 ml cooking oil, no appreciable difference in mean blood glucose levels was observed. this experiment was maintained as control against treatment groups. table iii: blood glucose levels after oral administration of ccl4 fractions of caralluma tuberculata (capsule form), metformin and 2% gum tragacanth in diabetic rabbits (n=21) time interval ccl4 fraction 100mg/kg body weight (capsule form) 500 mg/kg body weight 20 ml (hours) caralluma tuberculate a3; (n=07) metformin b3; (n=07) 2% gum tragacanth c3; (n=07) blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd 0 309.50±1.38 335.16±3.04 309.00±1.62 2 194.16±2.49 318.50±2.96 309.66±1.78 4 184.16±3.73 306.50±1.65 309.00±0.89 8 207.67±3.68 322.66±3.08 309.16 ± 3.25 12 206.67±2.59 327.00±2.50 312.00 ± 2.85 24 257.33±3.66 340.80±3.63 310.33 ± 2.50 table iv: blood glucose levels after oral administration of ccl4 fractions of caralluma tuberculata (in cooking oil), metformin and 20ml soybean cooking oil as control in diabetic rabbits (n=21) time interval ccl4 fraction 100mg/kg body weight (in cooking oil) 500 mg/kg body weight 20 ml (hours) caralluma tuberculate a4; (n=07) metformin b4; (n=07) soy bean cooking oil c4; (n=07) blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd blood glucose (mg/dl) mean±sd 0 287.55±1.96 335.16±3.04 301.00±2.08 2 142.33±1.74 318.50±2.96 301.00±2.35 4 151.33±2.26 306.50±1.65 302.66±3.48 8 153.16±3.13 322.66±3.08 301.16±1.58 12 158.00±2.80 327.00±2.50 303.16±2.24 24 164.66±3.23 340.80±3.63 303.16±2.24 it is worth mentioning here that from data given in table iii and iv, it is also observed that caralluma tuberculata reduced blood glucose levels more efficiently when administered in cooking oil than in capsule form i.e. at 2, 4, 8, 12and 24-hours interval (p<0.001). d i s c u s s i o n in the present study, experimentation was done on different forms of caralluma tuberculata i.e. crude extract and carbon tetrachloride fractions (ccl4) in both capsule and in cooking oil to find out the form in which it is more effective as hypoglycaemic agent. when crude extract of carallumain in a dose of 200mg/kg body weight was administered in capsule form to diabetic rabbits, it caused highly significant reduction in blood glucose level after 2 hours of treatment, which continued up to 12 hours. whereas, when carbon tetrachloride (ccl4) fraction of caralluma (100mg/kg body weight) in capsule form was administered, highly significant reduction in blood glucose level was seen from 2 hours after treatment till 24 hours. carbon tetrachloride (ccl4) fraction of caralluma (100mg/kg body weight) in cooking oil was also administered to diabetic rabbits. beside significant reduction (p<0.001) in blood glucose levels, it was found that caralluma tuberculata administered in cooking oil reduced blood glucose levels more than that administered in capsule form. j islamabad med dental coll 2019 38 unlike other studies, we used carbon tetrachloride fraction in capsule and cooking oil forms to compare their efficacy. the reported information regarding effects of medicinal plants in developing hypoglycaemia was observed at maximum 6 hours after administration of dose. in our study, strategy was adopted to evaluate effect after two hours of administration of dose and again after 4, 8, 12 and 24 hours. it was aimed to see how long the dose effect of caralluma sustains on blood glucose level. as far as the underlying mechanism for hypoglycaemia is concerned, it is deduced from various studies that this plant might contain multiple hypoglycaemic constituents, causing the release of insulin by stimulating beta cells and hence resulting in significant drop in blood glucose levels. moreover, they may also have insulin like orally active substance, as momordica charantia vegetable. 16 in addition, drugs such as biguanides are known to produce hypoglycaemia by decreasing gluconeogenesis and promoting glycolysis.17 biguanides prevent hypoglycaemia in normal individuals by balancing the increased peripheral glucose utilization and additional glucose output of hepatocytes. so, it is suggested that caralluma may contain specific constituents, which cause hypoglycaemia either by increasing the insulin secretion or mimicking insulin action.18 different substances, like anterior and posterior pituitary hormones, prostaglandins, corticosteroids etc and plants like trigonella foenum produces hypoglycaemia by different means and mechanisms.19 therefore, establishment of detailed phytochemical and pharmacological profile of this plant is necessary to identify the exact underlying mechanism of hypoglycaemia. c o n c l u s i o n caralluma tuberculata lowered the blood glucose levels in mammalian model of rabbits and turned out to be more effective when taken with cooking oil. however, the efficacy of herbal medications needs to be further evaluated by well designed, controlled clinical studies. r e c o m m e n d a t i o n s 1. conduct randomized controlled trial to establish efficacy and safety of caralluma tuberculata as an oral hypoglycemic agent in diabetic patients 2. the possible toxicity of the crude and ccl4 extracts of caralluma tuberculata should be investigated. r e f e r e n c e s 1. guariguata l, whiting dr, hambleton i, beagley j, linnenkamp u, shaw je. global estimates of diabetes prevalence for 2013 and projections for 2035. diabetes research and clinical practice. 2014;103(2):137-49 2. shera as, jawad f, maqsood a. prevalence of diabetes in pakistan. diabetes research and clinical practice. 2007;76(2):219-22 3. akhtar ms, ramzan a, ali a, ahmad m. effect of amla fruit (emblica officinalis gaertn.) on blood glucose and lipid profile of normal subjects and type 2 diabetic patients. international journal of food sciences and nutrition. 2011;62(6):609-616 4. patel d, prasad s, kumar r, hemalatha s. an overview on antidiabetic medicinal plants having insulin mimetic property. asian pacific journal of tropical biomedicine. 2012;2(4):320-330. 5. ponnusamy s, ravindran r, zinjarde s, bhargava s, ravi kumar a. evaluation of traditional indian antidiabetic medicinal plants for human pancreatic amylase inhibitory effect in vitro. evidence based complementary and alternative medicine: ecam; 2011:515647. 6. vaidya ad, devasagayam tp. recent advances in indian herbal drug research guest editor: thomas paul asir devasagayam current status of herbal drugs in india: an overview. journal of clinical biochemistry and nutrition. 2007;41(1):1-1 7. katzung b, master s,trevor a. blood glucose. basic and clinical pharmacology. united states:mc grew hell. 2012;12th ed.1245p. 8. rehman r.u., chaudhary m.f., khawar k.m, lu g, mannan a, zia m. et al. in vitro propagation of caralluma tuberculata and evaluation of antioxidant potential.biologia. 2014; 69:341-345. 9. poodineh j, feizabad ak, nakhaee a. antioxidant activities of caralluma tuberculata on streptozotocin induced diabetic rats. drug development research. 2015;76(1):40-47. 10. alamgeer, ahmad t, malik mnh, mushtaq mn, qayyum r, khan aq, akhtar s. et al. evaluation of antihypertensive effect of aqueous methanol extract of caralluma tuberculata j islamabad med dental coll 2019 39 n.e.br in sprauge dawley rats. tropical journal of pharmaceutical research. 2015;14(3): 455-462. 11. mudrikah, bibi y, tabassum s, zahara k, bashir t, haider s. ethnomedicinal and pharmacological properties of caralluma tuberculata n. e. brown. pure appl. bio. 2015; 4(4):503-510. 12. adnan m, jan s, mussarat s, tariq a, begum s, afroz a. et al. a review on ethnobotany, phytochemistry and pharmacology of plant genus caralluma r. br.journal of pharmacy and pharmacology. 2014; 66: 1351-1368. 13. ahmad b, abbas sj, hussain f, bashir s, ahmad d. study on caralluma tuberculata nutritional composition and its importance as medicinal plant. pak. j. bot. 2014; 46(5): 1677-1684. 14. liu t, zhao h, li j. korantzopoulos p, li j. rosiglitazone attenuates atrial structural remodelling and atrial fibrillation promotion in alloxan‐induced diabetic rabbits. cardiovascular therapeutics. 2014; 32(4): 178-183. 15. mushtaq, m.n, bashir s, ullah i, karim s, rashid m, hayat malik mn., et al., comparative hypoglycemic activity of different fractions of thymus serpyllum l. in alloxan induced diabetic rabbits. pak j pharm sci, 2016; 29(5): 1483-1488 16. efird jt, choi ym, davies sw, mehra s, anderson ej, katunga la. potential for improved glycemic control with dietary momordica charantia in patients with insulin resistance and pre-diabetes.int. j. environ. res. public health. 2014; 11(2): 2328-2345. 17. drahota z, palenickova e, endlicher r, milerova m, brejchova j, vosahlikova m. et al. biguanides inhibit complex i, ii and iv of rat liver mitochondria and modify their functional properties. physiol res. 2014; 63: 1-14. 18. sharma ra, singh b, singh d. ethnomedicinal, pharmacological properties and chemistry of some medicinal plants of boraginaceae. indian j. med. plants res. 2009;3(13):1153-75 19. swaroop a, bagchi m, kumar p, preuss hg, tiwari k, marone pa. et al. safety, efficacy and toxicological evaluation of a novel, patented anti-diabetic extract of trigonella foenum-graecum seed extract. toxicol mech methods. 2014; 24(7):495-503. j islamabad med dental coll 2021 110 open access frequency of incidental carcinoma in thyroids operated for multinodular goiter mudassira zahid1, anum usman2, kiran tauseef3, humaira zaffar3, awais niaz4, noor khan5 1associate professor, department of pathology, mohiuddin islamic medical college, mirpur, azad kashmir pakistan 2assistant professor, department of pathology, al nafees medical college & hospital, islamabad pakistan 3associate professor, department of pathology, al nafees medical college & hospital, islamabad pakistan 4lecturer, department of pathology, al nafees medical college & hospital, islamabad pakistan 5professor, department of pathology, al nafees medical college & hospital, islamabad pakistan a b s t r a c t background: multinodular goiter (mng) is a common disease in pakistan. however, malignancy can be found occasionally on histopathological examination of resected goiter specimens. the objective of this study was to determine the frequency of malignant lesions on histopathological examination in thyroid specimens operated for multinodular goiter. material and methods: a total of 154 patients undergoing thyroid surgery with preoperative diagnosis of multinodular goiter (mng) at al nafees medical college and hospital islamabad, pakistan were included in this study. the preoperative diagnosis of mng was made upon physical examination of thyroid and ultrasound (n=62 cases). fnac was done in selected cases (n=43). after gross examination, sections were taken from areas of thyroid with varied appearances including hemorrhagic, solid, firm, white, gray, gelatinous as well as necrotic areas. qualitative variables were calculated in terms of percentages and mean and standard deviation were used for quantitative variables. results: of the 154 patients with preoperative diagnosis of mng, there were 139 (90%) female and only 15 (10%) male patients. the age range was 14-60 years with a mean age of 36 ± 10 years the incidence of thyroid carcinoma in patients operated for clinical diagnosis of mng was 8% (n=12). papillary thyroid carcinoma (ptc) was the most frequent type of malignancy (83.3%; n=10). multifocality (60%; n=6), bilaterality (33.3%; n=4) and left lobe involvement (80%; n=8) of thyroid were more common with papillary thyroid carcinoma. microcarcinoma (measuring 1cm or less) was found in 50% (n=5) of these ptc. histological type of papillary carcinomas greater than 1 cm were follicular variant (n=3; 30%) and conventional (n=2; 20%) types. the maximum measurement of the tumor was 2 cm. in all cases of ptc, rest of the thyroid showed mng on histopathology. conclusions: incidental finding of thyroid malignancy in clinically diagnosed cases of mng is not unusual. papillary carcinoma of thyroid is the most common incidental malignant finding in these cases. multilocularity in thyroid is not an indicator of benign disease process. key words: incidental finding, multinodular goiter, papillary microcarcinoma, papillary thyroid carcinoma. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6 data analysis; manuscript editing. correspondence: mudassira zahid email: mudassirazahid@gmail.com article info: received: january 11, 2020 accepted: may 4, 2021 cite this article. zahid m, usman a, tauseef k, zaffar h, niaz a, khan n. frequency of incidental carcinoma in thyroids operated for multinodular goiter. j islamabad med dental coll. 2021; 10(2): 110-115. doi: 10.35787/jimdc.v10i2.487 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 111 i n t r o d u c t i o n thyroid is an important endocrine gland. it is affected by variable pathologies with different biological behaviors. thyroid enlargement is commonly encountered in surgical practice. in thyroidectomy specimens the most common benign pathology is multinodular goiter (mng) and the most common malignant lesion is papillary carcinoma.1,2 papillary carcinomas is characterized by its signature nuclear features including nuclear groves, inclusions and chromatin clearing along with papillary architecture.2 the incidence of thyroid carcinoma is increasing worldwide.3 in the united states, the incidence of thyroid carcinoma is reported to be 1% among all new cancer diagnosis.4 geographically, pakistan is considered an endemic area for iodine deficiency and thyroid enlargement is frequent. in pakistan, thyroid carcinomas have an incidence of 1.2% cases among all malignant tumors.5 the thyroid carcinomas mostly present in the third and fourth decades of life and are more common in females as compared to males.6 incidental thyroid carcinoma is diagnosed in patients operated for any benign thyroid pathology with no suspicion of neoplasm on preoperative physical examination, ultrasound or fnac.7 various studies documenting the frequent finding of malignancy in thyroids operated for benign conditions have been reported.7,8 not all enlarged thyroids with multilocularity on clinical examination turn out to be benign. increasing trends of thyroid surgery on mere clinical examination have been observed. this study is aimed at documenting the frequency of thyroid cancer in patients undergoing thyroidectomy for benign mng in our settings. it will emphasize the need for a complete thorough preoperative investigative workup of patients with enlarged thyroid including targeted fnac, thyroid scan and ultrasound examination in order to decrease the frequency of reoperations after initial partial thyroid surgery. m a t e r i a l a n d m e t h o d s it was a descriptive cross-sectional study carried out in al nafees medical college and hospital, islamabad pakistan. the study duration was two and half years from january 2016 to june 2018. consecutive sampling was done. all consecutive patients undergoing thyroid surgery (total, subtotal thyroidectomy or lobectomy) with preoperative diagnosis of multinodular goiter (mng) were included in this study. preoperative diagnosis of mng was made on the basis of physical examination and ultrasound of the thyroid. fnac was opted only for the patients having a suspicion of neoplastic pathology on physical examination. patients having a solitary thyroid nodule and a preoperative suspicion of neoplasia on ultrasound or on fnac were excluded from the study. patients with previous thyroid surgery and enlarged neck lymph nodes were also excluded. thyroid specimens were routinely fixed in formalin. gross examination was done and sections were taken from different areas of thyroid with varied appearances including hemorrhagic, solid, firm, white, gray, gelatinous as well as necrotic areas.2 data was analyzed using spss version 20. for the evaluation of qualitative variables frequencies were calculated in terms of percentages. mean and standard deviation were used for the quantitative variables to assess statistical inference. j islamabad med dental coll 2021 112 r e s u l t s during the two-year study period, 176 thyroid specimens were received for histopathology. out of these, 154 (88%) thyroids were preoperatively diagnosed as mng and there was no suspicion of any neoplasia on physical examination, ultrasound or fnac. there were 139 (90%) female and only 15 (10%) male patients. the age range was 14-60 years with a mean age of 36 ± 10 years. maximum number of patients (n=52; 34%) were in the 31-40 years age group. subtotal thyroidectomy was the most common surgical procedure (n=108; 70%), followed by lobectomy. based upon the variability of gross appearance of thyroid specimens, the mean number of sections taken from each specimen was 4 and ranged from 2 to 7 sections. after histopathology examination, the various diagnoses made in 154 patients with a clinical diagnosis of mng and their distribution along with mean age is shown in table 1. mng was the most common pathology. the mean age of ptc patients was 39 ± 9 years. table i: frequency distribution of postoperative histological diagnosis and mean age of patients postoperative histological diagnosis number of patients n (%) mean age (years) multinodular goiter 137 (89%) 36 ± 10 papillary thyroid carcinoma 10 (7%) 39 ± 9 medullary carcinoma 2 (1%) 42 ± 1 thyroiditis 5 (3%) 39 ± 1 total 154 36 ± 10 among all the thyroids examined, 12 (8%) had incidental thyroid carcinoma. female to male ratio was 5:1. the mean histological sections taken from malignant thyroids were 5. the thyroid carcinomas measured from 1 cm to 2 cm in terms of maximum diameter on gross examination with a mean measurement of 1.5 cm. only one of these patients had undergone fnac examination and was misdiagnosed as mng. in the rest of the cases, preoperative diagnosis of mng was made on physical findings and ultrasound alone and no fnac was done. among the 12 malignant tumors 10 (83.3%) were ptc, and 2 (16.7%) were medullary carcinomas (table i). multifocality was noted in 60% (n=6) and bilaterality in 33.3% (n=4) of ptc. the left lobe was more commonly involved (n=8; 80%). the papillary microcarcinomas measuring 1cm or less, were seen in 50% (n=5) of cases. these showed the characteristic diagnostic morphological features of papillary carcinoma as shown in figure 1. histological type of papillary carcinomas greater than 1 cm were follicular variant (n=3; 30%) and conventional (n=2; 20%) types. in all cases of ptc, rest of the thyroid showed mng on histopathology. d i s c u s s i o n the incidence of palpable thyroid nodules in women and men is about 5% and 1%, respectively. despite the availability of many diagnostic facilities, histopathology is still the gold standard to confirm the underlying pathology.9 thyroid cancer, although accounting for only 1% of all malignancies, is the most common endocrine malignancy. the reported statistics emphasize rising incidence of thyroid cancer over the last 10 years i.e., 5.5% annually. besides this, the mortality rate has also increased to 0.8% annually.10 the main attributable factor for this condition is the use of imaging studies that incidentally detect increasing numbers of thyroid nodules.11,12 majority of the patients with mng presented with a mean age of 36 ± 10 years and an age range of 31-40 years. bombil et al. reported mean age of 46 years with an age range of 15-79 years in thyroidectomy patients at chris hani baragwanath academic hospital, johannesburg, south africa,13 while miccoli et al. from department of surgery, university of pisa, italy documented a mean age of 49.5 years.4 j islamabad med dental coll 2021 113 figure 1: microscopic appearance of papillary thyroid carcinoma. a: papillary microcarcinoma adjacent to mng areas (h&e, 20x). b: nuclear features of papillary carcinoma characterized by nuclear inclusions and grooving along with ground glass appearance (h&e, 100x). the incidence of carcinoma was higher in females with a female-to-male ratio of 5:1 in the present study. this finding is in accordance with the available literature, proposing thyroid carcinoma to be more common in females.4 the mean age of patients with thyroid malignancies was 39 ± 9 years. qureshi et al. also reported maximum thyroid carcinomas in the same age group.15 however a study done in orleans, france recruited patients from an iodine deficient area. they reported a mean age of 55 ± 10 years for thyroid malignancies in patients undergoing thyroidectomy for mng.16 the current study revealed an incidence of 8% carcinoma in mng specimens. the incidence of thyroid malignancy in thyroidectomy specimens has been variously reported in the local data. an incidence of 7.6% and 8% has been reported by memon et al. and aurangzeb, respectively.17,18 relatively higher incidences of 15% has been reported by ullah et al.19 a study from multan, pakistan documented malignancy incidence of 11% in thyroidectomy specimens.20 a recent study conducted in new zealand highlighted the rising incidence of unsuspected carcinoma in patients operated for mng which accounted for 8% in nontoxic and 10% in toxic mng.21 the current study revealed ptc as the most frequent (83.3%) malignancy followed by medullary carcinoma. there was no case of follicular carcinoma in the current study. these findings are more or less in line with a local published study showing papillary carcinoma as the most common malignancy (90%), followed by medullary carcinoma (4.5%) and follicular carcinoma (2%), respectively.6 an indian study conducted in an endemic goiter region also had similar results.22 other studies have reported follicular carcinoma to be more frequent than medullary carcinoma.10,12 the absence of representation of follicular carcinoma might be due to the fact that these tumors clinically present as unifocal nodules3 while only multinodular thyroids were selected in the current study cohort. in our study group, multifocal papillary carcinomas comprised of 60% cases in contrast to 44% multifocal malignancies isolated by young et al.23 the carcinomas did not measure beyond 2 cm in diameter. also 50% were microcarcinomas, measuring not more than 1cm in diameter. similar observations were found in another study.24 all carcinomas observed in the current study were welldifferentiated and early carcinomas. gonzalez et al. studied the difference between clinically apparent thyroid carcinoma and incidental carcinoma. they found that incidental carcinomas were at the earlier j islamabad med dental coll 2021 114 biological stage and had a better prognosis with less mortality rates.25 considering the incidental finding of thyroid carcinoma in mng after histopathology, keliszewski et al. proposed total thyroidectomy or near total thyroidectomy for mng patients to avoid resurgery.26 another study proposes a dunhill procedure.27 the suggested surgical options for welldifferentiated thyroid carcinoma >1 cm is total or near total thyroidectomy whereas for a unifocal nodule measuring <1 cm, lobectomy will be sufficient12 in the absence of other risk factors. most of the cases observed in this study were multifocal and measured 1 cm or more, so a more radical procedure would decrease the need of reoperation in mng patients. nguyen et al narrated that thyroid nodules measuring >1 cm must be evaluated for malignancy by ultrasound and fnac.10 in addition knox also adds that nodules less than 1 cm should be followed by serial ultrasonography instead of fnac evaluation. also, multiple nodules necessitate the need for fnac of these nodules.10,11 multinodularity in thyroid on physical examination should not be considered as an indicator of a benign disease. any thyroid enlargement should be fully investigated by ultrasound and fnac. the neoplastic lesions observed in this study were not more than 2 cm in size and likely to be missed on palpation among the other nodules, in case of mng. the probability of their detection on blind fnac would be low. but 50% were more than 1 cm in size. these cases if investigated by preoperative ultrasound guided fnac, would have yielded a positive diagnosis. multicenter studies using preoperative ultrasound guided fnac followed by histopathological detection of microcarcinomas in thyroids could further validate this study finding. this study was conducted in a single tertiary care center and thyroid scans were not considered in making preoperative diagnosis of mng as they were not performed on all patients. these are regarded as the major limitations of this study. c o n c l u s i o n the clinical diagnosis of mng is not an indicator of a benign process. incidental carcinomas can be seen in thyroids operated for mng. this study emphasizes the occurrence of incidental thyroid carcinomas in our settings and a need for strict adherence to a systematic approach in evaluating patients with thyroid enlargement. this should include ultrasound examination and fnac, and when required an ultrasound guided fnac. this calls for an intricate multidisciplinary coordination between the departments for better patient care. r e f e r e n c e s 1. delellis ra, lloyd rv, heitz pu, eng c, editors. pathology and genetics of tumors of endocrine organs. in: kleihues p, sobrin lh, series editors. who classification of tumours. lyon: iarc press; 2004. 2. khan a, nose v. in: lloyd rv, editor. endocrine pathology: differential diagnosis and molecular advances, 2nd ed. new york: springer 2010; p. 181– 236. doi: 10.1007/978-1-4419-1069-1. 3. abboud b, sader ghorra c, rassy m, el naderi s, traksmayra v, abadjian g, et al. epidemiological study of thyroid pathology in a university hospital. acta chir belg. 2015; 115(6): 414–7. doi: 10.1080/00015458.2015.11681143. 4. davies l, welch hg. current thyroid cancer trends in the united states. jama otolaryngol head neck surg. 2014; 140(4): 317–22. doi:10.1001/jamaoto.2014.1. 5. zuberi lm, yawar a, islam n, jabbar a. clinical presentation of thyroid cancer patients in pakistan-akuh experience. j pak med assoc. 2004; 54(10): 526-8. pmid 15552288. 6. bukhari u, sadiq s, memon j, baig f. thyroid carcinoma in pakistan: a retrospective review of 998 cases from an academic referral center. hematol oncol stem cell ther. 2009; 2(2): 345–8. doi: 10.1016/s1658-3876(09)50023-4. 7. pezzolla a, marzaioli r, lattarulo s, docimo g, conzo g, ciampolillo a, et al. incidental carcinoma of the thyroid. int j surg. 2014; 12: s98–102. doi: 10.1016/j.ijsu.2014.05.041. j islamabad med dental coll 2021 115 8. pradhan gb, shrestha r, shrestha s, neupane j, bhattachan cl. the incidence of thyroid carcinoma in multinodular goiter: prospective study. nepal med coll j. 2011; 13(3): 169–71. pmid 22808807. 9. mitchell al, gandhi a, scott-coombes d, perros p. management of thyroid cancer: united kingdom national multidisciplinary guidelines. j laryngol otol. 2016; 130(s2): s150–60. doi:10.1017/s002221511 6000578. 10. nguyen qt, lee ej, huang mg, park yi, khullar a, plodkowski ra. diagnosis and treatment of patients with thyroid cancer. am heal drug benefits. 2015; 8(1): 30–40. pmid 25964831. 11. knox ma. thyroid nodules. am fam physician. 2013; 88(3): 193–6. 12. cooper ds, doherty gm, haugen br, kloos rt, lee sl, mandel sj, et al. revised american thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. thyroid. 2009; 19(11): 1167–214. doi: 10.1089/thy. 2009.0110. 13. bombil i, bentley a, kruger d, luvhengo te. incidental cancer in multinodular goitre post thyroidectomy. s afr j surg. 2014; 52(1): 5–9. doi:10.7196/sajs.1970. 14. miccoli p, minuto mn, galleri d, d’agostino j, basolo f, antonangeli l, et al. incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease. anz j surgery. 2006; 76(3): 123-6. doi: 10.1111/j.1445-2197.2006. 03667.x. 15. qureshi ia, khabaz mn, baig m, begum b, abdelrehaman as, hussain mb. histopathological findings in goiter: a review of 624 thyroidectomies. neuro endocrinol lett. 2015; 36(1): 48–52. pmid 25789588. 16. fama f, sindoni a, cicciu m, polito f, piquard a, saintmarc o, et al. preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter. arch endocrinol metab. 2018; 62(2): 139-48. doi: 10.20945/23593997000000017. 17. memon w, khanzada tw, samad a, kumar b. incidence of thyroid carcinoma in multinodular goiters. rawal med j. 2010; 35(1): 65-7. 18. mahmud aurangzeb sh. total thyroidectomy for benign bilateral multinodular goitre in an endemic region. pak j surg. 2006; 22(4): 195-200. 19. ullah i, hafeez m, ahmad n, muahammad g, gandapur s. incidence of thyroid malignancy in multinodular goiter. j med sci. 2014; 22(4): 164–5. 20. waqar t, younas s, riaz f. incidental thyroid carcinoma in multinodular goitre. ann king edward med uni. 2006; 12(4): 477–9. doi: 10.21649/akemu.v 12i4.929. 21. karalus m, tamatea ja, conaglen hm, meyerrochow gy, conaglen jv, elston ms. rates of unsuspected thyroid cancer in multinodular thyroid disease. nzmj. 2018; 131(1468): 69–74. 22. mathai am, preetha k, devi sv, vicliph s, pradeep r, shaick a. analysis of malignant thyroid neoplasms with a striking rise of papillary microcarcinoma in an endemic goiter region. indian j otolaryngol head neck surg. 2017; 71: 121-30. doi: 10.1007/s12070017-1156-8. 23. yong js, loh ks, petersson bf, thong m. multinodular goiter: a study of malignancy risk in nondominant nodules. ear nose throat j. 2017; 96(8): 336–40. doi: 10.1177/014556131709600821. 24. pezzolla a, lattarulo s, milella m, barile g, pascazio b, ciampolillo a, et al. incidental carcinoma in thyroid pathology: our experience and review of the literature. ann ital chir. 2010; 81(3): 165-9. pmid 21105480. 25. gonzález-sánchez-migallón e, flores-pastor b, pérezguarinos cv, miguel-perelló j, chaves-benito a, illángómez f, et al. incidental versus non-incidental thyroid carcinoma: clinical presentation, surgical management and prognosis. endocrinol nutr. 2016; 63(9): 475-81. doi: 10.1016/j.endoen.2016.10.008. 26. kaliszewski k, strutyńska-karpińska m, zubkiewiczkucharska a, wojtczak b, domosławski p, balcerzak w, et al. should the prevalence of incidental thyroid cancer determine the extent of surgery in multinodular goiter? plos one. 2016; 11(12): e0168654. doi: 10.1371/journal.pone.0168654 27. mauriello c, marte g, canfora a, napolitano s, pezzolla a, gambardella c, et al. bilateral benign multinodular goiter: what is the adequate surgical therapy? a review of literature. int j surg. 2016; 28: s7-12. doi: 10.1016/j.ijsu.2015.12.041. j islamabad med dental coll 2022 247 open access perception of ethics and professionalism teaching among dental professionals at a teaching hospital in karachi rubab jawed1, ruqayyah quresh hashmi2, hafsa usman3, mehtab4, saba sabir5. 1assistant professor, baqai dental college, karachi, pakistan. 2registrar, baqai dental college, karachi, pakistan. 3,4,5house officer, baqai dental college, karachi, pakistan. a b s t r a c t background: health care professionals come across many ethically difficult situations in their clinical practices and community; the students should be equipped with skills to resolve ethical and professional issues. methodology: a cross-sectional study was conducted at baqai dental college, karachi. all the faculty members and house officers of the dental teaching hospital were included in the study. the tool used for the data collection was a structured questionnaire, for drawing views of the participants on professionalism and ethics teaching. the survey instrument evaluated two domains; attitudes 25 items, and goals 19 items on ethics and professionalism education. data were recorded and analyzed in spss 24. to compare the responses of both the groups, that is, the house officers and the faculty member’s independent t-test was applied to compare the mean scores. a p-value of ≤ 0.05 was considered significant. results: the questionnaire was circulated to a total of 157 participants (75 faculty members and 82 house officers) with a 100% response rate. the faculty members and the house officers showed a positive attitude regarding ethics, professionalism, and teachings. the participants agreed with the goals that can be achieved by incorporating professionalism and medical ethics in education. the participant strongly affirmed the learning and teaching of professionalism (4.06 ± 0.989). conclusion: the realization of the need to teach ethics and professionalism by dental professionals is the first step to bringing change in their daily clinical practice and interpersonal qualities. keywords: ethics, professionalism, “education, medical”, “personality development”, “social desirability”. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; ,4,5data analysis; manuscript editing. correspondence: rubab javed email: rubab13@baqai.edu.pk article info: received: december 18, 2020 accepted: december 9, 2022 cite this article.jawed r, hashmi r q ,usman h, mehtab, sabir s. perception of ethics and professionalism teaching among dental professionals at a teaching hospital. j islamabad med dental coll. 2022;11(4): 247-255. funding source: nil conflict of interest: nil doi: https://doi.org/10.35787/jimdc.v11i4.645 i n t r o d u c t i o n ethical values, conduct, it’s practice and it’s understanding is essential for any professional including doctors. the teachings of ethics are the instructions about the role of values in the relationship of a doctor with patients, colleagues, other providers, and society.1-3 healthcare professionals come across many ethically difficult situations in their clinical practices and community home healthcare services.4 the ethical standards remain the same, though the underlying ethical standards of different professions may differ.5 the principles of medical ethics in terms of patient treatment are not emphasized and therefore have a diminished role in the medical and dental student's o r i g i n a l a r t i c l e j islamabad med dental coll 2022 248 mind.6 the use of superior knowledge, skill, and judgment, which coincides with both good conduct and character for the benefit of another, without considering self-interest is professionalism. there are two broad categories of the curricula of ethics and professionalism, first, the students should be equipped with skills to resolve ethical or professional issues, and second, virtuous health professionals should be produced through character building.7 in the dental setting to achieve proper ethical conduct, the patient first should be treated as an individual, and the patient's needs and wants should be kept on priority.8 principles of medical ethics have been greatly refined and revolutionized in the western world, focusing on the concepts of autonomy, beneficence, non-maleficence, justice, informed consent, disclosure, and confidentiality.6 the health care settings have changed in recent years and all health professionals face ethical challenges in health care that put them at risk of ethical conflict, therefore a study was conducted in nepal in a nursing institute regarding the need assessment for teaching ethics.9 in a qualitative study conducted in karnataka, india the ethical challenges encountered were taking informed consent, excessive treatment, maintaining confidentiality, competence of dentist, expensive dental care, rigorous training of dentist, lack of knowledge, practice of defensive medicine and development of new technologies.10 several studies have shown that teaching medical ethics assists in producing morally grounded and principled health professionals.11 according to the beneficence (do good) principle of ethics the dentist must promote the patient welfare and therefore the most important aspect of this is the timely and competent delivery of dental care within the bounds of clinical circumstances presented by the patient with due consideration being given to the needs, desires and values of the patient.12 the teaching of ethics and professionalism may help improve the dental professionals, in dealing with the ethical dilemmas; they face in clinics and hospitals and help manage them accordingly. the teaching of ethics and professionalism has not been a significant part of the dental curriculum. with increasing emphasis on interprofessional health management and patient safety, it is important to know the perception of dental professionals regarding ethics and professionalism. this study will help in making decisions to include these in the curriculum which will ultimately help in the production of better dental professionals in the future. m e t h o d o l o g y a cross-sectional study was conducted at baqai dental college, karachi. the study was conducted during 6 months period from july – december 2019. all the faculty members and house officers were included in the study. census type of sampling was used only those faculty members and house officers were excluded from the sample who were on leave for more than 15 days. the total number of participants included in the study was 157 out of these 75 were faculty members and 82 were house officers. a pre-structured, validated questionnaire drawing opinions on ethics and professionalism education was spread among the participants. the questionnaire consists of two domains regarding professionalism and ethics education, the domains include attitudes (25 items), and goals(11 items).13 a likert-type scale, ranging from 1 ‘strongly disagree’ to 5 ‘strongly agree’ was used to rate the items of the questionnaire. informed written consent was obtained from all the participants. the ethical review board of baqai dental college granted ethical approval for the study. data was entered and analyzed through spss version 22.14 the mean and standard deviations (sd) of each item were calculated and the p-value was obtained by applying an independent t-test to find the difference between the two groups i.e. faculty and house officers regarding the attitudes and goals of medical ethics and professionalism. j islamabad med dental coll 2022 249 r e s u l t s the survey was distributed to a total of 157 participants (75 faculty members and 82 house officers), eighty-three male and seventy-four female participants. all completed the survey (100% response rate). table 1 illustrates the attitude of faculty members and house officers towards ethics and professionalism it included 25 statements to rate from ‘1’ strongly agree to ‘5’ strongly disagree. mean ± sd, 4.06 ± 0.989 for the response regarding professionalism can be taught and learned indicates that participants agree with it and they disagree with the fact that ethics cannot be taught and learned. table i: overall and comparison of faculty and house officer’s attitude towards ethics and its teaching sno questions overall faculty house officers p-value mean sd mean sd mean sd 1 professionalism can be taught and learned 4.02 0.97 3.91 1.042 4.11 .889 0.190 2 ethics cannot be learned or taught 2.24 1.13 2.19 1.036 2.29 1.222 0.560 3 the medical school curriculum ought to formally teach ethics 3.9 0.98 3.92 .912 3.87 1.039 0.730 4 by the time students arrive at residency, attitudes and values have already been defined 3.59 1.05 3.51 1.107 3.67 1.019 0.335 5 no right and wrong responses to ethical dilemmas questions 2.90 1.04 3.01 1.033 2.78 1.006 0.155 6 ethics is a discipline with its own procedures, writings, terms, and ideas. 3.83 0.89 3.63 .802 3.99 .923 0.10 7 family, culture and religion all influences one’s attitudes and values. 4.03 0.93 3.88 .944 4.22 .930 0.025 8 values and attitudes should not be the main focus of medical education for undergraduate level. 2.44 1.14 2.55 1.166 2.32 1.076 0.201 j islamabad med dental coll 2022 250 9 should possess professionalism 4.31 0.83 4.29 .897 4.35 .791 0.655 10 selection of residents should not include assessment of professionalism 2.56 1.18 2.60 1.294 2.54 1.102 0.741 11 assessment of professionalism should not be used in the selection of residents 3.87 0.83 3.91 .825 3.87 .857 0.762 12 ethical conflicts are common in the everyday practice of medicine 3.82 0.97 3.87 .977 3.76 .963 0.477 13 training in ethics does not help medical students deal with ethical conflicts 2.29 1.14 2.29 1.194 2.29 1.105 0.997 14 at various stages of their training, students deal with a variety of ethical dilemmas 3.85 0.88 3.91 .975 3.80 .808 0.476 15 medical training fosters unethical behavior 2.83 1.03 3.03 1.127 2.67 .944 0.033 16 medical training fosters professionalism 3.32 0.88 3.32 .961 3.37 .868 0.754 17 medical training fosters cynicism 3.11 0.92 3.12 .972 3.09 .849 0.812 18 students receive sufficient instructions in handling potential ethical issues 3.15 1.03 2.93 1.004 3.34 1.021 0.013 19 medical education should pay attention to attitudes, values and ethical dilemmas to avoid 3.75 0.86 3.68 .961 3.80 .777 0.370 j islamabad med dental coll 2022 251 developing cynicism 20 it is crucial that medical students and residents take an oath or make commitment to support the principles of their profession 3.90 1.07 3.81 1.205 4.00 .956 0.282 21 psychiatrists must abide by a different set of ethical guidelines than physicians 3.41 1.09 3.48 1.131 3.37 1.083 0.519 22 psychiatrists are subject to a more stringent set of ethical rules than other doctors 3.40 1.05 3.53 .963 3.28 1.125 0.134 23 physicians are more ethical than the general public 3.39 1.04 3.27 .963 3.51 1.114 0.143 24 most faculty doctors treat students with integrity 3.32 1.09 3.23 1.008 3.41 1.165 0.283 25 most faculty doctors treat patients with ethics 3.56 0.99 3.40 1.013 3.71 .962 0.053 table ii: ideas about the goal of education in professional and medical ethics. sno question overall faculty house officer p-value mean sd mean sd mean sd 1 to become better people 4.23 0.823 4.05 .914 4.39 .698 0.010 2 to better recognize ethical issues 4.08 0.859 3.88 .915 4.26 .767 0.006 3 to cultivate interpersonal abilities necessary for addressing ethical disputes 4.03 0.920 3.95 .943 4.10 .897 0.306 j islamabad med dental coll 2022 252 4 to acquire a working knowledge of social science, philosophy, religion, and law as they apply to clinical care 3.97 0.869 3.93 .859 4.01 .882 0.572 5 to improve patient care and clinical decision making 4.20 0.866 4.16 .823 4.23 .907 0.606 6 to avoid being negative and detached when speaking with patients 4.06 0.798 4.13 .704 4.00 .875 0.297 7 to more cearly define values-driven (irrational; biased by personal interests)decisions 3.75 0.875 3.79 .874 3.72 .879 0.632 8 to lessen the possibility a doctor may later commit a legal mistake 3.71 0.934 3.79 .843 3.65 1.011 0.349 9 to lower the possibility that a medical liability will be incurred by a doctort during practice 4.24 4.630 4.87 6.593 3.67 .944 0.106 10 to reduce the likelihood that a physician may make an ethical error in the future 3.88 0.950 3.91 .947 3.85 .957 0.728 11 to acquire the skills necessary to not only treat but also heal our patients 4.03 1.025 3.85 1.159 4.18 .862 0.044 table 2 displays the participant’s ideas about the goal of education in professional and medical ethics. they strongly agree that education in professional and medical ethics can bring up better professionals and; a better understanding of the ethical issues and ultimately that will help in improving patient care and clinical decision making. d i s c u s s i o n the present study provides an overview of the perception of dental professionals towards ethics and professionalism teaching at a dental teaching hospital in karachi. the ethical issues faced by dentists in today's society have become more j islamabad med dental coll 2022 253 complex and seems to arise more often than those faced by dentist in the past. given the current direction of health and dental care, the holistic approach to patient care and safety in regard to interprofessional collaboration and teamwork has become a significant part of training and practice. oral physicians have become an integral part of a medical team to provide treatment and rehabilitation to patients.15 working as a part of a team requires strong work ethics and an understanding of the code of conduct. hence, it was necessary to inquire about the readiness of dental students and faculty for teaching and practice. the results of this study affirm positive attitudes towards ethics education by the faculty members and the house officers. the results of the present study are in line with the other studies examining medical students, attitudes towards the subject of ethics, and identifying the need for its teaching.16 the similarity is most probably due to the same problems faced in clinical and hospital setups by all the health professionals and knowledge to tackle these ethical problems is important for the health professionals. in the present study majority of the participants agreed that teaching and learning professionalism and ethics can be carried out, they affirm that a physician should possess professionalism, they want that students should be evaluated by assessing professionalism in them, and they assented that medical training promotes ethical and professional behavior and most of the faculty act ethically towards students and patients, these results are in line with the results of a study conducted by tahra al mahmouda in the united arab emirates,13 in few other studies also show that participants agree towards the subject of ethics and its need of teaching.16-18. the positive attitude toward ethics and professionalism teaching is due to the increased awareness regarding the importance of ethics teaching and learning among health professionals, which will eventually help all health professionals including dentists to be successful in their practical life. during the training period in dentistry it is very important that along with the technical competence, future dentists should be trained to take care of the ethical values of the patient. the need to perform and validate their clinical training causes the students to concentrate more on their objectives rather than the patient's needs.19 the present study indicated the interest of dental professionals in ethics and professionalism teaching to produce better doctors, having a better understanding of the ethical issues, and how to deal with them. these results are consistent with the previous surveys that valued the teachings of ethics and professionalism. in a national survey conducted in the us, the medical students reported that to be a good doctor it is important to have good character and endorsed the idea that all medical educators should teach students ethics. few studies support character-based medical education, that is, the patient is interested in getting treatment from a physician who exhibits good behavior and positive character.5 the compassion of the dental professionals undergoes gradual erosion, whereas successful traineeship slowly gives way to cynicism, a certain psychological detachment, and a vision of the patient as an object of study.19 in our study, the participants agree that medical training fosters unethical behavior, professionalism, and cynicism. these results are parallel with the results of other studies that met similar criticism among medical students. it has been observed that attempts to inculcate professionalism among students may not have the desired impact due to the surrounding work environment. unprofessional behavior among faculty and trainers led to cynicism among students. the reason behind this was found to be a lack of effort in faculty development and accountability in these areas.7 a study conducted by siddiqui in lahore pakistan highlighted that, both the teachers and the students are too occupied in covering the j islamabad med dental coll 2022 254 cognitive knowledge that they are unable to spare time to practice the necessary skills, behavior, and attitude in pakistan.20 the present study shows no statistically significant difference in perception toward medical ethics and professionalism teaching between faculty and house officers. whereas a study conducted in a private institute in southern india revealed differences in knowledge, attitude, and behavior among the postgraduates, staff, and house surgeons. this difference is mainly because medical ethics and professionalism is taught as a part of the curriculum in postgraduate studies.21 ethics education is gradually being recognized by dentists as a solution for many of the challenges faced in the dental profession. in the present study, the faculty and house officers both agree that ethics teaching is an important aspect of training dentists to maintain the standards of their profession. it is also essential to ensure continued patient confidence in dentistry. this education needs to start early, be reinforced continually throughout students' graduate training, and continue after they embark upon their professional career. barry and anant bhan in their research paper emphasize on the quality of teaching in dental colleges and also highlighted that teaching professionalism should be an integral part of the curriculum.22 the results of a study conducted in dental schools of sudan are also in line with the present study reporting positive perception of students both in private and public schools towards ethics teaching23 c o n c l u s i o n the realization of the need to teach ethics and professionalism by dental professionals is the first step to bringing change in their daily clinical practice and interpersonal qualities. r e f e r e n c e s 1. miles sh, lane lw, bickel j, walker rm, cassel ckjam. medical ethics education: coming of age. 1989. 2. auf ai, awadalla h, ahmed me, ahmed mhjjoph, emergency. perception, barriers, and practice of research among teaching staff at five sudanese medical faculties. 2018;2(22):1-8. 3. bashir a, mctaggart ijjjotums. importance of faculty role modelling for teaching professionalism to medical students: individual versus institutional responsibility. 2022;17(1):112-9. 4. rasoal d, skovdahl k, gifford m, kihlgren a. clinical ethics support for healthcare personnel: an integrative literature review. hec forum : an interdisciplinary journal on hospitals' ethical and legal issues. 2017;29(4):313-46. 5. woodall ir, bentley jm. legal, ethical, and management aspects of the dental care system. 1987. 6. farooq w, jafarey a, arshad ajtpjom, dentistry. awareness of medical ethics principles and their applications among healthcare professionals in pakistan. 2018;7(4):8-. 7. carey gb, curlin fa, yoon jdjbrn. medical student opinions on character development in medical education: a national survey. 2015;8(1):455. 8. bruscino tjtaodl, training o. basic ethics in dentistry. 2012:16-25. 9. piryani rm, piryani s, poudel rs, sharma mjabr. needs assessment for teaching/learning nursing ethics for master of nursing students. 2016;8(2):13442. 10. kemparaj vm, panchmal gs, jayakumar h, kadalur ugjjoe, dentistry ei. qualitative assessment of ethical issues in dental practice: an expert opinion. 2016;6(1):20. 11. imran n, haider ii, jawaid m, mazhar njjopmi. health ethics education: knowledge, attitudes and practice of healthcare ethics among interns and residents in pakistan. 2014;28(4). 12. rice mejtjotada. the ethics of presenting a fair and honest treatment plan. 2017;148(4):277-8. 13. almahmoud t, hashim mj, elzubeir ma, branicki fjmeo. ethics teaching in a medical education environment: preferences for diversity of learning and assessment methods. 2017;22(1):1328257. 14. morgan ga, leech nl, gloeckner gw, barrett kc. spss for introductory statistics: use and interpretation: psychology press; 2004. 15. gilbert jh, yan j, hoffman sjjjoah. a who report: framework for action on interprofessional education and collaborative practice. 2010;39(3):196-7. j islamabad med dental coll 2022 255 16. olukoya ajme. attitudes of medical students to medical ethics in their curriculum. 1983;17(2):83-6. 17. lehrmann ja, hoop j, hammond kg, roberts lwjap. medical students’ affirmation of ethics education. 2009;33(6):470-7. 18. al-abdulrazzaq d, al-fadhli a, arshad ajbme. advanced medical students’ experiences and views on professionalism at kuwait university. 2014;14(1):1-7. 19. tenenbaum a, moutel g, wolikow m, vial-dupuy a, azogui-levy sjjoisop, dentistry c. implementation of a medical ethics course in undergraduate dental education and assessment of knowledge and attitudes. 2020;10(5):569. 20. siddiqui f, malik aa. medical professionalism and culturally sensitive issues: thinking ahead for the future medical graduates. jpma the journal of the pakistan medical association. 2022;72(1):141-5. 21. deolia sg, prasad k, chhabra kg, kalyanpur r, kalghatgi sjjoc, jcdr dr. an insight into research ethics among dental professionals in a dental institute, india-a pilot study. 2014;8(9):zc11. 22. schwartz b, bhan ajijme. professionalism and challenges in dental education in india. 2005;2(4):119-21. 23. elsheikh nma, osman ima, husain ne, abdalrahman sma, nour h, khalil aa, et al. final year dental students' perception and practice of professionalism and ethical attitude in ten sudanese dental schools: a cross-sectional survey. journal of family medicine and primary care. 2020;9(1):87-92. j islamabad med dental coll 2020 235 open access symptom analysis of confirmed covid-19 patients at allied hospitals of rawalpindi medical university, pakistan javaria malik1, muhammad khurram2, arsalan manzoor mughal3, noman ahmed chaudhary4, qaiser aziz5, muhammad mujeeb khan6, muhammad shahzad manzoor7 1senior registrar, department of medicine, rawalpindi medical university & allied hospitals, pakistan 2 professor, department of medicine, rawalpindi medical university & allied hospitals, pakistan 3 assistant professor, department of anatomy, rawalpindi medical university & allied hospitals, pakistan 4 house officer, rawalpindi medical university, pakistan 5consultant, department of medicine, rawalpindi medical university & allied hospitals, pakistan 6associate professor, department of infectious diseases, rawalpindi medical university & allied hospitals, pakistan 7professor, department of medicine, rawalpindi medical university & allied hospitals, pakistan a b s t r a c t background: coronavirus can cause respiratory disease ranging from mild upper respiratory tract illness to severe pneumonia, acute respiratory distress syndrome, and death. the purpose of this research was to analyze the relationship of gender and age with symptoms of covid-19 disease. material and methods: this cross-sectional study was conducted at the rawalpindi institute of urology and transplantation (riut), rawalpindi medical university, rawalpindi pakistan during the month of march, 2020. consecutive sampling methodology was used, and all real-time polymerase chain reaction (rt-pcr) confirmed patients of covid-19 were included. data regarding age, gender, and symptoms with onset was recorded and analyzed using chi-square and student t-tests with p-value ≤ .05 considered as significant. results: ninety-eight patients, 68 (69.4%) males and 30 (30.6%) females were included in the study. fifty-five (56.1%) were symptomatic and the rest were asymptomatic. mean duration of symptoms in symptomatic cases was 2.8±1.1 days. of these, 60 (61.85%) were older than 40 years and 17 (17.34%) had a history of travel. fever and persistent cough were reported by more than 50% patients. fatigue, sore throat, shortness of breath and myalgias and headaches were reported by 32-21% patients. nausea, vomiting, runny nose, sputum, diarrhea and anorexia were reported by less than 11% patients. fever, dyspnea and nausea was more in individuals over 40 years. dyspnea was more in males and fatigue was more in females. conclusions: many of our covid-19 infected patients were symptomatic with fever and cough as the most common symptoms. fatigue, sore throat, shortness of breath, myalgias and headaches were also reported by some patients. nausea, vomiting, runny nose, sputum, diarrhea and anorexia were the least reported symptoms. individuals older than 40 years are more likely to be symptomatic, regardless of gender. recognition of the pattern of these symptoms is essential for early diagnosis and management of the disease. key words: coronavirus, cough, covid-19, fever, symptoms. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-7data analysis; manuscript editing. correspondence: arsalan manzoor email: arsalanmanzoor@gmail.com article info: received: june 20, 2020 accepted: december 15, 2020 cite this article. malik j, khurram m, mughal am, chaudhary na, aziz q, khan mm, manzoor ms. symptom analysis of confirmed covid-19 patients at allied hospitals of rawalpindi medical university, pakistan. j islamabad med dental coll. 2020; 9(4): 235-241. doi: 10.35787/jimdc.v9i4.607 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 236 i n t r o d u c t i o n coronavirus belongs to the family coronaviridae.1,2 coronavirus disease 2019 (covid-19) is a respiratory disease caused by a novel coronavirus that was first reported in december, 2019 at wuhan, china. this highly infectious disease manifests at first as dry cough, fever, myalgia and difficulty in breathing. on the other side of the spectrum, this disease may manifest as acute respiratory distress syndrome, septic shock, bleeding and coagulopathy.3,4 though coronaviruses are generally thought to be zoonotic, covid-19 is believed to spread from human to human.5,6 this virus has been spreading very quickly and has prevailed over more than 180 countries and territories causing more than 1.9 million cases and 123010 deaths worldwide until april 15, 2020. in pakistan, 5988 confirmed cases and 107 deaths have been reported so far.7,8,9 symptom-based evaluation of covid-19 patients in our population is deficient. the use of laboratory investigations for diagnosis of covid-19 infection needs to be on a large scale, keeping in mind the pandemic nature of the disease.10 this can exhaust resources of even the developed countries let alone the developing ones. in this situation, an understanding of covid-19 symptomatology becomes an utmost necessity for the initial screening of suspected cases and to prioritize them for further investigations. the objective of this study was to note the symptoms of real-time polymerase chain reaction (rt-pcr) confirmed covid-19 patients. additionally, the age group wise differences in symptomatology were also sought. m a t e r i a l a n d m e t h o d s this cross-sectional, observational study was conducted at rawalpindi institute of urology and transplant (riu&t), which is the covid-19 patient management center of rawalpindi medical university (rmu), rawalpindi pakistan, during march 2020. ethical approval was obtained from the institutional research forum of rawalpindi medical university. informed consent was taken from the patients. by consecutive sampling, 98 rt-pcr positive, confirmed cases of covid-19 were included in the study. patients with comorbidities such as chronic respiratory and hematological illnesses, neoplastic disorders, endocrinopathies, immunodeficiency states, gastrointestinal diseases, and cardiovascular disease were excluded. five patients were excluded from the study due to presence of comorbidities. asymptomatic patients were followed up regularly to observe the development of symptoms. after their discharge, they were also contacted through telephone to confirm their asymptomatic status. age, gender, symptoms and their duration, and travel history were sought from all the patients. data was entered and analyzed using statistical package for social sciences (spss) version 25.0. quantitative variables like age and duration of symptoms were reported as mean and standard deviation. qualitative ones like gender, symptoms, and travel history were recorded as frequencies and percentages. the presence or absence of symptoms and the individual symptoms were compared between, age groups, gender, and travel history. individual symptoms were also compared between different age groups. chi-square and student t-tests were used for this purpose. p-value ≤ .05 was considered significant. r e s u l t s out of the 98 patients, 55 (56.1%) were symptomatic and the rest were asymptomatic. mean duration of symptoms in symptomatic cases j islamabad med dental coll 2020 237 was 2.8±1.1 days. median time from symptom onset to admission was 3 days. sixty-eight (69.4%) were male and 30 (30.6%) were females. of these 39 (57.4%) males and 16 (53.3%) females were symptomatic, respectively. the mean patient age was 45.5±17.8 years with 38 (38.77%) were younger than 40 years and 60 (61.85%) older than 40 years. of these 20 (52.6%) and 35 (58.3%) patients were symptomatic in each group, respectively. seventeen (17.34%) had a history of travel with 68.8% symptomatic while 81 (83.50%) did not have a travel history with 53.1% symptomatic individuals (table i). fever and persistent cough were observed in more than 50% of the patients as shown in figure 1. fatigue, sore throat, shortness of breath, myalgias and headaches were reported by 32.7%, 29.1%, 27.3%, 27.3% and 21.8% of our patients. nausea, vomiting, runny nose, sputum, diarrhea and anorexia were reported by less than 11% patients. there was a significant difference in the presence or absence of fever between age groups with only 26.3% of the under 40-year-old having fever as compared to 48.3% of over 40-year-olds (p = .03) (table ii). regarding presence or absence of dyspnea, 2.6% of under 40-year-olds had dyspnea as compared to 23.3% of over 40-year-olds (p = .006). the difference in the presence of dyspnea between genders was significant with 20.6% males reporting dyspnea compared to 3.3% females (p = .029) (table ii). there was a significant difference between age groups in the presence or absence of nausea (p = .044), as well as presence or absence of fatigue between genders (p = .011) (table iii). figure 1: symptoms of patients presenting with covid-19 table i: comparison of age, gender and travel history of symptomatic and asymptomatic patients parameter total n=98 (100%) symptomatic n= 55 (56.1%) asymptomatic n= 43 (43.87%) p-value* mean age (years) 45.5±17.8 46 ± 15.8 44.93 ± 19.46 .774 age quartiles (years) <40 38 (38.77%) 20 (52.6%) 18 (47.4%) .579 ≥40 60 (61.22%) 35 (58.3%) 25 (41.7%) gender male 68 (69.38%) 39 (57.4%) 29 (42.6%) .712 female 30 (30.61%) 16 (53.3%) 14 (46.7%) history of travel yes 17 (17.34%) 11 (68.8%) 6 (31.3%) .249 no 81 (82.65%) 43 (53.1%) 38 (46.9%) *p-value < .05 was considered statistically significant table ii: relationship of fever and dyspnea with age groups and gender variable fever n (%) no fever n (%) p-value* dyspnea n (%) no dyspnea n (%) p-value* age quartile <40 years old 10 (26.3) 28 (73.7) .03 1 (2.6) 37 (97.4) .006 ≥40 years old 29 (48.3) 31 (51.7) 14 (23.3) 46 (76.7) gender male 29 (42.6) 39 (57.4) .385 14 (20.6) 54 (79.4) .029 female 10 (33.3) 20 (66.7) 1 (3.3) 29 (96.7) *p-value < .05 was considered statistically significant j islamabad med dental coll 2020 238 table iii: relationship of fatigue and nausea with age groups and gender variable fatigue present n (%) no fatigue n (%) p-value* nausea n (%) no nausea n (%) p-value* age quartile <40 years old 6 (15.8) 32 (84.2) 0.600 0 (0) 38 (100) 0.044 ≥40 years old 12 (20) 48 (80) 6 (10) 54 (90) gender male 8 (11.8) 60 (88.2) 0.011 3 (4.4) 65 (95.6) 0.288 female 10 (33.3) 20 (66.7) 3 (10) 27 (90) *p-value < .05 was considered statistically significant d i s c u s s i o n clinical features of covid-19 may vary depending on the region. they may differ even in the same country. according to a study, clinical features of covid-19 at wuhan were different from those in other areas of china, at least in the initial period of the pandemic.10 the reason behind this might be the different host, environment and agent factors. important findings of our study are male preponderance, mean age less than 40 years, only 60% of covid-19 patients managed were symptomatic, fever and shortness of breath were commonest symptoms noted in more than 50% patients, and anorexia, myalgia and fatigue were relatively uncommon symptoms. males show a comparatively weaker immune response to infectious agents as compared to females.11-15 this is due to the difference in hormones between the sexes, the difference in the number of copies of x-linked genes related to immunity, and the difference in the disease susceptibility genes between males and females.11,12 this and possibly more outdoor exposure may increase the chances of male gender predominance with reference to covid-19 infection as has been noted in various studies.16,17 in a chinese covid-19 analysis focusing 44,672 confirmed patients, male to female ratio was 54.4%:48.6%.18 we also noted male predominance in our study with 69.4% of the male patients. around 40% of our patients were less than 40 years old. according to an analysis, 27.2% of covid-19 patients managed in china were younger than 40 years and 86.6% patients were in the age range of 30-79 years.18 in the study by huang et al., the median age was 49 years while in the study by xu et al., it was 41 years.10,16 the reason for the lesser median age in our patients is that the pakistani population mainly consists of younger persons with a median age of 22.8 years.20 travel history of countries where covid-19 infection is prevalent is important in the context of the spread of infection. according to a study, travel history is more important than chest radiograph findings for early detection and isolation.21 the first case in the usa had also traveled from china.22 about a quarter of our patients had a positive travel history while the rest had locally transmitted infections. interestingly none had visited china. persons with rt-pcr confirmed covid-19 infection who neither had any symptoms at the time of test nor did they showed any symptoms on follow-up were termed as asymptomatic laboratoryconfirmed cases. about 5%-80% of persons who are mostly children and young adults are tested positive, but do not have symptoms according to an analysis.23 asymptomatic cases are important in the spread of the disease as a false sense of security might compromise the practice of preventive measures. asymptomatic patients can also be a source of continuous infection and a sustained level of infected cases in the community. they can become a hurdle in complete eradication of the disease even if the pandemic is over. according to j islamabad med dental coll 2020 239 who, although asymptomatic transmission of covid-19 is rare according to the available data, but it cannot be ignored.24 a study reports the transmission of covid-19 from one asymptomatic family member to five members of the same family.25 more than forty percent of our covid-19 confirmed cases were asymptomatic. out of these, 47.4% were less than 40 years old. a better immune response can be the reason for the same in young infected persons.26 in a study by xu et al., cough (81%) and fever (77%) were the commonest symptoms.10 in another study by huang et al., fever was present in 98%, cough in 76%, and sputum production in 28.6% of the patients.16 about 1.4-7.6% of mild and 32.6% of severe covid-19 infected patients complained of shortness of breath.27 according to menni et al., anosmia was present in 59.4% of covid-19 cases.28 out of the 56% symptomatic cases in our study, fever (61.9%) and cough (57%) were most frequently noted. we did not observe anosmia in any patient. in our study, fatigue, anorexia, and myalgia were least reported symptoms, although these have been reported in 44-50% of covid-19 patients.10,16 interestingly, anorexia and myalgia were significantly more common in our older patients. time from symptom onset to admission in our patients was three days. this is lesser than the median time of 6.5 days reported in a previous study.10 this might be due to the anxiety of the community towards minor symptoms of the disease, when mild to moderate disease can be managed safely at home. this study focused on laboratory-confirmed covid19 patients as riu&t is the center point of such patient management of the rawalpindi district of pakistan. the majority of these patients were diagnosed with contact tracing rather than attending a health care facility for symptoms. this along with the fact that many infected persons are asymptomatic may have skewed our findings. additionally, a smaller sample is a limitation. this however, has to be kept in mind that to our knowledge this study is the first of its kind in our country that can help in the standardization of covid-19 symptoms for improving symptom-based initial screening. due to lack of specific treatment until now and the role of conservative management in mild to moderate symptoms of covid-19, the rush to hospitals can be discouraged, which will prevent the spread of the disease. c o n c l u s i o n many of our covid-19 infected patients were symptomatic. fever and cough were the commonest symptoms in these patients. fatigue, sore throat, shortness of breath, myalgias and headaches were also reported by some. nausea, vomiting, runny nose, sputum, diarrhea and anorexia were the least reported symptoms. individuals older than 40 years are more likely to be symptomatic regardless of gender. recognition of the pattern of these symptoms is essential for early diagnosis and management of the disease. a c k n o w l e d g m e n t we would like to acknowledge the efforts of all our colleagues who are fighting against the covid-19 pandemic. r e f e r e n c e s 1. fehr ar, perlman s: coronaviruses: an overview of their replication and pathogenesis. methods mol biol. 2015; 1282: 1-23. doi: 10.1007/978-14939-2438-7_1. 2. q&a on coronaviruses (covid-19) [internet]. who.int. 2020 [cited 27 march 2020]. available from: https://www.who.int/news-room/q-adetail/q-a-coronaviruses. 3. the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china. zhonghua liu xing bing xue za zhi. 2020; j islamabad med dental coll 2020 240 41(2): 145-51. doi: 10.3760/cma.j.issn.02546450.20 20.02.003. 4. chen n, zhou m, dong x, qu j, gong f, han y, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395(10223): 507-13. doi: 10.1016/s01406736(20)30211-7. 5. chan jf-w, yuan s, kok kh, to kk, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet 2020; 395(10223): 514523. doi: 10.1016/s0140-6736(20)30154-9. 6. zhou p, yang xl, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020; 579(7798): 270-3. doi:10.1038/s415860202012-7. 7. who.int. 2020 [cited 15 april 2020]. available from: https://www.who.int/docs/defaultsource/coronaviruse/situationreports/2020041 5-sitrep-86-covid-19.pdf?sfvrsn=c615ea20_2 8. covid.gov.pk. 2020 [cited 8 april 2020]. available: from: http://covid.gov.pk/ 9. naming the coronavirus disease (covid-19) and the virus that causes it [internet]. who.int. 2020 [cited 8 april 2020]. available from: https://www.who.int/emergencies/diseases/ novel-coronavirus2019/technicalguidance /naming-the-coronavirus-disease-(covid-2019)and-the-virus-that-causes-it 10. xu xw, wu xx, jiang xg, xu kj, ying lj, ma cl, et al. clinical findings in a group of patients infected with the 2019 novel coronavirus (sars-cov-2) outside of wuhan, china: retrospective case. bmj. 2020; 368: m606. doi: 10.1136/bmj.m606 11. klein sl, flanagan kl. sex differences in immune responses. nature rev immunol. 2016; 16(10): 626–38. doi: 10.1038/nri.2016.90.. 12. rettew ja, huet-hudson ym, marriott i. testosterone reduces macrophage expression in the mouse of toll-like receptor 4, a trigger for inflammation and innate immunity. biol reprod. 2008; 78(3): 432–37. doi: 10.1095/biolreprod. 107.063545. 13. roberts cw, walker w, alexander j. sexassociated hormones and immunity to protozoan parasites. clin microbiol rev. 2001; 14(3): 476–88. doi: 10.1128/cmr.14.3.476488.2001. 14. garcia-gomez e, gonzalez-pedrajo b, camachoarroyo i. role of sex steroid hormones in bacterial-host interactions. biomed res intl. 2013; 2013: 928290. doi: 10.1155/2013/928290. 15. bouman a, heineman mj, faas mm. sex hormones and the immune response in humans. hum reprod update. 2005; 11(4): 411–23. doi: 10.1093/humupd/dmi008. 16. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020; 395(10223): 497–506. doi: 10.1016/s 0140-6736(20)30183-5. 17. mers clinical features [internet]. centers for disease control and prevention. 2020. https://www.cdc.gov/coronavirus/mers/clinical features.html 18. the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) — china, 2020[j]. china cdc weekly, 2020, 2(8): 113-22. 19. robinson dp, huber sa, moussawi m, roberts b, teuscher c, watkins r, et al. sex chromosome complement contributes to sex differences in coxsackievirus b3 but not influenza a virus pathogenesis. biol sex differ. 2011; 2: 8. doi: 10.1186/2042-6410-2-8. 20. pakistan population worldometer: worldometers.info.2020.https://www.worldom eters.info/worldpopulation/pakistanpopulation/ 21. kim jy, choe pg, oh y, oh kj, kim j, park sj, et al. the first case of 2019 novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures. j korean med sci. 2020; 35(5): e61. doi: 10.3346/jkms.2020.35.e61. 22. holshue ml, debolt c, lindquist s, lofy kh, wiesman j, bruce h, et al. first case of 2019 novel coronavirus in the united states. n engl j med. 2020; 382(10): 929-36. doi: 10.1056/nejmoa2001191. 23. covid-19: what proportion are asymptomatic? cebm [internet]. cebm. 2020. https://www.cebm.net/covid-19/covid-19-what -proportion-are-asymptomatic/ 24. who.int. 2020. https://www.who.int/docs/ default-source/coronaviruses/situation-reports /20200402-sitrep-73-covid-19.pdf? sfvrsn=5ae25bc7_2 25. bai y, yao l, wei t, tian f, jin d, chen l, et al. presumed asymptomatic carrier transmission of covid-19. jama. 2020; 323(14): 1406-07. doi: 10.1001/jama.2020.2565. j islamabad med dental coll 2020 241 26. simon ak, hollander ga, mcmichael a. evolution of the immune system in humans from infancy to old age. proc biol sci. 2015; 282(1821): 20143085. doi:10.1098/rspb.2014.3085. 27. young be, ong swx, kalimuddin s, low jg, tan sw, loh j, et al. epidemiologic features and clinical course of patients infected with sars cov-2 in singapore. jama. 2020; 323(15):14881494. doi: 10.1001/jama.2020.3204. 28. menni c, valdes am, freidin mb, ganesh s, moustafa js, visconti a, et al. loss of smell and taste in combination with other symptoms is a strong predictor of covid-19 infection. nat med. 2020; 26: 1037–40. doi: 10.1038/s41591-0200916-2 radiological images paediatric chest and cardiovascular system fig 1: respiratory distress syndrome fig 2: meconium aspiration syndrome fig 3: pneumothorax fig 4: congenital diaphragmatic hernia fig 5: congenital lobar emphysema on left side fig 6: tetrology of fallot (boot shaped heart) fig 7: persistant ductus arteriosus (left to right shunt) fig 8: ebstein anomaly (box shaped heart) fig 9: total anomalous pulmonary venous return (snow man sign) fig 10: transposition of great vessels (egg on string appearance). contributed by: prof dr manal niazi head department of radiology islamabad medical and dental college 194 j i m d c 2 0 1 7 194 diabetes and the role of tertiary care hospitals usman zafar assistant professor of medicine, islamabad medical and dental college, islamabad diabetes mellitus is a worldwide health problem affecting more than 415 million individuals; this estimate is expected to be projected to 642 million individuals by end of the year 2040. diabetes prevalence, deaths attributable to diabetes, and health expenditure due to diabetes continue to rise across the globe with important social, financial and health system implications.1 in cross-sectional survey conducted in urban and rural areas of four provinces of pakistan, the overall prevalence of glucose intolerance (diabetes mellitus and impaired glucose tolerance) was estimated as 22.04% in urban and 17.15% in rural areas. the major risk factors of diabetes mellitus identified were increasing age, positive family history and obesity especially central obesity.2 in another limited survey published from the area of dir (kpk) in the year 2016, similar rising trends of the disease were verified.3 the prevalence is higher among males than in females and more common in urban areas compared to the rural areas.4 these results imply that almost every fourth adult pakistani is now suffering from this disease and total numbers are estimated to be above 35 million. this is very alarming news which really calls for some extra ordinary response at the level of government, institutions and individuals alike. diabetes mellitus is associated with wide ranging and devastating complications, affecting almost all organs and tissues in the body, particularly manifesting with macrovascular (atherosclerosis) and microvascular (renal, ophthalmic, etc.) complications. the high prevalence of the disease is very much reflected by a high percentage of bed occupancy in almost all the discipline of medicine in any hospital. tertiary care hospitals (tchs) have traditionally played a role in the management of diabetes by looking after chronically ill patients who usually come with complications. as the number of diabetics in the country has almost quadrupled from the previous estimates and there are only thin efforts to contain this tide, we think that tchs should adopt a very proactive, coordinated and multidisciplinary approach to management of the disease. these hospitals are the places where people, most well versed with this problem, are actually found. these are the people whose input would be very valuable at this juncture. in addition to managing the admitted patients with uncontrolled diabetes and those who have presented with complications, every tch should run an elaborate outpatient diabetic clinic, where the following services are available in an integrated manner:  laboratory services for diagnosis of the disease and its control  advice for control of the disease  early detection of complications  prompt and easily available services of nephrologists, ophthalmologists, surgeons, neurologists and cardiologists, as and when required  extended family screening of the index patient for diabetes mellitus and impaired glucose tolerance it is proposed that a model of community out-reach programme is established through patients admitted in inpatient departments and those attending the diabetic clinics. these clinics should be used as hubs focusing on mass education, risk identification, capacity building, advocacy and prevention of the disease thereby guiding the patients, their family members and the public at large. in addition, the research departments of all these institutions should aim at epidemiological study of the disease in surrounding areas. keeping under consideration that diabetes is a polygenic disease, there are many questions which need to be addressed; some of these need to be probed into: e d i t o r i a l 195 j i m d c 2 0 1 7 195  why there has been such a steep rise in diabetes?  is there anything in our food which is causing the problem?  how our social habits have changed and what is their impact?  how are we inherently different for getting diabetes and what genes confer this susceptibility? all these questions need to be answered and their answers can only determine the way we combat diabetes. these are the new avenues of research and hospitals should come forward for this with a collaborative effort of their different departments. early screening for complications like retinopathy, nephropathy and neuropathy should be done in all diabetic patients to prevent complications and more centres in the country should be established for the training in endocrinology to serve people at district level hospitals.5 diabetes is an important cause of mortality and morbidity, and it should be managed at all levels of medical care.6,7 it should be particularly prevented and treated at primary care level and our gps need to be more prepared in this regard. hospitals should play a role in equipping the surrounding primary medical care providers with a locally relevant knowledge base for identifying high risk population, preventing diabetes and then properly managing the disease. the liaison between general practice and hospitals needs to be reorganized, even on the initiative of the second party. primary prevention of diabetes is a practical and cost-effective method of reducing incident diabetes in populations of varied ethnicity and biological characteristics.8 r e f e r e n c e 1. ogurtsova k, da rocha fernandes jd, huang y, linnenkamp u, guariguata l, cho nh, cayan d, shah je and makaroff le. idf diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. diabetes research and clinical practice. 2017;128:40-50) 2. shera as, jawad f, maqsood a. prevalence of diabetes in pakistan. diabetes res clin pract. 2007;76(2):219-22. 3. akhtar s, khan z, rafiq m, khan a. prevalence of type ii diabetes in district dir lower in pakistan. pak j med sci. 2016;32(3):622-625 4. meo sa, zia i, bukhari ia, arain sa. type2 diabetes mellitus in pakistan: current prevalence and future forecast. j pak med assoc. 2012;66(12):1637 1642 5. mahar sa and shahid m. diabetes care in pakistan a real challenge (editorial). jlumhs.2014(13):1-2 6. shaw je, sicree ra, zimmet pz/ global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract 2010; 87:4–14 7. zimmet pz, magliano dj, herman wh, shaw je. diabetes: a 21st century challenge. lancet diabetes endocrinol 2014;2:56–64 8. ramachandran a, snehalatha c. diabetes prevention programs. med clin north am 2011;95:353–372 javascript:void(0); javascript:void(0); https://www.ncbi.nlm.nih.gov/pubmed/?term=shera%20as%5bauthor%5d&cauthor=true&cauthor_uid=17005289 https://www.ncbi.nlm.nih.gov/pubmed/?term=jawad%20f%5bauthor%5d&cauthor=true&cauthor_uid=17005289 https://www.ncbi.nlm.nih.gov/pubmed/?term=maqsood%20a%5bauthor%5d&cauthor=true&cauthor_uid=17005289 https://www.ncbi.nlm.nih.gov/pubmed/17005289 j islamabad med dental coll 2020 158 open access diagnostic value of transthoracic ultrasonography for covid-19 pneumonia: a cross-sectional study abdul rasheed qureshi1,2, huma bilal3, muhammad sajid3, zeeshan ashraf4 1 head, department of pulmonology, gulab devi teaching hospital lahore, pakistan 2 director, institute of biotechnology, gulab devi educational complex lahore, pakistan 3 medical officer, gulab devi teaching hospital lahore, pakistan 4 lecturer, department of statistics, gulab devi educational complex lahore, pakistan a b s t r a c t background: corona virus infection requires early detection and precise diagnosis for an effective control in community . covid-19 pcr is the gold standard diagnostic test having low sensitivity and adequate availability constraints. because of high false negative rate, a large number of undetected patients remain a constant source of inadvertent disease dissemination in the community. this study was conducted to determine the diagnostic usefulness of transthoracic ultrasonography for the detection of covid-19 pneumonia during the ongoing pandemic. material and methods: this cross-sectional study was conducted in the pulmonology opd of gulab devi teaching hospital, lahore-pakistan from april 1, 2020 to july 30, 2020. a total of 237 patients with dry cough, fever and shortness of breath of sudden onset, clinically diagnosed as covid-19 pulmonary infection, were included in the study. patients were investigated with chest x-ray/hrct, transthoracic ultrasonography, covid-19 rt-pcr on nasopharyngeal samples and hematological tests. sensitivity, specificity, ppv (positive predictive value), npv (negative predictive value) and diagnostic accuracy of transthoracic ultrasonography was calculated with p-value <0.05 considered as statisticall y significant. spss-26 software was used for statistical analysis. results: of the total 237 patients (mean age 41.23±17.5 years) presenting with complaints of a pulmonary infection, 228 were diagnosed as covid-19 pulmonary infection by transthoracic ultrasonography and pcr. bilateral lesions and b-lines were the most frequent characteristic features on ultrasonography (n=237 patients; 100%). transthoracic ultrasound diagnosed 228 patients as cases of covid-19 pneumonia with 100% sensitivity, 66.67% specificity, 98.7% ppv, 100% npv, and 98.73% diagnostic accuracy. only 135/228 (59.21 %) patients were diagnosed by rt-pcr. the pvalue by fisher exact test was highly significant at 0.001 (cut-off pvalue <0.05). conclusions: transthoracic ultrasonography is a useful diagnostic tool with a high sensitivity, is free from radiation exposure and capable of providing foundations for evidence based, early detection of coronavirus pneumonia in a pandemic situation. key words: coronavirus pneumonia, diagnostic accuracy, pandemic, transthoracic ultrasonography authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: abdul rasheed qureshi email: drrasheed57@gmail.com article info: received: june 29, 2020 accepted: september 15, 2020 cite this article. qureshi ar, bilal h, sajid m, ashraf z. diagnostic value of transthoracic ultrasonography for covid-19 pneumonia: a prospective study. j islamabad med dental coll. 2020; 9(3): 158-167. doi: 10.35787/jimdc.v9i3.581 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 159 i n t r o d u c t i o n the outbreak of unusual viral pneumonia started in china, in december 2019 and was later on recognized as coronavirus disease -2019 (covid19).1 by the end of july 2020, this fatal disorder had infected about 170,53,642 patients globally with a death toll of 6,66,461 people, worldwide. covid-19 disease was subsequently declared as a public health emergency of international concern (pheic) by who (world health organization).2 this disease is highly contagious and number of cases multiplied rapidly over the globe. according to the current literature, one infected patient may lead to more than two new patients and at times the disease is too drastic to be controlled and the outcome is disastrous. coronavirus infection has affected not only the general public but senior health care providers and eminent figures from the society have been lost to this lethal disease. at the end of july, there were 279,146 confirmed cases and 5,970 mortalities in pakistan, indicating the load and damage caused by this devastating sickness. presentation of covid-19 disease ranges from mild to extensive, requiring mechanical ventilation. early diagnosis is essential for effective control to preclude further dissemination. covid-19 rt-pcr (reverse transcription polymerase chain reaction) is the gold standard diagnostic test, which has high specificity but low sensitivity of around 60%, meaning that about 40% cases with disease are missed.3 furthermore, this test is not capable of calculating the magnitude of the disease and the expected decline in respiratory functions. chest xray pa view can identify moderate to severe disease but is unable to detect early involvement because less than 3.0 mm nodule is not resolved by cxr (chest x-ray). in this way, a large number of patients are not diagnosed and remain a constant source of inadvertent dissemination within the community. many researchers have been recommending the use of hrct (high-resolution computed tomography) chest as a screening tool for covid-19 pneumonia in the setting of an epidemic.4 hrctchest can provide immediate results with a high sensitivity and adequate specificity for covid-19 pneumonia, but it is neither cost-effective nor feasible and safe for use in pregnant patients and children due to hazards of ionizing radiations.5 similarly, due to same reasons, cxr with limited sensitivity and specificity, cannot be considered as an alternative tool for detecting covid-19 pneumonia. the ultrasound, using sound waves rather than ionizing radiations, with no deleterious effect on young children and pregnant patients, can be used safely without any fear of mutagenic e ffects. recently, researchers have indicated the usefulness of transthoracic ultrasound for detecting covid-19 pneumonia. particularly, chinese and italian task forces have recommended that pulmonary ultrasound can be a useful tool for diagnosing and monitoring the course of covid-19 pneumonia.6,7 chest ultrasonography is under-used in pakistan due to lack of adequate understanding and training in the field. although, it is being adequately used for the detection and aspiration of pleural fluid but its use in detecting pulmonary parenchymal lesions is still in the beginning phase. according to research reports on hrct, covid-19 pneumonic lesions are distributed in peripheral part of the lung, which can be easily recognized by chest ultrasound. 8 it has also been reported that transthoracic ultrasonography is superior to cxr and hrct for the investigation of pneumonia with an added advantage of use at point of care, easy availability, cost-effectiveness, repeatability and absence of radiation exposure.9 j islamabad med dental coll 2020 160 b-lines are generated by interaction of ultrasound waves with sub-pleural consolidation or irregular pleural margins, indicating covid-19 pulmonary disease, in the setting of an epidemic. but these lines can also be seen in other interstitial diseases of various etiologies.10-12 the chinese authors named this sign as “waterfall”, without further elaborating it.13 the use of bedside ultrasound could reduce the need of cxr and hrct and shows amazing results during the follow-up of pneumonia. the current study was conducted to determine the diagnostic usefulness of transthoracic ultrasonography for the detection of covid-19 pneumonia, during the ongoing pandemic. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in the pulmonology department of gulab devi teaching hospital, lahore pakistan (a 1500-beded tertiary care hospital in the heart of lahore, the capital city of punjab) from april 1, 2020 to july 30, 2020. after obtaining informed consent, 237 patients with oneweek history of dry cough, fever and shortness of breath (of sudden onset) and a presumptive diagnosis of covid-19 pulmonary infection were included in the study. patients with bronchial asthma, tuberculosis, bronchiectasis, copd, ild, and overt heart failure were excluded. sample size was calculated with the help of online open-epi calculator for cross-sectional studies. a sample size of 234 was calculated against the prevalence of 16.3%14 with a confidence interval of 95%. but we included 237 patients to compensate for the missing data. ethical approval was obtained from institutional review board of the hospital (vide: no. admin/gdec/20/326). the patients were subjected to x-ray chest pa view and transthoracic ultrasound. all patients underwent routine hematological tests including white blood cell count, lymphocyte count, c-reactive protein, serum ldh, ferritin and d-dimer test in pertinent cases. nasopharyngeal samples from patients were tested with rt-pcr for covid-19. xray and hrct chest images were evaluated. transthoracic ultrasonography was performed by qualified and experienced radiologist using sonovista fx (siemens) and toshiba-japan machines with convex and linear probes, utilizing 3-12-mhz frequency. guidelines of world federation for ultrasound in medicine and biology (wfumb) for performing a safe ultrasonographic examination and ensuring use of clean equipment in the covid-19 scenario were strictly followed during the study. 15 patients were scanned in supine and sitting positions. anterior, lateral and posterolateral scanning was performed. anterior scanning was done between parasternal and anterior axillary lines. area for lateral scanning was located between anterior and posterior axillary lines while posterolateral scanning was done beyond the posterior axillary line, in subscapular and interscapular regions. all regions were scanned in upper and lower parts. following sonographic signs were noted: any scan with regular sliding, a-lines all over the chest and absent b-lines, was considered as normal lung scan. a covid-19 scan included11,13,16 (figure-1): 1. bilateral patchy involvement; 2. b-lines which are vertical lines, originating from pleural surface, running down to the lower edge of the screen without fading away. these lines can be single, multiple, discrete or confluent (figure -2); 3. bilateral patchy b-lines, appearing and disappearing during inspiration and expiration, looking like on-off phenomenon of a light beam; 4. a cluster of b-lines creating the appearance of white -lung (figure-2); 5. irregular or fragmented pleural line with preserved sliding sign (figures 1 & 2); 6. sub-pleural patchy consolidations of variable sizes with a light beam and irregular pleural line; 7. pleural effusion-uncommon sign. j islamabad med dental coll 2020 161 cxr, hrct, ultrasound-findings, rt-pcr reports, demographic and clinical data of 237 patients were recorded on a proforma. clinical diagnosis was established by correlating clinicopathological data and diagnostic accuracy of covid-19-pcr and transthoracic ultrasound was calculated by considering clinical diagnosis as reference. sensitivity, specificity, ppv (positive predictive value), npv (negative predictive value), diagnostic accuracy and p-value were calculated for both modalities. spss-26 software was used for statistical analysis. quantitative data was represented by means and standard deviations and categorical variables were expressed by frequency (percentage). fisher exact test was used for comparison and a p-value < 0.05 was considered as significant. r e s u l t s this study included 237 patients with a mean age of 41.23 years ± 17.5 (age range 18 to 87 years). about 126 cases (53.16%) were above the age of 50 years. of these, 144 patients were male while 93 were female with a male to female ratio of 1.54. all patients showed positive history of contact from their familial clusters. patients presented with typical respiratory complaints as shown in table i. history of cigarette smoking was found in 67 (28.27%) patients, diabetes mellitus in 77 (32.48%) and obesity was seen in 17 cases (7.17%), respectively. about 163 patients (68.77%) displayed elevated crp levels with mean crp level of 9.6 + 6.8 mg/dl. in only 135/237 (56.96%) patients, covid-19, pcr-test was positive. of the 237 clinically diagnosed cases, 231 were diagnosed covid-19 pneumonia by transthoracic ultrasonography while 06 reports were equivocal. all cases displayed bilateral radiological abnormalities (table i). the b-line morphology revealed 111 (46.83%) separate b-lines, 103 (43.46%) confluent and 23 (9.7%) compact b-lines, respectively. anterior scan was positive in 64 patients (27%) while 173 cases (73%) exhibited abnormal findings in lateral and posterior scans. maximum findings were found in posterior scans in inter-scapular and subscapular regions. detailed radiological morphologies and their frequencies were recorded (table i). regarding disease severity, 64.97% patients had mild disease, 31.22% moderate while only 3.79% had severe disease. about 228 cases were diagnosed as covid-19 pulmonary infection on clinical grounds by correlating ultrasound findings, history, physical examination, pcr and blood reports. rt-pcr performed on nasopharyngeal samples detected covid-19 in 135 patients (135/228; 59.21%). bilateral shadows were noted in 126 chest x -rays while 111 reports were unremarkable. efficacy of rt-pcr was calculated by considering the clinical diagnosis as reference and 135 tp (true -positive) cases, 00 (zero) fp (false positive) cases, 93 fn (false negative) cases and 09 tn (true negative) cases (table ii). similarly, efficacy of transthoracic ultrasound was determined by considering tp: 228, fp 03, fn: 00 and tn cases: 06 (table ii). table i: frequency distribution of clinical and ultrasound features on transthoracic ultrasonography in covid-19 patients (n=237) clinical features n (%) high grade fever 189 (79.74) dry cough 137(57.80) shortness of breath 209 (88.18) muscle pain and weakness 170 (71.72) chest pain 71 (29.95) headache 46 (19.40) diarrhea 27 (11.39) ultrasound features n (%) bilateral lesions 237 (100) b-lines 237 (100) pleural surface irregularities 206 (86.91) sub-pleural consolidation 183 (77.21) pleural effusion 01 (0.42) pericardial effusion 00 pneumothorax 01 (0.42) j islamabad med dental coll 2020 162 figure 1: ultrasound morphology of covid-19 pulmonary infection. a: b-lines, b: irregular pleural line, b-lines, bilateral haze, c: sub-pleural consolidation, irregular pleura and b-lines. d: irregular pleura and b-lines. e: consolidation with air-bronchogram. f: consolidation without air-bronchogram. j islamabad med dental coll 2020 163 table ii: diagnostic accuracy of pcr and ultrasound for covid-19 pneumonia (n=237) efficacy of rt-pcr statistics value (%) 95% confidence interval sensitivity 59.21 52.53 to 65.65 specificity 100 66.37 to 100 ppv 100 npv 8.82 7.64 to 10.17 diagnostic accuracy 60.76 54.23 to 67.02 efficacy of transthoracic ultrasonography sensitivity 100 98.40 to 100 specificity 66.67 29.93 to 92.51 ppv 98.70 96.79 to 99.48 npv 100 diagnostic accuracy 98.73 96.35 to 99.74 ppv-positive predictive value; npv-negative predictive value the p-value by fisher exact test was highly significant at .001 (cut-off pvalue < 0.05). figure 2: b-line morphology in covid-19 pneumonia. a: compact b-line. b: white lung sign. c: multiple confluent blines. d: multiple discrete b-lines. j islamabad med dental coll 2020 164 d i s c u s s i o n in the background of low detection rate of covid-19 pulmonary disease by rt-pcr, this study highlights the usefulness of transthoracic ultrasonography with superior efficacy which can be a benchmark for evidence-based management and good disease control in the community. the age of the study population (n=237 patients) ranged between 18 to 87 years. mean age was 41.23 years (± 17.52), which is comparable to the report of hu and co-authors (mean age 39.2 years + 9.6) from wuhan, china.17 the male gender preponderance of this study is in agreement with the published studies of lomoro et al. and bhandari et al.18,19 the reduced susceptibility of females to covid-19 infection could be due to the protection from x-chromosome and sex hormones, providing innate and adaptive immunity.20 in this study, 126 patients (53.16%) were above the age of 50 years, indicating that this age can be a relative risk factor for covid-19 pulmonary disease. similarly, co-morbidities like obesity, cigarette smoking and diabetes mellitus, collectively accounting for 161 cases, may have a positive association with the respiratory disease, which is well supported by the literature.21,22 about 64.97% patients had mild disease while less than 4% cases had severe covid-19 pneumonia. this finding may be due to weak virulence of the virus, and may be a cause for a fatality rate of less than 3% in asia as compared to european countries and the usa where case fatality rate ranged between 10-15%.23 rt-pcr is regarded as the gold standard diagnostic test but has low sensitivity of around 60%, due to which it is unable to detect 40% patients with disease. these patients feel satisfied with the negative report, attribute their symptoms to minor ailments, do not seek any medical help for the fatal disorder and remains a constant source of inadvertent disease dissemination in the community and non-covid-19 wards. these patients may enter silently into severe covid-19 pulmonary disease, requiring mechanical ventilation. in this study, only 135 patients (59.21%) were diagnosed by pcr while 93 cases (40.79%) were missed. chest x-ray detected disease in 53.16% cases while 46.83% were equivocal but abnormal findings were noted on hrct of the same patients. this finding is in agreement with the report of jacobi and coauthors.24 the low sensitivity of cxr may be, because, majority of our cases belonged to mild category with subtle disease which could not be manifested on cxr.25 the efficacy of hrct is superior to those of cxr and pcr (around 90%) but the issues of cost, unavailability and exposure to ionizing radiations are main constraints. as this virus is highly contagious and very unpredictable in behavior, its control needs early diagnosis for timely isolation or quarantine. not every covid-19 patient requires mechanical ventilation on the first day of infection. it takes ample time for developing mild to severe covid-19 disease. the track of transition from mild to severe disease can be blocked by early diagnosis and prompt management. in these circumstances, there is an urgent need of some alternative high sensitivity test, capable of detecting the disease early and with precision. on the other hand, lung ultrasound has shown superior sensitivity for acute respiratory distress syndrome.26 because of peculiar ultrasound features, it can successfully be used for early approach to covid-19-suspects. in italy, lung ultrasound has been proposed as an alternative to hrct for patients suspected of having covid-19.27,28 although, ultrasound signs for covod-19 are not as specific as rt-pcr, but correlation with history and j islamabad med dental coll 2020 165 blood tests in the milieu of a pandemic provide adequate specificity. b-lines, the earliest manifestation, correspond to ground glass appearance on hrct can be of tremendous help for timely isolation and triage of the suspects. 29 in this study, ultrasound patterns like pleural irregularities, sub-pleural consolidation and vertical artifacts (b-lines), discrete, confluent and white lung, pointing towards ards were encountered. with further disease progression, consolidation with air-bronchogram sign was exhibited. by serial scanning, progression or resolution of the disease can be assessed successfully. only one case of pleural effusion and pneumothorax each, was noted. pleural effusion was bilateral and cardiogenic, secondary to coronary bypass surgery, superimposed by covid-19. pleural effusion is not common in covid-19 but huang et al. reported that it may be noted in severe covid-19 pneumonia.30 more than 50% pneumothorax was found on the left side in a 72-year-old male patient of severe pulmonary covid-19 with diabetes mellitus, which is a rare complication. when identified, there is always evidence of positive pressure ventilation, but our patient developed pneumothorax on the day third of the fever, without any ventilation. probability of pneumothorax is due to advanced alveolar damage, bronchiolar distortion and narrowing resulting in bullae formation while dry irritating cough, increases the intrapulmonary pressure, precipitating bullae rupture and pneumothorax. literature search showed that the sensitivity of pcr is as low as 60%, which can be enhanced utilizing tracheal aspirates or bal (broncho-alveolar lavage) but there is a very high risk of aerosolization and disease transmission to healthcare workers during these procedures.31,32 transthoracic ultrasound is free of such drawbacks and capable of providing rapid and valuable information for triaging isolation and treatment procedures. the current study displayed the efficacy of transthoracic ultrasound with 100% sensitivity, 66.67% specificity and 98.73% diagnostic accuracy for pulmonary covid-19 disease. the comparative efficacy revealed low sensitivity of rt-pcr. there is a statistically significant difference between the two modalities and the results show that ultrasound has remarkable capability of detecting covid-19 pulmonary disease during an epidemic. thoracic ultrasonography has numerous advantages over cxr and hrct like, being a bed-side procedure, widely available, inexpensive, easily performed, no involvement of ionizing radiation or contrast medium and widely accepted by the patient. it can be tremendously useful in scenarios where hrct is not available or undesirable, especially in pregnancy and immobile patients. in summary, b-lines, consolidation and pleural line abnormalities are common abnormal findings in covid-19 pneumonia. bilateral involvement is frequent, maximum findings are found in posterior scan in inter-scapular and sub-scapular regions. that is why lung ultrasound could serve as a safe and valuable tool for the detection and follow -up of covid-19 disease. we have no hesitation in suggesting that chest ultrasound can be used during an epidemic, especially where high sensitivity, reliable laboratory testing tool for covid-19 infection is not available. we hope, this study findings can facilitate early identification and good management of symptomatic and suspected covid-19 pneumonia cases by judicious use of ultrasound thorax, under strict biosafety measures. limitation: the main limitation of our study is that it is a single center study performed on a limited sample size, hence the study may not reflect the full range of sonographic morphology and distribution patterns of covid-19 pulmonary disease. to further elucidate, a multi-center study with a larger sample j islamabad med dental coll 2020 166 size can additionally explore the sonographic behavior of this disease. c o n c l u s i o n transthoracic ultrasonography, having high sensitivity for covid-19 pulmonary infection, is an excellent modality with a positive role in early detection and management of pulmonary coronavirus disease during pandemic. it precludes radiation hazards and is of tremendous help as point-of-care evaluation tool in immobile patients. a c k n o w l e d g m e n t the authors are thankful to dr. shahid raza and muhammad tahir for their valuable co-operation during the study. r e f e r e n c e s 1. chen n, zhou m, dong x, qu jm, gong fy, han y, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395(10223): 507-513. doi: 10.1016/s0140-6736(20)30211-7 2. world health organization, 2020. novel coronavirus (2019-ncov) situation report-1. available at: https://www.who.int/emergencies /diseases/novelcoronavirus-2019/situation-reports. accessed june 5, 2020. 3. kanne jp. chest ct findings in 2019 novel coronavirus (2019-ncov) infections from wuhan, china: key points for the radiologist. radiol. 2020; 295(1): 200241. doi:10.1148/radiol.2020 200241 4. ai t, yang z, hou h, zhan c, chen c, lv w, et al. correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases. radiol. 2020; 296(2): e32 –e40. 5. moro f, buonsenso d, moruzzi mc, inchingolo r, smargiassi a, demi l, et al. how to perform lung ultrasound in pregnant women with suspected covid19 infection. ultrasound obstet gynecol. 2020; 55(5): 593-598 doi: 10.1002/ uog.22028 6. peng qy, wang xt, zhang ln. chinese critical care ultrasound study group (ccusg). findings of lung ultrasonography of nove l corona virus pneumonia during the 2019-2020 epidemic. intensive care med 2020. 46(5): 849-850. doi: 10.1007/s00134 -02005996-6. 7. soldati g, smargiassi a, inchingolo r, buonsenso d, perrone t, briganti df, et al. is there a role for lung ultrasound during the covid-19 pandemic? j ultrasound med 2020; 39(7): 1459 -1462. doi: 10.1002/ jum.15284 8. han x, jiang n, cao y, alwalid o, gu j, fan y, et al. radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study. lancet infect dis. 2020; 20(4): 425-34. doi:10.1016/s1473-3099(20)30086-4 9. shah vp, tunik mg, tsung jw. prospective evaluation of point-of care ultrasonography for the diagnosis of pneumonia in children and young adults. jama pediatr. 2013;167(2):119–25. 10. volpicelli g, lamorte a, villén t. what’s new in lung ultrasound during the covid-19 pandemic. intensive care med. 2020; 46: 1445–1448. doi: 10.1007/s00134-020-06048-9 11. volpicelli g, gargani l. sonographic signs and patterns of covid-19 pneumonia. ultrasound j. 2020; 12: 22. doi: 10.1186/s13089-020-00171-w 12. reissig a, copetti r, mathis g, mempel c, schuler a, zechner p, et al. lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. chest. 2012; 142(4): 965–72. doi: 10.1378/chest.120364 13. tan g, lian x, zhu z, wang z, huang f, zhang y, et al. use of lung ultrasound to differentiate coronavirus disease 2019 (covid-19) pneumonia from community-acquired pneumonia. ultrasound med biol. 2020; 46(10): 2651-2658. doi: 10.1016/j.ultrasmedbio.2020. 05.006. 14. accuracy of lung ultrasound in the diagnosis of covid19 pneumonia (pocusars-cov-2) . https://clinicaltrials.gov/ct2/show/nct04370275 15. abramowicz js, basseal jm. world federation for ultrasound in medicine and biology position statement: how to perform a safe ultrasound examination and clean equipment in the context of covid-19. ultrasound med biol. 2020; 46(7): 1821 -6. doi: 10.1016/j.ultrasmedbio.2020.03 .033 j islamabad med dental coll 2020 167 16. huang y, wang s, liu y, zhang y, zheng c, zheng y, et al. a preliminary study on the ultrasonic manifestations of peripulmonary lesions of non critical novel coronavirus pneumonia (covid-19) (february 26, 2020). doi: 10.2139/ssrn.3544750. available at ssrn: https://ssrn.com/ abstract =3544750 17. hu q, guan h, sun z, huang l, chen c, ai t, et al. early ct features and temporal lung changes in covid-19 pneumonia in wuhan, china. eur j radiol. 2020; 128: 109017. doi:10.1016/j.ejrad. 2020.109017 18. lomoro p, verde f, zerboni f, simonetti l, borghi c, fachinetti c, et al. covid-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and ct: single-center study and comprehensive radiologic literature review. eur j radiol open. 2020; 7: 100231. doi:10.1016/j. ejro.2020.100231 19. bhandari s, singh a, bagarhatta m, rankawat g, dube a, kakkar s, et al. evaluation of clinico– radiological profile and correlation with ultrasonography of the chest in coronavirus disease 2019 pneumonia. indian j med spec 2020; 11(2): 70 5. doi: 10.4103/injms.injms_ 55_20 20. jaillon s, berthenet k, garlanda c. sexual dimorphism in innate immunity. clin rev allergy immunol. 2019; 56(3): 308 –321. doi: 10.1007/ s12016-017-8648-x 21. wang xf, shi gc, wan hy. clinical features of three avian influenza h7n9 virus-infected patients in shanghai. clin respir j. 2014; 8(4): 410 –416. doi: 10.1111/crj.12087 22. kornum jb, thomsen rw, riis a, lervang hh, schønheyder hc, sørensen ht. diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study. diabetes care. 2008; 31(8): 1541-1545. doi:10.2337/dc080138 23. salahuddin n. the covid-19 pandemic. jpma. 2020; 70(5), s4-6. doi: 10.5455/jpma.02 24. jacobi a, chung m, bernheim a, eber c. portable chest x-ray in coronavirus disease -19 (covid-19): a pictorial review. clin imaging. 2020; 64: 35-42. doi: 10.1016/j.clinimag.2020.04.001 25. aljondi r, alghamdi s. diagnostic value of imagin g modalities for covid-19: scoping review. j med internet res. 2020; 22(8): e19673. doi: 10.2196/19673 26. peng q, wang x, zhang l. findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. intensive care med. 2020; 46(5): 849-850 doi: 10.1007/s00134020-05996-6 27. lichtenstein da, malbrain mlng. lung ultrasound in the critically ill (luci): a translational discipline. anaesthesiol intensive ther. 2017; 49(5): 430 -436. doi:10.5603/ait. a2017.0063 28. poggiali e, dacrema a, bastoni d, tinelli v, demichele e, ramos pm, et al. can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid-19) pneumonia? radiology . 2020; 295(3): e6. doi: 10.1148/radiol. 2020200847 29. soldati g, smargiassi a, inchingolo r, buonsenso d, perrone t, briganti df, et al. is there a role for lung ultrasound during the covid-19 pandemic? j ultrasound med. 2020; 39(7): 1459 -62. doi: 10.1002/jum.15284 30. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020; 395(10223): 497-506 doi: 10.1016/s01406736(20)30183-5. 31. fang y, zhang h, xie j, lin m, ying l, pang p, et al. sensitivity of chest ct for covid-19: comparison to rt-pcr. radiology 2020; 296(2): e115 -e117. doi: 10.1148/radiol.2020200432 32. wölfel r, corman vm, guggemos w, seilmaier m, zange s, müller ma et al. virological assessment of hospitalized patients with covid-2019. nature . 2020; 581(7809): 465 -469. doi:10.1038/s41586020-2196-x j islamabad med dental coll 2020 233 o p e n a c c e s s ibn-e-sina’s “canon of medicine” syed irfan ahmed professor and head, department of medicine, islamabad medical & dental college, islamabad pakistan perhaps the most famous philosopher-scientist of a thousand years hence was ibn-e-sina (avicenna) who was born near bukhara in 980 ad. while his writings on astronomy, islamic theology, mathematics as well as poetry gained fame, it is for his contribution in medicine that he is remembered. al-qanun (the canon of medicine), his most famous work on the subject was the standard textbook for students and practitioners alike, both in east and west and taught in medical schools of baghdad and europe right up to the 18th century.1 al-qanun consists of five books, each subdivided into fanns, then fasl and finally maqala. book one deals with the constitution and parts of human body. common afflictions, with their causes, complications and treatment are also described here. materia medica is dealt with in the second book. diseases affecting a specific part of the body, or entire body as in fever, are highlighted in books three and four respectively. pharmacology, with a formulary of compound medications is outlined in book five.1 in avicenna’s own words: “my plan is to deal with the general aspects of each of the two divisions of medicine, the speculative and the practical. then i shall treat of the general principles applicable to the diagnosis of the properties of the simples, following this with a detailed account of them. then i shall take up the disorders which befall each individual member, beginning with an account of its anatomy and that of its auxiliary. the anatomy of several members and their auxiliaries is dealt with in the first book. having completed the account of the anatomy, i shall show the health of member is to be maintained.” “this subject being completed, i proceed to a general discourse about general diseases, their causes, the signs by which they are recognized and the modes of treatment. after this, i pass on to the special diseases and will point out in as many cases as possible.2 i. the general diagnosis of their characters, causes and signs. ii. the special diagnostic features. iii. the general rules of treatment by a. singles, b. compounded medicines” the section on “the urine” is very extensive and outlines in great detail various points about its collection, characters, variations in normality, abnormalities, relationship to various disease states and methods of examination. “points to observe in a sample of urine are quantity, odor, color, foam, texture, clarity and sediment.” these points are then discussed in detail with reference to their pathological significance. ibn-e-sina’s description of the pulse is remarkably close to what is practiced in present times. method of examination of the pulse at the wrist is described in great detail, with special reference to rate, rhythm, condition of the vessel walls, “emptiness” e d i t o r i a l correspondence: syed irfan ahmed email: irfan.ahmad@imdcollege.com cite this editorial: ahmed si. ibn-e-sina’s “canon of medicine. j islamabad med dental coll. 2020; 9(4): 233-234 doi: 10.35787/jimdc.v9i4.629 j islamabad med dental coll 2020 234 or “fullness” of successive beats and the pauses or intermissions, whether regular or irregular.2 according to dr. o. cameron gruner, the author of “treatise on the canon”, a delightful classic, the canon of medicine of avicenna has an esteemed position in modern thought. the importance of idea over material achievement is not to be forgotten. the accomplishments of any age are subject to decay with the lapse of eras, but the ideas which give rise to them remain living through all cycles. it is agreed that there is an elevated place for avicenna in modern thought and he shall be viewed as one, who was entrusted with a mission to express for that age, by means of various tools he found in it, an unchanging and impersonal wisdom. today, there is the need that this wisdom should be re-expressed for this age by means of the new data, which lie in our hands.3 r e f e r e n c e s 1. habib m, ahmed si. prince of physicians. the life and times of ibn-e-sina (avicenna). islamabad, 2017. 2. shah mh. the general principles of avicenna’s canon of medicine. karachi, 1966. 3. gruner oc. a treatise on the canon of medicine of avicenna. london, 1930. special edition, the classics of medicine library, birmingham, alabama, 1940 journal of islamabad medical & dental college (jimdc); 1211(1):41-47 41 review article dengue fever saeed alam,* naghmi asif **, and huma mushtaq*** * prof of pathology, islamabad medical & dental college, islamabad ** assistant prof pathology, islamabad medical & dental college, islamabad *** assistant prof pathology, islamabad medical & dental college, islamabad (bahria university, islamabad) dengue fever (df) is the most common viral disease transmitted by the arthropods.1 dengue fever manifests as flu like illness affecting all age groups including infants, children and adults. dengue hemorrhagic fever (dhf) is a life threatening complication of dengue characterized by high fever, hemorrhagic phenomena, thrombocytopenia and sometimes circulatory failure.2 early diagnosis is essential, based mainly on history, physical examination and laboratory investigations. there is mortality rate of 1-5% in untreated cases and in less than 1% with treatment. however with severe disease the mortality rate reaches to 26%.3 dengue and dhf are fast emerging as a global health problems. 4 dengue is endemic in more than 110 countries. it affects 50 to 100 million people worldwide a year with half a million hospitalizations and almost 12,500-25,000 deaths.5 the incidence of dengue has increased 30 folds between 1960 and 2010. factors responsible for dengue’s spread include explosive population growth, unplanned urban overpopulation with inadequate public health systems and poor vector control. epidemiology in pakistan dengue virus is now endemic in pakistan with a peak incidence in the post monsoon period. introduction of a new serotype (den-3) and a genotypic shift of endemic serotype (den-2) are the most probable factors for the recent outbreak of dhf in this region.6 first confirmed outbreak of dhf in pakistan was reported from karachi in 1994 and in the following year an epidemic of df occurred in baluchistan. 7,8 later, a large outbreak occurred in 2006 in karachi.9 in 2011, more than 15,000 cases have been recorded in lahore alone with a high mortality rate. transmission dengue fever virus (denv) is an rna virus of the family flaviviridae; genus flavivirus. most are transmitted by arthropods (mosquitoes or ticks). there are four serotypes of the virus; these are referred to as denv-1, denv-2, denv-3 and denv-4. all four serotypes can cause the full spectrum of disease. infection with one serotype is believed to produce lifelong immunity to that serotype but only short term protection against the others.10 the severe complications on secondary infection occur particularly if someone previously exposed to one serotype then contracts another serotype.11 in pakistan the genotypes denv-2 and denv-3 were found to be prevalent. the reservoirs for dengue are both man and mosquito (aedes aegypti). man acts as a host. the viremia among humans builds up high titers two days before the onset of the fever and lasts 5–7 days after the onset of the fever. it is only during these two periods that the vector species get infected. thereafter, the humans become dead-end for transmission. aedes aegypti mosquito generally acquires the virus while feeding on the blood of an infected person and transmits disease to another non infected person. it is primarily a daytime feeder and lives around human habitation. 12 the mosquitoes breed in stored, exposed, water collection systems and other dark places. pathogenesis the pathogenesis of dhf is poorly understood. abnormal immune response has the major role in its pathogenesis. production of cytokines or chemokines: these include c3a, c5a, tnf-α, il-2, il-6, il-10, interferon-α and histamine 13 activation of t lymphocytes: the level of t-cell activation is enhanced particularly in secondary dengue infection. many dengue specific t cells have low affinity for other, probably previously encountered serotypes. profound t cell activation may suppress or delay viral elimination leading to higher level of viral loads and thus enhanced symptoms seen in dhf. antibody mediated immune response: it has been observed that certain strains of dengue virus complex with non neutralizing antibodies and enter the mononuclear cells. infected monocytes release vasoactive mediators resulting in increased vascular permeability and hemorrhagic manifestations that characterize dhf and dengue shock syndrome (dss). halstead described the antibody dependent enhancement upon the second infection with dengue virus.14 antibodies directed against dengue virus also cross react with human platelets and endothelial cells.15 increased platelet destruction, platelet dysfunction and endothelial cell dysfunction are also the result of cross reactivity between these antibodies to platelet gylcoproteins and endothelial cells. passively transferred antibodies: antibodies, predominantly of the igg1 subclass, are the only journal of islamabad medical & dental college (jimdc); 1211(1):41-47 42 immunological substances known to be transferred from mother to fetus.16 the fact that infants fail to develop clinical dengue illnesses until around 6 months of age accords with the presence of broadly reactive dengue neutralizing antibodies in their mothers’ serum samples and the protection afforded by passively transferred dengue antibodies. 17 table 1: clinical and laboratory findings in dengue fever course of illness febrile phase critical phase recovery phase days of illness 1-3 4-5 6-10 clinical findings dehydration bleeding/sh ock organ impairment reabsorption hematocrit n ↑↑ n platelet count n ↓↓ n viremia present absent absent serology negative positive positive mechanism o various manifestations: studies have shown that median age of dengue patients has decreased now and younger patients may be more susceptible. severity of disease depends on virus strain, previous infection, host genetics and age. epidemic potential is dependent on level of viremia, infectivity and virus serotype. dhf risk is the greatest for den-2; followed by den-3, den-4 and den1, respectively.18 various factors underlie the clinical manifestations of dhf. 1. plasma leakage: the plasma leakage is due to the increased vascular permeability induced by several mediators such as c3a and c5a during the acute febrile stage and this is more pronounced during toxic stage. the evidence of plasma leakage includes hemoconcentration, hypoproteinemia/hypoalbuminemia, pleural effusion, ascites and shock. sometimes the rising hematocrit may not be evidenced because of either severe bleeding or early intravenous fluid administration. 2. bleeding tendency: the bleeding diathesis is caused by:  vasculopathy  thrombocytopenia/ platelet dysfunction  coagulopathy a. vasculopathy: a positive tourniquet test indicating the increased capillary fragility is found in the early febrile stage. it may be a direct effect of dengue virus as it appears in the first few days of illness during the viremic phase. b. thrombocytopenia and platelet dysfunction: thrombocytopenia is almost always present in patients with dengue. patients with dhf usually have platelet counts less than 100×109/l. bone marrow suppression combined with increased peripheral destruction of platelets during the febrile and early convalescent phase of dengue disease are two important factors leading to profound thrombocytopenia.19 thrombocytopenia is most prominent during the toxic stage. however, during the recovery period, platelet count rises due to return of marrow cellularity. in the absence of substantial bleeding prophylactic platelet transfusions should be avoided to minimize risk of long-term complications. 20 platelet dysfunction is another factor leading to bleeding. the platelet dysfunction might be the result of exhaustion from platelet activation triggered by immune complexes containing dengue antigen, absence of adenosine diphosphate (adp) release and impaired platelet aggregation response to adp. an increase in plasma-thromboglobulin and platelet factor4, indicating increased platelet secretary activity have also been observed. 21 c. coagulopathy: the coagulopathy associated with dengue infections is well described. several groups have noted the presence of plasminogen cross-reactive antibodies and fibrinolytic activity during and after dengue infection. during the acute febrile stage, mild prolongation of the prothrombin time (pt) and partial thromboplastin time (aptt), as well as reduced fibrinogen levels, have been reported.22 variable reductions in the activities of several coagulation factors, including prothrombin, factors v, vii, viii, ix and x, antithrombin and antiplasmin, have also been demonstrated. fibrin degradation product or d-dimer may be elevated. low levels of anticoagulant proteins c and s and antithrombin iii were found to be associated with increasing severity of shock, presumably due to plasma leakage. elevated levels of tissue factor, thrombomodulin and plasminogen activator inhibitor-1 reflect endothelial, platelet and/or monocyte activation and may be a secondary response to direct activation of fibrinolysis by the dengue virus. release of heparin like substances e.g. heparan sulphate or chondroitin sulfate might also contribute to the overall picture.23 thrombocytopenia together with these abnormalities correlates with overall severity of disease. the coagulation abnormalities however are well compensated in the majority of patients without circulatory collapse.24, 25 clinical manifestations clinical course of dengue infection changes as the disease progresses. dengue virus infection may be asymptomatic or may cause undifferentiated febrile illness (viral syndrome), dengue fever, or dengue hemorrhagic fever including dengue shock syndrome (dss). (figure1) various diseases (viral/bacterial/parasitic) may mimic dengue fever and should be considered in differential diagnosis while evaluating a patient with suspected dengue. incubation journal of islamabad medical & dental college (jimdc); 1211(1):41-47 43 period is 4–6 days (range 3–14 days). after an incubation period full spectrum of disease develops and is followed by 3 phases. (table 1)  febrile phase  critical phase  recovery phase febrile phase: after an incubation period, various nonspecific, symptoms are seen. these include headache, backache and general malaise. typically, the onset of df is sudden with a sharp rise in temperature (usually lasting 5–7 days, occasionally accompanied by chills). other manifestations include retro-orbital pain, photophobia, backache, and pain in the muscles and joints/bones, anorexia, constipation, colicky pain and abdominal tenderness, dragging pain in the inguinal region, sore throat and general depression. these symptoms usually persist from several days to a few weeks and vary markedly in frequency and severity. these clinical features are indistinguishable between df and dhf. 26,27 mild hemorrhagic manifestations like positive tourniquet test or petechiae and mucosal membrane bleeding may be seen in df and dhf. vaginal and gastrointestinal bleeding may also occur during this phase but are not common. 28 the findings of an enlarged and tender liver are more suggestive of dhf the earliest abnormality in the complete blood count is a progressive decrease in total white cell count and this with previously mentioned clinical features should alert the physician to a high index of suspicion of dengue. critical phase: the critical phase occurs towards the late febrile phase (usually between 3rd to 5th day of illness but may go up to 7th day) when a rapid drop in temperature may coincide with an increase in capillary permeability in some patients. in other viral infections, the patient’s condition improves as the temperature subsides, but the contrary happens in dhf. at this point the patient will either become better if no or minimal plasma leak occurs, or worse if a critical volume of plasma is lost. the critical phase lasts about 24-48 hours. varying circulatory disturbances can develop. in less severe cases, these changes are minimal and transient. many of these patients recover spontaneously, or after a short period of fluid or electrolyte therapy. in more severe forms of plasma leakage, the patients may sweat, become restless, have cool extremities and prolonged capillary refill time. the pulse rate increases, diastolic blood pressure increases and the pulse pressure narrows. abdominal pain, persistent vomiting, restlessness, altered conscious level, clinical fluid accumulation, mucosal bleed or tender enlarged liver are the clinical warning signs of severe dengue or high possibility of rapid progression to shock. 29,30 the patient can progress rapidly to profound shock and death if prompt fluid resuscitation is not instituted. thrombocytopenia and hemoconcentration (evidenced by a raised hematocrit (hct) are usually detectable before the subsidence of fever and the onset of shock. the hct level correlates well with plasma volume loss and disease severity. however, the levels of hct may be equivocal when there is frank hemorrhage, early and excessive fluid replacement or untimely hct determinations. leucopenia with relative lymphocytosis, clotting abnormalities, elevation of transaminases [typically the level of ast is about 2-3 times the level of alt], hypoproteinemia and hypoalbuminemia are usually observed in this phase. recovery (convalescent) phase: after 24-48 hours of defervescence, plasma leakage stops and is followed by reabsorption of extravascular fluid. patient’s general condition improves, appetite returns, gastrointestinal symptoms disappear, hemodynamic status stabilizes and diuresis ensues. some patients may have a rash or generalized pruritus. bradycardia and electrocardiographic changes are not uncommon during this stage. during this phase, hct level stabilizes or drops further due to hemodilution following reabsorption of extravascular fluid. the recovery of platelet count is typically preceded by recovery of white cell count. it is very important that every probable or confirmed case of dengue fever must be reported. figure 1: clinical course of dengue virus infection dengue hemorrhagic fever the features of dengue hemorrhagic fever include: •fever: acute onset of fever of 2-7 days duration •hemorrhagic manifestations, shown by any of the following: o petechiae , ecchymosis or purpura o bleeding from mucosa, gastrointestinal tract, injection sites, or other locations. o positive tourniquet test • thrombocytopenia • objective evidence of plasma leakage due to increased vascular permeability shown by any of the following: o rising hematocrit/hemoconcentration o evidence of plasma leakage such as pleural effusion, ascites or hypoproteinemia /hypoalbuminemia journal of islamabad medical & dental college (jimdc); 1211(1):41-47 44 dhf is further divided in four grades. grade iii and iv are classified as dengue shock syndrome (dss) dengue shock syndrome criteria for dengue hemorrhagic fever as above with signs of shock: tachycardia, cool extremities, delayed capillary refill, weak pulse, hypotension, lethargy or restlessness which may be a sign of reduced brain perfusion expanded dengue syndrome in 2011 who guidelines the term of expanded dengue syndrome has been used to include unusual manifestations of dengue infection. these include neurological, hepatic, renal and other isolated organ involvement. these could be explained as a complication of severe profound shock or associated with underlying host conditions/diseases or coinfections. laboratory diagnosis laboratory investigations of dengue fever include disease monitoring laboratory tests and diagnostic tests. 1. diagnostic tests: laboratory confirmatory tests include:  antibody detection (serology)  pcr  detection of dengue virus protein (ns1 antigen) dengue serology: igm detection (by elisa) igm detection by elisa is the most widely used method for diagnosis of dengue fever. once igm is detectable, it rises quickly and peaks at about 2 weeks after onset of symptoms and it wanes to undetectable levels by 60 days. however in some patients it may persist for more 90 days. a positive result thus has to be interpreted and correlated cautiously with the clinical picture. if igm dengue test is the only test available then establishing a negative igm early in illness and demonstrating a positive serology later will be essential to exclude false negative results. in one study, igm was detected in only 55% of patients with primary dengue infections between day 4-7 onset of fever, and it became positive in 100% of the patients after day 7. however, in secondary dengue infections, igm was detected in only 78% of patients after day 7.31 in another study, 28% of secondary dengue infections were undiagnosed when igm was the only test performed. 32,33 igg detection by elisa in primary and secondary dengue infection, dengue igg was detected in 100% of patients after day 7 of onset of fever. therefore dengue igg is recommended if dengue igm is still negative after day 7 with the negative igg in the initial test sample. igm/igg ratio the igm/igg ratio is used to distinguish primary infection from secondary dengue infection. a dengue virus infection is defined as primary if igm/igg ratio is greater than 1.2, or as secondary if the ratio is less than 1.2. rapid diagnostic tests (rdt) simple rapid tests such as the strip assays (immunochromatography test) are available for qualitative detection of dengue igm and igg. the yield of rapid tests was shown to be higher when samples were collected later in the convalescent phase of infection, with good specificity and could be used when elisa test were not available.34 however the result had to be interpreted in the clinical context because of false positive and negative results. 35,36 it is recommended that the dengue igm be done by elisa test after a rapid test, to confirm the status. other tests: dengue viremia in patients is short, typically occurs 2–3 days prior to the onset of fever and lasts for four to seven days of illness. during this period the dengue virus, its nucleic acid and circulating viral antigen can be detected. during the early stages of the disease (up to six days of onset of illness), virus isolation, viral nucleic acid or antigen detection can be used to diagnose infection. at the end of acute phase of infection, immunological tests are the methods of choice for diagnosis. polymerase chain reaction (pcr) molecular tests such as the reverse transcriptase – polymerase chain reaction (rtpcr) are useful for the diagnosis of dengue infection in the early phase (< 5 days of illness). it has a good sensitivity in the first 5 days of disease, but reduces after this, following the disappearance of the viremia. an additional advantage of rtpcr is the ability to determine dengue serotypes. 37,38 it is useful in early phase of illness and its use is particularly considered for in-patients who present with diagnostic challenges in the early phase of illness. non-structural protein-1 (ns1 antigen) the ns1 gene product is a glycoprotein produced by all flaviviruses and is essential for replication and viability of the virus. the protein is secreted by mammalian cells but not by insect cells. ns1 antigen appears as early as day 1 after the onset of the fever and declines to undetectable levels by 5–6 days. hence, tests based on this antigen can be used for early diagnosis. this antigen is present in high concentrations in the sera of dengue infected patients during the early phase of the disease. 39,40 the detection rate is much better in acute sera of primary infection (75%-97.3%) when compared to the acute sera of secondary infection (60% 70%). 41 the sensitivity of ns1 antigen detection drops from day 4-5 of illness onwards and usually becomes undetectable in the convalescence phase. 42 journal of islamabad medical & dental college (jimdc); 1211(1):41-47 45 laboratory findings in df the laboratory findings during an acute df episode of illness are as follows: • total wbc is usually normal at the onset of fever; then leucopenia develops with decreasing neutrophil count and lasts throughout the febrile period. • platelet counts are usually normal, as are other components of the blood clotting mechanism. mild thrombocytopenia (100,000 to 150 000 cells/mm3) is common and about half of all df patients have platelet count below 100,000 cells/mm3, but severe thrombocytopenia (<50 000 cells/mm3) is rare. 43 • mild hematocrit rise (10%) may be found as a consequence of dehydration associated with high fever, vomiting, anorexia and poor oral intake. • serum biochemistry is usually normal but liver ast levels may be elevated. laboratory findings in dhf: • the wbc count may be normal or with predominant neutrophils in the early febrile phase. thereafter, there is a drop in the total number of white blood cells and neutrophils, towards the end of the febrile phase. a relative lymphocytosis with increased atypical lymphocytes is commonly observed by the end of the febrile phase and into convalescence. these changes are also seen in df. • the platelet counts are normal during the early febrile phase. a mild decrease could be observed thereafter. a sudden drop in platelet count to below 100,000 occurs by the end of the febrile phase before the onset of shock or subsidence of fever. the level of platelet count is correlated with severity of dhf. in addition there is impairment of platelet function. these changes are of short duration and return to normal during convalescence. • a rise in hematocrit occurs in all dhf cases, particularly in shock cases and is objective evidence of plasma leakage. it should be noted that the level of hematocrit may be affected by early volume replacement and by bleeding. • thrombocytopenia and hemoconcentration are constant findings in dhf. a drop in platelet count to below 100,000 cells/mm3 is usually found between the 3rd and 10th days of illness. • other common findings are hypoproteinemia/ hypoalbuminemia (as a consequence of plasma leakage), hyponatremia, and mildly elevated serum alt (=200 u/l) with the ratio of ast: alt > 2. • a transient mild albuminuria is sometimes observed. • occult blood is often found in the stool. • in most cases, assays of coagulation and fibrinolytic factors show reductions in fibrinogen, prothrombin, factor viii, factor xii, and antithrombin iii. a reduction in antiplasmin (plasmin inhibitor) has been noted in some cases. in severe cases with marked liver dysfunction, reduction is observed in the vitamin k-dependent factors such as factor v, vii, ix and x. • partial thromboplastin time and prothrombin time are prolonged in about half and one third of dhf cases respectively. thrombin time is also prolonged in severe cases. • hyponatremia is frequently observed in dhf and is more severe in shock. • hypocalcemia (corrected for hypoalbuminemia) has been observed in all cases of dhf. • metabolic acidosis is frequently found in cases with prolonged shock. blood urea nitrogen is elevated in prolonged shock. 2. disease monitoring laboratory tests: patients of dengue fever require continuous monitoring for proper management and following tests along with clinical judgment should be carried out serially to monitor the response of treatment ant determination of overall prognosis of these patients  complete blood count (cbc) with particular attention to; white blood cell count hematocrit platelet count  coagulation tests  liver function tests elevated liver enzymes is common and is characterized by greater elevation of the ast as compared to the alt. 44 the frequency and degree of elevation of the liver enzymes are higher with dhf compared to df. management: there is no specific treatment for dhf. therapy for dhf is wholly symptomatic and aims at controlling the clinical manifestations of shock and hemorrhage. patients who do not receive a proper treatment usually die within 12–24 hours after shock ensues. the most important aspect of management of patients with dhf is close observation by the attending physicians and nurses with frequent clinical and laboratory monitoring. adequate fluid replacement to overcome the plasma leakage: it is recommended that patients must take full rest and plenty of fluids. during the febrile stage ingestion of adequate soft diet and drink is encouraged. for reducing fever, frequent sponging and paracetamol are provided. aspirin and nonsteroidal anti-inflammatory drugs such as ibuprofen are contraindicated. the patient with suspected dengue infection should have daily follow-up at the outpatient clinic starting from the third day of fever to defervescence for 24 hours approaching the convalescent stage. the mortality and morbidity rates of patients with dhf can be reduced by early hospitalization and optimal supportive care. prompt and adequate fluid replacement to overcome massive plasma leakage is a medical emergency. after proper management in the toxic stage for 24– 48 hours, the fluid in the extravascular space spontaneously journal of islamabad medical & dental college (jimdc); 1211(1):41-47 46 returns to the intravascular space. patients uneventfully recover. good prognostic signs are adequate urine output and regaining of appetite. control of bleeding: some patients whose platelet count is reduced markedly may require platelet transfusion to avoid bleeding and shock. the risk factors for bleeding include the duration of shock, ingestion of aspirin or nsaid, administration of large amounts of plasma expanders and the improper management in the febrile and toxic stages. the packed red blood cells may be required for patients who exhibit massive bleeding. fresh frozen plasma is indicated for patients who have massive bleeding due to coagulopathy, or circulatory failure, which does not respond to intravenous crystalloid replacement. however, no evidence supports the benefit of preventive transfusion of platelet concentrate and ffp in patients with dhf, as the risk of bleeding is not solely based on the number of platelet counts or coagulopathy. immunization: no vaccine is yet available to provide protection against dengue fever. future scenario of dengue in pakistan in pakistan, the first confirmed outbreak occurred due to serotype dv-2 reported in 1994, thereafter, sporadic cases of dhf continued to be reported from different parts of the country. analyzing the 2010 post monsoon situation, according to leading clinicians, by 2012, around 50 to 60 million people of pakistan especially living in lahore and karachi might get infected with dengue virus. thus urgent and efficient surveillance is required to prevent this catastrophe.45 references 1. rodenhuis-zybert ia, wilschut j, smit jm (august 2010). dengue virus life cycle: viral and host factors modulating infectivity. cell. mol. life sci. 67 (16): 2773–86. 2. shah i, deshpande g.c, tardeja p.n. outbreak of dengue in mumbai and predictive markers for dengue shock syndrome. journal of tropical pediatrics, vol. 50, no. 5:301 3. who (2009), pp. 10–11. 4. gulati s & maheshwari a. atypical manifestations of dengue. tropical medicine and international health 2007;12 (9):1087–1095 5. whitehorn j, farrar j. "dengue". br. med. bull 2010; 95: 161–73. 6. jawad k a, masood s, tassawar h, inam b, waheeduz zt: outbreak of dengue hemorrhagic fever in karachi. pak armed forces med j 2001, 51(2):94-8. 7. chan yc, salahuddin ni, khan j, tan hc, seah cl, li j, et al. dengue haemorrhagic fever outbreak in karachi, pakistan, 1994. trans r soc trop med hyg 1995;89:619– 20. 8. paul re, patel ay, mirza s, fisher-hoch sp, luby sp. expansion of epidemic dengue viral infections to pakistan. int j infect dis 1998;2:197–201. 9. khan e, hasan r, mehraj v, nasir a, siddiqui j, hewson r. co-circulation of two genotypes of dengue virus in 2006 outbreak of dengue hemorrhagic fever in karachi, pakistan. j clin virol 2008;43:176–9. 10. chen lh, wilson me (october 2010). "dengue and chikungunya infections in travelers". curr. opin. infect. dis. 23 (5): 438–44. 11. guzman mg, halstead sb, artsob h, et al.(december 2010). "dengue: a continuing global threat". nat. rev. microbiol. 8 (12 suppl): s7–s16. 12. jahan f. dengue fever (df) in pakistan. asia pacific family medicine 2011, 10:2 13. kurane t, ennis fa. immunopathogenesis of dengue virus infection. in: gubler dj, kuno g (eds). dengue and dengue hemorrhagic fever. cab international: wallingford, 1997, pp. 273–90. 14. halstead sb. the pathogenesis of dengue: challenges to molecular biology. science 1988; 239: 476–81. 15. lin cf, wan sw, cheng hj, lei hy, lin ys. autoimmune pathogenesis in dengue virus infection. viral immunol 2006; 19: 127–32. 16. simister ne. placental transport of immunoglobulin g. vaccine 2003; 21: 3365–69. 17. kliks sc, nimmannitya s, nisalak a, burke ds. evidence that maternal dengue antibodies are important in the development of dengue hemorrhagic fever in infants. am j trop med hyg 1988; 38: 411–19.. 18. humayoun ma, waseem t, jawa aa, hashmi ms, akram j: multiple dengue serotypes and high frequency of dengue hemorrhagic fever at two tertiary care hospitals in lahore during the 2008 dengue virus outbreak in punjab, pakistan. int j infect dis 2010, 14s3:e54-e59. 19. mitrakul c. bleeding problem in dengue haemorrhagic fever: platelets and coagulation changes. southeast asian j trop med public health 1987; 18: 407–12. 20. lum lc, goh ay, chan pw, el-amin al, lam sk. risk factors for hemorrhage in severe dengue infections. j pediatr 2002; 140: 629–31. 21. srichaikul t, nimmannitya s, sripaisarn t, kamolsilpa m, pulgate c. platelet function during the acute phase of dengue hemorrhagic fever. southeast asian j trop med public health 1989; 20: 19–25. 22. funahara y, sumarmo sp, shirahata a, setiabudy-dharma r. dhf characterized by acute type dic with increased vascular permeability. southeast asian j trop med public health 1987; 18: 346–50. 23. wills ba, oragui ee, dung nm, et al. size and charge characteristics of the protein leak in dengue shock syndrome. j infect dis 2004; 190: 810–18. 24. krishnamurti c, kalayanarooj s, cutting ma, et al. mechanisms of hemorrhage in dengue without circulatory collapse. am j trop med hyg 2001; 65: 840–47. 25. wills ba, oragui ee, stephens ac, et al. coagulation abnormalities in dengue hemorrhagic fever: serial investigations in vietnamese children with dengue shock syndrome. clin infect dis 2002; 35: 277–85. 26. hombach j. vaccines against dengue: a review of current candidate vaccines at advanced development stages. revista panamericana de salud pública, 2007, 21:254 –260. 27. whitehead ss et al. prospects for a dengue virus vaccine. nature reviews. microbiology, 2007, 5:518 – 528. 28. anderson kb et al. burden of symptomatic dengue infection in children at primary school in thailand: a prospective study. lancet, 2007, 369:1452 –1459. 29. rigau-perez jg, laufer mk. dengue-related deaths in puerto rico, 1992-1996: diagnosis and clinical alarm signals. clin infect dis 2006; 42(9):1241-1246. 30. ong a, sandar m, chen mi, sin ly. fatal dengue hemorrhagic fever in adults during a dengue epidemic in singapore. int j infect dis 2007; 11(3):263-267. 31. schilling s, ludolfs d, van an l, schmitz h. laboratory diagnosis of primary and secondary dengue infection. j clin virol 2004; 31(3):179-184. journal of islamabad medical & dental college (jimdc); 1211(1):41-47 47 32. chanama s, anantapreecha s, nuegoonpipat a, sa-gnasang a, kurane i, sawanpanyalert p. analysis of specific igm responses in secondary dengue virus infections: levels and positive rates in comparison with primary infections. j clin virol 2004; 31(3):185-189. 33. wichmann o, stark k, shu py, niedrig m, frank c, huang jh et al. clinical features and pitfalls in the laboratory diagnosis of dengue in travellers. bmc infect dis 2006; 6:120 34. blacksell sd, doust ja, newton pn, peacock sj, day np, dondorp am. a systematic review and meta-analysis of the diagnostic accuracy of rapid immunochromatographic assays for the detection of dengue virus igm antibodies during acute infection. trans r soc trop med hyg 2006; 100(8):775-784. 35. berlioz-arthaud a, gurusamy a. comparison of panbio dengue igm elisa assay with pentax dengue igm particle agglutination assay to evaluate factors affecting false positive results. southeast asian j trop med public health 2008; 39(1):55-61. 36. wu sj, paxton h, hanson b, kung cg, chen tb, rossi c et al. comparison of two rapid diagnostic assays for detection of immunoglobulin m antibodies to dengue virus. clin diagn lab immunol 2000; 7(1):106-110. 37. grobusch mp, niedrig m, gobels k, klipstein-grobusch k, teichmann d. evaluation of the use of rt-pcr for the early diagnosis of dengue fever. clin microbiol infect 2006; 12(4):395-397. 38. seah cl, chow vt, chan yc. semi-nested pcr using ns3 primers for the detection and typing of dengue viruses in clinical serum specimens. clin diagn virol 1995; 4(2):113-120. 39. young pr, hilditch pa, bletchly c, halloran w. an antigen capture enzyme-linked immunosorbent assay reveals high levels of the dengue virus protein ns1 in the sera of infected patients. j clin microbiol 2000; 38(3):1053-1057. 40. alcon s, talarmin a, debruyne m, falconar a, deubel v, flamand m. enzyme-linked immunosorbent assay specific to dengue virus type 1 nonstructural protein ns1 reveals circulation of the antigen in the blood during the acute phase of disease in patients nexperiencing primary or secondary infections. j clin microbiol 2002; 40(2):376381. 41. kumarasamy v, wahab ah, chua sk, hassan z et al. evaluation of a commercial dengue ns1 antigen-capture elisa for laboratory diagnosis of acute dengue virus infection. j virol methods 2007; 140(1-2):75-79. 42. wang sm, sekaran sd. evaluation of a commercial sd dengue virus ns1 antigen capture enzyme-linked immunosorbent assay kit for early diagnosis of dengue virus infection. j clin microbiol 2010; 48(8):2793-2797.. 43. kalanarooj s, chansiriwongs v, nimmanitya s. dengue bulletin. world health organization, 2002 44. souza lj, alves jg, nogueira rm, gicovate nc et al. aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases. braz j infect dis 2004; 8(2):156-163. 45. iqbal r, munir mk. dengue fever. pak j med research 2011; 50 (1): 42-44. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):139-141 139 case report bilateral persistent hyperplastic primary vitreous saimasattar 1 , manal niazi 2 , naushaba malik 3 , muhammad ashraf farooq 4 and muhammad afzal khan niazi 5 1 resident, department of radiology, social security hospital, islamabad 2 associate professor, department of radiology. islamabad medical and dental college. social security hospital islamabad 3 assistant professor, department of radiology, islamabad medical and dental college. social security hospital islamabad 4 professor/head, department of radiology, islamabad medical and dental college, social security hospital, islamabad 5 professor/head department of ophthalmology, wah medical college wah cantt ( 1-4 shaheed zulfiqar ali bhutto medical university, islamabad) abstract persistent hyperplastic primary vitreous (phpv) is a congenital developmental anomaly of the eye caused by the failure of regression of primary vitreous with the abnormal persistence of hyaloid vasculature. here we present a case of bilateral persistent hyperplastic primary vitreous (phpv) which is a rare entity, in a 2 months old infant who presented in our department with history of bilateral microopthalmia and leukocoria. in this regard ultrasound doppler, ct scan and mri findings of phpv will be discussed. we suggest that this entity, although rare, should be considered in the differential diagnosis while evaluating bilateral leukocoria. key words: bilateral, persistent hyperplastic primary vitreous, retinoblastoma. introduction bilateral persistent hyperplastic primary vitreous (phpv) is an uncommon entity which usually presents as leukocoria, microphthalmia, and cataract. 1 most cases are unilateral and sporadic, with no difference of incidence between males and females. it is the second most common cause of acquired cataract during the first year of life. 2 it is a developmental disorder of the eye which occurs due to abnormal persistence of fetal intraocular vessels in the anterior or posterior segments of the eye. primary vitreous forms around 7 th week of intra-gestation life and starts involuting around 20 th week and nearly always disappears at the time of birth. failure of regression of primary vitreous results in many of the abnormalities seen in phpv. 1 case report a 3-month-old male infant presented with bilateral leukocoria. birth history of the child was unremarkable. the child was referred for contrast enhanced mri with a clinical suspicion of retinoblastoma. on magnetic resonance imaging (mri) abnormal signals were seen in bilateral vitreous, appearing heterogeneous to hypointense on t2ws and isointense on t1ws, representing organized vitreous hemorrhage.(figure1) a tubular structure was seen extending from the posterior surface of the lens through the vitreous canal to the posterior and inner surface of the globe bilaterally and showed enhancement on post contrast t1ws on the left. total axial length of both eye balls in the present scan was approx 17mm which is normal for the age. however anterior segment length was slightly decreased bilaterally measuring approximately. 6mm in right eye and 5mm in left. optic nerve, optic tract and optic chiasma appeared normal. diagnosis of bilateral persistent hyperplastic primary vitreous was made. figure 1: mri: t1 post contrast image showing bilateral vitreous detachment and retrovitreal haemorrhage more so on the right. an enhancing tubular structure seen in the left eye suggestive of persistent hyaloid artery. ct and grey scale ultrasound orbit of this patient had already been done at another center. ct or mri images showed vitreous detachment and diffusely hyperdense attenuation of vitreous in both globes, suggesting hemorrhage. no mass or calcification was seen. corresponding author: dr manal niazi e mail:manalniazi39@gmail.com received: sept 21, 2016; accepted: oct 15, 2016 journal of islamabad medical & dental college (jimdc); 2016:5(3):139-141 140 grey scale ultrasound evaluation revealed vitreous detachment and retrovitreal haemorrhage.(figure 2) figure 2: grey scale ultrasound showing vitreous detachment and vitreous haemorrhage. colour doppler examination revealed presence of blood flow in a tubular structure extending from the posterior surface of the lens to posterior surface of globe bilaterally ,representing persistent hyaloid artery in the cloquet’s canal. (figure 3) spectral analysis of this blood vessel showed arterial waveforms. there was no evidence of calcification confirming our diagnosis of bilateral phpv. phpv is differentiated from retinoblastoma by the absence of a calcified mass, artery running through cloquet's canal, and absence of typical signal characteristics of retinoblastoma on mri, i.e., hyperintense on t1-weighted images and hypointense on t2-weighted images. differentiation from advanced retinopathy of prematurity (rop) can be difficult on imaging alone. history of a premature, low birth weight infant undergoing prolonged supplemental oxygen therapy helps to distinguish it from bilateral phpv. a patent hyaloid artery, as noted in this case, is not a feature of retinopathy of prematurity and vitreoretinal dysplasias. figure 3: doppler ultrasound showing persistent hyaloid artery in cloquet’s canal discussion phpv occurs because of an incomplete regression of the embryonic vitreous and hyaloid vasculature. the primary vitreous is formed during the first month of development and contains branches of the hyaloid artery. this hyaloid artery begins to regress during the formation of the avascular secondary vitreous at 9 weeks. by the third month, the secondary vitreous, which ultimately forms the adult vitreous, fills most of the developing vitreous cavity. the primary vitreous becomes condensed into a narrow band (cloquet's canal), running from the optic disc to the posterior aspect of the lens. 3 phpv is usually isolated and unilateral. bilateral lesions are usually rare and associated with systemic or syndromic conditions such as trisomy 13, 15 and 18, norrie disease and warburg disease. 1 the most common presenting signs and symptoms are leukocoria, poor vision, small eye and strabismus. phpv is classified into three types: anterior, posterior, or combination of anterior and posterior. clinically leukocoria, strabismus and a small eye may be present in all types. 4 anterior phpv has the best prognosis for vision, but approximately half of the patients also have an associated posterior component. the anterior type of phpv includes a shallow or collapsed anterior chamber, a retrolental vascular membrane, cataract and anterior chamber anomalies. abnormalities of lens and anterior chamber are signs of combined anterior and posterior variant of phpv. 1 typical imaging findings of posterior phpv includes the demonstration of cloquet canal which contains the hyaloid artery. 4 diagnosis of phpv can be made on imaging. ultrasound reveals a hyperechoic, inhomogenous linear structure bilaterally in the vitreous chamber extending from the posterior wall of the lens till the optic nerve head and retina . 1 it may also show echogenic vitreous due to vitreal hemorrhage and hyperechoic band extending from papilla to oraserrata presenting retinal detachment. doppler may show arterial flow within this band representing a persistent hyaloid artery. 2 ct findings of phpv are absence of calcification, increased density of the entire vitreous, tubular intravitreal density (cloquet's canal or nonattached retina) , decubitus positioning showing a gravitational effect on fluid-fluid level, micro-ophthalmia, enhancement of abnormal intravitreal tissue, and small or irregular lens. 2 mri findings of phpv consist of a tubular structure representing hyaloid artery, a funnel-shaped retinal detachment, with the subretinal fluid hyperintense on both t1and t2-weighted images; fluid-fluid level due to the presence of hemorrhage in the subretinal space; a retrolental mass; microophthalmia, and vitreous hemorrhage. 2 journal of islamabad medical & dental college (jimdc); 2016:5(3):139-141 141 differential diagnosis of phpv includes retinoblastoma, coat's disease, vitreoretinal dysplasia, ocular toxocariasis, and a condition contributing to subretinal fluid or hemorrhage and retinopathy of prematurity. it is important to exclude retinoblastoma in all cases of lenkocoria. phpv has a typical imaging appearance which allows reliable differentiation from retinoblastoma. complications of phpv include rupture of the lens capsule, cataract formation, intraocular hemorrhage, secondary glaucoma, tractional retinal folds, and subsequent phthisis bulbi. the friability of the hyaloid vasculature predisposes to vitreous hemorrhage, which was noted in both globes in the present case. majority of patients with posterior phpv never obtain useful vision. 2 typical imaging features of ultrasound, ct, and mri can be helpful in the diagnosis. 1 however a rational sequence of imaging modalities could prove cost effective and prevent unnecessary radiation exposure, as in this case a definitive diagnosis could have been made with the help of color doppler without proceeding to ct and mri. references 1. galhotra r, gupta k, kaur s, singh p. bilateral persistent hyperplastic primary vitreous: a rare entity. oman journal of ophthalmology. 2012;5(1):58-60 2. morales ms, tartarella mb, gouveia eb, mandello mh, allemann n. ophthalmic doppler in persistent hyperplastic primary vitreous atypical presentation: case report. arquivos brasileiros de oftalmologia. 2015 ;78(5):320 2. 3. .tarun p jain .bilateral persistent hyperplastic primary vitreous. indian j ophthalmol. 2009; 57(1): 53–54. 4. bari v, murad m. persistent hyperplastic primary vitreous. journal-pakistan medical association. 2003 ;53(4):165-6.. http://www.ncbi.nlm.nih.gov/pubmed/?term=jain%20tp%5bauth%5d summary journal of islamabad medical & dental college (jimdc); 2016:5(4):157-160 157 original article association between raised serum c-reactive protein and arteriovenous fistula failure rashid usman1, muhammad jamil2 and hanifabbassi3 1department of vascular surgery combined military hospital, lahore cantt 2department of vascular surgery combined military hospital peshawar cantt 3department of surgery combined military hospital peshawar cantt abstract objectives: to study the association between serum creactive protein (crp) and arteriovenous fistula (avf) failure rate. patients and methods: this case control study department of vascular surgery combined military hospital lahore and peshawar between january 2015 and march 2016. total 126 consecutive patients who had serum crp checked preoperatively and underwent avf procedure were included. patients were divided into case (with raised crp) and control (normal crp) groups. data regarding serum crp level were recorded and analysed to evaluate the impact of preoperative crp levels on avf failure rates. results: the avf failure rate was significantly high (53.2%) in case group as compared to control group (14.5%). age, gender, diabetes and hypertension did not show statistically significant difference between the two groups. conclusion: raised level of crp is related to significantly higher avf maturation failure rate. therefore, it is recommended to check crp levels preoperatively to identify those patients who can be at higher risk of fistula failure. keywords: arteriovenous fistula, association, c-reactive protein introduction the morbidity and mortality in end stage renal disease (esrd) patients has been decreased with recent advances in medicine and improvement in general health measures in spite of increased prevalence of the disease.1,2 the major role in improving the survival of esrd patients has been played by hemodialysis (hd) as renal replacement therapy.3 hd needs vascular access and the best way of getting this vascular access is by creating an avf.4 avf can be a good option due to decrease rate of complication and increase durability. but increase tendency of vasospasm in small vessels decreases its effectiveness and can lead to both early and late failures. in a clinical setting, early failure of av fistula can be defined as fistula that does not have any effective development for dialysis or after initiation of dialysis failure occurs within 3 months. late failure is defined as malfunction after successful use. definition of adequate av fistula based on rate of blood flow, diameter of fistula and its distance from skin. early failure or failure to maturity is main issue in about 23% to 46 % of all av fistulas. avf has to be functionally mature before its use. many factors like advancing age, female gender, smoking, diabetes, hypertension, hyperlipidemia, hyperparathyroidism, vascular disease, technical errors, high hemoglobin level, thrombophilia, low albumin levels, malnutrition and inflammatory biomarkers affect this maturation process and can result in avf failure.5-10 in vessels reduction in blood flow and oscillatory shear stress results in increased levels of inflammatory and procoagulant substances.5 crp that is an important inflammatory marker, not only has a role in prediction of development of cardio vascular disease in patients undergoing hd. but its importance regarding development of vascular stenosis and thrombosis through the process of vascular intimal hyperplasia is also under discussion.5 fewer studies have been conducted with conflicting evidence to evaluate the effects of inflammatory biomarkers on avf maturation11,12. we designed this study to evaluate relationship between preoperative raised crp and avf failure in esrd patients. patients and methods all patients between january 2015 and march 2016, reporting to vascular surgery clinic in combined military hospital lahore and peshawar for avf creation, were consecutively included in this study. patients with uncontrolled diabetes (fasting blood sugar of more than 126mg/dl) and uncontrolled hypertension (blood pressure of more than 160/90 mmhg) were excluded. serum crp of all corresponding author: dr rashid usman email: drrashidusman@yahoo.com received: sept 19,2016 accepted december 20,2016 mailto:drrashidusman@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):157-160 158 patients was checked in the hospital laboratory using enzyme-linked immuno-sorbent assay (elisa) method. crp level more than 10mg/l was considered as positive value. based on the serum crp results, patients were assigned into two groups. group a(control) had all patients with normal crp and group b (case) has patients with raised crp. other procedure related complications were also recorded. all patients underwent avf procedure by a consultant vascular surgeon who had a minimum of five years of experience of doing such procedure under local anaesthesia. in order to remove the operator bias, the operating surgeon was kept unaware about the crp status of the patient before and during the procedure. patients were given oral antibiotics and analgesia on discharge. they were provided written instructions about hand and forearm exercises and general care of the avf. patients were regularly followed up in clinic at 2 weeks, 4 weeks, 2 months and 3 months. a functionally mature avf is defined as per kidney disease outcome quality initiative (kdoqi) guidelines as one that can be easily cannulated and has at least six successful consecutive dialysis sessions.13 the failure rate and association with crp was recorded. the data was analyzed using statistical package for social sciences (spss) version 20. the numerical outcomes e.g. age was calculated as mean and standard deviation. gender was recorded as frequency and percentage. chi square test was applied to assess the association between failure of fistula and qualitative variables like diabetes, hypertension and crp. independent t-test was applied to see the association between failure of fistula and quantitative variables like age. logistic regression analysis was also done to assess the effect of age, gender, diabetes mellitus, hypertension and crp on fistula failure rates. the results were considered statistically significant if the p value was found to be less than or equal to 0.05. results total 126 patients fulfilling the inclusion criteria were included in this study. the age range was 31 years 64 years with mean age of 37.5±8.4 years. out of 126 cases, 99 (78.5%) were males and 27 (21.4%) were females. male to female ratio was 3.6:1. there were two groups: group a (control) had 62 patients with normal crp and group b (case) had 62 patients with raised crp. among factors like, age (p value 0.754), gender (p value 0.867), diabetes (p value 0.812) and hypertension (p value 0.835); there was no statistically significant difference in the two groups (table 1). in control group, 53 fistulae matured however in case group only 29 avf became functionally mature. hence the failure rate was 14.5% in patients with normal crp as compared to 53.2% in patients with raised crp (table 2). this difference between the two groups was statistically significant with a p value of 0.003. table 1: comparison of variables between control and case groups variable group a (control) n =62 group b (case) n =62 p value age(yrs) mean±sd 38.1 ± 9.3 36.9 ± 7.8 0.754 gender male no (%) 47 (75.8) 52 (83.8) 0.867 diabetic no (%) 42 (67.7) 39 (62.9) 0.812 hypertensive no (%) 38 (61.2) 35 (56.4) 0.835 table 2: distribution of crp in control and case groups group category number percentage group a n (62) failed 09 14.5 mature 53 85.5 group b n (62) failed 33 53.2 mature 29 46.8 table 3: logistic regression analysis showing effect of different variables on fistula failure variable b se p value odd ratio 95% confidence interval lower upper age 0.013 0.026 0.914 0.885 0.854 1.124 gender -0.294 0.526 0.794 0.726 0.384 1.754 diabetes -0.354 0.559 0.857 0.998 0.926 1.212 hypertension -0.261 0.591 0.932 0.869 0.442 1.954 crp 2.985 0.416 <0.002 21.254 5.316 67.214 logistic regression analysis of the variables was also done. the effect of age, gender, hypertension, diabetes mellitus and crp was assessed on avf failure. only crp had statistically significant effect on fistula failure rate with a p value of <0.002 (table 3). discussion hd in esrd patients needs a vascular access. vascular access can be achieved by a catheter insertion, arteriovenous graft or by creating a native avf.2-4 avf is used for hd once it is matured functionally within 4-6 weeks.14-16 many factors like age, female gender, diabetes, hypertension, vessel diameter and hematological factors affect this process and can result in avf failure.16,17,11 in our study we specifically concentrated on association of inflammatory biomarker many studies suggest that inflammation causes intimal hyperplasia and higher chances of thrombosis at anastomotic site and hence responsible for failure of avf.11,12 hence measuring inflammatory markers like crp can point out journal of islamabad medical & dental college (jimdc); 2016:5(4):157-160 159 those patients who are at a higher risk of avf maturation failure. wong et al found for the first time that aggressive intimal hyperplasia at anastomotic site is associated with thrombotic closure of avf thus pointing out inflammation as a culprit for higher avf failure.11 neutrophil-lymphocyte ratio (nlr) is also a marker of systemic inflammation and is also used by certain studies as a benchmark to assess the association between inflammation and failure of fistula. yilmaz et al in his logistic regression model has recently advocated that nlr is an independent positive predictor of avf failure.18 similar inference was also deducted by roy-chaudhury et al who found a strong positive association between inflammatory cell markers like crp and fibrinogen, and failure of vascular access.19 chou et al suggested that elevated crp is strong positive predictor for avf thrombosis and they have found it as an independent risk factor for avf failure.12 our study also shows that patients who had a higher levels of inflammation as evident from elevated crp had higher rates of avf failure. kaygin et al in their study of 213 patients also found that high crp levels in their patients who had failed avf had significant impact.20 a p-value of less than 0.001 was strongly suggestive of statistically significant effect of raised crp on the fistulae failure rate. we have also found similar effect of raised crp with a p-value of 0.003. however, certain studies suggest that there is no relation of crp levels and avf failure. meta-analysis by morton et al in 2016 suggested that the current inflammatory biomarkers available are yet to identify the fistulas which are at risk.21 hence they have suggested that more robust biomarkers are needed which can predict the fistula failure rate. similarly, choice for healthy outcome in caring for end stage renal disease (choice) study by banerjee et-al in 2010 reported higher failure of catheter related vascular access in patients with elevated crp, however they did not find higher failure rates of avf in patients with raised crp levels.22 low level of hemoglobin (hb) is also thought to cause low grade inflammation and hence some workers have also labeled low hb as a positive predictor for higher failure rates of avf.23,24 hence those esrd patients who have anemia may also be at a higher risk for failed avf and probably crp can be used as a marker to predict failure in such cases. we did not assess the hb level and its association with crp and avf failure rate in this study. conclusion inflammation has a definite role in failure of avf. measurement of inflammatory markers like crp can help in identifying those patients who are at high risk of access failure. we recommend further studies with larger sample size to define the exact role of inflammatory biomarkers. conflict of interest this study has no conflict of interest as declared by any author. references 1. lomonte c, meola m, petrucci i, casucci f, basile c. the key role of color doppler ultrasound in the work-up of hemodialysis vascular access. semin dial. 2015;28(2):2115. 2. tessitore n, bedogna v, verlato g, poli a. the rise and fall of access blood flow surveillance in arteriovenous fistulas. semin dial. 2014;27(2):108-18. 3. tessitore n, bedogna v, poli a, lipari g, pertile p, baggio e, et al. should current criteria for detecting and repairing arteriovenous fistula stenosis be reconsidered? interim analysis of a randomized controlled trial. nephrol dial transplant. 2014;29(1):179-87. 4. almasi-sperling v, galiano m, lang w, rother u, rascher w, regus s. timing of first arteriovenous fistula cannulation in children on hemodialysis. pediatr nephrol. 2016;31(10):1647-57. 5. roy-chaudhury p, spergel m, besarab a, asif a, ravani p. biology of arteriovenous fistula failure. jnephrol. 2007;20(2):150-63. 6. spergel m, ravani p, roy-chaudhury p, asif a, besarab a. surgical salvage of the autogenous arteriovenous fistula (avf). j nephrol. 2007;20(4):388-98. 7. gagliardi m, rossi s, condino f, mancuso d, greco f, tenuta r et al. malnutrition, infection and arteriovenous fistula failure: is there a link? j vasc access. 2011;12(1):5762. 8. khavanin zadeh m, mohammadipour s, omrani z. correlation between crp and early failure of arteriovenous fistula (avf).med j islam repub iran. 2015;29(8):1-5. 9. ozdemir n, akcay a, bilgic a, akgul a, arat z, haberal m. effects of smoking and blood eosinophil count on the development of arteriovenous fistulae thrombosis in hemodialysis patients. transplant proc. 2005;37(7):291821. 10. vascular access work group. clinical practice guidelines for vascular access. vscular access work group. clinical practice guidelines for vascular access. am j kidney dis. 2006; s-1:s248-73. 11. wong v, ward r, taylor j, selvakumar s, how tv, bakran a. factors associated with early failure of arteriovenous fistulae for haemodialysis access. eur j vasc endovasc surg. 1996;12(2):207-13. 12. chou y, kuo l, yung f, liu l, huang c. c-reactive protein predicts vascular access thrombosis in hemodialysis patients. blood purificat. 2006;24(4):342–6. 13. rayner c, besarab a, brown w, disney a, saito a, pisoni l. vascular access results from the dialysis outcomes and practice patterns study (dopps): performance against kidney disease outcomes quality initiative (k/doqi) clinical practice guidelines. am j kidney dis. 2004;44(5 s2):22–6 14. rayner c, pisoni l, gillespie w, goodkin a, akiba t, akizawa t, etal. creation, cannulation and survival of arteriovenous fistulae: data from the dialysis outcomes and practice patterns study. kidney int. 2003;63(1):323–30. 15. lok e, oliver j, su j, bhola c, hannigan n, jassal v. arteriovenous fistula outcomes in the era of the elderly dialysis population. kidney int. 2005;67(6):2462–69. 16. conte s, nugent m, gaccione p, roy-chaudhury p, lawson h. influence of diabetes and perivascular allogeneic endothelial cell implants on arteriovenous fistula remodeling. .j vasc surg. 2011;54(5):1383–9. 17. salmela b, hartman j, peltonen s, alback a,, lassila r. thrombophilia and arteriovenous fistula survival in esrd. clin j am socnephrol. 2013;8(6):962–8. journal of islamabad medical & dental college (jimdc); 2016:5(4):157-160 160 18. yilmaz h, bozkurt a, cakmak m, celik t, bilgica, bavbek n, et al. relationship between late arteriovenous fistula (avf) stenosis and neutrophil-lymphocyte ratio (nlr) in chronic hemodialysis patients. ren fail.2014;36(9):1390-4. 19. roy-chaudhury p, arend l, zhang j, krishnamoorthy m, wang y, banerjee r, et al. neointimal hyperplasia in early arteriovenous fistula failure. am j kidney dis 2007;50(5):782-90. 20. kaygin a, halici u, aydin a, dag o, binici n, limandalk, et al. the relationship between arteriovenous fistula success and inflammation. ren fail. 2013;35(8):1085-8. 21. morton k, rodríguez j, morris r, bhandari p, moxon v, golledge j. a systematic review and meta-analysis of circulating aiomarkers associated with failure of arteriovenous fistulae for haemodialysis. plos one. 2016;11(7):e0159963. 22. banerjee t, kim s, astor b, shafi t, coresh j, powe n. vascular access type, inflammatory markers, and mortality in incident hemodialysis patients: the choices for healthy outcomes in caring for end-stage renal disease (choice) study. am j kidney dis. 2014;64(6):954–61. 23. furuland h, linde t, ahlmen j, christensson a, strombom u, danielson g. a randomized controlled trial of haemoglobin normalization with epopetin alfa in predialysis and dialysis patients. nephrol dial transplant. 2003;18(2):353-61. 24. coronado daza j, martí-carvajal aj, ariza garcía a, rodelo ceballos j, yomayusa gonzález n, páez-canro c, etal. early versus delayed erythropoietin for the anaemia of end-stage kidney disease. cochrane database syst rev. 2015;12:cd011122.. authorship contribution: author 1: conception, synthesis and planning of the research, active participation in active methodology author 2 active participation in active methodology, interpretation, analysis and discussion author 3 active participation in active methodology, interpretation, analysis and discussion journal of islamabad medical & dental college (jimdc); 1211(1):2-5 2 original article comparison of single dose with multiple dose antibiotic prophylaxis with cefuroxime in open cholecystectomy shaukat ali shaikh*, mohammad iqbal**, ihtasham muhammad ch*** *associate professor of surgery, islamabad medical and dental college, islamabad **professor & hod surgery, islamabad medical and dental college, islamabad ***senior registrar surgery, islamabad medical and dental college, islamabad (bahria university, islamabad) abstract objectives: to compare single dose with multiple dose antibiotic prophylaxis with cefuroxime in open cholecystectomy in terms of post operative surgical site infection, hospital stay and cost effectiveness. study design: quasi experimental study. place and duration of study: the study was conducted in the surgical unit of punjab employees social security institution islamabad and ahmed hospital rawalpindi teaching hospitals of imdc islamabad, from 1st august 2010 to 30th september 2011. methodology: a total of one hundred and ten patients requiring elective open cholecystectomy were included. patients with acute cholecystitis, jaundice, diabetes, malignancy, choledocholithiasis and co morbidity were excluded. patients were divided in to two groups, 55 patients in each group, group a received only single dose of cefuroxime and group b received multiple doses (six). results: in this study, 97 (88%) patients were females and 13 (12%) were males. the mean age was 40.69 years. in group a, 4 (5.5%) patients, and in group b, 7 (12.7%) patients developed surgical site infection. mean hospital stay in group a was 2.18 days and in group b 2.43 days. cost of antibiotics in group a was six times less than group b. conclusion: there is no difference in single dose and multiple doses prophylaxis with cefuroxime in low risk patients for elective open cholecystectomy in terms of post operative surgical site infection and hospital stay however single dose is more cost effective. key words: open cholecystectomy, single dose, prophylaxis, cefuroxime introduction cholelithiasis is very common problem in general surgery practice all over the world. in pakistan the overall incidence of cholelithiasis is 9.03%.1 cholelithiasis affects approximately 10% of the adult population in the united states.2 currently, the most frequently performed operation for symptomatic gall stones and cholecystitis is laparoscopic cholecystectomy in developed countries. open cholecystectomy involves major abdominal surgery and is used as the first line treatment where laparoscopic facilities are not available.3-4 wound infection is not a new problem; it has been documented for at least 4000-5000 years. egyptians had some concept of infection. the concept of prophylaxis had also been known earlier by assyrians. greeks independently explained it and later on hippocratic teaching described the use of antimicrobials.5 in abdominal surgery, infectious complications are the main causes of postoperative morbidity and financial cost.6 although surgical infection rate has decreased dramatically during the last 25 years, morbidity and mortality of these infections in surgical treatment remains substantial.7 the incidence of surgical site infections in general surgery is related to many factors, and the main risk factors for developing infections are: endogenous, host-related, exogenous, procedure and environment related.8 therefore, antibiotics have long been used in surgery, for prevention and treatment of infections. the world health organization has established the rationale of use of antibiotics as a priority in its campaign.9 peri-operative antibiotic prophylaxis is safe and its effectiveness is proven.10,11 inappropriate use of surgical antibiotic prophylaxis is common, e.g., incorrect timing, improper duration, and oral route of administration of antibiotics.12 the timing of first dose is very important7, and improper timing is one of the most common faults regarding surgical prophylaxis.13 the agent selected should be the one to which the expected organisms are highly sensitive14, and the dose should have large volume of distribution, lower toxicity, and longer halflife, allowing single dose administration. the effectiveness of prophylactic antibiotics in elective cholecystectomy is well-established and the choice of antibiotic remains a concern. cholecystectomy is a clean contaminated type of surgery and with prophylaxis surgical site infection is less than 10% and without prophylaxis journal of islamabad medical & dental college (jimdc); 1211(1):2-5 3 surgical site infection can be up to 20%.5 the source of infection can be endogenous (infected bile/gallbladder wall) or exogenous. in certain trials, the frequency and type of bacteria in bile, the factors predicting the presence of bacteria in bile, and the relationship between bacteria in bile and subsequent wound sepsis have been evaluated.15-16 in this article we report the use of second generation cephalosporin (cefuroxime), as mentioned in the text17, for prophylaxis and comparison of single dose with multiple doses of intravenous cefuroxime in terms of wound infection, hospital stay and cost effectiveness. material and methods it was a quasi experimental study. the study was conducted in the surgical unit of punjab employees social security institution islamabad and ahmed teaching hospital of islamabad medical & dental college, from 1st august 2010 to 30th september 2011. total 110 patients without any gender discrimination were included in the study with chronic cholecystitis due to gall stones or acalculous choric cholecystitis or symptomatic gall stones. age of the patients ranged from 20 to 65 years. patients with acute cholecystitis, choledocholithiasis, malignancy, co morbid like diabetes, hypertension, hepatitis, jaundice, chronic renal failure and history of pancreatitis were excluded from the study. all the patients were admitted through the opd in the surgical ward for open cholecystectomy. permission was taken from the hospital ethical committee for the study. the patients were thoroughly examined in the wards and all the routine and specific investigations done to confirm the diagnosis. detailed informed consent was taken. the patients were divided into two groups group a and b by randomization selection. in group a patients were given 750 mg of cefuroxime intravenously, one hour before induction of anesthesia. in group b, multiple doses of 750 mg of cefuroxime were given intravenously; first dose at 1 hour before induction of anesthesia, and subsequent doses were given at an interval of 8 hours after surgery for 2 days (six doses). after operation, the patients were observed for postoperative sepsis in the ward for two days table 1: grades of wound infection grade-i infection slight reddening and induration of wound edges requiring no intervention. grade-ii infection slight serous discharge from wound, requiring no intervention grade-iii infection obvious infection or purulent discharge from wound, requiring repeated change of dressings and institution of antibiotics . daily record of pulse, temperature, respiratory rate, abdominal tenderness, and bowel sounds was maintained. blood complete picture was done on 2nd post op day and wound was examined before discharging the patient. subsequently, the patients were observed on the 5th, 7th, 15th, 21st and 30th day, in surgical outpatient department, for wound infection and fever. wound infection was categorized into three grades depending on severity (table i): the data was collected on a preformed proforma and entered into spss software version 16 and analyzed. mean ± standard deviation will be calculated for age and hospital stay. frequencies and percentages were calculated for gender and wound infections in both groups. chi square test was used to compare the frequency of wound infection in group a and group b patients. p-value <0.05 was considered significant. results in a total number of 110 patients included in the study, the age ranged from 20 years to 65 years with a mean + sd of 40.69 + 7.76 years. maximum number of patients was in the age group of 36 to 45 years (figure i). there were 97 (88%) females and 13 (12%) male patients. figure 1: distribution of patients by age groups in group a, 3 patients (5.5%) developed surgical site infection, while 52 patients had normal wound healing; 2 patients developed grade ii infection, while one patient developed grade iii infection. in group b, 7 patients (12.7%) developed surgical site infection; of them, 1 patient developed grade i, 4 patients developed grade ii and 2 patients developed grade iii infection. (figure 2) on comparing the results of both groups by applying chi square test a value 0.990 was obtained which was insignificant. mean hospital stay in the group a patients was 2.18 days with standard deviation (sd) of ± 0.181, while mean hospital stay in the group b patients was 2.43 days with standard deviation (sd) of ± 1.21 in terms of cost effectiveness the cost of antibiotics in group b were 6 times more as compare to group a. discussion gall stones are a very common problem in every part of the world and cholecystectomy is most common procedure in surgical settings.2 in developed countries and institution where facilities of laparoscope are available, laparoscopic cholecystectomy is the procedure of choice. open cholecystectomy is still first line of treatment where journal of islamabad medical & dental college (jimdc); 1211(1):2-5 4 facilities, cost effectiveness and expertise matter.3 leo and colleagues published a study in 2006 and discussed the open cholecystectomy for gall bladder disease and concluded this procedure as effective, compatible with short hospital stay, evidence-based gall-bladder surgery, and training of surgical residents.18 cholecystectomy is clean contaminated type of procedure, and wound infection without prophylaxis can affect 20% of individuals.5 prophylaxis is still a debatable issue and different studies are conducted on the issue.19 pea and colleagues published a study in 2003 and advised second generation cephalosporin prophylaxis for clean contaminated cases for ultra short period and also recommended that post surgical prophylaxis is not advisable.20 similarly the concept of chemoprophylaxis which is the base of our study is also recommended by the bowater and his colleagues in the study published in 2009. they concluded that the prophylaxis is effective in post operative wound infections.21 figure 2: frequency and grades of wound infections in both groups the results of our study showed that females were mostly affected by the gall bladder disease (88%) as compared to males (12%). the results of gender frequency of our study are similar to a previous study published in 2008 , showing that incidence of gallbladder disease among females in pakistan is 3.3 time more as compared to males.1 the results of our study showed that the 3 patients (5.5%) developed wound infection in group amongst these patients, 2 patients developed grade ii, and one patient developed grade iii wound infection; all the patients in this group were receiving single dose of cefuroxime for prophylaxis. in group b which was receiving multiple doses for prophylaxis, 7 patients (12.7%) developed wound infection. in this group one patient had grade i, 4 patients had grade ii and 2 patients had grade iii wound infections. on comparing the results of both groups the p value had showed statistically insignificant result, but clinically the group a had better results as compared to the group b. compliance of the patients were also better in group a as compared to group b. in a previous study, zahid et al compared the results of single dose versus three-dose prophylaxis by cefotaxime sodium in patients undergoing elective cholecystectomy. the results were like our study; single dose group had 4% wound infection, while three doses group had 5.3% wound infection. the authors recommended single dose antibiotic prophylaxis with cefotaxime.22 another study showed 4.3% wound infection with single antibiotic in two doses, and recommended single antibiotic prophylaxis for elective cholecystectomy.23 kufman conducted a double blind, controlled randomized trial to evaluate the effectiveness of a single dose of prophylactic antibiotic (gentamycin) for elective cholecystectomy. all patients recognized pre-operatively as being at risk were excluded. the treatment group comprised of 102 patients received a single dose of antibiotic and the 74 patients in the control group received a placebo. of the patients who received antibiotic, wound infection developed in 4.9% as compared to13.5% in the control group.24 mean hospital stay in our study was 2.18 days for group a patients and 2.43 days for group b patients which were slightly high as compared to the study conducted by leo and colleagues18, but our results are better as compare to study conducted by zahid.22 in our study cost of antibiotics of group a is simply six times less with group b that is also major concern for the underdeveloped countries and for patients also. conclusion there is no difference in single dose and multiple doses prophylaxis with cefuroxime in low risk patients for elective open cholecystectomy in terms of post operative surgical site infection and hospital stay. the risk of postoperative wound infection can be effectively managed by single dose prophylactic antibiotic (cefuroxime). the single dose prophylaxis also has the benefit of cost effectiveness. we recommend large scale multi centre studies in pakistan to augment our conclusion. references 1. channa n a. gallstone disease: a review. pak armed forces med j 2008; 58:197-208. 2. 1schirmer bd, winters kl, edlich rf. cholelithiasis and cholecystitis. j long term eff med implants 2005; 15:32938. 3. zacks sl, sandler rs, rutledge r, brown rs jr. a population based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. am j gastroenterol 2002; 97:334-40. 4. richards c, edwards j, culver d, emori g, tolson j, gaynes r.national nosocomial infections surveillance (nnis) system, centers for disease control and prevention. does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection? ann surg 2003; 237: 358-62. journal of islamabad medical & dental college (jimdc); 1211(1):2-5 5 5. leaper dj. wound infection. in: russell rcg, williams ns, bulstrode cjk, (edi). bailey and love’s short practice of surgery. 25th ed. london: arnold, 2008; 32-48. 6. pessaux p, msika s, atalla d, hay jm, flamant y. french association of surgical research. risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis-based on a prospective multicentre study of 4718 patients. arch surg 2003; 138:314-24. 7. novelli a. antimicrobial prophylaxis in surgery: the role of pharmacokinetics. j chemother 1999;11: 565-72. 8. simo j, matis p, durdik s, martinec a, kubis j. antibiotic prophylaxis in surgery. bratisl lek listy 1999;100:6944. 9. american society of health-system pharmacists. ashp therapeutic guidelines on antimicrobial prophylaxis in surgery. am j health syst pharm 1999; 56:1839-88. 10. hayashi h, yaginuma y, yamashita t, morizaka a, ishiya t, katou y, ishikawa m. prospective randomized study of antibiotic prophylaxis for non laparotomy surgery in benign conditions. chemotherapy 2000;46:213-8. 11. wolters u, schrappe m, mohrs d, bollschweiler e, holscher ah. [do guidelines bring an improvement in the perioperative course? a study of perioperative antibiotic prophylaxis. chirurg 2000;71:702-6. 12. mcdonald lc, yu ht, yin hc, hsing ac, ho m. use and abuse of surgical antibiotic prophylaxis in hospitals in taiwan. j formos med assoc china 2001;100;5-13. 13. di piro jt. short term prophylaxis in clean-contaminated surgery. j chemother 1999;11:551-5. 14. furukawa k, onda m, suzuki h, maruyama h, akiya y, ashiksri m, et al. the usefulness of conducting investigations on intra-abdominal bacterial contamination in digestive tract operations. surg today 1999;29:701-6. 15. mahatharadol v. a re-evaluation of antibiotic prophylaxis in laparoscopic cholecystectomy: a randomized controlled trial. j med assoc thai 2001; 84:105-8. 16. . kuthe sa, kaman l, verma gr, singh r. evaluation of the role of prophylactic antibiotics in elective laparoscopic cholecystectomy: a prospective randomized trial. trop gastroenterology 2006 ; 27:54 7. 17. konlon k. the gall bladder and bile ducts. in: russell rcg, williams ns, bulstrode cjk, (edi). bailey and love’s short practice of surgery.25th ed. london: arnold, 2008; 11111129. 18. leo j, filipovic g, krementsova j, norblad r, söderholm m, nilsson e. open cholecystectomy for all patients in the era of laparoscopic surgery a prospective cohort study. bmc surg 2006; 6:5. 19. gul ya, hong lc, prasannan s. appropriate antibiotic administration in elective surgical procedures: still missing the message. asian j surg. 2005 ;28:104 8. 20. pea f, viale p, furlanut mi. antimicrobial agents in elective surgery: prophylaxis or "early therapy"? j chemother 2003; 15:3-11. 21. bowater rj, stirling sa, lilford rj. is antibiotic prophylaxis in surgery a generally effective intervention? testing a generic hypothesis over a set of meta-analyses. ann surg. 2009; 249:551-6. 22. zahid ma, bakhsh r, dar fs, akhter n, malik zi. comparison of single dose and three dose antibiotic prophylaxis with cefotaxime sodium in cholecystectomy. j ayub med coll (abbottabad) 2003; 15:38-40. 23. malik sa, yasin ma, nasreen g. single and simple antibiotic prophylaxis for elective cholecystectomy. j coll physicians surg pak. 2009; 19:154 7. 24. kaufman z, engelberg m, eliashiv a, reiss r. systemic prophylactic antibiotics in elective biliary surgery. arch surg 1984; 119:1002-4.. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):134-138 134 original article evaluation of faculty development program: a collaborative project of nih&ss pakistan and phmi, usa kauser abid1, farzana majeed2 and abdul majeed3 1assistant professor, physiology department, pbl coordinator, medical education department, faculty of medicine, university of tabuk, ksa 2assistant professor department physiology, islamabad medical & dental college 3professor, hod, department of physiology, islamabad medical & dental college (2&3 shaheed zulfiqar ali bhutto medical university, islamabad) abstract objective: to develop logic model for the planning, evaluation and assessment of the process of collaborative faculty development program of partners harvard medical international (phmi) and national institute of health and social sciences (nih&ss). material & methods: this study was done in the capacity development building of nih&ss in march 2010. the faculty development program was carried out by nih&ss in collaboration with phmi, usa. at the initial stage a logic model was developed to highlight the planning and evaluation of the program for all the stake holders. in second stage, quasiexperimental study was designed and data was collected from mediation. comparison of the groups was obtained by carrying out pretest and a post-test questionnaire. purposive sampling was done from target population being mentors serving as faculty in healthcare profession. descriptive statistics was done using univariate and bivariate analysis. results: univariate analysis showed that 95% of program participants did meet their personal professional needs; more than 95% reported change in attitude towards team work in diverse group setting, more than 98% reported gain in knowledge and skill for innovative teaching strategies, 96% of participants considered experimental learning helpful in developing assessment items. the bivariate analysis showed that the educational activities and exercises of the program succeeded to accomplish the outcomes. conclusion: capacity building of mentors in health profession at the workplace can address the needs of all the stakeholders in terms of time and resource management key words: capacity building, educators, health care logic model, work place learning. introduction to maintain academic vigor, faculty development is an important milestone which in turn helps to meet the changing needs in the field of medical education. 1 continuous professional development (cpd) for mentors is the process through which health profession educators can maintain, improve and expand current standards of best professional practices. faculty development programs (fdps) are crucial for the existing and new incoming faculty members for professional development in order to fulfill their varying roles in planning and implementing curricular changes. these programs are meant to empower the medical educator’s community in a way to create a positive institutional environment and can range from basic orientation programs for new faculty members to postgraduate medical education programs for health professionals. overall, the aim of all these training programs is to support educators in the health profession to bring reforms in the teaching strategies and to enhance the efficiency and performance of their teaching skills. this would not only improve their work satisfaction but also teaching confidence. moreover, institutes should design faculty development models according to their own needs and setting. 2-5 in clinical setting we observe that clinicians have time constrains for arranging fdps that can fit in their tight schedule. anupma wadhwa, et al designed a limited time committed fdp for the clinicians which showed improvement in their scholarly efficacy. 6 faculty development program context fdps for educators in the healthcare profession was launched for the first time in the region of islamabad, pakistan. national institute of health & social sciences (nih&ss), pakistan in collaboration with partners, harvard medical international (phmi), usa offered a platform that could provide support and teaching/learning mentoring services to the educators of health care profession. for this program logic model was developed which provided a chance to communicate with all the stakeholders about the corresponding author: dr kauser abid email address: drkauserabid@gmail.com received: sept 2015; accepted: oct 9, 2016 http://www.hindawi.com/93834740/ mailto:drkauserabid@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):134-138 135 program's theory of collaboration. the objectives and outcomes that could be achieved in the first three years of the project will help in elaborating program activities and strategies, and identifying methods and procedures for monitoring and evaluation. literature survey strongly recommend its utility as developing a logic model and great way forward to show the feasibility of any program before implementing it. 7,8 in a nutshell it provides an insight into the program resources, planned activities, expected outputs and initial outcomes.  program objective: to inculcate philosophical foundation of education, appraise current trends in curriculum development with emphasis on teaching and learning strategies, and update educators on essentials of leadership and management skills.  rationale: at institutional level professional development does not accompany educational reforms and it is the need of time for teaching the faculty in health profession. the availability and effectiveness of faculty development has been identified as a predictor of the success or failure of reforms initiatives.  project settings: these interventional activities took place in the capacity building center; phase i islamabad, pakistan, the first functional unit of nih&ss mega purpose built project for the professional development of faculty. over twenty-nine intensive weeks, participants immersed themselves in the learning process acquiring the skills they need to effectively lead their educational strategies. in a diverse group setting learning environment, they were exposed to experience a range of different teaching and learning techniques from six unique perspectives.  intervention activities: collaborative faculty partners from phmi and local universities in the education discipline facilitated sessions in the light of best evidence and feedback from literature survey. guest speakers participated to provide enhanced knowledge in different disciplines. integrated activities were offered by diverse group of educators from health professional institutes. logistic support was provided throughout the program for face to face & virtual learning environment. the stake holders provided in time consultancy and support to the program evaluator.  intervention targets: the faculty and staff who facilitate the sessions in the fdp, the participating educators of basic sciences, clinical sciences, nursing, social sciences and information technology, students taught by the participants of the program, patients whom they care, faculty and committees that deal with curriculum, and educational leadership. materials & methods logic model: a logic model was developed (fig 1) to share with the organizing committee and the facilitators of the fdp and the outcomes of current program for future improvement strategies.  study design: a case study approach with nonequivalent control group quasi-experimental design was used to evaluate the program retrospectively from different contexts likewise how the program operated, what were the inputs and activities that ultimately led to the outcomes. a pretest/post-test approach with non-randomization to intervention/comparison group was used to gather data.  sample selection procedures: the target population comprised of participants who were educators serving as faculty in medicine, nursing, and basic sciences, social sciences and information technology. the comparison group selected was similar to the intervention group on all relevant characteristics and other factors associated with program exposure. purposive sampling was done as the unit selected had the potential to reveal the reasons to produce the desired outcomes. number of participants who attended the study was 27 and those who did not participate was 30. a change in educator’s knowledge, skills and attitude was studied as an outcome of the intervention.  data collection: the data was collected before and after the fdp as pre and post intervention difference in different domains of professional development from educators of intervention group. from comparison group same information was collected before and after the fdp as pre and post but without exposure to intervention. in data collection mixed method employing both qualitative and quantitative approaches were utilized. the information was collected about the program participants, their perceptions for the program, activities they had, how and where activities were done, and any change in knowledge, attitude and skills occurred as a result of these activities, how much their professional needs met at personal as well as institutional level. tools for data collection were direct observation, review of documents, and rated questionnaire. a 10 item rated questionnaire on 5 point likert scale with 5= strongly agree to 1= strongly disagree was developed to get feedback of program participants. pre and post program questionnaire was used for both intervention and comparison groups on 5 point likert scale about the impact of program. for comparison group not exposed to intervention disclosing any change was attributed to factors other than the program for their knowledge and skills as educators.  data analysis and interpretation: data collection and data analysis was done concurrently. for descriptive statistics spss 19 version was used. univariate and bivariate analysis was done to interpret the rated questionnaire journal of islamabad medical & dental college (jimdc); 2016:5(3):134-138 136 input/resources activities outputs short term outcomes outcomes outcomes intermediate outcomes long term outcomes administration of capacity development building, education deans and educational university consultants. faculty partners: from nih&s, pakistan and phmi, usa. resources: capacity development building, literature, elearning supportive class rooms, educational expertise, experienced facilitators, logistic support, library, supportive leadership, program evaluation office. funding: defence phase i authority islamabad and revenue generated from the program fee time: participants twice a week sessions to be attended in person, for facilitators to prepare and facilitate sessions and faculty and staff to develop, and implement program. design instructional approaches to meet the needs of the participants, collaboration with faculty partners from phmi and local universities in the education discipline, designing and developing sessions and methods in light of best evidence and feedback from literature survey, arranging guest speakers, integrating faculty development for diverse group of educators from health professional institutes, providing logistic support in the face to face& virtual learning environment, providing in time consultancy and support for program evaluators. scope and sequence of the program, schedule of the three terms with expectations from the participants for each term module, well designed sessions by trained facilitators, nihs & phmi faculty, provide consultancy to participants, evaluation results, timely feedback by facilitators and from other teaching faculty. video recording of micro teaching with feedback from facilitator and peers, case studies, working in similar and diverse group setting., designing course curriculums with value addition. participants’ satisfaction with the teaching approaches. participants practicing educational theories and learned teaching strategies for adult learning in the sessions, participants change in behavior by working in teams, participants identifying educational leader ship concept in different situations, participants level of satisfaction by the gain in knowledge, skill and attitudes as educators applying educational theories and philosophy in developing different course curriculums in a diverse group setting with multiple input leading to value addition. developing assessment plans in the light of new educational technology using diverse test items and identifying their strengths and weaknesses, improvement in teaching methodology constructivist approach and facilitation of small group pbl sessions. practice competency in different teaching methodologies, designing teaching strategies to address the learning needs of different learning styles students, staying in touch with literature to have best evidence, change in attitude for working in diverse group setting with a spirit of team work, using assessment tools which are reliable and valid, practicing educational leadership and be a source of value addition when designing curriculums. program structure program outcomes contextual factors diverse participants of fdp: basic medical sciences, physicians, nurses, social sciences, information technology. similar activities started by other agencies, electricity crises, petrol prices going high capacity development building too far away from main city, security issues needing rescheduling of session timings. the logic model for faculty development program journal of islamabad medical & dental college (jimdc); 2016:5(3):134-138 137 results univariate and bivariate analysis was done. univariate analysis (figure 1) showed that 95% of the program participants met their personal professional needs, 95% reported change in attitude in terms of team work in diverse group setting. about 98 % reported a gain in knowledge and skills for designing new teaching strategies, 96 % of participants considered while experiential learning to develop assessment items useful, 100 % of the participants agreed that the hand on activity of curriculum exercise is a proper method to learn curriculum development. the bivariate analysis showed that the interventional educational activities and exercises succeeded to accomplish the program outcomes. the pre post test questionnaire for intervention and comparison groups showed achievement of program outcomes in the intervention group. for comparison group no change was documented showing that the group not exposed to intervention with no change in the baseline from any other source during the 29 weeks’ period. 92% 93% 94% 95% 96% 97% 98% 99% 100% 101% personal professional needs met team work attitude developed knowledge for new teaching strategies experiential learning of assessment items hands on activity for curriculum figure 1: frequency distribution of different variables of fdp discussion overall satisfaction with faculty development programs was high. participants consistently found program, useful and relevant to their objectives. participants reported positive changes in attitude toward faculty development and teaching. regarding the faculty development program all the participants have felt its need and considered it as a mandatory part of training for the new entering faculty in teaching profession. in the study done by ozvaris sb et al, 83 faculty participants expressed a high degree of satisfaction with the content and organization, as well as the course of trainers' teaching. 9 but their study had utilized a test of knowledge related to the course content and participants also performed a microteaching session. in the present faculty development program experiential learning was utilized while bransford et al reported that the faculty in their study learned what was taught in the workshop, but they were left alone to successfully develop and implement active-learning teaching strategies. 10 the importance of on-site network of expert support in the form of performance feedback is an essential part of any professional development activity. in the nih&ss program the replays of teaching, with expert’s feedback, were the most powerful tools that were utilized. the study done by rogan et al suggested that faculty development programs with communities of educators with similar goals can support one another through expert feedback while practicing implementation strategies. 11 mcquiggan ca and later desselle bc addressed the time constrains at the work place by designing one day workshop for faculty teaching in pediatric residency program. 12,13 the pre and post workshop questionnaire showed increase in self-efficacy and confidence. at personal level several participants believe that such activities to be carried out at institutional level as a comprehensive program instead of patchy efforts of faculty training. with proper training as an educator effectiveness of teaching can benefit the learners as identified by most of the participants. majority of participants suggested that such activities should be welcomed at working place as value addition in the educational programs. as far as participants views regarding the satisfaction level all have taken it as a knowledgeable practical experience that has given them a chance to work together as a team in diverse group setting. conclusion professional development at the workplace for the teaching faculty to have in job training will not only help in time management but also resource management. at institutional level this is the best solution to bring change in teaching attitudes and behaviors among today’s educator of health care profession. use and dissemination of results nih&ss experiential learning fdp is a bench mark in this region that has provided evidence that professional development at work place can help in resource management and gives a sense of owner ship to the faculty. such programs should be planned and implemented by the institutions under supervision of accrediting bodies like pakistan medical and dental council and higher education commission for enhancing effectiveness of educators for their potential new roles. conflict of interest this study has no conflict of interest to declare by any author. references 1. amin z, khoo he, chong ys, tan ch, goh ps, samarasekera dd, etal. a multi-institutional survey on faculty development needs, priorities and preferences in medical education in an asian medical school. med educ online. 2009;14:16 http://www.tandfonline.com/action/dosearch?contrib=bahar%5c-ozvaris%2c+s http://www.ncbi.nlm.nih.gov/pubmed/?term=desselle%20bc%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=amin%20z%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=eng%20kh%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=seng%20cy%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=hoon%20tc%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=sun%20gp%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=samarasekera%20dd%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed?term=samarasekera%20dd%5bauthor%5d&cauthor=true&cauthor_uid=20165530 http://www.ncbi.nlm.nih.gov/pubmed/20165530 journal of islamabad medical & dental college (jimdc); 2016:5(3):134-138 138 2. bransford jd, brown al, cocking rr, editors. how people learn: brain, mind, experience, and school. washington, dc, us: national academy press; 2000. 3. dennick r. log-term retention of teaching skills after attending the teaching improvement project: a longitudinal, self-evaluation study. med teach. 2003; 25(3): 314–8. 4. finucane p, allery la, hayes tm. comparison of teacher at a traditional and an innovative medical school. med educ. 1995;29(2):104-9. 5. lancaster jw, stein sm, maclean lg, amburgh jv, persky am. faculty development program models to advance teaching and learning within health science programs. am j pharm educ. 2014;78(5):99. 6. wadhwa a, das l, ratnapalan s. faculty development effectiveness: insights from a program evaluation. j biomed educ. 2014; 2014:5. 7. irby dm, wilkerson l. educational innovations in academic medicine and environmental trends. j gen intern med. 2003;18(5):370–6. 8. hernandez m. using logic models and program theory to build outcome accountability. educ treat children. 2000;23(1):24–40. 9. mayeske gw, lambur mt. how to design better programs: a staff centered stakeholder approach to program logic modeling. crofton md: program design institute; 2001. 10. rogan jm. how much curriculum change is approp riate? defining a zone of feasible innovation. sci educ. 2007;91(3):439–60. 11. bahar-ozvaris s, aslan d, sahin-hodoglugil n, sayek i. faculty development program evaluation: from needs assessment to long-term effects, of the teaching skills improvement program. teach learn med. 2004;16(4):36875 12. mcquiggan ca. faculty development for online teaching as a catalyst for change. j asynchronous learn netw. 2012;16(2):27-61 13. desselle bc, english r, hescock g, hauser a, roy m, yang t, etal. evaluation of a faculty development program aimed at increasing residents' active learning in lectures. j grad med educ. 2012;4(4):516–20. authorship contribution: author 1: conception, planning, active participation in research, analysis of results and final review. author 2: conception, planning, analysis and interpretation of results, discussion and final review. author 3: analysis and interpretation of results, discussion and final review. http://www.ncbi.nlm.nih.gov/pubmed/?term=lancaster%20jw%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=stein%20sm%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=maclean%20lg%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=van%20amburgh%20j%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=persky%20am%5bauth%5d http://www.hindawi.com/93834740/ http://www.hindawi.com/25694309/ http://www.hindawi.com/73501759/ http://www.sciencedirect.com/science/article/pii/s0149718914000354#bib0055 http://www.sciencedirect.com/science/article/pii/s0149718914000354#bib0085 http://www.tandfonline.com/action/dosearch?contrib=bahar%5c-ozvaris%2c+s http://www.tandfonline.com/action/dosearch?contrib=aslan%2c+d http://www.tandfonline.com/action/dosearch?contrib=sahin%5c-hodoglugil%2c+n http://www.tandfonline.com/action/dosearch?contrib=sayek%2c+i http://www.ncbi.nlm.nih.gov/pubmed/?term=desselle%20bc%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=english%20r%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=hescock%20g%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=hauser%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=roy%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20t%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chauvin%20sw%5bauth%5d 55 j i m d c 2 0 1 7 55 address of correspondence: prof saeed alam email: drsaeed_alam@hotmail.com pathologist-clinician collaboration and patient care saeed alam professor of histopathology, islamabad medical and dental college, islamabad in this era of personalized medicine pathology plays a pivotal role and pathologists are at the forefront of establishing a correct diagnosis, on the basis of which further management of any disease is carried out. infect the glorification of modern medicine and understanding of human body owes a lot to advances in pathology. a practicing physician or a surgeon is stranded without the help of a diagnostic pathology laboratory and guidelines from pathologist. clinician suspects a disease and advises a battery of laboratory tests encompassing all the differential diagnosis and quite often, the confirmation requires a microscopic examination or more sophisticated tests involving molecular or genetic studies. it is believed that 70% of clinical decisions are based upon laboratory tests. collaboration between the pathologist and clinician has been found to be indispensable in improving the quality of patient care especially in, but not limited to, the areas of cancer management and care.1 knowledge about the sample collection, the right container used and proper documentation can minimize the pre-analytic errors. laboratory request form is the first contact between the patient and laboratory and inadequately completed laboratory request forms or illegible clinical information provided limits pathologists advice to clinician and may contribute to medical errors. majority of laboratory errors occur in pre-analytic phase of laboratory workflow and inadequately completed forms have been described as a contributory pre-analytic error.2 awareness about the limitations and interpretation of different test results is an essential component of patient care. despite all precautionary measures “zero lab error” is a utopian target for any lab however only 15% of errors occur in analytic phase. 3 availability of relevant clinical history, imaging results, supportive laboratory results and procedural details contribute a lot towards establishing a correct cytological or histopathological diagnosis. in a study titled as “clinicians are from mars and pathologists are from venus” it is highlighted that a communication gap exists between pathologists and surgeons and surgeons misunderstood pathologists report 30% of the time.4 the practice of deliberately hiding the relevant clinical details from pathologist can lead to detrimental consequences for the patient. seeking advice of microbiologist is of immense value in selecting the best arsenal to combat infectious diseases and to minimize hospital acquired infections by utilizing guidelines of hospital infection control committee. similarly, a hematologist can provide the best advice in conditions like dic and other life threatening hematological disorders. when to transfuse and which component of blood is required for the particular patient falls under the domain of blood transfusion specialist or a hematologist and a coordinated effort is of utmost benefit for the patient. to shorten the communication gap between the pathologist and clinician, various strategies have been suggested. most convenient is to share the patient’s clinical details on telephone or a junior doctor can visit the laboratory in a hospital setting and exchange clinical details. interdepartmental meetings and clinicopathological conferences are quite useful in this regard. multidisciplinary teams involving a pathologist, radiologist and other clinical specialties also add quality to diagnosis and best patient management decisions. e d i t o r i a l s 56 j i m d c 2 0 1 7 56 address of correspondence: dr.rafiq ahmad email: rafiqahmad2012@gmail.com r e f e r e n c e s 1. suleiman de. pathologist clinician collaboration: a marriage of necessity toward improving the quality of patient care. ann nigerian med. 2015; 9(1):1-3. 2. osega id, afolabi o, onyenekwu cp. the effectiveness of clinical education on the adequate completion of laboratory test request forms at a tertiary hospital. ann med health sci res. 2016; 6(2):90-4. 3. association of clinical pathologists of nepal. right test cycle. j pathol. 2013; 3(2):1. 4. powsner sm, costa j, homer rj. clinicians are from mars and pathologists are from venus: clinical interpretation of pathology reports. arch pathol lab med. 2000; 124:10406. microalbuminuria: a urinary biomarker of diabetic kidney disease rafiq ahmad assistant professor, department of pathology, islamabad medical & dental college islamabad diabetes mellitus is a chronic metabolic disorder characterized by persistent hyperglycemia and disorders of carbohydrate, protein and lipid metabolism.1 it is expected that by the year 2030, about 552 million people globally will be affected from diabetes mellitus.2 if not well controlled, diabetes mellitus leads to both microvascular and macrovascular complications.2 diabetic mellitus is the most common cause of diabetes nephropathy that has a momentous impact on quality of life and survival of the patient.1 it is estimated that about 40 % of type i and type ii diabetes mellitus develop diabetic kidney disease.2 if not timely diagnosed and properly treated, diabetic nephropathy eventually leads to end stage renal disease that requires dialysis or renal transplantation. multiple serum and urinary biomarkers are used to diagnose diabetic nephropathy before it is clinically evident.2 urinary microalbumin has been used as a clinical biomarker of diabetic kidney disease since 1982.4 it is used to screen both type i and type ii diabetes mellitus.5 microalbuminuria results when albumin crosses glomerular filtration barrier due to ultrastructural changes in endothelial glycocalyx.6 microalbuminuria also represents a marker of systemic endothelial dysfunction with increased risk of cardiovascular and cerebral insults in patients with diabetes mellitus.7 in addition to glomerular injury, newer biomarkers of tubular, vascular, inflammation, podocytes and oxidative stress have been verified in some patients that detect diabetic nephropathy much earlier than microalbuminuria.3 usefulness of these biomarkers is still debatable in research due to limited studies performed and requires further validation.3 microalbuminuria even disputed as biomarker of early diabetic nephropathy, is still considered as an important screening test to detect glomerular and tubular injury in diabetic population.3 american diabetes association guidelines recommend initial assessment of urinary albumin excretion in type i diabetes mellitus who have had diabetes for at least five years and in all patients with type ii diabetes mellitus at the time of presentation and during pregnancy.8 all diabetic patients with negative screening test for microalbuminuria should be assessed for kidney functions on annual basis.9 microalbuminuria (although a misnomer term) is detection of small quantity of albumin (and not small-size albumin) in the urine i.e. 30-300 mg/24 hours or 20 to 200 µg/min in the absence of clinical proteinurea as measured by standard analytical methods.7 more appropriate term for microalbuminuria is paucialbuminuria or albumin excretion rate.10 normal urinary albumin excretion is less than 30 mg/24 hours (20ug/min). this small amount is not detectable by j islamabad med dental coll 2020 225 open access saliva as a diagnostic tool for detection of coronavirus-a review abhishek lal1, mahnoor khawaja1, naseer ahmed2 1 student, altamash institute of dental medicine, karachi, pakistan 2 assistant professor, department of community dentistry, altamash institute of dental medicine, karachi, pakistan a b s t r a c t we aimed in this literature review to demonstrate the association and potential of detecting novel coronavirus in saliva of patients and how its implication in future can aid in diagnosis as a non-invasive diagnostic modality. the specimen can be easily obtained and tested from suspected individuals. review of available literature in pubmed, google scholar, ebsco, and semantic scholar was carried out using keywords and combination of “coronavirus”, “saliva” and “diagnosis”. of 1846 articles found, 110 were screened and included in this literature review. currently, nasopharyngeal swab is the standard diagnostic tool as it has been reported to be accurate and sensitive towards detection of coronavirus. testing of saliva specimens is now being considered to aid rapid detection, because saliva collection and its testing are relatively simple, cheap, and safe for both patients as well as healthcare professionals. further research on this will be beneficial to control and contain the virus. key words: coronavirus pandemic, diagnostic tool, salivary specimen authors’ contribution: 1-3conception; literature search; manuscript design and drafting; critical analysis and manuscript review; manuscript editing. correspondence: abhishek lal email: abhishekdarshan@yahoo.com article info: received: july 18, 2020 accepted: september 8, 2020 cite this article. lal a, khawaja m, ahmed n. saliva as a diagnostic tool for detection of coronavirus a review. j islamabad med dental coll. 2020; 9(3): 225-232 funding source: nil conflict of interest: nil i n t r o d u c t i o n in december 2019, an unknown number of pneumonia cases were reported from wuhan, china which were later categorized as cases of novel coronavirus.1 as the disease started to spread rapidly throughout china, this generated stress, panic, and anxiety among the individuals. later on, healthcare authorities-imposed protection guidelines and protocols to contain this virus and prevent its further spread. although this notion is still being debated upon, the possible origin of coronavirus is thought to be from bats.2 on 11 march 2020, the world health organization (who) categorized novel coronavirus 2019 as a pandemic, providing guidelines to the world community for their protection.3 coronavirus is known to infect the respiratory, hepatic, and nervous systems of human beings as well as animals.4 the current rapid spread of coronavirus mandates the identification of effective diagnosis as well as treatment of the patients. the genome of the novel coronavirus consists of 4 genera (alpha, beta, gamma, and delta), with singlestranded positive-sense rna. once inside the body, sars-cov-2 uses ace2 receptor for entry into the r e v i e w a r t i c l e j islamabad med dental coll 2020 226 cell. this process is facilitated by a serine protease, tmprss2 which also cause viral activation by cleavage of s glycoprotein.5 zhou et al., proved further that novel coronavirus does not use any other receptors to initiate its action.2 all tissues and organs of the body that expresses ace2 receptors are prone to face coronavirus invasion and may present with various symptoms.6 large number of ace2 receptors have been detected in type ii alveolar cells, cholangiocytes, upper esophagus and myocardial cells, respectively.7 the mode of transmission for covid-19 is primarily through respiratory droplets, by direct human-tohuman contact and touching objects that have been contaminated by an infected person. characteristic clinical features of coronavirus mainly include fever, sore throat, dry cough and myalgia with some patients also experiencing stomach upset and disturbed smell sensation.8moreover, the elderly and those with underlying co-morbidities tend to suffer more severe infection as well as mortalities from the pathology.9 symptomatic individuals are identifiable, but one of the major hurdles in tackling this pandemic are the asymptomatic individuals who unknowingly transmit the disease.10 moreover, severe infections and deaths have been reported in healthy individuals without any co-morbidities.11 handwashing, wearing a mask, social distancing and quarantine are some important preventive steps conveyed by who and centers for disease control and prevention (cdc). recently it has been reported that male gender tends to contract the virus more frequently as compared to the female gender.12 additionally, some professions are particularly prone to contract the virus such as dental surgeons.13 understanding the etiology, mode of transmission, and diagnostic tools can help in the rapid treatment as well as diagnosing the patients for timely interventions. presently, the novel coronavirus pandemic is a major dilemma worldwide, where governments, healthcare authorities, and individuals are striving to control its further spread. most of the countries in the grip of this virus are pressurizing the medical community for coming up with treatments, vaccinations, and rapid and effective diagnostics modalities to control and contain it. various studies have been carried out regarding the detection of coronavirus as indicated in the literature. many studies report a positive correlation between coronavirus and its presence in saliva. the introduction of saliva as one of the diagnostic modalities for coronavirus can aid in the rapid testing of individuals whether at home or hospital. review of available literature in pubmed, google scholar, ebsco, and semantic scholar was carried out using keywords and combination of “coronavirus”, “saliva” and “diagnostic tool”. of 1846 articles found on the subject, 110 were screened independently by contributing authors to determine suitability for inclusion in this literature review. saliva as a physiological requirement for oral health saliva is a secretion produced in the oral cavity by major salivary glands which include parotid, submandibular and sublingual glands along with numerous minor salivary glands distributed throughout the mouth. normally, a person produces around 600 ml of saliva, of which 90% is produced by major salivary glands with the remaining 10% by minor glands.14 many functions are performed by saliva including cleansing and protection of teeth, digestion, buffering, antimicrobial effect, and phonation along with other functions as well. saliva consists of various molecules including electrolytes, carbohydrates, proteins, enzymes, and antibodies that are vital for oral cavity protection.15 saliva as a source of virus spread saliva has been known to harbor many viruses, presence of which aid in detection of many j islamabad med dental coll 2020 227 pathologies. previously, viruses such as zika virus has also been inoculated from saliva of the infected patients, indicating interaction of various salivary biochemicals with the virus.16 as previously stated, ace2 receptor is the primary site of action for coronavirus and salivary glands have an abundant number of these receptors. apart from novel coronavirus, many other viruses have been detected in saliva such as epstein-barr virus, herpes simplex virus, chikungunya virus and ebola virus.17 lastly, extrapulmonary sites have also been reported to harbor coronavirus in both patients who have recovered from the infection as well as those who were asymptomatic.18 pathogenesis of covid-19 angiotensin-converting enzyme 2 (ace2) is an important receptor, through which sars-cov-2 mainly initiate its action. in previous experimental studies, ace2 receptors were highly expressed in the salivary glands as compared to the lungs.19 sites in the oral cavity which have abundant number of ace2 receptors include tongue and floor of the mouth.20 in rhesus macaques, the epithelial cells lining the salivary glands were early targets of sarscov-2.21 particular emphasis has been given to the induction of cytokine storm by sars-cov-2, whereby increased cytokine levels (il-6, il-10, and tnf-α), lymphopenia, and decreased ifn-γ expression in cd4+ t cells has been associated with severe covid-19 infection.22 this can lead to respiratory distress in the affected individuals which might even require need for ventilator support. in addition to the presence of coronavirus in human saliva, animals infected with coronavirus, have also shown the presence of the virus in their saliva.23 moreover, the presence of ace2 receptors in salivary glands indicate that these glands are a potential target for inflammation by sars-cov-2.24 regarding human coronavirus replication, recently discovered cystatin d, a salivary cysteine protease inhibitor has been found to be a potent inhibitor of replication of the novel coronavirus.25 xu et al. also report that saliva is a reservoir for coronavirus in asymptomatic patients, who can also transmit the virus to other healthy individuals.19 current diagnostic modalities for coronavirus currently, nasopharyngeal and oropharyngeal swabs are collected for detection of coronavirus from suspected patients. these specimens are tested using real-time rt-pcr.26 both nasopharyngeal and oropharyngeal swabs are regarded as sensitive for sars-cov-2 detection, but the collection of specimens at the right time is particularly emphasized.27 by using this method, the healthcare workers are in close proximity with the suspected individuals posing a potential risk of being infected e.g. patient sneezing at the time of sample collection either due to discomfort or bleeding especially with patients suffering from thrombocytopenia. the recent development of detecting biological markers in saliva has aided in diagnosing various pathologies caused by an array of bacteria, viruses, and fungi. there has been a tremendous potential of using saliva as a potential diagnosing modality as this offers an edge over other diagnostic tools as the collection of saliva is relatively non-invasive and easy to collect.28 method for saliva collection saliva is relatively easy to collect and the procedure can be performed at a hospital as well as homes, keeping the convenience of patients in mind.29 the patient is asked to cough so that saliva is derived from their throat and spit in the sterile container. viral medium is then added to the container as reported in the studies.30 advantages of using saliva as a diagnostic tool limitations of collecting and using nasopharyngeal and oropharyngeal swabs have been studied which includes the risk of nosocomial infection, a risk to the healthcare professional during sample collection j islamabad med dental coll 2020 228 and causing patient discomfort.31 while collecting the nasopharyngeal sample, it is known that the method can cause sneezing and cough in patients thereby generated aerosols with an increase in the risk of transmission of the virus.32 saliva is relatively easy to collect, economical and multiple samples can be collected from the patient without any unnecessary discomfort, even at home.33 moreover, since the method is non-invasive, healthcare workers are safe from cross-infection when collecting saliva for diagnosis. storage and shipping can also be carried out more easily.34 furthermore, no additional trained medical staff is required to perform the collection process.35 saliva does not clot like blood, so it can be manipulated easily and disposed of as well.36 saliva, as a potential diagnostic tool for covid-19 keeping in mind how rapidly the pandemic has been spreading, quick and accurate diagnosis of coronavirus is a must to control undesired effects on the global community. a study by to et al. reported that molecular testing of saliva compared with a nasopharyngeal swab, leads to an improved detection of respiratory viruses. 30 in a cohort study at two hospitals in hong kong, high levels of coronavirus were reported in the posterior oropharyngeal saliva samples of covid-19 infected patients, especially during the first week after the presentation of the symptoms.37 additionally, a previous study by wang et al. also reported detecting sars-associated coronavirus in the saliva of the infected individuals.38 it has been reported that initially the saliva sample detected high viral load, but with serial samples, the load declined eventually to the negative status of both saliva viral load and nasopharyngeal swab.39 virus was detected in saliva of an infected individual, but the difference of viral load was observed in those with mild and severe infections.40 furthermore, studies point out that coronavirus has also been found in the saliva of neonates and their mothers infected with sars-cov2.41 additionally, countries with less resources can be benefited by the potential low-cost and noninvasive method of using saliva for diagnosis. comparison between saliva and nasopharyngeal swabs for coronavirus detection nasopharyngeal swabs are widely used specimen in clinical practice for the detection of respiratory viruses, including coronavirus through pcr.25 however, the risk of nosocomial transmission of 2019-ncov is associated with collection of nasopharyngeal specimens, especially if the patient coughs during the procedure. 27,29 additionally, the collection method of saliva overcomes these issues related to nasopharyngeal swabs. kim et al. collected paired saliva and nasopharyngeal specimens from patients with suspected acute respiratory viral infections and reported that both samples were equally sensitive for isolation of the viruses.42 however, a previous study by jeongs et al. reported more optimal detection of respiratory viruses in sputum as compared with a nasopharyngeal swab.43 literature presents conflicting evidence of superiority and sensitivity of one method over the other. robinson et al. reported saliva as more sensitive for detection of respiratory viruses44 while becker et al. noted that nasopharyngeal swab is more sensitive in detecting coronavirus (covid-19) as compared to saliva specimen.45 hence, it can be said that both saliva and nasopharyngeal swab have their own importance as diagnostic modalities, with the conclusion that saliva testing should also be introduced, specifically for healthcare workers at risk of infection with covid-19.27 j islamabad med dental coll 2020 229 table i: description of covid-19 articles using saliva and/or other samples as a diagnostic modality in this review type of study targeted sample method of sample collection tests done on sample results reference no. cross-sectional study 530 patients tongue, nasal, and mid-turbinate samples collected by patient. nasopharyngeal collected by healthcare workers reverse transcriptase pcr (rt-pcr) tongue, nasal, or midturbinate samples have more clinical usefulness compared with nasopharyngeal samples for the diagnosis of covid-19 sars-cov. 31 observational cohort study 23 patients blood, urine, posterior oropharyngeal saliva and rectal swab reverse transcriptase quantitative pcr (rt-qpcr) salivary viral load highest during 1st week after onset of symptoms. posterior oropharyngeal saliva samples more acceptable. 37 epidemiological surveillance study 12 patients saliva collected by coughing out from throat nucleic acid extraction and real-time reverse transcription– quantitative pcr for 2019ncov the 2019-ncov was detected in the initial saliva specimens of 11 patients (91.7%) with highest viral load in 5 patients (83.3%). serial saliva specimens showed declines in salivary rna levels after hospitalization. 39 retrospective cohort study 96 patients (3497 samples) respiratory, stool, serum and urine samples real-time pcr sars-cov-2 mean duration of detection longer in stools sample than respiratory and serum samples. virus persists longer with higher load in respiratory tissue of patients with severe disease. 40 descriptive study 2 patients (mother & neonate) nasopharynx, oropharynx, stool, ncov real-time polymerase chain reaction highest rna copies of the viruses detected in nasopharynx. stool viral 41 j islamabad med dental coll 2020 230 saliva, plasma, and urine samples. load remained higher than other samples. prospective study 236 patients paired nasopharyngeal swabs and saliva specimens multiplex rtpcr nasopharyngeal swabs and salivary specimens equally effective to detect respiratory viruses. 42 prospective study 154 patients nasopharyngeal swabs and sputum samples. multiplex real‐ time rt‐pcr detection rates of respiratory viruses from sputum samples were significantly higher than from nasopharyngeal swabs. 43 comparative study 137 patients nasopharyngeal swabs, throat swabs and saliva specimens direct fluorescent antigen testing and nucleic acid amplification tests throat swabs and saliva specimens are inferior to nasopharyngeal swabs for detection of respiratory viruses. 44 c o n c l u s i o n coronavirus is transmitted by person-to-person contact through respiratory droplets. saliva is a potential reservoir for the novel coronavirus. saliva specimens can be easily collected from the suspected patients with a relatively simple, cheap and comfortable method. saliva diagnostics is an evolving field that can be incorporated as part of the disease diagnosis process, along with other diagnostic modalities. to analyze the potential of detecting coronavirus in salivary samples, more research is required to develop rapid testing methods which can be beneficial for the healthcare professionals, scientists and virologist for early and easy detection. r e f e r e n c e s 1. li q, guan x, wu p, wang x, zhou l, tong y, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n engl med. 2020; 382: 1199-1207. doi: 10.1056/nejmoa2001316. 2. zhou p, yang x lou, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020; 579(7798): 270–3. doi: 10.1038/s41586-020-2012-7 3. who director-general’s opening remarks at the media briefing on covid-19 11 march 2020. 2020; available from: https://www.who.int/dg/speeches /detail/who-director-general-s-opening-remarks-atthe-media-briefing-on-covid-19---11-march-2020 4. chen y, liu q, guo d. emerging coronaviruses: genome structure, replication, and pathogenesis. j med virol. 2020; 92(4): 418–23. doi: 10.1002/jmv .25681 5. hoffmann m, kleine-weber h, schroeder s, krüger n, herrler t, erichsen s, et al. sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor. cell. 2020; 181(2): 271-280.e8. doi: 10.1016/j.cell.2020.02.052 6. zou x, chen k, zou j, han p, hao j, han z. single-cell rna-seq data analysis on the receptor ace2 expression reveals the potential risk of different j islamabad med dental coll 2020 231 human organs vulnerable to 2019-ncov infection. front med. 2020; 14(2): 185–92. doi: 10.1007/s11684 -020-0754-0 7. zhang h, kang z, gong h, xu d, wang j, li z, et al. the digestive system is a potential route of 2019-ncov infection: a bioinformatics analysis based on singlecell transcriptomes. biorxiv. 2020; doi: 10.1101/2 020.01.30.927806v1 8. chen n, zhou m, dong x, qu j, gong f, han y, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395(10223): 507–13. doi: 10.1016/s0140-6736(20)30211-7 9. wang t, du z, zhu f, cao z, an y, gao y, et al. comorbidities and multi-organ injuries in the treatment of covid-19. lancet. 2020; 395(10228): e52. doi: 10.1016/s0140-6736(20)30558-4 10. cai j, sun w, huang j, gamber m, wu j, he g. indirect virus transmission in cluster of covid-19 cases, wenzhou, china, 2020. emerg infect dis. 2020; 26(6): 1343–5. doi: 10.3201/eid2606.200412 11. chang d, lin m, wei l, xie l, zhu g, dela cruz cs, et al. epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china. jama. 2020; 323(11): 1092. doi: 10.1001/jama.2020.1623 12. özdin s, bayrak özdin ş. levels and predictors of anxiety, depression and health anxiety during covid19 pandemic in turkish society: the importance of gender. int j soc psychiatry. 2020; 002076402092705. doi: 10.1177/0020764020927051 13. ali s, zeb u, khan m, muhammad a. transmission routes and infection control of novel coronavirus2019 in dental clinics – a review. j islam med dent coll. 2020; 9(1): 65–72. doi: 10.35787/jimdc.v9i1.517 14. zhang c-z, cheng x-q, li j-y, zhang p, yi p, xu x, et al. saliva in the diagnosis of diseases. int j oral sci. 2016; 8(3): 133–7. doi: 10.1038/ijos.2016.38 15. humphrey sp, williamson rt. a review of saliva: normal composition, flow, and function. j prosthet dent. 2001; 85(2): 162–9. doi: 10.1067/mpr.2001 .113778 16. li y, ren b, peng x, hu t, li j, gong t, et al. saliva is a non‐negligible factor in the spread of covid‐19. mol oral microbiol. 2020; 35(4): 141-45. doi: 10.1111/ omi.12289 17. guidry j, birdwell c, scott r. epstein-barr virus in the pathogenesis of oral cancers. oral dis. 2018; 24(4): 497–508. doi: 10.1111/odi.12656 18. kalkeri r, goebel s, sharma gd. sars-cov-2 shedding from asymptomatic patients: contribution of potential extrapulmonary tissue reservoirs. am j trop med hyg. 2020; 103(1):18-21. doi: 10.4269/ajtmh.200279 19. xu j, li y, gan f, du y, yao y. salivary glands: potential reservoirs for covid-19 asymptomatic infection. j dent res. 2020; 002203452091851. doi: 10.1177/0022034520918518 20. xu h, zhong l, deng j, peng j, dan h, zeng x, et al. high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa. int j oral sci. 2020; 12(1): 8. doi: 10.1038/s41368-020-0074-x 21. liu l, wei q, alvarez x, wang h, du y, zhu h, et al. epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques. j virol. 2011; 85(8): 4025–30. doi: 10.1128/jvi.02292-10 22. pedersen sf, ho y-c. sars-cov-2: a storm is raging. j clin invest. 2020; 130(5): 2202–5. doi: 10.1172/ jci137647 23. barton mc, bennett k v., cook jr, gallup gg, platek sm. hypothesized behavioral host manipulation by sars-cov2/covid-19 infection. med hypotheses. 2020; 141:109750. doi: 10.1016/j.mehy.2020.109750 24. wang c, wu h, ding x, ji h, jiao p, song h, et al. does infection of 2019 novel coronavirus cause acute and/or chronic sialadenitis? med hypotheses. 2020; 140: 109789. doi: 10.1016/j.mehy.2020.109789 25. collins ar, grubb a. cystatin d, a natural salivary cysteine protease inhibitor, inhibits coronavirus replication at its physiologic concentration. oral microbiol immunol [internet]. 1998; 13(1): 59–61. doi: 10.1111/j.1399-302x.1998.tb00753.x 26. corman vm, landt o, kaiser m, molenkamp r, meijer a, chu dkw, et al. detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr. euro surveill. 2020; 25(3): 2000045. doi: 10.2807/15607917.es.2020.25.3.2000045 27. loeffelholz mj, tang y-w. laboratory diagnosis of emerging human coronavirus infections – the state of j islamabad med dental coll 2020 232 the art. emerg microbes infect. 2020 ;9(1):747–56. doi:10.1080/22221751.2020.1745095 28. han p, ivanovski s. saliva—friend and foe in the covid-19 outbreak. diagnostics. 2020; 10(5): 290. doi: 10.3390/diagnostics10050290 29. aro k, wei f, wong dt, tu m. saliva liquid biopsy for point-of-care applications. front public heal. 2017; 5. doi: 10.3389/fpubh.2017.00077/full 30. to kk, lu l, yip cc, poon rw, fung am, cheng a, et al. additional molecular testing of saliva specimens improves the detection of respiratory viruses. emerg microbes infect. 2017; 6(1): 1–7. doi: 10.1038/emi. 2017.35 31. tu y-p, jennings r, hart b, cangelosi ga, wood rc, wehber k, et al. swabs collected by patients or health care workers for sars-cov-2 testing. n engl j med. 2020; 383(5): 494–96. doi: 10.1056/nejmc2016321 32. wang h, liu q, hu j, zhou m, yu m, li k, et al. nasopharyngeal swabs are more sensitive than oropharyngeal swabs for covid-19 diagnosis and monitoring the sars-cov-2 load. front med. 2020; 7. doi: 10.3389/fmed.2020.00334/full 33. chiappin s, antonelli g, gatti r, de palo ef. saliva specimen: a new laboratory tool for diagnostic and basic investigation. clin chim acta. 2007; 383(1–2): 30–40. doi: 10.1016/j.cca.2007.04.011 34. fanyue sun ejr. saliva as a source of genomic dna for genetic studies: review of current methods and applications. oral health dent manag. 2014;13(2): 217-22. pmid: 24984625 35. chojnowska s, baran t, wilińska i, sienicka p, cabajwiater i, knaś m. human saliva as a diagnostic material. adv med sci. 2018; 63(1): 185–91. doi: 10.1016/j.advms.2017.11.002 36. mittal s, bansal v, garg s, atreja g, bansal s. the diagnostic role of saliva a review. j clin exp dent. 2011; 3(4): e314–20. doi:10.4317/jced.3.e314 37. to kk-w, tsang ot-y, leung w-s, tam ar, wu t-c, lung dc, et al. temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: an observational cohort study. lancet infect dis. 2020; 20(5): 565–74. doi: 10.1016/s14733099(20)30196-1 38. wang w-k, chen s-y, liu i-j, chen y-c, chen h-l, yang c-f, et al. detection of sars-associated coronavirus in throat wash and saliva in early diagnosis. emerg infect dis. 2004; 10(7): 1213–9. doi: 10.3201/eid 1007.031113 39. to kk-w, tsang ot-y, yip cc-y, chan k-h, wu t-c, chan jf-wjm-c, et al. consistent detection of 2019 novel coronavirus in saliva. clin infect dis [internet]. 2020; ciaa149. doi: 10.1093/cid/ciaa149 40. zheng s, fan j, yu f, feng b, lou b, zou q, et al. viral load dynamics and disease severity in patients infected with sars-cov-2 in zhejiang province, china, january-march 2020: retrospective cohort study. bmj. 2020; 69:m1443. doi: 10.1136/bmj.m1443 41. han ms, seong m-w, heo ey, park jh, kim n, shin s, et al. sequential analysis of viral load in a neonate and her mother infected with severe acute respiratory syndrome coronavirus 2. clin infect dis. 2020; ciaa447. doi: 10.1093/cid/ciaa447 42. kim y, yun sg, kim my, park k, cho ch, yoon sy, et al. comparison between saliva and nasopharyngeal swab specimens for detection of respiratory viruses by multiplex reverse transcription-pcr. mcadam aj, editor. j clin microbiol. 2017; 55(1): 226–33. doi: 10.1128/jcm.01704-16 43. jeong jh, kim kh, jeong sh, park jw, lee sm, seo yh. comparison of sputum and nasopharyngeal swabs for detection of respiratory viruses. j med virol. 2014; 86(12): 2122–7. doi: 10.1002/jmv.23937 44. robinson jl, lee be, kothapalli s, craig wr, fox jd. use of throat swab or saliva specimens for detection of respiratory viruses in children. clin infect dis. 2008; 46(7): e 61–4. doi: 10.1086/529386 45. becker d, sandoval e, amin a, hoff p de, diets a, leonetti n, et al. saliva is less sensitive than nasopharyngeal swabs for covid-19 detection in the community setting. medrxiv. 2020 doi: 10.1101/ 2020.05.11.20092338. 255 j i m d c 2 0 1 7 255 open access f u l l l e n g t h a r t i c l e acute appendicitis: relationship of total leucocyte count with per-operative stage muneeb-ullah1, awais saeed abbasi2, seemabniaz3, umair ashfaq4 1, 2 registrar, accident and emergency department, dr. akbar niazi teaching hospital, islamabad 3 post graduate trainee, pims hospital, islamabad 4 registrar, cmh rawalpindi a b s t r a c t objective: to correlate total leucocyte count(tlc) with per-operative stage of acute appendicitis. patients and methods: this cross sectional study was conducted in department of surgery, pakistan institute of medical sciences (pims) from june 2016 to june 2017. a total 77 patients were included through consecutive sampling technique. statistical package for social sciences (spss) version 20 was used to analyze data. results: a total of 77 patients were included in the study, among them 47 (61%) were males, and 30(39%) were females. mean age was 22.25 ± 5.19 years. mean tlc was 12,900 ± 4087 cells/µl patients having acute appendicitis were labeled as, acute appendicitis stage i which included 59 (76.6%) patients, gangrenous appendicitis was named as stage ii which included 11 (14.3%) patients. perforated appendicitis was labeled as stage iii in which 7 (9.1%) patients were inducted. in stage i, mean age was 21.89 ± 5.50 years and mean tlc was 12,344 ± 4162 cells/µl. in stage ii, mean age was 22.36 ± 3.90 years and mean of total leukocyte count was 15,072 ± 3497 cells/µl. in stage iii, mean age was 25.57 ± 3.50 years and mean leukocyte count was 14,214 ± 4141cells/µl (p-value >0.05). conclusion: significant statistical association was not found in patients in different stages of appendicitis with respect to tlc (p value >0.05), although patients in all stages had raised mean tlc with mean tlc highest in patients having stage ii (gangrenous appendicitis). key words: acute appendicitis, gangrenous appendicitis, perforated appendicitis; total leucocyte count. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 ,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection address of correspondence muneeb-ullah email: muneebullah@gmaill.com article info. received: october 7, 2017 accepted: november 20, 2017 cite this article. muneeb-ullah, abbasi as, ashfaq u. acute appendicitis: relationship of total leucocyte count with per-operative stage. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n acute appendicitis is the most common surgical abdominal emergency in patients with abdominal pain, occurring in 10% of general population.1,2 vermiform appendix can have a variable course, retrocecal being the most common.3 it is positioned near the ileocecal valve where the taenia coli converge on the cecum. appendix is a true diverticulum of the cecum and it contains all layers of the colonic wall, i.e. mucosa, submucosa, muscularis and the serosa. this is in contrast to the acquired diverticular disease which only consists of protuberance of subset of the enteric wall layers.4 incidence of appendicitis is approximately 233/100,000 population, being highest in the 10-19-year-old age group. it frequently occurs in the second and third decade of life. male to female ratio is 1.4:1 and lifetime incidence is 8.6% in males as compared to 6.7% in females. the primary cause of appendicitis is proposed to be appendicular obstruction.5 escherichia coli and streptococcus are the o r i g i n a l a r t i c l e 256 j i m d c 2 0 1 7 256 common gram positive organisms to cause appendicitis.6,7 abdominal pain is reported as the most common symptom in almost all confirmed cases of appendicitis. patients with acute appendicitis present with some of the classical symptoms as, anorexia, nausea, vomiting and right lower quadrant abdominal pain.8 mc burney’s point tenderness, rovsing’s sign, psoas sign and the obturator sign are some commonly described signs in acute appendicitis. most of the patients with acute appendicitis have mild leukocytosis (white blood cell (wbc) count more than 10,000 cells/µl).9 approximately 80% of the patients presenting with acute appendicitis have leukocytosis with left shift which is increased total leucocyte count (tlc), immature neutrophils (bands) and neutrophils.10 sensitivity and specificity of tlc in acute appendicitis is 80% and 55% respectively. except in very early course of disease, tlc is usually raised.11 mean tlcs are higher in patients with gangrenous or perforated appendicitis. in acute appendicitis level of tlc are found to be 15,500 ± 7300 cells/µl, in gangrenous appendicitis levels are 17,100 ± 3900 cells/µl and in perforated appendicitis tlc count to be 17,900 ± 2100 cells/µl.12 the main aim of this study was to find out the association of tlc with per-operative stage of acute appendicitis. it was also aimed to determine age group and gender distribution among patients with acute appendicitis. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted in department of surgery, pakistan institute of medical sciences (pims) hospital after approval from ethical review board. duration of study was one year, from june 2016 to june 2017.total 77 patients presenting with signs and symptoms suggestive of acute appendicitis were included in this study13 through consecutive sampling technique. patients having alvarado score of 5-10 were included in the study. patients on steroids, immunosuppressive medication, having serious co-morbid condition and pregnancy were excluded from the study. total four milliliter of venous blood was drawn from all patients for estimation of tlc, before antibiotic administration. complete blood count (cbc) was carried out on an automated 5-part differential cell dyn®3700 coulter counter from abbot laboratories usa. staging of acute appendicitis was based on surgical and pathological findings as follows: stage 1: acute appendicitis, stage 2: gangrenous appendicitis and stage 3: perforated appendicitis.statistical package for social sciences (spss) version 20 was used to analyze and access data. quantitative data was entered as mean±sd. qualitative data was expressed as number and percentage. one-way anova and chi-square test were applied to find out the association of different stages of appendicitis with tlc, gender and age. r e s u l t s total 77 patients were included in the study. among them 61% were males and 39% were females with male to female ratio of 1.5:1. age range of participants in study was from 14 years to 34 years with mean age of 22+ 5.22 years (table 1). table 1: age and gender distribution of participants (n=77) characteristics results age (in years) range (mean±sd) 14-34 (22±5.22) gender; n(%) male 47(61) female 30(39) stage of appendicitis; n(%) stage 1 59 (76.6) stage 2 11(14.3) stage 3 07 (9.1) total leukocyte count ranged between 4900-26100/µl with mean of 12900+4087/µl. association of different stages of appendicitis with tlc count was non-significant. maximum tlc levels was found in stage ii (table 2). table 2: association of different stages of appendicitis with tlc (n=77) stages of appendicitis tlc (cells/µl) (mean ± sd) p-value stage i (n=59) 12,344 ± 4162 0.09 stage ii (n=11) 15,073 ± 3497 stage iii (n=07) 14214 ± 3963 257 j i m d c 2 0 1 7 257 association of stages of appendicitis with age and gender was also found to be non-significant. out of 77 patients, maximum number of patients (both male and female) had stage i appendicitis. mean age (third decade) was almost same in all three stages of appendicitis (table 3). table 3: association of different stages of appendicitis with gender and age (n=77) stages of appendicitis gender pvalue age mean±sd pvalue male n(%) female n(%) stage i (n=59) 40(52) 19(25) 0.069 22 ±5.29 0.864 stage ii (n=11) 5(6) 6(8) 22 ±4.24 stage iii (n=7) 2(3) 5(6) 21± 6.60 d i s c u s s i o n patient in our study were selected on the basis of alvarado score which is a 10-point clinical scoring system, also known by the acronym mantrels. in this scoring system, migration of pain, anorexia, nausea, rebound pain, elevated temperature and shift of white blood cells to the left are given 1 point each, while tenderness in right lower quadrant and leukocytosis are given 2 points each. this score enables risk stratification, linking the probability of appendicitis to recommendations regarding discharge, observation or surgical intervention.13 in present study a male predominance was noted among patients presenting with acute appendicitis; 61% males versus 39% females having male to female ratio of 1.5:1. in a study conducted in saudi arabia 67% patients were male and 33% were females having male to female ratio of 2:1.14 male to female ratio was 1.4:1 in another study.4 in one study conducted in islamabad, 52.2% patients were male while 47.8% patients were females with male to female ratio of 1.1:1.15 mean age was 22± 5.22 years in current study. in a similar study conducted in islamabad mean age was 28.7 ± 11.9 years.15 in another study mean age was 26 ±12 years.16 incidence of acute appendicitis has been reported highest in the 10-19-yearold age group and it frequently occurs in the second and third decade of life.4 current study clearly indicates highest frequency of acute appendicitis in third decade of life while it was noted to be highest in second decade of life in united states. in present study, mean tlc was 12,900 ± 4087 cells/µl in overall study group. in stage i mean tlc was 12,344 ± 4162 cells/µl; in stage ii mean tlc was 15,073 ± 3497 cells/µl and in stage iii mean tlc was 14,214 ± 3963 cells/µl. in one study, it was noted that mean tlcs are higher in patients with gangrenous or perforated appendix. acute appendicitis (stage i): 15,500 ± 7300 cells/µl, gangrenous appendicitis (stage ii): 17,100 ± 3900 cells/µl and perforated appendicitis (stage iii): 17,900 ± 2100 cells/µl.12 our study in comparison to above study is somewhat different as our study shows that mean tlc is highest in gangrenous appendicitis followed by perforated and acute appendicitis. c o n c l u s i o n significant association was not noted in patients with different stages of appendicitis with respect to tlc, age and gender. although patients in stage ii (gangrenous appendicitis had highest mean tlc but it was not statistically significant. a c k n o w l e d g e m e n t prof. dr. tanwir khaliq, dr. tariq abdullah, dr. azmat ali. r e f e r e n c e s 1. sacerio sd, birindelli a, kelly md, catena f, weber dg, sarteli m, et al. wses jerusalem guidelines for diagnosis and treatment of acute appendicitis. world j emerg surg. 2016;11(1):34. 2. kirkil c, karabulut k, aygen e, ilhan ys, yur m, binnetoa lu k, et al. ulus travma acil cerrahi derg, 2013;19(1):13-9 3. schumpelick v, dreuw b, ophoff k, et al. surg clinc north am. 2000;80(1):295-318 4. mulholland mw, lillemoe kd, doherty gm, maier rv, simeone dm, upchurch gr. greenfield's surgery: scientific principles and practice, 4th ed, lippincott williams & wilkins, philadelphia 2005. 5. birnbaum ba, wilson sr. appendicitis at the millennium. radiology 2000; 215(2):337-48. 6. guillet-caruba c, cheikhelard a, guillet m, bille e, descamps p, et al. digan microbiol infect dis 2011;69(4): 376-381 258 j i m d c 2 0 1 7 258 7. chen cy, chen yc, pu hn, tsai ch, chen wt, et al. surg infect (larchmt) 2012;13(6): 383-390 8. lee sl, walsh aj, ho hs. computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. arch surg 2001; 136(5):556-62. 9. cope z, silen w. cope's early diagnosis of the acute abdomen, 19th ed, oxford university press, new york 1996. p.70. 10. tehrani hy, petros jg, kumar rr, chu q. markers of severe appendicitis. am surg 1999; 65(5):453. 11. grönroos jm, grönroos p. leucocyte count and c-reactive protein in the diagnosis of acute appendicitis. br j surg 1999; 86(4):501-4. 12. guraya sy, al-tuwaijri ta, khairy ga, murshid kr. 13. validity of leukocyte count to predict the severity of acute appendicitis. saudi med j 2005; 26(12):1945-7. 14. ohle r, o'reilly f, o'brien kk, fahey t, dimitrov bd. the alvarado score for predicting acute appendicitis: a systematic review. bmc medicine. 2011;9(1):139. 15. shafi sm, afsheen m, reshi fa. total leucocyte count, c-reactive protein and neutrophil count: diagnostic aid in acute appendicitis. saudi j gastroenterol. 2009; 15(2): 117–120. 16. siddiqui zr, khaliq t, shah sa. a new simple scoring system for the diagnosis of acute appendicitis. j pak med students 2011;1(2):32-7. 17. nshuti r, kruger d, luvhengo te. clinical presentation of acute appendicitis in adults at the chris hani baragwanath academic hospital. int j emerg med. 2014; 7(1): 12. j islamabad med dental coll 2020 311 op e n ac c e s s intraparotid facial nerve schwannoma in a 40-year-old male with hearing loss – a case report nosheen nabi1, qudsia ishaq1, muhammad tahir2, aslam shah3 1senior lecturer, department of pathology, rawal institute of health sciences, islamabad pakistan 2professor, department of pathology, rawal institute of health sciences, islamabad pakistan 3professor & hod, department of surgery, rawal institute of health sciences, islamabad pakistan a b s t r a c t schwannoma is a benign tumor of axonal nerve sheath. head and neck area, particularly parotid gland is an uncommon site for schwannoma, however it can rarely arise from the intraparotid part of facial nerve and present as either a symptomless mass or facial paresis. its diagnosis before surgical intervention is important for the conservation of parotid gland and facial nerve. on clinical examination and imaging studies, it can be misdiagnosed easily. fnac is a helpful tool for its diagnosis. this entity should not be ignored while dealing with parotid masses. we present a case of a patient who came with the complaint of a parotid mass. magnetic resonance imaging (mri) scan suggested a parotid tumor which proved to be a spindle cell neoplasm on fine needle aspiration cytology (fnac). a definite diagnosis of schwannoma of intraparotid facial nerve was made on histopathological examination of the excision sample. key words: facial nerve, fine needle aspiration cytology, magnetic resonance imaging, parotid gland, schwannoma. correspondence: nosheen nabi email: nosheen.nabi@yahoo.com article info: received: october 12, 2020 accepted: november 11, 2020 cite this case report: nabi n, ishaq q, tahir m, shah a. intraparotid facial nerve schwannoma in a 40-year-old male with hearing loss – a case report. j islamabad med dental coll. 2020; 9(4): 311-314. doi: 10.35787/jimdc.v9i4.616 funding source: nil conflict of interest: nil i n t r o d u c t i o n schwannoma is a slow growing encapsulated benign tumor arising from the schwann cells of the nerve fiber sheath.1 approximately 25-30% of all reported schwannomas occur in the head and neck region. schwannoma of the facial nerve is a rare entity with very few cases reported in the literature.2 preoperative diagnoses of parotid schwannoma is difficult because clinically it presents as a parotid gland tumor and on imaging, it is indistinguishable from pleomorphic adenoma.3 we report a case of intraparotid schwannoma involving the extratemporal part of the facial nerve, which is exceedingly rare. c a s e r e p o r t a 40-year-old male presented with a history of gradually increasing swelling of the left-sided parotid region for one and a half year (figure 1). he had gradual hearing loss with on and off complaint of pain in the affected area. on clinical examination, there was a firm and immobile swelling measuring 5x4 cm in the left parotid region. a clinical diagnosis c a s e r e p o r t j islamabad med dental coll 2020 312 of parotid gland tumor was made. mri and fnac was advised. figure 1: patient with left parotid swelling. a: before surgery. b: after surgery mri revealed an altered mixed signal intensity, heterogeneously enhancing lesion in the left parotid region, extending medially along posterior aspect of ramus of left hemi-mandible into the left parapharyngeal space. this was suggestive of a neoplastic disease process, possibly originating from the parotid gland. fnac was performed as per standard techniques and the moderately cellular smears showed benign looking spindle cells arranged in a fascicular pattern. cytology favored benign spindle cell neoplasm, most likely, schwannoma (figure 2). figure 2: smears were moderately cellular showing fascicles of spindle cells. a: giemsa stain 100x. b: h&e 400x. patient was operated for the removal of the lesion. the facial nerve trunk was found deeper and inferior due to the pushing effect of the tumor (figure 3a). on anterior dissection the tumor was found to originate from the buccal and zygomatic branches of the facial nerve. the mass was removed successfully with careful dissection. on gross examination the tumor was well circumscribed, encapsulated, measuring 5x4 cm in diameter (figure 3a). microscopic examination showed an encapsulated tumor composed of hypercellular spindle cell areas (antoni a) (figure 3b) and hypocellular areas (antoni b) (figure 3c). hyalinized vessels were also seen (figure 3d). figure 3 a: gross specimen of the resected parotid mass. b: antoni a areas showing verocay bodies (h&e 400x). c: antoni b areas showing myxoid matrix with entrapped macrophages (h&e 400x). d: hyalinized blood vessels (h&e 400x). d i s c u s s i o n schwannoma can arise from facial nerve anywhere along its course; from cerebellopontine angle to its terminal branches, so it can be found extraor intraparotid. majority of the facial nerve schwannoma are extraparotid and only 9% occur inside the parotid gland. intraparotid schwannoma j islamabad med dental coll 2020 313 accounts for 0.2%–1.5% of all facial nerve tumors in the parotid gland.4 intratemporal facial nerve schwannoma presents as a nerve dysfunction in the form of facial paresis while extratemporal nerve involvement presents as a parotid mass without nerve dysfunction.5 there are no definite radiological findings of intraparotid schwannoma.6 mri is the radiological test of choice for detecting facial nerve schwannoma. the most common signs are a mass with signal intensity isointense to muscle on t1 and hyperintense to muscle on t2 sequence, respectively. the target sign (central low and peripheral higher signal intensity on t2 weighted images) is a sign of tumor of nerve sheath which includes schwannoma or malignant nerve sheath tumor.7 as mri cannot differentiate between benign or malignant neoplastic process fnac is regarded as a useful procedure for the diagnosis. fnac of schwannoma reveals moderately cellular smears comprising of clusters of spindle cells in a background composed of pink fibrillary matrix. the individual neoplastic cells have spindle cell wavy hyperchromatic nuclei with scant cytoplasm. no foci of necrosis or mitosis are seen.8 microscopically, schwannoma has a specific pattern of hypercellular antoni a and antoni b areas. verocay bodies are seen in antoni a areas showing palisaded neoplastic cells and this is a diagnostic sign of schwannoma. antoni b is composed of degenerative myxoid stroma and may contain macrophages. presence of hyalinized blood vessels is also a constant feature of schwannoma.9,10 intraparotid facial nerve schwannomas are classified into four types by marchioni et al. for better evaluation and management. type a tumors include those neoplasms which can be operated with conservation of the facial nerve. tumors in this type do not cause facial paresis preoperatively. in type b tumors, the tumor is resectable with removal of some part of the nerve, which is usually peripheral branch or distal division. the resected part is reconstructed by neurorrhaphy or nerve graft. in type c tumors, the main trunk of the facial nerve is resected while in type d, the main trunk and at least one of the temporofacial or cervicofacial branches is also removed.11 the goal of the treatment is to remove the tumor with preservation of the facial nerve but frequently it is not possible to preserve the nerve. the management of intraparotid schwannoma depends on extent of facial nerve dysfunction, localization of tumor to parotid gland and intratemporal extension. these include conservative approaches like extracapsular dissection and partial lateral parotidectomy, and more extensive interventions like lateral parotid lobectomy and total parotidectomy, respectively.12 c o n c l u s i o n preoperative diagnosis of intraparotid schwannoma is difficult because of its rarity and nonspecific radiological findings. this entity should be considered in the differential diagnosis of any parotid mass to avoid any unnecessary extensive surgery. we advocate the use of fnac as a useful technique for the preoperative diagnosis of intraparotid schwannoma. r e f e r e n c e s 1. rodriguez fj, folpe al, giannini c, perry a. pathology of peripheral nerve sheath tumors: diagnostic overview and update on selected diagnostic problems. acta neuropathol. 2012; 123(3): 295-319. doi: 10.1007/s00401-012-0954-z. 2. bayindir t, kalcioglu mt, cicek mt, karadag n, karaman a. schwannoma with an uncommon upper lip location and literature review. case rep otolaryngol. 2013; 2013: 363049. doi: 10.1155/2013/363049. j islamabad med dental coll 2020 314 3. carlson ml, deep nl, patel ns, lundy lb, tombers nm, lohse cm, et al. facial nerve schwannomas: review of 80 cases over 25 years at mayo clinic. mayo clin proc. 2016; 91: 1563–76. doi: 10.1016/j.mayocp.2016.07.007. 4. seo bf, choi hj, seo kj, jung s-n. intraparotid facial nerve schwannomas. arch craniofac surg. 2019; 20(1): 71-74. doi: 10.7181/acfs.2018.02250. 5. jaiswal a, mridha ar, nath d, bhalla as, thakkar a. intraparotid facial nerve schwannoma: a case report. world j clin cases. 2015; 3(3): 322-6. 6. elbouderkaoui m. intra parotid facial nerve schwannoma in a 10-year-old child. a rare finding. j otolaryngol res. 2019; 2(1): 1-4. 7. jayashankar n, sankhla s. facial schwannomas: diagnosis and surgical perspectives. neurol india. 2018; 66(1): 144-6. doi: 10.4103/0028-3886.222821. 8. sharma p, zaheer s, goyal s, ahluwalia c, goyal a, bhuyan g, et al. clinicopathological analysis of extracranial head and neck schwannoma: a case series. j can res ther. 2019; 15: 659-64. doi: 10.4103/jcrt.jcrt_1125_16. 9. khalele ba. intraparotid facial nerve schwannoma: a case report. future dental j. 2016; 2(2): 102-5. 10. demay rm. the art and science of cytopathology: exfoliative cytology/aspiration cytology. 1st ed. chicago: american society of clinical pathologists; 1996. 11. damar m, dinç ae, eliçora ss, bişkin s, erten g, biz s. facial nerve schwannoma of parotid gland: difficulties in diagnosis and management. case rep otolaryngol. 2016; 2016: 3939685. doi: 10.1155/2016/3939685. 12. awan z, azam a. an intraparotid schwannoma mimicking a warthin’s tumour. j case rep: clin & med. 2019; 2(3): 139. j islamabad med dental coll 2021 239 o p e n a c c e s s iniencephaly feriha fatima khidri1, hina riaz2, faiza kamran ali3 1assistant professor, department of biochemistry, liaquat university of medical and health sciences, jamshoro 2assistant professor, department of physiology, liaquat university of medical and health sciences, jamshoro 3women medical officer, department of gynaecology and obstetrics, liaquat university of medical and health sciences, jamshoro a b s t r a c t iniencephaly is an uncommon form of neural tube defects which is characterized by retroflexion of the head and absence of neck as a consequence of defective closure of the vertebral body and arch. multiple identified risk factors for its causation include environmental, genetic and drugs. we report a case of 38-year-old woman with prior history of still birth and abortions who presented at 35 weeks of gestation with lower abdominal pain and high blood pressure. mother had consanguineous marriage. her hypothyroidism was untreated in the first and second trimester. she delivered an iniencephalic baby girl via emergency c-section with multiple malformations at 38 weeks gestation secondary to fetal cardiac deceleration. baby survived for less than 18 hours. in this case, proper antenatal care and follow up visits were needed along with postnatal genetic and pathological evaluation including assessment of risk factors. appropriate management is important to prevent complications and recurrence in subsequent pregnancies. keywords: hypothyroidism, iniencephaly, pregnancy correspondence: feriha fatima khidri email: abdulmudabbir@yahoo.com article info: received: december 22, 2020 accepted: december 16, 2021 cite this case report. khidri ff, riaz h, ali fk. iniencephaly. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n iniencephaly is a rare form of neural tube defects (ntds). it is manifested by the retroflexion of the head and absence of neck due to the abnormalities in vertebral body and arch closure. the exact mechanisms involved in its pathogenesis are not completely known; however, various environmental and genetic factors have been implicated in its causation.1 its incidence has been reported to be 0.1 to 10 per 10,000 births. the majority of the affected babies are females. severe forms have a very short duration of survival however; milder forms are not usually fatal. 2 here we report a case of iniencephaly born to a hypothyroid mother in the third trimester. in the present case report, modifiable risk factors for iniencephalic baby were obesity, socioeconomic status, folate intake, hypothyroidism, hypertension and consanguineous marriage whereas, female fetal sex and genetic factors may have played role as non-modifiable factors. c a s e r e p o r t a 38-year-old obese female g9 p6 a2 (none of the baby alive), admitted to gynecology and obstetrics unit-i, liaquat university hospital, hyderabad with 35 weeks of gestational amenorrhea, increased blood pressure and lower abdominal pain. she was a known case of hypothyroidism and hypertension for 9 years. she did not receive antenatal visits in her first trimester and did not take folic acid supplementations before and during pregnancy. before pregnancy, she was non-compliant in taking medication for hypothyroidism and hypertension. patient stopped taking thyroxine medication as she came to know about her pregnancy. however, in her third trimester, she was prescribed tablet thyroxine (dose: 200mcg/day) and tab methyldopa by a local doctor due to the hypothyroid and hypertensive profile, c a s e r e p o r t j islamabad med dental coll 2021 240 respectively. no previous ultrasound scans and thyroid profile reports were available from the patient. she had a consanguineous marriage to her first cousin; however, no significant family history was found. she had history of late intrauterine fetal deaths (iufd) in her first, second, sixth and eighth pregnancy and stillbirths in fifth and seventh pregnancy; however, no congenital anomaly was detected. in addition, she had history of two abortions in the third and fourth pregnancy. during her hospital stay, she was vigilantly monitored by cardiotocography, kick count and blood pressure monitoring. on the ultrasound, unstable lie, short and rotated spine with the retroflexed head was observed and ctg showed decelerations with loss of variability and bradycardia at 35th week. she was shifted to operation theatre for emergency lower segment caesarean section and alive baby girl was delivered with difficulty. the baby was in breech presentation and with the hyperextended neck for which uterine incision was extended. the baby was sent to the paediatric ward for evaluation. the baby had low set ears, depressed nasal bridge, fixed retroflexed head and multiple cardiac and pulmonary abnormalities. baby died after 18 hours of birth. autopsy was refused by the parents, so further evaluation was not possible. d i s c u s s i o n iniencephaly occurs before the closure of cephalic neural folds and characterized by the defects in the occipital bone, abnormalities of cervicothoracic vertebrae and retroflexion of the head. its risk factors include low socioeconomic conditions, obesity, poor folic acid intake prior to conception and during pregnancy, drugs (such as antihistamines, sulphonamides and tetracyclines), methylenetetrahydrofolate reductase gene (mthfr) c677t mutation, hyperhomocysteinemia and chromosomal defects such as monosomy x, trisomy 13 and 18.3,4 it is associated with multiple anomalies, including anencephaly, hydrocephalus, cardiac septal defects, cleft lip and palate, pulmonary hypoplasia, genital malformations and skeletal abnormalities.5 in the present case; obesity, poor socioeconomic conditions and female fetal sex, were important risk factors. moreover, low levels of folate have been linked to increased homocysteine levels in a hypothyroid patient further increasing risk.6 as patient did not take folic acid before and during pregnancy, the risk may have further increased. patient had a marriage with her first cousin. the consanguineous marriages have been reported as a significant risk factor for neural tube defects in the pakistani population.7 furthermore, hypothyroidism itself is associated with increased risks of abortion, prematurity, iufd, intrauterine fetal growth restrictions (iugr), congenital anomalies in the fetus, impaired brain development of the fetus, increased maternal and fetal morbidity and mortality8; suggesting risk factors for poor obstetrical outcomes in the present case. although chronic hypertension is considered as a risk factor for congenital malformations in the fetus9, its role in iniencephaly causation has not been discussed earlier. the ultrasound imaging in the second trimester is sufficient to diagnose neural tube defects; nonetheless, it requires competent ultrasonologist and proper equipment for detailed anatomical evaluation. prenatal magnetic resonance imaging (mri) may also provide an important tool for detailed neurological examination of the fetus, especially associated with neural tube defects.10 it is therefore advised to have antenatal and follow up visits along with postnatal genetic and pathological examination. furthermore, proper evaluation of risk factors and relevant management is important to prevent complications and recurrence in subsequent pregnancies.11 c o n c l u s i o n iniencephaly is one of the less common and complex neural tube defects that requires proper obstetrical management. patients with previous history should be counselled and recommended to take folic acid supplementations. j islamabad med dental coll 2021 241 figure i and ii: an iniencephalic baby presented with retroflexion of head, low set ears and depressed nasal bridge. consent: an informed consent from the patient to report the study and for publishing photograph was taken. r e f e r e n c e s 1. tanriverdi ec, delibas ib, kamalak z, kadioglu bg, bender ra. a fetus with iniencephaly delivered at the third trimester. case reports in medicine. 2015. doi:10.1155/2015/520715 2. kulkarni pr, rao rv, alur mb, joshi s. iniencephaly clausus: a case report with review of literature. journal of pediatric neurosciences. 2011;6(2):12123. doi: 10.4103/1817-1745.92831 3. singh a, gupta v. iniencephaly: a rare birth defect. int j reprod contracept obstet gynecol. 2018;7(3):12368.doi:10.18203/23201770.ijrcog20 180926 4. elsirgany s, salama s, alfy ma, aboulghar m. a rare case of a fetal neural tube defect: iniencephaly. imaging in medicine. 2018:17-9. 5. chikkannaiah p, srinivasamurthy v, satish prasad bs, lalyanayak p, shivaram dn. iniencephaly: radiological and pathological features of a series of three cases. j neurosci rural pract. 2014;5(4):38993. doi: 10.4103/0976-3147.139994 6. ziaee a, hajibagher tehrani n, hosseinkhani z, kazemifar a, javadi a, karimzadeh t. effects of folic acid plus levothyroxine on serum homocysteine level in hypothyroidism. caspian j intern med. 2012;3(2):417-20. pmid: 24358436 7. nauman n. consanguinity and neural tube defects. jrmc. 2016;20(2):120-3. 8. tudosa r, vartej p, horhoianu i, ghica c, mateescu s, dumitrache i. maternal and fetal complications of the hypothyroidism-related pregnancy. maedica. 2010;5(2):116-23. pmid: 21977134 9. bellizzi s, ali mm, abalos e, betran ap, kapila j, pileggi-castro c, et al. are hypertensive disorders in pregnancy associated with congenital malformations in offspring? evidence from the who multicountry cross sectional survey on maternal and newborn health. bmc pregnancy and childbirth. 2016;16(1):198. doi:10.1186/s12884016-0987-8 10. wilson rd, audibert f, brock j-a, campagnolo c, carroll j, cartier l, et al. prenatal screening, diagnosis, and pregnancy management of fetal neural tube defects. jogc. 2014;36(10):927-39. doi:10.1016/s1701-2163(15)30444-8 11. dane b, dane c, kıray m, dural s, çetin a, yayla m. iniencephaly: a rare neural tube defect. the medical bulletin of haseki. 2005;43(4):251-4. 116 j i m d c 2 0 1 7 116 op e n ac c e ss c a s e r e p o r t testicular germ cell tumor with a rare combination of seminomatous and nonseminomatous components ayesha ali 1, noor khan lakhnana 2, mudassira zahid 3 1,3 assistant professor, department of pathology 2 professor and head of dept, department of pathology (al nafees medical college & hospital, islamabad) a b s t r a c t testicular neoplasms constitute 1% of all tumors in men. with new therapeutic regimens, the cure rate in testicular germ cell tumors is more than 90%. accurate histologic typing of the neoplasm plays a pivotal role in planning treatment in each case. most testicular germ cell tumors (gct) are of mixed type. various combinations can be present but the occurrence of seminomatous component in mixed germ cell tumor is unusual. we report a case of a 26 years old man who presented with painless enlargement of testis. histological examination revealed a mixed gct of seminoma with syncytiotrophoblast cells, immature teratoma and embryonal carcinoma. key words: germ cell tumor, embryonal carcinoma, seminoma, teratoma. address of correspondence dr. ayesha ali email; ayeshaali1019@gmail.com case report info. received: march 19, 2017 accepted: may 13, 2017 cite this case report: ali a, lakhnana nk, zahid m. testicular germ cell tumor with a rare combination of seminomatous and nonseminomatous component. jimdc. 2017; 6(2):116-118 i n t r o d u c t i o n testicular cancer is rather a rare neoplasm and it accounts for approximately 1% of all tumors in men.1 globally, an increasing trend has been noticed especially in united states and northern europe.2 more than 90% tumors are classified as germ cell tumors (gct). rather than a single pure histologic form, mixed germ cell tumors that contain more than one germ cell component are much more common and represents 32-60% of all germ cell tumors in the testis.3 among the germ cell tumors, pure teratoma in the testis is rare (4% of gcts in testis) compared to pure teratoma in 95% of gcts found in the ovary.4 pre-pubertal teratomas are usually mature and benign and constitute approximately 30% of testicular germ cell tumors in children. post-pubertal (adult) testicular teratomas are malignant. chance of metastasis in malignant testicular teratomas is about 20% as opposed to their ovarian counterparts.5 various combinations of mixed germ cell tumors occur like teratoma and embryonal carcinoma (25%), embryonal carcinoma and seminoma (15%), teratoma, embryonal carcinoma and seminoma with or without syncytiotrophoblast like cells (15%).3 in more than half cases of malignant teratoma in adults, a mixed type tumor with yolk sac or embryonal carcinoma components is present. a combination of seminoma with a non seminomatous germ cell tumor is rare. mixed germ cell tumors containing seminoma behave like nonseminomas.6 although they are aggressive neoplasms, they are among the most curable cancers in humans. management of testicular neoplasms depends upon type and stage of the tumor. early and accurate diagnosis is essential for successful management of testicular tumors as a delay in diagnosis results in a higher stage at the presentation for treatment. in newly diagnosed cases, the cure rate is about 90%. combination chemotherapy and surgery has markedly decreased the mortality in these lesions.7 here, we present a rare case of a mixed germ cell tumor composed of both seminomatous and non seminomatous omponents (immature teratoma, embryonal carcinoma and seminoma with syncytiotrophoblast cells) c a s e r e p o r t 117 j i m d c 2 0 1 7 117 c a s e r e p o r t a 26 years old boy presented with painless enlargement of right testis. ultrasonography showed a complex mass, partly solid and partly cystic. there were multiple enlarged para aortic lymph nodes in the abdomen. blood sample for serum marker was sent. beta-hcg and ldh were found to be mildly elevated. the patient underwent right sided orchiectomy and specimen was sent for histopathology. it revealed an unusual combination of a mixed germ cell tumor which was, seminoma with syncytiotrophoblast cells, embryonal carcinoma and immature teratoma (figure 1, 2, 3). the three components were highlighted by using immunohistochemistry (cd117, cd30, and oct3). figure 1. immature teratoma in mixed gct (100x100) figure 2. seminoma in mixed gct (100x100) figure 3. embryonal carcinoma in mixed gct (40x100) d i s c u s s i o n cancer of the testis constitutes 0.5% to 1.5% of all male cancers and approximately forty-nine thousand new cases are diagnosed each year. the risk factors for testicular tumors are not well established but hormonal and genetic factors appear to play a role along with other factors like effects of heat. a solid, firm mass within the testis must be considered a testicular cancer until proven otherwise.7, 8 practically testicular germ cell tumors can be classified as seminomatous and non-seminomatous tumors, with seminoma accounting for 40% and the nonseminomatous tumors accounting for 60% of the cases. this distinction is a primary consideration in the patient management plan and helps the clinician in both prognosis and treatment.9 among the non-seminomatous tumors, the largest group is comprised of embryonal carcinoma, yolk sac tumor, choriocarcinoma and teratoma. pre-pubertal testicular teratoma can be benign (dermoid cyst) but post pubertal teratomas, no matter how mature they look, are deemed malignant as they frequently metastasize. the presence of somatic type malignancy is also a poor prognostic feature.10 more than half of the germ cell tumors consist of more than one cell type, which calls for thorough sampling for the correct diagnosis and also correlation with the serum tumor markers (human chorionic gonadotropin [hcg] and αfetoprotein.11 mostofi classified more than 6000 testicular tumors and found more than one histological patterns in approximately 60% of the cases. he found that the most frequent combination was embryonal carcinoma, yolk sac tumor and choriocarcinoma.12 mosharafa et al statistically analyzed various germ cell tumor combinations and found 10 possible pair combinations with the strongest correlation between teratoma and yolk sac tumor.13 according to carver et al, teratoma in adults frequently presents as a mixed germ cell tumor, with yolk sac or embryonal cell tumor component in 50% of cases.14 in his study on testicular tumors mutahir et al found that commonest histologic pattern was mixed (embryonal cell carcinoma+yolk sac tumor+teratoma) germ cell tumor in 45% cases.7 prahdan reported that, most testicular mixed germ cell tumors consist of yolk sac tumors with embryonal carcinoma, choriocarcinoma and 118 j i m d c 2 0 1 7 118 mature teratoma, but combinations of seminoma with immature teratoma are rare.15 about 5% of seminomas are associated with syncytiotrophoblast like cells which are widely dispersed as compared to those in choriocarcinoma.16 the etiology of germ cell tumors is largely unknown. cytogenetically germ cell tumors exhibit a gain of chromosome 12p as isochromosome (i12p). there are a few exceptions in the gct family, most of which have an indolent behavior, that do not share this common genetic makeup. this includes spermatocytic seminoma, dermoid cyst, and epidermoid cyst in post-pubertal individuals, as well as pediatric gct (yolk sac tumor and teratoma).17 to guide the surgeon in selecting the best treatment plan for individual patients, a pathologist must incorporate the following information in the pathology report of a testicular germ cell tumor: (1) gross features of the tumor such as size, necrosis, or hemorrhage (2) local extension of the tumor, including involvement of the spermatic cord or scrotum, and the status of spermatic cord resection margin (3) histologic tumor classification group i-e seminoma or non-seminoma (mention if pure or mixed form) (4) for mixed gct, the names of all histologic components with the approximate percentage of each component (5) vascular or lymphatic invasion and (6) presence of intratubular germ cell neoplasia (igcn) in the uninvolved testicular tissue.18,19 c o n c l u s i o n seminoma as part of germ cell tumor is rare. a thorough sampling with high degree of suspicion to look for non seminomatous component in testicular germ cell tumor must always be kept in mind. r e f e r e n c e s 1. ferlay j, steliarova-foucher e, lortet-tieulent j, rosso s, coebergh jw, comber h, forman d, bray f. cancer incidence and mortality patterns in europe: estimates for 40 countries in 2012. european journal of cancer. 2013; 49(6):1374-403. 2. ghazarian aa, trabert b, devesa ss, mcglynn ka. recent trends in the incidence of testicular germ cell tumors in the united states. andrology. 2015; 3(1):13-8. 3. stamatiou k, papadopoulos p, perlepes g, galariotis n, olympitis m, moschouris h, vasilakaki t. mixed germ cell tumor of the testicle with ravdomuosarcomatous component: a case report. cases journal. 2009; 2(1):9299. 4. wetherell d, weerakoon m, williams d, beharry bk, sliwinski a, ow d, manya k, bolton dm, lawrentschuk n. mature and immature teratoma: a review of pathological characteristics and treatment options. med surg urol. 2014; 3(124):2. 5. bhatti ab, ahmed i, ghauri rk, saeed q, mir k. clinical profile, treatment and survival outcome of testicular tumors: a pakistani perspective. asian pac j cancer prev. 2014; 15(1):277-80. 6. islam r, boksh z, rahman s, pasha k. a rare combination of mixed germ cell tumour of testis-a case report. anwer khan modern medical college journal. 2015; 6(1):50-4. 7. tunio ma, hashmi a, naimatullah n, mohsin r, maqbool sa, rafi m. fifteen years of experience in the management of non-seminomatous testicular germ cell tumors at a tertiary care center in pakistan. pak j med sci. 2011; 27(4):806-811. 8. mushtaq s, jamal s, mamoon n, akbar n, khadim t. the pathological spectrum of malignant testicular tumours in northern pakistan. jpma. 2007; 57(499). 9. ulbright tm. germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues. mod pathol. 2005; 18(2):61-79. 10. jemal a, siegel r, ward e, hao y, xu j, thun mj. cancer statistics. ca: a cancer journal for clinicians. 2009; 59(4):22549. 11. sesterhenn ia, davis jr cj. pathology of germ cell tumors of the testis. cancer control. 2004; 11(6):374-87. 12. mostofi fk, sesterhenn ia. pathology of germ cell tumors of testes. progress in clinical and biological research. 1985; 203:1-34. 13. mosharafa aa, foster rs, leibovich bc, ulbright tm, bihrle r, einhorn lh, donohue jp. histology in mixed germ cell tumors. is there a favorite pairing? the journal of urology. 2004; 171(4):1471-3. 14. carver bs, serio am, bajorin d, motzer rj, stasi j, bosl gj, vickers aj, sheinfeld j. improved clinical outcome in recent years for men with metastatic nonseminomatous germ cell tumors. journal of clinical oncology. 2007; 25(35):5603-8. 15. pagaro pm, gore cr, patil t, chandanwale s. mixed germ cell tumors: report of two cases. medical journal of dr. dy patil university. 2013; 6(3):298-301. 16. aneja a, bhattacharyya s, mydlo j, inniss s. testicular seminomatous mixed germ cell tumor with choriocarcinoma and teratoma with secondary somatic malignancy: a case report. journal of medical case reports. 2014 jan 1; 8(1):1. 17. sheikine y, genega e, melamed j, lee p, reuter ve, ye h. molecular genetics of testicular germ cell tumors. american journal of cancer research. 2012; 2(2):153-167. 18. bahrami a, ro jy, ayala ag. an overview of testicular germ cell tumors. archives of pathology & laboratory medicine. 2007; 131(8):1267-80. 19. leman es, gonzalgo ml. prognostic features and markers for testicular cancer management. indian journal of urology: iju: journal of the urological society of india. 2010; 26(1):76. 18 j i m d c 2 0 1 8 18 open access f u l l l e n g t h a r t i c l e laparoscopy versus laparotomy in the management of ectopic pregnancy muhammad murtaza 1, hina hameed 2, rana m. zeeshan khan 3, bilal nazar 4 1 ex house officer, bahawal victoria hospital, bahawalpur. 2 ex house officer, bahawal victoria hospital, bahawalpur. 3 ex house officer, dhq hospital, sahiwal 4 house officer, nishter medical college, multan a b s t r a c t objective: to compare the outcome of laparoscopy with laparotomy in the management of ectopic pregnancy (ep), both ruptured and un-ruptured. patients and methods: this cross-sectional study was conducted in department of obstetrics and gynecology at multiple centers in sahiwal, bahawalpur and multan, during the period from january 2015 to june 2017. total no. of 167 patients of ectopic pregnancy were included in our study. of these 167 patients, 32 came with ruptured ectopic pregnancy and other 135 with un-ruptured ep. following outcome variables were collected; operative time, complications, estimated blood loss and postoperative hospital stay. mean and standard deviation was calculated for demographic variables while frequency and percentage was calculated for outcome variables and association of these variables with groups was checked using computer software spss version 16. p value < 0.05 was considered as significant. results: out of total 167 patients, ruptured ep was found in 19.2% and non-ruptured in 80.8% patients. regarding blood transfusion and need of analgesia, significant association (p=0.000) was found between laparoscopy and laparotomy. as compared to laparotomy, during laparoscopy large number of patients did not require blood transfusion ((95.3%) and analgesia (64.1%). regarding total operating time, duration of hospital’s stay and estimated blood loss, significant difference (p=0.000) was found between the two groups. conclusion: postoperative outcomes suggested that laparoscopy proved to be more efficient regarding blood loss, need for blood transfusion, need for analgesia and duration of postoperative hospital stay as compared to laparotomy. key words: laparoscopy, laparotomy, ruptured ectopic pregnancy. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3,4 active participation in data collection. address of correspondence bilal nazar email: bnazar001@gmail.com article info. received: august 31, 2017 accepted: december 21, 2017 cite this article. murtaza m, hameed h, khan rm.z, nazar b. laparoscopy versus laparotomy in the management of ectopic pregnancy. jimdc.2018; 7(1):18-22 funding source: nil conflict of interest: nil i n t r o d u c t i o n implantation of the fertilized egg anywhere other than the uterine cavity is known as ectopic pregnancy (ep), including cervix, cornual region of the uterus, abdominal cavity and the most common site fallopian tubes which account for 97.7% of ep. 1among the tubal pregnancies, different sites of the tubes are involved including interstitia (2-3%), cornua (2%), fimbria (5%), isthmus (12%) and commonest part of the tube involved is ampulla (80%). 2 ectopic pregnancies have increased over the course of last thirty years, from 0.5% to 1-2%. 3 multiple factors are responsible for increased incidence including age, smoking, tubal inflammation, carrying sterilization devices o r i g i n a l a r t i c l e 19 j i m d c 2 0 1 8 19 and tubal surgeries and applying arts 4. ep is most common cause of maternal mortality related to early pregnancy and it is increasing in incidence all over the world. common symptoms associated with ep are abdominal pain and vaginal bleeding along with other less specific symptoms of normal pregnancy such as breast tenderness, nausea and vomiting. hemoperitoneum and dilated tube, causing peritoneal irritation are the reasons for abdominal pain. ectopic pregnancy is diagnosed on the basis of clinical presentation, physical examination, ultrasound, and beta-hcg levels in serum. early and accurate diagnosis of ep is possible nowadays. this is because of the fortunate advent of beta-hcg tests and transvaginal ultrasonography 5. in developing countries like ours, high fatality rates are due to the late diagnosis of ep as late diagnosis in almost all cases results in severe complications and emergency surgery. surgery is treatment of choice for ep. different surgical procedures are in practice, salpingectomy or salpingostomy, which are performed by either laparotomy or laparoscopy 6. ectopic pregnancy which has not ruptured is treated by linear salpingostomy which involves removal of conception products along antimesenteric border in ampullary portion of the fallopian tube, while ruptured ep is best treated with salpingectomy. when deciding between laparoscopy and laparotomy, following parameters must be considered; past surgical history, patient’s hemodynamic status and experience of the physician conducting the procedure. therapeutic and diagnostic use of laparoscopy has been documented for years now 7. laparoscopy has multiple advantages over laparotomy including lesser blood transfusion, lower cost, lesser need for analgesia, shorter duration of the procedure and lesser duration of postoperative hospital stay 8. indications for laparotomy are previous history of surgery leading to adhesions or infection and deteriorated hemodynamics. frequency of postoperative adhesions is lower in laparoscopic surgery. in current study we analyzed the outcomes of laparoscopy and laparotomy in the management of ruptured and unruptured pregnancies. p a t i e n t s a n d m e t h o d s this cross sectional multicenter study was conducted in department of obstetrics and gynecology; city hospital multan, fatima medical center multan and medicare hospital multan, from january 2015 to june 2017. sample size was calculated through open epi web site by using 95% confidence interval and 80% power. mean difference was noted from reference study.14 ep was the inclusion criteria. patients treated with methotrexate were excluded from the study. total 167 patients were included in our study. of these 167 patients, 32 came with complaint of ruptured ep and other 135 were with unruptured ep. these patients were admitted through emergency or outpatient department. authorization for the study protocol was obtained from the hospital ethics committee and informed consent was taken from the patients. patients were divided in two groups; group 1 and group 2 depending upon the undergoing procedure, laparoscopy and laparatomy respectively. total 64 patients were included in group 1 and 103 in group 2. age, bmi, parity, beta-hcg level and gestational age of ectopic pregnancy were the patient characteristics recorded during clinical examination. as described earlier the final diagnosis was based upon clinical presentation, physical examination, transvaginal ultrasound, and betahcg level in serum. semi lithotomy position was used to perform the laparoscopic procedure. laparatomy was performed using standard surgical protocol. all the procedures were performed by a well experienced surgeon with 5 years of experience. pethidine 1.5 mg/kg i/m was used as analgesic and was prescribed on demand. other analgesic used was diclofenac sodium 100mg. analgesia was prescribed at every eight hours. following outcome variables were collected; operative time, complications, estimated blood loss and postoperative hospital stay. spss 16 was used to analyze the data. mean and standard deviation was calculated for demographic quantitative variables. frequency and percentage was calculated for outcome categorical variables. student t test and fisher exact tests were used to calculate significance level. r e s u l t s out of total 167 patients, ruptured ep was found in 19.2% and non-ruptured in 80.8% patients (figure 1). demographic characteristics of both groups are mentioned (table i). regarding blood transfusion and need of analgesia, significant association (p=0.000) was 20 j i m d c 2 0 1 8 20 found between laparoscopy and laparotomy. as compared to laparotomy, during laparoscopy large number of patients do not require blood transfusion ((95.3%) and analgesia (64.1%) (table 2). regarding total operating time, duration of hospital’s stay and estimated blood loss, significant difference (p=0.000) was found between two groups (table 3). table 3: comparison of outcome variables between two groups (n=167) outcome variables laparoscopy (n=64) group i mean ±sd laparotomy (n=103) group ii mean ±sd p-value estimated blood loss (ml) 188.50±84.18 460.77±126.79 0.000 operative time (minutes) 53.50±19.56 84.74±30.82 0.000 hospital stay (days) 1.26±0.44 5.09±0.29 0.000 d i s c u s s i o n due to great procedural advancement in the field of minimally invasive surgery effective diagnosis and treatment of ep is possible today. 9 shapiro and adler 10 excised a tubal pregnancy through laparoscope for the first time decades ago. since then, it has been used frequently and it replaced laparotomy as a procedure for management for ep. 11 predisposing factors like age, smoking, tubal inflammation, carrying sterilization of devices, tubal surgeries and applying arts which are demonstrated in this study are similar to those discussed in past studies by different authors.12,13 in our study we used transvaginal ultrasonography and beta-hcg levels to make the diagnosis and other studies have also shown that use of these modalities has improved the diagnosis of ep.14 laparoscopy is considered as a method of choice for early ectopic pregnancy but it has also been proved to be effective in cases of ruptured ectopic pregnancy and hemoperitoneum, unless the patient is massively unstable hemodynamically.15,16 in one of the many similar studies it was quite evident that laparoscopy is a better technique in terms of blood loss, need for blood transfusion, less requirement of postoperative analgesia and shorter postoperative hospital stay.17 ectopic pregnancy is a life threatening disease which requires early diagnosis and prompt treatment. a study upon the comparison of laparoscopy and laparotomy was done in china which showed that even though laparoscopy is the novel approach in management of ectopic pregnancy yet it has more advantage as compared to the conventional approach. it has been widely accepted by surgeons as well as patients but the rate of use of this technique is still low in china as compared to other developed countries.18 all this advancement and frequent use of laparoscopy has made early diagnosis greatly possible and effectively lifesaving and it has been documented in literature.19 another study compared the efficacy of laparoscopy and laparotomy and has shown that laparoscopy is an effective and feasible approach in the treatment of ectopic pregnancy in terms of less duration of postoperative hospital stay, early diagnosis of the disease and improved reproductive outcomes as compared to the conventional laparotomy. in spite of these advantages there are few things which are table 1: demographic characteristics of participants in two groups (n=167) characteristics laparoscopy (n=64) group i mean±sd laparotomy (n=103) group ii mean±sd age (years) 30.29±4.89 31±3.88 parity 2.84±0.99 1.47±1.11 beta-hcg (miu/ml) 4683±2350.91 5387±2499.64 gestational age (months) 7.20±1.32 7.61±0.86 bmi (kg/m2) 23.62±4.38 22.53±3.43 21 j i m d c 2 0 1 8 21 table 2: association of blood transfusion and no need for analgesia between groups (n=167) variable groups total p-value laparoscopy laparotomy blood transfusion y n(%) 3(4.7) 77(74.7) 80 p=0.000 n n(%) 61 (95.3) 26 (25.24) 87 total 64 103 167 no need for analgesia y n(%) 41(64.1) 0(0) 41 p=0.000 n n(%) 23(35.9) 103(100) 126 total 64 103 167 inevitable even in laparoscopic procedure like, duration of the surgery, blood loss and postoperative complications rate is similar to the laparotomy provided that surgeon is an expert in laparoscopy.20 similarly, in another study, the same conclusion was made describing that laparoscopic management of ectopic pregnancy is very effective, safe and economical when compared to laparotomy and thus it has benefits for the patients and surgeon as well. they suggested that laparoscopy should be considered as gold standard for the condition of ectopic pregnancy 21. site of the ep is important when type of procedure is decided. for instance, linear salpingostomy is best procedure to deal with an ampullary pregnancy. while laparotomy and surgical excision is best suited for cornual pregnancies. but cornual pregnancies have also been efficiently treated with laparoscopic procedure. currently ectopic pregnancy is best treated by operative laparoscopy.12 its advantages are quite evident from our study and these findings are fully supported in literature. although laparoscopy is method of choice for ectopic pregnancy treatment but if the patient presents with unstable vital signs, laparotomy should be considered.22 c o n c l u s i o n even though operative outcomes were comparable in both laparotomy and laparoscopy but postoperative outcomes suggest that laparoscopy proved to be more efficient regarding blood loss, need for blood transfusion, need for analgesia and duration of postoperative hospital stay. r e f e r e n c e s 1. shobeiri f, tehranian n, nazari m. trend of ectopic pregnancy and its main determinants in hamadan province, iran (2000-2010). bmc research notes. 2014; 7(1):733. 2. saritha k, sowjanya r, sudha s. outcome of ectopic pregnancy: a prospective clinical study in a teaching hospital. shock. 2015; 21:30-43. 3. jahan s, das tr, habib sh, jahan a, joarder m, nahar n, banarjee m. a comparative study between laparoscopic management of ectopic pregnancy and laparotomy: experience in tertiary care hospital in bangladesh: a prospective trial. bangladesh journal of endosurgery. 2014; 2(1):1-4. 4. li c, zhao wh, zhu q, cao sj, ping h, xi x, qin gj, yan mx, zhang d, qiu j, zhang j. risk factors for ectopic pregnancy: a multi-center case-control study. bmc pregnancy and childbirth. 2015; 15(1):187. 5. hamza a, meyberg-solomayer g, juhasz-böss i, joukhadar r, takacs z, solomayer ef, baum s, radosa j, mavrova l, herr d. diagnostic methods of ectopic pregnancy and early pregnancy loss: a review of the literature. geburtshilfe und frauenheilkunde. 2016; 76(04):377-82. 6. taheri m, bharathan r, subramaniam a, kelly t. a united kingdom national survey of trends in ectopic pregnancy management. journal of obstetrics and gynaecology. 2014; 34(6):508-11. 7. johnson jj, garwe t, raines ar, thurman jb, carter s, bender js, albrecht rm. the use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year 22 j i m d c 2 0 1 8 22 experience at a level 1 trauma center. the american journal of surgery. 2013; 205(3):317-21. 8. cohen a, almog b, satel a, lessing jb, tsafrir z, levin i. laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum. international journal of gynecology & obstetrics. 2013;123(2):139-41. 9. ghosh s, mann c, khan k, gupta jk. laparoscopic management of ectopic pregnancy. inseminars in laparoscopic surgery. sage ca: thousand oaks, ca: sage publications. 1999; 6(2):68-72. 10. shapiro hi, adler dh. excision of an ectopic pregnancy through the laparoscope. american journal of obstetrics and gynecology. 1973; 117(2):290-1. 11. vasile c, litta p, sacco g, minante m.laparoscopic surgical approach to ectopic pregnancy. clin exp obstet gynecol 1999;26(1):35-8. 12. pisarska md, carson sa, buster je. ectopic pregnancy. lancet 1998; 351: 1115-1120. 13. mitchell de, mcswain hf, mccarthy ja, peterson hb. hysterosalpingographic evaluation of tubal patency after ectopic pregnancy. am j obstet gynecol 1987; 157: 618-622. 14. kumar sp. comparing laparoscopic and laparotomy for the surgical management of ectopic pregnancy. world j lap surg. 2013; 6(1):29-32. 15. maruri f, azziz r. laparoscopic surgery for ectopic pregnancies: technology assessment and public health implications. fertil steril 1993; 59:487. 16. baumann r, magos al, turnbull a. prospective comparison of videopelviscopy with laparotomy for ectopic pregnancy. br j obstet gynaecol 1991; 98:765. 17. saleh am, mahjoub mm, el-kurdy am. laparoscopy versus laparotomy management of tubal pregnancy. saudi med j. 2001; 22(9):771-5. 18. xiang xd, tang yq, mao jf. a comparison of laparoscopic surgery and laparotomy in the treatment of ectopic pregnancy. singapore medical journal. 1999; 40(2):88-90. 19. alkatout i, honemeyer u, strauss a, tinelli a, malvasi a, jonat w, mettler l, schollmeyer t. clinical diagnosis and treatment of ectopic pregnancy. obstetrical & gynecological survey. 2013; 68(8):57181. 20. mehra s, gujral a, mehra g. endoscopic vs. conventional surgery for tubal gestation. international journal of gynecology & obstetrics. 1998; 61(3):2978. 21. banu h, hui jw, hua l. role of laparoscopy in management of ectopic pregnancy. journal of enam medical college. 2015 nov 10;5(3):170 4. 22. hajenius pj, mol bw, bossuyt pm, ankum wm, van d, v. interventions for tubal ectopic pregnancy. cochrane database syst rev 2000; (2): cd000324. j islamabad med dental coll 2020 140 open access antibiotic sensitivity pattern of uropathogens in diabetic women with asymptomatic bacteriuria nadeem islam sheikh 1 , ambreen zahoor 2 , mehreen baber 3 , zaidan idrees choudhary 4 professor, department of medicine, hbs medical & dental college, islamabad, pakistan assistant professor, department of medicine, hbs medical & dental college, islamabad, pakistan assistant professor, department of ent, hbs medical & dental college, islamabad, pakistan assistant professor, department of psychiatry, hbs medical & dental college, islamabad, pakistan a b s t r a c t background: more than 150 million people around the globe are diagnosed with urinary tract infections every year. failure to treat these infections with proper antibiotics can lead to serious complications. the objective of this study was to investigate antibiotic sensitivity and resistance pattern of urinary isolates in type-2 diabetic women with asymptomatic bacteriuria. material and methods: this cross-sectional descriptive study was conducted at the hbs general hospital, islamabad, from march 2017 to august 2019. a total of 270 females with the diagnosis of type-2 diabetes mellitus were included in the study. uropathogens were isolated from urine samples and antibiotic sensitivity testing was conducted. demographic and clinical information was recorded on a pre-designed proforma. the data was analyzed using spss version 20. results: the mean age of the study sample was 50 years (sd ± 5.5) while the mean hba1c levels were 8.98 g/dl (sd ± 0.8 g/dl). uropathogens were found in the urine cultures of 106 (39.3%) patients. extended spectrum beta-lactamase producing (esbl) escherichia coli (e. coli) was the most common organism (n=46, 43.4%) which was sensitive to tazobactam, tazocin and co-trimoxazole. nitrofurantoin was the most effective antibiotic with 62.5% isolates sensitive to it. all of the pathogens were resistant to ciprofloxacin. conclusions: asymptomatic bacteriuria is common in type-2 diabetic women with esbl e. coli being the most common organism isolated from urine cultures. there is a significant resistance to antibiotics among the uropathogens isolated from these patients. key words: asymptomatic bacteriuria, diabetes mellitus, e. coli, urinary tract infection authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; 4 manuscript editing. correspondence: nadeem sheikh email: nadeem.islam@hotmail.com article info: received: december 4, 2019 accepted: june 19, 2020 cite this article. sheikh ni, zahoor a, baber m, choudhary zi. antibiotic sensitivity pattern of uropathogens in diabetic women with asymptomatic bacteriuria. j islamabad med dental coll.2020; 9(2): 140-144. doi: 10.35787/jimdc.v9i2.469 funding source: nil conflict of interest: nil i n t r o d u c t i o n the incidence of diabetes mellitus is increasing throughout the world and it poses a serious public health threat in developing countries. chronic hyperglycemic state in diabetics is associated with long term organ damage and dysfunction. diabetics are more prone to urinary tract infections 1 and the risk of complications is increased in those with poor glycemic control. 2 the underlying mechanism involves presence of static pool of urine due to dysfunctional bladder which serves as a favorable o r i g i n a l a r t i c l e j islamabad med dental coll 2020 141 medium for bacterial growth. 3 on the other hand, hyperglycemic urine promotes rapid pathogen proliferation. 4 even though the precise mechanism for the predilection of pathogens to cause uti in diabetics is unclear, the defect in il-8 and il-6 release increases the adherence of microorganisms to uroepithelial cells. experimentally it has been seen that osmotic diuresis secondary to glycosuria predisposes to ascending e. coli infections. 5, 6 in the last three decades inappropriate use of antibiotics has increased microbial resistance and pattern of infection. 7 change in organisms responsible for uti and resistance to commonly prescribed medicines is also reported. the worldwide escalation in both community and hospital acquired antimicrobial resistance is threatening the ability to treat patients with uti. 8,9 successful management of uti in diabetics is dependent upon the isolation of microorganism and use of effective antibiotic, as indiscriminate use often results in organ damage secondary to poor control of infection. this study was undertaken to identify the microbial organisms responsible for silent urinary tract infections in type-2 diabetic women and to find out their drug susceptibility to commonly used antibiotics. this is important as injudicious use of antibiotics is common in our settings. with the identification of latest susceptibility and resistance patterns, local clinicians may be provided with evidence-based guidelines for the treatment of uti in their patients. m a t e r i a l a n d m e t h o d s this descriptive cross-sectional study was conducted at the hbs general hospital, islamabad, from march, 2017 to august, 2019. ethical approval was taken from the institutional ethics review committee. non-probability convenience sampling technique was used and all type-2 diabetic women presenting to the medical opd were included in the study. patients with urogenital abnormalities and renal failure, those on antibiotics or immune suppressive medications and pregnant females were excluded. the design and objectives of the study were explained to the patients before taking informed consent. a total of 270 females with a diagnosis of type-2 diabetes mellitus were included in the study. laboratory investigations for patients comprised of complete blood picture, fasting blood glucose level, glycosylated hemoglobin level, urine culture and routine examination (re). urinary samples were collected by standard mid-stream clean catch method in a sterilized wide-mouth container that was covered with a tight-fit lid. microscopic examination of a wet film of non-centrifuged urine was carried out to detect presence of pus cells, red blood cells and microorganisms. the urine samples were then processed for sensitivity and resistance by following the clinical laboratories standards institute (clsi) guidelines. 10 the antibiotics tested were imepenum, tazobactam, amikacin, gentamicin, fosomycin, nitrofurantion, cefixime, cefotaxime, norfloxacin, ciprofloxacin, amplicillin, amoxicillin-clavaulanic acid, tetracycline, cotrimoxazole, erythrocin, itraconazole and fluconazole. asymptomatic bacteriuria was defined as presence of 10 5 cfu/ml bacteria in urine without any symptoms of uti. 11 the demographic and clinical data was recorded on a pre-designed proforma and uploaded to spss version 20 for analysis. results were reported as mean ± standard deviation (sd) for continuous variables and as frequencies for categorical variables. r e s u l t s a total of 270 women with type-2 diabetes mellitus were included in the study. the mean age of the study sample was 50 years (sd ± 5.5) with an age j islamabad med dental coll 2020 142 range of 35-65 years. the mean duration of diabetes in the patients was 7 years (sd ± 1.2) while the mean hba1c levels were 8.98 g/dl (sd ± 0.8 g/dl). out of the study samples, 106 urine cultures (39.3%) were found to be positive for bacterial growth. the association of the demographic and clinical variables with positive urine culture is given in table i. table i: association of clinicopathological characteristics with positive urine culture no. of patients n (%) positive urine culture n (%) pvalue* total 270 (100) 106 (39.3) age (year) 0.15 < 50 162 (60) 58 (35.8) > 50 108 (40) 48 (44.4) illness duration (year) 0.84 < 7 161 (59.6) 64 (39.7) > 7 109 (40.4) 42 (38.5) hba1c level (g/dl) 0.43 < 8.9 148 (54.8) 55 (37.1) > 8.9 122 (45.2) 51 (41.8) *p-value <0.05 was considered statistically significant the most common organisms isolated from the cultures were esbl e. coli (43.4%) followed by e. coli (33%), respectively. the details of the bacterial pathogens isolated from urine samples are given in table ii. table ii: pathogens isolated from the urine samples of the study patients bacteria in urine culture n (%) e. coli (esbl) 46 (43.4) e. coli 35 (33) enterococcus (spp) 7 (6.6) klebsiella (esbl) 5 (4.7) enterococcus 5 (4.7) klebsiella (spp) 4 (3.7) pseudomonas 3 (2.8) proteus 1 (0.9) esblextended-spectrum β-lactamase-producing; sppseveral species the sensitivity and resistance patterns revealed that most common urinary isolate (esbl e. coli) was sensitive to fosomycin, tazocin, cefotaxime, cotrimoxazole and levofloxacin. the details of the sensitivity and resistance patterns of the organisms are given in table iii. d i s c u s s i o n urinary tract infections occur more frequently in diabetics than the general population and predispose to renal failure if not treated adequately with appropriate antibiotics. the resistance to antibiotics is continuously increasing but there is great variation in data regarding resistance rates from different countries. this study looked at the antibiotic sensitivity pattern of uropathogens isolated from female diabetic patients presenting to the medical opd of a tertiary care hospital in islamabad. the current study showed that a significant number of the female patients had a positive urine culture (n=106, 39.3%). these results agree with the findings reported by tahir and qazi that showed prevalence of positive cultures to be 43% in diabetic population in pakistan. 12 this study included patients with symptoms of uti, whereas the patients in our study were asymptomatic. the high number of diabetic females with a positive urine culture, without symptoms of uti, raises the question of routine screening of these patients for bacteriuria to ensure early intervention and decrease in long term complications. the association between clinical variables and positive urine cultures was also assessed in our study. the current study found esbl e. coli (n=46, 43.4%) as the most common organisms in diabetic females with asymptomatic bacteriuria followed by e. coli (n=35, 33%). the other organisms isolated from the study patients included enterococcus spp (n=7, 6.6%), klebsiella (n=5, 4.7%), enterococcus (n=5, 4.7%) and pseudomonas (n=3, 2.8%) while proteus j islamabad med dental coll 2020 143 table iii: antibiotic sensitivity and resistance pattern of isolated bacterial uropathogens antibiotic ec ec (esbl) klebsiella (esbl) klebsiella (spp) enterococcus enterococcus (spp) proteus pseudomonas fm s s r r s r r r gm s r r r r r r r mem s r r s r r s r ctx s s r r r r r r tgn s r r r s r r r lev s s r s r r s r cot s s r r r r s r mcn s r r r r s r r ave s s r r r r s r tn s s s s r r r r nfn s s s r s s r r va r s r r r r r s ak r s r r r r r r cip r r r r r r r r spr r r r s s r r r cfm r r r r r r r s ctz r r r r r s r r ap r s r r r r r s cps r s s r r r r r cxt r r r r r s r s olf r r r r s s r s imi r r r r s s r s pxn r r r r s s r s r-drug resistance; s-drug sensitive; ec-e. coli; esbl-extended-spectrum beta-lactamase; spp-several species; fm-fosomycin; gmgentamycin; mem-meropenum; ctx-cefotaxime; tgn-tigecycline; lev-levofloxacin; cot-cotrimoxazole; mcn-minocycline; aveamoxiclav; tn-tazocin; nfn-nitrofurantion; va-vancomycin; ak-amikacin; cip-ciprofloxicin; spr-sparfloxicin; cfm-cefixime; ctzceftazadime; ap-ampicillin; cps-cefoperazoneculbactam; cxt-cefoxitine; olf-ofloxacine; imi-imipenum; pxn-polymyxin was isolated from one (0.9%) sample only. in a number of similar studies, the most common organism isolated from the urine samples has been e. coli. however, the other organisms show a broad variety. a study published by bharti et al. showed e. coli as the most common organism (47.6%), followed by candida (33.3%), pseudomonas (9.5%), klebsiella (4.76%) and citrobacter (4.76%). 13 in a study by simkhada on 100 diabetic patients, e. coli was the most common organism (52.38%), followed by klebsiella (14.28%), pseudomonas, and proteus (9.52% each), respectively. 14 in this study, we also assessed the antibiotic sensitivity of various pathogens to a number of antibiotics and the results paint a worrying picture. no single antibiotic was effective against all organisms isolated from the samples. nitrofurantoin was the most effective antibiotic with 62.5% isolates sensitive to it, followed by tazocin and levofloxacin, which were effective against 50% of the isolates. all of the pathogens were resistant to ciprofloxacin which is one of the most commonly used treatments for uti in our settings. significant resistance was also observed against amikacin, cefixime and ceftazadime as they were effective against only 12.5% of the pathogens. the common uropathogen isolated from our study patients, esbl e. coli was found to be most sensitive to tazobactam, tazocin and cotrimoxazole. the latter presents an interesting scenario of an old drug, which has been out of use for a number of years that may again become useful as the organisms become resistant to newer j islamabad med dental coll 2020 144 medications. a similar study was conducted by boyko et al. who concluded that among the antibiotics, aminoglycosides (34%) and nitrofurantoin (21%) showed robust activity against the isolates and could be used for empirical treatment 15 . however, according to our results the local population is fast becoming resistant to all of these agents and no single empirical treatment can be advised across the board. hence, it becomes even more important that individual treatments be tailored according to the sensitivity patterns determined from urine culture. otherwise we will be adding further resistance to antibiotics in the organisms responsible for bacteriuria. c o n c l u s i o n the urine analysis of females with type-2 diabetes mellitus show a significant number of positive urine cultures. esbl e. coli, the most frequently isolated organism, was resistant to commonly used antibiotics. the high resistance to antibiotics is of public health importance and highlights the need to administer antibiotics according to culture and sensitivity in order to avoid emergence of resistance strains. r e f e r e n c e s 1. tandogdu z, wagenlehner fm. global epidemiology of urinary tract infections. curr opin infect dis. 2016; 29(1): 73‐9. doi:10.1097/qco.00000000 00000228 2. olin sj, bartges jw. urinary tract infections: treatment/comparative therapeutics. vet clin north am small anim pract. 2015; 45(4): 721‐46. doi:10.1016/j.cvsm.2015.02.005 3. schneeberger c, erwich hm, van den heuvel er, mol bwj, ott a, geerlings se. asymptomatic bacteriuria and urinary tract infection in pregnant women with and without diabetes: cohort study. eur j obstet gynecol reprod biol. 2018; 222: 176‐81. doi:10.1016/j.ejogrb.2017.12.013 4. schneeberger c, kazemier bm, geerlings se. asymptomatic bacteriuria and urinary tract infections in special patient groups: women with diabetes mellitus and pregnant women. curr opin infect dis. 2014; 27(1): 108‐114. doi:10.1097/qco.0000000000000028 5. geerlings se. urinary tract infections in patients with diabetes mellitus: epidemiology, pathogenesis and treatment. int j antimicrob agents. 2008; 31(suppl 1): s54‐s57. doi:10.1016/j.ijantimicag.2007.07.042 6. ye c, kumar d, carbonneau m, keough a, ma m, tandon p. asymptomatic bacteriuria is an independent predictor of urinary tract infections in an ambulatory cirrhotic population: a prospective evaluation. liver int. 2014; 34(6): e39‐e44. doi:10.1111/liv.12435 7. yeshitela b, gebre-selassie s, feleke y. asymptomatic bacteriuria and symptomatic urinary tract infections (uti) in patients with diabetes mellitus in tikur anbessa specialized university hospital, addis ababa, ethiopia. ethiop med j. 2012; 50(3): 239‐249. 8. nicolle le. asymptomatic bacteriuria. curr opin infect dis. 2014; 27(1): 90‐6. doi:10.1097/qco.000000000000001 9. schnarr j, smaill f. asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. eur j clin invest. 2008; 38 (suppl 2): 50‐7. doi:10.1111/j.1365-2362.2008.02009.x 10. clsi. clsi supplement m100s. 26th ed. wayne, pa: clinical and laboratory standards institute; 2016. performance standards for antimicrobial susceptibility testing 11. givler dn, givler a. asymptomatic bacteriuria. in: statpearls. treasure island (fl): statpearls publishing; 2020. 12. tahir n, uddin qt. frequency of urinary tract infection in diabetic females. kust med j 2009; 1(2): 55-58. 13. bharti a, chawla sps, kumar s, kaur s, soin d, jindal n, garg r. asymptomatic bacteriuria among the patients of type 2 diabetes mellitus. j family med prim care. 2019; 8(2): 539-43. doi:10.4103/jfmpc. jfmpc_403_18 14. simkhada r. urinary tract infection and antibiotic sensitivity pattern among diabetics. nepal med coll j. 2013; 15:1–4 15. boyko ej, fihn sd, scholes d, abraham l, monsey b. risk of urinary tract infection and asymptomatic bacteriuria among diabetic and nondiabetic postmenopausal women. am j epidemiol. 2005; 161:557–64 j islamabad med dental coll 2022 110 open access the diagnostic accuracy of magnetic resonance imaging (mri) for detection of spinal tuberculosis (tb) maryam ehsan khokar1,nighat haroon khan2,saira bilal3,saima ameer4 1post graduate trainee, fcps radiology, lahore general hospital. 2,3associate professor of radiology, lahore general hospital. 4professor and hod radiology, lahore general hospital. a b s t r a c t background: diagnosis of spinal tuberculosis is a major challenge. it is usually made using a blend of, laboratory , imaging investigations, clinical and none of these are 100% confirmatory. the objective of this study was to determine the diagnostic accuracy of magnetic resonance imaging (mri) for detection of spinal tuberculosis (tb) methodology: this cross-sectional study was conducted in the department of radiology, lahore general hospital, on 150 patients, with suspicion of spinal tb from january,2020 to august,2020. patients having backache for >6 months, loss of appetite, loss of weight >10% in previous one month, raised esr >15 mm/hour, and positive sputum results for afb were included. the patients underwent full spinal mri scan. mri was done using 1.5 tesla mr for diagnosis of spinal tb. the diagnosis of spinal tb was then confirmed on histopathologic reporting. results:mean age of study participants was 47.83±9.65 years. there was male predominance with 93 (62.0%) males and 57 (38.0%) female patients. the mean duration of spinal tb symptoms was 11.52±3.12 months. on accuracy of mri, there were 83 (55.3%) true positive cases, 10 (6.67%) false positive, 08 (5.33%) false negative and 49 (32.67%) true negative. the sensitivity of mri was 91.2%, specificity 83.1%, positive predictive value (ppv) 89.2% and negative predictive value (npv) 86.0%. conclusion: sensitivity of mri was 91.2% and specificity 83.1%.mri is an ideal non-invasive imaging modality for the diagnosis of spinal tb. keywords: magnetic resonance imaging, spinal, tuberculosis. authors’ contribution: 1conception; literature research; manuscript design and drafting1,2critical analysis and manuscript review;3,4data analysis; manuscript editing. correspondence: maryam ahsan khokhar email: shezamaryam67@gmail.com article info: received: december 5, 2020 accepted: september 26, 2020 cite this article. khokhar m e, khan n h, bilal s, ameer s. the diagnostic accuracy of magnetic resonance imaging (mri) for detection of spinal tuberculosis (tb). j islamabad med dental coll. 2022; 11(2):110-113. doi: https://doi.org/10.35787/jimdc.v11i2.641. funding source: nil conflict of interest: nil i n t r o d u c t i o n tuberculosis though being an ancient disease, is still a major health concern.1,2 in 2018, 10 million cases of tb were reported and deaths reported were1.5 million.3 in the past two decades, progress was made in elimination of tuberculosis and as a response, a reduction of 0.2/100,000 cases has been reported in us and 7.3/100,000 cases in uk.4,5 spinal tuberculosis has a total prevalence up to 35% among all cases of extra-pulmonary tuberculosis.6 diagnosis is still a major challenge. diagnosis is usually made using a combination of clinical, laboratory and imaging investigations, and none of o r i g i n a l a r t i c l e j islamabad med dental coll 2022 111 these are 100% confirmatory. the clinical symptosms are axial malaise and axial pain, however these are non-specific. the specific symptoms appear at advanced disease stage and include; development of neurologic deficit, cold abscess and kyphotic deformity but at this stage the mortality is very high.7, 8 the laboratory markers such as ziehl nielson stain, culture reporting have poor accuracy because of less bacterial load in spinal tb (<105 bacteria/ml).9 magnetic resonance imaging (mri) is now commonly used for evaluation of patients having suspicion of spinal tuberculosis. mri has several benefits as it is non-invasive, can be performed to diagnose spinal tb at early stages, the whole spinal cord at a single time can be scanned and repeated scans can be performed, without any significant harm to the patient.10 the aim of the study is to determine the diagnostic accuracy of mri for diagnosis of spinal tuberculosis taking histopathological findings as a gold standard test. as very little is published regarding accuracy of mri for diagnosis of spinal tuberculosis, and that too with variable results, the study can be helpful in determining whether mri can be reliably used for diagnosis of spinal tuberculosis. m e t h o d o l o g y this cross-sectional study was conducted on 150 patients with suspicion of spinal tb. the study duration was 8 months, conducted from period of january 2020 to august 2020 in the department of radiology, lahore general hospital, lahore. patients having backache for >6 months, loss of appetite, loss of weight >10% in previous one month, raised esr >15 mm/hour, and positive sputum results for afb were included. patients having contra-indication to mri ( those having permanent pacemaker, ocular implants or defibrillator or allergy to contrast media) were excluded. informed consent from each patient was taken. the sample size for this study was calculated by taking estimated prevalence of spinal tuberculosis 35%,6 expected sensitivity of mri 97.9% and specificity 81.1% for diagnosing spinal tuberculosis11, taking desired precision level of 4.0% for sensitivity and 8.0% for specificity. for all patients, detailed information regarding clinical symptoms, and laboratory findings was collected. the patients underwent full spinal mri scan (as a routine protocol for evaluation of underlying pathology). mri was done using 1.5 tesla mr. the following criteria was used to diagnose spinal tb on mri findings; on t2 images, increase in signal strength on on t1 images and vertebral bodies, decrease in signal intensity on both vertebral discs and bodies, existence of collections within the in adjacent paravertebral soft tissues or vertebra, vertebral body damage with reduction in body height of more than half, or irregularity of margins of vertebral body end plate. biopsy specimens of the affected segments were taken either transpedicular or after surgical debridement and the diagnosis was confirmed using histopathological examination, presence of acid-fast bacilli on biopsy specimens, or presence of epithelioid cells. data analysis was done using spss v25. 2×2 table was formulated to calculate diagnostic accuracy of mri against histopathologic examination. r e s u l t s mean age of the study participants was 47.83±9.65 years. there was male predominance with 93 (62.0%) males and 57 (38.0%) female patients. mean body mass index (bmi) was 28.56±3.28 kg/m2. the mean duration of spinal tb symptoms was 11.52±3.12 months. on accuracy of mri, there were 83 (55.3%) true positive cases, 10 (6.67%) false positive, 08 (5.33%) false negative and 49 (32.67%) true negative. the accuracy of mri was 91.2%, specificity 83.1%, ppv 89.2% and npv 86.0%. (table 2). j islamabad med dental coll 2022 112 d i s c u s s i o n spinal tb is a common problem around the globe. it occurs in 1.0% patients infected by pulmonary tuberculosis. according to literature, 25% to 60% of all bone contaminations are caused by tuberculosis.12,13 incidence of pyogenic spondylitis (0.15% to 3.0%) is much lower as compared to the tuberculous disease. the accurate differential diagnosis of spinal tb is necessary as the treatment of tb spondylitis is entirely different from that of pyogenic spondylitis.14 mri has made huge improvements in the evaluation of spinal infections. because of its non-invasive nature, it provides rapid diagnosis of underlying pathologies.15,16 the specific nature of mri imaging can help to diagnose disease even at early stages of infection. however, some authors have reported that mri findings in some cases may overlap the diagnosis of spinal tb in patients with other spinal disorders.17,18 therefore, determining the diagnostic accuracy of mri for diagnosis of spinal tb is of prime importance. in present study, we found that mri is 91.2% sensitive and 83.1% specific for diagnosis of spinal tb. a similar study by ahmad et al. on accuracy of mri containing 147 patients with suspicion of spinal tb reported sensitivity of 92.13%, specificity 84.48%, ppv 90.11% and npv 87.50%.19 kanna et al. conducted a study on correlation of mri findings with tissue studies. the authors used different individual clinical findings on mri to determine the accuracy. among these, subligamentous spread, vertebral collapse and large abscess formation with thin wall were found to have highest accuracy, with sensitivity ranging from 91.14% to 69.62% and specificity ranging from 81.69% to 50.70%.15 while sexena et al. reported much higher sensitivity and specificity of mri. they reported that mri is 97.9% sensitive, and 81.1% specific for diagnosis of spinal tuberculosis taking histopathology as gold standard.11 there are still limited number of studies that have determined the accuracy of mri for evaluation of spinal tb. there is a still a need to conduct more studies with larger sample sizes to strengthen the evidence about the accuracy of mri for spinal tb. there are certain limitations of this study, we took histopathology as gold standard test but it can give false negative results in some cases, that may affect accuracy of mri. the other highly sensitive test for diagnosis of spinal tb is pcr but this test also gives false positive results as it also detects dead bacteria, therefore cannot be used as gold standard test. however, on the basis of the study results and existing literature, it is recommended that early mri scans should be done in patients having suspicion of spinal tb. early diagnosis of disease can help to prevent mortality associated with spinal tb. table i: baseline characteristics. mean age 47.83±9.65 gender male 93 (62.0%) female 57 (38.0%) bmi (kg/m2) 28.56±3.28 disease duration (months) 11.52±3.12 table ii: accuracy of mri in diagnosis of spinal tb. spinal tb on mri spinal tb on histopathology total yes no yes 83 10 93 no 08 49 57 total 91 59 150 sensitivity: 91.2% specificity: 83.1% positive predictive value (ppv):89.2% negative predictive value (npv): 86.0% j islamabad med dental coll 2022 113 c o n c l u s i o n sensitivity of mri was 91.2% and specificity 83.1%. mri is an ideal non-invasive imaging modality for the diagnosis of spinal tb.diagnosis of spinal tb. r e f e r e n c e s 1. rajasekaran s, soundararajan dcr, shetty ap, kanna rm. spinal tuberculosis: current concepts. glob spine j. 2018;8(4):96-108. doi: 10.1177/2192568218769053. 2. dunn r, ben husien m. spinal tuberculosis: review of current management. bone joint j. 2018;100(4):425-31. doi: 10.1302/0301-620x.100b4.bjj2017-1040.r1 3. macneil a, glaziou p, sismanidis c, date a, maloney s, floyd k. global epidemiology of tuberculosis and progress toward meeting global targets worldwide, 2018. mmwr morb mortal wkly rep. 2020;69(11):281-5. doi: 10.15585/mmwr.mm6911a2 4. salinas jl, mindra g, haddad mb, pratt r, price sf, langer aj. leveling of tuberculosis incidence—united states, 2013–2015. mmwr morb mortal wkly rep. 2016;65(11):273-8. doi: 10.15585/mmwr.mm6511a2 5. uk health security agency. tuberculosis in england 2021 report. available at; https://assets.publishing.service.gov.uk/government/upl oads/system/uploads/attachment_data/file/1064395/tb _annual-report-2021.pdf 6. batirel a, erdem h, sengoz g, pehlivanoglu f, ramosaco e, gülsün s, et al. the course of spinal tuberculosis (pott disease): results of the multinational, multicentre backbone-2 study. clin microbiol infect. 2015;21(11):1008.e9-1008.e18. doi: 10.1177/2192568218769053. 7. louw qa, tawa n, van niekerk sm, conradie t, coetzee m. spinal tuberculosis: a systematic review of case studies and development of an evidence-based clinical guidance tool for early detection. j eval clin pract. 2020;26(5):1370-82. doi: 10.1111/jep.13309 8. shetty a, kanna rm, rajasekaran s. tb spine— current aspects on clinical presentation, diagnosis, and management options. semin spine surg. 2016;28(3):15062. doi: https://doi.org/10.1053/j.semss.2015.07.006 9. riello fn, brígido rt, araújo s, moreira ta, goulart lr, goulart im. diagnosis of mycobacterial infections based on acid-fast bacilli test and bacterial growth time and implications on treatment and disease outcome. bmc infect dis. 2016;16:142. doi: 10.1186/s12879-016-1474-6 10. jain ak, sreenivasan r, saini ns, kumar s, jain s, dhammi ik. magnetic resonance evaluation of tubercular lesion in spine. int orthop. 2012;36(2):261-9. doi: 10.1007/s00264-011-1380-x. 11. sexena s, lal b, meena d, khokhar h, godara c, gupta a. magnetic resonance imaging whole spine in tuberculosis of spine and its histopathological correlation. j dental med sci. 2019;18(5);1-6. doi: 10.9790/0853-1805090106 12. kanna rm, babu n, kannan m, shetty ap, rajasekaran s. diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies. eur spine j. 2019;28(12):3003-10. doi: 10.1007/s00586-019-06031-z 13. lee ky. comparison of pyogenic spondylitis and tuberculous spondylitis. asian spine j. 2014;8(2):21623.doi: 10.4184/asj.2014.8.2.216 14. yueniwati y, evelyn c. the challenges in differentiating tuberculous from pyogenic spondylitis using magnetic resonance imaging. reports in medical imaging. 2017;10:37. doi: https://doi.org/10.2147/rmi.s129533 15. kanna rm, babu n, kannan m, shetty ap, rajasekaran s. diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies. eur spine j. 2019;28(12):3003-10. doi: 10.1007/s00586-019-06031-z 16. kumar y, gupta n, chhabra a, fukuda t, soni n, hayashi d. magnetic resonance imaging of bacterial and tuberculous spondylodiscitis with associated complications and non-infectious spinal pathology mimicking infections: a pictorial review. bmc musculoskelet disord. 2017;18(1):244. doi: 10.1186/s12891-017-1608-z 17. leonard mk, blumberg hm. musculoskeletal tuberculosis. microbiol spectr. 2017;5(2):371-92. doi: 10.1128/microbiolspec.tnmi7-0046-2017 18. gambhir s, ravina m, rangan k, dixit m, barai s, bomanji j. imaging in extrapulmonary tuberculosis. int j infect dis. 2017;56:237-47. doi: 10.1016/j.ijid.2016.11.003. 19. ahmad n, irshad s, rehan a, rauf a, shaukat a, israr s. diagnostic accuracy of magnetic resonance imaging in diagnosis of spinal tuberculosis. ann punjab med coll. 2020;14(2):168-72. doi: https://doi.org/10.29054/apmc/2020.839 174 j i m d c 2 0 1 7 174 op e n ac c e ss f u l l l e n g t h a r t i c l e laparoscopic cholecystectomy with and without vacuum suction drain muhammad asif 1, ahsan ali mirza 2, majida zafar 3 1 general surgeon, smo, pakistan atomic energy commission (paec), hospital islamabad 2 general and laparoscopic surgeon, hod surgery, paec, islamabad 3 senior registrar, pakistan institute of medical sciences (pims), islamabad a b s t r a c t objective: to compare the frequency and severity of pain due to vacuum suction drain placement postoperatively, in patients of laparoscopic cholecystectomy. patients and methods: this randomized control trial study was carried out at surgical unit paec general hospital islamabad from jan 2015 to dec 2016. in total two hundred and twenty cases of gallstone disease were registered who fulfilled the inclusion criteria. the cases were divided into two study groups by random number table. patients’ in-group “a” underwent laparoscopic cholecystectomy with vacuum suction drain placement and those in-group “b” had cholecystectomy without vacuum suction drain. results: at 24th hour, a total of 42 patients experienced no pain. among these 11 were from group a and 31 were from group b. in 178 patients, pain was present (group a = 109 and group b = 79). number of patients suffering from pain was significantly high in group a and severity of pain was also significantly higher in group a (p-value = 0.002). conclusion: laparoscopic cholecystectomy without drain is better as compared to the one with drain, with less postoperative pain. keywords: drain, laparoscopic cholecystectomy, pain. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, active participation in data collection address of correspondence muhammad asif email. dr.asif394@yahoo.com article info. received: august 31, 2017 accepted: september 11, 2017 cite this article: asif m, mirza aa, zafar m. laparoscopic cholecystectomy with funding source: nil and without vacuum suction drain jimdc. 2017; 6(3): 174-177. conflict of interest: nil i n t r o d u c t i o n laparoscopic cholecystectomy is a safe and effective treatment for patients with gallstones. it reduces postoperative pain with minimal scar with short hospital stay and early recovery.1 laparoscopic cholecystectomy has become one of the most common general surgical procedures.2 this new minimal invasive procedure has become the gold standard in the management of cholelithiasis as well as in acute appendicitis.2,3 laparoscopic technology has progressed to singleincision laparoscopic surgery (sils) and natural orifice trans-luminal endoscopic surgery.5 laparoscopy for emergency surgery is now considered easy and is usually preferable management option.6 drains are often used after laparoscopic cholecystectomy to prevent postoperative abdominal collections.7 majority of the patients with laparoscopic cholecystectomy are dealt with as day care cases now a days, therefore placing drain in every case would merely delay the patient’s discharge.4,5 drains o r i g i n a l a r t i c l e 175 j i m d c 2 0 1 7 175 may be very uncomfortable for some of the patients undergoing cholecystectomy and may cause increased morbidity, shoulder tip pain and in some cases may increase infective complications. use of drain in open cholecystectomy is an issue that is not resolved yet. the same is the issue in laparoscopic cholecystectomy, where the lack of evidence for usefulness of drain is present. surgeons have different practices; some placing a drain selectively while others never place a drain, based on their individual experience and believes.4 this randomized controlled comparative study was designed to assess the value of drain in laparoscopic cholecystectomy. p a t i e n t s a n d m e t h o d s this randomized control trial was carried out at surgical unit paec general hospital islamabad from jan 15 to dec 16. all the patients coming to the paec general hospital for laparoscopic cholecystectomy were enrolled in the study. sample size was calculated using who sample size calculator with confidence level of 5%, power of test: 80%, pooled standard deviation: 24.4. test value of the population mean was 58.68 and anticipated population mean was 39.5.8 the calculated sample size was 110 patients in each group. informed written consent was taken from all the patients and the study design was approved from the ethical committee of hospital. patients with gallstones between18 to 85 years and from either sex were included in the study. while those with acute cholecystitis, copd or with history of bleeding tendency were excluded. total 220 cases fulfilling the inclusion criteria were selected from outpatient department of surgical unit of paec general hospital islamabad. these patients were randomly allotted into two groups using random number table. patients with post-operative drain were assigned in-group a and without drain were assigned in-group b. all patients were prescribed standard antibiotics and wound care. patients were observed on 24 hours for presence or absence of postoperative pain on visual analogue scale (vas) (score 010). when there was no pain, it was considered as zero while 10 was considered maximum pain. all information was recorded on a performa and analyzed on spss 20. data was analyzed for age, gender and presence or absence of pain. chi-square test was applied and a pvalue of< 0.05 was considered statistically significant. r e s u l t s the average age of patients in group a was 49.02 ± 11.94 years and the average age of patients in group b was 48.07±12.94. in total there were 52 (23.64%) males in which 30 were treated in group a and 22 were treated in group b. there were 168 (76.36%) female patients in which 80 were treated in group a and 88 were treated in group b (table 1). during the follow up i.e. at 24th hour, 36 (16.36%) patients were pain free and in 184 (83.64%) patients, the pain was present. number of patients suffering from pain was significantly high in group a (table 2). out of 184 patients having pain, 74 had mild pain, 71 patients had moderate and 39 had severe pain. the severity of pain was also significantly higher in group a (table 3). table 3: severity of pain in patients at 24 hour (n=220) study groups pvalue group a (n=110) group b (n=110) severity no pain; n (%) 9 (8.18) 27 (24.54) 0.002 mild; n (%) 36 (32.73) 38 (34.54) moderate; n(%) 43 (39.09) 28 (25.45) severe; n (%) 22 (20) 17 (15.45) table 1: demographic characteristics of participants (n=220) study groups group a (n=110) group b (n=110) age (years) minimum maximum mean±sd 18 85 49.02±11.94 18 85 48.07±12.94 gender male: no (%) female: no (%) 30 (27.27) 80(72.73) 22 (20) 88(80) table 2: number of patients suffering from pain at 24 hour (n=220) study groups pvalue group a (n=110) group b (n=110) pain absent; n (%) 9 (8.181) 27 (24.54) 0.002 present; n(%) 101 (91.82) 83 (75.45) 176 j i m d c 2 0 1 7 176 d i s c u s s i o n lamgenebuch performed the first cholecystectomy in 1882, placed a drain. the routine placement of drains evidence. many surgeons are now not placing drain. surgeons used to put drains routinely after laparoscopic cholecystectomy because of the fear of collection of bile or blood, later requiring open procedures. billroth used to put drains after surgeries. becomes a part of operation for a long period without any however, many studies concluded that drain has no advantage and it just prolonged the hospital stay of the patient leading to increase cost of health care. according to gurusami ks et al wound infection was more in patients who underwent laparoscopic cholecystectomy with use of drain.9 sims was the first surgeon who used prophylactic drains after gynecologic operations in the last quarter of the 19th century.11 since that time, surgeons have routinely used prophylactic drainage of the peritoneal cavity after abdominal surgery. many surgeons now consider that drainage of the peritoneal cavity is impossible and, therefore, placing drain after abdominal surgeries is useless.9-15 single-incision laparoscopic surgery (sils) cholecystectomy was first performed in the anglophone caribbean in 2009; now getting more popularity is usually drain free procedure. for putting drain in sils we have to make a second incision so further increasing chance of postoperative morbidity.16,17 during the last 3 decades, surgeons have made efforts to investigate the value of prophylactic drainage after abdominal surgery. even after many studies demonstrating no advantage of placing prophylactic drain, many surgeons are still inserting drains due to fear of post-operative intra-abdominal collections.18,19 this study was conducted to look for the outcomes and to evaluate role of prophylactic drainage after laparoscopic cholecystectomy. according to yong l, guang b pain 24 hours after surgery was less severe in no drain group (md1.31; 95% ci, 0.96 to 1.65; p < 0.00001).20 abdominal drainage also causes prolonged operative time.21 in our study, significantly higher number of patient in-group a had severe pain at 24 hours with pain score ranging from 8 to 10. group b patients had less severity of pain (pvalue = 0.000). our study had limitations. we did not measure the amount and nature (bile, blood etc.) of body fluids in the drain bottles, so further studies with larger number of patients can be more helpful in future. c o n c l u s i o n in uncomplicated laparoscopic cholecystectomy drain placement will cause more and prolonged pain and discomfort to the patient and therefore should be avoided. we recommend that experienced surgeons may avoid putting a drain in a clean operative case, however younger colleagues with less experience may insert the drain for safety purpose. r e f e r e n c e s 1. haris r. shaikh, asad abbas, salik aleem, and miqdad r. lakhani. is mini-laparoscopic cholecystectomy any better than the gold standard? a comparative study. j minim access surg. 2017; 13(1): 42–46. 2. piccolo g, piozzi gn. laparoscopic radical cholecystectomy for primary or incidental early gallbladder cancer: the new rules governing the treatment of gallbladder cancer. gastroenterology research and practice. 2017, article id 8570502;1-10. doi:10.1155/2017/8570502. 3. cawich so, mitchell dig, newnham ms, arthurs m. a comparison of open and laparoscopic cholecystectomy done by a surgeon in training. west indian med j 2006; 55(2): 103-9. 4. ko-iam w, sandhu t, paiboonworachat s, pongchairerks p, chotirosniramit a, chotirosniramit n, et al. predictive factors for a long hospital stay in patients undergoing laparoscopic cholecystectomy. international journal of hepatology.2017;article id 5497936: 1-8. https://doi.org/10.1155/2017/5497936 5. tebala gd, belvedere a, keane s, khan aq, osman a. daycase laparoscopic cholecystectomy: analysis of the factors allowing early discharge. updates in surgery. 2017: 69(4):461419. 6. mandrioli m, inaba k, piccinini a, biscardi a, sartelli m, agresta f, catena f, cirocchi r, jovine e, tugnoli g, di saverio s. advances in laparoscopy for acute care surgery and trauma. world journal of gastroenterology. 2016; 22(2):668.. 7. nursal tz, yildirim s, tarim a, noyan t, poyraz p, tuna n, haberal m. effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy. langenbeck's archives of surgery. 2003 ;388(2):95-100.. 8. uchiyama k, tani m, kawai m, terasawa h, hama t, yamaue h. clinical significance of drainage tube insertion in laparoscopic cholecystectomy: a prospective randomized controlled trial. journal of hepato-biliary-pancreatic sciences. 2007; 14(6):5516. 9. ishikawa k, matsumata t, kishihara f, fukuyama y, masuda h, kitano s. laparoscopic cholecystectomy with and without abdominal prophylactic drainage. digestive endoscopy. 2011; 23(2):153-6. 10. gurusamy ks, koti r, davidson br. routine abdominal drainage versus no abdominal drainage for uncomplicated laparoscopic cholecystectomy. the cochrane library. 2013. doi: 10.1002/14651858.cd006004.pub4 11. kumar m, yang sb, jaiswal vk, shah jn, shreshtha m, gongal r. is prophylactic placement of drains necessary after subtotal gastrectomy?. world journal of gastroenterology: wjg. 2007; 13(27): 3738. https://doi.org/10.1155/2017/5497936 177 j i m d c 2 0 1 7 177 12. carraro a, el mazloum d, bihl f. health-related quality of life outcomes after cholecystectomy. world journal of gastroenterology: wjg. 2011; 17(45):4945. 13. kohn gp, martinie jb. laparoscopic robot‐assisted completion cholecystectomy: a report of three cases. the international journal of medical robotics and computer assisted surgery. 2009; 5(4):406-9. 14. jamry a. diagnosis of biliary leakage after laparoscopic cholecystectomy in aspect of indication to endoscopic treatment. polski merkuriusz lekarski: organ polskiego towarzystwa lekarskiego. 2009; 26(152):153-5.. 15. rm j, rb s. early experience of day care surgery in nepal. journal of the nepal medical association. 2010; 49(179):191 4. 16. gurusamy ks, samraj k, mullerat p, davidson br. routine abdominal drainage for uncomplicated laparoscopic cholecystectomy. cochrane database syst rev. 2007. doi: 10.1002/14651858.cd006004.pub3 17. park js, kim jh, kim jk, yoon ds. the role of abdominal drainage to prevent of intra-abdominal complications after laparoscopic cholecystectomy for acute cholecystitis: prospective randomized trial. surgical endoscopy. 2015; 29(2):453-7. 18. sharma a, mittal s. role of routine subhepatic abdominal drain placement following uncomplicated laparoscopic cholecystectomy: a prospective randomised study. journal of clinical and diagnostic research: jcdr. 2016; 10(12): pc03. 19. antoniou s, koch o, antoniou g, köhler g, chalkiadakis g, pointner r, et al. routine versus no drain placement after elective laparoscopic cholecystectomy: meta-analysis of randomized controlled trials. minerva chirurgica. 2014 jun;69(3):185-94. 20. yong l, guang b. abdominal drainage versus no abdominal drainage for laparoscopic cholecystectomy: a systematic review with meta-analysis and trial sequential analysis. international journal of surgery. 2016:406. http://dx.doi.org/10.1016/j.ijsu.2016.11.083. 21. cawich so, albert m, singh y, dan d, mohanty s, et al. clinical outcomes of single incision laparoscopic cholecystectomy in the anglophone caribbean: a multi centre audit of regional hospitals. international journal of biomedical science: ijbs. 2014; 10(3):19. j islamabad med dental coll 2020 280 open access common radiological findings in children with suspected foreign body inhalation muhammad junaid1, mansoor alam2, sahibzada fawad khan3, sajid ali4, khalid saeed5, hamid mukhtar6 1assistant professor, ent, head & neck surgery, khyber teaching hospital, peshawar pakistan 2registrar, ent, head & neck surgery, khyber teaching hospital, peshawar pakistan 3associate professor, ent, head & neck surgery, qazi husain ahmed medical complex, nowshera pakistan 4senior registrar, ent, head & neck surgery, qazi husain ahmed medical complex, nowshera pakistan 5senior registrar, ent, pak international medical college, peshawar pakistan 6resident, ent, head & neck surgery, khyber teaching hospital, peshawar pakistan a b s t r a c t background: aspirated foreign bodies, an emergency situation, affecting children mostly in the first decade of life, either go undetected, are misdiagnosed or discovered unexpectedly. the purpose of this study was to determine the common radiological findings among children with suspected foreign body inhalation at khyber teaching hospital, peshawar pakistan. material and methods: this cross-sectional descriptive study was conducted at the department of ent, khyber teaching hospital, peshawar, from april 2017 to october 2017. all patients (n=141) were subjected to detailed history and clinical examination. x ray chest (ap and lateral views) was performed to detect common radiological findings i.e., radiopaque foreign body (fb), pneumonia, emphysema, atelectasis and air trapping. the age and gender -stratified radiological findings were analyzed using chi square test to see effect modifications, with p-value < .05 as statistically significant. results: in this study, mean age was 8±3.563 years, with most of the children with suspected fb inhalation presenting in the 1-6 years age group (n=82; 58%). sixty percent children were male while 40% were female, with emphysema (28%) and air trapping (25%) as the most common radiological findings. radiopaque fb was detected in 16% of children on x-ray chest. conclusions: children with suspected foreign bodies should be thoroughly evaluated by both clinical and radiological examination. key words: air trapping, atelectasis, chest x-ray, emphysema, pneumonia, radiopaque foreign body. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2-6 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad junaid email: drjunaident@gmail.com article info: received: june 29, 2020 accepted: december 24, 2020 cite this article. junaid m, alam m, khan sf, ali s, saeed k, mukhtar h. common radiological findings in children with suspected foreign body inhalation. j islamabad med dental coll. 2020; 9(4): 280-284. doi: 10.35787/jimdc.v9i4.608 funding source: nil conflict of interest: nil i n t r o d u c t i o n foreign body (fb) aspiration remains a public health problem in many countries, attested by the recent publications.1 miniature equipment, advances in anesthesia and removal procedure achieved by o r i g i n a l a r t i c l e j islamabad med dental coll 2020 281 experienced teams, improved the outcome of this medical emergency.2 more than 80% cases of foreign body aspiration occur during early childhood, with a peak incidence between the ages of 10 and 24 months.3-5 the absence of molars and premolars and the tendency to put all objects in the mouth predisposes children of this age-group. symptoms can vary considerably according to the site of the foreign body in the airways. when the foreign body is trapped in the larynx or trachea, respiratory distress or stridor are immediately suggestive of the diagnosis. however, in the majority of cases (75% to 94%), the foreign body migrates to the bronchi with no clear and typical symptoms.6 imaging plays an important role in the diagnosis of ingested and aspirated foreign bodies in children and can be crucial to guiding the clinical management of these patients.7 radiographic methods for the diagnosis of tracheobronchial foreign body include chest radiograph, inspiration and expiration chest x-rays, inspiratory and assisted expiratory chest radiographs, fluoroscopy, isotope examination of the lungs and multidetector computed tomography virtual bronchoscopy which is a non-invasive diagnostic tool which provides a three-dimensional view.8,9 to demonstrate the consequences of airway obstruction, various radiological techniques are employed to inhale air producing collapse consolidation or to exhale air giving obstructive emphysema.10,11 in children with a foreign body in the airway, radiographic features depend on the size, location, duration, and nature of the foreign body. chest radiography that has been used as the first imaging modality in children suspected for upper airway obstruction may show a variety of findings, including air-trapping, consolidation, atelectasis and bilateral over aeration.12 the present study was designed to determine the frequency of various radiological findings among children presenting with suspected foreign body inhalation. the results of this study will be useful in the initial management of fb inhalation as it will delineate the local trend of common radiological findings among children with suspected inhalation of a foreign body. m a t e r i a l a n d m e t h o d s this cross-sectional descriptive study was conducted at the department of ent, khyber teaching hospital, peshawar, from april 2017 to october 2017. the sample size was 141 patients using 15.6% proportion of atelectasis in patients with fb inhalation, 95% confidence interval and 6% margin of error calculated using who software. non probability (consecutive) sampling was done. children of both genders, aged 01-18 years, with history of fb inhalation in the last 48 hours were included. those diagnosed with asthma or with previous history of fb removal were excluded from the study. detailed history, clinical examination and chest x ray (ap and lateral views) was done to detect the common radiological findings of foreign bodies i.e., radiopaque fb, pneumonia, emphysema, atelectasis and air trapping. demographic details like name, age, gender, address and contacts were recorded on a pre-designed proforma. the data collected was analyzed in spss v 20.0. mean ± sd was calculated for continuous variable like age and duration of illness. frequencies and percentages were calculated for categorical variable like age, gender and common radiological findings. the age and gender-stratified radiological findings were analyzed to see effect modifications. post stratification was done through chi square test keeping p value < .05 as statistically significant. j islamabad med dental coll 2020 282 r e s u l t s a total of 141 patients, 85 (60%) male and 56 (40%) females, and aged 1-18 years were categorized into age groups, as shown in table i. mean age of the study cohort was 8 years ± 3.56. table i: age distribution (n=141) age groups (years) frequency percentage 1-6 82 58 >6-12 45 32 >12-18 14 10 table ii shows frequency distribution of common radiological findings of suspected foreign body inhalation among the 141 children. table ii: common radiological findings (n=141) radiological findings frequency percentage radiopaque fb 24 16 pneumonia 18 13 emphysema 39 28 atelectasis 25 18 air trapping 35 25 when age and gender stratification was done with common radiological findings of patients with foreign body inhalation, no significant relationship was observed, as shown in table iii. d i s c u s s i o n foreign body aspiration is a significant cause of mortality in children for anatomic as well as developmental reasons. the obstruction can lead to difficulties with ventilation and oxygenation, thus resulting in significant morbidity and/or mortality.13 it is a serious medical condition and early diagnosis and prompt treatment is mandatory. in a study by wu et al. on children with fb aspiration admitted to pediatric icu of child's hospital, zhejiang university, all 28 patients died due to asphyxia and serious complications of foreign bodies inhalation.14 in our study, mean age of children was 8 years and 90% patients were below 12 years of age, with 60% male and 40% female children. common radiological findings included radiopaque fb (16%), pneumonia (13%), emphysema (28%), atelectasis (18%), and air trapping (25%). brian et al. in a study mentioned plain radiography as the most important modality in evaluation of aspirated foreign bodies.7 oke et al. mentioned foreign body aspiration occurring in 80% children who were below 15 years of age.15 similar results were observed in another study conducted by hitter et al. in which mean age was 10 years with 62% male and 38% female children. twenty percent children had radio opaque fb, 12% had pneumonia, 30% had emphysema, 15% had atelectasis and 23% children had air trapping.10 sattar et al. also reported radiopaque fb in 4.4%, air trapping in 26.7%, pneumonia in 17.8% and atelectasis in 15.6% cases of fb aspiration.12 in a retrospective study on 2624 children in algeria, boufersaoui et al. reported normal chest x ray in 11.83% cases of fb inhalation with obstructive emphysema in 34.26%, atelectasis in 20.35%, pneumonia in 9.48% and radio opaque fb in 16%, respectively.16 in another retrospective analysis of 67 patients of suspected fb aspiration, admitted to pediatric otolaryngology of medical university of warsaw, both posteroanterior (pa) and lateral decubitus chest x-rays were done.13 the most common radiological findings were emphysema (35%), mediastinal shift (14%), atelectasis (12%) and alveolar consolidations (10.5%). almost all of the fbs were radiolucent in nature (n=56). there was one radiopaque fb, which was a pin. according to the authors, chest x-rays may confirm a radiopaque fb, though mostly radiolucent objects are inhaled by children.13 j islamabad med dental coll 2020 283 lack of awareness of the parents regarding this condition and late presentation of these patients to the ent department can be regarded as major limitations of this study. c o n c l u s i o n children with suspected foreign bodies should be thoroughly evaluated and at least a radiological investigation should be performed before deciding any treatment for its removal. r e f e r e n c e s 1. foltran f, ballali s, passali fm, kern e, morra b, passali gc et al. foreign bodies in the airways: a metaanalysis of published papers. int j pediatr otorhinolaryngol. 2012; 76: s12–s19. 2. fidkowski cw, zheng h, firth pg. the anesthesic considerations of tracheobronchial foreign bodies in children: a literature review of 12.979 cases. anesth analg. 2010; 111(4): 1016–1025. 3. zhijun c, fugao z, niankai z, jingjing c. therapeutic experience from 1428 patients with pediatric tracheobronchial foreign body. j pediatr surg, 2008; 43(4): 718–21. 4. saki n, nikakhlagh s, heshmati sm. 25-year review of the abundance and diversity of radiopaque airway foreign bodies in children. indian j otolaryngol head neck surg. 2015; 67(3): 261-6. 5. lena gordon, patrik nowik, shahla mobini kesheh, marika lidegran, sandra diaz. diagnosis of foreign body aspiration with ultralow-dose ct using a tin filter: a comparison study. emerg radiol. 2020; 27(4): 399-404. 6. saki n, nikakhlagh s, rahim f, abshirini h. foreign body aspirations in infancy: a 20-year experience. int j med sci. 2009; 6(6): 322–3. 7. brian s pugmire, ruth lim, laura l avery. review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. radiographics. 2015; 35(5): 1528-38. 8. cutrone c, pedruzzi b, tava g, emanuelli e, barion u, fishetto d et al. the complimentary role of diagnostic and therapeutic endoscopy in foreign body aspiration in children. int j pediatr otorhinolaryngol. 2011; 75(12): 1481–5. 9. behera g, tripathy n, maru yk. role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree. j laryngol otol. 2014; 128(12): 1078-83. 10. hitter a, hullo e, durand c, righini ca. diagnostic value of various investigations in children with suspected foreign body aspiration: review. eur ann otorhinolaryngol head neck dis. 2011; 128(5): 24852. 11. tseng hj, hanna tn, shuaib w, aized m, khosa f, linnau kf. imaging foreign bodies: ingested, aspirated, and inserted. ann emerg med. 2015; 66(6): 570-82. 12. sattar a, ahmad i, javed am, anjum s. diagnostic accuracy of chest x-ray in tracheobronchial foreign table iii: ageand gender-stratified radiological findings in suspected cases of fb inhalation age groups (years) radiological findings radiopaque fb pneumonia emphysema atelectasis air trapping yes no yes no yes no yes no yes no 1-6 14 68 10 72 23 59 15 67 20 62 >6-12 8 37 6 39 12 33 8 37 12 33 >12-18 2 12 2 12 4 12 2 12 3 11 total 24 117 18 123 39 102 25 116 35 106 p-value* .95 .97 .96 .94 .92 gender radiopaque fb pneumonia emphysema atelectasis air trapping yes no yes no yes no yes no yes no male 14 71 11 74 23 62 15 70 21 64 female 10 46 7 49 16 40 10 46 14 42 total 24 117 18 123 39 102 25 116 35 106 p-value* .83 .94 .84 .97 .97 j islamabad med dental coll 2020 284 body aspiration in paediatric patients. j ayub med coll abbottabad. 2011; 23(4): 103-5. 13. ryczer t, zawadzka-głos l, chmielik m, szczupak p. the clinical characteristics and radiographic findings in patients with foreign body aspiration. borgis new medicine. 4/2012, s. 105-107. 14. wu x, wu l, chen z, zhou y. fatal choking in infants and children treated in a pediatric intensive care unit: a 7year experience. int j pediatr otorhinolaryngol. 2018; 110: 67-9. 15. oke v, vadde r, munigikar p, bhattarai b, agu c, basunia r, et al. use of flexible bronchoscopy in an adult for removal of an aspirated foreign body at a community hospital. j community hosp intern med perspect. 2015; 5(5): 285-9. 16. boufersaoui a, smati l, benhalla kn, boukari r, smail s, anik k et al. foreign body aspiration in children: experience from 2624 patients. int j ped otorhinol. 2013; 77(10): 1683-8. j islamabad med dental coll 2019 18 open access comparative efficacy and safety of low dose versus high dose isotretinoin in severe acne vulgaris patients maria syed 1, syed afaq ahmed 2 1 consultant dermatologist, shifa college of medicine islamabad 2 head of department dermatology, akbar niazi teaching hospital islamabad a b s t r a c t background: oral isotretinoin is the recommended treatment for acne vulgaris, a skin disease especially common in teenagers and adolescents. this study was designed to compare the efficacy and safety of low dose with high dose isotretinoin in severe acne vulgaris patients. material and methods: this randomized controlled trial included 110 patients with a clinical diagnosis of acne vulgaris. they were divided into two groups. both groups were matched for age (mean 18.2±3.7 vs 17.6±3.2 years), weight (mean 58±10.2 vs 60.7±9.3 kg), gender and disease duration (3±1.1 vs 3±1.0 years). group a received low dose oral isotretinoin (20 mg/day) while group b received standard high dose regimen (1mg/kg/day). all patients were followed up for 16 weeks to assess efficacy (assessment of complete remission) and safety (mucocutaneous side effects). all calculations were performed using spss v. 16 with p value <0.05 considered as statistically significant. results: there was no statistically significant difference in efficacy. however, significantly fewer mucocutaneous side effects were reported in group a (80%) as compared to group b (100%). this safety profile spectrum was observed across all pre-defined subsets i.e chielitis (78.1% vs 98.2%), dry skin (69.1% vs 92.7%), dry mouth (47.2% vs 72.7%) and facial rash (12.7% vs 30.9%). conclusion: in patients with severe acne vulgaris, efficacy (complete remission) of low dose oral isotretinoin is almost equal to conventional high dose regimen but it is statistically superior in terms of safety (mucocutaneous side effects). key words: acne vulgaris, isotretinoin, mucocutaneous, nodulocystic author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, data analysis, active participation in data collection. address of correspondence maria syed email: maria.syed@live.com article info. received: july 22, 2018 accepted: november 10, 2018 cite this article. syed m, ahmed sa. comparative efficacy and safety of low does versus high dose isotretinoin in severe acne vulgaris patients. j islamabad med dental coll.2019; 8(1):1822 funding source: nil conflict of interest: nil i n t r o d u c t i o n acne vulgaris (av) is the most common skin disease worldwide characterized by chronic inflammation of pilosebaceous units which, if left untreated, may lead to detrimental physical and psychological effects.1 the disease is more common in younger age groups, ranging from 70%2 in teenagers to as high as 90% in adolescents.3 currently, oral and topical antibiotics and retinoids represent the most widely accepted conventional therapies for acne. isotretinoin (13-cis retinoic acid) represents the single most important pharmacological advancement in acne therapeutics. its conventional dose is 0.5-1 mg/kg/day in single or divided doses. the current practices follow a cumulative oral isotretinoin dose of 120150 mg/kg of body weight in severe acne, over a period of 16-24 weeks. however, the common dose-dependent side-effects have compelled the researchers to look for substitute protocols.4 some recent studies have proposed a safer and almost as efficacious regimen with lower doses of oral isotretinoin, while others have failed to show any significant alternative.4-6 sardana et al and agarwal et al reported comparative efficacy of 69% vs. 96% (low dose isotretinoin vs. high dose isotretinoin) in terms of o r i g i n a l a r t i c l e j islamabad med dental coll 2019 19 complete remission of acne vulgaris over a period of sixteen weeks.5,6 similarly, low dose to high dose mucocutaneous side effects at 89% vs. 100% have been documented.6 however, such protocols have not been advocated in the guidelines so far due to the paucity of published data for an optimal dosage regimen. some of the physicians are thus opting for institution-based practices of high dose, low dose, pulsed and alternate day isotretinoin, while others have failed to show any dosage regimens. the pursuit of a robust regimen becomes all the more important in our setting considering the unique acne dynamics of south asian population7 as well as the financially constrained healthcare system. this study aims to find the efficacy and safety of high and low doses of oral isotretinoin in severe acne vulgaris patients presenting in our tertiary care hospital set-up. m a t e r i a l a n d m e t h o d s this randomized controlled trial was conducted at dermatology out-patient department of pakistan institute of medical sciences (pims), islamabad from 10th march, 2013 to 9th january, 2014. sample size was computed using who calculator taking 5% level of significance with 95% power of the test.6 calculated sample size was 55 in each group. both male and female patients with severe acne vulgaris, more than 12 years of age, presenting at the out-patient of dermatology unit were included. pregnant and breast-feeding, married females desiring to have pregnancy within 6 months after initiation of therapy were excluded. patients having hypersensitivity to retinoids, patients with baseline triglyceride levels > 400 mg/dl and/or total cholesterol > 300 mg/dl, alt > 60/ul and/or ast > 80/ul were also excluded from the study. drug induced acne i.e. acne in patients on isoniazid, phenytoin, lithium, azathioprine, cyclosporine and those already on anti-acne treatment were not included in the study. permission was taken from the hospital’s ethical committee. informed written consent was taken from the enrolled patients and confidentiality was maintained throughout the study. detailed history and clinical examination of all severe acne vulgaris patients was done at first hospital visit to assess for the suitability for enrollment in the study. fda global acne scale was applied to assess the baseline severity of disease. liver function tests (lfts) and lipid profile were obtained. all enrolled patients were equally divided into group a (low dose isotretinoin) and group b (high dose isotretinoin) by lottery method. single blinded protocol was followed by concealing any information about their allotment group from the patients. group a was prescribed oral isotretinoin at a dose of 20 mg once a day while group b was given 1 mg/kg/day in divided doses. all patients were asked to swallow the capsule with meal to avoid gastrointestinal side effects. furthermore, all patients were advised to apply topical 1% clindamycin gel twice daily as per the standard acne guidelines. strict compliance with the treatment protocol was advocated throughout the study period. patients were followed for sixteen weeks at monthly intervals. lfts and lipid profile were checked on each follow up visit. therapy was discontinued if blood tests showed ast > 80/ul or alt > 60/ul or cholesterol > 300mg/dl or triglycerides > 400mg/dl. treatment protocol was termed efficacious if there was complete resolution of acne vulgaris features on clinical examination at 16 weeks of therapy. patients were asked to report in clinic if they experienced any mucocutaneous side effects as already described. patients not presenting for follow up were contacted on telephone and early clinic visit was emphasized. subjects withdrawing consent and those who discontinued therapy by themselves for more than a week were addressed as "drop out" and excluded in the outcome analysis, same as for patients lost to follow up. all statistical calculations were performed using spss version 16 (statistical package for the social sciences, spss inc. usa). mean and standard deviation were calculated for age, weight and duration of the disease. frequency and percentages were calculated for categorical variables such as gender, efficacy and safety. effect modifiers like site and duration of disease, age, gender was controlled by stratification. independent sample t test was applied to test baseline characteristics. chi square test was used to compare efficacy and safety outcomes. p value of less than 0.05 was considered statistically significant. j islamabad med dental coll 2019 20 r e s u l t s a total of 110 patients were included in the analysis (55 in each group). table i shows the baseline characteristics of the study sample. in group a, females were more while in group b, there was male dominancy. in group a, median age was 17 years with an age range 12-27 years. in group b, median age was 17 years with a range of 12-25 years. subjects of group a had median weight of 57 kg (range 36-85 kg) while in group b, median weight was 60 kg (range was 37-82 kg). no statistically significant difference was noted in both groups as far as age (p=0.38), weight (p=0.15), gender (p=0.18) and duration of disease (p=1.0) were considered. table ii shows efficacy and safety outcomes of both groups after 16 weeks follow-up. although complete remission of acne was observed in 52 patients (94.5%) of group a and all patients of group b (100%), the difference was not statistically significant (p= 0.07). however, significantly fewer mucocutaneous side effects were reported in low dose isotretinoin group (80%) as compared to conventional high dose isotretinoin group (100%) (table ii) (rrr 20%, p 0.0004) (figure 1). figure 1: safety outcome at 16 weeks this safety profile spectrum was observed across all predefined subsets (table ii) i.e. cheilitis (rrr 20%, p 0.001), dry skin (rrr 25%, p 0.002), dry mouth (rrr 34%, p 0.006) and rash (rrr 60%, p 0.02) (figure 1). an excellent (100%) follow up in both groups was achieved at 16 weeks and no major side effect leading to discontinuation of study drug was reported. d i s c u s s i o n acne vulgaris (av) is an extremely prevalent skin condition1,2 affecting majority of teenagers to a certain degree at some point. the onset of av is usually shortly before or during early adolescence; however, some cases start in latter childhood with the subset of preadolescent acne defined within the ages of 7 and 11 years.8 the impact on the quality of life of young people is highly significant. it has a greater negative effect on the emotions and social functioning of teenagers than diseases like asthma and epilepsy.3 it is often associated with anxiety, depression and unemployment3. the impact of the condition is often difficult to determine clinically, but table i: baseline characteristics of patients (n= 110) variables group a (low dose) (n=55) group b (high dose) (n=55) age (years); mean + sd 18.2 ± 3.7 17.6 ± 3.2 male; n (%) 27 (49) 34 (61) female; n (%) 28 (51) 21 (39) weight (kg); mean + sd 58.0 ± 10.2 60.7 ± 9.3 duration of disease (years); mean + sd 3.0 ± 1.1 3.0 ± 1.0 table ii: efficacy and safety outcomes of isotretinoin at 16 weeks (n=110) efficacy outcome group a (n=55) n (%) group b (n=55) n (%) odds ratio (or) relative risk reduction (rrr %) 95% confidence interval (ci) p value complete remission 52 (94.5) 55 (100) 0.48 0.40-0.59 0.07 safety outcome mucocutaneous side effects 44 (80) 55 (100) 0.44 20 0.35-0.55 <0.001 cheilitis 43 (78.1) 54 (98.2) 0.06 20 0.008-0.53 0.001 dry skin 38 (69.1) 51 (92.7) 0.17 25 0.05-0.56 0.002 dry mouth 26 (47.2) 40 (72.7) 0.33 34 0.15-0.74 0.006 rash 7 (12.7) 17 (30.9) 0.32 60 0.12-0.86 0.02 j islamabad med dental coll 2019 21 one can assume that almost all acne patients will experience this impact to some degree. medical treatment can make a very big difference, often clearing the condition completely, or bringing about significant improvement in those who do not experience complete clearance. isotretinoin is regarded as a useful therapeutic advance in the management of acne. it has been recommended for the treatment of severe nodulocystic acne in the doses of 1-2 mg/day.5,6 while using this treatment protocol, the incidence of sideeffects is quite high and requires regular monitoring including a watch on the serum lipid profile.9 in this study, we have tested the notion that compared to conventional high dose, lower dose of oral isotretinoin is superior in terms of complete remission as well as carries a much better safety profile in patients of severe av. although no statistically significant superiority in efficacy is established in this regard, it cannot be ascertained at present whether lower doses are actually inferior to conventional (high) dosing in terms of complete remission of acne. however, in our study, lower doses have shown significant superiority by limiting mucocutaneous side effects. this superiority is dictated throughout the spectrum of predefined side effects i.e. cheilitis, dry skin, dry mouth and rash. another interesting finding is the possible association of efficacy to the duration of disease. all three cases of treatment failure had acne for more than four years. however, this study was not designed or powered to assess such parameter. to decrease the incidence of side-effects and to make the therapy protocol simpler, the lower dose regimen has been tried by various authors before.5,6,10 however, unlike our study, most of these studies targeted mild to moderate acne population. sardana et al5 studied lower doses of oral isotretinoin in mild to moderate acne and reported efficacy of up to 90% with statistically significant non-inferiority to conventional high dose regimen. long-term relapse rate was also same across both groups. similarly, agerwal et al 6 reported better efficacy (69% vs 96%) and safety outcomes (89% vs 100%) in favor of lower doses of oral isotretinoin across different stages of acne. each of these studies had one or more major limitations, including retrospective nature of the data collection, statistically insignificant number of patients and selection of low acne load patients with mild to moderate class. this study may be influenced by several limitations as well. only patients with severe acne load were addressed. it was left up to the discretion of patients which isotretinoin preparations to buy from available brands. furthermore, relevance on patient interview or clinician impression may be insufficient to detect poor adherence to medications. despite these limitations, this study provides new insights into the possibility of finding a more robust, efficacious, much safer regimen of oral isotretinoin than the one in practice for severe acne vulgaris. c o n c l u s i o n low dose oral isotretinoin, over a period of 16 weeks, is not superior to conventional high dose regimen in terms of complete remission of severe acne vulgaris. however, it has a statistically significant safety profile accounting for fewer mucocutaneous side effects as compared to latter. future studies should be designed to prospectively test such unorthodox regimens for the overall cost effectiveness, and to assess for both superiority as well as non-inferiority compared to high dose regimen. r e f e r e n c e s 1. collier cn, harper jc, cafardi ja, cantrell wc, wang w, foster kw et al. the prevalence of acne in adults 20 years and older. j am acad dermatol. 2008; 58(1): 56-9. 2. hanisah a, omar k, shah sa. prevalence of acne and its impact on the quality of life in school-aged adolescents in malaysia. j prim health care. 2009;1(1):20-5. 3. ghdsi sz, orawa h, zouboulis cc. prevalence, severity and severity risk factors of acne in high school pupils: a community-based study. j invest dermatol. 2009; 129(9): 2136-41. 4. rathi sk. acne vulgaris treatment: the current scenario. indian j dermatol. 2011; 56(1): 7-13. 5. sardana k, garg vk. efficacy of low-dose isotretinoin in acne vulgaris. indian j dermatol venereol leprol. 2010; 76(1): 7-13. 6. agarwal us, besarwal rk, bhola k. oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial. indian j dermatol venereol leprol. 2011; 77(6): 688-94. j islamabad med dental coll 2019 22 7. khunger n, kumar c. a clinic-epidemiological study of adult acne: is it different from adolescent acne? indian j dermatol venerol leprol. 2012; 78(3): 33541. 8. james wd. clinical practice. acne. n engl j med. 2005; 352(14):1463-72. 9. strauss js, krowchuk dp, leyden jj, lucky aw, shalita ar, siegfried ec et al. guidelines of care for acne vulgaris management. j am acad dermatol. 2007;56(4): 651-63. 10. kellett sc, gawkrodger dj. the psychological and emotional impact of acne and the effect of treatment with isotretinoin. br j dermatol. 1999; 140(2): 273-82. j islamabad med dental coll 2019 193 ope n ac cess clinicopathological characteristics of breast carcinoma in premenopausal women nazia ishaque1, muhammad asad2 1senior registrar, department of general surgery, pakistan institute of medical sciences, islamabad, pakistan 2senior registrar, department of general surgery, islamic international medical college rawalpindi, pakistan a b s t r a c t background: breast cancer is one of the leading causes of mortality world-wide. the objective of this study was to see the pattern and characteristics of carcinoma breast in premenopausal women reporting at a tertiary care hospital. material and methods: this cross-sectional study was conducted at surgical unit of pakistan institute of medical sciences (pims), islamabad from may 2012 to april 2015. a total of 144 female patients were admitted during this period as diagnosed cases of carcinoma breast. of these patients, all cases of breast carcinoma diagnosed in premenopausal women were selected and assessed for tumor type, tnm classification and involved breast quadrants. results: out of 144 patients 70 (48.6%) cases of carcinoma breast were reported in premenopausal women. the ages ranged from 14 to 48 years with a mean age of 33 ± 7.95 years. according to tnm classification, 2.9% patients were in t1, 25.7% were in t2, 32.9% were in t3 and 38.6% were in t4. similarly, 37.1% patients presented with a nodal status of n0, 38.1% with n1, 21.4% with n2 and 2.9% with n3. out of 70 patients, 11 (15.7%) presented with distant metastasis (m1) at the time of diagnosis. the upper outer quadrant of breast (32.9%) was most commonly involved site, followed by upper inner, lower outer and lower inner quadrants, respectively. most common tumor type was invasive ductal carcinoma (85.7%), followed by invasive lobular carcinoma (7.1%), papillary carcinoma (4.3%), medullary carcinoma (1.4%) and malignant phylloides (1.4%). regarding exposure to risk factors of breast cancer in these patients, 35.7% women did not breast feed and 27.1% were nulliparous. there was no history of use of oral contraceptive pills in 82.8% and positive family history was reported in 27.1% patients. conclusions: late presentation with advanced disease in premenopausal women is more common in our part of the world as compared to international literature. more studies on larger sample sizes should be carried out to validate these findings. key words: breast carcinoma, premenopausal women, clinicopathological characteristics, risk factors authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, active participations in data collection data analysis. correspondence: muhammad asad email: m.asad@riphah.edu.pk article info: received: march 12, 2019 accepted: november 20, 2019 cite this article. ishaque n, asad m. clinicopathological characteristics of breast carcinoma in premenopausal women. j islamabad med dental coll.2019; 8(4): 193-197. doi: 10.35787/jimdc.v8i4.476 funding source: nil conflict of interest: nil i n t r o d u c t i o n data from united states has reported breast carcinoma as the second most common tumor diagnosed in women after skin carcinoma. the related mortality and morbidity are also quite high, especially in underdeveloped countries because of poor access to health care and late presentation. as far as cancer related deaths are concerned, it is the second most common cause following lung cancer.1 breast carcinoma is also one of the leading causes of death due to malignancies in developing countries like pakistan.2 mortality related to breast cancer is decreasing in the west because of public awareness, good screening programs and rapid access to health care system. about 268,600 new invasive breast cancer cases were diagnosed in us in 2019 only with 41,760 deaths.1 previously, the incidence and mortality of breast cancer had a lower trend in asia than in the west, but now it is rapidly increasing.3 developing countries like pakistan have only hospital-based data so that country-wide statistics regarding breast cancer is still lacking. the probability of developing breast cancer in pakistani or i gi n a l a r ti c le j islamabad med dental coll 2019 194 women has been reported to be 1 in 9 women4, with some studies reporting an incidence rate of 69.1/100,000 population.5 mortality rate varies with different factors including, age, stage, treatment response, tumor type and other comorbidities.6 response to treatment and outcome varies in different histological subtypes of breast cancer.7 tao et al reports higher mortality rate in african-american women as compared to non-hispanic white women.8 t h e incidence of breast cancer in asia differs from the west, however in most asian countries and african-american women incidence of breast cancer is rising, whereas in western countries and whites the incidence is static.1 age is one of the most important factors affecting prognosis in carcinoma breast, as in other malignancies. a study reported the mean age of diagnosis in african patients as 57.6 years with large tumor size, compared to 62.6 years in white patients.9 in western countries the incidence of breast carcinoma is higher in postmenopausal group. screening and post-menopa u sa l hormonal therapy may have contributed towards the increased incidence in this group. in our part of world, increasing incidence of carcinoma breast is noted in premenopausal age group. environmental factors and genetic variance may be responsible for disease presentation at earlier age in developing countries.10 it is important to know about the characteristics of disease in both postmenopausal and premenopausal group, because of the difference in behavior and patterns of disease in both age groups. our study is focused on the premenopausal group. it has been seen that about one third of breast cancer can be prevented by risk factor modifications like healthy life style, reducing weight and avoiding alcohol.11 the objective of the study was to see the clinicopathological characteristics of carcinoma breast in premenopausal women at surgical unit of pakistan institute of medical sciences (pims), islamabad. m a t e r i a l a n d m e t h o d s in this cross-sectional study, record of 144 female patients admitted as diagnosed cases of carcinoma breast at surgical unit pims was collected from may 2012 to april 2015. from this retrospective data, all cases of breast carcinoma diagnosed in premenopausal women were selected, while cases of breast carcinoma in postmenopausal age group were excluded from the study. the selected cases were assessed for tumor type, tnm classification, involved breast quadrants and risk factors like history of breast feeding, smoking, use of oral contraceptive pills, previous pregnancies and positive family history. data was entered in spss version 17. mean and standard deviation were calculated for quantitative variables like age. frequencies and percentages were calculated for qualitative variables like tumor type, lymph node status, site of involvement and risk factors. r e s u l t s out of a total of 144 patients, 70 patients of carcinoma breast were present in premenopausal women. the a g e s ranged from 14 to 48 years with mean age of 33 ± 7.95 years. according to tnm classification, 2 (2.9% ) patients were in t1, 18 (25.7% ) were in t2, 23 (32.9% ) were in t 3 and 27 (38.6% ) were in t4, respectively. regarding lymph node status, 26 (37.1% ) women presented with n0, 27 (38.1% ) with n1, 15 (21.4% ) with n2 and 2 (2.9% ) with n3 nodal involvement. out of 70 patients, 11 (15.7% ) ha d distant metastasis (m1). the upper outer (32.9% ) was most commonly involved, followed by upper inner, lower outer and lower inner quadrant (table i). the most common tumor type was invasive ductal carcinoma (85.7% ), followed by invasive lobular carcinoma, papillary carcinoma, medullary carcinoma and malignant phylloides (table ii). regarding exposure to risk factors, 25 (35.7% ) women did not breast feed and 19 table i: quadrant involvement in premenopausal women with breast cancer (n=70) breast quadrants frequency percentage upper outer quadrant 23 32.9 lower outer quadrant 7 10.0 upper inner quadrant 14 20.0 lower inner quadrant 6 8.6 centre of breast 13 18.6 whole breast 7 10.0 total 70 100.0 j islamabad med dental coll 2019 195 (27.1% ) were nulliparous. there was no history of use of oral contraceptive pills in 58 (82.8% ) women and a positive family history was reported in 19 (27.1% ) cases. d i s c u s s i o n the present study reported clinicopathological characteristics of carcinoma breast in premenopausal women presenting at a younger age with advanced disease manifesting as more lymph node involvement and distant metastasis. these patients were also assessed fo r exposure to risk factors of breast cancer. there are certain factors that increase the risk of breast cancer indirectly by increasing estrogen levels such as obesity, prolonged duration of estrogen exposure, advanced maternal age at first delivery, early menarche and late menopause, nulliparity, use of alcohol and high fat diets.12,13 there are certain factors that protect from breast cancer such as reduced exposure to estrogen, long duration of breast feeding, lactation and moderate exercise.14 women in the younger age group have been reported to have breast cancer with a larger tumor size, higher expression of her2/egfr and worse prognosis.15 age is one of the most important prognostic factors in carcinoma breast especially the menopausal age. endocrine physiology keeps on changing throughout life in females. use of hormonal therapy after menopause affect the prognosis of disease. prognosis is better in older age group as compared to younger women.16 this improvement in prognosis may be attributed to the hormonal changes in female body after menopause. in the current study, mean age was 33 years with 42.9% women below 33 years of age. majority of the patients in this study were in 33 to 48 years age group. this is consistent with the data found in local literature. in our part of world, carcinoma breast is more common in premenopausal age group, whereas in western countrie s, it is more common in postmenopausal women. in countries like pakistan, women of the middle age group (30–59 years) are at a higher risk of developing breast cancer.5 other local studies have also found this age group to be the commonest.17 the most common tumor type was found to be infiltrating ductal carcinoma in this study, as also found in national and international literature.18 in almost all type of carcinomas including breast carcinoma, lymph node status is a very important prognostic indicator. in our study most of the women presented with advanced nodal disease (63.9% ). our findings are comparable to a local study carried out in karachi reporting 56.9% premenopausal women with advanced breast carcinoma (>3 lymph nodes involved).19 another local study reporte d 40% of patients with metastasis in more than three lymph nodes.5 poor socioeconomic status of patients in under developed countries may be an important factor for the advanced presentation of breast carcinoma with nodal and distant metastasis. this is contradictory to international literature, which show relatively fewer premenopausal women or younger women with advanced nodal disease. kocaöz et al. reported in a study that in premenopausal females with breast cancer, the tumor size was larger with more lymph node metastasis.20 this difference in national and international literature may be because of the lack of proper screening programs in underdeveloped countries like pakistan. previous studies especially from western countries have shown increased incidence of carcinoma breast among postmenopausal women, mostly because of the screening programs targeted at this age group, and postmenopausal hormonal therapy. therefore, patterns and characteristics of carcinoma breast have been extensively studied in postmenopausal women, but much less attention had been given to premenopausal women. it is evident from the literature now that it may not be appropriate to use the data from developed countries for under developed countries as patterns and characteristics of breast carcinoma is different for both populations. table ii: histological type of tumor in premenopausal women with breast cancer (n=70) type of tumor frequency percentage invasive ductal carcinoma 60 85.7 invasive lobular carcinoma 5 7.1 medullary carcinoma 1 1.4 papillary carcinoma 3 4.3 malignant phyllodes 1 1.4 total 70 j islamabad med dental coll 2019 196 therefore, we have tried to focus on premenopausal women in our current study, with the aim of contributing towards the global literature on this group c o n c l u s i o n late presentation with advanced disease in premenopausal women is more common in our population as compared to rest of the world. more studies on larger sample sizes should be carried out to validate these findings. r e f e r e n c e s 1. desantis ce, ma j, gaudet mm, newman la, miller kd, sauer ag et al. breast cancer statistics, 2019. ca cancer j clin 2019; 69(6): 438–51. doi: 10.3322/caac.21583 2. mamoon n, hassan u, mushtaq s. breast carcinoma in young women aged 30 or less in northern pakistan the armed forces institute of pathology experience. asian pac j cancer prev. 2009; 10(6): 1079-1082. pmid: 20192588. 3. ghoncheh m, pournamdar z, salehiniya h. incidence and mortality and epidemiology of breast cancer in the world. asian pac j of cancer prev. 2016; 17(s3): 43-46. doi: 10.7314/apjcp.2016.17.s3.43 4. asif hm, sultana s, akhtar n, jalil ur rehman, riaz ur rehman. prevalence, risk factors and disease knowledge of breast cancer in pakistan. asian pac j cancer prev. 2014; 15 (11): 4411-4416. doi: 10.7314/apjcp.2014.15.11.4411 5. arshad s, masood ur rehman, abid f, yasir s, qayyum m, ashiq k et. current situation of breast cancer in pakistan with the available interventions. int j biosci. 2019; 14(6): 232-240. doi: 10.12692/ijb/14.6.232-240 6. danforth dn jr. disparities in breast cancer outcomes between caucasian and african american women: a model for describing the relationship of biological and nonbiological factors. breast cancer res. 2013; 15(3): 208. doi: 10.1186/bcr3429. 7. dieci mv, orvieto e, dominici m, conte p, guarneri v. rare breast cancer subtypes: histological, molecular, and clinical peculiarities. oncologist. 2014; 19(8): 805-813. doi: 10.1634/theoncologist.20140108 8. tao l, gomez sl, keegan th, kurian aw, clarke ca. breast cancer mortality in african-american and non-hispanic white women by molecular subtype and stage at diagnosis: a population-based study. cancer epidemiol biomarkers prev. 2015; 24(7): 1039-1045. doi: 10.1158/1055-9965.epi-15-0243 9. rambau pf, chalya pl, manyama mm, jackson kj. pathological features of breast cancer seen in northwestern tanzania: a nine years retrospective study. bmc research notes. 2011; 4: 214 doi:10.1186/1756-0500-4-214 10. chouchane l, boussen h, sastry ks: breast cancer in arab populations: molecular characteristics and disease management implications. lancet oncol. 2013, 14(10): e417-e424. doi: 10.1016/s14702045(13)70165-7. 11. world cancer research fund/american institute for cancer research. continuous update project report: cancer preventability estimates for diet, nutrition, body fatness, and physical activity. washington, dc: aicr; 2017. (available from: https://www.aicr.org/continuous-updateproject/reports/breast-cancer-report-2017.pdf). 12. nattenmüller cj, kriegsmann m, sookthai d, fortner rt, steffen a, walter b et al. obesity as risk factor for subtypes of breast cancer: results from a prospective cohort study. bmc cancer 2018; 18: 616. doi: 10.1186/s12885-018-4548-6 13. scoccianti c, cecchini m, anderson as, berrino f, boutron-ruault mc, espina c et al. european code against cancer 4th edition: alcohol drinking and cancer. cancer epidemiol 2016; 45: 181-188.doi: 10.1016/j.canep.2016.09.011 14. kruk j. lifetime physical activity and the risk of breast cancer: a case control study. cancer detect prev. 2007; 31: 18-28 doi: 10.1016/j.cdp.2006.12.003 15. wang k, ren y, li h, zheng k, jiang j, zou t et al. comparison of clinicopathological features and treatments between young (≤ 40 years) and older (> 40 years) female breast cancer patients in west china: a retrospective, epidemiological, multicenter, case only study. plos one. 2016; 11: e0152312 doi: 10.1371/journal.pone.0152312 16. dirier a, burhanedtin-zincircioglu s, karadayi b, isikdogan a, aksu r. characteristics and prognosis of breast cancer in younger women. j boun. 2009; 14(4): 619-23. pmid: 20148452 17. baloch ta, iqbal p. breast carcinoma in karachi clinical & pathological features. med channel. 2006; 12(1): 47–8. j islamabad med dental coll 2019 197 18. zahra f, humayoun f, yousaf t, khan na. evaluation of risk factors for carcinoma breast in pakistani women. j fatima jinnah med assoc. 2013; 7(1): 34-8 19. hadi ni, jamal q. comparison of clinicopathological characteristics of lymph node positive and lymph node negative breast cancer. pak j med sci. 2016; 32(4): 863–8. doi: 10.12669/pjms.324.10324 20. kocaöz s, korukluoğlu b, parlak ö, doğan ht, erdoğan f. comparison of clinicopathological features and treatments between pre-and postmenopausal female breast cancer patients–a retrospective study. przegla ̜d menopauzalny= menopause review. 2019; 18(2): 68. doi: 10.5114/pm.2019.857861 j i m d c 2 0 1 7 263 263 open access f u l l l e n g t h a r t i c l e knowledge and awareness about genetic problems associated with consanguineous marriages among non-medical students of islamabad memoona rasheed1, naghmi asif2, khalid hassan3 1 research officer, department of pathology, islamabad medical and dental college. 2 professor, department of pathology, islamabad medical and dental college 3 professor, head department of pathology, islamabad medical & dental college (shaheed zulfiqar ali butto medical university, islamabad) a b s t r a c t objective: to access the level of knowledge of non-medical students about genetic problems related to consanguinity. methodology: a descriptive study was conducted from september 2015 to june 2016 to collect information regarding acquaintance and perceptions about, consanguineous marriages among students of different colleges and universities of federal capital. specially designed performa was used to collect data. the collected data was analyzed by using statistical package for social sciences (spss) software version 16.0. demographic characteristics of participants were calculated as mean±sd. chi-square test was applied to check the level of significance among different categorical variables. results: a total of 424 students were surveyed, out of which 155 (36.6%) were male and 269 (63.4%) were female. the mean age of the study population was 20.39 ±2.44. the data analysis showed only 9.7% of students are fully aware of the problems associated with consanguinity. girls were found to be more aware as compared to boys (p= 0.05) and among all ethnic groups, punjabis were found to be more aware (16.9%). in subjects with a history of parental consanguinity and consanguinity in siblings, low level of awareness (8.8% and 8.5% respectively) was found. conclusion: efforts should be made to increase the knowledge about consanguinity and its association with genetic diseases among non-medical students. key words: awareness, consanguinity, genetic diseases. author`s contribution 1 conception, synthesis, planning of research and manuscript writing, 2 data analysis, 3 conception, review the study,3 address of correspondence memoona rasheed email: memoona_rasheed@hotmail.com article info. received: june 4, 2017 accepted: august 29, 2017 cite this article. rasheed m, asif n, hassan k. knowledge and awareness about genetic problems associated with consanguineous marriages among non-medical students of islamabad. jimdc. 2017: 6(3): 189-193. funding source: nil conflict of interest: nil i n t r o d u c t i o n consanguinity, a union between close biological kin, is most common in the middle east, south and west asia and north africa1. these unions vary widely from the patrilateral parallel consanguineous union in the middle east to uncle-niece marriages in parts of south india.2 rate of intermarriages varies greatly among a population and is influenced by factors such as religion, education, socio-economic status, geography and local tradition.3,4 due to such unions, gene flow between communities has been highly restricted resulting in a very different inherited disease profile, reflecting local founder effect and gene drift.5 the level of homozygosity is 12.5% among first cousin union while the homozygosity level in second cousin marriage is also higher from that in general o r i g i n a l a r t i c l e mailto:memoona_rasheed@hotmail.com j i m d c 2 0 1 7 264 264 population.6 currently, 10.4% of world’s population is married to a second cousin or closer (coefficient of inbreeding ≥0.0156).7 the rate of consanguineous marriages in pakistani population is ~62.7% of which ~80.4% unions are between first cousins.8 the common reasons being the protection of property, close family ties, familial compatibility, low divorce rate and a part of faith.9 prevalence of congenital recessively inherited disorders is high among consanguineous parents.10 during the last few decades, many rare disease genes have been identified and their chromosomal location has been mapped by studying multiplex consanguineous families. these studies have led to the identification of novel disease-causing gene mutations in pakistani families showing various abnormal phenotypes such as intellectual disability.11 eye abnormalities,12-14, deafness15 and thalassemia16. this study is aimed to access knowledge of adolescent of islamabad about consanguinity and its probable outcomes. p a t i e n t s a n d m e t h o d s a descriptive study was conducted in capital territory of pakistan from september 2015 to june 2016. a structured questionnaire was designed to collect demographic information such as age, gender, ethnicity, residence, native language, and education. questions were included to evaluate overall knowledge of respondents about consanguinity and prevalence of consanguinity in their families. the study was approved by the institutional review board and informed consent was obtained from all the participants. students of higher secondary school certification and university level were included in the study. students of medical colleges and of secondary school certificate were excluded from the study. the data was collected from students of various departments studying at quaid-i-azam university, air university, federal urdu university, international islamic university, comsats institute of information technology and various public-sector colleges of islamabad. the data were recorded and analyzed by using statistical package for social sciences version 16. the questionnaire consisted of 16 questions to assess the level of knowledge of the respondents about consanguinity. awareness was calculated by using the method described by jaber et al,17 with slight modification in numbering. each question contributed 1 point to the final score. the students who answered 0-8 questions correctly were considered to have a low level of awareness, students who answered 9-12 questions correctly were considered to have a moderate level of awareness and students who responded 13-16 correctly, were considered to have a high level of awareness. questions were also included to access the acceptability of cousin marriages in families of the respondents and presence of congenital disorders. r e s u l t s a total of 424 students participated in this study. the mean age of the participants was 20.39 ±2.44. more than 99% of the participants were muslims belonging to different ethnic backgrounds. the data analysis showed that 54.5% students have a low level of awareness, 35.8% have a moderate level of awareness while 9.7% of the students have a high level of awareness about the problems associated with consanguinity. among students surveyed, 66% knew that consanguinity was associated with high incidence of congenital malformations in children. among these, only 69.6% knew which congenital malformations were associated with consanguinity. (figure 1) figure 1: awareness level of the respondents about problems related to consanguinity. table 1 represents the demographic characteristics of the participants. among total participants, 116 (27.4%) were enrolled students of business administration, 163 (38.4%) were from natural sciences, 67 (15.8%) were from applied sciences and 78 (18.4%) of respondents were from higher secondary school education (table 1). j i m d c 2 0 1 7 265 265 table 2 represents demographic characteristics showing an impact on an awareness level. according to the type of degree, education was divided into three groups i.e. intermediate level, undergraduate level and postgraduate level. the data analysis showed that postgraduate students have more awareness (19.8%) as compared to those enrolled in the undergraduate or intermediate programme (3.4% and 12.7%). out of the surveyed students, 155 (36.6%) were male and 269 (63.4%) were female. among the two genders, the percentage of girls with a high level of awareness was found to be significantly greater than that of boys (p=0.00). we also compared the level of education with gender. a number of female enrolled in postgraduate degree was high (31.2%) as compared to boys (27.1%) (table 2). table 1: demographic characteristics of the participants demographic characteristics number (percentage) gender male 155 (36.6) female 269(63.4) religion islam 421 (99.3) hindu/sikh 2 (0.5) christian 1 (0.2) ethnicity urdu speaking 240 (56.6) punjabi 108 (25.4) pashto 44 (10.3) sindhi 6 (1.4) balochi 5 (1.2) others 21 (4.9) residential area urban 356 (84) sub-urban 19 (4.5%) rural 49 (11.5) education business administration bba 80 (18.9) mba 36 (8.5) natural sciences pharm d 42 (9.9) bsc 79 (18.6) msc 42 (9.9) applied sciences bscs 27 (6.5) bsse 40 (9.4) others 78 (18.3) institution quaid-i-azam university 128 (30.2) federal urdu university of science and technology 93 (21.9) international islamic university 52 (12.3) comsats institute of information technology 54 (12.7) air university 33 (7.8) others 64 (15.1) table 2: awareness level of the participants about problems related to consanguinity variables low level of awareness moderate level of awareness high level of awareness p value gender male 104 (67.1) 46 (29.7) 5 (3.2) female 126 (46.8) 107 (39.8) 36 (13.4) 0.00 religion islam 227 (54) 153 (36.3) 41 (9.7) 0.00 hindu/sikh 2 (100) 0 0 christian 1 (100) 0 0 residential area urban 196 (55.1) 126 (35.4) 34 (9.5) suburban 8 (42.1) 8 (42.1) 3 (15.8) 0.00 rural 25 (51) 20 (40.8) 4 (8.2) ethnicity urdu speaking 137 (57.1) 85 (35.4) 18 (7.5) punjabi 43 (51.8) 26 (31.3) 14 (16.9) pathan 14 (31.8) 29 (65.9) 1 (2.3) 0.00 sindhi 4 (66.6) 1 (16.7) 1 (16.7) balochi 5 (100) 0 0 others 27 (58.7) 12 (26.1) 7 (15.2) education intermediate 38 (60.3) 17 (27) 8 (12.7) undergraduate 122 (51.9) 105 (44.7) 8 (3.4) 0.00 postgraduate 70 (55.6) 31 (24.6) 25 (19.8) parental consanguinity consanguineous 111 (54.4) 75 (36.8) 18 (8.8) 0.00 nonconsanguineous 93 (46.8) 74 (39) 23 (12.1) not known 26 (86.7) 4 (13.3) 0 (0) consanguinity in siblings consanguineous 60 (56.6) 37 (34.9) 9 (8.5) nonconsanguineous 170 (53.8) 115 (36.4) 31 (9.8) 0.00 congenital disorders in family yes 35 (64.8) 19 (35.2) 0 no 194 (52.6) 134 (36.3) 41 (11.1) 0.00 j i m d c 2 0 1 7 266 266 however, number of boys enrolled in the undergraduate programme (72.3%) was more as compared to girls (45.7%) (table 3). among all ethnic groups, punjabi (16.9%) and sindhi (16.7%) were found to have more awareness (table 2). comparison between ethnic groups and education level showed that number of students belonging to pathan community (36.4%) are higher in postgraduate level than other ethnic groups while the number of urdu speaking students are enrolled more in undergraduate level (58.3%) (table 3). table 3: comparison between gender and ethnicity with education level variable education level pvalue inter mediate under graduate post graduate gender male 1 (0.6) 112 (72.3) 42 (27.1) 0.00 female 62 (23.1) 123 (45.7) 84 (31.2) ethnicity urdu speaking 36 (15) 140 (58.3) 64 (26.7) punjabi 20 (18.5) 57 (52.8) 31 (28.7) 0.00 pathan 4 (9.1) 24 (54.5) 16 (36.4) parental consanguinity consanguineous 28 (13.7) 117 (57.4) 59 (28.9) nonconsanguineous 31 (16.2) 102 (53.4) 58 (30.4) 0.00 not known 4 (13.8) 16 (55.2) 9 (31) comparison of knowledge between students of consanguineous and non-consanguineous parents showed that even children of consanguineous parents had low awareness. (table 2). students whose one or more siblings were married within the family have relatively less awareness (8.5%) as compared to those whose siblings were not married within family or cast (9.8%). the students were questioned about the presence of any congenital disorder in their siblings such as deafness, mental retardation or blindness. of the 424 respondents, 54 (12.7%) reported the presence of at least one disorder in their siblings. students who had siblings with congenital abnormality showed a significantly lower level of knowledge as compared to those without such abnormalities (p=0.00) (table 2). d i s c u s s i o n the study results showed that almost half (54.2%) of the students were unaware of the problems associated with consanguinity. among the two genders, girls were found to be more aware (13.4%) as compared to boys (3.2%). the probable reason for this finding can be that more female were enrolled in post-graduation level as compared to male. this finding is in line with the findings of similar studies conducted on saudi adults, egyptian and israeli arab population.17-19 students belonging to urban and rural areas showed a lower level of awareness as compared to those belonging to suburban areas. among all ethnic groups, punjabis showed more awareness as compared to others. a number of sindhi and balochi respondents were less in our target population. extending similar studies in these populations can give more details. studies conducted in azad kashmir showed an increase in consanguinity in literate subjects.20 consanguinity among parents and sibship was found to be associated with lower level of awareness. same trends were observed in the comparison between awareness level and presence of congenital malformation. our findings are in line with the studies conducted on israeli, arab adolescent.17 the comparison between parental consanguinity and education level of participants showed that percentage of children belonging to nonconsanguineous parents enrolled in the postgraduate level were more (30.4%) as compared to consanguineous parents (28.9%). ghafoor et al., 21 showed that even level of awareness about thalassemia among parents of diseases patients was low. as parents are the primary source of information for children lack of awareness of parents can be a probable reason for unawareness in their children despite the presence of consanguinity and congenital disorders. c o n c l u s i o n our finding showed an overall low of awareness about problems associated with consanguinity among nonmedical students. we suggest that this topic should be considered while planning educational curriculum in secondary and higher secondary education system so that they can educate their family members and thus can j i m d c 2 0 1 7 267 267 contribute to reducing the burden of such genetic diseases from our society. moreover, awareness talks in colleges and universities and through electronic media will also reduce the percentage of consanguinity and rate of genetic diseases seen with consanguineous marriages. r e f e r e n c e s 1. bittles ah. consanguinity, genetic drift, and genetic diseases in populations with reduced numbers of founders. in: speicher mr, antonarakis se, motulsky ag, editors. vogel and motulsky’s human genetics. springer-verlag.: berlin heidelberg; 2010. 507–528. 2. bittles ah the role and significance of consanguinity as a demographic variable. pop dev rev. 1994; 20:561–584. 3. fuster v, colantonio se. socioeconomic, demographic, and geographic variables affecting the diverse degrees of consanguineous marriages in spain. hum biol. 2004;76:1-14. 4. kerkeni e, monastiri k, saket b, rudan d, zgaga l, ben cheikh h. association among education level, occupation status, and consanguinity in tunisia and croatia. croat med j. 2006;47:65661. 5. bittles ah, black ml. consanguinity, human evolution, and complex diseases. proceedings of the national academy of sciences. 2010;107(suppl 1):1779-86. 6. miguel a, alfonso-sa’nchez, jose ap. effects of consanguinity on pre-reproductive mortality: doesdemographic transition matter? american journal of human biology. 2005; 17(6): 773786. 7. chisholm js and bittles ah. consanguinity and the developmental origins of health and disease. journal of evolutionary medicine. 2015;3(4); article id 235909. doi:10.4303/jem/235909 8. hussain r, bittles ah. the prevalence and demographic characteristics of consanguineous marriages in pakistan. j biosoc sci. 1998;30(2):261–75. 9. khan hga, sultana a, awais-e-siraj. consanguinal marriages in pakistan: a tradition or a cultural politics and possible management measures? canad soc sci. 2011;7(1):119-23. 10. ahmed s, saleem m, sultana n, et al. prenatal diagnosis of bthalassaemia in pakistan: experience in a muslim country. prenat diagn. 2000; 20:378-83. 11. harripaul r, vasli n, mikhailoy a, rafiq ma, et al., mapping autosomal recessive intellectual disability:combined microarray and exome sequencing identifies 26 novel candidate genes in 196 consanguineous families. doi: https://doi.org/10.1101/092346. 12. ravesh z, el asrag me, weisschuh n, et al. novel c8orf37 mutations cause retinitis pigmentosa in consanguineous families of pakistani origin. molecular vision. 2015;21:236-243. 13. rauf b, irum b, kabir f, et al. a spectrum of cyp1b1 mutations associated with primary congenital glaucoma in families of pakistani descent. human genome variation. 2016;3:16021-. doi:10.1038/hgv.2016.21. 14. ullah e, saqib man, sajid s, shah n, zubair m, khan ma, ahmad i, et al., slayotinek a. genetic analysis of consanguineous families presenting with congenital ocular defects. experimental eye research, 2016, 146: 163-171. 15. rehman au, santos-cortez rlp, morell rj. mutations in tbc1d24, a gene associated with epilepsy, also cause nonsyndromic deafness dfnb86. ajhg. 2014; 94(1): 144– 152. 16. yasmeen h, toma s, killen n, hasnain s, foroni l. the molecular characterization of beta globin gene in thalassemia patients reveals rare and a novel mutations in pakistani population. 2016 ;59(8):355-62. 17. jaber l, shohat m, halpern gj. demographic characteristics of the israeli arab community in concentration with consanguinity. isr j med sci 1996; 32(12): 1286-1289. 18. ahmed ae, alharbi oa, al-hamam aa, al-shaia wa, al-marzoug hm, bagha m. awareness of health consequences of consanguineous marriages among saudi adults. jphdc. 2016, 2(1):121-129. 19. shelkamy fr, alaaef-din s, kotb sa, sharkawy sa. knowledge and attitude of students living in assiut university dorms about consanguinity. the medical journal of cairo university, 2013;81(2):39-46. 20. jabeen n, malik s. consanguinity and its socio-demographic differentials in district bhimber, azad jammu kashmir, pakistan. j health pop nutr. 2014;32(2):301–13. 21. ghafoor mb , leghari ms , mustafa g , naveed s. level of awareness about thalassemia among parents of thalassaemic children. jrmc. 2016; 20(3):209-211. https://doi.org/10.1101/092346 summary journal of islamabad medical & dental college (jimdc); 2016:5(4):172-176 172 original article pattern and causes of tooth extraction in patients reporting to a teaching dental hospital haafsa arshad sahibzada1, arooj munir2, khalid mahmood siddiqi3, muhammad zeeshan baig4 1post-graduate trainee oral medicine, islamabad dental hospital. 2post-graduate trainee in international health, bergen university, norway. 3associate professor, oral and maxillofacial surgery, islamabad dental hospital. 4assistant professor, oral and maxillofacial surgery, islamabad dental hospital. abstract objective: the present study was conducted to evaluate the pattern and causes of tooth loss. this will be helpful for dental practitioners to be more vigilant regarding oral health care. methodology: a cross sectional study was carried out at islamabad dental hospital, an affiliated teaching dental hospital of islamabad medical & dental college, bharakahu. dental extractions carried out over a period of one year and eight months were included in the study. results: a total of 8355 patients (12562 extractions in a total) were evaluated with majority 50 years and above and predominance of females. mandibular posterior teeth were frequently extracted, with mandibular 1st molar in dominance due to caries. conclusion: regardless of age, gender and set of dentition, caries was the key reason of most of the extractions. mandibular first molar was the most commonly extracted tooth. gender distribution indicated females in majority. keywords: dental caries, female, mandibular posterior teeth, molar, permanent dentition. introduction teeth serve individuals not only for functional reasons but also for esthetics.1 the importance of permanent teeth can be exemplified by the fact that they are supposed to last for life time. unsalvageable teeth inevitably result in tooth loss, if voluntary then known as extraction. dental extraction is one of the most common and affordable procedure for patients to achieve instant results and relief from pain. islamabad dental hospital in barakahu, is a training institute for undergraduate as well as postgraduate dental education. a full range of dental treatment procedures are offered to all patients seeking dental care. developing countries have the limitation of resources which prove a barrier to both patients and doctors. pakistan being the developing country (classified by who) also faces the same problems. this may result in simple dental care procedures like extractions as more preferred choice. tooth loss can be linked to many factors primarily characterized into clinical and non-clinical. clinical factors include dental caries (unsalvageable), periodontitis, dental trauma, eruption problems (impactions, pericoronitis), prosthodontic reasons and orthodontic reasons. from nonclinical perspective socioeconomic demographic factors, lack of education, oral hygiene practices, lack of awareness and patients demand of tooth extraction even after restorative treatment are available.2,3 a number of studies have been conducted worldwide owing to the pattern of tooth extractions, however only a few studies have been conducted locally in pakistan. most studies indicated caries as the major cause of tooth extraction. other reasons reported from various studies included trauma, pericoronitis or impacted teeth, supernumery teeth, prosthodontics reasons, failed endodontic, local pathologies, and poor oral hygiene.4-6 extractions have been reported in all ages. but as age progresses the causes of extractions differs. caries, orthodontic reason, and to a lesser extent impactions and fractures accounted for majority of the extractions in individuals below the age of 40.7,8 with progression of age, periodontitis becomes the leading cause.9 non-clinical factors, primarily patient demand, constitutes 30% of the causes of dental extractions in a survey conducted in iran.10 the aim of present study was to investigate the patterns and reasons for tooth extraction in patients operated in the department of oral & maxillofacial surgery, islamabad dental hospital. based on the results of this study we will take steps towards the prevention of tooth loss. this study will be also helpful in planning areas of future research. methodology this cross sectional quantitative study, was conducted in islamabad dental hospital, barakahu. the data form was corresponding author: dr. haafsa arshad sahibzada e-mail: haafsa1990@gmail.com received: october 4, 2016; accepted: dec 16 ,2016 mailto:haafsa1990@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(4):172-176 173 specifically designed for the oral and maxillofacial surgery department including demographic variables as well as categories (primary/secondary dentition), quadrant of maxilla and mandible; tooth extracted and reasons for tooth extractions. the study was conducted over a time period of one year eight months. sampling technique was nonprobability convenient sampling. all the extractions carried out during this period were included in the present study. the patient operated under general anesthesia for extractions and incomplete data forms of extractions were excluded. data was encoded and entered in spss. descriptive analyses were done and results presented in frequencies and percentages (table and figures). cross-tabulation of pattern and reasons of dental extractions were done in relation to age, gender, primary and secondary dentition, site and type of tooth extraction. results the present study included 8355 patients in which a total of 12562 teeth were extracted. male to female ratio was 0.7:1. mean and standard deviation of age was 37.75+16.84. the most frequently reported age for extraction was 50 years and above. the secondary teeth are more commonly extracted as compared to primary teeth with a total 92% accounting for the permanent dentition and 8% for the primary dentition. in both dentitions mandibular posterior teeth is the dominant group for extractions followed by maxillary posterior teeth (figure 1). mandibular left first molar was the most frequently extracted tooth. figure 1: primary/secondary teeth extractions in different quadrants extractions procedures were more in females as compared to males (7420 extractions in females and 5142 in males) but in both genders highest dental extractions were done in mandibular posterior quadrant followed by maxillary posterior quadrant (table i). when dental extractions were analyzed according to age groups again highest were in mandibular posterior quadrant and least in mandibular anterior (table 2). table 1: dental extraction in different quadrants compared with gender tooth extraction quadrant gender total male (n) female (n) maxillary anterior teeth 690 1073 1763 mandibular anterior teeth 446 723 1169 maxillary posterior teeth 1829 2614 4443 mandibular posterior teeth 2172 3008 5180 total 5137 7418 12555 table2: dental extraction in different quadrants compared with age age groups tooth extraction quadrants total (n) maxillary anterior teeth (n) mandibular anterior teeth (n) maxillary posterior teeth (n) mandibular posterior teeth (n) 1-9 years 168 95 132 140 535 10-19 years 113 46 290 461 910 20-29 years 143 42 717 1101 2003 30-39 years 260 131 1089 1211 2691 40-49 years 294 244 920 942 2400 50 years & above 785 611 1295 1325 4016 total 1763 1169 4443 5180 12555 journal of islamabad medical & dental college (jimdc); 2016:5(4):172-176 174 caries was the most predominant reason for tooth extraction accounting for 85.3% followed by periodontal reasons 7.6% and impactions 0.5% being the least (figure 2). figure 2: reasons for dental extractions comparison of dental extractions reasons in gender shows no difference as caries was found to be most common reason in both genders and impactions the least. when reasons were compared according to age, caries was again most common reason in all age groups. most of dental extractions due to impaction were carried out in age bracket of 20-29 years (table 3). reasons of teeth extraction were also analyzed according to site of extractions and presented in table 4. table 3: comparison of dental extraction reasons in different age groups reasons for dental extractio ns age groups in years total (n) 1-9 (n) 10-19 (n) 20-29 (n) 30-39 (n) 40-49 (n) 50 & above (n) caries 399 673 1814 2467 2076 3283 10712 periodont al disease 9 8 31 108 260 541 957 orthodon tic purpose 46 120 47 5 0 6 224 endodonti c failure 3 9 30 40 17 29 128 tooth fracture 3 5 22 15 12 21 78 impaction 0 6 32 16 2 3 59 others 76 93 29 40 33 133 404 total 536 914 2005 2691 2400 4016 12562 table 4: reasons of teeth extractions according to site reasons of teeth extraction tooth extraction quadrants total (n) maxillary anterior (n 1167) mandibular anterior (n) maxillary posterior (n) mandibula r posterior (n) caries 898 425 2622 3166 7111 periodontal diseases 103 125 162 190 580 orthodonti c purpose 50 26 63 22 161 endodontic failure 8 5 38 63 114 tooth fracture 22 1 26 17 66 impactions 1 0 7 40 48 others 85 56 65 62 268 total 1167 638 2983 3560 8348 discussion knowing the pattern of dental extractions and reasons are always beneficial to the dental practitioner for better services to community. in the present study, mandibular posterior teeth specifically the first molar are most frequently extracted. first molar is the earliest permanent tooth to erupt in oral cavity so more prone to caries and periodontal diseases. in young age, adequate hygiene cannot be achieved along with unhealthy oral habits.11 morphology of the molars (prominent fissures and pits) is another reason for accumulation of plaque, which leads to caries after bacterial invasion. the misconception among the caretakers, assuming first molar to be a deciduous tooth, which eventually shed can also be added reasons. they do not seek treatment even if the tooth is decayed. pain being the most debilitating factor in patient’s opinion for which immediate treatment is demanded leading to an extraction instead of salvaging the tooth. in pakistan a population of 150 million is catered by only 5000 registered dentist. this makes treatment in the remote areas considerably difficult in terms of traveling and cost hence extractions becomes more popular as compared to dental restoration.1 maxillary central incisors were the least extracted teeth in this study. a great variation exists in the pattern of tooth extraction in different countries. the primary dentition barely makes 10% of the entire sample again with the mandibular posterior teeth being extracted in higher percentage. however, it was noted that the maxillary anterior and posterior teeth were journal of islamabad medical & dental college (jimdc); 2016:5(4):172-176 175 being extracted at the same rate in deciduous group. regarding the permanent dentition, saudi study revealed mandibular molars as most commonly extracted (60%) tooth but maxillary lateral incisors as least (0.7%).1 a study conducted in scotland reported premolars to be extracted in higher percentage rather than molars which were also proven by a recent study done in sulaimani and mosul.14-16 study conducted in nigeria concluded that lower molars were most commonly extracted (79%) while canine were the least (1.2%).17 amongst the molars the frequency of extractions are in the following order mandibular first molars, maxillary first molars, mandibular second molar followed by maxillary second molars. right side extractions were more frequently involved. amongst the anterior teeth maxillary teeth are more abundantly extracted. a drastically high percentage of anterior teeth are extracted in the age group of 50 and above. caries was found to be the highest reason for dental extractions. it was considered the most common cause for tooth loss regardless of the developing or developed countries. other studies reported similar results with caries being responsible for majority of the extractions in a wide range from 32.6% to 86.2%.4,8,9,17,18 caries as a reason for extraction was also more in females which was in accordance with the other studies conducted in south africa, nigeria, saudiarabia, benin city, nigerain rural, nepal, sulaimani but contrary results were reported from rawalpindi, peshawar, karachi and turkey.7,8,11,13,15,17-23 in our society females are more homebound, dependent on males for traveling and neglect their dental health. this leads them for preferring treatments which are easier, affordable, time restrained and with minimal number of dental appointments. such patients instead of a root canal treatment even if advised they preferred dental extraction. periodontal reasons were predominantly involved in extractions above 45 years of age. poor oral hygiene including plaque deposition, calculus deposits (supra and sub gingival) combined with age would lead to a rapid regression of the gingiva particularly in the molars. this is accompanied by bone loss which is cumulative, irreversible and chronic in nature and result in loss of tooth. other studies had various results with periodontal causes being the primary, secondary and least involvement.12,14,19,20,22,24,25 impactions and orthodontic reasons were the rare conditions in which extractions were performed. similar results were also reported by other studies conducted worldwide.13,18,19 orthodontic treatment was only sought by the upper middle class or upper class individuals of the society due to financial constraints. on the other hand a survey in riyadh city reported dental caries followed by orthodontic reasons as the primary cause.13 the higher contribution of caries and periodontal reasons for dental extractions in present study suggest the need of better working for prevention of these diseases and so the teeth loss. it is also recommended that community awareness should be increased for vigorous oral hygiene maintenance and early dental visits. government should bring an oral health policy in which dental institutions and organizations are made responsible for community awareness campaigns. a health system should be developed for effective dental care, prevention and treatment of dental diseases on national level especially for females. authors also recommend that hospitals should be equipped accordingly. conclusion 1. the most commonly extracted tooth was mandibular first molar. more number of teeth were extracted from posterior quadrants of both jaws. 2. dental caries and periodontal diseases were the predominant reasons of dental extraction regardless of the age and gender. dental extractions due to periodontal reasons significantly increase with age. 3. male were less frequent visitors than the females for extractions. higher percentage was reported in middle age group. recommendations keeping in view the results, every dental practitioner needs to bear in mind the potential sources of tooth loss and their consequences. in accordance with the present study majority of the extractions are caused by caries especially the molars hence giving the practitioner a clear view of the teeth to be more vigilant about. also guidance of the patients and general public regarding this should be sought by the dentists. conflict of interest this study has no conflict of interest as declared by any author. references 1. fuller jl, denehy ge, schulein tm. anatomic and physiologic considerations of form and function. in: concise dental anatomy and morphology.5th ed. delhi: prince print process; 2010:23-40. 2. george b, john j, saravanan s, arumugham im. prevalence of permanent tooth loss among children and adults in a suburban area of chennai. indian j dent res. 2011;22(2):364-7. 3. hassan ak. reasons for tooth extraction among patients in sebha, libyan arab jamahiriya: a pilot study. east mediterr health j. 2000;6(1):176-8. 4. zadik y, sandler v, bechor r, salehrabi r. analysis of factors related to extraction of endodontically treated teeth. oral surg oral med oral pathol oral radiol endod. 2008;106(5):31-5. 5. toure b, faye b, kane aw, lo cm, niang b, boucher y. analysis of reasons for extraction of endodontically treated teeth: a prospective study. j endod.2011;37(11):1512-5. 6. hupp jr. principles of routine exodontia. in: hupp jr, ellis e, tucker mr, editors. contemporary oral and maxillofacial surgery. 6th edition. china: elsevier; 2014.p.88-118. 7. miladinović m, mihailović b, janković a, tošić g, mladenović d, živković d, vujičić b. reasons for extraction obtained by artificial intelligence. acta facultatis medicae naissensis. 2010;27(3):143-58. journal of islamabad medical & dental college (jimdc); 2016:5(4):172-176 176 8. afridi sh, rehman b, din qu. causes of tooth extraction in oral surgery an analysis of 400 patients reporting to khyber college of dentistry. j pak dent assoc. 2010:19(2):110-4. 9. chrysanthakopoulos na. periodontal reasons for tooth extraction in a group of greek army personnel. j dent res dent clin dent prospects. 2011;5(2):55-60. 10. kakoei s, fatemian m, eskandari za, haghdoost aa. evaluation of reasons of permanent teeth extraction in iranian people. j dent shiraz univ med scien. 2012; 4(1):429-37. 11. lesolang rr, motloba dp, lalloo r. patterns and reasons for tooth extraction at the winterveldt clinic. south african dental journal. 2009;64(5):214-18. 12. shah sa, khitab u, chughtai ma, khan as. causes of dental extractions among 2000 patients a study conducted at oral and maxillofacial surgical unit, khyber college of dentistry, peshawar, pakistan. pak oral and dental j. 2004;24(2):20912. 13. alesia k, khalil hs. reasons for and patterns relating to the extraction of permanent teeth in a subset of saudi population. clin cosmet investig dent.2013; 5:51-6. 14. mccaul lk, jenkins wmm, kay ej. the reasons for the extraction of various tooth types in scotland: a 15-year follow up. j dent. 2001;29(6):401-7. 15. hamagharib ds, abdasada as, saeed hmm, khursheed da, noori aj, talabani rm. pattern of tooth extraction in relation to age and sex in patients attended school of dentistry university of sulaimani. iosr-jdms. 2015;14(9):101-4. 16. mohammed ag. causes of primary and permanent tooth extraction in children aged 3-12 years in mosul city. alrafidain dent j. 2008;8(2):24-9. 17. saheeb bd, sede ma, reasons and patterns of tooth mortality in a nigerian urban teaching hospital. ann afr med. 2013;12(2):110-4. 18. hayran m, aktas a, kasaboglu o, adiloglu i, oktemer k, karabulut e, etal. analysis of reasons for extractions in 1149 teeth in a university clinic. clin dent res. 2012;36(1):13-7. 19. odai cd, azodo cc, ehizele ao, braimoh ob, obuekwe on. pattern of tooth extraction among adult patients attending a general dental practice in benin-city. annals of biomedical sciences.2011;10(1). 20. danielson oe, chinedu ac, olympus ea, bashiru bo, ndubuisi oo. frequency, causes and pattern of adult tooth extraction in a nigerian rural health facility. odontostomatol trop. 2011;34(134):5-10. 21. upadhyay c, humagain m. the pattern of tooth loss due to dental caries and periodontal disease among patients attending dental department (opd), dhulikhel hospital, kathmandu university teaching hospital (kuth), nepal. kathmandu univ med j. 2009;7(1):59-62. 22. janjua os, hassan sh, azad aa, ibrahim mw, luqman u, qureshi sm. reasons and patterns of first molar extraction a study. pak oral dental j. 2011; 31(1): 51-4. 23. askari j, shameem a, zafar bs. pattern of tooth loss in the maxillary arch: a study conducted at dr. ishrat-ul-ibad institute of oral health sciences, duhs karachi. j pak dent assoc. 2009;18(1):15-8. 24. al-shammari kf, al-ansari jm, al-melh ma, al-khabbaz ak. reasons for tooth extraction in kuwait. med princ pract. 2006;15(6):417-22. 25. aida j, ando y, akhtar r, aoyama h, masui m, morita m. reasons for permanent tooth extractions in japan. j epidemiol. 2006;16(5):214-19 authorship contribution: author 1,2,3: conception, synthesis and planning of the research author 4: interpretation, analysis and discussion j islamabad med dental coll 2019 1 correspondence: muhammad ahmed abdullah email: drahmedabdullah83@gmail.com o p e n a c c e s s structural violence and pakistan’s health situation muhammad ahmed abdullah assistant professor, community medicine, islamabad medical and dental college structural violence was first defined by johan galtung as “a form of violence wherein some social structure or social institution may harm people by preventing them from meeting their basic needs”1 the concept has been studied extensively over the years and is considered as a major reason for strangled development in various resource limited settings around the world. the idea of structural violence implies that people in power fail to provide essential services for the people they are responsible for; this failure can be intentional or unintentional, nevertheless long-term effects influence the marginalized population adversely.2 pakistan is no stranger to structural violence; which is evident from the persistently deteriorating human development indicators of the country. despite being the sixth most populous country in the world, a nuclear armed state, and a resource rich agricultural land, the health situation has gone from bad to worse. according to the pakistan demographic health survey 2017-18, the neonatal mortality of the country is 42 per 1000 live births, the infant mortality rate is 62 per 1000 and the under 5 mortality rate is 74 per 1000.3 lack of effective health services, underutilized primary and secondary level healthcare delivery systems, an overburdened tertiary care system and a reactive rather than a proactive approach towards the health needs of the people are just some of the reasons for the dismal state of affairs. pakistan’s political terrain has been uneven and fluctuant, yet no politico-social variations have been able to halt the constant deterioration in the health circumstances.4 pakistan is a triple disease burden country where infectious diseases, non-communicable diseases and accidents/violence all have their due share in the morbidity and mortality.5 one major point to consider here is the trivial proportion of our gdp spent on health. according to the economic survey of pakistan for the financial year 2017-18, only 0.49% of the gdp was spent on health. this meager amount is no surprise because the highest ever percentage was 0.77% of the gdp in 2015-16.6 these figures when viewed through the lens of human behaviors, are magnified in the form of the government’s intent for improving the health of the people. most expenditure on health is out of pocket and is spent in the thriving private health care sector of the country. mentioning the idea of the poverty disease cycle, at this point is also imperative, as diseases have dire consequences not only on the health but also the financial circumstances of people.7 in the larger scheme of things, a health systems-based approach is the need of the hour, which has a proactive instead of a reactive outlook. in the current case scenario, the health system fails to solve problems that have been complicated by lack of awareness of the people and limited service delivery structure; this in turn further extrapolates the burden on the already crumbling health systems of the country. a robust leadership and governance model are probably the most needed rung in the ladder of health improvement and promotion in the country.8 r e f e r e n c e s 1. galtung j, höivik t. structural and direct violence: a note on operationalization. jpr. 1971; 8(1):73-6 2. rotberg ri. the new nature of nation‐state failure. washington quarterly. 2002;25(3):83-96 3. national institute of population studies, pakistan. pakistan demographic health survey (pdhs) 201718 e d i t o r i a l mailto:drahmedabdullah83@gmail.com mailto:drahmedabdullah83@gmail.com j islamabad med dental coll 2019 2 4. nizar h, chagani p. analysis of health care delivery system in pakistan and singapore. int j nurs stud. 2016; 8(2). 5. hyder aa, morrow rh. applying burden of disease methods in developing countries: a case study from pakistan. am j public health. 2000; 90(8):1235 6. ministry of finance, pakistan. economic survey of pakistan 2017-18. 7. abdullah ma, basharat z, lodhi o, wazir mh, khan ht, sattar ny, zahid a. a qualitative exploration of pakistan’s street children, as a consequence of the poverty-disease cycle. infectious diseases of poverty. 2014; 3(1):11 8. shaikh bt. health systems research in pakistan: issues, challenges and way forward. j ayub med coll abbottabad. 2015; 27(2):257-8. 64 j i m d c 2 0 1 7 64 op e n ac c e ss f u l l l e n g t h a r t i c l e clinico-biochemical profile in neonates with birth asphyxia naveed ashraf 1, naveed butt 2, shahzad munir 3, maham zahid 4, kaneez fatima 5 and atiqa minhas 6 1 assistant professor, pediatric department, federal govt. polyclinic hospital (pgmi), islamabad 2 physician, pediatric department, federal govt. polyclinic hospital (pgmi), islamabad 3 associate professor/head, department of pediatric, federal govt polyclinic hospital, islamabad 4 research officer r&d department, armed forces institute of cardiology, rawalpindi 5 neonatologist, pediatric department, federal govt. polyclinic hospital (pgmi), islamabad 6 trmo, pediatric department, federal govt. polyclinic hospital (pgmi), islamabad a b s t r a c t objective: to study the biochemical derangements in neonates with asphyxia having different clinical presentation. patients and methods: this cross-sectional study was conducted at neonatal intensive care unit, federal govt. polyclinic (pgmi) hospital, islamabad from 1st november 2016 to 30th april 2017. all neonates with history suggestive of birth asphyxia were inducted in study. complete history, examination and laboratory investigation (complete blood count, blood sugar, serum calcium, serum electrolytes, serum urea, serum creatinine, liver function tests, cardiac enzymes) were done. the data was entered in spss version 23 for further analysis. results: out of 39 babies, 66.7% had moderate and 33.3% had severe birth asphyxia. severity of birth asphyxia was associated with lower apgar scores. multi-organ involvement was observed with increasing severity of birth asphyxia as; respiratory system 71.8%, cardiovascular system (shock) 25%, central nervous system (convulsion)15.4%, renal tract (acute renal failure) 12.8% and gastro intestinal tract 5.1%. significant mortality was noted with shock, convulsion and hypoglycemia. cardiac and liver enzymes were deranged and were significantly related to severity of birth asphyxia. conclusion: multi-organ dysfunction is common in birth asphyxia. early assessment of clinical and biochemical profile will help in managing disease, reducing severity and improving the outcome of illness. key words: birth asphyxia, clinico-biochemical profile, multiorgan dysfunction, neonates, author`s contribution 1 conception, synthesis, planning of research and writing of manuscript, 2 active participation in methodology, interpretation and discussion, review of manuscript, 3 review of literature 4 statistical data analysis, 5,6 data collection, data entries and data analysis address of correspondence dr. shahzad munir doctor.shahzadmunir@gmail.com article info. received: april 19, 2017 accepted: may 20, 2017 cite this article: ashraf n, butt n, munir s, zahid m, fatima k,minhas a. clinico-biochemical profile in neonates with birth asphyxia. jimdc. 2017; 6(2):64-68. funding source: nil conflict of interest: nil i n t r o d u c t i o n despite of important advances in perinatal care, asphyxia remains a severe condition leading to significant mortality & morbidity. prevalence of hypoxic ischemic encephalopathy (hie) ranges from 0.1%-0.5% of total live births.1 according to who, in pakistan 49% deaths occur in first 28 days of life out of total mortality under five years of age. birth asphyxia and birth trauma together are the second most common cause of neonatal deaths and contribute to approximately 23% of total neonatal deaths.2 birth asphyxia results in damage to multiple organs including brain, heart, lungs, kidney, liver and git.3,4 the common complications of birth asphyxia are hypoxic ischemic encephalopathy, persistent pulmonary hypertension, hypotension, cardiogenic shock or heart failure and renal tubular necrosis.3 a number of metabolic derangements coexists with the above mentioned complications like acidosis, hypoglycemia, hypocalcaemia, hyponatremia, raised liver enzymes, raised cardiac enzymes, which may alter the outcome of the disease process.4 due to involvement of different o r i g i n a l a r t i c l e mailto:doctor.shahzadmunir@gmail.com 65 j i m d c 2 0 1 7 65 organs in birth asphyxia, a number of metabolic derangements have been analyzed to estimate quick and reliable markers of tissue damage for diagnostic and prognostic purpose respectively. this study was conducted to identify different clinical manifestations and biochemical changes in neonatal birth asphyxia, in order to make early interventions, so that asphyxia related morbidity and mortality could be reduced. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at nicu, pediatrics department, federal govt. polyclinic hospital, islamabad from 1st november 2016 to 30th april 2017. the study was approved by ethical committee of the hospital. all neonates admitted and managed for birth asphyxia during the study period, with gestational age of ≥ 38 weeks and apgar score of < 7 at 1 minute were inducted in the study. informed consent from parents was taken. neonates with respiratory distress syndrome, prematurity, low birth weight, neonatal sepsis, congenital anomalies, syndromes, tumors, trauma and maternal history of drug addiction or analgesia were excluded from the study. the diagnostic criteria jointly released by american college of obstetricians and gynecologists (acog) and american academy of paediatrics (aap) was: (i) umbilical cord ph of < 7 (mixed or metabolic) (ii) apgar score of 0-5 for longer than 5 mins (iii) neurological complications including hypotonia, convulsion, coma (iv) multiorgan failure.5 according to nnpd (national neonatal perinatal database) moderate birth asphyxia was defined as apgar score between 4-6 at 1 minute of age or slow gasping breathing at 1 minute of age and severe birth asphyxia was defined as apgar score 3 or less at 1 minute of age or no breathing at 1 minute of age.6 in our study, we have used history suggestive of birth asphyxia, apgar score at 1 minute of age and clinical evidence of hypoxic ischemic encephalopathy. detail history and examination was done by trained paediatricians. organ dysfunction was defined as follows: 4, 7,8,10 cns: evidence of hypoxic ischemic encephalopathy as sarnat & sarnat classification. respiratory system: respiratory distress with respiratory rate >60/min or hypoxia needing o2 to maintain oxygen saturation (spo2) >92% for >24 hours or requirement for cpap / mechanical ventilation. renal failure: oliguria <1ml/kg/hr for > 24 hours or serum creatinine of >1.5mg/dl. cardiac dysfunction: signs of poor perfusion in terms of increased capillary refill time, poor pulses, tachycardia h/r >160/min, with or without hypotension, need of ionotropic support or raised cardiac enzymes than normal (cpk upto 325u/l, ckmb upto 25u/l and ldh 230460u/l). 4, 10 gastrointestinal disturbance: evidence of necrotizing enterocolitis (nec) in the form of gi bleed, abdominal distension, or x ray abdomen suggestive of nec. hepatic dysfunction: elevation of alanine amino transferase (alt) or aspartate amino transferase (ast) of more than two times of its normal value (alt upto 40u/l and ast upto 37u/l). metabolic derangements: hypoglycemia <40 mg/dl, hyponatremia <135 meq/l, hypokalemia <3.5 meq/l and hypocalcemia <8mg/dl. laboratory investigations included were cbc, blood sugar, serum calcium, serum electrolyte (na+& k+), urea, creatinine, liver enzymes and cardiac enzymes. venous sample of 2ml was sent to measure serum ca+ by direct complexometric method, serum electrolyte by ise method, liver enzymes and cardiac enzymes by kinetic ifcc method. all the babies were monitored and treated according to their clinical condition as standard protocol of nicu. the data was entered in spss version 23. continuous data was expressed as mean and median along with standard deviation values. categorical data was expressed as number & percentages. different groups of continuous variables were compared by using independent samples student’s t-test or mann-whitney test while categorical variable groups were compared by applying chi-square test and fisher’s exact test. r e s u l t s a total of 39 neonates were included in the study. all of the neonates were full term and were admitted in hospital within 24 hours after birth. out of 39 neonates, 23 were 66 j i m d c 2 0 1 7 66 males and 16 were females. there were increased number of spontaneous vaginal deliveries (svd’s) followed by cesarean sections and assisted vaginal deliveries (avd’s) (table 1). distribution of moderate and severe birth asphyxia was 26(66.7%) and 13(33.3%) respectively. severe birth asphyxia was observed to be more common in combined vaginal deliveries (61.54%) as compared to caesarean sections (38.46%) but the difference was not statistically significant. a statistically significant difference was observed in the mean apgar score of moderately and severely asphyxiated neonates at i minute and 5 minutes. single organ system involvement was observed in 11 (28.2%) neonates. multiorgan dysfunction with two organs and more than two organs were found in 17 (43.6%) and 11 (28.2%) cases respectively. incidence of multiorgan dysfunction was more frequently observed among severely asphyxiated neonates as compared to moderately asphyxiated neonates (table 2). sarnat & sarnat grading criteria was used to classify cns involvement in terms of hypoxic ischemic encephalopathy (hie). among total of 39 neonates, 30(76.9%) were in hie grade i, while 7(17.9%) and 2(5.1%) neonates were categorized as hie grade ii and iii respectively. among neonates with severe birth asphyxia, a significantly large proportion was hie grade ii (71.43%) and iii(100%) as compared to infants with moderate birth asphyxia 28.57% and 0% respectively. therefore, with lower apgar score, there are more significant chances of developing hie of higher grade. mortality rate in this study was 10.3% (4). a large proportion of patients (50%) belonged to hie grade iii. ventilatory support was required by 10.3% (4) of neonates. proportion of discharged patients was high in hie grade i (100%) as compared to grade ii (57.14) and iii (50%) (table 3) percentage involvement of various organ dysfunction is shown in figure 1. 100.0% 71.8% 25.6% 15.6% 12.8% 5.1% organ involvement figure 1: percentage of organ involvement in neonates presenting with birth asphyxia table 1: demographic characteristics of participants (n=39) variable number percentage gender male female 23 16 59 41 mode of deliveries spontaneous vaginal deliveries assisted vaginal deliveries cesarean sections 17 3 19 43.6 7.7 48.7 table 2: association of clinical profile with moderate and severe birth asphyxia clinical profile moderate birth asphyxia (n=26) n(%) severe birth asphyxia (n=13)n(%) pvalue mode of delivery combined vaginal; n (%) c-section; n (%) 12(46.15) 14(53.85) 8(61.54) 5(38.46) >0.05 organ involvement single; n (%) multiple; n (%) 10(38.46) 16(61.54) 1(7.69) 12(92.31) 0.063 apgar score at 1 minute (mean±sd) at 5-minutes (mean±sd) 4.85±0.78 6.62±0.63 2.46±0.77 4.92±0.76 0.000 0.000 table 3: association of hie grades with different variables variables hie grade i n=30 hie grade ii n=7 hie grade iii n=2 pvalue birth asphyxia moderate severe n (%) 24(80) 6(20) n (%) 2(28.57) 5(71.43) n (%) 0(0) 2(100) 0.004 outcome discharge expire (mortality) 30(100) 0(0) 4(57.14) 3(42.86) 1(50) 1(50) 0.000 67 j i m d c 2 0 1 7 67 cns involvement was present in all neonates (100%) followed by respiratory distress (71.8%) and others. comparison of outcome with clinico-biochemical profile of neonates presenting with birth asphyxia is shown in table 4. regarding organ dysfunction, a significant mortality was associated with convulsions and shock (p=0.001, p=0.04) respectively. hypocalcaemia was observed in 46.2% (18) neonates, while 10.3% (4) neonates had hypoglycemia. hyponatremia, hypokalemia and hyperkalemia were observed in 35.90% (14), 20.51% (8) and 2.56% (1) neonates respectively. hypoglycemia was significantly associated with mortality (p = 0.045). cardiac enzymes were strikingly high in majority of neonates. cpk was raised (range: 342 – 5295 u/l) in 29 (74.35%) while ck mb and ldh were high (range: 26– 650 u/l; 590-6001u/l) in 34 (87.17%) and 25(64.10%) neonates respectively. median ck, serum concentration in severe birth asphyxia was significantly higher than the moderate birth asphyxia (u=56.0, p=0.002). similarly, median cpk mb and ldh serum concentration in severe birth asphyxia was significantly higher than the moderate birth asphyxia (u=66.0, p=0.005 and u=75.0, p=0.21 respectively). liver enzymes were also deranged where serum alt level was more than two times raised in 15.4% (6) (ranging from 175– 377 units/l) and serum ast level was double the normal in 41.0% (16) neonates (ranging from 82– 590 units/l) but no significance was noted with severity and mortality of birth asphyxia. d i s c u s s i o n in our study, moderate birth asphyxia caused hie grade i in 92.3% (24), hie grade ii 7.7% (2) and no case found with hie grade iii as compared to severe birth asphyxia whereas 46.2% (6), 38.5% (5) and 15.3% (2) babies had hie grade i, ii and iii respectively. in our study hie grade i is more common than grade ii and iii as compared to the study conducted by shah et al, in which 27.58% belonged to hie grade ii out of 56.8% of babies with hie.3 multiorgan dysfunction is a part of birth asphyxia due to redistribution of blood flow to the vital organs. hypoxic ischemic injury to vital organs like brain, kidney, heart, gut and liver results in organ dysfunction and even failure, if not corrected promptly. multiorgan involvement is 71.7% (28) in our study as compared to 80.7% (46) in study conducted by pattar rs et al.4 mortality with multiorgan failure is 14.2% (4) in our study as compared to 17.3% (8) with patter rs et al and 27.6% by singh ks et al.4,8 respiratory system was most commonly involved organ second to cns which was 71.8% (28) and more common with severe birth asphyxia and low apgar score table 4: comparison of outcome with clinico-biochemical profile of neonates presenting with birth asphyxia clinico-biochemical profile clinical outcomes (n = 39) pvalue discharge n=35 death n=4 organ dysfunction central nervous system (hie) • hie grade i • hie grade ii • hie grade iii n (%) 30 (85.7) 4 (11.43) 1 (2.86) n (%) 0(0) 3 (75) 1 (25) 0.001 central nervous system (convulsions) 2 (5.71) 4 (100) 0.001 respiratory system 24 (68.57) 4 (100) 0.249 cardio vascular system (shock) 7 (20) 3 (75) 0.045 renal system 4 (11.43) 1 (25) 0.4 gastrointestinal system (nec) 2 (5.71) 0(0) 0.8 metabolic derangements hypocalcaemia (<8 mg/dl) 16 (45.71) 2 (50) 0.636 hypoglycemia (<40 mg/dl) 2 (5.71) 2 (50) 0.045 hyponatremia (<135 mg/dl) 14 (40) 0(0) 0.154 hypokalemia (<3.5 mg/dl) 7 (20) 1 (25) 0.617 hyperkalemia(>5.5mg/dl) 1 (2.86) 0(0) 0.897 68 j i m d c 2 0 1 7 68 (p=0.04), similar findings have been observed and reported by shah p et al and linderkamp o et al.3,9 involvement of cardiovascular system is frequent involvement after respiratory distress which is 25.6% (10) with mortality of 40% (4) as compared to the that reported by pattar rs et al, which was 54.3% (31) with mortality of 22.5% (7).4 renal system involvement was observed in 12.8% (5) in our study. these findings are comparable to those reported by parkash et al11 and kapil kapoor et al 12 (16 %( 19) and 9.6 %( 44) respectively). however almost double i.e. 29.8% (17) have been reported by pattar rs et al.4 hypoglycemia, hypocalcemia and hyponatremia were more pronounced with increasing severity of birth asphyxia, similar findings have been observed and reported by shah et al3 and by pallab basu et al.13 we have also observed association of hypokalemia [17.9% (7)] with severe asphyxia as well. cardiac enzymes included cpk, ckmb, ldh and were raised in 74.35%, 87.17% and 64.10% respectively and more marked with severe birth asphyxia, findings comparable to that noted by rajakumar ps et al and asutosh pc et al.10,14 liver enzymes were raised in asphyxiated babies, however with no significance in mortality. gurdeep sd et al and chaitali patra et al 16 found a significant correlation with severity and outcome of asphyxia.15,16 c o n c l u s i o n birth asphyxia is associated with multiorgan dysfunction and its severity directly correlates with morbidity and mortality. different clinical presentation and altered biochemical parameters can help us in prompt recognition, early intervention and improvement of outcome. r e f e r e n c e s 1. bryce j, boschi-pinto c, shibuya k, black re, who child health epidemiology reference group. who estimates of the causes of death in children? lancet.2005; 365(9465):1147-52. 2. world health organization, pakistan: cherg/who/unicef for distribution of causes of neonatal and under five deaths (published in liu et al, lancet 2014). 3. shah s, mishra pk, goel ak. clinico biochemical profile of birth asphyxia in neonates of western odisha. indian journal of child health. 2014; 1(3):114-8. 4. pattar rs, raj a, yelamali bc. incidence of multiorgan dysfunction in perinatal asphyxia. int j contemp pediatric 2015; 2(4):428-32. 5. apgar s. use and abuse of the apgar score. pediatrics. 1996; 98(1):141-2. 6. national neonatogy forum. report of the national neonatal perinatal database. new delhi, india:national neonatology forum; 2003. 7. antonucci r, porcella a, pilloni md. perinatal asphyxia in the term newborn. journal of pediatric and neonatal individualized medicine (jpnim). 2014; 3(2):e030269. 8. singh ks, sengar gs. a study of multiorgan dysfunction in asphyxiated neonates. international journal of contemporary pediatrics. 2016; 3(2):625-30. 9. linderkamp o, versmold ht, fendel h, riegel kp, betke k. association of neonatal respiratory distress with birth asphyxia and deficiency of red cell mass in premature infants. european journal of pediatrics. 1978; 129(3):16773. 10. rajakumar ps, bhat bv, sridhar mg, balachander j, konar bc, narayanan p, chetan g. cardiac enzyme levels in myocardial dysfunction in newborns with perinatal asphyxia. indian journal of pediatrics. 2008; 75(12):1223-5. 11. r parkash.clinical profile and neurobehaviour at discharge of term neonates with perinatal asphyxia-a prospective observational study. international .journal of contemporary medical research 2016; 3(10):3073-3076. 12. kapoor k, jajoo m, dabas v. predictors of mortality in out born neonates with acute renal failure; an experience of a single center. iranian journal of pediatrics. 2013; 23(3):321. 13. basu p, som s, das h, choudhuri n. electrolyte status in birth asphyxia. indian j paediatrics.2010; 77(3):259-62. 14. chauhan ap, tailor pb, bhabhor p, mehta mm, joshi rm. study of myocardial involvement and lactic acid production in perinatal asphyxia. natl j med. 2013; 3(1):76-9. 15. dhanjal gs, kaur n, kaur h. study of liver function test in perinatal asphyxia at a tertiary care center in haryana. int arch biomed clin res.2016; 2(4):26-28. 16. patra c, sarkar s, dasgupta mk. study of hepatic enzyme activity as a predictor of perinatal asphyxia and its severity and outcome. indian journal of health sciences and biomedical research (kleu). 2016; 9(3):297. journal of islamabad medical & dental college (jimdc); 1211(1):14-17 14 original article prognostic scoring in patients of chronic myeloid leukemia: correlation between sokal and hasford scoring systems roohi khalil*, khalid hassan** and naghmi asif*** *department of pathology, federal government services hospital, islamabad **head, department of pathology, islamabad medical and dental college, islamabad ***assistant prof, pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) abstract: background: chronic myeloid leukaemia (cml) is a clonal myeloproliferative disorder of transformed primitive hematopoietic progenitor cells. chronic myeloid leukaemia is one of the commonest leukemias. patients of cml are usually subjected to risk stratification according to various prognostic criteria. the sokal scoring system is popular as a prognostic discriminator for survival in patients treated with chemotherapy. hasford et al proposed a new cml scoring system referred to as euro score. objective: correlation of various prognostic risk groups of hasford scoring system with comparable prognostic groups of sokal scoring system in chronic myeloid leukemia. material and methods: this descriptive study was conducted at department of pathology, pakistan institute of medical sciences from march 2003 to october 2006. a total of 59 consecutive freshly diagnosed untreated cases of cml were subjected to sokal and hasford scoring systems, and the results were correlated with each other. results: in total of 59 cases of cml age range was from 8 to 70 years with mean ± sd of 35.39 ± 17.12 years. six (10.1%) patients belonged to pediatric age group i.e. <15 years. male: female ratio was 1.3:1. according to sokal criteria about half of the patients were found in intermediate risk group; 44% were in high risk group and only 5% in low risk group. using hasford scoring system, 44% of patients were placed in intermediate risk, 30.5% in high risk and 15% in low risk groups. conclusion: hasford score identifies more patients still in low risk group as compared to sokal scoring system and prospective studies should be carried out to see overall survival and disease free survival of these risk groups. key words: chronic myeloid leukemia; cml; sokal scoring; hasford scoring; prognostic stratification introduction chronic myeloid leukaemia is a clonal myeloproliferative disorder of transformed primitive hemopoietic progenitor cells, and is characterized by expansion of proliferating myeloid cell pool especially in the bone marrow, spleen and peripheral blood. cml is the commonest type of chronic leukemia in pakistan, and accounts for about 15 percent of leukemias in adults. the median age of patients at presentation is 45 to 55 years. from 12-30 % of patients are 60 years of age or older.1 in more than 90% cases of cml, philadelphia chromosome is observed. this chromosome is produced as a result of reciprocal translocation between chromosomes 9 and 22. this translocation results in the production of a fusion gene, i.e. bcr-abl gene; the latter perturbs downstream signalling pathways in hematopoietic progenitor cells and produces the clinical phenotype of overproduction of mature myeloid cells.2 the majority of cml patients have wbcs in excess of 100,000/µl at diagnosis. depressed erythropoiesis proportional to the increase in myeloid cells results in anaemia in some patients. platelet counts are elevated in 30% to 50% of cases at diagnosis.3 cml usually runs a biphasic or triphasic course. this process includes an initial chronic phase and a terminal blastic phase, which is preceded by an accelerated phase in 60% -80% of patients.4 many patients, especially if they present with delay, may have accelerated or even blast stage at the onset. splenomegaly is documented in 30-70% of cases. the liver is enlarged in 10-40% of cases. 5 risk stratification of cml patients on the basis of variable prognostic factors was first proposed by tura et al ( 1981) who stratified their patients into three groups, depending on presence or absence of six variables (splenomegaly, hepatomegaly, blast cells, leukocytosis, thrombocytosis and a rise in granulated precursor cells ) as follows: low risk group; upto one risk factor present intermediate risk group; upto two or three risk factors high risk group; more than three risk factors present 6 journal of islamabad medical & dental college (jimdc); 1211(1):14-17 15 carvantes and rozman (1982) emphasized on splenomegaly, erythroid precursors in blood and over 5% myeloblasts in the marrow as main prognostic factors, and stratified their patients as under: 7 low risk group; upto one factor present intermediate risk group; two factors present high risk group; three or four risk factors present kantarjian et al (1990) introduced the so called simple synthetic prognostic staging system. 8 the sokal score achieved widespread usage as a prognostic discriminator for survival in patients treated with chemotherapy (mainly busulfan and hydroxyurea).9 this scoring system was based on a formula that takes into account the patients age, the blast cell count and the spleen size at the time of diagnosis. the hasford cml score also called the euro score, uses age, spleen size (measured from the left costal margin), blast cell count, platelet count, and eosinophil count. all variables are measured at the time of diagnosis.10 this study was aimed to correlate various prognostic groups of sokal and hasford scoring systems in freshly diagnosed untreated cases of cml. material and methods this cross-sectional study was conducted at the department of pathology, pakistan institute of medical sciences from march 2003 to october 2006. a total of 59 consecutive freshly diagnosed cases of cml belonging to all age groups, both sexes and all the three clinical phases were included. patients of cml who had received cytotoxic treatment previously were excluded from the study. a detailed account of clinical history and physical examination was entered in a performa specially pertaining to age, sex, duration of symptoms, history of fever and other constitutional features due to anaemia, bleeding, splenomegaly and hepatomegaly. in every patient about 5ml edta blood sample was collected. complete blood counts were performed on a fully automated haematology analyzer (sysmex kx-21). peripheral blood smears were freshly prepared and stained using wright stain. the slides were examined under a microscope and differential count was performed. neutrophil alkaline phosphatase (nap) scoring was done on peripheral blood films to differentiate from leukemoid reaction. bone marrow aspiration was done; multiple smears were made and at least two smears were stained by wright stain. the smears were examined and at least five hundred cells were counted for myelogram. table 1: stratification of cases of cml into clinical phases diagnosis no. of patients % cml in chronic phase cml in accelerated phase cml in blastic phase 55 03 01 93.2 5.1 1.7 patients were placed in chronic, accelerated and blastic phases according to the known criteria. cytogenetic and molecular studies could not be done due to lack of these facilities at pims. sokal prognostic scoring was performed on all the cases using the following formula: exp.[0.0116(age -4.34)+0.0345(spleen-7.51)-0.188(% of blasts-2.1)] according to sokal score the patients were stratified into various prognostic groups as shown below; low risk (good prognosis) group with score <0.8 intermediate risk (moderate prognosis)group with score of 0.8 -1.2 high risk (poor prognosis) group with score >1.2 hasford score was also performed on all cases using the formula: 0.6666 x age [0 when age <50 years;1,otherwise]+0.0420 x spleen size[cm below costal margin] + 0.0584 x blasts[%]+0.0413 x eosinophils [%]+0.2039 x basophils[0 when basophils < 3%; 1. otherwise] + 1.0956 x platelet count[0 when platelets < 1,500 x 109/l; 1, otherwise]x1,000. based on the score obtained, the patients were stratified into various groups as follows: low risk group <780 intermediate risk group >780 and <1480 high risk group >1480 the results were statistically analyzed using the statistical programme spss version 13. correlation of various prognostic groups of hasford and sokal scoring system was also done. table 2: prognostic stratification of cml cases prognostic groups sokal score hasford score low risk intermediate risk high risk 03 (5.1%) 30 (50.8%) 26 (44.1%) 15 (25.4%) 26 (44.1%) 18 (30.5%) results age distribution: in a total of 59 cases of cml included in this study, the age of patients ranged from 8 to 70 years with mean ± sd of 35.39 ± 17.12 years. the median age was 35 years. among these 34 were male and 25 female. the male to female ratio was 1.3:1. feeling of weakness and lassitude were invariably present. history of low grade fever was given by 85% of cases. in 76% of cases, pallor was a presenting manifestation. hepatomegaly was present in 37 (63%) of cases. spleen was enlarged in 95% cases. the range of blasts in the bone marrow was 1-22% with mean of 3.6% + 3.75 sd. as shown in table 1, majority (93.2 %) of patients were in chronic phase; 6.8% were in accelerated phase, and 1.7% presented with blast crisis. journal of islamabad medical & dental college (jimdc); 1211(1):14-17 16 according to hasford score 26 (44%) of patients were placed in intermediate risk group; 18 (30.5 %) were in high risk group and 15 (25.5%) patients were grouped under low risk group. whereas according to sokal score, majority of the patients were in intermediate (50.8%) and poor (44.1%) prognosis groups; only 5.1% cases were observed to be in good prognosis group. (table 2) discussion typically cml if diagnosed in chronic phase can usually be controlled for some years; however, the disease invariably progresses eventually to more advanced (accelerated phase or blast transformation) which (particularly the blastic phase) are resistant to therapy and lead to death within 6–8 months.11 the management of cml has progressively revolutionized during the last two decades. the treatment modalities switched on from busulphan and hydroxyurea to bone marrow transplantation and interferon therapy, and now molecular lesion targeted therapy using imatinib mesylate (glevac) has incredibly improved the outlook of cml patients. considering the importance of prognostic factors and their impact on various treatment modalities, many cml study groups have worked in this area. many attempts have been made in the last 20 years to define clinical factors assessed at the time of diagnosis that may predict survival for individual patients with cml.12 for example, sokal et al identified factors that allow them to classify patients treated predominantly with busulphan into three prognostic groups and hasford et al performed a similar analysis in patients treated predominantly with ifnα. in the present study we evaluated our freshly diagnosed cases of cml for sokal and hasford score and graded them accordingly. according to sokal score 5.1 % of our 59 patients were placed in low risk group (score of < 0.8); 44.0% in high risk group (score >1.2 %); and 50.8% in intermediate risk group (score 0.8 to 1.2). according to hasford score 25 % were grouped under low risk group, 44% in intermediate risk group and 30.5 % in high risk group. thus hasford score has placed 20% more patients in low risk group than sokal score. the age range of these low risk patients is from 24 to 43 years. all sokal low risk group patients were also hasford low risk group patients, whereas the correspondence was much less for high risk patients. thirteen of 26 patients of high sokal were also high hasford and the remaining 13 high sokal cases were intermediate or even low with hasford scoring system. in cml survival varies from few months to years from diagnosis and an accurate prediction of duration of survival could help patients and clinicians make decisions about many treatment options. we have analyzed prognostic stratification of patients using both hasford and sokal scores. the main difference between these scores is that hasford score assesses the impact of eosinophils and basophils on differential white cell count at diagnosis. although sokal score is still widely used, studies suggest that it is no more the best method of reliability. in a study done by thomas et al looking at survival of these groups (grouped both by sokal and hasford criteria) it was found that 5 years survival was better in their low risk groups.13 they also suggested that sokal was less informative as their survival curve of high risk group crossed the survival of low and intermediate risk groups several times. they recommended that hasford is a better scoring system and is highly predictive of survival particularly in patients <60 years age. in another study done by hasford et al 9 (to validate hasford scoring system) the hasford scoring system was reinforced by finding that sokal et al 14, 15 and kantarjiar et al 8 do not separate the survival curves. in this study total number of their low risk group according to hasford scoring system is 41.4% (with 5 year survival; 75%) as compared to 25.5% in our study; intermediate group represented 44.5% (with 5 year survival of 56%) vs. 44% in our study and 14.5% high risk group (with 5 year survival; 28%) vs. 30.5% in our study. thus number of low risk group is quite low in our study and probably this is due to difference in selection criteria of patients as we have included patients in all phases and they included patients only in chronic phase. the results would have been different if we had followed the above mentioned criteria. in another study by thomas et al11 (analyzing the patients using both hasford and sokal scoring systems) the number of their high risk group according to hasford system was still lower (7% vs. 30.5% in our study), intermediate group (39% vs. 44% in our study) and the number of patients in their low risk group was quite high (55% vs. 25.5% in our study) the variables used in hasford scoring system are routinely measured in clinical practice and their measurement is highly reliable. thus one can get a reliable data needed for the calculation of this prognostic score. this scoring system has also shown a good discrimination of survival and can be considered a good tool for evaluation of risk adopted treatment. allogeneic stem cell transplant is the only therapy that can cure cml, but age and lack of a suitable donor limit this procedure to a minority of patients.16 sokal and hasford scores however do not predict survival after allogenic stem cell transplant.17 as for these patients pretransplant risk factors, i.e. donor type, stage of disease at time of transplantation, age of recipient, sex of donor and recipient, and interval between diagnosis and transplant are more important to predict their survival rate.18 similarly with use of imatinib (particularly in previously untreated patients in chronic phase), different factors predict the duration of survival and overall survival is significantly better for patients treated initially with imatinib.19 journal of islamabad medical & dental college (jimdc); 1211(1):14-17 17 conclusion hasford score identifies more patients still in low risk group as compared to sokal scoring system prospective studies to see overall survival and 5 year survival of patients in chronic phase particularly those less than 60 years who are unable to get imatinib and are on interferon therapy (after their prognostic categorization according to hasford scoring system) will provide valuable information to oncologists/physicians both in stratifying patients into risk groups and modifying their treatment accordingly. references 1. stefan f, talpaz m. the biology of cml n engl j med.1999;341:164-172. 2. john g. chronic myeloid leukemia ---past, present and future. semin hematol.2003;40:1-3. 3. kantarjian hm, deisseroth ab, kuzrock r, estrov z. chronic myeloid leukemia:a concise update. blood 1993; 82:691-703. 4. cortes jorge, kantarijian h. advanced phase chronic myeloid leukemia.seminars in haematology 2003;40:7986. 5. jorge c, kantarijian h. advanced phase chronic myeloid leukemia. seminars in haematology 2003; 40:79-86. 6. tura s baccarani m, corbelli g. the italian cooperative study group on chronic myeloid leukemia; staging of chronic myeloid leukemia. br j haematol.1981; 47:105. 7. canventes f, rozman c.a multivariate analysis of prognostic factors in chronic myeloid leukemia. blood 1982; 60:2470. 8. kantarjian hm, keating mj, smith tl, talpaz. proposal for a simple synthesis prognostic staging systems in chronic myelogenous leukemia. am j med 1990; 88:1-8. 9. sokal j.e, baccariani m, russo d, sante tura s. staging and prognosis in chronic myelogenous leukemia. semin hematol 1988; 25:49-61. 10. hasford j, piffrmann m, rudiger helmen, norman c. a new prognostic score for survival of patients with cml with interferon alpha.j natl cancer inst.1998; 90:850-8. 11. wadhwa j, szydlo rm, apperley jf and chase a et al. factors affecting duration of survival after onset of blastic transformation of chronic myeloid leukemia. blood 2002; 99: 2304–2309. 12. marin d, marktel s, bua m and szydlo rm et al. prognostic factors for patients with chronic myeloid leukaemia in chronic phase treated with imatinib mesylate after failure of interferon alfa leukemia 2003;17: 1448–1453 13. thomas m j, eirving ja, lennard a l and proctor s j et al. validation of the hasford score in a demographic study in chronic granulocytic leukaemia j clin pathol 2001; 54:491–493 14. sokal je, baccarani m, tura s and fiacchini m et al. prognostic discrimination among younger patients with chronic granulocytic leukemia: relevance to bone marrow transplantation. blood 1985; 66: 1352–7. 15. goldman jm, druker bj. chronic myeloid leukemia: current treatment options. blood 2001; 98: 2039–2042. 16. sokal je, cox eb, baccarani m, tura s, gomez ga, robertson je, et al. prognostic discrimination in ‘‘goodrisk’’ chronic granulocytic leukemia. blood 1984; 63:789– 99. 17. basel k, basel, switzerland. validation and extension of the ebmt risk score for patients with chronic myeloid leukaemia (cml) receiving allogeneic haematopoietic stem cell transplants. br j haematol. 2004; 125(5):613-20. 18. muzaffar h. qazilbash, marcel p, abraham j, lynch j.p. charles l. et al. utility of a prognostic scoring system for allogeneic stem cell transplantation in patients with chronic myeloid leukemia. acta haematol 2003;109:119123 19. brien sg, guilhot f, larson ra, on behalf of the iris investigators. interferon and low dose cytarabine compared with imatinib for newly diagnosed chronic phase chronic myeloid leukemia. n engl j med 2003; 348: 994–1004.. summary journal of islamabad medical & dental college (jimdc); 1211(1):48-49 48 continuing medical education febrile convulsion and guidelines for management (based on rcp and bpa guideline bmj 1991 303;634-636) prof. mumtaz hassan head, department of paediatrics, islamabad medical & dental college islamabad. (bahria university, islamabad) definition a simple febrile convulsion is a generalized tonic–clonic convulsion occurring in a child aged 6 months to 5 years, precipitated by fever of more than 38°c, arising from infection outside the nervous system in a child who is otherwise neurologically normal. it is typically short lasting (approx. 5 minutes) prevalence ➢ 3% children are affected ➢ m/f ratio= 2:1 ➢ blacks are affected more commonly than the whites pathophysiology cause is still unknown. fever, illness and age all seem to play an important role. some studies suggest that the seizures are related to the sudden rise of the temperature, while others purpose that a high sustained fever is of a greater importance. aetiology 80% due to viral infections 20% due to bacterial infections 40% due to urti’s 30% have a family history history: type and length of febrile illness type and length of convulsion pmh especially convulsions and development clinically, characteristics of simple febrile convulsions are: ❖ age 6 months to 5 years ❖ generalized tonic-clonic convulsion ❖ less than 20 minutes duration ❖ complete recovery within 1 hour ❖ no focal neurological signs or fundal abnormalities ❖ no developmental or neurological problems management: 1. admit all 1st febrile convulsions and all ill children 2. search for focus of infection and treat appropriately 3. no investigation is routinely necessary but; ➢ if still convulsing check bm ➢ consider fbc, blood cultures, msu, cxpto ascertain the cause of fever. ➢ consider lp if <12/12 age; if signs of meningism are present: after a complex convulsion: if child is unduly drowsy or irritable or systemically unwell. the decision for no lp in high risk children should be made after discussion/review by the registrar. be aware of risk of coning following lp in a comatose child. 4. antipyresis -regular calpol +/ibuprofen -undress child -adequate fluids 5. advise parents: o reassurance o information leaflets about nature of febrile convulsions including prevalence & prognosis o temperature regulation o first aid in a fit, and management of a convulsion +/use of rectal diazepam o take to a doctor if unwell or fit is prolonged o future immunization should go ahead 6. follow up if:  any developmental concerns  parental anxiety  other pediatric or social issue risk of recurrent convulsions in subsequent febrile illness: the risk of recurrent febrile fits is 30% with no risk factors. the risk of recurrent febrile fits is 50% if the onset is before 12/12 age or if a first degree relative has seizures of any type or following a complex convulsion. the risk of recurrent febrile fits is 75–100% if three or more of the following are present: ➢ onset before 12/12 age ➢ first degree relative affected ➢ complex seizures ➢ neurodevelopment problems ➢ adverse social circumstances therefore, it may be that the latter group is the one to be given solids to take home after adequate parentral infusions. journal of islamabad medical & dental college (jimdc); 1211(1):48-49 49 risk of later development of epilepsy: risk of development of epilepsy in the general population is 0.5% by age of 25 years. neurologically normal children with simple febrile convulsions have a low chance of later epilepsy; only 2.5% have had two or more febrile seizures by 25 years of age. presence of complex seizures is associated with an increased risk for later epilepsy. atypical / complex febrile convulsions: • convulsion lasting more than 20 minutes. • focal component to convulsion. • less than 6 months of age. • more than one convulsion within same febrile illness. • residual neurological deficit. • pre-existing neurological abnormality or abnormal neurodevelopment. advice to parentsfebrile convulsions: “your child has had a febrile convulsion. we know it was a very frightening experience for you. you may have thought that your child was dead or dying, (as many parents think when they first see a febrile convulsion). febrile convulsions are not as serious as they appear.” what is a febrile convulsion? it is an attack brought on by fever in a child aged between 6 months and 5 years. what is convulsion? a convulsion is an attack in which the child becomes unconscious and usually stiff, with jerking of the arms and legs. it is caused by unusual electrical activity of the brain. the word convulsion, fit and seizure have the same meaning. what shall i do if my child has another convulsion? lay him on his side, with his head on the same level or slightly lower than the body not the time. do not try to force anything into the mouth. the hospital may give you a medicine to insert into your child`s bottom. this is called rectal diazepam. if the convulsion has not stopped by the time that you have found the tube, insert it into the child`s bottom and express the contents of the tube. this treatment should stop the convulsion within 10 minutes. if it does not, take your child to the hospital. you may need to call for an ambulance. let your doctor know what has happened. about one child in 30 have had a febrile convulsion by age of five years. is it epilepsy? no. this word is applied to fits without fever, usually in older children and adults. do febrile convulsions lead to epilepsy? rarely. ninety nine out of 100 children with febrile convulsions never have convulsions after they reach school age, and never have fits without fever. do febrile convulsions cause permanent brain damage? almost never; very rarely a child who has a very prolonged febrile convulsion lasting half an hour or more may suffer permanent damage from it. what starts a febrile convulsion? any illness that causes a high temperature, usually a cold or other virus infection may start a febrile convulsion. will it happen again? three out of 10 children who have a febrile convulsion will have another one. the risk of having another febrile convulsion falls rapidly after the age of 3 years. does the child suffer discomfort or pain during a convulsion? no. the child is unconscious and unaware of what is happening. what shall i do when my child has fever? you can take the child`s temperature by placing the bulb of the thermometer under his armpit for three minutes with his arm held against his side. keep him cool by taking off his clothes and reducing the room temperature. give plenty of fluids to drink. give children`s paracetamol medicine to reduce the temperature. the following doses should be given. up to 1 year one 5ml spoonful (120mg) aged 1 to 3 years two 5ml spoonful (240mg) aged 4 years and over three 5 ml spoonful (360mg) repeat the dose every four hours until the temperature falls to normal, and then every six hours for the next 24 hours. if the child seems ill or has ear ache or sore throat, let your doctor see him in case any other treatment, such as an antibiotic, is needed. antibiotics are not usually necessary, as majority of children have fever due to virus infections. is regular treatment with tablets or medicine necessary? usually not. the doctor will explain to you if your child needs regular medicines. j islamabad med dental coll 2019 40 open access differences in brain waves and blood pressure by listening to quran-e-kareem and music noor-ul-ain irfan 1, hafsa atique 2, ayesha taufiq 3, asma irfan 4 1,2,3 third year mbbs. islamabad medical and dental college, islamabad 4 professor, department of physiology, islamabad medical and dental college, islamabad a b s t r a c t background: quranic recitation and music do not share any features in terms of content besides the use of melodies, but it is a common belief, that both have positive effect on reducing blood pressure and anxiety level of patients. this research investigates and compares the effects of listening to quranic recitation and soft music on human brain waves especially alpha and beta waves by electroencephalogram (eeg) using power-lab. material and methods: a clinical trial was carried out in the physiology department of islamabad medical and dental college. there were 22 participants, divided into two groups (a and b) with 11 participants in each group. group a included students with ages 20-25 years and group b comprised of teaching faculty between 40-60 years. all the study participants were urdu-speaking, pakistani muslims having normal hearing. sample selection was based on non-random convenient sampling. paired t-test was used to compare means of alpha and beta waves amplitude, with p value < 0.05 considered as statistically significant. results: listening to quranic recitation results in greater amplitude of alpha waves in both younger and older age groups (p=0.01). the cross comparisons of systolic blood pressure at rest and after music for group a showed significant results (p=0.04) indicating that soft music increases systolic blood pressure in younger people. diastolic blood pressure comparison proves that it decreases by tilawat in older age-groups (p<0.05). conclusion: eeg showed that quran generates comparatively higher amplitudes of alpha than beta waves, which reflects the calmness and relaxation of the participants while listening to quranic recitation. furthermore, there was a mild reduction in diastolic blood pressure in older subjects after listening to quranic recitation. key words: blood pressure, eeg, quranic recitation, soft music authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3,4 interpretation, discussion, data analysis, active participation in data collection. correspondence: noor-ul-ain irfan email: nu.ain.efaan@gmail.com article info: received: december 22, 2018 accepted: january 10, 2018 cite this article. irfan n, atique h, taufiq a, irfan a. differences in brain waves and blood pressure by listening to quran-e-kareem and music. j islamabad med dental coll. 2019; 8(1):40-44 funding source: nil conflict of interest: nil i n t r o d u c t i o n many previous research studies have shown that music has physiological effects which are quantifiable. some studies have made use of eeg to verify the influence of music on human brain activity.1 sound activates the pituitary adrenal-cortical axis and the sympatheticadrenal-medullary axis.2 chepesuik (2005) in his review article on noise pollution has cited a number of studies reporting the effect of loud sounds on human behaviors and physiological measurements such as blood pressure, heart rate and blood flow.3 the cerebral cortex contains a large number of neurons. eeg signals acquisition is a reliable tool in biomedical engineering for signal analysis. a common method to measure human brain activity is by using electroencephalography, which is a medical imaging technique that reads scalp electrical activity generated by brain structures. when brain cells (neurons) are activated, local current flows are produced. only large collections of active neurons can generate recordable o r i g i n a l a r t i c l e j islamabad med dental coll 2019 41 electrical activity on the head surface.4 activity of these neurons is to some extent synchronized in regular firing rhythms (brain waves).5 electrodes placed in pairs on the scalp can pick up variations in electrical potential that derive from this underlying cortical activity.6 eeg recordings contain a great deal of information that can be used to characterize the signals for clinical and research purposes.7 eeg mainly consists of four basic frequency components namely: (a) delta 0.5-4 hz associated with the deep sleep, (b) theta 4-8 hz associated with drowsiness, (c) alpha 8-12 hz associated with relaxed, alert state of consciousness, (d) beta 14-30 associated with active, busy or anxious thinking. the amplitudes of the eeg signals typically vary between 10 and 100 μv (in adults more commonly between 10 and 50 μv).1 listening to music plays an important role among higher brain centers.8 quran is the holy book of muslims which covers all aspects of human life and treatment of diseases can be one of the aspect of verses of the holy quran.9 quranic recitation and mainstream music are generally opposed to each other in terms of content, but it is a common belief, that both have positive effect on reducing blood pressure and anxiety level of patients.10 soft music, “morning light” is played in this study while others have used hard music like rock or relaxing music like mozart k.448.11 this research investigated and compared the effects of listening to holy quran and soft music on alpha and beta brain waves by eeg using power-lab with only 2 electrodes, while others have used 1912 or 21 electrodes respectively.13. verses from surah rehman (25th to 40th verses) were used in this study.12 moreover, differences in blood pressure at rest and after listening to soft music and quran were also noted.14 m a t e r i a l a n d m e t h o d s the present study was designed as a clinical trial comparing two groups of participants. group a comprised of 11 healthy imdc students of age range 20 to 25 years and group b had 11 imdc teaching faculty members of age range 40 to 60 years. sample selection was based on non-random convenient sampling. sample size was calculated using who calculator, taking 95% confidence interval (ci) and 80% power of the study. the initial calculated sample size was 6 (3 in each group), but in order to increase the significance of the study we included 22 participants (11 in each group). mean magnitude of alpha waves before listening to quran-e-kareem 0.18571429 and during listening to quran-e-kareem is 1.27142857. variance is 0.00809524 and 0.36238095 respectively.11 all urdu-speaking pakistani muslims having normal hearing were included in the study, while subjects with neurological disorders, formal music education, formal quran recitation training and those on drugs like tranquilizers were excluded from the study. this study was conducted in the morning from 9-11 am. the subjects were made to sit on a relaxing chair. eeg was derived from two electrodes of power lab. a frontal electrode was placed on the forehead and an occipital electrode on the scalp at the back of head. a third (ground or earth) electrode was also attached to record electrical interference. before placing the electrodes, the placement area was swept using eeg abrasive skin prepping gel. the experiment was conducted at room temperature (25°c) with air conditioning. the participants were instructed to rest and close their eyes. then, with the help of head phones, they listened to soft music (“morning light”) by serenity studio for 2 minutes. eeg was noted in this duration. after a rest of ten minutes, the participants then listened to surah-al-rehman for 2 minutes in the voice of qari abdul basit from 25th to 40thverse, and eeg was again recorded. blood pressure was checked with the help of sphygmomanometer before and after play of each audio and mean b.p was calculated using the formula diastolic b.p +1/3 pulse pressure. ethical approval was obtained from the institutional review board (irb) of islamabad medical and dental college. written informed consent was taken from all the study participants. confidentiality was maintained during and after the study and the participants were also informed about the results of the study. statistical analysis was performed using spss version 23. paired t test was applied to the obtained data to compare eeg after soft music and after listening to quran-e-kareem; and to compare blood pressure before and after play of each audio. p value less than 0.05 was taken as statistically significant. j islamabad med dental coll 2019 42 r e s u l t s current study consisted of 22 participants, divided into two groups. group a, comprised of 11 students with ages ranging from 20 to 22 years and mean age of 20.6 ± 0.68 years. while group b consisted of 11 faculty members with age range of 40 to 70 years and mean age of 46.2 ± 8.7 years. paired t-test was applied to compare mean values of systolic and diastolic blood pressure recorded at rest and in response to each audio played. the cross comparisons of systolic blood pressure at rest and after music for group a are given in table i showing statistically significant elevation of systolic blood pressure in younger age group with soft music (p=0.04). however, in group b no effect on blood pressure was noted (p>0.05). table i: comparison of mean systolic and diastolic blood pressure recorded for group a and group b after listening to tilawat and soft music blood pressure group a (n=11) p value mean + sd total group a systolic at rest 124 + 8.1 0.6 + 5.2 0.69 after tilawat 123.4 + 6.9 at rest 124 + 8.1 -3 + 4.4 0.046* after music 127 + 8.3 diastolic at rest 79.5 + 4.6 -2.3 + 3.3 0.04* after tilawat 81.7 + 5.3 at rest 79.5 + 4.6 -3.4 + 9.9 0.29 after music 82.8 + 10.9 blood pressure group b (n=11) p value mean + sd total group b systolic at rest 118.8 + 8.4 3.18 + 9.2 0.28 after tilawat 115.6 + 5 at rest 118.8 + 8.4 -1. + 7.9 0.69 after music 119.8 + 10 diastolic at rest 74.4 + 4.6 2.4 + 3.6 0.05 after tilawat 72 + 5.5 at rest 74.4 + 4.6 2.4 + 3.6 0.58 after music 74.9 + 4.7 on comparison of mean diastolic blood pressure, no change was observed in group a at rest and after playing of tilawat, while the difference was statistically significant for group b (table i). regarding comparison of mean amplitude and frequency of alpha and beta waves, tilawat results in greater amplitude of alpha waves in both younger and older age groups (table ii). independent t-test was also applied to compare mean values of amplitude during tilawat in groups a and b for which non-significant results were obtained (p=0.659). table ii: comparison of alpha wave amplitude in response to tilawat and soft music in group a and group b alpha wave amplitude group a group b p value group a group b mean + sd mean + sd 0.004* 0.000* for tilawat 46.4 + 11.5 40.4 + 9.5 for music 26.4 + 15.4 21.05 + 8.12 total 20.05 + 17.7 19.4 + 10.3 d i s c u s s i o n quranic recitation and conventional music are generally opposed to each other in terms of content, but both have a positive effect on reducing blood pressure and anxiety level of patients.10 this research aimed at investigating the effects of listening to holy quran as compared to soft music also corroborates these findings by a reduction in blood pressure and increase in alpha wave amplitude indicating a rested and calm state. in a similar study, comparing the effects of listening to classical music and quran-e-kareem, it was observed that quranic recitation demonstrated a positive transformation of the subjects' emotions from negative precursor emotions to calmness and happiness.15 these positive emotions were denoted by a positive valence for the eeg and ecg signals. in contrast, classical music showed a positive transformation with regard to the valence in the eeg analysis, however, with respect to the ecg music data analysis, the results revealed a negative transformation for most of the music tracks.15 eeg signals showed increased alpha waves and reduced beta waves while listening to quranic recitation. in contrast, beta waves increase when listening to rock music. another study compared the alpha waves of subjects listening to quranic recitation and classical music. the results j islamabad med dental coll 2019 43 showed that 12.7% of the samples demonstrated increases in the alpha band during quranic recitation, while 9.97% of samples showed similar increases for classical music.16 alternately, relaxing music data generated almost equal beta and alpha magnitudes but not as high as quran recitation. in the current study, paired t-test was applied to compare mean values of systolic and diastolic blood pressure recorded at rest and in response to each audio played. the cross comparisons of systolic blood pressure at rest and after music for group 1 showed significant results (p=0.04) indicating that soft music results in elevation of systolic blood pressure in younger age group. however, in group 2 it was non-significant (p>0.05). the cross comparisons of diastolic blood pressure recorded at rest and then after playing of tilawat audio was non-significant in group a, however in group b, significant results (p<0.05) were obtained, which proved that tilawat improved diastolic blood pressure in older age groups. mirbagher (2011) compared music and quran sound effects on anxiety and vital signs of patients before abdominal surgery and concluded that both had positive effect on reducing blood pressure, pulse rate, and respiratory rate as well as anxiety level of patients, and quran sound is more effective, which is consistent with current research findings.10 according to nilsson, music stabilizes vital signs.16 wallace et al. also found no change in blood pressure, pulse and respiratory rate.17 these differences among different studies may be due to variation in patient selection techniques and environmental or cultural conditions. c o n c l u s i o n eeg analysis showed that quranic recitation generates higher alpha wave amplitudes than beta wave, which reflects the calmness and relaxation of the subjects while listening to the quran. another positive finding was a mild reduction in diastolic blood pressure especially in older participants, indicating the soothing and beneficial effects of reciting the quran. r e f e r e n c e s 1. shilawani rs. kadir a, ghazali mh, murat z, taib mn, rahman ha, aris sa, “the preliminary study on the effect of nasyid music and rock music on brainwave signal using eeg”, faculty of electrical engineering university teknologi mara (uitm) shah alam, selangor, malaysia 2010. 2. a.saidatul, m.r tamjis, n.f mohammad and sazali yaacob, “a preliminary study of noise on pulse reate, blood pressure and eeg signal,” unpublished. proceeding internation conference on man machine systems (icomms).2009 3. chepesiuk r. decibel hell: the effets of living in a noisey world. environ health perspect. 2005; 113(1): a34-a41. 4. teplan m. fundamentals of eeg measurement. measurement science review. 2002;2(2):1-1. 5. shekha ms, hassan ao, othman sa. effects of quran listening and music on electroencephalogram brain waves. egypt. j. exp. biol. 2013;9(1):119-21. 6. ad instruments. listening to music plays an important role among higher brain centres 2010. 7. lu h, wang m, yu h. eeg model and location in brain when enjoying music. in2005 ieee engineering in medicine and biology 27th annual conference 2006: 2695-2698 8. sakhrov ds, davyod v1, pavlygina ra. intercentral relation of human ecg during listening to music. human physiol 2005; 31(4): 392-397. 9. mansouri a, vahed as, sabouri ar, lakzaei h, arbabisarjou a. investigating aid effect of holy quran sound on blood pressure, pulse, respiration and o2 sat in icu patients. int j sci stud 2017;5(7):1-5. 10. mirbagherajorpaz n, aghajani m, shah shahani ms. the effects of music and holy quran on patient’s anxiety and vital signs before abdominal surgery. evidence based care. 2011: 1 (1): 63-76. 11. abdullah aa, omar z. the effect of temporal eeg signals while listening to quran recitation. international journal on advanced science, engineering and information technology. 2011;1(4):372-5. 12. ahmed s, yahya al-galal sa, alshaikhli a, alshaikhli t . analyzing brainwaves while listening to quranic recitation compared with listening to music based on eeg signals. international journal on perceptive and cognitive computing (ijpcc) 2017; 3(1):1-5. j islamabad med dental coll 2019 44 13. bhoria r, singal p, verma d. analysis of effect of sound levels on eeg. international journal of advanced technology & engineering research (ijater). 2012; 2(2):121-4. 14. rafique r, anjum a, raheem ss. efficacy of surah al-rehman in managing depression in muslim women. journal of religion and health. 2017:1-11. 15. zulkurnaini na, kadir rs, murat zh, isa rm. the comparison between listening to al-quran and listening to classical music on the brainwave signal for the alpha band. in2012 third international conference on intelligent systems modelling and simulation 2012: pp. 181-186. 16. nilsson u. the anxiety‐and pain‐reducing effects of music interventions: a systematic review. aorn journal. 2008 apr 1;87(4):780-807. 17. al-galal sa, alshaikhli if, rahman aw. automatic emotion recognition based on eeg and ecg signals while listening to quranic recitation compared with listening to music. in2016 6th international conference on information and communication technology for the muslim world (ict4m) 2016; pp. 269-27. j islamabad med dental coll 2019 13 open access etiological spectrum of pregnancy-related acute renal failure among females at a tertiary care hospital syed muhammad muzaffar hussain 1, khalid mahmood nasir 2, qazi adil inam 3, khalid mahmud khan 4 1 pgr medical unit 1, allama iqbal medical college/jinnah hospital, lahore 2 assistant professor, medical unit 1, allama iqbal medical college/jinnah hospital, lahore 3 associate professor of urology, nawaz sharif medical college, gujrat 4 associate professor, medical unit 1, allama iqbal medical college/jinnah hospital, lahore a b s t r a c t background: acute renal failure in pregnancy can be induced by any of the disorders leading to renal failure in the general population, such as acute tubular necrosis due to infection, glomerulonephritis related to lupus, or drug toxicity. there are, however, pregnancy complications characteristic of each trimester that can result in renal failure. the objective of this study was to determine the frequency of various causes of pregnancy-related acute renal failure among females presenting to a tertiary care hospital. material and methods: this cross-sectional study was conducted in jinnah hospital, lahore from january to august, 2017. a total of 110 patients with pregnancy-related acute renal failure presenting to the labour room were enrolled in this study. demographic data and history of antepartum and postpartum haemorrhage or bleeding from any site of the body were noted. patients having sepsis, disseminated intravascular coagulation (dic), acute fatty liver of pregnancy, hellp syndrome, pregnancyinduced hypertension (pih) and preeclampsia were noted. data was stratified for age of females and parity to control any effect modifier and chi-square test was applied post-stratification, taking p-value < 0.05 as significant. results: among 110 patients, the mean for age was 29.27 ± 8.40 years, for parity was 4.03 ± 2.01, and for bmi was 24.05 ± 3.94 kg/m2. antepartum hemorrhage was present in 25.5% patients, post-partum hemorrhage in 21.8%, sepsis in 48.2%, dic in 16.4%, acute fatty liver of pregnancy in 11.8%, pih in 53.6%, pre-eclampsia in 55.5%, hellp syndrome in 12.7% and intrauterine death of the fetus in 14.5% patients. age was significantly associated with dic (p=0.006) and intrauterine death of the fetus (p=0.020). antepartum hemorrhage (p=0.014) and dic were significantly associated with parity (p=0.022). conclusion: antepartum haemorrhage was found to be the most common etiological factor causing pregnancy-related acute renal failure, followed by post-partum hemorrhage. key words: antepartum hemorrhage, hellp syndrome, pregnancy-related arf, preeclampsia, post-partum hemorrhage authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3,4 interpretation, discussion, data analysis, active participation in data collection. correspondence: muhammad muzaffar hussain email: drmuzaffar05@gmail.com article info: received: july 22, 2018 accepted: november 10, 2018 cite this article: hussain sm, nasir km, inam qa, khan km. etiological spectrum of pregnancy related acute renal failure females presenting to tertiary care hospital. j islamabad med dental coll.2019; 8(1):13-17 funding source: nil conflict of interest: nil i n t r o d u c t i o n acute renal failure in pregnancy can be induced by any of the disorders leading to renal failure in the general population, such as acute tubular necrosis due to infection, glomerulonephritis related to lupus, or drug toxicity. there are however, pregnancy complications characteristic of each trimester, that can result in renal failure.1 early in pregnancy, most common renal problems are pre-renal disease due to hyperemesis gravidarum or acute tubular necrosis, resulting from a septic abortion. several different uncommon disorders can lead to acute renal failure later in pregnancy 1,2 mild to moderate preeclampsia is not part of this differential diagnosis since the renal function is generally o r i g i n a l a r t i c l e j islamabad med dental coll 2019 14 maintained in the normal or near-normal range. an important and difficult differential diagnosis is that of acute renal failure in late pregnancy in association with microangiopathic hemolytic anemia and thrombocytopenia.3 other main entities that must be considered as a cause of renal failure include thrombotic thrombocytopenic purpura hemolytic uremic syndrome (ttp hus), severe preeclampsia, and hellp syndrome (hemolysis with a microangiopathic blood smear, elevated liver enzymes, and a low platelet count). 3-5 women who present with significant renal failure (which is typical of syndromes described as hus) more frequently present in the postpartum period.6 women who present without significant renal failure (which is typical of syndromes described as ttp and often associated with severe adamts13 deficiency) also most commonly present near-term or postpartum but also may occur as early as the first or second trimester.7 severe preeclampsia is much more common than ttp-hus and is usually preceded by characteristic clinical features of hypertension, proteinuria and occasionally edema, which can be severe. generalized coagulopathy may be present when severe abruptio placentae, hepatic rupture, or liver failure complicate preeclampsia. low levels of clotting factors, if present, are important diagnostically since they are almost always absent in ttp-hus in which thrombocytopenia is usually the only hemostatic abnormality.7,8 ttp-hus is characterized by the otherwise unexplained combination of thrombocytopenia and microangiopathic anemia. thrombotic microangiopathy can lead to renal failure in either pregnancy-associated ttp or hus, though it is more prevalent among patients with hus. postpartum disease may follow a normal pregnancy or be preceded by findings indistinguishable from preeclampsia.8,9 the objective of this study was to determine the frequency of various causes of pregnancyrelated acute renal failure among females presenting at our tertiary care hospital. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in jinnah hospital, lahore during the period of january to august, 2017. through nonprobability consecutive sampling, 110 patients diagnosed with pregnancy-related acute renal failure presenting to the labour room of jinnah hospital lahore were selected for this study after an informed written consent. demographic data and history of vaginal bleeding (antepartum and postpartum haemorrhage) or bleeding from any site of the body (for dic) along with all other causes of acute renal failure were noted in a predesigned proforma. inclusion criteria included females aged 15 to 45 years, with acute renal failure due to pregnancy diagnosed during last 24 hours. exclusion criteria included pre-existing renal disease before pregnancy (on history and medical records, urea > 50mg/dl, and creatinine >1.3mg/dl), patients with chronic kidney failure (shrunken kidney on usg) and those not willing to participate in the study. all patients underwent a pelvic examination to confirm vaginal bleeding. using aseptic techniques, blood samples were collected for total leukocyte count (tlc) to determine sepsis, prothrombin time (pt), activated partial thromboplastin time (aptt), and platelet count for dic, serum bilirubin level for acute fatty liver of pregnancy and serum lactate dehydrogenase (ldh) and ast for hellp syndrome. in case of raised tlc and history of fever, blood cultures were sent to confirm sepsis. in patients with raised blood pressure, urine analysis was done to determine proteinuria to label as pih or preeclampsia. ultrasonography was performed in case of suspicion of antepartum haemorrhage, fatty infiltration of the liver and intrauterine death (iud) of the fetus. confidentiality of the data was ensured. data was entered and analyzed using spss version 17.0. numerical variables i.e. age, parity, and bmi were calculated as means and standard deviation. qualitative variables like causes of pregnancy-related acute kidney failure i.e. antepartum hemorrhage, postpartum hemorrhage, sepsis, dic, acute fatty liver, pih, preeclampsia, hellp syndrome, iud of the fetus were presented in the form of frequencies and percentages. data was stratified for the age of females and parity to control any effect modifier and chi-square test was applied post-stratification taking p-value < 0.05 as statistically significant. j islamabad med dental coll 2019 15 r e s u l t s out of 110 patients, the mean age was 29.27 years±8.40, mean parity was 4.03±2.01 and mean bmi was 24.05 kg/m2±3.94. frequency of various complications in pregnant females presenting with acute renal failure is as follows: antepartum hemorrhage was present in 28 (25.5%) cases, post-partum hemorrhage in 24 (21.8%), sepsis in 53 (48.2%), dic in 18 (16.4%), acute fatty liver of pregnancy in 13 (11.8%), pih in 59 (53.6%), preeclampsia in 61 (55.5%), hellp syndrome in 14 (12.7%) and iud of fetus was seen in 16 (14.5%) patients (figure 1). using chi-square test, no significant association of age was seen with acute fatty liver of pregnancy (p-value 0.663), pih (p-value 0.585), pre-eclampsia (p-value 0.316) and hellp syndrome (p-value 0.884). however, a significant association was found between age and intrauterine death of a fetus (p-value 0.020). there was a significant association of parity with antepartum haemorrhage (p-value 0.014) and dic (p-value 0.022) while no significant association was seen with postpartum haemorrhage (p-value 0.306), sepsis (p-value 0.791), acute fatty liver of pregnancy (p-value 0.428), pih (p-value 0.469), pre-eclampsia (p-value 0.235) and hellp syndrome (p-value 0.057) and iud of fetus (pvalue 0.395) (tables i and ii). figure: 1 frequency of pregnancy related complications. table i: age group-wise stratification of pregnancy-related complications age group (year) antepartum haemorrhage total p value yes no <30 17 40 57 0.275 >30 11 42 53 post-partum haemorrhage <30 16 41 57 0.100 >30 8 45 53 sepsis <30 25 32 57 0.347 >30 28 25 53 dic <30 4 53 57 0.006 >30 14 39 53 acute fatty liver of pregnancy <30 6 51 57 0.663 >30 7 46 53 pih <30 32 25 57 0.585 >30 27 26 53 preeclampsia <30 29 28 57 0.316 >30 32 21 53 hellp syndrome <30 7 50 57 0.884 >30 7 46 53 intrauterine fetus death <30 4 53 57 0.020 >30 12 41 53 table ii: parity based stratification of pregnancy-related complications parity antepartum haemorrhage total p value yes no <4 17 28 45 0.014 >4 11 54 65 post-partum haemorrhage <4 12 33 45 0.306 >4 12 53 65 sepsis <4 21 45 45 0.791 >4 32 33 65 dic <4 3 42 45 0.022 >4 15 50 65 acute fatty liver of pregnancy <4 4 41 45 0.428 >4 9 56 65 pregnancy induced hypertension <4 26 19 45 0.469 >4 33 32 65 preeclampsia <4 28 17 45 0.235 >4 33 32 65 hellp syndrome <4 9 36 45 0.057 >4 5 60 65 intrauterine fetus death <4 5 40 45 0.395 >4 11 54 65 j islamabad med dental coll 2019 16 d i s c u s s i o n although pregnancy-related acute renal failure is a very serious health issue, however few studies are available from pakistan. in 1996, naqvi and colleagues reported 18 cases of obstetrical arf from karachi with 23% mortality and 26% morbidity.10 the incidence of pregnancy-related acute renal failure in developed countries is 1% 2.8%, in sharp contrast to 9% 25% in developing countries, mostly due to late referral of pregnancy-related complications.11-13 in northern areas of pakistan, obstetrical related acute renal failure was reported to be 7% 10% of total acute renal failure cases with 18% mortality.14 present study reported a mean age of 29.27 ± 8.4 years, which is in agreement with other studies carried out in india12 and pakistan.13,15,16 regarding pregnancy related complications, pre-eclampsia was the commonest in our patients followed by pregnancy-induced hypertension, sepsis, antepartum hemorrhage, post-partum hemorrhage, disseminated intravascular coagulation, intrauterine death of fetus, hellp syndrome, and acute fatty liver of pregnancy, respectively. hassan et al reported, among 43 patients with pregnancy-related arf, the puerperal group comprised of 36 patients (83.7%). hemorrhage was the etiology for arf in 58.1% patients, followed by pph, puerperal sepsis, aph, pre-eclampsia, eclampsia and hellp syndrome and dic, respectively. 13 clinical spectrum of pregnancy-related arf reported by ansari et al include puerperal sepsis, septic abortion and dic as the commonest followed by pph, aph, iud and pre-eclampsia / eclampsia, respectively. according to the authors, blood loss causing hypotension due to aph and pph are regarded as common causes of arf.15 many of the pregnancy complications like pre-eclampsia / eclampsia, pregnancy induced hypertension, iud, aph, and pph etc. can be prevented by proper and timely antenatal check-ups and early and effective treatment strategies.13 moreover incidence of sepsis can be effectively reduced by use of aseptic techniques during examinations and later on delivery of the baby.13 according to the present study, maternal age showed a significant association with two pregnancy complications: dic and intrauterine death of fetus. while parity showed a significant association with antepartum haemorrhage and dic respectively. c o n c l u s i o n pregnancy-related acute renal failure is a cause of concern in our hospitals. pre-eclampsia/eclampsia was found to be the most common etiological factor causing pregnancy-related acute renal failure in our series of patients. this was followed by pregnancy-induced hypertension, sepsis, antepartum hemorrhage, postpartum hemorrhage, disseminated intravascular coagulation, intrauterine death of fetus, hellp syndrome, and acute fatty liver of pregnancy, respectively. effect modifiers have no significant association, except age with dic and intrauterine death of fetus and parity with antepartum haemorrhage and dic. r e f e r e n c e s 1. krane nk. acute renal failure in pregnancy. archives of internal medicine. 1988;148(11):2347-57. 2. grünfeld j-p, pertuiset n. acute renal failure in pregnancy. american journal of kidney diseases. 1987;9(4):359-62. 3. mcminn jr, george jn. evaluation of women with clinically suspected thrombotic thrombocytopenic purpura‐hemolytic uremic syndrome during pregnancy. journal of clinical apheresis. 2001;16(4):202-9. 4. martin jn, blake pg, perry kg, mccaul jf, hess lw, martin rw. the natural history of hellp syndrome: patterns of disease progression and regression. american journal of obstetrics and gynecology. 1991;164(6):1500-13. 5. sibai bm, ramadan mk. acute renal failure in pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets. american journal of obstetrics and gynecology. 1993;168(6):1682-90. 6. fakhouri f, roumenina l, provot f, sallée m, caillard s, couzi l, et al. pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. journal of the american society of nephrology. 2010;21(5):859-67. 7. egerman rs, witlin ag, friedman sa, sibai bm. thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in pregnancy: review of 11 cases. j islamabad med dental coll 2019 17 american journal of obstetrics and gynecology. 1996;175(4):950-6. 8. mccrae kr, samuels p, schreiber ad. pregnancyassociated thrombocytopenia: pathogenesis and management. blood. 1992;80(11):2697-714. 9. weiner c. thrombotic microangiopathy in pregnancy and the postpartum period. semin hematol. 1987;24:119-29. 10. naqvi r, akhtar f, ahmed e, shaikh r, ahmed z, naqvi a, et al. acute renal failure of obstetrical origin during 1994 at one center. renal failure. 1996;18(4):681-3. 11. prakash j, tripathi k, pandey l, sahai s, srivastava p. spectrum of renal cortical necrosis in acute renal failure in eastern india. postgraduate medical journal. 1995;71(834):208-10. 12. goplani k, shah p, gera d, gumber m, dabhi m, feroz a, et al. pregnancy-related acute renal failure: a single-center experience. indian journal of nephrology. 2008;18(1):17. 13. hassan i, junejo am, dawani ml. etiology and outcome of acute renal failure in pregnancy. j coll physicians surg pak. 2009;19(11):714-7. 14. ali a, zafar s, mehmood a, nisar a. obstetrical acute renal failure from frontier province: a 3 years prospective study. journal of postgraduate medical institute (peshawar-pakistan). 2011;18(1). 15. ansari mr, laghari ms, solangi kb. acute renal failure in pregnancy: one year observational study at liaquat university hospital, hyderabad. jpma the journal of the pakistan medical association. 2008;58(2):61. 16. erdemoğlu m, kuyumcuoğlu u, kale a, akdeniz n. pregnancy-related acute renal failure in the southeast region of turkey: analysis of 75 cases. clinical and experimental obstetrics & gynecology. 2009;37(2):148-9. j islamabad med dental coll 2022 3 o p e n a c c e s s impact of caffeine and vitamin d3 on the development of neonate mice femur growth plate maimoona khan1, abdullah qamar2, ayesha ali3, faiza umbreen4, fareeha mushtaq5 1assist prof anatomy, mohi-ud-din islamic medical college, ajk 2,4assist prof anatomy, army medical college, rawalpindi 3pg trainee, army medical college, rawalpindi 5assist prof anatomy, mohtarma benazir bhutto shaheed medical college, ajk a b s t r a c t background: high dosage of caffeine can influence histological changes during bone development in the newborns, while vitamin d3 has also its effect on such changes. main objectives of the study were to determine the effects of caffeine on the histomorphology of developing femur and the role of vitamin d3 along with caffeine on the femur of balb/c mice. methodology: the animal experimental study was carried out in the national institute of health, islamabad in collaboration with the anatomy department, army medical college, rawalpindi, from october 2014 till october 2015. thirty pregnant mice, weighing 26-28g, were chosen and grouped into 3 equal sets of ten mice each. control group g1 was fed normal diet with ad libitum access to water. experimental group g2, along with the above diet, was provided caffeine at 10mg/100g body weight as a single dose on every second day using oral gavage for 3 weeks. experimental group g3 was administered with caffeine at 10mg/100g body weight on every second day along with vitamin d3 0.1µg/day for 3 weeks. at completion of the study, neonate mice femurs were analysed to see the changes on the proliferative and hypertrophy zone heights of growth plate. results: proliferative and hypertrophy zones of control group g1 mice mean height ±sd was measured as 540±10.99μm and 164±6.609μm, respectively, while for experimental group g2 the same height was observed as 443.5±12.258μm and 138.25±6.129μm, respectively. for experimental group g3 mice mean height ± sd of these zones was found as 474±3.839μm and 144.25±3.726μm, respectively. conclusion: ingestion of caffeine modified the femur's proliferative and hypertrophy zones height of the growth plate; however, vitamin d3 dosage mitigated this consequence. key words: caffeine, femur, hypertrophy zone, proliferative zone, vitamin d3. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing5. correspondence: maimoona khan email: maimoonakhan@hotmail.com article info: received: june 16, 2021 accepted: march 28, 2022 cite this article. khan m, qamar a, ali a, ambreen f, mushtaq f. impact of caffeine and vitamin d3 on the development of neonate mice femur growth plate. j islamabad med dental coll. 2022; 11(1):3-7. doi: 10.35787/jimdc.v11i1.728 funding source: nil conflict of interest: nil i n t r o d u c t i o n caffeine is one of the major components in tea, coffee, carbonated drinks, energy drinks, chocolate derived from cocoa seads1, and it is the most common psychoactive drug(legal) in the world. the role of caffeine in improving pain has been less known in the past, but now its being increasingly considered.2 worldwide utilization of caffeine has been evaluated at 120,000 tons per year.3 at present, a great rise in soft drinks ingestion has been seen throughout the world resulting in o r i g i n a l a r t i c l e j islamabad med dental coll 2022 4 caffeine abuse; this is especially due to massive publicity campaign and lack of appropriate understanding regarding outcomes of excessive caffeine use.4 experimental studies on young animals have reported that caffeine causes impaired bony ossification and maturation. moreover, it impedes osteoblast differentiation, formation as well as mineralization of extracellular bony matrix.5 previous research works have investigated that ingesting more than 500-600mg of caffeine in a single day might cause agitation, sleeplessness, anxiety, irritability, nervousness, an upset appetite, tachycardia and even muscle twitching.6 in females, the half life of caffeine is approximately 5.2 to 5.4 hrs, which becomes longer during pregnancy. the consumption of 300mg of caffeine per day during gestation may potentiate the risk of premature fetal births, reduced crown rump length, micrognathia, cleft palate, limb malformations, hydrocephalus and in severe cases may even cause early death of the developing fetus.7 the metabolism of caffeine is relatively slower in pregnant females, fetuses, infants and chronic hepatic illnesses.8 vitamin d exists in two forms, specifically ergocalciferol (vitamin d2) – gotten from plants and cholecalciferol (vitamin d3) in all other dietary sources including skin production of vitamin d.9 vitamin d performs a fundamental role in controlling as well as sustaining the mineralization of osseous tissue in all age groups and plays a central role in the regulation of mineral homeostasis and skeletal health.10 the previous experimental studies have not sufficiently focused on the histology of the developing long bones in the proliferative and hypertrophy phases. consequently, the combined effect of caffeine and vitamin d consumption on these developing histological zones has not been investigated. therefore, objective of this experiment was to find the outcome of caffeine consumption as well as the added effect of vitamin d3 on the growth plate of neonate femur of balb/c mice. m e t h o d o l o g y the animal experimental study was conducted in the national institute of health (nih), islamabad in collaboration with the anatomy department, army medical college, rawalpindi from october, 2014 till october, 2015 after necessary approval from ethical-committee (no. 02 / cream-a / 11 feb, 2015). convenience based non-probability sampling technique was used. healthy pregnant mice, weighing 26-28g, total thirty (30) in number, were taken for the experiment. non-pregnant and un-healthy female mice were not used in this research. room environment was controlled between 20-260c. using lottery method, pregnant mice were divided into three equal group sets of 10. control group g1 was provided with usual laboratory food for 3 weeks. experimental group g2 was given pure caffeine of 10mg/100g body weight, on every second day for 3 weeks, using oral gavage needle. group g3 was administered caffeine 10mg/100g body weight on every second day, three days a week along with vitamin d3 0.1µg per day, also through oral gavage needle for 3 weeks. after 21 days of gestation period, the animals were euthanized using ether as anesthesia. when mouse became unconscious, it was placed on a clean sheet of paper on a dissecting board. the abdominal cavity was opened and gravid uterus was exposed to take foetuses out. the total number of foetuses within the uterus of all the animals were counted as 206. two foetuses were taken randomly from each pregnant animal and right femur of newborns was dissected by separating from hip and knee joints. fixation of femurs was done in 10% formalin and the bottles were marked appropriately. the samples were decalcified through 5% nitric acid solution for 18-24 hrs.11 later, further processing was done in leica tp 1020 automatic tissue processor. infiltration and embedding was performed in paraffin wax using embedding center leica eg 1160. rotary microtome was used to make 5µm thickness longitudinal bone tissue sections on warm water bath at 450c and slides j islamabad med dental coll 2022 5 were prepared. staining using leica auto-stainer x in hematoxylin and eosin was performed in pathology laboratory of amc. heights of proliferative and hypertrophy zones were measured through ocular micrometer (40x lens). average of three readings in the central portion of each zone was noted down as the height of the zone.12 ibm-spss version 20 was used for analyses using anova test, while for inter-group comparison of quantitative variables, post hoc tukey`s test was used. a p value ≤ 0.05 was taken as significant. r e s u l t s the mean heights ±sd of proliferative and hypertrophy zones for all the three groups (g1, g2 and g3) as well as statistical findings are given in table 1. the height of both the zones was decreased in caffeine nourished g2 group in comparison to the control group g1 and experimental group g3 (fig 1-3). in g3 experimental group, vitamin d3 showed a role in diminishing some of the effects of caffeine, through protection of the architecture of osseous tissue. table 1: mean values of zones height of femur (growth plate) of new-borns zone group g1 mean height ±sd (µm) (n=20) group g2 mean height ±sd (µm) (n=20) group g3 mean height ±sd (µm) (n=20) pvalue prolifer ative 540.5±10.99 443.5±12 .258 474±3.839 < .001* hypert rophy 164±6.609 138.25±6 .129 144.25±3. 726 < .001* *p value ≤ .05 is statistically significant fig 1. control group g1, indicating proliferative zone (p), hypertrophy zone (h), chondrocyte with lacunae (c) and column of chondrocyte (col) of femur (40x) fig 2. experimental group g2, indicating decrease in proliferative (p) and hypertrophy (h) zones' height of femur(40x) fig 3. experimental group g3, indicating relative increase in proliferative (p) and hypertrophy (h) zones' height of femur (40x) d i s c u s s i o n the present study showed that the height of proliferative and hypertrophy zones of the femur was appreciably reduced in caffeine nourished mice in comparison with the control group. it was determined that the caffein appeared to inhibit the action of endo-chondrocytes and reduce the thickness of epiphyseal cartilage.13 thus, in caffeine nourished mice, smaller heights of proliferative and hypertrophy zones caused lesser longitudinal growth of the femur.14 similar findings were noted in previous studies in which caffeine altered osteogenic activity, leading to impaired matrix mineralization and maturation15 j islamabad med dental coll 2022 6 and had detrimental effects on cartilage growth, with severity of adverse effects dependent on dose.16, 17 caffeine passes into off-spring through the placenta, which causes teratogenic transformations and can reduce the formation, growth, and mass of the bones.18 the mesenchymal stem cells are responsible for ossification of the whole skeleton. the caffeine that goes from the mother to the fetus during pregnancy decreases the osteogenic differentiation of mesenchymal stem cells. the reduction in the osteogenic potential of mesenchymal stem cells is implicated in the pathogenesis of osteopenia resulting from caffeine ingestion.19 in another study, significant histological changes were observed in caffeine treated rats. thickness of epiphyseal plate (particularly proliferating and hypertrophic zones) was reduced in a group which received caffeine. the diaphysis of caffeine treated group manifested thinning out of the outer compact bone with multiple osteoporotic cavities in the bone matrix.20 the, addition of caffeine in rat chondrocytes cultures diminished cellularity, viability, and matrix synthesis activity.21 these results match with the findings of current research. caffeine fed neonates and young rats demonstrated marked decrease in longitudinal bone growth and maturation.22 caffeine ingestion during early years resulted in harmful effects on the bony structure in the subsequent life, hence altering the bone mineral density perpetually, decreasing calcium retention and reducing height of hypertrophic zone.22 observations of the present study are also comparable. the cells of epiphyseal cartilage control the longitudinal growth of bone.23 therefore, it has been determined that high doses of caffeine can inhibit endochondral ossification in young rats.24 experimental group (g3) in the current study also showed reduction in detrimental effect of caffeine on bones due to addition of vitamin d in the diet. the role of vitamin d is critical for normal growth and mineralization of the bony skeleton of the developing fetuses.25 vitamin d intake improved maternal calcium retention from gastrointestinal tract and enhanced offspring bone mineral density.26 the current study focused on observing the development of histological zones in the newborn using conventional microscope and thus did not examine the changes in shape, size and number of the cells in the respective zones. it is, therefore, recommended that electron microscope may be used to observe the ultra structural changes in the developing bone zones in future studies. c o n c l u s i o n caffeine stimulated decrease in height of proliferative and hypertrophy zones of growth plate of new born mice's femur, possibly due to inhibition of endochondral ossification. the dosage of vitamin d3, however, alleviated this negative influence of caffeine. r e f e r e n c e s 1. abidi s, gilani u, zehra r. extraction and analysis of caffeine from various brands of tea leaves marketed in pakistan. j pharmacogn phytochem. 2020;9(1):09-10. issn: 2278-4136 2. baratloo a, rouhipour a, forouzanfar mm, safari s, amiri m, negida a. the role of caffeine in pain management: a brief literature review. anesth pain med. 2016;6(3). doi: 10.5812/aapm.33193 3. alsabri sg, mari wo, younes s, elsadawi ma, oroszi tl. kinetic and dynamic description of caffeine. j caffeine adenosine res. 2018;8(1):3-9. doi: 10.1089/caff.2017.0011 4. wassef b, kohansieh m, makaryus an. effects of energy drinks on the cardiovascular system. world j cardiol.. 2017;9(11):796. doi: 10.4330/wjc.v9.i11.796 5. hua r, zou j, ma y, wang x, chen y, li y, et al. psoralidin prevents caffeine-induced damage and abnormal differentiation of bone marrow mesenchymal stem cells via the classical estrogen receptor pathway. annals of translational medicine. 2021;9(15).1245. doi: 10.21037/atm-2131530 6. sanchis-gomar f, pareja-galeano h, cervellin g, lippi g, earnest cp. energy drink overconsumption in adolescents: implications for arrhythmias and other cardiovascular events. can j j islamabad med dental coll 2022 7 cardiol.2015;31(5):572-5. doi: 10.1016/j.cjca.2014.12.019 7. del-ponte b, santos is, tovo-rodrigues l, anselmi l, munhoz tn, matijasevich a. caffeine consumption during pregnancy and adhd at the age of 11 years: a birth cohort study. bmj open. 2016;6(12):e012749. doi: 10.1136/bmjopen-2016012749 8. liu j, sui x, lavie cj, hebert jr, earnest cp, zhang j, et al. association of coffee consumption with allcause and cardiovascular disease mortality. in mayo clinic proceedings. elsevier.2013 ;88 (10):1066-1074). doi: 10.1016/j.mayocp.2013.06.020 9. roth de, abrams sa, aloia j, bergeron g, bourassa mw, brown kh, et al. global prevalence and disease burden of vitamin d deficiency: a roadmap for action in low-and middle-income countries. ann. n. y. acad. sci. 2018 oct;1430(1):44. doi: 10.1111/nyas.13968 10. ryan ba, kovacs cs. maternal and fetal vitamin d and their roles in mineral homeostasis and fetal bone development. j endocrinol invest. 2021;44(4):643-59. doi: 10.1007/s40618-02001387-2 11. h liu, zhu r, liu c, ma r, wang l, chen b, et al. evaluation of decalcification techniques for rat femurs using he and immunohistochemical staining. biomed res int.2017. doi.org/10.1155/2017/9050754 12. mizuhashi k, ono w, matsushita y, sakagami n, takahashi a, saunders tl, et al. resting zone of the growth plate houses a unique class of skeletal stem cells. nature. 2018;563(7730):254-8. doi: 10.5061/dryad.3qq5bm7 13. choi h, choi y, kim j, bae j, roh j. longitudinal bone growth is impaired by direct involvement of caffeine with chondrocyte differentiation in the growth plate. j anat. 2017;230(1):117-27. doi:10.1111/joa.12530 14. kwak y, choi h, roh j. the effects of caffeine on the long bones and testes in immature and young adult rats. toxicol res. 2017;33(2):157-64. doi:10.5487/tr.2017.33.2.157 15. reis am, oliveira kp, de paula ih, da silva ap, tarrago jf, de melo ocarino n, et al. nonlinear effects of caffeine on the viability, synthesis and gene expression of chondrocytes from the offspring of rats treated during pregnancy. acta histochemica. 2018;120(6):505-12. doi:10.1016/j.acthis.2018.06.001 16. guillán-fresco m, franco-trepat e, alonso-pérez a, jorge-mora a, lópez-fagúndez m, pazos-pérez a, et al. caffeine, a risk factor for osteoarthritis and longitudinal bone growth inhibition. j. clin. med. 2020;9(4):1163. doi:10.3390/jcm9041163 17. tan y, li j, ni q, zhao z, magdalou j, chen l, et al. prenatal caffeine exposure increases adult female offspring rat’s susceptibility to osteoarthritis via low-functional programming of cartilage igf-1 with histone acetylation. toxicology letters. 2018; 295:229-36. doi: 10.1016/j.toxlet.2018.06.1221 18. wikoff d, welsh bt, henderson r, brorby gp, britt j, myers e, et al. systematic review of the potential adverse effects of caffeine consumption in healthy adults, pregnant women, adolescents, and children. food chem toxicol. 2017; 109:585-648. doi: 10.1016/j.fct.2017.04.002 19. reis am, ocarino nd, boeloni jn, gomes da, goes am, ferreira ad, et al. inhibition of the osteogenic differentiation of mesenchymal stem cells derived from the offspring of rats treated with caffeine during pregnancy and lactation. connect tissue res. 2016;57(2):131-42. doi:10.3109/03008207.2015.1117075 20. farag ai, ahmad mm, hassanein gh. effect of carbonated soft drinks consumption on the bone of wistar albino rat: a histomorphometric study. j am sci. 2016;12(8):78-84. doi:10.7537/marsjas120816.11. 21. raines bt, stannard jt, stricklin oe, stoker am, choma tj, cook jl. effects of caffeine on intervertebral disc cell viability in a whole organ culture model. global spine journal. 2022;12(1):61-9. doi:10.1177/2192568220948031 22. khan m, abdullah ms, ambreen f, qamar k. effect of caffeine and vitamin d3 on proliferative and hypertrophy zones of epiphyseal cartilage of mice femur. pafmj. 2018;68(5):1116-20. 23. haraguchi, r., kitazawa, r., kohara, y., ikedo, a., imai, y. and kitazawa, s., recent insights into long bone development: central role of hedgehog signaling pathway in regulating growth plate. int. j. mol. sci.2019; 20(23):5840. doi:10.3390/ijms20235840 24. minematsu a, nishii y, imagita h, sakata s. longterm intake of green tea extract causes malconformation of trabecular bone microarchitecture in growing rats. calcif tissue int. 2018;102(3):358-67. doi:10.1007/s00223-0170358-0 25. miliku k, vinkhuyzen a, blanken lm, mcgrath jj, eyles dw, burne th,et al. maternal vitamin d concentrations during pregnancy, fetal growth patterns, and risks of adverse birth outcomes. am. j. clin. nutr. 2016;103(6):1514-22. doi:10.3945/ajcn.115.123752 78 j i m d c 2 0 1 7 78 op e n ac c e ss f u l l l e n g t h a r t i c l e comparison of efficacy of canal wall up mastoidectomy with canal wall down mastoidectomy in surgical management of otitis media with cholesteatoma sadaf raffat mustafa assistant professor, department of ent, railway hospital, rawalpindi a b s t r a c t objectives: to compare the efficacy of canal wall up (cwu) mastoidectomy with canal wall down (cwd) mastoidectomy in the surgical management of chronic otitis media with cholesteatoma in local population. patients and methods: a total of sixty patients with chronic otitis media, cholesteatoma and granulation tissue were enrolled. patients were randomly divided into two groups; group a patients underwent cwu mastoidectomy while group b patients underwent cwd mastoidectomy. both groups were followed for 6 months, for recurrence of the disease and associated complications. chi-square test was applied as a test of significance, to compare the outcomes of cwu mastoidectomy and cwd mastoidectomy. a p-value <0.05 was considered as statistically significant results: disease recurrence rate was significantly higher in group a (cwu) while complications rates were higher in group b (cwd) patients. persistent discharge, conductive deafness, and development of mastoid cutaneous fistula were reportedly higher in group b patients (p<0.05). conclusion: cwd operations have a higher probability of permanently curing the patient of the cholesteatoma but with higher rates of post-surgical complications. cwu procedures have the advantage of maintaining a near normal anatomy but with a higher risk of residual or recurrent cholesteatomas. choice of a particular surgical procedure depends on the preference of the surgeon, the nature, and extent of the pathology and the general health of the patient. key words: cholesteatoma, chronic otitis media, mastoidectomy, otitis media. author`s contribution 1,2conception, synthesis and planning of the research, discussion & analysis address of correspondence dr. sadaf raffat mustafa drsadafrafat@yahoo.com article info. received: mar 24, 2017 accepted: may 14, 2017 cite this article: mustafa sr. comparison of efficacy of canal wall up mastoidectomy with canal wall down mastoidectomy in surgical management of otitis media. jimdc. 2017; 6(2):78-82. funding source: nil conflict of interest: nil i n t r o d u c t i o n chronic otitis media (com) is an inflammatory disease of the middle ear, that lasts for more than three months.1 when associated with cholesteatoma, it is characterized by the presence of keratinized stratified squamous epithelium within the cavities of the middle ear. the incidence of cholesteatoma has been reported in between 1.0-12.6 cases per 100,000 inhabitants.2,3 cholesteatomas may grow large enough to erode the middle ear structures and the mastoid bone behind the middle ear.4 problems with the middle ear, such as fluid in the middle ear, a hole in the eardrum, or injury to the small, middle ear bones, can cause hearing loss.5 in rare situations, infections in the middle ear can spread deep inside the inner ear, causing a sensorineural hearing loss and dizziness.6 rare, but serious, complications include brain infections, such as an abscess or meningitis. a chronic infection and a cholesteatoma can also cause injury to the facial nerves and facial paralysis.7 surgical management of chronic otitis media with and without cholesteatoma has been a matter of debate for years.8,9the primary goal of surgery for com is to eradicate disease and obtain a dry and safe ear. restoration of hearing is by necessity, a secondary consideration because any attempt at middle ear o r i g i n a l a r t i c l e 79 j i m d c 2 0 1 7 79 reconstruction will fail in the setting of persistent inflammation and otorrhea.10 there are two major types of mastoidectomies: canal wall down (cwd) and canal wall up (cwu), and the debate as which technique is to be adopted still exists in 21st century.11 the mastoid bowl or cavity created by a cwd technique often fills with earwax and need frequent ear canal cleaning, protection from water and possible hearing changes. another disadvantage of the cwd mastoidectomy is that the operation changes the architecture of the ear canal. therefore, the hearing may be diminished to some degree as a result of this change of architecture. the cwu mastoidectomy was developed to address some of the limitations of cwd mastoidectomy but is associated with higher rates of recurrence.12 recent publications have emphasized the need for clinicians to take note of the outcomes of their surgery, not just in terms of technical success, but also in relation to the impact of the treatment upon the patient's lifestyle and wellbeing.13 currents study rationale was based on authors’ experience and belief for a need of individualized treatment in these patients. this study aims to compare the efficacy of cwu mastoidectomy with cwd mastoidectomy in the surgical management of chronic otitis media with cholesteatoma in the local population. p a t i e n t s a n d m e t h o d s this experimental study was conducted after ethical approval and informed consent from all the enrolled patients. the study was carried out at ent department, pims, islamabad from july 2007july 2008. a total of sixty patients with chronic otitis media, cholesteatoma and granulation tissue were enrolled. patients were randomly divided in two groups; group a patients underwent cwu mastoidectomy while group b patients underwent cwd mastoidectomy. both the groups were followed for 6 months (monthly basis) and observed for hearing outcome, recurrence of disease including cholesteatoma, granulation tissue and complications such as facial paralysis, meningitis, suppurative labyrinthitis, persistent ear discharge, conductive deafness and mastoid cutaneous fistula. data was analyzed using spss software version 20.0. chi-square test was used as a test of significance to compare the outcomes of cwu mastoidectomy and cwd mastoidectomy. p-value <0.05 was considered as statistically significant. r e s u l t s the present study includes 60 patients; 30 in each group. demographic data is presented in table 1. as shown in the table, mean age of the patients in group a was 27.10+2.29 sd and in group b it was 27.33+2.95 sd. there were 70 males and 30 females in group a and in group b there were 63 males and 37 females. disease recurrence rate was significantly higher in group a (cwu) (p<0.05), however complication rate was found higher in group b (cwd) patients. persistent discharge, conductive deafness, and mastoid cutaneous fistula were reportedly significantly higher in group b patients (p<0.05) (table 2). table 1: demographic profile of study population (n=60) gender group a (n=30) n (%) age (years) mean ± sd group b (n=30) n (%) age (years) mean ± sd male 21 (70) 26.64 ± 1.91 19 (63) 28.18 ± 2.48 females 9 (30) 27.67 ± 2.06 11 (37) 26.18 ± 3.63 total 30 (100) 27.10 ± 2.29 30 (100) 27.33 ± 2.95 table 2: comparison of recurrence and complications of disease in both groups (n=60) variables group a (n =30) n (%) group b (n=30) n (%) p-value recurrence 25(83.33) 12 (40) 0.001 complications facial paralysis 01(3.33) 5 (16.67) 0.085 meningitis 07(23.33) 2 (6.67) 0.071 suppurative labyrinthitis 0(0) 2 (6.67) 0.150 persistent discharge 03(10) 12 (40) 0.007 conductive deafness 09(30) 18 (60) 0.020 fistula 1(3.33) 07(23.33) 0.023 80 j i m d c 2 0 1 7 80 d i s c u s s i o n the objectives of mastoidectomy in cholesteatoma are to get a disease-free and dry ear, the prevention of recurrent disease and the maintenance of hearing or the possibility to reconstruct an affected hearing mechanism. the choice of the surgical technique for chronic ear disease depends on a number of factors including preference of the surgeon, nature of the pathology and the general health of the patient. our results showed that with canal wall up technique the rate of recurrence of disease is significantly higher as compared to those in canal wall down technique. our results are comparable with the published data by hulka and mc elveen et al. in their randomized, blinded study, they suggested that with canal wall up mastoidectomy rate of recurrence was significantly higher as compared to the rate after canal wall down surgery.14 the results of a national comparative audit of 611 mastoidectomies by 55 consultants were published by the royal college of surgeons of england in 1995. the study also showed the higher rate of recurrence after canal wall up mastoidectomies.15 a recent paper by sadé et al which examined the strategies used in cholesteatoma surgery, presented data on 200 cwd procedures found the same higher rates of recurrence after canal wall up procedures.16 gantz et al analyzed 130 cases studied in 2005, and according to his results the recurrence rate after canal wall reconstruction technique was significantly higher and the patients required a repeat surgery.17 a possible explanation of the increased rate of recurrence in cwu technique may due to the fact that external auditory canal wall is conserved. however, preservation of the pneumatized epitympanum and mastoid cavity creates conditions conducive to the development of tympanic retraction pockets and recurrence of cholesteatoma. as pointed out by palva and virtanen, the more air-filled spaces there are, the higher the probability of retraction pockets.18 accordingly, there have been several efforts aimed at reducing the air-filled mastoid cavity. several surgeons have attempted obliteration of the mastoid cavity with abdominal fat or soft tissue after a cwu mastoidectomy and have reported slightly better results with respect to hearing and drum retraction compared with the air space reservoir technique.19 however, a retraction pocket is still developed in the remaining epitympanic space in these techniques. other surgeons have attempted to seal off the mastoid cavity with a bony septum at the antrum level, but the functional result was disappointing because of the absorption of bony septum, which resulted in an incomplete block between the middle ear and the mastoid cavity.20 others also tried combination of canal wall up mastoidectomy and type i tympanoplasty to evaluate the therapeutic effects in terms of disease clearance and hearing improvement, and reported better outcomes.21 our results also showed that with canal wall down technique, the rate of developing complications (conductive deafness, persistent ear discharge and developing a fistula) was significantly higher when compared with those in canal wall up technique. with cwd mastoidectomy, the operation changes the architecture of the ear canal which results in diminished hearing to some degree as a result of this change of architecture. similar findings were observed by kos mi et al, who reported that complication rate was higher with canal wall down surgery.22 hulka and mcelveen in their study concluded that canal wall down mastoidectomy was significantly superior to the intact canal wall technique in visualizing middle ear pathology and in getting permanent eradication of the disease.14 however, they reported significantly higher rate of complications after canal wall down procedure. a national comparative audit published by the royal college of surgeons of england in 1995, reported significantly greater number of "wet" ears with canal wall down than with canal wall up mastoidectomies.15 findings of persistent ear discharge after canal wall down technique reported by sadé et al are comparable to our results.16 gantz bj in his study of 130 cases, reported the same higher rates of complications after canal wall down surgeries.19 several surgeons have improvised to get slightly better results. they reported that the use of endoscope has improved visualization in cwu techniques with better outcomes.23-25 others tried mastoid obliteration with autologous bone and reported it to be safe, low-cost, with low recurrence rates similar to traditional canal wall down procedures and with greater water resistance and quality of life improvements.26-27 in summary, numerous factors help in determining which technique is best. sometimes, this decision is not possible 81 j i m d c 2 0 1 7 81 until the operation has begun and a clear understanding of the extent of disease has been obtained. canal-walldown operations have the highest probability of permanently curing the patient of cholesteatoma but with higher rates of post-surgical complications. canal-wall-up procedures have the advantage of maintaining a near normal anatomy, but they have a higher risk of persistent or recurrent cholesteatomas. the risk of recurrence is sufficiently high so that most surgeons advise an obligatory second-look tympanomastoidectomy, 6 months to 1 year following the initial operation. our study results are similar. keeping in view all the arguments in favor and against different types of surgical techniques, it is difficult to recommend one type as a technique of choice. what surgical procedure would be best for the patient depends on the preference of the surgeon, the nature and extent of the pathology, and the general health of the patient. furthermore, surgeons have personal beliefs regarding specific techniques which are largely based on their own area of expertise. we recommend, that for patients who are difficult to follow, have the extensive disease, or have the disease in an ear with severe to profound hearing loss, cwu surgery may be preferred. c o n c l u s i o n canal-wall-down operations have a higher probability of permanently curing the patient of the cholesteatoma but with higher rates of post-surgical complications. canalwall-up procedures have the advantage of maintaining a near normal anatomy but with a higher risk of residual or recurrent cholesteatomas. choice of a particular surgical procedure depends on the preference of the surgeon, the nature, and extent of the pathology and the general health of the patient. r e f e r e n c e s 1. de azevedo af, pinto dc, de souza nj, greco db, gonçalves du. sensorineural hearing loss in chronic suppurative otitis media with and without cholesteatoma. brazilian journal of otorhinolaryngology. 2007; 73(5):671-4. 2. deantonio r, yarzabal j-p, cruz jp, schmidt je, kleijnen j. epidemiology of otitis media in children from developing countries: a systematic review. int j pediatr otorhinolaryngol. 2016; 85:65–74. 3. chaudhry s, ahmad z, khan fb, afzal m. frequency of otitis media in patients of nasal polypi. j ayub med coll abbottabad jamc. 2010; 22(2):83–5. 4. cho ys, seo is, woo hc, kang mk, chung wh, hong sh. changes in external ear resonance after 3 types of surgery in the patients with chronic otitis media. otolaryngol--head neck surg off j am acad otolaryngolhead neck surg. 2001; 125(4):364–9. 5. minovi a, dombrowski t, shahpasand s, dazert s. audiometric results of open cavity tympanomastoidectomy in advanced attic cholesteatoma. orl. 2015 ;77(3):180–9. 6. anwar k, gohar ms. otomycosis; clinical features, predisposing factors and treatment implications. pak j med sci. 2014; 30(3):564. 7. jindal m, riskalla a, jiang d, connor s, o’connor af. a systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma. otol neurotol off publ am otol soc am neurotol soc eur acad otol neurotol. 2011; 32(8):1243–9. 8. trinidade a, page jc, dornhoffer jl. therapeutic mastoidectomy in the management of noncholesteatomatous chronic otitis media: literature review and cost analysis. otolaryngol--head neck surg off j am acad otolaryngol-head neck surg. 2016; 155(6):914–22. 9. tomlin j, chang d, mccutcheon b, harris j. surgical technique and recurrence in cholesteatoma: a metaanalysis. audiol neurotol. 2013; 18(3):135–42. 10. minovi a, dombrowski t, shahpasand s, dazert s. audiometric results of open cavity tympanomastoidectomy in advanced attic cholesteatoma. orl. 2015; 77(3):180–9. 11. shirazi ma, muzaffar k, leonetti jp, marzo s. surgical treatment of pediatric cholesteatomas. the laryngoscope. 2006; 116(9):1603–7. 12. kim m-b, choi j, lee jk, park j-y, chu h, cho y-s, et al. hearing outcomes according to the types of mastoidectomy: a comparison between canal wall up and canal wall down mastoidectomy. clin exp otorhinolaryngol. 2010; 3(4):203–6. 13. azevedo af de, soares ab de c, garchet hqc, sousa nja de. tympanomastoidectomy: comparison between canal wall-down and canal wall-up techniques in surgery for chronic otitis media. int arch otorhinolaryngol. 2013; 17(3):242–5. 14. hulka gf and mcelveen jt jr: a randomised blinded study of canal wall up versus canal wall down mastoidectomy determining the differences in viewing middle ear anatomy and pathology. am j otol 1998, 19(5):574-578 15. harkness p, brown pm, fowler sm, grant hr, ryan rm and topham jh: mastoidectomy audit: results of the royal college of surgeons of england comparative audit of ent surgery. clin otolaryngol 1995; 20(1):89-94. 16. sadé j: surgical planning of the treatment of cholesteatoma and post-operative follow-up. ann otol rhinol laryngol 2000; 109(4):372-6. 82 j i m d c 2 0 1 7 82 17. gantz bj, wilkinson ep, hansen mr. canal wall reconstruction tympanomastoidectomy with mastoid obliteration. laryngoscope. 2005; 115(10):1734-40 18. palva t, virtanen h. ear surgery and mastoid air cell system. archotolaryngol 1981;107(2):71–3 19. montandon p, benchaou m, guyot jp. modified canal wall-upmastoidectomy with mastoid obliteration for severe chronic otitismedia. orl j otorhinolaryngolrelat spec 1995; 57(4):198–201 20. villarejo pl, banos ec, ramos j.the antrum exclusion technique in cholesteatoma surgery. j laryngol otol 1992; 106(2):120–3 21. zhang l. therapeutic outcomes of canal wall up mastoidectomy in combination with type i tympanoplasty in otitis media. pak j med sci. 2016; 32(3):565–9. 22. kos mi, castrillon r, montandon p, guyot j-p. anatomic and functional long-term results of canal wall-down mastoidectomy. ann otol rhinol laryngol. 2004; 113(11):872–6. 23. badr-el-dine m. value of ear endoscopy in cholesteatoma surgery. otol neurotol off publ am otol soc am neurotol soc eur acad otol neurotol. 2002 ;23(5):631–5 24. ayache s, tramier b, strunski v. otoendoscopy in cholesteatoma surgery of the middle ear: what benefits can be expected? otol neurotol off publ am otol soc am neurotol soc eur acad otol neurotol. 2008; 29(8):1085– 90 25. wahid fi, khan a, khan ia. an otogenic trapezius abscess: a case report. iran j otorhinolaryngol. 2012; 24(68):147. 26. alves rd, cabral junior f, fonseca ac de o, bento rf. mastoid obliteration with autologous bone in mastoidectomy canal wall down surgery: a literature overview. int arch otorhinolaryngol. 2016; 20(1):76–83. 27. suzuki h, ikezaki s, imazato k, koizumi h, ohbuchi t, hohchi n, et al. partial mastoid obliteration combined with soft-wall reconstruction for middle ear cholesteatoma. ann otol rhinol laryngol. 2014; 123(8):571–5 j islamabad med dental coll 2020 219 ope n acce ss giant pulmonary chondroid hamartoma in welder’s lung: a unique case report abdul rasheed qureshi1,2, huma bilal3, muhammad sajid3 1 pulmonologist, gulab devi teaching hospital lahore, pakistan 2 director, institute of biotechnology, gulab devi educational complex lahore, pakistan 3 medical officer, gulab devi teaching hospital lahore , pakistan a b s t r a c t pulmonary hamartomas are benign lung tumors, containing cartilage, connective tissue, fat and usually appear as peripheral lesions. they are 2-4 cm in size, frequently asymptomatic, comprising of 5 –8% of all solitary pulmonary nodules. the peak incidence occurs in 40 -70 years of age with a male preponderance. we describe a unique case of centrally located, giant chondroid hamartoma, in the background of pulmonary hemosiderosis. patient presented with cough, shortness of breath and left sided chest pain, masquerading as pleural effusion, lung cancer and left sided chest pain mimicking myocardial disease. chest x-ray raised the suspicion of pleural effusion but ultrasound and ct-scan indicated a benign calcified central mass. a presumptive diagnosis of cartilage -containing benign mass was made on ultrasound-guided percutaneous biopsy, while surgical resection followed by histopathology revealed a chondroid hamartoma. no recurrence was noted on follow-up. chondroid hamartoma can be large, symptomatic and requires modern modalities for diagnosis while its association with pulmonary hemosiderosis, stil l requires to be investigated. key words: benign lung tumor, pulmonary chondroid hamartoma, welder’s lung correspondence: abdul rasheed qureshi email: drrasheed57@gmail.com article info: received: august 12, 2020 accepted: september 10, 2020 cite this case report: qureshi ar, bilal h, sajid m. giant pulmonary chondroid hamartoma in welder’s lung a unique case report. j islamabad med dental coll. 2020; 9(3): 219-224. doi: 10.35787/jimdc.v9i3.584 funding source: nil conflict of interest: nil i n t r o d u c t i o n hamartoma is defined as a focal lesion, consisting of normal cells at normal site but with faulty arrangement, simulating a tumor. organ architecture is not preserved inside the lesion.1 pulmonary hamartoma was first described by albrecht in 1904. goldsworthy in 1934, defined it as a benign tumor of lung composed, predominantly of a combination of fat and cartilage.2 pulmonary hamartoma has an estimated incidence of 0.0250.032% and constitutes about 5-8% of all solitary pulmonary nodules.3 the hamartoma usually appears rounded with well-defined margins. solitary nodules are commonly encountered in males with peak incidence in 40-70 years, while multiple pulmonary lesions are found in females. 4 if cartilage tissue predominates, it is termed as chondroid hamartoma, which are only 1% of all pulmonary hamartomas.5 the size usually ranges from 1 to 4 cm with average size of 2 cm. majority of the lesions arise from connective tissue in the peripheral lung parenchyma, with only 10% originating from the lining of the bronchi.6 most hamartomas show slow c a s e r e p or t j islamabad med dental coll 2020 220 annual growth and patients are asymptomatic, but some may grow rapidly and exhibit malignant transformation.7 most patients are detected incidentally on x-ray chest or autopsy. symptomatic hamartomas demand for a thorough diagnostic approach, and surgical resection. precise etiology is not known but evidence from cytogenetic analysis points towards recombination of chromosomal bands.8 c a s e r e p o r t our patient was a 63 years old male, five feet eight inches tall, and weighing 74kg. he has been associated with gas and electric arc welding profession for the last forty-five years. he also gave history of cigarette smoking for the past 45 years (55 pack-years), but now has quit smoking in the last two months. he had no history of any other addiction. patient is married with six issues, all alive and healthy. his father suffered from chronic obstructive pulmonary disease (copd). there was no history of bronchial asthma, diabetes mellitus, hypertension, ischemic heart disease or cancer in the family. the patient presented with cough (1.5 years duration), shortness of breath (10 months duration), left-sided chest pain (for the last 6-7 month) and epigastric burning (6 months duration), which was relieved temporarily by various antacids. the cough was not associated with fever, hemoptysis, hoarseness of voice, nasal blockage or any ear problem. according to the patient, shortness of breath was mild initially and responded temporarily to medications from local practitione rs. it worsened with heavy work, but was not associated with tachycardia, palpitation, syncope attacks, orthopnea or swelling of feet. it progressed gradually to grade 2 of modified medical research council (mmrc) dyspnea scale during the last few months. patient also complained of left-sided chest pain for the last six months. pain was dull, continuous and exacerbated with cough or heavy work. it was localized to the back-middle and front-lower aspect of the chest, for which he had to take pain killers off and on. eight years back, patient was treated for pulmonary tuberculosis with a full course of anti-tb drugs for a period of six months. there was no past history of any surgical procedure. on physical examination pulse was 82/min, blood pressure 130/80 mmhg, temperature 98°f and respiratory rate was 26/min. respiratory system findings included abdominothoracic respiration, elliptical chest with a vague bulge on the posterolateral aspect of the left lower chest. chest movements and chest expansion were decreased on the left side. percussion note was dull and air entry was reduced on the left side. crackles and rhonchi were auscultated on both sides of the chest, predominantly on the left side in middle and lower part, while no pleural rub was appreciated. differential diagnosis of pleural effusion, left lung mass, myocardial disease, chronic obstructive pulmonary disease (copd) and gastro-esophageal reflux disease (gerd) were considered. x-ray chest pa view showed an opacity in left lower lung field, obscuring cardiac and diaphragmatic silhouette and obliterating left costophrenic angle, raising the suspicion of pleural effusion and lung mass. transthoracic ultrasonography ruled out pleural effusion and a solid mass measuring 12 cm x 8 cm, containing internal calcifications was noted on the left side (figure 1). high-resolution computed tomography (hrct) thorax reported a calcified left lung mass along with features of pulmonary hemosiderosis (figure 2). ultrasound guided transthoracic tru-cut needle biopsy suggested the diagnosis of a hamartoma or teratoma and excisional biopsy was advised for further evaluation. two sputum sample were tested for acid-fast bacilli (afb) by fluorescent microscopy to rule out j islamabad med dental coll 2020 221 tuberculosis. hematological results were unremarkable (table i). table i: hematological and biochemical tests test result reference value hematological tests hemoglobin 12.8 13-18 g/dl esr 45 1-10 mm1st hour wbc 8.700 4-11 x 103 /µl rbc 4.1 4.5-6.5 hct 32 40-54 % mcv 78 76-96 mch 28 27-32pg mchc 35 30-35 g/dl platelets 175 150-450 x 103 /µl polys 60% 40-75 % lymphocytes 35% 20-45 % monocytes 3% 2-10 % eosinophils 2% 1-6 % biochemical tests serum bilirubin 1.0 0.2-1.1 mg/dl sgot (ast) 31 5-45 µ/dl sgpt(alt) 27 5-42 µ/dl alkaline. phosphatase 257 100-270 µ/dl serum protein 6.8 6-8 g/dl urea 42.0 10-50 mg/dl serum creatinine 1.1 0.5-1.4 mg/dl sodium level 142 135-155 mmol/l potassium level 3.5 3.4-5.5 mmol/l blood sugar random 124 80-160 mg/dl tibc 542 250-450 µg/dl serum ferritin level 24.66 38-457 ng/ml hbs ag negative negative anti hcv negative negative ecg and echocardiography were reported normal. pulmonary function test (pft) revealed moderately severe restriction. bronchoscopy displayed hypervascular mucosa of main bronchial tree and compression from outside of the left main and lower lobar bronchus but no endobronchial mass or foreign body was noted. trans-abdominal ultrasonography showed a 2.2 cm echogenic focus in the right lobe of liver with an impression of hemangioma. metallic depositions were noted in splenic and renal parenchyma (figure 2). the patient underwent left posterolateral thoracotomy and a 14 cm x 10 cm rounded mass, adherent to lung, pericardium and diaphragm was excised in toto and bronchial communication was noted. cut-surface of the mass was grey-white and gritty. histopathology revealed a cartilaginous neoplasm composed of islands of normal cartilage, fibro-adipose tissue with intervening clefts, lined by ciliated respiratory epithelium and finally diagnosed as chondroid hamartoma. postoperative x -ray chest showed complete lung expansion. no residual or recurring tumor was found on follow-up ct scans. pulmonary function tests returned to normal indicating that objective of the surgery has been achieved. patient had an uneventful follow -up nine months after surgery. d i s c u s s i o n this 63-year-old, male patient, diagnosed as chondroid hamartoma is well justified because of age and gender. most of the hamartomas are small in size (2.0-4.0 cm) but this lesion with a size of 14 cm x 10 cm is an uncommon finding. these tumors are usually asymptomatic while our patient presented with an array of symptoms, compromising his pulmonary functions, for which he had to take treatment from various physicians, time and again. on the grounds of history and physical examination findings, this case was initially misdiagnosed as pleural effusion, lung cancer and myocardial disease, making the case atypical. the presence of chondroid hamartoma on the background of pulmonary hemosiderosis is a unique feature, while there is scarcity of medical literature regarding the question of association between the two conditions. the frequency of the tumor (1.0% of all pulmonary hamartomas) additionally, indicates its rare nature. j islamabad med dental coll 2020 222 figure 1: radiology of hamartoma. a. x-ray chest (pa view) showing suspicion of pleural effusion/mass left side. b. ultrasonographic image showing a solid mass with internal calcifications. c & d. hrct-image showing well-defined rounded mass with pop-corn calcification. e. ultrasonographic image of a hemangioma in the right lobe of liver. f. xray chest (pa view) showing complete lung expansion after surgery and chest drain in situ this neoplasm has a slow growth rate while recurrence and malignant transformation are extremely unusual.9 in this case, the lesion has acquired a size of 14 cm within a period of eight years. there was no evidence of the tumor eight years back when he was treated for pulmonary tuberculosis, indicating a comparatively rapid growth rate. older age, history of heavy smoking and hemosiderosis further added to the suspicion of a malignant process.10,11 transcutaneous needle biopsy ruled out malignancy. similarly, a centrally located hamartoma, compressing left main and lower lobe bronchus is also a quite unexpected feature, because over 90% of these lesions occur in a peripheral location.12 risk factors of older age, 55-pack years of cigarette smoking and left-sided chest pain, raised the suspicion of myocardial disease , but ecg and echocardiography ruled out any cardiac problem. xray chest and physical examination suggested pleural effusion, but transthoracic ultrasound indicated a mass lesion with internal calcification (figure 1), reflecting the usefulness of chest ultrasound. hrct described it as a calcified mass. ct scan further reported the presence of multifocal metallic deposition (figure 1) leading to the diagnosis of pulmonary hemosiderosis and highlighting the precision of hrct. metallic deposition was noted in the subcutaneous tissue, hilum, around great vessels of neck, lung, mediastinum, pericardium, spleen and left kidney (figure 2). j islamabad med dental coll 2020 223 figure 2: radiological signs of hemosiderosis. a. sub-cutaneous metallic deposition. b. mediastinal metal deposition. c. metal deposited around great vessel. d. metal deposition within the lung. e. signs of bronchiectasis and ground glass appearance secondary to hemosiderosis. f. metal deposition within splenic parenchyma bronchoscopy was performed to rule out the possibility of concurrent endobronchial hamartoma. while abdominal ultrasound revealed a 2.2 cm hemangioma, in right lobe of liver (figure 1). very rarely, hamartoma become aggressive after surgery, so a follow-up was done at three-month interval and patient remained uneventful up to nine months after surgery. the presentation of a giant, central, rapidly growing, benign hamartoma on the background of welder’s lung is actually the unique feature of this case. there is dearth of literature regarding the question of association between the two pathologies. further work up is required to explore this phenomenon . c o n c l u s i o n this case is reported because of its unique features of a central chondroid hamartoma, associated with pulmonary hemosiderosis, masquerading as pleural effusion, lung cancer and myocardial disease. modern modalities like ultrasound, ct-scan and invasive procedures combined with histopathology can unfold the mystery. furthermore, excisional surgery is curative for symptomatic patients, capable of restoring the normal lung functions. j islamabad med dental coll 2020 224 r e f e r e n c e s 1. leiter hf, restrepo cs, alvarez gómez di, suby-long t, ocazionez d, vargas d. hamartomas from head to toe: an imaging overview. br j radiol. 2017 mar; 90(1071):20160607. doi: 10.1259/bjr.20160607 2. hua x., huang x., liao z, xian q, yu l. clinicopathological and ebv analysis of respiratory epithelial adenomatoid hamartoma. diagn pathol . 2014; 9: 70. doi: 10.1186/1746-1596-9-70 3. rajasekhar s, patnayak r, kale pg, chandra a, jena a. a case of solitary pulmonary nodule (large pulmonary chondroid hamartoma). med j dy patil univ. 2016; 9(6): 744-6. doi: 10.4103/0975-287 0.19 4203 4. fan m, lin y, liu l. multiple pulmonary chondroid hamartoma. j thorac oncol. 2014; 9(7): 1053-1054. doi:10.1097/jto.0000000000000175 5. itoga m, kobayashi y, takeda m, moritoki y, tamak i m, nakazawa k, et al. a case of pulmonary hamartoma showing rapid growth. case rep med. 2013; 2013: 231652. 6. ahmed s, arshad a, mador mj. endobronchial hamartoma; a rare structural cause of chronic cough. respir med case rep. 2017; 22: 224-227. doi: 10.10 16/j.rmcr.2017.08.019 7. byoung jun l, hye-ryoun k, gi jeong c, jae soo k, cheol hyeon k, jae cheol l, et al. squamous cell carcinoma arising from pulmonary hamartoma. clin nucl med. february 2011; 36(2): 130 -131. doi: 10 .1097/rlu.0b013e318203bc27 8. sylvain t, johnson e, michele r, fausto r, marie christine a, john c, et al. formation of the 12q14 -q15 amplicon precedes the development of a welldifferentiated liposarcoma arising from a non chondroid pulmonary hamartoma. the am j surg pathol. october 2006; 30(10): 1326 -9. doi: 10.1097/01.pas.0000213257.69478.2f 9. saadi mm, barakeh dh, husain s, hajjar wm. large multicystic pulmonary chondroid hamartoma in a child presenting as pneumothorax. saudi med j. 2015; 36(4): 487-9. doi: 10.15537/smj.2015.4.10210 10. zheng m, marron rm, sehgal s. hard metal lung disease: update in diagnosis and management. curr pulmonol rep. 2020; 9: 37–46. doi: 10.1007/s13665020-00247-x 11. liu c, wang j, zhu y, chen c. successful use of snare electrocautery via flexible fiberoptic bronchoscopy for removal of an endobronchial hamartoma causing chronic lung atelectasis and mimicking malignancy . ther adv respir dis. 2017; 11(12): 435 –8. doi: 10.1177/1753465817736745 12. kishore m, gupta p, preeti, deepak d. pulmonary hamartoma mimicking malignancy: a cytopathological diagnosis. j clin diagn res. 2016; 10(11): ed06-ed07. doi: 10.7860/jcdr/2016 /22597 .8844. 58 j i m d c 2 0 1 7 58 open access f u l l l e n g t h a r t i c l e efficacy of spot urinary albumin excretion test for the detection of early nephropathy adeeba fakhar 1, syed sohail tanvir 2, ghiasud din butt 3, naghmi asif 4 1 senior registrar, department of nephrology, pakistan institute of medical sciences, islamabad 3 associate professor /head of dept, department of nephrology, pakistan institute of medical sciences, islamabad 3 professor / head of dept, department of nephrology, pakistan institute of medical sciences, islamabad 4 professor, department of pathology islamabad medical & dental college, islamabad a b s t r a c t objective: to compare the effectiveness of spot urinary microalbumin excretion for detection of early diabetic nephropathy in comparison with 24 hours urinary proteins in patients with diabetes mellitus. materials and methods: the study was conducted at nephrology department of pakistan institute of medical sciences, islamabad. it included diagnosed cases of type 1 or 2 diabetes mellitus, (with type 2 diabetes of any duration and type 1 diabetes of more than 5 years duration) who tested negative for overt albuminuria on standard urinary dipstick done on two occasions. each patient was provided a plastic container with capacity of 4000 ml for 24 hours collection of urine. the study group subjects were requested to provide early morning urine sample for spot urine test. urinary microalbumin was determined by the immunoturbidimetric method. 24-hour urinary albumin excretion was determined by photometric test according to biuret method. spss version 12 was used to record and analyze the gathered data. descriptive statistic and frequencies of the spot urine albumin and 24 hours urinary albumin were measured. the sensitivity, specificity, negative predictive value, positive predictive value, accuracy and efficacy of spot urine microalbumin test was calculated in comparison to 24-hour urine protein test. results: out of 289 patients of diabetes mellitus included in the study, 39 (13.5%) had type 1 diabetes mellitus and 250 (86.5%) had type 2 diabetes mellitus. the mean age of the patients was 54.079.5 years. among total patients 113 (39.1%) patients had positive 24-hour urine protein and 98 (33.9%) had positive spot urine microalbumin test. the sensitivity, specificity, positive predictive value and negative predictive value of the spot urinary microalbumin test in comparison to 24-hour urine protein test was 83%, 97.7%, 96% and 90% respectively. in total spot urinary microalbumin test was accurate in 92% cases. when the results of spot urine microalbumin test and 24-hour urinary protein test were compared using the chi-square test, it was found that patients with a positive spot urine microalbumin test had a statistically significant probability of having a confirmed diabetic nephropathy on 24-hour urinary protein test; p= 0.00. conclusion: spot urine microalbumin test is a highly sensitive and specific tool in the diagnosis of early diabetic nephropathy with high positive predictive value. spot urine microalbumin test offers the advantage of speed, simplicity and early diagnosis. spot urine microalbumin test has acceptable accuracy as compared to 24-hour urine protein test. key words: albuminuria, diabetes mellitus, microalbumnuria, nephropathy, proteinuria, spot urinary albumin author`s contribution 1active participation in active methodology, interpretation and discussion 2synthesis and planning of the research, conception-, review the study, 3,4 review and paper writing address of correspondence adeebaammad@yahoo.com article info. received: dec 29, 2016 accepted: may 21, 2017 cite this article: fakhar a, tanvir ss, but gd, asif n. efficacy of spot urinary albumin excretion test for the detection of early nephropathy. jimdc. 2017; 6(2):58-63. funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e mailto:adeebaammad@yahoo.com 59 j i m d c 2 0 1 7 59 i n t r o d u c t i o n diabetes mellitus (dm) is one of the major illness affecting 284 millions of people worldwide. it caused approximately 88014 deaths in pakistani population at the end of year 2010, according to international diabetes federation.1 diabetic nephropathy affects 25 percent of patients with diabetes that progress to chronic renal failure.2 it occurs both in type 1 and type 2 dm. diabetic kidney disease presents in its earliest stage with microalbuminuria (defined as albumin–to–creatinine ratio between 30-299 μg albumin/milligram of creatinine) in the urine, also called as incipient nephropathy. with the disease progression, urine albumin levels increase until the patient develops overt proteinuria (defined as more than 300mg per 24 hours or more than 200 mcg per minute). overt proteinuria is followed by a gradual decrease in glomerular filtration rate that ultimately leads to kidney failure.3 increased urinary protein excretion is the earliest clinical manifestation of diabetic nephropathy.4,5 however, when assessing protein excretion, the urine dipstick is a relatively insensitive marker for initial increases in protein excretion, not becoming positive until protein excretion exceeds 300 to 500 mg/. using a specific assay for albumin is a more sensitive technique. the normal rate of albumin excretion is less than 20 mg/day (15 µg/min); persistent albumin excretion between 30 and 300 mg/day (20 to 200 µg/min) is called microalbuminuria and, in patients with diabetes (particularly type 1 diabetes), is often indicative of early diabetic nephropathy, unless there is some coexistent renal disease. protein excretion above 300 mg/day (200 µg/min) is considered to represent macroalbuminuria (also called overt proteinuria, clinical renal disease, or dipstick positive proteinuria).6 in general, immunoassay methods are the standard for measurement of microalbuminuria, and comprise four different techniques. these include, ria (radioimmunoassay), elisa (enzyme-linked immunosorbent assay), rid (radioimmunodiffusion) and immunoturbidometry. these four methods have a similar level of sensitivity and specificity, and are used in different areas according to the resources available.7 immunoturbidometry is more frequently used because of its greater simplicity. microalbuminuria is considered as a reliable predictor of nephropathy in diabetic patients. early detection of microalbuminuria is pivotal because the condition at this stage is potentially reversible, and appropriate treatment may prevent progressive diabetic renal damage.8 diagnosis of microalbuminuria can be carried out by number of approaches however three most common methods used are measurement of albumin-to-creatinine ratio on a spot urine test, albumin from a 24-hour urine collection, and albumin from a timed collection (e.g.10 hours overnight).9 twenty-four hours’ quantitative assessment of albuminuria is considered as gold standard but it is time consuming and sometimes difficult for the patient to understand the voiding and collection precautions.10 spot urinary test is practical with negligible collection errors. role of spot urine test in the primary prevention of diabetic nephropathy is clearly understood to detect the change from normal urinary albumin excretion to microalbuminuria with regular follow up.11 predictive power of urinary proteins, changes over the time as the disease progresses. positive test indicates disease duration of more than 05 years.12 there is no definitive “cure” for diabetic nephropathy, but if it is diagnosed at early stage, its progression can be slowed down with good glycemic and weight control, optimized blood pressure and other factors effecting its progression.13 this study was designed to evaluate the efficacy of spot urinary albumin excretion for detection of early diabetic nephropathy in comparison with 24 hours urinary proteins in patients with diabetes. operational definitions diabetic nephropathy: it is a condition in diabetic patients that damages on kidney function. it starts with microalbuminuria, proteinuria and progresses to kidney failure. if we can detect microalbuminuria early then we can slow down the disease process, even reverse it in microalbuminuria stage. this is the stage in diabetic nephropathy when overt proteinuria is not present i.e. the routine dipstick proteinuria will be absent. however, they may have microalbuminuria detected on either 24-hour urine sample or spot urine microalbuminuria testing. the urine dipstick is also a relatively insensitive marker for 60 j i m d c 2 0 1 7 60 initial increases in protein excretion, not generally becoming positive until protein excretion exceeds 300 to 500 mg/day. spot urinary albuminuria it is an immunoturbidimetric technique by which microalbuminuria can be detected in a spot urine sample. 24 hours urinary albumin it is the gold standard method to calculate the renal loss of protein over 24 hours for the correct estimation of the proteins to access the renal failure. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at nephrology department, pakistan institute of medical sciences, islamabad, over 6 months’ time. in total 289 patients diagnosed with type 1 diabetes (of more than 5 years duration) or type 2 diabetes of any duration, of either gender and negative for overt albuminuria on standard urinary dipstick done on two occasions were included in the study. patients with overt proteinuria, known chronic kidney disease, patients with urinary tract infections, hematuria of any cause, nephrolithiasis, hypertension, febrile illness, patients recently using nephrotoxic drugs, chronic liver failure, hepato-renal syndrome, organ transplant, kidney transplant, liver transplant, immunocompromised states, hiv-aids, patients with known malignancy, those on chemotherapeutic agents and pregnant females were excluded from the study data were collected on a specially designed performa. institutional ethical committee approved this study and a written informed consent was obtained from all subjects. a random sample of 289 subjects with type 1 & 2 dm were included in the study, provided they were negative on routine urinary dipstick testing on two occasions in their initial outdoor visit using (multistix 10, sg, bayer, bridgend, uk. each demographic details were documented. each patient was provided, a plastic container with capacity of 4000ml for 24 hours collection of urine. oral and written instructions on how to collect 24hour urine were given. patients were directed to start the 24 h urine collection immediately after discarding their first void of urine in the morning, and to include a final void at completion of the collection period. between 7 and 9 am, when patients went to the laboratory to deliver the collected urine, they were asked to collect (via the midstream technique) a fasting spot urinary sample for uac. the renal status of the subjects was assessed by the serum creatinine levels. the study group subjects were requested to provide early morning urine sample for spot urine test or a sample (collected anytime between 8 am – 8 pm) and 24 hours urine sample. the urinary albumin was estimated in both the 24 hours and spot urine samples. the two samples were processed immediately and analyzed by two different technicians; the values were unknown to each other. urinary microalbumin was determined by the immunoturbidimetric method. reference value was 0-25 mg/l and range of 0-400 mg/l with a detection limit of 0.7 mg/l. 24-hour urinary albumin excretion was determined by photometric test according to biuret method. spss version 12 was used to record and analyze the gathered data. descriptive statistic and frequencies of the spot urine albumin and 24 hours urinary albumin were measured. the sensitivity, specificity, negative predictive value, positive predictive value, accuracy and efficacy of spot urine microalbumin test was calculated in comparison to 24-hour urine protein test. r e s u l t s the study included 289 patients with dm, who did not have overt proteinuria on routine urine dipstick testing on two occasions. demographic characteristics of the patients are presented in table 1. table 1: demographic characteristics of study population (n=289) age (years) range (mean± sd) 22-66(54.06±9.5) gender males; n(%) females; n(%) 155 (53.63) 134 (46.37) type of dm type 1 dm; n(%) type 2 dm; n(%) 39 (13.49) 250 (86.50) 61 j i m d c 2 0 1 7 61 figure 1: 24 hour urinary protein among 289 patients with diabetes, 113 (39.1%) patients had positive 24-hour urine protein and 176 (60.9%) patients had negative 24-hour urine protein (figure 1). total 98 patients (33.9%) had positive spot urine microalbumin test and 191 (66.1%) had a negative spot urine microalbumin test (figure 2). figure 2: microalbuminuria the calculated sensitivity (tp/tp+fn) of the spot urine microalbumin test in comparison to 24-hour urine protein test was 83%. the calculated specificity (tn/tn+fp) of the spot urine microalbumin test in comparison to 24-hour urine protein test was 97.7%. the calculated positive predictive value (ppv=tp/tp+fp) of the spot urine microalbumin test in comparison to 24-hour urine protein test was 96%. the calculated negative predictive value (npv=tn/tn+fn) of the spot urine microalbumin test in comparison to 24-hour urine protein test was 90%. in total spot urinary microalbumin test, accuracy (tp+tn/tp+tn+fp+fn) was 92%. when the results of spot urine microalbumin test and 24-hour urinary protein test were compared using the chi-square test it was found that patients with a positive spot urine microalbumin test had a statistically significant probability of having a confirmed diabetic nephropathy on 24-hour urinary protein test; p= 0.00 (table 2). d i s c u s s i o n measurement of albumin excretion in a 24-h urine collection has long been the “gold standard” for quantitative evaluation of albuminuria in diabetic patients; however, collection errors due to improper timing and missed samples may lead to significant overand underestimation of albuminuria. for convenience and consistency, the american diabetes association and the national kidney foundation have recently recommended measurement of albumin-to-creatinine ratio (acr) in a random spot urine collection for the diagnosis of microalbuminuria. the guidelines recommended using a first-morning sample because of the potentially higher correlation with 24-h albumin excretion, but a random sample is also considered acceptable if a first-morning specimen is not available. the significance of microalbuminuria is that it is the predictor of clinical proteinuria and chronic renal failure in insulin dependent diabetes mellitus (iddm) and the early index of cardiovascular morbidity and mortality as well as diabetic nephropathy in non-insulin dependent diabetes mellitus (niddm). therefore, it is important to assess the validity of a random urine sample as a screening test of diabetic nephropathy. previous studies have also shown that albumin measurements in a random urine sample presented almost perfect accuracy for the screening of microand macroalbuminuria in diabetic patients and suggested it as a valid test in screening for diabetic nephropathy.14 the study clearly shows that the spot microalbuminuria test provides an equivalent result compared to 24 hours in both type 1 and 2 diabetics. our table 2: efficacy of spot urine microalbumin test 24-hour urine protein pvalue positive negative 0.00 spot urine microalbumin positive tp = 94 fp = 4 negative fn = 19 tn =172 60.9% 39.1% 33.9% 66.1% 62 j i m d c 2 0 1 7 62 study also concludes that spot urine samples can be effectively used to detect microalbuminuria in patients of diabetes mellitus especially in the pakistani subset of diabetics. some patients have microalbuminuria at the time of diagnosis, which may be due to previously undiagnosed diabetes or some other disease that is responsible for the microalbuminuria. microalbuminuria is associated with declining kidney function, progression to macroalbuminuria, and increased long-term mortality. however, remission to normoalbuminuria may occur. factors associated with remission include short duration of microalbuminuria, better glycemic control, better blood pressure control, and use of ace inhibitors or angiotensin receptor blockers. diabetic nephropathy is the commonest cause of renal failure in end-stage renal disease [esrd]. mortality rates in these patients during dialysis are much higher than they are for non-diabetic cases. given the worldwide high prevalence of both diabetes and hypertension, and of renal involvement in both disorders, it is important to detect renal disease promptly–through screening for microalbuminuria– when it is still at the reversible stage, in order to reduce both mortality and treatment cost in those affected. in type 1 diabets, approximately 20 to 30 percent will have microalbuminuria after a mean duration of diabetes of 15 years.15 less than half of these patients will progress to overt nephropathy. microalbuminuria may regress or remain stable in a substantial proportion, probably related to glycemic and blood pressure control. various studies have reported that the renal prognosis of type 1 diabetes, including the rate of progression to esrd, has dramatically improved over the last several decades.16 the prevalence of progressive renal disease has generally been lower in type 2 diabetes than in type 1 disease. however, current data suggest that the renal risk is equivalent in the two types of diabetes.3 in both types there is regression of microalbuminuria with good glycemic control.17 apart from glycemic control various risk factors have been found associated with development of overt nephropathy in these patients. these include genetic susceptibility (more chances of nephropathy in patients having diabetic sibling or parent) age (increased risk with increasing age and increases duration of disease in type 2 diabetes/ lower risk in patients diagnosed before the age of 5 years in type 1 diabetes), obesity (increased bmi related to higher glucose level), hypertension, smoking and use of oral contraceptives etc.18-21 microalbuminuria is now widely recognized as a sign of abnormal vascular function and increased vascular permeability. it has also been considered the first indication of renal injury in patients with diabetes. in addition, accumulating evidence suggests that microalbuminuria is associated with a higher cardiovascular risk as well as with a higher mortality independent of other risk factors. thus screening for microalbuminuria is currently recommended for all patients with diabetes or kidney disease because it also provides valuable information about their cardiovascular risk profile. in a study conducted on a total of 717 adult diabetic in diabetes centere in tokyo, japan, a strong relationship was found between acrs measured from first-morning and spot urine samples, yielding a linear correlation on a logarithmic scale.22 other studies have also proved that convenient and accurate protein: creatinine ratio on random urine samples is a reliable method for estimation and screening of early proteinuria than the quantification by collection of 24 hours urine samples 23-25 c o n c l u s i o n spot urine microalbumin test is a highly sensitive and specific tool in the diagnosis of early diabetic nephropathy with high positive predictive value. spot urine microalbumin test offers the advantage of speed, simplicity and early diagnosis. spot urine microalbumin test has fairly acceptable accuracy as compared to 24hour urine protein test. r e f e r e n c e s 1. http://www.diabetesatlas.org/content/prevalenceestimates-diabetes-mellitus-dm-2010. 2. winter w. diabetic nephropathy: the role of microalbumin testing 2003;11:4. 3. thorp m. diabetic nephropathy. am fam physician 2005;72:96–99. 4. k/doqi clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. am j kidney dis 2007;49:12. http://www.diabetesatlas.org/content/prevalence-estimates-diabetes-mellitus-dm-2010 http://www.diabetesatlas.org/content/prevalence-estimates-diabetes-mellitus-dm-2010 63 j i m d c 2 0 1 7 63 5. gross, jl, de azevedo, mj, silveiro, sp. diabetic nephropathy: diagosis, prevention, and treatment. diabetes care 2005; 28:164 6. eknoyan g, hostetter t, bakris gl, hebert l. proteinuria and other markers of chronic kidney disease: a position statement of the national kidney foundation (nkf) and the national institute of diabetes and digestive and kidney diseases (niddk). am j kidney dis 2003;42:617. 7. burtis ca, tietz er. textbook of clinical chemistry (2nd edition). 988-91 (1994) 8. ricardo c, gonzalez l. kidney international 2005;68:69– 75. 9. molitch m, defronzo r, franz m, keane w, mogensen c. nephropathy in diabetes. diabetes care 2004;27:79–83. 10. thorp m. diabetic nephropathy. am fam physician 2005;72:96–99. 11. tabaei b, al-kassab a, ilag l, zawacki c, herman w. does microalbuminuria predict diabetic nephropathy? diabetes care 2001;9:1560-1566. 12. brantsma a, bakker s, zeeuw d, jong p, gansevoort r. extended prognostic value of urinary albumin excretion for cardiovascular events. j am soc nephrol 2008;19:178591. 13. kidney disease outcomes quality initiative (k/doqi). k/doqi clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. am j kidney dis 2004; 43:1–290. 14. shahbazian n, hosseini-asl f. a comparison of spot urine protein-creatinine ratio with 24-hour urine protein excretion in women with preeclampsia. ijkd 2008;2:12731. 15. newman dj, mattock mb, dawnay ab. systematic review on urine albumin testing for early detection of diabetic complications. health technol assess 2005; 9:iii. 16. finne p, reunanen a, stenman s. incidence of end-stage renal disease in patients with type 1 diabetes. jama 2005; 294: 1782. 17. araki s, haneda m, sugimoto t. factors associated with frequent remission of microalbuminuria in patients with type 2 diabetes. diabetes 2005;54: 2983. 18. pavkov me, bennett ph, knowler wc. effect of youthonset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged pima indians. jama 2006; 296:421. 19. svensson m, nystrom l, schon s, dahlquist g. age at onset of childhood-onset type 1 diabetes and the development of end-stage renal disease: a nationwide population-based study. diabetes care 2006; 29:538. 20. gelber rp, kurth t, kausz at. association between body mass index and ckd in apparently healthy men. am j kidney dis 2005;46:871. 21. ahmed sb, hovind p, parving hh. oral contraceptives, angiotensin-dependent renal vasoconstriction, and risk of diabetic nephropathy. diabetes care 2005;28:1988. 22. babazono t, takahashi c, iwamoto y. definition of microalbuminuria in first-morning and random spot urine in diabetic patients. diabetes care 2004;27:1838-9 23. rm.hasanato. diagnostic efficacy of random albumin creatinine ratio for detection of micro and macroalbuminuria in type 2 diabetes mellitus. saudi med j. 2016 mar; 37(3): 268–273. 24. vyankatesh t. anchinmane, shilpa v. sankhe. evaluation of protein: creatinine ratio on random urine samples in assessment of proteinuria int j res med sci. 2016 dec;4(12):5201-5203. 25. jayasekara jmkb, dissanayake dm, gunaratne mdn, amunugama k. estimation of 24 hour protein in ckd patients by analyzing the protein/creatinine ratio of four spot urine samples. inter j scie res pub. 2013;3(3):1-5. https://www.ncbi.nlm.nih.gov/pubmed/?term=hasanato%20rm%5bauthor%5d&cauthor=true&cauthor_uid=26905348 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4800890/ j islamabad med dental coll 2021 9 open access auricular cartilage interposition arthroplasty in recurrent temporomandibular joint ankylosis in pediatric patients ahmad liaquat1, arun kumar shah2, nabeela riaz3 1assistant professor, department of oral and maxillofacial surgery, university college of medicine and dentistry, university of lahore, pakistan 2senior lecturer, department of oral and maxillofacial surgery, chitwan medical college, nepal 3professor & head, department of oral and maxillofacial surgery, king edward medical university, lahore, pakistan a b s t r a c t background: temporomandibular joint (tmj) ankylosis in early childhood can lead to disturbances in growth, facial asymmetry and difficulties in eating as well as in breathing. the objective of the study was to evaluate the effectiveness of auricular cartilage as an interpositional material after gap arthroplasty in pediatric patients with temporomandibular joint ankylosis in maintaining the achieved postoperative mouth opening. material and methods: this prospective study was conducted at the oral and maxillofacial surgery department of king edward medical university, lahore, from 1st january 2019 to 30th november 2019. thirty patients, aged 5 to 15 years with clinical and radiological diagnosis of tmj ankylosis were included in the study. tmj ankylotic mass was removed, the gap was created and interposition of auricular cartilage graft was done in these patients. mouth opening was measured as a distance between the incisal edges of mandibular central incisors to maxillary central incisors using the scale. preoperative and postoperative mouth opening was noted and compared using the paired t -test. results: among the thirty patients, 19 were male and 11 were female. the mean (±sd) age of patients was 9.23±3.23 years (age range 5 to 15 years). the mean preoperative mouth opening (t1) was 7.3±3.1 mm, while the mean postoperative mouth opening (t2) was 29.2±3.3 mm. the mean interincisal distance was 29.0 mm (range 21 mm to 35 mm). the mean difference in pre and postoperative mouth opening (t2 -t1) was 21.6 ± 5 mm. conclusions: autogenous auricular cartilage graft is an efficient and reliable interpositional material for achieving early postoperative mouth opening in tmj ankylosis patients. key words: auricular cartilage graft, temporomandibular joint ankylosis, trismus. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: ahmad liaquat email: ahmadliaquat@hotmail.com article info: received: may 2, 2020 accepted: march 3, 2021 cite this article. liaquat a, shah ak, riaz n. auricular cartilage interposition arthroplasty in recurrent temporomandibular joint ankylosis in pediatric patients . j islamabad med dental coll. 2021; 10(1): 9-14. doi: 10.35787/jimdc.v10i1.545 funding source: nil conflict of interest: nil i n t r o d u c t i o n temporomandibular joint ankylosis (tmj) is characterized by difficulty or limited mouth opening. tmj ankylosis is associated with feeding problems, occlusal disharmony, upper airway obstruction, inability to maintain oral hygiene, dental caries, and facial asymmetry in developing children. 1 in tmj or i gi n a l a r ti c le j islamabad med dental coll 2021 10 ankylosis, the condyle of mandible fuses with the articular surface of the temporal bone and limits the mouth opening. development of tmj ankylosis in childhood causes facial disfigurement, nutritional imbalances due to inability to eat food and psychological problems.1 trauma to the mandible or tmj is the leading cause of ankylosis in paedriatic population (13-100%).2 other etiological factors include systemic or local infection (40%) or systemic diseases (10%), such as rheumatoid arthritis, ankylosing spondylitis, and psoriasis in the adult patient.2 orhan guven described a higher rate of post-traumatic ankylosis in children.3 a study conducted in pakistan showed peak incidence of tmj ankylosis in 6-10 years and the most common causes for tmj ankylosis were reported as fall (82.8%) and dysphonia (66.7%) due to impairment of upper airways. dysphasia, facial deformity, and psychological disturbances are consequences of tmj ankylosis.2,4 treatment of tmj ankylosis is very challenging because of frequent recurrences. 5 however, gap arthroplasty and insertion of interposition material to prevent re-ankylosis is the mainstay of treatment. gap arthroplasty without interposition results in recurrence of ankylosis in almost 53% of patients.2 timing of the surgery and choice of the interposition material may vary from center to center, but the main treatment is the same. interpositional materials separate the condylar area from the glenoid fossa, so their anchorage and viability are very important.6 various types of interposition materials have been used in the literature for augmentation of height of ramus and prevention of re -ankylosis. these materials are autologous grafts (rib grafts, auricular cartilage, temporalis fascia etc.) and alloplastic material (silastic material, custom-made titanium condylar prosthesis etc.). temporalis fascia with or without temporalis muscle is the most commonly used interpositional material because of its proximity to the operating site and being a pedicled flap, it can resist the wear and tear forces. 7,8 auricular cartilage is another reliable graft present very close to the operating site and has been used as an interposition graft after tmj ankylosis surgery with good results.8 the main advantages include safety, viability, preserving the function of the condyle, non-antigenicity and low donor site morbidity. availability of auricular graft adjacent to the surgical field makes it the most attractive choice for surgeons.9 auricular cartilage is fixed to the condyle by sutures. the rationale of this study was to evaluate the auricular cartilage as an interpositional material in terms of maintaining the postoperative mouth opening. although different types of autogenous graft and alloplastic material are used for interposition, no material has produced uniformly successful results. limited data is available on the use of auricular cartilage as an interpositional material in recurrent tmj ankylosis cases. moreover, a previous study using auricular cartilage was conducted on a small number of patients (n=10).9 so the present study was designed to generate more reliable results for our local population. m a t e r i a l a n d m e t h o d s this prospective study was conducted at the oral and maxillofacial surgery department of king edward medical university, lahore, pakistan from 1st january 2019 to 30th november 2019. approval for the study was obtained from the ethical review board of the university (reference number 1697/18). patients aged 5 to 15 years with unilateral and bilateral or recurrent tmj ankylosis were included in the study. patients with an ear deformity or medically unfit for surgery were excluded. after explaining the outcome of surgical procedures to every patient, informed consent was taken from j islamabad med dental coll 2021 11 their parents/guardians before the scheduled surgery. to diagnose tmj ankylosis, orthopantomograms and computer tomography was done. for removal of fibrous adhesions or ankylotic mass, preauricular incision was used. dissection was done layer by layer to reach up to the ankylotic mass, preserving the zygomatic and temporal branches of the facial nerve. ankylotic mass was removed and auricular cartilage graft was harvested from the posterior aspect of the helix. the auricular cartilage was secured with condyle using proline sutures. postoperative management was done in the ward until the removal of sutures. mouth opening was measured from the incisal edges of mandibular central incisor to maxillary central incisor by the scale. mouth opening was measured preoperatively (t1) and recorded. postoperative mouth opening was measured after three months (t2). the mean difference of mouth opening (t2-t1) was calculated for each patient, using the paired t-test with p-value < .05 considered as statistically significant. r e s u l t s among the thirty patients included in this study 19 were males and 11 were females. the mean (± sd) age of the patients was 9.23 ± 3.23 years. the mean preoperative mouth opening (t1) was 7.3±3.1 mm. there was no significant difference among male and female patients in terms of preoperative mouth opening (p = .29). the mean postoperative mouth opening (t2) was 29.2 ± 3.3 mm, with no significant difference among male and female patients ( p = .99). the mean difference in preand postoperative mouth opening (t2-t1) was 21.6 ± 5 mm, which was statistically significant (p < .001). seventeen patients (56.66%) had unilateral tmj ankylosis with 58.82% (n=10) having right-sided and 41.17% (n=7) patients having left-sided tmj ankylosis. thirteen patients (43.33%) had bilateral tmj ankylosis. the most common cause of tmj ankylosis was history of fall (80%), followed by roadside accidents (13.33%) and birth trauma (6.67%). table i: gender wise comparison of preand postoperative mouth opening male female mean age (years) 9.47 ± 3.2 8.82 ± 3.4 mean preoperative mouth opening (mm) 7.6 ± 3.5 7.8 ± 2.4 mean postoperative mouth opening (mm) 29.8 ± 3.3 28.2 ± 3 mean difference in mouth opening 22.3 ± 5.7 20.4 ± 3.2 paired t value -22.3 -20.4 95% ci -25.0 to -19.5 -22.5 to -18.2 p-value* < .001 < .001 *p-value < .05 was considered statistically significant table ii: duration of tmj ankylosis duration of ankylosis (years) n (%) 1-2 8 (26.67) 2-4 13 (43.33) >5 9 (30) total 30 d i s c u s s i o n this study aimed to evaluate auricular cartilage as an interpositional material in gaining the postoperative mouth opening. tmj is a main part of the joint of the temporal region. ankylosis of the joint in a growing child may result in disfigurement of the face, difficulty in eating, speech, and maintaining oral hygiene. tmj ankylosis can result in retrognathic mandible, causing cosmetic and functional deformities. the main objective of treatment is to correct the jaw opening and prevent the development of disfigurement and psychological distress.10 tmj ankylosis is classified according to the type of tissue involved (bony, fibrous, or both), location j islamabad med dental coll 2021 12 (intracapsular or extracapsular), and extent of fusion (incomplete or complete).11 in children, the head of the condyle is small, so its injury can result in hemarthrosis. pain causes the hypomobility of the joint, which in turn favors bone formation leading to ankylosis.12 tmj can be infected by infection of the ear or distal spread from scarlet fever or tuberculosis.13 trauma to the mandible and in the tmj region is the leading cause of ankylosis in children. many cases with previous history of trauma to the chin or a history of fall and trauma to jaws in childhood develop trismus later on in life.14 they become nutritionally deficient and trismus also poses a great hindrance in maintaining good oral hygiene. so, these patients have severe malaligned teeth and caries. due to mandibular retrognathism and facial disfigurement, these patients are socially rejected and develop psychological issues. many graft materials are available, which can be classified as autologous or alloplastic. grafts from the clavicle, iliac crest, costochondral, auricular cartilage and dermal fat are considered autologous grafts.15 alloplastic grafts include silicon, protoplast, and acrylic, etc.15 alloplastic material have adverse effects like foreign body reactions, infection, instability, and extrusion. therefore, alloplastic material is not the preferred choice. among the autogenous materials, cartilage has many physiological and mechanical advantages. it is available within the same operative field with less donor site morbidity. the study by krishnan showed that the shape of the cartilage is well-fitting the condylar process, and maintaining its viability thus helping in the condyle function. he reported temporary facial nerve paralysis in two patients. 9 in our study, temporary facial nerve paralysis was observed in five patients. postoperative use of steroids resolved the facial injury and only one patient had permanent damage to the frontal branch of the facial nerve. the injury occurred during surgery as branches of the facial nerve were in the course of the surgical site. it was not related to the choice of graft. there was no donor-site morbidity noted in our cases. in this study, 30 patients were included, out of which 63% were male and 37% were female. ten patients had recurrent tmj ankylosis. the patients’ age ranged from 5 to 15 years with a mean±sd of 9.23±3.23 years, which is comparable to the study conducted by gupta et al., where the mean±sd age was 11.1±3.3 years.16 similarly, out of 87 patients reported from the orthodontic and oral and maxillofacial surgery departments of khyber college of dentistry, 63.2% were male and 35.6% were female, ranging from 2 to 16 years.1 however, svensson et al. reported 18 patients with 15 females and three males and a mean age of 39 years.17 figure 1. a: preoperative mouth opening. b: postoperative mouth opening in the same patient . figure 2: exposure of ankylotic mass by preauricular incision. j islamabad med dental coll 2021 13 figure 3: a shows harvesting of auricular cartilage, while b reveals harvested cartilage. krishnan reported the mean preoperative mouth opening to be 2.5 mm in his study while svensson et al. reported 28 mm.9,17 muller et al. reported the preoperative mouth opening to be 17 mm in their single patient study.18 in the present study, the preoperative mean mouth opening was 7.6±3.5 mm for males and 7.8±2.4 mm for females and the range of mouth opening preoperatively for males and females was 3-15 mm and 4-12 mm respectively with a mean preoperative mouth opening of 7.7 mm. this is somewhat comparable to the study by krishnan9 but varies considerably from figures reported by svensson et al. 17 the mean postoperative mouth opening in our study was 29.2 mm, which is comparable to 29.6 mm reported by krishnan.9 other studies report variable figures of 5mm (muller et al.) 18 and 35 mm (svensson et al.),17 respectively. the postoperative mouth opening of all these studies is comparable.9 the similarity in the postoperative mouth opening but the variability in preoperative mouth opening may be because of the time of surgery and duration of tmj ankylosis. we followed-up our patients for two years, but after that many patients were lost to follow-up. the most frequent etiology of tmj ankylosis in the pediatric population is fall history.1 in our study, 80% of patients had ankylosis secondary to fall history. children do not perform postoperative physiotherapy regularly that resulted in re -ankylosis in our cases. these patients should be put on a longterm follow-up to see re-ankylosis. we found this graft very useful in recurrent cases of tmj ankylosis where temporalis fascia or muscles have already been used, so we recommend its use in recurrent cases of tmj ankylosis. future studies are suggested to explore its long-term effects in maintaining the jaw opening. c o n c l u s i o n an autogenous auricular cartilage graft is good interpositional material for the successful treatment of tmj ankylosis pediatric patients in terms of achieving adequate postoperative mouth opening. r e f e r e n c e s 1. murad n, rasool g. trauma as a most commo n cause of tmj ankylosis. j pak oral dent j. 2011; 31 (1): 45-47. 2. khan za, alam j, khan s, abid h, warriach ra. correlation between childhood chin trauma, condylar fracture and tmj ankylosis. pak oral dent j. 2010; 30 (1): 47-51. 3. güven o. a clinical study on temporomandibular joint ankylosis in children. j craniofac surg. 2008; 19(5): 1263-9. doi: 10.1097/scs.0b013e318157 7b1b. 4. shetty p, thomas a, sowmya b. diagnosis of temporomandibular joint (tmj) ankylosis in children. j indian soc pedod prev dent. 2014; 32(3): 266. doi: 10.4103/0970-4388.135848. 5. chen s, he y, an jg, zhang y. recurrence -related factors of temporomandibular joint ankylosis: a 10 year experience. j oral maxillofac surg. 2019; 77(12): 2512-21. doi: 10.1016/j.joms.2019.06.172. 6. goswami d, singh s, bhutia o, baidya d, sawhney c. management of young patients with temporomandibular joint ankylosis—a surgical and anesthetic challenge. indian j surg. 2016; 78 (6): 4829. doi: 10.1007/s12262-016-1551-5. 7. guruprasad y, chauhan ds, cariappa km. a retrospective study of temporalis muscle and fascia flap in treatment of tmj ankylosis. j maxillofac oral surg. 2010; 9(4): 363-8. doi: 10.1007/s12663-0100139-z. j islamabad med dental coll 2021 14 8. makwana r, ranadive p, deshpande m. use of temporalis fascia flap in the treatment of temporomandibular joint ankylosis–a clinical audit of 5 years. int j oral maxillofac surg. 2015; 44(supp 1): e108.doi: 10.1016/j.ijom.2015.08.691 . 9. krishnan b. autogenous auricular cartilage graft in temporomandibular joint ankylosis—an evaluation . oral maxillofac surg. 2008; 12(4):189 -93. doi: 10.1007/s10006-008-0136-2. 10. gulsen a, sibar s, ozmen s. orthognathic treatmen t of facial asymmetry due to temporomandibular joint ankylosis. arch plast surg. 2018; 45(1): 74 -9. doi: 10.5999/aps.2016.01774. 11. he d, yang c, chen m, zhang x, qiu y, yang x, et al. traumatic temporomandibular joint ankylosis: our classification and treatment experience. j oral maxillofac surg. 2011; 69(6): 1600 -7. doi: 10.1016/j.joms.2010.07.070. 12. ramly ep, jason wy, eisemann bs, yue o, alfonso ar, kantar rs, et al. temporomandibular joint ankylosis in pediatric patients with craniofacial differences: causes, recurrence and clinical outcomes. j craniofac surg. 2020; 31(5): 1343-7. doi: 10.1097/scs .0000000000006328. 13. he d, ellis iii e, zhang y. etiology of temporomandibular joint ankylosis secondary to condylar fractures: the role of concomitant mandibular fractures. j oral maxillofac surg. 2008; 66(1): 77-84. doi: 10.1016/j.joms.2007.08.013. 14. kaban lb, bouchard c, troulis mj. a protocol for management of temporomandibular joint ankylosis in children. j oral maxillofac surg. 2009; 67(9): 1966 78. doi: 10.1016/j.joms.2009.03.071. 15. park mw, eo my, seo by, nguyen tt, kim sm. gap arthroplasty with active mouth opening exercises using an interocclusal splint in temporomandibular joint ankylosis patients. maxillofac plast reconstr surg. 2019; 41: 18. doi: 10.1186/s40902 -019-0200-x. 16. gupta vk, mehrotra d, malhotra s, kumar s, agarwal gg, pal us. an epidemiological study of temporomandibular joint ankylosis. natl j maxillofac surg. 2012; 3(1): 25. doi: 10.4103/09755950.102146. 17. svensson b, wennerblom k, adell r. auricular cartilage grafting in arthroplasty of tmj: a retrospective clinical follow-up. oral surg oral med oral pathol oral radiol endod. 2010; 109(3): e1 -e7. doi: 10.1016/j.tripleo.2009.10.029. 18. mueller ck, thorwarth mw, mosgau ss. combined treatment protocol for tmj ankylosis. j craniofac surg. 2009; 20(1): 258-60. doi: 10.1097/scs.0b013e31818432fb. j islamabad med dental coll 2020 168 open access health capacity and vulnerability in context of covid-19 outbreak: an analysis of 185 countries usama waqar1, shaheer ahmed2, daniyal ali khan1 1medical student, aga khan university medical college, karachi, pakistan 2medical student, islamabad medical and dental college, islamabad, pakistan a b s t r a c t background: the coronavirus disease 2019 (covid-19) pandemic has affected most countries, afflicting severe damage. mitigation measures to control the pandemic rely heavily on existing health capacity and vulnerability of each country. the health capacity and vulnerability with respect to covid-19 outbreak for 185 countries was assessed in this study to identify those where capacity-building needs to be prioritized. material and methods: the state parties annual reporting data based on who international health regulations monitoring and evaluation framework was used to extract an indicator for national health capacity. another indicator for vulnerability was extracted from inform epidemic risk index. these metrics were selected after evaluating their complementarity and availability. results: among 185 countries, 111 (60%) had health capacities at level 4 and 5 with most of them having vulnerability at level 3 and 4. twenty-two (11.89%) countries had level 2 health capacity in place coupled with moderate to high vulnerability. among continents, europe had best while africa had worst mean functional capacity and vulnerability scores. conclusions: the results showed that most countries had sufficient response and reaction capacities to handle the pandemic. however, resources, intensified surveillance, and capacity building should be prioritized in vulnerable countries with ill-equipped national health capacities. key words: covid-19 pandemic, disease outbreaks, epidemiology, international health regulations authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: abdul usama waqar email: usamawaqar777@gmail.com article info: received: july 23, 2020 accepted: september 25, 2020 cite this article. waqar u, ahmed s, khan da. health capacity and vulnerability in context of covid-19 outbreak an analysis of 185 countries. j islamabad med dental coll. 2020; 9(3): 168-174. doi: 10.35787/jimdc.v9i3.567 funding source: nil conflict of interest: nil i n t r o d u c t i o n in december 2019, an outbreak of viral pneumonia of unknown cause was reported in wuhan, china, which was identified as a novel coronavirus (2019ncov).1 coronaviruses are rna viruses found widely in humans and other mammals.2 while they are mostly associated with mild diseases, coronaviruses have previously caused two major epidemics: severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov) epidemics.3 or i gi n a l a r ti c le j islamabad med dental coll 2020 169 following the spread of the novel coronavirus (now called sars-cov-2) outside china, the who declared the outbreak a pandemic.4 as of 10th july 2020, 12,102,328 cases of coronavirus disease 2019 (covid-19) and 551,046 associated deaths have been confirmed worldwide.5 usa has been hit the hardest with 3,038,325 cases and 131,884 deaths. meanwhile in china, where the first case was identified, the highest number of new cases diagnosed was on 5th of february 2020. 6 for each country, the potential to limit and control this pandemic depends upon its ability of rapid identification of suspected cases, case isolation, early diagnosis, contact tracing, and follow-up. however, this is limited by the existing national health capacity and vulnerability to the pandemic. health capacity is determined by the existing healthcare delivery system, public health infrastructure, and diagnostic infrastructure. national vulnerability is influenced by socioeconomic, demographic, ecological, and political characteristics that can influence the mitigation measures. the international health regulations (ihr) monitoring and evaluation framework is developed by who to help countries evaluate and strengthen their capacities to prevent, detect, assess, and respond effectively to potential public health risks and emergencies.7 it consists of a mandatory annual reporting component and three voluntary components: after-action review, simulation exercise and voluntary external evaluation. 7 we analyzed the ihr monitoring and evaluation framework to generate an indicator for national health capacity while another indicator was used to assess vulnerability for 185 countries in light of the covid-19 pandemic.7 m a t e r i a l a n d m e t h o d s who provides the state party self-assessment annual reporting (spar) and joint external evaluation (jee) tools to countries for uniform mandatory annual reporting and voluntary external evaluation processes.8,9 spar is based on internal evaluation while jee combines both internal and external evaluations to promote transparency.7 however, jee mission reports were only available for 95 who member states from 2016 to 2019.10 spar 2019 data was unavailable for 29 member states, and spar 2018 was used for 25 of these. 11 indicators of health capacity were extracted from spar and jee data (supplementary material p 1). both these metrics assess national health capacity by accounting for physical infrastructure, health delivery system, management capacity, chemical hazards, and radiation hazards.8,9 inform epidemic risk index (ieri) and infectious disease vulnerability index (idvi) were used to extract indicators for vulnerability.12,13 all indicators were rescaled from 0-100 with increasing health capacity and decreasing vulnerability (table i). a multivariate correlation analysis was performed to identify the most complementary pair of metrics (figure s1 supplementary material p 2). the analysis showed a high correlation between health capacity indicators from spar and jee, and between vulnerability indicators extracted from ivdi and ieri. after reviewing the availability and complementarity of potential pairs, we decided to use the spar-ieri pair for capturing health capacity and vulnerability of 185 countries (supplementary material p 3). the methodology employed for extraction and selection of indicators for health capacity and vulnerability in this study was influenced by the methodology of marius and colleagues. 14 j islamabad med dental coll 2020 170 r e s u l t s 111 (60%) out of 185 included countries were found to have a health capacity at level 4 or 5. among these, canada, malaysia, and russia had the highest health capacity (spar = 99.22; figure 1) with moderate to low vulnerability (53, 53, and 55 respectively). the remaining 108 members states mostly had vulnerability at level 3 and 4 (48 and 51 countries respectively) while 9 countries were found to have vulnerability at level 2. table i: criteria for defining levels in this study level indicator score health capacity vulnerability 1 ≤20 very low very high 2 ≤40 low high 3 ≤60 moderate moderate 4 ≤80 high low 5 >80 very high very low 22 (11.89%) countries had health capacity at level 2 with 19 of them having vulnerability at level 2 and 3. bosnia and herzegovina, equatorial guinea, and gabon were found to have vulnerability at level 4 among these 22. central african republic had the lowest health capacity at level 1 with a level 2 vulnerability (spar = 17.78; ieri = 24). none of the countries included were found to have vulnerability at level 1 or 5. among the worst-hit countries (confirmed cases ≥200,000), most countries had health capacity at level 4 or 5 and vulnerability at level 3 and 4. exceptions included pakistan and peru in terms of health capacity (level 3; 44.11 and 49.00 respectively) and india and turkey in terms of vulnerability (level 2; 34 and 40 respectively). in the least hit group (cases ≤5,000), most countries had health capacity and vulnerability at levels 3 and 4. among the continents, europe had the highest mean spar and ieri scores while africa had the lowest (table ii). figure 2 represents a comparison between the health capacity and vulnerability among the six continents. d i s c u s s i o n covid-19 pandemic has brought unprecedented disasters with over half a million associated deaths and severe economic recession. with vaccine expected no earlier than 2021, its management, control and prevention are the only methods available to mitigate the crisis. rapid identification of suspected cases, isolation, diagnosis, contact tracing, and follow-up are crucial to break the lines of transmission and limit further spread. this has proved to be a public health challenge for all countries and is even worse for those with high vulnerabilities and limited functional health capacities. we found that most countries had adequate spar health capacity scores with moderate to low vulnerability to respond to the covid-19 pandemic. however, our results should be interpreted carefully. these health capacity scores often corresponded to different contributions to mean spar indicators, reflecting different aspects of a country’s functional health capacity. for example, brazil and israel both had same health capacity score (83.67). brazil had a score of 100 in surveillance capacity and 40 in health service provision while israel scored 80 in surveillance and 100 in health service provision. another limitation in this study was the use of self-reported spar data from 2018 and 2019 which lacked an independent verification from external evaluation processes. the use of joint external evaluation data would have been useful in this case, but it was available for a limited number of countries only. most of the countries (18 out of 23) with insufficient functional health capacities and moderate to high vulnerability were found to be in africa. africa also has some of the poorest countries in the world, and j islamabad med dental coll 2020 171 figure 1: spar capacity and ieri vulnerability of 185 countries afg=afghanistan. alb=albania. dza=algeria. ago=angola. atg=antigua and barbuda. arg=argentina. arm=armenia. aus=australia. aut=austria. aze=azerbaijan . bhs=bahamas. bhr=bahrain. bgd=bangladesh. blr=belarus. bel=belgium. blz=belize. ben=benin. btn=bhutan. bih=bosnia and herzego vina. bwa=botswana . bra=brazil. bgr=bulgaria. bfa=burkina faso. bdi=burundi. cpv=cabo verde. khm=cambodia. cmr=cameroon. can=canada. caf=central african republ ic. tcd=chad. chl=chile. chn=china. col=colombia. com=comoros. cog=congo. cri=costa rica. civ=côte d'ivoire. hrv=croatia. cub=cuba. cyp=cyprus. cze=czech republic. dpr=democratic people’s republic of korea. cod=democratic republic of the congo. dnk=denmark. dji=djibouti. dma=dominica. dom =dominican republic. ecu=ecuador. egy=egypt. slv=el salvador. gnq=equatorial guinea. eri=eritrea. est=estonia. swz=eswatini. eth=ethiopia. fji=fiji. fin=finland. fra=france. gab=gabon. gmb=gambia. geo=georgia. grc=greece. deu=germany. gha=ghana. gtm=guatemala. gin=guinea. gnb=guinea -bissau. guy=guyana. hti=haiti. hnd=honduras. hun=hungary. isl=iceland. ind=india. idn=indonesia. irn=iran. irq=iraq. irl=ireland. isr=israel. ita=italy. jam=jamaica. jpn=japan. jor=jordan. kaz=kaz akhstan. ken=kenya. kir=kiribati. kor=republic of korea. kwt=kuwait. kgz=kyrgyzstan. lao=lao people's democratic republic. lva=lat via. lbn=lebanon. les=lesotho. lbr=liberia. lby=libya. ltu=lithuania. lux=luxembourg. mdg=madagascar. mwi=malawi. mys=malaysia. mdv=maldives. mli=mali. mlt= malta. mai=marshall islands. mrt=mauritania. mus=mauritius. mex=mexico. mic=federated states of micronesia. mda=republic of moldova. mng=mongolia. mne=montenegro. mar=morocco. moz=mozambique. mmr=myanmar. nam=namibia. nau=nauru. npl=nepal. nld=netherlands. nzl=new zealand. nic=nicaragua. ner=niger. n ga=nigeria. mkd=north macedonia. nor=norway. omn=oman. pak=pakistan. pal=palau. pan=panama. png=papua new guinea. pry=paraguay. per=peru. phl=philippines. pol=poland. prt=portugal. qat=qatar. rou=romania. rus=russian federation. rwa=rwanda. kna=saint kitts and nevis. lca=saint lu cia. vct=saint vincent and the grenadines. sam=samoa. stp=sao tome and principe. sau=saudi arabia. sen=senegal. srb=serbia. syc=seychelles. sle=sierra leone . sgp=singapore. svk=slovakia . svn=slovenia. sol=solomon islands. som=somalia. che=switzerland. zaf=south africa. ssd=south sudan. esp=spain. lka=sri lanka. sdn=sudan. sur=suriname. swe=sweden. syr=syrian arab republic. taj=tajikistan. tza=united republic of tanzania. tha=thailand. tls=timor -leste. tgo=togo. ton=tonga. tto=trinidad and tobago. tun=tunisia. tur=turkey. tuk=turkmenistan . tuv=tuvalu. uga=uganda. ukr=ukraine. are=united arab emirates. gbr= united kingdom of great britain and northern ireland. usa=united states of america. ury=uruguay. uzb=uzbekistan. van=vanuatu. ven=venezuela. vnm=viet nam. yem=ye men. zmb=zambia . zwe=zimbabwe table ii. mean spar health capacity and ieri vulnerability of the continents continent countries included mean spar mean ieri africa 54 48.24 ± 15.43 45·35 ± 10.78 asia 45 71.67 ± 17.79 53.93 ± 11.77 europe 40 75·20 ± 15.06 63.50 ± 7.37 north america 20 69.56 ± 18.01 59.00 ± 7.89 oceania 14 60.32 ± 19.27 54.43 ± 6.44 south america 12 70.29 ± 12.30 60.42 ± 5.91 j islamabad med dental coll 2020 172 figure 2: comparison of spar and ieri among the continents the healthcare infrastructure there requires significant improvements to be self-sufficient against pandemics like covid-19.15 similarly, 9 out of 10 countries with least number of doctors per 10,000 population are based in africa. it also has the 10 countries with least health expenditure per capita.16 hence, efforts are being made to assist africa during the pandemic. an african task force for coronavirus preparedness and response (aftcor) has been established to help with diagnoses, surveillance, prevention and control, treatment, risk communication, and supply chain management.17 these capacity-building efforts might have contributed to the effectiveness of african countries to respond and should be prioritized for other high risk areas as well. we found that the spar and ieri scores are linked to the wealth of the countries. high-income countries, i.e. oman and qatar, etc., often had better functional health capacity with less vulnerability while the contrary was true for most low -income countries. this is important because the outbreak in the worst-hit countries has highlighted that covid19 can rapidly strain existing hospital capacity and require significant investments to maintain the required capacity.18 a potential exacerbation of outbreak would require development of more quarantine facilities, ventilators, and other health infrastructure which can be an added challenge for these resource-limited countries. however, it was found that high-income countries with high spar and ieri scores have been mostly hit harder by the pandemic than those with low scores. europe has been affected worst and earliest while the least-affected are african countries. this can be explained by different case importation risks for africa and europe (1% vs 11%, respectively).14 having learned from ebola, african countries started issuing recommendations to avoid travel to china following case importations in europe along with other measures to strengthen their preparedness.19 however, cases are still increasing in some resourcelimited countries, i.e. pakistan. resource investment in preventative measures like africa should be prioritized to avoid a potential exacerbation in these j islamabad med dental coll 2020 173 vulnerable countries with inadequate functional health capacities. another underlying factor which might have contributed to the difference between high-income and low-income countries could be their experience with previous outbreaks. low-income countries often experience relatively more outbreaks, making them battle-hardened. according to who, 265 outbreaks were reported between 2018 and 2020, out of which only 8 were in europe (5 in france, 2 in netherlands, and 1 in the uk).20 the covid-19 pandemic requires extensive coordinated efforts at the global, national, and subnational levels to allow countries to respond and control the outbreak. our findings should be triangulated with other risk assessments available for covid-19 to help inform prioritization for intensified support in terms of deployment of resources and assistance in developing response and reaction capacities. countries with limited capacities can also use these findings to invest resources in capacity-building efforts to be better prepared for any future public health emergency. limitations: spar data was self-reported and lacked external verification. the use of jee would have been more transparent as it employs external evaluation processes. however, jee data was only available for 95 countries, so it could not be used. another limitation was the unavailability of spar 2019 data for 29 countries, and we relied on spar 2018 for 25 of these. these included antigua and barbuda, belarus, belize, bulgaria, cook islands, estonia, fiji, finland, haiti, iran, italy, kiribati, malaysia, marshall islands, montenegro, nauru, new zealand, papua new guinea, samoa, san marino, solomon islands, somalia, tonga, tuvalu, and vanuatu. c o n c l u s i o n countries vary in terms of health capacity and vulnerability to the covid-19 outbreak with most of them having sufficient functional capacities in place to respond. however, cases are significantly increasing in some vulnerable and ill-equipped countries. our findings can help policymakers identify the lack of response and reaction capacities in their countries which can lead to urgent capacitybuilding efforts, improving the effectiveness of pandemic mitigation measures. supplementary material : https://jimdc.org.pk/index.php/jimdc/article /view/567/460 r e f e r e n c e s 1. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020; 382(8): 727-33. doi: 10.1056/nejmoa2001017 2. richman d, whitley r, hayden f. clinical virology . washington, usa: asn press; 2016. 3. petrosillo n, viceconte g, ergonul o, ippolito g, petersen e. covid-19, sars and mers: are they closely related? clin microbiol infect. 2020; 26(6): 729-734. doi: 10.1016/j.cmi.2020.03.026 4. world health organization. rolling updates on coronavirus disease (covid-19). 2020. available from: https://www.who.int/emergencies/diseas e s / novel-coronavirus-2019/events-as-they-happen 5. world health organization. coronavirus disease 2019 (covid-19) situation report-202. 2020. available from: https://www.who.int/docs/defau l t source/coronaviruse/situation-reports/20200809covid-19-sitrep-202.pdf?sfvrsn=2c7459f6_2. 6. gourinchas p-o. flattening the pandemic and recession curves. mitigating the covid economic crisis: act fast and do whatever. 2020;31. https://voxeu.org/content/mitigating-covideconomic-crisis-act-fast-and-do-whatever-it-takes 7. world health organization. international health regulations (2005): ihr monitoring and evaluatio n https://jimdc.org.pk/index.php/jimdc/article/view/567/460 j islamabad med dental coll 2020 174 framework. geneva: world health organization; 2018. 8. world health organization. international health regulations (2005): state party self-assessmen t annual reporting tool. geneva: world health organization; 2018. 9. world health organization. joint external evaluatio n tool: international health regulations (2005). geneva: world health organization; 2018. 10. world health organization. joint external evaluatio n (jee) mission reports. available from: https://www.who.int/ihr/procedures/missionreports/en/. 11. world health organization. electronic state parties self-assessment annual reporting tool. available from: https://extranet.who.int/e -spar. 12. karmen p, montserrat mf, luca v, laura m. incorporating epidemics risk in the inform global risk index. luxembourg: publications office of the european union; 2018. doi:10.2760/990429 13. moore m, gelfeld b, okunogbe at, paul c. identifying future disease hot spots: infectious disease vulnerability index. santa monica, usa: rand corporation; 2016. 14. gilbert m, pullano g, pinotti f, valdano e, poletto c, boëlle p-y, et al. preparedness and vulnerability of african countries against importations of covid-19: a modelling study. lancet. 2020; 395(10227): 871 -77. doi: 10.1016/s0140-6736(20)30411-6 15. martinez-alvarez m, jarde a, usuf e, brotherton h, bittaye m, samateh al, et al. covid-19 pandemic in west africa. lancet glob health. 2020; 8(5): e631 e632. doi: 10.1016/s2214-109x(20)30123-6 16. world health organization. global health observatory data repository. 2020. available from: https://apps.who.int/gho/data/?the me=main#ndx h 17. nkengasong jn, mankoula w. looming threat of covid-19 infection in africa: act collectively, and fast. lancet. 2020; 395(10227): 841 -42. doi: 10.1016/s0140-6736(20)30464-5 18. news aj. as coronavirus spreads in europe, hospital s are overwhelmed. available from: https://www.aljazeera.com/news/2020/03/coronav irus-spreads-europe-hospitals-overwhelmed200325072333193.html. 19. monde l. coronavirus: l'afrique en état d'alerte. available from: https://www.lemonde.fr/afriq u e / article/2020/01/28/coronavirus-l-afrique-sur-sesgardes_6027538_3212.html. 20. world health organization. emergencies preparedness, response: disease outbreaks by year 2020. available from: https://www.who.int/csr / d o n /archive/year/en/. 234 j i m d c 2 0 1 7 234 open access f u l l l e n g t h a r t i c l e diagnostic accuracy of ivu compared to unenhanced ct kub for detection of urinary tract calculi fatima imran 1, zonia zaman 2, muhammad javaid iqbal 3 1 associate professor, department of radiology, aziz fatimah hospital, faisalabad 2 professor, department of obstetrics and gynecology, aziz fatimah hospital, faisalabad 3 postgraduate resident haematology, department of haematology, shifa international hospital, islamabad a b s t r a c t objective: to compare the diagnostic accuracy of ivu to unenhanced ct kub for detection of urinary tract calculi. patients and methods: this cross-sectional study was carried out at department of radiology, aziz fatimah hospital faisalabad, from october 2016 to july 2017. all the patients having suspected urolithiasis or ureteric colic indicating urolithiasis and referred to the radiology department for ivu or ct kub were selected in study sample. all the patients were briefly described about the study and informed written consent was obtained. a sample of 83 suspected patients of urolithiasis were included in the study sample. all patients in study sample who were referred for ct kub or ivu were offered the other test free of cost. all the information including demographics, ivu and ct kub were recorded on a predesigned performa. the data was entered and analyzed on spss version 21. results: there were 48 (57.83%) males and 35 (42.17%) female patients. the mean age of the patients was 46.58 ± 9.42 years, ranging from 25 to 60 years. the final diagnosis showed that there were 59 (71.10%) positive patients for renal or ureteric stone. on the basis of ivu screening test 45 (54.21%) patients were positive, 38 (45.78%) were negative and 21.69% (16/83) patients had inconclusive results. ct kub diagnosed 58 (69.87%) positive and 25 (30.12%) negative patients. the diagnostic parameters of ivu were considerably poor as compared with the ct kub having sensitivity (72.08%), specificity (91.67%), ppv (95.56%), npv (57.89%) and accuracy of 78.31%. the sensitivity, specificity, ppv, npv and accuracy of 96.61%, 95.83%, 98.28%, 92.00% and 96.39% respectively. conclusion: ct kub provides more efficient information about the patients, presenting with acute renal colic. it has significantly higher rate of diagnosing urolithiasis in comparison of ivu. key words: ct kub, diagnostic accuracy, ivu, renal colic, urolithiasis. author`s contribution 1, conception, synthesis, planning of research and manuscript writing 2,3 interpretation and discussion data analysis, interpretation, manuscript writing and active participation in data collection address of correspondence fatima imran email: dr.fatimaimran@gmail.com. article info. received: october 6, 2017 accepted: november 7, 2017 cite this article. imran f, zaman z, iqbal m.j. diagnostic accuracy of ivu compared to unenhanced ct kub detection of urinary tract calculi. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n renal and ureteric stone disease is very prevalent globally and affects a large population throughout the world. it is equally prevalent among all races and cultures. there is no variation in its occurrence with respect to geographic areas of the world. its incidence is increasing both in developed and developing countries from last few decades. the foremost cause for this increasing trend is considered as obesity due to life style changes and sedentary living habits.1 acute loin pain due to renal or ureteric stone is a common diagnosis in the accident and emergency department. a stone in the kidney alone does not warrant emergency management apart from superimposed infection, but a stone impacted within the ureter requires prompt diagnosis, urological referral and o r i g i n a l a r t i c l e 235 j i m d c 2 0 1 7 235 urgent intervention in specific circumstances. the classical clinical symptoms of ureteric colic, such as loin pain that radiates to the groin, vomiting and microscopic hematuria, frequently overlap with other clinical presentations such as pyelonephritis, appendicitis, gynecological problems or diverticulitis. therefore, imaging plays an important role in obtaining an accurate diagnosis with this clinical presentation so that the patient can be promptly triaged into the correct clinical management pathway.2, 3 urolithiasis is not life threatening condition but it can cause very severe complications including chronic renal disease and infections so its proper management is essential for better prognosis of the patients. the recurrence rate of urolithiasis is also quite high which makes its proper management more crucial. the initial diagnosis, planning of the treatment and efficacy of the treatment of urolithiasis is mainly dependent upon imaging studies of urolithiasis.4 there are many imaging modalities, which are commonly used for study of urolithiasis, and with time, these modalities are improving in identification of ureteric stones. for the radiological study of ureter, bladder and intra renal collecting system, intravenous urography (ivu) has been used as modality of choice for a long time. it has quite high sensitivity (6687%) and specificity (92-94%) in diagnosing ureteric stones.2,5 in patients with raised level of serum creatinine, contrast material cannot be used so in such patients imaging modalities are required, which can effectively diagnose ureteric diseases without use of contrast materials. the imaging modalities, which can be used, include combination of plain abdominal radiography (kub) and gray scale ultrasound (us) kidney, ureter and bladder.6, 7 another imaging modality which has got a lot of attention these days is unenhanced ct (ct kub). it is used mainly for assessment of suspected renal colic but now it has become primary screening tool for diagnosis of urolithiasis with a high sensitivity and specificity. this test is being prescribed by all specialists along with urologists. a disadvantage of ct kub is its greater exposure to radiations. previous studies have shown very high sensitivity (> 95%) and specificity (96%) for diagnosis of ureteric stones. this technique has many other advantages of faster speed of acquisition without any administration of intravenous contrast and easy availability. the multi-detector ct has further enhanced the management of urolithiasis.8, 9 non-enhanced ct (nect) is equal to the ivu in diagnosing the obstruction and more reliable in diagnosing nephrolithiasis. an added advantage of ct over ivu is its ability to diagnose other causes of flank pain, such as appendicitis or acute gynecological conditions. radiation dose is currently one of the major disadvantages of ct.10 when ct is available, it is the study of choice in the nonpregnant adult presenting with flank pain. ivu is still the best investigation if nect is not available. p a t i e n t s a n d m e t h o d s this cross sectional validation study was carried out at department of radiology, aziz fatimah hospital faisalabad, from october 2016 to july 2017. all the patients having suspected urolithiasis or ureteric colic indicating urolithiasis and referred to the radiology department for ivu or ct kub were selected in study sample. all the patients were briefly described about the study and informed written consent was obtained. after taking ethical approval from the institutional ethics committee a sample of 83 suspected patients of urolithiasis were included in the study sample. the sample size was calculated by who sample size calculator with sensitivity (93.6%) and specificity (95.6%), expected prevalence of 40% and with required precision level of 7% and confidence level of 95%. patients of both genders and age range of 25 to 60 years were included in the study. patients, who presented with history of urolithiasis in last 6 months, or patients having positive finding on any imaging modality for urological problems and patients having renal disease were excluded from the study. patients who were pregnant or who had renal function impairment or previous allergic reaction to contrast medium were also excluded from this study. all patients in study sample who were referred for ct kub or ivu were offered the other test free of cost. the non-enhanced ct (nect) were obtained on a 16 slice helical ct scanner (tosihba alexion). all scans were obtained from the upper border of t12 vertebral body to the lower border of symphysis pubis, without the use of oral or intravenous contrast material. patients were placed in supine position with full urinary bladder at the 236 j i m d c 2 0 1 7 236 time of the non-enhanced ct (nect). additional prone films were taken whenever the radiologist needed a better description of suspected distal ureteric calculi. the ct report was reviewed by consultant radiologist on workstation (with 1mm reconstructed images in coronal, sagital and axial planes) for the diagnosis of a stone in the urinary tract or secondary cause of obstruction. for ivu, a plain abdominal film was taken at the beginning of the examination. after intravenous administration of non-ionic contrast medium (contrast calculated according to weight of the body), 5 minutes’ anteroposterior view, 15 minutes anteroposterior and bilateral oblique views, 30 minutes’ anteroposterior view and post voiding view were taken. further delayed images were taken if necessary. the final diagnosis was confirmed according to the endoscopic evaluation, operative findings, pathology report and follow-up course for at least 3 months. all the information including demographics like name, age, gender, results of ivu and ct kub were recorded on a predesigned performa. the data was entered and analyzed with spss v 21. a 2x2 cross table was used to calculate sensitivity, specificity, positive predictive value and negative predictive values. r e s u l t s in this cross sectional validation study a total of 83 suspected patient of urolithiasis were included, among them 48 (57.83%) were males and 35 (42.17%) were female patients. the mean age of the patients was 46.58 ± 9.42 sd years, ranging from 25 to 60 years. most of the patients 37 (44.58%) were of age > 45 years followed by 29 (34.94%) patients in the age interval of 35-45 years. seventeen (20.48%) patients were in the age interval 2535 years. (table 1). the final diagnosis was confirmed according to the endoscopic evaluation, operative findings, pathology report and follow-up course for at least 3 months. the final diagnosis showed that 59 (71.10%) patients were diagnosed as positive for renal or ureteric stone and 24 (28.91%) patients were negative for urolithiasis. among these patients, two had concomitant renal cell carcinoma and one had transitional cell carcinoma. among the patients who were negative for ureteric stone, 15 (62.50%) had no certain urologic abnormality. six (25%) patients were confirmed with acute pyelonephritis and 3 (12.5%) pelvic mass. table 1: demographic characteristics of the patients characteristics frequency percentage gender of the patients male 48 57.83 female 35 42.17 age of the patients 25 60 years mean ± sd 46.58 ± 9.42 range 25-35 17 20.48 35-45 29 34.94 > 45 37 44.58 the results of the diagnostic tests showed that 45 (54.21%) patients were positive and 38 (45.78%) were negative for urolithiasis on the basis of ivu screening test, having a rate of true positive as 43 (72.88%) and true negative as 22 (91.67%). (table 2). table 2: diagnostic results of the ivu and ct kub final diagnosis positive negative total final result on ivu positive 43 2 45 negative 16 22 38 final results on ct kub positive 57 1 58 negative 2 23 25 total 59 24 83 based on ivu study 21.69% (16/83) patients had inconclusive results on the basis of ivu and further required other imaging investigations. in patients of pyelonephritis there were no significant findings on ivu study, but ct images showed clear unilateral renal enlargement with fat stranding adjacent to peri and pararenal areas as classic inflammatory changes. the results on the basis of ct kub showed that there were 58 237 j i m d c 2 0 1 7 237 (69.87%) positive and 25 (30.12%) negative patients for urolithiasis in the study. the rate of true positive and true negative cases in ct kub were noted as 57 (96.61%) and 23 (95.83%) respectively as elaborated in table 2. according to the results of the study, the diagnostic parameters of ivu were considerably poor as compared with the ct kub having sensitivity (72.08%), specificity (91.67%), positive predictive value (95.56%) and negative predictive value of (57.89%). the accuracy of ivu for detection of urolithiasis is 78.31%. the sensitivity, specificity, positive predictive value and negative predictive value of ct kub for detection of urolithiasis is 96.61%, 95.83%, 98.28% and 92.00% respectively. according to the results, the accuracy of ct kub for diagnosis of urolithiasis was found to be 96.39% as given in table 3. table 3: diagnostic accuracy of ivu and ct kub diagnostic parameters ivu ct kub sensitivity 72.08% 96.61% specificity 91.67% 95.83% positive predictive value 95.56% 98.28% negative predictive value 57.89% 92.00% accuracy 78.31% 96.39% d i s c u s s i o n there is some limitation of normal abdominal radiography (kidney, ureter and bladder (kub) alone, when it is used for diagnosis of urolithiasis. the factors which can confound the results include bowel gas, large physical stature of the patient and extra renal calcification. factors like these have a very poor effect on sensitivity of kub radiography for diagnosis of renal or ureteric stones. although ultrasound is cost effective and easily available modality but it has reduced accuracy for detection of suspected renal stones. this diagnostic accuracy does not have any added advantage of experienced radiologist for diagnosis of ureteric calculi.11 some advanced imaging modalities like unenhanced helical ct has become very popular and acceptable for diagnosis of suspected ureteric stones. it has become primary investigation technique for evaluation of urinary tract calculi. the reason of its popularity is because of very high sensitivity which ranges from 95%–98% and specificity ranging from 96%–100%.12 additional advantages of ct over other imaging techniques is that it does not require contrast medium; it can be performed very rapidly. the ct has the ability of diagnosing small size stones along with large ones. the ct also has the capacity to identify the urinary and extra urinary abnormalities.13,14 recent studies have found increasing prevalence of urolithiasis worldwide. past literature shows that urolithiasis was most common in male patients as compared to females. however, this trend is changing and the incidence of urolithiasis is increasing considerably in female patients. this rising incidence of urinary stone is alarming because it has direct effect on cost involved, morbidity including complication like chronic renal failure and risk of infections in the patient.15 in this present study the proportion of female patients has been observed quite high (57.83% vs 42.17%) as compared to previous some studies who have noted a considerably lower rate of female patients as compared to males like in study of chaudhry et al, in which the ratio of female patients was very low (27.5% vs. 57.5%) as compared to male patients.16 similar results were found in a study of nadeem m et al, who found 30% females and 70% male patients.17 literature shows that it has significantly higher prevalence in males as compared to females. the common age interval of its occurrence is 30 to 60 years.18 in this study the mean age of the patients was 46.58 ± 9.42 years, ranging from 25 to 60 years. in patients of urolithiasis the diagnosis, management and follow up, all is dependent on imaging. the use of different imaging modalities has a long history; many techniques have been in practice for diagnosis of urolithiasis. the commonly used imaging modalities by urologist include plain radiography of kidneys, ureter and bladder (kub), ivu, ultrasound (us), magnetic resonance urography (mru) and computed tomography (ct), each with its advantages and limitations. ivu has been accepted as a gold standard technique for a long time in diagnosis of ureteric stones. recently, new imaging modalities like non-enhanced computed tomography is getting more reputation as a 238 j i m d c 2 0 1 7 238 diagnostic tool for urolithiasis. the reason being its ease in performing the test and high sensitivity and specificity.19 in patients diagnosed with urolithiasis, the proper treatment and follow up is essential, which is possible through imaging. the imaging techniques used for follow up are postoperative x-ray kub or ivu for the assessment of outcomes after treatment and recurrence. these imaging modalities are not very sensitive for identification of small stones or residuals fragments. nonenhanced ct is considered as more sensitive for proper detection of residual fragment and better decision making for prognosis of the patient. when kub and us are used alone for follow up of ureteroscopy, according to a recent study the results of diagnosis for urolithiasis can be overestimated with kub and us alone.20 according to the previous studies, ct kub has many advantages over ivu. especially for ureteric stones, it is the most preferred modality these days. it also has higher diagnostic accuracy over other imaging modalities. it has sensitivity and specificity of 96-100% respectively.17 another advantage of ct over ivu is its proficiency of identifying renal colic with alternate causes of flank pain. according to the results of this present study, ivu showed a sensitivity (72.08%), specificity (91.67%), positive predictive value (95.56%) and negative predictive value of (57.89%). the accuracy of ivu for detection of urolithiasis was 78.31%. the sensitivity, specificity, positive predictive value and negative predictive value of ct kub for detection of urolithiasis was noted to be 96.61%, 95.83%, 98.28% and 92.00% respectively. according to the results, the accuracy of ct kub for diagnosis of urolithiasis was found to be 96.39%. the results are in agreement with previous findings of different studies like studies of nadeem m, ather mh and rekant mn who found similar sensitivity parameters of ct kub.17, 21, 22 a study by amin z et al, revealed a very high sensitivity and specificity of ivu in contrast to this present study. he found the sensitivity of ivu as 93.6%, specificity of 95.6 %, negative predictive value of 91.6%, and positive predictive value of 96.8% with an accuracy of 94.5%,23 which is quite higher than the results of this present study. due to many advantages non-contrast enhanced ct is becoming preferred imaging modality of physicians in emergency response departments. it is favored because in busy emergency response it has the ability to rapidly triage the patient. however, this hastily prescription of ct test is increasing the rate of negative ct. in this present study, the efficacy of ivu was compared with ct kub for diagnosis of urolithiasis and it was observed that efficacy of ct was extremely high in contrast to ivu and the finding of ct study identified more stones of small size as well. some of which did not require vigorous interference at the time of diagnosis but required active surveillance. these incidental findings of ct also make it better than ivu. one major advantage of ivu is the evaluation of delayed excretion, which cannot be evaluated by noncontrast enhanced ct. c o n c l u s i o n the results of this study reveal that unenhanced ct kub has more accuracy as compared with ivu for diagnosis of urolithiasis in suspected patients. it provides more efficient information about the patients presenting with acute renal colic. ct kub has significantly higher rate of diagnosing urolithiasis in comparison of ivu. the ct also reduces the risk of adverse reactions of nephrotoxicity caused by the administration of contrast agents. so the use of ivu could be replaced by ct kub as diagnostic tool for urinary tract calculi. r e f e r e n c e 1. andrabi y, patino m, das cj, eisner b, sahani dv, kambadakone a. advances in ct imaging for urolithiasis. indian j urol. 2015;31(3): 185–93. 2. wah tm. unenhanced ct in the evaluation of renal/ureteric colic. imag med. 2013;5(4):371-82. 3. patatas k, panditaratne n, wah tm, weston mj, irving hc. emergency department imaging protocol for suspected acute renal colic: re-evaluating our service. br j radiol. 2012;85(1016):1118–22. 4. neisius a, preminger gm. stones in 2012: epidemiology, prevention and redefining therapeutic standards. nat rev urol. 2013; 10(2):75–7. 5. pfister sa, deckart a, laschke s. unenhanced helical computed tomography vs intravenous urography in patients with acute flank pain: accuracy and economic impact in a randomized prospective trial. eur. radiol. 2003;13(11):2513–20. 6. ather mh, jafri ah, sulaiman mn. diagnostic accuracy of ultrasonography compared to unenhanced ct for stone and obstruction in patients with renal failure. bmc med imag 2004;4(1):2. 239 j i m d c 2 0 1 7 239 7. ahmed na, ather mh, rees j: unenhanced helical computed tomography in the evaluation of acute flank pain. int j urol 2003; 10(6):287-92. 8. dhar m, denstedt jd. imaging in diagnosis, treatment, and follow-up of stone patients. adv chronic kidney dis. 2009;16(1):39–47. 9. kaza rk, platt jf, cohan rh, caoili em, al-hawary mm, wasnik a. dual-energy ct with singleand dual-source scanners: current applications in evaluating the genitourinary tract. radiographics. 2012; 32(2):353–69. 10. ather mh, memonwa. stones: impact of dose reduction on ct detection of urolithiasis. nature reviews urology 2009;6(10):526–7. 11. sandhu c, anson km, patel u. urinary tract stones. i. role of radiological imaging in diagnosis and treatment planning. clinradiol 2003;58(6): 415–21. 12. hamm m, wawroschek f, weckermann d. unenhanced helical computed tomography in the evaluation of acute flank pain. eururol 2001;39(4): 460–5. 13. mitterberger m, pinggera gm, maier e. value of 3dimensional transrectal/transvaginalsonography in diagnosis of distal ureteral calculi. j ultrasound med 2007;26(1):19–27. 14. ege g, akman h, kuzucu k, yildiz s. acute ureterolithiasis: incidence of secondary signs on unenhanced helical ct and influence on patient management. clinradiol 2003;58(12):990–4. 15. scales cd jr, curtis lh, norris rd. changing gender prevalence of stone disease. jurol 2007; 177(3):979–82. 16. chowdhury fu, kotwal s, raghunathan g, wah tm, joyce a, irving hc. unenhanced multidetector ct (ct kub) in the initial imaging of suspected acute renal colic: evaluating a new service. clinradiol 2007;62(10):970e7. 17. nadeem m, ather mh, jamshaid a, zaigham s, mirza r, salam b. rationale use of unenhanced multi-detector ct (ct kub) in evaluation of suspected renal colic. int j surg 2012; 10(10):634-637. 18. kirpalani a, khalili k, lee s, haider ma. renal colic: comparison of use and outcomes of unenhanced helical ct for emergency investigation in 1998 and 2002. radiol 2005;236(2):554-8. 19. khana n, anwara z, zafarb am, ahmeda f, ather mh. a comparison of non-contrast ct and intravenous urography in the diagnosis of urolithiasis and obstruction. african j urol 2012; 18(3):108–11. 20. macejko a, okotieot, zhao lc, liu j, perry k, nadler rb. computed tomography-determined stone-free rates for ureteroscopy of upper-tract stones. journal of endourology 2009;23(3):379–82. 21. ather mh, faizullah k, achakzai i, siwani r, irani f. alternate and incidental diagnoses on noncontrastenhanced spiral computed tomography for acute flank pain. urol j. 2009; 6(1):14-18. 22. rekant em, gibert cl, counselman fl. emergency department time for evaluation of patients discharged with a diagnosis of renal colic: unenhanced helical computed tomography versus intravenous urography. j emerg med. 2001;21(4):371-4. 23. amin z, salam a. role of ultrasound and intravenous urography in patients with renal colic. pak armed forces med j. 2011;61(4):42-9. 95 j i m d c 2 0 1 7 95 op e n ac c e ss f u l l l e n g t h a r t i c l e motorcycle accidents, a real burden & challenge of health care system in tertiary care hospital ali akhtar1, muhammad shoaib2, ali shami3 associate professor, dept. of orthopedics, pakistan institute of medical sciences, islamabad postgraduate resident, dept. of orthopedics, pakistan institute of medical sciences, islamabad assistant professor, dept. of orthopedics, pakistan institute of medical sciences, islamabad (shaheed zulifqar ali bhutto medical university islamabad) a b s t r a c t objectives: to find out the incidence, modalities, reasons of injuries and existing burden of motorcycles trauma in the orthopedics department, of a tertiary care hospital. patients and methods: this study was performed among patients that presented to the department of orthopedic surgery unit ii, via accident and emergency from 1st september 2015 to 1st december 2015. patients of both gender, age above 11 years, presented in emergency calls of unit ii were included in the study. all patients were initially managed as per “advance trauma and life support” principles in emergency department of pims and later either discharged or admitted. results: total 973 patients were categorized into four major groups, including 709 road traffic accidents, 186 incidental traumas, 29 assaults and 49 miscellaneous injuries. road traffic accidents which were 73% of a total number of cases had a major share in the data. among these 709 patients of road traffic accidents, 71% cases were the motorcycle riders. among all motorcycle accidents, 36% riders were between 16 years to 25 years of age and the most grievous trauma was seen in this age group. regarding license holding age, only 34% people had a driving license while remaining all were without a license. conclusions: the motorcycle trauma ranges from minor abrasions to the long live disability. it is a huge percentage among all types of trauma and casualties showing the burden on the health system and ultimately the families who would be end sufferers. younger population is more prone to the grievous injuries that ultimately pertain for a long time or some of them would be living with the permanent disability. key words: disability, fractures, motorcycles, trauma author`s contribution 1,3active participation in active methodology, review the study, 2synthesis and planning of the research 1,2conception-, interpretation and discussion address of correspondence dr. muhammad shoaib drmshoaib@hotmail.com article info. received: dec 29, 2016 accepted: may 21, 2017 cite this article: akhtar a, shoaib m, shami a. motorcycle accidents, a real burden & challenge of health care system in tertiary care hospital. jimdc. 2017; 6(2):95-99. funding source: nil conflict of interest: nil i n t r o d u c t i o n mankind has been progressing towards the prosperity and financial stability since its beginning. transport and roads are the cardinal facts and truths of this development. as the development has been progressing, the population per unit area is increasing. ultimately the frequent and rapid mobility by two wheelers is increasing the risk of trauma and accidents. the increase in population load per unit area has been distorting the available resources, exhausting the infrastructures, imbalance between rights and obligations. road side accidents and trauma have been increasing enormously for past twenty years. it has been observed that the resources of dealing with drastic o r i g i n a l a r t i c l e 96 j i m d c 2 0 1 7 96 trauma and major accidents are declining in trauma centers and hospitals. a remarkable increase has been observed in vehicles in last 15 years. in economic terms, the cost of road crash injuries is projected at roughly 1% of gross national product (gnp) in low-income countries, 1.5% in middle-income countries and 2% in high-income countries.1 the economic cost of road crashes and injuries is estimated to be over rs100 billion for pakistan.2 public transport usage has declined and not preferred on personal vehicles irrespective to that they are two or four-wheel vehicles. two wheelers and three wheelers are the priority of lower socioeconomic groups as they are in the financial range.3 there are many contributing factors in this reality, including the decline in the profile of public transport, over filling of that, more time consuming and no schedules. no supervision, no check and balance on the public transport system is a contributing factor in its down fall. according to the world health organization (who) 2011 fact sheet, "over 90% of the world's fatalities on the roads occur in low-income and middle-income countries, even though these countries have less than half of the world's vehicles.4 in a 2009 report, who estimated that in pakistan road traffic injuries result in 25.3 deaths per 100,000, which is high by the international organization’s standards.5 traditionally, the data sources for epidemiological assessments of rtas in pakistan have records from accident and emergency departments, surgical and intensive care units of specific hospitals and, more commonly, the police stations but the hidden data which has not been registered is an ice burg of unknown.6,7 it is estimated that 45% of road traffic fatalities in low-income countries are among pedestrians, whereas an estimated 29% in middleincome and 18% in high-income countries are among pedestrians.8 in hong kong, pedestrians accounted for 70% of rta fatalities. on the other hand, in china, malaysia, and thailand, pedestrian deaths are between 10-15% but over 50% of deaths due to rta involved motorcyclists.9 high-velocity vehicles, carpeted and smooth roads, poor legislation and weak implementation of penalties and fine are leading causes of uprising road traffic accidents. in past one and half decade, the number of vehicles has been enormously raised in the cities and the inter city and intra-city movements of public as well. among all vehicles, motorcycle trauma is most challenging and drastic for the sufferers, families of the victims. drastic traumas require technical skillful professionals and gadgets which are not widely available in our country health system. complicated surgeries, special implants, and prosthesis, post-surgical icu care, ventilators support in public hospitals, all are not well advanced. even the five big cities of the country do not fulfill the technical requirements of public sector health care system. specialties are not available in our dhq and thq services of small towns. if some the consultants are working there, they don’t have the backup support. ultimately the complicated trauma cases are referred to main cities which are already exhausted and overcrowded. thus, our emphasis is prevention from drastic trauma on motorcycles. strict legislation and tough implementation of rules with heavy fines on violation can bring a decline in the major trauma and if this decline is successful, the overall health care system will be more efficacious for other deprives. all effort is made because the massive bike injuries are preventable. in this study, most important aspect of the preventable trauma of road traffic accidents that is motorcycle trauma was aimed to be studied in detail. p a t i e n t s a n d m e t h o d s in this cross-sectional study, a total number of cases of trauma presenting to orthopedics department, via emergency were included. duration of this study was 1st september 2015 to 1st december 2015. these cases were first categorized into four types of trauma: road traffic accident, incidental trauma, assault injuries and miscellaneous. the incidental trauma included all other varieties of trauma including direct and indirect trauma, sports injuries and trivial trauma. there was no gender discrimination in the data. all geriatric fractures, pathological fractures, and associated injuries were the part of this group. fresh trauma cases, old referred cases from the periphery, infected trauma cases and neglected trauma cases all were included in this study. however, cases of soft tissue and bone infections like chronic osteomyelitis, septic arthritis of joints, abscess or empyema at the extremity and pediatric trauma were excluded from this study. the assault injuries were kept into a separate group because they were medico legal 97 j i m d c 2 0 1 7 97 cases and needed other departmental involvement. the assault category included fire arm injuries, stab injuries and aimed injuries. regarding road traffic accidents, the data was subdivided with respect to the nature of vehicles. there were four groups designed; four-wheel vehicles, motorcycle, bicycles and miscellaneous. although motorbikes and cycles both are of the same category but still they were kept into two main groups. the reason is, use of cycle in our society is limited now a day. either it is used by a low socioeconomic group or as a sports vehicle. in a miscellaneous group, three wheels (auto rikshaws, ching chee, carts) were included. the number of patients received in accident and emergency were grouped into three categories to see the commonest age group presenting with trauma. first group included patients below the age of 15 years. remaining two groups were from 16 years to 25 years and from 26 years to 60 years respectively. the patients were also grouped on basis of holding the driving license or not. r e s u l t s the total number of reported cases in an emergency were 973. they were categorized into four groups. out of these, 709 (73 %) cases were road traffic accidents, 186 cases (19%) were of incidental trauma, 29 (3 %) were assault injuries and 49 (5 %) were the miscellaneous injuries. regarding vehicle types, road trauma in 503 patients (71%) was due to motorcycles. in 188 (26%) patients’ accident and trauma was due to four-wheel vehicles. only 11 (2%) cases were due to bicycle injuries (figure 1). figure 1: types of vehicle responsible for road trauma among patients presented in emergency (n=709) as regards the age group of motorcycle accidents cases (503), 226 (45%) riders were in the age group between 26 to 50 years. total 183(36 %) cases were in the age group between 16 to 25 years (figure 2). regarding license holding age, only 168(34%) people had a driving license while 268(53%) riders had never a license. total 67(13%) individuals were below the age of holding a bike riding license. figure 2: age groups among victims of motorbike accidents (n=503) d i s c u s s i o n road traffic accidents are major series of trauma presenting to the orthopedic department via emergency. the accidents range from minor abrasions to poly-trauma cases and often the life-threatening situations. among all sorts of motor vehicle injuries, motorcycle trauma is most debilitating and disastrous.10 it accounts almost three fourth of the total emergency cases presenting to the department of orthopedic. their trauma is of high velocity, leading to prolonged disability and financial burden on the family.11 there is no social or government based designed backup mechanism for the people support.12 another study from a developing country showed 66% of lower limb injuries in motorbike accidents where cases of fracture of the tibia were in the highest proportion of cases followed by femur injuries, though study had a limitation of small sample size.13 a swedish cohort study revealed heavy burden of accidents involving young motorbike riders (age 16 to 30 years).14 the same age group is observed to be the most vulnerable to motorbike accidents in our part of the world and this study has also shown the highest number of motorbike injuries in the same age group.15 lower limb injuries would put a behavioral and social impact on individuals. in this regard, lower extremity assessment project (leap) in the united states has elaborated on the demographic and social 98 j i m d c 2 0 1 7 98 effects of lower limb injuries.16 rolison et al, reported that fatality and injury rate among the motorcyclists and their pillion riders is the highest in comparison to other road users.17 among the emerging economic countries, malaysia is among the association of southeast asian nations (asean) countries that have the highest rate of fatality and more than 50 percent of road deaths are among the motorcyclists.18,19 in this study, it was a trembling point that majority of motorcycle riders had never applied for a license, they never needed it. there was a significant population of youngsters who were below 15 years of age, not capable of getting a license, not allowed to ride bikes on main roads but still, they were facing a significant trauma. it was not surprising for us that majority of children facing motorcycle accidents below the age of 15 were the owner of motorbikes. either they were gifted by their parents or assigned by some authority where they were working. such youngsters usually encounter the fatal or disabling trauma because they are unable to tackle the situations rapidly during the trauma. we received many youngsters in our emergency that either died or ended up with amputation of a limb out of four. in addition, since children, teenagers and active economic population are highly involved in motorcycle crashes, much attention is directed to this kind of accident due to the high rate of life lost ratio and cost involved.20, 21 youngers population is riding the unsafe and high-velocity motorcycles which are emerging popular source of traveling and are increasing the frequency of disabilities in this age group.22 penalties for violations are very low. red signal breaking for a motorcyclist charges him with 200 rupees only. not wearing the safety helmet charges a motorcyclist only 200 rupees. similarly, rash riding, drifting with ordinary bikes and mechanical modifications for speed enhancement is not a punishable offense in our country. over speeding, one wheeling and drifting are supposed a tiny violation of traffic rules in pakistan. on serious violations, motorbikes are fined with a small amount of fine. there is no firm legislation or punishment on all above-said objectives. we need the improvement in law, increase in fines of violations and better designed safe motorcycles with improved breaking and road grip mechanics. by this number of massive traumas and debilitating injuries that are the socioeconomic burden and loss of lives can be declined. c o n c l u s i o n we concluded that the huge number of motorcycle trauma is preventable if awareness programs at different levels and law enforcement with heavy fines on violations of rules are implemented. r e f e r e n c e s 1. nantulya vm, reich mr. equity dimensions of road traffic injuries in low-and middle-income countries. injury control and safety promotion. 2003; 10(1-2):13-20. 2. ahmad, b. country report on road network in pakistan, ministry of communications, islambad. 2006 3. ghaffar a, hyder aa, masud ti. the burden of road traffic injuries in developing countries: the 1st national injury survey of pakistan. public health. 2004; 118 (3):211-7. 4. world health organization. who: road traffic injuries. fact sheet n°358. (online). september 2011 5. world health organization. global status report on road safety: time for action. (online). 2010 6. hassan q, bashir rm, shah m. physical trauma: a leading cause of medico-legal cases at dhq hospital abbottabad. j ayub med coll abbottabad. 2010; 22(2):156-9. 7. khan mh, ahmed i, zia ni, babar ts, babar ks. road traffic accidents, study of risk factors. professional medical journal. 2007; 14(2):323-7. 8. naci h, chisholm d, baker td. distribution of road traffic deaths by road user group: a global comparison. injury prevention. 2009; 15(1):55-9. 9. jacobs go, aeron-thomas a. a review of global road accident fatalities. paper commissioned by the department for international development (united kingdom) for the global road safety partnership. 2000 mar.. 10. box-steffensmeier jm, freeman jr, hitt mp, pevehouse jc. time series analysis for the social sciences. new york: cambridge university press; 2014. 11. box ge, jenkins gm, reinsel gc. time series analysis: forecasting and control. vol 734. new york: wiley; 2011. 12. quddus ma. time series count data models: an empirical application to traffic accidents. accident analysis & prevention. 2008; 40(5):1732-41.. 13. oluwadiya k, olassindi aa, odu oo, olakulehin oa, olatoke sa. management of motorcycle limb trauma in a teaching hospital in south-western nigeria. niger j med. 2008; 17(1):53-6. 14. zambon f, hasselberq m. factors affecting the severity of injuries among young motorcyclists: a swedish nationwide cohort study. traffic injury prevention.2006; 7(2):143-9. 99 j i m d c 2 0 1 7 99 15. aziz k, khalil iu. road traffic accidents in peshawar. ann king edward med coll lahore. 2002; 8(2):103-4. 16. cannada lk, jones al. demographic, social and economic variables that affect lower extremity injury outcomes. injury. 2006; 37(12):1109-16. 17. rolison jj, hewson pj, hellier e, hurst l. risks of highpowered motorcycles among younger adults. american journal of public health. 2013; 103(3):568-71.. 18. manan mma, várhelyi a. motorcycle fatalities in malaysia. iatss research. 2012; 36(1):30–9. 19. salehi s, hamid h, arintono s, hua lt, davoodi sr. effects of traffic and road factors on motorcycling safety perception. proceedings of the ice-transport. 2012; 166(5):289–93. 20. zargar m, sayyar roudsari b, shadman m, kaviani a, tarighi p. pediatric transport related injuries in tehran: the necessity of implementation of injury prevention protocols. injury. 2003; 34(11):820–4. 21. forjuoh sn. traffic-related injury prevention interventions for low-income countries. inj control saf promot. 2003; 10(1-2):109–18. 22. rolison jj, hewson pj, hellier e, hurst l. risks of highpowered motorcycles among younger adults. am j public health. 2013; 103(3):568–71. i radiological images covid-19 pneumonia: bilateral peripheral consolidations with basal predominance images from different patients with covid-19 pneumonia showing characteristic x-ray findings of this disease ii iii contributed by: department of radiology dr. akbar niazi teaching hospital, islamabad 67 j islamabad med dental coll 2021 66 o p e n a c c e s s medical education during covid-19 pandemic: lessons learnt and future priorities kamran ali1,2 1professor of dental education and consultant oral surgery, faculty of health, university of plymouth, uk 2national teaching fellow the coronavirus disease (covid-19) caused by the novel coronavirus (sars-cov-2) has had the most remarkable impact on the delivery of clinical services and medical education in our living memory. even the most advanced healthcare systems in the world have struggled to deal with the challenges of covid-19 pandemic. it has also posed serious tests for the political leadership across the globe due to the financial and social fallout and also exposed the vulnerabilities and lack of preparedness of modern healthcare infrastructures.1 the death rate from covid-19 in the western world including the usa, canada, europe, australia etc. and more recently in india has been alarming.2 the ongoing vaccinations against covid-19 provide a glimmer of hope that a fair degree of normality might be restored in the future. however, the rapid emergence of mutant strains of sars-cov-2, and lack of clarity regarding the longevity of immune protection imparted by vaccines add to the existing uncertainties related to covid-19.3 in addition, fake propaganda on social media platforms fueled by conspiracy theories is a barrier to widespread uptake of vaccines particularly amongst some sections of the society. given the risks of additional waves of covid-19 in the future, it is unlikely that covid-19 will be controlled fully, and the healthcare professions must continue to adapt in the light of emerging scientific evidence. the delivery of education across the board has been through a rollercoaster ride and has faced numerous impediments since the start of the pandemic. social distancing and cross-infection control measures have also impacted adversely on healthcare services with significant resource and logistic implications for the providers. educational environments in healthcare settings may require appropriate physical and temporal separation measures during face-to-face teaching and training for the foreseeable future and it is sensible to have plans in place for mitigating circumstances mandated by resurgence of covd-19 in the future. medical educators must continue to use a blended approach for delivery of teaching and training through efficient use of technology. a range of online platforms such as, zoom, microsoft teams, google rooms, skype, webex etc. along with numerous other bespoke applications have been used widely for remote teaching, assessments, meetings, interviews, and remote patient consultations etc. during the last decade, medical institutions in the developed countries have been striving to mirror the rapid digitization of core societal functions by downsizing lectures; flipping the classroom; development of interactive digital platforms to impart active self-directed and self-paced e d i t o r i a l correspondence: kamran ali twitter: @dentalacademic cite this editorial: ali k. medical education during covid-19 pandemic: lessons learnt and future priorities. j islamabad med dental coll. 2021; 10(2): 66-67 doi: 10.35787/jimdc.v10i2.721 j islamabad med dental coll 2021 67 independent learning activities.4 web-based digital learning environments offer several advantages: teachings sessions can be conducted in real time (e.g., on zoom) with opportunities for live interactions between the facilitators and the students. alternatively, sessions can be recorded as narrated powerpoint presentations; podcasts, vodcasts etc. and shared with students on the digital learning environment independent of time and place, offering flexibility to the students. findings from the developed countries show that students tend to view digital learning positively.5 a recent review of digital learning in medical education highlighted several barriers which affect the development and implementation including inadequate infrastructure, absence of institutional strategies and support, lack of technical skills and negative attitudes due to lack of familiarity.6 development of a comprehensive business case is the first step institutions may need to take. this is essential to evaluate the feasibility and financial viability of an effective and secure digital learning platform as it requires dedicated technical support, staff and student training, availability of appropriate digital devices for staff and students, unlimited webconnectivity. it would also be sensible to conduct meaningful consultations with all stakeholders to gauge their views about online learning based on their local circumstances and experiences. feedback from stakeholders should be used to inform the development and use of digital learning platforms for healthcare education in pakistan. based on the evidence from the developed countries, a blended learning approach in medical education is here to stay for the foreseeable future. notwithstanding the upfront financial implications, investing in digital education not only promises longterm savings of time and costs, but can also serve to enhance the quality of learning experiences for the students. healthcare institutions in pakistan may developing robust strategies to create comprehensive digital learning environments to facilitate education of undergraduate and postgraduate students and trainees. r e f e r e n c e s 1. centers for disease control and prevention. cdc science agenda for covid-19, 2020-2023. 2. who coronavirus disease (covid-2019) situation reports. available at: https://www.who.int/ emergencies/diseases/novel-coronavirus2019/situation-reports. [accessed 12 june 2021] 3. hodgson sh, mansatta k, mallett g, harris v, emary krw, pollard aj. what defines an efficacious covid19 vaccine? a review of the challenges assessing the clinical efficacy of vaccines against sars-cov-2. lancet infect dis. 2021; 21(2): e26-e35. doi: 10.1016/s1473-3099(20)30773-8 4. mcgrath c, palmgren pj, liljedahl m. beyond brick and mortar: staying connected in post-pandemic blended learning environments. med educ. 2021 may 12. doi: 10.1111/medu.14546. 5. iyer p, aziz k, ojcius dm. impact of covid‐19 on dental education in the united states. journal of dental education. 2020; 84(6): 7182. doi: 10.1002/jdd.12163 6. o'doherty d, dromey m, lougheed j, hannigan a, last j, mcgrath d. barriers and solutions to online learning in medical education an integrative review. bmc med educ. 2018 7;18(1):130. doi: 10.1186/s12909-018-1240-0 summary journal of islamabad medical & dental college (jimdc); 2016:5(4):152-153 152 editorial management of thalassemia in pakistan naghmi asif1 and khalid hassan2 1.associate prof, department of pathology, islamabad medical & dental college 2.prof/hod, department of pathology, islamabad medical & dental college beta thalassemia is the most common genetic disorder. the disorder is prevalent worldwide. about 3% of the world’s population carries the genes for beta thalassemia and it is estimated that every year about 60000 thalassemic babies are born all over the world.1 approximately 79% of affected births are in the asian population. carrier rate in pakistan ranges between 5-8%, and around 5000 children are diagnosed each year with beta thalassemia in pakistan.2 consanguinity is the main factor leading to high prevalence in pakistan. there are 25,000 children registered with thalassemia federation of pakistan however the actual figure is much higher which may be around one lac, as a lot many are living in villages that are not registered with any thalassemia center. the main components of management of thalassemia include 1. conservative management which take into account, medical consultation, lab investigations, safe blood transfusion, chelation therapy, treatment with hbf augmenting agents, 2. curative management comprising of bone marrow transplant and 3. preventive management comprising of thalassemia screening and genetic counselling. accomplishment of ideal management thus requires multidisciplinary team addressing all these aspects. however, very few centers furnish for all these components of optimal thalassemia management under one roof. management of thalassemia in developing countries like pakistan poses a major challenge. there are more than 40 thalassemia centers across the country. majority of them are giving only transfusional support. government does not provide required support and majority of burden is borne by ngos. the main stay of conservative management is blood transfusion, iron chelation, management of complications of iron overload, and prevention. frequent blood transfusion leads to iron overload requiring treatment with iron chelating agent serum ferritin level vary widely and could not be controlled due to poor compliance to chelation. the main reason for this noncompliance is the cost of treatment, that is beyond the reach of the common man. majority of patients thus have high ferritin level, and present with complications of iron overload. pakistan baitulmal is providing some support in this regard but majority of patients remain unaddressed. as far as transfusion therapy is concerned, majority of centers are trying to fulfil needs of patients but there are reservations about screening methods. the well-functioning blood bank is of primary importance for the management of thalassemia. its functions are not only to provide the regular supply of blood for the treatment of thalassemia, but also to ensure supply of safe blood, in order to minimize the risk of transfusion-transmitted infections. various studies have shown that 30-40% thalassemics show seropositivity for hcv and about 4-6 % become hbv positive, despite the availability of vaccine for hepatitis b.3-5 though, some studies have reported that for the past 10-12 years the better screening methods in blood banks in pakistan have significantly reduced the frequency of these diseases. further improvements need to be done to implement uniform screening of blood throughout the country.6 another big dilemma is that, many of the private centers do not have a full time treating physician/clinical hematologist. as regards curative aspect, there are very few centers (public and private) throughput the country that are offering bone marrow transplant and due to high cost, it is out of reach of majority of people. regarding preventive aspects, awareness and availability of antenatal diagnosis is limited. the main preventive strategies for thalassemia include appropriate information of the disease and importance of screening through awareness programmes, screening and counselling of target families, premarital and prenatal screening. premarital and prenatal screening have significantly reduced the prevalence of β thalassemia in various countries as italy, greece, cyprus, iran, and saudi arabia with significant reduction in births of affected children.7 in pakistan premarital screening and even antenatal screening is almost nonexistent even in urban areas. some hospitals have started with antenatal screening and prenatal diagnosis but still due to economic constraints most of the couples are underprivileged. there is thus a dire need for dedicated thalassemia unit in all big hospitals that oversees all aspects of treatment and where patients may be referred to the specialists whenever required. the centre should offer free medical consultation, genetic counselling, specialized pathology investigations, safe blood transfusion and chelation therapy to the patients. there should be multidisciplinary team comprising of hematologist, pediatrician, cardiologist, endocrinologist, psychiatrist/psychologist, social worker and dedicated and trained staff. the unit should also try to establish bone journal of islamabad medical & dental college (jimdc); 2016:5(4):152-153 153 marrow transplant unit and offer this facility at minimum bearable cost. in nutshell an ideal thalassemia centre should have three main units; one dealing with diagnosis and treatment, having close liaison with pediatrician, endocrinologist, cardiologist, psychologist etc. one unit focusing on preventive measures including screening and genetic counselling programme and the third one bone marrow transplant unit. the centre should also have collaboration with national and international organizations. the centre should aim at providing greatest possible level of comfort and convenience for patients and their families and ensure their long and quality life. references 1. eleftheriou a. about thalassemia. thalassemia int pub 2003; 2: 11-2. 2. ansari sh and shamsi ts. thalassaemia prevention programme. hematology updates 2010:23-28 3. rehman a. beta thalassemia prevention and pakistan pak paed j 2011; 35(2): 55-62. 3. khattak i, shah m , ahmed i, rehman a , sajid m. frequency of hepatitis b and hepatitis c in multitransfused beta thalassaemia major patients in district swat. journal of saidu medical college 2013; 3(2). 4. hussain h, iqbal r, khan mh, iftikhar b, aziz s, and burki fk et al. prevalence of hepatitis c in beta thalassaemia major.. gomal journal of medical sciences 2008;6(2): 87-90 5. ali mr, arif m, arif a and fatima t. viral hepatitis c in thalassaemia: determination of antibody hcv frequency in mutitransfused thalassaemia patients a.p.m.c 2016;10 (1): 20-25. 6. saqib h. ansari, tahir s. shamsi, mohammed tahir khan, kousar perveen, tasneem farzana, sajida erum and iqra ansari seropositivity of hepatitis c, hepatitis b and hiv in chronically transfused β-thalassaemia major patients journal of the college of physicians and surgeons pakistan 2012; 22 (9): 610-611 7. baig sm, sabih d, rahim mk and azhar a et al.beta thalassemia in pakistan: a pilot programme on prenatal diagnosis in multan. j. pediatic hematol oncology 2012;34:90-92 summary journal of islamabad medical & dental college (jimdc); 2016:5(3):112-115 112 original article frequency of benign and malignant ovarian lesions: a histopathological analysis anum usman1 , sadaf humaun2, nauman noor3, , noor khan lakhanna4, humaira zafar5 1residentmphil histopathology, al nafees medical college & hospital, islamabad 2senior registrar, rawal institute of health sciences, islamabad 3assist prof of operative dentistry, rawal institute of health sciences, islamabad 4professor & hod of pathology department, al nafees medical college & hospital, islamabad 5assistant prof. of pathology, al nafees medical college & hospital, islamabad abstract objective: to find the frequency of ovarian lesions in various ages at pathology department, anmc islamabad material and methods: this cross sectional study was conducted in department of pathology anmc islamabad from 1 st january 2015 to 30 th june 2016. about 178 cases of ovarian lesions were included in the study. the samples were processed as per recommended steps for histopathological diagnosis. data was recorded and analyzed by using spss version 20. frequencies for specific diseases were calculated in terms of percentages. mean and standard deviation were calculated for numerical values. results: among 178 ovarian specimens, commonest pathology was non-neoplastic cysts in 78 cases (43.8 %) followed by benign tumors in 74 cases(41.6 %) and malignant tumors in 26 cases (14.6 %). the common lesions were endometriotic cysts 21.3 %, serous cystadenoma 17.4 %, benign cystic teratoma 14 %, follicular cyst 12.3 %, hemorrhagic cysts 10.1% and mucinous cystadenoma 7.3 %. common malignant tumors were serous cystadenocarcinoma 6.7%, mucinous cystadenocarcinoma 2.8% and endometroid carcinoma 1.7% . conclusion: non neoplastic cysts were the most common ovarian lesions (43.8%). this was followed by benign (41/6%) and malignant tumors (14.6%) cases. surface epithelial tumors were more common than other tumors. key words: frequency, malignant ovarian tumors, serous cystadenoma, teratomas. introduction ovaries are paired bean-shaped female reproductive organs. the germ cells along with the multipotential and totipotential mesenchymal cells are mainly performing the ovarian functions. in case of any ovarian pathology, definitely the reproductive functions will be disturbed. some of the nonneoplastic lesions of the ovary form large masses and mimic malignant neoplasms and therefore they should be properly recognized and classified to allow appropriate therapy. 1 prompt diagnosis, categorization, stage of disease, and hence management of any benign or malignant ovarian pathology is a challenging task for gynecologists. 2 ovarian cancer is the seventh leading cause of cancer death in females and in postmenopausal women 30% of ovarian tumors are malignant whereas in premenopausal females only 7% of the ovarian tumors are malignant. 1 berek et al in 2007 described that the benign ovarian pathology is most commonly seen in younger aged females of around 20 years. however, the malignant ones are either seen between the ages of 50-60 years or in premenopausal ages. it was also highlighted that the prognostic outcomes are good in ages less than 40 yrs. 3 delay in diagnosis leads to the disease progression along with the emergence of complications. thus, the management options in that situation used to be limited, resulting in increased mortality rate. 4 the current study was planned to identify the spectrum of ovarian pathologies in our setup. awareness regarding their presentation in various age groups, can be helpful for the gynecologists to diagnose early and hence manage them prior the development of complications. material and methods the current study was conducted at pathology department of al nafees medical college & hospital, islamabad, pakistan from january 01 st , 2015 to june 30 th , 2016. all specimens received during the study period for diagnosis of ovarian diseases were included in the study. a total of 178 specimens were analyzed. all specimens were collected in 10% buffered formal saline and processed in automated tissue processor. paraffin embedded sections were made and stained with the hematoxylin and eosin stains. data was entered on spss version 20.0 for statistical inference. results among various ovarian lesions, non-neoplastic and functional cysts were the most common lesion found in 43.8% (n=78) of patients. these comprised endometriotic cysts 21.3% (n=38), follicular cyst 12.3% (n=22) and corresponding author dr. anum usman email: dranumusman@gmail.com received: august 12, 2016; accepted: sept 18, 2016 mailto:dranumusman@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):112-115 113 hemorrhagic cysts including luteal cysts 10.2% (n=18). among the ovarian tumors, the benign tumors were about three times common as compared to malignant ones as benign lesions were seen in 74 (85.4%) cases while 26 (14.6%) of the cases were malignant. the detail of these lesions is given in table 1. malignant ovarian tumors were all primary tumors except one case of metastatic signet cell carcinoma (krukenberg tumor). among the primary malignant tumors, epithelial tumors were the most common accounting for 84 %(n=21), followed by germ cell tumors 12% (n=3) and one case of undifferentiated sarcoma (4 %). on the basis of histogenesis, surface epithelial tumors comprised two third of cases-66% followed by germ cell tumors 28 %. among epithelial tumors, mostly were benign (45%) while 21% were malignant. serous tumors both benign and malignant were the commonest tumour in this study as shown in table 2. table 1: frequency of various ovarian lesions with mean ages (n=178) sr. no types of lesions no. of cases (n) percen tages (%) age (years) mean±sd a. non-neoplastic/functional cysts 78(43.8 %) 30+ 1.6 37 + 1.8 1. endometriotic cyst 38 21.2 2. follicular cyst 22 12.3 3. hemorrhagic/ luteal cyst 18 10.3 b. primary tumors i. benign74 (41.6%) 1. serous cystadenoma 31 17.4 2. benign cystic teratoma 25 14.0 3. mucinous cystadenoma 13 7.3 4. thecoma-fibroma 02 1.1 5. granulosa cell tumor 02 1.1 6. brenner tumor 01 0.6 ii. malignant 26 (14.6%) 52+1.4 1. serous cystadenocarcinoma 12 6.7 2. mucinous cystadenocarcinoma 05 2.8 3. endometroid carcinoma 03 1.7 4. immature teratoma 02 1.1 5. clear cell carcinoma 01 0.6 6. dysgerminoma 01 0.6 7. undifferentiated sarcoma 01 0.6 c. secondary / metastatic tumor 1. krukenberg tumor 01 0.6 table 2: frequency of ovarian tumors according to histogenesis (n=100) sr.n o. primary tumors no of cases (n) percentage (%) i. surface epithelial tumors (n = 45) a. benign 1. serous cystadenoma 31 31 2. mucinous cystadenoma 13 13 3. brenner tumor 01 01 b. malignant 1. serous cyst adenocarcinoma 12 12 2. mucinous cystadenocarcinoma 05 05 3. endometroid carcinoma 03 03 4. clear cell carcinoma 01 01 ii. germ cell tumors (n=28) 1. mature teratoma + dermoid cysts 25 25 2. immature teratoma 02 02 3. dysgerminoma 01 01 iii. sex cord –stromal tumors (n=04) 1. granulosa cell tumor 02 02 2. fibroma-thecoma 02 02 iv. undifferentiated sarcoma 01 01 secondary / metastatic carcinoma (krukenberg tumour) 01 01 figure 1: endometriotic cyst; cyst wall lined by tall columnar epithelial cells and hemosiderin laden macrophages (h&e x 200) figure 2: mucinous cystadenoma; multiple cystic spaces lined by cells having apical mucin and basal nuclei (h&e x 200x) journal of islamabad medical & dental college (jimdc); 2016:5(3):112-115 114 figure 3: granulosa cell tumor; sheets of granulosa cells having coffee bean nuclei (h&e x 400) discussion ovarian cancer is the second commonest gynecological malignancy. 5 the indian literature review had narrated that ovarian malignancies ranks on the seventh number regarding the cancer related mortalities. 6,7 the findings and results of current study showed that the non-neoplastic lesions are the commonest ones (43.8%), followed by benign ovarian tumors (41.6%) and then malignant ones (14.6%). endometriotic ovarian cysts were seen in 21.2% cases of non-neoplastic pathologies. the results of current study are in accordance with the findings of busacca et al reporting endometriotic ovarian cysts is 17%, amongst all benign ovarian lesions. 8 maggiore et al in 2015, concluded that these benign ovarian endometriotic cysts do not affect the ovulation. 9 other published studies had shown that in 60% of the cases left ovary is affected. the common reason for this is the anatomical variation between right and left hemipelvis along with the menstrual reflux theory. 10, lower levels of anti-mullerian hormone (amh) levels and antral follicle count are seen in women with endometriomas as compared to those who donnot have ovarian cysts, thus becoming the reason for reduced ovarian reserve. 12 follicular cysts were seen in 12.3% of our cases; this finding is supported by the results of study conducted by kreuzer gf et al who reported that the follicular cysts were the most common (55%) ones followed by corpus luteal cysts in 45% cases of all benign ovarian disorders. 13 mavromatidis et-al, reported that follicular cysts usually have a benign course, but due to their rapidly enlarging tendency, they can become symptomatic requiring the surgical interventions. 14 in order to avoid the false diagnosis, the accurate cytological diagnosis is necessary so that proper treatment can be initiated timely. 15 corpus luteal hemorrhagic cysts were present in 10.3% of the cases of current study and these findings are comparable with another study who further added that their presence in 2531% of cases can result in fatal outcomes. 16 the anticoagulation therapy is considered as one of the predisposing factor for such pathology. 17 the results of current study are supported by the findings of a published report for the year 2001, which showed that the frequency of benign lesions is more i.e 41.67%, as compared to the malignant ones. 18 this finding is different from the published results of hartageet al in 2000. he described that prevalence of benign ovarian lesions was 14% in his study. 19 the non-neoplastic lesions and benign neoplastic lesions are common in the mean age of 30+1.6 and 37+1.8 years. while the malignant lesions were seen in the females with the mean of 52+1.2 years. these findings are consistent with the published report of berek et al in 2007. he observed that the non-neoplastic and benign ovarian lesions are more common in the age group of less than 40 yrs. while malignant ones are more common in the age range between 50-60 years. 3 the current study showed that serous cystadenoma was present in 17.4% of the cases. this finding is consistent with the results of cheng et al. he concluded that ovarian serous cystadenomas are the common ovarian disorders and they are the precursors of low-grade serous carcinomas, because they are the hyperplastic expansion from epithelial inclusions, having clonal/neoplastic transformation potential. 20 in another study della et al reported that, ovarian serous cystadenomas are amongst the rare disorders. 21 benign cystic teratomas are present in 14% of the total cases. this is consistent with the findings of kahraman et-al who reported that 10-20% of all ovarian tumors comprises of benign cystic teratomas. 22 serous cyst adenocarcinoma was detected in 6.7% of all malignant tumors. jemal et al in their study found serous cyst adenocarcinomas in 3% of all malignant tumours. 23 mucinous cystadenocarcinoma was present in 2.8% of cases. this is supported by the harrison et al; he described that the incidence of primary mucinous adenocarcinoma is usually low. 24 the prognosis and treatment modalities of primary and metastatic mucinous adenocarcinomas are different. so, the accurate diagnosis is necessary for proper treatment. 25 conclusion non neoplastic cysts were the most common ovarian lesions seen in 43.8% cases. this was followed by benign ovarian lesions – 41.6 ±% and malignant ones in 14.6% cases. surface epithelial tumors are the commonest. conflict of interest this study has no conflict of interest as declared by any author. references 1. kanthikar sn, dravid nv, deore pn, nikumbh db, suryawanshi kh. clinico-histopathological analysis of neoplastic and non-neoplastic lesions of the ovary: a 3-year prospective study in dhule, north maharashtra, india. j clin diagn res. 2014;8(8):04–07. http://www.ncbi.nlm.nih.gov/pubmed/?term=s.n.%20k%5bauthor%5d&cauthor=true&cauthor_uid=25302198 http://www.ncbi.nlm.nih.gov/pubmed/?term=k.h.%20s%5bauthor%5d&cauthor=true&cauthor_uid=25302198 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4190719/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4190719/ journal of islamabad medical & dental college (jimdc); 2016:5(3):112-115 115 2. gupta n, bisht d, agarwal ak, sharma vk. retrospective and prospective study of ovarian tumours and tumour-like lesions. indian j pathol microbiol. 2007;50(3):525–7. 3. berek js, natarajan s. berek and novak’s gynecology. in: berek js, editor. ovarian and fallopian tube cancer. new delhi: wolters kluwer health (india) private limited; 2007. p. 457–547. 4. saxena hmk, devi g, prakash p, pankajam p. ovarian neoplasms: a retrospective study of 356 cases. j obstet gynecol india. 1980;20(6):523–27. 5. modugno f. ovarian cancer and polymorphisms in the androgen and progesterone receptor genes. am j epidemol. 2004;159(4):319–35. 6. basu p, de p, mandal s, ray k, biswas j. study of patterns of care of ovarian cancer patients in a specialized cancer institute in kolkatta, eastern india. indian j cancer. 2009;46(1):28–33. 7. mondal sk, banyopadhyay r, nag dr, roychowdhury s, mondal pk, sinha sk. histologic pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms: a 10-year study in a tertiary hospital of eastern india. j can res ther. 2011;7(1):433–37. 8. busacca m, vignali m. ovarian endometriosis: from pathogenesis to surgical treatment. curr opin obstet gynecol. 2003;15(2):321-26. 9. maggiore ur, scala e, venturini vl, remorgida v, ferrero s. endometriotic ovarian cysts do not negatively affect the rate of spontaneous ovulation. hum reprod. 2015;30(2):299-307. 10. ferrero s, ragni n, fulcheri e. lateral distribution of benign ovarian cysts. int j gynaecol obstet. 2005;89(4):150-51. 11. vercellini p, busacca m, aimi g, bianchi s, frontino g, crosignani pg. lateral distribution of recurrent ovarian endometriotic cysts. fertil steril. 2002;77(3):848-49. 12. uncu g, kasapoglu i, ozerkan k, seyhan a, oral yilmaztepe a, ata b. prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve. hum reprod 2013;28(2):2140-45. 13. kreuzer gf, parodowski t, wurche kd, flenker h. neoplastic or nonneoplastic ovarian cyst: the role of cytology. acta cytol. 1995;39(3):882–86. 14. mavromatidis g1, sotiriadis a, dinas k, mamopoulos a, rousso d. large luteinized follicular cyst of pregnancy. ultrasound obstet gynecol. 2010;36(4):517-20. 15. dejmek a1.fine needle aspiration cytology of an ovarian luteinized follicular cyst mimicking a granulosa cell tumor. a case report. acta cytol. 2003;47(6):1059-62. 16. ghafri wa, gowri v, khaduri ma, shukri ma. life threatening corpus luteal hemorrhage. gynecol.2013;1:2 17. jamal a, mesdaghinia s: ruptured corpus luteum cysts and anticoagulant therapy. int j gynaecol obstet .2002;76(4):319-20. 18. onsurbe mp, villaespesa ap, anquela jms. aspiration cytology of 147adnexal cysts with histologic correlation. acta cytol. 2001;45(2):941–47. 19. hartge p, hayes r, reding d. complex ovarian cysts in postmenopausal women are not associated with ovarian cancer risk factors: preliminary data from the prostate, lung, colon, and ovarian cancer screening trial. am j obst gynecol. 2000;183(5):1232–37. 20. cheng ej, kurman rj, wang m, oldt r, wang bg, berman dm, etal. molecular genetic analysis of ovarian serous cystadenomas. lab invest. 2004;84(6):781-4. 21. pepa dc, tonini g, santini d, losito s, pisano c, di napoli m, etal. low grade serous ovarian carcinoma: from the molecular characterization to the best therapeutic strategy. cancer treat rev. 2015;41(2):136-43. 22. kahraman k, cetinkaya se, kankaya d, dunder i, soylemez f. squamous cell carcinoma arising from mature cystic teratoma of the ovary with synchronous endometrial adenocarcinoma. j obstet gynaecol res. 2011;37(3):14650 23. jemal a, siegel r, ward e, hao y, xu j, murray t, thun mj. cancer statistics. ca cancer j clin. 2008,58(4):71-96. 24. harrison ml, jameson c, gore me. mucinous ovarian cancer. int j gynecol cancer. 2008;18(3):209–14. 25. jung es, bae jh, lee a. mucinous adenocarcinoma involving the ovary: comparative evaluation of the classification algorithms using tumor size and laterality. j korean med sci. 2010;25(2): 220–25. . authorship contribution author1:active participation, analysis and interpretation of results author2:active participation of results author3:analysis and interpretation of results and discussion author4:conception, critical review of article and final approval http://www.ncbi.nlm.nih.gov/pubmed/?term=cheng%20ej%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=kurman%20rj%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20m%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=oldt%20r%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20bg%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=berman%20dm%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=berman%20dm%5bauthor%5d&cauthor=true&cauthor_uid=15077125 http://www.ncbi.nlm.nih.gov/pubmed/15077125 http://www.ncbi.nlm.nih.gov/pubmed/?term=della%20pepa%20c%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=tonini%20g%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=santini%20d%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=losito%20s%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=pisano%20c%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=di%20napoli%20m%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/?term=di%20napoli%20m%5bauthor%5d&cauthor=true&cauthor_uid=25573350 http://www.ncbi.nlm.nih.gov/pubmed/25573350 j islamabad med dental coll 2020 88 open access prevalence of dental caries and its association with risk factors amongst preschool children of bharakahu, islamabad saba masoud 1 , sheze haroon qazi 2 , rubina mumtaz 3 1 lecturer, department of community dentistry, islamabad medical and dental college, pakistan 2 assistant professor, department of community dentistry, islamabad medical and dental college, pakistan 3 associate professor, department of community dentistry, islamabad medical and dental college, pakistan a b s t r a c t background: it is necessary to understand the prevalence and pattern of distribution of dental caries for better planning and execution of preventive activities in the right dimension. this study provided the base line data about prevalence of dental caries in pre-school children of bharakahu, islamabad, and its association with brushing, sugar consumption and previous dental visits. material and methods: a total of 384 preschool children aged 3-5-year-old were screened from periurban area of bharakahu, islamabad, using type iv screening method. data about decayed, missing and filled teeth was recorded using decayed-missing-filled teeth (dmft) index. socio-demographics, brushing, sugar consumption and previous dental visits were also recorded and analyzed and their association with dental caries was assessed using chi square and odds ratio. results: the overall caries prevalence among the sample was 49%. the mean dmft score was 2.07±3.215. there was no significant difference in caries prevalence in relation to gender of the children. the most significant association was for brushing and low dmft. children who brushed their teeth were 4 times more likely to have a low dmft score of <1 than those who did not brush at all (p<0.001). likewise, those who had visited a dentist in the past were twice more likely to have a low dmft (p=0.003). the association of low sugar consumption and a low dmft score was statistically insignificant (or 1.4; p=0.878). hence, brushing turned out to be the most significant factor in determining the presence of caries in a child. conclusions: this study provided us with the baseline data regarding the prevalence of caries in primary school going children of bharakahu. the prevalence of unmet dental treatment needs was reflected through a high number of ‘decayed teeth’ as compared to missing and filled ones highlighting the need for restorative care in these children. key words: dental caries, preschool children, sugar consumption, tooth brushing authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: saba masoud email: saba.commd17@iideas.edu.pk article info: received: november 18, 2019 accepted: june 3, 2020 cite this article. masoud s, qazi sh, mumtaz r. prevalence of dental caries and its association with risk factors amongst preschool children of bharakahu, islamabad. j islamabad med dental coll.2020; 9(2): 88-94. doi: 10.35787/jimdc.v9i2.463 funding source: nil conflict of interest: nil i n t r o d u c t i o n oral health problems in children revolve around dental caries predominantly. 1 dental caries is often referred to as pandemic disease, with characteristics of high proportion of untreated caries causing pain, functional restrictions, distress, premature tooth loss, malnutrition and ultimately o r i g i n a l a r t i c l e j islamabad med dental coll 2020 89 less growth and development. 2 functional restrictions also include problems in speech, sleeping, swallowing and breathing etc., all due to pain. 3 it is necessary for the pediatrician to understand the disease burden (prevalence), pattern of distribution and characteristics. 4 dental caries occurs due to association of four factors including susceptible tooth surface, bacteria, duration of exposure to bacteria and diet rich in carbohydrates. 3 with respect to data collected from 1973 to 2008 on 190 who countries, worldwide average dmft (decayed, missing and filled teeth) index was 2.11 among children. 5 the prevalence of caries in asia is estimated to be about 60-90%. 6 dental illnesses account for more than 51 million school hours lost every year. 7 the prevalence of dental caries is on the decline in developed countries and on the rise in developing countries, 8 as evidenced by a prevalence of 80%, 64.2% and 69.2% among 2-5 year old children in studies done in saudi arabia, india and bangladesh. 9,10 similarly, a cross sectional survey in bangladesh showed that prevalence of caries was 69.2% among 2-5 year old, with only 44% observing correct brushing method. 11 in pakistan, according to pathfinder survey conducted in 1988, the mean dmf for all ages was 3.1. 12 independent studies conducted in karachi, lahore and peshawar indicated a high prevalence of caries amongst 3-5-year-old. the highest recorded prevalence was 88.6% in peshawar, followed by 51% in karachi and 40.5% in a similar age bracket of children in lahore. 2,4,8 the association of dental caries with variables like age of the child, consumption of non-sweetened milk and oral hygiene was also established in this study. in islamabad, a descriptive study conducted on 543 children in dental opd of pakistan institute of medical sciences showed mean dmft for each child as 6.33. 13 the association of caries with low socioeconomic status, female gender and rural areas of residence too were found to be significant. data on the prevalence of caries among pre-school children in pakistan is deficient. the primary dentition was the focus of our study because this age is most prone to dental caries, as evidenced by literature. this study established the base line data for prevalence of caries among preschool children of bharakahu, islamabad and also provided evidence on association of dental caries with certain socio-demographic characteristics. dental caries can be prevented if factors causing it can be identified so that better preventive activities can be planned and executed. 14 m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in a peri urban area of islamabad during the academic year of 2018. for sample size calculation, open source software called “open epi” was used. a sample size of 384 was calculated taking caries prevalence at 50% among 3-5-year-old children (as it was unknown otherwise) and 5% margin of error, with 95% confidence interval. a non-probability convenience sampling technique was used. ethical consent was taken from institutional review board of islamabad medical & dental college and administration of the participating schools under study. for accessibility purposes, the schools already participating in islamabad medical and dental college (im&dc) screening program were made part of the study. the complete list of participating schools was generated and those with a preschool section identified. once the school screening program started, the investigators accompanied the second-year dental students along with house officers to collect data. the study population included 3-5-year-old pre-school children screened during these visits. the schools that could not be reached due to unavailability of contact information or were not interested in the j islamabad med dental coll 2020 90 screening program were excluded from the sample. uncooperative children or those absent on the day of data collection were also excluded. once the estimated sample size was reached, the data was organized and analyzed. the screening was carried out by the dental teams from im&dc with each team having two to three second year bds students and one house-officer or a post graduate student for supervision. prior to the visit, the schools were requested to set up examination stations in well-illuminated areas of the school with three chairs and a table. the type iv examination method was used to screen children. this type of examination entails the use of a mouth-mirror and a tongue depressor only under good illumination. the child to be screened was seated across the examiner who visually examined the oral cavity with help of a tongue depressor and torch/daylight. the second team member recorded data on a standardized screening form used by the community dentistry department of im&dc. data including demographic information like name, age, gender along with caries prevalence (based on dmft index), brushing habits, sugar intake and previous dental visits was recorded. the screening procedure was carried out under the supervision of a house officer or post graduate student. the caries status was assessed using the dmft index as defined by the who (1997). the dmft index expresses the number of affected teeth in the primary dentition, with scores ranging from 0 to 20 for children. they were examined and their score expressed as the total number of decayed, missing and filled teeth in the oral cavity. the teeth that could not be unquestionably categorized as carious were not added to the score and marked sound. furthermore, children were classified as having high dmft (>3) and low dmft (≤3) depending on the child’s score.8socio-demographicdata such as age, gender, brushing habits, sugar consumption and previous dental visits were also recorded. brushing habits were categorized as brushing and no brushing, likewise sugar consumption was categorized as high and low depending on the number of high sugar content items consumed by the child. those consuming 3 or more than three items with high sugar content were categorized as high consumers. to assess sugar consumption, teachers were asked about the lunch the children brought to class in routine, availability of sugar rich foods at the school canteen, and the preschoolers’ access to the canteen. the children were also questioned about their breakfast, lunch and dinner routine. the history of previous dental visits was assessed by the presence of any restorative fillings in the mouth and also by questioning the child if he/she had ever visited a dental hospital or dentist. if the child affirmed a previous dental visit he was further questioned about the purpose of the visit for further assurance. relevant data from the filled screening forms was extracted and analyzed for different associations using chi square and odd’s ratio (spss version 22). r e s u l t s the study sample consisted of 384 pre-school children with 220 boys and 164 girls with a mean age of 4.36±0.702. the prevalence of caries in preschool children of bharakahu was 49% (n=189) with a mean dmft score of 2.07±3.21. overall prevalence was higher in females (51%) than males (48%). caries experience showed a progressive pattern with an increase in the dmft score with advancing age (table i). the dmft score was calculated for each child having either a decayed, missing or filled tooth and then adding them all. regarding the dental caries status, any child having all three that is a carious lesion or a missing tooth (due to caries) or a filled tooth was accounted for in all three categories of dmft. j islamabad med dental coll 2020 91 table i: distribution of variables regarding dental caries status variable dmft ≥ 1 n percentage decayed (d) 177 46.1 missing (m) 28 7.3 filled (f) 6 1.6 gender wise distribution of dmft male (n=220) 106 48 female (n= 164) 83 51 age wise distribution of dmft 3yrs (n= 50) 19 38 4yrs (n= 144) 70 49 5yrs (n= 190) 100 53 children with carious lesions and a dmft score of >1 were 46% (n=177). out of these 55% (n=97) had a low dmft score of ≤ 3 whereas 45% (n=80) had a high dmft score of >3 teeth (table ii). table ii: severity of decayed component (d) of dmft variable frequency percentage dental caries status (d) (n= 384) positive 177 46.1 negative 207 53.9 decayed category for severity (d) (n=177) 1-3 (low) teeth involved (n= 97 55 4+ (high) teeth involved (n= 80 45 in the children with a dmft score of ≥ 1, the decayed component accounted for 94% of the score. in the two categories of low and high dmft score, 54.5% (n=103) children had a low dmft score and 45.5% (n=86) had a high dmft score of 3 or above. 8 median dmft score was found to be 3. regarding oral hygiene practices of pre-school children, 90.6% (n=348) cleaned their teeth at least once a day and only 9.4% (n=36) confessed to no brushing at all. the percentage of children on high sugary diet was greater at 58.9% (n=226) than children on a low sugar diet. majority of the study population (81.8%; n=314) had never visited a dentist or a dental hospital previously. odds ratio was used to compare the relative probabilities between variables of interest and outcomes of interest. the odds ratio showed that a low sugary diet, regular brushing and previous dental visits were significantly associated with a child caries experience and a low dmft score. the most significant association was for brushing and low dmft. children who brushed their teeth regularly (at least once a day) were 4 times more likely to have a low dmft score of <1 than those who did not brush at all (p< 0.001). likewise, those who had visited a dentist in the past were twice more likely to have a low dmft(p=0.003). the association of low sugar consumption and a low dmft score was statistically insignificant (or 1.4; p=0.878). hence, brushing turned out to be the most significant factor in determining the caries experience for a child (table iii). table iii: values of odds ratio and p value regarding variables variable or (odds ratio) pvalue* brushing 4 < 0.001 previous dental visits 2.2 0.003 sugary diet 1.4 0.878 *p-value<0.05 was considered as statistically significant d i s c u s s i o n according to who, caries is the most prevalent non communicable disease globally. in 2015, the “global burden of disease study” established its high prevalence ranking it “first” for decay of permanent teeth (2.3 billion people) and 12th for deciduous teeth (560 million children). 15 it affects humans of all ages in all parts of the world, because it involves an inter-play of social, behavioral, cultural, dietary and biological risks that are associated with its initiation and progress. 16 however, caries can easily be prevented through simple and cost-effective interventions, especially in countries where treatment is unaffordable or inaccessible. j islamabad med dental coll 2020 92 globally, the statistics for caries prevalence in children of developing nations is quite distressing. a systematic review conducted in saudi arabia showed that 80% of the children with primary dentition had caries. 9 the prevalence of 64.2%, 67.9% 69.2% and 95.4%, was reported in studies conducted in india, argentine, bangladesh and thailand, respectively. 10,11,14,17 conversely, preschool children in industrialized nations have lower caries prevalence with 34% in great britain, 18 40% in singapore, 19 20% (among 3 year old) and 52% (among 5 year old) respectively in norway. 20 the present study reported a caries prevalence of 49% in preschool children. this percentage is quite high in perspective of biological consequences and financial burden of treating the disease in a low budget healthcare system. two indian studies showed prevalence of 53% and 54% among 3-5year olds. 21,22 the similarity in distribution was perhaps due to similarities in culture, dietary patterns and socio demographic characteristics. however, there is a great disparity in caries prevalence in preschoolers among different cities of pakistan with 40.5% in lahore, 51% in karachi, 88.6% in peshawar and 90% in hyderabad. 2-4, 8 in our study, decayed teeth formed the major portion (94%) of total dmft score. this is a common finding in most of the literature, e.g. 90% in a bangladeshi study and 69% in a singaporean study. 11,19 the reasons for children’s under treatment can be multifactorial ranging from dental anxiety, treatment cost, lack of parent’s awareness, to the dearth of affordable and accessible dental services in low and middle income countries. this fact is supported by the finding that the number of children who had visited a dental hospital/ clinic is much more than the number of fillings observed in our study sample. the possible explanation can be that in case of pain, they go to the hospital, take medication and even go for extraction to get rid of pain, but they do not pursue the treatment in the form of fillings or other restorative procedures. previous dental visits are also found to be low in studies of other developing nations, like india and argentine. 14,21 regarding dental visits, another point that can be deduced is that those who go to the dentist stay more aware about oral hygiene, and therefore have low caries and ultimately less fillings. the female children in our study had higher caries prevalence (51%) as compared to males (48%). a pakistani study also showed higher caries prevalence in females (58.4%), 2 whereas, a lahorebased study showed a prevalence of 54% in the male population. 8 regarding the disease severity among caries positive children in our study, 54% had 1-3 teeth involved whereas, 46% had 4 or more teeth involved. it is very rare to find children with greater number of teeth involved in dmft in the literature as well. for example, 54% of the study population has 1-3 teeth involved in a study conducted on preschool children in hyderabad and 45% have more than 3 teeth involved. 3 the decay of one or two teeth can make children more conscious of their oral health status and prompt them to adapt better oral hygiene practices, thus restricting further decay of teeth. the dmft score of 3-5 years old children incremented with age i.e. from 38% among 3-yearold to 49% and 53% among 4 and 5-year-old, respectively. similar findings have been reported in literature. for example, caries prevalence increasing from 33% to 48% to 75% among 3, 4 and 5 years of age respectively in a pakistani study and increasing from 26% to 37% to 49% in a singaporean study. 8,19 the most convincing rationale of this caries advancement would be the shift of dietary habits from healthy homemade food to unhealthy snacks available at canteen, decreased involvement of parents in tooth brushing with advancing age and the increased duration of teeth exposure to oral environment. 11 j islamabad med dental coll 2020 93 the strongest association of dmft observed in our study was with brushing followed by its association with previous dental visits. no statistically significant association found with sugar consumption in our study can be attributed to the less reliable information collected. as the children were 3-5-year-old and they could give wrong information regarding the frequency of sugar consumption. however, considering them all together, they all contribute in caries etiology. for example, some children consume high amount of sugars but have low dmft, because they take care of the oral hygiene very well. on the other hand, some children clean their teeth regularly but are found with high dmft scores, because they consume large amounts of sugar. all this reaffirms the significance of brushing, dental visits and sugar consumption in maintaining a healthy oral status in children. c o n c l u s i o n this study provided us with the baseline data regarding the prevalence of caries in primary school going children of bharakahu, islamabad. the study also accentuated the significance of brushing in these young children. the prevalence of unmet dental treatment needs was also highlighted with a high number of ‘decayed teeth’ in these children. raising awareness and training these youngsters is the key to a better oral health status. one can certainly address these issues through the endowment of oral health education or promotion programs in their schools. ideally teachers are the best guides to steer these young children in the right direction. the primary school teachers should undertake the role of mentors and train these children to adopt healthy oral hygiene practices. our focus should switch to these youngsters so that our future generations enjoy good oral health. limitations: since it was a cross sectional study, it could not establish any temporal association. another limitation of the study was the complete reliability of the information collected as the study population was very young i.e. 3-5-year-old preschool children. future recommendations: more research needs to be conducted on communities in the rural and peri-urban areas of islamabad, pakistan so that reported data may be consolidated. the key to preventing caries in these communities is raising awareness regarding the importance of oral health. children are the ideal audiences for such oral health promotional activities. thus, schools in these areas should collaborate with dental institutes and integrate oral health awareness programs in their curricula. a c k n o w l e d g e m e n t we are really thankful to the dental students and house officers, who helped in data collection. we specially acknowledge the administration of the schools for giving permission to conduct the screening. a special word of thanks to all the 3-5 years old children who were part of this project. r e f e r e n c e s 1. bader jd, rozier rg, lohr kn, frame ps. physicians’ roles in preventing dental caries in preschool children: a summary of the evidence for the u.s. preventive services task force. ajpm. 2004; 26(4): 315–25. doi: 10.1016/j.amepre.2003.12.001 2. sufia s, chaudhry s, izhar f, syed a, qayum mirza ba, ali khan a. dental caries experience in preschool childrenis it related to a child’s place of residence and family income? oral health prev dent. 2011; 9(4): 375-9. 3. sahito n, sahito ma, fazlani ka. prevalence of caries among school children in hyderabad pakistan. ijas. 2015; 2(1):034-8. 4. ahmad s, khan h, khan m, maryam w. prevalence and patterns of early childhood caries among school children in peshawar. jkcd. 2015; 6(1): 36-9. j islamabad med dental coll 2020 94 5. rafael da silveira moreira (2012). epidemiology of dental caries in the world, oral health care pediatric, research, epidemiology and clinical practices, prof. mandeep virdi (ed.), isbn: 978-95351-0133-8, in tech, available from: http://www.intechopen.com/books/oral-healthcare-pediatric-research-epidemiology-andclinicalpractices/epidemiology-of-dental-caries-in-theworldhttp://cdn.intechopen.com/pdfs/29340/intec h-epidemiology_of_dental_caries_in_the_ world.pdf 6. baghdady vs, ghose lj. dental caries prevalence in schoolchildren of baghdad province, iraq. community dent oral epidemiol. 1982; 10(3): 14851. doi: 10.1111/j.1600-0528.1982.tb01340.x 7. u.s department of health and human services (usdhhs). oral health in america: a report of surgeon general. national institute of dental and craniofacial research. 2000. 8. dawani n, nisar n, khan n, syed s, tanweer n. prevalence and factors related to dental caries among pre-school children of saddar town, karachi, pakistan: a cross-sectional study. bmc oral health. 2012; 12(1): 59. doi: 10.1186/1472-6831-12-59 9. al agili de. a systematic review of population-based dental caries studies among children in saudi arabia. saudi dent j. 2013; 25(1): 3-11. doi: 10.1016/j.sdentj.2012.10.002 10. reddy ks, reddy s, ravindhar p, balaji k, reddy h, reddy a. prevalence of dental caries among 6-12 years school children of mahboobnagar district, telangana state, india: a cross sectional study. indian j dent sci. 2017; 9 (1): 1-7 11. khan mai, raihan mm, hossain mm, shahin as. dental caries and associated factors among 2-5 years children attending opd of a selected dental hospital in bangladesh. update dent coll j. 2011; 1(1): 2-5. doi: 10.3329/updcj.v1i1.13945 12. mehar r. dental disorders in pakistan – a national pathfinder survey. jpma. 1991; 41(10): 250-2. 13. abdullah s, qazi h s, maxood a. dental caries status in 6-9 years old children. podj; 2008; 28(1): 107-12 14. llompart g, marin gh, silberman m, merlo i, zurriaga o. oral health in 6-year old schoolchildren from berisso, argentina: falling far short of who goals. med oral patol oral cir bucal. 2010;15(1):101–5. 15. sugars and dental caries technical information note. https://www.who.int/oral_health. [cited 2019 dec 25], [updated 2017]; available from https://www.who.int/oral_health/publications/ sugars-dental-caries-keyfacts/en/. 16. albino j, tiwari t. preventing childhood caries a review of recent behavioral research. j dent res. 2016; 95(1): 35–42 17. sutthavong s, taebanpakul s, kuruchitkosol c, ayudhya ti, chantveerawong t, fuangroong s, et al. oral health status, dental caries risk factors of the children of public kindergarten and schools in phranakornsriayudhya, thailand. j med assoc thai. 2010; 93(suppl 6): s71–s78. 18. pitts nb, boyles j, nugent zj, thomas n, pine cm. the dental caries experience of 5-year old children in great britain (2005/6). surveys co-ordinated by the british association for the study of community dentistry. community dent health. 2007; 24(1): 5963. pmid: 17405473 19. gao xl, hsu cys, loh t, koh d, hwang hb, xu y. dental caries prevalence and distribution among preschoolers in singapore. community dent health. 2009; 26(1): 12–7. 20. skeie ms, edpelid i, skaare ad, gimmestad a. caries patters in an urban preschool population in norway. europ j of paed dent. 2005; 6(1): 16–22. 21. simratvir m, moghe ga, thomas am, singh n, chopra s. evaluation of caries experience in 3-6year-old children, and dental attitudes amongst the care-givers in the ludhiana city. j indian pedod prev dent. 2009; 27(3): 164-9. 22. mahejabeen r, sudha p, kulkarni ss, anegundi r. dental caries prevalence among preschool children of hubli, dharwad city. j indian soc pedod prev dent. 2006; 24(1): 19–22. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4700662/ summary journal of islamabad medical & dental college (jimdc); 2016:5(4):161-164 161 original article correlation between glycated hemoglobin and dyslipidemia in type-2 diabetes mellitus maqsood ahmad1, iqra ijaz2, nadia rasheed3, muhammad saeed4, sumbla ghaznavi5, mohammad mahmood asghar saleemi6 1 medical lab scientist, dept of chemical pathology, university of health sciences, lahore 2dept of morbid anatomy and histopathology, university of health sciences, lahore 3 senior research officer, dept of chemical pathology, university of health sciences, lahore 4 medical lab scientist, dept of pathology, punjab institute of cardiology lahore 5assistant professor and hod chemical pathology, university of health sciences, lahore 6additional medical superintendent, jinnah hospital, lahore abstract objective: to evaluate correlation between glycated haemoglobin and dyslipidaemias in patients with type-2 diabetes mellitus (dm). patients and methods: participants were selected from out-patient department of sheikh zayed hospital, lahore and laboratory analysis was performed at department of chemical pathology, university of health sciences, lahore. total 60 patients of type-2 dm and 40 age and gender matched controls were included in study. glycated haemoglobin (hba1c), fasting blood glucose (fbg) and lipid profile was performed after overnight fasting. control group was labelled as group-a and patient group was labelled as group-b. mean of all parameters from both groups was compared and checked for significance by independent sample t-test and pearson correlation. results: there was no significant difference in mean values of all biochemical parameters between both genders, except total cholesterol, which was found higher in females (pvalue 0.047). only 3.3% (n = 02) patients had normal lipid profile, 76.6% (n = 46) had one-abnormal parameter of lipid profile, 28.3% (n = 17) patients had two-abnormal parameter of lipid profile and 58.3% (n = 35) had mixed type of dyslipidemia. hba1c was positively correlated with all parameters of lipid profile except hdl-c, which was negatively correlated. conclusion: there is positive correlation between level of glycemic control (hba1c) and severity of dyslipidemia in patients of type 2 dm. key words: cardiovascular diseases, diabetes mellitus type 2, dyslipidemia, glycated haemoglobin. introduction diabetes mellitus (dm) is cosmopolitan disease of the globe. dm is a group of metabolic disorders characterized by hyperglycemia either due to the lack of insulin secretion, or defects of insulin action or both.1 recent reports showed that there were 171 million people in the world with diabetes in year 2000 and this is expected to increase to 366 million by 2030.2 it is associated with reduced life expectancy, significant morbidity due to specific diabetes related microvascular complications, increased risk of macrovascular complications (ischaemic heart disease, stroke and peripheral vascular disease), and lessened quality of life. glycated haemoglobin (hba1c) is usually used as a monitoring tool for measuring glycemic control in dm patients. it gives glycemic control status for last 120 days.3 hba1c predicts risk for development of diabetic complication in diabetic patients. united kingdom prospective diabetes study (ukpds) has revealed that risk of diabetic complications was strongly associated with previous hyperglycemia. good glycemic control with decreased level of hba1c is likely to reduce risk of complications.4 estimated risk of cardiovascular disease (cvd) has shown to be increased by 18% for each 1% increase in absolute hba1c value in diabetics. 5 the chronic hyperglycemia can damage several body organs due to microvascular and macrovascular complications.6,7 macrovascular complications of diabetes include cardiovascular disease (cvd) such as stroke, which is the cause of death in 50% of diabetics.8,9 on the other hand, microvascular complications of diabetes include diabetic nephropathy, neuropathy, and retinopathy.10 cardiovascular risk of diabetes increases further if diabetes is related with dyslipidemia. however, this risk can be reduced by good management and control of both hyperglycemia and dyslipidemia.11,12 a few studies have previously tried to find relationship between hba1c levels, fasting blood glucose (fbg) and corresponding author: maqsood ahmad e-mail: maqsoodahmad64@yahoo.com received: received oct 21, 2016; accepted jan 9,2017 mailto:maqsoodahmad64@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):161-164 162 lipid profile. some of these have shown that all parameters of lipid profile have significant association with glycemic control.13 on the other hand, some studies do not report significant correlation between glycemic control and parameters of lipid profile.14 positive relationship between hba1c and cvd has been demonstrated in non-diabetic subjects even within normal range of hba1c. 15,16 these controversies motivated us to conduct this study, to find out correlation between glycemic control (hba1c), fbg and different parameters of lipid profile in type 2 diabetic patients coming to out-patients department of endocrinology at sheikh zayed hospital, lahore. patients and methods prior to the start of study ethical permission was obtained from ethical committee of the sheikh zayed hospital, lahore. total 60 patients of type 2 dm for > 05 years with overnight fasting were recruited from sheikh zayed hospital, lahore. patients with renal disease, thyroidal illness, history of alcohol intake and improper fasting were excluded from study. total 40 age and gender matched controls without history of any acute or chronic illness were also included. 02ml fasting blood samples were obtained after signing informed consent from all participants for the measurement of hba1c, fbg and lipid profile. hba1c, fbg and lipid profile were performed on monza chemistry analyzer by using randox reagent kits. the instrument was properly calibrated and quality control (qc) levels were also run along with patient sample. hba1c was performed by affinity chromomatography technique. statistical analysis was performed by using ibm – spss version 21.0. independent sample t-test (2-tailed) was used to compare mean of all parameters. pearson’s correlation test was done to evaluate correlations of hba1c with all other parameters. all values of different parameters were expressed using conventional units. p-value ≤ 0.05 was considered statistically significant. results among sixty patients, 66% (n = 40) were females and remaining 34% (n = 20) were males. out of forty controls, 47.5% (n = 19) were males and 52.5% (n = 21) were females. mean age for patient group was 51.17±6.85 years (male=52.85+7.12 years and female= 50.32+6.63 years) and for controls mean age was 42.82+13.66 years (male =45.53+12.69 years and female = 40.38+14.35 years). the frequency of dyslipidemia in our study population was 98%. only 02% showed normal lipid profile components. most common type of dyslipidemia was increased levels of low density lipoprotein cholesterol (ldl-c) (68.3%) followed by hyper-triglyceridemia (55%), hyper-cholesterolemia (46.7%) and decreased levels of high density lipoprotein cholesterol (hdl-c) (figure-1). 0 10 20 30 40 50 hyper-cholesterolemia hypertriglyceridemia low hdl-c high ldl-c no-abnormal parameter of lipid profile one-abnormal parameter of lipid profile two-abnormal parameters of lipid profile >2-abnormal parameters of lipid profile figure-1: frequency of dyslipidemia in diabetic patients in patient group (group-b) mean values of tc 42.33mg/dl, vldl-c 11.89mg/dl, ldl-c 93.49mg/dl, triglyceride 58.29mg/dl, hba1c 4.56% and fbg 89.52mg/dl were higher than control group (group-a). mean age for males in total study population was 2.52 years higher than females. mean levels (mg/dl) of vldl-c, hdlc, ldl-c, tg, fbg and hba1c (%) were relatively higher in females (table-1). table-1: comparison of lipid profile parameters and glycemic indices between group-a and groupb parameter group-a (n=40) mean±sd group-b (n=60) mean±sd pvalue tc (mg/dl) 158.30±19.01 200.63±54.60 0.000* vldl-c (mg/dl) 24.33±3.90 36.22±20.13 0.000* hdl-c (mg/dl) 83.43±18.55 48.28±15.88 0.000* ldl-c (mg/dl) 24.33±3.89 117.82±52.09 0.000* tg (mg/dl) 121.78±15.92 180.07±90.50 0.000* hba1c (%) 4.49±0.50 9.05±1.86 0.000* fbg (mg/dl) 87.85±6.11 177.27±65.73 0.000* *p-value≤0.05 is considered statistically significant we divided patient group (group – b) further in to two subgroups as good glycemic control (ggc) group and poor glycemic control (pgc) group. in ggc group patients had level of hba1c < 7% and in pgc patients had level of hba1c > 7%. we compared mean levels of lipid profile between these two groups. mean difference of fbg was journal of islamabad medical & dental college (jimdc); 2016:5(4):161-164 163 found 53.0 mg/dl higher in group pgc and this was found statistically significant (table-2). table-2: biochemical parameters categorize on the basis of hba1c parameters hba1c< 7 (ggc) (n=10) hba1c> 7 (pgc) (n=50) pvalue age (years) 52.90±7.97 50.82±6.64 0.385 tc (mg/dl) 211.40±49.36 198.48±55.80 0.449 vldlc(mg/dl) 32.80±13.88 36.90±21.20 0.561 hdl-c (mg/dl) 53.60±23.35 47.22±14.01 0.423 ldl-c (mg/dl) 124.80±46.43 116.42±53.48 0.646 tg-c (mg/dl) 175.90±67.32 180.90±95.00 0.875 fbg-c (mg/dl) 133.10±34.60 186.10±67.12 0.001* *p–value ≤0.05 is considered statistically significant, ggc: good glycemic control, pgc: poor glycemic control hba1c was positively correlated with all components of lipid profile except hdl-c which showed negative correlation. fbg showed significant positive correlation with hba1c (table-3). table 3: correlation between hba1c and all biochemical parameters (n = 60) parameters correlation r-value p-value tc (mg/dl) 0.082 0.532 vldl-c(mg/dl) 0.244 0.061 hdl-c(mg/dl) -0.058 0.658 ldl-c(mg/dl) 0.029 0.826 tg (mg/dl) 0.173 0.187 fbg (mg/dl) 0.396 0.002* *p-value ≤ 0.05 is considered statistically significant discussion despite many strategies for diagnosis and monitoring of dm, still this is a major challenge for public health around the globe. in conditions like uncontrolled dm the proportion of glycosylated haemoglobin increases substantially. this glycosylation of haemoglobin is result of non-enzymatic binding of haemoglobin a molecules with glucose which occurs only once during the life of single red blood cell. the levels of hba1c reflect the degree of glycemic control for last 120 days. so this is being used for diagnosis and monitoring diabetic control as well. the diabetic dyslipidemia is connected with raised levels of triglycerides, ldl-c and decreased hdl-c.17 in our study we evaluated correlation of hba1c with dyslipidemia. in group-b 98.0% patients showed significant dyslipidemia. high ldl-c is most common followed by hyper-triglyceridemia, hyper-cholesterolemia and low ldl-c. al-alawi et al in 2014 reported high prevalence of hypercholesterolemia, hypertriglyceridemia, high ldl-c and low hdl-c. they revealed that increase ldl-c level is more frequent type of dyslipidemia.18 it is well known that high ldl-c and low hdl-c levels are risk factors for development of cardiovascular diseases. insulin effects the liver apolipoprotein production which is responsible for enzymatic activity of lipoprotein lipase and cholesterol esters transport protein. all these factors collectively cause dyslipidemia in dm.19 hyper triglyceridemia can be due to alteration of lipoprotein in type2 dm. it is caused by hyperglycemia, insulin resistance which results in overproduction of vldl-c, defective clearance of vldl-c, decreased activity of lipoprotein lipase and decreased production of apolipoprotein b. consumption of vldl is altered which ultimately results in atherosclerosis. in type–2 dm, hyperglycemia increases the activity of hepatic lipase which leads to enhanced clearance of hdl-c while impaired catabolism of vldl-c which causes decreased production of hdl-c.20 in present study, diabetic patients (n = 60) were divided into two groups as ggc group which included only 10 patients and pgc group which contained 50 patients. severity of dyslipidemia was higher in patients with increased levels of glycated hemoglobin (hba1c >7%). elevated hba1c and dyslipidemia are sovereign risk factors of cardiovascular diseases. through improvement in glycemic control, one can markedly diminish risk of cardiovascular events in diabetics. it has been assessed that reducing hba1c level by 0.2% could lower mortality by 10%.6 khan et al reported that impact of glycemic control is directly related to the severity of dyslipidemia.21 the dyslipidaemia in diabetic is frequent because insulin resistance or deficiency affects vital enzymes and lipid metabolism.22,23 it affects the following processes: apoprotein production, regulation of lipoprotein lipase, action of cholesteryl ester, transfer proteins and hepatic and peripheral actions of insulin.22 it has been suggested that composition of lipid particles in diabetic dyslipidaemia is more atherogenic than other types of dyslipidaemia. this means that even normal lipid concentrations might be more atherogenic in diabetic than in nondiabetic people.22,24,25 pearson correlation was observed between hba1c and other components of lipid profile and fbg. a significant positive correlation was seen with fbg. our findings were strongly matched with previous literature reports.26,27 we also found positive but non-significant correlations between hba1c and cholesterol, triglycerides, ldl-c and vldl-c in type-2 diabetic patients. hdl-c was found negatively correlated with hba1c. previously many researchers have reported the journal of islamabad medical & dental college (jimdc); 2016:5(4):161-164 164 importance of hba1c for controlling dyslipidemia in patients with type-2 dm.28,29 conclusion positive but non-significant correlation is found between glycemic control and severity of dyslipidemia in patients with type-2 dm. thus by maintaining a good glycemic control, risk for the development of dyslipidemia and cardiac diseases can be reduced. further studies should be conducted on a larger scale to significantly explore the role of hba1c in the development of dyslipidemia in type-2 diabetic patients. acknowledgment we appreciate support from syed mohsin raza bokhari for statistical analysis of data. conflict of interest this study has no conflict of interest as declared by any author. references 1goldberg ij. diabetic dyslipidemia: statins versus fibrates in the treatment of diabetic dyslipidemia. paper presented at: symposium, program and abstracts of the 6st scientific sessions of the american diabetic association; 2001 june 22-26; philadelphia, pennsylvania. 2wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047-53. 3delamater am. clinical use of hemoglobin a1c to improve diabetes management. clin diabetes. 2006;24(1):6-8. 4stratton im, adler ai, neil ha, matthews dr, manley se, cull ca, etal. association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (ukpds 35): prospective observational study. bmj. 2000;321(7258):405-12. 5selvin e, marinopoulos s, berkenblit g, rami t, brancati fl, powe nr, golden sh. meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. ann intern med. 2004;141(6):421-31. 6genuth s, alberti kg, bennett p, buse j, defronzo r, kahn r, et.al. follow-up report on the diagnosis of diabetes mellitus. diabetes care. 2003;26(11):3160-67. 7uk prospective diabetes study (ukpds); viii study design, progress and performance. diabetol. 1991; 34(12):877-90. 8world health organization. diabetes, fact sheet [internet]. nov 2016. available from :http://www.who.int/mediacentre/factsheets/fs312/en/ 9glycosylated haemoglobin, hba1c. nov 2013. available from: https:// clinlabnavigator. com/testinterpretations/haemoglobina1c. html?letter=h 10fowler mj. microvascular and macrovascular complications of diabetes. clin diabetes. 2008; 26(2):77-82. 11haffner sm, lehto s, rönnemaa t, pyörälä k, laakso m. mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. n engl j med. 1998;339(4):229-234. 12windler e. what is the consequence of an abnormal lipid profile in patients with type 2 diabetes or the metabolic syndrome? atheroscler suppl. 2005;6(3):11-14. 13ramona g, ioan c, simona t, luminita p, simona g, lavinia m. relationship between glycosylated hemoglobin and lipid metabolism in patients with type 2 diabetes. studia universitatis vasile goldiş seria ştiinţele vieţii. 2011;21(2):313-8. 14yan z, liu y, huang h. association of glycosylated hemoglobin level with lipid ratio and individual lipids in type 2 diabetic patients. asian pac j trop med. 2012;5(6):469-71. 15khaw kt, wareham n, bingham s, luben r, welch a, day n. association of hemoglobin a1c with cardiovascular disease and mortality in adults: the european prospective investigation into cancer in norfolk. ann intern med. 2004;141(6):413-20. 16bucolo g, david h. quantitative determination of serum triglycerides by the use of enzymes. clin chem. 1973;19(5):476-82. 17hongbing xiao. method and composition for determining high density lipoprotein cholesterol. chinese patent. 2002; cn1379235a. 18al-alawi. serum lipid profile and glycated hemoglobin status in omani patients with type2 diabetes mellitus attending a primary care polyclinic. biomed res india. 2014;25(2):1616. 19goldberg ij. lipoprotein lipase and lipolysis: central roles in lipoprotein metabolism and atherogenesis. j lipid res. 1996;37(4):693-707. 20wexler dj, grant rw, meigs jb, nathan dm, cagliero e. sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. diabetes care. 2005;28(3):514–20. 21khan ha, sobki sh, khan sa. association between glycaemic control and serum lipids profile in type 2 diabetic patients: hba1c predicts dyslipidaemia. clin exp med. 2007;7(1):249. 22elnasri h, ahmed a. patterns of lipid changes among type 2 diabetes patients in sudan. east mediterr health j.2008;4(2):314-4. 23dixit ak, dey r, suresh a, chaudhuri s, panda ak, mitra a, et al. the prevalence of dyslipidemia in patients with diabetes mellitus of ayurveda hospital. j diabetes metab disord. 2014;13(1):58. 24necht le, zaccaro d, espeland ma, karter aj, o’leary dh, haffner sm. diabetes and progression of carotid atherosclerosis the insulin resistance atherosclerosis study. arterioscler thromb vasc biol. 2003;23(6):1035-41. 25taskinen mr. diabetic dyslipidemia. atheroscler suppl. 2002;3(1):47-51. 26rosediani m, azidah ak, mafauzy m. correlation between fasting plasma glucose, post prandial glucose and glycated haemoglobin and fructosamine. med j malaysia.2006;61(1):67-7. 27ito c, maeda r, ishida s, sasaki h, harada h. correlation among fasting plasma glucose, two hour plasma glucose levels in ogtt and hba1c.diabetes res clin pract. 2000;50:225-30. 28faulkner ms, chao wh, kamath sk, quinn l, fritschi c, maggiore ja, etal. total homocysteine, diet, and lipid profiles in type 1 and type 2 diabetic and non diabetic adolescents. j cardiovasc nurs. 2006;21(1):47-55 29chan wb, tong pc, chow cc, so wy, ng mc, ma rc, etal. triglyceride predicts cardiovascular mortality and its relationship with glycaemia and obesity in chinese type 2 diabetic patients. diabetes metab res rev. 2005;21(2):1838. authorship contribution: author 1,3: conception, synthesis and planning of the research author 2,6: active participation in active methodology author 4,5: interpretation, analysis and discussion https://www.ncbi.nlm.nih.gov/pubmed/?term=genuth%20s%5bauthor%5d&cauthor=true&cauthor_uid=14578255 https://www.ncbi.nlm.nih.gov/pubmed/?term=alberti%20kg%5bauthor%5d&cauthor=true&cauthor_uid=14578255 https://www.ncbi.nlm.nih.gov/pubmed/?term=bennett%20p%5bauthor%5d&cauthor=true&cauthor_uid=14578255 https://www.ncbi.nlm.nih.gov/pubmed/?term=buse%20j%5bauthor%5d&cauthor=true&cauthor_uid=14578255 https://www.ncbi.nlm.nih.gov/pubmed/?term=defronzo%20r%5bauthor%5d&cauthor=true&cauthor_uid=14578255 https://www.ncbi.nlm.nih.gov/pubmed/?term=kahn%20r%5bauthor%5d&cauthor=true&cauthor_uid=14578255 histopathological images ovarian mucinous carcinoma figure 1: gross specimen of ovarian mucinous carcinoma showing solid and cystic appearance with papillary projections figure 3: photomicrograph of ovarian mucinous carcinoma showing areas of stromal invasion (arrow) (h&e x 40) figure 2: microscopic view showing a complexity of glands with papillae formation. cytological features of atypia and stratification are present (h&e x 100) figure 4: photomicrograph of ovarian mucinous carcinoma showing abundant intracellular and extracellular mucin (h&e x 400) figure 5: photomicrograph showing extravasated mucin highlighted by pas stain (arrow) (h&e x 100) a case of huge lipoma in the mandibular region clinically masquerading as a salivary gland neoplasm figure 1: a 60 year old male presenting with a huge left mandibular swelling figure 3: cut surface of tumor showing a homogeneous yellowish appearance along with focal areas of hemorrhage figure 2: gross specimen of left mandibular swelling showing a well circumscribed tumor figure 4: photomicrograph showing sheets of mature adipocytes separated by fibrous septa consistent with microscopic appearance of lipoma contributed by: prof dr. saeed alam, dr. huma mushtaq, dr. naima tariq department of pathology islamabad medical and dental college 268 j i m d c 2 0 1 7 268 op e n ac c e ss c a s e r e p o r t primary adenosquamous carcinoma of prostate: a rare aggressive tumor aribah atiq 1, noreen akhtar 2, usman hassan 3, asif loya 4, sajid mushtaq 5, muhammad azam 6 shaukat khanum memorial cancer hospital and research centre, lahore, pakistan a b s t r a c t adenosquamous carcinoma is an aggressive tumor of prostate with only 30 cases reported so far in literature. we present a case of this rare entity that was seen in our department. a 70 years old male presented with urinary outflow obstruction and slightly raised psa levels [5mg/ml (normal; 0-4 mg/ml)]. transuretheral resection of prostate was done and specimen was sent to our department. histologically, it composed of both malignant squamous and glandular components. squamous component showed large tumor cells with abundant cytoplasm and nuclei with prominent nucleoli. glandular component showed tumor cells arranged in acinar pattern, predominantly in cribriform architecture. as the current guidlines, gleason grading is not required for adenosquamous carcinoma of prostate. the case was reported as the adenosquamous carcinoma of prostate. this rare tumor has an extremely poor prognosis with most of the patients dying within 1 year of diagnosis. key words: adenosquamous carcinoma, primary, prostate address of correspondence usman hassan email: drusmanhassan256@gmail.com article info. received: august 24, 2017 accepted: september 12, 2017 cite this case report: atiq a, akhtar n, hassan u, loya a, mushtaq s, azam m. primary adenosquamous carcinoma of prostate: a rare aggressive tumor. 2017; 6(4) funding source: nil conflict of interest: nil i n t r o d u c t i o n adenosquamous carcinoma of prostate is a rare, aggressive and unusual histological variant of prostatic carcinoma. its first description was given by thompson in 1942 and so far, less than 30 cases have been reported.1 although majority (two third) of the reported cases arise following hormonal or radiation therapy, approximately one third of cases arise spontaneously in patients without having any previous risk factors.2 here we present a case of adenosquamous carcinoma arising in a de novo setting without any history of radiations or hormonal therapy, which makes it even rarer. c a s e r e p o r t a 70-year-old male patient presented with a history of urinary retention. on digital rectal examination, prostate was enlarged, non-tender and felt to be extending into the bladder, occluding the lumen, thus causing urinary retention. serum psa level was 5mg/ml (normal; 0-4 mg/ml). the patient had no history of radiation or hormonal therapy. transuretheral resection of prostate was done and sent to the pathology department for histopathological examination. histological sections revealed carcinoma composed of malignant squamous and glandular component. squamous element was composed of large foci of squamous differentiation and glandular area was showing tumor cells arranged in acinar pattern. a transitional area comprising of both the components was also noted. we reported the case as the adenosquamous carcinoma of prostate (figure 1). d i s c u s s i o n adenosquamous carcinoma of prostate is a rare entity with an incidence of 0.03 cases/million individuals/year, which makes its prevalence even less than pure c a s e r e p o r t 269 j i m d c 2 0 1 7 269 squamous cell carcinoma of prostate, which is also a rare entity.3 figure1: sections of the prostate showing malignant squamous component and acinar type adenocarcinoma. several explanations have been proposed so far to explain the histological features of adenosquamous carcinoma; these include the metaplastic transformation of adenocarcinomatous cells, transformation of squamous metaplastic foci ; developed after radiation/hormonal therapy or in long standing inflammation or ischemia4 or from the deviation of pluripotent stem cells, which are capable of multidirectional differentiation.4 so far, there is no well-established criteria for the diagnosis of adenosquamous carcinoma of prostate and to differentiate it microscopically from the adenocarcinoma with concomitant squamous metaplasia, because of the close resemblance of squamous metaplasia and well differentiated squamous cell carcinoma in prostate. however, squamous component in adenosquamous carcinoma shows marked atypia pleomorphism. regarding psa level, there is no well-established criteria showing association of psa with adenosquamous carcinoma. patients have presented with both, high and normal psa levels. this tumor is associated with bad prognosis.5 c o n c l u s i o n adenosquamous carcinoma of prostate is a rare, aggressive and unusual histological variant of prostatic carcinoma. it has an extremely poor prognosis with most of the patients dying within 1 year of diagnosis. r e f e r e n c e s 1. thompson gj. transurethral resection of malignant lesions of prostate gland. jama 1942; 120(14):1105-9. 2. wang j, wang fw, lagrange ca, et al. clinical features and outcomes of 25 patients with primary asc of the pros.tate. rare tumors 2010; 2(3):130-4. 3. marcus dm, goodman m, jani ab, et al. a comprehensive review of incidence and survival in patients with rare histological variants of prostate cancer in the united states from 1973 to 2008. prostate cancer prostatic dis 2012; 15(3):283 4. nicoleta c arva and kasturi das.diagnostic dilemmas of squamous differentiation in prostate carcinoma case report and review of the literature.arva and das diagnostic pathology 2011,6(1):46. 5. mishra s, goel h, awasthi n, puri a, mahapatra r, d.k.pal.primary adenosquamous carcinoma of prostate;a rare aggressive tumor.clinical genitourinary cancer. 2014; 12(1);e29-31. j islamabad med dental coll 2021 116 op e n ac c e s s liddle syndrome in a six-year-old girl: a case report sumera akram1, abdul rehman2, muhammad ahmed khan3 1assistant professor, department of pediatrics, bacha khan medical college, mardan kpk, pakistan 2associate professor, department of pediatrics, bahawal victoria hospital, bahawalpur punjab, pakistan 3assistant professor, department of ent, national university of medical sciences, rawalpindi pakistan a b s t r a c t liddle syndrome is a cause of hypertension among children due to mutation in the epithelial sodium channels (enac ) located in the kidneys. it typically presents with hypertension, hypokalemia, metabolic alkalosis with low renin and aldosterone levels. although, most cases are children, but adults also present with this disorder owing to late diagnosis. amiloride and triamterene efficiently improve the condition. here we present the case of a 6-year-old girl admitted with history of hypertension, diarrhea, vomiting, weakness and palpitations on and off for the last four years. laboratory investigations revealed metabolic alkalosis, decreased renin and aldosterone levels, hypokalemia and an inverted t wave, u wave and prolonged qt interval on ecg. any pediatric case presenting with hypertension and electrolyte imbalance should promptly raise suspicion of liddle syndrome. timely diagnosis and management play a key role in reducing morbidity and mortality. key words: electrolyte imbalance, hypertension, hypokalemia, liddle syndrome correspondence: muhammad ahmed khan email: akawan79@gmail.com article info: received: december 9, 2020 accepted: may 22, 2021 cite this case report: akram s, rehman a, khan ma. liddle syndrome in a six-year-old girl: a case report. j islamabad med dental coll. 2021; 10(2): 116-119. doi: 10.35787/jimdc.v10i2.642 funding source: nil conflict of interest: nil i n t r o d u c t i o n liddle syndrome, a rare cause of early hypertension was first described by liddle and coworkers in 1963.1 this rare syndrome has an autosomal dominant inheritance and typically comprises of hypertension, hypokalemia and metabolic alkalosis.2 although the affected individuals have high blood pressure since childhood, early diagnosis is missed in some cases.3 hypokalemia, associated with this disorder causes muscle weakness, fatigue, pain and palpitations.4 liddle syndrome is often termed as “pseudoaldosteronism” because of typical features of hyperaldosteronism (i.e. hypertension, hypokalemia and metabolic alkalosis) in the absence of raised aldosterone levels.5 the syndrome is caused by mutation in genes responsible for making protein complex called epithelial sodium channel (enac).6 these channels are present in many parts of the body including kidneys, where they transport sodium into cells. gene mutations cause alteration in sodium channel structure, its subunit proteins are not degraded resulting in abnormally high sodium and water reabsorption, leading to hypertension.6 liddle syndrome is treated effectively with amiloride or triamterene (potassium sparing diuretic) and enac inhibitor combined with low sodium diet.7 the affected cases can present with complications like hypertensive encephalopathy, myocardial c a s e r e p o r t j islamabad med dental coll 2021 117 infarction, cerebrovascular ischemia, nephrocalcinosis and retinopathy, etc. c a s e r e p o r t a 6-year-old girl was admitted in pediatric icu of bahawal victoria hospital bahawalpur, pakistan with history of hypertension, diarrhea, vomiting, weakness and palpitations on and off for 4 years. she had generalized body weakness more marked in lower limbs and neck muscles. her birth history, feeding history, vaccination and developmental history were unremarkable except for growth retardation. her height, weight and occipitofrontal circumference were below the 5th centile. her family history revealed sudden death of one younger male sibling at two years of age due to similar complaints of diarrhea, vomiting and weakness. on examination, her bp was 200/110 mmhg. her blood pressure was same in all four limbs. she had abnormal facies with prominent ears and a triangular face. laboratory investigations revealed hypokalemia with serum potassium <2 meq/l. renal function tests, serum calcium levels and echocardiography were normal. electrocardiogram (ecg) revealed signs of hypokalemia with an inverted t wave, u wave and prolonged qt interval. potassium replacement was initiated and blood pressure was controlled with sodium nitroprusside and sublingual captopril. her serum potassium levels and blood pressure improved gradually. abgs showed metabolic alkalosis with raised serum hco3 levels (44 mmol/l) and ph (7.92) and decreased serum chloride (53 mmol/l) (table i). hypokalemia, metabolic alkalosis and hypertension raised suspicion of liddle syndrome in this child. next renin and aldosterone levels were checked for confirmation of our diagnosis. both levels were markedly decreased (renin 0.3 ng/ml/h, aldosterone 0.5 ng/dl) (table i). she was put on tablet amiloride (5mg, twice daily), to which she responded and hypertension gradually improved. she was discharged after a week and advised regular follow-up every four weeks. d i s c u s s i o n in pediatric cases with hypertension, clinicians should suspect renal, vascular, cardiac (coarctation, etc.) or endocrine disorders (hyperthyroidism or pheochromocytoma). however, children presenting with hypertension along with electrolyte imbalance should raise suspicion of monogenic causes of hypertension, which include liddle syndrome, gordon syndrome and familial hyperaldosteronism.8 these disorders are called monogenic because they are caused by single gene mutations, which are inherited in mandelian pattern.8,9 to investigate further, serum renin and aldosterone should be checked. serum renin level is decreased uniformly in all these diseases; however, serum aldosterone is decreased in liddle syndrome in contrast to others.8,9 literature search revealed that only one case of liddle syndrome has been reported in pakistan by aziz et al. in 2016 in a 10-month-old female.3 another research carried out by gilani et al. in rawalpindi, pakistan reported 80 cases of young hypertensives with renin-angiotensin-aldosterone disorders, but they did not find any case of liddle syndrome in their cohort.10 teoh et al. reported three cases of liddle from department of pediatrics, university of louisville, kentucky usa with almost similar age group and clinical pictures as our case.8 patel and kuriacose reported a case of liddle syndrome from johnson city, tennessee usa, but the age of the patient was 48 years.2 tetti et al. reported a case of liddle in a 13-year-old caucasian boy with history of sudden death of a sibling, just like in our case.11 j islamabad med dental coll 2021 118 table i: detailed laboratory investigations of the patient laboratory test patient result normal range hemoglobin 10.3 mg/dl 12-18 mg/dl total leucocyte count 7.7 x 103/ mm3 4-11 x 103/ mm3 platelet count 193 x 103/ mm3 150-400 x 103/ mm3 serum bilirubin 14 mg/dl 1-17.1 mg/dl serum alanine transaminase 38 u/l <40 u/l serum alkaline phosphatase 163 g/dl <279 g/dl serum urea 42 mg/dl 10-50 mg/dl serum creatinine 0.9 mg/dl 0.6-1.1 mg/dl serum magnesium (mg) 0.94 mmol/l 0.85-1.10 mmol/l serum sodium (na) 142mmol/l 136-146 mmol/l serum potassium (k) <2mmol/l 3.5-5.1 mmol/l serum chloride level 53 mmol/l 98-108 mmol/l serum bicarbonate 44 mmol/l 20-31 mmol/l serum aldosterone level (recumbent position) 0.5 ng/dl 3-90 ng/dl plasma renin level 0.3 uiu/l 8-35 uiu/l blood sugar random 126mg/dl <140mg/dl urine chloride 64 mmol/l 140-250 mmol/l 17-hydroxyprogesterone 6 nmol/l <10nmol/l (females) serum calcium 2.3 mmol/l 2.2-2.7 mmol/l c o n c l u s i o n any pediatric case presenting with hypertension and electrolyte imbalance should promptly raise suspicion of liddle syndrome. timely diagnosis and management can reduce morbidity and mortality. since, it is an autosomal dominant disorder, other family members and siblings should also be screened for a definitive diagnosis of this rare illness. r e f e r e n c e s 1. liddle gw, bledsoe t, coppage wsj. a familial renal disorder simulationg primary aldosteronism but with negligible aldosterone secretion. trans assoc am phys. 1963; 76: 199-213. 2. patel p, kuriacose r. liddles syndrome: a case report. saudi j kidney transpl. 2015; 26(4): 769-72. doi: 10.4103/1319-2442.160211. 3. aziz da, memon f, rahman a, ali m. liddle’s syndrome. j ayub med coll abbottabad 2016; 28(4): 809-11. 4. bogdanovic r, kuburovic v, stajic n, mughal ss, hilger a, ninic s, et al. liddle syndrome in a serbian family and literature review of underlying mutations. eur j pediatr. 2012; 171(3): 471-8. doi: 10.1007/s00431-011-1581-8. 5. yang kq, xiao y, tian t, gao lg, zhou xl. molecular genetics of liddle syndrome. clin chim acta. 2014; 436: 202-6. doi: 10.1016/j.cca.2014.05.015. 6. hanssen jh, nelson-williams c, suzuki h, schild l, schimkets r, lu y et al. hypertension caused by a truncated epithelial sodium channel gamma subunit: genetic heterogeneity of liddle syndrome. nat genet. 1995; 11(1): 76-82. doi: 10.1038/ng0995-76. 7. yamaguchi e, yoshikawa k, nakaya i, kato k, miyasato y, nakagawa t, et al. liddle’s-like syndrome associated with nephrotic syndrome secondary to membranous nephropathy: the first case report. bmc nephrol. 2018; 19(1): 122. doi: 10.1186/s12882-018-0916-3. 8. teoh z, shah s. a case report of three children with secondary hypertension caused by liddle syndrome. clin nephrol case stud. 2020; 8: 37–40. doi: 10.5414/cncs109972. j islamabad med dental coll 2021 119 9. vehaskari vm. heritable forms of hypertension. pediatr nephrol. 2009; 24: 1929-37. doi: 10.1007/s00467-007-0537-8. 10. gilani m, asif n, akram a, gilani m, ijaz a, malik ss. spectrum of rennin angiotensin aldosterone system disorders in young hypertensives. j pak med assoc. 2018; 68(8): 1179-82. pmid: 30108382. 11. tetti m, monticone s, burrelo j, matarrazo p, veglio f, pasisi b, et al. liddle syndrome: review of literature and description of a new case. int j mol sci. 2018; 19(3): 812. doi: 10.3390/ijms190300812. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):142-143 142 case report cerebellar tubercular abscess adil aziz khan1, shafiq umar2 and huma mushtaq3 1senior registrar, department of neurosurgery, hoy family hospital rawalpindi 2registrar department of neurosurgery, holy family hospital rawalpindi 3associate prof. department of pathology, islamabad medical & dental college, islamabad abstract tubercular brain abscess is an uncommon lesion and tubercular cerebellar abscess is rarely reported. almost all case reports of tuberculous abscess are described in hivinfected or immunocompromised patients. we report a case of presented with an immunocompetent patient who was diagnosed with probable tuberculous brain abscess of the cerebellum. she complained of headache, neck pain and unsteadiness of gait since two months and associated diplopia on clinical examination. she did not have any history of pulmonary tuberculosis. diagnosis was made by ct scan/mri of brain. she responded well to anti tuberculous treatment and her symptoms resolved without any surgical intervention. keywords: immunocompetent adult, solitary cerebellar abscess, tuberculous abscess, introduction in the cns, tuberculosis is usually presented as meningeal infection or as tuberculoma; rarely is it an abscess. 1 for this reason, tuberculous abscess should be considered in patients with preexisting extracranial tuberculosis presenting with brain abscess especially individuals from areas where tuberculosis is endemic. 2 tuberculous brain abscess is a focal collection of pus containing abundant acid fast bacilli (afb), surrounded by a dense capsule consisting of vascular granulation tissue. 2 this condition is more commonly seen in immunocompromised patients who are unable to mount a granulomatous inflammatory response. 3,4 the pathogenesis of tuberculous brain abscess is similar to other forms of cns tuberculosis. it is postulated to be a hematogenous dissemination from the lung. the appearance of tuberculomas on ct scan usually reveals small rings or nodular-enhancing lesion with only mild edema and mass effect, and on magnetic resonance imaging (mri), they often have an isointensity or hypointensity center on t-2 weighted images. 3 tuberculous abscess of the posterior cranial fossa risks rapid deterioration from brainstem compression, obstructive hydrocephalus and tonsillar herniation, thus necessitating surgical intervention. 5 other reports, however, have suggested that treatment with prolonged antituberculous therapy may be adequate especially in patients who have relatively early lesions with poorly formed capsules, such as in our case. 5 case report a 19-year-old girl presented with a 4-week history of headache, gradually increasing in intensity, associated with persistent vomiting. there was no history of previous medication. on admission, the patient was found to have temperature of 37.4 °c, pulse rate of 76 beats/min, respiratory rate of 20 breaths/min, blood pressure of 110/80 mmhg. the neurological examination revealed an alert patient with diplopia, truncal ataxia, impaired finger-to-nose test with dysdiadochokinesia of the left side. she had neither nuchal rigidity nor abnormality of the cranial nerves. laboratory examinations showed normal serum electrolyte levels, renal and liver function tests. complete blood cell count showed: hb13.0 g/dl, tlc:5600/mm 3 (66% neutrophils, 18% lymphocytes, 12% monocytes, 4% eosinophils) and 275,000 platelets/mm 3 . a chest roentgenogram was unremarkable. mri brain showed two ring enhancing lesions in the left cerebellum , with perilesional edema (figure 1). the mass resulted in compression over the adjacent cerebellar parenchyma and dorsal brain stem. the fourth ventricle was effaced while rest of the ventricles were prominent. the sulci and cisterns were unremarkable. no significant shift of midline structures was observed. the findings revealed ring enhancing lesions in the left cerebellum, suggestive of tubercular abscess. antituberculous treatment including rifampicin, isoniazid, streptomycin and pyrazinamide was given and in 15 days the patient’s headache along with vomiting was relieved. the follow-up mri after 4 months of att, revealed resolution of cerebellar abscess (enhancing nodules) (figure 2). the patient made an uneventful recovery with resolution of her neurological deficits and is being continued on antituberculous chemotherapy. corresponding author dr huma mushtaq e mail:dr_kat18@hotmail.com received: september 5,2016; accepted: oct 15, 2916 http://www.ijmm.org/viewimage.asp?img=indianjmedmicrobiol_2009_27_4_363_55464_f1.jpg journal of islamabad medical & dental college (jimdc); 2016:5(3):142-143 143 figure 1: mri axial view with contrast, with enhancing nodules figure 2: mri axial view with contrast, resolution of the enhancing nodules discussion tuberculous brain abscess (tba) is one of the rare forms of central nervous system tuberculosis. cerebellar abscess due mycobacterium tuberculosis is extremely rare even in a country where tuberculosis is an alarming public health problem. it is usually associated with foci of infection either in the lung or with an immunocompromised state. an isolate or primary tba with no evidence of tuberculosis elsewhere is even rarer, as seen in our case with no evidence of pulmonary tuberculosis. the criteria for diagnosis include pus within the brain, the presence of acid fast bacilli (afb) in the pus and the absence of caseation and granuloma formation. 6 tuberculous meningitis (tbm) is the most common form of tuberculosis of brain; however solitary or multiple intracranial tuberculomas, in particular occur less frequently. 7 in the differential diagnosis of intra-cranial tuberculosis (icts), images on the radiological findings should be differentiated from other causes of space occupying lesions, which include malignant diseases such as glioma or lymphoma, pyogenic abscess, toxoplasmosis, neurocysticercosis, sarcoidosis, hydatid cysts. and late syphilitic involvement of cns. 7 cerebral tuberculosis manifests predominantly as tuberculous meningitis, followed by tuberculomas, other forms of cns tuberculosis include, cerebral abscess, cerebral miliary tuberculosis, tuberculous encephalopathy, tuberculous encephalitis and tuberculous arteritis. tuberculous abscess of the brain is very uncommon. though tuberculosis in cns occurs due to hematogenous spread of mycobacteria from elsewhere; tbm may occur via lymphatic spread from cervical lymph nodes. tubercle bacilli are immobilized in end-arteries, which leads to formation of sub-meningeal tubercular foci, which may further lead to various presentations of tuberculosis. 8 in tuberculoma, bacilli get lodged in brain and once tuberculoma is formed, it evokes secondary reaction, leading to capsule formation. the surrounding brain edema and gliosis may resemble low-grade astrocytoma. in rare cases, there may be central caseation, liquefaction and formation of an abscess. this phenomenon is very rare, tuberculous abscess commonly occurs in patients with abnormal cell mediated immunity and are mostly focal. 8 these lesions usually occur secondary to lung disease, but in our patient it was a primary tuberculoma. the presentation is reported mostly in 3 rd or 4 th decade. there may be supratentorial abscess and rarely in cerebellum as observed in the present case. 7,8 tuberculomas of the brain are isolated foci of caseous or proliferative tuberculosis. they may remain silent for a long time and later create symptoms. they routinely respond to antituberculous treatment. surgical management is very rarely needed. 9 references 1. nathoo n, nadvi ss, van dellen jr, gouws e.intracranial subdural empyemas in the era of computed tomography: a review of 699 cases. neurosurgery 1999; 44:529-36. 2. mathisen ge, johnson jp. brain abscess. clin infect dis. 1997; 25:763-81. 3. farrar dj, flanigan tp, gordon nm, gold rl, rich jd.tuberculous brain abscess in a patient with hiv infection:case report and review. am j med 1997; 102:297301. 4. elder nc. extrapulmonary tuberculosis. a review. archfam med 1992; 1:91-8. 5. tangviriyapaiboon t, suwansirikul s. mycobacterial brain abscess of the cerebellum. journal of infectious diseases and antimicrobial agents. 2005;22(2):71-6. n okacha , b omar, e mostapha, a ali, g miloudi, e brahim , b mohamed. primary tuberculous cerebellar abscessin an immunucompetent adult.inter med 2010; 49:875-876. 6. oncul o, baylan o, muttu h, cavulsu s, dogan l. tuberculous meningitis with multiple intracranial tuberculomas mimicking neurocysticercosis. clinical & radiological findings. jpn j infect dis 2005; 58:387-9. 7. 8. babu ml, shavindar. tuberculous brain abscesses. jkpractitioner 2002; 9:262-63. 8. 9. s.k. ajay,b.b. lakhkar n. bhaskaranand . intracranial tuberculoma manifesting during treatment. indian paediatrics 1996; 33: 231233 170 j i m d c 2 0 1 7 170 op e n ac c e ss f u l l l e n g t h a r t i c l e comparison of syringing of the ear wax with plastic disposable & metallic syringe muhammad farooq associate professor, department of ent, azad jammu and kashmir medical college muzaffarabad a b s t r a c t objective: ear syringing is a very common procedure performed by both general physicians and ear nose and throat specialists & consultants. to compare the effectiveness of plastic disposable and metallic syringes for removal of ear wax. patients and methods: this experimental study was conducted on one hundred patients, over a period of one year from january to december 2016. these patients were divided into two groups by odd and even serial numbers. group-a included 50 patients who were treated by syringing with a plastic disposable syringe to remove their ear wax while group-b consisted of 50 patients who were treated by syringing with a traditional higginson metallic syringe for the removal of their ear wax. the discomfort score, cost, efficacy, safety, and complications were recorded and compared in patients of both groups. results: syringing with a plastic disposable syringe was more cost-effective, safer, lesser cumbersome and has less complications rate than syringing with a metallic syringe. however, the efficacy was similar in both types of procedures. conclusion: syringing of the ear with a plastic disposable syringe is safer, more feasible, economical but equally effective as compared to syringing with a metallic syringe. keywords: ear syringing, wax ear, metallic syringe, plastic disposable syringe author`s contribution conception, synthesis, planning of research and manuscript writing interpretation and discussion data analysis, interpretation and manuscript writing and active participation in data collection address of correspondence muhammad farooq email. dr.farooqak@gmail.com article info. received: june 12, 2017 accepted: august 10, 2017 cite this article: farooq m. comparison of syringing of the ear wax with plastic funding source: nil disposable and metallic syrings.jimdc. 2017; 6(3):170-173. conflict of interest: nil i n t r o d u c t i o n syringing of the ear is often needed for the removal of occluding wax from the ear. wax is composed of secretions of sebaceous and ceruminous glands, desquamated epithelial debris, keratin, hair, and dirt. wax has protective functions as it lubricates the external ear canal and traps any foreign material. its smell discourages the entry of insects.1 normal wax is composed of water (80%), volatile substances (15%) and ash (5%), which includes na, k, ca, mg, cu and other trace elements.2 it’s color is brownish or yellowish due to oxidative causes.3 different types of earwax are produced in asian and nonasian population. the gene for dry or wet type of earwax is located at chromosome 16 with predominance of wet variant. kate prigge from monell says that their analysis of the smell of ear wax can be used to diagnose various genetic disorders like “maple syrup urine disease”. o r i g i n a l a r t i c l e 171 j i m d c 2 0 1 7 171 swabbing someone's ears is a much simpler and cheaper process than doing a genetic test.4 determination of type of the ear wax is done by a single nucleotide polymorphism in the abcc 11 gene. genotype aa is responsible for dry wax and ga and gg for wet wax. human earwax is a mendelian trait having two forms dry and wet. dry wax lacks cerumen, is yellowish or grey and brittle. wet wax is brownish and sticky. the incidence of impacted wax is 7-35% in children and adults. it is more common in men than in women and in mentally retarded persons.5 its incidence is increased by the use of cotton buds, earphones and hearing aids and in old age (about 50%) due to the production of hard wax.6, 7 normally a small amount of earwax is produced which dries up and is expelled from the meatus by movements of the jaw. the most common cause of earwax blockage is the removal of the earwax at home by cotton buds, pins, scoops or other objects which actually pushes the wax deeper into the canal leading to complete blockage. frequent use of earphones can also prevent natural expulsion of ear wax leading to blockage.8 other causes of impaction of earwax are excessive production of wax, narrow and tortuous ear canal, stiff excessive hair, exostosis, dusty occupation, selfcleaning by cotton buds and use of hearing aids. the secretion of ceruminous (sweat) glands can be affected by fever, adrenergic drugs and emotions resulting in an increase or altered secretion of wet wax. impacted earwax is removed by one of three methods; syringing, suction or with instruments such as wax hook, scoop or jobson horn probe.5, 9 hard wax can be softened by instilling olive or almond oil into the ear; 35 drops, 3-5 times daily. use of sodium bicarbonate drops are probably more effective because it not only softens but also dissolves the wax.10 waterjet of ear syringe should be directed to postero-superior wall of the ear canal to prevent eardrum perforation and further impaction of earwax.11 syringing is contraindicated if there is a history of eardrum perforation, infection and previous ear surgery or grommet insertion. alternate methods mostly used by ent specialists and consultants is the use of irrigation machine, instruments or suction clearance (micro-suction) of the wax often under a microscope.12 we planned this study to compare the effectiveness of plastic disposable and metallic syringes for removal of ear wax. p a t i e n t s a n d m e t h o d s this experimental study was conducted at united hospital, rawlakot on 100 patients to find out the benefits of syringing of the ear with a disposable plastic syringe as compared to syringing of the ear with a metallic syringe. the duration of the study was 01 year from january to december 2016. all patients were followed-up for 4-8 weeks. approval from the ethical committee was taken prior to the start of the study. informed consent was taken from each patient after explaining the pros and cons. those patients having a history of previous otitis media, earache, otorrhoea, grommet insertion, vertigo during syringing or eardrum perforation were excluded from the study. the selected patients were divided by odds and even serial numbers into two equal groups. group-a included 50 patients who were treated by syringing with a plastic disposable syringe to remove their ear wax while group-b consisted of 50 patients who were treated by syringing with a traditional huginson metallic syringe for the removal of their ear wax. main outcome variables to check the effectiveness of both methods were discomfort or pain score, complications, efficacy and cost. the discomfort or pain score was assessed in each patient on a scale from zero (no discomfort) to 100 (maximum discomfort or pain). the efficacy was judge by complete evaluation of ear wax. these variables were recorded on a performa and compared in both groups. statistical analyses of the obtained results were performed using spss version-23. for quantitative data, the mean and standard deviation was calculated. qualitative data was represented as number and percentage. the p-value was calculated by using independent t-test and chi-square test on www. graphpad.com. significance was given to a pvalue of equal or less than 0.05. r e s u l t s total 100 patients were included in the study. mean age of patients was 42.5 years ranging from 3 months to 98 years. male to female ratio was 2:1.2. the mean and total discomfort scores were found significantly less in patients of group-a, who received syringing of ear wax by plastic disposable syringe as compared to group-b, who received syringing of earwax by metallic syringe (table1). 172 j i m d c 2 0 1 7 172 table 1: discomfort scores of syringing for earwax in patients (n=100) features group-a (n=50) group-b (n=50) p-value total discomfort score 70 135 ---- discomfort score (mean±sd) 14 ±6.04 27±27.37 <0.0001 the rate of complications such as vertigo and external ear canal injury were more common in group-b as compared to group-a patients (table-2). there were many other benefits of using plastic syringe for removal of earwax over metallic syringe as depicted in table-3. the efficacy, judged by complete evacuation of the earwax was similar in patients of both groups. table 3: comparison of features of syringes used for ear wax removal (n=100) features plastic syringe (group-a) metallic syringe (group-b) cost less more disposable yes no pressure control easy difficult acceptability more less rusting nil yes need of sterilization no yes holding and stabilization of syringe more easy mild difficulty availability easily available not easily available need of greasing no yes pressure of water jet low and easy to control medium/high and difficult to control d i s c u s s i o n the management of symptomatic impacted ear wax is a frequent demand in medical practice, but less research has been done on this topic.13 a sound knowledge and understanding of the anatomy of normal parts of the ear is necessary to manage impacted earwax properly by the procedure of syringing.14 impacted wax can cause hearing loss of about 30-40 decibels.15 ears blocked by wax are usually uncomfortable leading to irritation, reduced hearing and pain and these patients often seek rapid relief. ear wax removal is a time-consuming procedure in both gp and ent specialist care centers. some of the primary health care centers also advocate home treatment of ear wax by bulb syringing.7,16 however effectiveness and safety of home treatment of ear wax is doubtful. due to more risk of complications, it is not advocated for individuals to syringe their own ears. moreover, without examination of their ears by a doctor, it can’t be assured that the symptoms are due to impacted wax or some other cause.17 syringing can cause some discomfort but it should not cause actual pain which if occurs then syringing should be stopped and ear must be inspected for ear canal injury or eardrum perforation. rarely vertigo and tinnitus can occur and should be managed by cession of syringing and placing the patient flat on a couch for few minutes.18 results of this study showed that total and mean discomfort scores were significantly less in group-a (70 & 14) as compared to group-b patients (135 & 27). moreover, the prevalence of complications like dizziness, vertigo, ear canal trauma and eardrum perforation was less common in group-a as compared to group-b patients. the most probable reason for more risk of complications is the high pressure of water jet of the metallic syringe as compared to low pressure of water jet of a plastic syringe. the rate of otitis externa was almost similar in both groups. statistical analysis of this data showed a p-value of 0.0001 which is considered to be statistically significant favoring group-a patients. these results are almost similar to the findings by thomas et al in 2012 who also found more complications in using a metallic syringe for ear wax removal. they also found traumatic facial nerve palsy in one patient. it is very important to be aware of this unusual complication which should be managed properly. they also suggested use of safer 50 or 100 ml plastic syringes.29 however results of this study are contrary to findings by vlantis and soo table 2: complications of syringing for earwax in patients (n=100) features group-a n(%) group-b n(%) p-value fainting, dizziness and vertigo 2 (4) 4 (8) 0.3492 ear canal injury nil 2 (4) <0.0001 otitis externa 2 (4) 2 (4) ≥0.05 tinnitus 1(2) 1 (2) ≥0.05 173 j i m d c 2 0 1 7 173 in 2004; who found that syringing of earwax by 50ml plastic syringe is equally effective and safer as compared to syringing of the ear with metallic syringe.20 there is no need for routine ear care for ear wax. the more aggressively you remove earwax, the more aggressively body will produce it, and this can lead to a “vicious cycle”. therefore, it is better to stop cleaning the ears; the body will adapt and gradually produce less earwax. normally, the movement of the jaw will propel the earwax to empty itself out of the ear canal.21 it is important to detect and manage asymptomatic impacted earwax appropriately at general physician and consultant levels to prevent its potential long-term effects and complications.22 c o n c l u s i o n syringing for removal of soft earwax is effective and safe when performed correctly after taking all precautions. the results of this study showed that use of the plastic disposable syringe is more beneficial and safer than the use of the metallic syringe for removal of soft earwax. r e f e r e n c e s 1. dhingra pl, dhingra s. diseases of external ear. diseases of ear, nose and throat & head and neck surgery. 6th edition, elsevier, editor india, 2014:53-54. 2. udaipurwala ih. diseases of the external ear. in principles & practice of oto-rhino-laryngology, 5th edition 2013: 65-67. 3. hazarika p, nayak dr, balakrishnan r. diseases of the external ear. text book of ear, nose, throat and head & neck surgery 3rd edition; 2013: 123-24. 4. mcgrath p. secretion secrets: things you didn’t know about ear wax. bbc health news; 16 march 2014. 5. gleeson m. scott brown's otolaryngology.7th edition. edward arnold (pub), 2008; vol-3; page3108, 3311-3314. 6. aung t, mulley gp. removal of ear wax. bmj. 2002; 325(7354):27. 7. coppin r, wicke d, little p. managing earwax in primary care: efficacy of self-treatment using a bulb syringe. br j gen pract. 2008; 58(546):44-9. 8. pietrangelo a, cherney k (written by) and kim s (reviewed by). earwax buildup and blockage. health line newsletter. october 5, 2015. 9. bansal m. diseases of ear, nose and throat, head & neck surgery. 5th edition; 2013: 190-91. 10. corbridge rj. pharmacology in ent; in, essential ent, second edition hodder arnold; 2011: 168. 11. george s. smart study series, ent and head & neck surgery. 2010. elsevier india. coppin r. 12. roychaudhuri bk. diseases of the ear. synopsis of otorhinolaryngology. cbs publishers india, 5th edition 2013: 65. 13. coppin r, wicke d, mehta r, little p. management of ear wax in primary care—postal survey of uk gps and practice nurses. family practice. 2004; 21(4):413-4 14. harrison e, otalgia cm. australian family physician, 2016; 45(7):493 15. jafek b w, murrow bw. ent secrets; 3rd edition; 2005, reprinted in 2013. elsevier, india. 16. hand c, harvey i. the effectiveness of topical preparations for the treatment of ear wax: a systemic review. br j gen pract, 2004; 54(508): 862-67. 17. ellis r. cost-cutting gps telling patients to do it themselves-but is it safe to syringe out your own ears? health mail online; 2009. 18. maran agd. diseases of the external ear, in: logan turner’s diseases of the nose, throat & ear; 10th edition 2007: 265 67. 19. thomas am, poojary b, badaridatta hc. facial nerve palsy as a complication of ear syringing. the journal of laryngology & otology, 2012; 126(7):714-6. 20. vlantis ac, soo g. office based ent procedures. the journal of the hong kong college of family physicians hc pract, 2004; 26: 242-247. 21. lul h. how to properly maintain your ears and earwax. lifehacker email newsletter filed to health; 2014. 22. macharia im. common ear conditions underdiagnosed at primary level. community ear and hearing health. 2016;13(17):1-2. 91 j i m d c 2 0 1 7 91 op e n ac c e ss f u l l l e n g t h a r t i c l e role of magnetic resonance imaging in caries spine waqar alam1, faaiz ali shah2, umair nadeem3, saeed ahmad4, abdullah shah5, naeem ahmed6, amer aziz7 1 spine fellow, department of orthopedics and spine surgery, ghurki trust teaching hospital lahore 2 assistant professor, govt. lady reading hospital peshawar 3 postgraduate resident, department of orthopedics and spine surgery, ghurki trust teaching hospital lahore. 4 senior registrar, department of orthopedics and spine surgery, ghurki trust teaching hospital lahore. 5 assistant professor, department of orthopedics and spine surgery, ghurki trust teaching hospital lahore. 6 department of orthopedics and spine surgery, ghurki trust teaching hospital lahore. 7 head, department of orthopedics and spine surgery, ghurki trust teaching hospital lahore. a b s t r a c t objective: to evaluate the usefulness of magnetic resonance imaging (mri) in caries spine, avoiding invasive procedures for the diagnosis of the spinal tuberculosis. patients and methods: this cross-sectional study was conducted at department of orthopedic and spine surgery, ghurki |trust teaching hospital lahore, from january 2012 to may 2016. patients who underwent surgery for cervical, thoracic and lumbar spinal tuberculosis were inducted in the study. their mri were reviewed and eight parameters namely t1 hypo intensity, t2 hyper intensity, epiphyseal involvement, disc involvement, pedicle involvement, anterior subligamentous extension, paraspinal extension and no spinous process involvements were noted. each of the variables were given 1 point when present and zero when absent. score of ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non-tuberculous etiology. results: we evaluated 243 patients of histopathologically proven cases of caries spine. among these, 129 (53.08%) were females and 114 (46.91%) were males. mean age of patients was 39.04 years ranging from 8 years to 71 years. dorsal spine was mainly involved in 105 (43.21%) patients followed by lumbar spine in 91(37.45%) and cervical spine in 47 (19%) patients. number of vertebrae involved were two or more in each case. data showed that 238 (97.94%) patients had score ≥ 6 which favored a tuberculous spine whereas 5 (2.06%) patients had scores 5 which suggest antituberculous cause. conclusion: our study revealed that objectively outlined eight-point mri criteria of vertebral lesions is expected to diagnose caries spine with confidence in majority of cases. the proposed scoring system will mitigate the dependency on histopathological diagnosis or invasive method, so that early initiation of anti-tuberculous therapy may be possible. keywords: caries spine, magnetic resonance imaging, scoring system. author`s contribution 1,2conception, synthesis and planning of the research,-3-5active participation in active methodology, interpretation and discussion, 6,7 review the study address of correspondence dr. waqar alam waqaryousafzai@yahoo.com article info. received: feb 11, 2017 accepted: may 26, 2017 cite this article: alam w, shah fa, nadeem u, ahmad s, shah a, naeem a, aziz a. role of magnetic resonance imaging in caries spine. jimdc. 2017; 6(2):91-94. funding source: nil conflict of interest: nil i n t r o d u c t i o n spinal tuberculosis is an ancient disease and the causative agent, mycobacterium tuberculosis is still detectable in the bones of egyptian mummies.1 the first description of spinal tuberculosis was given by sir percival pott in 1779.2 today spinal tuberculosis constitutes 50% of skeletal tuberculosis, 50-60% of extra pulmonary tuberculosis and 1-5% of all tuberculosis cases. it continues to be a fatal disease in developed and under developed countries.3 although the thoracolumbar junction seems to be the most common site of the spinal o r i g i n a l a r t i c l e mailto:waqaryousafzai@yahoo.com 92 j i m d c 2 0 1 7 92 column involvement in caries spine, any part of the spine can be affected.4 furthermore, the incidence of neurologic complications in caries spine varies from 10% to 43%.5 the diagnosis of spinal tuberculosis is not easy and in almost all cases, the illness manifests in advanced stages.6 conventional radiological imaging is noninvasive but it takes nearly three to four months for spinal tuberculous lesion to be evident on plain radiographs and unfortunately, more than 50% of the vertebra are destroyed before the formation of the lesions to be seen on a plain radiograph.7,8,9 the advent of magnetic resonance imaging (mri), with reported sensitivity and specificity of 100% and 88.2% respectively, for caries spine has revolutionized the diagnosis of the condition.10 it can identify the pathological lesions in the early stages of the disease, correctly demonstrate the extent of the disease involvement and can monitor the response to treatment. however, the usefulness of mri in diagnosis depends on accurate interpretations of the findings seen. although the literature outlined the broad-spectrum features of mri in spinal tb,11 but what exactly defined the tubercular lesion on a spinal mri is still not mutually agreed.11 hence, this study was conducted to outline, various pathological changes seen on mri in established cases of caries spine and to evaluate its diagnostic accuracy. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at department of orthopedic and spine surgery, ghurki trust teaching hospital lahore, pakistan, from january 2012 to may 2016.the research protocols were approved from ethical review board (erb) of the hospital. mris of all the patients who underwent surgery for cervical thoracic and lumbar spinal tuberculosis during this period, were reviewed and the mri assessment was broadly divided into eight parameters (table 1).12 a score of ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non-tuberculous etiology. the cases included were those with a definitive diagnosis of caries spine on histopathological examination of tissue obtained at the time of definitive surgery or biopsy. the patients with an inconclusive or doubtful diagnosis of spinal tb and those with infection due to nontuberculous mycobacteria were excluded from the study. surgical procedures (anterior strut grafting, anterior instrumentation and posterior instrumentation) changed according to the progression of the disease. posterior instrumentations and fusion was done in same session with anterior surgery or after 10–15 days in sever khyphosis (sagittal index more than 20 degrees) all the patients eligible for the study had a pretreatment mri done at the time of diagnosis. a retrospective assessment of the pre-treatment mri of the eligible patients was done and the findings were noted. data entered into spss version 15. frequency and percentages were calculated for qualitative variables. r e s u l t s a total of 243 patients of histopathologically proven caries spine were evaluated in our study. among these, 129 (53.08%) were females and 114 (47%) were males. their mean age was 39.04 years, ranging from 08 years to 71 years. the patients in the study group presented with backache, deformity and neurological deficit. dorsal spine was mainly involved, in 105 (43.21%) patients followed by lumbar spine 91(37.45%) and cervical spine (n=47, 19%). number of vertebrae involved were two or more in each case. in total cases, 238 (97.94%) patients had mri scores ≥ 6 which favored a tuberculous whereas 5 (2.06%) had score 5 which is a grey zone in this scoring system but all of our patients were histopathologically proven caries spine. the mri characteristic findings are shown in table 2. table 1. scoring system for mri characteristic findings in spine tuberculosis mri characteristic involvement score when present score when absent t1 hyposensitivity 1 0 t2 hypersensitivity 1 0 epiphyseal involvement 1 0 disc involvement 1 0 pedicle involvement 1 0 anterior subligamentous extension 1 0 paraspinal extension 1 0 no spinous process involvements 1 0 93 j i m d c 2 0 1 7 93 table 2: mri characteristic findings mri characteristic findings number of patients percentage t1 hyposensitivity 243 100 t2 hypersensitivity 243 100 epiphyseal involvement 243 100 disc involvement 238 98.3 pedicle involvement 238 98.3 anterior subligamentous extension 243 100 paraspinal extension 242 99.5 spinous process involvements 06 2.4 d i s c u s s i o n early diagnosis is the keystone in the management of caries spine. delay in diagnosis leads to extensive bony destruction, progressive deformity and permanent neurological deficit. spinal mri show early bone involvement of tb than plain x-ray.9 several studies recommend the use of mri for the early diagnosis of caries spine 9,13 but lack of guidance on the appropriate interpretation could complicate the diagnosis and pose a great problem for the accurate diagnosis.6 in our study, dorsal spine was most common site (43.21%) of involvement of tb spine, followed by lumbar spine(37.45%).similar pattern of tuberculous involvement was reported in previous studies.14,17 with a mean patient age of 39.04 years in our study, the finding outlines the predominant prevalence of tb in the younger, active & outgoing population group, having a higher incident exposure to the airborne tubercle bacilli. the number of vertebrae involved were two or more in each case in our study. average vertebral involvement in spinal tb is reported to be between 2.5 to 3.8.14 pedicle was involved in 238 (97.9%) patients while six (2.46%) patients had involvement of the spinous process or the facet. accurate diagnosis of isolated posterior element tb is essential, since similar picture is seen in spinal tumors and treatment strategy would encompass a laminectomy in addition to chemotherapy.18 disc involvement was reported in large majority (98%) of our patients. based on the involvement of disc interval, pertuiset et al identified two patterns of spinal tb, namely tuberculous spondylodiscitis (spd) or classic potts disease, and tuberculous spondylitis without disc involvement (spwd).19 involvement of the disc space was a common finding observed in our study which varied from pure signal intensity changes, suggesting inflammatory edema (spwd), to partial reduction of disc height, to complete destruction by granulation tissue. demographically, since tb affects the younger population more frequently, disc involvement is seen frequently in spinal tb because it is more vascularized at the younger age.20 regarding the eight point mri criteria of the vertebral lesions we found that majority (n=237, 97.53%) of our patients had mri scores ≥ 6 which favored tuberculous pathology whereas 5 (2.06%) had score 5 and 1 (0.41%) patient had a score ≤4 suggestive of non-tuberculous pathology, but all of our patients were histopathologically proven caries spine. similar to our study chandrasekhar evaluated the eight parameters in 45 spinal mri and noted that scores ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non-tuberculous etiology.12 he concluded that the eight-point mri criteria of the vertebral lesions are very useful and reliable in diagnosing spinal tb thereby reducing the utility of invasive biopsy. c o n c l u s i o n mri is an indispensable modality of primary investigation in suspected patients of spinal tb, which aids in early, rapid, noninvasive and accurate confirmation of the diagnosis of spinal tb. by objectively outlining the eight point mri criteria of the vertebral lesions, caries spine can be diagnosed with confidence in majority of cases. the proposed scoring system is expected to mitigate costs of surgery (when indicated) and dependency on histopathological diagnosis or invasive procedure. moreover, early initiation of anti-tuberculous therapy will be beneficial for the patients. amidst the multitude findings seen on mri, the constellation of these eight pathological findings on a spinal mri in the form of a scoring system would serve as a clinician’s tool for rapid and confident diagnosis of spinal tb r e f e r e n c e s 1. ziskind b, halioua b. la tuberculose en ancienne egypte. revue des maladies respiratoires. 2007; 24(10):1277-83. 94 j i m d c 2 0 1 7 94 2. anley cm, brandt ad, dunn r. magnetic resonance imaging findings in spinal tuberculosis: comparison of hiv positive and negative patients. indian journal of orthopaedics. 2012; 46(2):186. 3. chandrasekhar yb, raj esh a, purohit ak, rani yj. novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: a preliminary report. journal of neurosciences in rural practice. 2013; 4(2):122. 4. moorthy s, prabhu nk. spectrum of mr imaging findings in spinal tuberculosis. american journal of roentgenology. 2002; 179(4):979-83. 5. kiran na, vaishya s, kale ss, sharma bs, mahapatra ak. surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients. journal of neurosurgery: spine. 2007; 6(4):320-6. 6. cormican l, hammal r, messenger j, milburn hj. current difficulties in the diagnosis and management of spinal tuberculosis. postgraduate medical journal. 2006; 82(963):46-51. 7. desai ss. early diagnosis of spinal tuberculosis by mri. j bone joint surg br. 1994; 76(6):863-9. 8. jain ak. tuberculosis of the spine. bone & joint journal. 2010; 92(7):905-13. 9. moore sl, rafii m. imaging of musculoskeletal and spinal tuberculosis. radiologic clinics of north america. 2001; 39(2):329-42. 10. de vuyst d, vanhoenacker f, gielen j, bernaerts a, de schepper am. imaging features of musculoskeletal tuberculosis. european radiology. 2003; 13(8):1809-19. 11. jain ak, sreenivasan r, saini ns, kumar s, jain s, dhammi ik. magnetic resonance evaluation of tubercular lesion in spine. international orthopaedics. 2012; 36(2):261-9. 12. chandrasekhar yb, rajesh a, purohit ak, rani yj. novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: a preliminary report. journal of neurosciences in rural practice. 2013; 4(2):122. 13. le page l, feydy a, rillardon l, dufour v, le hénanff a, tubach f, et al. spinal tuberculosis: a longitudinal study with clinical, laboratory, and imaging outcomes. in seminars in arthritis and rheumatism 2006; 36(2): 124129. 14. tuli sm. tuberculosis of the skeletal system. jp medical ltd; 2016 mar 30. 15. pertuiset e, beaudreuil j, lioté f, horusitzky a, kemiche f, richette p, et al. spinal tuberculosis in adults: a study of 103 cases in a developed country, 1980-1994. medicine. 1999; 78(5):309-20. 16. colmenero jd, jimenez-mejias me, sanchez-lora fj, reguera jm, palomino-nicas j, martos f, et al. pyogenic, tuberculous, and brucellar vertebral osteomyelitis: a descriptive and comparative study of 219 cases. annals of the rheumatic diseases. 1997; 56(12):709-15. 17. hayes aj, choksey m, barnes n, sparrow oc. spinal tuberculosis in developed countries: difficulties in diagnosis. journal of the royal college of surgeons of edinburgh. 1996; 41(3):192-6. 18. smith as, weinstein ma, mizushima a, coughlin b, hayden sp, lakin mm, et al. mr imaging characteristics of tuberculous spondylitis vs vertebral osteomyelitis. american journal of roentgenology. 1989; 153(2):399405. 19. pertuiset e, beaudreuil j, lioté f, horusitzky a, kemiche f, richette p, et al. spinal tuberculosis in adults: a study of 103 cases in a developed country, 1980-1994. medicine. 1999; 78(5):309-20. 20. ansari s, amanullah mf, ahmad k, rauniyar rk. pott's spine: diagnostic imaging modalities and technology advancements. north american journal of medical sciences. 2013; 5(7):404. https://www.ncbi.nlm.nih.gov/pubmed/7983108 100 j i m d c 2 0 1 7 100 op e n ac c e ss f u l l l e n g t h a r t i c l e surgical audit of patients at a tertiary care hospital s h waqar 1, asif ali 2, altaf hussain 3 1 associate professor, department of general surgery, pakistan institute of medical sciences, islamabad 2 postgraduate resident surgery, pakistan institute of medical sciences, islamabad 3 administrator pakistan institute of medical sciences, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad a b s t r a c t objective: analysis of various cases admitted to surgical unit of pakistan institute of medical sciences (pims), islamabad. patients and methods: this cross-sectional study was conducted from jan 2016 – dec 2016 at department of general surgery, pims islamabad. the record of all the cases admitted in surgical unit ii during the year 2016 was reviewed. all data was collected on a specially designed performa that included basic information of patients like demographics characters, mode of admission i.e. emergency, outpatient department, referred or transferred from another unit, management i.e. operation or conservative treatment, the outcome of management i.e. discharge, referred or death, and the presence of co-morbidities. data was recorded and analyzed by using spss version 20. results: total number of admissions during the study period was 822, out of these 54.3% (n=447) were males and 45.60% (n=375) were females. the mean age of the patients was 35.9. the record showed that 33.09% procedures were performed in an emergency while 66.91% were elective. among these appendicectomy was the commonest emergency procedure while cholecystectomy was the commonest elective procedure. majority of patients (94.89%) were discharged with full recovery and there were 19 (2.31%) deaths. conclusion: most patients were managed by surgery elective. cholecystectomy being the most common elective procedure followed by breast surgeries and appendicectomy was the most common operation performed in emergency. in pakistan, there is a need for surgical audit in our hospitals for proper planning and betterment of health care system of the country. it is recommended to start computerized audit and sharing of patient’s database. keywords: appendicectomy, cholecystectomy, clinical audit. author`s contribution 1conception, synthesis and planning of the research,, critical review of the article for final approval, 2,3active participation in active methodology address of correspondence dr. s h waqar drshwaqar@gmail.com article info. received: april 19, 2017 accepted: may 23, 2017 cite this article: waqar sh, ali a, hussain a. surgical audit of patients at a tertiary care hospital jimdc. 2017; 6(2):100-103. funding source: nil conflict of interest: nil i n t r o d u c t i o n the surgical audit is an important strategy to maintain standards in surgical care in the hospitals. this is systematic, critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognized standards, and then used to further inform and improve surgical practice with the ultimate goal of improving the quality of care for patients. this standard should encourage administrators to provide adequate resources for these important activities. the word “audit” comes from the latin word audire, meaning “to hear”.1 clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change".2 adapting audit system for the diversified field of surgery makes possible to analyze huge data and identifies areas for improvement of the clinical working. it may help in estimation of work burden, sorting of common o r i g i n a l a r t i c l e mailto:drshwaqar@gmail.com 101 j i m d c 2 0 1 7 101 problems and preparing for their management in future.3 in 1988, flint under the title of “philosophy and principles of auditing” described it as a social phenomenon with no purpose of gaining the reward except making the things serviceable and usable for ease. in the light of his philosophy audit emerged and evolved to fulfill the needs and interests.1 prof david johnson defined audit as “means of quality control for medical practice by which the profession shall regulate its activities with the intention of improving overall patient care”.4 so when it comes to the field of medicine it becomes the mean which represents medical practice quality control. it also assures the prevention and restriction of malpractice and promotes patient care as an outcome to it.3 the term audit is usually associated with accounting and implies the numerical review by an outside investigator for the prevention of fraud but in the clinical setting it is the collection of the data for the purpose of setting professional standards, assessing clinical performances and modifying the clinical practice.4 clinical audits combined with feedback are a well-established quality improvement intervention, which is acceptable to practitioners and widely used in primary care.5 the evidence that quality assessment and quality assurance audits have improved medical practices is not much stronger than the evidence for utilization review. many studies suggest that medical care evaluation studies have a marginal effect on the practitioner.6 a review of the historical development of auditing has shown that the objective of auditing and the role of auditors are constantly changing and auditing is seen to be evolving all the times.7 in the surgical audit, it is difficult to set standards and to apply, so we need to measure the variations in outcome. it is nonpunitive, an educational process aimed at improving the outcome of patients. locally relevant criteria should be compared to guide local resource allocation, surgical practice, and decision making. a good surgeon must never hide his/her faults but should learn from them in order to serve better his patients and improve his practice. in pakistan, a structured program for the clinical audit is not available except in very few institutions. it is not a regular practice to conduct surgical audit routinely therefore proper clinical data is not available which can be reviewed and analyzed in terms of morbidity, mortality and other clinical outcomes, in order to improve the overall clinical practice.8 this study will help to predict the mortality and morbidity and will provide an idea and planning for future risks management from the current medical record. the aim of the study is to report the analysis of all admitted cases in surgical unit ii of pakistan institute of medical sciences, islamabad. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at department of general surgery unit ii, pims islamabad from january 2016 to december 2016. an emergency day covered by the general surgery unit ii was the every 4th day of the week and a weekend on the 4th week. it has two out patient days and three operation theatre days in a week. data was collected on a self-designed performa which comprised of evaluation patient’s basic information, demography, mode of admission to surgical unit i.e. emergency/outpatient department/referred/transferred from another unit, management i.e. operation or conservative treatment, the outcome of management i.e. discharge/referred/death, and the presence of comorbidities. details of the admissions were noted from the admission register that records patient’s demographic data, date and mode of admission. details of the surgical procedures (emergency/elective) were recorded from the computerized data maintained by the paramedical staff at the reception of major ot and the department of hims. the collected data was recorded and analyzed by using spss version 20. r e s u l t s a total of 822 admissions were made during the year 2016. among them, 54.9% (n=447) were males and 45% were females (n=375). the mean age of the patients was 35.9 years. viral marker for hepatitis b was reactive in 0.24% (n=2) and for hepatitis c was reactive in 3.1% (n=26) patients. the minimum inpatient admission stay was only 1 day while the longest duration of stay was 63 days with a mean hospital stay of 8.2±5.2 days. the record showed that these were 272 emergency operations, appendicectomy being the commonest emergency procedure done in 57.35% (n=156) patients. laparotomies accounted for 17.65% (n=48) of total operations performed in an emergency which include 102 j i m d c 2 0 1 7 102 exploratory laparotomy for gastrointestinal perforation, penetrating, non-penetrating abdominal trauma, gunshot and stab wounds (table 1). the elective procedures make up 66.91% of total surgeries performed at our unit. cholecystectomy being the commonest elective operation, performed in 181 (32.91%) cases, followed by breast surgery done in 85 (15.45%) cases (table 2). as shown in table 3, 780 patients (94.89%) were discharged to home, while the mortality was 2.31% (n=19) in the year of 2016. d i s c u s s i o n the surgical audit has become an important part of the modern practice of surgery and an integral requirement for the surgeons, continuing professional development and commitment by further analysis thereby resulting in improved practice habits. in the developed world, a very successful national system for audit and comparative audit services are available9. in our study, a total of 822 patients were admitted in surgical unit ii from different modes of admission. ali sa. et al reported a higher number of admissions in one year.10 we observed the male predominance of 54.9% in our study; similar finding (56%) has been reported in an indian study.11 the mean age of the patients was 35.9 years and this finding is consistent with another local study.12 in this study frequency of elective procedures were much higher than those performed in an emergency. cholecystectomies were on the top among all procedures. a local study reported similar results with a higher number of cholecystectomies in elective procedures followed by breast surgeries13. among all the cases appendicectomies were the most commonly performed procedures followed by exploratory laparotomies in an emergency. qureshi et al and bhatti et al also reported appendiceal diseases as a most common emergency in their audit.13,14 another study showed acute appendicitis as the commonest emergency procedure.8 and one of the local studies depicted inguinal hernia is the most common elective procedure.15 comorbidities included diabetes (12.02%), hypertension (6.9%) and tuberculosis (1.76 %) cases. a british study conducted on minor surgical procedures at general practitioner level, reported head and face being the commonest sites observed.3 in our table 1: frequency of treatment given in emergency cases (n=272) type of treatment number percentage exploratory laparotomy /gi perforation / penetrating / non-penetrating abdominal trauma / gunshot / stab wounds / obstruction 48 17.65 acute appendicitis / appendectomy / appendicular mass 156 57.35 repair suturing of trauma wound 21 7.72 vascular repairs 7 2.57 anorectal diseases 8 2.94 amputations 6 2.21 conservative management 26 9.56 table 2: frequency of treatment given in elective cases (n=550) type of treatment number percentage conservative management 56 10.18 cholelithiasis/ cholecystectomy 181 32.91 hernia repairs 59 10.73 anorectal diseases 35 6.36 breast diseases 85 15.45 thyroid diseases 42 7.64 abdominal lymph node biopsies 03 0.55 major abdominal procedures 35 6.36 congenital anorectal disorders 06 1.09 vascular diseases 15 2.73 stoma reversals 14 2.54 eosophagectomies 05 0.91 thoracotomy, thymectomy 04 0.73 splenectomy 09 1.64 liver abscess 01 0.18 table 3: outcome of all admitted patients (n=822) outcome number percentage discharges 780 94.89 death 19 2.31 referred 2 0.24 discharge on request 15 1.82 leave against medical advice 6 0.73 103 j i m d c 2 0 1 7 103 study, 7.7% cases were managed conservatively and discharged on medications which included acute pancreatitis, acute cholecystitis, patients with mild to the moderate liver or chest trauma, patients with ureteric colic and some patients with pelvic inflammatory diseases. the mortality was 2.31% which is more than other local studies (1.5%) 4 and (1.2%).14 in an international study, mcguire et al reported of 1.8% mortality in the audit of 44,603 surgeries.16 the higher mortality rate in our study might be due to increased number of morbids referred cases from the peripheral hospitals to pims, islamabad. the mortality rate of scottish study after emergency surgery is high (5.1%).1 it is suggested that proper structured surgical audit is done regularly for a good surgical practice. knowledge of the current pattern of admissions, diseases spectrum and health care resources should be known, as it is beneficial for both the patient and the clinician.18 c o n c l u s i o n elective procedures were 2/3rd of total operated cases in 2016, while 1/3rd were operated in an emergency. we recommend the need for evaluating surgical work in the hospitals and immediate implementation of a surgical audit of admissions and procedures performed in the hospitals. as, unless we know the diseases spectrum and the changes occurring in the pattern of admissions, proper and better health care planning becomes difficult. r e f e r e n c e s 1. flint d. philosophy and principles of auditing. hampshire: macmillan education ltd. 1988. 2. https://en.wikipedia.org/wiki/clinical_audit. 3. ahmed f, baloch q, rashid w, ahmed i, kumar d, surgical audit of cases admitted at surgical unit i of civil hospital karachi. ann pak inst med sc. 2016; 12(4):235-238. 4. khalid s, bhatti aa. audit of surgical emergency at lahore general hospital. journal of ayub medical college abbottabad. 2015; 27(1):74-7. 5. botting j, correa a, duffy j, jones s, de lusignan s. safety of community-based minor surgery performed by gps: an audit in different settings. the british journal of general practice. 2016; 66 (646): e323-e328. 6. sanazaro pj, worth rm. concurrent quality assurance in hospital care, report of a study by private initiative in psro. n eng j med. 1978; 298(11):1171–7. 7. teck-heang lee, ali am. the evolution of auditing: an analysis of the historical development. journal of modern accounting and auditing 2008; 4(1): 1-8. 8. shaikh r, jeddi mf, ali g, iqbal sa. patterns of diseases in a surgical unit at layari general hospital, karchi. med channel. 2000; 6(2):29-31. 9. bilal a, salim m, muslim m, israr m. two years audit of thoracic surgery department at peshawar. pakistan journal of medical sciences. 2005:12-6. 10. ali sa, soomro ag, tahir sm, memon as. prospective basic clinical audit using minimal clinical data set. j ayub med coll abbottabad. 2010 mar 1; 22(1):58-61. 11. shaikh m, woodward m, rahimi k, patel a, rath s, macmahon s, jha v. use of major surgery in south india: a retrospective audit of hospital claim data from a large, community health insurance program. surgery.2015; 157(5): 865–73. 12. jawaid m, masood z, iqbal sa, sultan t. the pattern of diseases in a surgical unit at a tertiary carepublic hospital of karachi. pak j med sci. 2004; (20)4: 311-314. 13. qureshi wi, durrani km. surgical audit of acute appendicitis. proceedings of the shaikh zayed postgraduate medical institute. 2000; 14(1):7-12. 14. bhatti g, haider j, zaheer f, khan sq, pirzada mt, khan tm. surgical audit of unit ii, department of surgery, abbasi shaheed hospital, karachi. ann abbasi shaheed hosp karachi med dent coll. 2006; 11(2):54–8. 15. alam sn, rehman s, raza sm and manzar s. audit of a general surgical unit: need for self-evaluation. pakistan journal of surgery. 2007; 23(2): 141-144. 16. mcguire hh, horsley js, salter dr, sobel m. measuring and managing quality of surgery: statistical vs. incidental approaches. arch surg. 1992; 127:733–7. 17. scottish audit of surgical mortality. 2001 annual report glasgow: sasm, royal college of physicians and surgeons of glasgow. http://www.sasm.scot.nhs.uk /reports/2001report/sasm2001report.pdf 18. johnston g, crombie ik, alder em, davies ht, millard a. reviewing audit: barriers and facilitating factors for effective clinical audit. quality in health care. 2000; 9(1):23-36. https://en.wikipedia.org/wiki/clinical_audit http://www.sasm.scot.nhs.uk/reports/2001report/sasm2001report.pdf http://www.sasm.scot.nhs.uk/reports/2001report/sasm2001report.pdf j islamabad med dental coll 2020 242 open access histomorphometric variations of placenta in normal and hypertensive pregnancies rizwan ali talpur1, samia siddiqui2, sehar khowaja3, naila noor1, muhammad saqib baloch3, mansoor mukhtar qazi4 1 senior lecturer, department of physiology, isra university hyderabad, pakistan 2 associate professor, department of physiology, isra university hyderabad, pakistan 3 senior lecturer, department of anatomy, isra university hyderabad, pakistan 4 lecturer, department of anatomy, isra university hyderabad, pakistan a b s t r a c t background: pregnancy-induced hypertension is a leading cause of deleterious changes in the placenta resulting in decreased blood supply towards the organ. the objective of the current study was to analyze the histomorphometric variations in the placenta of normotensive and hypertensive women in a tertiary care hospital of hyderabad, pakistan. material and methods: this cross-sectional study was carried out in the gynecology and obstetrics section of nazeer hussain medical complex, hyderabad in collaboration with isra university, hyderabad pakistan from march 2019 to august 2019. a total of 100 placentae were collected and divided into two groups. group i had placentae of normotensive women and group ii comprised of placentae of hypertensive women. all the placentae were observed for morphometric and histological changes. student t-test was done to study morphometric differences between the two groups, while chi-square test was used to analyze the categorical variables. p-value < .05 was considered as statistically significant. results: there was an increase in the mean weight of placentae among group i as compared to group ii and the difference was statistically significant (p < .05). various gross and histological changes (hyalinized villi, intervillous hemorrhage, decreased villous vascularity) with a statistically significant difference were also observed in the placentae of the hypertensive group as compared to the normotensive placentae (p < .05). conclusions: this study concluded that pregnancy-induced hypertension poses harmful and serious histomorphometric variations in the placental tissues that may affect fetal outcome. key words: normotensive pregnancy, placenta, pre-eclampsia, pregnancy-induced hypertension. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4data analysis; manuscript editing. correspondence: mansoor mukhtar qazi email: dr.lumhs119@yahoo.com article info: received: april 20, 2020 accepted: november 20, 2020 cite this article talpur ra, siddiqui s, khowaja s, noor n, baloch ms, qazi mm. histomorphometric variations of placenta in normal and hypertensive pregnancies. j islamabad med dental coll. 2020; 9(4): 242-248. doi: 10.35787/jimdc.v9i4.540 funding source: nil conflict of interest: nil i n t r o d u c t i o n gestational hypertension, also known as pregnancyinduced hypertension (pih), is a serious condition that not only risks the life of a mother but also of the embryo/fetus growing in a mother’s womb.1 it is o r i g i n a l a r t i c l e j islamabad med dental coll 2020 243 said to occur when a pregnant lady has, with or without any previous history of hypertension, blood pressure (bp) readings of over 140/90 mmhg on two distinct occasions. pih is mainly categorized into 3 major types: chronic or pre-existing hypertension, gestational hypertension (recently diagnosed) and pre-eclampsia (a more complicated form of pih which may lead to eclampsia).2 pih affects over 5% of all pregnancies worldwide which results in immature/ premature deliveries.3 placenta is a vital organ connecting the fetus to the endometrium of the maternal uterine wall, providing passage of essential nutrients and oxygen to meet the demands of the developing baby.4 hypertension during pregnancy affects the development of the placenta by disturbing the blood supply to the placental tissue, which leads to compromised uteroplacental circulation.5 the compromised circulation is probably due to various histopathological changes in the placenta of the hypertensive pregnant, mother which interrupts the passage of essential nutrients from mother to fetus complicating the process of pregnancy.6,7 moreover, pregnant women with pre-eclampsia are often observed to have a distinct pathological lesion called placental infarct which is secondary to arterial atherosis.8 it is estimated that seventy percent (70%) of the global fetal mortality is associated with infarction of placental tissue among women with pih.9 world health organization (who) conducted a survey on maternal and newborn health in 29 countries across africa, asia, latin america, and the middle east. it was reported that almost 0.30% of women were having chronic hypertension (range 0.21% in africa to 0.32% in western pacific countries), while in pakistan, the pih has been reported to complicate 2%–3% of deliveries.10 placental ischemia leading to small-sized placenta is a classical feature seen in women with preeclampsia.11,12 as mentioned, placenta is the main connecting point between mother and developing fetus. any abnormality in the placental tissue due to vascular pathology or morphology may result in toxemia that compromise the normal development of the fetus and may also further complicate the pregnancy. the findings of the current study will be helpful for clinicians in identifying histological alterations in the placenta secondary to maternal hypertension and possible obstruction to the fetal blood flow resulting from placental vessel obstruction. furthermore, controlling hypertension or its related complications in early phase may save maternal and fetal life. the objective of the current study was to compare and analyze the histomorphometric variations in the placentae of normotensive and hypertensive women. m a t e r i a l a n d m e t h o d s a cross-sectional study was carried out in the gynecology and obstetrics section of nazeer hussain medical complex (nhmc), hyderabad in collaboration with isra university, hyderabad pakistan from march 2019 to august 2019. a total of 100 women were admitted and delivered at the nhmc during the study duration. all the placentae were collected along with the umbilical cord. the collected placentae were divided into two groups: group-i had placentae from normotensive women and group-ii had placentae from hypertensive women. weight of new-born babies and fetoplacental weight ratios were also noted soon after delivery. placentae of women with history of hypertension or pregnancy-induced hypertension (blood pressure ≥ 140/90 mmhg after 20 weeks of gestation) with or without edema, fits and/or proteinuria were included in the study. placentae belonging to women with history of other co-morbidities (like diabetes mellitus, thyroid-related problems, any feto-maternal complication, pre-mature deliveries j islamabad med dental coll 2020 244 <30 weeks of gestation, those who received injection ergometrine or similar drugs for uterine contractions) were excluded from the study. the study was approved by the ethical review committee of isra university, hyderabad while the permission from the administration of nazeer hussain medical complex, hyderabad was also obtained for conducting the study. the details of the study were explained to all the study participants in their native languages before obtaining informed written consent. after collection, placentae were washed gently in normal water and weighed using an electronic balance. gross features were observed by assessing changes in marginal veins, cotyledons, the status of placental membranes, presence or absence of infarction, and calcification. area of umbilical cord attachment in each placenta was also noted. placentae were then transferred to a glass jar with 10% formalin solution. all jars were labeled and transferred to the postgraduate research laboratory of isra university, hyderabad for further evaluation. placental tissue sections were passed in alcohol of increasing concentration (70%, 80%, 95%, 100%) and then in xylene solution for removing excess alcohol. placental tissues were embedded in melted paraffin. approximately 4-micron thick sections were cut from paraffin blocks via microtome and slides were prepared. slides were stained with hematoxylin and eosin for histopathological examination under light microscope. spss version 23 was used for statistical analysis. mean ± standard deviation (sd) was used to represent the descriptive statistics. analysis of statistical difference between the groups was done by using student’s t-test and chi-square test. the level of significance was set at p-value < .05. r e s u l t s the mean differences in maternal age, gestational age, birth weights of the newborns, placental weight, feto-placental weight ratio and cotyledons per placenta between group i and group ii are demonstrated in table i. a statistically significant difference between maternal age (p=.0001), gestational age (p=.0001), birth weight (p=.001), placental weight (p=.001) and feto-placental weight ratio (p=.04) was observed between placentae of group i and group ii (table i). table i: mean maternal, gestational fetal age and morphometric information of placenta of both groups parameter groups mean+sd p-value* maternal age (years) group i 22.6+2.94 .0001 group ii 25.4+3.12 gestational age (weeks) group i 36.81+1.20 .0001 group ii 34.22+1.29 birth weight (grams) group i 2784+43.0 .001 group ii 2438+24.1 placental weight (grams) group i 465.0+64.01 .001 group ii 417.0+57.01 feto-placental weight ratio group i 6.26+0.402 .04 group ii 6.11+0.316 cotyledons per placenta group i 16.0+3.01 .05 group ii 15.0+2.01 *p < .05 was taken as statistically significant the morphological presentation of the placentae with an area of infarction, calcification and marginal attachment of the umbilical cord is shown in figure 1b. there was a statistically significant difference between the presence of infarction, calcification, retroplacental hematoma and marginal attachment of umbilical cord between the two groups (p < .05) (table ii). marked histopathological changes were observed between the placentae of normotensive and hypertensive mothers (p < .05) (table iii) (figure 2). j islamabad med dental coll 2020 245 figure 1: morphological presentation in normotensive (a) and hypertensive (b) placentae figure 2: photomicrographs of placentae of pih group (group ii). a: homogenous areas of infarction (h&e, 100x). b: calcification (h&e 400x). c: syncytial knots seen as clumping of syncytial-trophoblastic nuclei over the villous surface (h&e 400x). d: endothelial wall of the villous vessel is shown to have been replaced by deep, red fibrinoid necrosis which appears as a homogenous nodular mass in the villi (h&e 100x). e: hyalinized villi showing degeneration of rbcs, vascular endothelial cells and fibroblasts of villous stroma (h&e 400x). f: cytotrophoblastic proliferation seen as uniform thickening of basement membrane underneath the cytotrophoblasts (h&e 400x) table ii: comparison of gross features of placentae in both groups (n=100) gross features findings group i n (%) group ii n (%) p-value* infarction present 04 (8) 21 (42) .001 absent 46 (92) 29 (58) calcification present 11 (22) 30 (60) .001 absent 39 (78) 20 (40) hematoma (retroplacental) present 05 (10) 13 (26) .037 absent 45 (90) 37 (74) umbilical cord attachment (marginal) present 06 (12) 14 (28) .045 absent 44 (88) 36 (72) j islamabad med dental coll 2020 246 table iii: histopathological changes in placentae in both groups parameters findings group i n (%) group ii n (%) p-value* syncytial knots formation per / 100 villi present 11(22) 31 (62) .001 absent 39 (78) 19 (38) fibrinoid necrosis/100 villi present 9 (18) 34 (68) .001 absent 41 (82) 16 (32) hyalinized villi/10 low power fields present 4 (8) 12 (24) .029 absent 46 (92) 38 (76) cytotrophoblastic proliferation/100 villi present 7 (14) 33 (66) .001 absent 43 (86) 17 (34) *p-value < .05 was considered statistically significant d i s c u s s i o n hypertension during pregnancy is a serious condition that risks the life of a pregnant woman and her growing embryo/fetus. it poses damaging impacts on the development of the placental tissue by disturbing its blood supply which leads to compromised uteroplacental circulation.5 keeping this in mind, placentae from normotensive as well as hypertensive women were analyzed in this study for the presence of any histomorphometric alterations. in the current study, mean birth weight of the newborns was greater in the normotensive group as compared to the hypertensive group. this is consistent with the findings of gore and coworkers, who conducted a study in a tertiary care center of western india.14 moreover, research studies carried out by ezeigwe et al. and kambale et al. also demonstrated a significant difference in the mean birth weight of the newborn in their studies.13,15 a study by goswami et al. reported pregnancyinduced hypertension as an independent risk factor for causing low birth weight.16 the mean fetoplacental weight ratio was decreased in the placentae of hypertensive group compared with their normal counterparts in the present study. mehare et al. and goswami et al. also reported decrease in ftp ratio in hypertensive groups compared to the normal placentae.16,17 these findings are consistent with those observed in our study. this decline in ftp may be due to placental insufficiency associated with altered dimension of placental tissue, neonatal morbidity and ultimately with preterm deliveries. infarcted areas were also observed more in the placentae of hypertensive women. similar findings have been reported by bar et al., dhawle et al. and butt et al.8,18,19 infarctions may be due to thrombotic blockage of maternal blood vessels involved in uteroplacental circulation from pih, which leads to progressive uteroplacental ischemia causing hypoxia in developing fetuses, intrauterine growth restriction and fetal mortality. marginal attachment of the umbilical cord in the placenta was found to be 28% in hypertensive groups in our study. awuah et al. and agarwal et al. also reported that majority of placentae were having marginal attachment of the umbilical cord.12,20 syncytial knots were more commonly observed in the hypertensive group placentae. the formation of syncytial knots is directly related to the hypoxia of placental tissue as a result of thrombotic occlusion of uteroplacental vessels and also due to reactive oxygen species. ranjan et al., pramar et al. and chhatwal et al. in their studies also observed and reported the findings that are consistent with our study. 11,21,22 limited funds and time duration were one of the major constraints of the present study. the current j islamabad med dental coll 2020 247 study focused on histomorphometric changes in the placenta, while the status of the newborn babies in terms of apgar score should also be evaluated in association with microscopic studies of the placenta. c o n c l u s i o n this study concluded that pregnancy-induced hypertension poses harmful and serious histomorphometric variations in the placental tissues that may affect fetal outcome. r e f e r e n c e s 1. meher p, meher sk, jena sk. cord blood parameters change in pregnancy-induced hypertension. int j res med sci. 2017; 5(5): 2099. doi: 10.18203/23206012.ijrms20171850. 2. keche ha, keche as. morphometric differentiation between placenta in pih and normal pregnancy. int j med sci public health. 2015; 4(2): 62-7. doi: 10.5455/ijmsph.2015.0711201457. 3. razak a, florendo-chin a, banfield l, wahab ma, mcdonald s, shah p, et al. pregnancy-induced hypertension and neonatal outcomes: a systematic review and meta-analysis. j perinatol. 2018; 38(1): 4653. doi: 10.1038/jp.2017.162. 4. rohini p, siddharth t, fathima a, dhiren p. human placentae in pregnancy-induced hypertension-a histologic and morphometric analysis. int j anat appl physiol. 2018; 4(3): 95-8. doi: 10.19070/2572-74511800017. 5. bandekar pk, kale pb. placenta in pregnancy-induced hypertension. int j reprod contracept obstet gynecol. 2018; 7(2): 467-9. doi: 10.18203/23201770.ijrcog20180156. 6. porwal v, jain d, gupta s, khandelwal s, kasliwal n. spectrum of placental changes in pregnancy-induced hypertension. annals pathol lab med. 2017; 4(1): a69-a76. 7. bian j, lei j, yin x, wang p, wu y, yang x, et al. limited at1 receptor internalization is a novel mechanism underlying sustained vasoconstriction induced by at1 receptor autoantibody from preeclampsia. j am heart assoc. 2019; 8(6): e011179. doi: 10.1161/jaha.118.011179. 8. butt sy, ejaz s, waheed k. frequency of placental infarct and fetal outcome in hypertensive primigravidas. rmj. 2016; 41(3): 335-8. 9. akshara v, ramakrishnan p, chitra s, kumar sai sailesh sks, seema valsalan e. morphology and the morphometric measurements of hypertensive and normotensive placenta. biomed res. 2018; 29 (18): 3522-25. 10. magee la, sharma s, nathan hl, adetoro oo, bellad mb, goudar s, macuacua se, mallapur a, qureshi r, sevene e, sotunsa j. the incidence of pregnancy hypertension in india, pakistan, mozambique, and nigeria: a prospective population-level analysis. plos medicine. 2019 apr 12; 16(4): e1002783. 11. ranjan ds, gyanaranjan n, bhusan mb, sreepreeti c. histopathological study of placenta in pregnancy with hypertension in western odisha. hypertension. iosrjdms. 2017; 16(6): 100-04. 12. awuah sp, okai i, ntim ea, bedu-addo k. prevalence, placenta development, and perinatal outcomes of women with hypertensive disorders of pregnancy at komfo anokye teaching hospital. plos one. 2020; 15(10):e0233817.doi: 10.1371/journal.pone.0233817 13. ezeigwe co, okafor ci, eleje gu, udigwe go, anyiam dc. placental peripartum pathologies in women with preeclampsia and eclampsia. obstet gynecol int. 2018; article id 9462938. doi: 10.1155/2018/9462938 14. gore c, pandey a, shetty a, rao r, paranjape s. a study on histopathological changes in placenta in preeclampsia/eclampsia: a case-control study in tertiary care centre, western india. ijop. 2018; 5(3): 385-90. doi: 10.18231/2394-6792.2018.0075. 15. kambale t, iqbal b, ramraje s, swaimul k, salve s. placental morphology and fetal implications in pregnancies complicated by pregnancy-induced hypertension. med j dy patil univ. 2016; 9(3): 341-47. doi: 10.4103/0975-2870.182505. 16. goswami p, memon s, rathore m. foeto-placental weight relationship in normal pregnancy and pregnancies complicated by pregnancy-induced hypertension and abruption of placentae. int j res med sci. 2015; 3(5): 1081. 17. mehare t, kebede d. fetoplacental weight relationship in normal pregnancy and pregnancy complicated by pregnancy-induced hypertension and abruption of placenta among mothers who gave birth in southern ethiopia, 2018. obstet gynecol int. j islamabad med dental coll 2020 248 2020; article id 6839416. doi: 10.1155/2020/ 6839416. 18. bar pk gs, gayen p, mandal s, de a. morphological study of placenta in hypertensive disorders in pregnancy. trop j path micro 2019; 5(6): 366-373. doi:10.17511/jopm.2019.i06.06. 19. dhawle ms, tangde ar, mundhe bp, rathod sg, bindu rs. morphological study of placenta in pregnancyinduced hypertension. int j res med sci. 2017; 5(7): 3214-7. doi: 10.18203/2320-6012.ijrms20173015. 20. agarwal g, saini p, pankaj j, pandey l, jain a. morphological study of placenta in normal and hypertensive pregnancies. iaim. 2015; 2(5): 121-8. 21. parmar km, shah gv, alamchandani rr. histological evaluation of placenta in hypertensive pregnancies. int j res med sci. 2019; 7(1): 40. doi: 10.18203/23206012.ijrms20185360 22. chhatwal j, chaudhary d, chauhan n. placental changes in hypertensive pregnancy: a comparison with normotensive pregnancy. int j reprod contracept obstet gynecol. 2018; 7(9): 3808. doi: 10.18203/2320-1770.ijrcog20183799. j islamabad med dental coll 2021 23 open access benefits of near-peer tutoring in small group discussions: a pilot study shazia muazam1, farzana majeed2, saima mumtaz khattak3 1associate professor, department of anatomy, hbs medical & dental college, islamabad pakistan 2associate professor, department of physiology, hbs medical & dental college, islamabad pakistan 3assistant professor, department of anatomy, federal medical & dental college, islamabad pakistan a b s t r a c t background: a year senior medical students can prove to be a useful teaching resource with added benefits for the tutors. the objective of this study was to explore the perceptions of near -peer tutors after facilitating small group discussions while delivering an integrated curr iculum in preclinical years. material and methods: this qualitative exploratory pilot study was conducted in rawal institute of health sciences islamabad, pakistan from july 2017 to november 2017. students of first year mbbs class (n=100), were divided into six small groups. seven second year mbbs students who had secured more than 60% marks throughout year one assessments and in professional examination were selected as near -peer tutors after informed verbal consent. in the first discussion, three groups were taught by three tutors and three by junior faculty. in the second discussion, the groups were swapped and exposed to the same strategy as above, with new learning objectives, but the remaining three tutors now took batches. one tutor acted as a substitute. qualitative data was collected after interviewing the tutors individually and responses were audio recorded. the collected data, both notes and audio recordings of the interviews, was transcribed into text to generate codes, theme and sub themes. results: transcription of data revealed that the tutors enjoyed teaching and were of the opinion that near -peer tutoring is more effective in small groups, for both tutors and the learners. the tutors felt a boost in self -confidence and improvement in communication skills, after facilitating a small group. tutoring also helped in developing their higher order cognitive thinking, learning skills and time management. conclusions: near-peer tutoring helped the tutors develop learning and communications skills while facilitating small group sessions, thus helping them in their future medical roles. key words: integrated curriculum, near-peer tutoring, peer assisted learning, small group discussions. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: shazia muazam email: shaziamuazam@gmail.com article info: received: july 30, 2020 accepted: january 15, 2021 cite this article. muazam s, majeed f, khattak sm. benefits of near-peer tutoring in small group discussions: a pilot study. j islamabad med dental coll. 2021; 10(1): 23-30. doi: 10.35787/jimdc.v10i1.577 funding source: nil conflict of interest: nil i n t r o d u c t i o n peer assisted learning (pal) is an instructional strategy where “learning is through active help of peer group members”. peer are the people belonging to the same social grouping. 1 near-peer or i gi n a l a r ti c le j islamabad med dental coll 2021 24 assisted learning (npal) is a variant of pal in which the tutor is at least one year senior to the learners in context of medical training.2 npal has been applied to deliver lectures, tutorials, laboratory practical and clinical skills formally worldwide.3,4 pal/npal leads to better cognitive congruence between the participants.5 the role of tutors is found to be equivalent to clinicians and nurses in clinical skills training.6 peer tutoring nurtures development of metacognitive, communication and professionalism skills among the peer tutors.7 they relieve the burden of teaching from the faculty thereby, enabling them to take part in productive activities.8 in pakistan, few pal studies led to the conclusion that pal is as effective as facilitator assisted learning.9,10 another national quantitative study showed that horizontal pal can actually replace expert assisted learning in teaching clinical skills to the undergraduates.11 small group discussions (sgds) are a commonly used teaching strategy in delivering concepts in an integrated curriculum, worldwide.12 rapid turnover and paucity of junior faculty involved in sgds, affects the quality of delivery. clinical experts due to busy hospital routine cannot justify their roles as teachers in preclinical integrated modules.13 scant literature is available on the use of near-peer tutors in sgds, along with faculty, to deliver correlational concepts, in an integrated curriculum in preclinical years. our study aims to generate qualitative data on the perceptions of near-peer tutors about npal and, their gains after tutoring small groups to deliver complex integrated concepts. m a t e r i a l a n d m e t h o d s this qualitative exploratory pilot study, based on theoretical framework of grounded theory, was conducted in rawal institute of health sciences, islamabad, pakistan, from july 2017 to november 2017. after approval from the ethical review committee of rawal institute of health sciences, the first year mbbs students were included by convenience sampling for npal intervention. seven students of second year mbbs were selected as near-peer tutors by purposive sampling, with the inclusion criteria set as the students who secured more than 60% marks throughout year one assessments and in the professional examination. undergraduate students of dentistry and other allied sciences, and faculty members of basic and clinical sciences were excluded as near-peer tutors. the curriculum in first two years of mbbs is delivered in three blocks each, where the basic sciences subjects are horizontally integrated with each other, and vertically with clinical sciences. block 2, concerned with integration of upper limb anatomy, nerve physiology, biochemical and clinical aspects, was selected for using npal in small groups. verbal consent was taken from the tutors after explaining the study and assuring them of maintaining their confidentiality by using pseudonyms in the data analysis. it was clarified, that out of seven tutors only six would participate in active teaching, while the seventh would act as a substitute, in case any tutor could not take the class. one of them volunteered, himself, for acting as a substitute. the tutors were given a training session of two hours by the principal investigator (pi) on different teaching and learning strategies, use of learning resources, facilitation of small groups and giving feedback. at the end of the training session, the tutors were handed learning objectives of both sgds, so as to prepare themselves. the first-year class was divided into six small groups/batches, a-f with 12 to 15 students in each batch. batches a, b and c first attended an sgd session with the junior faculty while batches d, e and f attended the session with three npal tutors. the session lasted for two hours. both the npal assisted and non-assisted groups had similar learning j islamabad med dental coll 2021 25 objectives regarding four nerves of upper limb, their injuries and correlation of symptoms with the site of lesion. in second sgd, the batches were flipped and exposed to the same strategy as above, with new learning objectives regarding three new nerves. those taught by junior faculty in first session were taught by the remaining three near-peer tutors, while the rest of three small groups were taught by junior faculty thus, exposing the whole first year to near-peer tutors. qualitative data was collected from all six tutors by holding individual interviews conducted by the pi, who holds an mphil degree and is currently enrolled as an mhpe (masters in health professions education) student. the interviews were held and audio recorded the next day after the second sgd in the pi office. an interview guide, prepared after consultation with a colleague and a medical educationist, in advance, guided the interviewer in the process. the interview started with open ended questions, proceeded forward with follow up and probe questions to make the tutors elaborate their responses. notes were taken. each interview lasted for fifty minutes, on an average. the collected data, both notes and audio recordings of the interviews, was transcribed by pi into text. the text was read multiple times to draw deeper meaning. being a pilot study, the data was small, so it was analyzed manually. the text was divided into segments of information. different colored highlighters were used to mark familiar texts to generate codes. same codes were overlapped or discarded, thus reducing 30 codes into four themes depending on their broad meaning and seven subthemes were extracted from themes. few amendments were made after review of raw data by a non-medical peer. to eliminate researcher bias, raw data was sent to a medical educationist who validated the transcriptions, codes, themes and subthemes. member checking was done by sending the text data to the tutors. r e s u l t s analysis of data resulted in emergence of four themes underlying four categories. seven subthemes were extracted from the four themes (table i). d i s c u s s i o n the tutors involved in our study enjoyed the experience of teaching in small groups and found it beneficial for themselves and for the learners. the first theme highlighted a new aspect where the tutors developed an insight of pursuing teaching as a profession. our near tutors, initially clinically oriented, started considering teaching as a profession, as they were attracted by the satisfaction which one attains after delivering a content. the second theme developed as the tutors felt that npal is beneficial for the learners. nearpeer tutors can understand the hurdles in learning as both learners and tutors are at the same mental status, therefore tutors try to overcome them. they can readily integrate new learning experiences and techniques into the curriculum. different researchers have proved that pairing junior and senior undergraduate students enhances psychological support and helps in improving professional and personal development in both.14 our tutors guided the learners about different learning resources and time management. peer tutors have been shown to create an atmosphere that allows learners to exchange ideas in a stressfree manner.15 theme three of our study exhibited that during small group preparation, tutors developed deeper understanding of the subject matter thus encouraging them to deliver confidently. revisit of previously learnt topics helped in strengthening their own concepts which would prove beneficial in their future medical career. j islamabad med dental coll 2021 26 table i: categories, themes and few verbatim categories themes/ subthemes 1. npal as a teaching experience theme 1: concept about teaching subtheme a: teaching is a skill all six tutors affirmed that their concept about teaching changed altogether. they had become aware of the efforts required for conducting a teaching session and how well prepared a teacher had to be to answer the queries of the learner. three of the tutors, being overwhelmed by the experience, thought to pursue it as a career “teaching is a technique and a skill.” “the experience was a bit of adventure for me” “teaching was most attractive feature of this strategy” “i never felt as if i can think about teaching as a profession, but after these sessions i have started thinking about it.” subtheme b: improved communication skills the teaching experience gave them the confidence to speak in public, thus enhanced their communication skills. they particularly enjoyed when they were able to answer the questions asked by the learners. “i gained confidence; my way of talkin g improved.” “i was unaware of my confidence until now and felt proud to be able to answer the queries asked by learners.” “...communication skills are so much important i had no idea.” “i have learned that for one to be a good teacher one should be a good listener and have patience.” 2. npal as a learning strategy for learners theme 2: beneficial for learners the tutors were of opinion that npal is an effective teaching strategy regarding tutees as first year students mostly require guidelines about the course content and time management, which can be best provided by the ones who have gone through the same situation only a year ago. near tutors are also aware of complex concepts which the learners usually are unable to understand, so their teaching is targeted unlike faculty. npal stimulated the learners as they seemed to be more vocal and interested even at the end of two hours session. “i think it is a good learning strategy for tutees because as a tutor i guided them about how to use various learning resources, which topics to focus on; guided them on time management while preparing for exam as well as in attempti n g paper.” “even the students who initially seemed to be uninterested, asked questions at the end thus showing their interest.” “if this has been practiced with us, we would have performed better than this time.” j islamabad med dental coll 2021 27 3. npal as a learning strategy for tutors theme 3: beneficial for tutors subtheme a: development of ability to do a comprehensive literature search regarding their own learning experience while delivering npal sessions, all the 6 tutors felt it to be beneficial for them. while preparing for the sessions they did not restrict themselves to course books but used reference books and internet. this enhanc ed their knowledge which they felt would be very beneficial in their clinical years. “i got lots of information regarding content while searching for the sessions” “.... because of thorough study while preparing for lectures i can now relate many clinical symptoms; the sympto ms were not explained by the teachers to us but as i came to know them, i explained it to the class.” “the questions put forward by the learners made me search once again. i consulted internet for more images to clarify my own concepts; this was a new experience as i had never done that before when i was in 1st year; i only read my course books” subtheme b: development of higher order cognitive thinking they also felt that by consulting different learning resources they could now comprehend the clinical scenarios with much ease which would help in their exams while attempting mcq’s. they were of the opinion that their concept building was improved while preparing for the sessions “after this when i sat for my usml e preparation it took me less time to solve the mcq’s of nerve injuries than i used to do before.” “i feel like by being a tutor our approach will definitely be better than our colleagues in the clinics.” subtheme c: effective time management two of the tutors were very positive of developing effective management of their time while preparing for their sessions. they realized that by doing clinically oriented study their basic concepts were clarified and now could correlate basics and clinical with more ease and in less time, which would help them in future. “while preparing for sessions i fixed 15 min each day out of one hour of my studies for searching and preparing for npal session thus managed time effectively.” “studying the signs and symptoms of nerve injuries before studying gross anatomy saved me time to understand the boring courses of nerves; the images of shapes of arm and hand due to nerve lesions enforced the anatomical concepts in less time” j islamabad med dental coll 2021 28 4. npal teaching in small groups theme 4: beneficial in small groups subtheme a: easily manageable all six of them found it better to conduct npal in a small group as it was easy to handle the learners. maintenance of discipline was easy in small groups. delivering npal lectures would have been difficult for the tutors and might have not been productive for learners. one tutor appreciated the seating arrangements in small groups which could be readjusted according to needs. “smaller the group lesser the deviation, more the attention.” “even i would suggest to reduce the number of tutees to 10 for more effectiveness of npal session.” “i found myself more powerful and confident while managing a small group. the students also behaved very well in small group. i didn’t feel the need to discipline them.” “npal lecture format will be tiring and scary at the same time for tutor; it would be difficult to control a class of 100 students as they have some respect for the teacher but may not have such feeling for tutors” “in the beginning of session, i was a bit nervous but after seeing a small group my spirits were boosted; i can’t imagine how could i have stood in front of whole class? ” “altering the seating arrangement in the small group and making boys and girls sit as a mixed group will make them concentrate more on the topic as when they sit with their friends, they lose concentration.” subtheme b: easy and productive transfer of knowledge the tutors found it easy to explain the difficult concepts and to answer learners’ questions. transfer of knowledge was easy due to one -to-one interaction. “giving a mcq test at the end of smal l group session is a quick way to assess knowledge gain by npa tutoring ......even a quiz at the end will be very helpful. such formative assessments can be easily applied in small groups and a constructive feedback can be given appropriately.” “i thought that it was difficult to make them understand different hand appearances in nerve injuries and their correlation with site of lesion but smal l group made me ask all the students individually if they understood or not “ j islamabad med dental coll 2021 29 it is a known fact that teaching others result in a 90% retention of material.16 alveraz and shultz also observed that tutoring in anatomy made the tutors learn better use of available resources.17 peer tutoring increases tutors’ confidence in their own performance assessments.18 tutoring experience provides not only the opportunity to refresh tutor’s subject knowledge but also develops employability skills such as leadership, facilitation, projectmanagement, communication and inter-personal skills.19 our tutors felt more confident in communication and their self-efficacy was enhanced after answering learners’. it may be because of the fact that the tutors were one year senior to the learners but even same level peers had been shown to develop competency skills.20 studies on peer assisted tutoring has been documented to develop the skills, attitudes and practices of a competent teacher,20,21 though no studies are found to see the long-term effect of such interventions on tutors. a noticeable theme detected in our study is that all tutors found ‘small groups’ ideal for delivering complex concepts integration by peer-assisted learning. from facilitation point of view, our tutors felt confident when they had to manage small number of students and it was easy to maintain discipline. though large group pal strategy is more effective for the tutor as it gives them the ability to prepare and present in front of a large audience but lack of feedback and fewer interactions due to less developed teaching skills are the drawbacks.22 our study was limited in scope, as being a pilot study, it was restricted to only two sgds due to conflict in scheduling of near-peer tutors and learners’ classes. thus, the number of tutors was restricted. it is recommended to conduct such learning strategy in a whole block with a number of different tutors having different academic ranking, to see the effect of such an intervention on tutors. we would also recommend to follow-up the tutors to see the long-lasting effects of tutoring. c o n c l u s i o n students when used as near-peer tutors in small group discussions in preclinical years of medical school develop strong learning and communication skills which will be beneficial for them in their future roles as competent physicians. they can act as an adjunct resource with faculty, in delivering an integrated curriculum in small groups. r e f e r e n c e s 1. olaussen a, reddy p, irvine s, williams b. peer assisted learning: time for nomenclature clarification. med educ online. 2016; 21(1): 30974. doi: 10.3402/meo.v21.30974 . 2. de menezes s, premnath d. near -peer education: a novel teaching program. int j med educ. 2016; 7: 160-67. doi: 10.5116/ijme.5738.3c28 . 3. rosenberg cj, nanos kn, newcomer kl. the “near‐ peer” approach to teaching musculoskeletal physical examination skills benefits residents and medical students. pm&r. 2017; 9(3): 251 -7. doi: 10.1016/j.pmrj.2016.06.004 . 4. de los ángeles cambrón-carmona m, de lara cnt, caracuel ir, cepas fl, gonzález rg, lozano sz, et al. near-peer teaching in histology laboratory. int j med stud. 2016; 4(1): 14-8. 5. loda t, erschens r, loenneker h, keifenheim ke, nikendei c, junne f, et al. cognitive and social congruence in peer-assisted learning–a scoping review. plos one. 2019; 14(9): e0222224. doi: 10.1371/journal.pone.0222224. 6. abay eş, turan s, odabaşı o, elçin m. who is the preferred tutor in clinical skills training: physicians, nurses, or peers? teach learn med. 2017; 29(3): 24754. doi: 10.1080/10401334.2016.1274 262. 7. clarke aj, burgess a, menezes a, mellis c. senior students’ experience as tutors of their junior peers in the hospital setting. bmc res notes. 2015; 8(1): 743. doi:10.1186/s13104-015-1729-0. 8. khalid h, shahid s, punjabi n, sahdev n. an integrated 2-year clinical skills peer tutoring scheme in a uk-based medical school: perceptions of tutees and peer tutors. adv med educ pract.2018; 9: 423 -32. doi: 10.2147/amep.s159502. 9. sarwar s, tarique s. peer-assisted learning: who should be the tutor, fellow student or senior resident. jcpsp. 2016; 26(7): 573 -76. pmid: 27504547. 10. usman r, jamil b, waheed n, ali l, ali s, orakzai n, et al. comparison between facilitator and peer assisted j islamabad med dental coll 2021 30 learning: an interventional study at peshawar medical college. jpma. 2019; 69(11): 1588-90. doi: 10.5455/jpma.286712. 11. shah i, mahboob u, shah s. effectiveness of horizontal peer-assisted learning in physical examination performance. jamc. 2017; 29(4): 559 65. pmid: 29330977. 12. ju h, choi i, yoon by. do medical students generate sound arguments during small group discussions in problem-based learning? an analysis of preclinical medical students’ argumentation according to a framework of hypothetico-deductive reasoning. korean j med educ. 2017; 29(2): 101 -09. doi: 10.3946/kjme.2017.57. 13. van der hoeven d, van der hoeven r, zhu l, busaidy k, quock rl. integration of basic and clinical sciences: faculty perspectives at a us dental school. j dent educ. 2018; 82(4): 349-55. doi: 10.21815/jde.018.038. 14. bugaj t, blohm m, schmid c, koehl n, huber j, huhn d, et al. peer-assisted learning (pal): skills lab tutors’ experiences and motivation. bmc med educ. 2019; 19(1): 353. doi: 10.1186/s12909 -019-1760-2. 15. khalid h, shahid s, punjabi n, sahdev n. an integrated 2-year clinical skills peer tutoring scheme in a uk-based medical school: perceptions of tutees and peer tutors. adv med educ pract. 2018; 9: 423 32. doi: 10.2147/amep.s159502. 16. ferreira jj, maguta l, chissaca ab, jussa if, abudo ss. cohort study to evaluate the assimilation and retention of knowledge after theoretical test in undergraduate health science. porto biomed j. 2016; 1(5): 181-5. 17. alvarez s, schultz jh. professional and personal competency development in near‐peer tutors of gross anatomy: a longitudinal mixed‐methods study. anat sci educ. 2019; 12(2):129-37. 18. agius a, stabile i. undergraduate peer assisted learning tutors’ performance in summative anatomy examinations: a pilot study. ijme. 2018; 9: 93. 19. burgess a, mcgregor d. peer teacher training for health professional students: a systematic review of formal programs. bmc med educ. 2018; 18(1): 263. doi: 10.1186/s12909-018-1356-2. 20. nshimiyimana a, cartledge pt. peer -teaching at the university of rwanda-a qualitative study based on self-determination theory. bmc medical educ. 2020; 20(1): 230. doi: 10.1186/s12909 -020-02142-0. 21. donohoe cl, conneely jb, zilbert n, hennessy m, schofield s, reynolds jv. docemur docemus: peer assisted learning improves the knowledge gain of tutors in the highest quartile of achievement but not those in the lowest quartile. j surg educ. 2015; 72(6): 1139-44. doi: 10.1016/j.jsurg.2015.07.001. 22. ningrum r. students’ perception of peer tutor roles in the small group discussion. ms&e. 2018; 434(1): 012343. doi:10.1088/1757 -899x/434/1/012343. 113 j i m d c 2 0 1 7 113 op e n ac c e ss f u l l l e n g t h a r t i c l e frequency of depression in mothers of learning-disabled children muhammad fahim1, fatima aamir khan2, asad tamizuddin nizami3 1,2 assistant professor of psychiatry, wah medical college, pof wah cantt 3 assistant professor of psychiatry, rawalpindi medical college, rawalpindi a b s t r a c t objective: to determine the frequency of depression in mothers caring for learning-disabled children. subjects and methods: this cross-sectional study was conducted at department of psychiatry, benazir bhutto hospital rawalpindi from may 2011 till 14th january 2012. in total 96 mothers of learning disabled children, were consecutively recruited, from out patient department of institute of psychiatry, benazir bhutto hospital. after obtaining written informed consent, beck depression inventory (bdi) urdu version was administered to assess the severity of depression; rated as ‘mild’. ‘mild-moderate’, moderatesevere’ and ‘severe’ depression. the data were entered on spss version 10 for further analysis. results: in total 89.6% of the mothers were found depressed. among these 27.1% had mildmoderate depression, 26.4% had moderate-severe depression and 36.1% were found to have severe depression. conclusion: a high frequency of depression was observed in mothers caring for learning disabled children; frequency steadily increasing with severity of depression. this issue thus needs immediate attention for better heath related quality of mothers and better childcare. key words: anxiety, caregiver burden, depression, maternal depression. author`s contribution 1acquisition of data and compilation of results 2final review of draft before submission 3conception and design of article address of correspondence dr asad tamizuddin nizami drasadnizami@gmail.com article info. received: oct 25, 2016 accepted: april 4, 2017 cite this article: fahim m, khan fa, nizami at. frequency of depression in mothers of learning disabled children jimdc. 2017; 6(2):113-116. funding source: nil conflict of interest: nil i n t r o d u c t i o n care giving and care receiving can occur at any point in the life-course, particularly in chronic diseases or disabilities, leading to losses of independence and disturbed overall functioning.1 no consistent and standard definition of family care giving exists, thus the meaning of the term is still unclear and varies considerably.2 successful management of major mental illness in the community depends largely on an informal or nonprofessional network of caregivers. the needs and experiences of such caregivers have not been extensively studied with respect to major chronic mood disorders.3 care giving itself neither causes depression nor everyone who offer care, experience the negative emotions associated with depression. however, in order to offer the best possible care for a close family member, caregivers might have to sacrifice their own physical and emotional needs. moreover, the overall experience of providing care would strain even the most capable and emotionally strong person, leading to negative emotions, irritability, and easy fatigability etc. which are clear warning signs of depression.4 learning disability offers tremendous caregiver burden particularly on the part of mothers. the combined effect of stigmatization plus the burden of caring for the intellectually challenged child leads them to develop a variety of stress related symptoms including anxiety and depression.5 o r i g i n a l a r t i c l e mailto:drasadnizami@gmail.com 114 j i m d c 2 0 1 7 114 previous studies revealed that the mothers of children with language developmental disorders had a higher incidence of anxiety and depression. therefore, while managing such cases, this issue must be given serious consideration.6 studies have revealed a poor quality of life in mothers of mentally and physically handicapped children matched with controls.7,8 a study conducted in iran revealed the prevalence of depression in mothers of children with serious physical conditions to be 46.3%.9 similarly, a high prevalence of anxiety and depression was found amongst the caregivers of individuals with mental illness, in another study from pakistan.4 to date, very little data is available regarding the prevalence of depression in the mothers caring for their learning-disabled children. the current study will be a useful study, as it would indicate the frequency and severity of depression in such mothers. it would also highlight the importance of diagnosing and treating depression in the mothers of learning-disabled children, which thus has an impact on the care of these patients. s u b j e c t s a n d m e t h o d s this cross-sectional, descriptive study was carried out at the institute of psychiatry, benazir bhutto hospital, a tertiary care setting, for a period of 8 months from 14 may 2011 until 14 january 2012. the study was conducted after seeking hospital ethical committee approval. the total sample included 96 mothers who had been caring for learning-disabled children, recruited through consecutive, non-probability sampling method, after obtaining written informed consent. mothers ages 65 years and above, with severe cognitive impairment, and those who could not speak in urdu, were excluded from the study. urdu version of beck depression inventory was administered to diagnose and rate the severity of depression. the mothers filled in socio-demographic proforma to obtain basic demographic details. all data was entered and analyzed in spss 10.0. r e s u l t s the mean age of the participants was 39.12(sd±13.04), with an age range of 19-60 years. amongst the participants, 10(10.4%) had no depression, whereas 86(89.6%) had been diagnosed with depression. among these, 26(27.1%) had mildmoderate depression, 25(26.4%) had moderate-severe depression and 35(36.1%) had severe depression. (table 1) table 1: frequency of different grades of depression amongst the study participants (n=96) diagnosis frequency (%) no depression 10(10.4%) depression 86(89.6% mild-moderate depression 26(27.1%) moderate-severe depression 25(26.4% severe depression 35(36.1% there were 80 true positive cases and 16 false positive cases, 78 true negative and 18 false negative cases. the bdi questionnaire showed a sensitivity of 81.63% ( determined by the formula ( true positive cases-tp/true positive + true negative x 100), specificity of 82.98% determined by the formula ( true negative cases / false positive + true negative cases), positive predictive value of 83.33% determined by the formula (true positive cases / true positive + false positive cases) and negative predictive value of 81.25% determined by the formula ( true negative cases / true negative + false negative cases). d i s c u s s i o n in this study, the primary aim was to determine the frequency and severity of depression in mothers of children with learning disability. overall, the study found that 89.6% of the mothers were depressed. among these 27.1% had mildmoderate depression, 26.4% had moderate-severe depression and 36.1% were found to have severe depression. this finding is of great significance and calls for more attention to be paid to this vulnerable group, in order to ensure early interventions for better mental health and wellbeing of the mothers and improved care of the mentally disabled children. this finding is comparable to a number of local and international studies that would be highlighted in this section. nazish imran conducted a research on 100 primary caregivers of mentally unwell patients in mayo hospital, and found higher rates of anxiety and depression i.e 85% 115 j i m d c 2 0 1 7 115 and 86% respectively, based on hamilton anxiety and depression scale scores.10 this finding is comparable with our finding, showing high frequency of depression i.e 89.6%. however, unlike our study, the aforementioned study sought to probe into other aspects too, for example caregiver burden, quality of life, all of which were found impaired. previously a research was conducted at the institute of psychiatry, benazir bhutto hospital, which also supports the finding of higher rates of anxiety and depression among the caregivers of mentally unwell children.4 this supports the current research finding of a higher frequency of depression in mothers of learning disabled children, but unlike our research, the aforementioned study has looked into factors affecting caregiver burden, for example, long duration of mental illness. another local study has findings similar to the current research of higher caregiver burden in parents caring for chronic mental illnesses.11 at this point now, it is worthwhile to discuss a few international studies on this subject and see how they compare with the findings of the current study. cadman, et al found parents of children with disabilities were more likely to experience depression and distress than parents of children without disabilities, and therefore supports the current research finding.12 however, in our study, we did not have a control group for comparison, which poses a methodological weakness to our study. similarly, dyson et al in his research found significantly higher degree of parental stress in parents of children with disabilities, who were also found to have negative and pessimistic views about the future.13 the family functioning in this study was also found to be markedly impaired. moreover, the parents' perception of how tough it was to care for the child was related to feelings of depression.14 it has been shown that these mothers are more stressed than mothers of children without disabilities due to the extra daily tasks which leaves very little time for the mothers to take care of themselves.15 this is thus a clinically useful study and has important implications for clinical practice. the study found a high frequency of depression among mothers caring for learning disabled children. this calls for immediate attention by the healthcare providers for early interventions and early detection and treatment of maternal depression thus leading to decreased caregiver stress and burden with improved quality of caring for these mentally challenged, vulnerable children. however, there are certain limitations of the study. firstly, the sample size was small thus limiting generalizability of results/findings of the study. secondly, the study did not have a control group for comparison. moreover, we did not address various factors associated with maternal depression while caring for the learning-disabled children. c o n c l u s i o n the study found a high frequency of depression in mothers caring for learning disabled children. this is a finding of striking significance as it calls for immediate intervention by the mental health care providers/psychiatrists for early recognition and prompt treatment of maternal depression, which would lead to lessened caregiver burden and improved quality of care for the mentally challenged, vulnerable children and improved quality of life. further studies with large sample size, including control group and addressing various factors associated with maternal depression in the study population, are suggested. r e f e r e n c e s 1. bastawrous m. caregiver burden--a critical discussion. int j nurs stud. 2013;50(3):431-41. 2. rigaux n. informal care: burden or significant experience? psychol neuropsychiatr vieil. 2009;7(1):57-63. 3. grässel e, bock v, rosanowski f. [critical factors for subjective burden of mothers of children with developmental language disorders] hno 2007;55:575-82. 4. basheer s, niazi rs, minhas fa, ali w, najam n. depression and anxiety in the caregivers of mentally ill patients. j pak psych society 2005; 2:27-33 5. abasiubong f, obembe a, ekpo m. a controlled study of anxiety and depression in mothers of children with learning disability in lagos, nigeria. niger j med 2006;15:124-7. 6. kirby av, white tj, baranek gt. caregiver strain and sensory features in children with autism spectrum disorder and other developmental disabilities. am j intellect dev disabil. 2015;120(1):32-45 7. ones k, yilmaz e, cetinkaya b, caglar n. assessment of the quality of life of mothers of children with cerebral palsy (primary caregivers). neurorehabil neural repair 2005;19:232-7. 116 j i m d c 2 0 1 7 116 8. raina p, o'donnell m, rosenbaum p, brehaut j, walter sd, russell d, et al. the health and well-being of caregivers of children with cerebral palsy. pediatrics 2005;115:e626-36. 9. sharghi a, karbakhsh m, nabaei b, meysamie a, farrokhi a. depression in mothers of children with thalassemia or blood malignancies: a study from iran. clinical practice and epidemiology in mental health. 2006;4;2(1):27. 10. imran n, bhatti mr, haider ii,azhar l, omar a, sattar a. caring for the caregivers: mental health, family burden and quality of life of caregivers of patients with mental illness. j pak psych society. 2010;7(1):23-28. 11. anjum w, chaudhry hr, irfan m. burden of care in caregivers of patients with schizophrenia and epilepsy. j pak psych society 2010;7(2):79-83. 12. cadman d, rosenbaum p, boyle m, offord dr. children with chronic illness: family and parent demographic characteristics and psychosocial adjustment. pediatrics. 1991;87:884-9. 13. dyson ll. response to the presence of a child with disabilities: parental stress and family functioning over time. am j ment retard 1993;98:207-18. 14. gowen jw, johnson-martin n, goldman bd, appelbaum m. feelings of depression and parenting competence of mothers of handicapped and nonhandicapped infants: a longitudinal study. am j ment retard. 1989;94:259-71. 15. estes a, olson e, sullivan k, greenson j, winter j, dawson g, et al. parenting-related stress and psychological distress in mothers of toddlers with autism spectrum disorders. brain dev. 2013;35(2):133-8. summary journal of islamabad medical & dental college (jimdc); 2016:5(4):177-180 177 original article effect of different sizes of intraocular lens on early changes of posterior capsular opacification munir amjad baig1, nadir mehmood,2 rabeeya munir3 1 assistant professor of ophthalmology, ajk medical college, muzaffarabad 2 assistant professor of general surgery, rmc, rawalpindi 3 demonstrator, rawal institute of health sciences, islamabad abstract objectives: to evaluate the effect of different sizes of intra ocular lens (iol) on frequency of development of early changes of posterior capsular opacification (pco) patients and methods: a descriptive study of 12 months’ duration was conducted in department of ophthalmology, federal government services hospital islamabad. a non-probability convenient sample of 100 patients aged 58 to 77 years was divided equally into two groups, a and b. each group was again divided into a-1, a2 depending on overall lens diameter of 12 mm, 13 mm respectively and b-1, b-2 for optic diameter of 5.25 mm, 6mm respectively. each subgroup comprised of 25 patients. planned phacoemulsification was performed on all patients. follow up with patient’s symptoms, snellen’s charts and slit lamp examination was done on day 7, 30 days, 6 months and a year after surgery. all the results were entered on patient's performa. results: in group a where overall iol size was used, comprising a1(12 mm) & a2(13 mm), 12% (n=3) of (a1) group developed pco in 1st 12 months and 16% (n=4) of (a2) group developed pco in 1st 12 months. in group b where optic size was used, comprising b1 (5.25 mm) & b2 (6mm), 24% (6 patients) of b1 group developed pco and 16% (4 patients) of b-2 group developed pco during 1st 12 months. conclusion: iol of smaller optic size was associated with higher percentage of early changes of pco than that of larger optic size. iol of larger overall size was associated with higher percentage of early changes of pco than that of smaller overall size. keywords: cataract, elschnigs pearls, intraocular lens sizes, phacoemulsification, introduction cataracts were very common in antiquity.1-3 the word cataract, means both an opacity of the lens and a torrent of water, comes from the greek word υπόχυσις (kataráktēs), meaning the fall of water. the latins called it suffusio, an extravasation and coagulation of humor behind the iris; and the arabs, white water.2 worldwide, 285 million people are visually impaired, 39 million are blind and 18 million are due to cataract. about 82% of all blind above the age of 50 years live in developing countries.4 there is increasing backlog of cataract leading blindness in developing countries. globally about 15 million cataract operations are performed annually, an increase of 5 million in 5 years.5 about 570, 000 adults are estimated to be blind (<3/60) as a result of cataract in pakistan, and 3,560,000 eyes have a visual acuity of <6/60 because of cataract.6 elschnigs pearls were first described by hirschberg caused by proliferation of equatorial lens fibres located on the posterior capsule to differentiate from posterior capsular fibrosis.7 it is a major complication of successful cataract surgery, which causes reduction in vision.8,9 time after cataract surgery and onset of capsular opacification is variable and the rate for laser capsulotomy ranges from 10% to 37%.10 posterior capsular opacification (pco) ranges from 50% to as low as <5% in eyes, develops over the clear posterior capsule in a few months to a few years.11 pco reduces visual acuity12 especially central 3 mm zone of the posterior capsule affects high contrast sensitivity.13 the pco involves three basic phenomena: proliferation, migration, and differentiation of lecs.14-16 it is a multi-factorial problem, related to patient factors such as age, surgical factors, and iol design. even newer techniques of cataract surgery do not delay pco. in this study, an account of relation between different lens sizes and the development of early posterior capsular opacification is given. patients and methods a descriptive study, in which effect of lens sizes on early changes of posterior capsule opacification was described, was conducted in department of ophthalmology, federal government services hospital corresponding author: dr. munir amjad baig e mail: drmuneeramjad@yahoo.com received: nov 19,2016; accepted: dec 13,2016 mailto:drmuneeramjad@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):177-180 178 islamabad from january 2012 to december 2012. about 100 willing patients with uncomplicated cataract were selected from outpatient department. the age ranged from 58-77 years with mean age of 67.5 years. both male and female patients having senile mature cataract were admitted in ophthalmology unit were selected by non-probability convenient sampling. patients with history of major medical and surgical illness, glaucoma, exfoliation syndrome, uveitis, history of trauma and myopia were excluded from the study. patients were divided equally into two groups a and b. each was further divided into a-1, a-2 (where overall lens diameter was used (12 mm, 13 mm) and b-1, b-2 (where only optic diameter was used (5.25 mm, 6 mm). each group comprised of 25 patients. decrease in snellen's bestcorrected vision (bcv) of more than one line or major visual symptoms or both, were examined. slit lamp examination with full-dilated pupil was performed on 7, 30, 90, 180 and 360 days. pco grading was done, as presence of lens epitheleal cells (lecs) behind the iol, elschnigs pearls, called early changes and wrinkling/fibrous changes called late changes. operative procedure: during one-year study period, a total of 100 uncomplicated patients were operated for standard phacoemulsification by a single surgeon after taking written consent. patients were enquired for ocular and systemic disease history. pre-operative assessment of vision, slit lamp biomicroscopy, fundoscopy, intraocular pressure check-up and sac wash was performed. pco was evaluated by a decrease of visual acuity compared to the first postoperative best-corrected visual acuity. postoperative follow up: patients were followed up on day 7, 30, 90, 180 and 360 days. best corrected visual acuity and lec's migration behind the centre of iol was noted using slit lamp bio-microscopy. a thorough personal history, presenting complaints, complete examination findings and investigations were entered into the patient’s performa. data collected from patient performa was entered on data base s heet and analyzed for the early changes of pco with different sizes of lens. results the age range of patients was 58 to77 years with mean age was 67.5 years, 52% were male and 48% female patients. about 22(22%) patients were in their late fifties, 35(35%) were in their early sixties and 43(43%) in their late sixties. preoperative visual acuity was hand movement (hm) 43%, counting fingers (cf) 39% and 6/6018% (table-1). out of 100 patients, 28 male and 23 female were operated for right eye while 25 male and 24 female were operated for left eyes. decrease in snellen's best corrected vision of more than one lines, significant visual symptoms or both were noted after first week and 24 weeks. hm: hand movement, cf: counting fingers among 52 males, 78.8% had good, 17.3% had borderline and 3.8% had poor visual acuity results. among 48 females, 54.1% had good, 29.1% had borderline and 16.6% had poor visual results. overall 67% had 6/18, 23% had <6/18 and 10% had<6/60 visual results. 22% patients, 9 males and 13 females showed irregular pupil having va<6/18 17% of the total patients showed early changes of pco (elschnig's table 2: association of early changes of pco with different sizes of lens (n=100) groups total a1 a2 b1 b2 >=12mm >=13mm >=5.25mm >=6mm pco present (n) 3 4 6 4 17 % 12.0 16.0 24.0 16.0 17.0 absent (n) 22 21 19 21 83 % 88.0 84.0 76.0 84.0 83.0 total 25 25 25 25 100 100.0% 100.0% 100.0% 100.0% 100.0% table 1: pre-operative visual acuity (n=100) total patients 100 no. percentage h.m 43 43 cf 39 39 6/60 18 18 pearls) within 12 months of surgery. pco in different iol sizes (n=100) shown in (table 2) group a (where overall iol size (12mm and 13mm was used), in group a-1, 3 patients (12%) who received 12mm iol size developed pco (elschnig's pearls) in group a-2, 4patients (16% ) who received 13 mm developed pco. in group b-1 (where optic size (5.25mm and 6 mm) was used, 06 out of 25 patients (24%) who received 5.25 mm developed pco. in group b-2, 04 out of 25 patients (16%) who received 6mm developed pco during first 12 months. discussion in pakistan, blindness due to cataract is a major problem. this is clearly reflected by the long waiting lists for cataract surgeries in public hospitals. the prevalence of bilateral cataract blindness (va <3/60) among people over 50 years journal of islamabad medical & dental college (jimdc); 2016:5(4):177-180 179 was 4.8% (95% ci: 3.8% to 5.9%), which is highest reported in pakistan.17 about 570,000 adults are blind (3/60) as a result of cataract in pakistan, and 3560000 eyes have cataract with visual acuity of 6/60.18 the prevalence of cataract surgery in india was reported, 8.0% in patients aged 30 years and 17% in those aged 50 years and older.19 in current study among 52 males, 78.8% had good and 3.8% had poor visual results. among 48 females, 54.1% had good, and 16.6% had poor visual results. overall 67% had good, and 10% had poor visual results. the who recommends that poor visual outcomes should not be more than 5% after cataract surgery.20 in this study the visual results are poorer than the who categories but still better than those found in most of other studies and consistent with the findings of the “pakistan national blindness and visual impairment survey”.21,22 in this study overall 22% of patients comprising higher percentage of women than men (13% vs 9%) had irregular pupil and presenting visual acuity( pva)<6/18. another important finding in this study was high percentage of poor visual outcome among females than males (presenting visual acuity<6/18). the high rate of poor visual outcome in females may explain the apprehension how “fears” of operation plays the role in poor results.23 out of 100 senile cataract patients, 17 (17%) developed posterior capsular opacification after one year. in this study, the incidence of pco was higher (24%) in the eyes that received iol of 5.25mm optic size than those (16%) which received iol of 6.0mm optic size. this finding is similar to the study conducted by william r. meacok et al, who found the incidence to be low (1.5%) in the 6.0mm group as compared to (6.9%) in 5.5mm group at 1 year.24 mamalis n and colleagues reported that in the large iol group, 106 of 280 patients (38%) required yag laser posterior capsulotomy, in the small iol group, 25 of 157 patients (16%) required the same. this difference was statistically significant even though the average follow-up was 84.1weeks in the large iol group and 54.1 weeks in the small iol group. this study has similar results with mamalis n. et al and nishi o et al. and colleagues.25,26 conclusion a higher percentage of patients developed early pco changes with smaller optic size iol while higher percentage of patients developed early pco changes with larger overall size iol. conflict of interest this study has no conflict of interest as declared by any author. references 1. aruta a, marenco m, marinozzi s. history of cataract surgery. med secoli. 2009. 21(1):403-28. 2. ascaso fj, cristóbal ja. the oldest cataract in the nile valley. j cataract refract surg. 2001. 27:1714-15. 3. bernscherer g. selection from the history of cataract surgery from 2640 b.c. to 1750 a.d. orv hetil. 2001; 142(30):1623-25. 4. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96(5):614-8. 5. pb17 session. vision 2020: the right to sight – the first five years, world ophthalmology congress, sao paulo, brazil; 2006. 6. bourne r, dineen b, jadoon z, lee ps, khan a, johnson gj, et al. the pakistan national blindness and visual impairment survey—research design, eye examination methodology and results of the pilot study. ophthalmic epidemiol. 2005;12(5):321-33. 7. elschig a. klinisch-anatomischer eitrag zur kenntnis des nachstares. klin monatsbl augenke ilkd 1911; 49:444–51 8. awasthi n, guo s, wagner bj. posterior capsular opacification: a problem reduced but not yet eradicated. arch ophthalmol. 2009; 127:555–62. 9. cheng jw, wei rl, cai jp, xi gl, zhu h. efficacy of different intraocular lens materials and optic edge designs in preventing posterior capsular opacification: a meta-analysis. am j ophthalmol. 2007;143(3):428-36. 10. ding wj, wei q, liang h, chen jm, li x, tan sj. changes of lens epithelial cells proliferation in posterior capsular opacification models on diabetic rabbits. rec adv ophthalmol. 2012;5–7. 11. dholakia sa, vasavada ar. intraoperative performance and long term outcome of phacoemulsification in age-related cataract. indian j ophthalmol. 2004; 52(4):311. 12. buehl w, sacu s, findl o. association between intensity of posterior capsule opacification and visual acuity. j cataract refract surg. 2005;31(3):543. 13. meacock wr, spalton dj, boyce j, marshall j. the effect of posterior capsule opacification on visual function. invest ophthalmol vis sci. 2003;44(11):4665. 14. wallentin n, wickström k, lundberg c. effect of cataract surgery on aqueous tgf-beta and lens epithelial cell proliferation. invest ophthalmol vis sci. 1998;39(8): 1410– 18. 15. mathew mr, mclean sm, murray sb, bennett hg, webb la, esakowitz l. expression of cd18, cd49b, cd49c and cd49e on lens anterior capsules in human cataracts. eye. 2003; 17(4): 473–77. 16. neumayer t, findl o, buehl w, georgopoulos m. daily changes in the morphology of elschnig pearls. am j ophthalmol. 2006;141(3): 517–23. 17. anjum km, qureshi mb, khan ma, jan n, ali a, ahmad k, et al. cataract blindness and visual outcome of cataract surgery in a tribal area in pakistan. br j ophthalmol. 2006;90:135–8. 18. bourne r, dineen b, jadoon z. the pakistan national blindness and visual impairment survey research design, eye examination methodology and results of pilot study. ophthalmic epidemiol. 2005;12:321–33. 19. murthy gv, gupta s, ellwein lb, munoz sr, bachani d, dada vk. a population-based eye survey of older adults in a rural district of rajasthan: central vision impairment, blindness, and cataract surgery. ophthalmol. 2001;108(4):679-85. 20. world health organization. prevention of blindness and visual impairment. who, geneva, 2004. available from: http://www.who.int/blindness/data_maps/en/ 21. tabin g, chen m, espandar l. cataract surgery for the developing world: current opinion in ophthalmology. 2008;19(1):55–9. 22. bourne r, dineen b, jadoon z, lee ps, khan a, johnson gj, et al. outcomes of cataract surgery in pakistan: results from journal of islamabad medical & dental college (jimdc); 2016:5(4):177-180 180 the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007;91(4):420–6. 23. ahmad k, zwi ab, tarantola dj, chaudhry ta. selfperceived barriers to eye care in a hard-to-reach population: the karachi marine fishing communities eye and general health survey. invest ophthalmol vis sci. 2015;56(2):1023– 32. 24. meacock wr, spalton dj, boyce jf, jose rm. effect of optic size on posterior capsule opacification: 5.5 mm versus 6.0 mm acrysof intraocular lenses. j cataract refract surg. 2001;27(8):1194-8. 25. mamalis n, crandall as, linebarger e, sheffield wk, leidenix mj. effect of intraocular lens size on posterior capsule opacification after phacoemulsification. j cataract refract surg. 1995;21(1):99-102. 26. nishi o, nishi k. effect of the optic size of a single-piece acrylic intraocular lens on posterior capsule opacification. j cataract refract surg. 2003;29(2):348-53. authorship contribution: author 1: conception, synthesis and planning of the research, interpretation, analysis and discussion author 2: active participation in active methodology author 3: interpretation, analysis and discussion https://www.ncbi.nlm.nih.gov/pubmed/?term=nishi%20o%5bauthor%5d&cauthor=true&cauthor_uid=12648648 https://www.ncbi.nlm.nih.gov/pubmed/?term=nishi%20k%5bauthor%5d&cauthor=true&cauthor_uid=12648648 https://www.ncbi.nlm.nih.gov/pubmed/12648648 https://www.ncbi.nlm.nih.gov/pubmed/12648648 403 forbidden<br> 23 j i m d c 2 0 1 8 23 open access f u l l l e n g t h a r t i c l e role of surgical feeding gastrostomy in patients requiring prolonged nutrition in a neurosurgical department muhammad mujahid sharif 1, rayif rashid kanth 2, umar farooq 3, asim shahzad 4, mehwish aslam 5, sami ur rehman6, khaleeq uz zaman 7 1 classified neurosurgeon, fouji foundation hospital rawalpindi 2 assistant prof neurosurgery islamabad medical & dental college, islamabad 3-6 postgraduate residents pakistan institute of medical sciences islamabad 7 professor neurosurgery pakistan institute of medical sciences islamabad. a b s t r a c t objective: to build up the nutritional status of the neurosurgical patients with an easy and practical way. patients and methods: this prospective study was conducted in neurosurgery department of pakistan institute of medical sciences islamabad in a six months’ time. in total thirty adult patients of either gender with h/o road traffic accident with severe head injury and gcs less than 8/15, persistent vegetative state, brain tumor patients who had developed lower cranial nerve palsies were included in the study. 28 for two way foleys catheter was used in feeding gastrostomy. results: thirty patients, with the median age of 35 years (range, 18-55 years) underwent feeding gastrostomy. before the gastrostomy tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (pn), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. buried bumper syndrome developed in 1 patient. two patients died 8 and 34 days after the procedure in the neurosurgical icu. twenty-eight patients were discharged from the hospital while being fed via the gastrostomy tubes. in 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. there was no procedure-related mortality. conclusion: an improvised method of nutritional support according to our circumstances. this study can be extended to other surgical and medical patients who need nutritional support for longer period of time. key words: surgical gastrostomy, enteral feeding, nutrition, nasogastric tube, percutaneous endoscopic gastrostomy. author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-5 data analysis, interpretation and manuscript writing, 6,7 active participation in data collection. address of correspondence rayif rashid kanth email: rayif.kanth@gmail.com article info. received: september 20, 2017 accepted: january 11, 2017 cite this article. sharif mm, kanth rr, farooq u, shehzad a, aslam m, sami ur rehman, zaman k. role of surgical feeding gastrostomy in patients requiring prolonged nutrition in neurosurgical department. jimdc.2018; 7(1):23-28 funding source: nil conflict of interest: nil i n t r o d u c t i o n there is a consensus that nutritional support, which must be provided to patients in intensive care, influences their clinical outcome.1 malnutrition is associated in critically ill patients with impaired immune function and impaired ventilator drive, leading to prolonged ventilator dependence and increased infectious morbidity and mortality.2,3 enteral nutrition is an active therapy that attenuates the metabolic response of the organism to stress and favorably modulates the immune system.4,5 it is less expensive than parenteral nutrition and is preferred in most cases because of less severe complications and o r i g i n a l a r t i c l e 24 j i m d c 2 0 1 8 24 better patient outcomes, including infections, and hospital cost and length of stay.6,7 the use of gastrostomy has expanded over the past decade, and new techniques have been developed, that have made the procedure simpler and less risky.8-10 gastrostomy is specifically a technique that allows direct access to the stomach to provide food to disabled patients for several reasons.11,12 most commonly, this condition occurs in patients with neurological diseases, impairment following a stroke or obstructive head and neck tumors.13,14 percutaneous endoscopic gastrostomy (peg) feeding is widely used in stroke patients suffering from persistent dysphagia.15-18 there is widespread acceptance of peg as the insertion technique of choice owing to its simplicity and effectiveness, but certain patients are not candidates for an endoscopic approach.19-21 there are evidences that percutaneous endoscopic gastrostomy (peg) is associated with deficiencies of the minerals and trace elements.22-25 the objective of this study was to highlight the importance of open surgical gastrostomy in building up the nutritional status of the patients as this technique is cost effective, diet plan is very simple; just mash and grind and give through the wide bore 28 fr foley’s catheter whatever is cooked for the rest of the family. p a t i e n t s a n d m e t h o d s this prospective study was conducted in the department of neurosurgery, pakistan institute of medical sciences (pims) islamabad in six months’ duration. in total 30 patients were recruited in this study after the informed consent from every patient. patients were selected using non-probability consecutive sampling. patients of severe head injury cases with age from 18-55 years, persistent vegetative state, brain tumors with lower cranial nerves involvement and patients who would not resume oral feeding within 3 to 4 weeks were included in the study. detailed history was taken and thorough central nervous system examination performed to assess the preoperative status of patient and relevant investigations were done. all the patients who meet the inclusion criteria were included in the study. their gcs recorded. only severe (gcs:3-8) head injury patients were included in the study. after preoperative assessment, informed consent was taken for inclusion in study. surgery was performed by the trainee researcher. outcome was assessed at three months of follow up. follow up was ensured through telephonic contact. data was collected on preformed performa and results were compiled. data was analyzed on spss version 17.0. surgical gastrostomy was compared with nasogastric feeding with different variables like risk of aspiration, malnutrition and cost effectiveness. surgical gastrostomy was also compared with percutaneous endoscopic gastrostomy with different variables like availability, cost effectiveness, expertise, tube diameter. r e s u l t s adult patients of either gender who were cases of severe head injuries were included. detailed history taken. surgical feeding gastrostomy was performed in the same setting when patient was taken for traechostomy in severe head injury cases. midiline linear supraumbilical incision was used for the mini laparotomy (figure 1). dissection proceeded further till stomach was visible and held with babcock forceps (figure 2) in the mean time the gastrostomy tube which is 28fr foleys catheter was passed from skin into abdomen (figure 3) with a mini stab introduced into the stomach (figure 4). figure 1: linear midline supra-umbilical incision. figure 2: exposure of stomach through mini laparotomy figure 3: introduction of gastrostomy tube into the peritoneum. figure 4: insertion of gastrostomy tube into stomach 25 j i m d c 2 0 1 8 25 stomach was anchored with the posterior abdominal wall and balloon of the gastrostomy tube inflated n filled with water. abdomen was closed in layers and dressing applied on the wound and around the feeding tube (figure 5). there was no heroic diet plan or any liquid formulation to feed the tube. food which was given to the patients by the hospital was grinded/blended and given to the patients through gastrostomy tube with the 60ml syringe. this grinded food is in the form of thick paste which cannot not be given by a nasogastric feeding tube or percutaneous endoscopic gastrostomy tube.it can be given by this wide bore 28fr foley’s catheter. if this tube is blocked, then it can be washed or totally changed by just deflating the balloon and inserting the new tube and inflate it. we trained the attendants to feed their patients and take care of the gastrostomy tube. figure 5: closure of laparotomy with dressing applied on the wound and around the feeding tube. graph 1: frequency of complications associated with feeding gastrostomy graph 2: comparison of different variables of nasogastric tube feeding and surgical feeding gastrostomy d i s c u s s i o n the primary indication for enteral and parenteral feeding is the provision of nutritional support to meet metabolic requirements for patients with inadequate oral intake.1-3 enteral feeding is usually the preferred method over parenteral feeding in patients with a functional gastrointestinal (gi) system due to the associated risks of the intravenous route, higher cost and inability of parenteral nutrition to provide enteral stimulation and subsequent compromise of the gut defense barrier.5,6 it has been shown that enteric feeding can decrease the risk of bacterial translocation and corresponding bacteremia.7-9 tube feeding through the gi tract is mainly considered in patients with insufficient oral intake who have a functional gi system and tube insertion into their alimentary tract can be safely maintained.10-11 in our patients we placed gastrostomy tube through mini laparotomy. we selected those head injury patients who would require prolonged nutritional support due to unconsciousness. nasogastric tube is a norm in most of the setups in our country but we observed that the patients who are on nasogastric tube feeding are getting weaker day by day. we thought about other different options of feeding and the most feasible method was gastrostomy feeding. in percutaneous endoscopic gastrostomy, the diameter of the feeding tube was not large enough to feed the semisolid feed and it was proving to me equivalent to nasogastric tube feeding, 26 j i m d c 2 0 1 8 26 moreover the cost of gastrostomy was very high and the formulae milk the patients used to buy were costly as well. expertise for the peg was another problem. therefore, we innovated the technique, and placed gastrostomy tube through mini laparotomy and placed a 28fr foley’s catheter, which is big enough to feed the semisolid food. qureshi az et al 1 studied the risks associated with prolonged ngt include aspiration, ulceration, and infection in posterior cricoid region causing vocal cord dysfunction, pharyngeal discomfort, erosion of nares, epistaxis, sinusitis, gastroesophageal reflux, gastritis, psychological trauma, and bronchopulmonary complications. when a patient requires long-term enteral feeding (longer than 3-4 weeks) and there is a reasonable prospect of patient survival, consideration should be given to peg tube placement.1the most frequent indication for peg insertion is neurological disorders (58%).3 in the united states, there are approximately 123,000 peg tube insertions performed annually; however, this is not necessarily the case around the world particularly in underdeveloped healthcare systems.4 postulated factors contributing to this include limited resources, lack of expertise and training, and even lack of awareness to this alternative and this is exactly the message of our study. due to poor resources and affordability issues peg is not the feasible option in our setup and surgical gastrostomy proved to be the best alternative which is not only cost effective but also a better option for building up the nutritional status of the patients. pulkkinen j et al conducted a comprehensive review of the literature.2 patients with head and neck cancers (hncs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. advances in the treatment of hncs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. prophylactic placement of percutaneous endoscopic gastrostomy (peg) tubes before treatment may be beneficial in patients with hnc, especially those undergoing more intense treatment regimens. peg tube placement, however, is not without risks. systematic evidence assessing both the benefits and harm associated with prophylactic peg tube placement in patients undergoing treatment for hnc is weak, and benefits and harm have not been established. same is the case with our study.it shows that surgical gastrostomy not only practical but also result oriented in setups where peg is not the option. li j et al 3 conducted a retrospective study of 3504 consecutive stroke patients admitted to two metropolitan hospitals during the period january 2005 to december 2013 and who also underwent peg insertion for feeding due to persistent dysphagia. a total of 102 patients were included in the study. there were 22 deaths in 6 months after insertion of peg tubes and 20 deaths of those occurred within 3 months post peg. they proposed that age, asa score and albumin level pre-peg insertion to be included as factors to assist in the selection of patients who are likely to survive more than 3 months post peg insertion. yarmus l et al, prospectively collected data of patients in a medical icu undergoing peg tube placement from 2003 to 2007 at a tertiary-care center were reviewed.5 data were collected on mortality, peg tube removal rate, total number of days with peg tube, and complication rates. follow-up included hospital length of stay and phone contact after discharge. procedural and long-term peg-related complications were recorded. seventy-two patients were studied. they concluded that the ability to place both peg and tracheostomy tubes at the same time has the potential for decreased costs, anesthesia exposure, procedural times, ventilator times, and icu days. this study carries the same message that the tracheostomy tube and the gastrostomy tube can be placed in the same setting. ja allen et al sought to compare the outcome and complications of gastrostomy tube placement by endoscopic (peg) and multiple radiologic (rig) methods in als patients.12 a retrospective analysis was conducted. one hundred and eight gastrostomy tube attempts were made on 100 different patients. their findings supported gastrostomy tube placement by radiographic methods in als patients. gastrostomy tube placement by rig was more often successful and less often associated with aspiration. their findings added to the growing body of literature that argues for early gastrostomy tube placement.in our study we also placed the gastrostomy tube in a day or two in whom we anticipated that patient would need long term nutritional support. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5224417/#ref3 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5224417/#ref4 27 j i m d c 2 0 1 8 27 c o n c l u s i o n surgical feeding gastrostomy is an easy and practical way to build up the nutritional status of the patients. it is an improvised method of nutritional support according to our circumstances. this study can be extended to other surgical and medical patients who need nutritional support for longer period. r e f e r e n c e s 1. qureshi az, jenkins rm, thornhill th. percutaneous endoscopic gastrostomy versus nasogastric tube feeding during neurorehabilitation. ifs, ands, or buts. neurosciences. 2016 ;21(1):69 2. pulkkinen j, rekola j, asanti m, grénman r. prophylactic percutaneous endoscopic gastrostomy in head and neck cancer patients: results of tertiary institute. eur arch otorhinolaryngol. 2014;271:1755– 1758. 3. li, j, zhang, j, li, s, guo, h, qin, w, hu, wl. predictors of percutaneous endoscopic gastrostomy tube placement after stroke. can j neurol sci. 2014;41(1):24–28. 4. bäck, l, benders, a, pietarinen, p. percutaneous endoscopic gastrostomy tube placement by otorhinolaryngologist-head and neck surgeons. acta otolaryngol. 2014;134(7):760–767 5. yarmus, l, gilbert, c, lechtzin, n, melhem, i, ernst, a, feller-kopman, d. safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrotomy tube placement. chest. 2013;144(2):436–440. 6. black mt, hung ca, loh c. subcutaneous tfastener gastropexy: a new technique. am j roentgenol. 2013;200:1157–9. 7. dubin, ph, boehme, ak, siegler, je. new model for predicting surgical feeding tube placement in patients with an acute stroke event. stroke. 2013;44(11):3232–3234. 8. camilleri m, parkman hp, shafi ma, abell tl, gerson l. clinical guideline: management of gastroparesis. am j gastroenterol. 2013;108:18–37. 9. alagiakrishnan k, bhanji ra, kurian m. evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review. arch gerontol geriatr. 2013;56:1–9. 10. rossi ug, petrocelli f, seitun s, patrone l, ferro c. percutaneous radiological gastrostomy: singlepuncture double-anchor technique. radiol med. 2013;118:356–65. 11. rahnemai-azar, a, rahnemaiazar, a, naghshizadian, r, kurtz, a, farkas, t. percutaneous endoscopic gastrostomy: indications, technique, complications and management. world j gastroenetrol. 2014;20(24);7739–7751. 12. ja allen , r chen , s ajroud-driss , et al. gastrostomy tube placement by endoscopy versus radiologic methods in patients with als: a retrospective study of complications and outcome. amyotroph lateral scler frontotemporal degener. 2013;14:308-314. 13. j dorst , l dupuis , s petri , et al. percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis: a prospective observational study. j neurol. 2015;262:849-858. 14. seron-arbeloa c, zamora-elson m, labarta-monzon l, mallor-boneta t. enteral nutrition in critical care. j clin med res. 2013;5:1–11. 15. peev mp, yeh dd, quraishi sa, osler p, chang y, gillis e, albano ce, darak s, velmahos gc. causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. j parenter enteral nutr (jpen) 2015;39(1):21-7. 16. cristian d, poalelungi a, anghel a, burcoş t, grigore r, berteşteanu s, richiteanu g, grama f. prophylactic percutaneous endoscopic gastrostomy (peg)-the importance of nutritonal support in patients with head and neck cancers (hncs) or neurogenic dysphagia (nd). chirurgia. 2015;110(2):129-36. 17. schlein km, coulter sp (2014) best practices for determining resting energy expenditure in critically ill adults. nutr clin pract 29:44–55. 18. mcclave sa, taylor be, martindale rg . guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine (sccm) and american society for parenteral and enteral nutrition (a.s.p.e.n.) j parenter enteral nutr (jpen) 2016 40:159–211. 19. rowat a. enteral tube feeding for dysphagic stroke patients. br. j. nurs. 2015;24:138–144. 20. wu k, chen y, yan c, huang z, wang d, gui p, bao j. effects of percutaneous endoscopic gastrostomy on survival of patients in a persistent vegetative state after stroke. j clin nurs. 2017 oct 1;26(19-20):3232 8. 28 j i m d c 2 0 1 8 28 21. parker e.k., faruquie s.s., talbot p. trends in home enteral nutrition at a tertiary teaching hospital: 2005– 2013. nutr. diet. 2015;72:267–275. 22. richards dm, tanikella r, arora g, guha s, dekovich aa. percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. dig dis sci 2013; 58: 768–776. 23. cyrany j, rejchrt s, kopacova m, bures j. world j gastroenterol. 2016 jan 14; 22(2):618-27. 24. kimyagarov s, turgeman d, fleissig y, klid r, kopel b, adunsky a. percutaneous endoscopic gastrostomy (peg) tube feeding of nursing home residents is not associated with improved body composition parameters. j nutr health aging. 2013;17:162–165. 25. faigle, r, marsh, eb, llinas, rh, urrutia, vc, gottesman, rf. novel score predicting gastrostomy tube placement in intracerebral hemorrhage. stroke. 2015;46(1):31–36. j islamabad med dental coll 2021 215 o p e n a c c e s s frequency of stress urinary incontinence in pregnant females fizah mahnoor khan1, tehmina gul2, syeda farah naqvi3, sumaiyah obaid4, mahwish hayee shahid5 1research associate, department of physiotherapy, fouji foundation university, islamabad 2demonstrator, aman medical institute, islamabad 3house officer, department of physiotherapy, benazir bhutto hospital, rawalpindi 4assistant professor, department of rehabilitation, riphah international university, islamabad 5health advisor, oxford policy management a b s t r a c t background: stress urinary incontinence (sui) is the most common type of urinary incontinence (ui) in pregnant women and is known to have detrimental effects on the quality of life. the objective of this study was to determine frequency of stress-induced urinary incontinence in pregnant females. methodology: a cross-sectional survey was conducted among 600 pregnant females selected via non probability purposive sampling technique from january to june 2018. data was collected from major cities of pakistan using validated questionnaires; international consultation on incontinence questionnaire” (iciq-sf) and self-structured questions assessing the referrals of pregnant women to physiotherapy, for stress urinary incontinence. statistical analysis was done using spss. frequency of qualitative variables was determined. association of urinary incontinence with pregnancy related characteristics was determined by chi-square test. results: out of 600 females, 84.3% (506/600) had experienced stress urinary incontinence in pregnancy with 64.5% reported among multigravida. 35.5% of the participants complained of increased urinary incontinence during the 9th month. quality of life was moderately affected by stress urinary incontinence. only 6.2% of the participants were referred to a physiotherapist for exercise. there was statistically significant difference between primigravida and multigravida in having urinary incontinence (p< .001). conclusion: frequency of stress urinary incontinence was high in pregnant women especially during the 9th month. referral to physiotherapy for urinary incontinence in pregnancy was extremely low. keywords: incontinence, pregnancy, trimester, third, urgency authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4,5manuscript editing. correspondence: fizah mahnoor khan email: drfizahpt@gmail.com article info: received: september 11, 2020 accepted: december 15, 2021 cite this article. khan fm, gul t, naqvi sf, obaid s, shahid mh. frequency of stress urinary incontinence in pregnant females. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n urinary incontinence (ui) is any kind of accidental, unintentional or involuntary flow of urine from the bladder, a common phenomenon and often embarrassing.1,2urinary incontinence has multiple reasons, for instance, weakness of pelvic muscles, persistent constipation, poor bowel control, restricted or low mobility, physical problems, old age, poor bladder control etc.3-7there are many types of incontinence, but the prevalence of stress urinary incontinence in pregnant females is quite high.8in pregnant women, several hormonal changes occur. moreover, the increased weight of the fetus also leads to stress incontinence. therefore, mostly pregnant women are afflicted with this issue. childbirth weakens muscles that are helpful in bladder control.9 previous research shows all pregnant women experience stress urinary incontinence frequently but ui symptoms in o r i g i n a l a r t i c l e j islamabad med dental coll 2021 216 multiparous women are more obvious due to pelvic floor structure changes in them.10 a 2016 study conducted in pakistan stated, 51.1% of females complained of urinary incontinence in pregnancy out of which 38.3% had stress urinary incontinence.11in another study, stress urinary incontinence (sui) was found in parous women of age 18-35 years. it was found that after just one vaginal delivery, the incidence of sui is markedly increased. research shows, many women afflicted by sui believe it to be normal and may not report it to clinicians.12 urinary incontinence, if treated timely, can be cured in many cases. exercises related to pelvic floor muscle in all pregnant women should be performed routinely.13 the physiotherapy care plan must be individualized for each patient. it must include standard physiotherapy interventions. such interventions comprise modalities to decrease pain; pelvic floor muscle exercise with or without biofeedback and/or electrical stimulation to improve strength and coordination of the pelvic floor muscles. moreover, stabilization exercises improve the strength of abdominal or lumbar stabilizer muscles. furthermore, educating the patient about bladder or bowel training, fluid management, and diet modification is helpful in this regard.14many studies have reported that stress urinary incontinence should be treated by conservative measures and physiotherapy and pelvic floor exercise are some of the best ways to treat it.15this study will bring awareness about magnitude of the problem, which can contribute in devising strategies for its timely prevention and management. m e t h o d o l o g y it was a descriptive cross-sectional study that was conducted in government hospitals of rawalpindi, islamabad, muzaffarabad and peshawar, from january to june 2018. the ethical approval was obtained from the review committee of riphah college of rehabilitation sciences and head of departments of all the hospitals. urinary incontinence criteria were based on ics definition regardless of the amount of leaked urine. in existing literature, prevalence of ui varies from 30%-70%, a conservative estimate of 45% is used, and sample size calculated according to the following formula was 410 12 but 600 pregnant females were enrolled to strengthen the study. n=z2p(1-p)/e2 pregnant females in 3rd trimester with ages from 20-40 years were included. females with anemia, gestational diabetes mellitus (gdm), cardiac diseases, pregnancy induced hypertension (pih), miscarriages, abortions, systemic disease, history of urinary incontinence other than pregnancy and any comorbidities were excluded. the non-probability purposive sampling technique was used in this study. a self-structured questionnaire was used for the demographics ( age, gender, area/complete address, contact number, month of pregnancy, primigravida or multigravida, occupation& referral to the physical therapist for urinary incontinence management) and the “international consultation on incontinence questionnaire” (iciq-sf) for evaluating the frequency, severity and impact on quality of life (qol) of urinary incontinence. its cronbach’s alpha coefficient was calculated 0.75, test-retest was 0.70, pearson correlation coefficient was calculated at 0.93 and the intraclass correlation coefficient was 0.84.13 before conducting research, written consent was taken from the patients. iciq-sf questionnaire was used after permission of the author. as it was only available in english language, few participants had the issue in understanding questions, expert physical therapists available helped patients to understand it in order to minimize the biasness. all the statistical data was analyzed through spss version 21. for quantitative data, mean±sd and for qualitative data (frequency) were determined. chi square test was used to find out association between parity and urinary incontinence. j islamabad med dental coll 2021 217 r e s u l t s mean age (in years) and standard deviation of participants was 27.15±4.63. data was collected from different cities with 16.7 %( n=100) participants from nawab-shah, 16.7% (n=100) from muzaffarabad, 16.8 %(n=101) from peshawar, 46% (n=276) from rawalpindi & islamabad and 2.3% (n=14) from zhob, baluchistan. maximum percentage (35.5%) of pregnant females having stress urinary incontinence reported it during 9th month (table: i). table i: stress urinary incontinence in the third trimester of pregnancy urinary incontinence percentage no complaint of urinary incontinence 15.7% (n=93) urinary incontinence during 7th month 17.5%(n=103) during the 8th month of pregnancy 31.3%(n=186) during the 9th month of pregnancy 36.5%(n=218) there was a significant difference between primigravida and multigravida in having urinary incontinence (p=< .001) (table: ii). table ii: urinary incontinence in multigravida and primigravida variable percentage urinary incontinence p-value primigravida 35.5% 25% .001* multigravida 64.5% 59.3% .001* =.001, highly statistically significant the “international consultation on incontinence questionnaire” (iciq-sf) for evaluating the frequency, severity and impact on quality of life (qol) of stress urinary incontinence has four parts. ‘how often do you leak urine, amount of leakage of urine, interference of stress urinary incontinence in daily life and when do you leak urine. as an overall trend, all questions showed a moderate impact on qol (figure: i) referral for stress urinary incontinence to physiotherapy was 6.2% while 93.8% said that there was no referral to physical therapist for urinary incontinence management. (figure ii) ‘figure i: international consultation on incontinence questionnaire figure ii: referral from physician for physiotherapy d i s c u s s i o n the result of this study shows stress urinary incontinence to be highly prevalent in pregnant females and incontinence level increasing with gestation period. these results are similar with the meta analysis in 2021 confirming urinary incontinence to be increasing with gestational j islamabad med dental coll 2021 218 period and causing bothersome situations for pregnant women. prevalence according to 44 studies was 41.0% (range of 9–75%). stress urinary incontinence (63%) was the most prevalent type of ui; 26% of the women reported daily loss, whereas 40% reported loss on a monthly basis. problem was experienced as mild to moderate. 17 a cross-sectional study was done by aruna et al 12 among 400, third trimester pregnant women which shows 75.25% prevalence and 47% affected quality of life. in this study, prevalence of stress urinary incontinence was 84.3 % (506/600) which is 10% higher as compared to their study. also, 29.10% of participants experienced a moderate level of interference in quality of life by stress urinary incontinence in this study. a study was conducted by semra kocaöz et al using international consultation on incontinence questionnaire short form and found stress incontinence to be the most common type of incontinence found in women with frequency of 57% among other types. 9 this study shows that multigravida women experienced 29.5% more ui symptoms than primigravida while another study conducted in 2017 showed that urinary incontinence symptoms and pelvic floor structure changes were more common in multiparous women as compared to nulliparous. 6,18 urinary incontinence was reported most commonly in the 9th month of gestation in this study which is similar to a cross-sectional study showing 18.96% and 39.76% first and third trimester urinary incontinence respectively ;thirdtrimester women showing 20.8% increase in prevalence. also, mostly third-trimester women leaked a “small amount” of urine. 19 according to another study, pelvic floor muscle exercises routinely in all pregnant women can help in pelvic floor muscle strengthening and controlling urinary incontinence. 20 kegels training help in stress urinary incontinence reduction. 21, 22 for management of stress urinary incontinence, timely referral for physical therapy is required but this study shows only 6.2% of women were referred to physiotherapists. the study was conducted in a very short span of time affecting its generalizability. c o n c l u s i o n frequency of stress urinary incontinence in thirdtrimester pregnant women especially during the 9th month was high affecting quality of life. referral to physiotherapy for urinary incontinence management in pregnancy was extremely low. recommendation: prompt action should be taken on the prevention of stress urinary incontinence by guiding mothers through educational programs about importance of regular pelvic floor exercises. r e f e r e n c e s 1. santini ac, santos es, vianna ls, bernardes jm, dias a. prevalence and factors associated with the occurrence of urinary incontinence during pregnancy. rev. bras. saude mater. infant. 2020;19:967-74. doi:10.1590/1806 93042019000400013 2. linde jm, nijman rj, trzpis m, broens pm. prevalence of urinary incontinence and other lower urinary tract symptoms in children in the netherlands. j peds urology. 2019;15(2):164-e1. doi: 10.1016/j.jpurol.2018.10.027 3. silverio aa, silverio la, silverio aa. design of a mixed signal bladder control system with sensor front-end readout and drug delivery actuator based on tsmc 0.18 um technology. in2020 ieee 8th r10 humanitarian technology conference (r10htc) 2020 (pp. 1-5). ieee. doi: 10.1109/r10htc49770.2020.9356960 4. moossdorff-steinhauser hf, berghmans bc, spaanderman me, bols em. urinary incontinence during pregnancy: prevalence, the experience of bother, beliefs, and help-seeking behaviour. int urogynecol j. 2021;32(3):695-701. doi:10.1007/s00192-020-04566-0 5. torgbenu el, aimakhu co, morhe ek. effect of kegel exercises on pelvic floor muscle disorders in prenatal and postnatal women-a literature review. current women's health reviews. 2021;17(3):202-7. doi:10.2174/1573404816999200930161059 6. kobashi kc, albo me, dmochowski rr, ginsberg da, goldman hb, gomelsky a, et al. surgical treatment j islamabad med dental coll 2021 219 of female stress urinary incontinence: aua/sufu guideline. j urology. 2017;198(4):875-83. doi:10.1016/j.juro.2017.06.061 7. sangsawang b, sangsawang n. stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. int urogynecol j. 2013;24(6):901-12. doi.org/10.1007/s00192-013-2061-7 8. jansson mh, franzén k, tegerstedt g, hiyoshi a, nilsson k. stress and urgency urinary incontinence one year after a first birth—prevalence and risk factors. a prospective cohort study. acta obstet gynecol scand. 2021;100(12):2193-201. doi:10.1111/aogs.14275 9. seshan v, muliira jk. self-reported urinary incontinence and factors associated with symptom severity in community-dwelling adult women: implications for women’s health promotion. bmc women's health. 2013;13(1):1-8. doi:10.1186/14726874-13-16 10. luo d, chen l, yu x, ma l, chen w, zhou n, et al. differences in urinary incontinence symptoms and pelvic floor structure changes during pregnancy between nulliparous and multiparous women. peer j. 2017;5:e3615. doi:10.7717/peerj.3615 11. sharif s, gondal mj, kamboh sm, adeel m, qamar m, chaudhry a, et al. urinary incontinence in pregnant multigravida from second trimester up to the delivery. annals of king edward medical university.2017;23(2).doi:10.21649/akemu.v23i2.15 64 12. nigam a, ahmad a, gaur d, elahi aa, batra s. prevalence and risk factors for urinary incontinence in pregnant women during late third trimester. int j reprod contracept obstet gynecol. 2017;5(7):218791. doi: 10.18203/2320-1770.ijrcog20162090 13. hajebrahimi s, nourizadeh d, hamedani r, pezeshki mz. validity and reliability of the international consultation on incontinence questionnaire-urinary incontinence short form and its correlation with urodynamic findings. urology j. 2012;9(4):685-90. doi:10.22037/uj.v9i4.1800 14. institute jb. the joanna briggs institute best practice information sheet: the effectiveness of pelvic floor muscle exercises on urinary incontinence in women following childbirth. nurs health sci. 2011;13(3):378-81. doi:10.1111/j.14422018.2011.00617.x 15. al-mehaisen lm, al-kuran o, lataifeh im, betawie s, sindiyani a, al-ttal of, et al. prevalence and frequency of severity of urinary incontinence symptoms in late pregnancy: a prospective study in the north of jordan. arch gynecol obstet. 2009;279(4):499-503. doi:10.1007/s00404-0080720-6 16. jaffar a, mohd-sidik s, nien fc, fu gq, talib nh. urinary incontinence and its association with pelvic floor muscle exercise among pregnant women attending a primary care clinic in selangor, malaysia. plos one. 2020;15(7):e0236140. doi: 10.1371/journal.pone.0236140 17. moossdorff-steinhauser hf, berghmans bc, spaanderman me, bols em. prevalence, incidence and bothersomeness of urinary incontinence in pregnancy: a systematic review and meta-analysis. international urogynecology j. 2021:1-20. doi:10.1007/s00192-020-04636-3 18. kocaöz s, talas ms, atabekoğlu cs. urinary incontinence in pregnant women and their quality of life. jcn. 2010;19(23‐24):3314-23. doi:10.1111/j.1365-2702.2010.03421.x 19. franco em, parés d, colomé nl, paredes jrm, tardiu la. urinary incontinence during pregnancy. is there a difference between first and third trimester? eur. j. obstet. gynecol. 2014;182:86-90. doi:10.1016/j.ejogrb.2014.08.035 20. stoner lm, way mm. stress urinary incontinence: parous versus nulliparous women ages 18–35 (doctoral dissertation, grand valley state university) 2000. 21. scott km, gosai e, bradley mh, walton s, hynan ls, lemack g, et al. individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain. int urol nephrol.2020;52(4):6559.doi:10.1007/s11255-01902343-7 22. jose pm, vijaya kumar rv. effect of combined pall of press and kegels training for urinary incontinence in multigravida women and quality of life. indian j physiother occup ther. 2020;14(1): 167-71. issn 0973-5674 23. mostafa abd el-aty e, el-ghareap hassan m. effect of kegel exercise training program on improving quality of life among women with urinary incontinence. egyptian journal of health care. 2021; 12(2):946-64. doi: 10.21608/ejhc.2021.172829 j islamabad med dental coll 2019 3 open access appraisal of national response to chronic hepatitis in pakistan amimah fatima asif 1, rana hussain asif 2, rana haider asif 3 1 medical officer, dhq hospital nankana sahib 2 research fellow, baptist health system, south florida usa 3 research assistant, baptist health system, south florida usa a b s t r a c t chronic hepatitis has emerged as a grave health crisis in pakistan that is becoming increasingly difficult to control. the national response in the public and private sector is lacking realism, direction and strategy. the aim of the present review was to analyze the efforts directed towards elimination of this menace, outline the challenges and make pragmatic recommendations. we searched pubmed, google scholar and google web search for relevant indexed literature in english using the mesh terms ‘chronic hepatitis’, ‘pakistan’, ‘hepatitis b’, ‘hepatitis c’, ‘hepatitis prevention’, ‘national hepatitis control’, etc. rigorous efforts to improve the capacity of the primary healthcare establishments are pivotal to contain further spread of hepatitis b and c infections. combating quackery, regulating the use of medical sharps and making affordable hepatitis treatment accessible to the masses should be the principal focus of the government. healthcare delivery units should be equipped to render complete coverage of essential quality hepatitis services in order to curb this menace. key words: hepatitis b, hepatitis c, pakistan authors’ contribution: 1,2conception, synthesis, planning of research and manuscript writing interpretation and discussion data analysis, interpretation and manuscript writing, 3 active participation in data collection. correspondence: amimah fatima asif email: amimahf_asif@hotmail.com article info: received: january 17, 2019 accepted: february 6, 2019 cite this article. asif af, asif rh, asif rh. appraisal of national response to chronic hepatitis in pakistan. j islamabad med dental coll.2019; 8(1):3-7 funding source: nil conflict of interest: nil i n t r o d u c t i o n the disease burden of chronic hepatitis in pakistan is one of the highest in the world.1 hepatitis b and c viral infections can potentially cause liver cirrhosis and hepatocellular carcinoma leading to increased morbidity and mortality.2 viral hepatitis is known as the ‘silent epidemic’ because a large number of people are unaware that they are infected while the disease is progressively causing liver damage.3 in pakistan 12 million people suffer from chronic hepatitis of which 75% suffer from hepatitis c and 25% from hepatitis b. pakistan has the second highest global burden of hepatitis c with 8 million people infected accounting for 5% of pakistan’s population.4 every year around 150,000 new cases of hepatitis b and c are diagnosed in pakistan.5 hepatitis b and c viruses are transmitted through blood and body secretions causing acute infections, which clear up in 6 months’ time in approximately 80% cases of hepatitis b and 20% cases of hepatitis c. the infection can acquire chronicity in 20% hbv and 80% hcv cases.6 common mode of transmission of the blood-borne hepatitis b and c virus in developing countries is the reuse of needles and syringes and incorrect sterilization of medical instruments. where as in developed countries the routes of transmission are intravenous drug use, needle stick injuries, tattooing, sexual intercourse and perinatal infections.7 a recombinant vaccine is available r e v i e w a r t i c l e j islamabad med dental coll 2019 4 for prevention of hepatitis b viral infection while there is no vaccine available for hepatitis c viral infection. globally, hepatitis caused 1.54 million deaths in 2013, showing a substantial increase from 0.89 million deaths in 1990. the increase in morbidity was noted in the form of years lived with disability from 0.65 million in 1990 to 0.87 million in 2013 and disability adjusted life years (daly) from 31.7 million in 1990 to 42.5 million in 2013. hepatitis b and c are the cause of 96% mortality and 91% of dalys in 2013 because they are chronic infections that deteriorate liver function and can potentially cause multi organ failure 8 according to world health organization, worldwide the highest mortality due to hepatitis (i.e. ≥33.5 deaths per 100 000 population per year) is in the regions of oceania, western sub-saharan africa and south asia. within the eastern mediterranean region, pakistan and egypt bear 80% of disease burden due to hepatitis.9 this is a review article that is corroborating pakistan’s disease burden due to chronic hepatitis. it aims to analyze the efforts being employed to eliminate hepatitis b and c infections, debunk the actual challenges hindering their elimination and make pragmatic recommendations. we searched pubmed, google scholar and google web search for relevant literature. we used the mesh terms ‘chronic hepatitis’, ‘pakistan’, ‘hepatitis b’, ‘hepatitis c’, ‘hepatitis prevention’, ‘national hepatitis control’, etc. the main aim of this literature search was to put in perspective the situation of chronic hepatitis in pakistan and the response of the government to this threat. articles relating to the prevalence, modes of transmission, risk factors and various community level interventions including both governmental and non-governmental response were included in this desk review. journal articles, government reports, non-government organization (ngo) reports, newspaper articles, information and reports published by international organizations were retrieved from january 2000 to january 2019. data was also retrieved from government of pakistan’s national hepatitis control program and other relevant bodies. national hepatitis control measures in order to restrain the burden of chronic hepatitis, efforts are being undertaken in the public and private sector of pakistan. preventive measures which include ensuring immunization of children for hepatitis b through the expanded program of immunization (epi) schedule, blood screening for safe blood transfusions, free hepatitis testing and treatment facilities are being taken by the government, private sector and international organizations. but these prevention strategies are lacking complete coverage; moreover, certain crucial initiatives are not being targeted and implemented. free hepatitis testing and treatment services are being provided in government hospitals of the four provinces of pakistan through the provincial hepatitis prevention and control program, however currently there is no integrated national hepatitis control program.10 in a public-private partnership endeavor the government of punjab has collaborated with the pakistan kidney and liver institute (pkli) to provide free testing service and free treatment to deserving patients. this program has expanded to 25 districts of the province of punjab.11 pakistan health research council (phrc, previously pmrc) has developed the national hepatitis strategy framework which is a 5-year plan (2017 to 2021) with the goal to eliminate hepatitis by 2030. this plan has a target to reduce hbv and hcv related deaths by 10 % and new cases of infection by 30%.12 the new direct acting antivirals (daas) are now approved by international drug regulatory authorities such as food and drug administration (fda) but the cost of these breakthrough drugs was extremely high which was a major barrier to access. after negotiating with 14 pharmaceutical companies the ministry of national health services, regulations and coordination (nhrc) registered generic and branded daas. in 2017, direct acting antiviral (daa) drug sofosbuvir 400mg was available for the treatment of hepatitis c at us $15 which is the lowest price in the world.13 this drug is being procured by provincial hepatitis control programs to dispense free of cost to non-affording patients. according to who, 95% of people infected with hepatitis c can be cured within 2-3 months with the new oral drug treatment.14 it seems evident that the epicenter of efforts by public and private health sector is on treatment of chronic hepatitis, but limited work is being done to address the root causes that are leading to uncontrolled infection transmission and spread in communities. focus on containing the infection reservoirs through j islamabad med dental coll 2019 5 implementation of disease prevention techniques, screening and early diagnosis are not the priorities. overcoming challenges in hepatitis control due to the frail primary healthcare set up of pakistan the enforcement and implementation of strategies for disease prevention is one of the key challenges in stifling the spread of hepatitis infection. screening of high-risk groups and timely diagnosis of hepatitis are the stepping stones of primary care delivery. according to statistics, 7 million people are infected with hepatitis c in pakistan but only 1 million (14%) of them are diagnosed. approximately 4 million people are infected with hepatitis b but only 0.1 million (3%) of them are diagnosed.15 delayed diagnosis leads to complications such as chronic liver disease, liver cirrhosis and hepatocellular carcinoma. managing these complications in tertiary care hospitals is expensive, which is an additional burden on the economy of the country. the government needs to focus on strengthening the primary healthcare delivery points; basic health units (bhu), rural health centers (rhc) and tehsil headquarters hospitals (thq) by promoting hepatitis prevention through community outreach campaigns, encouraging disease screening and providing rapid hepatitis testing kits. it is at these primary cares set ups that infected individuals in the catchment population can be identified and family mapping can be done to identify undiagnosed cases. proper documentation and follow up are crucial in slowing the spread of infection and the progression of the disease. additionally, efforts need to be galvanized for ensuring that every child is immunized for hepatitis b. babies who are not delivered in a healthcare unit, and are home-delivered in villages, are not receiving the hepatitis b vaccination. it is critical to ensure that every new born is immunized as per the epi schedule which includes the vaccination for hepatitis b (figure 1). although all adult population should be vaccinated for hepatitis b but coverage is inadequate particularly in high risk groups such as sex workers, transgender population, drug addicts and thalassemia patients.16 figure 1. recommended steps to control spread of hepatitis b and c infection interestingly, the major risk factor for hepatitis transmission in developed countries is intravenous drug use while in pakistan it is the reuse of syringes for unwarranted therapeutic purposes.17 according to a survey by pakistan medical research council, 48% of pakistan’s population is taking less than 5 injections per year, 22% are taking between 5-10 injections and 6% are taking over 10 injections per person per year.18 the ministry of national health services has introduced auto disabled syringes to eliminate the reuse of syringes in health facilities and by iv drug abusers.19 but unfortunately they are not being used in government hospitals and other health facilities. ensuring the use of auto disabled syringes and regulating their supply is needed to put an end to this major mode of spread for hepatitis infection (figure 1). furthermore, there is no proper guideline and training of staff to manage sharp waste disposal and medical waste disposal in public hospitals.20 another significant challenge in the spread of hepatitis is that of quackery in urban and rural areas (figure 1). a survey conducted in 2014 showed that there are 200,000 quacks working in pakistan.21 the reuse of syringes and lack of sterilization in quack clinics including dental clinics are key causes of spread of hepatitis infections in the j islamabad med dental coll 2019 6 masses. the government should take the local district authorities in confidence and conduct crackdown on the quack clinics. in addition to this curbing the patient influx in these quack clinics is the responsibility of doctors working in public and private sector to educate patients about the substandard and fraudulent medical practices of quacks. counseling the patients and their families that seeking treatment from these quacks will put their health at serious risk of contracting harmful infections can prove to be very beneficial and reformative. quacks are notorious for administering unwarranted intravenous steroids and antibiotics, such subpar treatment regimens lead to spread of infectious diseases and cause antibiotic resistance. in pakistan, pegylated interferon-based therapy is being used since the past 10 years for managing hepatitis. the new direct acting antiviral drugs such as sofosbuvir is now being used and has shown promising results.22 there is an urgent need to speed up the registration and availability of new direct acting antivirals for hepatitis in the local market. with the current state of affairs, the national response to hepatitis control is unsatisfactory and the prospects of eliminating hepatitis by 2030 are bleak. understanding that there is an emergent need to divert attention to the core public health issues, in order to reduce morbidity and mortality due to hepatitis in pakistan is of monumental importance. only the government’s unfaltering commitment and sound financial investment in this cause can pave the way for hepatitis elimination in pakistan. pakistan has a major epidemic of chronic hepatitis b and c. the high prevalence and the unchecked spread of infection through multiple modes of transmissions is a serious threat. in recent years pakistan has even been called a “cirrhotic state”, which tells a lot about the country’s disease landscape. the lack of awareness of general public, poorly regulated and unhygienic health practices, poor health services and a reactionary approach by the government, all add up to make pakistan a perfect incubator for not only chronic hepatitis but also other diseases that share similar modes of transmission. robust preventive and curative interventions which are resistant to the constantly changing socio-political environment of pakistan are imperative to limit the spread of these chronic ailments and their complications. r e f e r e n c e s 1. al kanaani z, mahmud s, kouyoumjian sp, aburaddad lj. the epidemiology of hepatitis c virus in pakistan: systematic review and meta-analyses. r soc open sci. 2018;5(4):180257. 2. ali sa, donahue rm, qureshi h, vermund sh. hepatitis b and hepatitis c in pakistan: prevalence and risk factors. int j infect dis. 2008;13(1):9-19. 3. world health organization. who urges governments to act on hepatitis threat [internet]. who.int. 2019 [cited 2 january 2019]. available from: https://www.who.int/mediacentre/news/releases/2013/ hepatitis_threat_20130724/en. 4. moin a., fatima h., qadir ft. tackling hepatitis c— pakistan's road to success. lancet. 2018;391(10123):834-835. 5. waheed m. world health organization-eastern mediterranean office. prevention and control of hepatitis. pakistan [internet]. emro.who.int. 2019 [cited 4 january 2019]. available from: http://www.emro.who.int/pak/programmes/preventiona-control-of-hepatitis.html. 6. bosan a., qureshi h., bile km, et al. a review of hepatitis viral infections in pakistan. j pak med assoc. 2010;60(12):1045-1058. 7. khan aj, luby sp, fikree f, karim a, obaid s, dellawala s,et al, unsafe injections and the transmission of hepatitis b and c in a periurban community in pakistan. bull world health organ 2000; 78: 956-63 8. wiktor sz1, hutin yj2. the global burden of viral hepatitis: better estimates to guide hepatitis elimination efforts. lancet. 2016;388(10049):10301031. 9. fikri m. eliminating hepatitis from the eastern mediterranean region. east mediterr health j-world health organization. 2017;23(7):459-460. 10. waheed m. who emro. prevention and control of hepatitis. pakistan [internet]. emro.who.int. 2019 [cited 7 january 2019]. available from: http://www.emro.who.int/pak/programmes/preventiona-control-of-hepatitis.html. 11. world health organization. fighting hepatitis in pakistan [internet]. who.int. 2019 [cited 8 january 2019]. available from: https://www.who.int/news j islamabad med dental coll 2019 7 room/feature-stories/detail/pakistan-tackles-highrates-of-hepatitis-from-many-angles 12. health minister saira afzal tarar addresses world hepatitis summit shares progress in fight against the disease. [internet]. ministry of national health services, regulations and coordination, government of pakistan. 2019 [cited 9 january 2019]. available from: http://www.nhsrc.gov.pk/press_release_detailes7468. html?pr_id=241. 13. optimizing medicines and treatment regimens for hepatitis c patients in pakistan. [internet]. worldhepatitissummit.org. 2019 [cited 10 january 2019]. available from: http://www.worldhepatitissummit.org/docs/defaultsource/posters/4a_dr-hassanmahmood.pdf?sfvrsn=2. 14. global hepatitis report, 2017. world health organization; geneva 2017. 15. world health organization. hepatitis c [internet]. who.int. 2019 [cited 10 january 2019]. available from: https://www.who.int/news-room/factsheets/detail/hepatitis-c. 16. memon ar, shafique k, memon a, draz au, rauf mu, afsar s. hepatitis b and c prevalence among the high-risk groups of pakistani population. a cross sectional study. arch public health. 2012;70(1):9. 17. moin a., fatima h., qadir ft. tackling hepatitis c— pakistan's road to success. lancet. 2018;391(10123):834-835. 18. prevalence of hepatitis b and c in pakistan. phrc.org.pk. 2019 [cited 10 january 2019]. available from: http://phrc.org.pk/assets/hepatitis-nationalsurvey.pdf. 19. janjua nz, butt za, mahmood b, altaf a. towards safe injection practices for prevention of hepatitis c transmission in south asia: challenges and progress. world j gastroenterol. 2016;22(25):5837-52. 20. kumar r., khan ea., ahmed j, et al. healthcare waste management (hcwm) in pakistan: current situation and training options. j ayub med coll abbottabad 2010;22(4):101-106 21. ilyas f. experts demand implementation of healthcare law to end quackery [internet]. dawn.com. 2019 [cited 11 january 2019]. available from: https://www.dawn.com/news/1439641. 22. waheed y, siddiq m. elimination of hepatitis from pakistan by 2030: is it possible? hepatoma research. 2018;4(8):45. j islamabad med dental coll 2020 175 open access protective effect of morus nigra leaf extract on diazinoninduced hepatotoxicity in rats hina majid1, salman shahid2, sadia shakeel3, mariam ashraf4, muhammad yasoob ali5, amna ahsan6 1 assistant professor, department of anatomy, postgraduate medical institute lahore, pakistan 2 audiologist, government special education department, lahore, pakistan 3 assistant professor, department of oral biology, postgraduate medical institute lahore, pakistan 4 associate professor, postgraduate medical institute lahore, pakistan 5 professor & head, department of anatomy and oral biology, postgraduate medical institute lahore, pakistan 6 demonstrator, department of oral biology, postgraduate medical institute lahore, pakistan a b s t r a c t background: diazinon is a globally used pesticide. morus nigra (black mulberry) possesses flavonoids and phenols, which act as antioxidants. the objective of this study was to determine the possible protective effects of morus nigra leaf extract on diazinon-induced hepatotoxicity in rats. material and methods: it was an experimental study conducted in the department of anatomy, postgraduate medical institute, lahore. a total of 36 healthy male wistar albino rats were divided into three groups with 12 rats in each group. group i was the control group. group ii was treated with 60 mg/kg body weight (bw) diazinon daily for 4 weeks through orogastric intubation. group iii was treated with diazinon 60 mg/kg bw daily along with 350 mg/kg bw of morus nigra extract daily for 4 weeks through orogastric intubation. blood samples were collected through cardiac puncture, for estimation of alanine transaminase (alt) and aspartate transaminase (ast) levels. liver dissection was done, slides of the hepatic tissue were prepared and studied under light microscope. the histology of hepatocytes, portal lobule, portal vein and sinuosoids was observed. spss 20 was used for data analysis. one -way anova followed by tukey’s test was applied to establish difference among groups with p-value ≤0.05 considered as statistically significant. results: histology of liver tissue in group i showed normal morphology while group ii revealed hypertrophy and vacuolization of hepatocytes, congested central vein and sinusoids and presence of necrotic foci. these toxic effects were reversed by the co-administration of diazinon with morus nigra in group iii which showed normal histology of the hepatic tissue. similarly, diazinon administration resulted in significant elevation of alt and ast levels ( p-value<0.05), while, morus nigra resulted in a considerable decline in the levels of these enzymes (p-value <0.05). conclusions: morus nigra extract has hepatoprotective effects against liver toxicity induced by diazinon . key words: alanine transaminase, antioxidants, aspartate transaminase, diazinon, morus nigra, pesticide . authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and 4-6manuscript review; data analysis; manuscript editing. correspondence: hina majid email: hinamajidmir@gmail.com article info: received: january 1, 2020 accepted: september 19, 2020 cite this article. majid h, shahid s, shakeel s, ashraf m, ali my, ahsan a. protective effect of morus nigra leaf extract on diazinon-induced hepatotoxicity in rats. j islamabad med dental coll. 2020; 9(3): 175-181. doi: 10.35787/jimdc.v9i3.483 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 176 i n t r o d u c t i o n for centuries, pesticides are used to exterminate organisms, which cause diseases in plant and to control insects, weeds, and pests in order to enhance the agricultural yield.1 diazinon is an organophosphorus pesticide used globally. 2 humans are exposed to diazinon through contamination of food and water by this insecticide. the residues of pesticide stick onto the leafy vegetables and fruits leading to various health hazards. diazinon inhibits the enzyme acetylcholinesterase and activates cholinergic, muscarinic and nicotinic receptors.3 exposure to organophosphorus insecticide causes salivation, lacrimation, nausea, vomiting, diarrhea arrhythmias, miosis, involuntary defecation, urination and arrthymias.4 studies have reported the harmful effects of diazinon on many organs including the brain, gonads, liver and kidneys. 5,6 diazinon affects the mitochondrial membrane transportation in the rat liver. it also disturbs cytochrome p450 system in human liver and causes changes in liver enzymes, biochemical indice s and provoke mitochondria swelling. diazinon inflicts oxidative stress by generating free radicals. 7 disproportionate production of reactive oxygen species and depletion of antioxidant capacity alters the balance and results in oxidative stress. therefore, it makes sense to say that potentiation of antioxidant capacity can be an effective approach to attenuate the toxic effects of diazinon. 8 morus nigra is cultivated all over the world. it is known by the name of black mulberry and shahtoot.9 morus nigra is a rich amalgam of polyphenols, flavonoids, and anthocyanins.10 the flavonoids and phenols exert strong antioxidant activity and have a protective action against oxidative damage to membranes and biomolecules.11 flavonoids are reported to show hepatoprotective effects.12 black mulberry is widely used in traditional medicine to stop bleeding, to soothe pain and reduce inflammation.13 the present research aimed to study the ameliorative effects of morus nigra on hepatotoxicity produced by diazinon in rats to elucidate the curative potential of the plant. morus nigra is a widely grown plant, thus it can serve as a low cost and easily available remedy for diazinon induced hepatotoxicity and liver diseases. m a t e r i a l a n d m e t h o d s it was an experimental study conducted in the department of anatomy, postgraduate medical institute lahore, pakistan between april 2019 to june 2019. a total of 36 healthy male wistar albino rats were used. sample size of 12 animals in each group was calculated using 95% confidence level, 90% power of test and mean ± sd for aspartate transaminase (ast) levels through power and precision 3.0 software. the leaves of morus nigra were collected from punjab university, lahore. after drying the leaves for a week, they were powdered by a grinder and then soaked in aqueous methanol. solution was filtered, evaporated and a gel like paste was produced. analytical grade diazinon pestanal® (cas number: 333-41-5) was purchased from sigmaaldrich. ethical approval was obtained from the ethical committee of postgraduate medical institute, lahore, pakistan on 29th april 2019. the male wistar albino rats (150–200 g) were acclimatized for a week and kept in the animal house of pgmi, lahore under standard conditions. the rats were randomly sorted into three groups, each having 12 animals. group i (control) received distilled water 1 ml/kg for four weeks. group ii was given 60 mg/kg bw diazinon daily using orogastric tube for 4 weeks. group iii was administered j islamabad med dental coll 2020 177 diazinon 60 mg/kg bw daily along with 500 mg/kg of morus nigra extract daily for 4 weeks through orogastric intubation. at the end of the experiment i.e. 24 hours after the last dose, rats were euthanized and cardiac puncture was done to get blood samples for the analysis of liver biochemical markers, ast and alt. liver dissection was done. the liver tissue was processed and paraffin blocks were prepared. approximately 5 µm thin sections were sliced, stained with hematoxylin and eosin and studied under a light microscope. the histology of hepatocytes, portal lobule, portal vein and sinuosoids was observed. the levels of ast and alt were presented as mean ± sd. spss 20 was used for data analysis. one-way anova followed by turkey’s test was applied to establish differences among groups. p-value ≤ 0.05 was considered statistically significant. r e s u l t s histological examination of liver belonging to control group i showed normal hepatocytes and hepatic lobules. normal kupffer cells were seen. no congestion was observed in the central vein and sinusoids (figure 1). figure 1: photomicrograph of rat liver (group i) showin g normal hepatocytes (h), normal central vein (cv) and normal sinusoidal space (s) (h&e, 200x). liver histology from group ii revealed vacuolization and ballooning of majority of the hepatocytes. some regions of the liver tissue exhibited necrosis. many intervening hepatic blood sinusoids showed congestion. most of kupffer cells appeared hypertrophied. congestion was also observed in central veins (figure 2). the liver sections of rats belonging to group iii showed normal histological structure of the hepatic tissue. normal parenchymal arrangement of polygonal hepatocytes was observed. the cytoplasm and the nuclei of the hepatocytes revealed no degenerative changes. sinusoids also exhibited normal features. kupffer cells appeared normal in size and the central veins were not congested (figure 3). figure 2: photomicrograph of rat liver (group ii) showin g ballooning and vacuolization of hepatocytes (h) (green arrows), dilated central vein (cv) (blue arrow) and congested sinusoids (s) (orange arrow) (h&e, 200 x). figure 3: photomicrograph of rat liver (group iii) show ing normal hepatocytes (h), normal central vein (cv) and normal sinusoidal space (s) (h&e, 200x). j islamabad med dental coll 2020 178 levels of alt and ast enzymes were significantly raised in the rats belonging to group ii. whereas, the co-administration of morus nigra significantly lowered serum ast ad alt levels (tables i & ii). table i: comparison of alt and ast levels among the three groups by one-way anova groups alt (u/l) mean ± sd p-value* ast (u/l) mean± sd p-value* group i 32.04 ± 11.93 27.47 ± 10.35 group ii 114.49 ± 11.81 <0.01 in comparison to group i 112.8 ± 20.63 <0.01 in comparison to group i group iii 38.50 ± 2.70 <0.01 in comparison to group ii 34.81 ± 4.27 <0.01 in comparison to group ii alt-alanine transaminase; ast-aspartate transaminase *pvalue ≤0.05 was considered significant table ii: post-hoc tukey analysis of alt and ast levels among groups groups means of alt levels *p-value means of ast levels *p-value group i and ii -82.45 <0.01* -85.33 <0.01* group i and iii -6.46 0.078 -7.34 0.042* group ii and iii 75.99 <0.01* 77.99 <0.01* *p-value ≤0.05 was considered significant d i s c u s s i o n diazinon, is a commonly used organophosphorous insecticide. it has been used for the control of soil insects and pests, on ornamental plants, and on fruits, vegetables and field crops. now it is used to control flies around animal facilities, greenhouses, grounds and public places where food or animal wastes might be accumulated. the undesired effects of pesticides have been recognized as a serious public health concern during the past decades. our study revealed histopathological alterations by diazinon in the liver tissue. diazinon resulted in damage to the hepatocytes and congestion of central veins and sinusoids. similar findings were observed by other researchers. 14 cakici and akat found that that diazinon produces vacuoles in the hepatocytes, increases kupffer and inflammatory cells and promotes congestion of the central veins in mice.7 ezzi et al, in their research also proved that diazinon causes distortion of portal triads and congestion of central veins and sinusoids. 15 diazinon induces histological alterations in the liver by lowering the capacity of antioxidant systems and increasing the levels of free radicals. 16 research done by saraei et al. revealed that inhalation of diazinon by pregnant mice increased the apoptosis in the developing hepatocytes.17 the liver sections of rats belonging to group iii showed normal histological structure of the hepatic tissue. normal arrangement of hepatocytes was observed. the cytoplasm and the nuclei of the hepatocytes revealed no degenerative changes. sinusoids exhibited normal features. kupffer cells appeared normal in size. the central veins were not congested. the results correspond with the findings of malhi et al., who indicated that mulberry has j islamabad med dental coll 2020 179 protective effects against paracetamol induced hepatic injury.18 tag suggested that morus nigra leaf extract exerts hepatoprotective effect against antirheumatic drug methotrexate.9 the levels of ast and alt in the serum are the indices of liver injury. the increased levels of these enzymes indicate severe liver injury. damage of hepatocytes is reflected by an elevation in the levels of hepatospecific enzymes (alt and ast). these enzymes are stored in the cytoplasm and are released into circulation after cellular damage. the current study showed that diazinon produced significant rise in the levels of ast and a lt. haghightjoo et al. also proved that diazinon increases level of liver enzymes and decreased total protein and causes the histological alterations in rat liver.19 however, morus nigra produced a significant decrease in the ast and alt levels, due to its antioxidant properties. antioxidants protect the cell membrane integrity and prevent enzyme leakage. they help in scavenging the free radicals. 20 mulberry extract contains large amounts of tannins, flavonoids, phenols. therefore, the presence of flavonoids may be responsible for its protective effects on diazinon induced liver injury in this study. the results also coincide with the observations of mallhi et al.18 pesticides exert their biological effects mainly through electrophilic attack of cellular constituents with simultaneous generation of reactive oxygen species (ros). ros may, therefore, be involved in the toxicity of various pesticides. pesticide induce oxidative stress leading to generation of free radicals and alteration in antioxidants or oxygen free radical scavenging enzyme systems.4 deniz et al. proved that morus nigra protects the liver against carbon tetrachloride and it can serve as a novel approach for treating various hepatic problems.21 agha et al. suggested that mulberry juice is rich in antioxidants and it can protect against hepatotoxicity induced by carbon tetrachloride.22 free radical scavenging activity is attributed to the flavonoids mainly quercetin and isoquercitrin found in black mulberry. 23 quercetin in the extract increases the expression of antioxidant enzyme system. while, oleanolic acid enhances the glutathione regeneration capacity and luteolin inhibits peroxidation of biomembranes. 24 limitations: the small sample size and shorter duration of the experiment to observe the effects of morus nigra can be considered as limitations of our study. another limitation is that the study was conducted on an animal model, so the results cannot be generalized to a human model, so similar studies on humans are recommended. c o n c l u s i o n morus nigra leaf extract protected the liver against diazinon induced hepatotoxicity in male rats. therefore, it can be considered as a protective agent against free radical-induced liver damage following exposure to diazinon. further clinical trials can be planned to evaluate the effects of morus nigra on other organs and on the levels of free radicals. further investigations are needed to explore the mechanism action of morus nigra against diazinon toxicity. r e f e r e n c e s 1. slotkin ta, skavicus s, seidler fj. diazinon and parathion diverge in their effects on development of noradrenergic systems. brain res bull. 2017; 130: 268-73. doi: 10.1016/j.brainresbull.2017.02.004 2. ghazala, mahboob s, ahmad l, sultana s, alghani m k, al-misned f, et al. fish cholinesterases as biomarkers of sublethal effects of organophosphorus and carbamates in tissues of labeo rohita. j biochem mol toxicol. 2013; 28(3):137 42. doi: 10.1002/jbt.21545 3. ajibade to, oyagbemi aa, omobowale to, asenuga er, afolabi jm, adedapo aa. mitigation of diazinon induced cardiovascular and renal dysfunction by j islamabad med dental coll 2020 180 gallic acid. interdiscip toxicol. 2016; 9(2): 66 -77. doi: 10.1515/intox-2016-0008 4. nili-ahmadabadi a, alibolandi p, ranjbar a, mousav i l, nili-ahmadabadi h, larki-harchegani a, et al. thymoquinone attenuates hepatotoxicity and oxidative damage caused by diazinon: an in vivostudy. res pharm sci. 2018; 13(6): 500 -508. doi: 10.4103/1735-5362.245962 5. karimani a, heidarpour m, moghaddam jafari a. protective effects of glycyrrhizin on sub-chronic diazinon-induced biochemical, hematological alterations and oxidative stress indices in male wistar rats. drug chem toxicol. 2019; 42(3): 300 -8. doi: 10.1080/01480545.2018.1497053 6. ahmadi-naji r, heidarian e, ghatreh-samani k. evaluation of the effects of the hydroalcoholic extract of terminalia chebulafruits on diazinon-induced liver toxicity and oxidative stress in rats. avicenna j phytomed. 2017; 7(5): 454-66. pmid: 29062807 7. cakici o, and akat e. effects of oral exposure to diazinon on mice liver and kidney tissues: biometric analyses of histopathologic changes. anal quan t cytol histol. 2013; 35(1): 7-16. pmid: 23469619 8. abdel-daim mm, taha r, ghazy ew, el-sayed ys . synergistic ameliorative effects of sesame oil and alpha-lipoic acid against subacute diazinon toxicity in rats: hematological, biochemical, and antioxidan t studies. can j physiol pharmacol. 2016; 94(1): 81 -8. doi: 10.1139/cjpp-2015-0131 9. tag hm. hepatoprotective effect of mulberry (morus nigra) leaves extract against methotrexate induced hepatotoxicity in male albino rat. bmc compl alt med. 2015; 15: 252. doi: 10.1186/s12906 -015-0744y 10. souzaa gr, oliveira-juniora rg, dinizb tc, brancob a, lima-saraivac sr, guimarãesa al, et al. assessmen t of the antibacterial, cytotoxic and antioxidan t activities of morus nigra l. (moraceae). braz. j. biol. 2018; 78(2): 248-254. doi: 10.1590/1519-6984.05316 11. mahmoud arh, shalaby nm. evaluation of hepatoprotective effect of propolis against subchronic diazinon induced hepatotoxicity. egypt j. forensic sci. appli. toxicol. 2018; 18 (4):53 -66. doi: 10.21608/ejfsat.2018.5216.1025 12. chen h, pu j, liu d, yu w, shao y, yang g. antiinflammatory and antinociceptive properties of flavonoids from the fruits of black mulberry (morus nigra l.). plos one. 2016; 11:153. doi: 10.1371/journal.pone.0153080 13. lim hh, yang sj, kim y, lee m, lim y. combined treatment of mulberry leaf and fruit extract ameliorates obesity related inflammation and oxidative stress in high fat diet-induced obese mice. j med food. 2013; 16(8): 673-680. doi: 10.1089/jmf.2012.2582. 14. karimani a, mamashkhani y, jafari am, akbarabadi m, heidarpour m. captopril attenuates diazinon induced oxidative stress: a subchronic study in rats . iran j med sci. 2018; 43(5): 514–522. pmid: 30214104 15. ezzil l, haouas z, salah i, sakly a, grissa i, chakroun s, et al. toxicopathic changes and genotoxic effects in liver of rat following exposure to diazinon. environ. sci. pollut. res. 2016; 23 (11):11163 -11170. doi: 10.1016/j.sjbs.2016.10.013 16. adampourezare m, sistani p, nemati hh. protective effect of dorema glabrum on induced oxidative stress by diazinon in hippocampus of rat. ijbcrr . 2019; 25(3): 1-7. doi: 10.9734/ijbcrr/2019/v25i33 0077 17. saraei f, sadoughi m, kaka g, sadraie s, foaddodini m. study of the effects of diazinon on fetal liver in balb/c mice. iran red crescent med. j. 2016; 18(4): 1-7. doi: 10.5812/ircmj.28076 18. mallhi th, qadir mi, khan yh. determination of phytoconstituents of n-hexane extract of leaves of morus nigra and evaluation of their effects on biochemical and histopathological parameters in paracetamol intoxicated mice liver. braz. j. pharm. sci. 2018; 54(3):18101. doi: 10.1590/s2175 97902018000318101 19. haghightjoo sa, shariati m, mokhtari m, moghadamnia d. effect of diazinon on functional tests and liver tissue alterations in adult rats. j gorgan univ med sci. 2019; 21(1): 38 -45. 20. karimi-khouzani o, heidarian e, amini sa. antiinflammatory and ameliorative effects of gallic acid on fluoxetine-induced oxidative stress and liver damage in rats. pharmacol rep. 2017; 69(4): 830 -5. 21. deniz gy, laloglu e, koc k, nadaroglu h, geyikoglu f. the effect of black mulberry (morus nigra) extract on carbon tetrachloride-induced liver damage. arch biol sci. 2018; 70(2): 371-378. doi: 10.2298/abs1710090 55d j islamabad med dental coll 2020 181 22. agha fg, fyiad aa, el safi h. comparative study of the protective role of black berry juice and silymari n against liver damage induced by carbon tetrachloride in rats. j appl sci res. 2012; 8(2): 727–38. doi: 10.1186/s12906-015-0744-y 23. elisana lima rodrigues el, marcelino g, silva gt, figueiredo ps, garcez ws, et al. nutraceutical and medicinal potential of the morus species in metabolic dysfunctions. int j mol sci. 2019; 20: 301. doi: 10.3390/ijms20020301 24. alamri zz. effect of luteolin and quercetin on thioacetamide induced hepatic fibrosis in rats. int. j. pharmacol. 2019; 15(7): 863-871. doi: 10.3923/ ijp.2019.863.871 j islamabad med dental coll 2020 285 open access mastalgia: risk factors and treatment strategies used at two breast clinics in pakistan razia bano1, sohail saqib chatha2, faiza sana3, zain farooq4, umar farooq5, abdullah zakaullah6 1consultant breast surgeon, combined military hospital rawalpindi, punjab pakistan 2consultant surgeon, combined military hospital thall, hangu, khyber pakhtunkhwa, pakistan 3medical officer, combined military hospital rawalpindi, punjab pakistan 4resident surgeon, combined military hospital rawalpindi, punjab pakistan 5medical officer, fauji foundation hospital, rawalpindi, punjab pakistan 6house officer, fauji foundation hospital, rawalpindi, punjab pakistan a b s t r a c t background: mastalgia is one of the commonest symptoms of breast disorder and a major cause of anxiety amongst women. the aim of this study was to determine the risk factors associated with the onset and severity of mastalgia, their association with various breast disorders, and response to strategies used for its treatment. material and methods: this prospective descriptive study was carried out at combined military hospitals (cmh) of rawalpindi and thall over a period of six months from january to july 2017. women presenting to breast surgery clinic with complaints of breast pain, heaviness, and tenderness were included in the study. patients were initially evaluated at the time of presentation, treatment was initiated, followed by re-evaluation after six months. a multiple logistic regression model was used to determine association of mastalgia with various conditions and their effect on severity of mastalgia. results: a total of 93 women presented to the breast clinics during this period. cyclical mastalgia was noted in 39.8% women while 60.2% had non-cyclical mastalgia. in 41.9% patients no underlying pathology was noted, 49.5% patients had benign disorders while 8.6% had malignancy. increased bmi (p = .002) and lack of exercise (p = .01) were associated with onset of mastalgia while use of oral contraceptive pills (p < .001) was associated with low risk of mastalgia. of all the patients, 45.1% responded to measures like reassurance, dietary and lifestyle modifications while 54.9% were treated with pharmacological therapy. those diagnosed having underlying malignant disorder were treated according to the type and stage of malignancy. conclusions: various factors affect the onset and severity of mastalgia and different treatment strategies can be used to alleviate the symptoms. hence, complete and thorough evaluation of the patients presenting with mastalgia should be carried out to rule out any underlying pathology. key words: onset of mastalgia, oral contraceptive pills, pharmacological treatment, severity of mastalgia authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: sohail saqib chatha email: drsohailchatha@hotmail.com article info: received: june 22, 2020 accepted: december 15, 2020 cite this article. bano r, chatha ss, sana f, farooq z, farooq u, zakaullah a. mastalgia: risk factors and treatment strategies used at two breast clinics in pakistan. j islamabad med dental coll. 2020; 9(4): 285-290. doi: 10.35787/jimdc.v9i4.561 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 286 i n t r o d u c t i o n mastalgia, or breast pain, is considered as one of the commonest breast symptoms with which woman present in breast surgery clinics. it can affect up to 70% of women in their life time.1 mastalgia is usually associated with various conditions such as infection, malignancy or extrathoracic conditions however fear of underlying malignancy is usually the cause for medical consultation. mastalgia can be both noncyclical and cyclical. its severity can range from mild to severe pain. the pain can be severe enough to the extent of interfering with routine life activities and can become a cause of anxiety and depression in certain cases.2 exact pathogenesis of mastalgia remains to be undetermined however, certain factors like hormonal changes, age, smoking, stress, caffeine and duct ectasia have been associated with it.3 in majority of woman presenting with mastalgia only reassurance is needed and it resolves the symptoms. in certain other conditions, various lifestyle modifications such as weight reduction, smoking cessation and exercise programmes can alleviate the symptoms.4,5 however certain subset of women with more intense pain need pain-relieving therapy in the form of oral and topical non-steroidal antiinflammatory drugs along with mechanical breast support and advice for consumption of low fat, high carbohydrate diet. various hormonal agents such as danazol, bromocriptine and tamoxifen have also been used with certain success in the treatment of mastalgia. due to variation in the prevalence and intensity of mastalgia and fear of its association with underlying breast cancer, complete investigation and treatment of mastalgia is essential. treatment can range from simple assurance to dealing with the underlying cause. despite being a common and benign issue mastalgia is the most common symptom for which breast consultation is done and is major cause of anxiety and concern amongst the affected women. there is no standardized treatment modality available and treatment and management is tailored on a case-to-case basis and is still a matter of debate and research in the literature. this study aimed to determine the risk factors associated with the onset and severity of mastalgia, their association with various breast disorders, and response to strategies used for its treatment. m a t e r i a l a n d m e t h o d s this prospective descriptive study was carried out at the breast surgery clinics of cmh rawalpindi, punjab pakistan and cmh thall, khyber pakhtunkhwa pakistan over a period of six months from january to july 2017. after obtaining ethical approval from combined military hospital, thall and written informed consent from the patients, a total of 93 woman fulfilling the inclusion criteria were enrolled in the study. sample size was calculated using online sample size calculator with 95% confidence level, 10% margin of error and population size of approximately 1500 (number of women presenting to breast surgery clinics over the period of previous seven months). women who presented with symptoms of breast pain, heaviness, burning sensation and tenderness were included, whereas women with already confirmed diagnosis of any benign or malignant breast disorder were excluded from the study. detailed history and clinical examination were carried out. intensity of mastalgia was determined with the help of visual analog scale (vas) ranging from 1 to 10. based on findings of history and examination, relevant investigations such as sonomammogram, mammogram, fnac, core biopsy etc. were done if needed in order to determine the association of mastalgia with any underlying pathology. treatment was given on the basis of final diagnosis ranging from simple j islamabad med dental coll 2020 287 assurance to surgery. patients were followed-up over a period of six months, were re-evaluated and resolution of symptoms noted. all relevant information was collected and noted in a standardized manner, which included various demographic characteristics such as age, preor postmenopausal status, unilateral or bilateral symptoms and any associated symptoms such as nipple discharge etc., along with relevant family history. results of the prescribed investigations along with final diagnosis and treatment prescribed were also noted. patients were then followed over a period of six months and effectiveness of treatment was noted in terms of resolution of the mastalgia. data was analyzed using spss version 20.0. data was analyzed using descriptive statistics in the form of mean ± standard deviation for quantitative variables and percentage for categorical variables. a multiple logistic regression model was used to determine association of mastalgia with various conditions and their effect on severity of mastalgia. r e s u l t s a total of 93 females were evaluated for symptoms of mastalgia. women ranged in age from 19-70 years with mean age of 35 ± 5.25 years. cyclical mastalgia was noted in 39.8% (n=37) women while 60.2% (n=56) had non-cyclical mastalgia. out of these 67.8% (n=63) had mild to moderate mastalgia while 32.2% (n=30) had severe mastalgia. the mean score of mastalgia was 4.56 ± 2.32 according to vas. regarding menopausal status, mastalgia occurred in 76.3% premenopausal women while 23.7% were postmenopausal. most of the women presenting with mastalgia (60.2%; n=56) had complaints of unilateral mastalgia. in 41.9% (n=39) patients, no underlying pathology was noted, while 49.5% (n=46) had benign disorders and only 8.6% (n=8) had underling malignancy which was confirmed with biopsy (figure 1). figure 1: bar chart showing comparison of frequency distribution of severity, laterality, types and treatment strategies of mastalgia. factors such as parity, marital status, educational status as well as duration and interval of menstrual cycle had no effect on mastalgia. using multiple logistic regression model, age of marriage, increased bmi, lack of exercise were associated with onset of mastalgia while use of ocp was associated with low risk of mastalgia (table i). table i: effect of various factors on onset of mastalgia factors p-value* odds ratio 95% ci age at marriage .030 1.052 1.030-1.095 increased bmi .002 1.460 1.447-2.451 lack of exercise .016 1.455 1.133-1.675 use of ocp <.001 0.568 0.357-0.622 marital status .88 0.911 0.430-1.301 parity .69 0.586 0.234-0.868 *p-value < .05 was considered statistically significant regarding effect on severity of mastalgia anxiety, increased age and increased age at time of marriage were positively associated whereas regular exercise and ocp use had beneficial effect in reducing the severity of mastalgia (table ii). about 45.1% (n=42) patients responded to simple measures like reassurance, dietary and lifestyle modifications while 54.9% (n=51) were treated nsaids, evening primrose oil (epo), danazol and tamoxifen. those having underlying malignancy diagnosed during j islamabad med dental coll 2020 288 workup of mastalgia were treated according to the underlying malignancy. table ii: effect of various factors on severity of mastalgia factors p-value* beta se anxiety .004 1.962 0.270 age .005 1.178 0.410 age at marriage .017 0.770 0.203 regular exercise .037 -0.422 0.031 use of ocp .001 -1.264 0.302 *p-value < .05 was considered statistically significant d i s c u s s i o n in our study factors like age at marriage, increased bmi and lack of exercise had adverse effects on the onset of mastalgia, while use of ocp reduced the risk of onset of mastalgia. factors like anxiety and increased age were associated with increased severity of mastalgia, while regular exercise and ocp use reduced the severity of mastalgia. mastalgia has been found to have association with various psychological disorders like anxiety and depression.6,7 in a study by ramirez et al., increased stress level was associated with severity of mastalgia.8 conflicting results were reported by shobeiri et al. who found no association between depression/anxiety and mastalgia in women attending health centers of hamadan city, iran.9 however various studies have suggested that clinicians dealing with patients suffering from mastalgia should inquire about anxiety, depression and any history of trauma.10,11 according to our study, 39.8% of woman had cyclical mastalgia which was closer to the results of ader et al. who also reported 30% of woman suffering from cyclical mastalgia.12 factors adversely associated with mastalgia in this study were age at marriage, increased bmi and lack of exercise, while use of ocp had beneficial effect on mastalgia. few studies have shown association of mastalgia with smoking, caffeine consumption,6,13 pregnancy and trauma. in our study, lack of exercise was a determinant factor for onset of mastalgia. however, this is in contrast to a study by brown et al. on female marathon runners, who reported that exercise can cause mastalgia.14 the severity of pain on the vas was 4.56 ± 2.32 in our study, which is consistent with the findings of deniz and co-workers with an average pain score of 4.54 ±2.1.15 about 41.9% of our patients had no underlying breast disorder, 49.5% had benign findings while only 8.6% had underlying malignancy. similar results were found in another study carried out by ader et al.16 where one third of the woman had normal mammographic findings, half had benign masses and only 3 cases had underlying malignancy. this indicates a poor association of mastalgia with underlying breast cancer, which can lead to anxiety and fear in woman suffering from mastalgia and can be a cause for needless surgical consultation. treatment of mastalgia is another matter of debate and ranges from simple reassurance to surgical therapies. in our study 45.1% of patients responded to simple measures like reassurance and lifestyle modifications. in the remaining cases, multiple modalities like nsaids, hormonal therapy, danazol and even surgery was used on case-to-case basis. in studies carried out by ader et al. and aa muhammad,17 it has been shown that after alleviating fear of breast cancer by proper evaluation, simple reassurance is a useful and firstline treatment option. in another study conducted in the department of breast surgery, st george's hospital london, authors argue that mastalgia may settle spontaneously without any treatment.18 lifestyle modifications such as low fat, high carbohydrates diet, weight reduction and regular exercise along with use of well-fitting bras has also been found as effective means of treatment in a number of patients19 and this fact was j islamabad med dental coll 2020 289 demonstrated in our study as well. in 54.9 % of our patient’s various pharmacological treatments including nsaids, epo, danazol and various hormonal preparations like tamoxifen were used with good results. other studies have verified these results. a study by rosolowich et al. recommend that topical non-steroidal anti-inflammatory gel, such as diclofenac 2% is effective for pain control for localized treatment of mastalgia and that tamoxifen or danazol can be used as a treatment option, if other measures fail.20 in a study by gupta et al. danazol was effective in alleviating mastalgia in 71% of patients, while tamoxifen was successful in 67% of cyclical mastalgia.21 though few studies have shown some relief in breast discomfort with reduction mammoplasty,22,23 especially in patients with symptomatic macromastia, in general surgery it has no role in the management of mastalgia. this finding was corroborated in our study as well, where surgery was done only for the treatment of malignancy, and not for mastalgia. this was an observational study with a small sample size. studies with larger sample size are needed in order to validate the results of this study. c o n c l u s i o n non-cyclical, mild-to-moderate, unilateral mastalgia is more common in our study. factors like age at marriage, increased bmi and lack of exercise are associated with high-risk of onset of mastalgia. anxiety, increased age, and increased age at time of marriage are positively associated whereas regular exercise and ocp use reduced the severity of mastalgia. different treatment options are available, ranging from simple assurance to pharmacological treatments and rarely surgery depending upon any associated disorder. r e f e r e n c e s 1. eren t, aslan a, ozemir ia, baysal h, sagiroglu j, ekinci o, et al. factors effecting mastalgia. breast care. 2016; 11(3): 188-93. doi: 10.1159/000444359. 2. smith rl, pruthi s, fitzpatrick la. evaluation and management of breast pain. mayo clin proc 2004; 79(3): 353-72. doi: 10.4065/79.3.353. 3. norlock fe. benign breast pain in women: a practical approach to evaluation and treatment. j am med women assoc. 2002; 57(2): 85-90. pmid: 11991427. 4. joyce dp, alamiri j, lowery aj, downey e, ahmed a, mclaughlin r, et al. breast clinic referrals: can mastalgia be managed in primary care? ir j med sci. 2014; 183(4): 639-42. doi: 10.1007/s11845-0131066-z. 5. shobeiri f, jenabi e. the effects of vitamin e on muscular pain reduction in students affected by premenstrual syndrome. iran j obstet gynecol infertil. 2014; 17(96): 1-5. 6. johnson km, bradley ka, bush k, gardella c, dobie dj, laya mb. frequency of mastalgia among women veterans. association with psychiatric conditions and unexplained pain syndromes. j gen intern med. 2006; 21(3): s70–5. doi: 10.1111/j.15251497.2006.00378.x 7. colegrave s, holcombe c, salmon p. psychological characteristics of women presenting with breast pain. j psychosom res. 2001; 50: 303e7. doi: 10.1016/s0022-3999(01)00196-9. 8. ramirez aj, jarret sr, hamed h, smith p, fentiman is. psychosocial adjustment of women with mastalgia. breast j. 1995; 4(1): 48-51. 9. shobeiri f, oshvandi k, nazari m. cyclical mastalgia: prevalence and associated determinants in hamadan city, iran. asian pac j trop biomed. 2016; 6(3): 275– 8. doi: 10.1016/j.apjtb.2015.12.008. 10. shobeiri f, oshvandi k, nazari m. clinical effectiveness of vitamin e and vitamin b6 for improving pain severity in cyclic mastalgia. iran j nurs midwifery res. 2015; 20(6): 723-7. doi: 10.4103/1735-9066.170003. 11. plu-bureau g, lˆe mg, sitruk-ware r, thalabard jc. cyclical mastalgia and breast cancer risk: results of a french cohort study. cancer epidemiol biomarkers prev. 2006; 15(6): 1229-31. doi:10.1158/1055-9965. 12. ader dn, south-paul j, adera t, deuster pa. cyclical mastalgia: prevalence and associated health and behavioral factors. j psychosom obstet gynaecol. 2001; 22(2): 71-6. doi:10.3109/01674820109049956 13. kataria k, dhar a, srivastava a, kumar s, goyal a. a systematic review of current understanding and management of mastalgia. indian j surg. 2014; 76(3): 217-22. doi: 10.1007/s12262-013-0813-8. j islamabad med dental coll 2020 290 14. brown n, white j, brasher a, scurr j. the experience of breast pain (mastalgia) in female runners of the 2012 london marathon and its effect on exercise behaviour. br j sports med. 2014; 48(4): 320–5. doi: 10.1136/bjsports-2013-092175. 15. deniz koçoğlu, serife kurşun, belgin akin, kamile altuntug. mastalgia and associated factors: a crosssectional study. agri. 2017; 29(3): 100–8. doi: 10.5505/agri.2017.91069. 16. ader dn, shriver cd, browne mw. cyclical mastalgia: premenstrual syndrome or recurrent pain disorder? j psychosom obstet gynaecol. 1999; 20(4): 198–202. doi: 10.3109/01674829909075596. 17. mohammed a. predictive factors affecting axillary lymph node involvement in patients with breast cancer in duhok: cross-sectional study. ann med surg. 2019; 44: 87–90. doi: 10.1016/j.amsu.2019.07.011. 18. gumm r, cunnick gh, mockbel k. evidence for management of mastalgia. curr med res optn. 2004; 20(5): 681-4. doi: 10.1185/030079904125003377. 19. olawalye a, withiam-leitch m, danakas g, kahn k. mastalgia: a review of management. j reprod med. 2005; 50(12): 933-9. pmid: 16444894. 20. rosolowich v, saettler e, szuck b, lea rh, levesque p, weisberg f et al. mastalgia. j obstet gynaecol can. 2006; 28(1): 49-71. doi: 10.1016/s17012163(16)32027-8. 21. gupta p, verma v, gupta r, kumar a, singh sp, gupta uk, et al. role of tamoxifen and danazol in mastalgia: prospective controlled trial. isj. 2016; 3(2): 553-6. doi: 10.18203/2349-2902.isj20160703. 22. chadbourne eb, zhang s, gordon mj, ro ey, ross sd, schneider pr, et al. clinical outcomes in reduction mammoplasty: a systematic review and metaanalysis of published studies. mayo clin proc. 2001; 76(5): 503-10. doi: 10.4065/76.5.503. 23. blomqvist l, eriksson a, brandberg y. reduction mammoplasty provides long-term improvement in health status and quality of life. plast reconstr surg. 2000; 106(5): 991-7. doi: 10.1097/00006534200010000-00005. j islamabad med dental coll 2020 79 correspondence: lawrence faulkner email: lawrence.faulkner@cure2children.org cite this editorial: faulkner l. telemedicine in covid-19 era: lessons from online co-management of bone marrow transplant patients. j islamabad med dental coll. 2020; 9(2): 79-81 doi: 10.35787/jimdc.v9i2.550 o p e n a c c e s s telemedicine in covid-19 era: lessons from online co-management of bone marrow transplant patients lawrence faulkner medical coordinator, cure2children foundation – italy recently, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has infected millions of people globally and killed hundreds of thousands. until an effective vaccine is available, prospects of definitive control of the covid-19 pandemic are uncertain. in fact, over 50% of the infection is being spread by asymptomatic individuals. 1,2 both mortality and admissions to intensive care units have increased several folds over baseline seasonal rates in most severely affected regions. pakistan might be particularly vulnerable to the covid-19 pandemic for several reasons. the first and foremost reason is difficulty in maintaining social distancing, which is regarded as a critical prevention strategy, as many pakistani communities live together in close quarters. moreover, pakistan has only 1.5 critical care beds per 100,000 population compared to 3.6 in china, 12.5 in italy or 9.7 in spain, respectively. 3,4 these proportions refer to physical beds and equipment, and, most importantly, to skilled personnel. in italy, a country severely affected by this pandemic with over 30,000 deaths, more than 160 health care workers died of covid-19, 80% of them being physicians. 5 some of these doctors were general practitioners acting solo, but, most importantly, physicians tend to be older males as opposed to nurses who are often young women and thus at decreased risk of morbidity and mortality from covid-19. 6 clearly, tools capable of minimizing direct patient contact without compromising quality of care are direly needed. the potential for information and communication technology to promote effective remote intensive care has been documented, at least in highresource settings. 7 the cure2children foundation, an international italian ngo also registered in pakistan, has extensively applied a cloud-based platform for co-management of children undergoing bone marrow transplantation (bmt). this procedure often requires prolonged subintensive to intensive care, in the indian subcontinent. 8 since 2008, close to 700 bone marrow transplants have been performed. of these, 170 were carried out at the children’s hospital, pakistan institute of medical sciences (pims) and at dr akbar niazi teaching hospital (anth) in islamabad, pakistan. these transplants were performed primarily in low-risk patients with hemoglobinopathies by local physicians and nurses with no previous bmt experience but assisted by daily online interactions with condition-specific bmt experts. 9 the it system employed provided several tools including pre-transplant check lists, electronic medical record, direct connection to hl7-compliant patient monitors, automatic patientspecific treatment plans, continuing quality improvement tools, inventory and cost monitoring. 8 the quality improvement tools e d i t o r i a l j islamabad med dental coll 2020 80 included drug and transfusion administration tracking, incident reporting, clinical practice guidelines, standard operating procedures, and real-time outcome analysis. 8 outcomes were not substantially different from those reported in highresource settings in a comparable patient group. 10 this proof of principle is potentially quite relevant to the current covid-19 pandemic, in as much as it shows how the physical presence of experienced physicians, presumably the ones most difficult to recruit and at highest mortality risk, may not be an absolute requirement. in fact, in units taking care of complicated patients with a single disease and a limited number of protocols and procedures which are thus amenable to focused training, professionally trained and properly supported nurses along with junior doctors can provide adequate care with online support from experienced physicians. the obvious consequence of this is the possible huge expansion of a flexible workforce of remote consultants with conditionspecific expertise. pandemics may come in asynchronous waves in different regions: for example, while it is peaking in pakistan and india it may be subsiding in china, uk or italy and very experienced professionals from the latter countries may be available for online consultation. 11 this approach may also have substantial costcontainment implications. data centralization offered by a cloud-based it platform will allow quick access for analysis, centralized protocols, and procedures and, most importantly, coordinated allocation of resources, real-time reliable medical data and well-designed clinical studies. remote co-management models may also be relevant to future public health emergencies, including natural disasters. the experience with fangcang shelter hospitals in china suggests that the rapid implementation of scalable and properly designed and equipped physical spaces is feasible 12 and that the bottle neck to timely scalable care might primarily be the lack of availability of skilled personnel. r e f e r e n c e s 1. arons mm, hatfield km, reddy sc, kimball a, james a, jacobs jr, et al. presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility. n engl j med. 2020. doi: 10.1056/ nejmoa2008457 2. sutton d, fuchs k, d’alton m, goffman d. universal screening for sars-cov-2 in women admitted for delivery. n engl j med. 2020. doi: 10.1056/ nejmc2009316 3. phua j, faruq mo, kulkarni ap, redjeki is, detleuxay k, mendsaikhan n, et al. critical care bed capacity in asian countries and regions. read online crit care med soc crit care med. 2020; 48(5): 654–662. doi: 10.1097/ccm.0000 000000004222 4. list of countries by hospital beds [internet]. wikipedia. 2020 [cited 2020 apr 17]; available from: https://en.wikipedia.org/w/index.php?title=list_of _countries_by_hospital_beds& oldid=951419991 5. more than 100 doctors have now died in italy’s coronavirus outbreak [internet]. 2020 [cited 2020 may 12]; available from: https://www.thelocal.it/ 20200409/more-than-100-doctors-have-now-diedin-italys-coronavirus-outbreak 6. cdc. coronavirus disease 2019 (covid-19) [internet]. cent. dis. control prev. 2020 [cited 2020 may 12]; available from: https://www.cdc.gov/ coronavirus/2019-ncov/ covid-data/investigationsdiscovery/assessing-risk-factors.html 7. udeh c, udeh b, rahman n, canfield c, campbell j, hata js. telemedicine/virtual icu: where are we and where are we going? methodist debakey cardiovasc j. 2018; 14(2): 126–33. doi: 10.14797/ mdcj-14-2-126. 8. agarwal rk, sedai a, dhimal s, ankita k, clemente l, siddique s, et al. a prospective international cooperative information technology platform built using open-source tools for improving the access to and safety of bone marrow transplantation in low and middle-income countries. j am med inform assoc. 2014; 21(6): 1125–8. doi: 10.1136/amiajnl2013-002594 j islamabad med dental coll 2020 81 9. faulkner lb, uderzo c, masera g. international cooperation for the cure and prevention of severe hemoglobinopathies. j pediatr hematol oncol. 2013; 35(6): 419–23. doi: 10.1097/ mph.0b013e31829 cd920 10. faulkner l, uderzo c, khalid s, marwah p, soni r, yaqub n, et al. atg vs. thiotepa with busulfan and cyclophosphamide in matched-related bone marrow transplantation for thalassemia. blood adv. 2017; 1(13): 792–801. doi: 10.1182/blood advances. 2016004119 11. xu s, li y. beware of the second wave of covid-19. the lancet. 2020; 395(10233): 1321–2. doi: 10.1016/s0140-6736(20)30845-x 12. chen s, zhang z, yang j, wang j, zhai x, bärnighausen t, et al. fangcang shelter hospitals: a novel concept for responding to public health emergencies. the lancet. 2020; 395(10232): 1305– 14. doi: 10.1016/ s0140-6736(20)30744-3 j islamabad med dental coll 2019 23 open access distribution of extended-spectrum β-lactamase and metallo-βlactamase-producing pseudomonas aeruginosa in tertiary care hospitals of lahore, pakistan syeda aneela 1, noor-ul-ain 2, samyyia abrar 3, muhammad saeed 4, shahida hussain 5, abdul hannan (†) 6, saba riaz 7 1-3,5, department of microbiology and molecular genetics, university of the punjab, lahore. 4 medical lab technologist-manager pathology, dhq hospital mandi bahauddin, primary & secondary health care department, government of punjab, pakistan. 6 professor, department of microbiology, university of health sciences, lahore († deceased). 7 assistant professor, department of microbiology and molecular genetics, university of the punjab, lahore a b s t r a c t background: pseudomonas aeruginosa (p. aeruginosa) is an important bacterial pathogen most frequently associated with nosocomial infections, especially in immuno-compromised patients. early detection of these life threatening, β-lactamase producing bacteria is essential for infection control and to prevent their dissemination. the aim of our study was to detect the presence of extended-spectrum β-lactamase (esbl) and metallo-β-lactamase (mbl) strains of pseudomonas aeruginosa. material and methods: eighty-eight identified strains of p. aeruginosa were collected from chughtai laboratories, combined military hospital and children hospital, lahore. these strains were sub-cultured and after confirming the cultural characteristics by gram staining and colony morphology, manual biochemical identification was done. susceptibility to various antibiotics and production of extended-spectrum β-lactamases (esbls) and metallo-β-lactamases (mbls) were determined using modified kirby bauer disk diffusion method, double disk synergy test, combined disk synergy test (cdst) and inhibitor-potentiated disk diffusion test (ipd) respectively. results: out of eighty-eight strains tested, three were esbl producers (3.4%) and eleven strains (12.5%) were found to be resistant to carbapenems. of these, eight were mbl producers (72.7%). all these β-lactamase producing strains (14 strains) were multidrug-resistant (mdr). piperacillin and piperacillin/tazobactam proved to be the most effective antibiotics in both types of βlactamase producing strains. conclusion: our study shows noticeable emergence of β-lactamases (esbls & mbls) in p. aeruginosa. all of these strains were mdr. it reveals a correlation of these β-lactamases with multidrug resistant genes. key words: esbl, mbl, mdr. pseudomonas aeruginosa, pakistan, ddst, cdst, ipd authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3-5 interpretation, discussion, 6,7data analysis, active participation in data collection. correspondence: saba riaz email: saba.mmg@pu.edu.pk article info: received: july 22, 2018 accepted: november 10, 2018 cite this article: aneela s, noor-ul-ain, abrar s, saeed m, hussain s, hannan a, riaz s. distribution of extended-spectrum β-lactamase and metallo-β-lactamase-producing pseudomonas aeruginosa in tertiary care hospitals of lahore, pakistan. j islamabad med dental coll.2019; 8(1):23-28 funding source: nil conflict of interest: nil i n t r o d u c t i o n pseudomonas aeruginosa is an important opportunistic pathogen responsible for various healthcare associated infections like pneumonia, sepsis, wounds and urinary tract infections.1,2 this organism can cause deadly infections and is most commonly isolated from wound infections in developing countries.3,4 it is professed to be associated with high mortality rate i.e. up to 61%.5 carbapenems are most effective antibiotics against o r i g i n a l a r t i c l e j islamabad med dental coll 2019 24 several pseudomonal infections. however resistance to this innovative antibiotic has been observed in recent years.6 metallo β-lactamase is usually associated with carbapenems-resistance in p. aeruginosa.7 mbl hydrolyzes most of the β-lactam antibiotics except monobactams. additionally, these enzymes are resistant to most of the β-lactam inhibitors like clavulanic acid, sulbactam.8 moreover, mbl-producing p. aeruginosa are responsible for high a mortality rate.9 pseudomonal infections are often burdensome because of an intrinsic and acquired resistance of the organism to common antimicrobials, eventually resulting in emergence of multidrug resistant strains of p. aeruginosa.10 among these different resistant mechanisms, β-lactamases including extended-spectrum β-lactamases and metallo β-lactamases are predominantly observed in p. aeruginosa.11 esbl hydrolyzes β-lactam drugs like cefotaxime, ceftriaxone, ceftazidime and monobactams with no efficacy on cephamycins and carbapenems. βlactamase inhibitors like clavulanic acid are effective against these enzymes.8,12 the aim of this research was to identify esbl and mblproducing p. aeruginosa and to determine the antimicrobial susceptibility patterns of these strains (esbl and mbl producing p. aeruginosa). m a t e r i a l a n d m e t h o d s the study was conducted at department of microbiology, university of health sciences, lahore. this was an observational, cross-sectional study conducted over a duration of one year from october 2008 to october 2009. eighty-eight strains of p. aeruginosa were collected from chughtai lahore laboratories, combined military hospital, lahore and children hospital, lahore, where these strains were isolated from wound swabs, pus, bronchial washings and blood. identified strains of p. aeruginosa were sub-cultured in department of microbiology, university of health sciences, lahore. after confirming the cultural characteristics by gram staining and colony morphology, manual biochemical identification was done by api 20ne identification system (biomerieux, france). bio-statistical analysis was done by pearson’s chi-square test as previously used by giriyapur et al.13 antimicrobial susceptibility of p.aeruginosa was performed using mueller-hinton agar (oxoid uk), according to clinical laboratory standards institute (clsi, 2009) guidelines. antibiogram profile was generated by using: amoxicillin/clavulanic acid (30𝜇g), ceftriaxone (30𝜇g), ceftazidime (30𝜇g), ciprofloxacin (5𝜇g), sulfamethoxazole/trimethoprim (25𝜇g), piperacillin (100𝜇g), piperacillin/tazobactam (100\10𝜇g), aztreonam (30𝜇g), meropenem (10𝜇g), imipenem (10𝜇g), and amikacin (30𝜇g). amoxicillin/clavulanic acid was used for screening of esbl producers and sulfamethoxazole/trimethoprim (sxt 5𝜇g) were used to check whether it is effective in β-lactamase producers (figure 1). esbl production in all the isolates was detected by double disc synergy test (ddst) as described byjarlier et al.14 synergistic effect of amoxicillin + clavulanic acid (20 + 10 μg) was checked with ceftazidime (30 μg) and ceftriaxone (30 μg). strains indicating >5mm synergistic zone were confirmed as esblproducers.15 mbl production in the carbapenem-resistant isolates was detected by following two methods. pseudomonas aeruginosa and enterobacter cloacae positive for mbl were used as positive control. for combination disc test (cdst), imipenem (10 µg) and meropenem (10 µg) discs (oxoid) alone and in combination with 0.5 m edta were used. increase in the inhibition zone of ≥ 7mm by the addition of edta indicates mbl-production.16 for inhibitor potentiated disk diffusion test (ipd), imipenem (10 µg) (oxoid) was used along with disc of 0.5 edta solution. presence of an augmentation zone (clearing zone) i.e. >7mm between edta and imipenem discs was interpreted as a positive test.17. r e s u l t s antimicrobial susceptibility pattern of p. aeruginosa strains (table i) showed piperacillin/tazobactam as the most sensitive antibiotic with 95.5% susceptible isolates. piperacillin (94.3%) was second most sensitive antibiotic. there was no significant difference between these two antibiotics. it was followed by meropenem (89.8%), imipenem (87.5%), amikacin (84.1%), ceftazidime (80.7%), aztreonam (71.6%), and ciprofloxacin (69.3%). http://b2bpakistan.com/11/health_beauty-chughtais_lahore_lab-34659.html http://b2bpakistan.com/11/health_beauty-chughtais_lahore_lab-34659.html j islamabad med dental coll 2019 25 ceftriaxone was least effective among βlactams with only 29.5% susceptible isolates. amoxicillin/clavulanic acid and co-trimoxazole were resistant in all isolates (figure 1). figure 1: antimicrobial resistance pattern of p. aeruginosa strains (n=88). here, amc =amoxicillin/calvulonic acid, cro =ceftriaxone, caz =ceftazidime, sxt=sulphamethoxazole/trimethoprim, atm aztreonam, ak =amikacin, cip = ciprofloxacin, prl= piperacillin, tzp=piperacillin/tazobactam, ipm=imipenem and mem= meropenem. figure 2: demonstration of esbl phenomenon by double disc synergy test (ddst) figure 3: mbl detection tests. a) combined disk synergy test and b) inhibitor potentiated disk diffusion n =total number of strains ns=number of sensitive strains nr= number of resistant strains s (%) = percentage of sensitive strains r (%) = percentage of resistant strains table ii: antimicrobial resistance pattern of esbl and mblproducing strains of pseudomonas aeruginosa sr. no antibiotics enr e (%) r mnr m (%) r 1. co-amoxiclav 3 100 8 100 2. ceftriaxone 3 100 8 100 3. ceftazidime 3 100 8 100 4. cotrimoxazole 3 100 8 100 5. ciprofloxacin 3 100 8 100 6. piperacillin 0 0.0 0 0.0 7. piperacillin/tazobactam 0 0.0 0 0.0 8. aztreonam 3 100 6 75 9. meropenem 0 0.0 8 100 10. imipenem 0 0.0 8 100 11. amikacin 2 66.6 8 100 enr= number of resistant strains among esbl producers e (%) r = percentageof resistant strains among esbl producers mnr=number of resistant strains among mbl producers m (%) r =percentageof resistant strains among mbl producers out of 88 cultured isolates of p. aeruginosa three (3.4%) were esbl-producers and eleven strains (12.5%) were resistant to carbapenems of which eight (72.7%) were mbl-producers. all the esbl and mbl-producing strains were found to be mdr. esbls were resistant to β-lactam antibiotics except carbapenems where 100% susceptibility towards these antibiotics was observed. table: i. antimicrobial susceptibility pattern of p. aeruginosa isolates (n=88) sr. no antimicrobials ns s (%) nr r (%) 1 co-amoxiclav 0 0 88 100 2 ceftriaxone 26 29.5 62 70.5 3 ceftazidime 71 80.7 17 19.3 4 cotrimoxazole 0 0 88 100 5 ciprofloxacin 61 69.3 27 30.7 6 piperacillin 83 94.3 5 5.7 7 piperacillin/tazobactam 84 95.5 4 4.5 8 aztreonam 63 71.6 25 28.4 9 meropenem 79 89.8 9 10.2 10 imipenem 77 87.5 11 12.5 11 amikacin 74 84.1 14 15.9 j islamabad med dental coll 2019 26 moreover, esbls also indicated high susceptibility towards amikacin (table ii). mbl-producers indicated 100% resistance towards applied antibiotics except piperacillin and piperacillin /tazobactam combination where 100% sensitivity was observed (table iii). table iii. antimicrobial susceptibility pattern of mbl-producing and non-producing isolates antimicrobials mbl producing (n = 08) mbl nonproducing (n = 80) x2 r s s (%) r s s (%) p value co-amoxiclav 8 0 0.0 80 0 0.0 * ceftriaxone 8 0 0.0 54 26 29.5 0.05 ceftazidime 8 0 0.0 09 71 80.7 0.00 cotrimoxazole 8 0 0.0 80 0 0.0 * ciprofloxacin 8 0 0.0 19 61 69.3 0.00 piperacillin 0 8 100 05 75 94.3 0.467 piperacillin/ tazobactam 0 8 100 04 76 95.5 0.517 aztreonam 6 2 25 19 61 71.6 0.02 meropenem 8 0 0.0 01 79 89.8 0.00 imipenem 8 0 0.0 03 77 87.5 0.00 amikacin 8 0 0.0 06 74 84.1 0.00 r= resistant s= sensitive * = no statistics is computed as amc and sxt are constant (resistant in all isolates). p value < 0.05 = significant difference d i s c u s s i o n p. aeruginosa is an important nosocomial pathogen, endowed with a variety of resistance mechanisms that may cause multidrug or even pan-drug resistance. extended-spectrum β-lactamases (esbls) and carbapenemases (mbls) are among the most common causative agents.18 in the present study, three strains (3.5%) were esbl producers detected by the double disc synergy test which is supported by the results of kotwal et al in which 6% of esbl were detected among cefepime resistant p. aeruginos.19,20 while the findings of wolska and jakubczak, (2008) showed no esbl detection in p. aeruginosa isolates.21 however, it is in contrast to the study conducted in pakistan, where 35.8% strains of p.aeruginosa were esbl-producers.22 this disparity might be due to the evidence that more mdrs are isolated from burn units.23 in the present study eleven strains (12.5%) of p. aeruginosa indicated resistance to carbapenems of which eight were detected as mbl-producers by using the cdst and ipd methods. our data indicates that frequency of mbl-producing strains among imipenem resistant p. aeruginosa is 72.7%. while irfan et al reported 100% of mbl-production among carbapenem resistant p. aeruginosa.24 our study results are similar to the findings of kali et al where 72.7% mbl-producers among carbapenem-resistant p. aeruginosa isolates were observed.25 a recent study in pakistan has described the incidence of esbl and mbl in clinical isolates of mdr p. aeruginosa as 23.94% and 40.84% respectively.26 our data showed increased resistance to commonly used antibiotics. piperacillin/tazobactam and piperacillin alone proved to be effective antibiotics. carbapenems were found to be the second most effective antibiotic group accounting for 12.5% and 10.2% resistance for imipenem and meropenem respectively, which is consistent with national antibiotic resistance data of pakistan in 2009.27 the β-lactamase-producers were resistant to all other antibiotics except the above-mentioned ones, so there was a narrow range for a suitable drug of choice. p. aeruginosa had shown an increased resistance to the fluoroquinolone (30.7%). resistance rates of amikacin, ceftazidime and aztreonam remained 15.9%, 19.3%, 28.4% respectively and similar reports of 22%, 30% and 19% resistance have been reported by pakistan antimicrobial resistance network (parn). ceftriaxone was least effective among β-lactams with only 29.5% susceptible isolates. all isolates were resistant to amoxicillin/clavulanic acid and co-trimoxazole (as already established). these values are comparable to the findings available in pakistan that are 83.8% and 79.24% resistance respectively.22 there were 14 (15.9%) isolates as mdr, three of these were esbl and eight out of twelve carbapenem resistant isolates were mblproducers. this is an alarming sign as few therapeutic options are left for the patients infected with these strains. early screening of p. aeruginosa isolates to detect esbl and mbl-production should be emphasized. therefore, routine testing of the isolates of p. aeruginosa for sensitivity to ceftazidime, cefotaxime and carbapenems may represent a cost-effective way for screening of j islamabad med dental coll 2019 27 esbls and mbls. our study has introduced an easy and cost-effective inhibitor potentiated disk diffusion (ipd) method for mbl detection in pakistan. thus, double disk synergy test and combined disk synergy test (cdst) / inhibitor-potentiated disk diffusion method (ipd) can easily be used to confirm the esbl and mbl phenotypically. the emergence of these β-lactamases along with mdr genes in p. aeruginosa may adversely muddle the clinical management of such patients. high frequency of these enzymes urges the infection control teams of hospitals to design some preventive measures to stop the dissemination of these resistant strains. c o n c l u s i o n our study shows noticeable emergence of these βlactamases in p. aeruginosa. all of these strains were mdr. it reveals a correlation of these β-lactamases with multidrug resistant genes. r e f e r e n c e s 1. jefferies j, cooper t, yam t, clarke s: pseudomonas aeruginosa outbreaks in the neonatal intensive care unit–a systematic review of risk factors and environmental sources. j. med. microbiol 2012, 61(8):1052-1061. 2. lister pd, wolter dj, hanson nd: antibacterialresistant pseudomonas aeruginosa: clinical impact and complex regulation of chromosomally encoded resistance mechanisms. j. clin. microbiol reviews 2009, 22(4):582-610. 3. rahbar m: laboratory evaluation of iranian commercially provided antibiotic disks with conventional e-test for susceptibility testing in three most isolated multi-drug resistant organisms. internet j microbiol 2008, 5(1). 4. aguila la, lopes mru, pretti fz, sampaio-barros pd, de souza fhc et al. clinical and laboratory features of overlap syndromes of idiopathic inflammatory myopathies associated with systemic lupus erythematosus, systemic sclerosis, or rheumatoid arthritis. int j clin rheumtol 2014, 33(8):1093-1098. 5. bassetti m, righi e, viscoli c: pseudomonas aeruginosa serious infections: mono or combination antimicrobial therapy? curr med chem 2008, 15(5):517-522. 6. hammami s, boubaker ib-b, ghozzi r, saidani m, amine s, redjeb sb: nosocomial outbreak of imipenem-resistant pseudomonas aeruginosa producing vim-2 metallo-β-lactamase in a kidney transplantation unit. diagn pathol 2011, 6(1):106. 7. franklin c, liolios l, peleg ay: phenotypic detection of carbapenem-susceptible metallo-β-lactamaseproducing gram-negative bacilli in the clinical laboratory. j. clin. microbiol 2006, 44(9):3139-3144. 8. bush k, jacoby ga, medeiros aa: a functional classification scheme for beta-lactamases and its correlation with molecular structure. antimicrob. agents chemother 1995, 39(6):1211. 9. zavascki ap, barth al, gonçalves als, moro ald fernandes jf, martins af et al. the influence of metallo-β-lactamase production on mortality in nosocomial pseudomonas aeruginosa infections. j antimicrob chemother 2006, 58(2):387-392. 10. strateva t, yordanov d: pseudomonas aeruginosa–a phenomenon of bacterial resistance. j. med. microbiol 2009, 58(9):1133-1148. 11. rafiee r, eftekhar f, tabatabaei sa, tehrani dm: prevalence of extended-spectrum and metallo βlactamase production in ampc β-lactamase producing pseudomonas aeruginosa isolates from burns. undishapur j.microbiol 2014, 7(9). 12. paterson dl, bonomo ra: extended-spectrum βlactamases: a clinical update. j. clin. microbiol reviews 2005, 18(4):657-686. 13. giriyapur rs, nandihal nw, krishna b, patil ab, chandrasekhar m: comparison of disc diffusion methods for the detection of extended-spectrum beta lactamase-producing enterobacteriaceae. j lab physicians 2011, 3(1):33. 14. jarlier v, nicolas m-h, fournier g, philippon a: extended broad-spectrum β-lactamases conferring transferable resistance to newer β-lactam agents in enterobacteriaceae: hospital prevalence and susceptibility patterns. clin infect dis 1988, 10(4):867-878. 15. abrar s, vajeeha a, ul-ain n, riaz s: distribution of ctx-m group i and group iii β-lactamases produced by escherichia coli and klebsiella pneumoniae in lahore, pakistan. microb pathog 2017, 103:8-12. 16. yong d, lee k, yum jh, shin hb, rossolini gm, chong y: imipenem-edta disk method for differentiation of metallo-β-lactamase-producing clinical isolates of pseudomonas spp. and j islamabad med dental coll 2019 28 acinetobacter spp. j. clin. microbiol 2002, 40(10):3798-3801. 17. oh e-j, lee s, park y-j, park jj, park k, kim s-i et al. prevalence of metallo-β-lactamase among pseudomonas aeruginosa and acinetobacter baumannii in a korean university hospital and comparison of screening methods for detecting metallo-β-lactamase. j microbiol methods 2003, 54(3):411-418. 18. potron a, poirel l, nordmann p: emerging broadspectrum resistance in pseudomonas aeruginosa and acinetobacter baumannii: mechanisms and epidemiology. int j antimicrob agents 2015, 45(6):568-585. 19. wang r, zeng yl, qin hm, lu yl, huang ht, lei m et al. association of interleukin 22 gene polymorphisms and serum il‐22 level with risk of systemic lupus erythematosus in a chinese population. clin. exp. immunol 2018; 193(2):143-51 20. kotwal a, biswas d, kakati b, singh m: esbl and mbl in cefepime resistant pseudomonas aeruginosa: an update from a rural area in northern india. j clin diagn res: jcdr 2016, 10(4):dc09. 21. wolska k, jakubczak a, soszyńska a: antibiotic susceptibility and occurrence of esbl, ibl and mbl in pseudomonas aeruginosa strains. med dosw mikrobiol 2008, 60(2):111-119. 22. ullah f, malik sa, ahmed j: antimicrobial susceptibility and esbl prevalence in pseudomonas aeruginosa isolated from burn patients in the north west of pakistan. burns 2009, 35(7):1020-1025. 23. al-jashamy k, bhuiyan m, sabet ns: esbl and mbl genes detection and plasmid profile analysis from pseudomonas aeruginosa clinical isolates from selayang hospital, malaysia. pjmhs. 2017;11(3):815-818. 24. irfan s, zafar a, guhar d, ahsan t, hasan r: metallo-β-lactamase-producing clinical isolates of acinetobacter species and pseudomonas aeruginosa from intensive care unit patients of a tertiary care hospital. indian j med microbiol 2008, 26(3):243. 25. kali a, srirangaraj s, kumar s, divya ha, kalyani a, umadevi s: detection of metallo-beta-lactamase producing pseudomonas aeruginosa in intensive care units. australas med j 2013, 6(12):686. 26. ullah w, qasim m, rahman h, khan s, ur rehman z, ali n et al. ctx-m-15 and oxa-10 beta lactamases in multi drug resistant pseudomonas aeruginosa: first report from pakistan. microb pathog 2017, 105:240244. 27. http://www.parn.org.pk/. 12 j i m d c 2 0 1 8 12 open access f u l l l e n g t h a r t i c l e spontaneous bacterial peritonitis and its common pathogens in hcv cirrhotic patients gordhan soothar 1, nand lal seerani 2, rabia akram 3 1 assistant professor, muhammad medical college, mirpur-khas 2 senior registrar, gastroenterology department, lumhs jamshoro 3 medical officer, muhammad medical college, mirpur-khas a b s t r a c t objective: to determine the spontaneous bacterial peritonitis and its common pathogens in hcv cirrhotic patients. patients and methods: this cross-sectional descriptive study was conducted at department of medicine, liaquat university hospital hyderabad/jamshoro. this study was carried out for period of six months, i.e. from 1st march, 2009 to 31st august, 2009. patients with liver cirrhosis caused by hepatitis c virus, ranging from 15 to 70 years of age and either gender were included in this study. ascitic fluid was sent to diagnostic and research laboratory of lumhs within half hour of collection and ascitic fluid culture was done on blood agar media. tlc count >500-cells/µl or polymorph nuclear leucocyte >250-cells/µl were labelled as sbp positive. growth positive on different disc was labelled with respect to the positive pathogen. all the data was entered on predesigned proforma. results: total 177 cases were studied and the mean age was 50.06±11.5 years with range of 20 to 70 years. males were found in majority (78.5%) of cases, with male/female ratio of 2.3:1. most of the patients 120(67.8%) were found having cirrhosis for 1-5 years’ duration. most of the cases 77(43.5%) presented with child pugh-class b. spontaneous bacterial peritonitis was present in 100(56.49%) patients. among these 100 cases, 85.0% were found with positive culture, which showed escherichia coli (most common) in 54.11% patients, followed by klebsiella in 16.47% patients, pneumococci in 9.41% and enterococci in 7.0% patients. conclusion: it is concluded that spontaneous bacterial peritonitis was 56.49%, which is a major complication of hcv cirrhosis and e. coli is the major culprit micro-organism. ascitic fluid culture is a sensitive method to detect the microorganism causing spontaneous bacterial peritonitis. key words: hcv cirrhosis, spontaneous bacterial peritonitis, micro-organisms. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection address of correspondence gordhan soothar email: dr.saeedarain786@gmail.com article info. received: october 7, 2017 accepted: january 1, 2018 cite this article. soothar g, seerani nl, akram r. spontaneous bacterial peritonitis and its common pathogens in hcv cirrhotic patients. jimdc.2018; 7(1):12-17 funding source: nil conflict of interest: nil i n t r o d u c t i o n liver cirrhosis is generally known as end stage liver disease which may develop by many causes and hepatitis c virus is a frequent cause of chronic liver disease, all over the world including pakistan.1 liver cirrhosis results from necrosis of hepatocytes followed by formation of fibrosis and nodules.2 world health organization stated that cirrhosis of the liver is the leading cause of mortality (1.1%) and it was 12th most important cause of mortality in us in 2013.3 in pakistan, accurate figure is still not known but definitely the problem seems much higher. it frequently presents with upper gastrointestinal bleed, portosystemic encephalopathy (pse), spontaneous bacterial peritonitis (sbp), hepatorenal syndrome (hrs), hepatopulmonary syndrome and o r i g i n a l a r t i c l e 13 j i m d c 2 0 1 8 13 hepatocellular carcinoma.4 hcv has been recognized as major health problem over the past two decades.5 cirrhosis of liver is defined as hepatic necrosis followed by fibrosis and nodule regeneration.[6] cirrhosis of liver is the commonest cause of mortality and morbidity throughout the world and hcv infection is rapidly increasing as major cause of cirrhosis.7 spontaneous bacterial peritonitis is a serious infection which occurs usually in cases having advanced liver cirrhosis. this disorder was defined previously as sterile ascitic fluid infection, without intra-abdominal source of infection. sbp diagnosis is based on total neutrophil count ≥250/mm3 or total leucocyte count ≥500/mm3 in ascitic fluid.8 all spontaneous ascitic infection incidents are symptomatic and the common clinical features are icterus (54.5%) and abdominal tenderness (54.5%) followed by hepatic encephalopathy (50.7%), fatigue (46.7%), pain of abdominal (44.4%), and fever (38.8%).9 sbp prevalence in cirrhotic cases by hepatitis c is 90%.10 common isolates are escherichia coli (42.8%), pneumococci (28.5%), klebseilla (14.28%) and enterococci (7.7%).11,12 severity of cirrhosis is graded in three categories as; child-pugh’s 'a', child-pugh’s 'b' and child-pugh’s 'c'.13 child-pugh’s classification is based on scoring of five parameters like serum bilirubin, prothrombin time, serum albumin, hepatic encephalopathy and ascites. patients who presented with cirrhosis and ascites showed very high susceptibility to the bacterial infections.14 spontaneous bacterial peritonitis is an ascitic fluid infection which occurs in absence of visceral perforation and lack of any focus of intra-abdominal inflammation like abscess, pancreatitis and cholecystitis. diagnostic criteria of sbp includes: total count of polymorph nuclear leucocytes (pmn) in ascitic fluid obtained by paracentesis must exceed 250 cells/mm3 and from bacterial culture only one germ must be isolated.15 very few studies are found in published literature, especially in our local setup. therefore, this study was conducted to determine the frequency and pathogens of sbp involved in hepatitis c cirrhotic patients so that empirical therapy against most common offending agents could be started at earlier stage, in order to improve survival from this deadly complication of ascites in hcv cirrhotic patients. p a t i e n t s a n d m e t h o d s this cross-sectional study was done at department of medicine liaquat university of medical & health sciences jamshoro /hyderabad. study was carried out for period of a six months, i.e. from 1st march 2009 to 31st august 2009. all the known patients of liver cirrhosis with positive hcv antibodies who presented with ascites, ranging from 15 to 70 years of age were included. all the patients with secondary causes of peritonitis e.g. perforated gall bladder, appendix, pancreas, diverticulum, duodenal/gastric ulcer, malignant or haemorrhagic ascites and those having history of antibiotic intake within 15days of admission were excluded. after obtaining an informed consent from patient who fulfilled selection criteria, abdominal paracentesis was done in hcv +ve cirrhotic patients, under aseptic measures. ascitic fluid was sent to diagnostic and research laboratory of lumhs within half hour of collection. direct microscopy was done for cells after grahm’s staining; biochemical analysis was done on cobas mira. ascitic fluid culture was done on blood agar media for the assessment of pathogens. all findings were recorded on a pre-designed proforma. tlc count >500-cells/µl or polymorphonuclear leucocyte >250-cells/µl were labelled as sbp positive. positive growth on different discs were labelled with respect to the positive pathogen. sample size was calculated by using proportion (sbp in 10% to 30% patients admitted to hospital)16 with margin of error 5% and 95% confidence level, the sample size for this study was calculated as 177. data was analysed by using spss version 16.00. frequency and percentage were computed for categorical data. mean and standard were computed for quantitative data. chi-square test was applied to see the association of sbp with severity of liver cirrhosis and p-value <0.05 was considered as significant. r e s u l t s total 177 cases were studied and the mean age was 50.06±11.5 years with range of 15 to 70 years. majority of the patients 48(27.1%) were with age group of 31 – 40 years. one hundred and thirty-nine (78.5%) were males and 38 (21.4%) were females with male/females ratio of 2.3:1. most of the patients 120(67.8%) included were having cirrhosis for the past 5 years, 52(29.4%) had 14 j i m d c 2 0 1 8 14 cirrhosis duration less than 1 year and only 05(02.8%) had cirrhosis history more than 5 years. according to the severity of cirrhosis mostly cases 77(43.5%) were presented with child pugh-class b, 39(22.0%) patients were with child pugh-class c and 61(345%) patients were presented with child pugh-class a (table no.1). out of 177 cases, the mean ascitic fluid protein (albumin) was 1.2 ± 0.8 g/dl whereas mean in patients with sbp was 1.54 ± 0.75 g/dl, and mean pmn cell count was 628.0±43.35 per mm3 while in sbp patients was 6770±4265 (n = 100) per mm3. mean of wbc count was 746.1±52.97/mm3 (table no.2). spontaneous bacterial peritonitis was present in 100 (56.49%) patients, while remaining 77(43.51%) cases were without sbp (figure no.1). according to the culture positivity among 100 patients of spontaneous bacterial peritonitis, positive culture was present in 85.0% cases and 15.0% were without positive culture (fig no.2). according to the culture positivity, escherichia coli was most common in 54.11% patients, followed by klebseilla in 16.47% patients, pneumococci in 9.41% and enterococci found in 7.0% patients (table no.3). no significant difference was found between with and without spontaneous bacterial peritonitis according to child pugh classification and calculated p-value was 0.08 (table no.4). table no. 1: demographic characteristics of study (n = 177) characteristic frequency(%) age group 15-20 14(7.9%) 21-30 22(12.4%) 31-40 48(27.1%) 41-50 40(22.6%) 51-60 25(14.1%) 61-70 28(15.8%) total 177(100.0%) gender male 139(78.5%) female 38(21.4%) total 177(100.0%) duration of cirrhosis < 1 year 52(29.4%) years 120(67.8%) >5 years 05(02.8%) total 177(100.0%) child pugh-class a 61(345%) b 77(43.5%) c 39(22.0%) total 177(100.0%) age(mean + sd) 50.06+11.5 years table no. 2 : ascitic fluid analysis of hcv cirrhotics (n=177) ascitic fluid analysis (mean+sd) wbc count (/mm3) 746.1±52.97/mm3 pmn count (/mm3) 628.0±43.35/mm3 protein (albumin) g/dl 1.2±0.8 g/dl table no. 3: frequency of different pathogens (n=85) pathogens n percentage escherichia coli 46 54.11% pneumococci 8 9.41% klebseilla 14 16.47% enterococci 6 7.0% others 11 12.94% table no. 4: spontaneous bacterial peritonitis in relation to severity of child pugh class (n = 177) child pugh class with sbp without sbp p-value n=100 n=77 a 30(30.0%) 31(40.3%) 0.08 b 44(44.0%) 33(42.9%) c 26(26.0%) 13(16.9%) total 100(100.0%) 77(100.0%) 15 j i m d c 2 0 1 8 15 d i s c u s s i o n this series revealed important aspect of the spontaneous bacterial peritonitis regarding its diagnosis and management, particularly in cases presenting with hcv cirrhosis. sbp is one of the major complication of cirrhosis with ascites, with a prevalence of about 10 – 30.16,17 in pakistan, cirrhosis is a common condition and puts economic burden on hospitals as well as on cirrhotic cases. these cases are very frequent, recurrent and related to very poor prognosis if left untreated. no such studies are available in published literature regarding the determination of risk factors in cirrhotic patients with spontaneous bacterial peritonitis and data regarding the frequency of sbp and its pathogens in hcv cirrhotic cases is scarce. therefore, this study is focused on hcv patients with cirrhosis so that empirical therapy against most common offending agents could be started at earlier stage in our setup, in order to improve prognosis in this devastating complication of ascites. this study was carried out to determine the different micro-organisms causing spontaneous bacterial peritonitis (sbp). in this study the mean age of the patients was 50.06 ± 11.5 years. consistently in the study conducted by khan z et al.18 in peshawar, the mean age was 54 years. on other hand, another study conducted by oladimeji aa et al19 stated that mean age 62±9 years of patients with range of 43-78 years, findings nearly correlate to this study. among the study participants, males were 78.5%, and females were 21.4% whereas imran m et al.20 reported 80% males and 20% female in their study respectively. in contrast to results of kamani l et al,21 reported 52% males in their study. this difference may be due to the fact that our study was done at tertiary care teaching hospital where most of the patients are illiterate who belong to poor socio-economic class whereas kamani l et al.21 conducted their study at a private setup that is one of the most expensive hospital of the province. in this series frequency of sbp was detected in 56.49% cases. this observation is comparable with some other local series as 54% reported by jalbani a et al,22 and his colleagues conducted at chandka medical college larkana. whereas in the study of iqbal s et al.23 conducted at peshawar reported 51% frequency of sbp. this study revealed mean + sd for ascitic fluid protein content in sbp patients as 1.54±0.75 g/dl. these findings are comparable well with other local studies conducted in different areas of pakistan i.e. 1.41 g/dl from scouts hospital wana, south waziristan agency and military hospital rawalpindi.24 syed va et al.19 showed 1.18 + 0.74 g/dl in sbp patients. in this study mean wbc count was 746.1±52.97/mm3 and mean pmn count was 628.0±43.35/mm3. on other hand, study conducted by iqbal s et al.23 reported mean pmn count as 1870.68 mm3, and jalbani a et al.22 showed 1619.06/mm3 whereas muhammad d et al.26 also found comparable findings. in this study 85% cases had positive culture of ascitic fluid, out of 100 cases of sbp. jain ap et al27 and his colleagues from india reported positive culture (81.81%) in sbp cases. kamani l et al.21 showed 72.7% in their study. these results are almost same to this study. in this study e.coli was found most common (54.11% cases) followed by klebsiella in 16.47% and pneumococci in 9.41% cases. these figures correlate well with other local studies of jalbani a et al.22 and his colleagues, e.coli was present in 57.40%, klebsiella in 18.51%, pneumococci in 12.96%. study of iqbals s et al.23 showed the frequency of e. coli as 58.13% whereas imran m et al. reported 60% of patients having e.coli.20 these findings were similar to our results as we also found e. coli as commonest pathogen followed by klebsiella and pneumococci. child-pugh system is an important factor for prognostic evaluation of cirrhosis. in this study prognosis was based on cirrhosis staging (child-pugh’s classification pugh class a, b and c) and observed that 30% patients presented with child-pugh’s class a grade of prognosis, 44% child-pugh’s class b, and 26% patients presented with child-pugh’s c. similarly, almani sa et al.28 observed that child-pugh’s a was in 37% cases, child-pugh’s b in 37% and child-pugh’s c was in 26% cases. while yan, et al13 stated that out of total cirrhotic cases child-pugh class a was in 22% patients, class b was in 41% and 36% cases presented with class c.13 in a study conducted by yu i, abola l et al.29 conducted in philippines, child-pugh’s a was in 39.1%, child-pugh’s b in 39.1% and child-pugh’s c in 21.9% cases. these findings nearly correlate to this study. 16 j i m d c 2 0 1 8 16 c o n c l u s i o n it is concluded that spontaneous bacterial peritonitis was present in 56.49% cases, which is a major complication of hcv cirrhosis and e.coli was the major culprit microorganism. ascitic fluid culture is a sensitive method to detect the micro-organism causing sbp. diagnosis of sbp becomes easier by paracentesis. further long-term studies are needed to establish the relationship between spontaneous bacterial peritonitis, microbial diagnosis of ascitic fluid, and cirrhosis secondary to hepatitis c. r e f e r e n c e s 1. sharif tb, tariq wz. seroprevalence of hepatitis b and c in healthy adult male recruits. pak j pathol 2006;17(4):142-6. 2. bataller r, brenner da. liver fibrosis. the journal of clinical investigation. 2005 feb 1;115(2):209-18. 3. yoon yh, chen cm, yi h. liver cirrhosis mortality in the united states: national, state, and regional trends, 2000-2013. national institute on alcohol abuse and alcoholism, surveillance report# 105. 2016:1-71. 4. giannelli v, lattanzi b, thalheimer u, merli m. betablockers in liver cirrhosis. annals of gastroenterology. 2014;27(1):20. 5. tariq wz. rational treatment monitoring for hepatitis c – role of hcv genotyping. pak j pathol 2006; 17(4):128-9. 6. nazish z, inayatullah m, nasir sa, arshad m, salma t, naqvi ab. liver cirrhosis; clinical presentation. professional med j 2002;9(3):207-12. 7. qureshi a, jamshaid, siddiqui m, zafar sa. clinical spectrum of cirrhosis of liver due to hcv in jinnah hospital, lahore. pak postgrad med j 2001;12(3):104-7. 8. thomas d, boyer td. diagnosis and management of cirrhotic ascites. in: hepatology: a textbook of liver disease. 4th ed. philadelphia, sounders, 2003, p 639. 9. filik l, unal s. clinical and laboratory features of spontaneous bacterial peritonitis. east afr med j 2004; 81(9):474-9. 10. agarwal mp, choudhury br, banerjee bd, kumara. ascitic fluid examination for diagnosis of spontaneous bacterial peritonitis in cirrhotic ascites. j indian acad clin med 2008; 9(1):29-32. 11. syed va, ansar ja, karki p, regmi m, khanal b. spontaneous bacterial peritonitis (sbp) in cirrhotic ascites: a prospective study in a tertiary care hospital, nepal. kathmandu univ med j 2007; 5(1):48-59. 12. haghighat m, dehghani sm, alborzi a, imanieh ah, pourabbas b, kalani m. organisms causing spontaneous bacterial peritonitis in children with liver disease and ascites in southern iran. world j gastroenterol 2006; 12(36):5890-2. 13. yan gz, duan yy, ruan lt, cao ts, yuan lj, yang yl. non-invasive quantitative testing of liver function using ultrasonography in patients with cirrhosis. hepatogastroentrology. 2006;53(67):15-20. 14. garcia-tsai g. bacterial infections in cirrhotics: treatment and prophylaxis. j hepatol 2005; 42(1): s85-92. 15. guarner c, soriano g. bacterial translocation and its consequences in patients with cirrhosis. eur j gastroenterol hepatol 2005; 17(1):27-31. 16. ribeiro tc, chebli jm, kondo m, gaburri pd, chebli la, feldner ac. spontaneous bacterial peritonitis: how to deal with this life-threatening cirrhosis complication? therapeutics and clinical risk management. 2008; 4(5):919-25. 17. rubinstein p, morales m, pandiani a, bagattini jc spointaneous bacterial peritonitis in hepatic cirrhosis with ascites. incidence, bacteriology and mortality in uruguary. acta gastroentrol latinoam, 2001; (4): 30712. 18. khan z, khan i, din ju, subhan f, khan b, khan h. frequency of spontaneous bacterial peritonitis in cirrhotic patients with ascites due to hepatitis c virus and efficacy of ciprofloxacin in its treatment. gomal j med scie 2009; 7(2):149-54. 19. oladimeji aa, temi ap, adekunle ae, taiwo rh, ayokunle ds. prevalence of spontaneous bacterial peritonitis in liver cirrhosis with ascites. pan african medical journal. 2013;15(1). 20. imran m, hashmi sn, altaf a, rashid h, hussain t. spontaneous bacterial peritonitis. professional med j 2006;13(2):201-5. 21. kamani l, mumtaz k, ahmed us, ali aw, jafri w. outcomes in culture positive and culture negative ascitic fluid infection in patients with viral cirrhosis: cohort study. bmc gastroenterol 2008; 8(1):59. 22. jalbani a, shah ah, ansari ia, chutto ma, gurbakhshani km. spontaneous bacterial peritonitis. an experience at cmch larkana. medical channel 2010;16(1):39-41. 23. iqbal s, imran n, alam n, rehman s. incidence of spontaneous bacterial peritonitis in liver cirrhosis, causative organism and antibiotic sensitivity, j postgrad med inst.2004;18(4):614-9. 24. rasheed a, quershi za, sarwar m. spontaneous bacterial peritonitis in patients with cirrhosis and ascites. professional med j.2008;15(3):371-4. 25. heo j, deo ys, yim hj, hahn t, park sh, ahn sh et al. clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study. gut liver 2009;3(3):197-204. 26. hussain a, qayyum a, muhammd d, javed m, iqbal mn. bacteriology of spontaneous bacterial peritonitis. professional med j 2007;14(4):55-5. 17 j i m d c 2 0 1 8 17 27. jain ap chandra la, gupta op, jajoo un, kalantri nsp. spontaneous bacterial peritonitis in liver cirrhosis with ascites. j assoc physicians india 1999;47(6):619-21. 28. almani sa, memon as, memon ai, shah mi, rahopoto mq, solangi r. cirrhosis of liver: etiological factors, complications and prognosis. j liaquat univ med health sci 2008; 7(2):61-6. 29. yu i, abola l. predicting prognosis among cirrhotic patients: child-pugh versus apache iii versus meld scoring systems. phil j gastroenterol 2006; 21: a45. j islamabad med dental coll 2020 76 correspondence: naila siddiqui kamal email: naila.siddiqui07@imperial.ac.uk cite this editorial: kamal ns. caught off guard by covid19: artificial intelligence for rescue!. j islamabad med dental coll. 2020; 9(2):. 76-78 doi: 10.35787/jimdc.v9i2.547 o p e n a c c e s s caught off guard by covid-19: artificial intelligence for rescue! naila siddiqui kamal senior lecturer, imperial college london associate director, medical education, lnwuht nhs uk needless to say, we are witnessing a once in a lifetime health crisis. the scale and impact of the pandemic has motivated researchers to understand the virus (sars-cov-2), 1 its mode of spread and search for effective treatments and vaccines. public health and population health sectors are at the forefront of predicting and preventing disease outbreaks. there is a subtle difference in their remits. public health works to protect and improve the health of communities through policy recommendations, health education and outreach, and research for disease detection and injury prevention. population health is defined by groups of stakeholders as “the health outcome of a group of individuals, including the distribution of such outcomes within the group”.2 population health departments look at proactive approaches to a given population with attention directed toward larger, socially grouped needs and prevention efforts while reducing disparity and variation in care delivery. hence, we have seen a paradigm shift from a reactive medical framework to a more proactive preventive approach. having said that, could covid-19 pandemic have been predicted? 3 it can be argued that traditional prototype of delivery of healthcare would be unable to make such a prediction. however, if there was a widespread engagement with disruptive technologies, that enthusiasts have been advocating for some time, then it was most likely possible as claimed by artificial intelligence (ai) experts. the world was unprepared for a disease of this level of contagiousness and impact on the vulnerable. what would have been a good warning trigger, is real time data for analysis. this is where artificial intelligence plays a major role. 4 when large data has to be collected and analyzed, ai based systems are invaluable. artificial intelligence relies on an intelligent agent (ia), an autonomous entity which directs its activity towards achieving goals upon an environment, using observation through data received either by manual input or directly by sensors and devices. intelligent agents may also learn or use knowledge to achieve their goals. they may be very simple or very complex. in plain words, ai can be developed by inputting algorithms that enable the machine to analyze data and make recommendations. in situations such as the covid-19 pandemic, what would have made a huge difference in combatting its onslaught? the first and foremost point would be a forewarning, with risk stratification of the susceptible population. this would be followed by assistance on resource management, real time tracking of spread and future predictions on flattening of the curve of incidents, respectively. e d i t o r i a l j islamabad med dental coll 2020 77 for these factors to be in place, there is a need for a behavioural change amongst populations as well as clinicians. people need to become more vigilant and insightful on their current health status and their vulnerability to emerging disease trends. for this, they would need to have a way of recording new onset symptoms which can be communicated to relevant population health stake holders, who have ai-based dashboards showing the emerging trends in new onset symptoms and outcomes (figure 1). figure 1: a visual info-graph made by the author depicting stakeholders of a basic health eco-system. (for explanation see “case study: introducing covidchk bot” at the end of this editorial). we are witnessing a watershed moment at this time, in this century, as far as transformation in health care delivery and management is concerned. remote access such as tele/video health systems will find a more central place in delivery models. in the near future, holograms will enable the clinician to the bedside of the patient wherever that may be; clinical decision making will be heavily reliant on evidence-based algorithm-based ai solutions; clinical data will be collated as big data for machine engines to spurn out forecast models of predicted health outbreaks; population health will take a central role in the myriad of specialties; precision health with specifics about individuals based on genomics data analysis, will become vogue and health care providers will be working in a more technologically enabled environments (figure 1). the main question left somewhat unanswered is, ‘will we be a healthier society?’ this depends on a number of ‘ifs’. if all factors become aligned and live up to their expectations, then an optimist would say ‘why not?’ but amongst all of these futuristic modelling, the one resource that remains central to all enabling factors is, the clinician. one cannot underestimate the emotional intelligence (et) 5 that human interaction brings to these models. ai does not disrupt the role of a clinician, rather it enables the clinician to be much more informed and capable to deal with health-related challenges. r e f e r e n c e s 1. janowitz t, tuveson da. the era of covid-19 and the rise of science collectivism in cancer research. cancer discov. 2020. doi: 10.1158/2159-8290.cd20-0657 2. kindig d, stoddart g. what is population health? am j public health. 2003; 93(3): 380-3. doi: 10.2105/ ajph.93.3.380. 3. yang z, zeng z, wang k, wong ss, liang w, zanin m, et al. modified seir and ai prediction of the epidemics trend of covid-19 in china under public health interventions. j thorac dis. 2020; 12(3): 165‐ 174. doi:10.21037/jtd.2020.02.64 4. davenport t, kalakota r. the potential for artificial intelligence in healthcare. future healthc j. 2019; 6(2): 94‐8. doi:10.7861/futurehosp.6-2-94 j islamabad med dental coll 2020 78 5. schuller d, schuller b. the age of artificial emotional intelligence. computer. 2018; 51(9). 38-46. doi: 10.1109/mc.2018.3620963 case study: in response to the emerging crisis, the author has collaborated with an ict stakeholder to develop an ai based application which is described here to show case how ai can make a difference in such situations and why it is important to engage with it to face the predicted second and third waves of covid-19 infection. introducing covidchk bot: https://covidchk.iplayxyz.com an ai algorithm-based bot that enables the users to input certain key health data points enables to give a risk stratification to the individual as low, medium or high risk for being infected by covid-19 virus. this is based upon the emerging data from lancet study on the wuhan reported cases. subsequently, published data was constantly reviewed to update the vectors in the app. there is an additional function of symptom diary carding as well as contact logging. these functions were embedded in response to the huge gap in current practice of not knowing which symptoms are collectively emerging in a population as well as to know exactly when the advocated self-isolation starts to predict when the person will be safe to come out of isolation. it also serves as a great digital companion to individuals for up to date valid information on the disease footprint and recommendations while in self-isolation. it is linked with a telehealth portal to enable the individual to be connected to a clinician who is registered for this service or a population health link portal. this ai based digital solution has been taken up by stakeholders in the caribbean population to introduce a holistic digital healthcare eco-system. the point here is the speed of products coming into practice from an idea to full implementation. this project took a mere three weeks to have the first prototype out. this is a reflection of how a crisis enables individuals and organizations to overcome the common barriers to reach effective solutions in time https://covidchk.iplayxyz.com/ j islamabad med dental coll 2020 155 ope n acce ss renal transplant unit, national institute of solid organ and tissue transplantation, dow university of health sciences, karachi, pakistan: on a road to minimize esrd burden rashid bin hamid1, muhammad tassaduq khan2 1 consultant urologist and renal transplant surgeon, renal transplant unit, national institute of solid organ and tissue transplantation, dow university of health sciences, ojha campus, karachi, pakistan. 2 consultant nephrologist and renal transplant physician, renal transplant unit, national institute of solid organ and tissue transplantation, dow university of health sciences, ojha campus, karachi, pakistan end stage renal disease (esrd) is clinically defined as the progressive and irrevocable impairment of kidneys to perform life-sustaining functions and represents the final stage of chronic kidney disease (ckd).1 with bulging morbidity and mortality and rampant rise in economic burden globally, esrd is now recognized as a major public health issue. 2-5 certainly, it goes without saying that coming decades will observe a high prevalence of esrd, and chronic non-communicable diseases such as hypertension and diabetes mellitus, with accumulating aging population as the driving force.6,7 this prognosticated upsurge in esrd pool has been gauged to occur mainly in the developing countries.8 pakistan currently encountered 100 new cases of esrd per million population.9 apart from strategies to mitigate the incidence of esrd, a state of equilibrium must be maintained between existing esrd cases and renal treatment modalities. the importance of renal replacement therapy as the best means of patient survival have led the government and private sectors to offer infrastructure for dialysis and transplantation, with 180 dialysis facilities and 30 transplant units operating across pakistan. 10,11 however the dearth of appropriate facilities and high costs deprives majority of the population suffering from esrd of renal replacement therapy.12 under such circumstances of deteriorating health and economic indicators, healthcare sector requires a firm stand in renal medicine that could devise unprecedented approach to prevent and tre at esrd. the contemplation and vision of the renal transplant unit, national institute of solid organ and tissue transplantation at dow university of health sciences, ojha campus successfully materialized on 1st march, 2017. it is a privilege for this unit to be recognized as the second largest transplant unit in public sector of sindh province. a manifesto was formulated with the guiding principle of overcoming the spiraling burden of esrd. against this challenging picture, the aim of the renal transplant unit is to provide highly advanced transplantation services. this unit has successfully performed renal transplants of over 250 patients, a milestone achieved in a brief duration of three and a half years. ever since its inception, the renal transplant unit has persistently pursued excellence in efficient delivery of renal transplant services. le tte r to e d i tor correspondence: muhammad tassaduq khan email: muhammad.tassaduq@duhs.edu.pk cite this letter to editor: hamid r, khan mt. renal transplant unit, national institute of solid organ and tissue transplantation, dow university of health sciences, karachi, pakistan: on a road to minimize esrd burden. j islamabad med dental coll. 2020; 9(3): 155-157 doi: 10.35787/jimdc.v9i3.465 j islamabad med dental coll 2020 156 here, we would draw the opportunity to extend our deepest gratitude to the indefatigable drive of our renal healthcare team with zero compromise policy on the quality of care of renal donor and renal recipient dyad. non-adherence to medication has been the deciding factor for candidate’s eligibility for organ transplantation. besides transplantation cost, longstanding expenses incurred by patients related to immunosuppressive drugs may contribute to poor compliance to medication, transplant rejection and ultimate death. optimum and desirable renal transplant results could only be achieved by providing financial assistance for buying the costly immunosuppressive drugs to the recipients.13 however, our renal transplant unit is presently functioning as a self-funded body. costs starting from pre-transplant consultancy, renal transplant therapy till post-transplant immunosuppressive medicines are endured by the patients. with that being said, we have embraced a cost-effective strategy, where patients with financial hardships are supported, wherever possible, through dow zakat fund. with renal transplant modality embracing scientific research as the mainspring of renal transplant decision making and practice, we aim to conduct research in renal transplant medicine, so as to be at par with international scientific community. the institution aims to create research impact through deeper understanding of renal transplant pathology especially renal transplant rejection. with emerging limitations in renal transplant such as immunologic rejections14, we seek to work along several renal research projects which includes, but are not limited to, non-invasive and molecular biomarkers of transplant rejection, hla antibody and chronic transplant rejection.15 we strongly believe in multidisciplinary research and a handful of research projects are currently in the pipeline. given the early phase of our renal transplant unit, we also plan to share a growth curve of our transplantation services in years to follow. indeed, our research plan, once accomplished, would help us in building and disseminating an enormous clinical research data. this is strongly in alignment with the core vision of dow university of health sciences; a research-driven tertiary healthcare organization. with this backdrop, we are optimistic that this renal transplant unit will fulfill the growing clinical need for a high-end and patient-focused solution to curb esrd burden in pakistan. population with resourceconstrained settings and disadvantaged from renal transplant therapy would be able to benefit from our initiative. our manifesto befits and, indeed, complements the vision of other renal transplant centers across pakistan and we aim to upscale and take this effort forward. r e f e r e n c e s 1. queeley gl, campbell es. comparing treatmen t modalities for end-stage renal disease: a metaanalysis. am health drug benefits. 2018; 11(3): 118 127. pmid: 29910844 2. roderick pj, jeffrey rf, yuen hm, godfrey km, west j, wright j. smaller kidney size at birth in south asians: findings from the born in bradford birth cohort study. nephrol dial transplant. 2016; 31(3): 455-65. doi: 10.1093/ndt/gfv274 3. levin a, tonelli m, bonventre j, coresh j, donner j-a, fogo ab, et al. global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy. lancet. 2017; 390(10105): 1888 -1917. doi: 10.1016/s0140-6736(17)30788-2 4. luyckx va, tonelli m, stanifer jw. the global burden of kidney disease and the sustainable development goals. bull world health organ. 2018; 96(6): 414 -22d. doi: 10.2471/blt.17.206441 5. agarwal r. defining end-stage renal disease in clinical trials: a framework for adjudication. nephrol dial transplant. 2016; 31(6): 864-67. doi: 10.1093/ndt/ gfv289 j islamabad med dental coll 2020 157 6. peer n, kengne a-p, motala aa, mbanya jc. diabetes in the africa region: 2013 update for the idf diabetes atlas. 2013. 7. twagirumukiza m, de bacquer d, kips jg, de backer g, vander stichele r, van bortel lm. current and projected prevalence of arterial hypertension in sub saharan africa by sex, age and habitat: an estimate from population studies. j hypertens. 2011; 29(7): 1243–52. doi: 10.1097/hjh.0b013e328346995d 8. halle mp, takongue c, kengne ap, kaze ff, ngu kb. epidemiological profile of patients with end stage renal disease in a referral hospital in cameroon. bmc nephrol. 2015; 16: 59. doi: 10.1186/s12882-0150044-2 9. ullah k, butt g, masroor i, kanwal k, kifayat f. epidemiology of chronic kidney disease in a pakistan i population. saudi j kidney dis transpl. 2015; 26(6): 1307-10. 10. human development report 2010 the real wealth of nations: pathways to human development united nations development programme. un plaza, new york, usa; p199. 11. naqvi saj. renal diseases in pakistan – ‘time to act'. j nephrol renal transplant. 2009; 2(1): 133 –35. 12. rizvi sah, naqvi saa, zafar mn, hussain z, hashmi a, hussain m, et al. a renal transplantation model for developing countries. am j transplant. 2011; 11(11): 2302–07. doi: 10.1111/j.1600-6143.2011.03712.x 13. evans rw, applegate wh, briscoe dm, cohen dj, rorick cc, murphy bt, et al. cost-relate d immunosuppressive medication nonadherence among kidney transplant recipients. clin j am soc nephrol. 2010; 5(12): 2323–2328. doi: 10.2215/cjn.04220510 14. abecassis m, bartlett st, collins aj, davis cl, delmonico fl, friedewald jj, et al. kidney transplantation as primary therapy for end-stage renal disease: a national kidney foundation/kidney disease outcomes quality initiative (nkf/kdoqitm) conference. clin j am soc nephrol. 2008; 3(2): 471 80. doi: 10.2215/cjn.05021107 15. rizvi sa, naqvi sa, zafar mn, akhtar sf. a kidney transplantation model in a low-resource country: an experience from pakistan. kidney int suppl (2011). 2013; 3(2): 236-240. doi: 10.1038/kisup.2013.22 journal of islamabad medical & dental college (jimdc); 1211(1):37-38 37 case report uterine leiomyomata –unusual number managed with conservation of uterus salma kafeel*, saeed alam**, huma mushtaq***, and riffat bibi**** * consultant gynaecologist & obstetrician, salma & kafeel medical centre, islamabad ** prof of pathology, islamabad medical and dental college, islamabad, (bahria university, islamabad) *** assistant prof. pathology, islamabad medical and dental college, islamabad(bahria university, islamabad) **** scientist, salma & kafeel medical centre, islamabad abstract uterine leiomyomata are the commonest neoplasms of female reproductive tract. on an average there are six to seven fibroids in the affected uterus. these neoplasms may lead to symptoms like menorrhagia, dysmenorrhea, pressure effects, urinary frequency, pelvic pain, infertility and pelvic mass. here we present a case report of 34 years old nulliparous women having an unusual number (48) of fibroids. as she was nulliparous and wanted to conceive, her uterus was conserved and all the fibroids were surgically removed. key words: uterine leiomyomata, fibroids, menorrhagia, infertility introduction uterine leiomyomata or fibroids are the commonest neoplasms of the female reproductive tract and effect 2040% of the premenopausal women.1 although benign, these neoplasms lead to symptoms like menorrhagia, dysmenorrhea, pressure effects, urinary frequency, pelvic pain, infertility and pelvic mass.2 uterine leiomyomata are present in three different locations in the uterine wall and are termed according to their site. sub-serosal leiomyoma projects outwards from the uterine surface: intra-mural leiomyoma lie within the wall of the uterus while submucosal project into the uterine cavity.3 over 75% of reproductive age females have on an average affected uterus containing six to seven fibroids.4 the size and location of fibroid within the uterus may lead to infertility and cause pregnancy related complications.5 a case report is being presented in which the number of uterine leiomyomata were unusual and forty eight fibroids were removed peroperatively with conservation of uterus. case report a thirty four years old nulliparous women having complaints of menorrhagia and pressure symptoms for the past six years presented in the private clinic of one of the authors for advise and treatment. the patient was examined and routine investigations were carried out. her ultrasonography revealed multiple uterine fibroids. these findings and available treatment options were explained and discussed with the patient. as she wanted to conceive, most suitable treatment option was to remove the fibroids and conserve the uterus. she was operated upon and peroperative findings included enlarged, distorted uterus containing multiple nodules of variable sizes. a total number of forty eight fibroids were carefully identified and surgically removed. specimen containing all the fibroids was sent for histopathological examination in formalin fixative. gross examination findings of the specimen confirmed a total number of forty eight fibroids of variable sizes collectively weighing 2.1 kg. (fig.1) the largest fibroid was 12 cms in diameter and smallest one measured 0.8 cms in diameter. cut surfaces showed a characteristic whorled pattern and in some of the fibroids there were focal degenerative changes. histopathological examination revealed features of benign leiomyomata and no evidence of malignancy was seen. figure 1: gross appearance of uterine leiomyomata surgically removed discussion uterine leiomyomas can occur singly but are often multiple and show variation in sizes. they are more frequently present in women of african origin than women of other ethnic groups. african american women are reported to have an earlier age of uterine leiomyoma diagnosis. these women have larger and more abundant tumors, more severe journal of islamabad medical & dental college (jimdc); 1211(1):37-38 38 symptoms and higher rates of hysterectomy. risk factors for leiomyomas include early age of menarche, nulliparity, oral contraceptive use and obesity.4 the list of treatment options for women having leiomyomas is expanding rapidly. new procedures have been introduced other than hysterectomy and myomectomy, such as uterine artery embolization (uae) and high intensity focused ultrasound (hifu). these procedures are in demand by women who want minimized recovery time and preservation of their uterus.6 the type and timing of intervention should be individualized, based upon factors such as size of the fibroid, its location, severity of symptoms, patient age, reproductive plans and obstetrical history.7 those women who are asymptomatic should be initially observed without any treatment. symptomatic women who desire fertility preservation should have non-surgical treatment first and then myomectomy. symptomatic women who do not desire future fertility but wish to preserve the uterus can have non-surgical treatment or myomectomy, myolysis or uterine artery embolization. women with pregnancy complications should have myomectomy procedure. whereas women having severe symptoms and who desire definitive treatment should have hysterectomy done.8 hysteroscopic myomectomy can be considered as first line surgical conservative therapy for management of intracavitary myoma. with a newer understanding of modern surgical techniques more tailored options are available for the patients. in nulliparous women myomectomy followed by gnrh analogs for 3 months seems to be the best surgical approach for multiple fibroids. asymptomatic fibroids may be managed by reassurance and careful follow-up. medical therapy should be tried as first line of treatment for symptomatic myomas while surgical therapy should be reserved only for appropriate indications. preoperative gonadotrophin hormone releasing hormone treatment decreases the size and vascularity of myoma, but may render the capsule more fibrous and difficult to resect. uterine artery embolization is an effective alternative treatment for women having large symptomatic myomas and are poor risk or wish to avoid major surgery.9 the mechanism that initiates uterine fibroid growth and pathogenesis is not completely understood. there is still no definitive evidence why fibroids develop and why do they grow. risk factors attributed to development of fibroids include earlier menopause, fewer births after age 24, alcohol intake, sedentary life style, prenatal des exposure and higher circulating levels of lh are also linked to fibroids.10 researchers are trying to find out the causative gene interaction, enzymes responsible for estrogen biosynthesis produced locally and mechanism responsible for cell cycle regulation in uterine fibroids. references 1. stenchever ma, droegemullar w, herbst al, mishell dr, eds. comprehensive gynecology. 4th eds. st louis: mosby inc; 2001. 2. buttram vc, jr, reiter rc. uterine leiomyomata: etiology, symptomatology, and management. fertil steril 1981; 36:433-445. 3. roohi m, tazeen dr. sub mucous fibroids (effective surgical approach). the professional 2005; 12: 2 4. lynch am, morton cc. uterus: leiomyoma. atlas genet cytogenet oncol haematol. may 2007.url : http://atlasgeneticsoncology.org/tumors/leiomyomid50 31.html 5. yoon sw, kim kh, kim sh, ha dh, lee c, lee sy, jung sg, kim sj. pregnancy and natural delivery following magnetic resonance imaging-guided focused ultrasound surgery of uterine myomas. yonsei med j 2010; 51(3):451-453. 6. alison f, jacoby md. new and emerging treatments for uterine leiomyomas. adv. stud. med 2006; 6 (6): 260266. 7. stewart ea. uterine fibroids. lancet 2001; 357:293. 8. evans p, brunsell s. uterine fibroid tumors: diagnosis and treatment. am fam physician 2007; 75:1503-8. 9. nirmila duhan. current and emerging treatments for uterine myoma-an update. international journal of women’s health 2011; 3 231-241 10. niehs study on fibroids. http://dir.niehs.nih.gov/direb\ /studies/ufs/home.htm. j islamabad med dental coll 2019 45 open access vitamin d deficiency in hcv antiviral treatment responders versus non-responders rana m arif 1, fahad aman khan 2, imran khan 3, muzammil aslam kataria 4, jawed iqbal 5, mukhtar ahmed 6 1,4,5 senior registrar medical unit i, jinnah hospital lahore 2 assistant professor medicine, medical unit ii, allama iqbal medical college, jinnah hospital lahore 3 senior registrar medical unit ii, jinnah hospital lahore 6 assistant professor medical unit ii, allama iqbal medical college jinnah hospital lahore a b s t r a c t background: hepatitis c virus (hcv) is a major cause of chronic liver disease (cld). pakistan has a high burden of infectious diseases, including hcv. its prevalence varies according to geographic regions in the country from about 2·4% to 6·5%. the objective of the study was to compare the frequency of vitamin d deficiency in responders and non-responders of antiviral treatment for chronic hepatitis c. material and methods: this comparative cross-sectional study was conducted in hepatitis clinic, jinnah hospital, lahore from 20th may to 20th november 2013. after ethical approval, participants were selected by using purposive non-probability sampling, 52 responder patients i.e. who were labeled negative for hcv rna by pcr after 12 weeks of antiviral treatment and 52 non-responder patients were included in this study. data was collected by using pretested structured questionnaire. vitamin d3 levels were measured by elisa and a cut-off value of below 30ng/ml was labeled as vitamin d deficiency. spss version 21 was used to analyze data with p value less than 0.05 taken as statistically significant. results: out of 104 patients (mean age 35±8.1 years), 61.5% were males and 38.5 % were females. there was a significant difference in frequency of vitamin d deficiency in treatment responder group when compared to non-responders (p = 0.016). mean level of vitamin d was 21.8±10.8ng/ml in responders whereas it was 15.6±7.5 in non-responders with a statistically significant difference (p = 0.001). conclusion: this study concludes that there is a significant vitamin d deficiency among treatment non-responders as compared to treatment responders in patients with chronic hepatitis c. key words: vitamin d, vitamin d deficiency, viral response authors’ contribution: 1-3 conception, synthesis, planning of research and manuscript writing interpretation, discussion, -4-6 data analysis, interpretation and manuscript writing, active participation in data collection. correspondence: rana arif email: rana-arif202@gmail.com article info: received: april 12, 2018 accepted: october 10, 2018 cite this article: arif mr, khan fa, khan i, kataria ma, iqbal j, ahmed m. vitamin d deficiency in hcv antiviral treatment responders versus non-responders. j islamabad med dental coll.2019; 8(1):45-49 funding source: nil conflict of interest: nil i n t r o d u c t i o n hepatitis c virus (hcv) is a major cause of chronic liver disease (cld). it is a global dilemma and an alarming health issue with global incidence of 200 million (3.3%).1 pakistan also has a high burden of infectious disease including hcv2,3. its prevalence varies according to geographic regions from about 2·4% to 6·5%.4,5 however, very low rate of hcv is reported from developed nations like canada 0.8%, france 1.1%, germany 0.6%, and australia 1.1%. similarly, prevalence rate of hcv lower than pakistan have also been reported from italy (2.2%) usa (1.8%), japan (12.3%) and china (3.2%) respectively.6-10 whereas, africa and asia have the highest burden of hcv infection. egypt alone with an estimated population of almost 73 million11 has a high o r i g i n a l a r t i c l e mailto:rana-arif202@gmail.com mailto:rana-arif202@gmail.com j islamabad med dental coll 2019 46 seroprevalence rate of about 22%.12 liver is a vital organ for the metabolism of vitamin d. it hydrolyzes vitamin d from skin and diet into 25-hydroxyvitamin d [25(oh)d] which can be estimated by elisa13. therefore, liver disease affect the metabolism of vitamin d leading to disturbance in calcium and bone metabolism.14 deficiency of vitamin d is associated with osteopenia, osteoporosis, osteomalacia and muscle weakness, resulting in higher chances of bone fractures.15 moreover, vitamin d deficiency is associated with multiple types of malignancies (e.g., prostate, colon, breast), as well as autoimmune inflammatory metabolic disorders. vitamin d also plays a major role in calcium metabolism and in differentiation, proliferation and immunomodulation of cells.16 similarly, vitamin d deficiency resists fibroblastic proliferation and augments the production of collagen. hcv infection leads to chronic liver disease (cld)17 and eventually to hepatic fibrosis.18 it is therefore essential to understand the role of vitamin d deficiency in the treatment of chronic hepatitis c, so that these patients may be screened and treated before starting the antiviral therapy. m a t e r i a l a n d m e t h o d s this comparative cross-sectional study was `conducted in hepatitis clinic, jinnah hospital, lahore from 20th may to 20th november, 2013 after obtaining approval from the institutional ethics committee. non-probability purposive sampling technique was used for sample collection. patients of either sex of age 20-60 years, coming for follow up in hepatitis clinic of jinnah hospital lahore were enrolled in this study. all patients had received 12-week treatment for chronic hepatitis c i.e. conventional interferon injection and ribavirin tablets. patient taking calcium/ vitamin d supplementation, having advanced impaired liver and /or renal functions were excluded from the study. after informed consent, 52 responders and 52 nonresponder patients were segregated into 2 groups. data was collected using pretested structured questionnaire. blood samples were collected using aseptic technique and vitamin d3 levels were assessed by enzyme-linked immunosorbent assay (elisa). genotype of hcv was also recorded to cater for effect modification. data was entered and analyzed in spss version 21. frequencies and percentages were calculated for qualitative variables while mean and standard deviation were computed for quantitative variables. vitamin d deficiency was compared in both groups i.e. responders and nonresponders using chi square test of homogeneity as a test of significance, with p value less than or equal to 0.05. data was cross tabulated to determine the effect of age, sex and genotyping on treatment response and vitamin d deficiency. independent sample t test and chi square were used to rule out effect of these confounders. vitamin d deficient patients were divided into two classes i.e. severe deficiency, if vit d level less was than 15 ng/ml and deficiency, if levels were between 15 and 30ng/ml. the difference in responders and non-responders was cross tabulated again. r e s u l t s out of 104 patients i.e. 52 responders and 52 nonresponders, patients with mean age of 35.3 8.1 years were included. mean vitamin d level came out to be 18.8 ng/ml 9.7 (range 7.7 to 44 ng/ml). there were 61.5% (n=64) males and 38.4% (n=40) females, respectively. genotype distribution showed 79 patients (76%) with genotype 3, 19 patients (18%) had type 1 and only 6 patients (5.8%) had type 2 genotype of hepatitis c virus. out of 104 patients 82 individuals (79%) were vitamin d deficient. mean level of vitamin d was 21.8 10.8 ng/ml in responders while it was 15.6 7.5 ng/ml in nonresponders. cross tabulation of vitamin d deficiency categories and treatment response groups among hepatitis c patients, showed significant difference of vitamin d deficiency among treatment responders as compared to non-responders (p= 0.016) (table i). response to antiviral treatment is also significantly associated with genotype of hepatitis c (p = 0.05). to rule out the effect of age and gender, we cross tabulated age groups of patients in both groups i.e. > 30 years and <30 years and gender with treatment response, which showed that younger patients have a better response to treatment than older groups. there was no correlation of gender with treatment response (p=0.314) (table ii). j islamabad med dental coll 2019 47 table iii: vitamin d levels in hcv treatment responders and non-responders and different hcv genotypes variables groups total p value severely deficient deficient normal study groups responders 22 14 16 52 pearson chi square 0.026 non-responders 34 12 6 52 hcv genotype gen 3 43 21 15 79 fisher’s exact <0.865 gen 2 3 1 2 6 gen 1a or 1b 10 4 5 19 table iv: distribution of vitamin d levels according to gender and age groups variables groups total p value severely deficient deficient normal gender male 34 19 11 64 pearson chi square 0.257 female 22 7 11 40 age grous >30 years 43 18 9 70 pearson chi square 0.01 < 30 years 13 8 13 34 an inverse relationship of response to interferon therapy with vitamin d deficiency was also reported (p=0.026). severity of vitamin d deficiency is not related to genotype and gender but is affected by age (tables iii and iv). d i s c u s s i o n the mean age of patients in our study shows that hepatitis has affected our population in the most productive age group. similarly, vitamin d deficiency is also very common involving almost 80% of our population. genotype 3 is the main circulating viral genotype in our population, and is easily treatable. our results also show higher frequency of genotype 3 in treatment responders. although previous studies showed that vitamin d levels are not associated with sustained virologic response (svr) to antiviral therapy (peg-ifn and rbv) in hepatitis c patients, but effect of vitamin d supplementation on svr was not clear.19 however, our study showed that vitamin d deficiency has significant negative correlation with response to hepatitis c treatment; but the causal relationship cannot be elicited due to the limitation of the study design. kitson et al reported mean 25(oh)d level of 79.6 nmol/l, with 48% prevalence of 25(oh)d <75 nmol/l and 16% <50 nmol/l respectively in chronic hepatitis c genotype 1 patients. their study showed no association of baseline 25(oh) level with svr or fibrosis in hcv-1, but significant association with high activity grade.20 similarly, ladero et table i: cross tabulation of vit d deficiency and hcv genotypes with responder and non-responders groups responders non-responders total p value vitamin d level normal 16 6 22 pearson chi square 0.016 deficient 36 46 82 genotypes gen 3 45 34 79 fisher’s exact 0.05 gen 2 2 4 6 gen 1a or 1b 5 14 19 table ii: cross tabulation of vit d deficiency and hcv genotypes with responder and non-responders groups responders non-responders total p value gender male 29 35 64 pearson chi square 0.314 female 23 17 40 age group >30 years 22 48 70 fisher’s exact <0.001 <30 years 30 4 34 j islamabad med dental coll 2019 48 al also mentioned presence of vitamin d deficiency among spanish chronic hepatitis c patients.21 about 41 vitamin d deficient patients were treated with vitamin d supplements and later on re-evaluated. vitamin d deficiency (<20ug/dl) was seen in 36.1% and suboptimal levels (20-30ug/dl) were observed in 40.9% patients.21 our study findings are in agreement with mohamed et al22 who reported low vitamin d levels in hcv patients as compared to the healthy population. higher levels of vitamin d were observed among responders of ribavirin plus pegylated interferon alpha 2a therapy while low levels were observed among non-responders. therefore, it was concluded that vitamin d deficiency may contribute to delayed or unfavorable response of antiviral therapy in hcv infected patients. another study by amanzada et al showed that lower pretreatment 25(oh)d levels and higher serum ferritin levels were significantly associated with fibrotic alteration and inflammatory activity.23 yu et al also reported significantly lower concentration of 25(oh)d in liver cirrhosis group than the control group with the conclusion that vitamin d might function as a protective factor against development of cirrhosis.24 similarly, villar et al reported in a systematic review that out of 1575 hepatitis c patients, 1117 (71%) were vitamin d deficient. with respect to treatment, this systemic review had included 8 studies of both hcv persons without previous treatment and pooled patients with sustained viral response. in patients with very high svr, vitamin d levels was >30 ng/dl which could be either supplemented or natural regardless of types of genotype. the results established high occurrence of vitamin d deficiency in hepatitis c patients and svr in persons with upper vitamin d levels or in patients getting vitamin d supplementation.25 c o n c l u s i o n there is a significant difference in vitamin d levels among treatment responders and non-responders in patients with chronic hepatitis c, with a very low rate of vitamin d observed among non-responders. severity of vitamin d deficiency is not related to genotype and gender but is affected by age. it is hereby recommended to screen every patient before the start of antiviral treatment for a better outcome of hepatitis treatment. r e f e r e n c e s 1. saeed m, iram s, hussain s, mobeen r, ahmad m, ashraf m. heatitis c in asymptomatic population. tpmj. 2016;2(5): 546-552 2. saeed m, hussain s, rasheed f, ahmad m, arif m, rahmani mth. silent killers: transfusion transmissible infections-tti, among asymptomatic population of pakistan. j pak med assoc. 2017;67(3):369-74. 3. shazad f, saeed m. comparison between elisa and ict techniques for the detection of anti hcv antibody among blood donors. biomedica. 2016;32(4):281-4. 4. gower e, estes c, blach s, razavi-shearer k, razavi h. global epidemiology and genotype distribution of the hepatitis c virus infection. j hepatol. 2014;61(1): s45-s57. 5. khattak m, salamat n, bhatti f, qureshi t. seroprevalence of hepatitis b, c and hiv in blood donors in northern pakistan. j pak med assoc. 2002;52(9):398-402. 6. alter mj, kruszon-moran d, nainan ov, mcquillan gm, gao f, moyer la, et al. the prevalence of hepatitis c virus infection in the united states, 1988 through 1994. n engl j med. 1999;341(8):556-62. 7. ohshima s, komatsu m, nakane k, meng xw, goto t, fujii t, et al. iatrogenic gb virus c/hepatitis g virus infection in an area endemic for hepatitis c virus. j hosp infect. 2000;44(3):179-85. 8. ito si, ito m, cho mj, shimotohno k, tajima k. massive sero–epidemiological survey of hepatitis c virus: clustering of carriers on the southwest coast of tsushima, japan. cancer science. 1991;82(1):1-3. 9. hayashi j, nakashima k, yoshimura e, hirata m, maeda y, kashiwagi s. detection of hcv rna in subjects with antibody to hepatitis c virus among the general population of fukuoka, japan. j gastroenterol. 1994;29(2):147-51. 10. puro v, petrosillo n, ippolito g, aloisi ms, boumis e, rava l. occupational hepatitis c virus infection in italian health care workers. italian study group on occupational risk of bloodborne infections. am j public health. 1995;85(9):1272-5. 11. mujeeb s, shahab s, hyder a. geographical display of health information: study of hepatitis c infection in karachi, pakistan. public health. 2000;114(5):413-5. j islamabad med dental coll 2019 49 12. frank c, mohamed mk, strickland gt, lavanchy d, arthur rr, magder ls, et al. the role of parenteral antischistosomal therapy in the spread of hepatitis c virus in egypt. the lancet. 2000;355(9207):887-91. 13. christakos s, dhawan p, verstuyf a, verlinden l, carmeliet g. vitamin d: metabolism, molecular mechanism of action, and pleiotropic effects. physiological reviews. 2015;96(1):365-408. 14. mann mc, hobbs aj, hemmelgarn br, roberts dj, ahmed sb, rabi dm. effect of oral vitamin d analogs on mortality and cardiovascular outcomes among adults with chronic kidney disease: a meta-analysis. clin kidney j. 2015;8(1):41-8. 15. bikle dd. vitamin d metabolism, mechanism of action, and clinical applications. chem biol. 2014;21(3):319-29. 16. lewiecki em. osteoporosis: clinical evaluation. endotext [internet]: mdtext. com, inc.; 2018. 17. yaşar e, adigüzel e, arslan m, matthews dj. basics of bone metabolism and osteoporosis in common pediatric neuromuscular disabilities. eur j paediatr neurol. 2018;22(1):17-26. 18. taguba aq, velasco mds, panlilio mtt, rubio mjm, villamayor mej, ong jp, et al. po-028: prevalence of vitamin d deficiency in chronic liver disease at the outpatient clinics of the university of the philippines-philippine general hospital. 춘· 추계 학술대회 (kasl). 2016;2016(1):93-. 19. kitson mt, sarrazin c, toniutto p, eslick gd, roberts sk. vitamin d level and sustained virologic response to interferon-based antiviral therapy in chronic hepatitis c: a systematic review and meta-analysis. j hepatol. 2014;61(6):1247-52. 20. kitson mt, dore gj, george j, button p, mccaughan gw, crawford dh, et al. vitamin d status does not predict sustained virologic response or fibrosis stage in chronic hepatitis c genotype 1 infection. j hepatol. 2013;58(3):467-72. 21. ladero jm, torrejón mj, sánchez-pobre p, suárez a, cuenca f, de la orden v, et al. vitamin d deficiency and vitamin d therapy in chronic hepatitis c. ann hepatol. 2013;12(2):199-204. 22. mohamed a, sabry n, abbassi m, ibrahim w, alieldin z. vitamin d levels in egyptian hcv patients (genotype 4) treated with pegylated interferon. acta gastro-enterologica belgica. 2013;76. 23. amanzada a, goralczyk ad, moriconi f, van thiel dh, ramadori g, mihm s. vitamin d status and serum ferritin concentration in chronic hepatitis c virus type 1 infection. j. med. virol. 2013;85(9):153441. 24. yu l, yin l, chen w, fan j, cui j, yin j, et al. prospective study on the relation between serum vitamin d levels and liver cirrhosis risk. zhonghua gan zang bing za zhi= zhonghua ganzangbing zazhi= chinese j hepatol. 2013;21(3):202-6. 25. villar lm, del campo ja, ranchal i, lampe e, romero-gomez m. association between vitamin d and hepatitis c virus infection: a meta-analysis. world journal of gastroenterology: wjg. 2013;19(35):5917. j islamabad med dental coll 2020 256 open access psychological impact of covid-19 pandemic on mental health of general population of islamabad, pakistan muhammad afzal1, hameed mumtaz durrani2, muhammad imran sohail3 1 biostatistician, research and publication, shaheed zulfiqar ali bhutto medical university, islamabad pakistan 2 assistant professor, department of community medicine , shifa college of medicine , islamabad pakistan 3 deputy director surveillance, ministry of health who, islamabad pakistan a b s t r a c t background: most of the ongoing research on covid-19 is related to development of an effective vaccine and treatment for this illness, while psychological impact on mental health remains underexplored. the objective of this study was to determine the psychological impact of covid-19 pandemic on the mental health of the general population of islamabad . material and methods: this cross-sectional study was conducted among the general population of islamabad, during a period of two months from 15th may to 15th july 2020. a total of 278 participants were given a structured questionnaire based on hospital anxiety and depression scale (hads) scoring system to calculate depression and anxiety. the possible scores for depression and anxiety ranged 0-21. a cut off value of 8 and above was used to identify anxiety and depression with higher scores indicating increased severity. results: the mean age of the participants was 33.42 ± 9.67 years and 148 (53.2%) were males. among these , 238 (85.6%) were residents of urban area, and 167 (60.1%) were married. most of the participants were graduate 102 (36.7%). thirty-six (12.9%) participants had a known patient of covid-19 in their family or friends. most of the participants 196 (70.5%) had no comorbidity. the mean anxiety score was noted to be 6.47 ± 5.51 and mean depression score was 6.65 ± 4.17. presence of any comorbidity showed a highly significant association with anxiety and depression score (p < .01). conclusions: there was no significant psychological impact of covid-19 on mental health of the population of islamabad. however, people with comorbidities showed a significantly raised anxiety and depression status on the hads score. key words: anxiety, covid-19, depression, general population, mental health authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad afzal email: afzal419@gmail.com article info: received: august 28, 2020 accepted: november 15, 2020 cite this article. afzal m, durrani mh, sohail mi. psychological impact of covid-19 pandemic on mental health of general population of islamabad, pakistan. j islamabad med dental coll. 2020; 9(4): 256-261. doi: 10.35787/jimdc.v9i4.592 funding source: nil conflict of interest: nil i n t r o d u c t i o n covid-19 is a global public health challenge now a days. it has emerged as a pandemic with growing number of cases worldwide. due to rapid spread, it has become a critical challenge for health systems world over, which are failing in prevention, identification and proper management of this infection.1 or i gi n a l a r ti c le j islamabad med dental coll 2020 257 various countries have minimized the spread of covid-19 infection through lock down and social distancing policies. however, in many developing countries like pakistan people are not taking these measures seriously.2 since the mode of spread is mainly droplet infection through person-to-person contact, so the compliance with social distancing interventions is vital to the control of spread. many studies have reported a significant reduction in covid-19 spread by strictly following social distancing measures.3,4 this infectious disease has many physical as well as mental health implications.5 people around the world have many fears and worries associated with it. people start fearing from falling sick or dying and helplessness.6 these feelings worsen due to closure of business and schools compounding the situation. thus, it is not only due to lack of effective treatment or unavailability of vaccine but also due to adverse socioeconomic consequences linked with it. people are affected by unemployment and shortage of necessary commodities as a result of lockdowns or quarantine. these kinds of psychological impacts have also been observed in non-infected community during previous pandemics like sars outbreak. 9 all these factors may have adverse impact on mental health, requiring special attention of health practitioners and researchers around the globe. 7,8 the studies conducted during previous pandemics showed that some factors are significantly associated with stress, anxiety. the factors include older age, female gender, people having higher education level, history of contact with positive cases and individuals having symptoms of disease. the information on impact of covid-19 on mental health of general population is lacking in our country. this information is specially required during a pandemic of such unparalleled magnitude.9,10 the research work on examining the psychological impact of covid-19 on the general population of pakistan is very limited. therefore, this study was planned to investigate the psychological impact and mental health in the general population during the covid-19 outbreak. this may assist government agencies and healthcare professionals in safeguarding the psychological wellbeing of our community in the face of covid-19 outbreak. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in islamabad, pakistan over a period of two months from 15th may to 15th july, 2020. throughout this period a smart or full lock down was enforced by government of pakistan in the country and the number of new and confirmed cases were at a peak. a total of 278 participants were selected for this study by non-probability consecutive sampling technique from the general population of islamabad. both males and females, between 18 to 65 years of age, were enrolled for the study. sample size was calculated with the help of who sample size calculator using confidence level of 95%, anticipated population proportion (rate of depression among general population) of 23.6% and absolute precision of 5%.11 this study was approved by the ethics review board of shaheed zulfiqar ali bhutto medical university dated june 4, 2020. a questionnaire with a statement regarding informed consent, was distributed amongst the participants for documenting demographic information (i.e., age, gender and marital status) in addition to questions related to anxiety and depression, which were part of hads scoring. hads consists of 14 questions, each of which is scored 0– 3. anxiety and depression are evaluated with seven questions each. the lowest possible scores for depression and anxiety are 0, and the highest possible scores are 21. a cut off value of 8 and above was used with higher scores indicating increased severity of anxiety or depression. j islamabad med dental coll 2020 258 all the collected data was entered in statistical package for social sciences (spss version 21.0) for analysis. quantitative data was presented in the form of mean and sd and qualitative data was presented with the help of frequency and percentages. independent sample t-test was applied to compare hads score on the basis of age and gender. one-way anova test was applied to compare mean values of hads score on the basis of education levels, profession, and comorbid diseases. chi-square test was applied to compare qualitative variables like gender, marital status, education level, profession, income loss and comorbid disease. pvalue ≤ .05 was taken as statistically significant. r e s u l t s a total of 278 participants were enrolled in this study. the mean age of the study participants was 33.42±9.67 years and the majority were males 148 (53.2%). most of the participants 238 (85.6%) were residents of urban area, and 167 (60.1%) were married. maximum number of the participants were graduates (n=102; 36.7%) followed by with higher secondary school certification (matriculation) only (n=93; 33.5%). majority of the participants were running their own business (n=99; 35.6%) followed by government employees (n=51; 18.3%). at the time of inclusion in the study, 84 (30.2%) respondents were jobless, mostly due to lockdown (table i). the results of our study showed that 81 (29.1%) participants had anxiety symptoms and 119 (42.8%) respondents appeared to have positive symptoms of depression on the basis of hads scoring system. the mean anxiety score was 6.47 ± 5.51 and the mean depression score was 6.65 ± 4.17 as shown in table ii. the comparison of anxiety and depression score on the basis of gender, marital status, education level, profession and income loss during pandemic showed that no variable had any significant relationship with anxiety or depression score (p > .05). however, presence of comorbidities like diabetes mellitus, hypertension or both had a highly significant association with anxiety and depression score (p < .01) (table iii). d i s c u s s i o n epidemics and pandemics have extreme influences on psychological wellbeing of a given population and the behaviors of the community are influenced by the fear and anxiety of being affected.12 during an infectious pandemic like the covid-19, various preventive measures are adopted to reduce the spread of disease. these measures include self isolation, social distancing and lockdowns, although table i: distribution of demographic characteristics characteristics frequency percentage age of the participant (years) mean ± sd 33.42 ± 9.67 gender of the participant male 148 53.2 female 130 46.8 place of residence urban 238 85.6 rural 40 14.4 marital status married 167 60.1 single 111 39.9 education level illiterate 18 6.5 matric 93 33.5 graduation 102 36.7 post-graduation 65 23.4 profession business 99 35.6 private job 44 15.8 govt. job 51 18.3 jobless 84 30.2 j islamabad med dental coll 2020 259 table ii: descriptive statistics of different variables characteristics frequency percentage income lost due to pandemic yes 131 47.1 no 147 52.9 known patient of covid-19 in family and friends yes 36 12.9 no 242 87.1 history of contact with covid-19 patient in the last week yes 48 17.3 no 230 82.7 comorbidities none 196 70.5 diabetes mellitus 39 14 htn 24 8.6 dm and htn 19 6.8 anxiety status on the basis of hads score no anxiety symptoms (< 8) 197 70.9 anxiety symptoms (≥ 8) 81 29.1 depression status on the basis of hads score no depression symptoms (< 8) 159 57.2 depression symptoms (≥ 8) 119 42.8 table iii: association of anxiety and depression score with different variables characteristics anxiety score p-value* depression score p-value* mean sd mean sd gender of the participant male 6.40 5.368 .806 6.71 4.208 .804 female 6.56 5.684 6.58 4.150 marital status married 6.63 5.65 .554 6.71 4.209 .786 single 6.23 5.305 6.57 4.138 education level illiterate 5.06 4.721 .239 6.94 4.556 .989 matric 5.95 5.378 6.58 4.079 graduation 7.27 5.880 6.68 4.191 post-graduation 6.37 5.222 6.63 4.267 profession business 7.01 5.618 .310 6.32 4.522 .420 private job 5.30 5.083 6.14 3.968 govt. job 5.98 5.210 6.82 3.871 jobless 6.76 5.741 7.20 4.026 income lost due to pandemic yes 6.92 5.559 .200 6.73 4.188 .780 no 6.07 5.451 6.59 4.174 comorbidities none 4.87 4.200 .001 5.84 3.889 .001 diabetes mellitus 10.28 5.987 9.05 4.365 hypertension 7.29 6.203 7.04 4.048 dm and htn 14.16 5.336 9.63 3.715 j islamabad med dental coll 2020 260 at the same time number of patients with the disease and death rates increases significantly. mental health of the society gets adversely affected by all these factors. the psychological effects of the pandemic may be expected in terms of high depression and anxiety levels.13,14 in our study, although 47.1% participants reported loss of income due to pandemic, but there was no statistically significant association with anxiety or depression. this is quite contrary to the findings of holmes et al. in their comparative study between israel and us respondents. they found a significant association between losing income due to covid-19 and anxiety and depression symptoms.15 there may be a chance that the difference in findings is due to difference in sample size as we had a limited sample size of 278 participant and holmes at al. compared two independent studies with a collective sample of around 6500 participants. we cannot ascertain that the use of different scales (hads in our study and gad-7 in other) for measuring anxiety and depression could have been responsible for different findings because both scales are termed equally reliable for the purpose. however, we believe that the magnitude of the disaster and sensitivity to its fatalness might have been one of the causes of difference in results. according to cao and colleagues, the chance of anxiety and depression increased three times (or = 3.00) if the participant had a positive case of infection in family or friends.16 in our study, we had a limited number of people (12.9%) having a patient of covid-19 in relatives and friends and this was not significantly associated with the symptoms of anxiety and depression. we think that this may be due to the limited spread of the disease in islamabad at the time of data collection (may to july, 2020). an important finding of our study was that the presence of comorbidities like diabetes mellitus and hypertension is the most significant risk factor of developing anxiety and depression. these observations are in-line with results of ozdin and coworkers.11 they reported similar findings in their study using the hads. in addition, they found that being females and residents of urban areas was also significantly associated with symptoms of anxiety and depression. in our study however, the mean scores of males and female participants of urban and rural areas was within the normal range of hads. psychological aspect of pandemic has equal importance in terms of proper management as the physical health.17 to minimize the effect of covid19 pandemic on mental health of the general population, attention should be given to the vulnerable groups like unemployed individuals and people with chronic comorbidities, like diabetes mellitus and hypertension. this study was conducted on the population of a single city; therefore, the results cannot be generalized. this became a major limitation of our study. more studies on a larger scale should be conducted to ascertain the exact impact of covid 19 pandemic on mental health of the general population of pakistan. c o n c l u s i o n there was no significant psychological impact of covid-19 on mental health of the population of islamabad. however, people with comorbidities showed a significantly raised anxiety and depression status on the hads score. r e f e r e n c e s 1. legido-quigley h, asgari n, teo yy, leung gm, oshitani h, fukuda k, et al. are high-performing health systems resilient against the covid-19 epidemic? lancet. 2020; 395(10227): 848 -50. doi: 10.1016/s0140-6736(20)30551-1. 2. shoaib m, abdullah f. risk reduction of covid-19 pandemic in pakistan. soc work public health. 2020; 35(7): 557-68. doi: 10.1080/19371918.2020.1806172 3. ahmed f, zviedrite n, uzicanin a. effectiveness of workplace social distancing measures in reducing j islamabad med dental coll 2020 261 influenza transmission: a systematic review. bmc public health. 2018; 18(1): 1–13. doi: 10.1186/s12889-018-5446-1 4. roy d, tripathy s, kar sk, sharma n, verma sk, kaushal v. study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid-19 pandemic. asian j psychiatr. 2020; 51: 102083. doi: 10.1016/j.ajp.2020.102083 5. galea s, merchant rm, lurie n. the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention. jama intern med. 2020; 180(6): 817 -8. doi: 10.1001/jamainternmed.2020.156 2. 6. van bortel t. psychosocial effect of an ebola outbreak at individual, community and international levels. bull world health organ. 2016; 94(3): 210 -4. doi: 10.2471/blt.15.158543 7. nicola m, alsafi z, sohrabi c, kerwan a, al-jabir a, iosifidis c, et al. the socio-economic implications of the coronavirus pandemic (covid-19): a review. int j surg. 2020; 78: 185-93. doi: 10.1016/j.ijsu.2020.04.018 8. holmes ea, o'connor rc, perry vh, tracey i, wessely s, arseneault l, et al. multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. lancet psychiatr. 2020; 7(6): 547-60. doi: 10.1016/s2215-0366(20)30168-1 9. xiong j, lipsitz o, nasri f, lui lmw, gill h, phan l, et al. impact of covid-19 pandemic on mental health in the general population: a systematic review. j affect disord. 2020; 277: 55-64. doi: 10.1016/j.jad.2020.08.001 10. wang c, pan r, wan x, tan y, xu l, ho cs, et al. immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. int j environ res public health. 2020; 17(5): 1729. doi: 10.3390/ijerph17051729 11. ozdin s, bayrak ozdin s. levels and predictors of anxiety, depression and health anxiety during covid19 pandemic in turkish society: the importance of gender. int j soc psychiatry. 2020; 66(5): 504 -11. doi: 10.1177/0020764020927051 12. banerjee d. the covid-19 outbreak: crucial role the psychiatrists can play. asian j psychiatr. 2020; 50: 102014. doi: 10.1016/j.ajp.2020.102014 13. shi l, lu za, que jy, huang xl, liu l, ran ms, et al. prevalence of and risk factors associated with mental health symptoms among the general population in china during the coronavirus disease 2019 pandemic. jama. 2020; 3(7): e2014053. doi: 10.1001/jamanetworkopen. 2020.14053 14. asmundson gjg, taylor s. how health anxiety influences responses to viral outbreaks like covid19: what all decision-makers, health authorities, and health care professionals need to know. j anxiety disord. 2020; 71: 102211. doi: 10.1016/j.janxdis.2020.102211 15. hertz-palmor n, moore tm, gothelf d, didomenico ge, dekel i, greenberg dm, brown la, matalon n, visoki e, white lk, himes mh, lifshitz-schwartz m, gross r, gur rc, gur re, pessach im, barzilay r. association among income loss, financial strain and depressive symptoms during covid-19: evidence from two longitudinal studies. medrxiv [preprint]. 2020 sep 18: 2020.09.15.20195339. doi: 10.1101/2020.09.15.20195339. 16. cao w, fang z, hou g, han m, xu x, dong j, zheng j. the psychological impact of the covid-19 epidemic on college students in china. psychiatry res. 2020; 287: 112934. doi: 10.1016/j.psychres.2020.112934. 17. betsch c, wieler lh, habersaat k; cosmo group. monitoring behavioral insights related to covid-19. lancet. 2020; 395(10232): 1255 -6. doi: 10.1016/s0140-6736(20)30729-7 87 j i m d c 2 0 1 7 87 op e n ac c e ss f u l l l e n g t h a r t i c l e inadequate glycemic control failure of counseling or compliance? namrah mahmood 1, haroon khan 2, saman waqar 3 1 house officer, department of pathology, pakistan institute of medical sciences, islamabad 2 associate professor of chemical pathology, pakistan institute of medical sciences, islamabad 3 assistant professor, department of pathology, pakistan institute of medical sciences, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) a b s t r a c t objectives: to find out the level of counseling provided by physician to diabetic patients with hba1c > 6.5% and to determine the patient’s compliance regarding diabetes and its control. material & methods: in this cross-sectional study type 2 diabetic patients were inducted using convenient sampling technique. a structured questionnaire with closed ended questions was used. interviews were conducted by researchers after obtaining written informed consent. spss version 20 was used for analysis. chi-square test was applied to find association between variables. result: out of 155 participants, 141 (91%) patients knew that they have high glucose level but they have no information regarding reason of these elevated levels. counselling regarding, pharmacological therapy, dietary changes, importance of exercise and about regular foot examination was provided to 92.3%, 86.5%, 61.9% and 19.4% patients respectively. patients compliance was highest to pharmacological treatment (67.7%) followed by regular visits and physical exercise (51.6% and 51%) respectively. however, 49.7% (n=77) of the participants do not check their blood glucose levels at all. there was statistically strong association between level of counseling with compliance of the participants regarding both pharmacological treatment (p=0.03) and exercise (p<0.001). conclusion: counseling played a pivotal role in compliance of treatment. in this study counseling was good about treatment regimens as compared to lifestyle changes. therefore, a large number of the participants showed good compliance for treatment. patient tailored approach should be adopted by physicians dealing with diabetes, with more emphasis to introduce lifestyle changes. keywords: diabetes mellitus, glycemic control, hba1c.. author`s contribution 1conception, synthesis, planning of research and manuscript writing interpretation and discussion, data analysis,2,3active participation in active methodology address of correspondence dr. namrah mahmood dr.namrahmahmood@gmail.com article info. received: mar 6, 2017 accepted: may 27, 2017 cite this article: mahmood n, khan h, waqar s. inadequate glycemic control failure of counseling or compliance? jimdc. 2017; 6(2):87-90 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus is prevalent throughout the world with a rising trend among developing countries. according to who, 9% of the total world population was diabetic in 2014.1 pakistan stands as the 7th largest country in terms of diabetes burden with 10% of its population having the disease out of which 66% have highly deranged hba1c value.2,3 according to pakistan national diabetes survey 13.9% adult population (>25 years) of sindh has type 2 diabetes mellitus.4 about 8.6% baluchi population has diabetes mellitus type 2.5 in nwfp 11.6% adult women and 9.2% adult men have type 2 diabetes mellitus.6 proper control of blood sugar level is needed in order to avoid long term complications and morbidity associated with diabetes mellitus. physician patient interaction is an o r i g i n a l a r t i c l e mailto:dr.namrahmahmood@gmail.com 88 j i m d c 2 0 1 7 88 important element for improvement of overall health. especially in uncontrolled diabetes, this interactive approach is proved to be more beneficial. it is a frequent observation that patient tailored approach is not considered by general practitioners while prescribing drugs or suggesting lifestyle changes. education regarding diabetes mellitus including proper instructions related to use of anti-diabetic drugs, lifestyle modification like dietary habits, maintenance of exercise and selfmonitoring of blood sugar levels, is a complex health intervention which is a cornerstone for improving glycemic control.7 the compliance of the patient is equally important in this regard. the management of diabetes is a life-long measure and it is difficult to carry out and maintain lifestyle changes. high levels of motivation and support is needed for the patient to be compliant. above stated voids result in poor glycemic control and highly deranged values of glycosylated hemoglobin (hba1c). aim of the study was to find out the level of counseling provided by physicians to diabetic patients, their compliance regarding diabetes and control. m a t e r i a l s a n d m e t h o d s a cross sectional study was conducted among patients of type 2 diabetes mellitus with deranged hba1c (value >6.5%) visiting department of pathology, pakistan institute of medical sciences (pims), islamabad from june-august 2016. permission from the hospital ethical committee was taken. participants were selected by convenient sampling technique with a sample size of 155, based on confidence level of 95%, confidence interval of 5 and population size of 260 (as calculated by a pilot survey). the questionnaires were filled by researchers after obtaining written informed consent from the participants. data including variables such as age, gender, bmi, education, diabetes duration, type of treatment offered, status of late complications, and current hba1c levels was recorded. counseling by the physician and compliance of the participant regarding diabetes and its management was assessed using a closed ended questionnaire. the collected data was analyzed using spss version 20 and presented as tables and graphs. chi square test was used to find associations between variables. r e s u l t s mean age of participants was 57.18 ±10.07. number of male participants was more than female participants. majority of the participants had education less than matriculation. most of the participants were in the category of overweight. duration of disease for most of the participants was between 5-10 years. hba1c levels of majority of the participants were between 7-10% (table 1). treatment offered to a vast majority was pharmacological only (n=89, 57.4%). late complications had occurred in 104 (67.1%) participants, hypertension was the comorbid (n=82, 52.9%). table 1: demographic characteristics of participants (n=155) variables frequency (n) percentage (%) age (years) 20-40 40-60 >60 15 81 59 10 52 38 gender distribution male female 82 73 53 47 education matric & above below matric 69 86 45 55 bmi normal overweight 37 118 24 76 duration of disease <10 years >10 years 115 40 74 26 hba1c (%) <6.5 6.5-7 7.1-10 >10 3 38 61 53 2 25 39 34 late complications present 104 67 regarding awareness of patients one hundred and forty one (91%) participants identified that they have high glucose levels but only 10 (6.5%) participants knew exactly that it is due to insulin resistance or deficiency. knowledge about late complications of the disease was good as 125 (80.6%) participants knew about at least one complication and 67 (43.2%) participants could identify most of the complications. 89 j i m d c 2 0 1 7 89 as far as counselling was concerned, more counseling was performed for pharmacological therapy (92.3%). large number of participants were counseled about dietary changes (86.5%) and importance of exercise (61.9%) in the treatment of diabetes but counseling regarding regular foot examination was conducted to only 19.4% participants. even less information (45.2%) was provided about glucometer and the importance of its regular use (figure 1). figure 1: counseling provided by physician to patients of type 2 diabetes mellitus (n=155) patient’s compliance to pharmacological treatment was good, as 67.7% participants followed their medications as prescribed. regular follow up and physical exercise was maintained by 51.6% and 51% patients respectively. however 49.7% of the participants do not check their blood glucose levels at all (table 2). table 2: frequency of checking blood sugar level in patients of type 2 diabetes mellitus (n=155) sugar checked frequency (n) percentage (%) everyday 35 22.6 only when you think sugar level is high 43 27.7 do not check 77 49.7 there was strong association between level of counseling with compliance of the participants regarding both pharmacological treatment (p=0.03) and exercise (p<0.001). patients having more knowledge of disease showed significantly low hba1c levels (p<0.001). education had also a significant association with compliance to follow-up (p<0.001). age group of 40-60 years and male gender had a significant association with compliance to pharmacological management (p=0.001) and physical activity (p<0.001) respectively. there was more compliance of participants with duration of disease less than 5 years (p<0.001). d i s c u s s i o n in our study it was observed that participants who had more knowledge regarding diabetes were more compliant to follow the treatment, both in the form of pharmacological management as well as lifestyle modification. in conformity to the findings of the current study, a work was done by girish et al in india.8 study reported that good knowledge regarding the disease was directly related to participant’s compliance in both pharmacological and non-pharmacological management options. study was conducted at a rural hospital of maharashtra. most of the participants had chronic diabetes but their knowledge regarding occurrence of disease and self-care was very poor. that study suggested that arrangement of seminars, counseling sessions and workshops for the patients of diabetes mellitus can be helpful in increasing disease awareness and improving patient’s compliance. however, another study conducted at china revealed no association between knowledge about diabetes and compliance.9 author study reported that there is a gap between information provided to the patients and practical demonstration performed by them. majority of the patients gave good response on question asked about factual knowledge of diabetes. but they failed to apply the provided knowledge in their real life for a quality time. this study suggested that only provision of knowledge is not sufficient, different strategies should to be adopted to improve patient’s attitudes, beliefs and learning abilities. in the current study 80.6% participants knew about at least one of the complications of diabetes, but only 19.4% knew about the importance of regular foot examination. in egypt, a study was conducted at outpatient clinics of three family health centers. among 750 respondents, 0.5% knew about compromised immunity in diabetes, 61.5% were aware of stroke, cardiac, renal and retinal complications while 77.5% of patients recognized the importance of diabetic foot protection and care.10 counseling by physician 90 j i m d c 2 0 1 7 90 comparable results were obtained in a study conducted at south india. study reported that patients have relatively good knowledge about risk factors of diabetes and its complications. about 79.3% individuals knew about at least one complication of diabetes mellitus including eye problems, renal diseases, heart diseases or neuropathies. about 54% of patients were aware of foot care.11 it is observed in the current study that apart from counseling, other variables may contribute to compliance including education, age group, gender and duration of disease. well educated participants, age group between 40-60 years, male gender and shorter duration of disease resulted in more compliance regarding treatment of diabetes. these findings are supported by iswarya et al in south india.11 they reported that education has significant positive impact on compliance of patients. besides this, patients having less than four years of disease showed non-significant but more compliance towards disease. similar results were also reported in south wales by ruth et al which stated that males performed more physical exercise than females.12 they also concluded that females have more inclination to visit dieticians, and old age group is less compliant with respect to dietary modifications and glucose monitoring. these associations are not proven significant in our study. c o n c l u s i o n it was found that counseling plays a pivotal role in compliance to treatment. other factors contributing to increased compliance included higher education status and male gender. as more counseling was provided regarding pharmacologic management, hence had better compliance as compare to lifestyle modifications. patient tailored approach should be adopted by physicians, with more emphasis on providing necessary motivation to introduce lifestyle changes. a detailed diet and exercise plan along with explanation regarding pharmacologic management should be provided to every patient at the time of diagnosis of diabetes after a thorough interview. r e f e r e n c e s 1. world health organization. diabetes.2016: http://www.who.int/mediacentre/factsheets/fs312/en/ 2. http://diabetespakistan.com/treatment/2013/05/08/diabetes -statistics-in-pakistan/ 3. zaidi smh, ghafoor a, randhawa fa. hba1c as an indirect marker marker of hypertriglyceridemia in type 2 diabetes mellitus. j ayub med coll abbottabad 2015; 27(3):601-603. 4. shera a, rafique g, khwaja i, ara j, baqai s, king h. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in shikarpur, sindh province. diabetic medicine. 1995; 12(12):1116-1121. 5. shera a, rafique g, khawaja i, baqai s, king h. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in baluchistan province. diabetes research and clinical practice. 1999; 44(1):4958. 6. akhter j. the burden of diabetes in pakistan: the national diabetes survey. jpma. 1999; 49(9):205-206. 7. pimouguet c, le goff m, thiebaut r, dartigues j, helmer c. effectiveness of disease-management programs for improving diabetes care: a meta-analysis. cmaj, 2011; 183(2):e115–e127. 8. chavan gm, waghachavare vb, gore ad, chavan vm, dhobale rv, dhumale gb. knowledge about diabetes and relationship between compliance to the management among the diabetic patients from rural area of sangli district, maharashtra, india. journal of family medicine and primary care. 2015; 4(3):439. 9. chan, y. m., and a. molassiotis. the relationship between diabetes knowledge and compliance among chinese with non-insulin dependent diabetes mellitus in hong kong. journal of advanced nursing. 1999; 30(2):431-438. 10. el-khawaga g, abdel-wahab f. knowledge, attitudes, practice and compliance of diabetic patient in dakahlia, egypt. european journal of research in medical sciences. 2015; 3(1):40-53. 11. santhanakrishnan i, lakshminarayanan s, kar ss. factor’s affecting compliance to management of diabetes in urban health center of a tertiary care teaching hospital of south india. journal of natural science, biology, and medicine. 2014; 5(2):365. 12. lo r, maclean d. a survey of people with diabetes in northern new south wales: problems with self-care. international journal of nursing practice. 1996; 2(1):11-20. http://diabetespakistan.com/treatment/2013/05/08/diabetes-statistics-in-pakistan/ http://diabetespakistan.com/treatment/2013/05/08/diabetes-statistics-in-pakistan/ j islamabad med dental coll 2019 208 op e n ac c e s s marsupialization followed by enucleation and chemical cauterization for treatment of odontogenic keratocyst involving maxillary sinus: a case report muhammad jamal1, muhammad zeeshan baig1, laiba saher2, muhammad asim2 1 assistant professor, department of oral and maxillofacial surgery, islamabad medical and dental college islamabad. 2 postgraduate resident, department of oral and maxillofacial surgery, islamabad medical and dental college, islamabad. a b s t r a c t odontogenic keratocysts are odontogenic cysts which have locally infiltrative behavior. they mostly occur in second and fourth decades but can occur at any age throughout life. in majority of cases, they are located in the posterior region of mandible, but can also be found in the maxilla especially in the canine region. in this article, we have discussed the diagnosis and management of a large odontogenic keratocyst cyst involving the maxillary sinus. a 22 years old male patient presented with pain and swelling on right side of the face since last one year. there was history of pus discharge and gradual increase in size of the swelling since last 3-4 months. patient took antibiotics but there was no improvement. odontogenic keratocyst is a developmental pathology which arises from additional remnants of dental lamina of oral epithelium. they present with swelling, pain and pus formation/discharge as signs of infection. often, when the lesion is large there can be paresthesia of the lower lip. these lesions can also be clinically asymptomatic. mostly they appear as well-demarcated unilocular radiolucency having a thin, sclerotic well-defined margin. there are many treatment options like enucleation, marsupialization, decompression, curettage, use of chemical agents like carnoy's solution, cryotherapy with liquid nitrogen or peripheral osteotomy and surgical resection of lesion. key words: chemical cauterization, enucleation, marsupialization, maxillary sinus, odontogenic kerotocyst correspondence: muhammad jamal email: jamal_kcd@hotmail.com article info: received: september 15, 2019 accepted: november 2, 2019 cite this case report: jamal m, baig mz, saher l, asim m, ahmed m. marsupialization followed by enucleation and chemical cauterization for treatment of odontogenic keratocyst involving maxillary sinus: a case report. j islamabad med dental coll. 2019; 8(4):208-212. funding source: nil conflict of interest: nil i n t r o d u c t i o n odontogenic keratocysts (okc) are odontogenic cysts which have locally infiltrative behavior.1 odontogenic keratocysts mostly occur in second and fourth decades but can occur at any age throughout life. they have a predilection for males and are more frequent in the posterior region of the mandible.2 most of the cases are incidentally discovered on routine radiographs for dental problems. mostly they appear as well-demarcated unilocular radiolucency having a thin, sclerotic well-defined margin. they can be multilocular or unilocular in nature, frequently penetrating the cortical bone of the jaw and adjacent anatomical structures. many times, teeth which are in approximation can be displaced and no root resorption occurs.1 involvement of the maxillary sinus by okc is rare with <1% of cases reported in the literature.3 the maxillary sinus is a part of the paranasal sinuses, in proximity with developing tooth and root apices of premolar and molars. it is vulnerable to odontogenic infection, cyst and tumors of odontogenic origin. diagnosis of such lesion is challenging as maxillary radiographs do not offer characteristic features due to overlapping of various structures.2 c a s e r e p o r t a 22-year-old male patient presented to omfs department with the complaints of pain and swelling on the right side of face for last one year. since last 3-4 months, there was c a s e r e p o r t j islamabad med dental coll 2019 209 gradual increase in size of the lesion. there was a history of pus discharge intraorally from upper right posterior teeth since last few months. patient was taking antibiotics for pain and swelling since last 3 months. clinically there was diffuse firm swelling involving the right maxillary premolarmolar region. permanent canine was missing in the arch and the deciduous canine was present intraorally. upper right premolars and first molar teeth were non-vital. patient was advised opg which showed impacted canine and radiolucency involving the premolar and first molar. biopsy was done and specimen was sent for histopathology examination. the lesion was diagnosed as odontogenic keratocyst. patient was sent for ct scan, which showed well defined lobulated cystic lesion arising from right maxillary alveolus and extending into the ipsilateral maxillary sinus superiorly (figure 1a). the lesion was centered around the crown of impacted right maxillary canine tooth measuring 3.8x2.2x3cm. there was bony erosion of the lateral wall of the lesion adjacent to the mesial border of the masseter muscle and anterior border of lateral pterygoid (figure 1b). posteriorly, it was limited by the posterior wall of the maxillary sinus and body of pterygoid bone and its plates were well-preserved. patient was informed about the clinical condition and with his consensus, marsupialization was planned. under local anesthesia, right upper vestibular incision was made in premolar-molar region. the lesion was exposed (figure 2a), irrigated and nasopharyngeal airway tube (cut to fit the size of the lesion) was placed and sutured with the surrounding mucosa. patient was given tablet augmentin (625mg), tablet gramex (400mg) and tablet torex ir (550mg) for 5 days and advised daily irrigation, maintenance of good oral hygiene and regular follow up. also, the involved teeth were endodontically treated. follow up radiograph (opg) was advised after 3 months. on follow up visit following surgery, size of the lesion and white cheesy discharge was reduced and there was no pus discharge. ct scan was advised 6 months postmarsupialization, which showed regression in size of the lesion (now measuring 1.8 x 2.3 x 1.9 cm), thick and smooth walls with internal foci of calcification along internal wall. bony erosion of the lateral wall of the lesion was still present. as the lesion was responding to marsupialization, it was planned to continue the same treatment for another 6 months. however, the patient was not willing to continue with a prolonged treatment, so enucleation with chemical cauterization under general anesthesia (ga) was planned as an alternative. all the pre-operative work up for ga fitness was done and surgery planned. under aseptic measures, standard draping and ga, nasopharyngeal airway tube placed for marsupialization was removed and right upper vestibular incision made from canine to second molar region. flap was elevated and the lesion was exposed. the lining of the lesion was detached from maxillary sinus membrane and overlying mucosa without disrupting the continuity of sinus membrane (figure 2b, c & d). impacted canine was exposed, sectioned and removed along with the lining (figure 2e, f & g). apicectomy of the involved endo-treated teeth was performed. gauze soaked in corney`s solution was placed in the cavity for 3 minutes after which the cavity was irrigated with copious saline, hemostasis achieved and the incision was closed with 3-0 vicryl. intraoral tail pack was placed in the oral cavity and the patient was shifted to the ward in a stable condition after recovery. patient was on regular follow up with postoperative radiograph at 3-month, 6 month and 1-year interval (figure 3) to rule out recurrence and amount of bone formation during healing. d i s c u s s i o n odontogenic keratocyst is a developmental pathology which arises from additional remnants of dental lamina of oral epithelium. it is 2-11% of all odontogenic cysts, can occur at any age throughout life and has a male to female ratio of 2:1.4 okc involves both the jaws, but the mandible is more often involved than the maxilla. j islamabad med dental coll 2019 210 figure 1: (a) coronal view shows the lesion involving the entire right maxillary sinus. (b) axial view shows the lesion causing bony erosion of the lateral wall of maxillary sinus j islamabad med dental coll 2019 211 in mandible, the highest frequency occurs in the body of the mandible (20%) followed by the angle of the mandible (18%) and vertical ramus (10%), but in the maxilla, it is seen most commonly in the canine area, followed by third molar tuberosity and anterior maxilla.2,3 maxillary sinus pathology can occur when the schneiderian membrane is breached by conditions such as the odontogenic pathology of the maxillary bone. odontogenic infections and pathology account for 11%–12% cases of maxillary sinusitis.3 figure 3: post-operative occipitomental view one year after surgery showing normal maxillary sinus with no haziness and adequate distal bone formation okcs presents with swelling, pain and pus formation/discharge as signs of infection. often, when the lesion is large, there can be paresthesia of the lower lip. these lesions can also be clinically asymptomatic. they are often associated with basal cell naevus syndrome, also called as gorlin's syndrome, in which there are okc lesions, skin basal cell carcinomas, falx calcifications and skeletal abnormalities. a perceptible number of cases are diagnosed incidentally during regular dental inspections.4,5 radiographs show unilocular or multilocular radiolucency with uniform sclerotic borders which may be involving an unerupted tooth, mostly impacted third molar. bone expansion is not well noted.6 on histopathological examination, a cystic lining with desquamated epithelium, 6-10 cell thick lining of para keratinized stratified squamous epithelium with palisading basal cell layer of even thickness is seen.7 there are many treatment options like enucleation, marsupialization, decompression, curettage, use of chemical agents like carnoy's solution, cryotherapy with liquid nitrogen or peripheral osteotomy and surgical resection of lesion.5,8 the choice of treatment is decided on various factors which include age, size and recurrence. but generally, in young patients, conservative treatment is always preferred.5 marsupialization has a promising outcome. in large lesions, if surgical approach is selected, there are chances of damage to adjacent structures like maxillary antrum and inferior alveolar canal. when treating large lesions, enucleation should be done to avoid sinusitis, mandibular fracture, mandibular continuity defect or fistulae formation of any form. allon and colleagues have quoted a number of studies advocating the use of decompression plus marsupialization as a definitive treatment approach.9 chemical cauterization is a treatment choice for the keratocystic odontogenic tumor. previously, carnoy’s solution composing of ethanol, chloroform, glacial acetic acid, ferric chloride was used because of its hemostatic action and local fixation. however, fda restricted agents that contained chloroform and since then carnoy’s solution is made without chloroform.9 because of increased mitotic activity, okc has increased aggressiveness. the epithelial cells of okc and microcysts, are often found in the mucosa of the alveolar ridges which can cause recurrence.10,11 long term follow-up with clinical and radiographic examination is essential up to five post-surgical years to rule out recurrence.12 c o n c l u s i o n accurate diagnosis of odontogenic keratocysts is essential for proper therapy and follow-up. marsupialization results in new bone formation and thickening of the cyst wall and makes enucleation at a later stage easier. treatment of odontogenic keratocysts by enucleation and chemical cauterization using carnoy’s solution shows a low recurrence rate. adherence to a therapeutic protocol in the treatment of okc and systematic and long-term postoperative follow-up are key elements of a successful outcome. j islamabad med dental coll 2019 212 r e f e r e n c e s 1. santos rs, de moraes ramos-perez fm, do amaral silva gk, rocha ac, prado jd, da cruz perez de. odontogenic keratocyst: the role of the orthodontist in the diagnosis of initial lesions. am j orthod dentofacial orthop. 2017; 152(4): 553-6. doi: 0.1016/j.ajodo.2017.06.013 2. mortazavi h, baharvand m, safi y, behnaz m. common conditions associated with displacement of the inferior alveolar nerve canal: a radiographic diagnostic aid. imaging sci dent. 2019; 49(2): 79-86. doi:10.5624/isd.2019.49.2.79 3. sheethal hs, rao k, umadevi hs, chuhan k. odontogenic keratocyst arising in the maxillary sinus: a rare case report. j oral maxfac pathol. 2019; 23 (suppl 1): 74-7. doi: 10.4103/jomfp.jomfp_319_18 4. marcelis s, van damme s, vanhoenacker f. odontogenic keratocyst of the mandible. eurorad. 2018. doi: 10.1594/eurorad/case.16132 5. de molon rs, verzola mh, pires lc, mascarenhas vi, da silva rb, cirelli ja, barbeiro rh. five years followup of a keratocyst odontogenic tumor treated by marsupialization and enucleation: a case report and literature review. contemp clin dent. 2015; 6 (suppl 1): s106. doi: 10.4103/0976-237x.152963 6. de castro ms, caixeta ca, de carli ml, júnior nv, miyazawa m, pereira aa, sperandio ff, hanemann ja. conservative surgical treatments for nonsyndromic odontogenic keratocysts: a systematic review and meta-analysis. clin oral investig. 2018; 22: 2089-101. 7. tarallo am, de souza matos f, de souza vf, paranhos lr, herval ám, valera mc, carvalho ca. odontogenic keratocyst: a case report emphasizing on root canal treatment after surgical intervention. iej. 2019; 14(2):160-5. doi: 10.22037/iej.v14i2.23984 8. ecker j, ter horst r, koslovsky d. current role of carnoy's solution in treating keratocystic odontogenic tumors. j oral maxillofac surg. 2016; 74(2): 278-82. doi: 10.1016/j.joms.2015.07.018 9. allon dm, allon i, anavi y, kaplan i, chaushu g. decompression as a treatment of odontogenic cystic lesions in children. j oral maxillofac surg. 2015; 73(4): 649-54. doi: 10.1016/j.joms.2014.10.024 10. us food and drug administration. "sec. 460.200 in fda compliance policy guides." fda, washington, dc: 219, 1992. 11. slusarenko da silva y, naclério-homem mg. conservative treatment of primary and nonsyndromic odontogenic keratocyst: an overview of the practice. int j oral dent health. 2018; 4: 070. doi: 10.23937/2469-5734/1510070. 12. gnanaselvi up, kamatchi d, sekar k, narayanan bs. odontogenic keratocyst in anterior mandible: an interesting case report. j indian acad dent spec res. 2016; 3: 22. doi: 10.4103/2229-3019.192466. summary journal of islamabad medical & dental college (jimdc); 2016:5(4):165-167 165 original article determination of reference range of glycosylated haemoglobin (hba1c) for different age groups nousheen bhatti1, anjum iqbal2, ayaz hussain qureshi3 1assistant professor, chemical pathologist, wah medical college, wah cantt 2 professor, chemical pathologist, wah medical college, wah cantt 3 professor, hod pathology, wah medical college, wah cantt abstract objective: to determine the reference interval of glycosylated haemoglobin for different age groups in our local pakistani population. subjects & methods: total number of 164 healthy adults (91 females and 73 males), were selected through nonprobability consecutive sampling. after informed consent, venous blood sample (3-4 ml) from each subject was collected in edta vial under aseptic conditions. haemolysed blood was used for estimation of hba1c by fast ion-exchange resin separation method on microlab 300. the participants of the study were divided into three groups according to their age distribution. all data was analysed using microsoft excel and statistical software minitab15. mean and sds were calculated for each group. reference range of hba1c was calculated for each group by using the formula mean ± 2sd. results: one hundred and sixty-four healthy individuals were included in the study. mean age of the individuals was 32±11.6 years and mean hba1c level was 4.17±0.93%. the reference range of hba1c for age group 20-30 years was 2.09-5.57% with the mean value of 3.83±0.87%. the reference range of hba1c for age group 31-40 years was 2.63-5.99% with the mean value of 4.31±0.84%.the reference range of hba1c for individuals > 40 years of age was 2.8-6.4% with the mean value of 4.31±0.9%. conclusion: for proper assessment of the diabetic status, it is mandatory that every lab should establish its own reference range of hba1c for both genders and different age groups representing its patient population. key words: glycosylated hemoglobin ,pakistan, population, reference range introduction diabetes mellitus is a major healthcare issue worldwide and the global burden of diabetes has been rising in both developed and developing countries. type 2 diabetes accounts for majority (90%) of the cases of diabetes mellitus. sedentary lifestyle and eating habits are the major contributory factors. according to national diabetes survey, 14.5 million cases of type 2 diabetes will be there in pakistan till 2025. regarding prevalence of diabetes, among the top ten countries of the world, pakistan will be at fourth number in 2025.1 diabetes mellitus is associated with long term microvascular and macrovascular complications like retinopathy, neuropathy, and nephropathy thus increasing the overall morbidity and mortality.2,3 glycosylated haemoglobin(hba1c) is an index of glycemic status in diabetics mellitus. blood glucose attaches hba1c non-enzymatically to n-terminal valine residue of the βchain of hemoglobin resulting in the formation of glycated hemoglobin.4 it provides an estimate of diabetic control over the preceding two to three months.5,6 in addition to monitoring of diabetic control, american diabetic association in 2010, finally recommended hba1c to be used as a diagnostic test.7 after a lot of resistance, who also endorsed this recommendation in 2011 and hba1c is now widely used as a diagnostic test.3 the biggest advantage of hba1c is that fasting state is not required. this has led to broadening of screening base and many of those patients can be screened who cannot get their test done in fasting state. in addition to that, hba1c analysis is associated with less biological variability and pre-analytic instability than that of fasting plasma glucose.8-11 it is not influenced by acute changes in blood glucose levels that occur in stress or illness. so the routine analysis of hba1c has gained importance regarding diagnosis, management and prevention of long term complications of diabetes.7 irrespective of all advantages of hba1c, there are some challenges related to its analysis. the foremost is the lack of standardization of methods used for hba1c analysis by most of the laboratories. there are different types of methods used for estimation of hba1c level.12,13 they include high corresponding author: dr. nousheen bhatti e-mail: nousheenbhatti@yahoo.com received oct 13, 2016; accepted dec 22,2016 mailto:nousheenbhatti@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):165-167 166 performance liquid chromatography, affinity chromatography, cation exchange chromatography, isoelectric focusing, radioimmunoassay, spectrophotometric assay, electrophoresis and electrospray ionization mass spectrometry.13 point of care testing devices have also been introduced but they are not much accurate and precise.7 although these assays are based on different principles, standardization should be achieved according to the reference method of the international federation of clinical chemistry (ifcc) and the national glycohemoglobin standardization programme (ngsp).14,5 there is broad variation in method selectivity by variable laboratories in the world leading to inconsistent results. harmonization of the results is the need of the day to achieve best clinical utility of hba1c.global standardization of hba1c results with respect to post-analytical issues like measurement units and reference interval should also be addressed.15 reference values of hba1c in different populations based on different age groups, ethnicity and specific patient group remains a challenge. it is mandatory that every lab should establish its own reference range.4,12 we planned the study to achieve the reference interval of glycosylated haemoglobin for different age groups of pakistani population in wah cantt. subjects and methods this cross sectional study was carried out in the department of pathology at wah medical college, wah cantt from february to august, 2016.total number of 164 healthy adults (91 females and 73 males), comprising the medical students and staff members of wah medical college/hospital who were normoglycemic and normotensive, had no other co-morbid condition were selected through non-probability consecutive sampling while the subjects who were diabetic or had impaired glucose tolerance were excluded based on history and laboratory investigations. after informed consent, venous blood sample (3-4 ml) from each subject was collected in edta vial under aseptic conditions. hemolysed blood was estimated for hba1c within one hour after sample collection on microlab 300, using human kit based on ion-exchange chromatography technique. the participants of the study were divided into three groups according to their age distribution. group 1 comprised of 75 individuals having age range of 20-30 years. group 2 comprised 46 individuals having age range of 31-40 years. group 3 had 43 participants more than 40 years of age. all data was entered and analyzed using microsoft excel and statistical software minitab15. mean and sds were calculated for each group. reference range of hba1c was calculated for each group by using the formula mean ± 2sd. results one hundred and sixty four healthy individuals were included in the study. mean age of the individuals was 32±11.6 years and mean hba1c level was 4.17±0.93%. male and female distribution of the subjects is shown in figure i. mean age of all the three groups were 22±2.93, 35±3.2 and 47±8.4 years respectively. the reference range of hba1c for age group 20-30 years was 2.09-5.57% with the mean value of 3.83±0.87%. the reference range of hba1c for age group 31-40 years was 2.63-5.99% with the mean value of 4.31±0.84%. the reference range of hba1c for individuals >40 years of age was 2.8-6.4% with the mean value of 4.31±0.9%. mean values of hba1c for each group along with their standard deviations are shown in figure 2.the reference range of hba1c for females (n=91) was 2.51-6.11% with the mean value of 4.31±0.9%. in males (n=73) reference range of hba1c was obtained as 2.11-5.87% with the mean value of 3.99±0.94%. figure 1: male and female distribution of subjects figure 2: mean and standard deviations of hba1c for individual groups discussion in our study we have established the reference interval of glycosylated haemoglobin for our local population. a study was conducted at armed forces institute of pathology, rawalpindi, pakistan to determine the reference ranges of hba1c in 254 healthy adults (18-80 years) included 169 males and 85 females. in total population reference range of hba1c was 4.6–6.56%. in our study mean value of hba1c in total population was 4.17±0.93%. when analysis was journal of islamabad medical & dental college (jimdc); 2016:5(4):165-167 167 done according to gender at afip, no significant difference was found between males and females. in our study reference range of hba1c for females was 2.51-6.11% while in males it was 2.11-5.87%. study conducted at afip showed increased hba1c levels in healthy elderly population. in healthy persons of less than 40 years of age, reference range of hba1c was 4.52-6.4% while in individuals having age more than 40 years; it was 4.86.68%. these results are comparable to our study. we also found high reference range of hba1c in elderly .16 the difference of values among different populations may be due to diversity in nutritional habits and life styles. reference range values determined for iraqi population for subjects age ranged between 20-75 years old was 5.34±0.67 for females and 5.67±0.73 for males.12 the values are slightly higher than our results, which are 4.31±0.9 and 3.99±0.94 for females and males respectively. in addition to that, the mean value of hba1c in females is slightly higher than that of males, which is in contradictory to iraqi population. in ghanaian pop ulation, the mean value of hba1c (for both sexes) was 5.4 ± 0.84% and reference range for the glycosylated haemoglobin was 3.72-7.08%, which is again different from that of pakistani population.4 in contrast to our findings, the reference range values of our neighbouring indian population (30-70 years) were found to be slightly higher. in indian women, mean hba1c value was 6.5±0.74% and overall range was found to be 4.8-7.56%. on the other hand, men had mean hba1c levels of 6.27±0.94% and overall range was 4.2-7.56%.2 as different populations have different hba1c levels and there is diversity in methods of estimation, it is recommended that every laboratory should establish its own reference interval of hba1c for its own population conclusion for proper assessment of the diabetic status, it is mandatory that every lab should establish its own reference range of hba1c for both genders and different age groups representing its patient population. acknowledgment my special thanks and utmost gratitude to my colleagues and staff of pathology department for providing me an excellent environment of research and all the facilities to complete this project. conflict of interest this study has no conflict of interest as declared by any author. references 1. farasat t, cheema am, khan mn. correlation among bmi, fasting plasma glucose and hba1c levels in subjects with glycemic anomalies visiting diabetic clinics of lahore. pak j zool. 2009;41(3):173-8. 2. dogra n, bhaskar n, pandey r, prasad s, singh j, sodhi ks. to establish the reference range of glycated hemoglobin. int j res med sci. 2015;3(7):1683-5. 3. weykamp c. hba1c: a review of analytical and clinical aspects. ann lab med. 2013;33:393-400. 4. arthur fkn, yeboah fa, nsiah k, nkrumah pkn, afreh ka, agyenim-boateng k. fasting blood glucose and glycosylated haemoglobin levels in randomly selected ghanaian diabetic patients – the clinical implications. j sci technol. 2005;25(2):13-17. 5. krishnamurti u, steffes mw. glycohemoglobin: a primary predictor of the development or reversal of complications of diabetes mellitus. clin chem. 2001;47(7):115765. 6. hoelzel w, weykamp c, jeppsson jo, miedema k, barr jr, goodall i, et al. ifcc reference system for measurement of hemoglobin a1c in human blood and the national standardization schemes in the united states, japan, and sweden: a method-comparison study. clin chem. 2004;50(1):166-74. 7. mahajan rd , mishra b. using glycated hemoglobin hba1c for diagnosis of diabetes mellitus: an indian perspective. int j biol med res. 2011;2(2):508-12 8. little rr, rohlfing cl, tennill al, connolly s, hanson s. effects of sample storage conditions on glycated haemoglobin measurement: evaluation five different high performance liquid chromatography methods. diabetestechnol ther. 2007;9:36–42. 9. ollerton rl, playle r, ahmed k, dunstan fd, luzio sd, owens dr. day-to-day variability of fasting plasma glucose in newly diagnosed type 2 diabetic subjects. diabetes care. 1999;22:394–98. 10. petersen ph, jorgensen lg, brandslund i, olivarius df, stahl m. consequences of bias and imprecision in measurements of glucose and hba1c for the diagnosis and prognosis of diabetes mellitus. scand j clin lab invest suppl. 2005;240:51–60. 11. rohlfing c, wiedmeyer hm, little r, grotz vl, tennill a, england j, etal. biological variation of glycohemoglobin. clin chem. 2002;48:1116–8. 12. salwa hn, emad ar. determining the reference range values of glycosylated hemoglobin (hba1c) by immunoturbid assay in iraqi population. natl j chem. 2011;41:127-34. 13. world health organization. use of glycated haemoglobin (hba1c) in the diagnosis of diabetes mellitus, abbreviated report of a who consultation. 2011. 14. jeppsson jo, kobold u, barr j, finke a, hoelzel w, hoshino t, et al. approved ifcc reference method for the measurement of hba1c in human blood. clin chem lab med. 2002;40:78-89. 15. mosca a. post-analytical factors: how should hba1c results be communicated to clinicians? biochemia medica.2014;24:s1-s78. 16. ali sk, khan da, khan fa. determination of glycosylated haemoglobin reference range in adult population attending a military care set up in rawalpindi. pafmj. 2011;61(4). authorship contribution: author 1,2: conception, synthesis and planning of the research, active participation in active methodology, interpretation, analysis and discussion author 3: conception, synthesis and planning of the research, interpretation, analysis and discussion summary journal of islamabad medical & dental college (jimdc); 2016:5(4):154-156 154 original article association between gly460trp polymorphism of αadducin gene and risk factors in hypertensive pakistani population hamid ali1, qurat-ul-ain zia2, mamoona shafiq3, amna faruqi 4 1.head of mlt department, islamabad medical & dental college, islamabad 2.senior lecturer, biochemistry department, islamabad medical & dental college, islamabad 3.associate professor, physiology department islamabad medical & dental college, islamabad 4.assistant professor, physiology department, islamabad medical & dental college, islamabad (shaheed zulfiqar ali bhutto medical university islamabad) abstract objective: to determine possible association between αadducin gene g460w polymorphism and risk factors like age & bmi in hypertensive pakistani population. material & methods: deoxyribonucleic acid (dna) samples from 200 patients with essential hypertension and 200 normotensive healthy individuals from pakistani population were genotyped for g460w polymorphism by polymerase chain reaction and restriction fragment length polymorphism. logistic regression analysis was used to find association between add1 gene g640w polymorphism and risk factors like age and bmi (body mass index) in hypertensive pakistani population. results: no significant association was found between g640w polymorphism and risk factors like age and obesity. conclusion: this study showed that there is no significant association between add1 gene g640w polymorphism and risk factors in our selected samples from pakistani population. key words: alpha adducin gene, body mass index, hypertension, rs4961 introduction blood pressure is a quantitative trail, which is influenced by multiple genetic and environmental factors.1 essential hypertensive subjects either inherit aggregate of hypertension causing genes or are exposed to exogenous factors that predispose them to hypertension.2 more than 100 genetic variants contributing to bmi have been indicated in different studies. according to genomic association studies, about 15 loci are identified that effect bmi.3 different studies suggest simultaneous emergence of interacting proteins with increase in age. proteins are synthesized by gene transcription; but despite the importance of gene duplication in genome, evolution with age, none consider protein family dynamics as a contributing factor.4 human addi gene contain 16 exons and is located on chromosome 4p16.3 and encodesα-adducin. adducin is a heterodimer cytoskeleton protein containing two subunits i.e. α units with β or γ subunit. adducin binds with high affinity to ca2+/ calmodulin and is a substrate for protein kinases a and c which increases calcium absorption and subsequently increases weight.5 alpha subunit of adducin plays an important role in sodium retention in renal tubules thus g460w polymorphism is thought to be associated with risk factors like age and obesity.6 a series of parallel studies in human indicated that replacement of glycine (gly) to tryptophan (trp) at position 460 leads to higher activity of na+k+ pump.7 the association of risk factors like age and bmi with addi gene polymorphism have been reported in asian population.8 amino acid substitution from glycine to tryptophan in adducin results in drastic change effecting the protein assembly and stability resulting in increased water and sodium retention inside renal tubules which ultimately causes high blood pressure. so, add1 gene is considered causative factor for increase in bmi.9 the results of various studies carried out in different nations to elucidate possible involvement of g460w polymorphism as a risk factor are widely inconsistent, so no definite conclusion can be drawn. however, in hans chinese population g460w polymorphism was strongly associated with risk factors of hypertension.10 in the japanese population, g460w polymorphism has no evidence for a positive association with age.11 in pakistani population, the tendency of obesity is considered contributing factor for many diseases. the corresponding author: ms. qurat-ul-ain zia e-mail: quratulain_imdc@yahoo.com received: august 25, 2016; accepted: dec 20 ,2016 mailto:quratulain_imdc@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(4):154-156 155 present study was designed to find association between add1 gene polymorphism with age and bmi. methodology in this study, 200 patients with essential hypertension and 200 healthy subjects (normotensive) were recruited from pakistan institute of medical sciences islamabad, benazir bhutto hospital rawalpindi and federal government services hospital islamabad. parameters like age, weight, blood sugar fasting, systolic blood pressure, diastolic blood pressure, height and body mass index were recorded. for measuring blood pressure, mercurial sphygmomanometer was used. total lipid profile and blood glucose level was measured using microlab 300 semi-automated chemistry analyzer. subjects of both genders with age limit 25-55 years were included in the study. already known patients with diabetes mellitus, dyslipidemia and renal disorders were excluded from study groups. blood samples were collected and genomic dna was extracted from blood samples using phenol-chloroform method.12 quantification of isolated dna was performed on spectrophotometer. extracted dna was amplified by using primers designed from flanking regions of the polymorphism (forward primer 5′-ctc ctt tgc tag tga cgg tga ttc-3′ and reverse primer 5′-gac ttg gga ctg ctt cca ttc tgcc-3′).total volume of reaction mixture was 20 µl containing: pcr master mixture 5µl, forward primer and reverse primer 4ul (stock concentration 100 µmolar, working conc.10 µmolar), pcr grade pure water 3.2 µl, genomic dna 1µl, betain 2.6 µl. restriction fragment length polymorphism was done by using sau961 restriction enzyme. for calculating genomic frequency direct gene counting method was employed13. logistic regression analysis was applied to find out possible association between risk allele and essential hypertension. all statistical analysis was performed with spss version 22. results clinical data of cases and controls such as systolic and diastolic blood pressure, weight, cholesterol level, lipid profile, bmi and bsf (blood sugar fasting) were recorded. table 1 shows the comparison of these variables in cases and controls. association analysis of g460w polymorphism of add1 gene and age revealed no significant relationship (p = 0.15). similarly, no significant relationship was found between add1 polymorphism and bmi (p= 0.26). table 1: comparison of anthropometric and clinical data in case &controls study of parameter controls (n 200) (mean ± sd) cases (n 200) (mean ± sd) age (year) 28.84 ± 5.80 41.19 ± 5.92 systolic (mm hg) 109.82 ± 6.97 138.05 ± 3.64 diastolic (mm hg) 71.17 ± 6.06 97.84 ± 3.68 weight (kg) 77.11 ± 8.76 82.37 ± 7.48 bmi (kg/m2) 26.88 ± 0.876 27.04 ± 1.02 bsf (mg/dl) 78.15 ± 10.19 76.82 ± 10.28 tc (mg/dl) 164.8 ± 26.30 325.90 ±50.93 tg (mg/dl) 134.31 ± 23.63 437.95 ± 79.50 hdl(mg/dl) 55.05 ± 7.19 29.12 ± 13.69 ldl (mg/dl) 80.30 ± 11.24 313.20 ± 95.76 table 2 shows the comparison of allele frequency with risk factors like age and obesity. table 2: association analysis of g460w with risk parameters (n 200) parameter risk allele odds ratio (g/g vs. t/g-t/t) p-value age 1.98(0.78-5.03) 0.15* bmi vs. overweight 0.44(0.10-2.05) 0.26* *p < 0.05 (significant) discussion the w allele of g460w polymorphism in adducin-1 gene has been occasionally associated with increased blood pressure.9,10 the aim of this study was to analyze whether the g460w variant is associated with age and bmi in pakistani population or not. in our studies, no significant corelation was developed between g460w polymorphism and age or bmi. a meta-analysis conducted on chinese hans population showed a strong association between add1 gene polymorphism with age, a finding which was not comparable with those reported in our studies.9, 14 a study conducted in the south china showed a significant association between add1 gene and age.9 in a meta-analysis of the add1 gene g460w polymorphism association has been reported with age in asians, but not in blacks and caucasians, however, the results of our studies are not supporting their findings.15 in another study conducted in a north indian population showed a significant association between the gly460trp gene polymorphism of α-adducin and age.16. another study elucidated a significant association between obesity and rs4961 and results indicate that the snp rs4961 has a protective role in the development of obesity.17 a significant association have been proven in south china, especially hans, mongolian and north indian population and those reported in some meta-analysis, which support our study results.9,14,16 meta-analysis results still did not reveal strong association between g460w polymorphism and age in studies conducted in caucasians and east asians. this meta-analysis failed to provide evidence for the genetic association of α-adducin gene gly460trp polymorphism with age.18 in another study conducted on caucasians and asians, no significant association of g460w polymorphism with age journal of islamabad medical & dental college (jimdc); 2016:5(4):154-156 156 was found.19 the cause of controversial results from different areas of the world are due to the difference in race, living style and may be due to different gene pool. a study involving proteomics and genomics might be more informative for future prediction regarding the onset of hypertension. further studies need to be done to find association of g460w polymorphism with ae and bmi in different ethnic groups with larger sample size in pakistan. conclusion there is no genetic association between α-adducin gene g460w polymorphism and age and bmi in our selected samples from pakistani population. further studies are required with large sample size in various regions of pakistan. conflict of interest this study has no conflict of interest as declared by authors references 1. pickering g. normotension and hypertension: the mysterious viability of the false. am j med. 1978; 65: 561–563. 2. parfrey ps, wright p, goodwin fj, vandenburg mj, holly jm, evans sj, et.al.. blood pressure and hormonal changes following alteration in dietary sodium and potassium in mild essential hypertension. the lancet. 1981;317(8211):59-63. 3. wrinkler tw, justice ae, graff m. the influence of age and sex on genetic associations with adult body size and shape: a large-scale genome-wide interaction study. plos one. 2015;10.1371;1005378 4. fokkens l, hogeweg p, snel b. gene duplication contribute to the over representation of interactions between proteins of a similar age. bio med central. 2012; 1471-2148: 12-19. 5. tripodi g, valtorta f, torielli l, chieregatti e, salardi s, trusolino l, et al. hypertension-associated point mutations in the adducin alpha and beta subunits affect actin cytoskeleton and ion transport. j clin invest. 1996; 97: 2815-22. 6. zhang ln, fei lj, yuan f , zhang ym, su xu j. association between polymorphisms of alpha-adducin gene and essential hypertension in chinese population. biomed res. int. 2013; 451094: 1-5. 7. yazdanpanah m, sayed-tabatabaei fa, hofman a, aulchenko ys, oostra ba, stricker bh. the α-adducin gene is associated with macrovascular complications and mortality in patients with type 2 diabetes. ada. 2006;55(10): 2922-2927. 8. adair ls. dramatic rise in overweight and obesity in adult filipino women and risk of hypertension. obes res. 2004; 12(8): 1335-41 9. li yy. alpha-adducin gly460trp gene mutation and essential hypertension in chinese population: a meta – analysis including 10,960 subjects. plos one. 2012; 7(1) :e30214. doi: 10.1371 /journal.pone.0030214 10. wang l, zheng b, zhao h, du p, sun a, hua k, gao y. αadducin gene g614t polymorphisms in essential hypertension patients with high low density lipoprotein (ldl) levels. indian journal of medical research. 2014;139(2):273. 11. niu wq, zhang y, ji kd, gao pj, zhu dl. lack of association between alpha-adducin g460w polymorphism and hypertension: evidence from a case-control study and a meta-analysis. j hum. hypertens. 2010; 24(7): 467 474. 12. sambrook j, fritsch ef, maniatis t (1989). molecular cloning: a laboratory manual, 2nd ed. cold spring laboratory, cold spring harbor ny. 13. arnbjerg j, christensen ak. polymorphism of serum albumin in dog breeds and its relation to weight and leg length. hereditas,1985; 102: 219-223. 14. liao x, wang w, zeng z, yang z, dai h, lei y.. association of alpha-add1 gene and hypertension risk: a metaanalysis. med sci monit. 2015; 21: 1634-1641. 15. wang l, zheng b, zhao h, du p, sun a, hua k, gao y. αadducin gene g614t polymorphisms in essential hypertension patients with high low density lipoprotein (ldl) levels. indian j med res 2014;139:273-8 16. naz q, serajuddin m, mehdi aa, et al. study of alpha adducin gene polymorphism in young essential hypertensive north indians. journal of cardiovascular disease research, 2015; 6(3): 124-130 17. han l, liu p, wang c, et al. the interactions between alcohol consumption and dna methylation of the add1 gene promoter modulate essential hypertension susceptibility in a population-based, case-control study. hypertension res, 2015; 38(4): 284-290. 18. niu wq, zhang y, ji kd, et al. lack of association between alpha-adducin g460w polymorphism and hypertension: evidence from a case-control study and a meta-analysis. j hum hypertens, 2010; 24: 467–474. 19. liu k, liu j, huang j.alpha-adducin gly460trp polymorphism and hypertension risk: a meta-analysis of 22 studies including 14303 cases and 15961 controls. plos one, 2010; 5(9): article id e13057 authorship contribution: author 1: active participation in active methodology, interpretation & analysis author 2: concept and planning author 3,4: discussion j islamabad med dental coll 2021 120 op e n ac c e s s nonsecretory multiple myeloma in a seropositive hepatitis b patient with thrombocytosis: a case report muhammad ali fayyaz medical officer, quaid e azam medical college, bahawalpur, pakistan a b s t r a c t non-secretory multiple myeloma is a rare variant of multiple myeloma with similar clinical and radiological findings. it is characterized by the absence/lack of monoclonal m proteins in the serum and/or urine. an early diagnosis can help in alleviating its adverse outcomes. we report a case of a 56-year-old female presenting with generalized body weakness and swelling, pain in right lower chest and anorexia. the patient was a known case of hepatitis b, treated a month ago. there was an incidental finding of thrombocytosis. serum biochemistry and protein electrophoresis showed no findings in favor of multiple myeloma. bence jones proteins were negative in the urine. x-ray revealed few lytic lesions on calvaria of the skull. bone marrow biopsy helped in diagnosing the patient as a case of non-secretory type of multiple myeloma highlighting the important role of this modality in saving the life of a patient through early diagnosis. key words: hepatitis b, lytic bone lesions, multiple myeloma, thrombocytosis. correspondence: muhammad ali fayyaz email: mafayyazbonamana1@gmail.com article info: received: november 27, 2020 accepted: june 25, 2021 cite this case report: fayyaz m a. nonsecretory multiple myeloma in a seropositive hepatitis b patient with thrombocytosis: a case report. j islamabad med dental coll. 2021; 10(2): 120-124. doi: 10.35787/jimdc.v10i2.632 funding source: nil conflict of interest: nil i n t r o d u c t i o n multiple myeloma (mm) is monoclonal gammopathy, mainly diagnosed by the detection of monoclonal immunoglobulins in the serum and urine. mm is a neoplasm of b-lymphocytes lineage, characterized by extravagant multiplication of the aberrant plasma cells, known as myeloma cells, secreting monoclonal paraprotein (m protein) which may be a complete immunoglobulin or one of its light or heavy chain.1 multiple myeloma is more frequent in males than females. body mass index (bmi) may play a role in developing mm.2 pesticides, insecticides or chemicals containing carcinogens may be potential causes of mm.3 non-secretory multiple myeloma (nsmm) is a rare variant of mm, in which immunoglobulins are neither found nor detected in the serum or urine. it is also a plasma cell cancer with the same clinical and radiological manifestations as that of classical mm, but plasma cells are unable to secrete immunoglobulins.4 moreover, unlike the classical disease, nsmm is also characterized by the absence of end-organ damage i.e., renal, hematological or other systemic complications. such cases are rare and challenging to diagnose. crab criteria indicate the presence of end-organ damage in mm. it is characterized by hypercalcemia with calcium level more than 11.5 mg/dl due to c a s e r e p o r t j islamabad med dental coll 2021 121 increased osteoclastic activity, renal insufficiency with creatinine level greater than 2 mg/dl, anemia with hemoglobin level less than 10 g/dl, and bony lesions (‘punched out’ or ‘soap bubbles’ lesions) that results in bone pain and fractures.1,3 pancytopenia, hyperviscosity syndrome, amyloidosis, recurrent infections due to decreased immunity, bone collapse and bence jones (bj) proteinuria are other associated signs of mm. hematological tumors along with mm are usually associated with decreased platelet count (thrombocytopenia). incidence of increased platelet count (thrombocytosis) is infrequent in cases of classic multiple myeloma.5 diagnosis of multiple myeloma is usually confirmed after a detailed medical history, physical examination, complete blood count, esr, serum biochemistry, serum and urine electrophoresis for immunoglobulins and bj proteins evaluation in urine. bone lesions can be detected by x-rays, mri, pet and ct scan.6 the percentage of plasma cells (>10%) in bone marrow biopsy is considered to be a diagnostic method for multiple myeloma or its variants. however, there are some discrepancies between the percentage of plasma cells in bone marrow aspiration and bone marrow biopsy for diagnosing the disease.7 hepatitis b infection is a worldwide public health problem, and very common in pakistan. association of hepatitis b virus with hematological malignancies has been stated earlier; however, there is a weak association between hepatitis b and mm.8 c a s e r e p o r t a 56-year-old housewife presented to the medical opd of bahawal victoria hospital, bahawalpur pakistan with generalized weakness (2 months), generalized body swelling (1.5 months), pain in right lower chest (1 month) and anorexia (1 week). on physical examination, she was conscious, active and cooperative. lymph nodes were not palpable. mild pallor and no signs of cyanosis were found. heart rate was regular at 96 bpm, blood pressure was 110/75 mmhg, respiratory rate 32 breaths per minute, temperature was 99.4°f, oxygen saturation was 99%. abdomen was soft but mild tenderness was present in the right hypochondrium. crepitations were audible in the right chest. she was admitted and treated first with intramuscular analgesics (diclofenac, tramadol and pregabalin), but no improvement was recorded. antibiotics and proton pump inhibitors were also given to the patient but her condition did not improve. the patient had been diagnosed as a case of hepatitis b and completed treatment one month ago. hepatitis b surface antigen (hbsag) was still positive and hbv dna was detected by real time pcr (1112 iu/l), while the ra factor was negative. bence jones (bj) proteins in the urine and serum were negative (table i; figure 1). figure 1: serum protein electrophoresis. normal peaks of alpha 1, alpha 2, beta and gamma globulins without any m spike multiple lytic lesions were observed on x-ray skull (figure 2), while bone scan was normal. bone marrow biopsy revealed 85-90% plasma cell infiltrate (figure 3). j islamabad med dental coll 2021 122 figure 2: x-ray skull pa and lateral view. lytic (‘punched out’) lesions resembling ‘soap bubbles’ can easily be observed in both views. d i s c u s s i o n multiple myeloma accounts for approximately 1015% of all hematological cancers and one to two per cent of all neoplasms.1 different variants of multiple myeloma are emerging with atypical features clinically, radiologically and pathologically, making diagnosis challenging for physicians. bone marrow biopsy and flow cytometry (cmf) can be useful tools in identifying different types of multiple myeloma.9 multiple myelomas is a manifestation of plasma cell neoplasm, classically presenting as multiple lytic (punched out) bony lesions accompanied by an increase in the number of bone marrow plasma cells (>10%). immunoglobulin or fragments of immunoglobulins are produced by the neoplastic plasma cells leading to a monoclonal band in serum protein electrophoresis (spe) and/or bj proteinuria. almost 1-5% of all cases may not show the band on spe and bj proteins in urine which are called ‘‘nonsecretory multiple myeloma (nsmm)’’ or “nonproductive multiple myeloma”. lack of m-spike in spe, bj proteinuria and normal serum calcium levels are uncommon features in classical multiple myeloma. so, our patient having none of the classical features, was diagnosed as non secretory/non-productive multiple myeloma. table i: hematology, biochemistry and serum electrophoresis reports complete blood count results normal range wbc’s 13700 / ul 4000-11000 / ul lymphocytes 37.9% 20-45% neutrophils 77% 40-75% rbc’s 3500000 / ul 3790000-5780000 / ul hemoglobin 10.5g / dl 11-15 / dl mch 28.8 pg 27.5-32.4 pg mcv 88 fl 84-98 fl mchc 34 g / dl 31.7-34.2 dl platelets 475000 / ul 150000-400000 / ul hematocrit 32.1 % 34-53% esr 40 mm/1st hour 0 20mm/1st hour blood biochemistry results normal range glucose (random) 80 mg/dl 70-140 mg/dl urea 42 mg/dl 10-50 mg/dl creatinine 1.7 mg/dl 0.5-0.9 mg/dl bilirubin 0.5 mg/dl <1 mg/dl alt 23 u/l <31 u/l alkaline phosphatase 125 u/l <120 u/l sodium 137 meq/l 135-155 meq/l potassium 4.0 meq/l 3.5-5.5 meq/l cpk 129 u/l 24-170 u/l albumin 3.2 g/dl 3.8-4.4 g/dl calcium 9.4 mg/dl 8.1-10.4 mg/dl serum protein electrophoresis results normal range albumin 2.90 g/dl 3.20 5.50 g/dl alpha 1 0.20 g/dl 0.10 0.40 g/dl alpha 2 0.90 g/dl 0.40 1.20 g/dl beta 0.65 g/dl 0.50 1.10 g/dl gamma 0.85 g/dl 0.50 1.60 g/dl a/g ratio 1.12 total protein 5.50 g/dl 6.40 – 8.30 g/dl j islamabad med dental coll 2021 123 figure 3: bone marrow trephine biopsy showing abundant plasma cells infiltrate the nsmm is further divided into two types; one in which the cancerous plasma cells produce immunoglobulins but do not secrete it and the true nonsecretors, which do not produce immunoglobulins at all.10 hepatitis b virus (hbv) is a dna virus with an oncogenic potential targeting different cells in blood, spleen, lymph nodes, thymus and bone marrow.11 hepatitis b infection may have some association with the development of mm.12,13 deletion of 8p chromosome in patients of mm was observed in 680 patients of the national center for tumor diseases heidelberg, germany in approximately 40% hbv-positive patients compared with 20–30% hbv-negative patients.14 the prevalence of acute and chronic hbv infection in patients with mm was observed in 11.5% and 14.54%, respectively.15 thrombocytosis is an atypical feature in mm as these cases are characterized by myelosuppression.5 our patient also had an incidental finding of thrombocytosis during routine workup. in a study involving 280 hospitalized patients with high platelet count, 82% (231 patients) had secondary thrombocytosis, 14% (38 patients) had myeloproliferative disorders while only 4% (11 patients) had thrombocytosis of unknown cause.16 myeloma has been reported in cases of mpds causing high platelet count. it can be paraneoplastic manifestation of plasma cell cancers. different studies describe it as poems syndrome, in which thrombocytosis is a minor feature.17,18 even some cases of mm having raised c-reactive protein (crp) are reported with thrombocytosis.19 the exact mechanism is still unknown. further study is still needed to identify the cause and mechanism behind thrombocytosis in multiple myeloma patients. multiple myeloma is a slowly progressing disease. therefore, survival time is about 4 to 6 years. there is no cure for multiple myeloma, but the period of survival can be enhanced by treatment with chemotherapy. informed consent verbal informed consent was obtained from the patient for her anonymized information to be published in this article. j islamabad med dental coll 2021 124 c o n c l u s i o n to the best of our knowledge, this is the first reported case of nsmm in association with hepatitis b and thrombocytosis. a bone marrow biopsy/trephine biopsy should be performed for any suspected case of mm or its variants. this will not only help in an early diagnosis but also save patient from life-threatening late-stage complications. a high index of suspicion should be kept in mind to avoid delay in diagnosing the disease. r e f e r e n c e s 1. puri a, wadhwa h, singh n. nonsecretory multiple myeloma with hcv infection: a rare case entity. iran j pathol. 2018; 13(2): 281-4. doi: 10.30699/ijp.13.2.281. 2. yao j, lv d, chen w. multiple myeloma, misdiagnosed as somatic symptom disorder: a case report. front psychiatry. 2018; 9: 557. doi: 10.3389/fpsyt.2018.00557. 3. packard e, shahid z, groff a, patel r, jain r. multiple myeloma in an agricultural worker exposed to pesticides. cureus. 2019; 11(5): e4762. doi: 10.7759/cureus.4762. 4. bensalah m, lamrabat s, lyagoubi a, aarab a, bouayadi o, seddik r. a rare case of nonsecretory multiple myeloma: a case report and literature review. ejifcc. 2019; 30(1): 88-94. pmid: 30881278. 5. naeem a, amar s, mehta d, malik mn. thrombocytosis as an initial presentation of plasma cell neoplasm: a case report. cureus. 2019; 11(3): e4286. doi: 10.7759/cureus.4286. 6. palumbo a, cerrato c. diagnosis and therapy of multiple myeloma. korean j intern med. 2013; 28(3): 263 -73. doi: 10.3904/kjim.2013.28.3.263. 7. lee n, moon sy, lee jh, park hk, kong sy, bang sm, et al. discrepancies between the percentage of plasma cells in bone marrow aspiration and bm biopsy: impact on the revised imwg diagnostic criteria of multiple myeloma. blood cancer j. 2017; 7(2): e530. doi: 10.1038/bcj.2017.14. 8. marcucci f, mele a. hepatitis viruses and nonhodgkin lymphoma: epidemiology, mechanisms of tumorigenesis, and therapeutic opportunities. blood. 2011; 117: 1792-8. doi: 10.1182/blood-2010-06275818. 9. olteanu h. role of flow cytometry in the diagnosis and prognosis of plasma cell myeloma. surg pathol clin. 2016; 9(1): 101-16. doi: 10.1016/j.path.2015.09.009. 10. janicki p, niemczyk s. non-secretory multiple myeloma in a patient with chronic kidney disease. pol merkur lekarski. 2020; 48(287): 344-5. pmid: 33130796. 11. sinha m, rao cr, premalata cs, shafiulla m, lakshmaiah kc, jacob la, et al. plasma epstein-barr virus and hepatitis b virus in non-hodgkin lymphomas: two lymphotropic, potentially oncogenic, latently occurring dna viruses. indian j med paediatr oncol. 2016; 37: 146-51. doi: 10.4103/0971-5851.190353. 12. li y, bai o, liu c, du z, wang x, wang g, et al. association between hepatitis b virus infection and risk of multiple myeloma: a systematic review and meta-analysis. intern med j. 2016; 46(3): 307-14. doi: 10.1111/imj.12981. 13. su th, liu cj, tseng tc, chou sw, liu ch, yang hc, et al. chronic hepatitis b is associated with an increased risk of b-cell non-hodgkin's lymphoma and multiple myeloma. aliment pharmacol ther. 2019; 49(5): 58998. doi: 10.1111/apt.15132. 14. becker n, byl a, friedrich s, jauch a, schnitzler p, egerer g, et al. hepatitis b virus infection is associated with deletion of chromosome 8p in multiple myeloma. eur j haematol. 2013; 90: 279-85. doi: 10.1111/ejh.12018. 15. guo d, xu p, guan c, xu y, yang y, xu j, et al. hepatitis b virus infection and 1q21 amplification in multiple myeloma. oncol lett. 2019; 18(6): 6196-206. doi: 10.3892/ol.2019.10926. 16. buss dh, cashell aw, o'connor ml, richards f, case ld. occurrence, etiology, and clinical significance of extreme thrombocytosis: a study of 280 cases. am j med. 1994; 96(3): 247-53. doi: 10.1016/00029343(94)90150-3. 17. dispenzieri a. poems syndrome: 2019 update on diagnosis, risk-stratification, and management. am j hematol. 2019; 94(7):812-827. doi: 10.1002/ajh.25495. 18. brown r, ginsberg l. poems syndrome: clinical update. j neurol. 2019; 266(1): 268-77. doi: 10.1007/s00415-018-9110-6. 19. král z, adam z, folber f, moulis m, tomíška m, říhová l, et al. systemic inflammatory response with high crp values as the dominant symptom of multiple myeloma. vnitr lek. 2019; 65(1): 37-44. pmid: 30823836. j islamabad med dental coll 2020 54 open access frequency of post-operative wound contamination in bakhtawar general hospital, jamshoro altaf hussain1, ambreen amna2, saifullah brohi3, farkhunda nadeem4, amin fahim5, muhammad imran ahmed6 1assistant professor, department of surgery, mohammadi medical college, mirpur khas 2associate professor, department of obstetrics and gynecology, isra university hospital, hyderabad 3general surgeon, bakhtawar general hospital and trauma center, sehwan shareef 4professor, department of pathology, isra university, hyderabad 5associate professor, department of pathology, isra university, hyderabad 6phd fellow, management sciences, shah abdul latif university, khairpur a b s t r a c t background: surgical site wound infection (ssi) imposes a great challenge worldwide. it is the third most commonly reported nosocomial infection. the objective of the study was to assess the frequency of postoperative wound infections in a newly developed health organization . material and methods: this cross-sectional study was conducted from june 2017 to may 2018 in bakhtawar general hospital, jamshoro. a total of 364 cases of surgery, from obstetrics and gynecology and general surgery department were included. surgical interventions involving an incision were assessed. infection (ssi ) rate was noticed and data was analyzed by spss version 18. results: healthy discharge rate was 97%. the overall surgical site wound infection rate was 3.1%. these infections were high in genitourinary surgeries (9.09%). among obstetrics & gynecology surg eries, maximum number of ssis were reported in cases of emergency lower segment cesarean section (lscs) . conclusions: the overall rate of ssi for different types of surgeries performed at bakhtawar general hospital, jamshoro was only 3.1%. frequency of ssi was highest in genitourinary surgeries followed by gastrointestinal and obstetrics and gynecology surgeries, respectively. key words: general surgery, genitourinary surgery, obstetrics & gynecology surgery, post -operative wound contamination authors’ contribution: 1conception; 2-3literature research; manuscript design and drafting; 4critical analysis and manuscript review; data analysis; 5,6manuscript editing. correspondence: amin fahim email: draminfahim@gmail.com article info: received: march 1, 2019 accepted: january 29, 2020 cite this article. hussain a, amna a, brohi s, nadeem f, fahim a, ahmed mi. frequency of post-operative wound contamination in bakhtawar general hospital, jamshoro. j islamabad med dental coll.2020; 9(1): 54-58. doi: 10.35787/jimdc.v9i1.294 funding source: nil conflict of interest: nil i n t r o d u c t i o n quality of health care is an important public health issue affecting the credibility of a newly-established hospital. surgical site infections (ssis) are wound infections that occur after invasive (surgical) procedures.1 ssis are quite common and have been estimated to occur in about 1.4% to 20% in surgical operations.2 they can lead to serious postoperative complications and consequences may affect both the patient and hospital. they represent one of th e major causes of postoperative morbidity and or i gi n a l a r ti c le j islamabad med dental coll 2020 55 mortality along with increased length of hospitalization.3 it is reported that ssis are the second most common form of nosocomial infections accounting for increased risk of death. 4 the situation not only affect the reputation of the organization but may also lead to huge added health care cost, thereby increasing the clinical and economic burden of surgery.5 ssis always have been an important factor in limiting the success of any major or minor surgery. they tend to occur at an undesirable rate despite constant efforts to improve the situation. 6 a combination of risk factors are linked with ssi including patient age, obesity, anemia, diabetes, tobacco use, urinary incontinence, bad nutritional status, repeated surgery, complete neurologic deficit, use of nsaids, blood transfusion, prolonged surgical time, and the occurrence of more than three co-morbid illnesses.7 in pakistan, like in any other developing country, surgical site wound infection rates are not documented and reported. besides this, contributing factors mentioned above are very common in many hospitals. keeping all these facts in mind, this hospital-based study was conducted to assess the frequency of postoperative wound infections in a newly developed health set-up (bakhtawar general hospital, jamshoro) . m a t e r i a l a n d m e t h o d s this cross-sectional study was performed at bakhtawar general hospital, jamshoro, a secondary care level general hospital, from june 2017 to may 2018. it is a newly developed private organization situated in the heart of jamshoro, sindh. this hospital is providing health care facilities to upper sindh and nearby villages of jamshoro city. in the previous year, total number of outpatients were about 5345 and about 2234 surgical procedures were performed during this period. major surgical procedures are defined as any invasive surgical approach for opening the body cavities for remov al of an organ or any procedure resulting in alteration of normal anatomy. about 364 patients, who underwent major surgical procedures (both planned and emergency surgeries) were included through convenient sampling technique. data was recruited from departments of obstetrics & gynecology and general surgery including gastrointestinal, genitourinary, hepatobiliary, orthopedics, breast and others. eye, ent and thyroid surgeries were included in “others”. all th e minor surgical procedures, including traumarelated surgeries and major surgeries done on immunocompromised patients were excluded from the study. all the patients were assessed for statu s of wound postoperatively on eighth post-operativ e day according to the categorization criteria set by usa national research council as; clean wound (category-1), clean and contaminated wound (category-2), and dirty and contaminated wound (category 3). the information of patients was recorded and data analyzed by spss version 18. mean age of the participants along with frequency and percentages of categorical variables were calculated. r e s u l t s the results of the present study revealed that out of total 364 major surgeries performed there were 267(73.3%) cases of obstetrics and gynecology surgeries while 97(26.4%) cases were of general surgery. the details of obstetrics and gynecology surgeries and general surgery cases are prese n te d in table i and ii, respectively. the mean age of the patients was 37+8 years and majority of the patients (316; 86.8%) were between 20 to 50 years of age while 39 (10.7%) were above 50 years and 9 (2.47%) of the patients were below 20 years, respectively. the overall ssi rate was 3.1% with highest rate reported in genitourinary surgeries followed by gastrointestinal and obstetrics and gynecology surgeries, respectively. j islamabad med dental coll 2020 56 out of 07 patients of obstetrics and gynecology surgeries having ssi, 05 cases were operated for emergency lscs and had dirty and contaminated wound while 01 case of laparotomy due to ovarian tumor and 01 case of vaginal hysterectomy had clean and contaminated wound, as shown in table iii. table i: frequency of different types of obstetrics and gynecology surgeries (n=267) obstetrics and gynecology surgeries n (%) elective caesarean section 118 (52.2) emergency caesarean section 108 (47.8) total number of caesarean sections 226 total abdominal hysterectomy 7 (17) evacuation 24 (58.5) laparotomy 04 (9.7) vaginal hysterectomy 04 (9.7) cervical cerclage 02 (4.8) total number of gynecology surgeries 41 total 267 table ii: frequency of different types of general surgeries (n=97) general surgeries n (%) gastrointestinal 28(28.9) hepatobiliary 22(22.7) genitourinary 33(34) orthopedic 3(3) breast 6(6.2) others* 5(5.1) total 97 *others included eye, ent and thyroid surgeries d i s c u s s i o n surveillance for ssi remains a great challenge, which is sometimes exacerbated by early discharge and outpatient surgeries. for better clinical and surgical outcome, it is recommended that surgical site wound infection should be diagnosed earlier and treated appropriately. present study assessed status of postoperative wound following different types of surgeries performed at bakhtawar general hospital, jamshoro, a secondary care level general hospital. the overall rate of ssi in the current stu d y was 3.1%. more or less similar results were obtained in other studies conducted in united states (ssi 2.8%), italy (ssi 2.7%) and some european countries (ssi 2.5%), respectively.8-10 on the other hand, surgical site infection rate as low as 1.0% has been reported by degli et al in a study conducted in a children hospital.11 on the contrary higher rates of ssi have also been reported from different countries. a study f rom sub-saharan africa by osakwe et al reported prevalence of surgical site infection as 15.5%,12 while yemen reported the rate of ssi as high as 34%. 13 a recent study carried out on surgical patients at ayub teaching hospital in abbottabad revealed a high ssi rate of 33.68%.7 type of surgery seems to play a profound role in determining the development of ssi as reported b y nandita pal in 2012. they reported 16.16% rate of ssi in open surgery as compared to ssi rate of 2.06% in minimally invasive surgery with multidrug resistant (mdr) bacteria and antimicrobial susceptibility pattern playing an important role. 14 the present study shows higher ssi rate in genitourinary surgeries (3; 9.09%). among the gynecological surgeries, majority of the ssi cases belonged to the surgeries done in emergency. similarly, in accordance with present study, another study showed ssi rates to be higher in emergency procedures (16%) as compared to elective procedures (3%).15 in present study, the follow up of postoperative patients specifically for the presence of infection table iii: surgical intervention and the frequency of wound contamination type of surgery (n; %) clean clean and contaminated dirty contaminated ssi rate (%) total gastrointestinal (28; 7.7) 27 1 3.5 28 hepatobiliary (22; 6) 22 0 22 genitourinary (33; 9) 30 3 9.09 33 orthopedics (3; 0.8) 3 0 03 breast (6; 1.6) 6 o 06 gynecology (267; 73.4) 260 02 5 2.62 267 others (5; 1.4) 5 0 05 j islamabad med dental coll 2020 57 was done on the eighth post-operative day. the dirty and contaminated wound found on follow -up might be due to substandard care at home. according to the results ssi rates were higher in gastrointestinal surgeries, which is similar to a study conducted at the khyber teaching hospital, peshawar by khan et al who also reported high prevalence rate of ssi with gastrointestinal surgeries (13.51%).16 c o n c l u s i o n the overall rate of ssi in the current study for different types of surgeries performed at bakhtawar general hospital, jamshoro was only 3.1%. frequency of ssi was highest in genitourinary surgeries followed by gastrointestinal and obstetrics and gynecology surgeries, respectively. r e c o m m e n d a t i o n s wound surveillance in the post-discharge period should be done by the primary surgeon, in orde r to rectify any surgical co-morbidity as well as for the correct estimation of ssi rate. tri-monthly postoperative audit should be done in order to keep the ssi ratio up to bench-mark. teaching and training of the surgical team regarding international surgical protocols should be done to achieve better health goals for all. a c k n o w l e d g m e n t the authors are thankful to the administrator of bakhtawar general hospital, mr. barkat ali jatoi and mr. imran for their kind support throughout the study and statistical analysis. hospital staff especially mr. sajid ali manager of information technology department also helped during collection of data. r e f e r e n c e s 1. webster j, osborne s. preoperative bathing or showering with skin antiseptics to prevent surgical site infection. cochrane database syst rev. 2015; 20(2): cd004985. doi: 10.1002/14651858.cd004985 2. pawłowska i, ziółkowski g, wójkowska-mach j, bielecki t. can surgical site infections be controlled through microbiological surveillance? a three -year laboratory-based surveillance at an orthopedic unit, retrospective observatory study. int orthop. 2019; 43(9): 2009–16. doi: 10.1007/s00264-019-04298-x 3. ohara lm, thom ka, preas ma. update to the centers for disease control and prevention and the health care infection control practices advisory committee guideline for the prevention of surgical site infection (2017): a summary, review and strategies for implementation. am j infect control. 2018; 46(6): 602-9. doi: 10.1016/j.ajic.2018.01.018 4. khan ha, baig fk, mehboob r. nosocomial infections: epidemiology, prevention, control and surveillance. asian pac j trop biomed. 2017; 7(5): 478–82. doi: 10.1016/j.apjtb.2017.01.019 5. badia jm, casey al, petrosillo n, hudson pm, mitchell sa, crosby c. impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six european countries. j hosp infect. 2017; 96(1): 1-15. doi: 10.1016/j.jhin.2017.03.004 6. elmously a, gray kd, michelassi f, afaneh c, kluger md, salemi a. operating room attire policy and healthcare cost: favoring evidence over action for prevention of surgical site infections. acs. 2019; 228(1): 98–106. doi: 10.1016/j.jamcollsurg.2018.06.010 7. sattar f, sattar z, zaman m, akbar s. frequency of post-operative surgical site infections in a tertiary care hospital in abbottabad, pakistan. cureus. 2019; 11(3): e4243. doi: 10.7759/cureus.4243 8. nichols rl. surveillance of the surgical wound. infect control hosp epidemiol. 1990; 11(10): 513-4. 9. national nosocomial infections surveillance (nnis) system report, data summary from january 1990 – may 1999, issued june 1999. am j infect control 1999; 27: 520–32. doi: 10.1016/s01966553(99)70031-3 10. leaper dj, van goor h, reilly j, petrosillo n, geiss hk, torres aj, berger a. surgical site infection – a european perspective of incidence and economic burden. int wound j. 2004; 1(4): 247 –73. doi: 10.1111/j.1742-4801.2004.00067.x 11. ciofi degli atti ml, serino l, piga s, tozzi ae, raponi m. incidence of surgical site infections in children: active surveillance in an italian academic children’s hospital. ann ig. 201; 29(1): 46-53. doi: 10.7416/ai.2017.2131. 12. osakwe jo, nnaji ga, osakwe rc, agu u, chineke hn: role of premorbid status and wound related j islamabad med dental coll 2020 58 factors in surgical site infection in a tertiary hospital in sub-saharan africa. family practice reports. 2014; 1: 2. doi: 10.7243/2056-5690-1-2 13. nasser a, zhang x, yang l, sawafta fj, salah b: assessment of surgical site infections from signs & symptoms of the wound and associated factors in public hospitals of hodeidah city, yemen. int j appl. 2013; 3(3): 101-10. 14. pal nd, guhathakurta. surgical site infection in surgery ward at a tertiary care hospital: the infection rate and the bacteriological profile. iosr j pharm. 2012; 2(5): 1-5. 15. khadilkar r, khsirsagar v, khadilkar s, bendre m, chavan s. a comprehensive study of 100 patients of ssi (surgical site infections) in patients undergoing abdominal surgery, elective/emergency, in our hospital. jmsclr. 2017; 5(4): 20947-50. doi: 10.18535/jmscr/v5i4.192 16. khan m, khalil j, zarin m, hassan tu, ahmed n, salman m, muhammad g. rate and risk factors for surgical site infection at a tertiary care facility in peshawar, pakistan. j ayub med coll abbottabad. 2011; 23(1): 15-8. pmid: 22830136 j islamabad med dental coll 2022 145 open access utility of cell block with p53 immunostain in diagnosing urothelial carcinoma alina ali1, nosheen nabi2, maryam fatima3, armaghana qamar khan4, henna azmat5, ashok kumar tanwani6. 1postgraduate resident, pathology department, szambu pims, islamabad. 2assistant professor, department of pathology, rawal institute of health sciences islamabad. 3senior registrar, department of pathology, hbs medical and dental college, islamabad. 4medical officer, department of pathology, szambu, pims, islamabad. 5medical officer, pathology, federal government polyclinic hospital islamabad. 6head of department, pathology, hbs medical and dental college, islamabad. a b s t r a c t background: urine cytology is an initial noninvasive screening test done in patients with suspected urothelial carcinoma. the objective of this study was to compare the sensitivity of conventional smear cytology with cell block technique for the diagnosis of malignant cells in urine and to assess the efficacy of p53 immuno-marker in the diagnosis and prognosis of urinary bladder cancer. methodology: the study was carried out in the department of histopathology, pakistan institute of medical sciences(pims), islamabad. cell blocks and cytology smears were prepared from urine samples of 80 patients of urothelial carcinoma and p53 stain was applied. data was analyzed using spss version 21. sensitivity of conventional smear and cell block techniques were calculated for both low and high grade urothelial carcinomas. results:the sensitivity of detecting atypical cells using conventional smear was 31% and 70.6% for low grade and high grade urothelial tumors respectively. the sensitivity increased to 41.4% and 84.3% for low and high grade urothelial carcinomas respectively with cell block technique. positive p53 stain was seen in 13.8% of cases with low grade tumors and 66.7% cases with high grade tumors. chi-square test was used to find the association of cytology findings with the histologic grade. conclusion: sensitivity of urine cell blocks is higher than the conventional smear method for detecting high grade lesions. it can be used as an efficient non-invasive technique and an adjunct tool for the determination of disease relapse and overall survival in patients. keywords: carcinoma, cytology, p53 protein, urine authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3, 4 critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: nosheen nabi email: nosheennabi@yahoo.com article info: received: april 22, 2021 accepted: september 6, 2022 cite this article. ali a, nabi n, fatima m, khan q a, azmat h, tanwani ka. utility of cell block with p53 immunostain in diagnosing urothelial carcinoma. j islamabad med dental coll. 2022; 11(3): 145-151 doi: https://doi.org/10.35787/jimdc.v11i3.709 funding source: nil conflict of interest: nil introduction carcinoma of urinary bladder is the 9th most common malignancy worldwide.1 risk factors include, male sex, aging, tobacco, schistosoma haematobium infection, occupational carcinogens and genetic alterations, p53 being the most important.2 o r i g i n a l a r t i c l e j islamabad med dental coll 2022 146 urine cytology is performed as an initial evaluation routine test for suspected bladder carcinoma although cystoscopic examination and biopsy are currently the gold standard method.3 it has a low sensitivity for detecting urothelial carcinoma but still performed as it is non-invasive and relatively inexpensive. 4 in patients with bladder cancer, the diagnostic accuracy is enhanced if cell blocks are made together with the conventional smears. 5 cell blocks are also useful for special stains and immunohistochemical staining.6 this study aims to determine whether urine cell block technique can improve the diagnostic sensitivity as compared to urine cytology alone for detecting urothelial carcinoma and also to evaluate the importance of p53 mutations and its diagnostic and prognostic value in bladder cancer some of the previous international studies strongly support this view while according to some authors, cell block technique has no significant role in improving the diagnostic utility of urine cell cytology. 7,8 we didn’t find any local study done regarding cell block technique in urine cytology. p53 expression is the most common gene involved in human cancers. p53 positivity on urine cell blocks can be used as a useful marker for assessment of urinary bladder cancer prognosis as p53 mutation is associated with increased recurrence rate of bladder cancer. 9 we also added p53 immunohistochemistry for even better results and to check the possibility of using cell blocks for ancillary techniques like immunohistochemistry. methodology this cross-sectional study was conducted in the department of histopathology, pakistan institute of medical sciences (pims), islamabad after approval from ethical committee at shaheed zulfiqar ali bhutto medical university. the study duration was 4 years (2016-2019). sample size was calculated to be 80 by using who sample size calculator taking 95% confidence level and 60% anticipated population proportion.10 consecutive samples of 80 patients with diagnosis of urothelial carcinoma on histopathology were included in the study after taking informed consent from the patients. patients with other urinary bladder tumors, punlump and other reactive conditions and those with inadequate smears were excluded. smears with any atypical cells were considered satisfactory as adequacy criteria for urine cytology and blocks is not yet established so those smears which didn’t show any atypical urothelial cells were considered inadequate were excluded.11 about 30 ml freshly voided samples of urine were collected from these patients, centrifuged immediately at 3000 revolutions per minute for ten minutes and subjected to the conventional smear cytology and cell block technique. from each of the case, two urine cytology smears were selected and each of the smear contained at least 10 atypical cells. these two slides were subjected to hematoxylin and eosin (h&e) staining. immunohistochemical staining for p53 was applied on sections made from all cell blocks. cell block containing at least 5% positively stained nuclei were labelled as positive p53 staining.12 data was analyzed using spss software version 21. sensitivity of conventional smear and cell block techniques were calculated for both high and low grades of urothelial carcinoma. specificity calculation was not useful in this study since already diagnosed cases of urothelial cancer were included and no true negatives or false positives were present in this study. chi-square test was applied to calculate the relationship between p53 expression and tumor grade. p values were also calculated to evaluate the statistical significance of conventional smear and cell block technique for low and high grades of urothelial cancer. p value of ≤0.05 was taken as significant. j islamabad med dental coll 2022 147 results among 80 study cases, 18 (22.5%) were females and 62 (77.5%) males. male to female ratio was 3.4:1. the peak age was 50-70 years for both males and females(range: 21-87 years) (table 1). table: i age distribution of cases age range (years) 21-30 31-40 41-50 51-60 61-70 71-80 81-90 males (n=62) 1(1.6%) 4(6.4%) 8 (12.9%) 17(27.4%) 22(35.4%) 8(12.9%) 2(3.2%) females (n=18) 0 (0%) 0 (0%) 1 (5.5%) 7 (38.8%) 4 (22.2%) 6 (33.3%) 0 (0%) total (n=80) 1(1.2%) 4(5%) 9(11.2%) 24(30%) 26(32.5%) 14(17.5%) 2 (2.5%) among 80 cases of urothelial cancer, 37% cases (29/80) were low grade while 63% cases (51/80) were diagnosed as high grade urothelial carcinoma on surgical biopsy. with conventional smear method, atypical cells were detected in 31% low grade & 70.6% high grade urothelial carcinoma cases. with cell block technique, atypical cells were seen in 41.3% cases of low-grade & 84.3% cases of high grade urothelial cancer. atypical cells were identified in 10 additional cases by cell block method. malignant cells were missed in 35 (43.8%) cases by conventional smear and 25 (31.2%) cases by the cell block method. (table 2). table ii: comparison of conventional smear, cell block and immunohistochemistry conventional smear cell block p53 staining p values positive for malignant cells negative for malignant cells positive for malignant cells negative for malignant cells positive negative lguc (n=29) 9 (31%) 20 (69%) 12 (41.4%) 17 (58.6%) 6 (20.7%) 23 (79.3%) 0.000 hguc (n=51) 36 (70.6%) 15 (29.4%) 43 (84.3%) 8 (15.7%) 34 (66.7%) 17 (33.3%) 0.000 total cases (n=80) 45 (56.2%) 35 (43.8%) 55 (68.8%) 25 (31.2%) 40 (50%) 40 (50%) (p53 staining among grades of tumor) 0.006 j islamabad med dental coll 2022 148 figure 1: microscopic examination of a high-grade urothelial carcinoma. figure 1; high grade urothelial carcinoma a, biopsy (h&ex400). b, cytology smear showing atypical urothelial cells (h&ex400).c, cell block showing few atypical cells (h&ex400). d, p53 immunostaining positive (x400). sensitivity for low grade urothelial carcinoma by conventional smear method was 31%. sensitivity for high grade urothelial carcinoma by conventional smear method was 70.6%.( 36 out of51 cases) sensitivity for low grade urothelial carcinoma by cell block method was 41.4%. (12 out of 29 cases) sensitivity for high grade urothelial carcinoma by cell block method was 84.3%. ( 43 out of 51 cases) with the use of cell block technique, the sensitivity improved. chi-square test was employed to find out the significance of tumor grade with cytology results considering p values of 0.05 or less to be statistically significant. in our results p values were found to be significant for both low grade (p=0.000) and high grade (p=0.000) urothelial cancers. p53 positivity was seen more in the cases of high grade urothelial cancer (table 2) j islamabad med dental coll 2022 149 p value was calculated to determine the significance of association of p53 immune stain expression with different hitopathological grades of urothelial carcinoma. significant association was observed between p53 expression for high grade urothelial cancer (p=0.006) urothelial cancers. (table 2) discussion routine cystoscopies are done at regular intervals for follow up of patients, it costs high and about 10% of the lesions are overlooked. 13 there is obviously a need for a non-invasive method for timely detection of urothelial cancer, in order to lessen the number of cystoscopies. conventional smear and cell block methods save the patient from undergoing repeated invasive procedures like cystoscopic biopsy. in a developing country like pakistan, it can save money and hospital resources which can be utilized effectively where needed. cytology is a widely used non-invasive test though its use is restricted by its poor sensitivity extending from 28-100% (median: 48%) reported by different authors. it is useful in diagnosing high grade tumors, however it is less sensitivity for low-grade urothelial tumors.15 the current study demonstrates that urine cytology and cell block methods are useful adjuvant tests in establishing the diagnosis of urothelial cancer. cell block method is cheap, simple to perform and help in better preservation of cells in comparison to conventional smear method. 16 it also reduces the gap between cytology and histology. paraffin embedded cell blocks can be handled like a biopsy specimen and multiple sections are available for other ancillary studies. 17 the sensitivity using conventional smear was 31% and 70.6% for low grade and high-grade tumors respectively. the sensitivity rates of urine cytology reported by yafi et al were 18.3% for low grade and 51.3% for high grade urothelial cancer.18 santwani et al reported that cell block technique demonstrates better architectural patterns, increases the positive results and can be used for application of different special stains and immunohistochemical markers.19qamar et al evaluated the association of immunohistochemical expression of p53 with grade and stage of urothelial cancers and found that only 16% cases of low grade carcinoma showed p53 positivity whereas 91% cases of high grade carcinoma were p53 positive. 20. in our study, cell blocks from low grade urothelial cancer showed 20.7% p53 positivity and from high grade urothelial cancer showed 66.7% p53 positivity. mumtaz et al found that p53 positive expression was seen in 72.9% cases of high grade urothelial carcinoma and only 36.2% cases of low grade tumors.21. according to v nassai et al ,39% cases of high grade urothelial carcinoma while 11% of low grade urothelial carcinoma were positive for p53 immunostain. 22 thakur et al found p53 expression more in the high grade urothelial carcinomas (52 cases) as compared to 32 cases of low grade. 23. this study demonstrates a sensitivity and specificity of cytologic diagnosis comparable to previously reported studies. cell block technique is clearly superior to conventional smears for diagnosis of atypical urothelial cells in urine. the results of both conventional smears and cell blocks were similar to the results found in literature. urinary cytology and cell block techniques can serve as non-invasive adjuncts to biopsy for detecting high-grade lesions. their usefulness is limited to low-grade tumors. the major limitation of this study is selection of those cases already diagnosed with urolethial carcinoma. including those as well would have strengthened the study. another limitation is low cellularity in urine samples and some conditions like infections, calculi or presence of blood may have masked atypical cells in the urine sample thus affecting the results. conclusion block technique is superior to conventional smears for diagnosis of atypical urothelial cells in urine. urinary cytology and cell block techniques can serve j islamabad med dental coll 2022 150 as non-invasive adjuncts to biopsy for detecting high-grade lesions. their usefulness is limited to lowgrade tumors. additionally, cell blocks can also be used for ancillary studies like immunohistochemistry. recommendations comparison of immunostaining on biopsy with that on cell blocks should be done. references 1. bukhari n, al-shamsi ho, azam f. update on the treatment of metastatic urothelial carcinoma. the scientific world journal. 2018 oct;2018. https://doi.org/10.1155/2018/5682078. 2. saginala k, barsouk a, aluru js, rawla p, padala sa, barsouk a. epidemiology of bladder cancer. medical sciences. 2020 mar;8(1):15. https://doi.org/10.3390/medsci8010015 3. zhu cz, ting hn, ng kh, ong ta. a review on the accuracy of bladder cancer detection methods. journal of cancer. 2019;10(17):4038. doi: 10.7150/jca.28989 4. hong m, he g, goh s, low aw, tay kj, lim tk, et al. biomarkers for precision urothelial carcinoma diagnosis: current approaches and the application of single-cell technologies. cancers. 2021 jan;13(2):260. https://doi.org/10.3390/cancers13020260 5. chan e, balassanian r, tabatabai zl, lou h, vohra p. improved diagnostic precision of urine cytology by implementation of the paris system and the use of cell blocks. cancer cytopathology. 2018 sep;126(9):80916. doi: 10.1002/cncy.22034 6. nambirajan a, jain d. cell blocks in cytopathology: an update. cytopathology. 2018 dec;29(6):505-24. doi https://doi.org/10.1111/cyt.12627. 7. wilson bl, russell d, evans sk, agrawal t. cell blocks in urine cytopathology: do they add value to the diagnosis? a pilot study. journal of the american society of cytopathology. 2021 jan 1;10(1):47-55. https://doi.org/10.1016/j.jasc.2020.08.003 8. dantey k, pantanowitz l, xing j, cuda j, nestler r, monaco se. cell block preparation in urine cytology: examination of utility and workflow in an academic practice. journal of the american society of cytopathology. 2019 mar 1;8(2):61-8. https://doi.org/10.1016/j.jasc.2018.11.001 9. bodoor k, al-ghabkari a, matalka i, haddad y, alkhateeb a, jaradat s, et al. assessment of p53 mutations, expression and prognosis in bladder s cancer patients from jordan: identification of novel deletion mutations in the dna-binding domain. meta gene. 2017 jun 1;12:33-42. https://doi.org/10.1016/j.mgene.2017.01.002 10. wilson bl, russell d, evans sk, agrawal t. cell blocks in urine cytopathology: do they add value to the diagnosis? a pilot study. journal of the american society of cytopathology. 2021 jan 1;10(1):47-55. doi: 10.1016/j.jasc.2020.08.003 11. renshaw aa, gould ew. adequacy criteria for voided urine cytology using cytospin preparations. cancer cytopathology. 2019 feb;127(2):116-9. doi: 10.1002/cncy.22090 12. choi sy, kim kh, suh ks, yeo mk. diagnostic significance of dual immunocytochemical staining of p53/cytokeratin20 on liquid-based urine cytology to detect urothelial carcinoma. cytojournal. 2020;17. doi: 10.25259/cytojournal_88_2019 13. zuiverloon t, de jong fc, theodorescu d. clinical decision making in surveillance of non--muscleinvasive bladder cancer: the evolving roles of urinary cytology and molecular markers. oncology (08909091). 2017 dec 1;31(12). 85562.pmid: 29297169 14. schmitz-dräger bj, droller m, lokeshwar vb, lotan y, m''liss ah, van rhijn bw, et al. molecular markers for bladder cancer screening, early diagnosis, and surveillance: the who/icud consensus. urologia internationalis. 2015;94(1):1-24. doi: 10.1159/000369357 15. glickman y, davis n, nativ o. combining color and morphology to detect low-grade urothelial cell carcinoma in urine specimens. arch can res. 2016; 4: 4. doi: 10.21767/2254-6081.1000121 16. brisuda a, háček j, čechová m, škapa p, babjuk m. clinical and cytopathological factors affecting the cellularity of urinary cell blocks and the implication for diagnosis and follow‐up of urinary bladder urothelial carcinoma. cytopathology. 2018 dec;29(6):537-44. doi: 10.1111/cyt.12580 17. krogerus l, kholová i. cell block in cytological diagnostics: review of preparatory techniques. acta cytologica. 2018;62:237-43. doi: 10.1159/000489769 18. yafi fa, brimo f, steinberg j, aprikian ag, tanguay s, kassouf w. prospective analysis of sensitivity and specificity of urinary cytology and other urinary biomarkers for bladder cancer. urol oncol. 2015; 33(2): 66-e25. doi: 10.1016/j.urolonc.2014.06.008. epub 2014 jul 15. 19. santwani pm, vachhani jh. analysis of diagnostic value of cytological smear method versus cell blocks method in body fluid cytology: study of 150 cases. ethiop j health sci. 2014; 24(2): 125-131. j islamabad med dental coll 2022 151 20. qamar s, inam qa, ashraf s, khan ms, khokhar ma, awan n. prognostic value of p53 expression intensity in urothelial cancers. j coll physicians surg pak. 2017; 27(4): 232-236. 21. mumtaz s, hashmi aa, hasan sh, edhi mm, khan m. diagnostic utility of p53 and ck20 immunohistochemical expression grading urothelial malignancies. int arch med. 2014; 7(1): 36-43. https://dx.doi.org/10.1186%2f1755-7682-7-36 22. nassa v, mahadevappa a. immunoreactivity of p53 in urothelial carcinomas of the urinary bladder. national journal of laboratory medicine. 2018; 7(4): 34-40. doi: 10.7860/njlm/2018/39790:2324 23. thakur b, kishore s, dutta k, kaushik s, bhardwaj a. role of p53 and ki-67 immunomarkers in carcinoma of urinary bladder. indian journal of pathology and microbiology. 2017 oct 1;60(4):505. https://doi.org/10.4103/ijpm.ijpm_246_17 j islamabad med dental coll 2019 163 correspondence: ghulam murtaza gondal email: drgmgondal@gmail.com cite this editorial: gondal gm. dengue fever: a challenge to health system. j islamabad med dental coll. 2019; 8(4):163-165. doi: 10.35787/jimdc.v8i4.474 o p e n a c c e s s dengue fever: a challenge to health system ghulam murtaza gondal professor of medicine, foundation university medical college, rawalpindi dengue fever is considered one of the most threatening mosquito transmitted disease with 30-fold rise in incidence world-wide. since the first ever known outbrea k of dengue infection in pakistan reported in 1994, there are increasing cases of variable intensity every year. in the current year, pakistan is undergoing one of its worstever dengue fever epidemics. the first case was reporte d on 8th july 2019 in peshawar and since then it has spread like a fire all over the country apart from islamabad, capital of pakistan. from july to november 2019, a total of 47,120 confirmed patients having this disease and 1 7 5 deaths are being notified1. the disease has hit urban areas of pakistan, placing hospitals under severe strain. authorities are conducting anti-mosquito spraying in urban areas to contain the spread of disease but due to limited resources, prolonged monsoon rains, lack of anticipation and timely measures by health authorities led to the outbreak.1 dengue fever is a viral infection caused by virus belonging to the flaviviridae family. it is transmitted by bite of an infected female aedes aegypti mosquitoes that feed during daytime (most cases at fajr and maghreb prayer time).2 this mosquito multiplies at places where there is plenty of clean stagnant water like ponds, underwater tank, jars, some empty container and old used tyres. lack of knowledge regarding disease prevention, proper sanitation and regular garbage collection is also contributing to the spread of the mosquitoes in urban as well as rural areas.3 risk of dengue exists worldwide in tropical and subtropical areas like central and south america, african countries and asia especially in the su b continent, including pakistan. therefore, all people travelling to affected areas should be considered at high risk for disease acquisition during outbreaks.4 the initial symptoms are mild body aches, fever with runny nose and itching go unnoticed and are usually not investigated. those who develop illness usually develop symptoms during the first week after the bite of infectious mosquito. early infection presents with flu-like symptoms (high-grade fever, redness and painful reddened eyes, severe myalgia, bone and joint pain, intractable headache), itching all over body along with a diffuse petechial or erythematous rash on skin.5 if untreated the illness occasionally may progress to dengue hemorrhagi c fever (dhf ), in which patients present with pain in abdomen, loose stools, fits, pleural effusion, ascites and excessive tendency to bleed. further complications may result in circulatory failure, shock and death (also known as dengue shock syndrome). an important fact to recognize is that if a patient gets infected by same serotype of dengue virus, it results in some immunity to future attacks of the virus. however, if the patient gets infected by another serotype, there is more chance to develop dengue hemorrhagic fever. therefore, once dengue infection occurs, it is very important to prevent patients from further attacks in same as well as in subsequent seasons.6 laboratory confirmation of dengue fever involves isolation of virus, nucleic acid of virus, its antigen, antibody to dengue virus, or any combination of these diagnostic methods. in any suspected patient of dengue fever, organism can be isolated from serum, circulating rbcs o r tissues for about 5 days by dengue ns1 antigen.7 after the acute phase of disease, serological tests like igm and igg antibodies in serum are considered as diagnostic tests for dengue infection.8 ultrasound done timely is al so a cost-effective and easily available diagnostic modality e d i tor i a l j islamabad med dental coll 2019 164 for evaluating cases of suspected dengue hemorrhagic fever. this technique detects pleural effusion, ascites a n d thickening of gall bladder wall, all of which represent significant permeability of blood vessels.9 the utility of ultrasound in previous studies was limited because patients underwent only a single scan. currently, serial ultrasound examination of thorax and abdomen of patients with dengue fever has been found very helpfu l i n detecting patients who are progressing to severe form of the disease.10 so far, there is no proper therapy for mild or severe dengue fever, except supportive care along with meth o d s for prevention. for severe aches, fever and pain paracetamol can be used orally or in intravenous infusion. patients are advised complete rest and plenty of fluids orally (i/v fluids if no oral intake due to vomiting). patients with worsening of symptoms in the first 24 hours should be admitted to hospital immediately to monitor for disease progression and complications.11 the only effective way of controlling this infection is protection from bite of infected mosquito, especially people travelling to endemic areas. measures include protection of human beings from mosquito bites and taking measures for keeping control on mosquito population. protective measures from dengue infection include use of anti-mosquito lotions, wearing long shirts and long pants which should be tucked into socks while going outside. the mosquito population can be reduced by getting rid of places where mosquitoes can breed e.g. used tyres, water cans, or household plant pots where rain water can collect, outdoor bird and pets' water dishes.12 recently fda has approved a vaccine, dengvaxia, which is claimed to help in prevention of dengue fever in children aged 9 to 16 years who are already infected by the dengue virus.13 however, it is not available worldwide to prevent the disease in the ge n e ra l population, especially in endemic and under developed countries. given the fact that dengue fever is a challenge to the existing health system and a burden on health services, i t could be tackled by applying simple, correct and timely treatment strategies. the management of dengue demands multi-pronged approach, involving relevant stakeholders beyond health sector and effectively implementing preventive strategies with cost-effective interventions. dengue is becoming a global threat and it is a need of time to adopt worldwide strategy for its prevention and treatment by promoting integrated approach of vector management and sustainable control measures at all levels to reduce morbidity and mortality from dengue fever. r e f e r e n c e s 1. world health organization press release on outbreak of dengue infection in pakistan. 2019 2. rasheed sb, butlin rk, boots m. a review of dengue as an emerging disease in pakistan. public health. 2013; 127(1): 11-7. doi: 10.1016/j.puhe.2012.09.006 3. bostan n, javed s, nabgha ea, eqani sa, tahir f, bokhari h. dengue fever virus in pakistan: effects of seasonal pattern and temperature change on distribution of vector and virus. rev med virol. 2017; 27(1): 112-7. doi: 10.1002/rmv.1899 4. heydari m, metanat m, rouzbeh-far ma, tabatabaei sm, rakhshani m, jahromi m. dengue fever as an emerging infection in southeast iran, am j trop med hyg. 2018: 98(5):1469-71. doi: 10.4269/ajtmh.17-0634 5. ahmad qureshi em, tabinda ab, vehra s. predicting dengue outbreak in the metropolitan city lahore, pakistan, using dengue vector indices and selected climatological variables as predictors. j pak med assoc. 2017; 67(3): 41621. pmid: 28303992 6. bhatt s, gething pw, brady oj, messina jp, farlow aw, moyes cl, et al. the global distribution and burden of dengue. nature. 2013; 496(7446): 504-7. doi:10.1038/nature12060 7. nascimento ejm, george jk, velasco m. development of an anti-dengue ns1 igg elisa to evaluate exposure to dengue virus. j virol methods. 2018; 257-8. doi: 10.1016/j.jviromet.2018.03.007 8. wilson me, chen lh. dengue: update on epidemiology. curr infect dis rep. 2015: 17 (1): 457-61. doi: 10.1007/s11908-014-0457-2 9. chatterjee r, mysore a, ahya k. utility of sonography in clinically suspected dengue. pediatr infect dis. 2012; 4(3): 107–11. doi: 10.1016/j.pid.2012.07.006 10. michels m, sumardi u, de mast q, jusuf h, puspita m. the predictive diagnostic value of serial daily bedside ultrasonography for severe j islamabad med dental coll 2019 165 dengue in indonesian adults. plos negl. trop. dis. 2013: 7(6): e2277. doi: 10.1371/journal.pntd.0002277 11. rajapakse s, de silva nl, weeratunga p. prophylactic and therapeutic interventions for bleeding in dengue: a systematic review. trans r soc trop med hyg. 2017; 111(10):433-7. doi: 10.1093/trstmh/trx079 12. who. dengue: guidelines for diagnosis, treatment, prevention and control new edition. who, geneva. 2009 13. world health organization. weekly epidemiological record. dengue vaccine: who position paper. 2018. j islamabad med dental coll 2021 76 open access outcome of infected nonunion of long bones treated by singlestage bone grafting and external fixation at northwest general hospital, peshawar, pakistan waqas raza1, raja irfan qadir2, shabir awan3, muhammad abu bakar4 1assistant professor, department of orthopedics, northwest general hospital and research center, peshawar, pakistan 2professor, department of orthopedics, northwest general hospital and research center, peshawar, pakistan 3consultant, department of orthopedics, northwest general hospital and research center, peshawar, pakistan 4specialist, department of orthopedics, northwest general hospital and research center, peshawar, pakistan a b s t r a c t background: infected nonunion of long bones after fractures is one of the most challenging complication to treat in clinical practice. it is commonly treated by a two-stage approach; controlling infection initially and then application of external fixator and bone graft. treatment with ilizarov had been the gold standard but is associated with few complications. the objective of the study was to evaluate the clinical, radiological and functional outcomes of infected non-union of long bones treated with single-stage bone grafting and external fixation. material and methods: this retrospective study was carried out at orthopedics department of northwest general hospital, peshawar pakistan from 2014 to 2019. medical records of 17 patients, aged 32 years and treated with singlestage bone grafting and external fixation were reviewed. nonunion included 7 humerii, 5 femurs, 3 tibias and 2 radius/ulna. preoperative plain radiographs for any sequestrum or sclerosed bone margins and baseline investigations (like cbc, esr, crp and vitamin-d status) were reviewed. all patients underwent radical debridement, reaming of intramedullary canals, external fixation and autogenous bone grafting. the outcomes evaluated were union of the bone (clinically and radiologically), resolution of infection, complication rate and number of re-intervention surgeries. results: among 17 patients, 10 were males and 7 were females. after treatment, mean follow-up duration was 9.414.48 months (4–18 months). none of the patients were lost to follow-up, had recurrence of infection or required further surgery. the mean duration of bone union was 8.4  4.48 months (range 3 to 17 months) and all of the patients achieved infection free union with satisfactory functional outcome. conclusions: single-stage bone grafting and external fixation is an effective technique in terms of resolution of infection and satisfactory bone union without any complications and can be used as an alternative to ilizarov for treating cases of infected nonunion of long bones. key words: external fixation, infected nonunion, long bones, single-stage bone grafting. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2-4 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: waqas raza email: mudassirazahid@gmail.com article info: received: august 20, 2020 accepted: june 15, 2021 cite this article. raza w, qadir r i, awan s, bakar m a. outcome of infected nonunion of long bones treated by single-stage bone grafting and external fixation at northwest general hospital, peshawar, pakistan. j islamabad med dental coll. 2021; 10(2): 76-82. doi: 10.35787/jimdc.v10i2.585 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 77 i n t r o d u c t i o n infected nonunion of bone is an inability of a fracture to heal for 6 to 8 months with persistence of infection.1,2 such nonunions are common in fractures caused by high-energy trauma, open fractures or as a post-operative complication of internal fixation of fractures.3 although not very common, this condition is quite difficult to treat and poses a great challenge to orthopedic surgeons due to various complications such as deformity, limb length discrepancy, joint stiffness, osteopenia, skin sinuses, resistance to antibiotics, bone and soft tissue defects.4 these complications exert a significant burden on the social, financial, physical and psychological aspect of the patient’s wellbeing.5,6 multiple surgical methods are being used for treatment of infected nonunions worldwide such as bone grafting,5 tissue transfer,6 antibiotic loaded cement,1 external fixation and ilizarov.7 bone grafting is a common technique but is associated with certain limitations/complications while treating larger bone defects, prolonged graft incorporation time and donor site morbidity.8 free tissue transfer is another feasible option for large bone defects and soft tissue loss but it is technically demanding and is associated with stress fractures and nonunion.9 antibiotic cement is also associated with certain limitations as it is only suitable for small defects and a second procedure of bone grafting is usually required to achieve bone union.1 the single-stage treatment with thorough debridement and irrigation, external fixation, and autogenous cancellous bone grafting is known to be an effective technique because of shorter hospital stay, reduced cost and less chances of reintervention surgeries. this technique has minimal complications as compared to the two-stage surgical management which is associated with increased chances of recurrence of infection and nonunion. the objective of this study was to assess the clinical, radiological (i.e., bone union, infection control, deformity and limb length discrepancy) and functional outcomes (i.e., limp, joint stiffness, reflex sympathetic dystrophy or pain) of infected nonunion of long bones treated with single-stage bone grafting and external fixation. m a t e r i a l a n d m e t h o d s this retrospective study was carried out at the orthopedics department of northwest general hospital, peshawar pakistan from 2014 to 2019 after being approved by the ethics committee of northwest general hospital. patients (n=17) above 18 years of age, of both genders with infected nonunion of long bones treated at our institute were included after obtaining written informed consent for the use of clinical details and images. since it is an uncommon presentation in our setting, hence only 17 cases could be evaluated for the study. no specific exclusion criteria were used as a smaller number of patients was anticipated. all the patients had active infection with purulent discharge through sinuses. antibiotics were stopped 72 hours before surgery. outcomes were evaluated by a multidisciplinary team including orthopedic surgeons, radiologists and infectious disease specialists. during surgery, standard incisions were given with patients placed in supine position, followed by radical debridement of the infected avascular tissue including skin, subcutaneous tissue, fascia, muscles, fibrous tissue and necrotic bone. paprika sign (active punctate bleeding bone) was taken as an indication of vital bone and proximal and distal medullary j islamabad med dental coll 2021 78 canals were curetted and reamed to remove all necrotic debris. bone and soft tissue cultures were taken for culture and antibiotic sensitivity (c/s). external fixation of the long bones was then done under image intensifier using schanz screws in unilateral uniplanar mode. cancellous bone graft, harvested from patient’s iliac crest was then applied at freshened bone ends. empirical antibiotics were given to all patients intravenously before culture and sensitivity report. the wounds were closed in layers with suction drain in place. postoperatively, all patients were given parenteral antibiotics according to their culture and sensitivity throughout their hospital stay and were discharged with enteral antibiotics for 6 weeks. c/s report of seven patients showed mrsa while growth of staphylococcus aureus, proteus mirabilis, serratia species and pseudomonas aeruginosa was seen in two patients, each. sample of one of the patients showed edwardsiella while another one had enterobacter infection. all mrsa patients were sensitive to linezolid, which was continued orally for 6 weeks. drains were removed on first or second postoperative day. patients were advised active assisted range of motion exercises for joints and isometric muscles exercises on second postoperative day. radiographs were taken and reviewed on first postoperative day and then monthly until union was achieved. the fixator was removed when radiographs showed solid union. the cost of all procedures including debridement, bone grafting and external fixation were borne by the patients. mean values were calculated and kruskal-wallis test was applied to determine the intergroup differences in terms of bone and time to complete union. the test statistic was adjusted for ties. multiple comparisons were performed if the test showed significant difference across samples. p-value less than .05 was considered as statistically significant. r e s u l t s out of 17 patients included in the study, 10 were males and 7 were females with a mean age of 31.76 + 7.59 years (age range 18–45 years). long bones with infected nonunion included humerus (n=7), femur (n=5), tibia (n=3) and radius/ulnas (n=2), respectively (figure 1). the previous procedures included plating (12 patients), interlocking nail (3 patients), rush nail (1 patients), and screw & k wires (1 patient). intraoperative specimen of all the patients were positive for bacterial growth. the patients were followed up for a mean duration of 9.41 + 4.48 months (range 4 to 18 months) after the surgery and none of the patient was lost to followup. figure 1: infected nonunion of tibia with broken implant in situ. a: ap view, b: lateral view. satisfactory bone union without infection was achieved in all patients (figures 2 & 3). there was statistically no significant difference in recovery gender wise. no bony complications such as deformity or limb length discrepancy were recorded. functional outcome was satisfactory in all patients with no limp, joint stiffness, reflex sympathetic dystrophy or pain (figure 4). j islamabad med dental coll 2021 79 figure 2: postoperative view of tibia after single-stage external fixation and bone grafting. a: ap view. b: lateral view. the mean duration of bone union was 8.41 + 4.48 months (3-17 months) in all patients. however, tibial nonunion took a little longer to heal than femur, with a mean duration of 69.11 days (range 33 to 137 days) in tibia compared to 64.45 days (range 45–86 days) in femur. intergroup differences in terms of bone and time to complete union were statistically insignificant (p>.05). figure 3: postoperative follow up x-rays after single-stage external fixation and bone grafting. a, b & c: ap and lateral view of humerus at 5 months. d: x-ray at seven months (lateral view tibia). e: x-ray at seven months (ap view tibia). f: x-ray at nine months (ap view tibia). g & h: x-rays at nine months showing fracture is united. figure 4 a & b: functional range of motion after union is achieved. j islamabad med dental coll 2021 80 d i s c u s s i o n this study aimed to evaluate the effectiveness of single-stage bone grafting and external fixation for treatment of infected nonunion of long bones. favorable outcomes were observed in terms of resolution of infection, complete union and regain of functional mobility. infected nonunion of long bones is one of the most difficult problems to treat in orthopedics practice.10 it is difficult to control the infection and achieve union1,2 and thus the management is challenging for both the patient and the treating surgeon.1,3,4 there are two main protocols for the management of infected nonunion; “one-stage” protocol involves simultaneous clearance of infection by radical debridement and bone stabilization with external fixation and a “two-stage” protocol wherein infection is eradicated in the first stage followed by bone stabilization with internal or external fixation. conventional strategy for infected nonunion is the two-stage technique. in the past decade ilizarov has been considered as the gold standard treatment for infected nonunion2 but it has a number of complications.11 however, this method increases hospital stay and is costly. many authors have reported success by treatment with antibiotic impregnated intramedullary nailing but this technique can lead to infection of entire medullary canal of the bone.11 furthermore, in locally infected cases some authors have reported good success rate with plating and bone graft also.12 bone grafting plays a critical role in promoting bone healing in infected non-union.13-15 external fixation has been proven preferable in infected nonunion for reasons like fixation away from infected area, easy to apply and reduced risk of infection recurrence.16,17 one-stage treatment has resulted in avoidance of multiple surgeries and anesthesia as well as reduced cost and hospital stay. emara et al. also confirmed that one stage strategy had lower risk of recurrence of infection.17 lei and yi treated 19 patients of infected non-union of femur utilizing single-stage protocol with external fixation or bone grafting and achieved infection-free union in all.18 their results are similar to our study using single-stage protocol with external fixation. some of the advantages of one-stage bone grafting and external fixation as observed in this study are a shorter hospital stay, cost-effectiveness, reduced time to bone healing and safer and predictable achievement of infection free union. study by liu et al.19 showed feasibility of one-stage open cancellous bone grafting in the treatment of infected nonunions in a rabbit model. many surgeons have also confirmed that satisfactory results can be achieved with one-stage procedure, including a shorter hospital stay.20-22 treatment of infected non-union by open bone grafting combined with external fixation is challenging because multiple dressings are used for wound coverage,14,23,24 thereby increasing time of bone union and wound healing. this leads to increased cost and hospital stay. we however report external fixation as a cost-effective procedure. regarding reduced time to bone healing, lei and yi also reported that all patients had achieved bony union with resolution of infection using single-stage protocol. their study had average follow-up of 3.5 years, hence longer time to achieve bone healing as compared to our study.18 bose et al. found that eradication of infection was more predictably achieved by the single surgical procedure which has also been reported by other authors.24,25 also, in infected non unions external fixation is preferred and safer method than internal fixation.26 in this study, infection free union has been achieved in all patients, which is almost similar to the average data recorded in the above-mentioned studies. in order to increase the success rates, we believe that j islamabad med dental coll 2021 81 preparing patients for surgery keeping in view their specific conditions, good patient’s compliance and meticulous post-operative care is necessary. favorable results of our study suggest that onestage bone grafting and external fixation may be a feasible alternative treatment option. the main limitation of our study is a small sample size, no comparison group, and absence of functional outcome scores. however, using our single-stage protocol we achieved infection free union in all cases and majority of our patients had attained full range of motion. moreover, the study lacks a direct comparison with any other treatment options and thus further randomized controlled trials are needed to draw a more valuable conclusion. c o n c l u s i o n this study suggested that single-stage technique is effective in treating infected nonunion with complete resolution of infection and bone union. the treatment with external fixation and one stage bone grafting can be used as alternative method of fixation for obtaining fracture union with a good functional and bone results. r e f e r e n c e s 1. yin p, zhang l, li t, zhang l, wang g, li j, et al. infected nonunion of tibia and femur treated by bone transport. josr. 2015; 10(1):1-9. doi: 10.1186/s13018-015-0189-5. 2. shahid m, hussain a, bridgeman p, bose d. clinical outcomes of the ilizarov method after an infected tibial non-union. arch trauma res. 2013; 2(2):71. doi: 10.5812/atr.11300. 3. harshwal rk, sankhala ss, jalan d. management of nonunion of lower-extremity long bones using monolateral external fixator–report of 37 cases. injury. 2014; 45(3):560-7. doi: 10.1016/j.injury.2013.11. 019. 4. deng z, cai l, jin w, ping a, wei r. one-stage reconstruction with open bone grafting and vacuumassisted closure for infected tibial non-union. ams. 2014; 10(4):764-72. doi: 10.5114/aoms.2013.34411. 5. ozaksar k, sugun t, toros t, gurbuz y, kayalar m, ozerkan f. free vascularized fibular grafts in type 3 open tibia fractures. aott. 2012; 46(6): 430-37. doi:10.3944/aott.v46i6.6049. 6. yin p, zhang q, mao z, li t, zhang l, tang p. the treatment of infected tibial nonunion by bone transport using the ilizarov external fixator and a systematic review of infected tibial nonunion treated by ilizarov methods. acta orthop belg. 2014; 80(3): 426-35. 7. naidu, kv dhanwantary. efficacy external fixator in the management of infected nonunion fractures. ijos. 2018; 4(1): 164-66. doi: 10.22271/ortho. 2018.v4.i1c.25. 8. sun y, zhang c, jin d, sheng j, cheng x, zeng b. treatment for large skeletal defects by free vascularized fibular graft combined with locking plate. arch orthop trauma surg. 2010; 130(4): 473-9. doi: 10.1007/s00402-009-0898-5. 9. chaudhary mm. infected nonunion of tibia. indian j orthop. 2017; 51(3): 256–68. doi: 10.4103/ortho. ijortho_199_16. 10. park j, yang kh. indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions. injury. 2013; 44(12): 1820-5. doi: 10.1016/j.injury.2013.02.021. 11. liu y, yushan m, liu z, liu j, ma c, yusufu a. complications of bone transport technique using the ilizarov method in the lower extremity: a retrospective analysis of 282 cases over 10 years. bmc musculoskelet disord. 2020; 21: 354. doi: 10.1186/s12891-020-03335-w. 12. archdeacon mt, messerschmitt p. modern papineau technique with vacuum-assisted closure. j orthop trauma. 2006; 20(2): 134-7. doi: 10.1097/01.bot. 0000184147.82824.7c 13. saleh m, kreibich dn, ribbans wj. circular frames in the management of infected tibial non-union: a modification of the papineau technique. injury. 1996; 27(1): 31-3. doi: 10.1016/0020-1383(95)00164-6. 14. tulner sa, schaap gr, strackee sd, besselaar pp, luitse js, marti rk. long-term results of multiplestage treatment for posttraumatic osteomyelitis of the tibia. j trauma acute care surg. 2004; 56(3): 63342. doi: 10.1097/01.ta.0000112327.50235.0a. 15. ueng wn, shih ch. semiopen cancellous bone grafting. a 2-step method for closing small infected tibial bone defects. clin orthop relat res. 1994; 306: 175-82. pmid: 8070192. 16. petty wi, spanier su, shuster jj, silverthorne ca. the influence of skeletal implants on incidence of infection. experiments in a canine model. j bone joint surg. 1985; 67(8): 1236-44. pmid: 3902846. j islamabad med dental coll 2021 82 17. emara km, ghafar ke, diab ra. one stage versus two stages strategies in the management of femoral shaft infected nonunion. moj sports med. 2017; 1(2): 246. 18. lei h, yi l. one-stage open cancellous bone grafting of infected fracture and nonunion. j orthop surg. 1998; 3(6): 318-23. doi: 10.1007/s007760050059. 19. liu dq, zhang bs, liu hb. experimental observation of open cancellous bone graft in treatment of infected fracture nonunion. chin j orthop trauma. 2004; 6: 1370-3. 20. chen z-w, liu h, zhai w-l, zeng j-h. treatment of infected bone defect with one stage open cancellous bone grafting. zhongguo gu shang (cjot). 2008; 21(5): 377-8. pmid: 19108471. 21. lu wj, qian hb, li b. treatment of chronic osteomyelitis by modified i-stage open cancellous bone grafting post debridement. chin j trauma. 2004; 20: 288-90. 22. papineau lj. excision-graft with deliberately delayed closing in chronic osteomyelitis. la nouvelle presse medicale. 1973; 2(41): 2753-5. pmid: 4589881. 23. sachs bl, shaffer jw. a staged papineau protocol for chronic osteomyelitis. clin orthop relat res. 1984; 184: 256-63. pmid: 6368084. 24. bose d, kugan r, stubbs d, mcnally m. management of infected nonunion of the long bones by a multidisciplinary team. bone joint j. 2015; 97(6): 8147. doi: 10.1302/0301-620x.97b6.33276. 25. raj m, singh j, mukhopadhya j, gill sp, sheopaltan sk, kumar h, et al. evaluation of single-stage protocol using locked plate as primary fixation in treatment of infected non-union of long bones. ijos. 2016; 2(4): 86-90. 26. thakeb mf. compression distraction for the management of complex femoral nonunion. egypt orthop j. 2017; 52(2): 91. doi: 10.4103/eoj.eoj_ 24_17. j islamabad med dental coll 2021 125 op e n ac c e s s covid-19 vaccines in pakistan: efficacy, adverse effects and availability soma siddique1, shaheer ahmed1 1second year mbbs student, islamabad medical and dental college, islamabad, pakistan a b s t r a c t in this review article, we aim to document the efficacy, adverse effects, mode of action, required doses, and availability of the major vaccines available in pakistan till 20 may 2021. we reviewed all available literature on covid-19 vaccines in pubmed and google scholar. we also reviewed articles from grey literature. currently, pfizer–biontech and moderna, sinopharm (china), sputnik v (russia), coronavac (popularly known as sinovac) (china), cansino, and vaxzevria vaccines have been authorized for emergency use in several countries. pakistan has sanctioned the use of all the aforementioned vaccines except pfizer and moderna. as per their efficacy, pfizer and moderna have been found most effective among all the vaccines with 95% effectiveness, while the vaxzevria, sputnik v, sinopharm, and cansino have shown 70%, 91.6%, 79.34%, and 90% effectiveness, respectively. all the vaccines have shown milder side effects like headache, fever, and pain on injection sites. to curb the pandemic, more clinical trials are being conducted throughout the world. importantly public awareness is warranted to achieve the target of vaccinating a large population. key words: covid-19, vaccination, efficacy, thrombosis with thrombocytopenia syndrome (tts), vaccine induced thrombotic thrombocytopenia (vitt). authors’ contribution: 1,2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing correspondence: soma siddique email: somamalik562@gmail.com article info: received: june 1, 2021 accepted: june 16, 2021 cite this review: siddique s, ahmed s. covid-19 vaccines in pakistan: efficacy, adverse effects and availability. j islamabad med dental coll. 2021; 10(2): 125-130. doi: 10.35787/jimdc.v10i2.723 funding source: nil conflict of interest: nil i n t r o d u c t i o n the covid-19 infection caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2) has posed a severe unprecedented social, economic, and healthcare crisis across the globe. it was declared as a pandemic by world health organization (who), on march 2020 following its spread outside of china.1 being a healthcare challenge itself, it has led to prevalence of other conditions, directly or indirectly as well, such as depression and anxiety endemics, and hindrance to vaccine dissemination and elective surgeries.2-4 as of may 2021, about 163,312,429 confirmed cases and 3386,825 associated deaths have been reported worldwide.5 to mitigate the global devastation and to curtail this pandemic, the world is in dire need of vaccines. different organizations are currently working on introducing effective vaccines and a global partnership has been established. in compliance s t u d e n t s c o r n e r j islamabad med dental coll 2021 126 with the situation, the development and the testing of vaccines have been accelerated to curb the spread of disease. currently, a number of sars-cov2 vaccines are under clinical (n=102) and pre-clinical (n=184) development throughout the world.6 who has approved nineteen vaccines for emergency use. meanwhile, different countries are approving different vaccines as per their own criteria and feasibility.7 south africa has granted emergency use authorization for six vaccines while pakistan and uk have authorized five and three major vaccines, respectively.8,9 the broad-spectrum definition of vaccine efficacy suggested by fda includes two important factors. firstly, the vaccines should have the ability to preclude the transmission of the virus from infected to susceptible person. secondly, it should be successful in curtailing progression of the diseases along with minimizing the utilization of intensive care resources.10 a minimum of 50% efficacy threshold for the vaccine has been determined by the fda.11 any vaccine above this threshold is allowed to be used for emergencies. one of the studies states that pfizer and moderna vaccines have reported 95% effectiveness following phase iii clinical trial, while the efficacy of vaxzevria (formerly known as astrazeneca) is claimed to be 70% in a study by voysey and colleagues.12,13 another report by logunov and colleagues affirms 91.6% effectiveness for the sputnik v vaccine of russia.14 from the list of these potential vaccines, pakistan has been able to provide five vaccines, namely: sinopharm (china), sputnik v (russia), cansino, and the vaxzevria.9,15 this study aims to document the efficacy, advantages, adverse effects, and mode of action and the availability of these major vaccines in pakistan. review of all available literature on the pubmed and google scholar was done using following key words and mesh terms where appropriate: “covid-19 vaccine”, “sars-cov-2 vaccine”, “coronavirus disease 2019 vaccine”, “2019-ncov vaccine” and “2019 novel coronavirus vaccine”. grey literature was also seen through different government websites and new published articles. all the available literature published till may 20, 2021 were included in this review. pfizer–biontech and moderna: pfizer–biontech and moderna were the first vaccines to get authorization for emergency use in december 2020, and have reported an efficacy of 95% following the phase iii clinical trials.12,16-19 both these vaccines use lipid nanoparticle delivery system or modified mrna system.20 in the latter system, modified mrna is used to encode the covid spike proteins, adding mutant mrna to lock them in a three-dimensional structure which is required to induce an interaction between spike proteins and viral neutralizing antibodies.21 these rna vaccines have a potent effect and can be manufactured rapidly at a very low cost. since, they are not developed with actual pathogens and are not incorporated into host dna as is the case with other viral vaccines, they show a better safety profile. however, due to their unstable mrna, they require extreme refrigeration for storage. refrigerating temperatures required for pfizer and moderna are 60°c to -80°c and -15°c to -25°c, respectively.22 since ultra-cold temperatures are required for their refrigeration, they are not available in pakistan.23 both vaccines have shown localized side effects like vomiting, pain, nausea, fever, headache, and muscle aches. in rare cases, these vaccines have also been found to cause anaphylactic reactions.22 vaxzevria: the vaxzevria uses replication-deficient chimpanzee adenovirus inoculating the sars-cov-2 proteins in the body to incite immune responses.13 after inoculation of the vaccine, body recognizes these j islamabad med dental coll 2021 127 proteins and begins to develop protective responses that later on preclude the entry of the sars-cov-2 virus into the body.24 storage temperature required for chadox1 ncov-19 vaccine/azd1222 is 2°c to 8°c.25 several trials for the efficacy of this vaccine were carried out in south africa and brazil, which showed an overall efficacy of 70%.13 milder systematic side effects of diarrhea, fatigue, headache, chills, and nausea have been observed with this vaccine.26 besides these side effects, rare events of thrombosis along with thrombocytopenia, recently termed as thrombosis with thrombocytopenia syndrome (tts), have also been noticed.27,28 however, these thrombotic events have been seen in rare cases even after the administration of millions of doses of the vaccine.29 after evaluation of the preliminary data, different international authorities including european medicines agency (ema), the who global advisory committee on vaccine safety (gvacs), and the uk medicines and healthcare products regulatory agency (mhra) have concluded that benefits of vaccine overweighs its risk.30 from the initial data available, it has been seen that thrombotic events are reported more in women than men. this finding might be attributed to the use of estrogen containing contraceptives, which are considered one of the risk factors of thrombosis.31 sputnik v: like other vaccines phase iii trials have also been conducted for sputnik v, which has reported 91.6% efficacy.14 sputnik v uses an adenovirus vector transport system, much the same as astrazeneca but it carries two adenovirus vectors ad5 and ad26 which aids in expression of gene for spike proteins.32 it has been approved for emergency use in 60 countries including china, india, and pakistan. according to one of the reports, pakistan has ordered 50,000 doses from russia.33 as per its side effects, mild headache and pain on the injection site are observed.34 furthermore, it is refrigerated at 18°c, and two doses are required to be administered at interval of 21 days, as suggested by ministry of national health services, regulations and coordination of pakistan.35 sinopharm: the sinopharm vaccine is the inactivated whole virus vaccine made from vero cells. these cells create multiple copies of the sars-cov-2 virus which are then treated with beta-propiolactone, deactivating the virus by binding to its genes. phase iii clinical trials conducted in argentina, bahrain, egypt, morocco, pakistan, peru, and the united arab emirates (uae), have shown 79.34% efficacy of the vaccine.36 following clinical trials, the vaccine was approved for emergency use in may by who. as per the guidance of who, two doses of vaccine are required to be administered with 3-4 weeks’ interval.37 data available on the side effects of the vaccine shows milder side effects like headache, fever, and pain on injection site, etc.38 cansino-bio: this vaccine is manufactured by cansinobio company china. modified common cold virus is being used as a vector for inoculation of coronavirus genetic material into the human body. it boosts the t cell response, which helps combat the disease. the clinical trials have been conducted in pakistan, russia, mexico and chile, which have shown 90% efficacy. importantly, this vaccine has shown no serious adverse effects.39 covid-19 vaccination in pakistan (table i): by now, sinopharm, cansino-bio, sinovac (coronavac), sputnik v, and the oxford universityastrazeneca vaccines have been allowed for emergency use in pakistan.9,15 the vaccination campaign commenced in pakistan on february 2, 2021.40 the initiation of the vaccination campaign in j islamabad med dental coll 2021 128 pakistan was marked by donation of vaccines by the chinese government. table i: summary of major sars-cov-2 vaccines vaccines efficacy age limit storage temperature doses authorization in pakistan vaccine manufacturer pfizer– biontech 95% 16 and above -60°c to -80 °c 2 shots 21 days apart not approved pfizer–biontech moderna 95% 18 and above -15 °c to -25 °c 2 shots 28 days apart not approved moderna, american pharmaceutical and biotechnology company vaxzevria 70% 18 and above regular fridge temperature 2 shots 21 days apart approved oxford university and astrazeneca sputnik v 91.6% 18 and above -18°c 2 shots 21 days apart approved gamaleya research institute of epidemiology and microbiology, russia sinopharm 79.34% 18 and above +2°c to +8°c 2 shots 21 days apart approved sinopharm group co., ltd, china. cansinobio 90% 18 and above +2°c to +8°c single shot approved cansinobio however, this vaccination campaign has not gained momentum as only 3 individuals per 100 of the population are currently vaccinated.41 to accelerate the vaccination campaign, pakistan has started purchasing vaccines. one of the reports state that 50,000 doses of sputnik v vaccine have been imported from russia and pakistan is going to receive more doses soon to accelerate underactive vaccination campaign.42 c o n c l u s i o n currently vaccination is the only effective and possible solution to curb this devastating pandemic. for this purpose, collaboration among the researchers and governments have been established throughout the world to put in best efforts to produce effective vaccines. moreover, clinical trials are being conducted to test the efficacy of these vaccines. about 70-80% efficacy has been achieved for majority of them. more clinical trials are required to produce effective vaccines and to curtail the spread of the disease completely. it is the government’s responsibility to make adequate vaccines available in the country as well as devising a system to monitor its administration and make sure it remains available to its people. r e f e r e n c e s 1. lurie n, sharfstein jm, goodman jl. the development of covid-19 vaccines: safeguards needed. jama. 2020; 324 (5): 439-40. doi:10.1001/jama.2020.12461. 2. meo sa, abukhalaf aa, alomar aa, sattar k, klonoff dc. covid-19 pandemic: impact of quarantine on medical students’ mental wellbeing and learning behaviors. pak j med sci. 2020; 36 (covid19-s4): s43-s48. doi: 10.12669/pjms.36.covid19-s4.2809. 3. ali i. impact of covid-19 on vaccination programs: adverse or positive? hum vaccines immunother. 2020; 16(11): 2594-600. doi: 10.1080/21645515 .2020.1787065. 4. iacobucci g. covid-19: all non-urgent elective surgery is suspended for at least three months in england. bmj. 2020; 368: m1106. doi: 10.1136/bmj.m1106. j islamabad med dental coll 2021 129 5. world health organization. who coronavirus (covid-19) dashboard 2021, may 1 [available from: https://covid19.who.int/. 6. who. draft landscape and tracker of covid-19 candidate vaccines 2021 [available from: https://www.who.int/publications/m/item/draftlandscape-of-covid-19-candidate-vaccines. 7. who. status of covid-19 vaccines within who eul/pq evaluation process 2021 [available from: https://extranet.who.int/pqweb/sites/default/files/ documents/status_covid_vax_18may2021 .pdf. 8. menni c, klaser k, may a, polidori l, capdevila j, louca p, et al. vaccine side-effects and sars-cov-2 infection after vaccination in users of the covid symptom study app in the uk: a prospective observational study. lancet. 2021. doi: 10.1016/s1473-3099(21)00224-3. 9. janjua h. in pakistan, covid-19 vaccines go on sale 18 march 2021 [available from: https://www.devex.com/news/in-pakistan-covid19-vaccines-go-on-sale-99438]. 10. development and licensure of vaccines to prevent covid-19 2021. us food and drug administration. [available from: https://www.fda.gov/regulatoryinformation/search-fda-guidancedocuments/development-and-licensure-vaccinesprevent-covid-19]. 11. national institute of health. fourth large-scale covid-19 vaccine trial begins in the united states september 23, 2020 [available from: https://www.nih.gov/news-events/newsreleases/fourth-large-scale-covid-19-vaccine-trialbegins-united-states]. 12. polack fp, thomas sj, kitchin n, absalon j, gurtman a, lockhart s, et al. safety and efficacy of the bnt162b2 mrna covid-19 vaccine. n engl j med. 2020; 383(27): 2603-15. doi: 10.1056/ nejmoa2034577. 13. voysey m, clemens sac, madhi sa, weckx ly, folegatti pm, aley pk, et al. safety and efficacy of the chadox1 ncov-19 vaccine (azd1222) against sarscov-2: an interim analysis of four randomised controlled trials in brazil, south africa, and the uk. lancet. 2021; 397(10269): 99-111. doi: 10.1016/ s0140-6736(20)32661-1. 14. logunov dy, dolzhikova iv, shcheblyakov dv, tukhvatulin ai, zubkova ov, dzharullaeva as, et al. safety and efficacy of an rad26 and rad5 vectorbased heterologous prime-boost covid-19 vaccine: an interim analysis of a randomised controlled phase 3 trial in russia. lancet. 2021; 397(10275): 671-81. doi: 10.1016/s0140-6736(21)00234-8. 15. bhatti mw. drap allows emergency authorisation to fifth covid-19 vaccine april 9, 2021 [available from: https://www.thenews.com.pk/print/817278-drapallows-emergency-authorisation-to-fifth-covid-19vaccine]. 16. soiza rl, scicluna c, thomson ec. efficacy and safety of covid-19 vaccines in older people. age ageing. 2021; 50(2): 279-83. doi: 10.1093/ageing/afaa274. 17. baden lr, el sahly hm, essink b, kotloff k, frey s, novak r, et al. efficacy and safety of the mrna-1273 sars-cov-2 vaccine. n engl j med. 2020; 384(5): 40316. doi: 10.1056/nejmoa2035389. 18. food, food daj, administration d. fact sheet for healthcare providers administering vaccine (vaccination providers): emergency use authorization (eua) of the pfizer-biontech covid-19 vaccine to prevent coronavirus disease 2019 (covid19). silver spring, md: us department of health and human services. 2021. 19. mahase e. covid-19: moderna vaccine is nearly 95% effective, trial involving high risk and elderly people shows. bmj. 2020; 371: m4471. doi: 10.1136/bmj.m4471. 20. dolgin e. covid-19 vaccines poised for launch, but impact on pandemic unclear. nature. 2020. doi: 10.1038/d41587-020-00022-y. 21. walsh ee, frenck jr rw, falsey ar, kitchin n, absalon j, gurtman a, et al. safety and immunogenicity of two rna-based covid-19 vaccine candidates. n engl j med. 2020; 383(25): 2439-50. doi: 10.1056/nejmoa2027906. 22. meo s, bukhari i, akram j, meo a, klonoff dc. covid19 vaccines: comparison of biological, pharmacological characteristics and adverse effects of pfizer/biontech and moderna vaccines. eur rev med pharmacol sci. 2021; 25(3): 1663-69. doi: 10.26355/eurrev_202102_24877. 23. getting a coronavirus vaccine in pakistan: what you should know. geo news. apr 07 2021. 24. knoll md, wonodi cjtl. oxford–astrazeneca covid19 vaccine efficacy. lancet. 2021; 397(10269): 72-4. doi: 10.1016/s0140-6736(20)32623-4. 25. cohen j. vaccine designers take first shots at covid19. american association for the advancement of science; 2020. doi: 10.1126/science.368.6486.14. 26. tsirtsakis a. astrazeneca and pfizer: what are the side effects of australia’s vaccines? 03 may 2021 [available from: https://www1.racgp.org.au/newsgp/clinical/astraze neca-and-pfizer-what-are-the-side-effects-f]. 27. 27. thrombosis with thrombocytopenia syndrome (also termed vaccine-induced thrombotic thrombocytopenia). american society of hematology. april 29, 2021 [available from: https://www.hematology.org/covid-19/vaccineinduced-immune-thrombotic-thrombocytopenia]. j islamabad med dental coll 2021 130 28. james b. bussel jmc, douglas b. cines, cynthia e. dunbar, laura c. michaelis, lisa baumann kreuziger, agnes y. y. lee, and ingrid pabinger-fasching. thrombosis with thrombocytopenia syndrome (also termed vaccine-induced thrombotic thrombocytopenia) 2021 [available from: https://www.hematology.org/covid-19/vaccineinduced-immune-thrombotic-thrombocytopenia]. 29. masten a. isth statement on astrazeneca covid-19 vaccine and thrombosis. march 12, 2021. 30. benefits of covid-19 vaccine astrazeneca outweigh risks of blood clots. reactions weekly. 2021; 1848(1): 2. doi: 10.1007/s40278-021-93004-3. 31. lancet haematology. covid-19 vaccines: building and maintaining confidence. lancet (editorial). 2021; 8(5): e305. doi: 10.1016/s2352-3026(21)00107-1. 32. logunov dy, dolzhikova iv, zubkova ov, tukhvatullin ai, shcheblyakov dv, dzharullaeva as, et al. safety and immunogenicity of an rad26 and rad5 vectorbased heterologous prime-boost covid-19 vaccine in two formulations: two open, non-randomised phase 1/2 studies from russia. lancet. 2020; 396(10255): 887-97. doi: 10.1016/s0140-6736(20)31866-3. 33. statista. number of doses of covid-19 vaccines sputnik v ordered from russia. 2021 [available from: https://www.statista.com/statistics/1123927/sputni k-v-exports-from-russia-by-country/]. 34. gulland a. sputnik vaccine: side effects, efficacy and is the russian covid jab safe? the telegraph. 1 april 2021. 35. government of pakistan monhs, regulation and coordination. covid-19 vaccination updated sputnik v vaccine guidelines. 03 may 2021. 36. jajja s. all you need to know about covid vaccines in pakistan. dawn news. 2021. 37. who strategic advisory group of experts (sage) on immunization. the sinopharm covid-19 vaccine: what you need to know 2021 [available from: https://www.who.int/news-room/featurestories/detail/the-sinopharm-covid-19-vaccinewhat-you-need-to-know. 38. pik h. sinopharm covid-19 vaccine: should you worry about the side effects? 2021 [available from: https://www.medicalnewstoday.com/articles/sinop harm-covid-19-vaccine-should-you-worry-aboutthe-side-effects. 39. ramasamy mn, minassian am, ewer kj, flaxman al, folegatti pm, owens dr, et al. safety and immunogenicity of chadox1 ncov-19 vaccine administered in a prime-boost regimen in young and old adults (cov002): a single-blind, randomised, controlled, phase 2/3 trial. lancet. 2020; 396(10267): 1979-93. doi: 10.1016/s0140-6736(20)32466-1. 40. standard b. pakistan to buy 7 mn doses of coronavirus vaccines from china: minister 2021 [available from: https://www.businessstandard.com/article/current-affairs/pakistan-tobuy-7-mn-doses-of-coronavirus-vaccines-fromchina-minister-121032600569_1.html. 41. hashim a. pakistan receives another large covid vaccine shipment from china. aljazeera. 1 apr 2021. 42. news it. corona vaccine available for all age groups 2021 [available from: https://www.thenews.com.pk/print/814174corona-vaccine-available-for-all-age-groups.]. i radiographic images acute intestinal obstruction retroperitoneal neurogenic tumor 2 extensive bilateral pneumonic consolidations leading to ards haemorrhagic transformation of subacute infarct iii acute occlusive portal vein thrombosis extending into superior mesenteric and splenic veins contributed by: professor manal niazi department of radiology dr. akbar niazi teaching hospital, islamabad j islamabad med dental coll 2021 176 open access sero-prevalence of brucellosis in occupationally high-risk groups in three different districts of khyber pakhtunkhwa, pakistan aman ullah1, hamaad ali2, falak niaz3, muhammad umair khan2, muhammad asif zeb1, noor rehman4 1lecturer, institute of paramedical sciences, khyber medical university, peshawar 2student, medical lab technology, national institute of health and management sciences, peshawar 3lecturer, medical lab technology, national institute of health and management sciences, peshawar 4lab technologist, institute of basic medical sciences, khyber medical university, peshawar a b s t r a c t objectives: brucellosis is a neglected zoonotic disease in pakistan, but it causes immense impact on livestock and public health. this study was done to determine the prevalence of brucellosis in occupationally high-risk groups encompassing butchers, milkers, and cattle caretakers in district swabi, mardan, and peshawar of khyber pakhtunkhwa, pakistan. methods: in this descriptive cross-sectional study, 300 blood samples were collected through a non-probability purposive sampling technique from occupationally high-risk groups including butchers, milkers, and cattle caretakers at district swabi, mardan, and peshawar from december 1, 2017, to march 31, 2018. all the blood samples were centrifuged and the serum was separated for further testing. serum agglutination test was used for the detection of brucellosis and the reagents used for this method were purchased from biosciences pte ltd, singapore. results: out of 300 blood samples, 111 samples were positive and the overall prevalence of brucellosis was 37% in occupationally high-risk groups. the overall 37% prevalence of brucellosis comprised of 70% of b. abortus, 21.6% of b. melitensis, and 8.1% of both b. abortus and b. melitensis simultaneously. the prevalence of brucellosis in butchers was 27.6%, milkers 13.3%, and cattle caretakers 45.7% while prevalence in males was 33% and in females 39.6%. the prevalence of brucellosis in district swabi was 45%, mardan 33.3%, and peshawar 30%. the socio demographic factors including age group, occupation, and locality showed statistically significant results. conclusion: the prevalence of brucellosis is considerably higher in occupationally high-risk groups in district swabi, mardan, and peshawar, pakistan. keywords: brucellosis, brucella abortus, brucella melitensis, malta fever, zoonosis authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6 data analysis; manuscript editing. correspondence: aman ullah email: khurramthalwi@hotmail.com article info: received: october 10, 2020 accepted: august 23, 2021 cite this article. ullah aman, ali h, niaz f, khan mu, zeb ma, rehman n. sero-prevalence of brucellosis in occupationally high-risk groups in three different districts of khyber pakhtunkhwa, pakistan. j islamabad med dental coll. 2021; 10(3): 176-180. doi: 10.35787/jimdc.v10i3.620 funding source: nil conflict of interest: nil i n t r o d u c t i o n brucellosis is a zoonotic disease caused by gramnegative bacteria of genus brucella (b.) and can cause infection both in animals and humans.1 according to the office international des, epizooties (oie) brucellosis is the second leading zoonotic disease in the world.2 world health organization o r i g i n a l a r t i c l e j islamabad med dental coll 2021 177 (who) reported that annually 500,000 cases of brucellosis occur across the globe.3 the high prevalence of this infection is gaining increasing attention worldwide. it is also a noticeable issue in pakistan because previously a study reported 37% prevalence in 2014.4 only four species are responsible for human brucellosis including b. abortus, b. melitensis, b. suis and b. canis, and their common reservoirs include cattle, sheep and goats, pigs, and dogs respectively.5, 6 in natural hosts, the transmission mostly occurs through milk or genital secretions during mating.7 this infection transfers from animals to humans by using raw milk and other dairy products made from milk like cheese, butter, and ice cream, etc.8 it can also be transmitted by inhalation of infectious aerosol, ingestion of infected meat, contact with conjunctival mucosa, or bacteria may enter through injured skin by close contact with animal or their products.9 direct contact with infected cattle and other animals is a common route of transmission, for high-risk groups including slaughterhouse workers, farmers, shepherds, and milkers.10 the clinical course of brucellosis includes undulant fever, sweating, anorexia, muscular pain, and weakness.11 consequently, brucellosis may lead to osteomyelitis, meningoencephalitis, arthritis, and endocarditis.12 duration of the disease maybe a few weeks or months to several years.13 in developing countries, brucellosis is most frequently diagnosed by many serological tests such as the serum agglutination test (sat), complement fixation test (cft), rose bengal test (rbpt), and enzyme-linked immunosorbent assay (elisa).2 in pakistan, brucellosis has been neglected, only a few studies have been reported from different areas of the country. there are groups of people in khyber pakhtunkhwa who rear cattle therefore, they remain in intimate contact with them for care, milking, and slaughtering the cattle. hence, they are at higher risk of transmission of zoonotic diseases including brucellosis. therefore, epidemiological data about prevalence of this disease is of utmost importance in devising preventive strategies for an effective infection control program. the current study aims to determine the seroprevalence of brucellosis in occupationally highrisk groups including butchers, milkers, and cattle caretakers in district swabi, mardan, and peshawar, khyber pakhtunkhwa, pakistan. m e t h o d o l o g y this descriptive cross-sectional study was conducted in three districts of khyber pakhtunkhwa including swabi, mardan, and peshawar from december 1, 2017, to march 31, 2018. a total of 300 blood samples were collected from all the participants enrolled in the study after meeting the inclusion criteria. a non-probability purposive sampling technique was used. the sample size was calculated using the sample size calculating formula as sample size (n) = z2 x (p x q)/e2 = 1.962 x 0.27 x (1-0.27)/0.052 = 302.8 where, n= required sample size p= prevalence of brucellosis in khyber pakhtunkhwa (27% from the previous study) q= 1-p e= margin of error, 5% z= 1.96 at 95 % ci the study was approved by the ethical review committee of the national institute of health and management sciences (nihms), peshawar, and all the participants were explained about the study and informed consent was obtained. the participants of the study comprised occupationally high-risk groups including 65 butchers, 45 milkers, and 190 cattle caretakers. all the blood samples were collected in a gel tube and transported to nihms on the same day. serum was separated from each blood sample by centrifugation and was screened qualitatively for the detection of antibodies against b. abortus and b. melitensis j islamabad med dental coll 2021 178 according to the instructions of the manufacturer (biosciences pte ltd, singapore).14 in detail, 40µl of both serum and reagent was mixed on a slide and gently agitated for 4 minutes. the slide was observed for agglutination and the result was recorded. the sensitivity and specificity of the reagent used was 98% and 97% respectively. the data obtained were entered into the spss version 22.0 for statistical analysis. descriptive analysis was used for the calculation of percentages and frequencies, while chi square test was applied to determine the statistical significance with age group, occupation, and locality. r e s u l t s out of 300 blood samples 37% (n=111) samples were positive for brucellosis, wherein 70.3% (n=78) samples gave positive results for b. abortus, 21.6% (n=24) samples were positive for b. melitensis, and 8.1% (n=09) blood samples were found positive for both b. abortus and b. melitensis. prevalence of brucellosis was higher in females than males, whilst the most affected age group was 21-40 years. amongst the occupationally high-risk group, brucellosis was most prevalent among cattle caretakers and geographically it was found more in district swabi as presented in table i. all the butchers included in the study were males while milkers comprised 11 males and 34 females and cattle caretakers consisted of 42 males and 148 females. among the total 39 positive male participants, 18 were butchers, 02 were milkers, and 04 were cattle caretakers while in 72 positive female participants 04 were milkers and 69 were cattle caretakers. the socio demographic factors encompassing age group, occupation, and locality showed statistically significant results. there was a significant difference between various age groups and seroprevalence of brucellosis with 21-40 years of age most frequently reporting it (p= <0.01). in occupationally high-risk groups, cattle caretakers had statistically significant higher seroprevalence as compared to butchers and milkers with p-value <0.01. geographically human brucellosis was more common in district swabi with p-value <0.01. table i: prevalence of brucellosis in occupationally high-risk groups total n positive n (%) b. abortus n (%) b. melitensis n (%) b. abortus & b. melitensis n (%) gender male 118 39 (11) 21 (07) 12 (04) 06 (02) female 182 72 (24) 57 (19) 12 (04) 03 (01) occupation butchers 65 18 (06) 12 (04) 03 (01) 03 (01) milkers 45 06 (02) 03 (01) 03 (01) 00 (00) cattle caretakers 190 87 (29) 63 (21) 18 (06) 06 (02) age groups <20 years 54 18(06) 12 (04) 06 (02) 00 (00) 21-40 189 75 (25) 51 (17) 15 (05) 09 (03) 40-60 57 18 (06) 15 (05) 03 (01) 00 (00) districts swabi 120 54 (18) 36 (12) 09 (03) 09 (03) mardan 90 30 (10) 24 (08) 06 (02) 00 (00) peshawar 90 27 (09) 18 (06) 09 (03) 00 (00) d i s c u s s i o n brucellosis is a zoonotic disease and still, a public health problem in developing countries including pakistan, therefore, the given study endeavored to measure the prevalence of brucellosis in occupationally high-risk groups. the overall prevalence of brucellosis in the current study was 37% while earlier studies reported 12.2% to 32.9% prevalence from different districts of the khyber j islamabad med dental coll 2021 179 pakhtunkhwa, pakistan4. our results show higher prevalence than others as we measured the prevalence in targeted occupationally high-risk groups, mostly with active symptoms of brucellosis. our findings documented a higher prevalence in cattle caretakers than other high-risk groups which is in agreement with previously published data,15 the possible reason could be their direct contact with infected animals. the prevalence of b. abortus (26%) is higher than the prevalence of b. melitensis (8%) which can be explained by the reason reported in the literature16 that b. abortus infects cattle while b. melitensis infects sheep and goat, and the participants of the given study were mostly found in close contact with cattle. a study was done by siddique et al also reported the higher prevalence of b. abortus from pakistan.17 our research also found a higher prevalence in females as compared to the males which validate the finding of another researcher 18. usually, females are housewives in this region, and they take care of their cattle at houses therefore, direct contact increases the chance of infection. hence, it is of utmost importance to educate the females about the symptoms of brucellosis both in animals and humans in order to make early diagnosis and treatment of brucellosis in either case, moreover, route of transmission should also be known to avoid the practices that put them at higher risk of contracting brucellosis. in addition to this, the female participants almost cover two-third of the sample size which could also be a factor of consideration for the increased prevalence of brucellosis in the females. in different age strata, the increasing prevalence was found in the 21-40 years group, which is in contradiction with the findings of shahid et al,4 it could be due to the number of participants included in different age groups because it was not standardized in both studies. moreover, the 21-40 years age group is comprised of the people with the most productive age, and thus, they are more likely to be involved in the laborious activities of cattle farming. the current study reported higher prevalence in district swabi as compared to other two districts; it can be explained with a reason that blood sample was collected from participants of district swabi who reside in extremely remote areas and rear animal folk at their houses, whilst it was not the case in other two districts. furthermore, the number of participants was higher from district swabi as compared to the other two districts which further increase the probability of detection of positive cases and subsequently increase prevalence. all the butchers recruited in the given study were males as due to societal norms and restrictions, females do not adopt this profession in pakistan. while milkers and cattle caretakers are largely comprised of female participants because females in these districts are usually housewives and they stay inside the houses and perform the duties of milking and taking care of their cattle while males work outside the houses in farms and other areas. limitations of the study include a relatively small sample size for three districts and the further confirmation of the positive screening test by any confirmatory test. c o n c l u s i o n the seroprevalence of brucellosis is significantly higher in occupationally high-risk groups encompassing butchers, milkers, and cattle caretakers in district swabi, mardan, and peshawar r e c o m m e n d a t i o n it is recommended to make a surveillance about the prevalence of brucellosis in high-risk areas of the country, furthermore, the people who rear cattle, sheep, and goats at their homes need proper education and training about the prevention and control of brucellosis. r e f e r e n c e s j islamabad med dental coll 2021 180 1. yousaf r, khan i, shehzad w, hussain r, ali s, neubauer h, wareth g. seroprevalence and molecular detection of brucellosis in hospitalized patients in lahore hospitals, pakistan. infectious disease reports. 2021; 13(1):166-72. doi: 10.3390/idr13010018 2. khan aq, haleem sk, shafiq m, khan na, ur rahman s. seropositivity of brucellosis in human and livestock in tribal-kurram agency of pakistan indicates cross circulation. thai j vet med. 2017;47(3):349. 3. o’callaghan d. human brucellosis: recent advances and future challenges. infectious diseases of poverty. 2020 dec;9(1):1-2. doi:10.1186/s40249-020-00715-1 4. shahid m, basit a, khan ma. prevalence of brucellosis among the hospital patients of peshawar, khyber pakhtunkhwa. j infect mol biol. 2014;2(2):19-21. doi:10.14737/jimb.2307-5465/2.2.19.21 5. franc ka, krecek rc, häsler bn, arenas-gamboa am. brucellosis remains a neglected disease in the developing world: a call for interdisciplinary action. bmc public health. 2018; 18(1):1-9. doi: 10.1186/s12889-017-5016-y 6. gonzález-espinoza g, arce-gorvel v, mémet s, gorvel jp. brucella: reservoirs and niches in animals and humans. pathogens. 2021;10(2):186. doi: 10.3390/pathogens10020186 7. tuon ff, gondolfo rb, cerchiari n. human‐to‐human transmission of brucella–a systematic review. tmih. 2017; 22(5):539-46. doi: 10.1111/tmi.12856 8. rahman aa, berkvens d, saegerman c, fretin d, muhammad n, hossain a, abatih e. seroprevalence of brucellosis in patients with prolonged fever in bangladesh. jidc 2016 sep 30;10(09):939-46. doi:10.3855/jidc.6844 9. yohannes m, mersha t, degefu h, tolosa t, woyesa m. bovine brucellosis: serological survey in gutogida district, east wollega zone, ethiopia. global veterinaria. 2012;8(2):139-43. issn 1992-6197 10. li n, yu f, peng f, zhang x, jia b. probable sexual transmission of brucellosis. idcases. 2020; 21: e00871. doi: 10.1016/j.idcr. 2020.e00871 11. roushan mr, ebrahimpour s, moulana z. different clinical presentations of brucellosis. jundishapur j microbiol. 2016; 9(4). doi: 10.5812/jjm.33765 12. zheng r, xie s, lu x, sun l, zhou y, zhang y, wang k. a systematic review and meta-analysis of epidemiology and clinical manifestations of human brucellosis in china. biomed research international. 2018 apr 22;2018. doi: 10.1155/2018/5712920 13. al-sultan ii, ali ti, ibrahim oe. incidental occurrence and risk factors of brucellosis in teaching hospital. j adv med res 2011;1(1):1-7. issn 2231-8313 14. hussain, m. a. seroprevalence of brucellosis in sheep and humans in district kohat, pakistan. adv anim vet sci. 2014 ;2(9), 516-523. doi: 10.14737/journal.aavs/2014/2.9.516.523 15. omer mk, assefaw t, skjerve e, tekleghiorghis t, woldehiwet z. prevalence of antibodies to brucella spp. and risk factors related to high-risk occupational groups in eritrea. epidemiology & infection 2002 aug;129(1):85-91. doi: 10.1017/s0950268802007215 16. gwida m, al dahouk s, melzer f, rösler u, neubauer h, tomaso h. brucellosis–regionally emerging zoonotic disease?. croat med j. 2010; 51(4):289-95. doi: 10.3325/cmj.2010.51.289 17. saddique a, ali s, akhter s, khan i, neubauer h, melzer f, et al. acute febrile illness caused by brucella abortus infection in humans in pakistan. int j environ res public health. 2019;16(21):4071. doi: 10.3390/ijerph16214071 18. din am, khan sa, ahmad i, rind r, hussain t, shahid m, et al. a study on the seroprevalence of brucellosis in human and goat populations of district bhimber, azad jammu and kashmir. j anim plant sci 2013; 23:113-8. issn: 1018-7081 journal of islamabad medical & dental college (jimdc); 2012(2):55-55 55 editorial medical researchlocal perspective saeed alam professor, department of pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) research in any field has primary importance for survival and progress of a nation. as compared to many other developing countries, pakistan is lagging much behind even in the field of medical research.1 “research is creating new knowledge” and it is through this new knowledge that we can identify and find a solution to our health issues with the ultimate goal of improving health of our population. we are all aware of the fact that academic success depends on research and publication, but traditionally the impetus behind research activities has remained the same for the past few decades; essentially it is either for completing the requirements for a post graduate qualification or for promotion in teaching cadre. a limited number of practicing physicians are sincerely involved in research and the situation is more discouraging in basic sciences. the strong reasons appear to be lack of motivation and scarcity of available funds. the importance of inculcating research culture at undergraduate level cannot be overemphasized and establishment of new medical colleges in private sector can contribute to a large extent, by promoting research activities amongst medical students. special incentives and awards can be introduced as a component of co-curricular activity. the faculty can play a pivotal role by providing guidelines and encouragement towards research and short term research proposals approved and monitored by faculty can easily be implemented. as the students get exposed to clinical teaching their interest in research grows. in a study at one of the institutions in karachi 49% of medical students had journal reading habits due to requirement of institution and 41% had already participated in research work to some extent.2 in another study positive attitude towards research was observed amongst post graduate trainees but deficiencies were found in terms of reading and writing literature.3 before undertaking any research project it is important to go through various guidelines on research methodology and objectives should be clearly defined. selecting appropriate study type, considering various variables and research questions for appropriate data collection and properly planned analysis are important parameters to be addressed thoroughly for drawing useful inferences. a comprehensive knowledge of epidemiology and biostatistics is essential for a meaningful message in any study. hands on workshop on medical writing should be conducted in every medical institution on regular basis and analyses have shown that such short interactive hands on workshops are helpful and beneficial in improving the knowledge and skill of participants.4 only good quality of research can earn respect to a medical journal, peer reviewing of articles has raised the standard of journals to some extent, but still the menace of plagiarism and bogus research is prevalent. it is needless to highlight the low standards of ethics and professional honesty we are practicing and medicine is no exception. someone has rightly said “if you steal from one author it is plagiarism and if you steal from many it is research” this holds true in our scenario where compulsive research dominates voluntary research. criteria for authorship and “ghostwriting” are other major issues that need to be addressed. enlisting a name in authors list with no contribution what so ever is not something unusual. there are guidelines available and many journals have endorsed “uniform requirements of international committee of medical journal editors” (icmje) criteria for enlisting authors names. accordingly an author should have made a substantial contribution to i) study conception and design ii) drafting the article or revising it critically for important intellectual content and iii) final approval of the version to be published. authors must fulfil all three criteria and everyone who meets the criteria should only be listed.5 we can just ask a question to ourself whether we meet the above criteria, before inserting our name as an author, without professional honesty and hard work we cannot improve the quality of medical research but still progress has been made in number and quality of medical journals during the past few years which is indicative of better times ahead references 1. abdul majeed, noor muhammad awan. procedures for developing a medical research studyj rawal med coll jan jun 2011;15(1):62 -4. 2. kiran ejaz, muhammad shahid shamim, syed abid hussain, muhammad shahzad shamim. involvement of medical students and fresh medical graduates of karachi, pakistan in researchj pak med assoc feb 2011;61(2):115-20). 3. aslam f, qayyum m a, mahmud h, qasim r, haque i u. attitudes and practices of postgraduate medical trainees towards research a snapshot from faisalabad j pak med assoc oct 2004;54(10):534 -6. 4. masood jawaid, shaukat ali jawaid, zubia masood, shams nadeem alam. an analysis of interactive hands-on workshops on medical writingj pak med assoc jan 2011;61(1):66-70. 5. current medical research and opinions vol21 no2 2005 317-321 36 j i m d c 2 0 1 8 36 open access f u l l l e n g t h a r t i c l e effect of losartan in comparison with pioglitazone on lipid profile in a rat model of type 2 diabetes mellitus muhammad nauman shad1, muhammad sair2, amir jalal3, sadia chiragh4, zeeshan ahmad5 1 associate professor of pharmacology, sahara medical college, narowal 2 assistant professor of pharmacology, islam medical college, sialkot 3 assistant professor of pharmacology, sahara medical college, narowal 4 retired professor of department of pharmacology, pgmi, lahore 5 phd research scholar, faculty of pharmacy, university of sargodha a b s t r a c t objective: to evaluate the effect of losartan in comparison with pioglitazone on lipid profile in a type 2 diabetic rat mode. materials and methods: this case control study was conducted in postgraduate medical institute (pgmi), lahore from june to august 2011. forty-five sprague-dawley rats of 5 weeks of age were randomized into three groups. all the rats were fed a high fat and sucrose diet. pioglitazone or losartan were given along with this diet to the rats in groups hfdpio and hfd-los respectively, while group hfd was kept as control. at the end of 12 weeks, serum samples were obtained from all the animals and total cholesterol, hdl-cholesterol and triglyceride levels were obtained using kit method. ldl-cholesterol was determined using the friedewald formula. results: at the end of study period, lipid profile parameters were statistically improved between hfd-pio and the control hfd group. the difference in the lipid profile parameters between the hfd-los and the control hfd group as well as between the hfd-pio and hfd-los groups was not significant. conclusion: the arb losartan has a small but insignificant effect on lipid profile. key words: lipid profile, losartan, pioglitazone, type-2 diabetes mellitus author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3,4 data analysis, interpretation and manuscript writing, 5 active participation in data collection. address of correspondence muhammad nauman shad email: mnauman2002saj@yahoo.com article info. received: september 20, 2017 accepted: january 11, 2017 cite this article. shad mn, sair m, jalal a, chiraghi s, ahmad z. effect of losartan in comparison with pioglitazone on lipid profile in a rat model of type 2 diabetes mellitus. jimdc.2018; 7(1):36-40 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus is one of the leading chronic diseases in almost every country1, is characterized by increased blood glucose levels. its associated complications including dyslipidemia lead to increased morbidity and mortality. patients with adverse lipid profile including hypertriglycedemia, high levels of low density lipoproteins (ldl) and low levels of high density lipoproteins (hdl) are at high risk of cardiovascular disease.2 many patients with type 2 diabetes have an abnormal lipid profile characterized by increased triglycerides and decreased high density lipoproteins hdl-c.3 studies have shown that a high fat plus high carbohydrate diet play a major role in the pathogenesis of type 2 diabetes mellitus and dyslipidemia.4 a diet that contains a high percentage of saturated fatty acids and refined carbohydrates in combination is an unhealthy diet that may lead to insulin resistance, type 2 diabetes mellitus, dyslipidemia and various other features of the metabolic syndrome. such o r i g i n a l a r t i c l e 37 j i m d c 2 0 1 8 37 diets have been used to induce diabetes and dyslipidemia in animal models.5 it is well known that cholesterol homeostasis is fundamental for appropriate insulin secretory function of β cells. excessive cholesterol accumulation in β cells, when exposed to chronically increased levels of free fatty acids (for example in obesity or due to high fat diet), may cause lipotoxicity and reduce insulin secretion, causing β cell dysfunction & decreased β cell mass.6 dyslipidemia has been seen to be associated with dysfunction of pancreatic β cells and this is particularly evident in people with elevated total cholesterol (tc) and ldl-c levels.7 thiazolidinediones (glitazones) are a group of drugs used for treatment of type 2 diabetes which have shown to preserve beta cell function by protecting beta-cell from lipotoxicity.8 glitazones are selective agonists of peroxisome proliferator activated receptor gamma (ppar𝛾), a nuclear receptor which is most highly expressed in adipose tissue and controls the transcription and translation of a variety of genes involved in glucose and lipid metabolism.9 ppar-γ is currently regarded as a therapeutic target in the metabolic syndrome.10 pioglitazone, one of the major glitazones being used in the treatment in t2dm has shown to improve lipid profile including decrease in triglycerides and low-density lipoprotein (ldl), increase in high-density lipoprotein (hdl) and decrease in serum fatty acids.11 renin-angiotensin-aldosterone system has been linked with obesity-related hypertension and it is also involved in the association among obesity, metabolic syndrome, dyslipidemia, insulin resistance, chronic kidney disease, and hypertension.12 ace inhibitors have shown positive effects on the lipid profiles in children with the metabolic syndrome. results in the study showed statistically significant decrease in ldl & triglyceride levels and significant increase in hdl levels.13 now several arbs (angiotensin receptor blockers) including telmisartan, irbesartan and losartan have shown to possess ppar-γ agonist activity. beneficial effects of ppar-γ agonist activity on improving insulin sensitivity have been mentioned. this provides a strategic rationale and pharmacological platform for the use of dual arb/ppar-γ agonists to target the metabolic syndrome and its cardiovascular sequelae.10 this provides the basis for the present study to observe effects, if any, of a dual arb/ppar-γ agonist losartan on lipid profile in a rat model of type 2 diabetes mellitus. m a t e r i a l s a n d m e t h o d s this randomized control trial was conducted at postgraduate medical institute (pgmi), lahore from june 2018 to august 2018. the sample size was estimated by using 5% level of significance and 80% power of test with expected frequency of diabetes mellitus; 36, 57 and 94 percent in glitazones, angiotensin receptor blockers and control groups respectively.15,16 the estimated sample size was 13 in each group (total 39). it was increased to 15 in each group (total 45) to increase the accuracy of the results and to decrease the margin of error. spraguedawley rats of 4 weeks of age were purchased from the university of veterinary & animal sciences, lahore and kept in the animal house of pgmi in iron cages under hygienic conditions. room temperature was maintained at 25 + 2c under natural day/night cycle with free access to rat chow and water. they were allowed one week to acclimatize. from 5 weeks of age rats were fed on high fat diet containing 30% beef fat and 10% sucrose.14 animals were divided randomly into 3 groups of 15 animals each. all three groups were fed high fat and sucrose diet throughout study period of 12 weeks. first group was given distilled water daily orally as a single morning dose and labeled as hfd (high fat diet) group. second group was given pioglitazone in dose of 10mg/kg body weigh daily orally as a single morning dose for 12 weeks and labeled as hfd-pio group.15 third group was given losartan in dose of 10mg/kg body weight daily orally as a single morning dose for 12 weeks and labeled as hfd-los group.1 drugs pioglitazone and losartan were obtained from mass pharmaceuticals. each rat was weighed initially and after every week. fasting blood glucose level was measured every week using a glucometer (accuchek) using a drop of blood obtained from the tail vein. after 12 weeks rats were kept on 12 hour fast and blood was collected by cardiac puncture. samples were then centrifuged at room temperature at 3000-4000 rpm for 5 minutes. serum was stored at –20°c until analyzed for lipid profile. total cholesterol, hdlcholesterol and triglyceride levels were obtained using 38 j i m d c 2 0 1 8 38 calorimetric kit methods. ldl-cholesterol was determined using the friedewald formula:17 ldl = total cholesterol – hdl cholesterol – triglycerides/5. the data was entered and analyzed using spss 17.0. mean ± sd was analyzed for quantitative variables like body weight, fasting blood glucose levels and lipid profile. one-way anova was applied to compare the variables among the groups. bonferroni’s post-test was applied to see whether variances were significantly different. r e s u l t s mean fasting blood glucose level of animals at the start of study was 92±9, 87±7 and 91±7 mg/dl in group hfd, hfd-pio and hfd-los respectively. fasting blood glucose level increased in all groups over the study period. at 12 week fasting blood glucose level was significantly less in hfd-pio and hfd-los group as compared to that of hfd group. difference between hfdpio and hfd-los group was not significant (table 1). at 12 weeks, mean serum cholesterol, ldl and triglyceride levels were higher and mean hdl level was lower in the control hfd group as compared to the hfd-pio and hfd-los groups (table 2). the mean serum cholesterol, ldl and triglyceride levels were higher and mean hdl level was lower in the hfd-los group as compared to the hfd-pio group (table 2). total cholesterol and ldl levels were found to be significantly less in the hfd-pio group as compared to that of hfd group. triglyceride levels were also significantly less. hdl levels showed no significance between hfd-pio and the control hfd group (table 2). there was no statistical difference in any of the lipid parameters between hfd-los and the control hfd group as well as between the hfd-pio and hfd-los groups (table 2). d i s c u s s i o n in the present study, the effect of losartan on lipid profile was evaluated on rats fed a high fat plus sucrose diet, in comparison with pioglitazone. for this purpose, 45 sprague-dawley rats of 5 weeks of age were randomized into three groups. all the rats in each group were fed a high fat and sucrose diet. such an animal model is the best model to study the human metabolic syndrome. numerous studies have shown that a diet rich in saturated fatty acids and refined carbohydrates increases the risk of developing the metabolic syndrome characterized by dyslipidemia, impaired glucose tolerance, insulin resistance and hypertension.5 pioglitazone and losartan were given along with this diet to the rats in group hfd-pio and hfd-los respectively, while group hfd was kept as control. at the end of 12 weeks, serum samples were obtained from all the animals and total cholesterol, hdl-cholesterol and triglyceride levels were obtained using kit method. ldl-cholesterol was determined using the friedewald formula. at 12 weeks, mean serum cholesterol, ldl and triglyceride levels were higher and mean hdl level was lower in the control hfd group as compared to the hfd-pio and hfd-los groups. total cholesterol, triglyceride and ldl levels were found to be significantly less in the group of rats fed pioglitazone along with the high fat diet (hfdpio), as compared to the rats fed high fat diet alone (hfd).the rise in serum cholesterol, ldl & triglyceride levels and decrease in hdl cholesterol in rats fed on a high fat diet are consistent with effects of development of the metabolic syndrome in such animals.5 similarly, findings are also seen in humans fed a high fed diet.18 the decrease in triglycerides, total cholesterol and ldl cholesterol by pioglitazone is also consistent with several studies on this drug. thiazolidinediones, especially pioglitazone, have shown to have favorable effects on plasma lipids. pioglitazone has shown in several studies to reduce triglyceride levels, total cholesterol and ldl cholesterol.19 increase in hdl cholesterol however was not significant in the present study. the mechanisms by which pioglitazone produces these effects are highly complex and may involve anti-oxidant, anti-thrombotic, antiinflammatory, anti-apoptotic and anti-infective properties, as well as effects on endothelial function and repair. these may be associated with their effects on peroxisome proliferator-activated receptor-gamma (pparγ) receptors.20 the present study showed a small but insignificant decrease in triglycerides, total cholesterol and ldl in rats fed a high fat diet plus losartan as compared to the rats fed on a high fat diet alone. hdl cholesterol also showed no significant change. studies have shown variation in effects by different arbs on lipid profile.21 it may also have been because the present 39 j i m d c 2 0 1 8 39 study was a preventive study in which some of the rats developed diabetes and some did not when fed on a high fat diet alone (hfd) or with pioglitazone (hfd-pio) or losartan (hfd-los). table 1: body weight, fasting blood glucose and insulin levels of hfd fed rats at end of 12 week study period (n=45) groups body weight (g) p-value* fasting blood glucose (mg/dl) p-value* serum insulin (µiu/ml) p-value* hfd (mean±sd) 382 ± 48 --152 ± 12 ---23.20 ± 5.52 --- hfd-pio (mean±sd) 345 ± 45 ≤ 0.05 123 ± 17 ≤ 0.001 12.07 ± 6.82 ≤ 0.001 hfd-los (mean±sd) 342 ± 38 ≤ 0.05 132±17 ≤ 0.001 14.13 ± 8.83 ≤ 0.01 table 2: lipid profile of hfd fed rats at end of 12 week study period (n=45) groups total cholesterol p-value* triglycerides pvalue* ldl pvalue* hdl pvalue* hfd (mean ± sd) 138.5±7.97 ___ 169.2±9.93 ____ 84.1 ± 7.17 ____ 20.6 ± 3.22 _____ hfd-pio (mean ± sd) 125.1±14.25 < 0.01 157.1 ± 16.35 <0.05 69.3 ± 13.94 < 0.01 24.4 ± 3.60 > 0.05 hfd-los (mean ± sd) 131.3±15.18 > 0.05 162.3 ± 17.44 >0.05 76.3 ± 14.59 > 0.05 22.6 ± 3.94 >0.05 there was also no significant difference in effects on lipid profile parameters between rats fed on a high fat diet plus losartan and rats fed a high diet plus pioglitazone. c o n c l u s i o n the topical nifedipine is more effective in relieving the pain and healing as compared to oral form in caf. further research work on large scale is recommended to evaluate the oral and topical forms of nifedipine for the treatment of caf. r e f e r e n c e s 1. shaw j, sicree r, zimmet p. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clinpract. 2010; 87 (1): 4-14. 2. kyvelou sm, vyssoulis gp, karpanou ea, adamopoulos dn, zervoudaki ai, pietri pg, stefanadis ci. effects of antihypertensive treatment with angiotensin ii receptor blockers on lipid profile: an open multi-drug comparison trial. hellenic j cardiol. 2006; 47(1):21-8. 3. mahboob a, taqweem a, alam i, ahmad i, ali z, bilal m. effect of pioglitazone on lipid profile in type 2 diabetic patients. j postgrad med inst. 2013; 27(1): 13-9. 4. gastaldelli, a. abdominal fat: does it predict the development of type 2 diabetes? am j clin nutr. 2008. 87 (5): 1118-1119. 5. panchal, s., and brown, l. rodent models for metabolic syndrome research. j biomed biotechnol, 2012.article id 351982. 6. giacca, a., xiao, c., oprescu, a., carpentier, a. and lewis, g. lipid-induced pancreatic -cell function: focus on in vivo studies. am j physiol endocrinol metab. 2011. 300 (2): e255-e262. 7. zheng t, gao y and tian h. relationship between blood lipid profiles and pancreatic islet β cell function in chinese men and women with normal glucose tolerance: a cross-sectional study. bmc public health. 2012. 12(1):634. 8. hanefeld, m. pioglitazone and sulfonylureas: effectively treating type 2 diabetes. int j clin pract. 2007. 61 (s153): 20-27. 9. abdelrahman, m., sivarajah, a. and thiermermann c. beneficial effects of ppar-γ ligands in ischemia, reperfusion injury, inflammation and shock. cardiovasc res. 2005. 65 (4): 772-781. 10. rossi, g. losartan metabolite exp3179: an at1receptor–independent treatment strategy for patients with the metabolic syndrome? hypertension. 2010. 54(4): 710-712. 40 j i m d c 2 0 1 8 40 11. nasser a, niafar m, dalir e, najafipour f, mohamadzadeh s, adabi k, et al. the effect of pioglitazone on weight, lipid profile and liver enzymes in type 2 diabetic patients. ther adv endocrinol metab. 2015; 6(2) :56–60. 12. steifel, p., vallejo-vaz, j., morillo, s., and villar, j. role of the renin-angiotensin system and aldosterone on cardiometabolic syndrome. int j hypertens. 2011; 2011: article id: 685238 13. bitkin e, boyraz m, taşkın n, akçay a, ulucan k, bedir m et al. effects of ace inhibitors on insulin resistance and lipid profile in children with metabolic syndrome. j clin res pediatr endocrinol. 2013. 5(3):164-169 14. panchal sk, brown l, 2011. rodent models for metabolic syndrome research. j biomed biotechnol, 2011:351982. 15. koufany, m., moulin, d., bianchi, a., muresan, m., sebillaud, s., netter, p., weryha g., jouzeau, j. antiinflammatory effect of antidiabetic thiazolidinediones prevents bone resorption rather than cartilage changes in experimental polyarthritis. arthritis res ther, 2008; 10 (1): r6. 16. chu, k., lau, t., carlsson, p. and leung, p., 2006. angiotensin ii type 1 receptor blockade improves beta-cell function and glucose tolerance in a mouse model of type 2 diabetes. diabetes.2006; 55 (2): 36774. 17. friedewald wt, levi ri, fredrickson ds. estimation of the concentration of low density lipoproteins cholesterol in plasma without use of the ultracentrifuge. clin chem. 1972; 18(6): 499–502 18. chiu s, williams pt, krauss rm. effects of a very high saturated fat diet on ldl particles in adults with atherogenic dyslipidemia: a randomized controlled trial. plos one. 2017; 12(2): e0170664. 19. betteridge dj. effects of pioglitazone on lipid and lipoprotein metabolism. diabetes obes metab. 2007; 9(5):640-7. 20. deeg ma and tan mh. pioglitazone versus rosiglitazone: effects on lipids, lipoproteins, and apolipoproteins in head-to-head randomized clinical studies. ppar research. 2008. 21. derosa g, ragonesi pd, mugellini a, ciccarelli l and fogari r. effects of telmisartan compared with eprosartan on blood pressure control, glucose metabolism and lipid profile in hypertensive, type 2 diabetic patients: a randomized, double-blind, placebo-controlled 12-month study. hypertens res. 2004. 27(7): 457–464. j islamabad med dental coll 2022 42 o p e n a c c e s s kap survey of dental students about scientific research aisha wali1, talha m siddiqui2, naqibullah ajmir3 1assistant director research, head of the department, baqai dental college, baqai medical university 2professor, head of the department, baqai dental college, baqai medical university 3house surgeon, baqai dental college, baqai medical university a b s t r a c t background: research is an essential component of the academic curriculum and its importance in health care must be appreciated. it enables the students to critically analyse the information in clinical decision making and care of patients. the objective of the study was to evaluate research-oriented knowledge, attitude, and practices amongst undergraduates and house surgeons. methodology: a cross-sectional study was conducted among undergraduate dental students and house surgeons of baqai dental college from november to december-2018. ethical approval was obtained from the ethical committee of the baqai dental college. permission for data collection was obtained from the research and development department, and the principal of the dental college. the sample size was calculated to be 243 using open epi version 3.03 by taking 20% prevalence rate with 95% confidence interval and 𝛼=5%. participants were selected by convenience sampling technique and a pretested questionnaire, was distributed. results: out of total,84 participants were males and 159 females. 1st and 2nd year students were more confident in interpreting and writing research paper. final year students and house surgeons were more interested in reading research journals and participating in research methodology workshops. 41.2% of the respondents preferred google scholar for literature search. conclusion: adequate knowledge about research was found among all the participants while research-based practice was more among final year dental students and house surgeons. keywords: attitude, knowledge, research, undergraduate authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: aisha wali email: aishawali@baqai.edu.pk article info: received: december 17, 2021 accepted: march 29, 2022 cite this article. wali a, sidiqui tm, ajmir m. kap survey of dental students about scientific research. j islamabad med dental coll. 2022; 11(1):42-48. doi: 10.35787/jimdc.v11i1.644 funding source: nil conflict of interest: nil i n t r o d u c t i o n research is an essential component of the academic curriculum and its importance in health care must be appreciated.1 it enables the students to critically analyze the information in clinical decision making and care of the patients.2 research experience is strongly linked to the future career achievements in undergraduates, yet a challenging task for the students.3 the students’ knowledge and attitude about scientific research is the most important aspect, to begin with, followed by the interest in a particular subject and the need to solve an unanswered question.4,5 critical thinking and clinical reasoning skills can be nurtured by encouraging students to participate actively in learning activities.6 research at the undergraduate level helps in the up-gradation of decision making in the medical profession rather than the repetition of old and sometimes obsolete concepts.7 students should have self-directed programs, mandatory research courses, and participation in research in order to be dental graduates who can meet international standards. worldwide, many universities have integrated research into medical school curricula by establishing medical research programs (mrps) recently. these programs provide medical students with research opportunities within the university. 8 research as an integral part of dental education can develop skills of the students at o r i g i n a l a r t i c l e j islamabad med dental coll 2022 42 undergraduate level.9 very little is known about involvement of students in scientific research.10previous studies of undergraduate medical students reported that they had inadequate knowledge of the scientific review process but they were nevertheless interested in pursuing research in the future.11according to a study conducted in undergraduate medical students in peshawar, majority emphasized that research should be mandatory component of medical school curriculum but considered lack of training in scientific research methodology as the main barrier.12 a study carried out in india reported undergraduates had good knowledge of research.13another study carried out in riyadh reported a moderate level of knowledge and attitude towards research.14 in pakistan, little emphasis is given on research in undergraduate years due to extensive medical curriculum and in practicing years, due to busy schedules and extensive workload. sufficient knowledge and attitude towards carrying out an ethical research is the basic element to develop a research-oriented culture. the objective of the study was to evaluate research –oriented knowledge, attitude and practices amongst dental students and house surgeons of a dental college, karachi. m e t h o d o l o g y a cross-sectional study was conducted amongst undergraduate dental students and house surgeons of baqai dental college from november-december, 2018. ethical approval was obtained from the ethical committee, baqai dental college. permission for data collection was obtained from the research and development department, and the principal of dental college. those who gave consent were included in the study. the sample size was calculated by taking a 20% prevalence rate13 and computed using open epi version 3.03 15 at a 95% confidence interval and 𝛼=5%. the sample size obtained was 243. a convenient sampling technique was employed. a pretested questionnaire,13 was distributed to the dental students and house surgeons and the purpose of the study explained. the completed questionnaires were collected on the same day. the questionnaire included four sections that comprised of demographic profile, questions regarding knowledge, attitude, and practices of undergraduates and house surgeons regarding research. the demographic profile included name, age, gender, and academic year. knowledge, attitudes and practices regarding the research were obtained by asking five questions from each domain. the data were analyzed using the ibm spss version 22.16 results were recorded as frequencies and percentages. chi square test was used to determine association between demographic profile and knowledge, attitude and practices of the participants. a p-value of less than 0.05 was considered statistically significant. r e s u l t s the study included 243 undergraduate dental students and house surgeons out of which 84 were males and 159 females. table 1 represents the gender-wise distribution of the participants according to academic year. regarding attitude of participants towards research, 1st year and 2nd year students were significantly more interested in interpreting, writing, planning and conduction of research. they were significantly more of the opinion that separate time should be allocated for research. table 2 shows frequency of various attitudes of participants towards research. regarding practices of participants, final year students and house surgeons were found to be more interested in reading journals regularly, participating in research methodology workshops, protocol writing and presenting research paper in conferences. table 3 shows frequency of various practices towards research. regarding knowledge of participant, dental students and house surgeons preferred google j islamabad med dental coll 2022 42 scholar for literature search. table 4 represents knowledge about the principles of research. table 1: distribution according to academic year and gender year of study total no of students male female 1st year bds 50 19(38%) 31(62%) 2nd year bds 51 16(31%) 35(68%) 3rd year bds 47 14(29.8%) 33(70.2%) final year bds 50 11(22%) 39(78%) house surgeons 45 24(53.3%) 21(46.7%) total 243 84(100%) 159(100%) table 2 attitudes of participants towards research s. no questions year of study yes (%) no (%) p-value 1 do you feel confident in interpreting and writing research paper 1st year 2nd year 3rd year final year house surgeons 41(82) 46(90.2) 31(66) 33(66) 27(60) 9(18) 5(9.8) 16(34) 17(34) 18(40) 0.003 2 do you feel that dental students can plan and conduct research paper 1st year 2nd year 3rd year final year house surgeons 42(84) 45(88.2) 30(63.8) 33(66) 33(73.3) 8(16) 6(11.8) 17(36.2) 17(34) 12(26.7) 0.015 3 do you think research time should be allotted separately to students 1st year 2nd year 3rd year final year house surgeons 44(80.4) 41(80.4) 29(61.7) 35(70) 36(80) 6(12) 10(19.6) 18(38.3) 15(30) 9(20) 0.025 4 do you think patient outcome will improve with continued clinical research 1st year 2nd year 3rd year final year house surgeons 38(76) 39(76.5) 36(76.6) 36(72) 38(84.4) 12(24) 12(23.5) 11(23.4) 14(28) 7(15.6) 0.708 5 do you feel research can be a good career option 1st year 2nd year 3rd year final year house surgeons 38(76) 38(74.5) 34(72.3) 32(64) 35(77.8) 12(24) 13(25.5) 13(27.7) 18(36) 10(22.2) 0.582 table 3: practices of participants regarding research s. no questions year of study yes (%) no (%) p-value 1 do you read journals regularly 1st year 2nd year 3rd year final year house surgeons 12(24) 10(19.6) 7(14.9) 13(26) 19(42.2) 38(76) 41(80.45) 40(85.1) 37(74) 26(57.8) 0.071 2 have you participated in workshops on research methodology recently 1st year 2nd year 3rd year final year house surgeons 8(16) 18(35.3) 7(14.9) 23(46) 34(75.6) 42(84) 33(64.7) 40(85.1) 27(54) 11(24.4) 0.000 j islamabad med dental coll 2022 42 3 do you have experience of writing research protocol 1st year 2nd year 3rd year final year house surgeons 10(20) 16(31.4) 8(17) 24(48) 20(44.4) 40(80) 35(68.6) 39(83) 26(52) 25(55.6) 0.002 4 are you confident in presenting a research paper or poster in a conference 1st year 2nd year 3rd year final year house surgeons 22(44) 24(47.1) 09(19.1) 28(56) 27(60) 28(56) 27(52.9) 38(80.9) 22(44) 18(40) 0.001 5 are you interested in doing research in future 1st year 2nd year 3rd year final year house surgeons 39(78) 27(52.9) 27(57.4) 43(86) 34(75.6) 11(22) 24(47.1) 20(42.6) 07(14) 11(24.4) 0.001 table 4: knowledge of participants about research variables options year of study n(%) p valu e 1st year 2nd year 3rd year final year house surgeons total (n) which website you would prefer to search literature review pubmed/cochrane/ medline 6(6.6%) 26(28.6%) 15(16.5%) 16(17.6%) 28(30.8%) 91 0.00 1 google scholar 28(26.7%) 19(18.1%) 21(20%) 21(20%) 16(15.2%) 105 text books 15(34.9%) 5(11.6%) 10(23.3%) 12(27.9%) 1(2.3%) 43 expert 1(25%) 1(25%) 1(25%) 1(25%) 0()%) 4 how do you define research hypothesis a proposed idea or thought 27(30%) 19(21.1%) 7(7.8%) 12(13.3%) 25(27.8%) 90 0.00 1 an answer or solution to a question 12(14%) 16(18.6%) 27(31.4%) 24(27.9%) 7(8.1%) 86 an answer of solution to a question which has a capacity of verification 7(13%) 11(20.4%) 12(22.2%) 14(25.9%) 10(18.5%) 54 logical deduction of the premises may or may not be verified 4(30.8%) 5(38.5%) 1(7.7%) 0(0%) 3(23.1%) 13 what is medline bibliographic database 9(12.2%) 19(25.7%) 20(27%) 9(12.2%) 17(23%) 74 0.00 4 medical literature analysis 18(20.9%) 16(18.6%) 15(17.4%) 17(19.8%) 20(23.3%) 86 first and best online medical journal 20(30.8%) 8(12.3%) 10(15.4%) 20(30.8%) 7(10.8%) 65 international association of medical journal 3(16.7%) 8(44.4%) 2(11.1%) 4(22.2%) 1(5.6%) 18 what is graduated scale 1-5 ratio scale 27(36.5%) 15(20.3%) 8(10.8%) 11(14.9%) 13(17.6%) 74 0.00 8 nominal 14(15.7%) 18(20.2%) 22(24.7%) 17(19.1%) 18(20.2%) 89 ordinal 4(8.2%) 12(24.5%) 14(28.6%) 12(24.5%) 7(14.3%) 49 interval 5(16.1%) 6(19.4%) 3(9.7%) 10(32.3%) 7(22.6%) 31 j islamabad med dental coll 2022 48 d i s c u s s i o n research is an important component of advancement and improvement in health care services.13 scientific development in medical research is still lacking behind amongst third-world countries, but within the last few years, a positive change has been noticed at the undergraduate level and house surgeons.17 knowledge and attitudes regarding research are the factors that are closely related to performing research activities.17 a literature review is considered as one of the most important steps,18 and it is done to avoid heavy work, to ensure an indepth understanding of the topic, to identify similar work done within the area, knowledge gaps that demand further analysis, compare previous findings, critical analysis of existing findings and to suggest further studies.19 four popular search engines in medical sciences included are pubmed, science direct, google scholar, and federated search of iran’s health, treatment, and medical education.19 the present study reports that 91(35.7%) of the students preferred medline/ pubmed for literature review search. madhu p et al 13 in a study reported that out of 701 participants, only 221(31.5%) preferred medline as the search engine. chellaiyan vg et al 20 reported that only 20% of students had proper knowledge of search engines while according to sarita ks21,only 29.5% of the students knew about the search engines. the dental students’ knowledge about scientific research seems to be lower compared to the medical students and possible reasons could be fewer teaching hours for research in dental schools.19 regarding knowledge, the present study reports that 90(35.29%) of the participants had the knowledge about research hypothesis. madhu p et al 13 in a study reported that 115(46%) of the students knew about research hypothesis while 202(28.8%) of the students according to another study were knowing about research hypothesis. 19 regarding interpreting and writing a research paper, the present study results show that 46(90.2%) of the 2nd year students feel confident in interpreting and writing a research paper when compared to house surgeons. when asked about planning and conducting research paper, 45(88.2%) of the 2nd year students and 33(73.3%) of the house surgeons replied ‘yes’. 44(80.4%) of the 1st year students and 36(80%) of the house surgeons were of the opinion that separate time should be allotted for the research. habib s et al 19 in a study reported that 356(50.8%) of the students felt confident while reading/ interpreting a research paper and 448(63.9%) of the students could plan and conduct a research project. madhu p et al 13 in a study reported that 130(52%) of the undergraduates were confident in writing and interpreting a research paper, 143(57.2%) undergraduates felt that they can conduct research projects without any supervision and 142(56.4%) of the students felt that research can be taken as a profession, 172(68.8%) of the students felt that time should be allotted separately while planning research work and 88(35.2%) of the students felt that they do not have adequate time to carry out their research and analyze the data. regarding practices of research, the present study reports that only 19(42.2%) of the house surgeons and 13(26%) of the final year students read journals regularly showing less number of students and house surgeons having experience of writing research protocol. madhu p et al 13 reported that 130(52%) of the participants experienced writing of research protocol. the present study reports that 28(56%) of the final year students and 27(60%) of house surgeons were confident in presenting research paper or poster in conferences. madhu p et al 13 reported that 140(56%) of the participants were confident in presenting paper. the reason was positive attitude towards research and having the opportunity of presenting a paper or poster at the conference. the present study reports that majority of the students and house surgeons were interested in future research. similar observations have been reported in other studies.1,13,21-24 j islamabad med dental coll 2022 48 c o n c l u s i o n adequate knowledge about research was found among all the participants while research-based practice was more among final year dental students and house surgeons. recommendations knowledge and practices of undergraduate students can be improved by incorporating the research as an essential part of the undergraduate (dental section) curriculum. house surgeons should also be encouraged to participate in research activities and a time should be allocated for research activities. the study was limited to a single center with a small sample size with low generalizability. r e f e r e n c e s 1. kashif, m., zareef, u., aftab, m., khan, s. i., & barakat, a. a. research awareness among dental undergraduates; a cross-sectional study conducted at karachi medical and dental college, karachi. ijehsr.2020;8(1): 28-33. doi: 10.29052/ijehsr.v8.i1.2020.28-33 2. pallamparthy s, basavareddy a. knowledge, attitude, practice, and barriers toward research among medical students: a cross-sectional questionnaire-based survey. perspect clin res 2019; 10:73. doi: 10.4103/picr. picr_1_8 3. bovijn j, kajee n, esterhuizen tm, schalkwyk scv. research involvement among undergraduate health sciences students: a cross-sectional study. bmc med educ. 2017; 17(6): 186-92. doi: 10.1186/s12909-017-1025-x 4. ismail i, bazli m, o’flynn s. study on medical student’s attitude towards research activities between university college cork and universiti sains malaysia. procedia-soc behav sci. 2014; 116: 2645–9. doi.10.1016/j.sbspro.2014.01.628 5. al-halabi b, marwan y, hasan m, alkhadhari s. extracurricular research activities among senior medical students in kuwait: experiences, attitudes, and barriers. adv med educ pract. 2014; 5: 95–101. doi: 10.2147/amep.s61413 6. amey, l., donald, k. j., & teodorczuk, a. teaching clinical reasoning to medical students. brit-ish journal of hospital medicine.2017;78(7): 399–401. doi:10.12968/hmed.2017.78.7.399 7. aslam f, shakir m, qayyum ma. why the medical students are crucial to the future of research in south asia. plos med 2005; 2: e322. doi:10.1371/journal.pmed.0020322 8. althubaiti a. undergraduate medical research programme: a cross-sectional study of students’ satisfactions, perceived challenges, and attitudes. glob j health sci.2015;7(5):117-123. doi: 10.5539/gjhs.v7n5p117 9. meyer mf, broman at, gnadt se, sharma s, antony km. a standardized post-cesarean analgesia regimen reduces postpartum opioid use. j matern fetal neonatal med. 2021;1–8. doi: 10.1080/14767058.2021.1970132 10. el achi d, al hakim l, makki m, mokaddem m, khalil pa, kaafarani br, et al. perception, attitude, practice and barriers towards medical research among undergraduate students. bmc med educ. 2020 ;20(1):195. doi:10.1186/s12909-020-02104-6 11. amin t, kaliyadan f, abdulatheem ea, majed m, khanjaf h, mirza m. knowledge, attitudes and barriers related to participation of medical students in research in three arab universities. educ med j. 2012; 4(1):47– 55. doi:10.5959/eimj.v4i1.7 12. raza f, nisa q. perception, attitudes and barriers in undergraduate medical students toward medical research at rehman medical college, peshawar, pakistan. khyber med univ j 2017; 9(3):146-149. 13. madhu p. saravana p. a survey of the knowledge, attitude and practices in research among undergraduate dental students. inter j pharmace sci rev res. 2017; 44(2):1-4. issn 0976 – 044x 14. alghamdi km, moussa na, alessa ds, alothimeen n, al-saud as. perceptions, attitudes and practices toward research among senior medical students. saudi pharm j. 2014; 22(2):113–7. doi: 10.1016/j.jsps.2013.02.006 15. dean ag, sullivan km, soe mm. openepi: opensource epidemiologic statistics for public health, version. www.openepi.com, updated 2013/04/06, accessed 2020/11/04. 16. corp ib. ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp. 2013. 417815 17. jeelani w, aslam sm, elahi a. current trends in undergraduate medical and dental research: a picture from pakistan. j ayub med coll abbottabad. 2014; 26(2):162-6. pmid: 25603668 18. samadzadeh gr, rigi t, ganjali ar. comparison of four search engines and their efficacy with emphasis on literature research in addiction (prevention and treatment). int j high risk behav addict. 2013; 1(4):166-71. doi: 10.5812/ijhrba.6551 19. habib sr, alotaibi ss, abdullatif fa, alahmad im.knowledge and attitude of undergraduate dental students towards research. j ayub med coll abbottabad 2018; 30(3):443–8. pmid: 30465383 20. chellaiyan vg, manoharan a, jasmine m, et al.medical research: perception and barriers to itspractice among medical school students of chennai. journal educ health promotion 2019; 8. doi: 10.4103/jehp.jehp_464_18 21. sarita ks, nithisha t, ujwala u. knowledge, attitude, practice and barriers for research j islamabad med dental coll 2022 48 amongst medical students of gmc, nagpur, j res med dent sci, 2021, 9 (4):41-47. issn no. 23472367 22. shifa ja, babu ky, and jayaraj g. awareness of importance of research in undergraduate dental students. int.j. res. pharm. sci.2020; 11: 1677-84. 23. liaquat a, tayyab tf, saeed t, azeem m, naheed a, riaz n, et al. interest in research among the undergraduate students of medical and dental colleges of pakistan. professional med j 2020;27(9):1942-1946. doi:10.29309/tpmj/2020.27.09.4530 24. gopika. g.g, krishnan rp, sundar s. knowledge and attitude of undergraduate dental students towards scientific research-a survey. nveo. 2021; 27:8633-43. issn: 2148-9637 j islamabad med dental coll 2020 153 ope n acce ss mitochondrial dna inheritance mystery irfan afzal mughal associate professor, department of physiology, hbs medical college, islamabad, pakistan mitochondrial dna (mtdna) was discovered in 1963. its inheritance was labeled as maternal type. some selective mechanisms are still mysterious, that how paternal mtdna is selectively destroyed. marking of ubiquitin to sperm mitochondria facilitates the deselection of paternal mitochondrial dna molecules. after fertilization (four to eight-cell stage) paternal mtdna is not detected usually. recently the concept of mixed mtdna haplotype was found, which suggests biparental mtdna inheritance.1 previously it was hypothesized that paternal mtdna molecules were diluted in the fertilized egg. later, in unicellular alga chlamydomonas and medaka fish, mtdna was found to be eliminated after fertilization.2 this theory remained under discussion for decades. researchers described the role of mitophagy in the selective elimination of paternal mitochondria.3 principally, the paternal inheritance from sperm mitochondria to egg at fertilization is 1,000-fold less than the mitochondrial number in the oocyte. there is always an inevitable sexual conflict in the competition between paternal and maternal mitochondrial inheritance, which suggests that paternal leakage and presence of heteroplasmy is due to this sexual conflict. in healthy people, heteroplasmy i.e. presence of more than one mtdna type, is common and this can increase with the advancing age, as there are more chances of mutations.4 in a recent study paternal inheritance of mtdna is revitalized in healthy people. in three independent families and moreover, several generations of these families, it was confirmed by dna sequencing which was performed in two different laboratories. luo et al sequenced mtdna of several members of a family where many individuals were found to carry a high level of mtdna heteroplasmy and suggested that inheritance of mtdna was from both parents due to genetic trait.5 the inheritance pattern as explained by luo et al suggested that elimination of paternal mitochondria was due to a gene on one of the autosomes. 5 this observation may be used to identify signal pathways which are responsible for paternal inheritance of mtdna.6 an autologous gene signature was seen in 7 out of 11,035 trios. the allelic fraction was 5-25% and biparental inheritance was seen in 0.06% of offspring. on whole-genome sequencing, it was found that unique nuclear mtdna segments (“mega-numts”) were transmitted by father in all these 7 families. these were 0.13% in fathers and this was an autosomal transmission of haplotype. it was concluded that rare paternal mtdna heteroplasmy can be due to rare cryptic meganumts (a large and rare mtdna segment).7 e d i tor i a l correspondence: irfan afzal mughal email: the.mughal@hotmail.com cite this editorial: mughal ia. mitochondrial dna inheritance mystery. j islamabad med dental coll. 2020; 9(3): 153-154 doi: 10.35787/jimdc.v9i3.606 j islamabad med dental coll 2020 154 these 11,035 were unrelated mother-fatheroffspring trios. in 10,764 trios, the father harbored at least one variant (allelic fraction >5%) which was not detected in the mother. it was observed that seven fathers-off springs pairs were carrying numt with two breakpoints on the mtdna sequence, 500 bp away from each other. the same mega rare numt was observed in one mother in a different family and subsequently her child also carried it. both of them were carrying the same haplotype allelic fraction.7 as these families were unrelated, the inheritance of rare numt in mixed haplotype adds more weightage to the argument of paternal inheritance. r e f e r e n c e s 1. vissing j. paternal comeback in mitochondrial dna inheritance. pnas. 2019; 16(5): 1475 -6. doi: 10.1073/pnas.1821192116 2. deluca sz, o'farrell ph. barriers to male transmissio n of mitochondrial dna in sperm development. dev cell. 2012; 22(3): 660-8. doi: 10.1016/j.devcel.2011. 12.021 3. mcwilliams tg, prescott ar, montava-garriga l, ball g, singh f, barini e, et al. basal mitophagy occurs independently of pink1 in mouse tissues of high metabolic demand. cell metab. 2018; 27(2): 439 -49. e5. doi: 10.1016/j.cmet.2017.12.008 4. radzvilavicius al, lane n, pomiankowski a. sexual conflict explains the extraordinary diversity of mechanisms regulating mitochondrial inheritance. bmc biol. 2017; 15(1): 1-2. doi: 10.1186/s12915-0170437-8 5. luo s, valencia ca, zhang j, lee nc, slone j, gui b, wang x, li z, dell s, brown j, chen sm. biparental inheritance of mitochondrial dna in humans. pnas. 2018; 115(51): 13039-44. doi: 10.1073/pnas.1810 946115 6. rius r, cowley mj, riley l, puttick c, thorburn dr, christodoulou j. biparental inheritance of mitochondrial dna in humans is not a common phenomenon. genet med. 2019; 21(12): 2823 -26. doi: 10.1038/s41436-019-0568-0 7. wei w, pagnamenta at, gleadall n, sanchis-juan a, stephens j, broxholme j, tuna s, odhams ca, fratter c, turro e, caulfield mj. nuclear-mitochondrial dna segments resemble paternally inherited mitochondrial dna in humans. nat commun. 2020; 11(1): 01. doi: 10.1038/s41467 -020-15336-3 j islamabad med dental coll 2022 20 o p e n a c c e s s determination of difficulty index in end of block examinations of preclinical undergraduate medical students ifra saeed1, arsalan manzoor mughal2, sidra hamid3, tehmina qamar4, ayesha yousaf5, aneela jamil6 1,2,5associate professor of anatomy, rawalpindi medical university 3assistant professor of physiology, rawalpindi medical university 4,6associate professor of biochemistry, rawalpindi medical university a b s t r a c t background: multiple choice questions (mcqs) are considered a good choice for undergraduate formative assessment as they have higher reliability and are generally feasible. the objective of this study was to evaluate the difficulty index of multiple-choice questions in the end of block examination of preclinical undergraduate medical students at rawalpindi medical university. methodology: this descriptive cross-sectional study was conducted at rawalpindi medical university. end of block assessment data was collected from the department of medical education, rmu for first-year and second-year mbbs comprising of 60 mcqs for each year. the difficulty index of the total 120 mcqs was calculated after entering data in ms excel. data was then entered in spss version 24. means and standard deviations of difficulty indices were calculated and compared between first-year and second-year students by independent samples students t-test and between subjects by anova. results: out of 120 multiple choice items analyzed, in the first year mbbs block exam, 30% were easy, 65% were acceptable and 5% were difficult. in the second year mbbs block exam, 36.67% were easy, 56.67% were acceptable and 6.67% were difficult. there was no significant difference (p=0.986) between the mean difficulty index of firstyear mbbs students and second-year mbbs students. however, the mean difficulty index was highest in physiology (66.53 ± 16.262) followed by biochemistry (64.36 ± 16.756) and anatomy (54.80 ± 17.665), and the mean difference between the subjects was statistically significant (p=0.005). the mean difficulty index in first-year mbbs students was highest for biochemistry followed by physiology and anatomy. in second-year mbbs students, the mean difficulty index was highest in physiology followed by biochemistry and anatomy. conclusion: the difficulty index of anatomy mcqs was lower indicating that the students find them more difficult than the other two subjects i.e., physiology and biochemistry in the first two years of their undergraduate medical studies. keywords: anatomy, biochemistry, medical education, physiology authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing.5,6 correspondence: arsalan manzoor mughal email: arsalanmanzoor@gmail.com article info: received: june 24, 2021 accepted: march 29, 2022 cite this article. saeed i, mughal am, hamid s, qamar t, yousaf a, jamil a. determination of difficulty index in end of block examinations of preclinical undergraduate medical students. j islamabad med dental coll. 2022; 11(1):20-24 funding source: nil conflict of interest: nil i n t r o d u c t i o n assessment is an essential component of the education cycle. formative assessment which is done during a training program is intended to provide feedback to the students regarding their knowledge base.1 it also provides feedback to the educator to evaluate the efficacy of teaching and training.2 the best assessment method must meet five criteria which include reliability, validity, o r i g i n a l a r t i c l e j islamabad med dental coll 2022 21 acceptability, feasibility, and educational impacts on learning and practice.3 multiple choice questions (mcqs) are considered a good choice for undergraduate formative assessment as they have higher reliability due to greater number of items and are generally feasible and acceptable to both the students and assessors.4,5 however, the reliability and validity of this form of assessment can be compromised if the mcqs are overly complex, out of course, or beyond the level of the learner.6 post hoc evaluation of mcqs involves various measures to ensure the quality of assessment.7 one of these measures is the difficulty index which can inform the assessor how easy or difficult the questions were for the examinees.8 at rawalpindi medical university, each undergraduate class has approximately three hundred and sixty students. they undergo end of block formative exams after every block. each block exam has a multiple choice and short answer component which is designed by subject specialist. each mcq has a single stem with five options including one correct answer and four distractors and carries one mark. maximum marks in mcq assessment are 60 and the minimum is zero, with no negative marking. as there is no current study on the difficulty index of mcqs in our local context especially preclinical undergraduate medical students, our objective in this study was to evaluate the degree of difficulty of mcqs at the end of the block examination by analyzing the post hoc difficulty index. this will help the medical educationists in developing better guidelines and recommendations for end of block assessments. m e t h o d o l o g y this descriptive cross-sectional study was conducted at rawalpindi medical university. a single block assessment was selected for each year. each block assessment comprised of 60 mcq. a total of 120mcqs (60 for first year and 60 for second year). the results of both papers were ranked in descending order, from highest to lowest marks. then they were divided into quartiles. the upper quartile (high score group) and lower quartile (low score group) were selected for analysis. papers with average scores (middle quartiles) were excluded from the study. data was entered into microsoft excel and the difficulty index (dif) of each item was calculated using the following formula, dif= [(h+l)/n] × 100 where h is the number of students who gave correct options in the high score group, l is the number of students who gave correct options in the low score group, n is the total number of students in both groups. results were interpreted as difficult (dif<30%), acceptable (dif 30-70%), and easy (dif >70%). for analysis, the data was entered in spss version 24. means and standard deviations of difficulty indices were calculated and compared between first-year and second-year students by independent samples student t-test and between subjects by anova. r e s u l t s out of 120 multiple choice items analyzed, in the first year mbbs block exam, 18 items (30%) were easy, 39 items (65%) were acceptable and 3 items (5%) were difficult. in the second year mbbs block exam, 22 items (36.67%) were easy, 34 items (56.67%) were acceptable and 4 items (6.67%) were difficult. there was no significant difference (p=0.986) between the mean difficulty index of first and second-year mbbs students. (table-i) table-i: comparison of mean and standard deviation of difficulty index in first and second year mbbs students by independent samples t-test year n mean ± sd p value first year mbbs 60 61.93 ± 16.329 0.986 second year mbbs 60 61.87 ± 18.784 j islamabad med dental coll 2022 21 there was a significant statistical difference (p=0.005) between the mean difficulty index of questions of various subjects for both classes. the mean difficulty index was highest in physiology followed by biochemistry and anatomy. (table-ii) table-ii: comparison of mean and standard deviation of difficulty index of mcqs of different subjects by anova n mean ± sd p-value anatomy 40 54.80 ± 17.665 0.005 physiology 40 66.53 ± 16.262 biochemist ry 40 64.36 ± 16.756 total 120 61.90 ± 17.525 the mean difficulty index in first-year mbbs students was highest for biochemistry followed by physiology and anatomy. among second-year mbbs students, the mean difficulty index was highest in physiology followed by biochemistry and anatomy. (figure-ii) figure-ii: bar graph for comparison of mean difficulty index in various subjects in first and second year mbbs students d i s c u s s i o n assessment in education has a key role in evaluating whether the goals of instruction are achieved.4 multiple choice questions are a frequently used tool for formative assessment of undergraduate medical students due to their high reliability compared to other assessment tools.9 post hoc difficulty analysis of mcqs can give us an insight into how easy or difficult the questions are for the students.10 for our undergraduate medical students, most of the items were of appropriate difficulty. the percentage of easy items was more than the difficult ones. ideally, most mcqs should have an appropriate difficulty which is noted in our block exams both for first and second-year students.11,12 in current practice for the block exams, no method of standard setting is used which could be a reason of this finding. other studies have also reported the average difficulty of mcqs in undergraduate medical assessments.13 according to a similar study conducted by thompson ar and giffin bf, there was no significant difference in the mean difficulty index on items between the first year and second-year mbbs students which indicates similar findings in both years.14 overall, the items of anatomy were the most difficult followed by physiology and biochemistry. in the first year mbbs block exam, biochemistry items were the easier and in the second year mbbs block exam physiology questions were easier compared to the other subjects. anatomy is generally reported to be a difficult subject for undergraduate medical students.15 areas such as pelvis and neuroanatomy are reported to be particularly challenging.16 due to the extensive nature of the subject comprising of various domains such as embryology, histology, and gross anatomy, it is more extensive and complex for undergraduate medical students compared to the other two subjects. 17 as our curriculum progresses into integration between subjects, the threat remains that students will focus less on difficult subjects such as anatomy and will gravitate towards spending more time on easier subjects such as physiology and biochemistry to pass their examinations. this may result in less j islamabad med dental coll 2022 21 retention of the subject over the course of mbbs program in the integrated modular curriculum.18,19 multicenter studies are required to see if a similar pattern of difficulty is observed in other medical institutes of the region. follow-up qualitative studies can further give insight into the key areas which our undergraduate medical students find difficult and appropriate academic interventions can be planned to address them. this is the first study on item analysis of undergraduate end of block examinations at rawalpindi medical university. due to lack of optical mechanical scanner, other item analysis indices i.e reliability coefficient, discrimination index and distractor analysis could not be performed which would give more information about the quality of these assessments. c o n c l u s i o n the mcqs in anatomy were more difficult than the other two subjects i.e., physiology and biochemistry in the first two years of undergraduate medical studies in the mbbs program. in future, mixedmethod studies are recommended to determine the reasons and devise strategies to improve assessment in this subject. r e f e r e n c e s 1. palacios bap. formative assessment as tool to improve on teaching process–learning for students. int j soc sci humanit. 2019;3(3):36-49. doi:10.29332/ijssh.v3n3.354 2. mccarthy j. enhancing feedback in higher education: students’ attitudes towards online and in-class formative assessment feedback models. act learn high educ. 2017;18(2):127-141. doi:10.1177/1469787417707615 3. dent j, harden rm, hodges bd, hunt d. a practical guide for medical teachers. elsevier; e-book. elsevier health sciences; 2021 apr 24. . 4. haris ali s, carr pa, ruit kg. validity and reliability of scores obtained on multiple-choice questions: why functioning distractors matter. j scholarsh teach learn. 2016;16(1):1-14. doi:10.14434/josotl.v16i1.19106. 5. holzinger a, lettner s, steiner-hofbauer v, capan melser m. how to assess? perceptions and preferences of undergraduate medical students concerning traditional assessment methods. bmc med educ. 2020;20(1):1-7. doi:10.1186/s12909-02002239-6 6. quaigrain k, arhin ak. using reliability and item analysis to evaluate a teacher-developed test in educational measurement and evaluation. cogent educ. 2017;4(1). doi:10.1080/2331186x.2017.1301013 7. ramzan m, imran ss, bibi s, khan kw, maqsood i. item analysis of multiple-choice questions at the department of community medicine, wah medical college, pakistan. life sci. 2020;1(2):4. doi:10.37185/lns.1.1.53 8. mahjabeen w, alam s, hassan u, zafar t, butt r, konain s, et al. difficulty index, discrimination index and distractor efficiency in multiple choice questions. annals of pims. 2017;13(4):310-5. 9. rai n. multiple choice questions: as formative assessment. int j med biomed stud. 2019;3(3). 75-79. doi:10.32553/ijmbs.v3i3.137 10. d'sa jl, visbal-dionaldo ml. analysis of multiple choice questions: item difficulty, discrimination index and distractor efficiency. international journal of nursing education. 2017 jul 1;9(3):109-114. doi: 10.5958/0974-9357.2017.00080.0 11. patel rm. use of item analysis to improve quality of multiple choice questions in ii mbbs. journal of education technology in health sciences. 2017 apr 29;4(1):22-9. 12. mehta g, mokhasi v. item analysis of multiple choice questions-an assessment of the assessment tool. int j heal sci res. 2014;4. www.ijhsr.org. accessed november 17, 2020. 13. islam zu, usmani a. psychometric analysis of anatomy mcqs in modular examination. pak j med sci. 2017 sep-oct;33(5):1138-1143. doi: 10.12669/pjms.335.12382. 14. thompson ar, giffin bf. higher‐order assessment in gross anatomy: a comparison of performance on higher‐ versus lower‐order anatomy questions between undergraduate and first year medical students. anat sci educ. october 2020. doi:10.1002/ase.2028 15. alvarez s, nikendei c, schultz j-h. development of a didactical training concept for peer tutors in gross anatomy. anat sci educ. 2017;10(5):495-502. doi:10.1002/ase.1691 16. hall s, stephens j, parton w, myers m, harrison c, elmansouri a, et al. identifying medical student perceptions on the difficulty of learning different topics of the undergraduate anatomy curriculum. med sci educ. 2018;28(3):469-472. doi:10.1007/s40670-018-0572-z 17. zill sn. rethinking gross anatomy in a compressed j islamabad med dental coll 2022 21 time frame: clinical symptoms, not case studies, as the basis for introductory instruction. clin anat. july 2020:ca.23645. doi:10.1002/ca.23645 18. doomernik de, van goor h, kooloos jgm, ten broek rp. longitudinal retention of anatomical knowledge in second-year medical students. anat sci educ. 2017;10(3):242-248. doi:10.1002/ase.1656 19. hołda mk, stefura t, koziej m, skomarovska o, jasińska ka, sałabun w, et al. alarming decline in recognition of anatomical structures amongst medical students and physicians. ann anat. 2019;221:48-56. doi:10.1016/j.aanat.2018.09.004 j islamabad med dental coll 2021 152 open access psychological impact of covid-19 pandemic on pregnant women rashida sultana1, anees fatima2 1associate professor, department of obstetrics and gynecology, sharif medical and dental college, lahore 2senior registrar, department of obstetrics and gynecology, sharif medical and dental college, lahore a b s t r a c t background: covid-19 pandemic has spread throughout the world in a short period of time. it has adversely affected the physical, mental and social well-being of communities including pregnant women. this study is aimed to determine the frequency, severity and associated factors of depression, anxiety and stress among pregnant women during covid19 pandemic. material and methods: this cross-sectional study was conducted in sharif medical city hospital, lahore, from august to september 2020.data was obtained on structured proforma comprised of two sections. section one consisted of sociodemographic and obstetric components while second two was based on urdu version of dass-21. data was analyzed using spss-23. results: total number of women was 350. their mean age was 27.47 ± 4.72 while mean duration of their pregnancy was 26.33±9.17weeks. mean dass-21 score of depression, anxiety, and stress was 8.00±2.89, 5.80±3.10 and 9.18±2.80 respectively. it was observed that depression was present in 123(35.1%) ranging from mild to moderate, anxiety in 127(36.3%) ranging from mild to very severe and stress in only 20(5.7%) women and was mild. education was significantly associated with all three domains. the women who were infected themselves or any other family member affected with covid-19 showed positive association for depression (p=0.00) and stress (p=0.00). stress was higher in young age groups (p=0.04) and in women with higher monthly income (p=0.00) while parity also showed association with anxiety (p=001). anxiety and depression were more in house wives (p=0.00) while stress in working women (p=0.00). conclusion: frequency of depression and anxiety was notable varying from mild to very severe however for stress it was low and mild. educational level was significantly associated with depression, anxiety, and stress. keywords: covid-19, pandemic, psychological impact, pregnancy, postnatal authors’ contribution: 1-2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: rashida sultana email: drrashidasultana@gmail.com article info: received: december 29, 2020 accepted: september 8, 2021 cite this article. sultana r, fatima a. psychological impact of covid-19 pandemic on pregnant women. j islamabad med dental coll. 2021; 10(3): 152-158. doi: 10.35787/jimdc.v10i3.653 funding source: nil conflict of interest: nil i n t r o d u c t i o n the first case of covid-19 was confirmed in pakistan on 26th february 2020 in karachi.1number of cases have been increasing day by day throughout the world and the second phase of this pandemic is more severe than the initial phase with higher infectivity and mortality.2this pandemic has caused severe social disruption, global recession and great uncertainty throughout the world.3covid-19 pandemic has not only disturbed daily life pregnant women but also affected their routine antenatal visits in developed world as well as in developing countries like pakistan. stress and anxiety during pregnancy is associated with preterm labor, premature births and increased risk of cesarean section. moreover, women who have stress and anxiety during pregnancy have more chances of o r i g i n a l a r t i c l e j islamabad med dental coll 2021 153 postpartum depression and problems related to breastfeeding. in long run, babies born to such mothers have more behavioral problems as compared to babies born to normal mothers.4 timely psychological interventions during the antenatal period may result in better feto-maternal outcome so mothers must be inquired regarding underlying risk factors during antenatal visits to identify and treat the cause. objective of this study was to determine the frequency and severity of depression, anxiety, and stress and its associated factors among pregnant women during covid-19 pandemic. literature review of studies conducted in different localities of pakistan over ten years revealed that prevalence of anxiety and depression ranges from 22% to 60% in pakistani population.5 however, prevalence of depression among pakistani women is reported high; ranging from 30%-65%.6 when a woman gets pregnant, her role is changed to a mother and she becomes more vulnerable to physical as well as mental changes during pregnancy and in postpartum period under the effect of hormones. covid-19 pandemic has detrimental effects on physical and mental health of people. pregnant and postnatal women are at increased risk of developing depression and anxiety during covid-19 pandemic.7,8 as anxiety, stress and depression during pregnancy have adverse feto-maternal implications so it is crucial to identify the psychological impact of covid-19 pandemic particularly on pregnant women in terms of frequency and severity of depression, anxiety and stress. m a t e r i a l a n d m e t h o d s this descriptive study was conducted after ethical approval from institutional review committee; letter no. smdc/smrc/66-20. place of study was sharif medical city hospital, lahore, pakistan from august to september 2020. all pregnant women with singleton pregnancy at any gestational age presenting in the outpatient department for antenatal visit were included in the study after their consent. women with past or current history of psychiatric disorders, postpartum depression or on antipsychotic medication, high risk patients such as patients with cardiac disease, moderate to severe anemia, uncontrolled diabetes and hypertension and bad obstetric history were excluded to minimize confounding and to ensure that it is not related to pre-existing illness or complicated pregnancy. a sample size of 350 patients was calculated. assumed proportion was taken as 0.65, acceptable difference of 0.05 and confidence level of 95%.9 non probability convenience sampling technique was used. data was collected on a structured questionnaire that had two sections. sociodemographic characteristics of the study participants were enquired in urdu language like age, parity, gestational age, personal or family history of covid-19 disease, education, occupation and monthly income. it was followed by twenty-one questions of dass-21 urdu version. study participants were explained that they must read the questionnaire carefully and encircle the response that applies most to them during last one week. depression, anxiety and stress scale is a 42-item scale (dass-42) with a shorter version comprised of 21 items known as dass-21 and is divided into three subscales. there were seven questions per subscale. it measures the negative emotional states of depression, anxiety and stress.10 in this study, “urdu version” of dass-21 was used.11 each question is scored using likert scale i.e., never=0, sometimes=1, often=2 and always=3. depression, anxiety and stress level of women was determined according to pre-defined cut-off scores such that depression ≥10, anxiety ≥8, and stress ≥15 which are further categorized into mild, moderate, severe and very severe for each subscale.10 data was entered and analyzed in spss 23. mean and standard deviation was calculated for quantitative variables e.g., age, number of j islamabad med dental coll 2021 154 pregnancies, gestational age and monthly income. qualitative variables like age groups, educational status, occupation and covid status was calculated in percentages. scores obtained by the likert scales were categorized according to predefined cut-off values of dass-21 and were calculated in percentages. independent sample t-test and oneway annova were used to assess the association between psychological impact (in terms of depression, anxiety and stress) and maternal age, parity, maternal education, monthly income, gestational age and covid status. table i: frequency, and severity of depression, anxiety, and stress depression n (%) anxiety n (%) stress n (%) normal 227 (64.9) 223(63.7) 330 (94.3) mild 96(27.4) 65(18.6) 20(5.7) moderate 27(7.7) 61(17.4) - severe -01(0.3) - total number of women were 350 with mean age of 27.47 ± 4.72 years. their mean gestational age was 26.33±9.17 weeks ranging from 6 to 40 weeks. the mean score of depression, anxiety and stress was 8.00±2.89, 5.80±3.10 and 9.18±2.80 respectively. it was observed that depression was present in 123(35.15), anxiety in 127(36.3%) and stress in 20(5.7%) study participants that varied from mild to severe as detailed in table i. there was significant association between level of education and all three domains as detailed in table ii. the women who were infected with covid-19 themselves or any of their family members affected with this infection, showed higher mean score for depression and stress such that 9.33±3.54 versus 7.86±2.78 and 10.80±2.60 versus 9.00±2.76. mean dass score for stress was higher in young age groups such that 9.12±3.07 and 9.57±2.65 for age groups of 18-25 and 26-30 years respectively versus 8.36±2.60 and 8.92±2.19 for age groups of 31-35 and 36-40 years respectively. similarly, stress was higher in women with higher monthly income (p=0.00) as shown in table ii. parity showed association with anxiety (p=001). mean anxiety was more in house wives (p=0.00) and also depression score was more in house wives (p=0.00) but stress level was more in working women (p=0.00) as detailed in table ii. table ii: mean dass score and associated sociodemographic factors n (%) depression p-value anxiety p-value stress p value age 18-25 124(35.4) 7.79±2.84 0.07 5.77±3.04 0.18 9.12±3.07 0.04 26-30 148(42.3) 8.40±2.81 6.07±3.15 9.57±2.65 31-35 58(16.6) 7.33±2.76 5.62±3.25 8.36±2.60 36-40 20(5.7) 8.30±3.85 4.51±2.37 8.92±2.19 parity primigravida 134(38.3) 7.92±3.15 0.10 5.87±3.31 0.01 9.37±3.14 0.50 multipara 162(46.3) 8.32±2.53 6.14±2.91 9.14±2.53 grand multipara 53(15.1) 7.21±3.10 4.56±2.76 8.77±2.68 great grand multipara 1(0.3) 9.14 7.14 11.28 j islamabad med dental coll 2021 155 trimester of pregnancy 1st trimester 41(11.7) 8.11±3.38 0.90 5.76±3.24 0.49 9.34±3.81 0.89 2nd trimester 124(35.4) 7.91±2.96 5.55±2.97 9.11±2.72 3rd trimester 185(52.9) 8.04±2.74 5.98±3.15 9.19±2.60 education illiterate 21(6.0) 7.02±2.86 0.00 5.06±2.51 0.00 8.05±2.85 0.00 primary 17(4.9) 6.12±2.77 3.79±3.47 8.36±2.94 middle 14(4.0) 7.26±2.84 4.80±2.18 8.03±2.82 matric 97(27.7) 7.90±3.24 5.85±3.10 8.75±2.75 intermediate 56(16.0) 8.75±2.42 6.80±2.96 10.23±2.96 graduate 92(26.3) 8.49±2.82 6.22±3.10 9.18±2.51 masters & above 53(15.1) 7.73±2.53 5.12±3.08 9.84±2.73 occupation housewives 332(94.9) 8.05±2.86 0.18 5.91±3.07 0.00 9.07±2.74 0.00 working women 18(5.1) 7.12±3.44 3.80±2.94 11.08±3.21 monthly income 20,000 54(15.4) 7.21±2.68 0.11 5.25±2.85 0.30 7.59±2.42 0.00 21-50,000 76(72.0) 8.07±2.83 6.00±2.99 9.22±2.73 51100,000 43(12.3) 8.58±3.40 5.34±2.90 10.87±2.59 >100,000 01(0.3) 8.14± 5.42±00 11.42±00 covid-19 infection no 315 (90) 7.86±2.78 0.00 5.80±3.08 0.97 9.00±2.76 0.00 yes 35(10) 9.33±3.54 5.78±3.25 10.80±2.60 d i s c u s s i o n this cross-sectional study evaluates the psychological impact of covid-19 pandemic on pregnant women. it reveals that frequency of depression and anxiety is notably high while for stress it is quite low. similarly, dass-21 score for depression is in the range of mild to moderate. however, anxiety score varies from mild to very severe. in the current study, level of stress is mild. none of the participants are categorized in score range of very severe. this may be because of lack of awareness about the magnitude of the pandemic situation. furthermore, all the women who had obstetric and medical risk factors including depression, anxiety and stress were excluded. in this study it is observed that depression was present in 123(35.1%), anxiety in 127(36.3%) and stress in 20(5.7%) participants with a mean dassscore of 8.00±2.89, 5.80±3.10 and 9.18±2.80 respectively. according to a study in iran, almost similar prevalence i.e., 32.7% each for depression and anxiety was seen. however, stress was present in 43.9% of women in contrast to our study.9 the j islamabad med dental coll 2021 156 similarities may be because of similar sociodemographics. the tool used in both of these studies is dass-21. in contrast, a study conducted on japanese women revealed depression in 24(17.7%), anxiety and stress in 17(12.5%) each while mean dass score was 4.8 ± 5.5, 3.0 ± 4.4, and 6.2 ± 7.1 for depression, anxiety and stress domain respectively.12 the prevalence and mean dass score for depression, anxiety and stress was lower in japanese women as compared to pakistani women. this may be due to the difference in ethnicity. in present study, anxiety found in 127(36.3%) respondents ranges from mild to severe with 18.6% mild, 17.4% moderate and 0.3% severe. a study conducted on indian pregnant women revealed that 73.6% of study population had minimal psychological impact with mean ies-r score of 16.93±11.23 and 69.4% of the study participants had minimal level of anxiety with mean gad-7 score of 3.09±3.73. the frequency of anxiety is almost double in their study but severity of anxiety is minimal as compared to our findings. however, the tool used in their study is different from our study.13 stress was significantly higher in young age groups i.e., 18-30 years (p=0.04). in contrast, study conducted by effati daryani revealed that abnormal depression, anxiety and stress score was associated with age more than 35 years.9 this may be because young population has more access to information sources related to the covid-19 pandemic, more aware of its consequences, myths and facts. higher level of education has significant association with all three domains in this study. similar association was found by shahid et al.14 according to moyer et al, mothers having university degree had more anxiety as compared to mothers who were less educated.15 this may be because of more awareness about the gravity of situation among educated women. the women who were infected with covid-19 themselves or any of their family member affected with this infection show significantly higher association with depression (p=0.00) and stress (p=0.00). stress is found to be more in women with higher monthly income (p=0.00). negative psychological impact, depression and anxiety prevalence was more in women with higher monthly income as revealed in a study conducted by shahid et al.14 anxiety and depression is more in house wives (p=0.00) while stress in working women (p=0.00) in our study. in contrast, working women had more negative perception of covid-19 pandemic according to another study. it may be because of more exposure as compared to housewives. 12 there is no significant association between depression, anxiety and stress and trimester of pregnancy. similar results were revealed by studies conducted by efatti-daryani et al.9 however a study conducted in italy revealed that women in first trimester had more anxiety and severe psychological impact as compared to women in their second or third trimester of pregnancy.16 number of pregnancies show association with anxiety (p=001) in this study. higher mean score of dass is observed in great grand multipara, multipara and primigravida respectively. study conducted in iran also disclosed association between anxiety and parity showing gravida three and above having more anxiety as compared to primigravida and gravida two.9 moyer et al reported that higher stress during pregnancy is due to fear of getting infected in 93%, losing job in 63.7%, loss of child care in 56.3%, food shortage in 59.2%and conflict between family members in 37.5%.15 fear of getting covid-19 infection, transmission of infection to newborn, risks to pregnant women, being more vulnerable to infection are the main underlying factors identified by shahid et al.14 lockdown due to covid-19 disease have also ill effects on mental health of women because of deprivation of sufficient availability and access to basic needs of life and pregnancy care so it is very important to address the underlying factors leading to negative psychological impact on health of pregnant women. continuous provision of j islamabad med dental coll 2021 157 support such as moral, social, family, financial and emotional aspects of their life on one hand and obstetric care on the other hand is crucial. awareness about the seriousness and sequel of the pandemic must be raised among females so they adopt preventive measures for their well-being and for the safety of their family. this cross-sectional study has evaluated a sufficient sample size for mental health of pregnant women in terms of depression, anxiety and stress however it is a single centered study. results of single centered study cannot be generalized. further research is needed to identify the underlying reasons of this psychological impact. c o n c l u s i o n frequency of depression and anxiety was notably high while for stress it was quite low. severity of depression varied from mild to moderate, anxiety from mild to severe. however, severity of stress was mild. dass-21 score was significantly associated with educational level in all three domains such that depression, anxiety and stress. the women who were infected with covid-19 themselves or any of their family members affected with it showed positive association for depression and stress. r e c o m m e n d a t i o n routine screening for mental wellbeing should be started in obstetrical settings. this will be helpful to address any deleterious effects on mental health and timely intervention if required for healthy fetomaternal outcome. r e f e r e n c e s 1. government of pakistan. coronavirus in pakistan. http://covid. gov.pk/. accessed march 27, 2020. 2. world health organization. pakistan: covid-19situation update as of 7 april 2020. updates: ministry of national health services regulations and coordination dashboard; 2020. 3. abid k, bari ya, younas m, tahir javaid s, imran a. covid19-progress of covid-19 epidemic in pakistan. asia-pac j public health. 2020; 32(4):154-6. doi: 10.1177/1010539520927259 4. hasanjanzadeh p, faramarzi m. relationship between maternal general and specific-pregnancy stress, anxiety, and depression symptoms and pregnancy outcome. jcdr. 2017;11(4):vc04. doi: 10.7860/jcdr/2017/24352.9616 5. ahmed b, enam sf, iqbal z, murtaza g, bashir s. depression and anxiety: a snapshot of the situation in pakistan. int j neurosci and behavi sci. 2016;4(2):32. doi: 10.13189/ijnbs.2016.040202 6. zahidie a, jamali t. an oerview of the predictors of depression among adult pakistani women. j coll physicians surg pak.2013; 23(8):574-80. pmid: 23930875 7. fan s, guan j, cao l, wang m, zhao h, chen l, et al. psychological effects caused by covid-19 pandemic on pregnant women: a systemic review with metaanalysis. asian j. psychiatr.2020:102533. doi: 10.1016/j.ajp.2020.102533 8. ceulemans m, hompes t, equlon v. mental health status of pregnant and breastfeeding women during the covid-19 pandemic: a call for action. int. j. gynecol obstet.2020; 151(1):146-7. doi: 10.1002/ijgo.13295 9. effati-daryani f, zarei s, mohammad a, hemmati e, yngyknd sg, mirghafourvand m. depression, stress, anxiety and their predictors in iranian pregnant women during the outbreak of covid-19.bmc psychology.2020;8(1):1-10. doi: 10.1186/s40359020-00464-8 10. “depression anxiety stress scale (dass)”. psychology foundation of australia. <http://www2.psy.unsw.edu.au/dass/> 11. aslam n, tariq n. trauma depression anxiety and stress among individuals living in earth quake affected and unaffected areas. pak j psychol res. 2010.25(2):131-48. 12. suda t, miura y, katayama m, senba h, takahata m, nakano s. worries and concerns about covid-19 lockdown aggravate stress reactions among pregnant women. research square.2020. doi: 10.21203.rs.3.rs-45832/v1. 13. jelly p, chadha l, kaur n, sharma s, sharma r, stephen s, et al. impact of covid-19 pandemic on the psychological status of pregnant women. cureus. 2021; 13(1).: e12875. doi: 10.7759/cureus.12875. 14. shahid a, javed a, rehman s, tariq r, ikram m, suhail m. evaluation of psychological impact, depression and anxiety among pregnant women during the covid-19 pandemic in lahore pakistan. int j gynae& obs. 2020; 151(3):462-5. doi: 10.1002/ijgo.13398 http://www2.psy.unsw.edu.au/dass/ https://doi.org/10.21203.rs.3.rs-45832/v1 https://doi.org/10.21203.rs.3.rs-45832/v1 j islamabad med dental coll 2021 158 15. moyer ca, compton sd, kaselitz e, muzik m. pregnancy-related anxiety during covid-19: a nationwide survey of 2740 pregnant women. arch womens ment health. 2020;23(6):757-65. doi: 10.1007/s00737-020-01073-5 16. saccone g, florio a, aiello f, venturella r, de angelis mc, locci m, bifulco g, zullo f, sardo ad. psychological impact of coronavirus disease 2019 in pregnant women. ajog. 2020;223(2):293-5. doi: 10.1016/j.ajog.2020.05.003 summary journal of islamabad medical & dental college (jimdc); 2016:5(3):144-146 144 case report scurvy “in the land of citrus fruits” parveen akhtar1, kiran mushtaq toor2, sumaira khalil3, huma saleem khan4, saima shabbir5 1. prof. & head department of pediatrics, foundation university medical college, islamabad 2.senior registrar, department of pediatric, foundation university medical college, islamabad 3.senior registrar department of pediatric, foundation university medical college, islamabad 4.assistant professor, department of pediatric, foundation university medical college, islamabad 5. senior registrar department of pediatric, foundation university medical college, islamabad abstract nutritional deficiencies including scurvy are still prevalent in developing countries though not as common as they once were. vitamin c deficiency has varied presentations including musculoskeletal problems, skin manifestations and bleeding tendency. we report a case of a five years old developmentally normal child who presented with debilitating bone pains and inability to walk. overall clinical and radiological features were suggestive of scurvy. treatment with vitamin c resulted in significant improvement. key words: ascorbic acid, gum hyperplasia, scurvy, metabolic complications, nutrition, pocalcemia, vitamin c. introduction vitamin c is a water soluble vitamin. citrus fruits are rich source of vitamin c. it is not stored in the body. foods containing vitamin c are commonly consumed and the vitamin is taken up by all the tissues. the classic disease was reported to occur in sailors due to diet deficient in vitamin c. since the discovery of link between vitamin c deficiency and scurvy, it is rarely seen in developed countries. case is not the same in developing countries where scurvy is still prevalent but overlooked. occurrence of scurvy is unfortunate in our country which is amongst the best citrus producing countries. it is important to identify individuals at risk and recognize the clear and classic sign and symptoms associated with scurvy. failure to diagnose this disease can potentially lead to expensive and unnecessary medical tests, as well as missing a very simple and easy to treat condition. this result in serious morbidity and even death due to life threatening bleeding or serious infections. early diagnosis and timely management can not only prevent complications but also results in improved quality of life. case report a 5 years old boy presented to the pediatric medicine department with complaints of progressively worsening pain in both legs for four months and inability to walk and sit for last one month. child was in his usual state of health four months back, when he started complaining of pain in the legs and started losing interest in play. pain was aggravated on walking and thus he preferred keep sitting. no joint swelling, stiffness or skin rash was noticed. he was taken to a local health facility where he was diagnosed as having growing bone pains and parents were counselled regarding benign nature of the problem. there was temporary relief with analgesics but general condition of the child did not improve much. over the course of weeks his pain worsened to the extent that he was extremely irritable and confined to bed due to inability to move because of pain. there was history of fracture femur one and a half year back following fall from the chair. he was treated at orthopedic department in another hospital. the fracture took longer than usual to heal. he was able to return to his usual activities following healing. he was born full term and vaccinated partially and was breast fed for one month only and then diluted cow’s milk was fed for one year. weaning started at about 7 months. his usual diet included roti, biscuits and tea. fruits, milk, meat and eggs were consumed rarely. both parents were laborers, had four children and the children were taken care of by the old grandmother in their absence. on examination he had wasted appearance. he was a sick looking, pale and irritable child without any respiratory distress. his weight was < 5th percentile and height 10 th centile for age. he had low grade fever of 100°f. his heart rate, blood pressure and respiratory rate were normal. the child was difficult to be examined due to extreme pain. he could not bear weight on legs. there was tenderness, and swelling in both lower limbs. there was no joint swelling, petechiae or bruises. there was generalized hypotonia. reflexes were normal in upper limbs however they could not be assessed in lower limbs due to extreme pain and tenderness. corresponding author dr kiran mushtaq toor email:m.kirantoor@gmail.com received: june 18, 2016; accepted: july 16, 2016 mailto:m.kirantoor@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):144-146 145 further examination revealed a non-healing ulcer on the forehead which according to his mother was a small scratch initially that failed to heal and increased in size over time. skin was dry and hyperpigmented without any evidence of bleeding. he had prominent costochondral junctions with sharp angulations (figure 1). examination of oral cavity revealed purple colored spongy gum swellings with bleeding and hematoma formation (figure 2). systemic examination was unremarkable. patient was admitted and i/v antibiotics started. labs results showed hb of 5.6 gm/dl, normal leukocyte count, platelet count and coagulation profile. peripheral smear showed microcytic hypochromic anemia. serum ferritin level was low. serum calcium, phosphate and vitamin d levels were within normal limits. findings on x-rays lower limbs revealed the diagnosis. there was reduced bone density, cortical thinning which was more marked in the region of epiphysis (ring sign), small fractures at the corner (pelkun spur) and dense calcification zone at physis (figure 3 and 4). clinical presentation and radiological findings of our patient strongly favor diagnosis of scurvy which needs serum vitamin c level for its confirmation. vitamin c levels are not done in our setup so we made the diagnosis of scurvy on clinical presentation and radiological findings. oral vitamin c was started and child showed marked improvement within 2 weeks and had no walking difficulty or pain. figure 1: prominent costochondral junction: scorbutic rosary figure 2: gingival hypertrophy figure 3: radiological findings figure 4: pencil thin cortex, ring sign, pelkun spur discussion vitamin c is a water soluble vitamin. its common sources are oranges, strawberries, tomatoes, leafy green vegetables and germinating pulses. 1 cooking destroys the vitamin. it is not found in meat. inadequate intake of vitamin c results in scurvy. vitamin c storage is depleted in 1 to 3 months. 1,2 it is a potent antioxidant and is also required for normal collagen synthesis. the recommended daily allowance is 50 to 60 mg per day during first year of life. the recommendation for the content of vitamin c in formula is 10 to 30 mg/100 kcal. 1,3 complementary feeding with fruits and formula or breast milk can help to meet vitamin c requirement. vitamin c is destroyed during the industrial processing of almond beverages. 4 scurvy like illness was described in egyptian medical scrolls and later on it was described as sailor’s disease. 5 initial symptoms of scurvy are vague and difficult to diagnose early. malaise, fatigue, and body aches occur in early stages. 6 musculoskeletal problems, skin manifestations, gum diseases and bleeding tendency occur later. frequently, easy bleeding of spongy gums is encountered. 7 these symptoms if go unrecognized can result in severe debilitating course rendering the patient confined to bed, loosening of teeth and skin ulcers occur. life threatening bleeding can occur due to fragile vessels. cause of death is intracranial bleed or infections of open wounds. 7,8 musculoskeletal manifestations are common in scurvy during childhood. in 19 th century clinicians concluded that the condition called “acute rickets” was actually scurvy. 9 journal of islamabad medical & dental college (jimdc); 2016:5(3):144-146 146 the constitutional symptoms in infantile scurvy include failure to thrive, anorexia and irritability. debilitating leg pains result in pseudoparalysis. joint pain and swelling may be the first presentation. 9,10 radiographs show sheathing of the diaphyseal shafts, broadening of the calcification front at the anterior end of the ribs and ends of the metaphyses, and demineralization with metaphyseal fractures. 5,10 subperiosteal hemorrhages are seen during healing phase and involve paraepiphyseal regions. these are palpable as painful swellings over the distal ends of long bones. epiphyseal separation may also result. 11 lab diagnosis requires estimation of serum ascorbic acid level. the normal range is 5–16 mg/l. classical clinical features occur when levels fall below 2.5 mg/l. leukocyte ascorbic acid assays are a more accurate indicator of the body pool but are not done on a routine basis. 11,12 treatment with vitamin c supplementation results in dramatic recovery. anemia and other coexisting nutritional deficiencies are also treated. scurvy line is lost with healing leaving behind a double line of ossification at the original site. 12 most of the reported cases had developmental or feeding issues but our case was a developmentally normal child. disease occurred due to primary malnutrition. conclusion scurvy can have varied symptoms and signs. due to multisystem involvement the differential diagnosis includes malignancy, connective tissue disorders or autoimmune diseases. symptomatic infants are often misdiagnosed as victims of child abuse. high index of suspicion is needed to diagnose this easily treatable condition. references 1. léger d. scurvy reemergence of nutritional deficiencies. canadian family physician. 2008 oct 1;54(10):1403-6. 2. weinstein m, babyn p, zlotkin s. an orange a day keeps the doctor away: scurvy in the year 2000. pediat. 2001;108(3): e55. 3. olmedo jm, yiannias ja, windgassen eb, gornet mk. scurvy: a disease almost forgotten. int j dermatology. 2006 ;45(8):909-13. 4. vitoria i, lópez b, gómez j, torres c, guasp m, calvo i, dalmau j. improper use of a plant-based vitamin c– deficient beverage causes scurvy in an infant. pediatrics. 2016:137(2):e20152781 5. haddad s, golli m, najjar mf, guediche mn. infantile scurvy: two case reports. international journal of pediatrics. ;2010:717518. doi: 10.1155/2010/717518 6. fain o. musculoskeletal manifestations of scurvy. joint bone spine. 2005;72(2):124-8. 7. wijkmans ra, talsma k. modern scurvy. journal of surgical case reports. 2016;2016(1):1-3. 8. bacci c, sivolella s, pellegrini j, favero l, berengo m. a rare case of scurvy in an otherwise healthy child: diagnosis through oral signs. pediatric dentistry. 2010;32(7):536-8. 9. attia bari bk, rehman s, naz s. scurvy: presenting as musculoskeletal pain. journal of the college of physicians and surgeons pakistan. 2009;19(3):198-200. 10. alqanatish jt, alqahtani f, alsewairi wm, al-kenaizan s. childhood scurvy: an unusual cause of refusal to walk in a child. pediatric rheumatology. 2015 jun 11;13(1):1. doi: 10.1186/s12969-015-0020-1 11. noordin s, baloch n, salat ms, rashid memon a, ahmad t. skeletal manifestations of scurvy: a case report from dubai. case reports in orthopedics. 2012. id 624628, http://dx.doi.org/10.1155/2012/624628 12. shah d, sachdev h. vitamin c (ascorbic acid) in: behrman r., kliegman r., stanton, editors. nelson textbook of pediatrics. 19th ed. elsevier science; philadelphia: 2012. 198–200. http://dx.doi.org/10.1155%2f2010%2f717518 http://dx.doi.org/10.1155/2012/624628 j islamabad med dental coll 2020 129 open access comparison of ti-rads classification with fnac for the diagnosis of thyroid nodules naushaba malik 1 , maryam rauf 2 , ghazala malik 3 1 head, department of radiology, pessi hospital, islamabad, pakistan 2 consultant, department of radiology, pessi hospital, islamabad, pakistan 3 radiologist, pakistan institute of medical sciences, islamabad, pakistan a b s t r a c t background: thyroid nodules are very common and its prevalence is largely dependent on the identification techniques. recently high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. this study aimed to determine the efficacy of ti-rads classification and its association with fnac findings in thyroid lesions. material and methods: this prospective study was carried out in the department of radiology of islamabad diagnostic centre, islamabad for a period of 6 months from 6 th january 2018 to 6 th july, 2018. all male and female patients presenting with thyroid nodules were selected for the study. ultrasound neck was performed with high frequency linear probes. ultrasonography findings were classified according to thyroid imaging reporting and data system (ti-rads) classification, as defined by horvath et al. patients with ti-rads ii-v were scheduled for us-guided fine needle aspiration (fna). all the specimens were sent to pathology laboratory for cytology (fnac). results: total 123 patients of thyroid nodules were studied. mean age of the patients was 45.78 ± 13.11 years, with a female predominance (73.2%). a significant association was seen between ti-rads classification of thyroid nodules and findings on cytology. thyroid nodules with ti-rads ii, iii and iva classification showed benign cytological findings, while ti-rads class v had a significant association with malignant findings on cytology (p=0.001). conclusions: ti-rads classification is a reliable modality in differentiating benign thyroid nodules from malignant ones and circumvent the need for fnac in every case with a thyroid nodule. key words: ti-rads, cytology, fnac, thyroid nodules authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: naushaba malik email: sazinlondon@gmail.com article info: received: november 21, 2019 accepted: june 16, 2020 cite this article. malik n, rauf m, malik g. comparison of ti-rads classification with fnac for the diagnosis of thyroid nodules. j islamabad med dental coll.2020; 9(2): 129-133. doi: 10.35787/jimdc.v9i2.485 funding source: nil conflict of interest: nil i n t r o d u c t i o n the thyroid gland (an essential endocrine gland) is present anterior to the trachea at the base of neck. 1 overall, thyroid nodules are quite prevalent, and most of these nodules are benign. a thyroid nodule is the development of a lump (solid or fluidfilled) in the substance of thyroid gland. ultrasonographically, thyroid gland lesions are distinguishable from the surrounding normal thyroid parenchyma. 2 in case of thyroid malignancies, treatment of thyroid nodules is becoming a debatable subject. about 2-6% of thyroid nodules are easily detected by palpation, o r i g i n a l a r t i c l e j islamabad med dental coll 2020 130 19-68% are diagnosed with ultrasonography (usg), however 8-65% are discovered on autopsy. 3,4 among those detected through palpation or the usg, the incidence of carcinoma is about 5-15%. 3,5 in a population-based research, the malignancy rate among fine-needle aspiration (fna) assessed non-palpable nodules was 8-12%, and among thyroid nodules detected through palpation was 1.6% . 3,5,6 among endocrine glands, thyroid cancer is the most prevalent malignancy, accounting for 3.8% of all newly appearing cancer patients in the u.s and is the ninth most prevalent cancer, in general. 1 the number of individuals diagnosed with thyroid malignancy has risen significantly over the last 30 years. 2 thyroid fnac is the primary thyroid nodule diagnostic test. thyroid fnac is graded into six groups by the bethesda system and also predicts the risk of carcinoma. 7 usg-guided fna has an important contribution in managing thyroid nodules because of its accuracy and safety. however, even with usg guidance, sampling errors or non-representative sampling can occur during fna. 8 still it is regarded as a cost-effective method of investigation for thyroid nodules. 9 horvath et al proposed ti-rads for ultrasonographic evaluation and classification of patients with thyroid nodule prior to fnac/fna biopsy to safeguard them from unwanted complications. 10,11 some studies found ti-rads classification as a sensitive method for identifying patients with thyroid cancer, 12,13 while others advocated the need of cancer prediction with more sensitive gold-standard technique of fnab. 13 this study was planned in the context of these controversies and unavailability of relevant data in local settings. the objective was to compare the effectiveness of ti-rads classification with cytological confirmation in diagnosing thyroid nodules. m a t e r i a l a n d m e t h o d s this prospective study was performed at the radiology department of islamabad diagnostic center, islamabad pakistan. the study duration was 6 months from 6 th january 2018 to 6 th july 2018. approval was obtained from ethics review committee of the hospital. patients were informed about the possible complications of fna procedure and outcome of the study and written, informed consent was taken from each one of them. sample size was calculated by taking prevalence of thyroid nodules as 13% 14 , with 90% confidence level and 5% margin of error. total of 123 patients of either gender, with thyroid nodules detected by ultrasound (ge logiq p7), classified as tirads ii-v and scheduled for fnac, were included. patients with normal scan of thyroid (ti-rads class i), already known thyroid pathology and those who refused to be a part of the study, were excluded. complete clinical examination and required laboratory investigation were done in all patients. all the patients underwent high-resolution b-mode ultrasound scan performed by an experienced radiologist, having more than 5 years of experience. ti-rads proposed by horvath et al. in 2009 was followed for classification of thyroid nodules because it has a fair inter-observer agreement. following ultrasound (usg) evaluation of thyroid gland, usg-guided fnac was carried out by the same radiologists who performed the usg. a 23gauge needle, linked to a 2ml disposable plastic syringe and aspirator, were used for fnac. aspiration of each lesion was done twice. all the specimens were sent to the pathology laboratory for cytology. the data was recorded on a proforma and analysis was done by using spss version 20. chi-square test was applied and a p-value <0.05 was considered as statistically significant. j islamabad med dental coll 2020 131 r e s u l t s total 123 patients with thyroid nodules were studied. mean age of the patients was 45.78±13.11 years and the most common age group was 25-40 years (41.5%). regarding gender predilection, there were more female patients (73.2%) with thyroid nodules than male patients (26.8%) (table i). table: i. distribution of study patients according to age groups and gender (n=123) variables frequency n (%) age groups (years) 25-40 51 (41.5%) 41-55 42 (34.1%) 56-70 30 (24.4%) total 123 gender male 33 (26.8%) female 90 (73.2%) total 123 most of the thyroid nodules detected on usg were classified as ti-rads class ii (56.10%) (figure 1). figure 1: ti-rads classification of thyroid nodules on usg(n=123) a significant association was seen between ti-rads classification of thyroid nodules and findings on cytology. thyroid nodules with ti-rads ii, iii and iva classification showed benign cytological findings, while ti-rads class v had a significant association with malignant findings on cytology (p=0.001) (table ii). d i s c u s s i o n the prevalence of thyroid nodules is increasing worldwide. currently, it is reported to be around 19-67%, of which about 5-15% are usually malignant. 15 in pakistan, the percentage of malignancy is reported to be 11-14.35%. 14 in this study, we found a significant association of the tirad class v with malignant thyroid nodules on fnac, while ti-rads ii, iii and iva were significantly associated with benign thyroid nodules. our results are comparable to that of dy and colleagues. 13 they carried out a retrospective study on 149 patients with thyroid nodules, with majority of them being female patients (87%). they compared ti-rad classification with fnab and concluded that higher ti-rad class is associated with greater risk of malignancy. they also reported that ti-rads classification varies between ti-rads 1 and 5. ti-rads 1 is compatible with a typical thyroid gland, ti-rads 2 with benign nodules, tirads 3 with possibly benign nodules, ti-rads 4 with usg characteristics suspicious of malignancy and ti-rads 5, nodules highly indicative of malignancy. 13 results of our study are also in line with the research by zhuang et al. 15 in their pursuit to develop a practical ti-rad system, they also compared the ti-rads findings with fnab in 153 patients. they found ti-rads to be 97% accurate and the ti-rad system they devised showed the risk of malignancy in different classes of tirads as follows; tirads 2(0% malignancy), tirads 3 (3.6% malignancy), tirads 4 (17-75% malignancy), and tirads 5 (98% malignancy). 15 j islamabad med dental coll 2020 132 table ii: association of ti-rads classification with cytology findings of thyroid nodules (n=123) ti-rad classification cytology findings total p-value* benign malignant suspected malignancy papillary carcinoma cystic fluid ii 64 0 2 0 3 69 0.001 iii 19 1 2 0 0 22 iva 6 0 0 0 0 6 ivb 0 1 1 0 0 2 ivc 1 1 1 0 0 3 v 12 3 3 3 0 21 total 102 6 9 3 3 123 *p-value <0.05 was considered statistically significant kwak et al. 16 utilized a simpler and more practical ti-rads scoring grounded on bi-rads category like category 3 (without any suspected features of us), 4a (one suspicious characteristic), 4b (2 suspicious characteristics), 4c (3/4 suspicious characteristics). this facilitated risk stratification of a malignant thyroid nodule. 16 vargas-uricoechea et al. 17 tried to find concordance of tirads with bethesda cytology criteria. the mean age of patients in their study was 57 years with a predominance of females (75%). they found the highest concordance between the two modalities in tirads class ii. they inferred that tirad classification of benign nodules usually complements the cytology results therefore unnecessary intervention can be avoided in such patients. the main limitation of this study was a small sample size and including patients from a single institution, so the results of this study cannot be generalized to the entire population. second employing fnab instead of fnac for comparison with ti-rads categories would give more reliable results as biopsy is regarded as gold standard for diagnosis of benign and malignant lesions. c o n c l u s i o n there is a significant association between ti-rad classification and cytological findings from fnac of thyroid nodules. ti-rads classification is a reliable diagnostic modality and can be used for detection of thyroid lesions independent of fnac, thus reducing the burden of unnecessary biopsies. r e f e r e n c e s 1. nguyen qt, lee ej, huang mg, park yi, khullar a, plodkowski ra. diagnosis and treatment of patients with thyroid cancer. am health drug benefits. 2015; 8(1): 30-40. pmid: 25964831 2. tamhane s, gharib h. thyroid nodule update on diagnosis and management. clin diabetes endocrinol. 2016; 2(1): 17. doi: 10.1186/s40842016-0035-7 3. shin jh, baek jh, chung j, ha ej, kim jh, lee yh, et al. ultrasonography diagnosis and imaging-based management of thyroid nodules: revised korean society of thyroid radiology consensus statement and recommendations. korean j radiol. 2016; 17(3): 370-95. doi: 10.3348/kjr.2016.17.3.370 4. mandel sj. a 64-year-old woman with a thyroid nodule. jama 2004; 292(21): 2632-42. doi: 10.1001/jama.292.21.2632 5. nam-goong is, kim hy, gong g, lee hk, hong sj, kim wb, et al. ultrasonography-guided fine-needle aspiration of thyroid incidentaloma: correlation with pathological findings. clin endocrinol (oxf). j islamabad med dental coll 2020 133 2004;60(1):21-8. doi: 10.1046/j.1365-2265.2003.01 912.x 6. smith-bindman r, lebda p, feldstein va, sellami d, goldstein rb, brasic n, et al. risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. jama intern med. 2013; 173(19): 1788-96. doi: 10.1001/ jamainternmed.2013.9245 7. alshaikh s, harb z, aljufairi e, almahari sa. classification of thyroid fine-needle aspiration cytology into bethesda categories: an institutional experience and review of the literature. cytojournal. 2018; 15: 4. doi: 10.4103/cytojournal. cytojournal_32_17 8. lee yh, baek jh, jung sl, kwak jy, kim jh, shin jh, korean society of thyroid radiology (ksthr). ultrasound-guided fine needle aspiration of thyroid nodules: a consensus statement by the korean society of thyroid radiology. korean j radiol. 2015; 16(2): 391-401. doi: 10.3348/kjr.2015.16.2.391. 9. basharat r, bukhari mh, saeed s, hamid t. comparison of fine needle aspiration cytology and thyroid scan in solitary thyroid nodule. patholog res int. 2011; 2011: 754041. doi: 10.4061/2011/754041. 10. songsaeng d. siriraj thyroid imaging reporting and data system and its efficacy. siriraj med j. 2017; 69(5): 262-7. doi: 10.14456/smj.2017.52 11. horvath e, majlis s, rossi r, franco c, niedmann jp, castro a, et al. an ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. j clin endocrinol metab. 2009; 94(5): 1748-51. doi: 10.1210/jc.2008-1724 12. ashamallah ga, el-adalany ma. risk for malignancy of thyroid nodules: comparative study between tirads and us based classification system. egypt j radiol nucl med. 2016; 47(4): 1373-84. doi: 10.1016/j.ejrnm.2016.08.021 13. dy jg, kasala r, yao c, ongoco r, mojica dj. thyroid imaging reporting and data system (tirads) in stratifying risk of thyroid malignancy at the medical city. j asean fed endocr soc 2017; 32(2): 108 14. kamran m, hassan n, ali m, ahmad f, shahzad s, zehra n. frequency of thyroid incidentalomas in karachi population. pak j med sci. 2014; 30(4): 79397. doi: 10.12669/pjms.304.4808 15. zhuang y, li c, hua z, chen k, lin jl. a novel tirads of us classification. biomedical engineering online. 2018; 17(1): 82. doi: 10.15605/jafes.032.02.03 16. kwak jy, kim hh, yoon, jh, moon hj, son ej, et al. thyroid imaging reporting and data system for us features of nodules: a step in establishing better stratification of cancer risk. radiology. 2011; 260(3): 892-9. doi: 10.1148/radiol.11110206 17. vargas-uricoechea h, meza-cabrera i, herrerachaparro j. concordance between the tirads ultrasound criteria and the bethesda cytology criteria on the nontoxic thyroid nodule. thyroid res. 2017; 10(1): 1. doi: 10.1186/s13044-017-0037-2 54 j i m d c 2 0 1 8 54 open access f u l l l e n g t h a r t i c l e efficacy of the epidural blood patch for the treatment of post epidural puncture headache hamid saeed 1, muhammad zia ur rehman 2, samee javed bhatti 3, aamir furqan 4 1-3 house officer, nishtar hospital multan 4 assistant professor of anaesthesia, nishtar institute of dentistry multan a b s t r a c t objective: to evaluate the efficacy of the epidural blood patch for the treatment of post-dural puncture headache (pdph). patients and methods: this cross sectional study was conducted in the department of anesthesia and intensive care, nishtar hospital multan. out of total 326 patients, 186 were male 140 were female. patients having age 16 years and above, presented with pdph started from previous 24 hours up to last six days were included in the study. efficacy of treatment was measured on patients comment about relief from pain after pdph. chi-square along with fisher exact test was used to see effect modification. results: overall, there were 326 (100%) patients in this study, among them 57% (n=186) were males and 43% (n=140) were females. asa-1 and asa-2 noted as 73.3% and 26.7% respectively. the main outcome of this study was efficacy of treatment. it was observed that after 1st patch, efficacy was noted as good in 75.8% (n=247) patients, while after 2nd patch it was good in 97.5% (n=318) patients. there was significant difference between the efficacy of 1st and 2nd patch. (p value=0.000), according to fisher exact test. conclusionresults of our study concluded that epidural blood patch (edbp) is the better choice for treatment of epidural puncture headache (edph). if one time it is incompletely effective its 2nd patch can be considered. key words: blood patch, effectiveness, epidural puncture headache. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3,4 active participation in data collection, review the manuscript address of correspondence aamir furqan email: draamir2009@hotmail.com article info. received: october 1, 2017 accepted: january 10, 2018 cite this article. saeed h, zia ur rehman m, bhatti sj, furqan a. efficacy of the epidural blood patch for the treatment of post epidural puncture headache. jimdc.2018; 7(1):54-58 funding source: nil conflict of interest: nil i n t r o d u c t i o n about 40% of patients given epidural anesthesia are complicated by headache and named as post-dural puncture headache (pdph).1 pdph is an orthostatic illness, which is aggravated in vertical and diminished in horizontal or lying position. headache is caused due to leakage of spinal fluid into epidural space through dural rent. leakage of spinal fluid leads to decrease in pressure and causes traction in upright position. other symptoms of csf leakage like tinnitus, mayalgia, dizziness and diplopia may be present along with headache.2 in 85 to 90% of cases, pdph occurs within 2 days (48 hours) but there is a possibility of complain immediately after epidural.3 pdph and its symptoms are limiting and are relieved in 6 to 7 days in 80% of patients. a very few patient’s complain pdph lasting for weeks or months, it may be psychological. pdph is episodic pain, during its episodes’ patients may confine to bed and have financial and psychological effects.4 many techniques and prophylactic measures like use of sprotte’s needle, needle of small size, direction correction o r i g i n a l a r t i c l e 55 j i m d c 2 0 1 8 55 (bevel perpendicular to dura) have been introduced and all are effective in reduction of pdph.5 after all these modalities if patient still complains about pain, then epidural blood patches (edbp) can be used. it is a new and beneficial intervention in the history of pdph. in this technique 10-20 ml blood of same group (autologous) injected in the epidural space.6 pdbp introduced by gormly in 1960 7, and observed that pdph reduced to a significant level after inadvertent bloody taps. blood patch converted into a clot at the site if tap and stop the leakage of spinal fluid into the epidural space. after this observation, he treated 6 patients of pdph with edbp and all were cured.8 another study was conducted by scavone b et al 9 on comparison of edbp with sham procedure, and reported that in both cases there was no complaint about pain after treatment and concluded that both techniques are equally effective. wong, ket al 10 conducted a similar study in 2017 and reported remarkable relief. aim of our study was to investigate the effectiveness of edbp technique in comparison with conservative management of pdph, this will be a unique and new gate towards modern treatment modalities of our region. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted in the department of anesthesia and intensive care, nishtar medical college multan. study was started after approval of ethical review board of institution. informed consent was obtained after complete information of the study to the patients or their guardians. patients of 16 years age or more presented with history of pdph from last 24 hours and not more than seven days were included in the study. patients with hemorrhagic diathesis, having contraindications of lumber puncture, and body temperature more than 38° celsius were excluded from the study. sample size was calculated through who sample size calculator by using 95% confidence interval, 80% power of study and 67% efficacy of patch.6 after complete diagnosis and confirmation of edph, a 20ml of blood was drawn from the vein of the patient with all aseptic measures. then blood was injected with epidural needle into the epidural space around spinal tap by consultant anesthetist having experience more than five years. injection was stopped when patients’ complaint about backache or after the completion of injection. patient was guided about contraindications like lifting heavy weight for 3 days, bending forward and straightening. patient’s complaint of headache with transdural leak was considered as treatment failure. in case of treatment failure, injection was repeated and named as 2nd patch. this whole procedure was started after failure of conservative treatment of edph. efficacy of treatment was measured on the basis of patients comments about pain relief after pdph. collected information was entered in spss version 23.1 and analyzed for possible results. mean and sd was calculated for quantitative data like maternal age. frequency and percentages were calculated for qualitative data such as gender, asa status and efficacy (good/poor). chi-square along with fisher exact test was used to see effect modification. p-value ≤ 0.05 was considered as significant. r e s u l t s overall, data was collected from 326 patients. there were 57.1% (n=186) males and 42.9% (n=140) females. mean age of the patients was 35.32±2.49 years. large number (90.2%) of patients were between 30-38 years of age. american society of anesthesiologists-1 score (asa-1) and asa-2 score was noted as 73.3% and 26.7% respectively (table 1). table 1: demographic characteristics of participants (n=326) characteristics frequency percentage gender male 186 57.1 female 140 42.9 stratified age 30-38 years 294 90.2 39-45 years 32 9.8 age; years (mean±sd) 35.32±2.49 asa asa 1 239 73.3 asa 2 87 26.7 56 j i m d c 2 0 1 8 56 table 2: comparison of efficacy between epidural 1st and 2nd patch (n=326) after 2nd patch after 1st patch total p-value good poor good 246 72 318 0.000 poor 1 7 8 total 247 79 326 after 1st patch, efficacy of treatment was 75.8% and it was significantly improved (p-value=0.00) up to 97.5% after 2nd patch (table 2). after 1st patch, there was no significant association of efficacy with gender, asa and age (table 3). after 2nd patch, significant association was found only with age (table 4). d i s c u s s i o n treatment of pdph with edbp is a globally accepted and is a best treatment after failure of conservative management. sometime one episode is not sufficient and patients need another episode of edbp. 11 through our study design we can measure its efficacy more precisely. days after headache named as incapacitated days. purpose of edbp is to reduce the incapacitated days; it may cause low back pain like side effects. after this study, we can estimate real effect of this mode of treatment. 12 p table 3: association of epidural 1st patch efficacy with effect modifiers (n=326) variable after 1st patch total p-value good poor gender male 142 44 186 0.439 female 105 35 140 total 247 79 326 asa asa1 182 57 239 0.447 asa2 27 65 92 total 247 79 326 age 30-38 years 225 69 294 0.220 39-45 years 22 10 32 total 247 79 326 table 4: association of epidural 2nd patch efficacy with effect modifiers (n=326) variable after 2nd patch total p-value good poor gender male 183 3 186 0.220 female 135 5 140 total 318 8 326 asa asa1 234 5 239 0.363 asa2 84 3 87 total 318 8 326 age 30-38 years 289 5 294 0.034 39-45 years 29 3 32 total 318 8 326 dph is a challenge for surgeons, patients and for anesthesiologists now in these days because it can damage the person’s life. incidence rate of pdph was reported in many studies from 0% to 70%, most common causes of pdph include large bore needle (29-g), needle level and design, angle of needle use, patient’s age, gender, patients posture at the time of puncture and bed rest duration (less or long). maximum cases of pdph were found after ambulatory surgeries as compared to hospitalized patients even in those patients in which needle size and level was the same. in our results we observed that after 1st patch, efficacy was noted as good in 75.8% (n=247) patients, while after 2nd patch it was good in 97.5% (n=318) patients (table 3). there was significant difference between the efficacy of 1st and 2nd patch. (χ2 = 17.879 df = 1, p value=0.000). safa-tisseront et al 10 conducted a similar study in 2001 and reported 75% complete relief and 18% incomplete relief with 7% treatment failure. about its complications, fever developed in three patients. williams e et al 13 conducted a study in 1999 and reported 34% complete relief after edbp, 54% incomplete relief and 12% failure. common complication of this study was back pain that occurred in three patients. results of our study are comparable with our results showing a better efficacy of this mode of treatment. banks et al 14 reported in 2001 57 j i m d c 2 0 1 8 57 67% complete relief and 28% incomplete relief with treatment of edbp. in 1993 taivainen et al reported initial relief in 91% patients and good results of 61 % permanent relief after edbp.15 these results show more successful is edbp than any other mode of treatment. stride et al reported 90% and 64% initial and permanent relief from pain respectively.16 goodman b reported 83% relief from spinal headache. all these results are comparable with our finding. 17 in 2012 dripps rdet al conducted a study on post dural puncture headache and reported that 54 % of patient’s relief their headache within 4 days of treatment given.18 these findings are comparable to our study. most of the pdph occurs after the use of large bore needle, which damages more epidural space, about 16-86% of cases suffered from pdph after the use of large bore needle.19 experience of clinician, also matters, expert clinicians have very small rate of edph, about 0.16 to 1.3%.20 in our study, we did not observe complications after edbp and after second patch 97.5% (n=318) patients show good efficacy of this treatment modality. c o n c l u s i o n epidural blood patch (edbp) is a better choice for the treatment of epidural puncture headache (edph). if one time it is incompletely effective, its second patch can be considered. r e f e r e n c e s 1. delpizzo k, cheng j, dong n, edmonds cr, kahn rl, fields kg, curren j, rotundo v, zayas vm. postdural puncture headache is uncommon in young ambulatory surgery patients. hss journal. 2017 ;13(2):146-51. 2. goh sy, thong sy. cerebrospinal fluid cutaneous fistula after uneventful epidural analgesia. glob j anesthesiol 2015;2(1):003-005. 3. ferrante e, rubino f, mongelli m, arpino i. subarachnoideal blood spread following epidural blood patch given to treat spontaneous intracranial hypotension: can it cause neurological complications? clin neurol neurosurg. 2016;140: 436. 4. katz d, beilin y. review of the alternatives to epidural blood patch for treatment of postdural puncture headache in the parturient. anesth analg. 2017;124(4):1219-1228. 5. booth jl, pan ph, thomas ja, harris lc, d'angelo r. a retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy. int j obstet anesth. 2017; 29:10-17. 6. banks s, paech m, gurrin l: an audit of epidural blood patch after accidental dural puncture with a tuohy needle in obstetric patients. int j obstet anesth. 2001;10(3):172-6. 7. darvish b, dahlgren g, irestedt l, magnuson a, möller c, gupta a. auditory function following post‐dural puncture headache treated with epidural blood patch. a long‐term follow‐up. acta anaesthesiol scand. 2015;59(10):1340-54. 8. dʼsouza g, seidel fg, krane ej. management of a ventral cerebrospinal fluid leak with a lumbar transforaminal epidural blood patch in a child with persistent postdural puncture headache: a case report. reg anesth pain med. 2017;42(2):263-266. 9. scavone b, wong c, sullivan j, yaghmour e, sherwani s, mccarthy r: efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. anaesthesiology. 2004;101(6):1422-1427. 10. wong, k, monroe, br. successful treatment of postdural puncture headache using epidural fibrin glue patch after persistent failure of epidural blood patches. pain pract. 2017;17(7):956–960. 11. hanling sr, lagrew je, colmenar dh, quiko as, drastol ca. intravenous cosyntropin versus epidural blood patch for treatment of postdural puncture headache. pain med. 2016;17(7):1337-42. 12. elwood jj, dewan m, smith jm, mokri b, mauck wd, eldrige js. efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension: preliminary report. springerplus. 2016;5(1):317. 13. williams e, beaulieu p, fawcett w, jenkins j: efficacy of epidural blood patch in the obstetric population. int j obstet anesth. 1999; 8(2):105-9. 14. banks s, paech m, gurrin l: an audit of epidural blood patch after accidental dural puncture with a tuohy needle in obstetric patients. int j obstet anesth. 2001;10(3):172-6. 15. taivanen t, pitkanen m, tuominen m, rosenberg p: efficacy of the epidural blood patch for postdural 58 j i m d c 2 0 1 8 58 puncture headache. acta anaesthesiol scand. 1993;37(7):702-705. 16. stride p, cooper g: dural taps revisited. anaesthesia. 1993;48(3):247-255. 17. goodman b, vallabhaneni s, cubitt b, mallempati s. transforaminal epidural blood patches for the treatment of postsurgical dural leaks: two case reports. pm r. 2017;9(1):83-87. 18. dripps rd, vandam ld. long-term follow-up of patients who received 10,098 spinal anesthetics: failure to discover major neurological sequelae. j am med assoc. 1954;156(16):1486–1491. 19. liu s, carpenter rl, neal jm. epidural anesthesia and analgesia. their role in postoperative outcome. anesthesiology. 1995;82(6):1474– 1506. 20. so y, park jm, lee pm, kim cl, lee c, kim jh. epidural blood patch for the treatment of spontaneous and iatrogenic orthostatic headache. pain physician. 2016;19(8): e1115-e1122. 72 j i m d c 2 0 1 7 72 op e n ac c e ss f u l l l e n g t h a r t i c l e association of portal hypertensive gastropathy with esophageal varices among patients of viral cirrhosis khalid mahmood nasir 1, muhammad salman walayt 2, fizza fatima 3, muhammad saeed aslam 4, sami ur rehman,5 noor ul ain6 muhammad saeed 7 1 assistant professor of medicine, medicine unit 1, jinnah hospital lahore 2,4registrar, medicine unit 1, jinnah hospital lahore 3house officer gynaecology department, services hospital lahore 5 department of microbiology and molecular genetics, punjab university lahore 5,7 medical lab technologist pathology department district head quarter hospital mandi bahauddin a b s t r a c t objectives: to find out the prevalence of portal hypertensive gastropathy among patients of viral cirrhosis undergoing endoscopy and to determine its association with esophageal varices in patients of cirrhosis. patients and methods: this cross-sectional study was conducted at medical unit, jinnah hospital lahore from 3rd september 2016 to 2nd january 2017. a total of 120 patients with liver cirrhosis fulfilling the inclusion criteria were approached and an informed consent was taken before enrolling in the study. all patients underwent upper gastrointestinal tract endoscopy by consultant endoscopist. data was entered on spss version 17 for further analysis. results: out of 120 patients, 43% were males and 57% were females. the mean age of participants was 39.71+11.6 sd years. portal hypertensive gastropathy was present in 12.5% patients and esophageal varices in 42.5% patients. hbsag and anti-hcv was positive in 60.8% and 45.8% patients respectively. non-significant association was found between portal hypertensive gastropathy and esophageal varices (p-value 0.364). conclusion: emergence of portal hypertensive gastropathy and esophageal varices was noticed among patients of viral cirrhosis. however non-significant association was found between portal hypertensive gastropathy and esophageal varices. keywords: cirrhosis, esophageal varices, portal hypertensive gastropathy author`s contribution 1conception, synthesis and planning of the research-2-4active participation in active methodology, 5interpretation and discussion, 6,7analysis address of correspondence muhammad salman walayt pastel_6@live.com article info. received: mar 21, 2017 accepted: may 25, 2017 cite this article: aslam ms,nasir km, hussain h, altaf mo, farrukjh s, saeed m. association of portal hypertensive gastropathy with esophageal varices among patients of viral cirrhosis. jimdc. 2017; 6(2):72-76. funding source: nil conflict of interest: nil i n t r o d u c t i o n cirrhosis being the decompensated disease, is responsible for high rate of morbidity and mortality. the quality of life and survival of patients with cirrhosis can be improved by appropriate and timely management. more than 25,000 deaths and 373,000 hospital discharges in the united states in 1998 have been reported according to a report from the national centre for health.1 portal hypertension leads to an increase in blood flow in veins of the lower esophagus and stomach. these veins are not designed for the higher pressure, and thus they begin to expand, resulting in varices. once varices develop, they can remain stable, increase in size (if the liver disease worsens), or decrease in size (if the liver disease improves). portal hypertension is a progressive complication of cirrhosis. therefore, management of the patient with cirrhosis and portal hypertensive gastrointestinal bleeding depends on the phase of portal hypertension, o r i g i n a l a r t i c l e mailto:pastel_6@live.com 73 j i m d c 2 0 1 7 73 practice guidelines for the diagnosis and treatment of gastroesophageal variceal haemorrhage, endorsed by the american association for the study of liver diseases (aasld), american college of gastroenterology (acg), american gastroenterological association (aga), and american society for gastrointestinal endoscopy (asge), were published in 1997.2 esophageal varices are a common complication of advanced cirrhosis that results directly from portal hypertension. in people with cirrhosis, varices develop when blood flow through the liver is obstructed by scarring, increasing the pressure inside the portal vein. the strongest predictor for the development of varices in those with cirrhosis who have no varices at the time of initial endoscopic screening is hepatic vein pressure gradient (hvpg) >10 mmhg.3 patients with an hvpg >20 mmhg (measured within 24 hours of variceal haemorrhage) have been identified as being at a higher risk for early rebleed (recurrent bleeding within the first week of admission) or failure to control bleeding and a higher 1-year mortality compared to those with lower pressure.4 esophagogastroduodenoscopy (egd) is a gold standard in the diagnosis of varices. in a consensus meeting on methodology and therapeutic strategies in portal hypertension, in italy, it was recommended that the size classification is as simple as possible, i.e. in 2 grades (small and large).5 either done by semi-quantitative morphological assessment or by quantitative size with a suggested cut-off diameter of 5 mm, with large varices being those greater than 5 mm. when varices are classified in 3 sizes—small, medium, or large—as occurs in most centres by a semi-quantitative morphological assessment (with small varices generally defined as minimally elevated veins above the esophageal mucosal surface, medium varices defined as tortuous veins occupying less than one-third of the esophageal lumen, and large varices defined as those occupying more than one-third of the esophageal lumen), the recommendations for medium-sized varices are the same as for large varices because this is how they were grouped in prophylactic trials.6 the presence of coarse irregular echo-texture of the liver on ultrasonography along with either hbsag or anti-hcv antibody positivity for 5-10 years was labeled as viral cirrhosis. the presence of mosaic-like pattern of gastric mucosa along with any of the three characteristics i.e. red point lesions, cherry red spots or black-brown spots, scattered diffusely over the gastric mucosa as seen on endoscopy, is labelled as portal hypertensive gastropathy.7,8 the presence of dilated mucosal veins (< 50% of adjacent normal veins) seen in a lower third of oesophagus with the help of endoscopy is labelled as having esophageal varices.8 present study was planned to find out the association of portal hypertensive gastropathy with esophageal varices in patients of cirrhosis. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at medical unit, jinnah hospital lahore from 3rd september 2016 to 2nd january 2017. about 120 patients diagnosed with viral cirrhosis and duration of illness between 5 to 10 years undergoing screening gastric endoscopy were included in the study. patients with (i) severe acute upper gi bleed (>250 ml of blood in vomitus in a day. (ii) hemodynamically unstable (bp < 80/60) determined by history and examination, (iii) previously diagnosed with varices or portal hypertensive gastropathy determined by history and previous medical records, (iv) patients on prophylactic beta-blocker or nitrates therapy determined by history and previous medical records (v) any evidence of portal vein or splenic vein thrombosis determined by abdominal ultrasound (vi) patients with a history of previous portosystemic shunt surgery or transjugular intrahepatic portosystemic shunt stent placement determined by history and previous medical records. (vii) patients with history of hematologic disorders such as aplastic anaemia, myelodysplastic syndrome, any other haematological malignancy or bleeding/coagulation disorder or those on anticoagulant therapy determined by history, (viii) pregnancy determined by history and investigations. (xi) patients on nsaid, steroids or antiviral therapy for more than 4 weeks determined by history and medical record were excluded from study. after taking informed consent, all patients underwent upper gastrointestinal tract endoscopy by consultant endoscopist. findings of endoscopy (presence of portal hypertensive gastropathy and varices) were noted. confidentiality of the data was ensured. data analysis was done by spss version 17.0, numerical variable were summarized as mean and standard 74 j i m d c 2 0 1 7 74 deviation (sd). qualitative variables were presented in the form of frequency and percentages. chi-square test was applied to check statistical significance. data was stratified by age, gender, duration of cld, hbsag, anti hcv and child-pugh class (a, b,c) to estimate cirrhosis severity. post-stratification chi-square test was applied. pvalue < 0.05 was considered as statistically significant r e s u l t s out of 120 patients, there were 52 (43.3%) males and 68 (56.7%) females. the mean age was 39.71+11.6 sd years. minimum and maximum duration of illness was 05 and 10 years respectively with the mean of 7.5+1.72 sd years. out of total 120 study subjects, portal hypertensive gastropathy and esophageal varices were present in 15(13%) and 51(43) patients respectively. table1 showed frequency distribution of hbsag, anti-hcv and class of child pugh, a, b, and c in patients of cirrhosis. association of portal hypertensive gastropathy with esophageal varices is shown in table 2. as shown in the table, non-significant association was found between portal hypertensive gastropathy and esophageal varices (p-value 0.364). table 3 showed associations of portal hypertensive gastropathy with different effect modifiers present in patients of cirrhosis. table.3 association of portal hypertensive gastropathy with related factors in patients of cirrhosis variables portal hypertensive gastropathy p-value yes (n=15) no (n=105) age (years) <40 (n=58) ≥ 40 ( n=62) 8 7 50 55 0.679 gender male (n=52) female (n=68) 9 6 43 62 0.164 duration of illness (years) < 8 (n=52) ≥ 8 (n=68) 9 6 43 62 0.053 hbsag positive (n=73) negative(n=47) 10 5 63 42 0.621 anti-hcv positive (n=55) negative(n=65) 6 9 49 56 0.628 child pugh class a (n=15) b (n= 57) c (n= 48) 0 8 7 15 49 41 0.93 d i s c u s s i o n the present study showed that frequency of portal hypertensive gastropathy and esophageal varices was 12.5% and 42.5% respectively. there was an insignificant association between portal hypertensive gastropathy and esophageal varices (p-value 0.364). similarly, there was not a significant association between portal hypertensive gastropathy and other factors like age, duration of illness, table 1: frequency of different factors in patients of cirrhosis (n=120) groups frequency (n) percentage (%) hbsag positive negative 73 47 61 39 anti-hcv positive negative 55 65 46 54 child pugh class a b c 75 57 48 13 47 40 table 2: association of portal hypertensive gastropathy with esophageal varices in patients of cirrhosis esophageal varices portal hypertensive gastropathy p-value yes (n=15) no (n=105) yes (n=51) 8 43 0.364 no (n=69) 7 62 75 j i m d c 2 0 1 7 75 gender, hbsag, anti-hcv and child pugh class, with p value >0.05. in one of the previous studies, a strong positive association has been reported between the presence of phg and esophageal varices (p < 0.0001). phg was also found associated with the histological and biochemical severity of liver disease in patients with hcv and advanced fibrosis.9 from another study, on univariate analysis lower platelet counts (117±55 vs. 167±90; p < 0.001), increased spleen size (14.1±2.9 cm vs. 12±2.4cm; p < 0.001) were found in phg patients as compared to those without it. similarly, lower platelet/spleen ratio was noted in patients with severe phg (916±400 vs. 1477±899; p < 0.001). furthermore, ctp score > 8 meld score > 12 and platelets/spleen ratio < 900 were significantly associated factors with severe phg.10 in existing research, significant positive correlation has been reported between esophageal variceal grade and phg but not with aetiology or hypersplenism. in one of the studies the frequency of phg was 79.27% compared to 12.5% in our study. they also observed that grade of oesophageal varices had significant association with phg, suggesting a common pathophysiology of both entities.12 in the same study it was reported that out of 217 patients, 66.4% were hcv positive,16.6% were hbv positive and 6.9% had coinfection with hcv/hbv, and only 1 (0.5%) had coinfection of hbv/hdv. twenty-one patients (9.7%) were classified as having cryptogenic cirrhosis.11 another report mentioned the 80% prevalence of gastropathy and it was correlated with the duration of disease, presence and size of esophago gastric varices, and a previous history of endoscopic variceal sclerotherapy. they also observed that during 18 ± 8 months of follow-up, gastropathy was stable in 29% of patients, deteriorated in 23%, improved in 23%, and fluctuated with time in 25%. the evolution of gastropathy with time was identical in patients with and without previous or current sclerotherapy. acute bleeding from gastropathy occurred in 8 of 315 patients (2.5%). the bleeding-related mortality rate was 12.5%. chronic bleeding occurred in 10.8 % patients.12 in another study done by fontana rj et al, out of 1,016 hcv patients, 37% of halt-c patients had phg with 34% having mild and 3% with severe changes. the mucosal mosaic pattern was identified in 33%, red marks in 15%, and gastric antral vascular ectasia (gave) features in only 3%. independent correlates of phg included biochemical markers of liver disease severity (lower serum albumin, higher bilirubin), portal hypertension (lower platelet count), insulin resistance (higher glucose), and non-african american race.9 in another study, out of 360 patients who underwent egd (esophago gastro deudenoscopy) screening, 63% were male and 37% were females. two hundred and eightyone (78%) had hepatitis c while 79 (22%) suffered from hepatitis b-related cirrhosis. three hundred patients (83.3%) had phg, among these 24% had severe phg. a higher proportion of esophageal varices (89.7%) was present among those who had phg (p < 0.001).10 it is recommended that patients with cirrhosis undergo endoscopic screening for varices at the time of diagnosis.13 since the prevalence of medium/large varices is approximately 15–25%, the majority of subjects undergoing screening egd either do not have varices or have varices that do not require prophylactic therapy.14 there is, therefore, a considerable interest in developing models to predict the presence of high-risk varices by non-endoscopic methods. several studies have evaluated possible non-invasive markers of esophageal varices in patients with cirrhosis, such as the platelet count, fibrotest, spleen size, portal vein diameter, and transient elastography.15,16 however, the predictive accuracy of such non-invasive markers is still unsatisfactory, and til large prospective studies of non-invasive markers are performed, endoscopic screening is still the main means of assessing for the presence of esophageal varices.16 cost-effective analyses using markov models have suggested either empiric β-blocker therapy for all patients with cirrhosis or screening endoscopy for patients with compensated cirrhosis, or universal β-blocker therapy without screening egd for patients with decompensated cirrhosis.17,18 however a recent trial shows that β-blockers do not prevent the development of varices and are associated with significant side effects, and do not consider endoscopic variceal ligation as an alternative prophylactic therapy.18 until prospective studies validate these approaches, screening egd is still the recommended approach. 76 j i m d c 2 0 1 7 76 egd also remains the main method for diagnosing variceal hemorrhage.13 the diagnosis of variceal haemorrhage is made when diagnostic endoscopy shows one of the following: active bleeding from varix, a “white nipple” overlying varix, clots overlying varix or varices with no other potential source of bleeding. c o n c l u s i o n emergence of portal hypertensive gastropathy and esophageal varices were noticed among viral cirrhosis patients with insignificant association between each other, moreover, modifiers have no significant association with phg. r e f e r e n c e s 1. national center for health statistics. plan and operation of the third national health and nutritional examination survey, 1988-94. series 1: programs and collection procedures. vital health stat 1. 1994; 32:1-407. 2. grace nd. diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. american journal of gastroenterology. 1997; 92(7) : 1081-1091. 3. pugh r, murray‐lyon im, dawson jl, pietroni mc, williams r. transection of the oesophagus for bleeding oesophageal varices. british journal of surgery. 1973; 60(8):646-9. 4. monescillo a, martínez‐lagares f, ruiz‐del‐arbol l, sierra a, guevara c, jiménez e, marrero jm, buceta e, sánchen j, castellot a, peñate m. influence of portal hypertension and its early decompression by tips placement on the outcome of variceal bleeding. hepatology. 2004; 40(4):793-801. 5. de franchis r, pascal jp, ancona e, burroughs ak, henderson m, fleig w, groszmann r, bosch j, sauerbruch t, soederlund c, lebrec d. definitions, methodology and therapeutic strategies in portal hypertension: a consensus development workshop, baveno, lake maggiore, italy, april 5 and 6, 1990. journal of hepatology. 1992; 15(1-2):256-61. 6. brocchi e, caletti g, brambilla g, la mantia l, lupinacci g, pisano g, puerari g, zambelli a, barbagli s, ciani p, manneschi l. prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. a prospective multicenter study. new england journal of medicine. 1988; 319(15):983-9. 7. de franchis r, dell’era a. invasive and noninvasive methods to diagnose portal hypertension and esophageal varices. clinics in liver disease. 2014; 18(2):293-302. 8. semenova ts, pal'tseva em, zhigalova sb, shertsinger ag. portal hypertensive gastropathy. arkhiv patologii. 2014; 76(6):64-8. 9. fontana rj, sanyal aj, mehta s, doherty mc, neuschwander-tetri ba, everson gt, et al. portal hypertensive gastropathy in chronic hepatitis c patients with bridging fibrosis and compensated cirrhosis: results from the halt-c trial. the american journal of gastroenterology. 2006;101(5):983-92. 10. ahmed s, mumtaz k, ahmed us, shah ha, abid s, hamid s, et al. frequency and characteristic features of portal hypertensive gastropathy in patients with viral cirrhosis. journal of the college of physicians and surgeons pakistan. 2010;20(11):714-8. 11. abbasi a, bhutto ar, butt n, munir s, dhillo ak. frequency of portal hypertensive gastropathy and its relationship with biochemical, haematological and endoscopic features in cirrhosis. j coll physicians surg pak. 2011;21(12):723-6. 12. primignani m, carpinelli l, preatoni p, battaglia g, carta a, prada a, cestari r, angeli p, gatta a, rossi a, spinzi g. natural history of portal hypertensive gastropathy in patients with liver cirrhosis. gastroenterology. 2000; 119(1):181-7. 13. grace nd, groszmann rj, garcia‐tsao g, burroughs ak, pagliaro l, makuch rw, et al. portal hypertension and variceal bleeding: an aasld single topic symposium. hepatology. 1998;28(3):868-80. 14. pagliaro l, d’amico g, pasta l, politi f, vizzini g, traina m, et al. portal hypertension in cirrhosis: natural history. bosch j, groszmann rj portal hypertension pathophysiology and treatment oxford, uk: blackwell scientific. 1994:72-92. 15. garcia-tsao g, damico g, abraldes jg, schepis f, merli m, kim wr, christensen e. predictive models in portal hypertension. inportal hypertension proceedings of the fourth baveno international consensus workshop on methodology of diagnosis and treatment. ed de franchis 2008; 2006: 47-100. 16. d'amico g, morabito a. noninvasive markers of esophageal varices: another round, not the last. hepatology. 2004;39(1):30-4. 17. spiegel bm, targownik l, dulai gs, karsan ha, gralnek im. endoscopic screening for esophageal varices in cirrhosis: is it ever cost effective? hepatology. 2003;37(2):366-77. 18. arguedas mr, heudebert gr, eloubeidi ma, abrams ga, fallon mb. cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices. the american journal of gastroenterology. 2002; 97(9):2441-52. j islamabad med dental coll 2021 15 open access immunohistochemical expression of bcl-2 in malignant salivary gland tumors faiz rasul1, sultan muhammad wahid2, iman imran3, zainab rizvi4, rozina jaffar5, ambereen anwar6 1assistant professor, department of oral pathology, de’montmorency college of dentistry, lahore pakistan 2head, department of dentistry, lahore general hospital, lahore pakistan 3final year mbbs, cmh lahore medical college, lahore pakistan 4associate professor, department of oral pathology, de’montmorency college of dentistry, lahore pakistan 5professor, department of pathology, rahbar medical & dental college, lahore pakistan 6professor, department of pathology, allama iqbal medical college, lahore pakistan a b s t r a c t background: malignant salivary gland tumors (msgts) consist of a heterogeneous group of neoplasms with complex clinicopathological features and biological behaviors. the purpose of this study was to determine the expression of bcl 2 antiapoptotic protein in mucoepidermoid carcinoma (mec), adenoid cystic carcinoma (adcc), acinic cell carcinoma (acc) and polymorphous low-grade adenocarcinoma (plga) of salivary glands and to find out its association with different grades of these tumors. material and methods: this descriptive study included 55 cases of msgts. tissue sections were stained with routine hematoxylin and eosin stain as well as bcl-2 immunostain. msgts were graded as low grade (low grade mec, acc, plga, and tubular pattern of a dcc), intermediate grade (cribriform pattern of adcc, and intermediate grade of mec) and high grade (high grade of mec and solid pattern of adcc) tumors on h&e sections. bcl -2 expression was scored as ‘negative’ (<5% of neoplastic cells), ‘1’ (5 -19% of neoplastic cells), ‘2’ (20-49% of neoplastic cells), and ‘3’ (>50% of neoplastic cells), respectively. results: msgts most commonly involved the parotid gland (52.7%), while adcc (40%) and mec (38.2%) were the most common tumors. expression of bcl-2 was strongly positive in 56.4% cases of msgts which included adcc (71%), mec (19.4%) and acc (9.7%), respectively. a significant association was found between bcl -2 staining and types of msgts i.e., mec, adcc, acc (p = .001) as well as between bcl-2 staining and grades of msgts (p = .013). conclusions: bcl-2 protein is expressed in malignant salivary gland tumors. its expression maybe helpful in grading small biopsies, predicting behavior, and planning targeted therapy of msgts. key words: bcl-2, immunohistochemistry, malignant salivary gland tumors. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6data analysis; manuscript editing. correspondence: faiz rasul email: bayfaiz871@gmail.com article info: received: april 27, 2020 accepted: march 18, 2021 cite this article. rasul f, wahid sm, imran i, rizvi z, jaffar r, anwar a. immunohistochemical expression of bcl-2 in malignant salivary gland tumors. j islamabad med dental coll. 2021; 10(1): 15-22. doi: 10.35787/jimdc.v10i1.542 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2021 16 i n t r o d u c t i o n salivary glands tumors (sgts) are rare tumors and their distribution varies according to geographic location and race.1,2 these comprise approximately 3-10% of the neoplasms of the head and neck region and 1 % of the neoplasms of the whole body.3 annual global incidence of sgts is between 0.4 to 13.5 cases per 100 000 individuals. among these, malignant salivary gland tumors (msgts) are 0.40 to 0.65 per 100 000 cases.4 msgts are 0.3% of all malignancies.5 early diagnosis of msgts plays an important role in better management of these tumors.6 different diagnostic procedure have been used such as diffusion-weighed magnetic resonance imaging and fluorodeoxyglucose positron emission tomography/ct which show good diagnostic accuracy in identifying local recurrence and distant metastases in msgts.7 fine-needle aspiration cytology (fnac) is also used as a screening or early diagnostic tool in these tumors, however its role is limited.3 core needle biopsy and intraoperative frozen section are also helpful techniques. accurate diagnosis depends upon the histological evaluation of msgts. the histopathological diagnosis of these tumors is usually made through the assessment of histological architecture, cellular features and differentiation, component of tumor stroma, the growth pattern of the tumor borde rs, along with the clinical information.9 msgts are comprised of a heterogeneous population of cells and show different architectural patterns which makes them complex histopathologically10 rendering diagnosis difficult even by expert histopathologists. although hematoxylin-eosin (h&e) staining is still the gold standard for diagnosing the msgts, yet its role is limited in certain cases. immunohistochemistry (ihc) can enhance the accuracy and may be a helpful tool when there is a need to investigate cell type and differentiation status, cell proliferation, and tumor protein expression that cannot be assessed by routine histological examination alone. there is also a need to investigate new biomarkers that can be useful in the diagnosis and grading of malignant salivary gland tumors.11 bcl-2 (the b-cell lymphoma) oncoprotein is a useful marker for investigation in msgts. apoptosis is a genetically predetermined process which is involved in the deletion of cells in normal tissues as well as in malignant tumors. it may be elicited by several molecular pathways. bcl-2 gene family consists of different regulators involved in apoptosis. these proteins are divided according to their function into two groups, namely the antiand pro-apoptotic proteins. the bcl-2, bcl-xl and mcl-1 are considered as anti-apoptotic proteins, while bax, bak, bad and bcl-xs promote apoptosis and are considered as proapoptotic proteins.12 deregulation of these genes controlling apoptosis may contribute to the process of tumor genesis by reducing the rate of cell death and allowing the accumulation of other genetic defects. frequently apoptosis is dysregulated in human cancers, which makes it a suitable target for anticancer therapy. bcl-2 proteins play a key role in preventing programmed cell death by favoring prolonged survival in normal and neoplastic cells. its increased expression has been seen in a number of tumors and is related to resistance to conventional cancer management.13 the present study was planned to determine the expression of bcl-2 proteins in mec, adcc, acc, and plga of salivary gland and to determine association of bcl-2 expression with different grades of these tumors. m a t e r i a l a n d m e t h o d s after the approval of research project from the ethical board of postgraduate medical institute, lahore and university of health sciences lahore, j islamabad med dental coll 2021 17 pakistan, this descriptive study was carried out on diagnosed cases of msgts (n=55) during a two years period (january 2015 to december 2016). samples were collected from the department of surgery lahore general hospital, lahore, oral and maxillofacial department of mayo hospital, lahore and de’montmorency college of dentistry, lahore through non probability purposive sampling, after taking informed consent from the patients. recurrent cases and patients on radiotherapy or chemotherapy were excluded from this study. clinical data such as age, gender and demographic characteristics of each individual along with site and size of msgts were also recorded in a proforma. standard procedure of gross e xamination of specimen size, color and consistency were recorded as per protocol. routine h&e and immunostains were performed. two histopathologists examined msgt for their histological type, grade, lymphovascular invasion and margin of tumor on hematoxylin and eosin (h&e) slides. grading of tumor was done as low grade (lg), intermediate (ig) and high grade (hg) tumors. lg tumors included low grade mec, acc, plga, and tubular pattern of adcc. ig tumors included cribriform pattern of adcc, and intermediate grade of mec while hg tumors included high grade of mec and solid pattern of adcc.5 the expression of bcl-2 was evaluated immunohistochemically. bcl-2 immunoreactivity was divided into four groups as follows:14 score ‘0’ or negative had less than 5% stained neoplastic cells, score ‘1’ or weak positive (wp) had 5-19% stained neoplastic cells, score ‘2’ or moderate positive (mp) had 20-50% neoplastic cells stained while score ‘3’ or strong positive (sp) had more than 50% neoplastic cells stained. observations were made on the basis of intensity of cytoplasmic staining. data were entered and analyzed by using spss version 21. chisquare test was used to determine the association between bcl-2 expression across different types and grades. p-value ≤ .05 was considered as statistically significant. r e s u l t s results showed that msgts were seen more frequently in females, with a male-to-female ratio of 5:6. the mean age of the patients was 50 ± 4.03 years. parotid gland was the most commonly involved gland (52.7%), followed by minor salivary glands (29.1%). the data showed no major difference between right and left sides. adcc (40%) and mec (38.2%) were the most common tumors followed by acc (12.7%) and plga (9.1%), respectively. details of comparison of bcl-2 staining with tumor types and tumor grades are shown in tables ii. a statistically significant association was found between bcl-2 staining and types of carcinomas (p < .001). a statistically significant association was found between bcl-2 expression and grades of tumor (p = .013). most of the low-grade tumors (75%) had weak bcl-2 positivity, intermediate grade had moderate (33.3%), while high grade tumors had mostly strong bcl-2 positivity (table ii; figures 1 & 2). d i s c u s s i o n manjunatha et al., reported 78% bcl-2 expression in msgts with 100% expression in adcc, similar to current study. they concluded that on varying intensity of bcl-2 there is not much difference in adcc with respect to grading and type. where as, in the current study, contrary to results above a significantly high association was found in bcl-2 staining and types of carcinomas as well as grade of cancer .15 kaur and gupta reported weak to strong positive bcl-2 expression in msgts. bcl-2 expression in mec was weakly positive in 4 cases and strong positive in one case. however, in the current study, total cases of mec were 21, out of them 7 expressed weak j islamabad med dental coll 2021 18 positive staining, 8 expressed moderate staining and 6 expressed strong positive staining. plga had weak positive expression of bcl-2 in both the studies.16 alrawi et al. described positive expression of bcl-2 in all cases of msgts, with high-grade adenocystic carcinomas showing highest bcl-2 expression (90%). its expression was lowest in low-grade cystic mec.17 table i: descriptive statistics of malignant salivary gland tumors (n=55) variables subgroups n (%) age 2040 19 (34.5%) 41-60 17 (30.9%) 61-80 19 (34.5) gender male 25 (45.5) female 30 (54.5) occupation industry 10 (18.2) farmer 8 (14.5) labor 14 (25.5) office job 1 (1.8) household 22 (40) hospital mayo hospital 17 (30.9) lahore general hospital 20(36.4) de'montmorency college of dentistry/ pdh 18(32.7) site parotid gland 29 (52.7) submandibular salivary gland 9 (16.4) sublingual salivary gland 1 (1.8) minor salivary gland on palate 10 (18.2) minor salivary gland on tongue 1 (1.8) minor salivary gland on labial mucosa 1(1.8) minor salivary gland on buccal mucosa 4 (7.3) laterality right 28 (50.9) left 27 (49.1) specimen type incisional 10 (18.2) excisional 40 (72.7) resection 5 (9.1) size less than 1cm maximum diameter 2 (3.6) 1cm to 2cm maximum diameter 4 (7.3) 2-5cm 42 (76.4) more than 5 cm in maximum diameter 7(12.7) mass solid 55 type of tumor mucoepidermoid carcinoma 21 (38.2) adenoid cystic carcinoma 22 (40.0) acinic cell carcinoma 7 (12.7) polymorphous low-grade adenocarcinoma 5 (9.1) grade low grade 22 (40.0) intermediate 13 (23.6) high grade 20 (36.4) j islamabad med dental coll 2021 19 invasion no lymphovascular or neural invasion 31 (56.4) neural invasion 22 (40.0) both lymphovascular or neural invasion 2(3.6) bcl-2 expression + weak positive [staining in 5-19% of neoplastic cells] 12 (21.8) ++ moderate positive [staining in 20 -50% of neoplastic cells] 12 (21.8) +++ strong positive [staining in more than 50% of neoplastic cells] 31 (56.4) table ii: comparison of bcl-2 staining with types and grades of msgts type of tumor bcl-2 positivity total weak moderate strong mec 7 (58.3%) 8 (66.7%) 6 (19.3%) 21 (38.2%) acc 0 (0%) 4(33.3%) 3 (9.7%) 7 (12.7%) adcc 0 (0%) 0 (0%) 22 (71%) 22 (40%) plga 5 (41.7%) 0 (0%) 0 (0%) 5 (9.1%) total 12 12 31 55 tumor grade bcl-2 positivity weak moderate strong total low 9 (75%) 6 (50%) 7 (22.6%) 22 (40%) intermediate 1 (8.3%) 4 (33.3%) 8 (25.8%) 13 (23.6%) high 2 (16.7%) 2 (16.7%) 16 (51.6%) 20(36.4%) total 12 12 31 55 however, in the current study, almost all cases of mec (n=21) had bcl-2 expression. in a study conducted by soini et al. expression of bcl-2 was strong positive in adcc as compared to mec and acc. in our study all cases of adcc showed strong positive expression of bcl-2. similarly, we also observed bcl-2 expression in all cases of msgts in contrast to soini et al.18 carlinfante et al. reported a high expression of bcl-2 (almost 90%) in adcc, which is similar to current study.19 we found a statistically significant association between bcl-2 expression and msgts. furthermore, significant association was also found between expression of bcl-2 and grades of msgts. hellquist et al. did not report any statistically significant difference between expression of bcl-2 and tunel in acc. they concluded that expression of bcl-2, mib-1, clinical staging and tunel are helpful prognostic tools for predicting prognosis of acinic cell carcinoma.20 on the other hand, in our study bcl2 was statistically significant with type and grades of msgts. janjua et al. reported positive expression of bcl-2 in 60% of mec and expression of bcl-2 was strong positive in low grades and weak positive for high grades of mec. however, in our study, high grade mec expressed strong positivity in most of the cases. out of 10 high grades mec, 6 were strong positive, 2 were intermediate positive and 2 were weak positive. while a significant association was seen between expression of bcl-2 and grades of mec in both the studies.21 jiang et al. aimed to determine the expression of bcl-2 in adcc (n=35) and reported its expression in 60% of tumors. although the sample size of adcc in the current study was smaller (n=22) but all cases of adcc expressed bcl-2 positivity as strong positive. in the current study a statistically significant association was found between bcl-2 positivity, type, and grades of msgts in contrast to study by jiang et al.22 j islamabad med dental coll 2021 20 figure 1: photomicrographs of bcl-2 immunostaining of malignant salivary glands tumors. a show s high grade mucoepidermoid carcinoma with strong positive expression (x 400). b shows intermediate grade adenoid cystic carcinoma with strong positive expression at low power (x 100) and c shows strong bcl-2 positivity at high power (x 400). d shows bcl-2 immunostaining of low grade acinic cell carcinoma with strong positive expression (x 100) . figure 2: bcl-2 immunostaining of polymorphous lowgrade adenocarcinoma showing weak positive expression (x 200). norberg-spaak et al. determined the biological behavior of adcc in its three subtypes; solid, cribriform, and tubular by using bcl-2 and its expression was statistically insignificant with grades of tumors which is in contrast to the current study.23 yin et al. analyzed bcl-2 expression in 71 cases of mec of minor salivary glands. they reported that low grade mec had higher expression of bcl-2 as compared to intermediate and high grade mec. this study reveals that higher the grade of mec, stronger is the expression of bcl-2 in contrast to yin’s findings.24 atarbashi reported 30% expression of bcl2 in mec which is lower than this study.25 rasul et al. conducted a study on 35 cases of adcc in lahore, pakistan and reported that these tumors https://www.ncbi.nlm.nih.gov/pubmed/?term=atarbashi%20s%5bauthor%5d&cauthor=true&cauthor_uid=24932199 j islamabad med dental coll 2021 21 were more common in females mostly in the fourth to sixth decade.26 in major salivary glands, parotid gland was the most common site while in minor salivary glands the most common site was palate. majority cases reported as excisional biopsies (54.3%) with sizes ranging between 2 cm to 5 cm (68.8%). histopathologically, 19 cases (54%) were categorized as high-grade tumors. all cases showed expression of bcl-2 irrespective of the grade of the tumor. expression of bcl-2 was strongly positive in all cases of adcc.26 epidemiological features of msgts have also been reported locally in pakistan by different authors. a study conducted in jamshoro pakistan reported that mucoepidermoid carcinoma was the most common malignant salivary gland tumor.2 in the current study, adcc was more common than mec of the salivary glands’ tumors. recently a study was conducted in armed forces institute of pathology on 30 cases of mec and it was reported that low grade mec was most common tumor similar to result of this study.28 there was certain limitation of the current study, which might be the cause of differences in results while comparing with other studies. malignant salivary gland tumors are rare, therefore the sample size in the current study was small (n=55) so, it was difficult to evaluate the definitive role of bcl-2. similarly, there was an unequal distribution of the different types and grades of these tumors. the distribution of these tumors was also unequal in the minor and major salivary glands. further studies with larger sample size are recommended to find out the definitive role of bcl-2 in benign and malignant salivary gland tumors. c o n c l u s i o n most of the low-grade tumors express weak positivity of bcl-2 while most of the high-grade tumors express strong positivity in malignant salivary gland tumors. positive expression of bcl-2 in malignant salivary gland tumors can help in predicting the behavior of these tumors regarding their potential for aggressiveness. in addition, molecular targeted therapy against bcl-2 can be planned in future for better management of salivary gland tumors. a c k n o w l e d g m e n t we are thankful to mr. amin and mr. sohail for their technical help in slide preparation for bcl-2 immunostaining. r e f e r e n c e s 1. araya j, martinez r, niklander s, marshall m, esguep a. incidence and prevalence of salivary gland tumour s in valparaiso, chile. med oral patol oral cir bucal. 2015; 20(5): 532-9. doi: 10.4317/medoral.20337 . 2. sando z, fokouo jv, mebada ao, djomou f, ndjolo a, oyono jle. epidemiological and histopathologic al patterns of salivary gland tumors in cameroon. pan afr med j. 2016; 23(1): 1-66. doi: 10.11604/pamj.2016.23.66.5105 . 3. carlson er, schlieve t. salivary gland malignancies . oral and maxillofacial surgery clinics. 20 19; 31(1): 125-44. doi: 10.1016/j.coms.2018.08.007 . 4. faur, ac, sas i, motoc agm, cornianu m, zamfir cl, lazar dc, et al. ki-67 and p53 immunostaini n g assessment of proliferativeactivity in salivary tumors . rom j morphol embryol. 2015; 56(4): 1429–39. pmid: 26743291. 5. stenner m, klussmann jp. current update on established and novel biomarkers in salivary gland carcinoma pathology and the molecular pathway s involved. eur arch otorhinolaryngol. 2009; 266(3): 333–41. doi: 10.1007/s00405-008-0882-7. 6. gupta a, koochakzadeh s, neskey dm, nguyen sa, lentsch ej. salivary carcinosarcoma: an extremely rare and highly aggressive malignancy. the laryngoscope. 2020; 130(5): e335-9. doi: 10.1002/lary.28183. 7. thakkar m, brahmbhatt p, raychaudhuri c. evaluation of salivary gland tumors by ultrasonography and ct scan. iaim. 2017; 4(4): 14-18. 8. oroz a, bokun z, antonijević đ, jevđić j. the determination of specificity, sensitivity and accuracy of core needle biopsy in the diagnosis of parotid and submandibular salivary glands tumors . j islamabad med dental coll 2021 22 vojnosanitetski pregled. 2019; 76(9): 921-8. doi: 10.2298/vsp170320001o. 9. nagao t, sato e, inoue r, oshiro h, takahash rh, nagai t et al. immunohistochemical analysis of salivary gland tumors: application for surgical pathology practice. acta histochem. cytochem. 2012; 45(5): 269–82. doi: 10.1267/ahc.12019. 10. moutasim ka, thomas gj. salivary gland tumours: update on molecular diagnostics. diagnosti c histopathology. 2020; 26(4). doi: 10.1016/j.mpdhp.2020.01.002 . 11. ibrahim tr, ahmed mm, hegazy aa. diagnostic utility of immunohistochemical expressions of imp3 versus dog1 and p63 in salivary gland tumors. turk patoloj i derg. 2020; 36(3). 227-236. doi: 10.5146/tjpath.2020.01496. 12. xie x, nordgård s, clausen f, petter o, boysen m. prognostic significance of bax and bcl-2 expressions in adenoid cystic carcinoma of major and minor salivary glands of nasal and oral epithelium. open otorhinolaryngol. j. 2010; 4(1): 20-26. doi: 10.2174/1874428101004010020 . 13. abdulhussain mm, mohsen as. immunohistochemical evaluation of bcl-2 in mucoepidermoid carcinoma and adenoid cystic carcinoma of salivary glands. journal of international dental and medical research. 2020; 13(1): 180-7. 14. al-rawi nh, ahmed jn, mohammed ho. immunohistochemical expression of p53 and bcl-2 in benign and malignant salivary glands tumors. mdj. 2007; 4 (1): 1-10. 15. manjunatha b, kumar g, raghunath v. immunohistochemical expression of bcl-2 in benign and malignant salivary gland tumors. med. oral patol . oral cir. bucal. 2011; 16(4): 503-7. doi: 10.4317/medoral.16.e503. 16. kaur h, gupta s. an analysis of the expression of bcl2, podoplanin and lymph angiogenesis in benign and malignant salivary gland tumours. j clin exp pathol . 2013; 3(3): 145. doi: 10.4172/2161-0681.1000145. 17. al-rawi nh, omer h, al kawas s. immunohistochemical expression of p53 and bcl-2 in benign and malignant salivary glands tumors. j oral pathol med. 2010; 39(1): 48-55. doi: 10.1111/j.16000714.2009.00816.x. 18. soini y, tormanen u, paakko p. apoptosis is inversely related to bcl-2 but not to bax expression in salivary gland tumors. histopathology. 1998; 32(1): 28-34. doi: 10.1046/j.1365-2559.1998.00334.x. 19. carlinfante g, lazzaretti m, ferrari s, bianchi b, crafa p. p53, bcl-2 and ki-67 expression in adenoid cystic carcinoma of the palate. a clinico-pathologic study of 21 cases with long-term follow-up. pathol res pract. 2005; 200(11-12): 791-9. doi: 10.1016/j.prp.2004.08.008. 20. hellquist hb, sundelin k, di bacco a, tytor m, manzotti m, viale g. tumour growth fraction and apoptosis in salivary gland acinic cell carcinomas . prognostic implications of ki-67 and bcl-2 expression and of in situ end labelling (tunel). j. pathol. 2008; 215(4): 458. doi: 10.1002/(sici)10969896(199703)181:3<323::ai d-path780>3.0.co;2-k. 21. janjua os, qureshi sm, khan ts, alamgir w. bcl-2 protein expression in mucoepidermoid carcinoma of salivary glands: a single institution experience. hematol oncol stem cell ther. 2012 5(2): 96-100. doi: 10.5144/1658-3876.2012.96. 22. jiang lc, huang sy, zhang ds, zhang sh, li wg, zheng ph, chen zw. expression of beclin 1 in primary salivary adenoid cystic carcinoma and its relation to bcl-2 and p53 and prognosis. braz. j med biol res. 2014; 47(3): 1-6. doi: 10.1590/1414-431x20133231. 23. norberg-spaak l, dardick i, ledin t. adenoid cystic carcinoma: use of cell proliferation, bcl-2 expression, histologic grade, and clinical stage as predictors of clinical outcome. head neck. 2000; 22(5): 489–97. doi: 10.1002/1097-0347(200008)22:5<489::aidhed8>3.0.co;2-x. 24. yin hf, okada n, takagi m. apoptosis and apoptotic related factors in mucoepidermoid carcinoma of the oral minor salivary glands. pathol int. 2001; 50(8): 603-9. doi: 10.1046/j.1440-1827.2000.01091.x. 25. atarbashi s, elahi m, khani m, rakhshan v. immunohistochemical analysis of b-cell lymphoma -2 in pleomorphic adenoma and mucoepidermoid carcinoma. dent res j. (isfahan). 2014; 11(2): 257–63. pmid: 24932199. 26. rasul f, rizvi z, wahid sm, haseeb mt, jaffar r, amjad a. immunohistochemical expression of bcl -2 in adenoid cystic carcinoma of salivary gland tumors. med forum. 2018; 29(12): 14-19. 27. baloch ma, ujjan i, munawar m. demography and histopathological presentations of oral and maxillo facial region tumours in jamshoro, pakistan. j muhammad med coll. 2018; 9(2): 81-4. 28. niazi z, khan i, farhan f, ilyas m, ali m, hasan sr. mucoepidermoid carcinoma: a demographic and histopathological profile. j islamabad med dental coll. 2020; 9(4): 298-302. doi: 10.35787/jimdc.v9i4.460. j islamabad med dental coll 2020 275 open access comparison of clipless and clipped laparoscopic cholecystectomy at nishtar hospital multan, pakistan abdul manan1, irfan ahmad1, asher ahmad1, tariq jamil1, muhammad usman2, muhammad afzal sajid2 1associate professor, department of surgery, nishtar medical university, multan, pakistan 2assistant professor, department of surgery, nishtar medical university, multan, pakistan a b s t r a c t background: laparoscopic cholecystectomy has become the procedure of choice in the management of gall stone diseases which is commonly performed using titanium clips. harmonic scalpel is an option for the clipless surgery. the objective of the study was to compare the efficacy of clipless cholecystectomy using harmonic scalpel and clipped conventional laparoscopic cholecystectomy. material and methods: this randomized controlled trial was conducted at nishtar hospital multan, pakistan from october 1st 2019 to march 31st 2020. total 188 patients of gallstone related cholecystitis were enrolled in the study. patients were divided by simple randomization into two equal groups for clipless and the conventional clipped laparoscopic cholecystectomy, respectively. age, gender, duration of cholecystitis, duration of procedure, hospital stay, usefulness in difficult procedures and biliary leakage were recorded for all the patients. data was compared between the two groups by applying student t-test on quantitative variables and chi square test on the qualitative variables. results: mean operation time was more for clipped (28.35±7.92 minutes) as compared to clipless cholecystectomy (21.15±4.47 minutes) (p < .001). mean hospital stay was 2.37±0.60 days in clipped surgery group and 1.71±0.74 days in clipless surgery group (p < .001). biliary leakage was reported in 2 (2.1 %) patients of the clipped group and 1 (1.1%) patient of the unclipped group (p = .561). clipless procedure was found to be more useful in difficult cases (n=8; 8.5%) as compared to the clipped cholecystectomy (p = .004). conclusions: the results in the current study show that clipless surgery is a better option as compared to the clipped conventional laparoscopic cholecystectomy, as it is associated with a shorter operating time and hospital stay along with better usefulness in difficult cases. key words: biliary leakage, cholecystitis, clipped laparoscopic cholecystectomy, clipless laparoscopic cholecystectomy authors’ contribution: 1conception; literature research; manuscript design and drafting; 2-6 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: abdul manan email: drmanan2001@yahoo.com article info: received: may 10, 2020 accepted: december 28, 2020 cite this article. manan a, ahmad i, ahmad a, jamil t, usman m, sajid ma. comparison of clipless and clipped laparoscopic cholecystectomy at nishtar hospital multan, pakistan. j islamabad med dental coll. 2020; 9(4): 275-279. doi: 10.35787/jimdc.v9i4.548 funding source: none conflict of interest: nil i n t r o d u c t i o n diseases related to gall stones have a diverse clinical presentation. such patients present in the surgical department with a wide spectrum of symptoms, ranging from mild biliary colic, requiring conservative management to gall stones pancreatitis, which is a life-threatening condition o r i g i n a l a r t i c l e j islamabad med dental coll 2020 276 and needs urgent surgery.1 in recent days, laparoscopic cholecystectomy has become the procedure of choice in the management of gall stone diseases.1 laparoscopic cholecystectomy is a simple and less invasive surgical procedure as compared to open surgery. usually, titanium clips are used in order to secure cystic duct and cystic artery. there are many drawbacks associated with this technique, as it needs more dissection to apply multiple clips, further it is also a time-consuming procedure. more laparoscopic manipulation can cause bleeding as well as damage to adjacent structures. this incidence has been reported to be 3% following clipped laparoscopic cholecystectomy as compared to 0.5% following open cholecystectomy.2 additionally, more sophisticated procedures including drainage and magnetic resonance retrograde cholangiopancreatography (mrcp) are required for the management of biliary leakage. all these prolong the hospital stay of the patient, thus increasing the financial burden on the patient, his family and the health facility and most of all increase the morbidity and mortality.3 harmonic scalpel is an option for the clipless surgery and has been considered as a better choice for securing the cystic artery and cystic duct in order to prevent the risk of biliary leakage following clipped laparoscopic cholecystectomy.4,5 multiple studies have reported that the incidence of biliary leakage was more in clipped as compared to clipless surgeries, respectively.6,7 similar frequency of biliary leakage was reported in another study which was conducted in rawalpindi, pakistan.8 others have also observed that the clipped procedures resulted in higher incidence of biliary leakage.3,9 the purpose of this study was to compare the efficacy of clipped and clipless cholecystectomy in the management of gallstone-related cholecystitis. local data regarding newer techniques is very limited. therefore, current study was planned to identify techniques used at our local health facilities, which can help the practitioners to implement evidence-based safer surgical techniques. m a t e r i a l a n d m e t h o d s this randomized controlled trial was conducted in the department of general surgery at nishtar hospital multan, pakistan from october 1st 2019 to march 31st 2020. ethical approval was obtained from the institutional ethical review board, nishtar medical university, multan. informed written consent was taken from all the patients. a sample of 188 patients of gallstone-related cholecystitis was calculated using incidence of clipless laparoscopic cholecystectomy (13.8%) and conventional clipped cholecystectomy (30.7%),10 with 80% power of study and 20% risk of type ii error (beta = 0.2).10 a nonprobability consecutive sampling technique was used. patients of both genders were randomly included in the study. patients having complicated diabetes mellitus, ischemic heart disease, deranged clotting profile, gallbladder malignancy and acute cholecystitis for more than 7 days were excluded from the study. patients were fully evaluated by the operating surgeon to meet the eligibility criteria of laparoscopic cholecystectomy before the surgery. patients were divided into two equal groups by simple randomization. one group was designated for clipless laparoscopic cholecystectomy and the other for conventional clipped laparoscopic cholecystectomy. harmonic scalpel using ultrasonic shear (olympus keymed sonosurg version g2 220240 v 3a. 50/60 hz.) was applied for removal of gall bladder in the clipless surgery. conventional clipping instruments were used for removing gall bladder in clipped surgery group. standard procedure and protocols were used by the consultant surgeon for the procedure. drain was kept in place at the end of surgical procedure. patients were kept under observation for 24 hours postoperatively and were monitored for the oozing of fluid or blood in the j islamabad med dental coll 2020 277 drain. patients were discharged from the hospital with the advice to follow up after one week. consultant radiologists performed magnetic resonance cholangiopancreatography (mrcp) in suspected cases of the biliary leakage. age, gender, duration of cholecystitis, operation time, hospital stay, usefulness in difficult cases and biliary leakage were recorded for all the patients. data was entered in spss version 23 and analyzed. quantitative variables such as age, procedure time and hospital stay were presented as mean and standard deviation. qualitative variables such as gender, duration of cholecystitis, usefulness in difficult procedures and incidence of biliary leakage were presented as number and percentage. data was compared between the two groups by applying student t-test on quantitative variables and chi square test on the qualitative variables. incidence of biliary leakage was compared between the two groups by chi square test and p-value less than .05 was considered as statistically significant. r e s u l t s mean age of the patients was 44.59 ± 7.52 years in the clipped group and 45.33 ± 11.45 years in the clipless group (p = .604). gender distribution for both groups is shown in table i. mean operation time was more for clipped (28.35±7.92 minutes) as compared to clipless cholecystectomy (21.15±4.47 minutes) (p < .001). mean hospital stay was 2.37±0.60 days in clipped surgery group and 1.71 ± 0.74 days in clipless surgery group (p < .001). biliary leakage was reported in 2 (2.1 %) patients of the clipped group and 1 (1.1%) patient of the unclipped group (p = .561). clipless procedure was found to be more useful in difficult cases (n=8; 8.5%) as compared to the clipped procedures (p = .004) (table ii). there were 8 (8.5%) difficult cases in the clipless group which were successfully dealt with laparoscopically. there were 10 (10.6%) difficult cases including 2 (2.1%) cases of biliary leakage in the clipped group which were converted into open cholecystectomy considering the safety of the patients. table i: demographic data of the two groups variable clipped (n=94) clipless (n=94) pvalue* mean age (years) 44.59 ± 7.52 45.33 ± 11.45 .604 male n (%) 35 (37.2 %) 37 (39.4%) .764 female n (%) 59 (62.8 %) 57 (60.6%) *p-value < .05 was taken as statistically significant table ii: outcome data regarding operating time, hospital stay and complications outcome clipped clipless pvalue* operation time (minutes) 28.35 ±7.92 21.15 ± 4.47 < .001 hospital stay (days) 2.37 ±0.60 1.71 ± 0.74 < .001 biliary leakage 2 (2.1 %) 1 (1.1 %) .561 usefulness in difficult procedures 0 (0.0 %) 8 (8.5 %) .004 *p-value < .05 was taken as statistically significant d i s c u s s i o n in contrast to open cholecystectomy, laparoscopic cholecystectomy is an economical, simple, and safe choice.11 the major procedures included in the cholecystectomy are removing the gall bladder, and securing the cystic artery and cystic duct. these structures can be secured either by extracorporeal or intracorporeal ligation.12 the common complication of ligation is the biliary leakage, and this demands a safer procedure such as clipless surgery. this type of surgery uses harmonic scalpel and ligasure, which are the latest advancement in the laparoscopic surgery.13,14 j islamabad med dental coll 2020 278 in the current study, biliary leakage was reported in 2 (2.1 %) patients of the clipped group and 1(1.1%) patient of the clipless group. the procedure time and hospital stay were significantly shorter in the clipless surgery patients and it was also found to be more useful in dealing with difficult cases. bessa et al.6 reported in their study that clipless surgery is safe with lesser complications related to biliary leakage, following gall bladder perforation. gall bladder perforation during clipped laparoscopic cholecystectomy was 30% as compared to clipless surgery in which incidence of gb perforation was 10%. however, no cases of postoperative biliary leakage were observed in both the groups. the median operation time was also significantly shorter in the clipless surgery group. another study reported significantly less incidence of gall bladder perforation in the clipless surgery, however the incidence of biliary leakage was not significantly different in the clipped (3.3%) and clipless surgery group (1.7%) (p= .45).9 the operation time was also shorter in the clipless surgery group. the conversion rate of laparoscopic procedure to open procedure was higher in the clipped group but the difference was not significant (p = .65).9 a study conducted in rawalpindi found similar results (3.6% vs. 3.4%) in both the groups (p=.972) but the operation time was shorter in the harmonic scalpel group.8 akhtar et al. observed biliary leakage in 9 patients of the clipless group and 20 patients of the clipped group (p = .020).10 saha et al. conducted a study in bangladesh and reported that the clipless cholecystectomy is an effective and safe method for removing gall bladder as it is associated with less incidence of gall bladder perforation and biliary leakage.15 another study conducted by gelmini et al. showed that mean operative time was significantly shorter in the group operated upon by the harmonic scalpel.16 the biggest hurdle in the way of using harmonic scalpel is the requirement of expertise and expensive instruments, which are difficult to procure in a developing country like pakistan. harmonic scalpels should at least be made available in the tertiary care health facility. this can facilitate clipless surgery reducing the procedure time of cholecystectomy along with postoperative morbidity and thus reducing mortality. this will also reduce the rate of conversion of laparoscopic cholecystectomy to open cholecystectomy. amarin suggested that the use of harmonic scalpel for conducting clipless laparoscopic cholecystectomy is an efficient, safe and practical approach and the role of this technique can easily be expanded including complete hemobiliary stasis.17 another study conducted in lahore observed no statistically significant difference between the groups in terms of postoperative complications, gall bladder perforation and biliary leakage.18 however, they observed that the duration of the surgery was significantly shorter in the clipless group in which surgery was performed using harmonic scalpel.18. c o n c l u s i o n clipless surgery is a better option as compared to the clipped conventional cholecystectomy, as it is associated with a shorter operating time and hospital stay along with better usefulness in difficult cases. however, there was no difference in terms of biliary leakage. clipless surgery can be applied easily in patients as it is associated with decreased morbidity and hence lower mortality. r e f e r e n c e s 1. demehri fr, alam hb. evidence-based management of common gallstone-related emergencies. j intens care med. 2016; 31(1): 3-13. doi: 10.1177/0885066614554192. 2. kassem mi, hassouna em. short‐term outcome of total clipless laparoscopic cholecystectomy for complicated gallbladder stones in cirrhotic patients. anz j surg. 2018; 88(3): e152-56. doi: 10.1111/ans.13855 j islamabad med dental coll 2020 279 3. hassan g, gulzar s, iqbal t, haque mi. clipless laparoscopic cholecystectomy: 3 port access. professional med j. 2020; 27(06): 1124-27. doi: 10.29309/tpmj/2020.27.06.3549 4. weber a, feussner h, winkelmann f, siewert jr, schmid rm, prinz c. long‐term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy. j gastroenterol hepatol. 2009; 24(5) :762-69. doi: 10.1111/j.14401746.2008.05713.x. 5. di lascia a, tartaglia n, fersini a, petruzzelli f, ambrosi a. endoscopy for treating minor postcholecystectomy biliary fistula. ann. ital. chir. 2018; 89(3): 270-77. pmid: 30588923 6. sanawan e, qureshi au, qureshi ss, cheema km, cheema ma. effectiveness of ultrasound shear for clipless laparoscopic cholecystectomy versus conventional unipolar electrocautery in patients with cholelithiasis. j coll physicians surg pak. 2017; 27(10): 611-5. pmid: 29056121 7. wills e, crawford g. clipless versus conventional laparoscopic cholecystectomy. j laparoendosc adv surg tech. 2013; 23(3): 237-9. doi: 10.1089/lap.2012.0387 8. khan js, qureshi u, fatima z, hassan h, khan mm, iqbal m. clipless laparoscopic cholecystectomy by ultrasonic. ann pak inst med sci. 2012; 8(4): 229-31. 9. el nakeeb a, askar w, el lithy r, farid m. clipless laparoscopic cholecystectomy using the harmonic scalpel for cirrhotic patients: a prospective randomized study. surg endoscop. 2010; 24(10): 2536-41. doi: 10.1007/s00464-010-0999-9 10. akhtar hs, farooq z, rathore h, farooq mu, ahmad a. clipped or clipless cholecystectomy; which option to choose to prevent postoperative biliary leakage in patients of cholecystitis. prof med j. 2018; 25(6). 11. singal r, zaman m, mittal a, singal s. the safety and efficacy of clipless versus conventional laparoscopic cholecystectomy–our experience in an indian rural center. maedica. 2018; 13(1): 44-50. pmid: 29868139 12. wang ey. the tips and tricks of the suture in urologic laparoscopy. in the training courses of urological laparoscopy 2012; 113-137. 13. kandil t, el nakeeb a, el hefnawy e. comparative study between clipless laparoscopic cholecystectomy by harmonic scalpel versus conventional method: a prospective randomized study. j gastrointestinal surg. 2010; 14(2): 323-8. doi: 10.1007/s11605-0091039-8 14. mahmoud ms, hamed ae, mekki m. clippless laparoscopic cholecystectomy using ultrasonic dissection. med j cairo uni. 2020; 88: 1157-63. doi: 10.21608/mjcu.2020.110852 15. saha pk, roy rr, rahman m, khan eh, reza sm, rabbani mg, et al. clipless laparoscopic cholecystectomy: an initial experience of 50 cases in bangladesh. j sci foundation. 2015; 13(1): 11-14. doi: 10.3329/jsf.v13i1.27828 16. gelmini r, franzoni c, zona s, andreotti a, saviano m. laparoscopic cholecystectomy with harmonic scalpel. jsls: j soc laparoendoscop surg. 2010;14(1):14. doi: 10.4293/108680810x12674612014301 17. amarin ns. harmonic scalpel and clipless cholecystectomy. world j laparosc surg. 2008; 1(2): 6-8. 18. baloch sh, afzal si, hamid t. use of harmonic shear vs titanium clips in laparoscopic cholecystectomy: experience in nawaz sharif social security teaching hospital lahore. pak j med health sci. 2015; 9(3): 999-1001. journal of islamabad medical & dental college (jimdc); 2012(2):97-98 97 case report aplastic anemia associated with dengue fever bushra anwar*, khalid hassan**, naghmi asif*** and roshan parveen**** *assistant professor of haematology, rawal institute of health sciences, islamabad **professor and head, department of pathology, islamabad medical and dental college, islamabad ***assistant professor of haematology, department of pathology, islamabad medical and dental college, islamabad ****department of pathology, pakistan institute of medical sciences, islamabad (**’***bahria university, islamabad) abstract bone marrow suppression with peripheral blood cytopenias has been reported with various viral infections. dengue fever is frequently associated with cytopenias particularly thrombocytopenia. this may be due to either bone marrow suppression or due to immunological effect. bone marrow aplasia however may rarely be seen in patients with dengue fever and needs to be diagnosed early, as these patients have favourable outcome with immunosuppressive therapy. we present a case of a 24 years old male patient with dengue fever who manifested persistent pancytopenia. on bone marrow biopsy, he was diagnosed to have severe aplastic anemia. he was treated with immunosuppressive therapy and steroid with a favourable response. key words: dengue fever; aplastic anemia introduction aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia and marrow hypoplasia. acquired aplastic anemia can be idiopathic or different infectious agents, drugs toxins and radiations can be identified as a trigger to disease. viral infections are frequently associated with a transient reduction of the number of circulating blood cells as a consequence of bone marrow suppression. bone marrow failure is frequently observed with dengue and other viruses. there are number of viruses like hav, hbv, hcv, parvovirus b19, epsteinbarr virus, cytomegalovirus and dengue virus which cause bone marrow suppression which may sometimes be very severe.1 some generalizations can be drawn from a review of virus-associated bone marrow failure. in vivo, few data analyzing virus and host mechanisms of suppressed bone marrow function are available. in vitro, various pathogenic mechanisms have been idemtified.2 some viruses may interfere with the proliferation and maturation of hematopoietic progenitors by infecting stromal fibroblasts (e.g., cytomegalovirus)3 or bm macrophages (e.g., human immunodeficiency virus).4 moreover, there is evidence suggesting a critical role of the host’s own immune response in causing bm suppression in several virus infections.5 abnormal bone marrow suppression with resultant cytopenias is one of the hallmarks of dengue virus infection. various studies have proved that infection with dengue virus leads to direct infection of bone marrow, which is likely to be a contributing factor for transient cell suppression in the peripheral blood characteristic of acute dengue virus infection.6 rarely there is sever bone marrow aplasia. incidence of aplastic anemia is higher in those areas of world where arbovirus infections are endemic.7 the pathophysiologic mechanisms involved are diverse.8 direct viral targeting of bone marrow has been reasoned to be a main contributing factor. diagnosis is made by features of bone marrow failure along with absolute reticulocytopenia. this report describes a patient of dengue fever who developed aplastic anemia during the course of disease. case report a 24 year old male was admitted with one week history of fever, vomiting, cough, petechiae and bleeding gums. he had no history of drug abuse and contact with possible toxins. his general physical examination showed bilateral cervical lymphadenopathy, liver was enlarged 2 cm and tip of spleen was palpable. his complete blood counts showed pancytopenia with hb 7.0g/dl, white cell count 2.9 x109/ul (lymphocytes 70%, neutrophil 23%, monocytes 5% and eosinophils 2%) and platelet 43 x 103/ul. reticulocyte count was 0.2%. dengue serology was positive for both igm and igg. screening for other viruses were done, and result was negative. all other investigations for any malignancy and workup for b12 and folic acid deficiency were within normal range. red cells and platelets were transfused to him and bone marrow was advised. bone marrow aspiration showed hypocellular bone marrow smears and fragments. erythroid, myeloid and megakaryocytic series cells were markedly decreased with increased lymphocytes and plasma cells. no abnormal cells were seen. findings of trephine biopsy were consistent with that of aspirate and confirmed the diagnosis of aplastic anemia. his treatment was started with intravenous immunoglobulin and methyl prednisolone. antibiotic cover was also given to prevent infectious journal of islamabad medical & dental college (jimdc); 2012(2):97-98 98 complications. the patient responded well to the treatment. he was then given long-term treatment with cyclosporine and showed complete remission. discussion this is one of the few cases of aplastic anemia reported in the medical literature. this patient presented with bleeding manifestations and pancytopenia. dengue and other arboviruses are sometimes associated with bone marrow failure. viruses can infect human hemopoietic cells and alter their proliferative capacity. clinically the early phase of dengue is dominated by viremia associated marrow failure with poorly characterized immune response. dengue can induce aplastic anemia through direct bone marrow invasion. bone marrow may be a major site of virus replication during clinical infection. in addition dengue virus antigen incites an immune response, t lymphocyte activation and γ interferon production,9 similar to abnormalities seen in idiopathic aplastic anemia.10 bone marrow failure syndrome is caused by different viruses and they appear to cause hemato-suppression by a variety of mechanisms. viral replication in the marrow cells leads to pancytopenia. this is a rare but serious complication which must be identified early. common manifestations are neutropenia and thrombocytopenia, whereas bone marrow is markedly hypocellular with abnormal megakaryopoiesis. infection related changes occur in lymphocytes in early phase of disease followed by reticulocytopenia, lymphocytopenia thrombocytopenia,and granulocytopenia. bone marrow biopsy confirms the diagnosis of aplastic anemia. severe marrow hypoplasia has been observed with hepatitis and hiv viruses. reports have been published about cases of aplastic anemia associated with hav, hbv, parvovirus b 19, epstein-barr virus, transfusion transmitted virus and dengue virus.11 the pathophysiology of dengue induced aplastic anemia is not well understood, however it is believed that immune complexes and direct viral injury to marrow cells leads to cellular destruction.12 there have been only few case reports of severe aplastic anemia in dengue fever. polianna et al reported a case of 15year-old girl with anemia, bleeding from the gums, petechiae and fever and pancytopenia. dengue serology was positive and biopsy showed severe aplastic anemia. she was treated with intravenous immunoglobulin and methyl prednisolone and had a favourable outcome.13 thus patients with acquired aplastic anemia treatment can be successfully treated with either immunosuppressive therapy or bone marrow transplant. immunosuppressive therapy is first line treatment, however for those who do not respond bone marrow transplant from hla-matched donor may be offered.14 it has been observed that majority of patients respond to this treatment and some of them undergo complete remission. dengue can induce aplastic anemia through direct bone marrow invasion. this is a rare complication which must be identified early. immunosuppressive therapy can be useful to induce complete remission. references 1. kurtzman g, young n. viruses and bone marrow failure. baillière's clinical haematology 1989; 2(1): 51–67 2. binder d, fehr j, hengartner h and zinkernagel rm. virusinduced transient bone marrow aplasia: major role of interferonα/β during acute infection with the noncytopathic lymphocytic choriomeningitis virus j. exp. med 1997;185(3): 517–530 3. apperley jf, dowding j, buiter hj, matutes e, sissons pj, gordon m, and goldman jm. the effect of cytomegalovirus on hemopoiesis: in vitro evidence for selective infection of marrow stromal cells. exp. hematol. 1989;17:38-45 4. molina jm., scadden dt, sakaguchi m, fuller b, woon a, and groopman je. lack of evidence for infection of or effect on growth of hematopoietic progenitor cells after in vivo or in vitro exposure to human immunodeficiency virus. blood 1990; 76:2476–2482. 5. liang dc, lin kh, lin dt, yang cp, hung kl, and lin ks. 1990. post-hepatitis aplastic anemia in children in taiwan, a hepatitis prevalent area. br. j. haematol. 74:487–491. 6. noisakran s, onlamoon n, hsiao h, clark kb, villinger f, ansari a, perng gc. infection of bone marrow cells by dengue virus in vivo. experimental hematology 2012;40(3): 250-259 7. young ns, issaragrasil 5, ch’en wc, takaku f: aplastic anemia in the orient. br j haematol 1986;62:1 8. nakao s, lai cj,young ns.dengue virus, a flavivirus, propagates in human progenitors and hematopoietic cell lines.blood 1989;74:1235-40. 9. kurane i, innis bl, nisalak a, hoke c, nimmannitya s. meager a, ennis fa: human t cell responses to dengue virus antigens. proliferative responses and interferon gamma production. j clin invest 1989;83:506 10. zoumbos nc, gascon p. djeu i y, trost sr, young ns: circulating activated suppressor t lymphocytes in aplastic anemia.n engi i med 1985;312:257 11. gonzalez-casas r, garcia-buey l, jones ea, gisbert jp, morenootero r. systematic revie: hepatitis-associated aplastic anaemia-a syndrome associated with abnormal immunological function aliment pharmacol ther 2009;30:436-43 12. albuquerque p l.m.m., silva junior geraldo b, diogenes saulo s. , silva herivaldo f.dengue and aplastic anemia-a rare association. travel medicine and infectious disease 2009;7,118-120. 13. polianna l.m, geraldo b , saulo s, herivaldo f. dengue and aplastic anemia – a rare association. travel medicine and infectious disaese 2009;7(2): 118 14. ullah k, satti tm, ahmed p, et al. successful allogeneic stem cells transplantation in severe aplastic anaemia complicated by dengue fever. j coll physicians surg pak. 2007;17(10):635 6. j islamabad med dental coll 2023 68 open access voluntary blood donation and social media usman waheed1, nasim hosseini2 1department of allied health sciences, islamabad medical and dental college, islamabad, pakistan 2department of international affairs, iranian blood transfusion organization, tehran, iran the availability and safety of blood is an essential concern from public health perspective. every single donation is a precious lifesaving gift and repeat donation is the key for building a safe and sustainable blood supply. in many countries, blood services face a challenge of sufficient availability of blood, while ensuring its quality and safety. a key component in assuring the safety and quality of blood transfusion is the collection of blood from voluntary, non-remunerated blood donors (vnrbds). vnrbds are regarded as the primary source of safest blood and blood products. every year on june 14, there is a global celebration known as world blood donor day (wbdd) to acknowledge and appreciate blood donors, who donate blood on voluntary, unpaid basis. wbdd offers a unique chance to increase public awareness of voluntary blood donation and foster its culture. each year, around 118.5 million donations of blood are collected worldwide. developing nations frequently lack voluntary blood donations. for instance, 54 countries receive more than 50% of their blood demands from family members or replacement donors, whereas 79 countries receive more than 90% of their blood demands correspondence: usman waheed email: drusman.waheed1@gmail.com cite this editorial: waheed u, hosseini n. social media and voluntary blood donation . j islamabad med dental coll. 2023;12(2) 68-70 doi: https://doi.org/10.35787/jimdc.v12i2.1010 from voluntary unpaid blood donors.1 in pakistan, (a country of 220 million people), 2.7 million units of blood are collected annually, of which only 18% come from voluntary, unpaid blood donors, despite the fact that 60% of pakistan's population is under the age of 29.2 for these reasons, enhancing voluntary blood donations is essential to ensure a sufficient and sustainable supply of blood especially from first-time blood donors. social media is a prime option to be used for establishing blood donation networks because more and more individuals are spending time there. considering the popularity of social media among young generation, the recruitment and motivation of blood donors through social media becomes more important. social media has the capacity to significantly alter the attitudes, and it has become the mainstay of many public health initiatives.3 a number of studies have shown the potential of social media as a tool for health intervention, attitude change and counselling, health campaigns, medical education, disease outbreak surveillance and health research.4 recent studies take into account how social media gives patients and healthcare professionals a chance to connect with each other, with a positive impact on current medical practices. moreover, several studies have reported that social media charity campaigns have a direct positive effect on pro-social and altruistic behaviours.5,6 blood donation relies on public's willingness to donate e d i t o r i a l j islamabad med dental coll 2023 69 blood voluntarily and without remuneration, so there is a constant need for fresh influx of donors to keep the donor pool steady.7,8 role of social media for collecting blood from voluntary donors, and its use in recruiting and sustaining blood donors has grown. latest studies have shown how social media may play a pivotal role to encourage blood donation attitudes. for example, a south african study revealed a favorable correlation between social media communication and blood donation knowledge, individual perceptions, perceptions of family and peer pressure, and donation intention.9 studies conducted in india10 and saudi arabia11 have reported the social media's potential as a tool to disseminate blood donation appeals. in netherlands, recruitment via internet and social media in particular have emerged as the main strategies for dutch donor attraction and retention.12 according to a german survey, social media represents the main motivator for firsttime donors and most significant reason to donate regularly.13 abassi et al.,10 piloted a study on the use of twitter to appeal for blood donations in india while shah et al.,14 reported the impact of emails, short text messages and social media in the enrollment of blood donors. rodrigues et al.,15 investigated the efficacy of the use of whatsapp in brazil, and siromani recommended the use of whatsapp as a means to motivate and recruit voluntary blood donors.16 however, it remains uncertain what features of social media have better motivational outcome. in pakistan, during the covid-19 pandemic, waheed et al.,17 conducted a study using whatsapp as an effective tool for donor mobilization campaigns. the survey revealed that 56.34% of donors donated blood after receiving the blood bank's whatsapp message, with a response rate of 31.6%. moreover the high proportion of female donors who responded to the call was also encouraging, (as according to national data, only less than 5% of women donate blood). it is pertinent to mention here that to attract the female blood donors, a renowned pakistani filmmaker ms. sharmeen obaid-chinoy (double oscar winner) was appointed as the ‘honorary ambassador for blood safety’ by the government of pakistan, while for the young donors, the national health ministry’s safe blood transfusion programme signed an agreement, with the renowned international football star, cristiano ronaldo, to promote the culture of voluntary blood donations in pakistan. facebook started developing a blood donation feature in 2018 with the goal of raising awareness of blood donation. according to a study from the usa, using facebook blood donation feature, blood donations increased by 4.0% and donations from first-time donors by 18.9%.18 a study from pakistan19 utilizing the same blood donation feature, demonstrated an improvement in the trend of voluntary blood donations, with 3-10 walk-in donors and an average of more than 20 phone calls per month (inquiring about voluntary blood donations) in each regional blood centre. currently, most of the present literature is related to donors, it is however deficient about nondonors. to address this gap national health ministry, pakistan conducted a nationwide kap survey21 in collaboration with a consultant from sanquin consulting services, netherlands. the study, (including 49% non-donors), highlighted the fact that widespread misconceptions and fear for blood donation exists among non-donors. the study concluded that the role of internet and social media seems encouraging for such a public awareness campaigns. however extensive donor surveys are still required to give us important data on, shifts in attitudes towards blood donation and change in thoughts regarding blood donation both from donors and non-donors, using social media. to conclude, in pakistan, where there is a dearth of voluntary blood donors, social media can play a significant role to fill the communication gap between blood centers, donors, and hospitals. j islamabad med dental coll 2023 70 social media apps have an enormous potential to enhance donor recruitment and retention, and its impact must be investigated in future. r e f e r e n c e s 1. world health organization. blood safety and availability; key facts. available at https://www.who.int/news-room/factsheets/detail/blood-safety-and-availability accessed on april 20, 2023 2. zaheer ha, waheed u, tahir s, nasir k. national blood banks data collection report (2019). safe blood transfusion programme, government of pakistan. 3. 3.bail ca. cultural carrying capacity: organ donation advocacy, discursive framing, and social media engagement. soc sci med. 2016;165:280288. https://doi.org/10.1016/j.socscimed.2016.01.049 4. abroms lc. public health in the era of social media. am j public health. 2019;109(s2):s130s131. https://doi: 10.2105/ajph.2018.304947. 5. fazio a, scervini f, reggiani t. social media charity campaigns and pro-social behavior. evidence from the ice bucket challenge. j. econ. psychol. 2023;96: 102624. https://doi.org/10.1016/j.joep.2023.102624 6. zheng x, zhu x, zhou x, xie f, huang l. internet altruistic motivation promotes internet altruistic behavior: a moderated mediation model. curr psychol. 2022:1-9. https://doi: 10.1007/s12144022-03918-x. 7. jóhannsdóttir v, gudmundsson s, möller e, aspelund t, zoëga h. blood donors in iceland: a nationwide population-based study from 2005 to 2013. transfusion. 2016;56(6 pt 2):1654-61. https://doi.org/10.1111/trf.13522. 8. williamson lm, devine dv. challenges in the management of the blood supply. lancet. 2013;381(9880):1866-75. https://doi.org/10.1016/s0140-6736(13)60631-5. 9. duh hi, dabula n. millennials’ socio-psychology and blood donation intention developed from social media communications: a survey of university students. telemat inform 2021;58: 101534. https://doi.org/10.1016/j.tele.2020.101534 10. abbasi ra, maqbool o, mushtaq m, aljohani nr, daud a, alowibdi js, et al. saving lives using social media: analysis of the role of twitter for personal blood donation requests and dissemination. telemat inform 2018;35(4):892912. https://doi.org/10.1016/j.tele.2017.01.010 11. alanzi t, alsaeed b. use of social media in the blood donation process in saudi arabia. j blood med. 2019;10:417-423. https://doi.org/10.2147/jbm.s217950. 12. ramondt s, kerkhof p, merz em. blood donation narratives on social media: a ttopic modeling study. transfus med rev. 2022;36(1):58-65. https://doi.org/10.1016/j.tmrv.2021.10.001. 13. sümnig a, feig m, greinacher a, thiele t. the role of social media for blood donor motivation and recruitment. transfusion. 2018;58(10):22572259. https://doi.org/10.1111/trf.14823. 14. shah a, joshi p, shah k. impact of various information technology tools on first-time donor recruitment and repeat blood donations in blood bank. int j med sci public health. 2016;5(9):17501753. https://doi.org/10.5455/ijmsph. 15. rodrigues lucena tf, queiroz negri l, marcon d, yamaguchi mu. is whatsapp effective at increasing the return rate of blood donors? telemed j e health. 2020;26(3):304-309. https://doi.org/10.1089/tmj.2019.0024. 16. siromani u, thasian t, isaac r, selvaraj kg, daniel d, mammen jj, et al. whatsapp: a new tool for recruitment and retention of voluntary blood donors. int j adv med health res. 2015;2(1):72. https://doi.org/10.4103/2349-4220.159176 17. waheed u, wazeer a, saba n, qasim z. effectiveness of whatsapp for blood donor mobilization campaigns during covid-19 pandemic. isbt science series 2020;15(4):378380. https://doi.org/10.1111/voxs.12572 18. harrell s, simons am, clasen p. promoting blood donation through social media: evidence from brazil, india and the usa. soc sci med. 2022;315:115485. https://doi: 10.1016/j.socscimed.2022.115485. 19. zaheer ha, waheed u, tahir s, nasir k. promotion of voluntary blood donation through facebook blood donation feature in pakistan. vox sang 2019; 114(suppl. 1):23. 20. waheed u, azmat m, zaheer ha: knowledge, attitude and practices towards blood donation in pakistan: a nationwide survey. hematol transfus int j. 2015;1(3):83-86. https://doi.org/10.15406/htij.2015.01.00018 https://doi.org/10.1016/j.joep.2023.102624 https://doi.org/10.1016/j.tele.2020.101534 https://doi.org/10.1016/j.tele.2017.01.010 journal of islamabad medical & dental college (jimdc); 2012(2):65-68 65 original article diagnostic yield of pleural fluid cytology in malignant pleural effusion marrium asim and nasir saleem department of pathology, pakistan institute of medical sciences, islamabad abstract background: pleural effusion is a common presenting feature of patients presenting in the pulmonology opd. examination of pleural fluid obtained by thoracocentesis is a simple way to diagnose pathologies of the pleura and peripheral parts of the lung. objective: to determine the diagnostic yield of pleural fluid cytology in malignant pleural effusions keeping pleural biopsy as the gold standard. materials and method: this retrospective study was carried out at pakistan institute of medical sciences, islamabad, from november 2010 to november 2011. twenty six patients (65% females; 35% males) presenting with pleural effusion in whom pleural fluid cytology with concurrent pleural biopsy was carried out were included in the study. the diagnostic yield of pleural fluid was determined keeping pleural biopsy as the gold standard. results: the age range of the patients was 23-76 years. pleural fluid was positive for malignant cells in 15 out of 26 patients, whereas pleural biopsy yielded definite evidence of malignancy in 21 cases. in 5 cases diagnosis of atypical infiltrate was rendered and immunohistochemistry was suggested for confirmation of malignancy. the diagnostic yield of pleural fluid cytology came out to be 58%. conclusion: pleural fluid cytological examination followed by pleural biopsy remains the initial diagnostic procedure in management of patients with suspected malignant pleural effusion. keyword: pleural fluid cytology, pleural effusion, thoracocentesis, malignant pleural effusion. introduction pleural effusion is a common feature in patients presenting in any pulmonology department. based on laboratory findings, it is of two types i.e. transudative and exudative. transudative type of effusion is caused by congestive heart failure, nephrotic syndrome, cirrhosis and lymphatic obstruction by a tumor. most common causes of exudative pleural effusion in our country are pulmonary tuberculosis followed by malignancy.1,2 malignancy is not only a consideration in the elderly but also in the younger patients. it is exudative in nature, and poses a diagnostic challenge to the treating physicians. malignant pleural effusions are most commonly caused by carcinomas of breast, lung, gastrointestinal tract, ovary and hematological malignancies. in males the most common cause of malignant pleural effusion is lung cancer followed by lymphoma and leukemia. in females the leading cause is carcinoma of breast followed by female genital tract malignancies and primary lung carcinomas.3 the most commonly carried out procedure in the initial investigation of patients with pleural effusion is thoracocentesis which may be followed by blind percutaneous pleural biopsy or thoracoscopic pleural biopsy if the effusion is exudative in nature. thoracoscopy is the procedure of choice in patients with suspected malignant pleural effusion, in whom cytology is negative. in this study we evaluated the diagnostic yield of pleural fluid cytology in malignant pleural effusion in our set up. materials and methods this was a retrospective, observational study carried out at pakistan institute of medical sciences, islamabad. nonprobability, consecutive type of sampling was done in which cases were taken out from the surgical pathology files of patients in whom pleural fluid cytology and pleural biopsy had been carried out between october 2010 and october 2011. patient’s clinical history or radiological findings were not taken into account as they were not available in all cases. inclusion criteria: 1. a pleural biopsy showing definitive evidence of malignancy. 2. patients in whom pleural fluid cytology and subsequently pleural biopsy was carried out exclusion criteria: 1. non diagnostic pleural fluid cytology. 2. non diagnostic pleural biopsy. journal of islamabad medical & dental college (jimdc); 2012(2):65-68 66 pleural fluid preparation the pleural fluid submitted for cytological examination was centrifuged and subsequently two slides were made. the slides were stained with hematoxylin and eosin. on microscopic examination, the findings were stratified in four diagnostic categories; category 1: no malignant cells seen. category 2: atypical cells seen. category 3: atypical cells suspicious of malignancy and category 4: malignant cells seen. cells designated as; ‘atypical’ were the ones having hyperchromatic nuclei, exhibiting variable degree of pleomorphism and variable amount of cytoplasm, but the features fell short of clear cut evidence of malignancy. malignant cells were defined as cells exhibiting marked pleomorphism, having hyperchromatic nuclei and high n/c ratio. pleural biopsy preparation the pleural biopsy specimens received were fixed in 10% formalin, embedded in paraffin wax after completion of processing and subsequently stained with hematoxylin and eosin. on microscopic examination two diagnostic categories were made; category 1: cases in which there was a definitive evidence of malignancy and category 2: cases which showed atypical infiltrate suggestive of malignancy. the cases in category 1 showed variable arrangement of malignant cells which may be in the form of sheets or glandular arrangement with the cells exhibiting marked pleomorphism, having hyperchromatic nuclei and high n/c ratio. cases in category 2 revealed cells exhibiting pleomorphism and having hyperchromatic nuclei and high n/c ratio but either due to scanty nature of biopsy or questionable invasion, with features falling short of clear cut evidence of malignancy. the cytology and the biopsy cases were examined by a senior resident and a consultant histopathologist at two different occasions and allocated a category so as to remove any bias. all data were analyzed using statistical package for social sciences (spss) version 10 for this study. for numerical data mean and standard deviation were determined. qualitative data e.g. gender were expressed in terms of frequency. at the end diagnostic yield was calculated (total number of cases positive in cytology divided by the total number of cytology cases). results the total number of patients was 26. the age range of the patients was 23-76 years, with the mean age being 55.6±12.7 sd years. the median age was 55.5 years. the gender distribution showed a female predominance (figure 1). most of the female patients of malignant pleural effusion were middle aged, whereas male patients with malignant pleural effusion were elderly (figure 2). the distribution of cytological diagnosis in each category is shown in table 1. most of the cases belonged to the category 1 (negative for malignant cells). all cases belonging to category 2, 3 & 4 were assigned as positive for malignancy. in routine practice as well, all cases diagnosed as malignant or atypical are investigated further in the work up for malignant cases. based on these criteria the number of positive cases on cytology was 15 out of 26 (58%). pleural biopsy provided conclusive evidence of malignancy in 21 cases and these cases were placed in category 1 (malignant). in 3 out of 21 cases, diagnosis of mesothelioma was favored and in 8 cases the diagnosis of adenocarcinoma was favored. in the rest of 10 cases a diagnosis of malignant neoplasm was made and immunohistochemistry was suggested for confirmation of diagnosis. 5 cases belonged to category 2 (atypical infiltrate suggestive of malignancy) and comment was made that immunohistochemistry was required for confirmation of diagnosis and exact subtyping of tumor. amongst these 5 cases, two cases were cytologically negative for malignancy. each of the remaining three cases was cytologically categorized as belonging to category 2, 3 and 4. of the cases that were diagnosed as malignant neoplasm on biopsy there were nine cases in which cytology was negative for malignancy, eight cases belonged to category 4, two cases placed in category 3 and one case to category 2. male,  35% femal e, 65% gender  distribution  (n=26) figure‐1 0 2 4 6 8 10 12 14 0‐20 yrs 21‐40 yrs 41‐60 yrs >60 yrs n u m b e r  o f  ca se s age of patients figure 2 distribution of cases in  accordance with age and gender  (n=26) females male journal of islamabad medical & dental college (jimdc); 2012(2):65-68 67 fig.3: malignant neoplasm fig.5: malignant cells – category 3 table 1. distribution of cytology cases category of cytological cases number of cases (%) category 1 11 (42.3) category 2 2 (7.7) category 3 4 (5.4) category 4 9 (34.6) immunohistochemistry was suggested for definitive diagnosis in cases in which a diagnosis of adenocarcinoma or mesothelioma was favored. immunohistochemical markers required for this differentiation were not available at our center during the period of study, therefore these cases were referred to other specialized centers. discussion the annual incidence of malignant pleural effusion in usa is 150,000 cases.4the cytological examination of the pleural fluid is the investigation of choice in patients with suspicion of malignant pleural effusion (mpe) as it is a simple and rapid procedure. not all the pleural effusions developing in a patient of known malignancy are malignant. some are negative on cytology as well as biopsy. these are termed as paramalignant effusion. the reasons for development of a paramalignant effusion include: bronchial obstruction, fig 4:malignant neoplasm suggestive of mesothelioma fig.6: atypical cells category 4 lymphatic duct obstruction, post obstruction pneumonitis, lymph node enlargement and pulmonary emboli. other causes of pleural effusion include underlying cardiac disease, liver disease and renal disease, these are termed as nonmalignant effusions. establishment of the exact cause of mpe is very important as the mean survival of the patient following a diagnosis of malignant pleural effusion is 3-6 months. furthermore, it is an indicator of surgical incurability and precludes the need for further investigations.5 in contrast, paramalignant pleural effusion may be amenable to surgical resection and non malignant pleural effusion may be treated by treating the underlying disease. this study highlights the importance of initial pleural fluid cytological examination in patients suspected of having a malignant pleural effusion. the diagnostic yield in our study was 58%. in a study carried out by ong kc et al on 103 patients, positive results of initial pleural fluid cytological examination was 48.5%.6 various studies have shown different diagnostic yields of pleural fluid cytology ranging from 60-90%.7a study done in pakistan on 150 patients revealed a very low diagnostic yield i.e. 8%.8despite the development of new diagnostic procedures cytological examination of the pleural fluid followed by closed pleural biopsy remain the initial diagnostic procedures, journal of islamabad medical & dental college (jimdc); 2012(2):65-68 68 thoracoscopy being reserved for cases not diagnosed by closed pleural biopsy. 9 several factors have been shown to influence the diagnostic yields in various reports. to begin with the different proportions of malignant, para malignant and non malignant cases affect the yield of fluid cytology in a manner such that if the study has a majority of non malignant cases then the diagnostic yield that will come at end will be small. then, location and type of tumor also has a great influence on whether the cytology will be negative or positive. a tumor located in the central bronchi which are mostly squamous cell carcinoma or small cell carcinoma is less likely to produce a malignant effusion as compared to peripherally situated adenocarcinomas. other factors which influence the diagnostic yield include specimen handling, volume of fluid submitted and extent of pleural involvement. quick sample processing that is within half an hour after reception of the sample along with preparation of cell blocks significantly increases the yield. different studies have highlighted that at least 30 ml of pleural fluid must be submitted and the entire sample must be processed in order maximize the yield. in our study the quantity of fluid submitted was approximately 5 ml. finally it is said that, greater the extent of pleural involvement greater the probability that cytology will be positive. despite all the above mentioned factors responsible for variation in diagnostic yield of pleural fluid cytology it is still the procedure of choice in patient with suspicion of malignant pleural effusion, as it is simple cost effective procedure which can be performed on out-patient basis without any major complication and it has a yield which is comparable to that of pleural biopsy.10,11 the major drawbacks of this study are a small sample size and its retrospective nature. however, there was no bias in this study as the cytology and the biopsy cases were examined by two different pathologists at two different occasions and allocation of cases to each category was not influenced by any information provided by the physician. references 1. khaliq mr. pleural biopsy by abrams punch needle pattern and frequency of histopathological lesions encountered in patients with exudative pleural effusion. ann abbasi shaheed hosp karachi med dent coll 2003;8:6-11 2. anwar r, faros ji. causes of lymphocytic exudative pleural effusion as revealed by percutaneous pleural biopsy: experience from peshawar. pak j med sci 2005;21: 39-43 3. johnston ww. the malignant pleural effusion. a review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients. cancer 1985;56:905-9 4. ozcaker b, martinez ch, morice rc, eapen ga, ost d, sarkiss mg, chiu ht et al. does pleural fluid appearance really matter? the relationship between fluid appearance and cytology, cell counts and chemical laboratory measurements in pleural effusions of patients with cancer. j cardiothorac surj 2010;5:63. 5. thomas sc, davidson lrr, mckean me. an investigation of adequate volume for the diagnosis of malignancy in pleural fluids. cytopathology 2011;22:179-83 6. ong kc, indumathi v, poh wt, ong yy. the diagnostic yield of pleural fluid cytology in malignant pleural effusions. singapore med j 2000;41:19-23 7. sahn sa. malignant pleural effusions. eur respir mon 2002;22:177-88 8. javed a, amjad m, shah n, samad a, ullah z. diagnostic evaluation of exudative pleural effusion the value of pleural biopsy. pak j chest med 2001; 7: 12-20 9. koegelenberg cf, diacon ah. pleural controversy: closed pleural biopsy or thoracoscopy-which first? respirology 2011;16:738-46 10. heidari b, bijani k, eissazadeh m, heidari p. exudative pleural effusion: effectiveness of pleural effusion analysis and pleural biopsy. east mediterr health j. 2007;13:765 73 11. james p, gupta r, christopher dj, balamugesh t. evaluation of the diagnostic yield and safety of closed pleural biopsy in the diagnosis of pleural effusion. indian j tuberc 2010;57:19-24 j islamabad med dental coll 2020 307 op e n ac c e s s two case reports of hereditary sensory autonomic neuropathy type iv khairunnisa mukhtiar1, qurat-ul-ain khalid1, sanam bano rajper1 1 department of pediatrics and child health, aga khan university hospital karachi, pakistan a b s t r a c t hereditary sensory autonomic neuropathy type iv (hsan-iv), previously known as congenital insensitivity to pain and anhidrosis (cipa), is an uncommon condition that presents in infancy with repeated episodes of fever, loss of pain sensations and self-mutilation. we are reporting two patients from two different families. both patients had history of recurrent fever, anhidrosis, and pain insensitivity and self-mutilation behavior. both had delayed motor developmental milestones with cognitive impairment. clinical diagnosis of hsan type iv was made on the basis of history, clinical examination and excluding other possible causes. diagnosis of this rare disease is commonly delayed and patients ultimately develop complications. as there is no definitive treatment, these patients and their families should receive proper education and counselling for rehabilitation. key words: hereditary sensory autonomic neuropathy, insensitivity to pain, self-mutilation correspondence: qurat-ul-ain khalid email: quratulainkhalid78@hotmail.com article info: received: august 31, 2020 accepted: december 10, 2020 cite this case report: mukhtiar k, khalid q, rajper sb. two case reports of hereditary sensory autonomic neuropathy type iv. j islamabad med dental coll. 2020; 9(4): 307-310 doi: 10.35787/jimdc.v9i4.595 funding source: nil conflict of interest: nil i n t r o d u c t i o n hsan-iv is a very rare autosomal recessive disease. it is one of the degenerative disorders affecting the sensory as well as autonomic nerves. it affects the numbers and distribution of small myelinated and non-myelinated nerve fibers, which is manifested by decreased sensitivity in response to pain, touch and pressure in distal extremities.1 hsan is caused by abnormal mutation of the neurotrophic tyrosine kinase receptor (ntrk) type 1 gene. this gene is responsible for nerve growth factor (ngf) effects, and it helps in the development of the nociceptive, sensory and sympathetic neurons during the embryological period.2 symptoms of this disease begins in infancy. common clinical presentations include anhidrosis, insensitivity to noxious stimuli leading to self-mutilating behavior, and intellectual disability.3 patients with hsan-iv are prone to develop multiple injuries, which lead to recurrent skin infections and deformities of bone. because of insensitivity to pain, they produce severe oral mutilations like bite wounds, dental attrition, premature tooth loss, and ulcerations of skin. the most vulnerable areas for self-inflicted injuries are lips and oral mucosa. these oral manifestations are especially characteristic features in hsan-iv. the uncommon nature of this disease leads to a delayed diagnosis and development of further complications. there should be regular and careful examination of all four limbs for injuries.4,5 here we c a s e r e p o r t j islamabad med dental coll 2020 308 are reporting two patients from two different families. both went to multiple physicians and they were treated as pyrexia of unknown origin, given multiple oral and intravenous antibiotics but no definitive diagnosis was made. c a s e r e p o r t s patient 1 a 12-year-old boy came in clinic with complaints of aggressive behavior and recurrent episodes of fever since infancy. there was also history of selfmutilating behavior, which started since infancy. past history revealed repeated episodes of highgrade fever in hot weather that did not respond to antipyretics and antibiotics. parents also give history of absence of crying during any kind of trauma and when parenteral antibiotics were given for fever. he was a product of consanguineous marriage and was healthy at the time of birth. there was a positive family history of similar illness in his elder brother who expired at the age of 10 year. all the other siblings were normal. on examination, he had mild developmental and speech delay. he had poor cognitive functions with an iq below 70. he was withdrawn from school due to aggressive behavior and tendency for self-mutilation. the skin of palm and sole was thick with deformity of his fingernails and toenails (figure 1). neurological examination revealed absence of response to temperature and painful stimuli. deep tendon and plantar reflexes were normal. all cranial nerves were intact. our initial differential diagnoses were lesch-nyhan syndrome and hsan. on investigation, serum uric acid was normal, thus ruling out lesch-nyhan syndrome. nerve conduction study was also normal. patient was diagnosed as a case of hsan-iv on the basis of typical history and clinical examination. parents were counselled regarding the child’s condition and benefits of lifelong supportive treatment. figure 1: patient 2 with self-mutilation injuries involving lips, angle of mouth, buccal mucosa (a) and ear pinna (b). patient 1 with self-mutilation injuries of hands (c) and toes (d). patient 2 this 6-year-old boy was brought to the clinic by his parents with issue of delayed developmental milestones. he was the third child of the family and born from a consanguineous marriage. the child suffered from repeated fever episodes, frequently worsening in summers. parents noticed that their child had absence of sweating even in the summer season, and he had poor responsiveness to painful stimulation. he demonstrated self-mutilating behaviors causing injury to himself, including biting his tongue, lips and the lining of the inside of the mouth (buccal mucosa), finger tips and toes. in addition, pain insensitivity led to multiple injuries. behavioral problems included irritability, hyperactivity, emotional lability, and episodes of anger. the first child of the family died at 8 years of life with similar issues and developed complicated pneumonia resulting in a fatal outcome. on physical examination, he had poor eye contact, selfmutilation injuries in the perioral area with damage to both upper and lower lips, angles of mouth and ear pinna (figure 1). the deep tendon reflexes were j islamabad med dental coll 2020 309 normal and he had reduced sensitivity to pain and temperature. on investigations his uric acid was normal. nerve conduction studies were not significant. diagnosis of hsan type iv was made by considering the typical clinical symptoms, age of onset, and normal electrodiagnostic test. d i s c u s s i o n here we report two case of hsan-iv belonging to two different families. the patients identified here have a classical presentation of this disease. until now, more than 20 genes have been identified which are associated with hsan-iv phenotype, characterized by sensory and autonomic dysfunctions.6 pain insensitivity, self-mutilation injuries and absence of sweat and tears are the hallmarks of this disorder. other features in common with hsan-iv are microcephaly, mental retardation, motor and speech delay and abnormal autonomic functions.7 both patients had poor cognitive functions and positive family history of similar illness in siblings. there are only few cases of hsan-iv reported in the literature. patients with hsan-iv can live a normal life. as there is no curative treatment for hsan-iv, parents should be educated to take precautions in daily life to ensure the safety of the child. they should regularly check for bruises and selfmutilation injuries. patients should visit their physician regularly for complete examination to rule out possibility of any issues due to pain insensitivity, which can be detrimental in future.8 self-mutilating behavior is accentuated by reduced pain sensitivity, rather, it may cause a pleasant sense instead of sense of pain.9 the major cause for death in patients with hsan-iv are the issues that can be treated with early intervention and management. heat stroke can be fatal in these patients because they cannot feel the heat and it can be easily underdiagnosed.10 one of our patients had auto-amputation of fingers due to self-mutilation injuries. the main purpose of reporting these cases is to increase awareness among physicians about this syndrome so that an accurate diagnosis can be made without unnecessary investigations. this will also avoid unnecessary surgical intervention as only supportive treatment is required. unfortunately, genetic analysis was not carried out in both our patients due to unavailability of this technique. we started conservative treatment along with family education and counselling to improve the quality of life of these patients. c o n c l u s i o n pain and temperature insensitivity, self-mutilation injuries, aggressive behavior, poor cognitive functions and positive family history were the hallmark features of our patients. diagnosis of hsan-iv is based on history, clinical examination, laboratory investigations, electrodiagnostic test and genetic testing, if available. as there is no known cure for this illness, conservative treatment along with family education and counselling is required to improve the quality of life of these patients. r e f e r e n c e s 1. ashwin dp, chandan gd, jasleen hk, rajkumar gc, rudresh kb, prashanth r. hereditary sensory and autosomal peripheral neuropathy-type iv: case series and review of literature. oral maxillofac surg. 2015; 19(2): 117-23. doi: 10.1007/s10006-015-04865 2. urfalioglu a, arslan m, duman y, gisi g, oksuz g, yildiz h, et al. anesthesia procedure for congenital insensitivity to pain in a child with anhidrosis syndrome: a rare case. j nippon med sch. 2017; 84(5): 237-40. doi: 10.1272/jnms.84.237 3. altassan r, saud ha, masoodi ta, dosssari ha, khalifa o, al-zaidan h, et al. exome sequencing identifies novel ntrk1 mutations in patients with hsan-iv phenotype. am j med genet a. 2017; 173(4): 1009-16. doi: 10.1002/ajmg.a.38120 4. gaur n, meel r, anjum s, singh p. hereditary sensory and autonomic neuropathy in a male child: 'the other side of not feeling pain'. bmj case rep. 2018; 2018. doi: 10.1136/bcr-2018-226873 j islamabad med dental coll 2020 310 5. paduano s, iodice g, farella m, silva r, michelotti a. orthodontic treatment and management of limited mouth opening and oral lesions in a patient with congenital insensitivity to pain: case report. j oral rehabil. 2009; 36(1): 71-8. doi: 10.1111/j.13652842.2008.01887.x 6. yuan jh, hashiguchi a, yoshimura a, sakai n, takahashi mp, ueda t, et al. wnk1/hsn2 founder mutation in patients with hereditary sensory and autonomic neuropathy: a japanese cohort study. clin genet. 2017; 92(6): 659-63. doi: 10.1111/cge.13037 7. schulman h, tsodikow v, einhorn m, levy y, shorer z, hertzanu y. congenital insensitivity to pain with anhidrosis (cipa): the spectrum of radiological findings. pediatr radiol. 2001; 31(10): 701-5. doi: 10.1007/s002470100506 8. daneshjou k, jafarieh h, raaeskarami sr. congenital insensitivity to pain and anhidrosis (cipa) syndrome; a report of 4 cases. iran j pediatr. 2012; 22(3): 4126. pmid: 23400697 9. baghdadi t, sadeghifar a, mortazavi smj, espandar r. indifference to pain syndrome in a twelve-year-old boy (case report). tehran univ med j. 2007; 4. pmid: 27247588 10. lafreniere rg, macdonald ml, dube mp, macfarlane j, o'driscoll m, brais b, et al. identification of a novel gene (hsn2) causing hereditary sensory and autonomic neuropathy type ii through the study of canadian genetic isolates. am j hum genet. 2004; 74(5): 1064-73. j islamabad med dental coll 2019 29 open access use of pregabalin as a pre-medication for post-operative pain in patients undergoing laparoscopic cholecystectomy tabish hussain 1, asifa anwar mir 2, jawad zahir 3, pervaiz minhas 4 1 head, department of anesthesia, icu and pain medicine, fauji foundation hospital, kallar kahar 2 registrar, department of anesthesia, icu and pain medicine, fauji foundation hospital, kallar kahar 3 head, department of anesthesia, intensive care and pain medicine, rawalpindi medical college. 4 anesthetist, department of anesthesia, intensive care and pain medicine, rawalpindi medical college a b s t r a c t background: postoperative pain creates complications by increasing circulating level of catecholamines and systemic vascular resistance, thus putting the patients on increased risks of having stroke and myocardial infarction. in addition, it increases hospital stay, causing burden over economic as well as healthcare infrastructure. the aim of this study was to determine the frequency of pain in the postoperative period while using pregabalin as pre-medication among patients undergoing laparoscopic cholecystectomy. material and methods: the randomized control trail was conducted at department of anesthesiology, holy family hospital, rawalpindi from 1st sept 2015 to 28th feb 2016 over a period of 6 months. a total of 200 patients undergoing laparoscopic cholecystectomy were randomly divided in group a and b by consecutive non-probability lottery method. group a received 100 mg oral pregabalin 1 hour before surgery and group b were not given pregabalin and were taken as controls. post-operative pain was measured by visual analog scale (vas) in terms of pain scores at 4 hours postoperatively after the arrival of patient in the postanesthesia care unit (pacu). spss version 17.0 was used to analyze the data. results: a total of 200 patients were included in the study. there were 100 patients in each group. based on the visual analog pain scores, 9 patients were pain free in group a compared with none in group b. similarly, there were 55 patients in group a, who reported a pain score of 1 whereas no patient in group b had a vas score of 1. there were 29 patients in group a and only 3 patients in group b with vas score of 2 (90.6% vs. 9.4%). for vas score of 3, there were 6 patients in group a and 34 patients from group b (15% vs. 85%). for a vas score of 4, there were 1 patient in group a and 61 patients in group b (1.6% vs. 98.4%). two patients in group b experienced a vas score of 5. all this data was significant with chi square p value of 0.0001. conclusion: oral pregabalin administered prior to laparoscopic cholecystectomy was effective in reducing postoperative pain in the patients. further studies are needed for post-operative evaluation of side effects, different dosing schedules at different time intervals for both rest and dynamic pain. key words: laparoscopic cholecystectomy; pregabalin; pre-medication; post-operative pain. authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3,4 interpretation, discussion, data analysis, active participation in data collection. correspondence: tabish hussain email: drtabish@hotmail.com article info: received: november 11, 2018 accepted: february 10, 2019 cite this article. hussain t, mir aa, zahir j, minhas p. use of pregabalin as a pre-medication for post-operative pain in patients undergoing laparoscopic cholecystectomy. j islamabad med dental coll.2019; 8(1):29-33 funding source: nil conflict of interest: nil i n t r o d u c t i o n pain is one of the commonest post-operative complaints all around the world after major surgical procedures.1 the post-operative pain control has a direct relationship with postoperative morbidity, reflecting its importance regarding time and adequate management.2 postoperative pain is involved in creating complications o r i g i n a l a r t i c l e j islamabad med dental coll 2019 30 by increasing circulating level of catecholamines and systemic vascular resistance, thus putting the patients at increased risks of having stroke and myocardial infarction.3 in addition, it increases hospital stay, which in turn cause burden over economic as well as healthcare infrastructure. the control of pain has been given less priority as reflected by number of health care programs conducted for pain education and its funding resources.4 early post-operative pain can decrease early ambulation, slows bowel function and be a major problem in early discharge of patients.5 inadequate post-operative pain control may also lead to the development of chronic pain after surgery. thus, attenuation of early post-operative pain remains an important concern for medical personal especially the anaesthtetist.5 pain after laparoscopic surgeries, especially laparoscopic cholecystectomy is a common complaint.6 various analgesics have already been tried for the control of postoperative pain among these patients ranging from simple non-steroidal anti-inflammatory drugs (nsaids) to strong opioids, but none of them is specific and the adequate control of such pain is only possible with multimodal approach. some recent studies have shown that use of pregabalin as premedication can effectively control the postoperative pain and consumption of rescue analgesic medications after surgical procedure, and among patients undergoing general anesthesia for laparoscopic cholecystectomy.7,8 a variety of post-operative anesthetic strategies ranging from simple analgesic agents administered orally to block nerve for pain management have been sought.9 a simpler strategy of preemptive analgesic agent may be more acceptable for both anesthetist and patients as a reliable pain relief technique.10 preemptive analgesia is defined as an anti-nociceptive treatment that prevents establishment of altered central processing of afferent input from injuries.11 this can effectively prevent earlier onset of the pain than that of the preventive administration of the drugs after surgical procedures, but it was controversial whether preemptive or preventive analgesia should be used to describe the difference between the two analgesic techniques.12,13,14 gabapentene and its derivate pregabalin had successfully been used in control of neuropathic pain in the past. pregabalin is a gabaergic drug that acts on the gaba receptors at the level of spinal cord and brain to inhibit the pain signals.15 they bind to the pre-synaptic voltage gated calcium channels, thus causing reduction of calcium influx leading to reduction in release of various excitatory neurotransmitters. it has rapid extensive absorption after oral intake, 90% bioavailability with maximal plasma levels achieved after about 1 hour. the efficacy of pregabalin has only been observed for limited procedures as in control of postoperative pain after laparoscopic hysterectomy orthopedic spinal fusion surgery and the dental procedures.16,17 the role of pregabalin for post-operative cholecystectomy has not yet been studied in detail especially in pakistan, where cholelithiasis is an emerging issue because of change in life style and dietary habits. the purpose of this study was to evaluate the effectiveness of pre-operative analgesia using pregabalin by measuring the frequency of postoperative pain following laparoscopic cholecystectomy. m a t e r i a l a n d m e t h o d s this randomized control trial was conducted at department of anesthesiology, holy family hospital, rawalpindi from 1st september 2015 to 28th february 2016 over a period of 6 months. approval from institutional ethics committee was taken at the start of this study. after written informed consent, 200 patients of ages 20-40 years, categorized as american society of anesthesiologists i (asa-i) (normal healthy patients) and asa-ii (mild systemic disease with no functional limitation) undergoing laparoscopic cholecystectomy were enrolled in the study. exclusion criteria included patients with concomitant co-morbid conditions like diabetes mellitus, hypertension, malignancy, pulmonary, hepatic or renal diseases, patients with bmi >35, patients already taking pregabalin, gabapenetene, opioid analgesic, long term nsaids/cox-2 inhibitors or other pain killers, or those patients in whom use of pregabalin, celecoxib or nsaids (due allergic/hypersensitivity reactions), or general anesthesia is contraindicated. all patients were assessed a day before surgery (at least 8 hours before surgery as preoperative anesthesia fitness procedure). after overnight fasting, patients were randomly divided into group a and b by consecutive non j islamabad med dental coll 2019 31 probability lottery method. group a received 100 mg oral pregabalin 1 hour before surgery and group b were not given pregabalin and were regarded as controls. laproscopic cholecystectomy was performed according to the standard protocol. at the end of surgery, patients were extubated and shifted to the post-anesthesia care unit (pacu) for 24 hours monitoring, where the control of post-operative pain was strictly monitored. the pain score was measured at 4 hours postoperatively by the trainee researcher. the post-operative pain was assessed by using visual analog scale (vas) graded no pain (0cm/0mm) to worst unbearable pain (10cm/100mm) (figure1). patients complaining of moderate to severe pain (pain score 5 or above) in either group at 4 hours or even before postoperatively were given rescue analgesic (ketorolac 30 mg slow intravenous injection), and the pain score was measured at that point. it was considered end point for that patient regardless of the fact that 4 hours have been passed and whatever the point score was present at that time. spss version 17 was used to analyze the data. continuous variables like age, weight, height, bmi, duration of surgery and pain score at 4 hours were entered as mean + sd. categorical variables like gender, pain score and pain category were analyzed as number and percentage. to compare the means, independent ttest was applied. chi-square and fischer exact test were used to determine the association between categorical variables. p value < 0.05 was considered as statistically significant. figure 1: visual analog scale for rating of pain intensity r e s u l t s a total of 200 patients were included in the study. there were 100 patients in each group. the baseline parameters of all study participants are given in table i. overall 198 (99%) patients complained of mild pain at 4hrs post operatively whereas only 02 (1%) patients had moderate pain. there were no patients with severe postoperative pain at 4hours. the baseline comparison of the two groups is given in table ii. base line characteristics were same between two groups. the mean pain score was significantly high in group b at 4hrs post operatively. in group b, large number of patients had vas score of 3 and 4 as compared to group a in which majority of patients had vas score of 0, 1 and 2. regarding vas pain category, in group b there was no patient with absence of post-operative pain while in group a, no patients presented with moderate or severe pain. frequency of mild pain was approximately equal in both groups (table iii). table i: baseline parameters of all study participants (n=200) parameter mean ± sd age (years) 33.12 ± 4.095 weight (kg) 57.82 ± 10.865 height (m) 152.85 ± 10.293 bmi (kg/m2) 24.67 ± 2.58 duration of surgery (hours) 48.44 ± 5.47 pain score at 4 hours 2.48 ± 1.32 no. of patients (percentage) gender male 38 (19) female 162 (81) pain score 0 09 (4.5) 1 55 (27.5) 2 32 (16.0) 3 40 (20.0) 4 62 (31.0) 5 02 (1.0) pain category no 09 (4.5) mild 189 (94.5) moderate 02 (1.0) table ii: baseline comparison of the two groups (n=200) gender n (%) group a group b p value males 23 (60.5) 15 (39.5) 0.15 females 77 (47.5) 85 (42.5) mean ± sd mean ± sd 0.52 age (years) 32.93 ± 4.38 33.30 ± 3.80 weight (kg) 56.93 ± 11.53 58.72 ± 10.14 0.25 height (m) 1.53 ± 0.11 1.52 ± 0.09 0.80 bmi (kg/m2) 24.32 ± 3.25 25.03 ± 1.62 0.52 duration of surgery (min) 48.53 ± 6.59 48.35 ± 4.09 0.82 pain score at 4hrs 1.35 ± 0.77 3.62 ± 0.58 0.0001 j islamabad med dental coll 2019 32 table iii: comparison of different visual analog scores (n=200) visual analog scale pain category group a n (%) group b n (%) 0 9 (100) 0 1 55 (100) 0 2 29 (90.6) 03 (9.4) 3 06 (15) 34 (85) 4 01 (1.6) 61 (98.4) 5 0 02 (100) chi square: p= 0.0001 visual analog scale pain category group a n (%) group b n (%) no pain 9 (100%) 0 mild 91 (48.1%) 98 (51.9%) moderate 0 02 (100%) severe 0 0 chi square p value 0.004 d i s c u s s i o n pain is thought to be inadequately treated in one-half of all surgical procedures. early postoperative pain is the most common complaint after elective laparoscopic cholecystectomy.18 our study participants experienced post-operative pain at 4hrs after laparoscopic cholecystectomy in more than 90% cases. the corresponding pain categories were mild in 9 (4.5%) and moderate in 189 (94.5%) patients. no patients reported severe post-operative pain. pain is the main reason for overnight hospital stay up to 40% patients after day care surgery. postoperative pain is the main reason for delayed recovery after laparoscopic cholecystectomy and major factor for development of “post-laparoscopic cholecystectomy syndrome”.19 in recent years, pregabalin has been introduced as an adjunct in the multimodal management of postoperative analgesia.20 according to a meta-analysis, the analgesic effect of pregabalin is best experienced in early postoperative period.21 numerous studies have evaluated the efficacy and adverse effects of pregabalin in reducing acute postoperative pain.21, 22. in our study, pregablin was found to be an effective drug for post-operative analgesia with 9 (9%) patients experiencing no pain and 91 (91%) had mild pain in the pregabalin group. our findings are congruent with agarwal and co-workers who also proved that single pre-operative dose of pregabalin can effectively control the post-operative pain among patients undergoing laparoscopic cholecystectomy. 8 evidence also shows that other surgical procedures where pregabalin was administered preoperatively had a clear reduction in post-operative pain. in a recently published article, it was seen that pregabalin use at least one hour prior to septoplasty reduced post-operative pain significantly, although the required dosage and associated adverse effects need further scientific probing.23 according to a set of recent guidelines published by the american pain society and based on an extensive review of literature, it was suggested that optimal postoperative pain management begins in the preoperative period. this observation is made on the basis of an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved, with follow-up assessments and adjustments as needed. 24 c o n c l u s i o n oral pregabalin administered preoperatively, was effective in reducing postoperative pain in patients undergoing laparoscopic cholecystectomy. it can also be concluded that the journey towards good pain control after surgery starts before the actual procedure is initiated. further studies are needed for post-operative evaluation of side effects, different dosing schedules at different time intervals for both rest and dynamic pain. r e f e r e n c e s 1. vadivelu n, mitra s, narayan d. recent advances in postoperative pain management. yale j biol med. 2010; 83(1): 11–25. 2. liu ss, wu cl. effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. anesth analg. 2007; 104(3):689-702. 3. brennan f, carr db, cousins m. pain management: a fundamental human right. anesth analg. 2007; 105(1): 205-21. 4. lynch me, schopflocher d, taenzer p, sinclair c. research funding for pain in canada. pain res manag. 2009; 14(2): 113-5. j islamabad med dental coll 2019 33 5. bellows c f, berger d h. infiltration of suture site with local anesthesia for management of pain following laparoscopic ventral hernia repairs: a prospective randomized trial. jsls. 2006; 10(3):345-50. 6. baidya dk, agarwal a, khanna p, arora mk. pregabalin in acute and chronic pain. j anaesthesiol clin pharmacol. 2011; 27(3):307-14. 7. peng pw, li c, farcas e, haley a, wong w, bender j, chung f. use of low-dose pregabalin in patients undergoing laparoscopic cholecystectomy. br j anaesth. 2010; 105(2):155-61. 8. agarwal a, gautam s, gupta d, agarwal s, singh pk, singh u. evaluation of a single preoperative dose of pregabalin for attenuation of postoperative pain after laparoscopic cholecystectomy. br j anaesth. 2008; 101(5):700-4. 9. ghafouri a, movafegh a, hakimian m, mehrkhani f, meysamie a. effect of incisional site infiltration of bupivacaine on post-operative pain and meperidine consumption after midline laparotomy. iran j med sci. 2009; 34(1): 65-7. 10. cantore f, boni l, di giuseppe m, rovera f, dionigi g et al. pre-incision local infiltration with levobupivacaine reduces pain and analgesic consumption after laparoscopic cholecystectomy: a new device for day-case procedure. int j surg. 2008; 6(1): s89-92. 11. kissin i. preemptive analgesia. anesthesiology: the journal of the american society of anesthesiologists. 2000; 93(4):1138-43. 12. dionne r. preemptive vs preventive analgesia: which approach improves clinical outcomes? compendium of continuing education in dentistry (jamesburg, nj: 1995). 2000; 21(1):48-51. 13. katz j, mccartney cj: current status of preemptive analgesia. curr opin anaesthesiol, 2002, 15, 435– 441. 14. pogatzki-zahn em, zahn pk. from preemptive to preventive analgesia. current opinion in anesthesiology. 2006; 19(5):551-5. 15. zhang j, ho ky, wang y. efficacy of pregabalin in acute postoperative pain: a meta-analysis. br j anaesth. 2011; 106(4):454-62. 16. jokela r, ahonen j, tallgren m, haanpää m, korttila k. a randomized controlled trial of perioperative administration of pregabalin for pain after laparoscopic hysterectomy. pain. 2008; 134(1-2):10612. 17. hill cm, balkenohl m, thomas dw et al. pregabalin in patients with postoperative dental pain. eur j pain. 2001; 5(2):119-24. 18. tufano r, puntillo f, draisci g, pasetto a, pietropaoli p, pinto g, et al. observational study of the management of mild-to-moderate post-operative pain(itospop). minerva anestesiol. 2012; 78(1):1525. 19. pergolizzi jv jr, raffa rb, tallarida r, taylor r, labhsetwar sa. continuous multimechanistic postoperative analgesia: a rationale for transitioning from intravenous acetaminophen and opioids to oral formulations. pain pract. 2012; 12(2):159-73. 20. şen m, özol d, bozer m. influence of preemptive analgesia on pulmonary function and complications for laparoscopic cholecystectomy. dig dis sci. 2009; 54(12):2742-7. 21. zhang j, ho ky, wang y. efficacy of pregabalin in acute postoperative pain: a meta-analysis. br j anaesth. 2011; 106:454-62. 22. page rl 2nd, cantu m, lindenfeld j, hergott lj, lowes bd. possible heart failure exacerbation associated with pregabalin: case discussion and literature review. j cardiovasc med (hagerstown). 2008; 9(9):922-5 23. chen n, soneru c, kacker a. does a single dose of pregabalin help with postoperative pain after septoplasty? the laryngoscope. 2018; 128(5):10234. 24. chou r, gordon db, de leon-casasola oa, rosenberg, j.m., bickler s, brennan, t et al. management of postoperative pain: a clinical practice guideline from the american pain society, the american society of regional anesthesia and pain medicine, and the american society of anesthesiologists' committee on regional anesthesia, executive committee, and administrative council. j pain. 2016; 17(2):131-57. http://www.ncbi.nlm.nih.gov/pubmed?term=%22peng%20pw%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22peng%20pw%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22chung%20f%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22chung%20f%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20pk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20pk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20pk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20pk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20u%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22singh%20u%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22cantore%20f%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22cantore%20f%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'int%20j%20surg.'); javascript:al_get(this,%20'jour',%20'int%20j%20surg.'); http://www.ncbi.nlm.nih.gov/pubmed/17507163 http://www.ncbi.nlm.nih.gov/pubmed/17507163 http://www.ncbi.nlm.nih.gov/pubmed/17507163 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 http://www.ncbi.nlm.nih.gov/pubmed/11465977 j islamabad med dental coll 2021 145 open access vaccination status and clinical spectrum of children with pyogenic meningitis in a tertiary care hospital of hazara division, pakistan bibi aalia1, syed sajid hussain shah2 1assistant professor, department of pediatrics, lady reading hospital peshawar, khyber pakhtunkhwa, pakistan 2assistant professor, department of pediatrics nephrology, institute of kidney diseases, khyber pakhtunkhwa, pakistan a b s t r a c t background: pyogenic meningitis is one of the serious causes of mortality and morbidity in children. it is more prevalent in third world countries with poor vaccination coverage. this study was done to determine the vaccination status and clinical spectrum of pyogenic meningitis in children presenting to a tertiary care hospital. methods: this cross-sectional study was carried out from august, 2017 till january, 2020 over 2.5 years. records of children who got admitted in pediatric b ward, of either gender between ages of 1 month to 14 years diagnosed as case of pyogenic meningitis were included. records of vaccination status along with signs of meningeal irritation, complications and outcome during hospital stay were documented. data was analyzed by spss 20 and chi square test applied. p value < 0.05 was taken as significant. results: there were 117 patients, 78 males and 39 females. age ranged from 1 month to 14 years with mean age of 5.51± 4.19 years. patients who were vaccinated up to date were 49.6% and 37.6% were not vaccinated at all. main presenting feature was fever and seizures especially under one year of age. there was significant association between seizures and age group with p value of 0.001. signs of meningeal irritation (neck stiffness, brudzinski sign, kerning sign) and paradoxical irritability were present in 85 (72.6%) patients mostly above 1 year of age. there was significant association between signs of meningeal irritation and age group (5 years and above) with p value of <0.001. 110 (94%) got discharged and one (0.9%) patient was referred while 6 (5.1%) patients expired. there was significant association between stay duration and vaccination status. (p = 0.018) conclusion: fever was the most common presentation and vaccinated children with pyogenic meningitis had shorter stay in hospital. keywords: irritability, meningitis, paradoxical, seizures, vaccination authors’ contribution: 1-2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: syed sajid hussain shah email: syed_sajid20@yahool.com article info: received: may 13, 2020 accepted: august 30, 2021 cite this article. aalia b, shah ssh. vaccination status and clinical spectrum of children with pyogenic meningitis in a tertiary care hospital of hazara division, pakistan. j islamabad med dental coll. 2021; 10(3): 145-151. doi: 10.35787/jimdc.v10i3.553 funding source: nil conflict of interest: ni i n t r o d u c t i o n pyogenic or bacterial meningitis is inflammation of meninges of spinal cord and brain. it is still one of the major causes of mortality and morbidity in children all over the world.1 worldwide there are almost 135000 deaths due to bacterial meningitis every year.2 streptococcus pneumonia is one of the leading pathogens in children causing the meningitis along with neisseria meningitides. haemophilus influenzae type b is also one of the major pathogens in infants and early childhood.3 streptococcus o r i g i n a l a r t i c l e j islamabad med dental coll 2021 146 pneumonia and haemophilus influenzae type b (hib) are responsible for the most of the bacterial meningitis sequelae in children.4,5 after introduction of pneumococcal conjugate vaccines including pcv-10 and pcv-13, reduction in rates of pneumococcal infections was expected globally.6 in pakistan, extended program on immunization (epi) was started in 1978 and it included vaccination against haemophilus influenza. in 2012 vaccine against streptococcus pneumonia was also included in epi schedule.7,8 though due to coverage of vaccination, there is decrease in incidence of pyogenic meningitis yet it is prevalent in the country. one of surveillance studies done in southern pakistan showed that majority of pyogenic meningitis in children is caused by streptococcus pneumonia and hib.9 another study done in lahore showed that pneumonia followed by meningitis are the leading infectious diseases especially in rural areas.10 the frequency of pyogenic meningitis was 7.6% in children presenting with fever with fits in one of the hospitals of islamabad, pakistan.11 the number of patients presenting and admitting with diagnosis of pyogenic meningitis has increased over the last few years. this study was conducted to determine the vaccination status and clinical spectrum of pyogenic meningitis in our setup that may help the health care professionals and public health administrators in identifying the magnitude of the problem and allocation of resources, giving emphasis on vaccination and educating masses. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in paediatric b ward of ayub teaching hospital, abbottabad. the data was collected retrospectively after taking approval from institutional review board. sample size was calculated by open epi sample size calculator taking frequency of pyogenic meningitis as 7.6% .11 the calculated sample size was 108 patients. data was retrieved from patient files from august, 2017 till january, 2020. records of children of either gender between ages of 1 month to 14 years were included who were diagnosed as case of pyogenic meningitis on clinical basis, cerebrospinal fluid (csf) findings along with ct scan. the csf finding suggestive of bacterial meningitis was increase in cell count and presence of neutrophils. records of patients with diagnosis of tuberculous meningitis, meningoencephalitis/encephalitis, febrile seizures and seizure disorders were excluded. records of vaccination status were considered as up to date vaccinated, if vaccine schedule was complete according to epi vaccine card. if any dose was found to be missed, according to age, it was taken as partially vaccinated and if none of vaccine given apart from polio drops then taken as not vaccinated. all patients initially suspected or diagnosed with pyogenic meningitis were started on intravenous antibiotics including ceftriaxone and vancomycin. due to non-availability of csf cultures, antibiotics covering gram negative and gram-positive bacteria were given. dexamethasone was also given as antiinflammatory for 72 to 96 hours. retrieved from data, presenting features included, fever, signs of meningeal irritation including neck stiffness, brudzinski sign, kerning sign, paradoxical irritability in children less than 1.5 years of age. development of complications during hospital stay secondary to meningitis were documented on specific proforma. data was analyzed using spss version 20. vaccination status, clinical spectrum of the disease, duration of hospital stays and patient’s outcome was analyzed and chi square test applied as test of significance. p value< 0.05 was considered as statistically significant. r e s u l t s in this study total of 117 patients were included. out of 117 patients, 78 (66.7%) were males and 39 (33.3%) were females. age of patients ranged from 1 month to 14 years. their baseline details have been given in (table i). total 82 (70.1%) patients j islamabad med dental coll 2021 147 stayed in hospital for up to 7 days. stay of remaining 35 (29.9%) patients was 8 days or more. majority (58.1%) of patients of pyogenic meningitis were less than five years of age. the main presenting feature of patients was fever present in 86 (73.5%) patients while 31 (26.5%) patients were not having history of fever. association of fever with gender and age category did not reveal any significant relation (p value 0.8 and 0.1 respectively). another presenting feature was seizure; which was present in 46 (39.3%) patients. out of 46 patients, 36 (78.3%) patients were having generalized tonic clonic seizures and 10 (21.7%) patients were having focal seizures. there was significant association between seizures and age group. majority of patients having seizures were under one year of age. association of seizures with gender was also significant. larger number of patients having seizures were males. association of seizures with fever was also significant. majority of patients presenting with seizures also had fever (table ii). at time of presentation, signs of meningeal irritation (neck stiffness, brudzinski sign, kerning sign) and paradoxical irritability were present in 85 (72.6%) patients. there was significant association between signs of meningeal irritation and age group. majority of patients presenting with seizures were above 5 years of age. association of meningeal irritation with gender was non-significant (table iii). out of 117 patients, 58 (49.6%) were vaccinated up to date, 15 (12.8%) were partially vaccinated while 44 (37.6%) were not vaccinated at all apart from taking polio drops. male children who were not vaccinated were 35.89% while female nonvaccinated children were 41%. fever, seizures and signs of meningeal irritation were not having significant relationship with vaccination status (p value > 0.5). association of vaccination status with patients stay in hospital was significant. children who were vaccinated up to date had stay duration of up to 7 days while unvaccinated children had more duration of stay in hospital (table iv). out of 117 patients, 110 (94%) got discharged and one (0.9%) patient was referred while 6 (5.1%) patients expired. majority (88.9%) were not having any complication at time of discharge from hospital. the most common complication observed in hospital was hydrocephalus which was present in 7 (6%) patients followed by hemiplegia in 5 (4.2%) patients. dural sinus thrombosis was present in one (0.9%) patient. there was also significant association between seizures as presenting feature and ct scan findings with p value of 0.033. association of duration of stay in hospital and outcome, complications or age category was non-significant. table i: baseline data of patients in study (n=117). minimum maximum mean std. deviation stay duration (days) 1 16 6.75 2.796 age (years) 0.10 13.00 5.1517 4.19448 csf cell count (cells/ul) 2 28000 3550.44 4841.232 polymorphs (percent) 0 95 64.85 30.390 lymphocytes (percent) 5 100 35.38 30.516 csf sugar (mg/dl) 1 157 47.11 29.075 csf protein (mg/dl) 5 649 125.32 106.891 table ii: association of seizures with age, gender and fever (n=117) variables seizures total n (%) p value yes n (%) no n (%) j islamabad med dental coll 2021 148 age (years) up to 1 20 (17.09) 12 (10.26) 32 (27.35) 0.001 1-5 16 (13.68) 20(17.09) 36(30.77) more than 5 10 (8.55) 39(33.33) 49(41.88) gender male 36 (30.77) 42 (35.90) 78 (66.67) 0.032 female 10 (8.55) 29 (24.79) 39 (33.33) fever yes 39 (33.33) 47 (40.17) 86 (73.50) 0.026 no 7 (5.98) 24 (20.51) 31 (26.49) total 46 (39.32) 71 (60.69) 117 (100) table iii: association of signs of meningeal irritation with age and gender (n=117) gender signs of meningeal irritation total n (%) p value yes n (%) no n (%) age (years) up to 1 15 (12.82) 17(14.53) 32 (27.35) 0.001 1-5 27(23.08) 9 (7.69) 36(30.77) more than 5 43 (36.75) 6(5.13) 49(41.88) gender male 57 (48.72) 21 (17.95) 78 (66.67) 0.883 female 28 (23.93) 11 (9.40) 39 (33.33) total 85 (72.65) 32 (27.35) 117 (100) table iv: association of vaccination status with duration of stay in hospital (n=117) duration of stay (days) vaccination status total n (%) p valu e up to date n (%) partially vaccinated n (%) not vaccinated n (%) up to 7 40 (34.19) 15 (12.82) 27 (23.08) 82 (70.08) 0.01 8 8 or more 18 (15.38) 0 (0) 17 (14.53) 35 (29.91) total 58 (49.57) 15 (12.82) 44 (37.61) 117 (100) d i s c u s s i o n though the incidence of bacterial meningitis has decreased with inclusion of new vaccines and expansion of immunization program especially in third world countries yet the morbidity and mortality associated with it is quite high. therefore, timely diagnosis of bacterial meningitis is one of the most important aspects in management including status epilepticus and prevention of the sequelae.8 the presenting features of bacterial meningitis are fever, neck stiffness, seizures and altered consciousness level. children appear sicker and in infants, the main presenting features are poor feeding, lethargy, seizures and paradoxical irritability.12,13 studies have shown that fluid management may be associated with decrease in neurological sequelae in children.14 hadi n et al15 did one study in iran and in their study positive csf cultures were more in children less than five years of age in 57.1% patients while inn our j islamabad med dental coll 2021 149 study about 60% of patients were aged less than five years.sallam aka16 study done in yemen showed that the age group which presented with meningitis was between 4 months and 3 years. bari a et al17 studied the clinical spectrum in children 1 month to 5 years of age with bacterial meningitis at children hospital, lahore. their male to female ratio was 1.7:1 in comparison to our study ratio of 2:1. majority of patients (68.3%) in bari a et al study was less than one year of age while in our study 27.4% children were less than one year of age. fayyaz j et al18 published one study about ct scan in children presenting with acute bacterial meningitis. their study male to female ratio was 2.3:1 while in our study it was 2:1. fayyaz j et al19 did study in aga khan university hospital and studied the presenting features of children with acute bacterial meningitis. their study included 192 patients. in their study the main presenting feature was fever in 86% of patients while in our study fever as presenting feature was present in 73.5% patients. we included the paradoxical irritability as signs of meningeal irritation, 72.6% patients in our study had signs of meningeal irritation at presentation, while in fayyaz j et al study, 78.56% patients had signs of meningeal irritation. their findings also included that the signs of meningeal irritation were more elicitable in children who were more than five years of age like in our study. complications were noted in 3.12% patients in contrast to our study in which complications were noted in 11.1% patients. iio k et al20 in one case report emphasized that absence of neck stiffness cannot rule out meningitis in infants, physical appearance and fever also matters. in our study 27.2% patients had no sign of meningeal irritation at time of presentation. in one of the studies by amin m et al21 done in bhawal victoria hospital, 63.2% children presented with history of seizures while in our study 39.3% children had history of seizures at presentation. in fayyaz j et al18 study, ct scan was done in 59.4% of patients and it was reported normal in 78.94% patients. while in our study ct scan was done in 40.2% of patients. in bari a et al17 study, 45.2% children were vaccinated up to date, as in our study where 49.6% children were vaccinated up to date. bari a et al study was done in lahore and patients presenting to children hospital were from rural areas. in our hospital also the majority of children presenting with meningitis are from rural areas that may be the reason for majority of children not being vaccinated. in amin m et al17study, only 50.5% children with meningitis were vaccinated up to date and 22.7% were not vaccinated at all while in our study 45.2% children were vaccinated up to date and 37.6% children were not vaccinated at all. in their study, 63.2% children presented with history of seizures while in our study 39.3% children had history of seizures at presentation. though they did csf culture yet in their study 24.1% patients had neisseria meningitides. in our study 12% with meningococcemia were having meningitis. truong j et al22 studied the impact of incorrect vaccination in france leading to meningitis in children. they reported 48 cases which were due to vaccine preventable bacteria. on the top of list was neisseria meningitides which was in 54.2% cases. in our study only 45.2% were vaccinated up to date and 12% cases were with meningococcal meningitis. andriatahirintsoa ejpr et al23 in their study observed for the impact of pneumococcal conjugated vaccine (pcv)10 in children and concluded that incidence of meningitis caused by pneumococcal bacteria was reduced after introduction of vaccine in immunization program. in pakistan, pcv was introduced in epi program in october 2012. in our study 37.6% children were not vaccinated at all and 12.8% children were only partially vaccinated. shrestha rg et al24 did one study in one of the hospitals of nepal and the objective was doing csf culture in children with meningitis. their study showed that 72.2% meningitis was caused by haemophilus influenzae. in pakistan, epi program http://www.pakmedinet.com/author/jabeen+fayyaz http://www.pakmedinet.com/author/jabeen+fayyaz http://www.pakmedinet.com/author/muhammad+amin http://www.pakmedinet.com/author/jabeen+fayyaz http://www.pakmedinet.com/author/attia+bari http://www.pakmedinet.com/author/muhammad+amin j islamabad med dental coll 2021 150 includes haemophilus influenzae vaccine. we did not do any csf culture due to various reasons. in sallam aka16 study; mortality was 14.28% in children with pyogenic meningitis. in comparison mortality was 5.13% in our study, which is quite less as compared to sallam aka study. in a study done by fayyaz j et al18 the mortality was 3.1%. there are limitations in this study as the data was collected retrospectively. also, we only documented the outcome in hospital. patients follow up is required for the possible long term neurological sequelae. c o n c l u s i o n fever was most common presentation in patients of pyogenic meningitis. seizures were common in infants reporting with meningitis, whereas signs of meningeal irritation were mostly absent in them. male gender was more likely to have seizures. vaccinated children had shorter stay in hospital. r e c o m m e n d a t i o n s infants less than one year presenting with paradoxical irritability and history of seizures, should be worked up for possible meningitis. multicenter studies are required to further confirm the findings. also, there are significant numbers of children who are not vaccinated at all or not up to date. public awareness on vaccination should be the priority. r e f e r e n c e s 1. qureshi maa, jesrani a, magsi k, nayab s. diagnostic accuracy of post contrast magnetic resonance imaging for meningitis taking lumbar puncture as gold standard. experience at nishtar hospitalmultan. tijmccs 2020;1(1):1-4. doi: 10.46718/jbgsr.2020.06.000150 2. mcneil hc, jefferies jmc, clarke sc. vaccine preventable meningitis in malaysia: epidemiology and management. expert rev anti infect ther 2015; 13:705–14. doi: 10.1586/14787210.2015.1033401 3. oordt-speets am, bolijn r, van hoorn rc, bhavsara, kyaw mh. global etiology of bacterial meningitis: a systematic review and meta-analysis. plos one 2018;13: e0198772. doi:10.1371/journal.pone.0198772 4. alamarat z, hasbun r. management of acute bacterial meningitis in children. infection and drug resistance 2020; 13:4077–89. doi: 10.2147/idr.s240162. 5. mcintyre pb, o’brien kl, greenwood b, beek dvd. effect of vaccines on bacterial meningitis worldwide. lancet 2012; 380:1703–11. doi: 10.1016/s01406736(12)61187-8. 6. fatima t, malik f, khan e, mir f, shakoor s. clinical features and outcomes of pneumococcal bacteremia among children at a tertiary care hospital. biomed biotechnol res j 2018; 2:152-5. doi: 10.4103/bbrj.bbrj_15_18 7. masud t, navaratne kv. the expanded program on immunization in pakistan. recommendations for improving performance. health, nutrition and population (hnp) discussion paper. the world bank. 2012. 8. chetan c, sharma s, mathur sb, jain p, aneja s. clinical profile and short-term outcome of pediatric status epilepticus at a tertiary-care center in northern india. indian pediatrics. 2020; 57:213-17. pmid: 32198859 9. zaidi ak, khan h, lasi r, mahesar w, sindh meningitis group. surveillance of pneumococcal meningitis among children in sindh, southern pakistan. clinical infectious diseases. 2009 ;48(supplement_2): s12935. doi: 10.1086/596491 10. rashid m, iqbal bano ah. prevalence of common infectious diseases in paediatric age group admitted in children’s hospital lahore, pakistan. int j front sci. 2017;1(1):19-28. doi:10.37978/tijfs.v1i1.12 11. siddiqui hb, haider n, khan z. frequency of acute bacterial meningitis in children with first episode of febrile seizures. j pak med assoc. 2017;67(7):1054-8. pmid: 28770886 12. abiy h, shiferaw z, tafere y. clinical outcome of meningitis and its risk factors among children admitted in debre markos referral hospital pediatric ward, northwest ethiopia,2019. research square; 2020. doi: 10.21203/rs.3.rs-36044/v1. 13. kumar a, shankar m, chaudhary ak. etiological profile of children admitted with seizures in a tertiary care hospital. iosr-jdms 2020;19(2):6-8. doi: 10.9790/0853-1902120608 14. maconochie ik, bhaumik s. fluid therapy for acute bacterial meningitis. cochrane database syst rev 2016;(11): cd004786. doi: 10.1002/14651858.cd004786.pub5. 15. hadi n, bagheri k. a five-year retrospective multicenter study on etiology and antibiotic resistance pattern of bacterial meningitis among http://www.pakmedinet.com/author/abdul+khaliq+a+sallam http://www.pakmedinet.com/author/abdul+khaliq+a+sallam http://www.pakmedinet.com/author/jabeen+fayyaz j islamabad med dental coll 2021 151 iranian children. iem. 2019;5(4):17-24. issn:2588-4115. 16. sallam aka. etiology and presentation of acute bacterial meningitis in children at al-thawrah hospital, sana`a, yemen. j ayub med coll 2004;16(4):40-3. pmid: 15762062 17. bari a, zeeshan f, zafar a, ejaz h, iftikhar a, rathore aw. childhood acute bacterial meningitis: clinical spectrum, bacteriological profile and outcome. j coll physicians surg pak 2016;26(10):822-6. pmid: 27806810 18. fayyaz j, khursheed m, zia n, feroze a, khan ur, rehman a, et al .ct scan in children with acute bacterial meningitis: experience from emergency department of a tertiary-care hospital in karachi, pakistan. j pak med assoc 2014;64(4):419-22. pmid: 24864636 19. fayyaz j, khursheed m, zia n, feroze a, rehman a, hamid a. age related clinical manifestation of acute bacterial meningitis in children presenting to emergency department of a tertiary care hospital. j pak med assoc 2014;64(3):296-9. pmid: 24864603 20. iio k, ogawa y, ihara t, horikoshi y, hataya h. nuchal rigidity in infantile bacterial meningitis. j pediatr 2019; 207:255. doi: 10.1016/j.jpeds.2018.10.008. 21. amin m, khurshid a, ahmad m, javed z. etiology and outcome of culture proven bacterial meningitis in children 6 to 24 months of age. professional med j 2019;26(09):1451-6. doi: 10.29309/tpmj/2019.26.09.2562 22. truong j, levy c, prot-labarthe s, nguyen hpk, grimpre e, faye a, et al. vaccine-preventable meningitis in french children with incorrect vaccination status from 2011 to 2013. archives de pe´ diatrie 2020; 27:1–5. doi: 10.1016/j.arcped.2019.10.008. 23. andriatahirintsoa ejpr, raboba jl, rahajamanana vl, rakotozanany al, nimpa mm, masembe yv, et al. impact of 10-valent pneumococcal conjugate vaccine on bacterial meningitis in madagascar. clin infect dis 2019;69(s2): s121–5. doi: 10.1093/cid/ciz504. 24. shrestha rg, tandukar s, ansari s, subedi a, shrestha a, poudel r, et al. bacterial meningitis in children under 15 years of age in nepal. bmc pediatrics 2015; 15:94. doi: 10.1186/s12887-015-0416-6. http://www.pakmedinet.com/author/abdul+khaliq+a+sallam http://www.pakmedinet.com/jamc http://www.pakmedinet.com/author/attia+bari http://www.pakmedinet.com/author/fatima+zeeshan http://www.pakmedinet.com/author/aiza+zafar http://www.pakmedinet.com/author/hassan+ejaz http://www.pakmedinet.com/author/aisha+iftikhar http://www.pakmedinet.com/author/ahsan+waheed+rathore http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/author/jabeen+fayyaz http://www.pakmedinet.com/author/munawar+khursheed http://www.pakmedinet.com/author/nukhbha+zia http://www.pakmedinet.com/author/asher+feroze http://www.pakmedinet.com/author/arshalooz+rehman http://www.pakmedinet.com/jpma http://www.pakmedinet.com/author/jabeen+fayyaz http://www.pakmedinet.com/author/munawar+khursheed http://www.pakmedinet.com/author/nukhbha+zia http://www.pakmedinet.com/author/asher+feroze http://www.pakmedinet.com/author/arshalooz+rehman http://www.pakmedinet.com/author/akhter+hamid http://www.pakmedinet.com/jpma http://www.pakmedinet.com/jpma http://www.pakmedinet.com/author/muhammad+amin http://www.pakmedinet.com/author/asim+khurshid http://www.pakmedinet.com/author/mukhtar+ahmad http://www.pakmedinet.com/author/zunaira+javed http://www.pakmedinet.com/professional http://www.pakmedinet.com/professional summary journal of islamabad medical & dental college (jimdc); 2016:5(4):187-191 187 original article reasons for delayed presentation of women with breast cancer fatima ayaz,1 saeed bin ayaz,2 muhammad farrukh3 1,3internee surgery, benazir bhutto hospital, rawalpindi, punjab, pakistan 2assistant professor physical medicine and rehabilitation, combined military hospital, institute of medical sciences, quetta, baluchistan, pakistan abstract objective: the purpose of this study was to determine the reasons for late presentation of women with breast cancer in rawalpindi and islamabad. the influence of sociodemographic factors on the major reason for late presentation was also investigated. subjects and methods: it was a cross-sectional survey conducted in the surgical departments of different government hospitals of rawalpindi and islamabad. through non-probability consecutive sampling, we included women diagnosed with breast cancer, who, in spite of presence of positive symptoms of breast cancer, delayed seeking medical advice for ≥ 3 months. the data was analyzed using spss version 20. results: out of 100 women (mean age: 47 years±11.2 sd), majority was married (85%), illiterate (53%), housewife by profession (93%), and belonged to rural areas (69%). the first symptom of breast cancer reported by the majority (81%) was a lump. most of the subjects (62.3%) reported late because they did not consider the symptoms important due to lack of information about breast cancer. this factor was not significantly related to age, primary area of living, education, marital status, and profession (p=0.274, p=0.415, p=0.304, p=0.654 and p=0.533 respectively). conclusion: majority of women with breast cancer in our sample delayed seeking professional health care because they did not consider their first symptom of breast cancer significant. this lack of knowledge and information was not significantly related to age, primary area of living, education, marital status, and profession. key words: breast cancer, delayed presentation, sociodemographic factors, women introduction breast cancer is the commonest malignancy in females all over the world, and second leading cause of death due to cancer among females. according to globocan 2012, 14.1 million new cancer cases were identified in 2012 worldwide, out of which 1.7 million women were diagnosed with breast cancer. since 2008 estimates, breast cancer incidence has risen by more than 20%, while mortality rate has increased by 14%.1 pakistan has the highest rate of breast cancer amongst all other asian countries (excluding israel) as over 90,000 women develop breast cancer annually.2 the diagnosis of breast cancer in most cases is delayed due to various factors including lack of awareness about the symptoms of breast cancer, hesitancy of females to get themselves examined by male doctors, poverty, and shyness to discuss their problems to spouses or other members of the family. the pakistani females, especially those belonging to rural areas prefer to go to spiritual healers for therapeutic touch or to traditional herbal medicine practitioners (hakims), and homeopaths, rather than reporting to allopathic doctors. ignorance, poverty, illiteracy, lack of resources, disease stigma, use of alternate medicine, and poor access to health care facilities are the key factors for delay in the diagnosis of breast cancer.3 previously, in pakistan, different studies have been carried out to find the causes of late presentation of women with breast cancer.3-10 this study was aimed to determine the reasons for delayed presentation in women of twin cities i.e. rawalpindi and islamabad, who reported to the government hospitals. the influence of socio-demographic factors on the primary cause of late presentation was also investigated. these results would further supplement the current native data to help devise better measures for earlier detection of breast cancer. subjects and methods this descriptive cross-sectional study was carried out in the surgical departments of different government hospitals of rawalpindi associated with rawalpindi medical college namely, holy family hospital, benazir bhutto hospital, and district headquarters hospital, rawalpindi and nuclear medicine, oncology and radiotherapy institute (nori), islamabad. the delayed presentation was defined as waiting for three or more months to seek help from a physician after corresponding author: dr saeed bin ayaz email: saeedbinayaz@gmail.com received: dec 12,2016 ; accepted january 19,2017 mailto:saeedbinayaz@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(4):187-191 188 identification of breast signs or symptoms.4,11,12 the permission for the study was obtained from the ethical review committees of rawalpindi medical college and allied hospitals and nori, islamabad. the study was carried out from march to april, 2015. we included all women suffering from breast cancer through non-probability consecutive sampling. these females in spite of presence of a lump or other positive symptoms or signs of breast cancer, delayed seeking any medical advice for at least 3 months. the women, who had breast cancer in stages 1 or 2 (early stage), were excluded.13,14 the study participants, after informed verbal consent, were interviewed using structured questionnaires, and their responses were recorded in written forms. we tried to identify the reasons for delay at two levels, i.e. at the level of the patients himself/herself, and at the level of spouse, family, friends, relatives, or peers. the reasons at both levels were suggested based on review of literature and our cultural traditions. the different reasons at the level of the patients were:1) i did not consider it important due to lack of knowledge and awareness about breast cancer, 2) i was shy of telling someone about my problem, 3) i had serious other family problems due to which i could not give due importance to my symptoms,4) i did not have enough financial resources to bear the expenses of treatment,5) i had a fear of diagnosis of serious ailment, 6) i had a fear that the treatment may cause serious side effects and make my life more difficult, 7) other reasons. the reasons at the level of family or friends were identified from the suggestions given to the patients by their family members or friends. i.e. 1) use home remedies for symptomatic relief, 2) wait for some time as symptoms may disappear, 3) go to spiritual healers for therapeutic touch, 5) consult traditional herbal medicine practitioners “hakims” 6) consult homeopaths, 7) consult doctors, 8) other suggestions. the data also included information about age, primary area of living (rural, urban), educational status (illiterate, grade 1 5, grade 6-10 and grade > 10), marital status (married, unmarried, divorced, widowed), professional status (house wives, working women), and the first symptom of breast cancer observed (pain, swelling, skin changes, others). the data were analyzed with the help of statistical package for social sciences v 20 (ibm corp., armonk, ny, usa). for all the socio-demographic factors and the responses of queries, frequencies along with percentages were calculated. to evaluate the impact of age, primary area of living, education, marital status, and profession, pearson chi-square or fisher’s exact tests were used where necessary. a p-value < 0.05 was considered significant. results a sample of 168 women was initially recruited. sixty-eight women were excluded because they had breast cancer in stages 1 or 2. the mean age of the final 100 participants was 47 ±11.2 years (median: 45.5 years) with a range of 25-75 years. majority of them were married (85%), illiterate table-1: demographic properties of women with breast cancer who delayed presentation to a health care physician variables no % age groups ≤ 45 years > 45 years 50 50 50 50 primary area of living rural urban 69 31 69 31 marital status married unmarried divorced widowed 85 12 2 1 85 12 2 1 reasons why patients did not inform anyone about first symptom (n=69) did not consider it important due to lack of knowledge and information shyness other serious family problems were more important fear of side effects of treatment fear of diagnosis of serious ailment inadequate financial resources others missing 43 9 6 6 2 1 2 31 62.3 13 8.7 8.7 2.9 1.4 2.9 educational status illiterate grade 15 grade 6-10 grade > 10 53 21 14 12 53 21 14 12 professional status house wives working women 93 7 93 7 the first symptom of breast cancer observed pain lump skin changes others 12 81 6 1 12 81 6 1 suggestions given by spouses, family or friends wait for some time for disappearance of symptoms try home remedies for symptomatic relief go to spiritual healers consult traditional herbal medicine practitioner “hakeem” consult homeopaths consult doctors others missing 2 1 17 1 4 65 1 9 2.2 1.1 18.7 1.1 4.4 71.4 1.1 journal of islamabad medical & dental college (jimdc); 2016:5(4):187-191 189 (53%), house wife by profession (93%), and belonged to the rural areas (69%). (table 1) the first symptom of breast cancer reported by the majority was “a lump” (81%) followed by “pain” (12%). table-2: association of demographic factors with the different reasons for delay in presentation of women with breast cancer (n=69) variables did not consider it important due to lack of knowledge and information other reasons ?? total p-value age groups ≤ 45 years > 45 years 17 26 13 13 30 39 0.274 marital status married single (unmarried, divorced or widowed) 38 5 23 3 61 8 0.654 professional status house wives working women 39 4 23 3 62 7 0.533 primary area of living rural urban 29 14 19 7 48 21 0.415 educational status low education (illiterate and grade 15) better education (grade 6-10 and grade > 10) 31 12 21 5 52 17 0.304 only 69 patients answered the question asked for the reasons for delayed presentation at the patients’ level. the bulk (62.3%) reported late because they did not consider it important due to lack of knowledge and information about breast cancer. this lack of knowledge and information was not significantly related to the age-group, primary area of living, education, marital status, and profession. (p=0.274, p=0.415, p=0.304, p=0.654 and p=0.533 respectively) (table 2) while exploring response of family members and friends towards the complaints of patients, 91 interviewees answered the question and we found a positive attitude from them as most of them i.e. 71.4% suggested to consult doctors. (table 1) discussion breast cancer, when compared to the western population, is more common in pakistan.5 one in every nine pakistani women suffers from breast cancer which is one of the highest prevalence rates in asia.6 the mean age of the patients in our study was found to be 47±11.2 years with a range of 25-75 years. this is parallel to the studies carried out in pakistani women at karachi and nawabshah (mean age: 47.5±12.1 years with a range of 2577 years and mean age: 43.5±10.4 years with a range of 2880 years). thus, our sample was a true representative of pakistani women with breast cancer.7,8 our study showed that majority of the women, who delayed their report of first symptoms of breast cancer, did so because they were unaware of the grave nature of those symptoms. these results are similar to other regional studies. memon et al. reported that majority of women delayed their consultation with doctors because they considered their symptoms harmless and momentary, and because the symptoms did not affect their routine life activities.7 malik et al. also reported lack of awareness as the key factor for delay in seeking medical attention in women with breast cancer.15 in other countries e.g. nigeria, germany, usa, colombia, and iran many studies have indicated that majority of the women with breast cancer delayed pursuing professional health care because they lacked knowledge about breast cancer or considered their symptoms harmless.16-20 why women have a tendency to consider their symptoms of breast cancer harmless? the answers are suggested by memon et al. and lodhi et al.7,9 they indicated that women, especially in pakistan, generally are considerate more towards their children, husband or other family members, and hold an overall care-free and casual approach towards their own health. they linger on with their problems unless the problems become unendurable. the second common reason for women to delay seeking medical attention was shyness of medical examination especially by male doctors. a study by gilani et al. from the city of rawalpindi identified that 13.1% of the study subjects showed shyness or unavailability of female doctor as the reason for delayed seeking of an appropriate medical advice.10 another pakistani study by khan et al. found that 10.6% (n=13) of the studied sample from northern pakistan who presented late, felt shy to let their breast examined by male doctors.4 an indian study by akhtar et al. found shyness as a cause of delay in 22% of the patients with locally advanced breast carcinoma.21 altwalbeh et al. found shyness as a motive for delay in 44.6 % of the study sample in saudi women.11 shyness was identified as a significant cause of delay in presentation of breast cancer in many other studies.22-24 the influence of age, primary area of living, education, marital status, and profession on the different causes of delay was also evaluated, but, we could not find any significant correlation. bhosai et al., in a thai study, abstracted that patient’s socio-demographic factors were not significantly associated with delay in care-seeking of patients with cancer (p>0.05).25another study by ramirez et journal of islamabad medical & dental college (jimdc); 2016:5(4):187-191 190 al. suggested no significant association (p>0.05) between marital status and patient delays.13 on the contrary, many studies have concluded different results. khan and colleagues discovered that advanced age, low education and low socioeconomic status were significantly associated with a delay in presentation for women with breast cancer (p<0.05 and or of 2.26, 2.29 with 95% ci: 1.25-4.10 and 1.06-4.94 respectively).4 memon et al. also found that marital status and decreased level of education (p<0.001 and p=0.002 respectively) was associated with more prolonged delays.7 harirchi et al. suggested that delay among iranian women with breast cancer was associated with older age, being married, lower income, less education, and residence in small cities.26 other studies have identified higher age groups, negative family history, low education, and low socioeconomic status as demographic factors associated with delayed presentation.2738 the findings of this study, and review of related literature endorses the view that women in pakistan have an alarmingly poor knowledge about breast cancer. resultantly, they fail to report to the appropriate health professional in the desired time. thus, they need to be educated about the earliest symptoms of breast cancer so that timely evaluation and intervention be commenced, and mortality related to breast cancer can be reduced. public health department need to do an enormous job to create awareness among the masses by the help of press and media in this regard. conclusion majority of women with breast cancer in our study delayed seeking professional health care because they did not consider their first symptom of breast cancer significant. this lack of knowledge and information was not significantly related to age, primary area of living, education, marital status, and profession. conflict of interest this study has no conflict of interest as declared by authors references 1. ferlay j, soerjomataram i, ervik m, dikshit r, eser s, mathers c, et al. globocan 2012 v1.0, cancer incidence and mortality worldwide: iarc cancerbase no. 11 [internet]. lyon, france: international agency for research on cancer.2013. available from: http://globocan.iarc.fr. 2. liede a, malik ia, aziz z, rios pd pde l, kwan e, narod sa. contribution of brca1 and brca2 mutations to breast and ovarian cancer in pakistan. am j hum genet. 2002;60(9):721-5. 3. iqbal j, bano k, saeed a, akram m, aziz z. survival of women with locally advanced breast cancer at a teaching hospital in lahore. j pak med assoc. 2010;60(9):721-5. 4. khan ma, hanif s, iqbal s, shahzad mf, shafique s, khan mt. presentation delay in breast cancer patients and its association with sociodemographic factors in north pakistan. chin j cancer res. 2015;27(3):288-93. 5. mahmood s, rana tf, ahmad m. common determinants of ca breast a case control study in lahore. ann king edward med uni. 2006;12(2):227-8. 6. sohail s, alam sn. breast cancer in pakistan awareness and early detection. j coll physicians surg pak. 2007;17(12):711-2. 7. memon za, shaikh an, rizwan s, sardar mb. reasons for patient's delay in diagnosis of breast carcinoma in pakistan. asian pac j cancer prev. 2013;14(12):7409-14. 8. talpur aa, surahio ar, ansari a, ghumro aa. late presentation of breast cancer: a dilemma. j pak med assoc. 2011;61(7):662-6. 9. lodhi fb, ahmad b, shah sih, naeem m, dab rh, ali n, et al. determinants of delayed presentation in breast cancer. apmc. 2010;4(2), 9-16. 10. gilani si, khurram m, mazhar t, mir st, ali s, tariq s, malik az. knowledge, attitude and practice of a pakistani female cohort towards breast cancer. j pak med assoc. 2010;60(3):205-8. 11. elobaid y, aw t-c, lim jn, hamid s, grivna m. breast cancer presentation delays among arab and national women in the uae: a qualitative study. ssm-population health. 2016;2:155-63. 12. altwalbeh d, el dahshan me, yaseen r. factors influencing delayed presentation of breast cancer among saudi women. int j sci res. 2015; 4(1):967-74. 13. ramirez aj, westcombe am, burgess cc, sutton s, littlejohns p, richards ma. factors predicting delayed presentation of symptomatic breast cancer: a systematic review. lancet. 1999;353(9159):1127-31. 14. stapleton jm, mullan pb, dey s, hablas a, gaafar r, seifeldin ia, et al. patient‐mediated factors predicting early‐and late‐stage presentation of breast cancer in egypt. psychooncology. 2011;20(5):532-7. 15. malik ia, gopalan s. use of cam results in delay in seeking medical advice for breast cancer. eur j epidemiol. 2003;18(8):817-22. 16. ukwenya ay, yusufu lm, nmadu pt, garba es, ahmed a. delayed treatment of symptomatic breast cancer: the experience from kaduna, nigeria. s afr j surg. 2008;46(4):106-10. 17. arndt v, stürmer t, stegmaier c, ziegler h, becker a, brenner h. provider delay among patients with breast cancer in germany: a population-based study. j clin oncol. 2003;21(8):1440-6. 18. gullatte mm, phillips jm, gibson lm. factors associated with delays in screening of self-detected breast changes in african-american women. j natl black nurses assoc. 2006;17(1):45-50. 19. piñeros m, sánchez r, cendales r, perry f, ocampo r. patient delay among colombian women with breast cancer. salud publica mex. 2009;51(5):372-80. 20. rastad h, khanjani n, khandani bk. causes of delay in seeking treatment in patients with breast cancer in iran: a qualitative content analysis study. asian pac j cancer prev. 2012;13(9):4511-5. 15. 21. akhtar m, akulwar v, gandhi d, chandak k. is locally advanced breast cancer a neglected disease? indian j cancer. 2011;48(4):403-5. 22. salih am, alfaki mm, alam-elhuda dm, nouradyem mm. factors delaying journal of islamabad medical & dental college (jimdc); 2016:5(4):187-191 191 presentation of sudanese breast cancer patients: an analysis using andersen's aodel. asian pac j cancer prev. 2016;17(4):2105-10. 23. gold ma. causes of patients' delay in diseases of the breast cancer. 1964;17:564-77. 24. facione nc, giancarlo ca. narratives of breast symptom discovery and cancer diagnosis: psychologic risk for advanced cancer at diagnosis. cancer nurs. 1998;21(6):430-40. 25. bhosai sj, sinthusake t, miwa s, bradley e. factors affecting patient access in thailand: understanding delay in care seeking for patients with cancer. glob public health. 2011;6(4):385-97. 26. harirchi i, ghaemmaghami f, karbakhsh m, moghimi r, mazaherie h. patient delay in women presenting with advanced breast cancer: an iranian study. public health. 2005;119(10):885-91. 27. brzozowska a, duma d, mazurkiewicz t, brzozowski w, mazurkiewicz m. reasons for delay in treatment of breast cancer detected due to breast self-examination in women from the lubelskie region. ginekol pol. 2014;85(1):14-7. 28. jones ce, maben j, jack rh, davies ea, forbes ljl, lucas g, et al. a systematic review of barriers to early presentation and diagnosis with breast cancer among black women. bmj open. 2014;4:e004076. 29. ermiah e, abdalla f, buhmeida a, larbesh e, pyrhönen s, collan y. diagnosis delay in libyan female breast cancer. bmc res notes. 2012;5:452. 30. norsa'adah b, rampal kg, rahmah ma, naing nn, biswal bm. diagnosis delay of breast cancer and its associated factors in malaysian women. bmc cancer. 2011;11:141. 31. ali r, mathew a, rajan b. effects of socio-economic and demographic factors in delayed reporting and late-stage presentation among patients with breast cancer in a major cancer hospital in south india. asian pac j cancer prev. 2008;9(4):703-7. 32. poum a, promthet s, duffy sw, parkin dm. factors associated with delayed diagnosis of breast cancer in northeast thailand. j epidemiol. 2014(2);24: 102-8. 33. innos k, padrik p, valvere v, eelma e, kütner r, et al. identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in estonia. bmc public health. 2013;13:947. 34. gullatte mm, brawley o, kinney a, powe b, mooney k. religiosity, spirituality and cancer fatalism beliefs on delay in breast cancer diagnosis in african american women. j relig health. 2010;49(1):62-72. 35. o'mahony m, mccarthy g, corcoran p, hegarty j. shedding light on women's help seeking behaviour for self-discovered breast symptoms. eur j oncol nurs. 2013;17(5):632-9. 36. norsa'adah b, rahmah ma, rampal kg, knight a. understanding barriers to malaysian women with breast cancer seeking help. asian pac j cancer prev. 2012;13(8):3723-30.32. 37. li yww, lam wwt, wong jhf, chiu a, chan m, or a, et al. waiting to see the doctor: understanding appraisal and utilization components of consultation delay for new breast symptoms in chinese women. psycho-oncology. 2012;21(12):1316-23. 38. o'mahony m, hegarty j, mccarthy g. women's help seeking behavior for self-discovered breast cancer symptoms. eur j oncol nurs. 2011;15(5):410-8. authorship contribution: author 1: conception, synthesis and planning of the research, active participation in active methodology author 2: interpretation, analysis and discussion author 3 active participation in active methodology, j islamabad med dental coll 2019 50 op e n ac c e ss primary renal squamous cell carcinoma: an unusual malignancy huma mushtaq 1, naima tariq 2, tehreem atif 3, saeed alam 4, mumtaz ahmad 5 1 associate professor, department of pathology, islamabad medical and dental college 2 assistant professor, department of pathology, islamabad medical and dental college 3 senior lecturer, department of pathology, islamabad medical and dental college 4 professor, department of pathology, islamabad medical and dental college 5 professor, department of urology, islamabad medical and dental college a b s t r a c t malignancies of the upper urinary tract are rare, accounting for about 8% of all malignancies of the renal system, presenting mostly as urothelial carcinoma. squamous cell carcinoma (scc) arising from the upper urinary tract is even more rare, accounting for about 0.5% of all malignancies of the renal system and 10% of all renal pelvic tumors. there are very few case reports in the indexed literature regarding renal squamous cell carcinoma. here we present a case of scc arising from the lower pole of left kidney, in a 35-year-old male resident of muzaffarabad, azad kashmir. key words: squamous cell carcinoma, kidney, hydronephrosis correspondence: huma mushtaq email: huma.mushtaq@imdcollege.edu.pk article info: received: february 15, 2019 accepted: march 2, 2019 cite this case report: mushtaq h, tariq n, atif t, alam s, ahmed m. primary renal squamous cell carcinoma: an unusual malignancy. j islamabad med dental coll. 2019; 8(1):50-53 funding source: nil conflict of interest: nil i n t r o d u c t i o n malignancies of the upper urinary tract are rare and account for almost 8% of all malignancies of renal system, presenting mostly with the histological type of urothelial carcinoma. squamous cell carcinoma (scc) arising from the upper urinary tract is even more rare, accounting for only 0.5% of all malignancies of the renal system and 10% of all renal pelvic tumors.1 scc arising from the upper urinary tract is a more aggressive tumor as compared to the common histological types, and it is clinically diagnosed at a later stage.2 primary scc presents mostly in an age group of 50-70 years and is slightly more common in females. histopathologically, scc of kidney is similar to sccs of other sites and it comprises of keratin pearls along with atypical squamoid cells and keratotic cellular debris in the background. radiologic examination reveals a variety of presentation of scc of kidney. it may present as a solid mass along with hydronephrosis and calcifications, or there may be an infiltrative lesion without any distinct margins. it may present as a nonfunctioning kidney having renal calculi or it may even present as a lowdensity mass arising from renal parenchyma.3although the exact cause of squamous cell carcinoma of kidney is unknown, there are certain etiological factors that are associated with its occurrence such as infections, renal calculi, chemicals, vitamin a deficiency and hormonal imbalance.4 according to previous research, this process initiates as urothelial metaplasia occurring secondary to chronic irritation and it further leads to dedifferentiation, dysplasia and finally development of scc .5 these tumors are treated by aggressive surgical efforts, but even then the prognosis is poor and mostly the patients die after one year of surgical treatment.6 there are very few case reports in the literature regarding renal squamous cell carcinoma, we thus presented with a case of scc arising from the lower pole of left kidney in a 35 year old male, resident of muzaffarabad, azad kashmir. c a s e r e p o r t j islamabad med dental coll 2019 51 c a s e r e p o r t a 35-year-old, chronic smoker, resident of muzaffarabad, azad kashmir presented in the out patient of urology department of akbar niazi teaching hospital (anth) with complaint of on and off fever and vomiting for the past 1 month. he also had left lower quadrant pain in abdomen for the last six months. initially he went to local clinics and took antibiotics, however there was no relief. there was no history of weight loss or hematuria. ultrasound examination performed at an outside clinic revealed a grossly enlarged kidney with multiple calculi, dilated pelvicalyceal system and marked thinning of cortex. computed tomography of kidneys, ureters and bladder (ct kub) revealed a suspected neoplastic/ infective mass in the lower pole of left kidney, hydronephrosis, along with perinephric fat stranding. no normal renal parenchyma was identified. ureters appeared normal in size, shape and position. an open nephrectomy was performed and specimen was sent for histopathological evaluation. gross examination revealed single enlarged left kidney along with the ureter. cut surface of the kidney showed a large tumor almost completely replacing the renal parenchyma. the tumor measured 10 x 9.0 cm and had ruptured through the outer surface of the nephrectomy specimen. it was grey-white and friable in appearance. moreover, multiple renal calculi were also found (figure 1) microscopic examination showed an infiltrative tumor comprising of nests and cords of atypical squamoid cells with keratin pearl formation. extensive sampling was performed; however, no urothelial component was found within the tumor. few residual tubules and glomeruli were also identified. proximal ureter margin along with outer renal capsule were involved by tumor however distal ureteric margin was uninvolved. it was labeled as well differentiated squamous cell carcinoma (figures 2 and 3). on follow up at six weeks, the bone scan of the patient was negative. bone marrow aspiration and trephine biopsy showed no evidence of infiltration by the tumor. ultrasound kub showed development of irregular thick wall hypoechoic collection suggestive of abscess in left renal area. surgical clearing of the area was done and tissue was sent for a histopathological opinion. microscopic examination showed fragments of tumor with similar morphology as seen in nephrectomy specimen, therefore representing remnants of squamous cell carcinoma. figure 1: grossly enlarged kidney along with ureter. cut surface shows a large tumor almost completely replacing the renal parenchyma, grey-white and friable in appearance figure 2: microscopic examination shows an infiltrative tumor comprising of nests and cords of atypical squamoid cells with keratin pearl formation (10 x magnification) figure 3: microscopic examination shows scc with individual cells exhibiting pleomorphism along with high n/c ratio and hyperchromatic nuclei (10 x magnification) j islamabad med dental coll 2019 52 d i s c u s s i o n squamous cell carcinoma arising from the kidney is a very rare and unusual tumor and it usually arises from the collecting system.7 renal squamous cell carcinoma usually presents as a high-grade tumor and therefore it is more aggressive. transitional cell carcinoma is the commonest histological type among the tumors arising from renal pelvis and this is followed by scc which is a very rare entity.8 histopathologically, the features of scc of kidney are the same as sccs arising from other areas, the microscopic features such as intercellular bridges, keratin pearls and keratotic cellular debris are present. metastasis from other sites should be carefully ruled out before labeling it as primary renal scc and despite rest of the findings there should be normal histopathology of the renal pelvis.9 as compared to other malignancies of the upper urinary tract, scc is more aggressive presenting as a high grade tumor with a poor prognosis.10 similar to other organs, conditions like inflammation, chronic irritation and infection are thought to develop squamous metaplasia in the urothelium present in the renal collecting system and this may further progress to dysplasia or even carcinoma in some patients.3 according to previous studies, the mean age of patients presenting with scc of renal pelvic area is around 56 years and usually there is no predilection for laterality or sex.6 in this case, the patient was a young male, aged 35 years, and tumor was present in the left kidney. this tumor usually arises from the urinary bladder, sometimes from the male urethra but very rarely from the renal pelvis. in patients presenting with this tumor, features of paraneoplastic syndromes have also been observed such as leukocytosis, hypercalcemia and thrombocytosis. previously 84% of renal scc presented as locally advanced or metastatic tumor.11 various etiological factors have been associated with the pathogenesis of ssc of upper urinary tract but the strongest association has been noted with renal calculi. in the previously reported cases, up to 100% of renal scc cases had nephrolithiasis.6 in this case, multiple renal calculi were also present. the radiologic findings of scc of kidney vary from case to case. in this case, plain ct kub was done and revealed a mass in lower pole of left kidney, hydronephrosis and perinephric fat stranding. in a study done by lee et al., the main two features of renal scc noticed on ct scan imaging were of enhancing extra luminal or exophytic mass and intraluminal component in some cases.12 this type of malignant tumor generally has a poor prognosis mainly because it usually presents at an advanced stage and therefore surgical resection along with adjuvant chemoradiotherapy is not so effective. in this condition, 5year survival rate is usually less than 10%.13,14,15 on the basis of extent of primary tumor invasion, involvement of regional lymph nodes by the tumor and evaluation of distant metastasis radiologically, staging of this tumor is done. 3 the renal pelvic scc is treated mainly by performing nephrectomy and urethrectomy may or may not be done. in metastatic cases, platinum-based chemotherapy is given along with radiotherapy but nephrectomy is also done to confirm the histopathologic diagnosis. methotrexate, cisplatin and bleomycin is given in combination to treat renal ssc but it has failed to give survival benefit to the patients.16 c o n c l u s i o n squamous cell carcinoma arising from the upper urinary tract region is very rare. it is usually detected when it has become locally advanced or has metastasized. possibility of renal squamous cell carcinoma should be kept in mind while evaluating upper urinary tract tumors, especially in cases having the above mentioned risk factors. in order to make an accurate diagnosis a detailed history should be taken along with proper imaging and histopathological evaluation. these tumors are treated aggressively by surgical resection and chemoradiation is given in patients having a metastatic tumor. r e f e r e n c e s 1. busby je, brown ga, tamboli p, kamat am, dinney cp, grossman hb et al. upper urinary tract tumors with nontransitional histology: a single-center experience. urology. 2006; 67(3):518-23. 2. lee ty, ko sf, wan yl, cheng yf, yang by, huang dl et al. renal squamous cell carcinoma: ct findings and clinical significance. abdominal imaging. 1998; 23(2):203-8. j islamabad med dental coll 2019 53 3. nachiappan m, litake mm, paravatraj vg, sharma n, narasimhan a. squamous cell carcinoma of the renal pelvis, a rare site for a commonly known malignancy. journal of clinical and diagnostic research: jcdr. 2016; 10(1): pd04. 4. talwar n, dargan p, arora mp, sharma a, sen ak. primary squamous cell carcinoma of the renal pelvis masquerading as pyonephrosis: a case report. indian journal of pathology & microbiology. 2006; 49(3):418-20. 5. mardi k, kaushal v, sharma v. rare co-existence of keratinizing squamous cell carcinoma with xanthogranulomatous pyelonephritis in the same kidney: report of two cases. j cancer res ther. 2010; 6: 339–41. 6. holmang s, lele sm, johansson sl. squamous cell carcinoma of the pelvis and ureter: incidence, symptoms, treatment and outcome. j urol. 2007; 178: 51-56 7. odabaþ ö, karakök m, yýlmaz y, atilla mk, akman e, aydýn s. squamous cell carcinoma of the kidney. eastern journal of medicine. 2000; 5(1): 35-6. 8. mizusawa h, komiyama i, ueno y, maejima t, and kato h. squamous cell carcinoma in the renal pelvis of a horseshoe kidney. international journal of urology, 2004; 11: 782–784. 9. sahoo tk, das sk, mishra c, dhal i, nayak r, ali i, panda d, majumdar sk, parida dk. squamous cell carcinoma of kidney and its prognosis: a case report and review of the literature. case reports in urology. 2015; 2015: article id 469327 10. berz d, rizack t, weitzen s, mega a, renzulli j, colvin g. survival of patients with squamous cell malignancies of the upper urinary tract. clin med insights oncol. 2012;6:11–18. 11. nativ o, reiman hm, leiber mm, et al. treatment of primary squamous cell carcinoma of the upper urinary tract. cancer. 1991; 68: 2575-2578. 12. lee ty, ko sf, wan yl, cheng yf, yang by, huang dl, et al. renal squamous cell carcinoma: ct findings and clinical significance. abdom imaging. 1998; 23: 203–08. 13. kalayci ot, bozdag z, sonmezgoz f, sahin n. squamous cell carcinoma of the renal pelvis associated with kidney stones: radiologic imaging features with gross and histopathological correlation. journal of clinical imaging science. 2013; 3: 14. 14. bhaijee f. squamous cell carcinoma of the renal pelvis. ann diagn pathol. 2012; 16: 124–27. 15. mardi k, kaushal v, sharma v. rare co-existence of keratinizing squamous cell carcinoma with xanthogranulomatous pyelonephritis in the same kidney: report of two cases. j cancer res ther. 2010; 6: 339–41. 16. attalla k, haines k, labow d, mehrazin r. squamous cell carcinoma of the renal pelvis: atypical presentation of a rare malignancy. urology case reports. 2017; 13: 137-9. j islamabad med dental coll 2019 156 op e n ac c e s s peutz-jeghers syndrome presenting as intussusception in a young female: a case report junaid zia hashmi1, masood ur rauf khan hira 2, waqas arshad3, zeeshan haider pirzada1, arifa zia hashmi4 1 post graduate resident, nishtar hospital multan 2 head of department, surgical unit iv, nishtar hospital multan 3 consultant surgeon, city hospital multan 4 demonstrator, bakhtawar amin medical college and hospital, multan a b s t r a c t peutz-jeghers syndrome (pjs) is rare condition with autosomal dominant inheritance. it is due to mutation in the tumor suppressor gene, serine threonine kinase 11 (stk11/lkb1) at chromosome 9. it has a very characteristic presentation. patient usually presents at a young age with intestinal obstruction due to polyps leading to intussusception. there is also melanosis on digits, perioral and perineal regions. there is a very strong association of cervical and breast carcinoma in females and testicular tumors in males. git, pancreatic and lung malignancies occur in both sexes. regular follow up and screening are necessary for early detection of malignancies. we present a case of a young girl, who presented with intestinal obstruction along with other signs and symptoms of peutz-jeghers syndrome. exploratory laparotomy revealed jejunoileal intussusception and hamartomatous polyps. patient and other family members were advised screening studies of associated malignancies and regular follow up. key words: hamartomatous polyps, intussusception, melanosis, peutz-jeghers syndrome correspondence: junaid zia hashmi email: juneehashmi@yahoo.com article info: received: february 15, 2019 accepted: march 19, 2019 cite this case report: hashmi jz, hiraj mk, arshad w, pirzada zh, hashmi az. peutz-jeghers syndrome presenting as intussusception in a young female: a case report. j islamabad med dental coll. 2019; 8(3):156-158. doi: 10.35787/jimdc.v8i3.348 funding source: nil conflict of interest: nil i n t r o d u c t i o n peutz-jeghers syndrome is an uncommon entity occurring only 1 in 8300 to 1 in 280,000 births.1 it is an autosomal dominant disease characterized by hamartomatous polyps in jejunum, ileum and colon. there is melanosis of mucocutaneous junctions such as in the mouth and perineal regions. melanin spots also appear on the digits.2the polyps are rarely premalignant, but colorectal cancer and malignancies of breast and cervix are strongly associated with this syndrome. lungs, pancreas, uterus, ovaries and testis may also undergo malignant transformation.3 polyps serve as pathological lead point and patient presents with acute intestinal obstruction due to intussusception at an early age. intussusception and gastrointestinal bleeding are common presentations, which are commonly treated by resection of the diseased bowel.2 regular surveillances for associated cancers and longterm follow-up is necessary to decrease mortality and morbidity. here we report case of a young girl who presented with intestinal obstruction and jejunoileal intussusception due to multiple polyps. she had melanosis around the mouth and inside the buccal mucosa and on the digits. she was diagnosed as a case of peutz-jeghers syndrome. c a s e r e p o r t a 15-year-old female resident of dera ismail khan, khyber pakhtunkhwa (kpk) presented at emergency department of nishtar medical university and hospital, multan with c a s e r e p o r t j islamabad med dental coll 2019 157 complaints of generalized abdominal pain which was acute in onset, vomiting for 3 days, constipation and abdominal distention for 02 days. patient gave history about the presence of brown spots around the mouth and fingers since childhood. two other siblings were also having such spots. she did not give history of fever, weight loss or previous surgery. there was no previous history of pulmonary tuberculosis. patient was a non-smoker and not addicted to anything. her eating habits were nonsignificant. her clinical examination revealed a lean female of average height, with melanin spots around the mouth (figure 1a) and on the fingers (figure 1b). heart rate was 108/minute, blood pressure 100/60 mmhg and respiratory rate 28/minute. on palpation, abdomen was distended, tense and tender with intact hernial orifices. lymph nodes were not palpable. bowel sounds were absent. digital rectal examination was unremarkable. cns, respiratory system and cardiovascular examination was also unremarkable. her hemoglobin was 13.9 g/dl and total leukocyte count was 15,490/mm3. renal and liver function tests were normal. abdominal supine x-ray showed valvulae conniventes indicating small bowel obstruction. ultrasound abdomen revealed aperistaltic gut loops. chest x ray was unremarkable. figure 1: patient with peutz-jeghers syndrome exhibiting circumoral melanin spots (a) and digital melanosis (b) exploratory laparotomy revealed jejunoileal intussusception leading to jejunal dilatation and small bowel obstruction. about 75cm of the diseased portion of jejunum was resected and primary anastomosis done. the diseased portion was having six hamartomatous polyps largest one was approximately 3cm in size and the smallest was of 1 cm as shown in figure 2. patient was kept nil per oral and on intravenous fluids for four days. she was discharged on fifth postoperative day. her postoperative follow-up visit was uneventful. she was advised ultrasound breast, ct scan abdomen and referred to gynecologist to screen for associated cervical malignancy. the other family members were also advised to go for the screening studies for early detection and management of anticipated pathologies. figure 2: gross specimen of resected portion of jejunum showing hamartomatous polyps d i s c u s s i o n peutz-jeghers is an uncommon autosomal dominant syndrome which presents with very typical signs and symptoms and mutation of tumor suppressor gene, stk11/lkb1 on chromosome 9.4 melanin pigmentation first appears during infancy and increases until puberty. this pigmentation appears at buccal mucosa, vermillion border of the lip, tip of fingers, toes and perianal region. usually melanosis at buccal mucosa persists throughout life while melanin spots in other areas fade away. vermillion border of the lip is most commonly involved, followed by the buccal mucosa, fingers and toes.5 melanin spots were present on the vermillion border of the lips, fingers and toes in this patient (figure 1). the following who criteria as outlined by riegert-johnson et al6 were used for confirming the diagnosis of peutzjeghers syndrome: 1. any number of hamartomatous polyps, 2. family history of pjs, 3. prominent melanosis at mucocutaneous junctions j islamabad med dental coll 2019 158 in our patient there were multiple hamartomatous polyps, pigmentation of mucocutaneous junctions and a positive family history of pjs. patients with pjs usually presents with intestinal obstruction due to intussusception. hamartomatous polyps are not premalignant and are mostly located in small intestine, colon and stomach.7 the life-time risk of gastrointestinal and non-gastrointestinal cancers is high and strict surveillance is necessary for early detection.8 our patient presented with intestinal obstruction due to jejunoileal intussuseption without any malignancy. screening for git malignancy was previously done by barium studies and enteroclysis. however newer technologies such as gastroscopy, colonoscopy, double balloon enteroscopy and capsule endoscopy have now taken the role of surveillance tools for gastrointestinal pathologies.8 according to a study by kastrinos and colleagues, pancreatic carcinoma is a common cancer associated with pjs with 36% risk. regular screening of high-risk patients is done by ct scan and more reliably by endoscopic ultrasound on yearly basis.9 pap smear, transvaginal usg and mammography are also advised on a yearly basis2. we discharged our patient with the advice of regular followup and screening. family of the patient was also counseled and advised about the screening of other two siblings with melanin spots. c o n c l u s i o n peutz-jeghers syndrome is a rare autosomal dominant disorder with melanosis (circumoral, perianal and digital) and hamartomatous polyps (intestinal) as characteristic features of this disease. regular screening of all the family members is necessary due to a very strong association of breast, cervical, colonic and other cancers as early detection of these associated malignancies can save many lives. r e f e r e n c e s 1. lindor nm, mcmaster ml, lindor cj, greene mh. concise handbook of familial cancer susceptibility syndromes second edition, jnci monographs 2008; 2008(38): 3–93. doi: 10.1093/jncimonographs/lgn001 2. giardiello fm, trimbath jd. peutz-jeghers syndrome and management recommendations. clin gastroenterol hepatol. 2006; 4(4): 408–15. doi: 10.1016/j.cgh.2005.11.005 3. kopacova m, tacheci i, rejchrt s, bures j. peutz-jeghers syndrome: diagnostic and therapeutic approach. world j gastroenterol. 2009; 15(43): 5397–408. doi: 10.3748/wjg.15.5397 4. chae h-d, jeon c-h. peutz-jeghers syndrome with germline mutation of stk11. ann surg treat res. 2014. 86(6): 32530. doi: 10.4174/astr.2014.86.6.325 5. traboulsi ei, maumenee ih. periocular pigmentation in the peutz-jeghers syndrome. am j ophthalmol 1986; 102(1): 126-7. doi: 10.1016/0002-9394(86)90229-1 6. reiget-johnson d, roberts m, gleeson fc, krishna m, boardman l. case studies in the diagnosis and management of peutz-jeghers syndrome. fam cancer. 2011; 10: 463-68. doi 10.1007/s10689-011-9438-x 7. brito s., póvoas m., dupont j., lopes a. i. peutz-jeghers syndrome: early clinical expression of a new stk11 gene variant. bmj case reports. 2015; 2015: bcr2015211345. doi: 10.1136/bcr-2015-211345. 8. goverde a., korsse s. e., wagner a., et al. small-bowel surveillance in patients with peutz-jeghers syndrome: comparing magnetic resonance enteroclysis and double balloon enteroscopy. j clin gastroenterol. 2017; 51(4): e27– e33. doi: 10.1097/mcg.0000000000000592. 9. kastrinos f, mukherjee b, tayob n, wang f, sparr j, raymond vm, et al. the risk of pancreatic cancer in families with lynch syndrome. jama. 2009; 302: 1790–95. doi: 10.1001/jama.2009.1529. histopathological images diseases of thyroid gland fig 1a: photomicrograph of hashimoto’s thyroiditis showing lymphoid follicle formation (arrow) (h&e x 100) fig 2a: photomicrograph of hurthle cell adenoma showing prominent follicular growth pattern (h&e x 100) fig 3a: papillary thyroid carcinoma showing complex, branching papillae with fibrovascular cores (h&e x 100) fig 1b: photomicrograph of hashimoto’s thyroiditis showing hurthle cell change (arrow) (h&e x 100) fig 2b: photomicrograph of hurthle cell adenoma showing cells having abundant eosinophilic cytoplasm (h&e x 400) fig 3b: papillary thyroid carcinoma showing papillae lined by overlapping cells with intranuclear inclusions (arrow) (h&e x 400) diseases of kidney and urinary bladder fig 4a: chronic granulomatous inflammation of kidney showing collection of epithelioid cells forming granulomas (arrow) (h&e x 100) fig 5a: well-differentiated squamous cell carcinoma of kidney displaying infiltrating nests of squamoid cells (arrow) (h&e x 400) fig 6a: photomicrograph showing high-grade urothelial carcinoma (micropapillary variant) (h&e x 100) fig 4b: chronic granulomatous inflammation of kidney showing caseous necrosis surrounded by giant cells (arrows) (h&e x 100) fig 5b: well-differentiated squamous cell carcinoma of kidney displaying cellular pleomorphism, nuclear irregularity and keratinization (arrow) (h&e x 100) fig 6b: photomicrograph showing high-grade urothelial carcinoma (sarcomatoid variant) (h&e x 400) contributed by: prof dr. saeed alam, dr. huma mushtaq, dr. naima tariq department of pathology islamabad medical and dental college 29 j i m d c 2 0 1 8 29 open access f u l l l e n g t h a r t i c l e comparison of peritonsillar injection of lignocaine-adrenaline and normal saline (placebo) before tonsillectomy in terms of mean peroperative blood loss muhammad junaid 1, ghafoor shah 2, anjum khawar 3, muhammad roohullah 4, murad ali khan 5 1 senior registrar, ent, head & neck surgery, pakistan institute of medical sciences 2 consultant, ent, head & neck surgery, pakistan institute of medical sciences 3 chairperson, department of ent, head & neck surgery, pakistan institute of medical sciences 4 post graduate resident, ent, head & neck surgery, pakistan institute of medical sciences 5 post graduate resident, ent, head & neck surgery, pakistan institute of medical sciences a b s t r a c t objective: to compare peritonsillar injection of lignocaine-adrenaline and normal saline (placebo) before tonsillectomy in terms of mean peroperative blood loss. patients and methods: this randomized controlled trial was carried out at department of ent head and neck surgery, pakistan institute of medical sciences, islamabad study in six months’ time. a total of 60 patients were included in the study, their demographics data and clinical findings were noted. subjects were randomly divide in two groups (30 in each group). group a received injection of lignocaine-adrenaline in peritonsillar region and group b received normal saline (placebo), prior to tonsillectomy. blood loss in both groups during surgery was measured by means of gauze pieces used and suction bottle. results: both groups were assessed for intraoperative blood loss. despite marked reduction of blood loss in group a, the difference in two groups was not statistically significance (p-value=0.213) after applying independent sample t test. post-stratification student t test showed a statistical significance in the age groups 15 – 20 years (p-value=0.018). conclusion: our study concludes that the group injected with lignocaine-adrenaline in the peritonsillar area had a marked reduction in peroperative blood loss as compared to the group that was injected with normal saline (placebo). key words: author`s contribution 1 conception, synthesis, planning of research and 2 manuscript writing interpretation and discussion 3,4 data analysis, interpretation and manuscript writing, 5 active participation in data collection. address of correspondence muhammad junaid email: drjunaident@gmail.com article info. received: september 28, 2017 accepted: december 11, 2017 cite this article. junaid m, shah g, khawar a, roohullah m, khan ma. compare peritonsillar injection of lignocaine-adrenaline and normal saline(placebo) before tonsillectomy in terms of mean preoperative blood loss. jimdc.2018; 7(1):29-35 funding source: nil conflict of interest: nil i n t r o d u c t i o n tonsils are important components of the immune system and their infections are one of the most frequently involved diseases in humans. tonsils are immunologically more active in the first years of life.1 with aging, however lymphoid tissue regresses, subepithelial tissue changes into fibrotic tissue and crypts alter into cavities filled with keratin. in case of infection, bacteria that inhabit the crypts spread into the tonsil and leave their toxins and other products in it, eventually leading to polymorphponuclear leukocyte infiltration, swelling, necrosis and surface ulceration in tonsils. consequently, after acute infection, bacteria may inoculate into the core.2 o r i g i n a l a r t i c l e 30 j i m d c 2 0 1 8 30 these infections are highly frequent especially in childhood. although antibiotic therapy may be sufficient in the treatment of acute tonsillitis, tonsillectomy remains the treatment of choice in the management of recurrent and chronic tonsillitis.3 tonsillectomy is a surgical procedure in which each tonsil is removed from a recess in the side of the pharynx called the tonsillar fossa.4 the procedure is performed in response to repeated occurrence of acute tonsillitis, sleep surgery for obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess.5 for children, the adenoids (also known as a pharyngeal tonsil or nasopharyngeal tonsil) are usually removed, a procedure called adenoidectomy (or tonsilloadenoidectomy or adenotonsillectomy when combined). adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial. although tonsillectomy is performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children.6 tonsillectomy can be performed in many different ways depending on the preference and experience of the surgeon. generally, it may be divided into two stages: excision of the tonsil followed by control of bleeding. however, newer techniques combine these stages so that they are undertaken simultaneously. cold dissection tonsillectomy involves cutting the pharyngeal mucosa with scissors followed by blunt dissection of the tonsil from the lateral pharyngeal wall, employing no form of heat or cautery. hemostasis can then be achieved by ligatures or sutures.7 although tonsillectomy is a worthwhile surgical intervention when indicated,11 it is not without its complications. the most serious risk associated with the procedure is postoperative hemorrhage, and a multitude of reports have discussed its relationship to operative technique.12,13 different techniques have attracted controversy around their complication rates, in particular the incidence of hemorrhage. this controversy perseveres due to the difficulty in reliably proving or disproving a small difference in the rate of a relatively uncommon complication.14 several treatment options have been used to minimize per and post-operative complications, including steroids, analgesics, antibiotics, and have been shown to have some positive outcomes in randomized controlled trials. one of these techniques is injection of adrenaline and local anesthetic agent into the peritonsillar region to reduce blood loss during and after tonsillectomy.18 the current study was planned to compare peritonsillar injection of lignocaine-adrenaline and normal saline (placebo) before tonsillectomy in terms of mean peroperative blood loss. p a t i e n t s a n d m e t h o d s this study was conducted in the department of ent head and neck surgery, pakistan institute of medical sciences, islamabad. it was a randomized controlled trial carried out in 6 months. sample of 60 patients were calculated through who sample size calculator by using level of significance = 5% and power of test = 80%. percentage change used for group a (local anesthetic with adrenaline group) and b (saline group) was 21% and 55% respectively. patients of both genders, between 15 to 40 years of age undergoing tonsillectomy in ent department were included in the study. patients with acute infection of the nose, upper respiratory tract and paranasal sinuses and diabetic patients due to increased chances of infection and post-operative complications were excluded from the study. hypertensive patients, patient with bleeding diathesis and deranged coagulation profile due to increased risk of bleeding and pregnant ladies which are considered as relative contraindication for tonsillectomy were also excluded. an approval letter was taken from the hospital’s ethics committee prior to start of this study. patients were collected and admitted from the outdoor department of the ent department, pakistan institute of medical sciences islamabad. patient demographic data along with registration number were entered on performa. informed written consent was obtained from all patients preoperatively. after the informed consent, patients were randomly divided into two groups on lottery basis. group a was injected lignocaine-adrenaline and group b was given normal saline. total 3 ml of 2% lignocaineadrenaline (1:100000) was injected in tonsillar region on each side in group a. normal saline of equal amount was injected to group b. intra operative blood loss was calculated in ml and compared in both groups. total blood loss was measured from suction bottle and gauze pieces 31 j i m d c 2 0 1 8 31 used. we used gauze pieces of sizes 4x4 cm and 2x2 cm, which absorbed 10 ml ± 2 ml and 3.25 ml ±1.25 ml of blood at 100% saturation respectively. blood from the suction bottle was measured by subtracting the amount of normal saline in the bottle from total blood present in the bottle. the overall blood loss was measured by adding the amount of blood from suction bottle and amount of blood absorbed on gauze pieces. all the collected data was entered in statistical package for social sciences (spss). quantitative variable like age, blood loss was presented by mean and standard deviation. the qualitative variable like gender was expressed by frequencies and percentages. mean blood loss was compared between the two groups by applying independent sample t-test. effect modifiers like age & gender were controlled by stratification. post stratification student t-test was applied. p-value ≤ 0.05 was considered statistically significant. r e s u l t s out of total 60 patients, 31(51.1%) were male and 29 (48.3%) were female. in group a, female was 56.7 % (n=17) and male were 43.3 % (n=13). in group b, female was 40% (n=12) whereas male was 60 % (n=18). mean age of total 60 patients was 24.32±8.18 years with an age range from 15 to 40 years. in group a, mean age was 24.87±8.71 years whereas in group b mean age was 23.77±7.727 years. regarding age wise distribution maximum number of patients were in age group 15-20 year; 46.7% in group a and 50% in group b (table 1). table 1: number of patients with respect to age group (n=60) age group (years) group a (n=30) n(%) group b (n=30) n(%) combined (n=60) n(%) 15 – 20 14 (46.7) 15 (50) 29 (48.33) 21 – 25 3 (10) 4 (13.3) 7 (11.3) 26 – 30 4 (13.3) 4 (13.3) 8 (13.3) 31 – 35 4 (13.3) 3 (10) 7 (11.7) 36 – 40 5 (16.7) 4 (13.3) 9 (15) mean peroperative blood loss was measured in ml in both groups. in group a, minimum and maximum blood loss was 34 ml and 45.4 ml respectively. overall mean peroperative blood loss was 39.44±2.62 ml (table 2). in group b, 66.5 ml and 106.2 ml was the minimum and maximum blood loss. whereas the mean peroperative blood loss was recorded as 86.9±9.28ml (table 3). comparison of mean of both groups showed insignificant difference, p=0.21 (table 4). table 2: mean preoperative blood loss from right and left tonsillar fossa in group a (n=30) preoperative blood loss (ml) right tonsillar fossa left tonsillar fossa both minimum 15.7 16 34 maximum 25.2 25 45.4 mean±sd 19.87±2.831 19.57±2.293 39.44±2.62 table 3: mean peroperative blood loss from right and left tonsillar fossa in group b (n=30) peroperative blood loss (ml) right tonsillar fossa left tonsillar fossa both minimum 33.5 28.9 66.5 maximum 56.2 56.2 106.2 mean±sd 42.86±5.967 44.03±6.27 86.9±9.28 table 4: comparison of mean peroperative blood loss between groups (n=60) peroperative blood loss (ml) mean±sd group a group b 39.44±2.62 86.9±9.28 t-test for equality of means degree of freedom 28 mean difference 0.73303 s.e difference 3.478 95 % ci 5.657 – 7.586 p-value 0.213 for further analysis, the mean of peroperative blood loss in both groups was compared with respect to different age groups (table 5). in group a, the maximum mean peroperative blood loss was 32 j i m d c 2 0 1 8 32 observed in the age group 21 – 25 years whereas, the minimum mean peroperative blood loss was observed in the age group 26 – 30 years. in group b, the maximum mean peroperative blood loss was observed in the age group 26 to 30 years whereas the minimum mean intraoperative blood loss was observed in the age group 36 to 40 years. analysis showed significant comparison for the age group 15 to 20 years (table 5). table 5: comparison of peroperative blood loss between groups with respect to age groups (n=60) age group (years) peroperative blood loss (ml) mean±sd p-value group a group b 15 – 20 39.38±2.61 85.95±8.72 0.018 21 – 25 40.25±4.49 84.55±9.82 0.253 26 – 30 38.03±3.01 95.60±5.54 0.687 31 – 35 39.10±3.00 94.43±5.56 0.964 36 – 40 40.27±1.81 78.45±8.09 0.398 the mean peroperative blood loss was also analyzed with respect to gender. female were observed with slightly greater blood loss than male. a significant difference was observed between the male of two groups however, no significant difference was seen between the female of group a and group b (table 6). table 6: mean peroperative blood loss with respect to gender (n=60) gender peroperative blood loss (ml) mean±sd male female group a 38.73±2.66 39.95±2.66 group b 82.76±8.33 93.12±7.06 p-valuea 0.42 0.106 p-valueb 0.046 0.310 p-valuea with in each group, p-valueb between two groups. d i s c u s s i o n in the present study, a total of 60 patients were included. the mean age of these patients was 24.32 years (sd± 8.183) with an age range from 15 to 40 years. the peak incidence was observed in the age group 15 to 20 years. moonka conducted a study regarding tonsillectomy in india and reported the peak incidence of tonsillectomies in the age group 11 to 20 years.22 however, the number study subjects were large (n=376) as compared to our study subjects where 60 patients were enrolled for the study. another study conducted in iraq also reported the peak incidence of tonsillectomies in the age group 15 to 20 years (n=250).23 in our study, males formed the predominant gender 51.1 % (n=31) whereas, females constituted 48.3 % (n=29). dash conducted a study in iran and reported the dominance of males (58 %, n=27), females constituted 42 % (n=19) of the study.24 adoga and okeke in his study reported male predominance as 22 (59.5%) were males and 15 (40.5%) were females, giving a male-female ratio of 1.5:1.25 in the present study, we found that the mean peroperative blood loss in group a (pretreated with epinephrine: lignocaine) male was 38.7308 ml and in female it was 39.9882 ml. in the second group (pretreated with placebo) the blood loss was found to be 82.98824 ml in male and 92.01538 ml in female. the blood loss in males of both groups was statistically significant (p=0.046), however, the blood loss in females of both groups was statistically not significant (p=>0.05). similar to our results, broadman et al have demonstrated the benefits of using peritonsillar infiltration with adrenaline and concluded that, infiltrations should be performed with either normal saline containing epinephrine (1:200,000) or lidocaine containing epinephrine (1:200,000).26 rasgon et al. reported that dissection is easier with peritonsillar injections with epinephrine and that it can be used safely with the appropriate inhalation anesthetics.27 manikandan et al,28 reported from his study that, in males, the mean blood loss was 98.48 ml and in female it was 88.45 ml. though the blood loss was 10.03 ml more in male, it was not statistically significant (p > 0.05).28 rugglesand prasad’s work revealed that, the blood loss during adenotonsillectomy was comparatively less than tonsillectomy alone.29 since the tonsillectomy alone was performed in adults, blood loss was more in tonsillectomy alone group than adenotonsillectomy group. the mean of actual blood loss was 90.57 ml and the mean of estimated blood loss was 94.35 ml. the average blood loss of these two parameters was 92.46 ml.29 contradictory to our 33 j i m d c 2 0 1 8 33 results, prasad et al,30 reported from his study that average blood loss in male during tonsillectomy was 106.91 ml whereas the average blood loss in female during tonsillectomy was 96.26 ml.30 in cases of adenotonsillectomy, the average blood loss in males was 81.44 ml and that in female was 76.82 ml. the average blood loss (in milliliters) in male and female in the 5 – 9 years’ age group was 79.79 and 72.70, respectively, in the 10–14 year group, 84.23 and 78.12, in the 15–19 year group 92.63 and 81.96, respectively.31 callanan et al, reported a blood loss of 130 ml in tonsillectomies in their control group.31 boliston and upton, reported a blood loss of 152 ml in their control group.32 in the series by shalom33, the average blood loss in tonsillectomy in adults was 179.3 ml (range 7 5–349 ml).33 de reynier found an average loss of 165 ml in 12 adults, when the operation was performed under general anesthesia but only 16 ml when performed under local anesthesia.34 maier and bogue measured the blood loss by the swab weighing technique and found an average loss of 130 ml (range 20–449 ml).35 in ten cases the loss was over 200 ml. they found that the older the children the greater were the losses. ruggles36 measured blood loss in tonsillectomy and adenoidectomy by blood volume studies utilizing 51cr in 17 children.36 he found an average loss of 119 ml. mann et al,reported tonsillectomies by electrocoagulation, which markedly diminished blood loss.37 they also compared blood loss by electrocoagulation method (hot) versus dissection method (cold) in 95 patients. according to them average blood loss by hot method was 11.8 ml and in cold was 66.3 ml for each tonsil. carithen et al, reported that 1.2% of tonsillar hemorrhage and 3.2% of adenoidal hemorrhage were severe, though he has not assessed the exact quantity of blood loss.38 our study demonstrated a marked reduction in intraoperative blood loss by pretreatment with adrenaline: lignocaine injection in tonsillar region. prasad et al, pretreated patients, undergoing tonsillectomy, with antibiotics and reported that the average blood loss in 46 patients who received antibiotics was 80.75 ml whereas in the other group of 54 patients who had not received the antibiotics the average blood loss was 97.06 ml.30 it was observed that bleeding was less after an antibiotic course. imperfections of anesthetic technique, which produce laryngospasm, gagging or straining, may contribute materially to blood loss.39 the present study found that the group that received pretreatment with adrenaline: lignocaine injection prior to surgery had reduced amount of blood loss during surgery, compared to the other group. however, regarding our results, a lot of similarities and contradiction exists in literature. there is a need for further research in this regard to have clear guidelines in the management of intraoperative blood loss in tonsillectomies. c o n c l u s i o n the group that was injected with lignocaine-adrenaline in the peritonsillar area had a marked reduction in peroperative blood loss as compared to the group that was injected with normal saline (placebo). although the result was statistically not significant, yet the intraoperative blood loss in group a was decreased 50%, compared to group b. furthermore, the peroperative blood loss in the age group 15 to 20 years was statistically significant (p=0.018). considering the reduced potential in intraoperative blood loss, it is recommended that patients, especially teenagers, undergoing tonsillectomy should be injected with lignocaineadrenaline, prior to surgery, to minimize the rate of intraoperative blood loss. r e f e r e n c e s 1. uppal k, bais as. tonsillar microflora—superficial surface vs deep. the j laryngol& otol. 1989;103(02):175-7. 2. discolo ch, darrow pj, koltai kh. infectious indications for tonsillectomy. pediatrclin na. 2003;50(2):445-58. 3. gul m, okur e, ciragil p, yildirim i, aral m, kilic ma. the comparison of tonsillar surface and core cultures in recurrent tonsillitis. american journal of otolaryngology. 2007;28(3):173-6. 4. baugh rf, archer sm, mitchell rb, rosenfeld rm, amin r, burns jj, darrow dh, giordano t, litman rs, li kk, mannix me. clinical practice guideline tonsillectomy in children. otolaryngology--head and neck surgery. 2011;144(1 suppl): s1-30. 5. blakley bw, magit a. response to: the role of tonsillectomy in reducing recurrent pharyngitis: a systematic review, from jeremy hornibrook. otolaryngology--head and neck surgery. 2009 ;141(1):155-6. 34 j i m d c 2 0 1 8 34 6. marshall t. a review of tonsillectomy for recurrent throat infection. br j gen pract. 1998 ;48(431):13315. 7. roy a, de la rosa c, vecchio ya. bleeding following tonsillectomy: a study of electrocoagulation and ligation techniques. archives of otolaryngology. 1976; 102(1):9-10. 8. temple rh, timms ms. paediatriccoblation tonsillectomy. international journal of pediatric otorhinolaryngology. 2001; 61(3):195-8. 9. philpott cm, wild dc, mehta d, daniel m, banerjee ar. a double‐blinded randomized controlled trial of coblation versus conventional dissection tonsillectomy on post‐operative symptoms. clinical otolaryngology. 2005; 30(2):143-8. 10. fox r, temple m, owens d, short a, tomkinson a. does tonsillectomy lead to improved outcomes over and above the effect of time? a longitudinal study. the journal of laryngology & otology. 2008; 122(11):1197-200. 11. aouad mt, nasr vg, yazbeck-karam vg, bitar ma, khalil mb, beyrouthy o, harfouche d, terrin n, siddik-sayyid s. a comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatients children: a randomized trial. anesthesia and analgesia. 2012; 115(4):913. 12. windfuhr jp, yue-shih c. incidence of posttonsillectomy hemorrhage in children and adults: a study of 4,848 patients. ear, nose & throat journal. 2002; 81(9):626. 13. hilton m. tonsillectomy technique—tradition versus technology. the lancet. 2004; 364(9435):642-3. 14. sarny s, ossimitz g, habermann w, stammberger h. hemorrhage following tonsil surgery: a multicenter prospective study. the laryngoscope. 2011; 121(12):2553-60. 15. o'leary s, vorrath j. postoperative bleeding after diathermy and dissection tonsillectomy. the laryngoscope. 2005;115(4):591-4. 16. beigh z, ul islam m, ahmad s, pampori ra. effects of peritonsillar injection of tramadol and adrenaline before tonsillectomy. iranian journal of otorhinolaryngology. 2013; 25(72):135. 17. ergil j, akkaya t, gozaydin o, gunsoy b, alicura s, aladag e, gumus h, akin i̇. vasoconstrictive and analgesic efficacy of locally infiltrated levobupivacaine in tonsillectomy patients. international journal of pediatric otorhinolaryngology. 2012; 31;76(10):142933. 18. bameshki sa, salari mr, bakhshaee m, razavi m. effect of ketamine on post-tonsillectomy sedation and pain relief. iranian journal of otorhinolaryngology. 2015; 27(83):429. 19. ali ns, ikram m, akhtar s, moghira i, nawaz a, arain a. harmonic scalpel versus electrocautery tonsillectomy: a comparative study in adult patients. journal of the pakistan medical association. 2011;61(3):256. 20. khan ar, khan a, ali f, khan ns. comparison between silk ligation and bipolar cautery in tonsillectomy. gomal journal of medical sciences. 2007; 5(1). 21. wiatrak bj, woolley al. pharyngitis and adenotonsillar disease. otolaryngology head and neck surgery. 1998; 5:188-215. 22. moonka pk. ligation vs. bipolar diathermy for haemostasis in tonsillectomy—a comparative study. ind j otolaryngol head and neck surg. 2002; 54(1):35-8. 23. adel sa, ahmed sh. haemostasis during tonsillectomy silk ligation versus bipolar diathermy. med j babylon. 2010; 7(1):274-80. 24. beigh z, ul islam m, ahmad s, pampori ra. effects of peritonsillar injection of tramadol and adrenaline before tonsillectomy. iranian j otorhinolaryngol. 2013; 25(72):135. 25. adoga aa, okeke ed. hemostasis during cold dissection tonsillectomy: comparing the use of adrenaline and normal saline. j clin med res. 2011; 3(7):105-8. 26. broadman lm, patel ri, feldman ba, sellman gl, milmoe g, camilon f. the effects of peritonsillar infiltration on the reduction of intraoperative blood loss and post-tonsillectomy pain in children. laryngoscope. 1989; 99(6):578–581. 27. rasgon bm, cruz rm, hilsinger rl jr, korol hw, callan e, wolgat ra, selby jv. infiltration of epinephrine in tonsillectomy: a randomized, prospective, double-blind study. laryngoscope. 1991; 101(2):114–118. 28. manikandan d, musarrat f, preetham ap, anjali r. measurement of blood loss during adenotonsillectomy in children and factors affecting it. case rep clin med. 2015; 4(5):151 29. ruggles rl. blood loss during adenoidectomy and tonsillectomy measured with radioisotopes. annals of otology, rhinology & laryngology. 1960; 69(2):360-374. 30. prasad kc, prasad sc. assessment of operative blood loss and the factors affecting it in tonsillectomy and adenotonsillectomy. indian j otolaryngol head and neck surg. 2011; 63(4):343 8. 31. callanan v, curran aj, smyth da, gormley pk. the influence of bismuth subgallate and adrenaline paste upon operating time and operative blood loss in tonsillectomy. j laryngol otol. 1995; 109(3) :206– 208. 32. boliston ta, upton jj. infiltration with lignocaine and adrenaline in adult tonsillectomy. j laryngol otol. 1980; 94(11):1257–1259. 33. shalom as. blood loss in ear nose and throat operations. j laryngol otol. 1964; 78:734. 35 j i m d c 2 0 1 8 35 34. de reynier jp. hemorrhage during tonsillectomy. practotorhinolaryngol. 1959; 21(1):18– 23. 35. maier hl, bogue cr. measurement of blood loss during tonsillectomy and adenoidectomy. northwest med. 1960; 59:910–913. 36. ruggles rl. blood loss during adenoidectomy and tonsillectomy measured with radioisotopes. ann otol. 1960; 69:360. 37. mann dg, george cst, scheiner gd, imber p, mlynarczyk fa. tonsillectomy-some like it hot. laryngoscope. 1984; 94:677–679. 38. carithen js, gebhart de, williams jua, columbus oh. postoperative risks of paediatrictonsilloadenoidectomy. laryngoscope. 1987; 97(4):422–429. 39. holden hb, maher jj. some aspects of blood loss and fluid balance in paediatricadenotonsillectomy. br med j. 1965; 2:1349–1351. journal of islamabad medical & dental college (jimdc); 2012(2):93-96 93 original article frequency of enteric gram negative rods isolated from various clinical samples shamim mumtaz*, salma zafar** and mumtaz ahmad *** * professor of pathology, islamabd medical & dental college, islamabad ** assistant professor pathology, islamabad medical and dental college, islamabad *** associate professor, department of urology, rawalpindi medical college, rawalpindi, (bahria university, islamabad) abstract objective: to determine the frequency of gram negative rods in both nosocomial and community acquired infections in our setting. material and methods: this descriptive study was conducted at the microbiology department of fauji foundation hospital, rawalpindi over a period of two years (april 2004 to march 2006). all pus, urine, blood and hvs received during the study period were included. samples without properly filled forms, dried swabs and improperly transported samples were excluded. results: two thousand and ninety one enteric gram negative rods (egnr) were isolated over a period of two years. they were most commonly found in urine samples (40.7%), followed by pus (37.1%), hvs (12.0%), sputum (6.12%) and blood (3.92%) samples. the most common egnr isolated was escherichia coli (49.7%) followed by klebsiella pneumoniae (23.4%), pseudomonas aeruginosa (19.5%) and proteus species (1.81%). the most commonly isolated enteric gram negative rod from urine samples (n 852) was e. coli (622) followed by klebsiella pneumoniae (189), providentia (18) and enterobacter species (13). the most commonly isolated gram negative rod from pus samples (n 852) was pseudomonas aeruginosa (290) followed by e. coli (227), klebsiella pneumoniae (18) and proteus species. the most commonly isolated egnr from hvs samples was e. coli (130) followed by klebsiella pneumoniae (68) and pseudomonas aeruginosa (51). the most common egnr found in sputum (n 128) was klebsiella pneumoniae (56) followed by pseudomonas aeruginosa (40) and e. coli (30). in blood samples the most common organism isolated was e. coli, followed by pseudomonas and klebsiella. key words: escherichia coli, klebsiella pneumoniae, pseudomonas aeruginosa introduction the human life has always been in danger from diseases caused by microorganisms. the history still mourns the death toll of epidemics of influenza, plague & malaria which occurred during the 19th century. gram negative bacilli (gnb) are a common cause of sepsis, pneumonia, urinary tract infections, and post surgical infections in patients in acute care hospitals.1 during 1970s prevalence of nosocomial infections at specific sites has varied from survey to survey. gram negative bacilli and staphylococcus aureus were most frequently isolated from patients with hospital-acquired infection.2 during 1980s there has been a major shift in the etiology of hospital-acquired infections leading to an increase in the laboratory isolation of coagulase-negative staphylococci, candida, staph aureus, enterococci, pseudomonas aeruginosa and enterobacter spp.3 etiologic shifts in nosocomial infections and development of antimicrobial resistance among these pathogens, particularly those isolated from intensive care units are alarming.4 taken as a whole, the shifts are away from more easily treated pathogens towards more resistant pathogens with fewer options left for therapy.5 keeping in view the importance of egnr (especially e. coli, klebsiella, pseudomonas) as major pathogens, and the emerging resistance against the commonly used antibiotics, the present study was designed to determine the frequency of gram negative rods in our setting. material and methods this study was carried out in the department of microbiology, fauji foundation hospital rawalpindi, over a period of two years (april 2004 to march 2006). the clinical samples including pus, high vaginal samples, urine, blood and sputum, received from various indoor and outdoor departments were inoculated on the special and enriched media depending on the type of the sample and were identified by the help of standard procedures. the aerobically incubated organisms were identified with the help of colonial morphology, gram staining and biochemical analysis like tsi, indole, urease, citrate and api depending upon the availability.6 results two thousand, ninety one egnr were isolated over a period of two years. the samples received during the study period were: urine samples 852 (40.7 %), followed by pus samples journal of islamabad medical & dental college (jimdc); 2012(2):93-96 94 table 1; distribution of enteric gram negative rods in various samples organisms urine pus hvs sputum blood total no-% (no) (no) (no) (no) (no) % escherichia coli 622-73.0 227-29.1 130-51.5 30--23.4% 30-36.5 % 1039 49.7 klebsiella pneumoniae 189-22.0 171--2.31% 68-26.9% 56--43.7% 6--7.31% 490 23.4 pseudomonas aeruginosa 290-37.3% 51-20.2% 40-31.2% 26-31.7 % 407 19.5 proteus species 33-3.87 1 4 38 1.81 providencia species 18--2.1 11 29 1.38 enterobacter species 13--1.52 12 4 29 1.38 acinetobacter species 12 1 13 0.62 citrobacter species 6 2 1 9 0.43 salmonella species 6 2 8 0.38 morganella species 7 1 8 0.38 salmonella typhi 6 6 0.28 hafnia species 3 1 4 0.19 serratia species 1 2 1 4 0.19 aeromonas species 1 3 4 0.19 yersinia atypical 1 1 0.05 fusobacteria species 1 1 0.05 xanthomonas species 1 1 0.05 total 852 777 252 128 82 2091 fig 1; frequency of egnr in various samples 777 (37.1%) 128 (6.12%) 82 (3.92%) 2091 852 (40.7%) 0 500 1000 1500 2000 2500 urine pus hvs sputum bloo total 252 (12.0%) journal of islamabad medical & dental college (jimdc); 2012(2):93-96 95 777 (37.1%), hvs 252 (12.0%), sputum 128 (6.12%) and blood 82 (3.92%) (figure 1). most common egnr isolated were escherichia coli 1039 (49.7%) followed by klebsiella pneumoniae 490 (23.4%), pseudomonas aeruginosa 407 (19.5%), proteus species 38 (1.81%). the rare occurring organisms were hafnia species, serratia species, aeromonas species 04 (0.19%) each followed by yersini, fusobacteria, xanthomonas species 01 (0.05%) each. the most commonly isolated enteric gram negative rod from urine sample was e. coli 622 (73.0%) followed by klebsiella pneumonia 189 (22.0%), providentia 18 (2.1%) and enterobacter species 13 (1.52%). the most commonly isolated gram negative rod from pus sample was pseudomonas aeruginosa 290 (37.3%) followed by e. coli (227-29.1%), klebsiella pneumoniae 171 (2.31%) and proteus species (33-3.87%). among hvs sample the most frequent egnr was e. coli 130 (51.5%) followed by klebsiella pneumoniae 68 (26.9%), pseudomonas aeruginosa 51 (20.2%). the most frequently found egnr found in sputum was klebsiella pneumoniae 56 (43.7%) followed by pseudomonas aeruginosa 40 (31.2%) and e. coli 30 (23.4%). in blood samples e. coli was the most commonly isolated pathogen 30 (36.5 %) followed by pseudomonas aeruginosa 26 (31.7 %) and klebsiella 6 (7.31%) (table1). discussion two thousand, ninety one enteric gram negative rods (egnr) were isolated over a period of two years. egnr were most common pathogens isolated from urine samples (40.7 %), followed by pus samples (37.1%), hvs (12.0%), sputum (6.12%) and blood samples (3.92%). in a previous study conducted on different bacterial isolates, the frequency rates of causative bacteria in various types of infectious diseases were mentioned. significant urine culture isolates were e. coli and other enterobacteriaceae in uncomplicated uti, and pseudomonas spp. in complicated uti with a urinary catheter. in respiratory tract infections (rtis), p. aeruginosa, were among common causative organisms. in common with hospital-acquired pneumonia, p. aeruginosa, and enterobacteriaceae were the frequent microorganisms isolated.7 these results correlate to our study which has shown enteric gram-negative and related rods to be the most common isolates from different clinical samples. most common egnr isolated were escherichia coli (49.7%) followed by klebsiella pneumoniae (23.4%), pseudomonas aeruginosa (19.5%), and proteus species (1.81%). this is comparable to previous studies which have shown e. coli (61%) to be the most common pathogen followed by k. pneumoniae (22%), p. aeruginosa (4.0%), a. baumannii (3.0%) and citrobacter spp (2.0%). 8-10 the most commonly isolated enteric gram negative rod from urine sample is e. coli (73.0%) followed by klebsiella pneumoniae (22.0%), providentia (2.1%) and enterobacter species (1.52%). of the 920 tested sample, 100 samples showed growth of pathogens among which the most prevalent were e. coli (61%) followed by klebsiella spp (22%).10 in a study conducted in iran, isolated bacteria in urine were as follows : escherichia coli 72.9%; klebsiella pneumoniae 24.5%; citrobacter spp 1%; proteus mirabilis 0.6% and pseudomonas spp 1%. 11 the second most common sample from which gram negative rods were obtained in this study were pus samples (37.1%) followed by high vaginal swabs (12%), sputum samples (6.12%) and blood samples (3.92%). the most commonly isolated gram negative rod from pus sample is pseudomonas aeruginosa (37.3%) followed by e. coli (29.1%), klebsiella pneumoniae (2.31%) and proteus species (3.87%). the results in previous studies showed e coli (25-31%), k pneumoniae (9.5-10%) & pseudomonas (8.6-38).12-15 in another study frequencies of pathogens in primary surgical infections in an order of decreasing frequency were escherichia coli, pseudomonas aeruginosa, acinetobacter, klebsiella pneumoniae and others.15 the most commonly isolated gram-negative rod from hvs samples is e. coli (51.5%) followed by kleb. pneumoniae (26.9%) and pseudomonas aeruginosa (20.2%), comparable to a previous study where e. coli was 21%.16 chow et al and izhar et al also made similar observations, as e coli were the commonest organisms (25&45%), followed by k pneumoniae (18 & 25%), p aeruginosa (22 & 28.7%), acinetobacter spp (7% each) and enterobacter spp (7 & 11%).17,18 pseudomonas aeruginosa (30.3%) was the most frequent isolate among gram-negative organisms, followed by e coli (18.6%), k pneumoniae (16.9%), acinetobacter baumannii (8.8%) and enterobacter cloacae (7.1%).19 majority of the above mentioned organisms are normal flora of female genital tract and may not be implicated with disease production. it seems unlikely that the gynecological infections are caused by the same mechanism throughout the world. the members of normal flora may themselves produce disease under certain circumstances if introduced into foreign locations in large numbers and if predisposing factors are present. the most common egnr found in sputum was klebsiella pneumoniae (43.7% ) followed by pseudomonas aerugonisa ( 31.2% ) and e. coli ( 23.4% ) comparable to a study by jawad et al 2011 where most prevalent gram negative rods causing respiratory tract infections were klebsiella pneumoniae (21.4%) & p. aeruginosa (15.3%).20 whereas the prevalent pathogens in other studies were h influenzae (73%), moraxella catarrhalis (12%),and h parainfluenzae (5%), klebsiella spp (7.7%), and p. aeruginosa (2.9%).21,22 blood stream infections (bsi) revealed e coli (36.5 %) and pseudomonas aeruginosa (31.7 %) followed by klebsiella pneumoniae (7.31%). the results were comparable to other studies whereas e. coli (17.2-37%), klebsiella spp (6.39.6%), and pseudomonas aeruginosa (6.5%) were the predominant organisms.23 during 1997-2002, a total of 81,213 bsi pathogens from north america, latin america, and europe were tested for antimicrobial susceptibility. e. coli, were the most common bsi pathogens in all three regions each year.6 in other studies e coli (8.1-21%), pseudomonas spp (6.7-17%), acinetobacter spp (5-10%), journal of islamabad medical & dental college (jimdc); 2012(2):93-96 96 salmonella spp (3.8%) and miscellaneous group (9.2%) were the most common pathogens.24,25 in a study by mamishi et al, (2005) klebsiella spp (31%) were most predominant, followed by escherichia coli (21%) and pseudomonas aeruginosa (17%). decousser et al, (2003) established escherichia coli, as one of the major bacterial isolates in bsi.26,27 in a study by mehta et al, (2005), among the 567 qualifying samples, pseudomonas aeruginosa (19.75%), escherichia coli (15.17%), klebsiella pneumoniae (14.99%), and salmonella enterica serovar typhi (12.87%) were the most frequently isolated gram-negative bacteria.28 conclusion the sample showing gram-negative rods as a major pathogens were urine samples followed by pus samples. escherichia coli is the most common gram-negative rod isolated followed by klebsiella pneumoniae and pseudomonas aeruginosa. references 1. yan jj, ko wc, tsai sh, wu hm, wu jj. outbreak of infection with multidrug-resistant kleb. pneumoniae carrying bla (imp-8) in a university medical center in taiwan. j clin microbiol 2001; 39(12):4433-9. 2. john e. mcgowan jr. and maxwell finland infection and antibiotic usage at boston city hospital: changes in prevalence during the decade 1964–1973 journal of infectious diseases;129(4):421-428. 3. banerjee sn, emori tg, culver dh, gyanes rp, jarvis wr and horan t, edward jr et al. secular trends in nosocomial primary bloodstream infections in united states. am j med 1991; 16(91): 86-89. 4. hsueh pr, chen ml, sun cc, chen wh, pan hj, yang ls, chang sc, ho sw, lee cy, hsieh wc, luh kt. antimicrobial drug resistance in pathogens causing nosocomial infections at a university hospital in taiwan, 1981-1999. emerg infect dis 2002; 8(1):63-8. 5. schaberg dr, culver dh, gaynes rp. major trends in the microbial etiology of nosocomial infections. am j med 1991; 91(3): 72-5. 6. colles jg and miles rs. tests for identification of bacteria. in: practical medical microbiology. eds. collee jg, deguid jp, fraser ag and marmion bp.13th edition churchill livingstone edinburgh1989, pp141-15. 7. igari j current state of causative bacteria in infections diseases and trends in resistance to antimicrobial agents in nihon rinsho 1994; 52(2):297-302. 8. khan mt, shah sh. experience with gramnegative bacilli isolated from 400 cases of urinary tract infection (uti) in abbottabad. j ayub med col 2000; 12(4): 21-3. 9. kumamoto y, tsukamoto t, hirose t, yokoo a, fujime m, fujita k, shigeta s, et al. comparative studies on activities of antimicrobial agents against causative organisms isolated from patients with urinary tract infections; susceptibility distribution. jpn j antibiot.1999; 52(2):93-129. 10. akram m, shahid m , khan a. etiology and antibiotic resistance patterns of community-acquired urinary tract infections in j n m c hospital aligarh, india ann clin microbiol antimicrob 2007; 6: 4. 11. irajian g, jazayerimoghadas a. frequency of extendedspectrum beta lactamase positive and multidrug resistance pattern in gram-negative urinary isolates, semnan, iran. jundishapur j microbiol 2010; 3(3): 107-13. 12. arshad m, khan nu, ali n, afridi nm. sensitivity and spectrum of bacterial isolates in infectious otitis externa. j coll physicians surg pak 2004; 14(3): 146-149. 13. mumtaz s, akhtar n, hayat a. antibiogram of aerobic pyogenic isolates from wounds and abscesses of patients at rawalpindi. pakistan j med res 2002; 41(1): 16-18. 14. fazlul mkk, zaini mz, rashid ma, nazmul mhm. antibiotic susceptibility profiles of clinical isolates of pseudomonas aeruginosa from selayang hospital, malaysia biomedical research biomedical research 2011;22(3):263266. 15. arya m, arya pk, biswas d, prasad r. antimicrobial susceptibility pattern of bacterial isolates from postoperative wound infections. indian j pathol microbiol 2005;48(2):266-9. 16. khan i & khan ua. a hospital based study of frequency of aerobic pathogens in vaginal infections. j rawal med coll 2004; 29(1):22-25. 17. chow jw, satishchandran v, snyder ta, harvey cm, friedland ir, dinubile mj. in vitro susceptibilities of aerobic and facultative gram-negative bacilli isolated from patients with intra-abdominal infections world wide: study for monitoring antimicrobial resistance trends (smart). surg infect 2005;6(4):439-48. 18. izhar m, khan s, naqvi a. anti-microbial resistance among gram-negative bacteria prevalent in intensive care units. pakistan j surg 2001; 17(3):23-6. 19. kiffer c, hsiung a, oplustil c, sampaio j, sakagami e, turner p, mendes c. mystic brazil group. advisory group on antimicrobials and clinical microbiology, fleury institute, sao paulo, brazil. antimicrobial susceptibility of gram-negative bacteria in brazilian hospitals: the mystic program brazil. braz j infect dis 2003; 9(3):216-24. 20. ahmed j, jan ah, nawaz g and khan m. epidemiology and antibiotic susceptibility of bacterial isolates from northern pakistan african journal of microbiology research 2011; 5(28):4949-4955. 21. butt t, rafi n, ahmed s, ahmed rn, salman m, mirza sh. community-acquired bacterial pneumonias in rawalpindi. pakistan j pathol 2005; 16(1):14-6. 22. qureshi ah, qamar rh, hannan a. the prevalence of bacterial pathogens in throat infections and their susceptibility pattern. pak armed forces med j. 1997;47(1):34-6. 23. aftab r and iqbal i. bacteriological agents of neonatal sepsis in nicu at nishter hospital multan. j coll physicians surg pak 2006; 16(3): 216-19. 24. asrat d and amanuel yw. prevalence and antibiotic susceptibility pattern of bacterial isolates from blood culture in tikur anbassa hospital, addis ababa, ethiopia. ethiop med j 2001; 39(2):97-104. 25. butt t, afzal rk, ahmad rn, salman m, mahmood a, anwar m. bloodstream infections in febrile neutropenic patients: bacterial spectrum and antimicrobial susceptibility pattern. j ayub med coll 2004;16(1):18-22 26. mamishi s, pourakbari b, ashtiani mh, hashemi fb. frequency of isolation and antimicrobial susceptibility of bacteria isolated from bloodstream infections at children's medical center tehran iran 1996-2000. int j antimicrob agents 2005; 26(5):373-9 27. decousser jw, pina p, picot f, delalande c, pangon b, courvalin p, allouch p. the colbvh study group; frequency of isolation and antimicrobial susceptibility of bacterial pathogens isolated from patients with bloodstream infections: a french prospective national survey. j antimicrobchemother 2003; 51(5):1213-22 28. mehta m, dutta p, gupta v. antimicrobial susceptibility pattern of blood isolates from a teaching hospital in north india. jpn j infect dis 2005; 58(3):174-6 [ summary journal of islamabad medical & dental college (jimdc); 2016:5(3):99-99 99 editorial noninvasive follicular thyroid neoplasms with papillary like nuclear features (niftp) birth of a new entity-an attempt to prevent cancer overdiagnosis nasir saleem consultant histopathologist, international medical center, jeddah, saudi arabia there is a worldwide emphasis on preventing overdiagnosis of disease. overdiagnosis is defined as the diagnosis of a disease or condition that is unlikely to ever cause harm. 1 overdiagnosis is a huge problem which has serious consequences for the patients as well as health care system. for the patients, these include unnecessary treatment with consequent adverse effects and unnecessary monetary burden, as well as the psychological trauma. for health care system, it causes waste of precious resources and unduly increased work load for the health professionals. such is the global concern for this problem that since 2013, health professionals from all around the world gather for “preventing overdiagnosis” conference, held every year. cancer overdiagnosis has a much greater potential for harm due to its enormous psychological trauma, arduous treatment protocol, rife with life threatening complications and staggering cost for the patient and healthcare system. 2 as a result, work is ongoing in various fields to identify cancers which have excellent prognosis and have shown to have an indolent disease-free course, with prolonged clinical trials. one such success story is recent revision of nomenclature for „encapsulated follicular variant of papillary thyroid carcinoma (efvptc).” for a long time, it was felt that efvptc has a much more indolent behavior than its infiltrative counterpart. but traditionally, all tumors with characteristic nuclear features of papillary thyroid carcinoma (ptc) were designated as carcinomas and treated as such. to address this issue, an international panel of expert pathologists and clinicians from around the world were assembled to review a set of cases with adequately long follow-up, to see if this group can be re-classified according to its behavior. 3 the endocrine pathology society working group, comprising of 24 experienced thyroid pathologists from 7 countries, reviewed 268 cases of efvptc. these cases were divided into 2 groups, those with capsular or vascular invasion and those showing no invasion. the results of this study showed that patients with noninvasive efvptc, followed up for a median period of 13 years, were all alive and disease-free despite the fact that majority of these patients did not undergo total thyroidectomy and none received radioactive iodine (rai). the study recommended that this group of cases should not be designated as “carcinoma” and proposed the term, “noninvasive follicular thyroid neoplasms with papillary-like nuclear features” (niftp). 3 the study and its recommendations have been hailed around the world as a step in the right direction. most centers dealing with thyroid cancer cases are now using this terminology and have modified their treatment protocols. it is however imperative that this diagnosis should only be rendered after extensive, preferably entire / complete sampling of the capsule, to rule out any focus of invasion. an important related issue, not directly addressed in this study, is the diagnosis of these lesions on fine needle aspiration (fna) cytology. traditionally, on fna cytology, lesions showing cells with characteristic nuclear features of ptc, but with follicle formation without any papillary structures, were diagnosed as follicular variant of papillary thyroid carcinoma or suspicious for malignancy, since they were considered as carcinoma whether they were invasive or noninvasive. but now, since it has been established that this group termed niftp is not malignant, such lesions on fna should be labeled as suspicious for malignancy or follicular neoplasm/suspicious for a follicular neoplasm 4 with a comment that differential diagnosis includes fvptc, efvptc and niftp. this important development will hopefully further invigorate efforts to identify cancers which are being over diagnosed and to re-classify them, in order to remove the psychological stigma, and to reduce treatment related adverse effects and medical expenses. references 1. walker mj, rogers w. defining disease in the context of overdiagnosis. med health care philos. 2016 nov 15. [epub ahead of print]. 2. welch hg, blackwc. overdiagnosis in cancer. j natl cancer inst. 2010;102(9):605-13. 3. nikiforov ye, seethala rr, tallini g, et al. nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma: a paradigm shift to reduce overtreatment of indolent tumors. jama oncol 2016;2:1023-9. 4. pusztaszeri m, rossi ed, auger m, et al. the bethesda system for reporting thyroid cytopathology: proposed modifications and updates for the second edition from an international panel. acta cytol 2016;60:399-405. j islamabad med dental coll 2020 182 open access issues in clinical learning environment among undergraduate nursing students in khyber pakhtunkhwa, pakistan asghar khan1, hamida begum2 1 principal, pak-swiss nursing college swat, khyber pakhtunkhwa, pakistan 2 nursing instructor, school of nursing bannu, khyber pakhtunkhwa, pakistan a b s t r a c t background: nursing students apply theoretical and evidence -based knowledge on real patients in clinical placements, thus poor clinical education may affect their performance along with patient care. the perceptions of nursing internees may serve as a solid evidence of issues in clinical learning. the objective of this study was to identi fy issues regarding clinical learning among undergraduate nursing students. material and methods: a descriptive cross-sectional design was employed to collect data from a sample of 72 graduated nursing internees from nursing colleges in the khyber pakhtunk hwa (kpk) province of pakistan. this study was conducted from april 2019 to august 2019. a questionnaire in the form of likert scale was developed for data collection regarding past experiences of their undergraduate studies. spss 22 was used for analysis. chi-squared test was used to compare between male/female, public/private clinical placements and public/private colleges, respectively . results: of the participants 79% (n=57) were male and 21% (n=15) were female. mean age of participants was 24.29±1.72 years. four barriers in clinical education due to deficiencies in educational institutions included: shortage of clinical teachers (76.4%), clinical teachers rarely visited students (75%), too many students were supervised by a single teacher (81.9%) and students are overloaded with too many written assignments (75%). the p-value for shortage of clinical teachers was statistically significant (p=0.016). the main barriers in clinical education attributed to clinical settings or the hospitals were behavior of the hospital staff resulting in the loss of students’ confidence (73.6%) and anxiety of students to perform wrong procedures (73.6%). however, none of these barriers in clinical education were statistically significant (p>0.05). conclusions: findings of the study illustrated dissatisfaction of graduate nursing internees regarding the clinical education as almost all the issues received more than 50% responses . key words: clinical placement, clinical nursing teacher, nursing internees, student nurses authors’ contribution: 1,2 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: asghar khan email: asghar802@gmail.com article info: received: november 29, 2019 accepted: september 16, 2020 cite this article. khan a, begum h. issues in clinical learning environment among undergraduate nursing students in khyber pakhtunkhwa, pakistan. j islamabad med dental coll. 2020; 9(3): 182-189. doi: 10.35787/jimdc.v9i3.467 funding source: nil conflict of interest: nil i n t r o d u c t i o n undergraduate nursing education consists of two interrelated elements: theoretical domain and practical training or clinical domain.1,2 in clinical education, nursing students acquire, develop and or i gi n a l a r ti c le j islamabad med dental coll 2020 183 gain practical skills and experiences and associate them to theoretical knowledge to resolve the complex problems of patient and to provide safe care with critical thinking.3 clinical placements are the learning environments that comprise of staff nurses, doctors, paramedical staff, constant shift changes, patients’ families and patients4 with complex medical and nursing needs. 5 therefore, clinical learning serves as an integral part of nursing curriculum in order to provide nursing students the opportunities to practice and become competent in the knowledge and skills which are important for professional practices.6 literature has identified a range of hindrances to clinical learning including anxiety of possible criticism from other students, committing mistakes, communication with health care team and patients, approach to critically ill patients, the inappropriate behavior of clinical staff nurses,7 ward environment, the culture and complexities of care and the supervisory relationship between students, clinical and educational institutions.8 poor learning environment has adverse effects on the professional development process, and its dynamic nature could pose challenges to the students.1 various studies have reported the failure of clinical settings and even claimed it as a source of stress, resulting in feelings of fear and anxiety, ultimately affecting the students’ responses to learning.8 consequently, the poor learning environment negatively affects patients’ care. 9 thus, there is a need for empirical and contextual evidence of clinical learning issues, in order to provide guidance for reforms in the nursing curricula, policy making for clinical rotations and decision making for clinical placement. the previous literature on the subject revealed both quantitative and qualitative studies but we did not find indigenous study regarding clinical learning based on perceptions of nursing internees. the nursing internees-based information may be more reliable due to the recent clinical exposure and their ability to recollect past experiences as a student. nursing education in pakistan includes two programs i.e. three years diploma in nursing (general nursing) and four years bachelor of science in nursing (bscn). during graduation, student nurses are required to complete specific hours on clinical placements according to the curriculum. during clinical placements, the students are supervised by the college faculty members and the hospital nursing staff. upon graduation, students need to complete one year of practical training as an internee under supervision of the hospital. in clinical placements, students confront multiple challenges stemming from clinical settings as well as from educational institutions. this study was designed to identify the barriers or problems encountered by the nursing students in clinical settings during the four-year undergraduate training period leading to graduation. the purpose of the study was to highlight clinical problems of undergraduate student nurses. the results of the study may be used to reorganize clinical practice by nursing teachers and educational institutions. m a t e r i a l a n d m e t h o d s a descriptive cross-sectional study design was used. data was collected from the bscn internees about their pre-graduation clinical experiences at nursing colleges of khyber pakhtunkhwa, pakistan, working under supervision of experienced nurses. this study was conducted from april 2019 to august, 2019. the sample comprised of 72 graduate nursing internees selected through census sampling technique. all nursing graduates in their internship, working in kpk were included in the study. those nursing internees who had exceeded longer than one year of duration between the completion of graduation and the beginning of internship were excluded from the study. ethical consent (psnc-eth-03) was taken from the ethical committee of pak-swiss nursing college, j islamabad med dental coll 2020 184 swat. data was collected through a pre-tested, selfdesigned, structured questionnaire ( cronbach's alpha=0.81). written informed consent was obtained from all the participants. they were fully informed of the purpose of the study and they had the right to refuse. the questionnaire was divided into three parts i.e. demographic data, clinical setting-related issues and college-related issues. it was in the form of likert scale, having options; strongly agree, agree, disagree and strongly disagree. likert scale responses were reduced to dichotomy “strongly/agree and disagree/strongly disagree” into agree and disagree in order to minimize differences in extreme responses and for simplification of analysis.10 agreement of participants’ opinion was considered as alarming barrier when ≥70% responded with agreed/strongly agreed. statistical package for social sciences (spss) software version 22 was used for analysis of data. descriptive statistics were utilized for demographic data including frequencies, and percentages. chisquared test was used to analyze the relationship of clinical issues and gender as well as organizations. analyses were performed between independent variable, organization (public and private) and the dependent variable i.e. barriers to clinical learning. a p-value of less than 0.05 was considered statistically significant. r e s u l t s the participants of this study consisted of 72 bsc nursing internees. the mean age of participants was 24.29±1.72 years (age range 22-34 years). table ii illustrates the barriers in clinical education attributed to deficiencies in clinical settings or the hospitals which the students had attended for their clinical practice. the alarming barriers were behavior of the hospital staff resulting in the loss of students’ confidence (73.6%) and anxiety of students to perform wrong procedures (73.6%). almost all of the barriers were equally present in both genders, public/private colleges and in public/private hospitals. a greater proportion of females as compared to males agreed that there was a shortage of patients (p=0.008). majority of the students from private colleges agreed that fundamental facilities were deficient in the clinical placement (p=0.043), experience on the first day of the clinical placement was not positive for the rest of the duration (p=0.031) and the learning resources were inadequate in the clinical areas ( p=0.003). table iii reveals barriers in clinical education due to deficiencies in educational institutions. four alarming barriers were reported by the participants: shortage of clinical teachers (76.4%), clinical teachers rarely visited students (75%), too many students were supervised by a single teacher (81.9%) and students were overloaded with many written assignments (75%). most of these barriers existed equally in male/female perceptions, public/private colleges and public/private clinical placements. all the female internees reported the shortage of clinical teachers (p=0.016). table i: demographic characteristics of the study participants demographic variables n (%) gender male 57 (79) female 15 (21) clinical placement public 31(43) private 41(57) nursing colleges public 15(21) private 57(79) d i s c u s s i o n findings of the current study revealed that majority of the students agreed with the existence of barriers in clinical settings through their responses, which gives an overall impression of dissatisfaction. moreover, only six of the issues were identified to be alarming. these issues may compromise learning environment with a negative impact on patients’ care. j islamabad med dental coll 2020 185 *significant with p-value of ˂0.05 table-ii: clinical setting barriers and their association with male/female, public/private colleges and public private hospitals s. no clinical issues responses x2 of demographic agree n (%) disagree n (%) m a le / f e m a le p u b li c/ p ri v a te c o ll e g e s p u b li c/ p ri v a te h o sp it a ls 1 adequate equipment was not available 42 (58.3) 30 (41.7) 0.883 0.106 0.658 2 hospital staff did not provide accurate information 47 (65.3) 25 (34.7) 0.089 0.899 0.703 3 hospital staff’s behavior made you lose your confidence 53 (73.6) 19 (26.4) 0.179 0.528 0.524 4 hospital staff was not cooperative 44 (61.1) 28 (38.9) 0.197 0.620 0.645 5 the hospital environment was not clean 39 (54.2) 33 (45.8) 0.610 0.216 0.921 6 fundamental facilities (drinking water, lift, wheelchair, and toilets) were not available 31(43.1) 41(56.9) 0.366 0.043* 0.202 7 the first day experience was positive for the rest of the clinical duration 37 (51.3) 35 (48.6) 0.866 0.031* 0.974 8 preceptor did not regularly supervise us in actual patient situations 39(54.2) 33(45.8) 0.512 0.942 0.392 9 the hospital nursing staffs did not supervise us efficiently 47 (65) 25 (34.7) 0.275 0.899 0.703 10 the hospital staff discourage d us to seek guidance from them in clinical duration. 38 (52.7) 34 (47.2) 0.594 0.594 0.435 11 the patient’s relatives were not cooperative 38 (52.7) 34 (47.2) 0.529 0.529 0.863 12 felt anxiety to perform wrong procedure 53 (73.6) 19 (26.3) 0.493 0.179 0.658 13 inappropriate behavior by doctors and nurses with nursing teacher and student 48 (66.6) 24 (33) 0.538 1.00 0.064 14 lack of opportunities to practice or not allowed taking part in practice according to objectives 47 (65.2) 25 (34.7) 0.275 0.275 0.537 15 the students were assigned inappropriate and heavy workload by the hospital staff. 47 (65.2) 25 (34.7) 0.899 0.899 0.537 16 the learning resources were inadequate in the clinical areas 43 (59.7) 29 (40.2) 0.571 0.003* 0.088 17 there was shortage of patients in the clinical areas 19 (26.3) 53 (73.6) 0.008* 0.493 0.524 18 non supportive environment due to many patients in the clinical areas 40 (55.5) 32 (44.4) 0.846 0.052 0.558 19 inadequate ppe (personal protective equipment) exposed to infection in the clinical areas 42 (58.3) 30 (41.6) 0.303 0.462 0.355 20 there was lack of coordination between the college and hospital 43 (59.7) 29 (40.2) 0.247 0.980 0.814 21 the clinical placement did not contribute to increase awareness for my future nursing role 45 (62.5) 27 (37.5) 0.410 0.330 0.424 j islamabad med dental coll 2020 186 table iii: institutional barriers and their association with gender, public/private colleges and hospitals s. no educational institutional issues responses x2 of demographic agree n (%) disagree n (%) m a le / f e m a le p u b li c/ p ri v a te c o ll e g e s p u b li c/ p ri v a te h o sp it a ls 1 inadequate information from the college to prepare us well for clinical work 39 (54.2) 33 (45.8) 0.512 0.610 0.392 2 inadequate teaching and skill training in the college to prepare us for clinical 29 (40.3) 43(59.7) 0.538 0.980 0.471 3 lack of supervision from the teacher to contribute to increased learning 39 (54.2) 33 (45.8) 0.942 0.942 0.564 4 there was inadequate guidance from the teachers to take initiative 36 (50) 36 (50) 0.147 0.772 0.475 5 assignments from the college were not consistent with learning opportunities at the clinical area 31(43.1) 41(56.9) 0.788 0.788 0.427 6 there was lack of cooperation from other students at the clinical area 40 (55.6) 32 (44.4) 0.330 0.436 0.709 7 the teachers did not evaluate students fairly 44 (61.1) 28 (38.9) 0.275 0.059 0.606 8 students were anxious about starting clinical practice 50 (69.4) 22 (30.6) 0.713 0.372 0.807 9 the students were afraid of criticism by clinical teachers 50 (69.4) 22 (30.6) 0.319 0.793 0.201 10 there was lack of competency of clinical teachers. 44(61.1) 28(38.9) 0.092 0.620 0.316 11 lack of guidelines for nursing practice or uneasiness in the working climate 49(68.1) 23 (31.9) 0.897 0.622 0.575 12 clinical teachers were not well prepared 49(68.1) 23 (31.9) 0.622 0.082 0.645 13 shortage of clinical teachers or someone to guide in clinical area 55 (76.4) 17 (23.6) 0.016* 0.711 0.858 14 clinical teachers rarely visited students in the clinical areas 54 (75) 18 (25) 0.065 0.615 0.216 15 too many students were supervised by a single teacher 59(81.9) 13(18.1) 0.197 0.826 0.108 16 students were overloaded with too much written assignments by the clinical teacher 54 (75) 18 (25) 0.615 0.132 0.216 * significant with p-value of ˂0.05 thus, the confidence and competence of nursing students will be reduced which is crucial for their professional development. the chi square test results show that majority of problems exist equally in all groups i.e. male/female, public/private hospitals and public/private colleges. the institutional based problems included shortage of clinical teachers, rare interaction of clinical teachers with students, too many students being supervised by a single teacher and the students being overburdened with too many written assignments. all the female internees reported the shortage of clinical teachers (p=0.016). the clinical settings or the hospital-based problems included behavior of the hospital staff resulting in the loss of students’ j islamabad med dental coll 2020 187 confidence and anxiety of students to perform wrong procedures. hart and rotem have defined the clinical learning environment as the attributes of the clinical work setting, which the nursing staff perceives to improve their professional development.7 researchers have discussed the dynamic nature of the clinical environment. they argue that students learning in the clinical environment is unpredictable and far beyond the control of faculty members. 8 therefore, a close collaboration is expe cted between the clinical staff and clinical teachers for the accomplishment of clinical practice, students’ satisfaction and competence. this fact has been highlighted by majority of students in the current study as they reported that the behavior of the hospital staff resulted in the loss of their confidence. the students provide care to the patients but they are not independent. these students need emotional support from the clinical staff as reported by chin from a previous study that students are concerned about the reaction of the health care staff to their efforts.7,11 literature illustrates that collaboration between clinical placement and educational institutes enhance nursing education, thereby ensuring accomplishment of learning outcomes.12 the anxiety level of students increases when they are sent to clinical placements to work with real patients after gaining theoretical knowledge. 9 in the current study, 73.6% of the respondents reported that they felt anxiety out of fear that they would perform wrong procedures. the clinical environment may cause anxiety in students due to the working process, the healthcare environment, the healthcare staff, fear of making errors, 13 and being evaluated by clinical teacher.14 in order to reduce their anxiety level, it is important for them to practice adequately in skill laboratory. low level of anxiety improves learning by improving self confidence. various studies have illustrated the factor of anxiety in the clinical setting of the nursing students.8,11,14,15 the factor of anxiety may also be minimized by increased collaboration between nursing institution and the staff of clinical placement and by the presence of a clinical teacher in the hospital. the shortage of qualified nurses in pakistan has challenged educational institutions to hire and retain the best qualified faculty staff. this shortage of clinical faculty affects the clinical learning environment directly. students in the current study have reported the shortage of clinical teachers as an alarming issue in nursing education. phillips et al. have also highlighted the shortage of clinical faculty.6 furthermore, they have identified the reasons for faculty shortage including lower compensation of faculty nurses compared to clinical nurses, less attractive position of faculty members, aging nursing faculty, and lack of facilities for nurses to obtain higher education.6 students in the current study have also reported that clinical teachers rarely visit them in clinical placement and too many students are supervised by a single clinical teacher as an alarming barrier. a study conducted in china demonstrated uncertainty among students in relation to what they could expect from the clinical teachers.16 in contrast to these findings, some studies have demonstrated positive perceptions of students regarding their clinical teacher. 17 few studies support the perceptions of these students and suggest that the number of students under a clinical teacher must be low.7 it is the responsibility of clinical teacher to identify students’ needs and work with clinical staff to foster a best possible environment conducive to undergraduate nursing students’ learning.15,18 some of the studies which reported the positive perceptions regarding clinical teachers have been conducted in countries where nursing is a developed profession. additionally, there is lesser shortage of qualified nurses and the work burden is low. the poor situation in clinical learning environment in relation to faculty can be j islamabad med dental coll 2020 188 improved by facilitating higher education. consequently, the shortage of clinical faculty may be minimized. clinical teachers rarely visit their students on clinical placement due to huge burden on them.19 this issue can be minimized by hiring an increased number of faculty in the educational institutions. extensive research is needed especially interventional,20 in order to produce deeper understanding of the inherent issues in the clinical learning environment. this would help in transforming the current situation to improve the level of satisfaction and thus produce skilled, qualified and professional nurses. limitation: during this study, the major limitations was a small sample because of a small target population, thus limiting generalizability of the study findings. moreover, census sampling technique was used instead of the probability sampling clinical learning environment, as the latter technique would have been more useful if we had a larger population of nursing interns. c o n c l u s i o n the current study concluded that nursing internees were not satisfied with the clinical learning environment comprising of issues related to clinical placements and nursing educational institutions. a concerted effort is required by the educators to modify nursing curriculum, improve collaboration with the management and nursing staff of the hospital and reduce the shortage of clinical faculty in the nursing institutions. otherwise, the chances of producing highly skilled, knowledgeable and professional nurses may be reduced. a c k n o w l e d g m e n t the authors express their gratitude to all the participants of this study, and to mr. ayaz khan, nursing manager of northwest general hospital and research center, for his utmost cooperation in the collection of data. r e f e r e n c e s 1. jamshidi n, molazem z, sharif f, torabizadeh c, kalyani mn. the challenges of nursing students in the clinical learning environment: a qualitative study. sci world j. 2016; id: 1846178. doi: 10.1155/2016/ 1846178 2. gemuhay hm, kalolo a, mirisho r, chipwaza b, nyangena e. factors affecting performance in clinical practice among preservice diploma nursing students in northern tanzania. nurs res pract. 2019; id: 3453085. doi: 10.1155/2019/3453085 3. farzi s, shahriari m, farzi s. exploring the challenges of clinical education in nursing and strategies to improve it: a qualitative study. j educ health promot. 2018; 7: 115. doi: 10.4103/jehp.jehp_169_17 4. mohamed n, mokadem el, ibraheem se. nursing students' satisfaction with their clinical learning environments. am j nurs res. 2017;5(4):104–8. doi: 10.12691/ajnr-5-4-1 5. stenberg m, carlson e. swedish student nurses’ perception of peer learning as an educational model during clinical practice in a hospital setting — an evaluation study. bmc nurs. 2015; 14(1): 48. doi: 10.1186/s12912-015-0098-2 6. phillips kf, mathew l, aktan n, catano b. clinical education and student satisfaction: an integrative literature review. int j nurs sci. 2017;4(2):205 –13. doi:10.1016/j.ijnss.2017.03.004 7. kapucu s, bulut h. turkish nursing students’ views of their clinical learning environment: a focus group study. pak j med sci. 2011;27(5):1149 –53. 8. papastavrou e, lambrinou e, tsangari h, saarikoski m, leino-kilpi h. student nurses experience of learning in the clinical environment. nurse educ pract. 2010; 10(3): 176–doi:10.1016/j.nepr.2009.07.003 9. makhlof eha, el-saman sea. internship nurses’ satisfaction with clinical learning environment in intensive care unit. iosr-jnhs. 2017; 6(2): 112–9. doi:10.9790/1959-060205112119 10. machaczek k, whietfield m, kilner k, allmark p. doctors' and nurses' perceptions of barriers to conducting handover in hospitals in the czech republic. am j nurs res. 2013; 1(1):1 –9 j islamabad med dental coll 2020 189 11. chan d. development of the clinical learning environment inventory: using the theoretical framework of learning environment studies to assess nursing students’ perceptions of the hospital as a learning environment. j nurs educ. 2002;41(2):69– 75. doi: 10.3928/0148-4834-20020201-06 12. phuma-ngaiyaye e, bvumbwe t, chn m, chipeta mc. using preceptors to improve nursing students’ clinical learning outcomes: a malawian students ’ perspective. int j nurs sci. 2017; 4(2): 164 –8. doi:10.1016/j.ijnss.2017.03.001 13. pajnkihar m, fekonja z. self-reflection during first clinical practice : the experiences of nursing students. nurse educ today. 2019; 72(2018): 61 –6. doi: 10.1016/j.nedt.2018.10.019 14. sharif f, masoumi s. a qualitative study of nursing student experiences of clinical practice. bmc nursing 2005; 4(1):7. doi: 10.1186/1472 -6955-4-6 15. ahmad n, hamidah n, anwar k. nursing stude nts and clinical instructors’ perceptions of clinical learning environments, supervision, and teaching (cles-t) . ijcs. 2018; 1(1): 10–3. 16. liu zx, liu xs, liu h, song yl. nursing undergraduates’ satisfaction of the clinical learning environment in china. international conference on informatio n , computer and education engineering (icicee). 2017; 143–149. doi: 10.12783/dtcse%2ficicee2017% 2f17136 17. meyer g, nel e, downing c. basic student nurse perceptions about clinical instructor caring. heal sa gesondheid. 2016; 21(1): 444–52. doi: 10.4102/hsag .v21i0.1007 18. moscaritolo lm. interventional strategies to decrease nursing student anxiety in the clinical learning environment. j nurs educ. 2009; 48(1): 17 – 24. doi: 10.3928/01484834 -20090101-08 19. khan a, begum h, rehman au, khan a. experiences of healthcare students and the challenges posed by their clinical learning environment. cejnm. 2020;11(1): 19–24. doi:10.15452/cejnm.2020.11. 0004 20. kurian rn, james mm. assessment of level of satisfaction of student nurses with their clinical learning environment in a selected college of nursing in new delhi, india. int j curr res. 2017; 9(12): 62589– 92 j islamabad med dental coll 2019 65 open access the expression of progesterone receptors in meningiomas of different grades mohammad tahir 1, tehreem atif 2, summaya sohail 3, arfa nawazish 4, huma mushtaq 5 1 associate professor, department of pathology, rawal institute of health sciences, islamabad 2 specialty doctor (histopathology), glan clywd hospital.wales.uk 3 md resident (histopathology), pakistan institute of medical sciences, islamabad 4 specialty doctor, anatomical pathology, australian clinical labs, perth, australia 5 associate professor, department of pathology, islamabad medical & dental college a b s t r a c t background: meningiomas are slow growing intracranial and intraspinal neoplasms with a tendency to recur locally. who grades them as i (benign), ii (atypical) and iii (anaplastic) in order of their increasing aggressiveness, based on histological parameters and brain parenchymal invasion. progesterone receptors (pr) are more prevalent amongst the lower grade meningiomas. the objective of this study was to determine the immunohistochemical expression of progesterone receptors in meningiomas of different grades. material and methods: a total of 100 cases were selected over a period of 2.5 years. three to five microns’ thick sections stained with hematoxylin and eosin were examined microscopically by a team of two histopathologists and graded into grades i, ii and iii, according to 2016 who classification criteria. another section of the original tumor was stained with progesterone receptor antibody using the conventional immunoperoxidase method. stained slides were than examined by the same team of histopathologists and declared positive (if nuclear staining was observed in more than 10% of tumor cells) or negative. statistical analysis was done using spss version 21. results: out of a total of 100 cases of meningioma, there were 79 cases of benign/typical who grade i, 15 cases of atypical/ who grade ii and 6 cases of anaplastic/ who grade iii tumor. pr status was positive in 89.8 % (71/79) of grade i meningiomas and 46.6 % (7/15) of grade ii/atypical meningiomas. the 06 cases of anaplastic/who grade iii tumors were negative for pr. there was a higher prevalence of progesterone receptors in female patients (89.8%; 53/59) as compared to male meningioma patients (60.9%; 25/41). conclusion: we observed a decreased expression of progesterone receptor in higher grades of meningioma in this study. it is an effort to explore conservative treatment options for inoperable lesions, as anti-progesterone therapy may hold a promise as a new treatment option in the near future. key words: meningioma, immunohistochemistry, progesterone receptor authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3 interpretation, discussion, 4,5 active participations in data collection data analysis. correspondence: huma mushtaq email: huma.mushtaq@imdcollege.edu.pk article info: received: january 24, 2019 accepted: may 20, 2019 cite this article. tahir m, atif t, sohail s, nawazish a, mushtaq h. the expression of progesterone receptors in meningiomas of different grades. j islamabad med dental coll.2019; 8(2):65--69 funding source: nil conflict of interest: nil i n t r o d u c t i o n meningiomas are benign, slow growing, locally recurring intracranial and intraspinal neoplasms that are known to have sex steroid receptors expression.1-3 the discovery of such receptors was based on the association of meningiomas with female gender, breast cancers4, pregnancy related growth and luteal phase of menstrual cycle.5 progesterone receptors status and proliferation indices are known prognostic indicators of meningiomas.6 o r i g i n a l a r t i c l e j islamabad med dental coll 2019 66 several studies indicate progesterone receptor correlation with gender , age as well as who grades (i, ii and iii).4 regarding sex hormone receptors expressed in meningiomas, about 70% are progesterone receptors,7 primarily associated with lower grade meningiomas. an indian study assessing the pr status in different grades of meningiomas observed that 70% of grade i meningiomas in contrast to only 20% grade ii meningiomas, were pr positive. there was a single grade iii meningioma case in this study, which was reported as pr negative.6 similarly recurrent meningiomas were characterized by a consistent negativity for progesterone receptors.8 variable progesterone receptor expression is frequently seen in atypical group of meningiomas.9 the role of hormones, specifically progesterone, in pathogenesis of meningiomas is further highlighted by the two-fold greater occurrence of meningiomas in females, the hormonal status of female patients and the use of exogenous hormones as contraceptive pills (oc).10,11 although underestimated in the past, introduction of novel chemotherapeutic options suggests that treatment with anti-progesterone receptor agents may prove fruitful for selected patients.12 this study was conducted to demonstrate the occurrence of progesterone receptors in meningiomas as there is a limited number of studies available in our part of the world. m a t e r i a l a n d m e t h o d s this study was conducted in the histopathology department of federal government polyclinic, pgmi, islamabad from 1st january, 2013 to 30th june, 2015. it was a cross-sectional study with a sample size of 100, which was calculated by who sample size calculator. consecutive nonprobability sampling technique was employed including all cases reported as meningiomas of any grade. cases of both genders in age range of 25 to 70 years were included. however, stereotactic biopsies, tissue exhibiting fixation artifacts and inadequate scant tissue were excluded. freshly cut, three to five microns’ thick sections, stained with hematoxylin and eosin (h & e) were examined microscopically by a team of two histopathologists (a consultant and a resident histopathologist). all cases were graded according to who grading system. another 6 microns thick section of the original tumor were stained with progesterone receptor antibody (anti-pr monoclonal antibodies purchased from dako) using the conventional immunoperoxidase method. benign breast tissue was used as positive controls. stained slides were than examined by the same team of histopathologists and declared positive (if nuclear staining was observed in more than 10% of tumor cells) or negative for pr expression.11 the data was entered in spss version 21. frequency and percentages were used to calculate qualitative variables like presence or absence of progesterone receptors by use of immunohistochemistry in meningiomas and its grades. mean and standard deviations were used to calculate quantitative variables like age of the patient. tumor areas were first scanned on low-power for maximally stained regions and the stained nuclei were then counted at high-power magnification (40x). r e s u l t s a total of 100 patients, with the diagnosis of meningioma were included, in this study. mean age of the patients was 50.33 ± 12 years. female predominance was observed with 59% females (n=59) and 41% males (n=41). according to who criteria, of all the subtypes of meningioma, the most commonly found entity was benign/typical who grade i tumors (n=79 cases), followed by atypical/grade ii tumors (n=15 cases) and anaplastic/grade iii tumors (n=6 cases), respectively. brain invasion was found in 3% of cases and none of the cases were recurrent tumors. overall the pr status was positive in 78% (n=78) of meningioma cases in this study, while pr expression was negative in all the three cases showing brain invasion. pr status was positive in 89.8 % (71/79) of grade i meningiomas and 46.6 % (7/15) of grade ii/atypical meningiomas. the 06 cases of anaplastic/who grade iii tumors were negative for pr (figure 1). there was higher prevalence of progesterone receptors in female patients j islamabad med dental coll 2019 67 (89.8%; 53/59) as compared to male meningioma patients (60.9%; 25/41) as shown in figure 2. figure 1: decreasing trend of pr expression in increasing grades of meningioma figure 2: gender distribution of pr positive and pr negative cases of meningioma. h&e stained tissue section of meningioma grade i along with progesterone receptor strong nuclear positivity is shown in figure 3. h&e stain of anaplastic meningioma grade -iii, showing loss of whorling pattern, nuclear atypia, nuclear pleomorphism and high mitotic activity is shown in figure 4, while progesterone receptor negative staining is shown in figure 5. figure 3: meningioma grade i showing meningothelial cells arranged in whorling/lobular pattern. pr ihc applied on the same case shows strong nuclear positivity. figure 4: h&e stain of anaplastic meningioma grade-iii, showing loss of whorling pattern, nuclear atypia & pleomorphism. figure 5: progesterone receptor ihc stain applied on the above case shows no nuclear staining with adequate controls applied. d i s c u s s i o n meningiomas account for 20–32% of all the primary intracranial tumors. according to the who 2016 classification system, meningiomas are classified into 3 histological grades and 15 subtypes. this histopathological classification is generally used to predict the clinical course of meningioma.13 even after complete removal, who grade i meningiomas frequently recur. the role of steroid hormones in the progression of meningiomas is still a matter of controversy. our study aims to highlight the expression of pr in different grades of meningiomas. the results establish that immunodetection of progesterone receptors is inversely proportional to the histological grade of the tumor. hence this can be used for assessing the biological behavior of meningiomas. statistics of this study are similar to several other studies, which concluded a more favorable prognosis for pr positive meningiomas.10,11 j islamabad med dental coll 2019 68 gender predilection for females in case of meningioma is evident in most of the studies available in the literature. in this study 59% of the patients were female while 41% were males. in a descriptive study conducted in france nagashima and colleagues collected 13,038 cases of meningiomas. among these 9769 (74.9%) were females and 3269 (25.1%) were males. this is in accordance with previously published data.14 according to the world health organization (who) classification, meningiomas are classified into three grades; grade i, ii and iii as already described. studies showed that 90% of all meningiomas are benign tumors and 10% are in grade ii or iii, with unfavorable clinical courses. this synchronizes with our data and several other studies.15 we observed that pr expression was higher in grade i tumors than grade ii and iii tumors. these findings are also in concordance to published literature. similar findings were noted by iplikcioglu and colleagues who found that pr expression was higher in who grade i meningiomas than grade ii and iii.16 cahill et al and brandis et al showed that malignant meningiomas are devoid of pr and estrogen receptors. furthermore, whittle et al reported that pr negative meningiomas were biologically more aggressive than pr positive meningiomas.17 our data confirms the presence of significantly higher pr values in benign meningiomas compared with who grade ii or iii tumors. the pr expression exhibits marked heterogenicity within the same tumor, owing to the various innovative surgical procedures applied as well as intrinsic heterogeneous nature of the tumor itself.10 in addition, our study observed that pr expression was more in female gender than males. in 89.8% of female patients, progesterone receptors were found in meningiomas while it was present in 60.9% of male patients. perrot-applanat and colleagues also found similar findings that progesterone receptors were immunostained in 79% of female patients in contrast to 58% of male patients.18 mukhopadhyay studied the pr expression along with er and ki -67 and found a reciprocal expression of pr and er i.e. higher the grade of the tumor the more is the immunoreactivity for er but pr expression was lost with higher grade.19 one limitation of our study is that we were unable to follow up the patients to see the behavior of the tumor in vivo due to time constraints. c o n c l u s i o n our study is a step towards better understanding of pathophysiology of meningioma. it supports the conservative management of meningioma through noninvasive hormonal therapy instead of surgery, which has its own complications. however, more work needs to be done, incorporating other clinical and histopathological parameters as well, so that newer treatment option of anti-progesterone therapy can be further explored. r e f e r e n c e s 1. strassner c, buhl r, mehdorn hm. recurrence of intracranial meningiomas: did better methods of diagnosis and surgical treatment change the outcome in the last 30 years? neurological res. 2009; 31(5): 478-82. doi: 10.1179/174313208x338043 2. shayanfar n, mashayekh m, mohammadpour m. expression of progestrone receptor and proliferative marker ki 67 in various grades of meningioma. acta medica iranica.2010; 48(3): 142-7. pmid: 21137648 3. claus eb, park pj, carroll r, chan j, black pm. specific genes expressed in association with progesterone receptors in meningioma. cancer res. 2008;68(1):314-22. doi: 10.1158/0008-5472.can-07-1796 4. rao g, giordano sh, liu j, mccutcheon ie. the association of breast cancer and meningioma in men and women. neurosurgery. 2009; 65(3):483-9. doi: 10.1227/01.neu.0000350876. 91495.e0 5. hatiboglu ma, cosar m, iplikcioglu ac, ozcan d. sex steroid and epidermal growth factor profile of giant meningiomas associated with pregnancy. surg neurol. 2008; 69(4):356-62; doi: 10.1016/j.surneu.2007.03.013 6. mukherjee s, ghosh sn, chatterjee u, chatterjee s. detection of progesterone receptor and the correlation with ki-67 labeling index in meningiomas. neurology india. 2011;59(6):817-22. doi:10.4103/0028-3886.91357 7. blitshteyn s, crook je, jaeckle ka. is there an association between meningioma and hormone replacement therapy? j clin oncol. 2008; 26(2): 279-82. doi:10.1200/jco.2007.14.2133. 8. fewings pe, battersby rd, timperley wr. long-term follow up of progesterone receptor status in benign meningioma: a prognostic indicator of recurrence? j neurosurg. 2000; 92(3): 401-5. doi:10.3171/jns.2000.92.3.0401 j islamabad med dental coll 2019 69 9. krayenbühl n, pravdenkova s, al-mefty o. de novo versus transformed atypical and anaplastic meningiomas: comparisons of clinical course, cytogenetics, cytokinetics, and outcome. neurosurgery 2007. 61(3): 495-503. doi: 10.1227/01.neu.0000290895.92695.22 10. elizabeth b. claus, lisa calvocoressi, mellisa l, wrensch m, wiemels jl, schildkraut jm. exogenous hormone use, reproductive factors, and risk of intracranial meningioma in females. j neurosurg. 2013; 118(3): 649–56. doi: 10.3171/2012.9. jns12811 11. ikeri nz, anunobi cc, bankole ob. progesterone receptor expression and ki-67 labelling index of meningiomas in the lagos university teaching hospital. niger postgrad med j. 2018 ;25(1):17-20. doi: 10.4103/npmj.npmj_16_18 12. touat m, lombardi g, farina p, kalamarides m, sanson m. successful treatment of multiple intracranial meningiomas with the antiprogesteronereceptor agent mifepristone (ru486). acta neurochirurgica. 2014; 156(10):1831-5. doi: 10.1007/s00701-014-2188-4 13. louis dn, perry a, reifenberger g. von deimling a, figarella-branger d, cavenee wk. the 2016 world health organization classification of tumors of the central nervous system: a summary. acta neuropathol. 2016 ;131(6):803-20. doi: 10.1007/s00401-016-1545-1 14. zouaoui s, darlix a, rigau v, mathieu-daude h, bauchet f, bessaoud f, et al. descriptive epidemiology of 13,038 newly diagnosed and histologically confirmed meningiomas in france: 2006-2010. neuro-chirurgie. 2018; 64(1): 15-21. doi: 10.1016/j.neuchi.2014.11.013. 15. kshettry vr, ostrom qt, kruchko c, al-mefty o, barnett gh, barnholtz-sloan js. descriptive epidemiology of world health organization grades ii and iii intracranial meningiomas in the united states. neuro-oncol. 2015; 17(8):1166-73. doi: 10.1093/neuonc/nov069 16. iplikcioglu ac, hatiboglu ma, ozek e, ozcan d. is progesteron receptor status really a prognostic factor for intracranial meningiomas? clin neurol neurosurg. 2014; 124: 119-22. doi: 10.1016/j.clineuro.2014.06.015 17. whittle ir, foo ms, besser m, vanderfield gk. progesterone and oestrogen receptors in meningiomas: biochemical and clinicopathological considerations. aust n z j surg.1984; 54(4):325-30 pmid: 6593026 18. perrot-applanat m, groyer-picard mt, kujas m. immunocytochemical study of progesterone receptor in human meningioma. acta neurochirurgica. 1992;115(12):20-30. pmid: 1595392 19. mukhopadhyay m, das c, kumari m, sen a, mukhopadhyay b, mukhopadhyay b. spectrum of meningioma with special reference to prognostic utility of er, pr and ki67 expression. j lab physicians 2017;9(4):308-13 doi: 10.4103/jlp.jlp_158_16. j islamabad med dental coll 2022 25 o p e n a c c e s s anxiety experienced by people searching internet for medical information mohi ud din1, syed fawad mashhadi2, shahrob khan3, tehreem safdar4, bilal ashraf5, zeeshan khalid awan6 1assistant professor, community medicine, aziz fatima medical and dental college, faislabad 2associate professor, community medicine, army medical college, rawalpindi 3,4,5,6final year mbbs student, army medical college, rawalpindi a b s t r a c t background: a large proportion of people use internet to search for information on medical symptoms. the objective of the study was to assess the frequency of internet use for medical information and its association with anxiety levels. methodology: a cross-sectional study was conducted in tertiary care hospitals affiliated with national university of medical sciences, islamabad from august to december 2020. ethical approval was taken. a total of 414 participants aged 20 and above, belonging to either gender, and having at least primary level education were included in the study, while participants belonging to medical background were excluded. non-probability convenient sampling technique was used to collect data through a validated questionnaire. frequencies and percentages were calculated. chi-square test of significance was applied. p-value less than .05 was considered as statistically significant. results: majority i.e. 301 (80%) of the participants stated that the health-related searches exacerbated their anxiety. participants from lower income groups were more prone to anxiety, while participants from higher income groups were more likely to visit a doctor. there was a significant association between age groups and perceptions, that and web searches lead to review of content on serious illness, persistence of query for illness after web search, and increase in web searches related to perceived condition (p<0.05). conclusion: there was an increase in anxiety levels after web searches. it was more pronounced in lowest income group people. higher income group were more likely to trust web searches results. keywords: anxiety, internet, information, medical authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing.5,6 correspondence: mohi ud din email: dr.md89@outlook.com article info: received: april 28, 2021 accepted: march 24, 2022 cite this article. mohi ud, mashhadi sf, khan s, safdar t, ashraf b, awan zk. anxiety experienced by people searching internet for medical information. j islamabad med dental coll. 2022; 11(1):25-29. doi: 10.35787/jimdc.v11i1.711 funding source: nil conflict of interest: nil i n t r o d u c t i o n health anxiety is defined as “an obsessive and irrational worry about having a serious medical condition”. as many as 17 to 25% of patients suffer from it and web searches have the potential to aggravate this anxiety.1 more than 30% of the population of pakistan have access to the internet, and more than 50% own a cell phone.2 many people use the internet for health-related searches. in fact the practice is so common that researchers have coined a term for it: “cyberchondria.” 3,4 while numerous researches have been conducted, in other countries on the possible harms and benefits of this deluge of information, no comprehensive study on this topic has been carried out in pakistan. in a country with a rapidly expanding it sector, the effects of this democratization of medical knowledge could be momentous.5 the possible benefits include greater medical literacy among the general public, improvement in doctor-patient interactions, ease of access, and more privacy in searching information about embarrassing medical conditions.6 the internet also provides people with support groups that can possibly help in the social and psychological aspect of the health-related condition.7 there are also many potential harms. it is a fact that online symptom checkers are often not reliable.8 the information available online is not regulated.9 in a country like pakistan, which has a literacy rate of around 57 percent, this abundance of misinformation can expose a scientifically illiterate population to unsound medical practices and beliefs. social networking websites are inundated with advertisements for dubious medications that offer cures for everything from hair-loss to impotence to obesity. there are online groups and forums that provide a bubble of delusion to people who believe in things as flat out wrong as the “antivax” movement, the supposed benefits of anorexia, and the efficacy of juices and oils in “detoxing” the body and curing it of ailments as serious as cancer.10 if such false beliefs can take root in developed, educated western countries, then who knows how insidious this dissemination of misinformation could be for a country lagging in literacy as pakistan. a patient’s lack of knowledge and poor information provided by a website are the two factors that can o r i g i n a l a r t i c l e j islamabad med dental coll 2022 26 turn the internet into a destructive tool for the patient. 11 in practice it is very hard to stop people from uploading untrustworthy information. what we can do is educate the populace on how to use the internet to their benefit: what websites they can trust, what information they can rely on, and for what issues they need to consult a doctor. maybe our government can even invest in an it programme dedicated to developing medical tools that are trustworthy and easily accessible by the general public. with an increasing proportion of the population using the internet, the implications could be farreaching. the aim of this study was to assess the frequency of internet use for medical information seeking by the general public and its association with anxiety levels. m e t h o d o l o g y a cross-sectional study was conducted in tertiary care hospitals affiliated with national university of medical sciences, islamabad from august 2020 to december 2020. the total sample size was calculated using raosoft sample size calculator with 95% confidence level, 5% margin of error, and 10% dropout, it was computed to be 414. 12 about 29 responses were found to be invalid making the total sample size to be 385. participants aged 20 and above, belonging to either gender, and having at least primary level education, visiting the hospitals during the study period and willing to participate in the study were included in the study while the participants with medical background were excluded from the study. non-probability convenient sampling technique was used for selection of study participants from outpatient departments. questionnaire used was adopted from a study on cyberchondria by ryen w. white et al,13 modified according to the demographics of our population and a pilot study was conducted to check its appropriateness in 5% of anticipated sample size. crohn bach alpha score measured for different items of the questionnaire was found to be within a range of 0.7-0.8. time required to complete the questionnaire was 15 min. the questionnaire was translated in urdu language before distribution and it consisted of four sections; demographic data, questions regarding web searches, conditions that have not been diagnosed and effect on behavior. the data was analysed using ibm spss statistics version 25. frequencies and percentages were calculated. chi-square test of significance was applied. p-value less than 0.05 was considered as statistically significant. ethical approval was taken from ethical approval committee of army medical college to which these hospitals are affiliated. r e s u l t s out of 414 participants, 29 responses were found to be invalid. therefore, analysis was done on the responses of 385 participants. majority i.e., 158(41%) belonged to the age group 20 – 25 years, 41 (10.6%) to 26 – 30 years, 96 (24.9%) to 31 – 35 years and 90 (23.4%) to 36 years and above. there were 209 (54.3%) females and 176 (45.7%). most of the participants i.e., 204 (53%) were having graduation and above level of education while majority i.e., 160 (41.6%) were earning upto rs.25,000 per month and 120 (31.2%) upto rs.50,000. a total of 370 (96.1%) participants were using google as the web search engine while 1 – 5 average web searches per month were done by 304 (79%) participants, 6 – 10 by 56 (14.5%), 11 – 15 by 7 (1.8%) and more than 16 web searches were done by 18 (4.7%) of the participants. web searches after getting concerned about their health was done by 228 (59.2%) of the participants. internet query of the sample population comprised of 3 types i.e., 188 (48.8%) participants searched through combination of words containing both symptoms and medical conditions; 100 (26%) of sample population searched through words representing symptoms only while 97 (25.2%) participant’s searched through words that describe medical conditions only. most of the study participants generally searched for information about common diseases comprising 232 (60.3%) of the total sample size while 95 (24.7%) searched for information on serious medical conditions (e.g. cancer, myocardial infarction). a total of 58 (15%) of the sample population searched for the forums and pages describing about other’s experience about the particular disease. different web searches may have differences in describing medical conditions and same was experienced by most of the participants i.e., 224 (58.2%) while remaining did not observe such difference. table 1 shows the effect of webs search on perceptions of participants regarding their illness and whether it interrupted their routine activities or not. table 1: participants’ perception about web searches variable always (%) often (%) occasionally (%) rarely (%) never (%) total (%) ranking of web search result indicate likelihood of illness 31 (8.1%) 110 (28.6%) 125 (32.5%) 83 (21.6%) 36 (9.4%) 385 (100%) j islamabad med dental coll 2022 27 web search lead to review of content on serious illness 43 (11.2%) 105 (27.3%) 121 (31.4%) 92 (23.9%) 24 (6.2%) 385 (100%) query for illness persist 20 (5.2%) 86 (22.3%) 128 (33.2%) 114 (29.6%) 37 (9.6%) 385 (100%) perception of illness interrupted online activities 23 (6%) 85 (22.1% 94 (24.4%) 115 (29.9%) 68 17.7%) 385 (100%) perception of illness interrupted other activities 25 (6.5%) 80 (20.8%) 101 (26.2%) 106 (27.5%) 73 (19%) 385 (100%) 52.2%(201) of the participants used web search as a medical expert system, 62%(239) had a perception that web search engine escalates medical concerns while 21% (81) mentioned an increase in anxiousness due to web searches. there are different factors which contributed to anxiety after web searches among participants. the most common one was mention of more serious explanations of their medical conditions or symptoms (n=90, 23.4%) as shown in table 2. table 2: factors related to anxiety after internet search by participants what contributed to anxiety frequency percent reliability of source 55 14.3 mention of more serious explanations 90 23.4 mention of more serious and few non-serious explanations 62 16.1 presence of escalatory terminology 72 18.7 presence of complex medical terminology 25 6.5 no anxiety 81 21.1 total 385 100 different behaviour patterns of the participants due to web searches such as becoming hypochondriac, taking an appointment, increased searches related to perceived condition are shown in fig 1. figure 1: effect of web searches on behaviour patterns of participants. there was significant association between age groups and perception that, web searches lead to review of content on serious illness (p = 0.022); query for illness persists after web search (p = 0.004), and web searches related to perceived condition increased (p = 0.039). also, differences in males and females were observed related to web searches; females found to be more anxious than males, web searches related to perceived conditions went up more in females and also visit to web pages describing condition increased more in females as compared to males but these differences were statistically insignificant.(table 3) web searches lead to review of content on serious illness always often occasionally rarely never total p-value age groups (years) 20-25 24 47 36 41 10 158 0.022 26-30 6 9 13 10 3 41 31-35 10 31 31 21 3 96 >36 3 18 41 20 8 90 query for illness persist always often occasionally rarely never total p-value age groups 20-25 17 32 46 49 14 158 0.004 26-30 1 15 12 8 5 41 j islamabad med dental coll 2022 28 (years) 31-35 0 15 38 34 9 96 >36 2 24 32 23 9 90 web searches related to perceived condition increased yes no p-value age groups (years) 20-25 102 29 48 49 56 12 48 41 0.039 26-30 31-35 >36 search made u more anxious yes no p-value gender male 135 40 0.38 female 169 40 searches related to perceived condition increased yes no p-value gender male 97 79 0.15 female 131 78 visit to web pages describing condition increased yes no p-value gender male 103 72 0.46 female 131 78 d i s c u s s i o n usefulness of the internet as a healthcare tool and devising methods for improving the quality of the health-related information reaching the general public through the web is needed more than ever, nowadays. 14this study investigated the use of the internet by the general public, to look up for the symptoms of a perceived medical condition and making self-diagnosis. a research done by teresa loda et al showed that participants found reliable medical knowledge online irrespective of the type of search engine while in this study, most of the participants (96.1%) used google.15 majority, in this study were of the opinion that no particular search engine was more likely to escalate medical concerns. a study conducted by liupu wang et al showed google to have the best search validity (in terms of whether a website could be opened), however bing had the highest score for usefulness.16 most of the participants of our study using internet for medical purpose had education till graduation or above and having lower income i.e. up to rs.25000 per month. a study conducted by fabienne reiners et al showed that high internet prevalence is associated with people having higher income and that the participants with higher education use internet more for medical purpose than those with lesser education.17 people from the lowest income group were slightly more likely to feel anxious after a web search. this is consistent with a previous study conducted by kate muse et al which showed that anxiety was more prevalent among low income groups.18 a study done by teresa loda et al showed that participants searched the internet on the basis of specific medical terms. this is in contrast to our study where participants internet search included symptoms also with medical terms.15 a study conducted by ryen w. white et al concluded that at least three quarters of the participants, suspected of having an illness, based on the results of web searches. this is similar to our study where more than 90% of our participants had a similar perception. a similar proportion of their subjects used web search as a health expert system in their study while only 48% of our participants did.19 several previous studies have found a positive correlation between health anxiety and online health information seeking, such as the twenty studies analysed by mcmullan and berle et al.20 majority (79%) of the subjects of our study stated that their anxiety was exacerbated after the web searches and that there is a positive relationship between anxiety and web searches. aiken and kirwan et al also found a positive relationship between looking up symptoms online and health anxiety. the same study found a positive correlation between anxiety and review of content on serious illnesses.21 a similar doherty-torstrick study found that longer duration online health related use was associated with “increased functional impairment, less education, and increased anxiety which is similar to our study”.22 majority of the study participants said that searching the web for health-related information made them feel more anxious about a perceived medical condition. this might vary with the nature of the condition under consideration. the results of our study showed that women were more likely to behave differently with regard to a medical condition after the web search, to review content on serious illnesses, to feel uncomfortable in bringing their own research to the health professional, and to feel that their other activities had been interrupted by the web search. a study conducted by dalia m corrales et al also showed that internet use for j islamabad med dental coll 2022 29 searching medical conditions is common among women, and its use is associated with increased anxiety.23 engagement with physicians went up to a greater extent for people from higher income groups. this is similar to the results of our study. this finding is similar to that of studies of iniquity in doctor utilization in developed countries which showed that people having a higher income are more likely to visit physicians and specialists.24 a little is known about the use of web searches by general public for medical information purposes so this study will add to the existing body of knowledge. non-probability convenience sampling was used, so the sample might not be representative of the population. also, the psychiatric history of subjects was not taken. further research should be done on this to see the positive impact of the use of internet, in terms of the knowledge it provides regarding medical information. c o n c l u s i o n most of the participants experienced increase in anxiety levels after web searches for their medical conditions. the effect was more pronounced in lowest income group people. higher income group were more likely to trust web searches results. r e f e r e n c e s 1. ayers jw, leas ec, johnson dc, poliak a, althouse bm, dredze m, et al. internet searches for acute anxiety during the early stages of the covid-19 pandemic. jama intern med. 2020;180(12):1706-7. doi:10.1001/jamainternmed.2020.3305 2. iftikhar s, saqib a, sarwar mr, sarfraz m, arafat m, shoaib q-u-a. capacity and willingness to use information technology for managing chronic diseases among patients: a cross-sectional study in lahore, pakistan. plos one. 2019;14(1):e0209654. doi: 10.1371/journal.pone.0209654 3. starcevic v, schimmenti a, billieux j, berle d. cyberchondria in the time of the covid‐19 pandemic. hum. behav. emerg. 2021;3(1):53-62. doi: 10.1002/hbe2.233 4. jungmann sm, witthöft m. health anxiety, cyberchondria, and coping in the current covid-19 pandemic: which factors are related to coronavirus anxiety? j. anxiety disord. 2020;73:102239. doi:10.1016/j.janxdis.2020.102239 5. akhtar m, fatima t. exploring cyberchondria and worry about health among individuals with no diagnosed medical condition. j pak med assoc. 2020;70(1):90-5. doi: 10.5455/jpma.8682 6. taylor c, graham ak, flatt re, waldherr k, fitzsimmons-craft ee. current state of scientific evidence on internet-based interventions for the treatment of depression, anxiety, eating disorders and substance abuse: an overview of systematic reviews and meta-analyses. eur. j. public health. 2020. doi:10.1093/eurpub/ckz208 7. griffiths km. mental health internet support groups: just a lot of talk or a valuable intervention? world psychiatry. 2017;16(3):247. doi: 10.1002/wps.20444 8. semigran hl, linder ja, gidengil c, mehrotra a. evaluation of symptom checkers for self diagnosis and triage: audit study. bmj. 2015;351:h3480. doi:10.1136/bmj.h3480 9. liu s-h. relationship between the factors influencing online help-seeking and self-regulated learning among taiwanese preservice teachers. comput. hum. behav. 2017;72:38-45. doi:10.1016/j.chb.2017.02.034 10. kanekar as, thombre a. fake medical news: avoiding pitfalls and perils. fam med community health. 2019;7(4):e000142-e. doi: 10.1136/fmch-2019000142 11. robertson n, polonsky m, mcquilken l. are my symptoms serious dr google? a resource-based typology of value co-destruction in online selfdiagnosis. australas. mark. j. 2014;22(3):24656.doi:10.1016/j.ausmj.2014.08.009 12. raosoft. sample size calculator. 2022; available from: http://www.raosoft.com/samplesize.html. 13. white rw, horvitz e, editors. experiences with web search on medical concerns and self diagnosis. amia annu symp proc. 2009 nov 14;2009:696-700 14. mian a, khan s. coronavirus: the spread of misinformation. bmc med. 2020;18(1):1-2. doi:10.1186/s12916-020-01556-3 15. loda t, erschens r, junne f, stengel a, zipfel s, herrmann-werner a. undergraduate medical students’ search for health information online: explanatory cross-sectional study. jmir med. inform. 2020;8(3):e16279. doi: 10.2196/23253 16. wang l, wang j, wang m, li y, liang y, xu d. using internet search engines to obtain medical information: a comparative study. j. med. internet res. 2012;14(3):e74. doi: 10.2196/jmir.1943 17. reiners f, sturm j, bouw ljw, wouters ejm. sociodemographic factors influencing the use of ehealth in people with chronic diseases. int. j. environ. res. public health. 2019;16(4):645. doi:10.3390/ijerph16040645 18. muse k, mcmanus f, leung c, meghreblian b, williams jmg. cyberchondriasis: fact or fiction? a preliminary examination of the relationship between health anxiety and searching for health information on the internet. j. anxiety disord. 2012;26(1):189-96. doi:10.1016/j.janxdis.2011.11.005 19. white rw, horvitz e. evaluation of the feasibility of screening patients for early signs of lung carcinoma in web search logs. jama oncol. 2017;3(3):398-401. doi:10.1001/jamaoncol.2016.4911 20. mcmullan rd, berle d, arnáez s, starcevic v. the relationships between health anxiety, online health information seeking, and cyberchondria: systematic review and meta-analysis. j. affect. disord. 2019;245:270-8. doi:10.1016/j.jad.2018.11.037 21. aiken m, kirwan g, berry m, o’boyle ca. the age of cyberchondria. r. coll. surg. irel. stud. med. j. 2012;5(1):71-4. 22. doherty-torstrick er, walton ke, fallon ba. cyberchondria: parsing health anxiety from online behavior. psychosomatics. 2016;57(4):390-400. doi:10.1016/j.psym.2016.02.002 23. corrales dm, wells ae, radecki breitkopf c, pena g, kaplan al, king ls, et al. internet use by gynecologic oncology patients and its relationship with anxiety. j. health commun. 2018;23(3):299-305. doi:10.1080/10810730.2018.1442529 24. papanicolas i, woskie lr, jha ak. health care spending in the united states and other high-income countries. jama. 2018;319(10):1024-39. doi:10.1001/jama.2018.1150. http://www.raosoft.com/samplesize.html 239 jimdc 2017 239 open access ful l le n gt h ar t i c l e imran khalid1, nisar ahmed2, abid sohail3, tariq masood4 1 assistant consultant, haematology department, akbar niazi hospital, islamabad 2 professor/head of haematology department, children hospital, lahore 3 professor/head of haematology department, khyber medical university, peshawar 4 assistant professor, haematology department, north west hospital, peshawar a b s t r a c t objective: to determine the frequency of common chromosomal aberrations in local population of idiopathic acquired aplastic anemia at the time of diagnosis, using g-banding cytogenetic analysis. patients and methods: this cross sectional study was conducted in department of haematology, pakistan institute of medical sciences, islamabad and department of genetics, children hospital, lahore from june 2015 to july 2017. sample size was calculated using who sample size calculator. a total of sixty-four cases of peripheral blood pancytopenia having clinical suspicion of acquired aplastic anemia participated in the study. bone marrow or peripheral blood samples were processed for cytogenetics by g-banding and karyotyping was done according to international system for human cytogenetic nomenclature (iscn) to determine frequency of chromosomal abnormalities in the patients of acquired aplastic anaemia. results: age of the study patients ranged from 184 years. sixty cases diagnosed to have acquired aplastic anaemia using bone marrow examination as gold were included in the study based on inclusion criteria. four cases were excluded from the study as per exclusion criteria. forty-five out of 60 patients (75%) had successful karyotyping whereas 15 out of 60 patients (25%) had inconclusive cytogenetics due to culture failure, inadequate metaphase cells and contamination. g-banding revealed normal karyotyping in 40 out of 45 patients (88.9%) while 5 out of 45 patients (11.1%) were found to have abnormal karyotyping. chromosomal abnormalities revealed by abnormal karyotyping included three numerical abnormalities i.e. monosomy 7, trisomy 8, trisomy 14 and two structural abnormalities i.e. deletion of 11q, deletion of 13q. the frequency of chromosomal abnormalities in patients with acquired aplastic anaemia in this study was found to be 11.1%. conclusion: cytogenetic analysis may be beneficial in finalizing diagnosis by differentiating acquired aa from other haemopoietic disorders of bone marrow failure, which may be missed based on cell morphology alone. it also guides in deciding appropriate mode of treatment earlier and predicting prognosis of the disease. key words: aplastic anemia, chromosomal abnormalities, cytogenetic nomenclature, karyotyping. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence imran khalid email: doctorimrankhalid@gmail.com article info. received: september 20, 2018 accepted: novemnber 10, 2018 cite this article. khalid i, ahmed n, sohail a, masood t. frequency of common chromosomal abnormalities in patients with idiopathic aquired aplastic anemia. jimdc.2018; 7(4):239-245 funding source: nil conflict of interest: nil frequency of common chromosomal abnormalities in patients with idiopathic acquired aplastic anemia original article mailto:doctorimrankhalid@gmail.com 239 jimdc 2017 249 aplastic anaemia is an immune mediated haemopoietic stem cell disorder characterized by pancytopenia with a hypocellular bone marrow in the absence of abnormal infiltrate and no increase in bone marrow reticulin.1 aplastic anemia is considered if at least two of the following defining criteria are fulfilled that includes haemoglobin level less than 10g/dl, neutrophil count less than 1.5 x 109/l, platelet count less than 50 x 109/l and bone marrow cellularity less than 25% or 25 to 50% with less than 30% residual haemopoietic cells.2 disease severity of aplastic anemia is based on the criteria given by camitta et al. in 1975.3 according to this criteria the severity of aplastic anemia is graded into very severe aplastic anaemia (vsaa), severe aplastic anemia (saa) and non-severe aplastic anemia (nsaa). severity of aplastic anaemia according camitta criteria is based on blood cell counts and bone marrow cellularity.4 grading of disease is significant in management decisions but has less prognostic value in terms of response to immunosuppressive therapy.5 incidence of aplastic anaemia in west is around 2 per million populations in a year, that is twofold higher (3 to 4 per million population) in asia.6 aplastic anaemia can be congenital or acquired.7 presence of somatic abnormalities and characteristic sensitivity of haemopoietic cells to chromosomal breakage on exposure to clastogenic agents such as diepoxybutane (deb) and mitomycin c (mmc) is suggestive of congenital aplastic anemia.8 some cases of congenital aplastic anemia may lack the characteristic phenotypic abnormalities.9 constitutional mutations result in increased genomic instability and reduced cell survival in congenital aplastic anaemia that leads to increased chromosomal dna damage by dna crosslinking agents due to aberration in brca pathway.10 brca gene (a tumor suppressor gene) is involved in dna damage response pathway; cells lacking brca protein are susceptible to chromosomal breakage after exposure to deb or mmc.11 acquired aplastic anaemia is associated with various etiological factors that include different drugs, chemicals, toxins, ionizing radiations, smoking, pregnancy, autoimmune diseases, graft versus host disease (gvhd) and viral infections such as hepatitis virus, varicella virus, parvo virus, cmv, ebv, hiv.12 no definitive causative factor is found in majority of the cases of acquired aplastic anaemia.13 cytogenetic abnormalities have been described infrequently worldwide in few patients (12%) with otherwise typical aplastic anaemia at diagnosis.14 common cytogenetic abnormalities related with idiopathic acquired aplastic anaemia include trisomy 6, trisomy 8, trisomy 14, trisomy 15, monosomy 7, monosomy 19, del 5q and del 7q.15 figure 1: g-banding chromosomal analysis of peripheral blood cell culture reveals male karyotype with a missing chromosome no.7 in 20 metaphase cells examined. this finding is consistent with diagnosis of monosomy 7 figure 2: g-banding chromosomal analysis of bone marrow cell culture reveals female karyotype with an extra chromosome no.8 in 20 metaphase cells examined. this finding is consistent with diagnosis of trisomy 8 i n t r o d u c t i o n 241 jimdc 2017 241 monosomy 7 is associated with a high risk to develop haematological malignancies (mds or aml) and has poor response to immunosuppressive therapy (ist) with poor prognosis.16 in contrast, trisomy 8 is associated with good response to ist and has better prognosis.17 cytogenetic analysis is attempted to detect cytogenetic abnormalities related with acquired aplastic anaemia, although it is difficult to perform because of inability to obtain sufficient metaphase cells for chromosomal analysis in a hypocellular bone marrow.18 in such situation, molecular cytogenetics by fluorescent in situ hybridization (fish) can be attempted which is limited to few centers only and has a higher cost constraint.19 clinical significance of cytogenetic abnormalities may also be that hypo plastic mds or hypo plastic aml may present as aplastic anaemia and it can be difficult to distinguish two conditions on basis of morphology alone, treatment options and response to therapy is also different in both conditions. 20 cytogenetic analysis is limited to a few centers in pakistan. incidence of aplastic anemia is relatively higher in southeast asian countries. no study has been conducted before to find association of cytogenetic abnormalities with acquired aa in pakistan. the objective of this study was to determine frequency of common chromosomal aberrations among the patients of idiopathic acquired aplastic anemia in local population at the time of diagnosis by g-banding cytogenetic analysis. figure 3: g-banding chromosomal analysis of peripheral blood cell culture reveals female karyotype with an extra chromosome no.14 in 16 metaphase cells examined. this finding is consistent with diagnosis of trisomy 14 figure 4: g-banding chromosomal analysis of bone marrow cell culture reveals male karyotype with deletion of q-arm of chromosome no.11 in 16 metaphase cells examined. (del 11q) figure 5: g-banding chromosomal analysis of peripheral blood cell culture reveals female karyotype with deletion of q-arm of chromosome no.13 in 16 metaphase cells examined. (del 13q) this cross-sectional study was conducted in department of genetics & department of haematology, children hospital lahore and department of haematology, pakistan institute of medical sciences (pims) islamabad from june 2015 to july 2017. total 64 patients (both male and female patients of all age groups) who presented to the department of haematology with peripheral blood pancytopenia having a clinical suspicion of acquired aplastic anemia, with features of bone marrow aplasia p a rt ici pa t ed in the study. patients with p a t i e n t s a n d m e t h o d s 242 jimdc 2017 242 congenital aplastic anaemia, patients with features of bone marrow dysplasia and abnormal infiltrates and patients with post chemotherapy and radiotherapy aplasia were excluded from the study. the study was approved by ethical board of each participating hospital. informed consent was taken from the patients or their parents. sample size was calculated according to who sample size calculator with 95% confidence interval, prevalence of 12% cases of aa with chromosomal abnormalities and 8% margin of error and sample size calculated was 64 and sampling was done by convenient random sampling technique. demographic profile and clinical data of the patients was taken. systemic examination was performed to find positive signs of anemia, haemorrhage, infections, lymphadenopathy, hepatomegaly, splenomegaly and especially any dysmorphic features to exclude congenital aa. biochemical and radiological findings, cbc, reticulocyte count, peripheral blood smear and bone marrow (aspiration and trephine biopsy was done to confirm diagnosis of aplastic anemia. cytogenetics or chromosomal analysis was done by giemsa trypsin banding prior to induction of immunosuppressive therapy. blood or bone marrow samples were collected under aseptic measures in sterile sample collection tubes (green top vacutainers) containing sodium heparin anticoagulant to prevent coagulation. samples were transported to genetics lab. at room temperature within 24 hours for cytogenetic analysis where they were processed for cell culture, culture harvesting, slide preparation and slide staining. karyotyping was done according to (iscn) international system for human cytogenetic nomenclature,21 metaphase and karyotype images were seen using cytovision system (microscope, camera, monitor, computer, software macktype 5.6) for chromosome analysis. at least 16 to 20 metaphase cells were analyzed at each microscopic examination for a successful result. cytogenetic analysis was labelled inconclusive if metaphase cells were less than 16. a cytogenetic abnormality was considered to exist when 2 or more cells had the same structural or numerical chromosomal abnormality (86). data was recorded and analyzed using statistical package for social sciences (spss) version 20. median was calculated for age of the study participants and frequency (%) of chromosomal abnormalities was calculated in the study patients diagnosed to have acquired aplastic anemia. age distribution of 64 study participants ranged from 1 to 84 years with a median age of 10 years. patients were divided into two age groups, children and adults. depending on their age 52 patients (81%) were classified in age group of 1 18 years whereas 12 patients (19%) were classified in age group of 19 84 years. most of the study participants were children. four out of 64 cases were excluded from the study as per exclusion criteria, among those two cases (3.1%) were diagnosed to have myelodysplastic syndrome based on peripheral blood and bone marrow findings while two cases (3.1%) were diagnosed as congenital aplastic anemia on chromosomal breakage analysis. sixty out of 64 cases (93.8%) diagnosed to have acquired aplastic anemia on the basis of clinical, peripheral blood and bone marrow findings, were included in this study as per inclusion criteria. diagnosis of aplastic anemia was confirmed by considering bone marrow findings as gold standard. among 60 patients of acquired aplastic anemia, 34 were male and 26 were female. forty five out of 60 patients (75%) had successful karyotyping among those 23 were male and 22 were female whereas 15 out of 60 patients (25%) had inconclusive cytogenetics among those 11 were male and 4 were female. table 1: severity distribution of aplastic anemia among study patients severity nsaa saa vsaa male 27 5 2 female 17 8 1 total 44 13 3 percentage 73.3% 21.7% 5% table 2: frequency breakup of cytogenetics results among study patients cytogenetics normal abnormal male 24 2 female 16 3 total 40 5 percentage 89.9% 11.1% r e s u l t s 242 jimdc 2017 243 table 3: categories of chromosomal abnormalities in acquired aplastic anemia numerical abnormalities (n=3) monosomy 7 trisomy 8 trisomy 14 structural abnormalities (n=2) deletion 11q deletion 13q inconclusive cytogenetics can be due to cell culture failure, inadequate metaphase cells or contamination. g banding revealed normal cytogenetics results in 40 out of 45 patients (89.9%) among those 24 were male and 16 were female, while five out of 45 patients (11.1%) had cytogenetic abnormalities among those two were male and three were female (table 2). majority of the patients of acquired aplastic anemia included in this study had normal cytogenetics. severity of the disease was graded into non severe, severe and very severe aplastic anaemia according to camitta criteria. out of 60 diagnosed cases of acquired aplastic anaemia 44 patients had nsaa, 13 patients had saa and 3 patients had vsaa (table 1). among 5 patients with chromosomal abnormalities, three patients had severe aplastic anaemia while two patients were diagnosed to have non-severe aplastic anaemia. chromosomal abnormalities revealed by g banding in 5 patients of acquired aplastic anemia were numerical and structural (table 3). three out of five patients had numerical chromosomal abnormalities among those one was male and two were female having monosomy 7, trisomy 8 and trisomy 14 respectively whereas two out of five patients had structural chromosomal abnormalities among those one was male and one was female having deletion of 11q and deletion of 13q respectively. all 5 patients of acquired aplastic anemia found to have abnormal cytogenetics in this study were in age group of 1-18 years. aplastic anaemia is haematological disorder of bone marrow failure characterized by t cell mediated destruction of haemopoietic cells.22 in the current study, cytogenetic abnormalities were observed in 11.1% patients of acquired aplastic anemia. trisomy was the commonest numerical cytogenetic abnormality seen in two patients followed by monosomy in one patient. deletions were the structural cytogenetic abnormalities found in two patients. clinical and haematological profile of the patients with abnormal cytogenetics were similar to those with normal cytogenetics.23 some of these characteristic cytogenetic abnormalities are also seen in myelodysplastic syndrome (mds) and acute myeloid leukemia (aml), however the morphological diagnosis was consistent with aplastic anemia. it may be difficult to distinguish two conditions on the basis of cell morphology alone therefore in this situation abnormal karyotype may suggest diagnosis of hypoplastic mds or hypoplastic aml. cytogenetic analysis can play a significant role in management of patients with cytogenetic interpretation, which can reduce risk of misdiagnosing hypoplastic mds and hypoplastic aml as aplastic anemia, monosomy and trisomy are mostly seen in aplastic anemia, deletions favor diagnosis of mds whereas translocations and inversions are commonly found in aml. cytogenetic analysis in this way may be most beneficial in differentiating aplastic anemia from other haemopoietic disorders of bone marrow hypoplasia/aplasia, therefore guides in suggesting appropriate mode of treatment that helps in avoiding possibility of mistreating the patients. some authorities exclude diagnosis of aplastic anaemia in patients with abnormal cytogenetics regardless of bone marrow morphology, however in some research centers patients with abnormal cytogenetics are diagnosed as aplastic anemia on morphological grounds.24 response to therapy and survival in patients of aplastic anaemia with normal and abnormal cytogenetics was also compared in some studies.25 patients without cytogenetic abnormalities have good response to immunosuppressive therapy (ist) and better survival therefore cytogenetic analysis helps in predicting prognosis of aplastic anemia. patients with persistent cytogenetic abnormalities after treatment are at higher risk of developing haematological malignancies (aml or mds). patients of mds presents with clinical d i s c u s s i o n 242 jimdc 2017 244 manifestations of bone marrow failure which are related to anaemia, neutropenia and thrombocytopenia.26 immunosuppressive therapy (ist) improves pancytopenia but response is relatively poor in patients of mds.27 in few patients, acquired aplastic anaemia may develop into acute leukemia.28 patients of aml presents with clinical features of bone marrow failure and organ infiltration by leukemic cells. chemotherapy regimens have limited role in treating patients with aml.29 in this study cytogenetic abnormalities in patients of acquired aplastic anemia were found to be 11.1% in our region. these findings are compatible with the study conducted by vineeta gupta et al. at institute of medical sciences, banaras university, india who found cytogenetic abnormalities to be 11.9% in patients of aa.30 similar figures are reported in various other studies, demonstrating chromosomal abnormalities in acquired aa.31 some patients with acquired aplastic anaemia are at higher risk of evolving into mds. it is sometimes difficult to distinguish the two conditions.32 prognosis of the patients with acquired aplastic has improved with better supportive care of anaemia, infections and bleeding.33 estimated 10-years survival is 68% in patients receiving ist and 73% in patients with hsct. mode of treatment in patients with aplastic anaemia depends on age of the patients, children with hla matched sibling donor are preferably treated with hsct whereas adults without hla matched sibling donor are generally treated with ist along with supportive therapy. approximately 25% patients of aa have inadequate response to therapy.34 hsct is the curative treatment option, however may be at additional risk of developing graft versus host disease (gvhd) and potential for graft rejection.35 cytogenetic analysis may be beneficial in finalizing diagnosis by differentiating acquired aa from other haemopoietic disorders of bone marrow failure, which may be missed, based on cell morphology alone. it also guides in deciding appropriate mode of treatment earlier and predicting prognosis of the disease. 1. victor hoffbrand, daniel catovsky, edward gd tuddenham. acquired aplastic anemia. in: postgraduate haematology, 6th edition. wiley blackwell, 2011. 2. dezern ae, brodsky ra. clinical management of aplastic anemia. expert rev hematol. 2011; 4(2):221 230. 3. kulasekararaj ag, jiang j, smith ae, mohamedali am, mian s, gandhi s, et al. somatic mutations identify a subgroup of aplastic anemia patients that progress to myelodysplastic syndrome. blood. 2014; 124(17):2698 – 704. 4. victor hoffbrand, paul moss. aplastic anaemia and bone marrow failure. in: essential haematology, 6th edition. john wiley & sons, 2011. 5. wali r, adil s, naqvi ma. aplastic anemia clinicohaematological features, treatment and outcome analysis. j coll physicians surg pak. 2011; 21(4):219 222. 6. biswajit h, pratim pp, kumar st, et al. aplastic anemia a common hematological abnormality among peripheral pancytopenia. n am j med sci. 2012; 4(9):384 88. 7. niemeyer c, baumann i. classification of childhood aplastic anemia and myelodysplastic syndrome. am soc hematol educ program. 2011; 2011:84 – 89. 8. dokal i, vulliamy t. inherited bone marrow failure syndromes. haematologica. 2010, 95: 1236 – 1240. 9. bacigalupo a, passweg j. diagnosis and treatment of acquired aplastic anemia. hematol oncol clin north am. 2009, 23:159 – 170. 10. victor hoffbrand, daniel catovsky, edward gd tuddenham. inherited aplastic anemia and bone marrow failure syndromes. in: postgraduate haematology, 6th edition. wiley blackwell, 2011. 11. scheinberg p, wu co, nunez o, young ns. predicting response to immunosuppressive therapy and survival in severe aplastic anaemia. british journal of haematology. 2009, 144(2): 206 – 216. 12. busque l, patel jp, figueroa me, et al. recurrent somatic tet2 mutations in normal elderly individuals with clonal hematopoiesis. nat genet. 2012, 44(11):1179 – 1181. 13. marsh jcw, gordon smith ec. aplastic anaemia and other causes of bone marrow failure. in: oxford textbook of medicine, 5th edition. oxford university press, 2009. 14. hussein k, tefferi a. conventional cytogenetics in haematological disorders. european journal of haematology. 2009, 82:329 – 338. 15. afable mg, wlodarski m, makishima h, shaik m, sekeres ma, tiu rv, et al. snp array based karyotyping, differences and similarities between aplastic anaemia and hypocellular myelodysplastic syndromes. blood. 2011, 117:6876 – 6884. r e f e r e n c e s c o n c l u s i o n 242 jimdc 2017 245 16. scheinberg p, wu co, nunez o, boss c, sloand em, young ns. treatment of severe aplastic anemia with a combination of horse antithymocyte globulin and cyclosporine, a prospective randomized study. haematologica. 2009, 94:348 – 354. 17. tichelli a, schrezenmeier h, socie g, marsh j, bacigalupo a, dührsen u, et al. a randomized controlled study in patients with newly diagnosed severe aplastic anemia receiving antithymocyte globulin (atg), cyclosporine, with or without g-csf. blood. 2011, 117:4434 – 4441. 18. kim sy. lee jw. cho bs. eom ks. the characteristics and clinical outcome of adult patients with aplastic anemia and abnormal cytogenetics at diagnosis. genes chromosomes cancer. 2010, 49:844 – 850 19. passweg jr, marsh jcw. aplastic anemia, first line treatment by immunosuppression and sibling marrow transplantation. am soc hematol educ program. 2010, 153:36 – 42. 20. eapen m, horowitz m. alternative donor transplantation for aplastic anemia. am soc hematol educ program. 2010, 2010:43 – 46. 21. shaffer lg, slovak ml, campbell lj. an international system for human cytogenetic nomenclature iscn, 2009. 22. xing j, zhang y, han k, salem ah, sen sk, huff cd, zhou q, kirkness ef, levy s, batzer ma and jorde lb. mobile elements create structural variation: analysis of a complete human genome. genome res. 2009, 19:1516 1526. 23. li j, yang s, lu s, et al. differential gene expression profile associated with abnormality of bone marrow mesenchymal stem cells in aplastic anemia. plos one. 2012, 7(11): 47764. 24. breakey vr, meyn s, ng v, allen c, dokal i, lansdorp pm, et al. hepatitis-associated aplastic anemia presenting as a familial bone marrow failure syndrome. j pediatr hematol oncol. 2009; 31(11):884 887. 25. dezern ae, brodsky ra. paroxysmal nocturnal hemoglobinuria: a complement mediated hemolytic anemia. hematol oncol clin north am. 2015 jun. 29 (3):479 494. 26. guidelines for the diagnosis and management of adult aplastic anaemia. british committee for standards in haematology 2015. 27. rathore s, pramanick a, regi a, lionel j. aplastic anemia in pregnancy. journal of obstetrics and gynaecology of india. 2014, 64(1):26 28. 28. tschiedel e, gierenz n, wieland r, wulff b, ballauff a. severe aplastic anemia in six children after non a e hepatitis. z gastroenterol. 2010, 48(8):825 828. 29. ferrer ra, wobus m, list c, et al. mesenchymal stromal cells from patients with myelodysplastic syndrome display distinct functional alterations that are modulated by lenalidomide. haematologica. 2013, 98(11):1677 – 1685. 30. gupta v, kumar a, saini i, et al. cytogenetic profile of aplastic anaemia in indian children. indian j med res. 2013; 137(3):502 – 506. 31. marsh jc, ball se, cavenagh j, darbyshire p, dokal i, gordon smith ec, keidan j, laurie a, martin a, mercieca j, killick sb. guidelines for the diagnosis and management of aplastic anaemia. british journal of haematology. 2009; 147(1):43 70. 32. arber da, orazi a, hasserjian r, thiele j, borowitz mj, le beau mm, et al. the 2016 revision to the world health organization classification of myeloid neoplasms and acute leukemia. blood. 2016; 127 (20):2391 2405. 33. gonzalez casas r, garcia buey l, jones ea, gisbert jp, moreno-otero r. hepatitis associated aplastic anaemia, a syndrome associated with abnormal immunological function. aliment pharmacol ther. 2009; 30(5):436 443. 34. geyh s, oz s, cadeddu rp, et al. insufficient stromal support in mds results from molecular and functional deficits of mesenchymal stromal cells. leukaemia. 2013, 27(9):1841 – 1851. 35. killick sb, bown n, cavenagh j, dokal i, foukaneli t, hill a, hillmen p, mufti g, et al. guidelines for the diagnosis and management of adult aplastic anaemia. br j haematol. 2016; 172(2):187 – 207. https://www.ncbi.nlm.nih.gov/pubmed/?term=tschiedel%20e%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=20687018 https://www.ncbi.nlm.nih.gov/pubmed/?term=gierenz%20n%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=20687018 https://www.ncbi.nlm.nih.gov/pubmed/?term=wieland%20r%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=20687018 https://www.ncbi.nlm.nih.gov/pubmed/?term=wulff%20b%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=20687018 https://www.ncbi.nlm.nih.gov/pubmed/?term=ballauff%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=20687018 https://www.ncbi.nlm.nih.gov/pubmed/20687018 j islamabad med dental coll 2020 35 open access comparative effects of alpha tocopherol and ascorbic acid on chronic stress induced neuropeptide y derangements saadia zainab1, tahir ahmad munir2, anjum ilahi3,4, adnan saleem khan5 1assistant professor, department of physiology, al-nafees medical college, islamabad 2professor, department of physiology, mohi-ud-din islamic medical college, mirpur ajk 3associate professor, department of medicine , al-nafees medical college, islamabad 4head, department of cardiology, al-nafees medical college, islamabad 5registrar, department of cardiology, al-nafees medical college, islamabad a b s t r a c t background: chronic stress decreases resilience of the body mainly due to hormonal imbalance. neuropeptide y -ergic system is abnormally regulated in chronic str ess due to reduction-oxidation imbalance. the antioxidants such as alpha-tocopherol and ascorbic acid reduce this imbalance with positive effect on neuropeptide y synthesis and release. this study was aimed to compare the protective effects of alpha-tocopherol and ascorbic acid on plasma neuropeptide y levels in chronic stress. material and methods: this quasi-experimental study was done at al-nafees medical college in collaboration with national institute of health islamabad from january 2015 to january 2016 after taking institutional approval. sixty male sprague dawley rats were obtained and divided equally into four groups ; group i (control), group ii (restraint stress group chronic restraint stress six hours daily for 28 days), group iii (restraint stress + alpha-tocopherol 50mg/kg body weight /day), and group iv (restraint stress + ascorbic acid 100mg /kg body weight /day). cardiac puncture was done to obtain blood for biochemical analysis. results: a significant decrease in plasma neuropeptide y levels was seen in group ii compared to group i, group iii and group iv. however, alpha-tocopherol administration in group iii showed positive effects on maintenance of plasma neuropeptide y concentration with better p trend than that of ascorbic acid supplementation in group iv. conclusion(s): alpha-tocopherol supplementation has more potent effect than that of ascorbic acid on chronic restraint stress induced derangements in neuropeptide y levels. it leads to less imbalance in neuropept ide y levels during chronic stress. key words: ascorbic acid, alpha-tocopherol, chronic stress, neuropeptide y authors’ contribution: 1-3conception; literature research; manuscript design and drafting; 4critical analysis and manuscript review; data analysis; manuscript editing correspondence: saadia zainab email: drsaadiakmu7@gmail.com article info: received: april 17, 2019 accepted: march 17, 2020 cite this article. zainab s, munir ta, anjum-ilahi, khan as. comparative effects of alpha tocopherol and ascorbic acid on chronic stress induced neuropeptide y derangements. j islamabad med dental coll.2020; 9(1): 35-41. doi: 10.35787/jimdc.v9i1.332 funding source: nil conflict of interest: nil i n t r o d u c t i o n stress disturbs body homeostasis and activates several adaptive responses. good stress, kno w n as eustress, is associated with positive motivational attitude while bad stress or distress is linked with body dysfunction and aversive behavioral changes in organism such as escape or avoidance of stressor which endanger the body.1 chronic stressors like prolonged illness, poverty, unemployment and or i gi n a l a r ti c le j islamabad med dental coll 2020 36 several other factors leads to repetitive stress and cause body dysfunction. stress affects immune system by activating sympathetic-adrenalmedullary system and the hypothalamic-pituitaryadrenal system that alter the byproducts of oxyge n metabolism.2 neuropeptide y (npy) is synthesized in many are as of brain including arcuate nucleus, locus coeruleus, nucleus tractus solitarii and septo-hippocampal nucleus and affects stress-related changes in emotional behavior and feeding. the stressrelieving, anxiolytic and the neuro-protective properties of npy enables the body to cope with stressful conditions. the rate of npy synthesis depends on the type and duration of stress exposure. stress, also contributes to and results from, neurodegenerative diseases such as alzheimer’s, parkinson’s and huntington’s diseas es but stress response with normal hormonal milieu has a neuroprotective role. npy functions through stimulation of y1, y2, y4 and y5 receptors, counteracts the biological actions of corticotropin releasing hormone and also exerts anxiolytic effects. a research showed that npy knockout mice were more anxious compared to healthy controls.3 an increased npy concentration in brain and plasma is also seen in inflammatory visceral stress of crohn’s disease and ulcerative colitis. a negative correlation between behavioral disruption and cerebral npy expression is seen in post-traumatic stress disorder in animal studies. 4 overstimulation of stress hormones like catecholamine, cortisol and arginine vasopressin tend to increase metabolism and formation of reactive oxygen species (ros) through metabolic oxidative phosphorylation resulting in a disturbance in the reduction-oxidation homeostasis.5 npy lessens the effects of these stress hormones and normalizes body functions. alpha-tocopherol (at) commonly known as vitam in e, is a low-molecular-weight, lipid-soluble, chainbreaking antioxidant, located in tissue membranes . it prevents lipid peroxidation of membranes by interfering with the proliferation of lipid radicals and is capable of scavenging ros.6 ascorbic acid (aa) or vitamin c is a hydrophilic compound, present in cytosol and extracellular fluid, either in reduced or oxidized forms, has the ability to act as a reducing agent or detoxifies various oxygen radicals in vivo. the antioxidant activity involves its conversion to oxidized form (dehydro-ascorbic acid) by donating two electrons to ros, and helps in recycling tocopherol. 7 so, at and aa antioxidants, are thought to prevent stress induced damage and work with endogenous antioxidants enzyme systems to decrease oxidativ e stress and widespread oxidative damage. altho u gh international literature points out the interaction of at and aa with npy-ergic system, scarcity of the data in our country urged us to do the current study. in this study the objective was to compare the stabilizing effect of antioxidants at and aa on plasma npy levels in oxidative stress caused by prolonged restraint of experime ntal animals. m a t e r i a l a n d m e t h o d s this quasi-experimental study was done at alnafees medical college (anmc) and hospital islamabad in collaboration with national institute of health (nih) islamabad after approval from the institutional review board of anmc (letter number: f.2/iuic-anmc/ec-58/2015). total duration of the study was one year from january 2015 to january 2016. sixty adult male sprague dawley rats were obtained from national institute of health islamabad. they were ere equally divid e d into four groups, with 15 rats in each group by convenient sampling technique. the mean body weight was 275±25 gm. sample size was calculated j islamabad med dental coll 2020 37 with 95% confidence interval, power of 80 and effect size by open epi calculator. grouping was done as follows: group i: control, group ii: restraint stress (keeping rats in mesh wire restrainer), group iii: restraint stress + alpha tocopherol 50mg/kg body weight /day by gavage)8 and group iv: restraint stress + ascorbic acid (100mg/kg body weight/day by gavage).9 rats were kept in stainless steel cages in a humidity and temperature-controlled room (22 ± 2°c) on a 12:12-h light-dark cycle and handled for 1 week before the start of the experiment. stress was induced in group ii rats through food deprivation and they were immobilized by keeping them individually in wire mesh restrainer for 6 hours/ day × 28 days.10 group iii was exposed to restraint stress and supplemented with at 50mg/kg body weight /day orally by gavage. after induction of restraint stress, group iv was supplemented with aa 100mg/kg body weight /day orally by gavage after mixing in 2 ml drinking water. doses of at and aa both were calculated on the basis of their antioxidant effects which can be achieved by selection of the oxidative stress dose in rats. control group and restraint group were given simple drinking water by gavage. after induction of chronic restraint stress for a period of 28 consecutive days, 5 rats at a time were placed in closed chamber with ether-soaked cotton. it took 5-6 minutes for rats to get anesthetized. cardiac puncture was done with 23-gauge cardiac puncture needle and 4 cc blood samples were taken from each rat.11 the blood samples were transferred to separate vacutainers containing anti coagulant edta for plasma. the samples were centrifuged at 3000 rpm for 15 minutes and transferred to labelled eppendorf tubes. plasma was stored at -20oc for npy, elisa biochemical analysis. means (+sd) of plasma npy levels in different groups were calculated. the difference in means o f plasma npy levels between and withing the gro u p s was calculated by one-way anova and post hoc tuckey test. p-value >0.05 was taken as statistically significant. r e s u l t s the results showed that plasma npy levels in control group i ranged between 0.502-0.690 ng/ml with a mean±sd 0.619±0.05, while in restraint stress group ii, plasma npy levels ranges between 0.221-0.513 ng/ml with a mean±sd value of 0.357± 0.07.9 (table i). the plasma npy levels of group iii restraint supplemented with alpha-tocopherol (50mg/kg/body weight/day) ranges between 0.5130.682 ng/ml with a mean ±sd value of 0.570± 0.05 ng/ml while npy levels in group iv, restraint with ascorbic acid (100mg/kg/body weight/day) ranges between 0.465-0.643 ng/ml with a mean ±sd value of 0.554± 0.04 ng/ml (table i). a linear relationship between npy absorbance against standard concentrations was obtained. (figure 1) this standard curve was plotted by presenting the known concentrations of standard on the log scale (x-axis) and its corresponding corrected absorbance on y-axis. the value of y intersect was used to calculate the concentration of samples. figure 1: calibration curve between standard concentration and absorbance of neuropeptide -y j islamabad med dental coll 2020 38 table ii. one way anova for npy between and within the groups sum of squares df mean square f p -value npy between groups .671 4 .168 41.219 .000 within groups .285 70 .004 a statistically significant difference was noticed when npy values were compared between gro u p i and ii, and i and iv, however, the values was fo u n d to be non-significant (p-0.212) when control group was compared with group iii (table i). the npy levels were also found statistically significant (p<0.05) when group ii was compared with group iii. same trend of significant difference (p<0.05) was noted between group ii and group i v . difference was non-significant when group iii and group iv were compared (p-0.916). a statistically significant value (p<0.05) was seen between the groups and within the groups (table ii) . d i s c u s s i o n our results showed an increased plasma concentration of npy in control group compared to restraint group. these results are consistent with grisé et al12 who showed increased plasma npy levels in control group compared to restraint group, while hassan et al13 showed same results in a stu d y conducted on mice. our results are not in agreement with zhang et al14 who showed decreased npy levels in control group, the difference may be due to use of rodent female rat strain and use of different kits. eskandarzade n et al15 showed same plasma npy level of control group and in starved rats. restraint stress in the form of food deprivation an d immobilization was induced in rats of group ii. data of group ii showed low plasma npy levels than th at of control group i and other experimental groups iii, iv. the results are similar with daubert et al16 who showed decreased plasma npy levels in rats with chronic restrained stress. results shown by kuo et al17 were different from our study, who concluded that chronic restraint stress raises plasma npy levels. the reason of difference could be lesser duration of stress exposure. our results showed low levels of plasma npy in restraint stress group given at compared to contro l group i. a study conducted by salehi et al18 showe d similar results that used high fat diet to induce oxidative stress that was later ameliorated by administration of at and aa in combination. in this study combination of two antioxidants was used because aa potentiates the action of at when used in combination, by recycling the radical of at to protect the cell membranes from lipid peroxidatio n caused by accumulation of ros. thereby antioxidants reduce neuronal toxicity by sparing action on neuronal cell membranes and secretion.18 similar results were noticed by hounsom et al19 who found depleted plasma npy levels in rats deficient in alpha-tocopherol compared to control group. another study conducted on mice given at table i: comparison of mean ±sd of plasma neuropeptide y in diff erent groups. variable groups mean ± sd 95% ci p -value npy i 0.619± 0.05 ii 0.357± 0.07 0.2120 -0.3148 0.001 iii 0.570± 0.05 0.0108 – 0.0904 0.212 iv 0.554± 0.04 0.0273 – 0.1035 0.047 ii 0.357± 0.07 iii 0.570± 0.05 -0.2618 -0.1638 0.001 iv 0.554± 0.04 -0.2454 -0.1505 0.001 iii 0.570± 0.05 iv 0.554± 0.04 -0.0201 – 0.0498 0.961 j islamabad med dental coll 2020 39 in fish oil showed improved cognitive functions an d maintenance of npy mrna in the brain. 20 at along with angiotensin converting enzyme inhibitors decrease the formation of ros in intima and media of aortic walls in mice with atherosclerosis. accumulation of ros is a feature of both atherosclerosis and high concentrations of angiotensin ii in vasculature.21 at increases the permeability of blood brain barrier in streptozotocin induced convulsions in albino rats and spare the action on npy release to attain the anticonvulsant effect of npy.22 at, in any form, inhibits oxidation of low density lipoproteins and decreases phenomenon of thromboembolism and clot formation and hence decreases heart attacks. when it is given in combination with ascorbic acid (aa) and carotenoids provides safer and effective results.23 in our study ascorbic acid (aa) supplementation given to rats exposed to restraint stress showed decreased npy plasma levels compared to control group. the results are in agreement with simonneaux et al24 who showed potentiating effects of npy on rhythmic pineal gland secretion by aa on rodent model. another study conducted by dixit et al25 have established link between aa deficiency, impaired cognition and oxidative stress showing membrane stabilizing effects of aa in oxidative stress. the intracerebroventricular administration of aa leads to markedly decreased food intake in rats by interfering with actions of dopamine and npy.26 at being lipophilic, acts readily on cell membranes and stops lipid peroxidation and quench free radicals potently. however, hydrophilic aa target cytosol and plasma alone and in synergism with at to mop ros directly.27 bartali et al showed more potent antioxidant ability of at for free radical scavenging as compared to aa by keeping membrane integrity and intact secretory activity of npy. it has been determined that deficiency of at with aging leads to a decline in physical function. 28 present study showed statistically significant decline in npy plasma levels after induction of chronic stress. comparable results of npy plasma levels of control group and experimental groups with supplementation of at and aa were obtained. although statistically insignificant results were obtained between the groups supplemented with at and aa, but p trend showed better maintenance of npy levels with at supplementation. limitation: biochemical analysis could not be done in duplicate due to financial and time constraint. c o n c l u s i o n alpha-tocopherol supplementation may exert more beneficial effects than ascorbic acid on chronic restraint induced oxidative stress and derangements in neuropeptide y levels. r e c o m m e n d a t i o n mechanism of action of npy at receptor level needs to be worked out. effects of antioxidants on other stress hormones like glutamate and gamma aminobutyric acid can be studied r e f e r e n c e s 1. kozusznik mw, rodríguez i, peiró jm. eustress and distress climates in teams: patterns and outcomes. international journal of stress management 2015; 22(1): 1-23. doi: 10.1037/a0038581 2. srivastava kk, kumar r. stress, oxidative injury and disease. indian j. clin. biochem. 2015; 30(1): 3-10. doi: 10.1007/s12291-014-0441-5 3. reichmann f, holzer p. neuropeptide y: a stressful review. neuropeptides. 2016 ; 55: 99-109. doi: 10.1016/j.npep.2015.09.008 4. holzer p, farzi a, hassan am, zenz g, jačan a, reichmann f. visceral inflammation and immune activation stress the brain. front immunol. 2017; 8: 1613. doi: 10.3389/fimmu.2017.01613 5. wood sk, bhatnagar s. resilience to the effects of social stress: evidence from clinical and preclinical studies on the role of coping strategies. neurobiol j islamabad med dental coll 2020 40 stress. 2015; 1: 164-73. doi: 10.1016/j.ynstr.2014.11.002 6. chen ay, lü jm, yao q, chen c. entacapone is an antioxidant more potent than vitamin c and vitamin e for scavenging of hypochlorous acid and peroxynitrite, and the inhibition of oxidative stressinduced cell death. med sci monit 2016; 22: 687. doi: 10.12659/msm.896462 7. bursać-mitrović m, milovanović dr, mitić r, jovanović d, sovrlić m, vasiljević p et al. effects of lascorbic acid and alpha-tocopherol on biochemical parameters of swimming-induced oxidative stress in serum of guinea pigs. afr j tradit complement altern med. 2016; 13(4): 29-33. doi: 10.21010/ajtcam.v13i4.5 8. ghorbel i, elwej a, fendri n, mnif h, jamoussi k, boudawara t, grati kamoun n, zeghal n. olive oil abrogates acrylamide induced nephrotoxicity by modulating biochemical and histological changes in rats. ren fail. 2017; 39(1): 236-45. doi: 10.1080/0886022x.2016.1256320 9. ahmed om, ashour mb, fahim hi, ahmed na. citrus limon and paradisi fruit peel hydroethanolic extracts prevent the progress of complete freund’s adjuvant-induced arthritis in male wistar rats. adv anim vet sci. 2018; 6(10): 443-55. 10. lodhi gm, latif r, hussain mm, naveed ak, aslam m. effect of ascorbic acid and alpha tocopherol supplementation on acute restraint stress induced changes in testosterone, corticosterone and nor epinephrine levels in male sprague dawley rats. j ayub med coll abbottabad. 2014; 26(1): 7-11. pmid: 25358206 11. kumar m, dandapat s, sinha mp, kumar a, raipat bs. different blood collection methods from rats: a review. balneo res. j. 2017; 8(2): 46-50. doi: 10.12680/balneo.2017.141 12. grisé kn, olver td, mcdonald mw, dey a, jiang m, lacefield jc, et al. high intensity aerobic exercise training improves deficits of cardiovascular autonomic function in a rat model of type 1 diabetes mellitus with moderate hyperglycemia. j diabetes res. 2016; 2016. 8164518e. doi: 10.1155/2016/8164518 13. hassan a, jain p, reichmann f, mayerhofer r, farzi a, schuligoi r, et al. repeated predictable stress causes resilience against colitis-induced behavioral changes in mice. front behav neurosci. 2014; 8: 386-90. doi: 10.3389/fnbeh.2014.00386 14. zhang p, qi yx, yao qp, chen xh, wang gl, shen br, et al. neuropeptide y stimulates proliferation and migration of vascular smooth muscle cells from pregnancy hypertensive rats via y1 and y5 receptors. plos one. 2015; 10(7): e0131124. doi: 10.1371/journal.pone.0131124 15. eskandarzade n, saeb m, nazifi s, saeb s, kazemipour n, ansari-lari m. the effect of longterm starvation on galanin, leptin, thyroid hormones, insulin, prolactin, growth hormone, ghrelin and factors involved in energy metabolism in adult goats. j fac vet med istanbul univ. 2015; 41: 143-50. 16. daubert dl, looney bm, clifton rr, cho jn, scheuer da. elevated corticosterone in the dorsal hindbrain increases plasma norepinephrine and neuropeptide y, and recruits a vasopressin response to stress. am j physiol regul integr comp physiol. 2014; 307(2): r212-24. doi: 10.1152/ajpregu.00326.2013 17. kuo le, czarnecka m, kitlinska jb, tilan ju, kvetňanský r, zukowska z. chronic stress, combined with a high‐fat/high‐sugar diet, shifts sympathetic signaling toward neuropeptide y and leads to obesity and the metabolic syndrome. ann n y acad sci. 2008; 1148(1): 232-7. doi: 10.1196/annals.1410.035 18. salehi i, saidijam m, vahidinia aa, sohrabi m, asl ss. high fat diet-induced neurotoxicity alters following vitamin e and c administration in hippocampus of male rats. gene cell tissue. 2017; 4(4): e58383. doi: 10.5812/gct.58383 19. hounsom l, corder r, patel j, tomlinson dr. oxidative stress participates in the breakdown of neuronal phenotype in experimental diabetic neuropathy. diabetologia. 2001; 44(4): 424-8. doi: 10.1007/s001250051638 20. avraham y, saidian m, burston jj, mevorach r, vorobiev l, magen i, et al. fish oil promotes survival and protects against cognitive decline in severely undernourished mice by normalizing satiety signals. j nutr biochem. 2011; 22(8): 766-76. doi: 10.1016/j.jnutbio.2010.07.001 21. abd alla j, el faramawy y, quitterer u. microarray gene expression profiling reveals antioxidant-like effects of angiotensin ii inhibition in atherosclerosis. front physiol. 2013; 4: 148. doi: 10.3389/fphys.2013.00148 22. yorulmaz h, seker fb, oztas b. effect of vitamin e on blood-brain barrier permeability in aged rats with ptz-induced convulsions. neurophysiol. 2011; 42(5): 349-53. 23. renata m, masha l, jose l, shahab k, gitanjali m, mayuree r. etiologic effects and optimal intakes of foods and nutrients for risk of cardiovascular diseases and diabetes: systematic reviews and meta-analyses from the nutrition and chronic diseases expert group. plos one. 2017; 12(4): e0175149. doi: 10.1371/journal.pone.0175149 j islamabad med dental coll 2020 41 24. simonneaux v, ouichou ah, craft c, pévet p. presynaptic and postsynaptic effects of neuropeptide y in the rat pineal gland. j neurochem. 1994; 62(6): 2464-71. doi: 10.1046/j.1471-4159.1994.62062464.x 25. dixit s, bernardo a, walker jm, kennard ja, kim gy, kessler es, et al. vitamin c deficiency in the brain impairs cognition, increases amyloid accumulation and deposition, and oxidative stress in app/psen1 and normally aging mice. acs chem neurosci. 2015; 6(4): 570-81. doi: 10.1021/cn500308h 26. abbasnejad m, sofiabadi m, moghimi a, sadeghian n. the effects of intracerebrove ntricular injection of ascorbic acid on feeding behavior in male rats. j jahrom univ med sci. 2012; 10(3): 47-50. doi:10.29252/jmj.10.3.57 27. forni lg. metabolic resuscitation in sepsis: could antioxidants be the answer? signa vitae. 2017; 13(3): 16-19. doi:10.22514/sv133.062017.2 28. bartali b, curto t, maserejian nn, araujo ab. intake of antioxidants and subsequent decline in physical function in a racially/ethnically diverse population. j nutr health aging. 2015; 19(5): 542-7. doi:10.1007/s12603-015-0449-4 j islamabad med dental coll 2019 79 open access pattern of angulations and common indications for extraction of impacted mandibular third molar at kmu-institute of dental sciences, kohat tariq sardar 1, gulrukh sheikh 2, saddique aslam 3, numan muhammad khan 4, javed akhtar rana 5 1 senior registrar, department of oral and maxillofacial surgery, kmu institute of dental sciences, kohat. 2 clinical attaché, department of periodontology, khyber college of dentistry, peshawar. 3 professor & head, department of oral and maxillofacial surgery, kmu institute of dental sciences, kohat. 4 registrar, department of oral and maxillofacial surgery, kmu institute of dental sciences, kohat. 5 post graduate resident, department of oral and maxillofacial surgery, shaheed zulfiqar ali bhutto medical university, islamabad a b s t r a c t background: the extraction of an impacted mandibular third molar (mtm), with associated pathologies or clinical manifestations is an important and one of the most frequent decisions in dentistry. the angle formed by the longitudinal axis of second and third molar is used to determine angulation of impacted mtm. the aim of this study was to identify the pattern of angulations of impacted mandibular third molar and common indications for extraction associated with these angulations. material and methods: this descriptive cross-sectional study was carried out at department of oral & maxillofacial surgery, khyber medical university institute of dental sciences, kohat, khyber pakhtunkhwa (kp) from november 2017 to july 2018. a total of 349 patients presenting with impacted mandibular third molars were included in this study. name, age, gender, address, the angulation of the impacted tooth and the indication for extraction of the impacted tooth were recorded. data comprising of qualitative and quantitative variables were analyzed using spss version 17. results: out of 349 patients, 206 were male and 143 females, with the male to female ratio of 1.4:1. the age range of the patients was from 18 years to 60 years with a mean age of 26 ± 6 years. the most common age group with impacted third molar was ≤ 25 years followed by 26 to 30 years’ age group. the most common angulation was mesioangular followed by vertical, horizontal and distoangular impacted mandibular third molar. pericoronitis was the most common indication for extraction in all angulations except horizontal impaction where root resorption of the second molar was more common. conclusion: mesioangular is the most common angulation in impacted mandibular third molars. pericoronitis is the main indication for all angulations of impacted mandibular third molars except horizontal angulation, occurring mostly in the third decade of life. key words: angulation, impacted tooth, third molar, tooth extraction authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3 interpretation, discussion, 4,5 active participation in data collection data analysis. correspondence: tariq sardar email: drtari561@gmail.com article info: received: october 24, 2018 accepted: april 2, 2019 cite this article. sardar t, sheikh g, aslam s, khan nm, rana ja. pattern of angulations and common indications for extraction of impacted mandibular third molar at kmuinstitute of dental science, kohat. j islamabad med dental coll.2019; 8(2):79-83 funding source: nil conflict of interest: nil i n t r o d u c t i o n an impacted tooth is one that fails to erupt into its normal functioning position in the mouth within its expected time.1 different reasons for a tooth becoming impacted include dense overlying hard and soft tissue, lack of space, abnormal eruption path, unusual positioning of tooth bud and associated pathological lesions.2 general factors like genetic abnormality, rickets, anemia, irradiation, congenital syphilis, tuberculosis, malnutrition and cretinism also cause impaction.3 the mandibuar third molar (mtm) is the most frequently impacted tooth o r i g i n a l a r t i c l e j islamabad med dental coll 2019 80 followed by maxillary third molar and maxillary canine.4-6 the angle formed by the longitudinal axes of second and third molar is used to determine angulation of impacted mtm. thus, the impaction can be mesioangular, distoangular, horizontal, transverse or vertically angulated.5,7 whether to extract or retain an impacted mtm is an important and one of the most frequent decisions in dentistry and oral surgery.8,9 there is complete consensus on the removal of impacted third molar with associated pathologies or clinical manifestations but their prophylactic removal is still a subject of debate.10,11 the pathologies associated with impacted mtm include pericoronitis, carries/pulpitis of second or third molar, periodontal problems, root resorption of second molar, neurogenic pain and cyst or tumors.4,8,12 in addition to associated pathologies, these impacted molars may need removal for orthodontic and prosthodontic or restorative reasons.13,14 the aim of this study was to analyze the pattern of angulation of mtm and the common indications for removal associated with different angulations of these impacted teeth at kmu-ids, kohat m a t e r i a l a n d m e t h o d s this descriptive cross-sectional study was conducted from november 2017 to july 2018 in the department of oral and maxillofacial surgery, at kmu-institute of dental sciences, kohat, kp. a total of 349 patients, aged 18 years and above, presenting to the outpatient department with impacted mandibular third molar were included in this study. after obtaining approval of the ethical committee of the institution, written informed consent from the patients was taken. inclusion criteria included all patients who required extraction of impacted mandibular third molars associated with pathologies or asymptomatic mandibular third molars requiring extraction for orthodontic or prosthodontic reasons. patients younger than 18 years, any maxillofacial trauma, with craniofacial anomalies and syndromes like apert syndrome, cleidocranial dysostosis and disease free asymptomatic mandibular third molars were excluded from the study. the parameters recorded included the age, gender, the angulation of the impacted tooth and the indication for extraction of the impacted tooth. the angulation of an impacted third molar was determined on the basis of winter’s classification with reference to the angle formed by the longitudinal axes of the second and third molars. the angulation and indication for extraction was determined on the basis of history, clinical examination and radiographs that included a standard periapical radiograph supplemented by orthopantomogram where necessary. data was analyzed in spss version 17. the qualitative variables in the demographic data like gender, patterns of angulation and indications for extraction were presented as proportions and percentages and quantitative variables like age were presented as means and standard deviation. r e s u l t s a total of 349 patients who reported for extraction of impacted mandibular third molar were included in this study. most of them were males (n=206, 59%) with a male to female ratio of 1.4:1. the age ranged from 18 years to 60 years with a mean age of 26 ± 6 years. most of the patients belonged to age group 25 years and below (57%) followed by 26-30 years’ age group (24.1%). details of different age groups are given in table i. table i: frequency distribution of impacted third molars according to age groups age groups (years) impacted mandibular third molars n (%) 25 and below 199 (57) 26-30 84 (24.1) 31 to 35 38 (10.9) 36 to 40 12 (3.4) 41 to 45 10 (2.9) 46 and above 6 (1.7) total 349 mesioangular impaction (48.7%) was the most common amongst the patients who reported for extraction of impacted mandibular third molar at kmu-ids. this was followed by vertical impaction (28.7%), distoangular impaction (12.6%) and horizontal impaction (10%) of the mandibular third molar, respectively. j islamabad med dental coll 2019 81 table ii: frequency distribution of indications for extraction of impacted mandibular third molars indications for extraction impacted mandibular third molars n (%) pericoronitis 169 (48.4) 2nd molar caries 48 (13.8) 3rd molar caries/pulpitis 52 (14.9) periodontal problems 31 (8.9) root resorption (2nd molar) 17 (4.9) cyst/tumor 2 (0.6) pain of unknown origin 28 (6) orthodontic purpose 7 (2) prosthodontic purpose 2 (0.6) total 349 the most frequent indication for extraction of mtm was pericoronitis (48.4%). other common indications for extraction of impacted mtm are shown in table ii. pericoronitis was the most common indication for extraction of mtm associated with all angulations except horizontal impaction, which commonly caused root resorption of the second molar. the relationship of different indications for extraction with various angulations is shown in table iii d i s c u s s i o n third molar extractions are frequently carried out procedures performed by oral surgeons and an indication for referral to oral and maxillofacial surgeons. this study was conducted at oral & maxillofacial surgery department, kmu-ids, kohat in which 349 patients with impacted mtm were observed. in this study, majority of the patients (59%) were males while 41% patients were females with an age range of 18 to 60 years. this is in contrast with other studies15,16 from around the world that reported a higher proportion of female patients while local studies17,18 showed similar male preponderance. the explanation for higher incidence of male patients may be attributed to the male dominant society and cultural restriction on females where males have more opportunities to seek medical and dental advice as compared to females who usually require male attendants to seek any treatment. the most common age group at the time of presentation was 25 years or less followed by 25-30 years (24.1%) declining to only 1.7% in 45 years or more age group. thus, most of the patients belonged to the 3rd decade of life with a sharp decline in older age groups. this sharp decline may be explained by the removal of impacted mandibular molars at younger age especially in the third decade of life. similar high incidence of impacted mtm in the third decade of life has been reported by other studies as well.1,8,18 the current study showed that the mesioangular impacted mtm was the most common (38.7%) followed by vertical (28.7%), distoangular (12.6%) and horizontal (10%) impactions. similar results were reported in other studies as well.18-20 pericoronitis was the main indication for extraction (48.4 %) of mesioangular (most common), vertical, distoangular and horizontal impactions respectively. this is in contrast to other studies, which show high incidence of pericoronitis associated with vertical impactions.18,21 we assume that this high incidence of pericoronitis with mesioangular impaction in our study might be due to a higher percentage of these impactions in our study population. the net percentage of pericoronitis is the highest for distoangular impaction followed by vertical and mesioangular. the second most common reason for removal of the impacted mtm was dental caries of third molar itself followed by caries and pulpitis of the second mandibular molar. third molar caries was common with vertical impaction while second molar caries was common with mesioangular impaction. these observations are similar to other studies conducted in libya, nigeria and pakistan.15,16,18 this high incidence of caries may be due to the food entrapment and difficulty in maintaining oral hygiene due to relative inaccessibility to this area. periodontal problems were the fourth common indication for removal of impacted mandibular molar in our study. most of these periodontal problems were associated with mesioangular impacted mtm which may be due to the food entrapment and bacterial colonization and inability to clean the area properly. similar results were reported in other studies as well.18,20 two important reasons for removal of impacted mtm are to preserve periodontal health or treat existing periodontitis. the association of visible third molar with periodontal conditions in young adults indicates negative impact on periodontal health. j islamabad med dental coll 2019 82 table iii: frequency of different indications for extraction in relation to angulations indications for extraction angulations mesioangular n horizontal n vertical n distoangular n total n (%) pericoronitis 74 5 56 34 169 (48.4) 2nd molar caries 38 4 5 1 48 (13.75) 3rd molar caries/pulpitis 20 5 23 4 52 (14.9) periodontal problems 25 4 2 0 31 (8.88) root resorption (2nd molar) 5 11 1 0 17 (4.87) cyst/tumor 1 0 1 0 2 (0.57) pain of unknown origin 2 3 11 5 21 (6) orthodontic purpose 5 2 0 0 7 (2) prosthodontic purpose 0 1 1 0 2 (0.57) total 170 35 100 44 349 root resorption of the second mandibular molar was more commonly reported with horizontal angulation of the impacted mtm in our study. similar results of root resorption with horizontal and mesioangular impactions were reported in other studies as well.20,22 this root resorption associated with horizontally impacted tooth is due to the pressure exerted by the crown of impacted tooth. in our study, only two patients (0.6%) reported with cyst/tumor, associated one each with mesioangular and vertical impacted tooth. this percentage is lower than other studies carried out by ishfaq et al (2%)18 and krishnan et al (5%).15 about 21 patients reported for extraction of mtm with undiagnosed pain. most of these patients (11) had vertical impacted tooth. similar indication of undiagnosed pain was reported in other studies as well.16,18,23 the undiagnosed pain may be attributed to the lack of more advanced imaging techniques like computed tomography scan, magnetic resonance imaging, cone beam computed tomography etc in our set-up and the unwillingness of patients to undergo further investigation before extracting the impacted tooth. most of these patients have already gone to a general dentist who had pointed out the impacted tooth as a possible cause of their pain. similarly, 07 patients were referred by orthodontist for extraction of the third molar while 02 patients extracted the impacted tooth for fabrication of denture. extraction of impacted mtm for orthodontic purposes has been reported in other studies as well.15,16,18.19 c o n c l u s i o n most of the patients were young males in the third decade of life. mesioangular impaction was the most common impacted tooth, while pericoronitis was the most common indication for removal of the impacted tooth associated with all angulations except horizontal angulation where root resorption was more common. r e f e r e n c e s 1. hassan ah. pattern of third molar impaction in a saudi population clin cosmet investig dent. 2010;2: 109-13. doi: 10.2147/cciden.s12394 2. ishihara y, kamioka h, yamamoto tt, yamashiro t. patients with nonsyndromic bilateral and multiple impacted teeth and dentigerous cysts. am j orthod dentofacial orthop. 2012; 141(2): 228-41. doi: 10.1016/j.ajodo.2010.02.043 3. brakus i, filipovic z, boric r, siber s, svegar d, kuna t. analysis of impacted and retained teeth operated at the department of oral surgery, school of dental medicine, zagreb. coll antropol. 2010;34(suppl 1):229-33. pmid: 20402324 4. chu fc, li tk, lui vk, newsome pr, chow rl, cheung lk. prevalence of impacted teeth and associated pathologies – a radiographic study of the hong kong chinese population. hong kong med j. 2003;9(3):158-63. pmid: 12777649 j islamabad med dental coll 2019 83 5. tarzona ba, paredes vb, llamas jm, cibrian re, gandia jl. influence of first and second premolar extractions or non-extraction treatments on mandibular third molar angulation and position. a comparative study. med oral pathol oral cir bucal. 2010;15(5): 760-66. doi: 10.4317/medoral.15.e760 6. zuccati gc, doldo t. multiple impactions in an adolescent girl. am j orthod dentofacial orthop. 2010;137(4):163– 72.doi: 10.1016/j.ajodo.2008.03.035. 7. quek sl, tay ck, tay kh, toh sl, lim kc. pattern of third molar impaction in singapore chinese population: a retrospective radiographic survey. int j oral maxillofacial surg. 2003;32(5): 548-52. doi: 10.0154/ijom.2003.0413 8. polat hb, ozan f, kara i, ozdemir h, ay s. prevalence of commonly found pathoses associated with mandibular impacted third molars based on panoramic radiographs in turkish population. oral surg oral med oral pathol oral radiol endod. 2008;105(6): e41-7. doi: 10.1016/j.tripleo.2008.02.013 9. malkawi z, al-omiri mk, khtaisat a. risk indicators of postoperative complications following surgical extraction of lower third molars. med princ pract. 2011;20(4):321-25. doi: 10.1159/000324550 10. adeyemo wl. do pathologies associated with impacted lower third molars justify prophylactic removal? a critical review of the literature. oral surg oral med oral pathol oral radiol endod .2006; 102(4): 448-52. doi: 10.1016/j.tripleo.2005.08.015 11. mettes tg, nienhuijs me, van der sanden wj, verdonschot eh, plasschaert aj. interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. cochrane database syst rev. 2005 18; (2): cd003879. doi: 10.1002/14651858.cd003879.pub2 12. stanley hr, alattar m, collett wk, stringfellow hr jr, spiegel eh. pathological sequelae of “neglected” impacted third molars. j oral pathol. 1988;17(3):113-7. pmid: 3135372 13. kruger e, thomson wm, konthasinghe p. third molar outcomes from age 18 to 26: findings from a populationbased new zealand longitudinal study. oral surg oral med oral pathol oral radiol endod. 2001;92(2):150-5. doi:10.1067/moe.2001.115461 14. chaparro-avendaño av, pérez-garcía s, valmasedacastellón e, berini-aytés l, gay-escoda c. morbidity of third molar extraction in patients between 12 and 18 years of age. med oral patol oral cir bucal. 2005;10(5):422-31. pmid: 16264374 15. krishnan b, el-sheikh mh, el-gehani r, orafi h. indications for removal of impacted mandibular third molars: a single institutional experience in libya. j maxillofac oral surg. 2009; 8(3): 246-8. doi: 10.1007/s12663-009-0060-5 16. odai ed, obuekwe on. study of indications for disimpaction of mandibular third molar and the frequently associated complications following such treatments. ann med surg prac. 2016;1(1):44-50. 17. khan m, mehmboob b, katpar s. extraction of wisdom teeth under general anesthesiaa study. jkcd. 2014;5(1):20-4. 18. ishfaq m, wahid a, rahim au, munim a. patterns and presentations of impacted mandibular third molars subjected to removal at khyber college of dentistry peshawar. pak oral dent j. 2006;26(2):221-6. 19. rahman sa, alam mk, woei kc, shaari r. pattern of angulations of mandibular third molar impaction in a malaysian population: a retrospective radiographic investigation. int med j. 2014;21(1):120-2. 20. shahzad ma, marath ma, chatha mr, sohail a. evaluation of patterns of mandibular third molar impactions and associated pathologies. pak oral dent j. 2016;36(2):92-6. 21. hazza’a a, bataineh a, odat a. angulation of mandibular third molar as a predictive factor for pericoronitis. jcdp. 2009;10(3):51-8. pmid: 19430626 22. oenning ac, neves fs, alencar pn, prado rf, groppo fc, haiter-neto f. external root resorption of the second molar accociated with third molar impaction: comparison of panoramic radiography and cone beam computed tomography. j oral maxillofac surg. 2014;72(8):1444-55. doi: 10.1016/j.joms.2014.03.023 23. abdulai ae, nauman ik, sackeyfio j, hewlett s. indications for surgical extraction of third molars: a hospital-based study in accra, ghana. int j med biomed res. 2014;3(3):155-60. j islamabad med dental coll 2020 262 open access comparison of quality of life in breast cancer survivors with lymphoma survivors mumtaz ahmad khan1, shaista zafar2, namrah mahmood3 1 associate professor, department of general surgery, pims, islamabad pakistan 2 senior registrar, department of general surgery, pims, islamabad pakistan 3 medical officer, department of general surgery, pims, islamabad pakistan a b s t r a c t background: breast cancer diagnosis and its subsequent treatment, especially surgical removal of the breast(s) cause changes in physical appearance that can be devastating to the quality of life (qol) of cancer survivors. the objective of this study was to assess the effect of surgical intervention on the qol of breast cancer survivors by comparing it with qol of lymphoma survivors. material and methods: this was a cross-sectional study, conducted in the departments of general surgery and oncology at pakistan institute of medical sciences (pims) islamabad, pakistan from 1st june to 31st december, 2019. six months’ post treatment patients of breast cancer (n=166) and lymphoma (n=50) were included. a standardized questionnaire was used to assess the quality of life in cancer survivors (qol -csv). chi square and independent t-test were applied to determine the association of qol among lymphoma and breast cancer survivors. linear regression model was applied to determine the confounding variables. results: all participants responded moderately in reporting overall quality of life in lymphoma survivors (ls) as compared to breast cancer survivors (bcs) group (100% vs 86.7%; p = .007). physical wellbeing parameters revealed a better mean score of 75.86 ±10.53 for ls group than the bcs group ( p < .001). psychological wellbeing mean score was similar for both groups (p = .46). distress associated with illness and treatment was dealt better by ls than bcs group (p < .001), whereas spiritual wellbeing was markedly better in bcs group ( p < .001). fear of recurrence and spread was poor amongst the bcs than ls, while the ls group performed worse i n social factors (mean value of 26.88±6.67) (p < .001). conclusions: both lymphoma and breast cancer negatively affect the quality of life of the patients, especially the psychological, social and spiritual wellbeing. however, surgical intervention in breast cancer patients led to considerable worsening of the quality of life with respect to physical and social wellbeing and increased distress of illness and fear factor. key words: breast cancer survivors, lymphoma survivors, psychological wellbeing, quality of life, spiritual wellbeing, surgical intervention. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: namrah mahmood email: dr.namrahmahmood@gmail.com article info: received: august 18, 2020 accepted: december 17, 2020 cite this article. khan ma, zafar s, mahmood n. comparison of quality of life in breast cancer survivors with lymphoma survivors. j islamabad med dental coll. 2020; 9(4): 262-268. doi: 10.35787/jimdc.v9i4.587 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 263 i n t r o d u c t i o n there is a surge in the cases of cancer globally with national indices following this trend. pakistan reported 148,000 new carcinoma cases in 2012. 1 early detection and better treatment options have led to improvement in the survival rates of cancer patients worldwide.2 this has caused an increased interest in assessing the quality of life (qol) of cancer survivors, based on the bio-psycho-social model of health care.3 there is an overall rise in the global and national incidence of lymphoma, with a reported incidence of 8.4 per 100,000 in males and 6.5 per 100,000 in female population in pakistan.4 similarly, the incidence of breast cancer has also increased globally, with pakistan reporting 50 per 100,000 of female population affected by breast cancer.5 the mainstay of treatment in lymphoma patients is chemotherapy with or without radiotherapy.6 however, in the treatment of breast carcinoma, different surgical options are considered, based on the underlying pathology, along with chemotherapy and/or radiotherapy.7 the diagnosis of cancer and its subsequent treatment impairs the quality of life of the affected individual in multiple ways causing altered pain threshold, fatigue, sleeplessness and fear of future diagnoses.8 however, surgical treatment especially breast surgeries, may further impair quality of life with respect to body image and personal outlook. social stigmas and concerns may further add to the distress of the patients.9 since mastectomy involves removal of breast, which defines female appearance and contribute to sexuality, it can have a profound impact on the qol of the patient in the long run. 10 the main aim of this study was to understand the effect of surgical intervention (i.e. mastectomy) on the quality of life of breast cancer survivors’. however, cancer diagnosis, fear of recurrence, lengthy and costly treatment options as well as the side effects of chemotherapy are multiple factors which can also contribute in deranging quality of life, making it difficult to study the isolated effect of mastectomy on qol. for this purpose, comparison is made with lymphoma survivors in this research in order to find the effect of mastectomy on the qol of the patients. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted at the outpatient department of general surgery and oncology at pims, islamabad pakistan, from 1st june 2019 to 31st december 2019. patients (age ≥ 18 years) who had undergone mastectomy (modified radical mastectomy) for breast cancer and had received treatment (chemotherapy and/ or radiotherapy) more than 6 months ago were included in the breast cancer survivors (bcs) group. whereas adult lymphoma patients (age ≥ 18 years) who had received chemotherapy and/ or radiotherapy at least 6 months ago were included in the lymphoma survivors (ls) group. patients who had residual disease, recurrence of disease or complications after treatment (related to surgery, chemotherapy or radiotherapy), and patients who had a previous history of any type of cancer, were excluded from this study. sample size for each group (bcs and ls) was calculated using national prevalence of breast cancer and lymphoma. 4,5 non probability consecutive sampling technique was employed to recruit participants. permission to conduct this study was obtained from the ethical review board of shaheed zulfiqar ali bhutto medical university, islamabad pakistan. a written informed consent was taken from the participants and their demographical variables including age, profession, gender, type of carcinoma, stage of disease at diagnosis, type of j islamabad med dental coll 2020 264 treatment received and time since treatment ended was recorded. the principal investigators interviewed the participants and filled in the questionnaires. a standardized questionnaire (qolcsv4) was used to assess the quality of life of the participants, with questions assessing physical, psychological, social and spiritual wellbeing as well as fear factor and distress of illness. data was entered and analyzed using spss version 20. comparison of the scores of both groups was made using mean values for each category (physical, psychological, distress of illness, fear factor, social and spiritual wellbeing). each of the 41 questions in qol-csv had values ranging from ‘0’ to ‘10’ with ‘0’ as worst outcome and ‘10’ as best outcome. scores for each category were analyzed into poor, moderate and good with cut-off value kept at <40%, 41-70% and >70% of the total score for each category, respectively. frequencies and percentages were reported for categorical data and mean ± standard deviation was recorded for numerical data. chi square test and independent t-test was applied to determine the association of quality of life among lymphoma and breast cancer survivors for categorical and numerical variables, respectively. linear regression model was applied to determine the confounder variables. p-value was considered as significant at < .05. r e s u l t s a total of 50 lymphoma survivors (ls) and 166 breast cancer survivors (bcs) participated in the study, with a mean age of 55.84 ± 8.82 years in lymphoma group and 54.65 ± 6.291 years in breast cancer group, respectively. in the ls group, a total of 24 (48%) female and 26 (52%) male patients were included, while in the bcs group, all participants were female. most of the participants were married in both groups (ls 96%; bcs 97.6%). regarding professions, all the bcs were housewives (100%), while 54% of ls were housewives followed by 24% in-service, 10% businessmen, and 12% unemployed, respectively. duration of treatment and stage of cancer at presentation in both groups are presented in figures 1a and 1b, respectively. figure 1a: duration of treatment among both groups figure 1b: stage of cancer at the time of diagnosis all participants responded moderately in reporting overall quality of life in ls group as compared to bcs group (100% vs 86.7%; p=.007). we found significant association among bcs group and ls group in overall comparison of qol (p<.001) (table i). in physical wellbeing, ls group took the lead with 55% of the participants scoring more than 80 out of 90 score and a mean value of 75.86 ±10.53 as compared to bcs group (p <.001). breast cancer survivors reported higher incidence of body aches, fatigue and menstrual problems (74% participants scoring less than 5 out of 10 in each question). both groups performed moderately (41%-70%) in psychological wellbeing, with mean value of 42.18 ±8.06 and 43.04 ±7.04 in ls and bcs groups, respectively ( p=.46). however, the responses about changes in appearance and self-concept revealed that more j islamabad med dental coll 2020 265 than 80% of breast cancer survivors reported extreme changes (scoring ≥ 8 out of 10) (table i). there was significant correlation in quality of life amongst ls and bcs for physical wellbeing, distress of illness and treatment, extent of fearfulness, social concerns, spiritual wellbeing (p<0.001) (table i). however, no significant correlation was found in psychological wellbeing between both groups. distress of illness and treatment showed that majority (56% vs 76%) were reported moderately (qol score 41%-71%) in bcs and ls groups, respectively with mean value of 40.84±6.17 vs 36.86±6.55 (p<.001). among extent of fear questions, fear of recurrence and second cancer was poor in bcs group as shown by less score in qol for most of the participants (72.3%) as compared to ls group (50%). quality of life regarding social concerns amongst ls group was poorer than with bcs group. however, in bcs group more participants reportedly felt that their sexuality has been negatively affected (64% participants scored more than 5 out of 10). spiritual wellbeing amongst ls was better as compared to bcs as shown in table ii. age, sex, marital status, duration of treatment, stage of cancer, profession type and treatment type showed significant association with overall quality of life in bcs group as compared to ls group (r= 0.276; adjusted r-squared 4.7%; p=.026 vs r=0.416; adjusted r-squared 5.8%; p=.201) in linear regression model. marital status and stage of cancer were the contributing factors in developing poor qol in bcs (table iii). table i: comparison of mean score of quality of life between breast cancer survivors and lymphoma survivors quality of life bcs (mean ± sd) ls (mean ± sd) p-value* overall score 48.25±6.94 55.27±4.31 <.001 physical well being 17.09±7.33 75.86 ±10.53 <.001 psychological well being 43.04 ±7.04 42.18 ±8.06 .461 distress of illness and treatment 36.86±6.55 40.84± 6.17 <.001 fearfulness 11.28± 8.2 16.58±4.30 <.001 social concerns 42.57 ±8.43 26.88 ±6.67 <.001 spiritual well being 47.15 ±6.27 30.64 ±6.83 <.001 *independent t-test was applied to determine the p-value considered significant at <.05 table ii: quality of life categories between breast cancer survivors and lymphoma survivors poor n (%) moderate n (%) good n (%) p-value* physical well being bcs 166 (100) 0 0 <.001 ls 0 6 (12) 44 (88) psychological well being bcs 18 (10.8) 148 (89.2) 0 .326 ls 8 (16) 42 (84) 0 distress of illness and treatment bcs 73 (44) 93 (56) 0 .011 ls 12 (24) 38 (76) 0 extent of fearfulness bcs 120 (72.3) 44 (26.5) 2 (1.2) .006 ls 25 (50) 25 (50) 0 social concerns bcs 25 (15.1) 135 (81.3) 6 (3.6) <.001 ls 39 (78) 11 (22) 0 spiritual wellbeing bcs 1 (0.6) 103 (62) 62 (37.3) <.001 ls 18 (36) 32 (64) 0 *chi square test was applied to determine the p-value considered significant at <.05 bcs-breast cancer survivors; ls-lymphoma survivors j islamabad med dental coll 2020 266 table iii: comparison of bio data variables in both groups variables breast cancer survivors lymphoma survivors b (ci 95%) p-value* b (ci 95%) p-value* age 0.095 (-0.10 0.29) .338 0.107 (-0.35 – 0.25) .137 sex -0.076 (-2.67 – 2.52) .953 marital status 14.31 (3.7 24.9) .008 4.67 (-1.9 11.2) .159 treatment duration -1.05 (-2.03 -0.08) .033 -1.59 (-3.66 – 0.49) .130 stage of cancer 1.2 (-0.68 – 3.11) .209 -0.51 (-2.95 – 1.92) .672 profession type -0.85 (-2.04 0.34) .157 treatment type 0.57 (-0.481.63) .285 *p <.05 was considered statistically significant d i s c u s s i o n in this study all the participants in bcs group were females. incidence of breast-related diseases in men is uncommon, with a prevalence ratio ranging from 0.1 to 3.4 cases per 100,000 populations.11 however, the difference in prevalence of lymphoma is not much affected by gender (8.4/100000 in male versus 6.5/100000 in female population4). in pakistan, breast cancer patients usually present during advanced stages of disease due to low awareness about the illness and socio-economic hurdles. a study conducted in karachi reported that most of the patients presented during stage 2 and 3 of the disease12. in our experience at pims hospital islamabad, most of the patients pre sented during stage 3. similarly, lymphoma patients in pakistan mostly present at stage 2 and 3.13 in the present study both ls and bcs groups had good quality of life post treatment in physical and psychological parameters, however the breast cancer survivor (bcs) group reported lower mean values as compared to lymphoma survivors (ls) group in physical health parameters. there was worse score in parameters like fatigue, body aches and menstrual and fertility issues in bcs group as compared to ls group. due to the unique characteristics of breast cancer and lymphoma, disparity in the sample size with respect to gender was seen. a study conducted at agha khan university karachi, pakistan reported that post chemotherapy cancer patients reported low qol due to issues in physical and emotional wellbeing.14 however, this is in contrast to a study conducted at combined military hospital, rawalpindi15 where breast cancer patients following mastectomy, described good qol perceptions in physical wellbeing parameters. raymond et al.16 reported that post mastectomy pain is present in almost 20-50% of the patients, which severely deteriorated the qol of these individuals and its risk factors included physical, genetic as well as psychological factors. in a study conducted in university of california,17 at least 25% of the patients reported postoperative pain after mastectomy and preoperative depression and anxiety was associated with higher levels of pain. costa et al. from brazil reported that more than 70% breast cancer patients reported pain, which directly affected the physical health and functional capacity of these individuals, resulting in increased morbidity.18 depression and post-traumatic stress disorder also resulted in low physical component of qol amongst lymphoma survivors as reported by compaci et al.19 although there was insignificant difference of overall psychological impact on qol in both groups in our study, the results showed breast cancer survivors had more concerns about their change of j islamabad med dental coll 2020 267 appearance and self-image, post-surgery and postchemotherapy. higher distress of disease and fear of recurrence was also noted by the researchers in this study among bcs group as compared to lymphoma group. sema et al. reported that women who had undergone mastectomy reportedly gave negative statements about their body image and felt they were half of themselves.20 sophia et al. reported that there was better physical health but worse psychological health in young lymphoma survivors after controlling demographic co-relations.21 poor psychological health amongst lymphoma survivors was associated with older age, higher co-morbidities and low education status.22-24 in our study, the patients who had undergone mastectomy reported feeling decreased sexuality. this is consistent with the findings reported by jose and maria with participants feeling that they had mutilated bodies with decreased femininity resulting in low self-esteem, less physical attractiveness and inability to keep social relationships.25 similar concerns were reported from turkey, where respondents felt that mastectomy negatively affected their relationship with their partners and their social interactions were also affected.20 the main limitation of our study was that we assessed the qol of cancer survivors at least 6 months after their treatment. however, a longer duration of follow-up is required to study long term psychosomatic and social effects of treatment in both bcs and ls groups c o n c l u s i o n both lymphoma and breast cancer negatively affect the quality of life of the patients especially the psychological, social and spiritual wellbeing. however, surgical intervention led to considerable worsening of quality of life with respect to physical and social wellbeing and increased distress of illness and fear factor. r e c o m m e n d a t i o n s psychological and social support groups as well as rigorous follow up for both physical and psychological illnesses should be considered in cancer survivors. breast reconstruction surgery should be made available in all breast cancer clinics and centers so that the social and psychological impact of the disease and its treatment can be minimized. a c k n o w l e d g m e n t authors are thankful to ms. mahwish raza (medical affairs, getz pharma) for providing assistance in statistical analysis and formatting manuscript. r e f e r e n c e s 1. index c. cancer index pakistan. cancerindex.org. 2020. available from: http://www.cancerindex.org/pakistan 2. van leeuwen m, husson o, alberti p, arraras j, chinot o, costantini a, et al. understanding the quality of life (qol) issues in survivors of cancer: towards the development of an eortc qol cancer survivorship questionnaire. health qual life outcomes. 2018; 16(1): 114. doi: 10.1186/s12955 -018-0920-0 3. ayanian jz, jacobsen pb. enhancing research on cancer survivors. j clin oncol. 2006; 24(32): 5149 –53. doi: 10.1200/jco.2006.06.7207 4. bhurgri y, pervez s, bhurgri s, faridi n, usman a, kazi la et al. increasing incidence of non-hodgkin's lymphoma in karachi, 1995-2002. asian pac j cancer prev. 2005; 6(3): 364-9. pmid: 16236001 5. khalfan z, edgar k, ali a z, sadruddin s. breast cancer in pakistani females. journal on nursing. 2014; 4(2): 13-17. doi: 10.26634/jnur.4.2.2771 6. nccn clinical practice guidelines in oncology (ncc n guidelines) for hodgkin lymphoma. version 2.2019. 7. sharma gn, dave r, sanadya j, sharma p, sharma kk. various types and management of breast cancer: an overview. j adv pharm technol res. 2010; 1(2):10926. pmid: 22247839 8. valdes-stauber j, vietz e, kilian r. the impact of clinical conditions and social factors on the psychological distress of cancer patients: an explorative study at a consultation and liaison service in a rural general hospital. bmc psychiatry. 2013; 13(1). j islamabad med dental coll 2020 268 9. fujisawa d, hagiwara n. cancer stigma and its health consequences. current breast cancer reports. 2015;7(3):143-150. 10. erturhan turk k, yilmaz m. the effect on quality of life and body image of mastectomy among breast cancer survivors. european journal of breast health. 2018;:205-210. 11. gill m, kayani n, khan m, hasan s. breast diseases in males a morphological review of 150 cases. jpma. 2000; 50(6): 177-9. pmid: 10979622 12. soomro r, faridi s, khurshaidi n, zahid n, mamshad i. age and stage of breast cancer in pakistan: an experience at a tertiary care center. jpma. 20 18; 68(11): 1682-85. pmid: 30410149 13. mumtaz t, roohi n, akhtar m. incidence and clinical manifestation of lymphoma in central punjab. pakistan j zool. 2012; 44(5): 1367 -72. 14. chagani p, parpio y, gul r, jabbar aa. quality of life and its determinants in adult cancer patients undergoing chemotherapy treatment in pakistan . asia pac j oncol nurs. 2017; 4(2): 140 -146. doi:10.4103/2347-5625.204499 15. ozair dn, kamran dj, asim ds, fatima da, hisam da, ujala dm. quality of life among post-surgical patients of breast cancer visiting a tertiary care hospital in rawalpindi. pafmj.2019; 69(suppl 2): s303 -9. 16. tait rc, zoberi k, ferguson m, et al. persistent postmastectomy pain: risk factors and current approaches to treatment. j pain. 2018; 19(12): 13671383. doi: 10.1016/j.jpain.2018.06.002 17. miaskowski c, cooper b, paul sm, west c, langford d, levine jd, et al. identification of patient subgroups and risk factors for persistent breast pain following breast cancer surgery. j pain. 2012; 13(12): 1172 1187. doi: 10.1016/j.jpain.2012.09.013 18. costa w, eleutério jr. j, giraldo p, gonçalves a. quality of life in breast cancer survivors. revista da associação médica brasileira. 2017; 63(7): 583 -89. doi: 10.1590/1806-9282.63.07.583 19. compaci g, conte c, oberic l, ysebaert l, laur ent g, despas f. sustained degradation of quality of life in a subgroup of lymphoma survivors: a two-year prospective survey. bmc cancer. 2019; 19(1): 1178. doi: 10.1186/s12885-019-6337-2 20. koçan s, gürsoy a. body image of women with breast cancer after mastectomy: a qualitative research. j breast health. 2016; 12(4): 145 -50. doi:10.5152/tjbh.2016.2913 21. smith s, crespi c, petersen l, zimmerman s, ganz p. the impact of cancer and quality of life for posttreatment non-hodgkin lymphoma survivors. psychooncology. 2010; 19(12): 1259-67. doi: 10.1002/pon.1684 22. ng d, leong y, gan g. quality of life amongs t lymphoma survivors in a developing country. supportive care cancer. 2016; 24(12): 5015 -23. doi: 10.1007/s00520-016-3364-2 23. drost fm, mols f, kaal sej, stevens wbc, van der graaf wta, prins jb, et al. psychological impact of lymphoma on adolescents and young adults: not a matter of black or white. j cancer surviv. 2016; 10(4): 726-35. doi:10.1007/s11764-016-0518-7 24. smith s, mayer d, zimmerman s, williams c, benecha h, ganz p, et al. quality of life among long-term survivors of non-hodgkin lymphoma: a follow-up study. j clin oncol. 2013; 31(2): 272 -279. doi: 10.1200/jco.2011.40.6249 25. arroyo j, lópez m. psychological problems derived from mastectomy: a qualitative study. int j surg oncol. 2011; 1-8. doi: 10.1155/2011/132461 summary journal of islamabad medical & dental college (jimdc); 2016:5(3):147-149 147 case report tuberculosis of gall bladder humaira zafar 1 , noor khan lakhnana 2 and mudassira zahid 3 1. associate professor, department of pathology, alnafees medical college, islamabad 2 prof/head department of pathology, alnafees medical college, islamabad 3 assistant professor, department of pathology, alnafees medical college, islamabad abstract gallbladder with chronic cholecystitis and cholelithiasis is an everyday routine diagnosis in surgical pathology practice. however, one may encounter some rare diseases of gallbladder. tuberculosis (tb) of gall bladder is a rare infection; should also be considered amongst the differential list of gall bladder disorders and management of gall bladder pathologies. key words: cholelithiasis, gall bladder, granulomatous inflammation, tuberculosis. introduction gall bladder is usually considered as a rare site for tuberculosis. 1 as compared to other gall bladder pathologies like cholelithiasis and cholecystitis, tuberculous infection is rarely seen at this site. therefore, very little literature is available on the subject. 2 gall bladder tb is usually a part of miliary tuberculosis. 1 moreover, besides mycobacterium tuberculosis, mycobacterium avium can also be responsible for gall bladder tb. 3 the clinical presentation of such infection in gallbladder can be of typical signs and symptoms ranging from anorexia, weight loss, abdominal pain, jaundice and low grade fever. 4,5 and vary from a mild inflammation upto gall bladder perforation. 6 the diagnosis of such cases as of tuberculous etiology is usually unanticipated on histopathological examination. case report we report a case of 63-year-old male who presented with typical features of chronic cholecystitis including dyspepsia, flatulence, and multiple episodes of abdominal pain in upper quadrants. he also gave a history of malaise and lethargy for several months. on examination he was febrile and had tenderness in the epigastrium and right hypochondrium. murphi’s sign was positive. his laboratory investigations showed raised esr 74 mm/hr. blood cp showed mild leukocytosis. other investigations like liver profile and xray abdomen revealed no abnormality. however, his ultrasound showed a contracted thick walled gall bladder containing multiple stones. the findings were suggestive of chronic cholecystitis. a presumptive diagnosis of chronic cholelithiasis with cholecystitis was made. the patient was admitted in the surgery department and an open cholecystectomy was performed. operative findings showed a thickened gall bladder adherent with the liver. the resected gall bladder received in histopathology lab consisted of multiple pieces. the largest one measured 2.5x3 cm and was 1cm thick on gross examination. the mucosal surface was brown and irregular signifying presence of chronic inflammation and fibrosis. multiple mixed stones were present in the container. the representative sections were taken from the wall and processed routinely for h&e staining. on microscopic examination the mucosa was flattened and widely ulcerated. the surface epithelium where present was unremarkable. all layers of gall bladder showed widespread chronic inflammation with multiple granulomas (figure 1). these were composed of epithelioid cells, langham’s giant cell and lymphocytes along with foci of caseation necrosis (figure 2). figure 1: multiple granulomas seen dispersed in inflammatory lesion dense and exuberant fibroblastic proliferation was noted. lymphoid aggregates were present in the mucosa and also in the perivascular spaces. the vessels and the nerves showed profound thickening and hypertrophy. the muscle layer was markedly thickened though disrupted by the dense corresponding author: dr.humaira zafar e mail:dr.humairazafar@yahoo.com received: august 15, 2016; accepted: sept 20, 2016 journal of islamabad medical & dental college (jimdc); 2016:5(3):147-149 148 inflammation and fibroblastic proliferation. rokitansky aschoff sinuses were not formed. the sections were searched for the presence of bile and any associated macrophages to account for the presence of giant cells and granulomas but no such evidence was found. pas stained sections also did not reveal any fungus. zn stained section of the gall bladder did not reveal any acid fast bacilli. a diagnosis of chronic caseating granulomatous inflammation was established. figure 2: caseation necrosis and langhan giant cell seen in the granulomas. discussion according to the published report by tauro et al, and khan et al only 50 cases of gall bladder tb have been reported. 7,8 tanwani et al described the pathogenesis of this infection. according to which obstruction of cystic duct leads to the reduction in bile acids, thus the environment becomes favorable for the growth of tubercle bacilli. moreover, the damage induced by cholelithiasis predisposes to tuberculous cholecystitis. the literature review is extremely deficient on gall bladder tb without gall stones, cystic or common bile duct obstruction and it is hypothesized that gallbladder mucosal damage due to these conditions is a prerequisite for tuberculous involvement. 9 a study report by ruhl et al showed that the pathogenesis of such infection is unclear rather controversial. 10 xanthogranulomatous cholecystitis though uncommon form of cholecystitis, is common cause of granuloma formation in gallbladder. it is characterized by presence of bile, foam cells and noncaseating granulomas. 11 crohn disease with noncaseating granulomas can also rarely involve the gallbladder. 12 sharara et al reported that schistosomal cholecystitis is another gall bladder granulomatous infection, which must be differentiated from the tuberculous one. these cases have parasites in the tissue. only about >10 such cases have been reported. 13 the presentation of current study findings i.e. presence of cholelithiasis without pus (empyema) were not comparable to the findings reported by leo et al. 7 sharma et al described that preoperatively, the radiological findings of gall bladder, tb mimics carcinoma of gall bladder and the right diagnosis is made conveniently by histopathological examination. 14 the study reports by raja et al and kaustova et al describe that the sensitivity of gall bladder tb for serological diagnosis i.e. for igg, iga, and igm antibodies is 62, 52, and 11%. while the specificities are 100, 97, and 95%, respectively, thus requiring confirmation by histopathological examination. 15,16 this fact highlights the importance of requirement of post-surgical histopathological examination of every specimen irrespective of the certainty of clinical diagnosis. since, tb of gall bladder is a rare occurrence so the preoperative diagnosis is extremely difficult and unsought. thus, all the gall bladder specimens after cholecystectomy should have a histopathological evaluation, especially in tb endemic areas. so, that provision of proper and timely management with anti-tuberculous therapy can reduce the miseries of such patients, moreover one should also look for a primary focus. conclusion gall bladder tb can coexist with cholelithiasis ultimately causing cholecystitis. all resected gallbladder specimens should be routinely examined histopathologically and this rare entity should be kept in mind while evaluating histopathology samples. references 1. kumar k, ayub m, kumar m, keswani nk, shukla hs. tuberculosis of the gallbladder. hpb surgery : a world journal of hepatic, pancreatic and biliary surgery. 2000;11(6):401-404. 2. yu r, liu y. gallbladder tuberculosis: case report. chinese medical journal. 2002;115(8):1259-61. 3. cacciarelli ag, naddaf sy, el-zeftawy ha, aziz m, omar ws and kumar m et al. acute cholecystitis in aids patients: correlation of tc-99m hepatobiliary scintigraphy with histopathologic laboratory findings and cd4 counts. clinical nuclear medicine. 1998;23(4):226-228. 4. abascal j, martin f, abreu l, pereira f, herrera j, ratia t, et al. atypical hepatic tuberculosis presenting as obstructive jaundice. the american journal of gastroenterology. 1988;83(10):1183-1186. 5. landis felix fj, villalobos talero j, mazure lenhoff ra, cabrerizo comitre e, polo camacho m, bravo arenzana l, et al. [tuberculosis of the biliary system: presentation of a case and review of the literature]. revista espanola de enfermedades digestivas : organo oficial de la sociedad espanola de patologia digestiva. 1990;78(1):43-45. 6. hahn st, park sh, shin ws, kim cy, shinn ks. gallbladder tuberculosis with perforation and intrahepatic biloma. journal of clinical gastroenterology. 1995;20(1):84-86. 7. tauro lf, martis jj, shenoy hd. tuberculosis of gall bladder presenting as empyema. saudi journal of gastroenterology : official journal of the saudi gastroenterology association. 2008;14(2):101-102. 8. khan r, vasenwala sm, arif sh, harris sh. granulomatous gall bladder: a surgico-pathological challenge. annals of saudi medicine. 2010;30(3):244-245. journal of islamabad medical & dental college (jimdc); 2016:5(3):147-149 149 9. rouas l, mansouri f, jahid a, zouaidia f, saidi h, nabih n, et al. [gallbladder tuberculosis associated with cholelithiasis]. revue medicale de liege. 2003 ;58(12):757760. 10. ruhl km, krones cj, hermanns b, schumpelick v. [tuberculosis of the gall bladder]. der chirurg; zeitschrift fur alle gebiete der operativen medizen. 2003 ;74(5):478481. 11. jetley s, rana s, khan rn, jairajpuri zs. xanthogranulomatous cholecystitis--a diagnostic challenge. journal of the indian medical association. 2012 ;110(11):833-837 12. andoh a, endo y, kushima r, hata k, tsujikawa t, sasaki m, et al. a case of crohn's disease involving the gallbladder. world journal of gastroenterology. 2006 ;12(6):977-978. 13. sharara ai, abi-saad g, haddad m, mansour a, tawil a. acute granulomatous schistosomal cholecystitis. european journal of gastroenterology & hepatology. 2001 ;13(8):1001-1003. 14. sharma s, bansal r, agrawal n, khare a, bharosay vv. tuberculosis of the gall bladder clinically mimicking carcinoma--a case report. journal of the indian medical association. 2012;110(6):402-403. 15. raja a, uma devi kr, ramalingam b, brennan pj. immunoglobulin g, a, and m responses in serum and circulating immune complexes elicited by the 16-kilodalton antigen of mycobacterium tuberculosis. clinical and diagnostic laboratory immunology. 2002;9(2):308-312. 16. kaustova j. serological igg, igm and iga diagnosis and prognosis of mycobacterial diseases in routine practice. european journal of medical research. 1996;1(8):393-403. i radiological images aspergilloma formation in chronic tuberculous cavity along with reactivation of tuberculosis adenocarcinoma left lung ii cavitating pneumonia in an infant cmv pneumonia in aids patient cmv: cytomegalovirus aids: acquired immunodeficiency syndrome contributed by: department of radiology dr. akbar niazi teaching hospital, islamabad 41 j i m d c 2 0 1 8 41 open access f u l l l e n g t h a r t i c l e limb defects in developing chick embryos after administration of glucose ruqqia shafi minhas 1, m. yunus khan 2, anber saleem 3 1 assistant professor, department of anatomy, fazaia medical college, air university, islamabad 2 professor/hod,department of anatomy, cpsp regional centre, islamabad 3 assistant professor anatomy department, islamabad medical and dental college, islamabad a b s t r a c t objective: to assess the role of administered glucose on gross development of limbs of the chick embryos, in comparison with age matched controls. materials and methods: fertilized eggs of egyptian fayyumi breed were injected with glucose (5% weight/volume solution) into egg albumen. the eggs were put in the incubator under standard conditions of temperature and humidity. eggs were divided in two groups, control (a) and experimental (b). each group is subdivided in two subgroups comprising of 30 eggs each. eggs were opened on day 10 of incubation in subgroup (a1, b1) while eggs from subgroup (a2, b2) were allowed to hatch on day 21 or day 22 of incubation. the exposed embryos were compared with age matched control subgroups. effects of glucose were assessed by observing limb defects in the embryos from two groups. results: the experimental animals had limb defects manifested as absent, one hind limb in 5 out of 53 (9.433%). both hind limbs were absent in 6/53 (11.32%). in turned phalanges with inability to stand and limping gait was found in 8/53 (13.79%). no embryo of the control group demonstrated such findings. conclusion: administration of glucose resulted malformation such as limb defects and turned digits in growing chick embryos. key words: glucose, chick embryos, limb defects. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence ruqqia shafi minhas email: dr.ruqqiabilal@hotmail.com article info. received: september 28, 2017 accepted: december 11, 2017 cite this article. minhas rs, khan my, saleem a. limbs defects in developing chick embryos after administration of glucose. jimdc.2018; 7(1):44-45 funding source: nil conflict of interest: nil i n t r o d u c t i o n congenital malformations occur when the development of a structure is arrested, delayed or misdirected in fetal life. evidence that maternal diabetes significantly increases the risk for congenital malformations has accumulated over the last several decades.1 the total number of people with diabetes is projected to rise from 382 million in 2013 to 592 million in 2035 as mentioned in a study estimating the prevalence of this disorder. the same study indicates that in pakistan this number will rise from 6,713,000 in 2013 to 12,798,000 in 2035.2 hyperglycemia, is a constant feature of diabetes mellitus 3 and a positive correlation is present between hyperglycemia during embryogenesis and congenital anomalies as evidenced by clinical and experimental data.4,5 chicken (gallus gallus domesticus) and its eggs is a good comparative model for basic sciences because of easy availability, and low cost. chicken genome is found to have significant similarities with that of humans.6 this animal model can be used to explore the adverse effects of glucose on development and contribute in avoidance of o r i g i n a l a r t i c l e 42 j i m d c 2 0 1 8 42 unfavorable consequences of pregnancy in humans. in chick embryos limb development is indicated as a small “bud,” protruding from the body and comprised of lateral plate mesoderm (lpm) cells and the overlying surface ectoderm. the mesenchymal cells in this bud give rise to the skeletal elements while the limb muscles arise from cells that migrate into the limb bud from the somites. limb development depends upon the maintenance of three signaling centers within the limb bud: the apical ectodermal ridge (aer), at the distal margin of the bud; the zone of polarizing activity (zpa) in the mesenchyme at the posterior margin of the bud and the non-ridge ectoderm of the bud.7 there are different signaling molecules for the development to proceed smoothly. sonic hedgehog (shh) is produced in the zone of polarizing activity (zpa) of the limb bud and it specifies muscle pattern in the chick limb.8 in addition to shh fibroblast growth factor-8 (fgf8) is another morphogen expressed in the aer responsible for maintaining the outgrowth and differentiation of the mesenchymal cells making up the limb bud.9 the current study was planned to investigate the outcome of exogenous glucose on gross limb development in chick embryos keeping in mind the increasing prevalence of diabetes, particularly among the women in their reproductive years.10 the administration of glucose provides an opportunity to access the direct effects of this individual metabolite. m a t e r i a l s a n d m e t h o d s this randomized control trial was carried out at anatomy department, regional centre, college of physicians and surgeons pakistan, islamabad from january 2013 to january 2014. a total of 120 eggs belonging to egyptian fayoumi breed of gallus domesticus, were obtained from poultry research institute, punjab, rawalpindi. the cracked eggs and those stored in the refrigerator were excluded from the study. all selected eggs were counted and numbered starting from 1 to total count and were given labels depicting the sample number, group, subgroup and date of injection. after marking, the eggs were randomly allocated into control group (a) and experimental group (b) of 60 eggs each using the random selection table. each group was again randomly divided into two subgroups 1 and 2 comprising of 30 eggs. the day on which eggs were put in the incubator was taken as day 1. eggs from subgroup (a1 and b1) were opened on day 10 of incubation while those from subgroup (a2 and b2) were allowed to hatch on day 21 or 22. the experimental group was injected 15mg of 5% weight/ volume solution of glucose into egg albumen while the control group was injected with same volume of normal saline before putting into incubator. the glucose used for injection was 5% weight/ volume solution. un-incubated egg of day 0 was sponged with sterile cotton gauze moistened with 70% ethanol. each egg was kept vertically with blunt pole upwards for sometimes so that the blastoderm floats up. then a hole was drilled into its upper pole where the air sac is located. another hole was drilled at a point about a finger span above the lower pole with a thumb pin. only the shell was punctured. next, the shell membrane of the upper pole was pierced through hole already drilled with an empty insulin syringe with needle size 30 gauges’ x 8mm.this was to release air from the air sac. another insulin syringe having measured dose of glucose was used to inject the contents into the albumen through the lower hole. the two holes were sealed soon after injecting the dose with melted paraffin and the eggs were placed in the incubator (manufactured by memmert electric company germany) after thoroughly cleaning the incubator. incubation was under standard monitoring with temperature maintained at 38 0c and relative humidity was kept between 60-70%. an uninterrupted electric supply was maintained to the incubator. eggs were rotated ½ turn twice daily. this change in position aids in gaseous exchange between the embryo and outside air and adequate nutrient distribution to the developing embryo.11 the embryos from subgroup a1 and b1 were dissected out of the eggs on day 10 of incubation. after breaking the shell from the broader end in a bowl of water, embryos were cleanly extracted avoiding trauma. those from subgroup a2 and b2 were allowed to hatch. the number and percentages of embryos with gross limb defects were recorded. data were entered on spss version 14 for analysis. fisher’s exact test was applied and p-value < 0.05 was considered statistically significant. r e s u l t s there were 120 eggs in the study that were divided equally into 4 groups of 30 each. the number of alive 43 j i m d c 2 0 1 8 43 chicks in experimental group (b1 and b2) was 53/60 (88.33%) while in control group (a1 and a2) this number was 60/60 (100%). the experimental animals had limb defects manifested as absent one hind limb in 5 out of 53 (table 1; figure 1). table 1: comparison of limb defects between experimental and control groups anomalies groups; n(%) p-value control (n=60) experimental (n=53) absent one lower limb 0 5 (9.43) 0.026 absent both lower limbs 0 6 (11.32) 0.013 in turned phalanges with difficulty to stand 0 8 (13.79) 0.006 figure 1: photograph of day 10 chick embryo belonging to experimental group b1 with one lower limb missing (arrow). compare with age matched control a1 figure 2: day 10 chick embryo belonging to experimental group b1 with both hind limbs missing along with protruded abdominal contents both hind limbs were absent in 6/53 (figure 2). in turned phalanges with inability to stand and limping gait was found in 8/58 (figure 3). no embryo of the control group demonstrated such findings (table1). figure 3: photograph of newly hatched chicks. the glucose exposed subgroup b2 showing in-turned fingers (arrow) with inability to stand properly while a2 belongs to control subgroup. d i s c u s s i o n embryogenesis is a complex process, which can be altered by genetic and environmental factors causing birth defects. one of the environmental factors having strong influence on developmental process and increasing the risk of congenital malformations is high blood glucose level, as a result of maternal diabetes. the offspring of mothers with unrecognized type 1, type 2, or gestational diabetes have a high risk for being born with congenital anomalies, macrosomia, and neonatal, childhood, and adult complications.12 although these complications are known, few models exist to determine the effects of glycemic stress on the development of congenital malformations during organogenesis. we administered glucose in fertilized chick eggs before incubation to mimic embryonic conditions during maternal hyperglycemia. in our study, high glucose abridged the development of limbs. our observations are consistent with the findings of the research done by yao chen and colleagues, which revealed that increased glucose concentration caused decreased number and changed morphology of somites accompanied by alteration in the limb bud development in chick embryos. the study also reported inhibition of shh by treating the chick embryos with high gucose.13 since cells from somites give origin to limb muscles and shh 44 j i m d c 2 0 1 8 44 specifies the muscle pattern8, alteration in these two factors might be responsible for limb defects seen in our work. the same study reported that in the presence of high glucose, fgf8 expression was significantly repressed in the aer of the limb buds. as fgf8 is essential for limb growth, and for the induction of shh expression, this would explain why limb buds did not develop in our embryos treated with glucose. another study reported complete arrest of hind limb development in mice in which fgf 8 was conditionally inactivated.14 exogenous glucose also resulted in impaired cartilage development in chick hind-limbs resulting from repressed formation of the myotome by disrupting shh signaling.13 this might be an underlying mechanism which in turn effected the development of the skeleton and musculature of limbs in our study. one possible reason might be the disruption of wnt signaling pathway by glucose as it is proposed that wnt signaling is involved in the aer formation in chick limb bud via β catenin pathway.13,15 inactivation of β catenin pathway leads to degeneration of aer and limb truncation.16 the development of cartilage and ossicles present in the sclera of chick was also disrupted by glucose as revealed by a research work done already. the study showed decreased number of chondrocytes in addition to disordered growth of bones in sclera in experimental animals.17 this abnormal limb phenotype has also been reported in infants whose mothers had gestational diabetes, or preexisting diabetes. caudal regression syndrome is particularly strongly associated with diabetes mellitus. it is a condition in which agenesis or hypoplasia of the femorae occurs in conjunction with agenesis of the lower vertebrae.18,19 one of our experimental animal had protruded abdominal contents along with absent hind limbs. the combination of two abnormalities necessitates further studies to guarantee better understanding of the extent of birth defects caused by increased concentration of glucose. c o n c l u s i o n exposure of developing chick embryos to glucose resulted in absent lower limbs along with in turned fingers and protruded abdominal contents. r e f e r e n c e s 1. zabihi s, loeken mr. understanding diabetic teratogenesis: where are we now and where are we going? birth defects res a clinmolteratol. 2010; 88(10):779-90. 2. guariguatal,whitingdr,hambletoni,beagleyj,linnen kampu,shaw je.global estimates of diabetes prevalence for 2013 and projections for 2035.diabetes res clin pract.2014;103(2):137 -49 3. american diabetes association.diagnosis and classification of diabetes mellitus.diabetic care.2010;33(suppl 1):62-69 4. negrato ca, mattar r, gomes mb. adverse pregnancy outcomes in women with diabetes. diabetology & metabolic syndrome. 2012;4(1):41. 5. liang j, gui y, goas s, li j, song h .elevated glucose induces heart defects by altering the expression of tbx 5 and tbx 20 in the developing zebrafish embryo. birth defects res a clinmol teratol.2010; 88(6):480-6 6. castelo r , reymond a , wyss c , camara f, parra g, antonarakis se, guigó, r, and eyras e. . comparative gene finding in chicken indicates that we are closing in on the set of multi-exonic widely expressed human genes.nucleic acids res. 2005. 33(6):1935-39 7. summerbell, d., lewis, j. h., wolpert, l. positional information in chick limb morphogenesis, nature.1973; 244(5417): 492–96 8. tickle c, towers m. sonic hedgehog signaling in limb development. front. cell dev. biol.2017; 5:14. 9. p.h. crossley, g. minowada, c.a. macarthur, g.r. martin. roles for fgf8 in the induction, initiation, and maintenance of chick limb development. cell. 1996;84(1): 127–136 10. guariguata l, linnenkamp u, beagley j, whiting dr, cho nh. global estimates of the prevalence of hyperglycaemia in pregnancy.diabetes res clinpract.2014 ;103(2):176-85. 11. tona k, onagbeasan o, bruggeman v, mertens k, decuypere e. effect of turning duration during incubation on embryo growth, utilization of albumen and stress regulation.poult sci. 2005;84(2):315-20 12. eriksson uj.congenital anomalies in diabetic pregnancy.semin fetal neonate med.2009; 14(2):8593. 13. chen y,wangg,mayzl,liy,wangxy,cheng x et all.adverse effects of high glucose on somite and limb 45 j i m d c 2 0 1 8 45 development in avian embryos.foodchemtoxicol. 2014; 71:1-9. 14. boulet am, moon am, arenkiel br,capecchi mr. signaling by fgf4 and fgf8 is required for axial elongation of the mouse embryo.dev biol.2012;371(2):235-245 15. narita t, sasaoka s, udagawa k, ohyama t, wada n, nishimatsu s, takada s, nohno t. wnt10a is involved in aer formation during chick limb development. dev dyn. 2005; 233(2):282-7. 16. hill tp, taketo mm, birchmeier w, hartmann c.multiple roles of mesenchymal beta catenin during murine limb patterning. development. 2006; 133(7):1219-29. 17. minhas rs, khan my. effect of glucose administration on development of sclera in chick embryos.j coll physcians surg pak.2016;26(9):7615. 18. aberga, westbom l, källén b. congenital malformations among infants whose mothers had gestational diabetes or preexisting diabetes.early hum dev. 2001; 61(2):85-95. 19. versiani br, gilbert-barness e, giuliani lr, peres lc, pina-neto jm.caudal dysplasia sequence: severe phenotype presenting in offspring of patients with gestational and pre gestational diabetes. clin dysmorphol. 2004; 13(1):1-5. http://www.ncbi.nlm.nih.gov/pubmed/?term=boulet%20am%5bauthor%5d&cauthor=true&cauthor_uid=15328019 http://www.ncbi.nlm.nih.gov/pubmed/?term=moon%20am%5bauthor%5d&cauthor=true&cauthor_uid=15328019 http://www.ncbi.nlm.nih.gov/pubmed/?term=arenkiel%20br%5bauthor%5d&cauthor=true&cauthor_uid=15328019 http://www.ncbi.nlm.nih.gov/pubmed/?term=aberg%2c+a.%2c+westbom%2c+l.%2c+kallen%2c+b.%2c+2001.+congenital+malformations+among+infants+whose+mothers+had+gestational+diabetes+or+preexisting+diabetes.+early+hum.+dev.+61%2c+85%e2%80%9395. http://www.ncbi.nlm.nih.gov/pubmed/?term=aberg%2c+a.%2c+westbom%2c+l.%2c+kallen%2c+b.%2c+2001.+congenital+malformations+among+infants+whose+mothers+had+gestational+diabetes+or+preexisting+diabetes.+early+hum.+dev.+61%2c+85%e2%80%9395. j islamabad med dental coll 2019 186 ope n ac cess antimicrobial sensitivity pattern for urine isolates in urinary tract infection kiran tauseef bukhari1, haseeb tauseef bukhari2, humaira zafar1, mudassira zahid3 1 associate professor, department of pathology, al nafees medical college & hospital, islamabad. 2 pg trainee fcps part-ii, surgical unit-ii, holy family hospital, rawalpindi 3 assistant professor, department of pathology, al nafees medical college & hospital, islamabad a b s t r a c t background: the increased frequency and management of antibiotic resistance pattern in urinary tract infection (uti) is a challenging task for the clinicians. therefore, the current study was planned to identify the microbial etiology of uti and t he most suitable antibiotics used. the objective of the study was to assess the frequency of antimicrobial sensitivity pattern in patients with urinary tract infection. material and methods: this cross-sectional study was carried out at al sayed hospital, kidney centre, rawalpindi over a period of seven months i.e. june 30, 2018 to january 30, 2019. a total of 152 patients were enrolled according to the inclusion and exclusion criteria of the study. urine culture proceedings were done as per latest recommended guidelines of clinical and laboratory standard institute (clsi) for uti. results: highest sensitivity was observed for carbapenems (83.5%), followed by polymyxin b (72.3% ), phosphonic acid derivatives (65.8%), aminoglycoside group (65.7%), extended spectrum penicillin (63.1%), imidazolidinedione (59.9%) and tetracycline (59.9%) groups. the least sensitivity was observed for oxazolidinone (linezolid) (14.5%), teicoplanin (13.8%), tigecycline (10.5%) and firstgeneration cephalosporins (1.3%). conclusions: carbapenems showed maximum sensitivity for all urine isolates. the second and third options were polymyxin b and phosphonic acid derivatives, respectively. key words: anti-microbial sensitivity, carbapenems, phosphonic acid derivatives, polymyxins, urinary tract infection, urine isolates authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3,4 active participations in data collection data analysis. correspondence: kiran tauseef bukhari email: drkirannmc@gmail.com article info: received: january 6, 2019 accepted: november 23, 2019 cite this article. bukhari kt, bukhari ht, zafar h, zahid m. antimicrobial sensitivity pattern for u rin e isolates in urinary tract infection. j islamabad med dental coll.2019; 8(4): 186-192. doi: 10.35787/jimdc.v8i4.325 funding source: nil conflict of interest: nil i n t r o d u c t i o n urinary tract infection (uti) is one of the most common bacterial infection in humans.1 the infection can be seen in any gender and age group.2 utis can be further grouped into hospital-acquired and community-acquired infections.3 the global statistics report concludes that in adult age group, urinary tract infections (utis) are more common in females due to their pelvic anatomy, and diverse physiological changes especially during pregnancy. however, in older age groups the chances of uti are almost equal in females and males. in cases of males of older age group, the presence of benign prostatic hyperplasia is the top most etiological factor. complicated utis can cause pyelonephritis, or even renal failure and end-stage renal disease. severe uti can l e a d to pre-term delivery and miscarriages in pregnant women.4 gram-positive and gram-negative bacteria have a ro l e i n causing uti, making it a common bacterial infection. the pathogenesis involves acquisition of genes by microorganisms, which encodes various mechanisms for antibiotic resistance of the organisms. most important amongst those include gram-negative organisms or i gi n a l a r ti c le j islamabad med dental coll 2019 187 producing extended-spectrum beta-lactamases (esbls), ampcβ -lactamases, and carbapenemases.5 uti can cause enormous economic burden on the patients from low income communities, and contribute to poor quality of life during the course of the disease.6 irrational and haphazard use of extensive antibiotics is leading to an increase in antimicrobial resistance, especially in the developing countries.7,8 hence, appropriate antibiotic use will not only decrease the resistance patterns in the uti causing organisms but al so help to eliminate the disease quickly, prevent complications and reduce the cost of treatment significantly.9 the increased frequency and management of antibiotic resistance in urinary tract infection (uti) is a challenging task for the clinicians globally. therefore, the current study was planned to identify the microbial etiology of ut i and the most suitable antibiotics used for treatment. this will be helpful to review the empirical therapy and management protocols of uti in our set-up. m a t e r i a l a n d m e t h o d s this cross-sectional study was carried out at al sayed hospital, kidney centre, rawalpindi from june 30, 2018 to january 30, 2019. a simple random sampling technique was used to enroll the participants. a sample size of 113 was calculated by taking 12% frequency of uti in pakistan,10 however, it was increased to 152 to increase the validity of the study. both male and female patients of ≥18years of age, having a confirmed diagnosis of uti based upon findings of urine routine examination (r/e) were included in the study. the presence of more than 10 pus cells in urine r/e were considered significa n t to label a patient as a suspected case of uti.11 an informed consent was taken from all the enrolled participants to fulfil ethical considerations. the non-willing patients and those with normal urine r/e were excluded from the study. three days of urine culture and sensitivity (c/s) were done as per recommended clinical laboratory standard institute (clsi) guidelines for the year 2017.12 on first da y the urine specimens were cultured on cled agar (oxoid company). bacteuric test strips were used for the inoculation of urine culture on cled agar, so that exact colony counts can be correlated. the cled agar plates were than incubated at 37ºc for 24 hours. on second day the colony counts were correlated with number of pus cells. gram staining was done to see the bacterial morphology. bacterial identification was done b y using analytical profile index (api-20 e) for biochemical testing. the antimicrobial sensitivity was applied on mueller hinton agar. for beta lactam group, piperacilin (100µg), augmentin (30µg), ampicillin (10µg), and oxacillin (1µg) discs w e re used. amongst glycopeptide group, vancomycin disc (30µg) was used. from quinolone group, ciprofloxacin (5µg), levofloxacin (5µg), norfloxacin (10µg), ofloxacin (1µg), pipemidic acid (20µg) discs were used. amongst the aminoglycoside group, amikacin (30µg) and gentamycin (10µg) discs were used. a doxycycline disc (30 µg) was used from tetracycline group. a 25µg disc of cotrimoxazole (nucleic acid inhibitors) was also used. regarding cephalosporins, 30µg cephradine disc was used from first-generation, cefoxitin (30µg), cefaclor (30µg), and cefuroxime (30µg) discs from secondgeneration cephalosporins, and cefotaxime (30µg), ceftriaxone (30 µg), cefoperazone (75µg) and cefixime (5µg) discs were used from third-generation cephalosporins. while from fourth-generation cephalosporins, cefipime (30µg) disc was used. amongst the carbapenem group, imipenam disc of 10µg was used. a 30µg linezolid disc was used from oxazolidinone group. amongst phosphonic acid derivatives, a fosfomycin disc of 50µg was used. while 300µg nitrofurantoin disc was used for imidazolidinedione group. more antibiotics used were tigecycline (15 µg), teicoplanin (30 µg), and polymyxin (50µg), respectively. on the third day, bacterial confirmation was done by interpreting the results of biochemical tests obtained from api-20e. the antimicrobial zone diameters were measured as per recommended clsi guidelines, in ord e r to label a drug as sensitive and resistant. the spss version 16 was used for statistical analysis. frequencies and percentages were calculated to assess the sensitivity rate, extended spectrum beta-lactamase producing organisms (esbl), vancomycin resistant j islamabad med dental coll 2019 188 enterococci (vre) and methicillin resistant staphylococcus aureus (mrsa). r e s u l t s out of 152 culture positive urine, most prevalent organisms was e. coli (n=81) followed by klebsiella pneumoniae (n=25) (table i). regarding sensitivity pattern, e. coli (n=77), klebsiella pneumoniae (n=25) a n d pseudomonas aeruginosa (n=7) were found maximally sensitive to polymyxin b. enterococcus faecalis showed maximum sensitivity (n=16) to carbapenem, teicoplanin and glycylcycline (tigecycline). enterobacter cloacae revealed highest sensitivity (n=7) to carbapenem and phosphonic acid derivatives. staphylococcus aureus w a s maximally sensitive (n=5) to oxazolidinone and tetracyclines (table ii a and b). table i: frequency of commonly prevalent organisms in urine isolates (n=152) organisms belonging to esbl group total number n (%) esbl n (%) e. coli 81 (53.3) 59 (72.8) klebsiella pneumoniae 25 (16.4) 21 (84) enterobacter cloacae 8 (5.3) 1 (12.5) pseudomonas aeruginosa 7 (4.6) 0 morganella morganii 3 (2) 0 proteus mirabilis 2 (1.3) 1 (50) burkholderia cepacia 1 (0.66) 0 serratia marcescens 1 (0.66) 0 organisms belonging to vre & mrsa group total number n (%) vre n (%) mrsa n (%) enterococcus faecalis 18 (11.8) 1 (5.5) 0 staphylococcus aureus 6 (3.9) 0 1 (16.6) esbl extended-spectrum beta-lactamases; vre – vancomycin resistant enterococci; mrsa – methicillin resistant staphylococcus aureus considering overall sensitivity of antibiotics for the pathogens of urine culture, highest sensitivity was observed for carbapenems (n=127), followed by polymyxin b (n=110), phosphonic acid derivatives (n=100), aminoglycoside group (n= 100), extended spectrum penicillin (n= 96), imidazolidinedione (n=91) and tetracycline groups (n=91). the least sensitivity was observed for first-generation cephalosporins (n= 02), tigecycline (n=16), teicoplanin (n=21) and oxazolidinone (linezolid) (n=22) (figure 1) amongst all the positive cultures, the highest sensitivity was observed for carbapenems (n=127; 83.5% ), phosphonic acid derivatives (n=100; 65.8% ) and polymyxin b (n=110; 72.3 % ), respectively. this was followed by aminoglycoside group (n= 100; 65% ) and extended spectrum penicillin (n= 96; 63.1% ). next in sequence are the imidazolidinedione and tetracycline groups (n=91; 59.8% for each) (figure 1). the least sensitivity was observed for first-generation cephalosporins (n= 02; 1.3 % ), tigecycline (n=16; 10.5% ), teicoplanin (n=21; 13. 8% ) and oxazolidinone (linezolid) (n=22; 14.4% ), respectively (figure 1). figure 1: overall sensitivity of antibiotic groups for pathogens in urine culture (n=152) d i s c u s s i o n urinary tract infections (utis) accounts for highly prevalent infection around the globe. it has been reporte d that annually 150 million people present with this infectio n worldwide.13 a study conducted in denmark on prescription for uti concluded that amongst all bacterial infections, prevalence of uti is 89.5% . j islamabad med dental coll 2019 189 table ii a: sensitivity pattern of different microbial isolates from urine cultures (n=152) antibiotics escherichia coli (n=81) n (%) klebsiella pneumoniae (n=25) n (%) enterococcus faecalis (n=18) n (%) enterobacter cloacae (n=08) n (%) pseudomonas aeruginosa (n=07) n (%) extended spectrum penicillin 63 (77.7) 04 (16) 14 (77.8) 01 (12.5) 05 (71.4) short acting penicillin 10 (12.3) 04 (16) 12 (66.7) 0 0 aminoglycosides 71 (87.6) 15 (60) 0 01 (12.5) 05 (71.4) fluoroquinolones 26 (32) 04 (16) 0 0 05 (71.4) sulphonamides 21 (25.9) 3 (12) 0 01 (12.5) 0 carbapenem 70 (86.4) 23 (92) 16 (88.9) 07 (87.5) 05 (71.4) phosphonic acid derivative 71 (87.6) 08 (32) 14 (77.7) 07 (87.5) 0 oxazolidinone 0 0 16 (88.9) 01 (12.5) 0 imidazolidinedione 65 (80.2) 10 (40) 12 (66.6) 0 0 tetracyclines 61 (75.3) 10 (40) 15 (83.3) 0 0 1st generation cephalosporins 0 0 02 (11.1) 0 0 2nd generation cephalosporins 22 (27.1) 0 0 0 0 3rd generation cephalosporins 22 (27.1) 0 0 0 06 (85.7) 4th generation cephalosporins 22 (27.1) 04 (16) 0 0 05 (71.4) polymyxin b 77 (95.06) 25 (100) 0 01 (12.5) 07 (100) teicoplanin 0 0 16 (88.9) 0 0 glycylcycline (tigecycline) 0 0 16 (88.9) 0 0 table iib: sensitivity pattern of different microbial isolates from urine cultures (n=152) antibiotics staphylococcus aureus (n=06) n (%) morganella morganii (n=03) n (%) proteus mirabilis (n=02) n (%) burkholderia cepacia (n=01) n (%) serratia marcescens (n=01) n (%) extended spectrum penicillin 04(66.7) 03(100) 01(50) 0 01(100) short acting penicillin 04(66.7) 0 01(50) 0 0 aminoglycosides 03(50) 02(66.7) 02(100) 0 01(100) fluoroquinolones 0 01(50) 01(100) 01(100) sulphonamides 03(50) 02(66.7) 01(50) 01(100) 01(100) carbapenem 0 02(66.7) 02(100) 01(100) 01(100) phosphonic acid derivative 0 0 0 0 0 oxazolidinone 05(83.3) 0 0 0 0 imidazolidinedione 04(66.7) 0 0 0 0 tetracyclines 05(83.3) 0 0 0 0 1st generation cephalosporins 0 0 0 0 0 2nd generation cephalosporins 04(66.7) 0 0 0 0 3rd generation cephalosporins 0 02(66.7) 01(50) 0 01(100) 4th generation cephalosporins 0 03(100) 0 0 01(100) polymyxins b 0 0 0 0 0 teicoplanin 04(66.7) 0 0 01(100) 0 glycylcycline (tigecycline) 0 0 0 0 0 the appropriate choice for empirical management of uti is always a challenging task for the clinicians many national and internationally published studies support th e fact that the selection of antibiotic should vary based upon the nature of uti, acute lower or upper uti, recurrent uti, or a case of complicated uti.13 in the current study results showed that escherichia coli infection was most common (55.4% ) followed by klebsiella pneumoniae (17.1% ), and enterococcus faecalis infection (12.3% ). only few cases were of burkholderia cepacia and serratia j islamabad med dental coll 2019 190 marcescens were reported. these findings are in line with the published data which also showed that escherichia coli, klebsiella pneumoniae, proteus mirabilis, enterococcus faecalis and staphylococcus saprophyticu s are the main causative organisms for uti.9,10,14 a canadian study revealed the same prevalence of uropathogens with the highest frequency seen for gramnegative rods (91.8% ) mainly the enterobacteriaceae family.15 the most common organisms included escherichia coli (39.7% ), klebsiella pneumoniae (15 .8 % ) pseudomonas aeruginosa (13.8% ), proteus mirabilis (10.6% ) and acinetobacter baumannii (5% ).15 we also reported the presence of resistant microorganisms like esbl, vre and mrsa. esbl producing escherichia coli and klebsiella pneumoniae were seen in 72.8% and 84% cases respectively. vre producing enterococcus faecalis was seen in 5.5% cases, while mrsa was seen in 16.6% cases. this is in agreement with the results of a published study where, nitrofurantoin and fosfomycin were the recommended first line treatment options for uncomplicated bacterial cystitis, while the fluoroquinolones and β-lactams were amongst the second line options.15 the results are different from another study conducted in denmark, where pivmecillinam hydrochloride (extended-spectrum penicillin) was the first line management option for both lower or upper uti.13 according to published data of various european countries, the identified frequency of esbls range from 70–100% , meaning that carbapenems often represent the only active available antibiotics.16 amongst all the positive cultures, the highest sensitivity was observed for carbapenems, followed by polymyxin b, phosphonic acid derivatives, aminoglycoside group, extended spectrum penicillins, imidazolidinedione and tetracycline groups. this finding is similar to another study in which treatment options for utis with or without esbls-producing enterobacteriaceae include nitrofurantion, fosfomycin, fluoroquinolones, cefoxitin, piperacillin-tazobactam, carbapenems, ceftolozanetazobactam, ceftazidime-avibactam, and aminoglycosides.13 the same study also reported that fosfomycin, ceftazidime-avibactam, polymyxin b, aztreonam, colistin, aminoglycosides, and tigecycline are treatment options for utis caused by carbapenemresistant enterobacteriaceae (cre).13 another study by alamri et al also support the results of current study by reporting that fosfomycin, nitrofurantoin and pivmecillinam can be the first line management options for treating uncomplicated utis.17 hence, ceftolozane/tazobactam are the approved antibacterial for empirical treatment of uti and pyelonephritis in adults.17,18 many relevant studies and trials have concluded that fosfomycin and nitrofurantoin are still the magic bullets to treat any type of uti.19,20 with fosfomycin found to be the most reliable option for managing any type of uti, whether complicated or non-complicated.14,21 a systematic literature review between 1946 to 2015 revealed that nitrofurantoin harbors the properties of sterilizing urine and prevent the occurrence of uti.22,23 however, the only point of concern regarding its prolonged use is severe gastrointestinal side effects.24 the results of current study showed that 94.1% cases of enterococcus feacalis cases were found sensitive to tigecycline. the efficacy of tigecycline for uti has not been extensively studied. although a metaanalysis concluded that it is a good treatment option for multi-drug resistant (mdr) gram-negative utis.25 tigecycline is known to play a significant role in cases of uti associated with polycystic kidney disease, impai red renal function and renal transplant.26 our study showed least sensitivity for first-generation cephalosporins, tegicycline, teicoplanin, and oxazolidinone (linezolid). this is in contrast to the published data which shows increased sensitivity of uropathogens to linezolid, daptomycin, and vancomycin.1 5 similar findings were observed in another study which concluded that all enterococci and staphylococci harbor great sensitivity for linezolid, fosfomycin, vancomycin and teicoplanin.27 a sri lankan study reported that 95-100% esbl producing organisms were sensitive to carbapenems, especially meropenem. therefore, this group can also be used as first-line therapy for complicated utis.28 moreover, the intravesical efficacy of gentamycin showed significant results in reducing the frequency of recurrent utis.29 the management options for esbl producing organisms is biggest health challenge around the globe.30 a case series reported better outcomes for prophylactic use of a combination preparation, ceftibuten plus amoxicillin j islamabad med dental coll 2019 191 clavulanic acid, ceftolozane/tazobactam and tegicycline even in esbl producing organisms.31-33 therefore, knowledge about the commonly prevalent organisms a n d their susceptibility pattern can serve as an essential requirement for accurate management of urinary tract infections.34 thus, the morbidity and mortality rates can be reduced due to proper management of complicated utis. c o n c l u s i o n carbapenems showed maximum sensitivity for all urine isolates. the second and third options were polymyxin b and phosphonic acid derivatives, respectively. r e f e r e n c e s 1. demilie t, beyene g, melaku s, tsegaye w. urinary bacterial profile and antibiotic susceptibility pattern among pregnant women in north west ethiopia. ethiop j health sci. 2012; 22(2): 121–28. pmid: 22876076 2. parveen ss, reddy sv, rao rmv, janardhan rr. uropathogens and their drug susceptibility patterns among pregnant women in a teaching hospital. ann biol res. 2011; 2(5): 516–21. 3. ahmed e, shahid hm, ikhlaque ss, ejaz m. urinary tract bacterial pathogens and their sensitivity pattern. j rawalpindi med coll. 2014; 18(2): 263–66. 4. badr a, shaikh ag. recurrent urinary tract infections management in women: a review. sultan qaboosuniv med j. 2013; 13(3): 359–67.doi: 10.12816/0003256 5. pallett a, hand k. complicated urinary tract infections: practical solutions for the treatment of multiresistant gram-negative bacteria. j antimicrob chemother. 2010; 65 (suppl 3): iii25–iii33. doi: 10.1093/jac/dkq298 6. kostakioti m, hultgren sj, hadjifrangiskou m. molecular blueprint of uropathogenic escherichia coli virulence provides clues toward the development of anti-virulence therapy. virulence. 2012; 3(7): 592–94. doi: 10.4161/viru.22364 7. foxman b. the epidemiology of urinary tract infection. nat rev urol. 2010; 7(12): 653–60. doi: 10.1038/nrurol.2010.190 8. yousef sa. clinical and laboratory profile of urinary tract infections associated with extended spectrum beta-lactamase producing escherichia coli and klebsiella pneumoniae. ann clin lab sci. 2016; 46(4): 393–400.pmid: 27466299 9. flores-mireles al, walker jn, caparon m, hultgren sj. urinary tract infections: epidemiology, mechanisms of infection and treatment options. nat rev microbiol. 2015; 13(5): 269–84. doi: 10.1038/nrmicro3432 10. ullah a, shah srh, almugadam bs, sadiqui s. prevalence of symptomatic urinary tract infections and antimicrobial susceptibility patterns of isolated uropathogens in kohat region of pakistan. moj biol med. 2018; 3(4): 85-89. 11. george ce, norman g, ramana gv, mukherjee d, rao t. treatment of uncomplicated symptomatic urinary tract infections: resistance patterns and misuse of antibiotics. j family med prim care. 2015; 4(3): 416–421. doi: 10.4103/2249-4863.161342 12. clsi performance standards for antimicrobial susceptibility testing. 27th ed. clsi supplement m100. wayne, pa: clinical laboratory standard institute; 2017. website: [https://clsi.org/media/1469/m100s27_sample.pdf] retrieved on 7th nov 2019. 13. holm a, cordoba g, aabenhus r. prescription of antibiotics for urinary tract infection in gener al practice in denmark. scand j prim health care. 2019; 28: 17. doi: 10.1080/02813432.2019.1569425. 14. bader ms, loeb m, brooks aa. an update on the management of urinary tract infections in the era of antimicrobial resistance. postgrad med. 2017; 129(2): 242-58. doi: 10.1080/00325481.2017.1246055. 15. ou lb, nadeau l. fosfomycin susceptibility in multidrug-resistant enterobacteriaceae species and vancomycin-resistant enterococci urinary isolates. can j hosp pharm. 2017; 70(5): 368-74. doi: 10.4212/cjhp.v70i5.1698 16. concia e, bragantini d, mazzaferri f. clinical evaluation of guidelines and therapeutic approaches in multi drug-resistant urinary tract infections. j chemother. 2017; 29(sup 1): 19-28. doi: 10.1080/1120009x.2017.1380397. 17. alamri a, hamid me, abid m, alwahhabi am, alqahtani km, alqarni ms, etal. trend analysis of bacterial uropathogens and their susceptibility pattern: a 4-year (2013-2016) study from aseer region, saudi arabia. urol ann. 2018; 10(1): 41-6. doi: 10.4103/ua.ua_68_17. j islamabad med dental coll 2019 192 18. scott lj1. ceftolozane/tazobactam: a review in complicated intra-abdominal and urinary tract infections. drugs. 2016; 76(2): 231-42. doi: 10.1007/s40265-015-0524-5. 19. popejoy mw, long j, huntington ja. analysis of patients with diabetes and complicated intraabdominal infection or complicated urinary tract infection in phase 3 trials of ceftolozane/tazobactam. bmc infect dis. 2017; 17(1): 316. doi: 10.1186/s12879-017-2414-9. 20. doesschate t, mens sp, nieuwkoop c, geerlings se, hoepelman aim, bonten mjm, et al. oral fosfomycin versus ciprofloxacin in women with e. coli febrile urinary tract infection, a double-blind placebocontrolled randomized controlled non-inferiority trial (forecast). bmc infect dis. 2018; 18(1): 626. doi: 10.1186/s12879-018-3562-2. 21. jadoon sa, ahmed a, irshadr.spectrumof bacterial culture and drug sensitivity vs resistance in uncomplicated urinary tract infection. j ayub med coll abbottabad. 2018; 30(3): 432-38. pmid: 30465381 22. keating gm. fosfomycin trometamol: a review of its use as a single-dose oral treatment for patients with acute lower urinary tract infections and pregnant women with asymptomatic bacteriuria. drugs. 2013; 73(17): 1951-66. doi: 10.1007/s40265-013-0143-y. 23. muller ae, verhaegh em, harbarth s, mouton jw, huttner a. nitrofurantoin's efficacy and safety as prophylaxis for urinary tract infections: a systematic review of the literature and meta-analysis of controlled trials. clin microbiol infect. 2017; 23(6): 355-62. doi: 10.1016/j.cmi.2016.08.003. 24. fallah f, yousefi m, pourmand mr, hashemi a, alam a, afshar d, etal. phenotypic and genotypic study of biofilm formation in enterococci isolated from urinary tract infections. microb pathog. 2017; 108: 85-90. doi: 10.1016/j.micpath.2017.05.014. 25. price jr, guran la, gregory wt, donagh ms. nitrofurantoin vs other prophylactic agents in reducing recurrent urinary tract infections in adult women: a systematic review and meta-analysis. am j obstet gynecol. 2016; 215(5): 548-60. doi: 10.1016/j.ajog.2016.07.040. 26. brust k, evans a, plemmons r. tigecycline in treatment of multidrug-resistant gram-negative bacillus urinary tract infections: a systematic review. j antimicrob chemother. 2014; 69(10): 2606-10. doi: 10.1093/jac/dku189. 27. yuan x, liu t, wu d, wan q. epidemiology, susceptibility, and risk factors for acquisition of mdr/xdr gram-negative bacteria among kidney transplant recipients with urinary tract infections. infect drug resist. 2018; 11: 707-15. doi: 10.2147/idr.s163979. ecollection 2018. 28. yang b, yang f, wang s, wang q, liu z, feng w, et al. analysis of the spectrum and antibiotic resistance of uropathogens in outpatients at a tertiary hospital. j chemother. 2018; 30(3): 145-49. doi: 10.1080/1120009x.2017.1418646. 29. fernando mm, luke wa, miththinda jk, wickramasinghe rd, sebastiampillai bs, gunathilake mp. extended spectrum beta lactamase producing organisms causing urinary tract infections in sri lanka and their antibiotic susceptibility pattern -a hospital based cross sectional study. bmc infect dis. 2017; 17(1): 138. doi: 10.1186/s12879-017-2250-y. 30. seo yb, lee j, kim yk, lee ss, lee ja, kim hy, et al. randomized controlled trial of piperacillintazobactam, cefepime and ertapenem for the treatment of urinary tract infection caused by extended-spectrum beta-lactamase-producing escherichia coli. bmc infect dis. 2017; 17(1): 404. doi: 10.1186/s12879-017-2502-x. 31. stuart cj, hall vm, kortmann w, verlind j, mulder f , scharringa j, et al. ceftibuten plus amoxicillinclavulanic acid for oral treatment of urinary tract infections with esbl producing e. coli and k. pneumoniae: a retrospective observational caseseries. eur j clin microbiol infect dis. 2018; 37(10): 2021-25. doi: 10.1007/s10096-018-3338-z. 32. golan y. empiric therapy for hospital-acquired, gramnegative complicated intra-abdominal infection and complicated urinary tract infections: a systematic literature review of current and emerging treatment options. bmc infect dis. 2015; 15: 313. doi: 10.1186/s12879-015-1054-1. 33. zhanel gg, chung p, adam h, zelenitsky s, denisuik a,schweizer f, et al. ceftolozane/tazobactam: a novel cephalosporin/β-lactamase inhibitor combination with activity against multidrug-resistant gram-negative bacilli. drugs. 2014; 74(1): 31-51. doi: 10.1007/s40265-013-0168-2. 34. alberici i, bayazit ak, drozdz d, emre s, fischbach m, harambat j, et al. pathogens causing urinary tract infections in infants: a european overview by the escape study group. eur j pediatr. 2015; 174(6): 783-90. doi: 10.1007/s00431-014-2459-3 119 j i m d c 2 0 1 7 119 address of correspondence: aliya batool email: aliya.batool@imdcolloge.edu.pk thrombophilia and pregnancy aliya batool 1, naghmi asif 2, khalid hassan 3 ¹assistent professor, department of pathology 2 professor, department of pathology 3 professor/hod, department of pathology (islamabad medical & dental college) pregnancy is a state of hypercoagulation, most likely an adaptive mechanism, in order to reduce the risk of hemorrhage during and after the delivery. there are substantial changes in the haemostatic system during normal healthy pregnancy including rise in clotting factors i, vii, viii, ix, and x, diminished protein s and fibrinolytic activity and resistance to activated protein c.¹ reduced fibrinolytic activity is due to fivefold increase in pai-1 (plasminogen activator inhibitor type 1) levels.² in addition venous stasis increases during pregnancy as the lower-extremity veins dilate due to venous compression by the gravid uterus. endothelial injury may also occur in antepartum or in postpartum period. the combination of these factors results in 4-5 times increased risk of venous thromboembolism (vte) in the pregnant and postpartum patients.3 the prevalence of vte in pregnancy is 0.8-2.0 per 1,000 pregnancies and accounts for 1.1 deaths per 100,000 pregnancies.4 the most important risk factor for women experiencing pregnancy-related vte is prior personal history of vte.5 the second most common risk factor is thrombophilia 6 7 studies have shown that at least 20%, and possibly over 50%, of pregnant patients diagnosed with vte have thrombophilia.8 there is a growing evidence that women with thrombophilia are also at risk of other vascular pregnancy complications, including recurrent fetal loss, pre‐eclampsia, stillbirths, abruption and intrauterine growth restriction. thrombophilia can be inherited or acquired. inherited thrombophilias are a group of genetic disorders, which can be classified as low or high risk based on the relative increased risk of vte. antiphospholipid antibody syndrome is considered as an acquired thrombophilia and its diagnosis is based upon clinical history and laboratory testing. low-risk inherited thrombophilias include heterozygous factor v leiden, heterozygous prothrombin g20210a mutation, protein s deficiency and protein c deficiency. high-risk inherited thrombophilias include homozygous factor v leiden, homozygous prothrombin g20210a mutation, compound heterozygous factor v leiden with prothrombin mutation and antithrombin deficiency. ideally, evaluation for thrombophilia should be done when the patient is not pregnant, does not have an acute thrombotic event, and is not on anticoagulation therapy. acog (american college of obstetricians and gynecologists) recommends screening a patient for thrombophilia during pregnancy only if test results are likely to alter management. screening should be performed when the presence of a thrombophilia may alter the intensity or duration of anticoagulation therapy. screening is unnecessary when treatment is indicated for other reasons.9 thrombophilia screening may be considered in: • patients with a personal history of vte that occurred in the setting of a transient nonrecurrent risk factor (eg, fractures, surgery, prolonged immobility) that was not estrogenor pregnancy-related • patients with a first-degree relative with a prior vte that occurred before age 50 years or with a prior diagnosis of high-risk thrombophilia. following are the recommended methods of evaluation of inherited thrombophilias in pregnancy: e d i t o r i a l 120 j i m d c 2 0 1 7 120 • factor v leiden: second-generation activated protein c resistance assay is reliable in pregnancy; if results are abnormal, evaluate for genotype for factor v leiden mutation; if the patient is on anticoagulation therapy, consider evaluation of factor v leiden mutation via genotype testing. • prothrombin g20210a mutation dna analysis • protein c functional activity level • protein s free, total, and functional levels. (protein s deficiency testing is less reliable in pregnancy, as levels decrease with increasing gestational age). • antithrombin-heparin cofactor assay for antiphospholipid antibody syndrome, in addition to specific clinical criteria for evaluation, laboratory criteria includes any one of the following (these laboratory findings must be abnormal twice, at least 12 weeks apart, to meet diagnostic criteria)10 • anticardiolipin immunoglobulin g (igg) or immunoglobulin m (igm) antibodies greater than 99th percentile • antibeta2-glycoprotein i igg or igm antibodies greater than 99th percentile • the presence of lupus anticoagulant the factors that affect the decision, to provide thromboprophylaxis, as well as the timing (antenatal or postpartum only) and intensity of therapy depends on the following: • any prior personal history of vte • the presence of highversus low-risk thrombophilia • the setting in which a prior vte occurred (pregnancy/estrogen-related, idiopathic, or in the setting of non-recurrent risk factors such as fractures, surgery, or immobilization) early recognition of risk factors and judicious implementation of thromboprophylaxis has significantly decreased maternal mortality due to thromboembolism r e f e r e n c e s 1. h bremme ka. haemostatic changes in pregnancy. best pract res clin haematol. 2003 jun. 16(2):15368. 2. mclean kc, bernstein im, brummel-ziedins ke.tissue factor-dependent thrombin generation across pregnancy. am j obstet gynecol.2012;135:16. 3. pomp er, lenselink am, rosendaal fr, doggen cj. pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the mega study. j thromb haemost. 2008;6(4):632-7. 4. liu s, rouleau j, joseph ks, et al. epidemiology of pregnancy-associated venous thromboembolism: a population-based study in canada. j obstet gynaecol can. 2009;31(7):611-20. 5. pabinger i, grafenhofer h, kyrle pa, et al. temporary increase in the risk for recurrence during pregnancy in women with a history of venous thromboembolism. blood. 2002;100(3):1060-2. 6. james ah. venous thromboembolism in pregnancy. arterioscler thromb vasc biol. 2009. 29(3):326-31. 7. bates sm, greer ia, middeldorp s, veenstra dl, prabulos am, vandvik po, et al. vte, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. chest. 2012;141 (2 suppl):e691s-736s 8. greer ia. the challenge of thrombophilia in maternalfetal medicine. n engl j med. 2000 feb 10. 342(6):424-5. 9. american college of obstetricians and gynecologists practice bulletin no 124. inherited thrombophilias in pregnancy. obstet gynecol. 2011. 10. miyakis s, lockshin md, atsumi t, et al. international consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (aps). j thromb haemost. 2006; 4(2):295306. j islamabad med dental coll 2021 101 open access diagnostic accuracy of fiber optic laryngoscopy rabia zaman khan1, asim iqbal2, ghulam saqulain3 1assistant professor, department of ent, sir ganga ram hospital lahore, punjab pakistan 2professor, department of ent, sir ganga ram hospital, lahore, punjab pakistan 3head of department & associate professor of otorhinolaryngology, capital hospital pgmi, islamabad, pakistan a b s t r a c t background: laryngeal examination of patients with hoarseness is essential to diagnose a wide range of pathologies. laryngeal visualization has progressed from simple indirect mirror examination to virtual laryngoscopy with flexible fiber optic laryngoscope as an acceptable option. this study was done to determine the diagnostic accuracy of fiber optic laryngoscopy in patients with hoarseness. material and methods: this cross-sectional comparative study included a sample of 155 participants, of both genders, aged 20 to 60 years with hoarseness of at least 1 month duration. participants were recruited through non probability consecutive sampling technique from ent department, sir ganga ram hospital lahore, pakistan over a period of six months (october 2015 to march 2016). patients fulfilling the selection criteria were subjected to fiber optic laryngoscopy (fol) under local anesthesia followed by direct laryngoscopy (dl) under general anesthesia and findings recorded. data was collected, tabulated and analyzed using spss 17. diagnostic value of fol versus dl was calculated with frequency, percentage, sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv). results: out of 155 participants, 48.39% (n=75) were males and 51.61% (n=80) females, with mean age of 31 ± 9.54 years. assessment of diagnostic accuracy of fiber optic laryngoscopy taking direct laryngoscopy as criterion standard showed an accuracy of 80.65% with 89.19% sensitivity, 77.96% specificity, 55.93% ppv, and 95.83% npv, respectively. conclusions: fiber optic laryngoscopy is an excellent tool for the diagnosis of hoarseness, with a diagnostic accuracy of 80.65%. key words: direct laryngoscopy, diagnostic accuracy, fiber optic laryngoscopy, hoarseness. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: october 2,2019 accepted: june 18, 2021 cite this article. khan rz, iqbal a, saqulain g. diagnostic accuracy of fiber optic laryngoscopy. j islamabad med dental coll. 2021; 10(2): 101-104. doi: 10.35787/jimdc.v10i2.426 funding source: nil conflict of interest: nil i n t r o d u c t i o n hoarseness, a symptom which points to laryngeal dysfunction, is described by the patients as an altered voice quality. diagnosis of hoarseness of more than one-month duration is important because a number of pathologies can cause hoarseness ranging from common cold to malignancy.1 persistent hoarseness may result from morphologic changes due to benign vocal cord lesions (nodules and polyps) or malignant pathology (squamous cell carcinoma of larynx).2 laryngoscopy is visual evaluation of larynx and is essential for the diagnosis of hoarseness. for this the armamentarium has progressed from garcia’s original indirect mirror laryngoscopy (idl), direct o r i g i n a l a r t i c l e j islamabad med dental coll 2021 102 laryngoscopy (dl) to virtual laryngoscopy (vl).3,4 although excessive gag reflex may make it intolerable in some (15%) patients,5 the usefulness and cost effectiveness of indirect mirror laryngoscopy makes it a commonly used procedure as it can be easily performed by an otolaryngologist in the clinic.6 both mirror laryngoscopy and fol are indirect methods of laryngeal examination.7 a number of indirect fiber optic laryngoscopes such as the flexible fiber optic bronchoscope and nasopharyngoscope are not only good alternatives to dl but are found to be superior to mirror idl as well.8 fol is also said to be a safer and non-invasive procedure to evaluate vocal cord paralysis and other laryngeal lesions.9 keesecker and colleagues however, pointed out that it showed high frequency of error in diagnosis.10 there is much debate in the existing literature and varied recommendations by the practitioners regarding suitability and diagnostic accuracy of various methods of laryngeal examination. we planned this study to determine the diagnostic accuracy of fiber optic laryngoscopy in patients with hoarseness considering the direct laryngoscopy as criterion standard. m a t e r i a l a n d m e t h o d s in this cross-sectional comparative study, 155 participants were enlisted through non-probability consecutive sampling at the department of ent, sir ganga ram hospital lahore, pakistan from october 2015 to march 2016. approval was obtained from ethics committee of sir ganga ram hospital. sample size of 152 was calculated with hypothesized expected sensitivity of 70 and specificity of 99 using wan nor arifin online calculator,11, with 5% precision and 95% level of significance, taking prevalence of hoarseness as 11.4%. 12 patients of both genders presenting with hoarseness of at least one-month duration with age between 20 to 60 years were included in the study. patients unfit for general anesthesia, allergic to lignocaine or those who did not consent for participation were excluded from the study. after informed consent and explaining the procedure a detailed history, including socio-demographic information was recorded by the investigator. before undergoing fol, nasal decongestant drops (xylometazoline) and 4% lignocaine were administered to every patient. fol was carried out with xion nasopharyngoscopy model ef-n, d: 3.4mm, l: 320mm, direction of view: 0o, angle of field of view: 80.0o, depth of focus: 150mm, angle: 130o/130o with complete visual system. larynx was examined after passing the flexible scope from the nasal cavity to the throat, findings noted from the video monitor and sketches were drawn for record by the researcher. next, the patients were admitted for dl under general anesthesia (ga). fol findings were not shared with the surgeon to avoid bias. the findings of both the procedures were compared. data analysis was done using spss 17. variables specially studied included diagnostic accuracy of fol versus dl and presented by frequency, and percentages. 2x2 contingency tables were used to calculate the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of fol compared to dl. r e s u l t s the ratio of male to female participants was roughly equal 48.39% (n=75) versus 51.61% (n=80) with the mean age of 31.01+ 9.54 years (table i). dl (criterion standard) proved to be diagnostic in 23.87% (n=37) while in 76.13% (n=118) cause of hoarseness could not be identified (table ii). fol picked up pathologies in additional 16.13% (n=26) patients and was found to have a diagnostic accuracy of 80.65% compared to the dl, while the sensitivity was 89.19%, specificity 77.96%, ppv 55.93% and npv of 95.83% (table ii). j islamabad med dental coll 2021 103 table i: frequency distribution of gender and age groups (n = 155) variable group absolute frequency (%) relative frequency (%) gender male 75 48.39 female 80 51.61 age (years) 20-30 87 56.13 31-65 68 43.87 table ii: diagnostic accuracy of fiber optic laryngoscopy taking direct laryngoscopy as criterion standard in patients presenting with hoarseness fiber optic laryngoscopy direct laryngoscopy total positive true positive(a) 33 false positive (b) 26 a + b = 59 negative false negative(c) 4 true negative (d) 92 c + d = 96 total a + c = 37 b + d = 118 155 sensitivity = 89.19%; specificity = 77.96%; ppv = 55.93%; npv = 95.83%; diagnostic accuracy = 80.65% d i s c u s s i o n present study revealed that fol with a diagnostic accuracy of 80.65% picked up 16.13% more pathologies compared to dl and had a sensitivity of 89.19% and specificity of 77.96%. williams et al.13 believed that fol has revolutionized the laryngeal examination and operations. they compared fol with indirect mirror and direct laryngoscopy in assessing various laryngeal disorders and found it a promising technique that in their opinion has an acceptable place in assessment of laryngeal disorders. the number of participants in our study is double to that of williams et al. however, our findings are comparable to theirs in evaluation of fol as a useful technique. moser in his review termed fol as a rapid, low risk diagnostic test for most common findings of laryngeal diseases in primary care setups.14 mahbub and colleagues, compared fol with idl and found that fol was superior to idl for diagnosis of persistent upper airway symptoms. they recommended fol in all patients with long-term progressive airway symptoms even if the mirror idl appears normal.8 although their focus was not diagnostic accuracy but only comparison of the percentage of lesions detected by both methods, nevertheless we believe our findings in terms of superiority of fol holds true when we compared it with dl, as it is now also being used for pediatric airway management.15 shafi et al. also reported fol as a safe and effective test for different ear, nose and throat pathologies.16 similarly, in a local study by hameed et al. with a sample size of 100 patients with hoarseness, it was noted that fol was a safer, noninvasive procedure with only two patients requiring dl.9 according to handler, fol was test of choice for evaluation of pediatric larynx while dl was preferred in laryngotracheal surgery.17 collins studied different laryngoscopy devices and concluded that the role and extent of fol was not yet fully recognized in airway management. however, it was promising in respect of routine clinical examination, when laryngoscopy fails as well as for teaching purposes.18 our study was unique because the participants were subjected to both fol and dl for comparison rendering the results more reliable. cohen and benyamini assessed the accuracy of trans-nasal fiber optic laryngoscopy (tfl) versus dl by comparing the pathologic results of 110 laryngeal tissue biopsies. they found out that the sensitivity of tfl was 70.6% with a specificity of 96.7%. although they acknowledged the cost effectiveness and safety as positive aspect of the technique, they expressed concerns about its sensitivity and recommended that suspicious lesion diagnosed by tfl biopsy must undergo dl for confirmation.19 our results nevertheless are conclusive in superiority of fol over dl with a sensitivity of 80.19%. j islamabad med dental coll 2021 104 the results of our study reveal that fol is an essential tool for diagnosis of voice disorders and has an excellent accuracy for the diagnosis of diseases causing hoarseness. therefore, we recommend fol laryngoscopy for all patients presenting with hoarseness. this study has a limitation of a small sample collected from a single hospital only, hence the results cannot be generalized. another limitation is inclusion of patients with hoarseness only. studies with large sample size including patients with all phonation disorders need to be conducted, which will give a more reliable account of accuracy of fiber optic laryngoscopy. c o n c l u s i o n we concluded that in patients with hoarseness, fiber optic laryngoscopy with a diagnostic accuracy of 80.65% and taking direct laryngoscopy as criterion standard is an excellent diagnostic tool. r e f e r e n c e s 1. sadoughi b, fried mp, sulica l, blitzer a. hoarseness evaluation: a transatlantic survey of laryngeal experts. laryngoscope. 2014; 124(1): 221-6. doi: 10.1002/lary.24178. 2. mau t. diagnostic evaluation and management of hoarseness. med clin north am. 2010; 94(5): 945-60. doi: 10.1016/j.mcna.2010.05.010. 3. jahn a, blitzer a. a short history of laryngoscopy. logoped phoniatr vocol. 1996; 21(3-4): 181-5. doi: 10.3109/14015439609098887. 4. ragheb as, el-gerby km, ahmed af, el-anwar mw, el-monaem sa. conventional endoscopy versus virtual laryngoscopy in assessment of laryngeal lesions. egypt j radiol nucl med. 2013; 44(3): 497503. 5. yamamoto k, tsubokawa t, shibata k, ohmura s, nitta s, kobayashi t. predicting difficult intubation with indirect laryngoscopy. anesthesiology. 1997; 86(2): 316-21. doi: 10.1097/00000542-19970200000007. 6. onotai lo, nwosu c. laryngoscopy: appraisal of 202 procedures carried out in two centers in port harcourt, nigeria. tnhj. 2017; 17(1). https://www.ajol.info/index.php/nhj/article/view/1 54263/143844. 7. pieters bm, eindhoven gb, acott c, van zundert aa. pioneers of laryngoscopy: indirect, direct and video laryngoscopy. anaesth intensive care. 2015; 43 suppl 4-11. doi: 10.1177/0310057x150430s103. 8. mahbub s, al-amin a, biswas ss, jamal ms. a study on diagnostic importance of fiber optic laryngoscopy (fol) in patients with upper airway disorders. j bangladesh coll phys surg. 2014; 32(4): 200-5. doi: 10.3329/jbcps.v32i4.26082. 9. hameed a, sheikh si, aziz b, mushwani m. vocal cord paralysis in 100 hoarse patients examined through flexible fibreopptic nasopharyngoscope/ laryngoscope. pjmhs. 2014; 8(1): 149-51. 10. keesecker se, murry t, sulica l. patterns in the evaluation of hoarseness: time to presentation, laryngeal visualization, and diagnostic accuracy. laryngoscope. 2015; 125(3): 667-73. doi: 10.1002/lary.24955. 11. buderer nm f. statistical methodology: i. incorporating the prevalence of disease into the sample size calculation for sensitivity and specificity. acad emerg med. 19996; 3(9): 895-900. 12. tavares el, brasolotto a, santana mf, padovan ca, martins rh. epidemiological study of dysphonia in 4– 12-year-old children. braz j otorhinolaryngol. 2011; 77(6): 736-46. 13. williams gt, farquharson im, anthony j. fibreoptic laryngoscopy in the assessment of laryngeal disorders. j laryngol otol. 1975; 89(3): 299-316. doi: 10.1017/s0022215100080403 14. moser se. nasolaryngoscopy. prim care. 2014; 41(1): 109-13. doi: 10.1016/j.pop.2013.10.009. 15. gupta a, sharma r, gupta n. evolution of videolaryngoscopy in pediatric population. j anaesthesiol clin pharmacol. 2021; 37: 14-27. 16. shafi m, shaikh aa, ahmed j. flexible fiberoptic naso-pharyngo-laryngosccopy: indications and outcome. j surg pak. 2015; 20(2): 56-59. 17. handler sd. direct laryngoscopy in children: rigid and flexible fiberoptic. ear nose throat j. 1995; 74(2): 100-4. 18. collins sr. direct and indirect laryngoscopy: equipment and techniques. respiratory care. 2014; 59(6): 850-64. 19. cohen jt, benyamini l. transnasal flexible fiberoptic in-office laryngeal biopsies-our experience with 117 patients with suspicious lesions. rambam maimonides med j. 2014; 5(2): e0011. doi: 10.5041/rmmj.10145. j islamabad med dental coll 2021 51 open access new onset heart failure after right ventricular pacing in patients with normal left ventricular function fawad qadir1, muhammad shahid1, hadi yousuf saeed1, muhammad tahir mohyudin2, abu bakar ali saad3, zahid iqbal4 1senior registrar, department of cardiology, cpe institute of cardiology, multan, pakistan 2associate professor, department of cardiology, cpe institute of cardiology, multan, pakistan 3assistant professor, department of cardiology, cpe institute of cardiology, multan, pakistan 4senior registrar, department of cardiology, dg khan medical college/hospital dg khan, pakistan a b s t r a c t background: cardiac pacing is the best optional treatment for cardiac rhythm disturbance s such as cardiac arrhythmias , high grade atrioventricular (av) block and heart failure (hf). right ventricular apical (rva) pacing in patients with normal left ventricular heart, may stimulate hf and cardiomyopathy. the objective of this study was to dete rmine the frequency of new-onset heart failure after right ventricular apical pacing in patients having normal left ventricular (lv) function . material and methods: this prospective study was conducted from march 2017 to january 2019 in chaudhry pervaiz elahi (cpe) institute of cardiology, multan pakistan. adult patients (n=50) who fulfilled the american college of cardiology (acc) guidelines for permanent pacemaker (ppm) insertion and with normal lv function were included in this study. pacemaker was implanted in all patients under local anesthesia. all patients were followed up for six months to determine the occurrence of heart failure. 2 -d echocardiography was done to determine heart failure at follow up in pacemaker clinic. results: mean age of the study participants was 50.53 ± 6.75 years with male predominance. mean pre -implantatio n ejection fraction (ef%) was 55.4 ± 4.2%. main reason of ppm insertion was third degree av block followed by right bundle branch block (rbbb). incidence of hf was 4% at 06 months’ follow-up. mortality occurred only in 1 (2%) patient. conclusions: right ventricular pacing is associated with risk of new onset heart failure in long term follow -up. in the present study, hf developed in 4% patients in a follow-up period of six months. key words: heart failure, permanent pacemaker, right ventricular pacing. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-7data analysis; manuscript editing. correspondence: hadi yousuf saeed email: doc.cpeic@gmail.com article info: received: july 14, 2019 accepted: december 22, 2020 cite this article. qadir f, shahid m, saeed hy, mohyudin mt, saad aba, iqbal z. new onset heart failure after right ventricular pacing in patients with normal left ventricular function . j islamabad med dental coll. 2021; 10(1): 51-55. doi: 10.35787/jimdc.v10i1.378 funding source: nil conflict of interest: nil i n t r o d u c t i o n cardiac pacing is the best optional treatment for cardiac rhythm disturbances such as cardiac arrhythmias, high grade av block and heart failure. 13 since decades, right ventricular apex is a suitable site for the conventional pacing. this is because endocardial pacing leads are stable and safe at rv or i gi n a l a r ti c le j islamabad med dental coll 2021 52 apical site. patients with high degree av block require a cardiac pacemaker. worldwide, every year 750,000 new cardiac pacemakers are being implanted with one quarter of them in the usa itself.4 in normal left ventricular heart, right ve ntricular apical pacing may increase symptoms of heart failure and cardiomyopathy.5 clinical and experimental data shows rva pacing may cause development of left ventricular systolic dysfunction.6 in a short-term study, sá et al. showed that there were non-significant effects in patients with normal lv function,7 even though, the development of lv dysfunction mechanism is still not understood. this might be caused by age, underlying disease spread and stimulation related issues.8 the aim of the present study was to find out the clinical and echocardiographic effects of onset heart failure in right ventricular apex pacing in patients treated for high degree av block with normal lv function. m a t e r i a l a n d m e t h o d s this prospective study comprising 50 patients was conducted from march 2017 to january 2019 in cpe institute of cardiology, multan pakistan. adult patients who presented with complete av block, type ii second-degree av block and sinus node disease with first-degree av block and pr interval >200 milli-seconds were included. these patients had normal lv function and also fulfilled the american college of cardiology/ american heart association guidelines for permanent pace -maker insertion. patients having ef <50%, or heart failure at the time of inclusion were excluded. written consent was taken from all the study participants. approval from ethics committee of cpe institute of cardiology was taken as well. pacemaker was implanted in all patients under local anesthesia. the leads were passed through left or right subclavian vein and were fixed the in right atrial appendage/septum, while the second lead was positioned in the right ventricular apex/septum. the rv lead was fixed by rotating it anti-clockwise using 3d stylet. the procedure was done in cardiac catheterization laboratory, under fluoroscopy guidance. narrow qrs complex was used as conformation. after pacemaker insertion, 12-lead ecg was done in each patient to program pacemaker at 150 to 180 milli-second on discharge. the paced qrs duration measured at each lead pacing spike manually in all 12 ecg leads. all patients were followed up for six months to determine the incidence of heart failure. 2-d echocardiography was done to determine heart failure at follow up in pacemaker clinic. only two patients were lost to follow-up and in their place two new patients were added. data was organized and analyzed using spss v23 software. qualitative variables like gender, onset of heart failure, diabetes and hypertension were presented as frequency and percentages, while the quantitative variables like age and ejection fraction were presented as mean and standard deviation (sd). r e s u l t s mean age of the study participants was 50.53 ± 6.75 years with a male predominance (78% males and 22% females). about 29 (58%) patients were hypertensive, and 18 (34%) patients were diabetic. mean pre-implantation ejection fraction (ef%) was 55.4± 4.2%. main reason of ppm insertion was third degree av block followed by rbbb. incidence of hf was 4% at six months’ follow-up. mortality occurred only in 1(2%) patient (table i). j islamabad med dental coll 2021 53 table i: clinicopathological characteristics of study participants (n=50) mean age (years) 50.53 ±6.75 gender n (%) male 39 (78) female 11 (22) diabetes n (%) 18 (34) hypertension n (%) 29 (58) baseline ef (mean) 55.4±4.2 reason of insertion n (%) lbbb 03 (6) rbbb 14 (28) av block second degree 04 (8) av block third degree 29 (58) new-onset heart failure n (%) yes 2 (4) no 48 (96) mortality n (%) yes 01 (2) no 49 (98) d i s c u s s i o n since the second half of the 20th century, right ventricular apex pacing has been selected for the pacemaker implantation because of stability and ease of implantation.9 even though, ppm stimulation is more often extensively related to ventricular dysfunction.10 in the present study, among 50 patients who were randomly selected over a period of 22 months in the rv apex pacing, two patients had ejection fraction of less than 40%. many studies have assessed the pacemaker-induced ventricular dysfunction without previous history of heart failure. in a single center study conducted on 257 pacemaker implanted patients with normal lv ejection fraction, about 20% of patients with rv apex pacing developed pacing-induced cardiomyopathy (a drop in lv ejection fraction of ≥15% from the baseline). the lv ejection fraction dropped to ≥20% at a mean follow-up time of 3 years.11 in pacing to avoid cardiac enlargement (pace) trial, 86 patients of ppm were included and followed for 1 year. they reported hf in 9% patients after rv pacing and in only 1% patients in biventricular pacing group.12 ebert et al. conducted a study to determine the reasons of ppm insertion on lv function. 13 the researchers divided the study patients into “sa node group” and “av block group”. they did not find any significant effect of predisposing factors on lv function in a mean follow-up of 44 months. in their study, only 6% patients developed heart failure. 13 another study by sa et al. reported that conventional rv pacing is a risk factor of worsening of 6-minute walk test, lv functional class, increased bnp levels, and prolongation of qrs in a long-term follow-up.14 some previous studies reported that right ventricular apex pacing should be avoided due to the chances of left ventricular dyssynchrony. 15,16 an abnormal generation and activation of electrical sequence leads to elevation of mitral valve insufficiency, ventricular hypertrophy and decreased ventricular ejection fraction. 17,18 other option of inserting leads is to select the right ventricular septal pacing rather than rv apex, that has been documented to reduce the risk of lv dyssynchrony.19,20 right ventricular septal pacing decreases the paced qrs duration on ecg and reduces the dyssynchony on 2-d echocardiography.21 a study conducted by domenichini et al. compared the se ptal and apical pacing and followed the patients for 4 years. the authors did not find any significant difference in the risk of lv dysfunction and concluded that both apical and septal pacing positions have similar impact on lv function.22 there are certain limitations of this study. firstly, a sample size of only 50 patients is not enough to draw significant conclusions. secondly, the study population was not homogenous and indications of pacemaker insertion were not the same for each j islamabad med dental coll 2021 54 patient. therefore, the underlying etiology may also have a different impact on rv function. c o n c l u s i o n in the present study new-onset hf developed in 4% patients after right ventricular apical pacing in a follow-up period of six months. rv pacing is associated with risk of new onset heart failure in long term follow-up. r e f e r e n c e s 1. kusumoto fm, schoenfeld mh, barrett c, edgerton jr, ellenbogen ka, gold mr, et al. 2018 acc/aha/hrs guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. j am coll cardiol. 2019; 74(7): e51-e156. doi: 10.1016/j.jacc.2018.10.044 . 2. cevik c, nugent k, perez‐verdia a, fish rd. prophylactic implantation of cardioverter defibrillators in idiopathic nonischemic cardiomyopathy for the primary prevention of death: a narrative review. clin cardiol. 2010; 33(5): 254 -60. doi: 10.1002/clc.20757. 3. yang b, cheng y, zhang d-e. the indications and notice of installation temporary pacemaker or permanent pacemaker. medicine and biopharmaceutical. 2016; 161-8. doi: 10.1142/9789814719810_0019 . 4. mond hg, proclemer a. the 11th world survey of cardiac pacing and implantable cardiove rterdefibrillators: calendar year 2009 --a world society of arrhythmia's project. pacing clin electrophysiol. 2011; 34(8): 1013-27. doi: 10.1111/j.15408159.2011.03150.x. 5. ooka j, tanaka h, hatani y, hatazawa k, matsuzoe h, shimoura h, et al. risk stratification of future left ventricular dysfunction for patients with indications for right ventricular pacing due to bradycardia. int heart j. 2017; 58(5): 724-30. doi: 10.1536/ihj.16-415. 6. freudenberger rs, wilson ac, lawrence -nelson j, hare jm, kostis jb. permanent pacing is a risk factor for the development of heart failure. am j cardiol. 2005; 95(5): 671-4. doi: 10.1016/j.amjcard.2004.10.049 . 7. crevelari es, silva krd, albertini cmm, vieira mlc, martinelli filho m, costa r. efficacy, safety, and performance of isolated left vs. right ventricular pacing in patients with bradyarrhythmias: a randomized controlled trial. arq bras cardiol. 2019; 112(4): 410-21. doi: 10.5935/abc.20180275 . 8. tops lf, schalij mj, bax jj. the effects of right ventricular apical pacing on ve ntricular function and dyssynchrony implications for therapy. j am coll cardiol. 2009; 54(9): 764 -76. doi: 10.1016/j.jacc.2009.06.006. 9. furman s, robinson g. the use of an intracardiac pacemaker in the correction of total heart block. surg forum. 1958; 9: 245-8. pmid: 13635360. 10. sweeney mo, hellkamp as. heart failure during cardiac pacing. circulation. 2006; 113(17): 2082 -8. doi: 10.1161/circulationaha.105.608356 . 11. khurshid s, epstein ae, verdino rj, lin d, goldberg lr, marchlinski fe, et al. incidence and pre dictors of right ventricular pacing-induced cardiomyopathy. heart rhythm. 2014; 11(9): 1619-25. doi: 10.1016/j.hrthm.2014.05.040 . 12. yu c-m, chan jy-s, zhang q, omar r, yip gw-k, hussin a, et al. biventricular pacing in patients with bradycardia and normal ejection fraction. n engl j med. 2009; 361(22): 2123 -34. doi: 10.1056/nejmoa0907555. 13. ebert m, jander n, minners j, blum t, doering m, bollmann a, et al. long-term impact of right ventricular pacing on left ventricular systolic function in pacemaker recipients with preserved ejection fraction: results from a large single -center registry. j am heart assoc. 2016; 5(7): e003485. doi: 10.1161/jaha.116.003485. 14. sá labd, rassi s, batista mal. is conventional cardiac pacing harmful in patients with normal ventricular function? arq bras cardiol. 2013; 101(6): 545 -53. doi: 10.5935/abc.20130205. 15. thambo jb, bordachar p, garrigue s, lafitte s, sanders p, reuter s, et al. detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. circulation. 2004; 110(25): 3766 -72. doi: 10.1161/01.cir.0000150336.86033.8d. 16. tse hf, lau cp. long-term effect of right ventricular pacing on myocardial perfusion and function. j am coll cardiol. 1997; 29(4): 744 -9. doi: 10.1016/s07351097(96)00586-4. 17. prinzen fw, augustijn ch, arts t, allessie ma, reneman rs. redistribution of myocardial fiber strain and blood flow by asynchronous activation. am j physiol. 1990; 259(2 pt 2):h300 -8. doi: 10.1152/ajpheart.1990.259.2.h300 . 18. nahlawi m, waligora m, spies sm, bonow ro, kadish ah, goldberger jj. left ventricular function during and after right ventricular pacing. j am coll cardiol. 2004; 44(9): 1883-8. doi: 10.1016/j.jacc.2004.06.074. j islamabad med dental coll 2021 55 19. yusu s, mera h, hoshida k, miyakoshi m, miwa y, tsukada t, et al. selective site pacing from the right ventricular mid-septum. follow-up of lead performance and procedure technique. int heart j. 2012; 53(2): 113-6. doi: 10.1536/ihj.53.113. 20. flevari p, leftheriotis d, fountoulaki k, panou f, rigopoulos ag, paraskevaidis i, et al. long-term nonoutflow septal versus apical right ventricular pacing: relation to left ventricular dyssynchrony. pacing clin electrophysiol. 2009; 32(3): 354 -62. doi: 10.1111/j.1540-8159.2008.02244.x. 21. cano o, osca j, sancho-tello mj, sanchez jm, ortiz v, castro je, et al. comparison of effectiveness of right ventricular septal pacing versus right ventricular apical pacing. am j cardiol. 2010; 105(10): 1426 -32. doi: 10.1016/j.amjcard.2010.01.004 . 22. domenichini g, sunthorn h, fleury e, foulkes h, stettler c, burri h. pacing of the interventricular septum versus the right ventricular apex: a prospective, randomized study. eur j intern med. 2012; 23(7): 621-7. doi: 10.1016/j.ejim.2012.03.012 . j islamabad med dental coll 2020 42 open access disease pattern and outcome among neonates in pediatric ward of pof hospital, wah robina mushtaq1, musarat ramzan2,3, anum jehan4, aqsa mushtaq4, areeba siddiqui4, abdul basit4, aroosha arif4, ali farooq4 1associate professor, department of community medicine, wah medical college 2dean, wah medical college 3professor and head, department of community medicine, wah medical college 4house officer, pof hospital, wah medical college a b s t r a c t background: neonatal period is the duration betwee n 0-28 days of birth and it is the most vulnerable period of life because of the exposure of the neonate to a large number of problems and diseases during this period. the objective of the study was to determine the disease pattern and outcome among neonates in pediatr ic ward of pof hospital. material and methods: a descriptive study was carried out at pediatric ward of pof hospital wah cantt. retrospective data regarding age, sex, reasons for admission, outcome and mode of delivery (from hospital record) was collected for all neonates admitted during the year 2016 from 1 st january to 31st december. the data was analyzed by using spss version-19. results: among total neonates (n=887) admitted during the year, 63.2% were males and 36.8% were females. mean weight of neonates was 2.54 + 0.75 kg while mean age was 2.39 + 5.8 days. most common causes of hospital admissions were prematurity, respiratory distress syndrome, seizures and sepsis. overall, 82.64% recovered from their illness while 17.02% expired. conclusion(s): prematurity, respiratory distress syndrome, seizures and sepsis were the major causes of neonatal admission in this study. key words: diagnostic value, immature-to-total neutrophil ratio, neonatal sepsis authors’ contribution: 1conception; 2-3literature research; manuscript design and drafting; 4critical analysis and manuscript review; data analysis; 7,8manuscript editing. correspondence: robina mushtaq email: robina.mushtaq@yahoo.com article info: received: july 22, 2019 accepted: february 20, 2020 cite this article. mushtaq r, ramzan m, jehan a, mushtaq a, siddiqui a, basit a, arif a, farooq a. disease pattern and outcome among neonates in pediatric ward of pof hospi t a l , wah. j islamabad med dental coll.2020; 9(1): 42-47. doi: 10.35787/jimdc.v9i1.386 funding source: nil conflict of interest: nil i n t r o d u c t i o n neonatal period is defined as the first 28 days of life and is further divided into very early (birth to 24 hours), early (24 hours to 7 days) and late neonatal period (7 days to 28 days).1 worldwide, 130 million neonates are born each year, of these, 4 million die in first 28 days of life. neonatal period (1st 28 days of life) is the most fragile and vulnerable period of life, because of th e large number of problems and diseases which a neonate is likely to face. moreover, a neonate is 500 times more likely to die on the first day of life than at one month of age 1-5 two third of the world’s total neonatal deaths occur in just 10 countries, mostly in asia. pakistan or i gi n a l a r ti c le j islamabad med dental coll 2020 43 ranks at number three among these countries. with a reported neonatal mortality rate of 49 per 1000 live births, pakistan alone accounts for 7% of global neonatal deaths. in the developed countries, the main cause of mortality and morbidity in the neonatal period are non-preventable like congenital anomalies, but in the developing countries preventable causes such as infections, jaundice, birth asphyxia and pneumonia predominate.5 the neonatal disease pattern is different from place to place and changes over time. it is believed that majority of the causes of neonatal morbidity are preventable. throughout the world, the major reasons of neonatal mortality were estimated to b e infections (35%), pre-term births (28%) and asphyxia (23%).2 sepsis is the main cause of deaths in newborn babies. approximately, 20% of all newborn babies develop sepsis and each year in developing countries, sepsis is liable for 30 – 50% of the total neonatal deaths.2,6 pre maturity alone accounts for majority of highrisk newborns as they are likely to f ace a large number of problems. though considerable improvement has occurred in the survival of newborns in advanced countries, but the mortality rate is still very high in the developing countries. neonatal mortality and disease pattern are a sensitive indicator of availability, utilization and effectiveness of mother and child health services in the community.1,5 the survival of the newborns depends upon the care, they receive. in most tertiary care institutions, a special unit is reserved for babies with illnesses in the neonatal period. prognosis of sick neonates depends upon severity of intrinsic illness and provided medical care. majority of the causes of neonatal morbidity and mortality in our country are preventable. lack of obstetrical and neonatal services, poor infrastructure of primary health care, and low awareness of the health needs of pregnant women are the contributory factors.3,4 the objective of the study was to determine the disease pattern and outcome among neonates in pediatric ward of pof hospital. in developed countries like pakistan, the neonatal morbidity and mortality is high. one of the important factors responsible for this is insufficient neonatal care at most of the hospitals. this study was conducted to find out the major diseases among neonates in wah cantt region, so that measures can be taken to initiate a program for better management of neonatal problems in order to reduce morbidity and mortality. m a t e r i a l a n d m e t h o d s a descriptive study was carried out at pediatric ward of pof hospital wah cantt. retrospective data regarding age, sex, reasons for admission, outcome and mode of delivery was collected from hospital record for all neonates admitted during the year 2016 from 1st january to 31st december. the data was analyzed by using spss version 19. chisquare test of significance was used to determine association between categorical variables at alpha value of 0.05. diagnosis was largely on clinical findings with specific laboratory and/or x-ray findings. sepsis was diagnosed clinically along with complete blood count (cbc), and positive blood culture. congenital heart disease was confirmed by echocardiography. neonates delivered before 37 weeks of gestation were labeled pre-mature and those having birth weight less than 2.5 kg were classified as low birth weight. neonates were diagnosed with intrauterine growth retardation (iugr) when their weight was below the 10th percentile for the gestational age. neonatal jaundice was diagnosed by checking serum bilirubin. pneumonia was diagnosed by j islamabad med dental coll 2020 44 clinical examination (respiratory rate >60 per minute and indrawing of chest wall) and radiological findings. r e s u l t s in this study, a total of 887 neonates were admitted in pediatric ward of pof hospital, wah cantt, from january 1 to december 31, 2016. among them, 63.2% were males and 36.8% were females. most of the neonates admitted were delivered through c-section (56%). the mean age of neonates was 2.39±5.8 days with 67% born within 24 hours, 22% aged 1-7 days, while 11% were more than 7 days old (table i). the mean weight of neonates was 2.54±0.75 kg. overall, 82.64% (n=733) recovered while 17.02% (n=154) expired and only 0.33% (n=3) were referred to other hospitals. about 330 (37.2%) patients were referred from opd of pof hospital, 277 (31.2%) from operation theatre (ot), 138 (15.6%) from gynecology ward and 4 (0.5%) were reported from emergency of same hospital, while 138 (15.6%) were referred from other hospitals. the main causes of hospital admissions included sepsis (243; 27.4%), respiratory distress syndrome (180; 20.3%), seizures (107; 12.1%) and preterm neonates (107; 12.1%). there were 71 (8%) cases of neonatal jaundice, 59 (6.7%) cases of meconium aspiration syndrome, 42 (4.7%) of pneumonia, 29 (3.3%) of intra uterine growth restriction, 13 (1.5%) of congenital heart disease, and 36(4%) h ad miscellaneous diseases (table i). the most common cause in both males and females was prematurity (preterm neonates) (67; 11.94% in males and 40; 7.1% in females), respiratory distress syndrome (111; 19.78% in males and 63; 19.32% in females), seizures (67; 11.94% in males and 40; 12.26%) and sepsis (155; 27.62% in males and 88; 26.99% in females) (figure 1) . regarding weight and gender 224 (25.2%) males and 161 (18.7%) females were underweight. mode of delivery had no significant effect on mortality (16.7% in c-section vs 17.4% in svd) (table i). disease pattern according to mode of delivery is shown in table ii. regarding outcome, higher mortality rates were noted among neonates having respiratory distress syndrome (49; 27.2%), prematurity (40; 37.3%) and sepsis (26; 10.7%), and in neonates who were admitted within 24 hours after delivery (table i). disease pattern according to age is shown in figure 2 figure 1: frequency distribution of diseases according to gender figure 2: disease pattern according to age groups j islamabad med dental coll 2020 45 table i: gender, age, mode of delivery, disease pattern and outcome of neonates variables attributes frequency outcome p-value recovered expired referred gender male 561 462 98 1 0.52 female 326 271 53 2 mode of delivery c-section 497 411 83 3 0.170 svd 390 322 68 0 age at admission < 1 day 598 474 121 3 0.000 1-7 days 195 170 25 0 > 7 days 94 89 5 0 diagnosis sepsis 243 216 26 1 0.000 respiratory distress syndrome 180 129 49 2 seizures 107 104 3 0 preterm 107 67 40 0 neonatal jaundice 71 69 2 0 meconium aspiration syndrome 59 50 9 0 pneumonia 42 37 5 0 iugr 29 22 7 0 congenital heart disease 13 6 7 0 miscellaneous 36 33 3 0 table ii: disease pattern according to mode of delivery disease at admission delivery mode total csection svd sepsis 125 118 243 respiratory distress syndrome 112 68 180 seizures 75 32 107 preterm 59 48 107 neonatal jaundice 32 39 71 meconium aspiration syndrome 31 28 59 pneumonia 21 21 42 iugr 16 13 29 congenital heart disease 7 6 13 miscellaneous 19 17 36 d i s c u s s i o n this study was conducted in pediatric ward of pof hospital, wah cantt to study the disease pattern and outcome among neonates. the percentage of male patient was 63.2% while that of female was 36.8%. this high proportion of male neonates is due to their genetic liability to many diseases as has been shown in a number of studies. 7-10 moreover studies conducted in tertiary care neonatal unit, kharian, nishtar hospital multan, teaching hospital of oghera, nigeria and in rehman medical institute, peshawar also showed male predominance in neonate’s admitted in pediatric ward.1-3,5 the percentage of neonates delivered through csection was 56% with similar results reported in tertiary care hospital, kharian, while in contrast sheikh zayed hospital, lahore reported 36% of neonates born by c-section.2,7 mortality among neonates delivered by c-section was insignificantly lower as compared to svd (16.7% vs 17.4%). the reasons may be poor practices in labour rooms with aseptic techniques (clean hands, clean delivery surface and better cord care) not being properly practiced in our community. more cesarean sections are noted in our society because many patients do not avail antenatal services and report in serious situation after being handle d by local dais, making cs necessary to save the life of mother as well as fetus.7 at the time of admission, 67% babies were less than 24 hours of age, as this period is vital for neonatal morbidity and mortality. in studies conducted by saleem et al, ali et al, and rahim et al, majority of the neonates were born within 24 hours.7,8,10 however, parkash and das reported only 18% neonates admitted during 24 hours. 11 in our study 44% neonates were underweight, while 56% were in normal birth weight range. many of the other studies in multan, northern nigeria, and delta j islamabad med dental coll 2020 46 region of nigeria also had more number of neonates in normal birth weight range, 6,5,12 while the studies held in peshawar and kharian showed more cases in low birth weight range.1,2 the main causes for low birth weight in our region are low literacy rate, lack of proper antenatal services, poverty and high rate of malnutrition among mothers. most common clinical conditions of neonates in our study are sepsis, rds, prematurity and seizures making 71.2% of all diseases. these results are similar to many local studies,2,3,13,14 as well as researches in other countries5,15-18 with almost the same disease pattern. in contrast, a research carried out in peshawar had maximum admissions due to low birth weight and iug r.1 in a study by udo et al and quddusi et al infections and birth asphyxia are the main reasons for admission of neonates, respectively.6,19 in our study, majority of patients (83%) recovered thus showing more recovery index and low mortality. this reflects quality of care being provided at hospital as well as dedication and hard work of health care providers. worldwide the trend of neonatal mortality is on the decline. 7 similar death trends among neonates was observed in different studies conducted in pakistan2, 10 and nigeria.5,12 as compared to our study, researches carried out in peshawar, multan and karachi showed lower mortality rate 1,6,8 while studies by saleem et al, rakhia et al and parkash and das have revealed somewhat higher mortality rates.4,11,14 higher death rates were noted among neonates having respiratory distress syndrome (32.4%), prematurity (26.4%) and sepsis (17.2%). these diseases were also responsible for mortality in neonates in a study by saini et al.20 sepsis was the leading cause in study by aijaz et al13 while prematurity and respiratory problems were main causes of death in study by tekleab et al. 17 as neonates are more susceptible to death within firs t 7 days of their life, in our study 96% deaths were recorded during this period, of which 80% neonates died within 24 hours after delivery. these results are comparable with other regional and international studies, respectively.7,16,19 c o n c l u s i o n prematurity, respiratory distress syndrome, seizures and sepsis were the major causes of neonatal admissions in our study population. proper antenatal and natal care of pregnant women, timely intervention and referral of all high risk pregnancies can significantly reduce neonatal admission due to these causes. r e f e r e n c e s 1. jan az, ahmad s, zahid sb. clinical audit of admission pattern and its outcome in a neonatal icu. gomal j med sci. 2013; 11(1): 31 -6. 2. hussain s. neonatal morbidity and mortality pattern in a tertiary care neonatal unit of a teaching hospital. ann pak. inst. med. sci. 2014; 10(1): 7-11. 3. tabassum s, ameen m, akram m, amanullah m. prevalence of neonatal diseases in multan region, pakistan. pakistan journal of nutrition. 2013; 12(6): 544-548. doi: 10.3923/pjn.2013.544.548 4. saleem m, ali m, anwar j, babar mi, rafi m, mehmood r, et al. clinical audit of neonatal admissions in a tertiary care hospital. jszmc. 2010; 2(4). 231-235. 5. ugwu gim. pattern of morbidity and mortality in newborn special care unit in a tertiar y institution in the niger delta region of nigeria: a two years prospective study. glo. adv. res. j. med. med. sci. 2012; 1(6): 133 – 138. 6. quddosi ai, razzaq a, hussain s, hussain a. pattern of neonatal admission at children’s hospital and the institute of child health, multan. j. ayub med. coll abbotabad. 2012; 24(2). 108 -110. 7. saleem m, iqbal r, bokhari s, ali m, khan z. pattern of neonatal admissions & its outcome in a tertiary care hospital of southern punjab (5 years study). p j m h s. 2014; 8(4): 916-921. 8. ali sr, ahmed s, lohana h. disease patterns and outcomes of neonatal admissions at a secondary care hospital in pakistan. sultan qaboos univ med j. 2013; 13(3): 424-428. pmid: 23984028 9. tabassum s, amin m, akram m, aman ullah m. prevalence of neonatal diseases in multan region, j islamabad med dental coll 2020 47 pakistan. pak j nutr. 2013; 12(6): 544 -548. doi: 10.3923/pjn.2013.544.548 10. rahim f, jan a, mohummad j, iqbal h. pattern and outcome of admissions to neonatal unit of khyber teaching hospital, peshawar. pak j med sci. 2007; 23(2): 249253. 11. parkash j, das n. pattern of admissions to neonatal unit. jcpsp. 2005; 15(6): 341-344. doi: 06.2005/jcpsp.341344 12. mukhtar-yola m, iliyasu z. a review of neonatal morbidity and mortality in aminu kano teaching hospital, northern nigeria. trop doc. 2007; 37(3): 130-132. doi: 10.1258/004947507781524683 13. aijaz n, huda n, kausar s. disease burden of nicu, at a tertiary care hospital, karachi. j dow univ health sci. 2012; 6(1): 32-35. 14. rakhia a, khan m, memon aa, dahar sa. pattern and outcome of neonatal ailments in a tertiary care hospital. pak j med res. 2014; 53(1): 14-16. 15. okposio mm, ighosewe oi. morbidity and mortality pattern among neonates admitted to the general paediatric ward of a secondary health care centre in the niger delta region of nigeria. sri lanka j. child health. 2016; 45(2): 84-89. doi: 10.4038/sljch.v45i2.7981 16. okechukwu aa, achonwa a. morbidity and mortality patterns of admissions into the special care baby unit of university of abuja teaching hospital, gwagwalada, nigeria. niger j clin pract. 2009; 12(4): 389-394. pmid: 20329678 17. tekleab am, amaru gm, tefera ya. reasons for admission and neonatal outcome in the neonatal care unit of a tertiary care hospital in addis ababa: a prospective study. research and reports in neonatology. 2016; 6: 17–23. doi: 10.2147/rrn.s95455 18. kunle-olowu oe, peterside o, adeyemi oo. prevalence and outcome of preterm admissions at the neonatal unit of a tertiary health centre in southern nigeria. ojped. 2014; 4(1): 67-75. doi: 10.4236/ojped.2014.41009 19. udo jj, anah mu, ochigbo so, etuck is, ekanem ad. neonatal morbidity and mortality in calabar, nigeria: a hospitalbased study. niger j clin pract. 2008; 11(3): 285-289. pmid: 19140371 20. saini n, chhabra s, chhabra s, garg l, garg n. pattern of neonatal morbidity and mortality: a prospective study in a district hospital in urban india. j clin neonatol. 2016; 5:183-8. doi: 10.4103/2249-4847.191258 j islamabad med dental coll 2021 31 open access ameliorative effects of withania coagulans and metformin on ovarian morphology in rats with polycystic ovarian disease hira ayaz1, abdul samad2, aiman farogh anjum3, nasar abbas shamsi4, sidra arshad5, mahvash khan6 1assistant professor, department of physiology, foundation university, islamabad pakistan 2assistant professor, department of physiology, pak international medical college, peshawar pakistan 3assistant professor, department of physiology, cmh kharian medical college, kharian cantonment pakistan 4assistant professor, department of physiology, foundation university, islamabad pakistan 5associate professor, department of physiology, rawal institute of health sciences, islamabad pak istan 6professor, department of physiology, rawal institute of health sciences, islamabad pakistan a b s t r a c t background: various medicinal herb plants are being used in place of metformin for treatment of polycystic ovarian disease for their less harmful e ffects. withania coagulans (wc) is a herb known for its insulin sensitizing and weight reducing properties. the present study was done to determine the influence of aqueous extract of withania coagulans (aqwc) and metformin on ovarian weight and ovarian fo lliculogenesis in polycystic ovarian disease -induced rats. material and methods: an experimental animal study was carried out at the physiology department of islamic international medical college, rawalpindi from april 2016 to march 2017. forty female sprague dawley rats were divided initially into two groups. group a (normal control) and disease induced group. standardized laboratory diet was fed to group a while the disease induced group was given standardized laboratory diet and letrozole solu tion orally (1mg/kg) for 21 days to induce polycystic ovary syndrome, which was established by observing estrous cycle of rats. disease induced group was then split into group b (pcos control), c (aqueous withania coagulans treated) and d (metformin treated) and observed after 14 days. groups a and b underwent ovarian dissection after 21 days and groups c and d underwent dissection at the end of experiment (after 35 days). independent sample t -test was used for the comparison between the control and disease induced group. results: group b showed a significant increase in ovarian weight in comparison to group a rats (p < .05). treatment with withania coagulans and metformin significantly decreased ovarian weight (p < .05) and increased primary, graafian, antral follicular count and corpus luteum along with reduction in cystic follicular count in letrozole -induced polycystic ovarian disease rats. improved folliculogenesis was also observed in the same groups (groups c & d) . conclusions: withania coagulans can be a substitute for improvement of ovarian follicular development in polycystic ovarian disease. key words: estrous cycle, metformin, polycystic ovarian disease, withania coagulans. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6data analysis; manuscript editing. correspondence: hira ayaz email: hiraayaz6@gmail.com article info: received: november 11, 2019 accepted: february 22, 2021 cite this article. ayaz h, samad a, anjum af, shamsi na, arshad s, khan m. ameliorative effects of withania coagulans and metformin on ovarian morphology in rats with polycystic ovarian disease. j islamabad med dental coll. 2021; 10(1): 31-36. doi: 10.35787/jimdc.v10i1.457 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2021 32 i n t r o d u c t i o n polycystic ovary syndrome (pcos) is a globally recognized reproductive endocrine disorder and a principal cause of anovulatory infertility affecting 8 to 13% of women of reproductive age. anovulation is recognized as a disorder in the development of follicles and exists in 70% of females having pcos.1 the dynamics of early follicular development in pcos are different from normal ovarian folliculogenesis. different studies have shown that decreased amounts of oocyte -secreted growth factors, androgen overproduction and increased responsiveness to luteinizing hormone (lh) and hyperinsulinemia give rise to production of large number of small sized antral follicles in early stage. these small follicles lead to higher anti-müllerian hormone (amh) levels, which reduce the follicular sensitivity to fsh due to which antral follicles cannot develop into mature follicles and undergo ovulation. as a result, excessive early follicular growth and failure of maturation of one follicle from the pool of follicles into a dominant follicle (under the influence of lh) takes place. this is known as follicular arrest, the main ovulatory disorder of pcos.2,3 management of infertility in pcos involves bringing about weight loss in obese, infertile women, inducing ovulation by use of clomiphene citrate and increasing insulin sensitivity by use of metformin. various studies have shown that metformin improves ovulation rate and clinical pregnancy rate.4,5 but continuous administration of metformin at high doses has its own hazardous effe cts. some patients also have reduced compliance to metformin due to its adverse effects (gastrointestinal upset, lactic acidosis and vitamin b12 deficiency), because of which its usage is limited or contraindicated in those cases.6,7 in place of metformin various kind of medicinal herb plants have been in use due to absence of side effects, easy availability and affordability. one of these herbs is withania coagulans dunal, also known as paneer doda, commonly found in north india, afghanistan and pakistan. it is well known for its insulin sensitizing features because of withanolides present in it.8,9,10 due to its known effects as antidiabetic and insulin sensitizer herb, it might help in reducing the severity of pcos by improving glucose intolerance and insulin resistance leading to increased fertility rate. the aim of this study was to investigate the effects of aqueous extract of withania coagulans (aqwc) and metformin on ovarian weight and morphology in pcos rats. by comparing the effects of wc and metformin, we might be able to identify whether withania coagulans can be substituted for metformin in alleviation of symptoms of pcos or not. m a t e r i a l a n d m e t h o d s this experimental animal study was conducted at the multidisciplinary research laboratory of islamic international medical college, riphah international university in collaboration with national institute of health (nih), islamabad pakistan from april 2016 to march 2017. it was conducted after getting approval from ethics review committee of islamic international medical college (ref # riphah/iimc/erc/16/0119). forty female sprague dawley rats weighing 180-250 g were acquired from nih (islamabad, pakistan). rats aged 6-8 weeks were included in the study as they attain sexual maturity at this age. pregnant rats and those having any obvious physical deformity were excluded from the study. the animals were kept at a temperature of 24⁰ c, humidity of 50% with a 12-hour light and dark cycle. the study rats (n=40) j islamabad med dental coll 2021 33 were randomly distributed into two groups; group a serving as normal control (n=10) and diseaseinduced group (n=30). standardized laboratory diet was given to group a, while standardized laboratory diet and letrozole (trade name lezra) 1 mg/kg, mixed in 0.5% carboxy methyl cellulose (cmc) 2 mg/kg, orally for 21 days to induce pcos were administered to the disease induced group. the disease induced group was then split into group b (pcos control) (n= 10), group c (withania coagulans-treated) (n=10) and d (metformintreated) (n=10). from nearby local market desiccated fruits of withania coagulans were acquired and used after getting recognized and certified by national agriculture research center (narc), islamabad (herbarium section voucher number iimc 03). dried fruit of withania coagulans (1 kg) was crumpled after the removal of calyx and pedicles and soaked overnight in 4l of purified water at moderate temperature. on the next day, the softened extract was sieved by using filter paper. after the process of filtration, water extract was evaporated at 55-60˚c on a magnetic stirrer evaporator for 7 hours to get a semi-solid material (yield 16% wt/wt). later on, this yield at a dose of 250mg/ml was diluted in purified water. an aqueous extract of wc, 1000mg/kg/day was dissolved in drinking water and fed orally to group c rats along with standardized laboratory diet. metformin (glucophage) was purchased from d. watson pharmacy, rawalpindi, pakistan. metformin tablet (500 mg) was dissolved in 25 ml of normal saline to prepare a solution of 2mg/100ml. the solution was kept covered by aluminum foil and stored at 4° c. metformin solution mixed in drinking water and standardized laboratory diet was given to group d for 14 days. vaginal smears were taken from the rats by swab smear technique for 21 days sequentially, to observe the phase of the estrus cycle and confirm pcos induction. if any phase of this cycle persisted continously for more than 3 days it showed irregularity in the cycle.10,11,12 rats with irregular ovarian cycles (diestrus phase for 3 consecutive days) were considered as pcos positive and were selected for the trial. on 22nd day, animals in group a and disease-induced group were sacrificed by cervical dislocation. after dissection, ovaries were removed, fat cleaned off and weighed on a scale (ts200 electronic compact scale, jiangyin ditai electronic technology co. ltd., china). at the time of removal, ovaries of rats in disease induced group were in diestrus phase whereas in groups a, c and d, the ovaries were in proestrus phase. ovaries were fixed in 4% paraformaldehyde in phosphatebuffered saline (pbs) for 1 hour at room temperature, soaked in pbs, dried and embedded in paraffin. for hematoxylin and eosin (h & e) staining, 4 μm tissue sections of ovaries were prepared. tissue sections were deparaffinized using xylene, hydrated through an ethanol series of 100%, 90%, 80% and stained with h&e. sections were then mounted with canada balsam after washing and observed under light microscope using x100 lenses. the primary follicles, antral follicles, graafian follicles and corpus luteum per ovary were identified and determined by counting 5 representative sections per ovary at least 20 μm apart. statistical analysis was performed by applying the statistical package for social sciences version 21 (spss 21). independent sample t-test was used for the comparison between the control and disease induced group. results were represented as mean ± sem. for both analyses, p-value < .05 was taken as significant. r e s u l t s group b showed a significant increase in ovarian weight in comparison to group a rats (p < .05). rats in groups c and d showed a significant reduction (p j islamabad med dental coll 2021 34 < .05) in ovarian weight in comparison to group b as displayed in table i. *p-value < .05 was considered statistically significant the average count of primary, antral and graafian follicles and corpus luteum was significantly reduced (p < .05) in group b as compared to group a, whereas the cystic follicular number was significantly increased (p < .05) in group b than group a. groups c and d depicted significant increase ( p < .05) in primary, antral and graafian follicles and corpus luteum in contrast to group b. cystic follicles were significantly reduced in groups c and d as compared to group b (table ii). rats in group d showed significant decrease (p < .05) in ovarian weight in comparison to group c. however, no significant results were observed in the count of primary follicle while comparing rats in group c and d. group d rats depicted significant increase (p < 0.05) in antral follicles, graafian follicles and corpus luteum in contrast to group c. cystic follicular count showed significant reduction (p < .05) in rats of group d in contrast to group c. histological analysis of group a showed several phases of development of follicles such as primary follicles (pf), antral follicles (af), graafian follicle (gf) and corpus luteum (cl) as shown in figure 1. group b rats showed major diffe rences than group a, as small-sized primary follicles and antral follicles were seen along with appearance of large cystic follicles (cf). no graafian follicle and corpus luteum were seen. morphological analysis of ovaries of rats in group c and d presented improved folliculogenesis than group b, showing pf, af, gf and cl (figure 1). d i s c u s s i o n in this study, ovarian weight and morphology of the rats treated with withania coagulans and metformin were compared with disease -induced rats (pcosinduced rats). the results showed that administration of aqueous extract of withania coagulans decreased ovarian weight and improved folliculogenesis as well. this effect might be due to the presence of active components, known as withanolides in aqwc. the most likely mechanism is that the withanolides increase the tissue receptivity to insulin, which then amends the gonadotropin levels. in the current study, effect of withania coagulans and metformin on ovarian weight (mg) and ovarian morphology (number and type of follicles) was assessed along with their comparison. findings of the present-day study are in concurrence with the study conducted by rajan et al. inspecting the consequence of soy isoflavones (100mg/kg) administration for 14 days on body weight, ovarian and uterine weight in letrozole (1mg/kg) induced pcos rats. they revealed that soy isoflavones (100mg/kg) treatment significantly improved the letrozole-induced pcos symptoms by bringing about a decrease in ovarian, uterine and general body weight. they also proposed that these weight lowering effects might be due to the presence of phytoestrogens in isoflavones.13 this study differed from our study as they administered two different doses of soy isoflavones and observed their effects on symptoms of pcos whereas we treated the rats with aqwc and metformin and compared their effects on pcos-induced rats. another study by bhutani et al. observed that administration of aqueous extract of symplocos racemosa roxb. (2000mg/kg) for 6 days resulted in reinforcement of folliculogenesis in ovaries. 14 these results were same as witnessed in the existing study though immature rats were not chosen. table i: comparison of mean ± sem of ovarian weight in rats in all four groups groups ovarian weight group a 57.20 ± 0.83 group b 64.68 ± 0.53* group c 61.60 ± 0.43* group d 58.54 ± 0.19* j islamabad med dental coll 2021 35 table ii: comparison of mean ± sem of different follicles in ovaries of rats in all four groups type of follicle group a group b group c group d primary follicle 5.8 ± 0.92 4.0 ± 0.47* 5.4 ± 0.33* 5.6 ± 0.45* antral follicle 3.9 ± 0.27 2.8 ± 0.49* 3.4 ± 0.27* 4.1 ± 0.26* graafian follicle 3.7 ± 0.23 0.0 ± 0.00* 2.0 ± 0.24* 2.2 ± 0.25* corpus luteum 3.4 ± 0.16 0.0 ± 0.00* 1.0 ± 0.26* 2.0 ± 0.51* cystic follicle 0.0 ± 0.00 4.0 ± 0.47* 1.5 ± 0.42* 0.5 ± 0.70* *p < .05 is considered statistically significant. table iii: comparison of mean ± sem of ovarian weight and follicular count between rats in groups c and d groups ovarian weight (mg) primary follicle antral follicle graafian follicle corpus luteum cystic follicle group c 61.4 ± 0.34* 5.4 ± 0.20 3.42 ± 0.02* 2.03 ± 0.05* 1.23 ± 0.25* 1.53 ± 0.05* group d 58.3 ± 0.22* 5.7 ± 0.10 4.19 ± 0.10* 2.26 ± 0.11* 2.03 ± 0.05* 0.53 ± 0.57* *p < .05 is considered statistically significant. figure 1: photomicrographs of ovarian tissue in groups a, b, c and d (h&e; x100). we used letrozole-induced pcos rats and also showed a comparison to metformin treatment. results reported by hojatullah et al. also witnessed restoration of folliculogenesis in estradiol valerate induced pcos rats after administration of palm pollen extract (400mg/kg) for 21 days. they proposed that glycosidal, flavonoids and saponins present in extract are responsible for antioxidant properties of palm pollen extract resulting in re establishment of normal ovarian functions. 15 similar j islamabad med dental coll 2021 36 results were observed in the present study but letrozole induced animal model with only a single dose of aqueous extract of aqwc was used. c o n c l u s i o n notable ameliorative potential of withania coagulans observed in this study illustrates that it may be used as a substitute for metformin in ameliorating ovarian histological features in pcos. a c k n o w l e d g m e n t we acknowledge the help and guidance provided by mr hussain, incharge of animal house at national institute of health, islamabad during this project. r e f e r e n c e s 1. neven ac, laven j, teede hj, boyle ja. a summary on polycystic ovary syndrome: diagnostic criteria, prevalence, clinical manifestations, and managemen t according to the latest international guidelines. semin reprod med. 2018; 36(1): 5 -12. doi: 10.1055/s-00381668085. 2. qiao j, feng hl. extra-and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence. hum reprod. 2011; 17(1): 17 -33. doi: 10.1093/humupd/dmq032. 3. franks s, hardy k. what cause s anovulation in polycystic ovary syndrome? curr opinion endocr metab res. 2020; 12: 59-65. doi: 10.1016/j.coemr.2020.03.001 . 4. sirmans sm, pate ka. epidemiology, diagnosis, and management of polycystic ovary syndrome. clin epidemiol. 2013; 6: 1–13. doi: 10.2147/clep.s37559. 5. sam s, ehrmann da. metformin therapy for the reproductive and metabolic consequences of polycystic ovary syndrome. diabetologia. 2017; 60(9): 1656-61. doi: 10.1007/s00125-017-4306-3. 6. practice committee of the american society for reproductive medicine. role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (pcos): a guideline. fertil steril. 2017; 108(3): 426 -41. doi: 10.1016/j.fertnstert.2017.06.026 . 7. urbano j, fernandes ac, ferreira p, pimenta j. severe neuropsychiatric symptoms due to vitamin b12 deficiency: a case of pernicious anemia or metformi n use? galicia clinica. 2015;76(4):178 -80. 8. peerzade n,sayed n, das n. antimicrobial and phytochemical screening of methanolic fruit extract of withania coagulans l dunal for evaluating the antidiabetic activity. pharma innovation j. 2018; 7(1): 197-204. 9. upadhayay a, shalini s, kumari s, rahman mu. evaluation of antidiabetic activity of fruits of withahnia coagulans in streptozocin induced diabetic rats. j drug deliv ther. 2018; 8(2): 25 -8. 10. samad a, rajpoot nn, ayaz h, sadiq n. effect of withania coagulans and liraglutide on serum glp-1, postprandial and fasting blood glucose in streptozotocin induced diabetic rats. jbumdc. 2019: 120. 11. mclean, a. c., valenzuela, n., fai, s., bennett, s. a. l. performing vaginal lavage, crystal violet staining, and vaginal cytological evaluation for mouse estrous cycle staging identification. j vis exp. 2012; 67: e4389. doi: 10.3791/4389. 12. westwood fr. the female rat reproductive cycle: a practical histological guide to staging. toxicol pathol. 2008; 36(3): 375-84. doi: 10.1177/019262330 8315665. 13. gulinello m. behavioral core protocols and training. elevated plus maze. albert einstein college of medicine: behavioral core facility. 2016. 14. rajan rk, balaji b. soy isoflavones exert beneficial effects on letrozole-induced rat polycystic ovary syndrome (pcos) model through anti-androgenic mechanism. pharm biol. 2017; 55(1):242 -251. doi: 10.1080/13880209.2016.1258425. 15. jadhav m, menon s, shailajan s. anti-androgenic effect of symplocos racemosa roxb. against letrozole induced polycystic ovary using rat model. j coastal life med. 2013; 1(4): 309-14. doi: 10.12980/jclm.1.2013c79. 16. karimi jashni h, kargar jahromi h, bagheri z. the effect of palm pollen extract on polycystic ovary syndrome (pos) in rats. int j med res health sci. 2016; 5(5): 317-21. j islamabad med dental coll 2020 134 open access comparison of transosseous wiring and miniplates in management of mandibular parasymphyseal fractures mehreen razziq 1 , muhammad jamal 2 , irum mushtaq 3 , nadia 4 , laiba saher 5 1 dental surgeon, qazi hussain ahmad medical complex, nowshera, pakistan 2 assistant professor, oral and maxillofacial surgery, islamabad medical and dental college islamabad, pakistan 3 head, department of omfs, ayub medical college/ayub teaching hospital, abbotabad, pakistan 4 postgraduate resident, department of omfs, ayub medical college/ayub teaching hospital, abbotabad, pakistan 5 postgraduate resident, department of omfs, islamabad medical and dental college, pakistan a b s t r a c t background: mandibular fractures are the most common type of facial fractures in the adult population, accounting for 36%-59% of all maxillofacial injuries and their treatment is one of the most frequent forms of therapy provided by maxillofacial surgeons. the objective of the study was to compare the outcome of transosseous wiring and miniplates in the management of mandibular parasymphyseal fractures in terms of infection and malocclusion. material and methods: this randomized control trial was carried out at oral and maxillofacial department, ayub medical college/ ayub teaching hospital abbottabad. a total of 124 patients were randomly allocated into two groups by lottery method. patients in group a were subjected to transosseous wiring with maxilla-mandibular fixation. patients in group b underwent miniplate fixation method. post-operative wound infection and malocclusion findings at 6 weeks were recorded. results: frequency of post-operative infection and malocclusion at 6 weeks of surgery was slightly more but statistically non-significant in patients of group a undergoing transosseous wiring method as compared to group b patients experiencing miniplate technique. conclusions: miniplate osteosynthesis causes slightly less post-operative morbidity in terms of infection and malocclusion as compared to transosseous wiring for the management of mandibular parasymphyseal fractures. key words: infection, malocclusion, mandibular parasymphyseal fractures, miniplates, transosseous wiring authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; 4,5 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: mehreen razziq email: mehreenkamran@gmail.com article info: received: november 18, 2019 accepted: june 3, 2020 cite this article. razziq m, jamal m, mushtaq i, nadia, saher l. comparison of transosseous wiring and miniplates in management of mandibular parasymphyseal fractures. j islamabad med dental coll.2020; 9(2): 134-139. doi: 10.35787/jimdc.v9i2.393 funding source: nil conflict of interest: nil i n t r o d u c t i o n mandibular fractures are the most common type of facial fractures in the adult population, 1 accounting for 36%-59% of all maxillofacial injuries and their treatment is one of the most frequent forms of therapy provided by maxillofacial surgeons. 2 the major causes of mandibular fractures include motor vehicle accidents, altercations and falls. these fractures are designated as occurring in the condylar, ramus, angle, body, symphyseal, alveolar, and rarely coronoid process areas. 3 fractures at the level of the symphysis and/or parasymphysis are relatively common and account for approximately 20% of mandibular fractures. o r i g i n a l a r t i c l e j islamabad med dental coll 2020 135 these fractures are often associated with a second fracture of the mandible, especially in the subcondylar region. 4 the goals of mandibular fracture management include the restoration of the pre-existing anatomical form, functional occlusion and masticatory function with minimal disability and complications. 5 the management of mandibular fractures has evolved from a closed approach to a more direct, open approach with experience from orthopedic surgery, relying on direct, anatomical reduction and fixation of these fractures. 6 many clinicians advocate the use of maxillomandibular fixation (mmf) technique for the treatment of mandibular fractures due to their non-invasive nature, low financial burden on the patient, ease of availability of material required and ease of instrumentation. 7-9 others advocate the use of open reduction techniques using compression plates, transosseous wiring, lagscrews and miniplates. 10-12 currently rigid fixation with one or two miniplates has become a widely acceptable method of providing internal fixation and eliminating the need for post-operative maxillomandibular fixation. 12,13 the advantage of open reduction and internal fixation include early restoration of occlusal function and proper repositioning of fracture with more stable and predictable results. 14 complications associated with miniplates and transosseous wiring includes infection, malocclusion, mal-union, non-union, nerve damage and tmj-dysfunction. 15 of these complications, postoperative infection and malocclusion was 15% and 10% after transosseous wiring 13 and 1.5% and 0.2% after miniplate osteosynthesis, 16 respectively. the indications for the various types of rigid internal fixations have evolved over the years with newest technique offering more advantages than the older surgical methods, without major additional disadvantages. however, due to unavailability and unaffordability of hardware osteosynthesis by some patients, it is not used in some oro-facial injury treatment centers in the third world countries. this has compelled surgeons' practicing in these parts of the world to use the older surgical treatment methods such as transosseous wire osteosynthesis with inter-maxillary fixation for the treatment of these fractures. 10 the objective of this study was to compare the outcome of transosseous wiring and miniplates in the management of mandibular parasymphyseal fractures in terms of infection and malocclusion. m a t e r i a l a n d m e t h o d s this randomized control trial was carried out at oral and maxillofacial department, ayub medical college / ayub teaching hospital abbottabad from 2nd january, 2015 to 12th june, 2015. study was conducted after approval of ethical committee of ayub teaching hospital abbottabad. sample size of 124 cases was calculated (62 in each group) using who calculator with 80% power of test, 5 % level of significance and 10% expected percentage of malocclusion in transosseous wiring group 13 and 0.2% in miniplate group 16 for the management of mandibular parasymphyseal fractures. nonprobability purposive sampling was carried out to induct the patients. both male and female patients between 18-50 years of age, presenting within seven days of trauma were included in the study through outdoor and emergency department. they were diagnosed with isolated parasymphyseal fractures on the basis of clinical examination and radiographs (orthopantomogram). comminuted mandibular parasymphysis fractures, panfacial trauma, pathological fractures (tumor, cyst) and immunocompromised patients were excluded from the study because these conditions can introduce bias in the study results. the purpose and benefit of the study was explained to the patient and informed written consent was obtained. detailed j islamabad med dental coll 2020 136 history, clinical examination and routine preoperative investigations (opg and pa mandible) of patients were recorded. preoperative extra-oral and intra-oral pictures were taken with photographic recording of occlusion. the surgical procedure was carried out aseptically under general endotracheal anesthesia (geta) using nasotracheal intubation. prophylactic antibiotics and dexamathasone were given. after infiltration with 2% lignocaine (containing 1:100,000 epinephrine) and a waiting period of ten minutes, fracture segments were exposed, reduced and fixed through intraoral buccal vestibular incision, except those with pre-existing skin laceration. all patients were randomly allocated into two groups by lottery method. patients in group a were subjected to transosseous wiring with maxillamandibular fixation. patients in group b were underwent miniplate fixation method. miniplate of five-hole was adapted at the lower border, while four-hole miniplate was adapted at the upper border. screws of 2 mm diameter with 7 mm length were used. all the surgical procedures were performed by the principal investigator. postoperative radiographs were obtained before discharge. all the patients were discharged within 8-12 hours of the procedure, with antibiotics, analgesics and strict instructions regarding fluid diet and maintaining oral hygiene till notified further. patients were called for follow-up on the second, fourth and sixth week by the principal investigator. the outcome variables were malocclusion and infection. the successful outcome measures were described as successful bone healing and acceptable occlusion. post-operative wound infection and malocclusion findings at 6 weeks were recorded on a proforma based on combined clinical and radiographic analysis. the collected data was entered and analyzed through statistical package for social sciences (spss), version 10.0 (spss inc., chicago, il, usa). the qualitative variables including gender and postoperative complications i.e. infection and malocclusion were calculated as frequency and percentages. the quantitative data like age was computed as means and standard deviation. infection and malocclusion were stratified among age and sex to see the effect modification. the variables were compared through chi square test/fisher’s exact test. a p-value of ≤0.05 was considered statistically significant. r e s u l t s out of total 124 patients, ratio of male to female was 1.6:1 in group a and 1.5:1 in group b. mean age of patients in group a and b was 32±1.62 and 33±2.53 years respectively. maximum number of patients were from 21-40 years of age in both groups (table i). table i: baseline characteristics of participants (n=124) variables group a (n=62) n (%) group b (n=62) n (%) gender male 38 (62) 37 (60) female 24 (38) 25 (40) age (years) ≤20 11 (18) 10 (16) 21-30 19 (31) 21 (34) 31-40 21 (33) 22 (35) 41-50 11 (18) 9 (15) site of parasymphysis fracture right 34 (55) 32 (52) left 28 (45) 30 (48) frequency of post-operative infection and malocclusion at 6 weeks of surgery was slightly more but statistically non-significant in patients of group a as compared to group b patients (table ii). age and gender wise stratification also revealed non-significant difference in frequency of infection and malocclusion between group a and group b (table iii). j islamabad med dental coll 2020 137 table ii: comparison of outcome variables at six weeks of treatment (n=124) group group a (n=62) n (%) group b (n=62) n (%) p-value* infection yes 2 (3) 1 (1) 0.56 no 60 (97) 61 (99) malocclusion yes 2 (3) 0 (0) 0.15 no 60 (97) 62 (100) *p-value ≤0.05 was considered statistically significant table iii: comparison of outcome variables after age and gender stratification at six weeks of treatment (n=124) variables infection mal-occlusion age (years) group a (n=62) group b (n=62) p-value* group a (n=62) group b (n=62) p-value* ≤20 yes 0 0 1.00 0 0 1.00 no 11 10 11 10 21-30 yes 0 0 1.00 0 0 1.00 no 19 21 19 21 31-40 yes 1 1 1.00 1 0 1.00 no 20 21 20 22 4150 yes 1 0 1.00 1 0 1.00 no 10 9 10 9 gender male present 1 0 1.00 1 0 1.00 not present 37 37 37 37 female present 1 1 1.00 1 0 1.00 not present 23 24 23 25 *p-value ≤0.05 was considered statistically significant d i s c u s s i o n the present study shows that most of the enrolled patients with parasymphysis fractures in both groups were of younger age group and predominantly of male gender. the predominant male numbers could be explained by the simple fact that men mostly work outside, hence their chances of involvement in assault, road traffic accidents, activities leading to falls, sport injuries etc. is relatively higher resulting in fractures. due to the socio-religious nature of this region, females are less active in outdoor activities and therefore, significantly lower ratio of fractures is seen. both infection and malocclusion as post-operative complications were comparatively more frequent in patients undergoing transosseous wiring as compared to miniplates technique. similar results were observed in other studies. post-operative infection and malocclusion after transosseous wiring was 15% and 10% respectively in a study carried at armed forces institute of dentistry, rawalpindi, pakistan 12 and 1.5% and 0.2%, respectively after miniplate osteosynthesis in centre hospitalier universitaire vaudois, switzerland. 15 this can be because of non-rigid fixation of transosseous wiring which does not provide sufficient inter-fragmentary stability during healing. it only serves the purpose of realignment of parts of the fractured bone segments and prevents their displacement by the muscles of mastication. j islamabad med dental coll 2020 138 different studies have been carried out comparing the traditional methods of treatment with newer techniques. theriot et al. compared compression plates, miniplates and transosseous wiring osteosynthesis. 17 similarly, renton and wiesenfeld compared miniplates with transosseous wiring osteosynthesis. 18 all of these researchers have supported the rigid internal fixation as the treatment of choice. on the other hand, moulton et al. found the traditional techniques superior to the newer techniques with regards to occurrence of postoperative complications. 19 in the current study, the results show differences between frequency of complications in both the procedures. although the comparison is clinically significant but statistically insignificant due to a small number of patients for comparison in each group as well as lesser number of patients with complications. our results regarding postoperative infection are comparable with that of international data. as according to moreno et al., infection rates for mmf and plating were 4.4 % and 12.5 % respectively. 20 similarly renton and wiesenfeld have also provided nearly the same data for tow (10 %) and plating (15 %). 18 higher infection rates for both groups were most probably due to the direct intraoral contamination of the fracture site from the intraoral incision. other factors like type of fracture, kind of treatment used, timing of treatment, oral hygiene, presence of tooth in the line of fracture, osteosynthesis material as a foreign body, mobility of the fracture site, etc., may also be involved. infected patients were treated with broad-spectrum antibiotics. the second most common complication in our study was post-surgical malocclusion. our results are more or less similar to those reported by renton and wiesenfeld 18 and moreno et al. 20 (mmf=2.9 % and 8.3% for other groups). the presence of post-surgical malocclusion depends on the patient’s dental condition, the number of fractures and their displacement, the reduction that can be achieved, the kind and time of immobilization. no doubt rigidity of the osteosynthesis material is an advantage because it allows for immediate jaw mobility, but it can also be a drawback, if it prevents correction of a postoperative malocclusion with mmf. 20 renton and wiesenfeld reported mmf in all the three groups but in the plating group mmf was done on a temporary basis for a shorter duration. the malocclusion noted was minimal and was treated easily by corrective occlusal adjustment. delayed union was defined as excessive mobility of the fracture site three to four weeks posttreatment. this occurred in 5% of the total patients. in mmf group, delayed union occurred in two patients (10%), in tow group one patient (5%) while none of the plating group faced this complication. our findings regarding delayed union are similar to those reported by renton and wiesenfeld. 18 none of the patients included in this study required further surgical intervention and progressed to normal union by only prolonging the period of mmf. non-union means that the fracture is nonhealing and will not unite on its own. radiographs show rounding off and sclerosis of the bone ends called eburnation. fortunately, none of our patients faced this complication. c o n c l u s i o n post-operative complications like infection and malocclusion are slightly less in miniplate group as compared to transosseous wiring in the management of mandibular parasymphyseal fractures. although there were relatively more complications in the transosseous wiring group, the use of trans-osseous wire osteosynthesis still gave considerably good results. this method can still be j islamabad med dental coll 2020 139 useful in centers that are less well equipped, and where access to rigid internal fixation is limited. r e f e r e n c e s 1. naeem a, gemal h, reed d. imaging in traumatic mandibular fractures. quant imaging med surg. 2017; 7(4): 469-79. doi: 10.21037/qims.2017.08.06 2. ghanem aw, elhayes ak, saad k. the management of unstable oblique infected mandibular fractures with a 2.3 mm mandibular osteosynthesis reconstruction bone plate. j craniomaxillofac surg. 2011: 39(8): 600-5. doi: 10.1016/j.jcms.2010.12.002. 3. cosimo n, chiara v, michele p, paolina t, calistri l, franchi l, et al. imaging of mandibular fractures: a pictorial review. insights imaging. 2020; 11: 2-15. doi:10.1186/s13244-020-0837-0 4. farwell gd. management of symphyseal and parasymphyseal mandibular fractures. oper tech otolaryngol. 2008; 19(2): 108-12 5. saad ka, nowair im, esa ef. three dimensional miniplate fixation in the management of mandibular fractures. eygpt dent j. 2017; 66: 241-48. doi: 10.1016/j.otot.2008.06.001 6. rahman p, aslam a, yunus m, luqman u, saleem mm, mughal j, et al. optimal and efficient management of mandibular fractures. pak oral dent j. 2015; 35(2): 198-203. 7. shetty v, atchison k, leathers r, black e, zigler c, belin tr. do the benefits of rigid internal fixation of mandibular fractures justify the added costs? results from a randomized controlled trial. j oral maxillofac surg. 2008; 66(11): 2203-12. doi:10.1016/j.joms.2008.06.058 8. qureshi aa, reddy uk, warad nm, badal s, jamadar aa, qurishi n. intermaxillary fixation screws versus erich arch bars in mandibular fractures: a comparative study and review of literature. ann maxillofac surg. 2016; 6(1): 25-30. doi: 10.4103/2231-0746.186129 9. ingole pd, garg a, shenoi sr, badjate sj, budhraja n. comparison of intermaxillary fixation screw versus eyelet interdental wiring for intermaxillary fixation in minimally displaced mandibular fracture: a randomized clinical study. j oral maxillofac surg. 2014; 72: 958e1-e7. doi: 10.1016/j.joms.2014.01.005 10. anyanechi ce, osunde od, saheeb bd. complications of the use of trans-osseous wire osteosynthesis in the management of compound, unfavorable and non-comminuted mandibular angle fractures. ghana med j. 2016; 50(3): 172-9. pmid: 27752192 11. khitab u, tariq m. outcome of rigid internal fixation of mandibular fractures: a prospective study. pak oral dent j. 2009; 29: 207-11. 12. amin m, babar a, ibrahim mw, awan mua. postoperative complications in mandibular fracture management comparison of three different treatment modalities. pak armed forces med j. 2016; 66(5): 720-25. 13. rahim a, waraich a. mandible fractures osteosynthesis: a comparison of three techniques. pak oral dent j. 2009; 29(2): 207-11. 14. kumar bp, kumar kj, venkatesh v, mohan ap, ramesh k, mallikarjun k. study of efficacy and the comparison between 2.0 mm locking plating system and 2.0 mm standard plating system in mandibular fractures. j maxillofac oral surg. 2015; 14: 799-807. doi: 10.1007/s12663-014-0718-5 15. jaques b, richter m, arza a. treatment of mandibular fractures with rigid osteosynthesis: using the ao system. j oral maxillofac surg. 1997; 55(12): 1402-6. doi: 10.1016/s0278-2391(97)906376 16. seemann r, lauer g, poeschl pw, schicho k, pirklbauer m, r russmüller g, et al. crooma, complication rates of operatively treated mandibular factures,paramedian and body. oral surg oral med oral pathol oral radiol endod. 2011; 111: 449-54. doi:10.1016/j.tripleo.2010.06.008 17. theriot ba, van sickels je, triplett rg, nishioka gj. intraosseous wire fixation versus rigid osseous fixation of mandibular fractures: a preliminary report. j oral maxillofac surg. 1987; 45(7): 577-82. doi: 10.1016/0278-2391(87)90267-9 18. renton tf, wiesenfeld d. mandibular fractures osteosynthesis: a comparison of three techniques. br j oral maxillofac surg. 1996; 34(2): 166-73. doi: 10.1016/s0266-4356(96)90372-1 19. moulton br, rubinstein aj, salzhauer ma, brown m, angulo j, alster c, et al. complications of mandibular fractures. ann plast surg. 1998; 41(3): 258-63. doi: 10.1097/00000637-199809000-00006 20. moreno jc, fernandez a, ortiz ja, montalvo jj. complication rates associated with different treatments for mandibular fractures. j oral maxillofac surg. 2000; 58(3): 273-81. doi: 10.1016/s0278-2391(00)90051-x out of total 124 patients, ratio of male to female was 1.6:1 in group a and 1.5:1 in group b. mean age of patients in group a and b was 32±1.62 and 33±2.53 years respectively. maximum number of patients were from 21-40 years of age in both groups (ta... frequency of post-operative infection and malocclusion at 6 weeks of surgery was slightly more but statistically non-significant in patients of group a as compared to group b patients (table ii). the present study shows that most of the enrolled patients with parasymphysis fractures in both groups were of younger age group and predominantly of male gender. the predominant male numbers could be explained by the simple fact that men mostly work ... both infection and malocclusion as post-operative complications were comparatively more frequent in patients undergoing transosseous wiring as compared to miniplates technique. similar results were observed in other studies. post-operative infection a... j islamabad med dental coll 2019 171 ope n ac cess superficial parotidectomy by retrograde approach through marginal mandibular nerve dissection altaf hussain1, alveena farid2, waqar uddin3 1 associate professor, department of ent/head and neck surgery, pakistan institute of medical science s, islamabad, pakistan 2 post graduate resident, department of ent/head and neck surgery, pakistan institute of medical sciences , islamabad, pakistan 3 associate professor, department of ent, naseer teaching hospital, peshawar, pakistan a b s t r a c t background: parotid gland is most commonly involved in tumors, comprising about 80% of the salivary gland neoplasms. majority of parotid tumors are benign in nature, the most common being pleomorphic adenoma. superficial parotidectomy is the preferred treatment option, using either anterograde or retrograde approach. the objective of this study was to determine the post-operative facial nerve status and other complications following superficial parotidectomy by retrograde dissection for benign lesions of parotid gland. material and methods: this prospective clinical study included a total of 22 patients who had superficial parotidectomy by retrograde technique involving marginal mandibular nerve dissection. these patients were studied post-operatively for facial nerve status, frey’s syndrome, wound infection and salivary fistula. results: out of a total of 22 patients, 54.54% developed temporary facial palsy on ipsilateral angle of mouth and all of them recovered by the end of 3 months post-surgery. two patients (9.09%) developed salivary gland fistula and both of them healed spontaneously within two weeks. frey’s syndrome and wound infection were not seen in any of the patients included in the study. histopathology of these lesions revealed pleomorphic adenoma (n=20) and warthin’s tumor (n=2), respectively. conclusion: the use of marginal mandibular nerve as a landmark for retrograde dissection of facial nerve in superficial parotidectomy is a reliable method to ensure lower percentage of facial nerve injury and associated complications. key words: facial nerve, marginal mandibular nerve, retrograde approach, superficial parotidectomy authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3, active participations in data collection data analysis. correspondence: alveena farid email: alveenafarid@hotmail.com article info: received: october 6, 2019 accepted: december 7, 2019 cite this article. hussain a, farid a, waqar uddin. superficial parotidectomy by retrograde approach through marginal mandibular nerve dissection. j islamabad med dental coll.2019; 8(4): 171-175. doi: 10.35787/jimdc.v8i4.431 funding source: nil conflict of interest: nil i n t r o d u c t i o n salivary gland tumors are generally rare head and neck tumors, representing less than 2% of all.1 of these tumors, the most commonly involved salivary gland is the parotid.2 parotid gland tumors may present in a vast variety of histological subtypes that have entirely different clinical behavior with majority of these tumors originating in the superficial lobe and are benign in nature. in the benign neoplasms, pleomorphic adenoma has the highest incidence, comprising about 80% of the salivary gland tumors.3 they are slow growing, painless tumors4 and are commonly seen in female patients 30-50 years o f age. pre-operative work up of patients for pleomorphic adenoma of parotid gland involves a thorough history followed by complete clinical examination. fine needle aspiration cytology (fnac) of parotid gland and a ct scan showing the extent of tumor, whether involving only the superficial lobe or deep lobe, or both are preferred investigations performed for these lesions. the involvement of facial nerve and any consequent paralysis, or i gi n a l a r ti c le j islamabad med dental coll 2019 172 both on clinical and radiological grounds is the most serious complication after a parotid gland surgery,4 and strongly suggests the presence of underlying malignant disease. treatment option for pleomorphic adenoma is purely surgical (i.e. parotidectomy). it is a fairly common, well standardized procedure for parotid tumors, whether benign or malignant. superficial parotidectomy is a more common surgery than total parotidectomy. total or subtotal conservative parotidectomy is most commonly carried out, with minimal morbidity, for benign conditions of parotid while more radical procedures are used consistently for high-grade malignancies.5 lately, a trend towards conservative surgical approach for benign parotid tumors have been observed. ease in perioperative facial nerve monitoring due to technological improvement has led to increased use of retrograde approach to facial nerve dissection in benign parotid tumor surgery.6 facial nerve status is the main pivoting factor in concluding a successful parotid surgery. the main aim is to avoid any damage to facial nerve that may cause faci a l disability.7 it supplies the muscles of facial expression and holds an important position in post-operative tenure as facial paralysis poses a deep anatomical, functional, and psychological impact on the welfare of patient. parotid gland has a very intimate relationship with the terminal branches of facial nerve, the later passing between the superficial and deep lobes of the gland.8 this close proximity is the deciding factor for a successful parotidectomy, since the most crucial series of steps in surgery involves identifying the facial nerve, protecting it from iatrogenic trauma and finally preserving it at the end of tumor removal.8 the other known complications after superficial parotidectomy include frey’s syndrome, salivary fistula, and wound infection.9 there are two principal approaches to identify and dissect the facial nerve.10 firstly, the more commonly used technique is anterograde dissection where the main tru n k of nerve is identified first and it is traced to its division into terminal branches.11 secondly, the less explored technique is the retrograde approach where one of the terminal branches is singled out and dissected back to its main trunk. in the past, antegrade approach was used entirely but with time, many surgeons in west have started practicing retrograde approach. however, in pakistan, no such studies have been conducted so far, making acquisition of such data on local population impossible. the objective of this study was to determine the postoperative facial nerve status as well as other complications with a three-month follow-up, after superficial parotidectomy by retrograde dissection for benign lesions of parotid gland. m a t e r i a l a n d m e t h o d s this prospective clinical study comprised of all the patients who had parotid gland neoplasms, and went through superficial parotidectomy at the department of ent/head and neck surgery in pakistan institute of medical sciences (pims), pakistan from january 2015 till december 2018. ethical approval was taken from ethics review board prior to the commencement of the study. non probability consecutive sampling technique was used for sample collection over a period of 4 years. all the patients were counselled about the details of their condition, proposed procedure and its complications, a n d informed consent was taken from each of the patient before registering them for the study. a total of 22 patients who underwent retrograde parotidectomy were included. all the patients gave detailed history, went through thorough clinical examinations and radiological investigations. patients with previous history of surgery and recurrences, malignant and metastatic lesions and pre-operative facial paralysis were excluded from the study. the retrograde approach was used which involved identification of the marginal mandibular nerve followed by dissection in a retrograde manner to find and preserve main trunk of facial nerve. all the specimens were sent fo r histopathology to ensure the benign nature of the lesion. the variables studied were facial nerve palsy, temporary and permanent, and the time taken by the patient to recover from any facial weakness (if facial nerve was damaged). j islamabad med dental coll 2019 173 r e s u l t s of the total 22 patients, 12 (54.54% ) were males and 10 (45.45% ) were females. the age of patients age of patients was years 17-66 and with mean age of 37.5 + 14.09. male patients included in this study had the age of patients was years 17-66 and with a mean of 34.41 while female patients rage of patients was years 28-51 with mean of 41.1 + 7.89. time taken for surgery ranged between 50 and 160 minutes. in post-operative patients, complications such as facial nerve weakness, frey’s syndrome, wound infection and salivary fistula were studied. of the total 22 patients, 12 patients exhibited facial nerve weaknes. among the 12 patients that experienced facial palsy, 9 (75% ) had slight weakness at the angle of mouth by the end of first week post-surgery, 3 (25% ) had persistent facial weakness at ipsilateral angle of mouth on one month follow up and by the end of three month, all of the patients had recovered completely. only two patients (9. 09% ) developed salivary gland fistula which healed spontaneously. (table i). table i: post-operative complications and three-month followup after superficial parotidectomy complications no. of patients n (%) follow up n (%) 1 2 3 4 facial nerve weakness 12 (54.54%) 9 (75%) -3 (25%) nil frey’s syndrome nil ---- wound infection nil ---- salivary fistula 2 (9.09%) 2 (9.09%) nil nil nil 1-first week, 2-second week, 3-first month, 4-third month other complications (frey’s syndrome and wound infection) were not seen in any of the patients in the study. all the specimens retrieved during surgery were sent for histopathology and were reported to be pleomorphic adenoma (n=20) and warthin’s tumor (n=2). d i s c u s s i o n a very small proportion of head and neck tumors (2-10 % ) constitutes salivary gland neoplasms. more than 80% of all salivary gland tumors are located in the parotid gland and roughly 80% of them are benign in nature.1 this study comprised of 22 patients of benign tumors of parotid gland, who underwent superficial parotidectomy by retrograde approach at the department of ent/head a n d neck surgery, pims islamabad. all the patients who underwent the surgery had their marginal mandibular nerve identified first and that was traced back to the main trunk of facial nerve. superficial parotidectomy is the surgery of choice in majority of these cases. facial nerve preservation is crucial to warrant a successful surgery. the successful identification and preservation of facial nerve can be done by two methods of dissection, anterograde and retrograde.4 in anterograde dissection, facial nerve is pinpointed as it comes out of stylomastoid foramen by identifying tragal pointer, posterior belly of digastric or tympanomastoid suture. the retrograde approach comprises of identifying one of the peripheral branches of facial nerve (i.e. marginal mandibular or buccal branch) and tracing it back to the main trunk. it has been observed that retrograde dissection guarantees a much higher rate of facial nerve preservation, lesser time to identify and reach facial nerve and overall lower incidence of complications.8 the marginal mandibular nerve is nearly the same thickness as the main trunk of facial nerve is a resilient nerve. one of the reasons for post-operative weakness of this nerve is the extent of exposure. this branch is exposed in its entirety and is manipulated throughout the surgery that can lead to temporary facial weakness at the angle of mouth. the retrograde approach is a preferred technique due to wider field of vision as compared to anterograde approach which has a very narrow field of vision to identify the mai n trunk of facial nerve. the former approach also does not require retraction of the surgical field to identify the landmarks for identification which are deeply buried in th e tissue planes. the incidence of bleeding in retrograde approach is much less and landmarks for marginal mandibular nerve identification are considerably superficial.9 o’ regan et al studied 138 patients undergoing retrograde superficial parotidectomy and reported that 66% of the patients exhibited facial weakness for the first week and 38% had it for the first month. but by the end of j islamabad med dental coll 2019 174 first six months, 99% of the patients had fully recovered.12 these results are comparable with our study that show e d a similar, if not identical pattern, where 40.9% patients showed facial weakness at first week and this percentag e reduced to 22.7% by the end of first month post-surgery. on three months follow up, all the patients with facial weakness had recovered completely. patel et al concluded in their study that retrograde dissection in superficial parotidectomy had an overall lower percentage of facial nerve damage and better tumor removal regardless of tumor size.13 this was in harmony with the results of our study as tumor was exposed sufficiently and removed completely. the facial nerve weakness too w a s limited only to the marginal mandibular branch in all the effected patients. it was reversible and for a short period of time. furusaka et al also demonstrated that retrograde parotidectomy is associated with lesser number of facial nerve paralysis, surgical time, blood loss when compa re d with anterograde parotidectomy.14 in addition to facial nerve weakness as a post-operative complication, only one other complication was seen in 2 (9.09% ) of our patients i.e., salivary gland fistula. these patients were managed with regular aseptic dressings with frequent follow-up assessment. both these patients exhibited resolution of fistula within two weeks by just daily dressings and reported no other complaints. in our study, the total number of operative times ranged between 50 and 160 minutes. the earlier attempts generally required more time due to lack of skill building and a relatively newer approach used in surgery. the time also depended on the size of tumor and its extent where large and more infiltrating tumors required more time for removal as compared to smaller and limited ones. in a study conducted by scarpini et al, it was seen that retrograde technique permitted a more conservative approach although the complication rates were almost the same.15 all of the above-mentioned studies were taken into account and their results were compared to our stu d y which showed that retrograde approach for parotidectomy is a more reliable method to ascertain the post-operative integrity of facial nerve. c o n c l u s i o n our study demonstrated that use of retrograde approach for marginal mandibular nerve in superficial parotidectomy in benign lesions of parotid gland is associated with low e r percentage of facial nerve injury and other complicatio n s. furthermore, it is also associated with less operative ti me and adequate removal of tumor. r e f e r e n c e s 1. korba m, chloupek a, dąbrowski j, piętka t, domański w, biernacka b et al. pleomorphic adenoma the results of a retrospective analysis of 104 patients treated at the clinical department of cranio-maxillofacial surgery, clinic of otolaryngology and laryngologic oncology of the military institute of medicine. otolaryngol pol. 2017; 71(4): 34-6. doi: 10.5604/01.3001.0010.2246 2. tarsitano a, pizzigallo a, giorgini f, marchetti c. giant pleomorphic adenoma of the parotid gland: an unusual case presentation and literature review. acta otorhinolaryngol ital. 2015; 35(4): 293–96. pmid: 26824218 3. jain s, hasan s, vyas n, shah n, dalal s. pleomorphic adenoma of the parotid gland: report of a case with review of literature. ethiop j health sci. 2015; 25(2): 189–194. doi:10.4314/ejhs.v25i2.13. 4. bittar rf, ferraro hp, ribas mh, lehn cn. facial paralysis after superficial parotidectomy: analysis of possible predictors of this complication. braz j otorhinolaryngol. 2016; 82(4): 447-51. doi: 10.1016/j.bjorl.2015.08.024 5. wood je, weiland lh, chong gc iron gb. pathology and surgery of primary tumors of the parotid. surg clin north am. 1977; 57(3): 565-73. doi: 10.1016/s0039-6109(16)41238-7 6. mantsopoulos k, koch m, klintworth n, zenk j, iro h. evolution and changing trends in surgery for benign parotid tumors. the laryngoscope. 2014; 125(1): 12227. doi: 10.1002/lary.24837 7. emodi o, el-naaj ia, gordin a, akrish s, peled m. superficial parotidectomy versus retrograde partial superficial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma). j oral maxillofac surg. 2010; 68(9): 2092-8. doi: 10.1016/j.joms.2009.09.075 j islamabad med dental coll 2019 175 8. adeyemo wl, taiwo oa, somefun oa, olasoji ho, ndukwe kc, fashina aa et al. a survey of facial nerve dissection techniques in benign parotid surgery among maxillofacial and ear, nose, and throat surgeons in nigeria. niger j clin pract 2011; 14(1): 83-7. doi: 10.4103/1119-3077.79272 9. kligerman mp, song y, schoppy d, divi v, megwalu uc, haughey bh, sirjani d. retrograde parotidectomy and facial nerve outcomes: a case series of 44 patients. am j otolaryngol. 2017; 38(5): 533-36. doi: 10.1016/j.amjoto.2017.05.00 10. gurung, n., shrestha, d., acharya, a., gurung, a., shrestha, s., poudel, s., et al. superficial parotidectomy by retrograde facial nerve dissection. journal of gandaki medical collegenepal. 2017; 10(1): 25-7. 10.3126/jgmcn.v10i1.17909 11. mashrah ma, al-dhohrah ta, al-zubeiry fa, yan l, al-hamed fs, zhao x et al. antegrade versus retrograde facial nerve dissection in benign parotid surgery: is there a difference in postoperative outcomes? a meta-analysis. plos one. 2018; 13(10): e0206028. doi: 10.1371/journal.pone.0206028 12. o’ regan b, bharadwaj g, bhopal s, cook v. facial nerve morbidity after retrograde nerve dissection in parotid surgery for benign disease: a 10-year prospective observational study. br j oral maxillofac surg. 2007; 45(2): 101-7. doi: 10.1016/j.bjoms.2006.03.009 13. patel dk, ahmad z, mortan rp. partial superficial parotidectomy with retrograde dissection of the facial nerve for clinically benign parotid tumors. ann of otology, rhinology & laryngology. 2016; 125(10): 808–14. doi: 10.1177/000348941665535 14. furusaka t, tanaka a, matsuda h, hasegawa h, asakawa t, shigihara s. cervical branch of the facial nerve approach for retrograde parotidectomy compared with anterograde parotidectomy. acta otolaryngologica. 2014; 134(11): 1192-97. doi: 10.3109/00016489.2014.900701. 15. scarpini m, amore bonapasta s, ruperto m, vestri a, bononi m, caporale a. retrograde parotidectomy for pleomorphic adenoma of the parotid gland: a conservative and effective approach. j craniofac surg. 2009; 20(3): 967-9. doi: 10.1097/scs.0b013e3181a86ead summary journal of islamabad medical & dental college (jimdc); 2016:5(3):100-103 100 original article frequency of hepatitis c and hepatitis b infection in a tertiary care hospital saba irfan1, rubina kamran2, ashok kumar tanwani3, zaha iqbal malik4, ahmareen khalid5 and azka fatima6 1 & 4 medical student, federal medical & dental college, islamabad 2 assistant professor of microbiology, department of pathology, pims, islamabad 3 professor and head, department of pathology, pims, islamabad 5 assistant professor, department of pathology, szabmu, pims, islamabad 6 post graduate resident, department of pathology, pims, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) abstract objective: to determine the frequency of hcv and hbv in patients referred for screening at zulfiqar ali bhutto medical university, pims, islamabad. material and methods: this retrospective study was conducted at the pathology department of shaheed zulfiqar ali bhutto medical university, pims, islamabad over duration of 3 months (from 1 st january, 2014 to 31 st december 2014). the data was analyzed with, microsoft excel 2010. results: total of 28319 (17040 + 11279) serum samples were tested by elisa for hcv antibody and hbv antigen respectively. among the positive samples, 3427 (12.1%) samples were found positive for hcv antibodies, while 843 (7.5%) were positive for hbv antigen. however, the number of samples testing positive for both hbv and hcv out of the total sample size of 28319 were 143 (0.5%). conclusion: hcv has a higher seropositivity, being more prevalent in females, effecting mostly patients between the ages of 36 years to 46 years compared to hbv that has a lower seropositivity, effecting mostly females with highest number of samples recorded between the ages of 25 years to 35 years. however, it should be kept in mind that these are patients and not healthy donors/ or population. key words: coinfection, enzyme-linked immunosorbent assay, hepatitis b, hepatitis c, liver damage. introduction world health organization (who) estimates that there are 350 million people with chronic hepatitis b (hbv) infection and 170 million people with chronic hepatitis c (hcv) infection worldwide. 1 hepatitis b is estimated to result in 563 000 deaths and hepatitis c in 366000 deaths annually. pakistan is amongst the worst afflicted nations. pakistan carries one of the world’s highest burden of chronic hepatitis and mortality due to liver failure and hepatocellular carcinomas. 2 in a recent note who has rated pakistan as a 2 nd country having high rate of chronic hepatic infection in the world. according to a national survey conducted in pakistan on the general population by pakistan medical research council in 2007-2008, the seroprevalence of anti hcv and hbsag was 4.8% and 2.5%, respectively suggesting a total chronic carrier population of hepatitis b and c of about 13 million. 1,3 hbv and hcv are blood borne hepatotropic viruses leading to significant morbidity and mortality worldwide. hbv is a member of hepadnaviridae family, harboring a dna genome, while hcv is rna virus that belongs to flaviviridae family. hcv infection results in number of complications including cirrhosis and hepatocellular carcinoma. hcv-related end stage liver disease is one of the leading reasons for liver transplantation today. 2 hepatitis c virus (hcv) is the major cause of parenterally transmitted non-a non-b hepatitis. about 15% of patients recover or have a benign outcome while the rest develop a chronic infectious state, out of these 20% patients will develop liver cirrhosis over a period of 10-20 years and will succumb their life to it in the absence of liver transplantation. one to five percent develop hepatocellular carcinoma. even in the asymptomatic carrier, a compromise in the quality of life has been reported. 4 hepatitis b is also potentially life-threatening liver infection. both, the whole, intact virion as well as the incomplete virus particles, consist entirely of hbsag and are produced during replication of hbv as the infected hepatocytes reproduce. it can cause chronic liver disease and chronic infection and puts the people at high risk of death from cirrhosis of the liver and liver cancer. about 90-95% of the patients contracting hepatitis b virus recover on their own due to corresponding author: dr. rubina kamran drrubinakamran@gmail.com received: may 6 th 2016; accepted: august 10 th 2016 http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index7.html#c mailto:drrubinakamran@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):100-103 101 their strong immune system, in 0.5% cases hepatitis ensues to a fulminant form and death of the patient occurs while the remaining patients tend to have a persistent infection, or become asymptomatic carriers, developing chronic persistent hepatitis, out of these 1-2% patients clear the virus while the remaining eventually develop chronic, active hepatitis leading to cirrhosis and hepatocellular carcinoma. 4 intra-familial spread, horizontal transmission of hepatitis b is quite high. hepatitis b is an important occupational hazard for health workers. 4 hcv infection is diagnosed through detection of hcv antibodies (anti hcv) that is produced when a person is infected with hcv. anti-hcv can be detected with a less sensitive method i.e. immuno chromatography (ict) and a more sensitive and specific test enzyme linked immunosorbant assay (elisa). elisa is used as the most reliable screening test. viral genome is detected in blood through pcr. during window period of one and half months anti-hcv test may be negative. due to the presence of hcv and hbv associated liver diseases and the development of effective treatments, the diagnosis of the two infections is a growing medical need. 5 purpose of this study is to estimate the frequency of hcv and hbv at shaheed zulfiqar ali bhutto medical university, pims islamabad. pims being a tertiary care hospital receives multiple referred cases from areas adjacent to islamabad. these figures and findings will be helpful for health policy makers, blood banks and national prevention and surveillance program for further research and investigations. materials and methods this cross sectional study was conducted at the pathology department of shaheed zulfiqar ali bhutto medical university, pakistan institute of medical sciences (pims), islamabad over a period one year (from 1 st january, 2014 to 31 st december, 2014). all the samples received in microbiology lab for screening of hepatitis b and c were included in the study. these samples were collected under standard procedures. the samples were collected in gel tubes and hbsag and anti-hcv were detected by 3 rd generation and 4 th generation kits respectively (bio kit, spain) on semi-automated elisa system best 2000. (bio. kit, spain) data variables included age, gender, and co infection of hcv and hbv. duplicate and follow-up samples were excluded. the data was analyzed with, microsoft excel 2010. results a total of 28,319 (17040 + 11279) serum samples were tested by elisa for hcv antibody and hbv antigens, respectively. among the positive samples, 3427 (12.1%) samples were found positive for hcv antibodies, while 843 (7.5%) were positive for hbv antigen. the number of samples positive for both hbv and hcv were 143 (0.5%). out of the total hcv positive samples, 1742 (50.8%) were of females while 1685 (49.0%) were of males, male to female ratio being 0.9:1.0. and out of the total hbv positive samples, 424 (51%) samples were of females while 419 (49%) were of males, male to female ratio being 0.9:1.0. however, out of the total number of samples that showed co infection, 58 samples were of females while 87 samples were of male. male to female ratio being 1.5:1. age group yielding the highest number of positive hbv ag results ranged from 25 years to 35 years while the lowest positive age group was below 14 years of age. (table 2, and figure 1). table 1: gender distribution of patients testing positive for hcv (n=3247), hbv (n=843), and co infection (n=143) gender males (n%) females (n%) hcv positive 1685 (49.0%) 1742 (51.0%) hbv ag positive 419 (49%) 424 (51%) co infection 87 (60%) 58 (40%) table 2: age distribution of positive cases (n=4270) age group (in years) hcv positive (n=3427) hbv positive (843) < 14 44 (1.3%) 14(1.7%) 14 to 24 266(7.7%) 192(22.8%) 25 35 880(25.6%) 245(29.1%) 36 46 978(28.5%) 189(22.4%) 47 57 687(20.0%) 119(14.1%) 58 68 403(11.8%) 78(9.3%) > 69 and above 155(4.5%) 24(2.8%) 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% h cv h bv age in years figure 1: age distribution of patients tested for hcv (n=3247) and hbv infections (n=843). journal of islamabad medical & dental college (jimdc); 2016:5(3):100-103 102 table 3: frequency of anti hcv on different population sample author’s name place population percentage nafees et al 8 faislabad visiting hospital 17.77% tareen et al 9 quetta blood donors 20.8% ali et al 10 mansehra general 10.3% ali et al 10 shamdhra general 11% khattak et al 11 d.i.khan visiting opd 6.54% discussion hepatitis b and c are a worldwide health hazard. multiple studies have been conducted for estimation of seroprevalence of hbsag and hcv antibodies targeting different populations of pakistan. results of the present study show the high rates of seroprevalence of hcv & hbv amongst the hospital based population of islamabad. according to this study, the percentage of hcv antibodies is much higher than the hbsag. abdul basit et al 2014 reported results consistent with our study, with lower prevalence of hbsag than hcv antibodies. 6 out of the total serum samples tested 12.1% were positive for hcv antibody, 7.5% were positive for hbv antigen while 0.50% patients tested positive for both, hbv and hcv. atif g. et al in 2009 reported 10.4% prevalence of hcv antibodies and basit a. et al in 2014 reported 0.7% co infection amongst the patients visiting pims, islamabad. 6,7 these results are similar to the present study. according to different studies conducted throughout pakistan, on different population groups the prevalence of anti hcv is between 6.54% to 17.7% as evident from the table 3 below. unlike our study where samples were either from in patient or out-patient departments of pims, having a relatively higher number of patients with deranged liver profile tests, transplant patients, patients on hemodialysis, hiv patients or higher number of drug abusers, hence, showing a relatively higher prevalence percentage compared to the subjects employed from the general population that participated in most of the studies mentioned in table above. there has been a lot of variation in the seroprevalence of anti hcv worldwide ranging 0.47% in nepal 12 to 13.9% in egypt 13 amongst general population. the prevalence of hcv as recorded in this study was higher in females, 51.0% compared to males, 49.0%. high rate of hcv seropositivity in our study is due to type of samples (i.e. from patients and not the general population) and is thought to be chiefly due to exposure during major and /or minor surgical procedures due to usage of improperly sterilized surgical equipment. 14 the highest hcv seropositivity recorded amongst the patients between the ages 36 46yrs. (28.5%) and the lowest being amongst patients below the age of 14 years (1.3%). unsafe injecting practices, intravenous drug abuse, high number of dental procedures, endoscopy, major and minor operation and unsafe sexual practices, all have a contributory effect on the overall seroprevalence of hcv especially in ages between 36 years to 46 years. the global prevalence of hbv infection varies widely; and its endemicity ranges from high (≥8%) to intermediate (27%) and low (<2%). 15 according to different studies, the seroprevalence hbsag (by elisa) of patients visiting different health facilities within islamabad is between 3.9% to 15% 6,16. this is compliant with the result of this study. according to a research conducted in liaqat university eye hospital sindh, pakistan on patients admitted for ocular treatment, 4.6% of the total tested samples were positive for hbv ag. however, patients above 30 years of age were employed for the study, unlike this study, and the hbv ag was done by the chromatographic method which is less sensitive than elisa. 17 in another study 5.7% prevalence of hepatitis b virus was recorded amongst the hospital care seeking population in eithopia, africa. 15 the highest hbv seropositivity recorded was amongst the patients between the ages of 25 yrs.-35 yrs. while the lowest being observed in patients below 14 years of age. a study conducted in china associates hbv infection with the different gender, however, the reason for this difference in result is unclear. it is speculated to have been due to differences in the immune response to the hbv infection. 18 the incidence of hbv infection is also related to different occupations, risky social activities, personal history of vaccination, and age in adults. 18 who also estimates that in developing countries due to the use of non-sterile, reused syringes or needles cause 12-18 million hbv infections annually. 15 it is also stated that the rate of positivity decreases with age due to the spontaneous seroconversion to the antibody against hbeag. 18 hbv and hcv may appear as co infections due to the same mode of transmission. 19 several studies have been documented that hcv and hbv co infection accelerates liver damage and may progresses to hepatocellular carcinoma. co-infection also alters the interferon dosage required for treatment. 19 hbv/hcv co infection is most commonly found amongst certain high risk personnel i.e. iv drug abusers, patients on hemodialysis, patients in immunocompromised states e.g. after organ transplantation and/ or hiv positive, and patients requiring frequent blood transfusions e.g. beta thalassemia patients. 20 however, due to lack of large scale population based studies conducted over different geographical areas and presence of silent hbv infection amongst many patients, the worldwide prevalence of hbv/hcv coinfection is not known. 20 a study conducted on adult, females in karachi estimated the co infection rate by both these viruses to be 1.4%. 21 however, according to another study conducted in 2011 in karachi the frequency of co infection by hcv and hbv was 1.1%. 22 whereas, the prevalence of co infection in journal of islamabad medical & dental college (jimdc); 2016:5(3):100-103 103 national survey was 0.1%. 23 co-infection indicates more severe and difficult to treat disease with higher morbidity and mortality. conclusion high number of samples were tested positive for hcv and hbv at pims. there is thus great need for improved health policies and to increase awareness against hcv and hbv amongst the general population and high risk population to prevent people from contracting the virus and/or early detection of the disease. conflict of interest this study has no conflict of interest as declared by any author. references 1. waheed m. who emro | prevention and control of hepatitis | programmes | pakistan [internet]. emro.who.int. 2015 http://www.emro.who.int/pak/programmes/prevention-acontrol-of-hepatitis.html 2. ali s, donahue r, qureshi h, vermund s. hepatitis b and hepatitis c in pakistan: prevalence and risk factors. int j infect dis. 2009; 13(1):9-19. 3. qureshi h, bile m, jooma r, alam s, afridi h. prevalence of hepatitis b and c viral infections in pakistan: findings of a national survey appealing for effective prevention and control measures. east mediterr health j. 2010; 16s:15-23. 4. kumar v, abbas a, aster j, cotran r, robbins s. robbins and cotran pathologic basis of disease. 9th ed. st. louis: saunders elsevier; p.614-620. 5. batool a, khan m, bano k. efficacy of immunoassay chromatography test for hepatitis-c antibodies detection. j ayub med coll abbottabad. 2009; 21(3):38-9. 6. basit a. prevalence of hepatitis b and c infection in pakistan. j inf mol biol. 2014; 2(3):35–8. 7. atif g, jamal n, abbas h. seropositivity of hbsag and anti hcv in rawalpindi and islamabad and analysis of risk factors. ann pak inst med sci.2009; 5(1):242-4. 8. nafees m, bhatti ms, i. haq iu, sero-prevalence of hcv antibodies in population attending madina teaching hospital, faisalabad. ann kemu. 2010;13(4):57–62. 9. khan a, tareen a, ikram a, rahman h, wadood a, qasim m, et al. prevalence of hcv among the young male blood donors of quetta region of balochistan, pakistan. j virol. 2013;10(1):83. 10. ali a, ahmad h, ali i, khan s, zaidi g, idrees m. prevalence of active hepatitis c virus infection in district mansehra pakistan. j virol. 2010; 7(1):334. 11. khattak a, nawaz h, khan j, khan h. frequency of hepatitis b and c on screening in dera ismail khan. gjms. 2012;10(1):84-6. 12. shrestha a, ghimire p, tiwari b, rajkarnikar m. transfusion-transmissible infections among blood donors in kathmandu, nepal. j infect dev ctries. 2009;3(10):794-7. 13. lehman en, wilson ml. epidemiology of hepatitis viruses among hepatocellular carcinoma cases and healthy people in egypt: a systematic review and meta-analysis. int j cancer. 2009; 124(3): 690-7. 14. qazi h, saleem k, mujtaba i, hashimi a, somroo j. prevalence and factors associated with hcv (hepatitis c virus) seropositivity in islamabad, pakistan. acta med iran. 2010;8(6):394-8. 15. negero a, sisay z, medhin g. prevalence of hepatitis b surface antigen (hbsag) among visitors of shashemene general hospital voluntary counseling and testing center. bmc res notes. 2011;4(1):35. 16. ali m, idrees m, ali l, hussain a, ur-rehman i, saleem s. hepatitis b virus in pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes. j virol. 2011;8(1):102. 17. junejo s, khan n, lodhi a. prevalence of hepatitis b and c infection in patients admitted at tertiary eye care centre: a hospital based study. 2009;25(4):597-600. 18. zhang h. seroprevalence and risk factors for hepatitis b infection in an adult population in northeast china. int j med sci. 2011;8(4):321-31. 19. mcmahon b. serologic and clinical outcomes of 1536 alaska natives chronically infected with hepatitis b virus. ann intern med. 2001;135(9):759. 20. jamma s, hussain g, lau d. current concepts of hbv/hcv coinfection: coexistence, but not necessarily in harmony. curr hepat rep. 2010;9(4):260-69. 21. chu c, lee s. hepatitis b virus/hepatitis c virus coinfection: epidemiology, clinical features, viral interactions and treatment. j gastroenterol hepatol. 2008;23(4):512-20. 22. hakim s, kazmi s, bagasra o. seroprevalence of hepatitis b and c genotypes among young apparently healthy females of karachi-pakistan. libyan j. med. 2008;3(2):66-70. 23. khan r, ahmed w, alam s, arif a. screening of hbsag and anti hcv from tertiary care, private and public sector hospitals. pak j med res. 2011;50(1):20-3. authorship contribution: author 1& 4: active participation in research author 2&3: conception, planning, critical review of article and final approval author 5 & 6: interpretation and analysis of results http://www.emro.who.int/pak/programmes/prevention-a-control-of-hepatitis.html http://www.emro.who.int/pak/programmes/prevention-a-control-of-hepatitis.html 230 j i m d c 2 0 1 7 230 open access f u l l l e n g t h a r t i c l e inhibitory effect of sodium cromoglycate on insulin induced airway hyper-reactivity mahjabeen sharif 1, bushra tayyaba khan 2, fatima qasim malik 3, muhammad asim anwar 4 1 assistant professor pharmacology, army medical college, national university of medical sciences (nums) rawalpindi 2 associate professor pharmacology, army medical college/ national university of medical sciences (nums) rawalpindi 3 senior lecturer, department of pharmacology & therapeutics, yusra medical and dental college islamabad 4 consultant physician paec general hospital islamabad a b s t r a c t objective: to explore the acute effect of insulin on airway reactivity of guinea pigs and protective effects of sodium cromoglycate against insulin induced airway hyper-reactivity on isolated tracheal tissues of guinea pigs in vitro. subjects and methods: effects of insulin (10-710-3 m) and insulin pretreated with sodium cromoglycate (10-6 m) were observed on isolated tracheal strip of guinea pig (n=12) in vitro by constructing cumulative concentration response curves. the tracheal smooth muscle contractions were recorded with transducer on four channel oscillograph. results: insulin produced a concentration dependent reversible contraction of isolated tracheal muscle of guinea pig. the mean ± sem of maximum amplitudes of contraction with insulin and insulin pretreated with sodium cromoglycate were 35 ± 1.13 mm and 14.55 ± 0.62 mm respectively. cromoglycate shifted the concentration response curve of insulin to the right and downwards. conclusion: sodium cromoglycate significantly reduced the insulin mediated airway hyper-reactivity in guinea pigs. so we suggest that pretreatment of inhaled insulin with cromoglycate may have clinical implication in amelioration of its potential respiratory adverse effects such as bronchoconstriction. key words bronchoconstriction, inhaled insulin, oscillograph, sodium cromoglycate, tracheal muscle. author`s contribution 1, conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion data analysis, 3,4 interpretation, manuscript writing and active participation in data collection address of correspondence mahjabeen sharif email: mahjabeen30@hotmail.com. article info. received: august 25, 2017 accepted: november 3, 2017 cite this article. sharif m, khan b.t, malik f.q, anwar m.a. inhibitory effect of sodium cromoglycate on insulin induced airway hyper-reactivity. jimdc.2017;6(4): funding source: this research study was financially supported by national university of sciences and technology (nust) islamabad. conflict of interest: nil i n t r o d u c t i o n the predominant mode of insulin administration is by subcutaneous injection.1 injection related anxiety leads to poor compliance and suboptimal glycemic control.2,3 consequently alternative noninvasive inhalational route of insulin administration was approved in 2006.4 inhalational insulin causes similar reduction in hbaic and fasting blood sugar, compared with regular insulin and less risk of hypoglycemic episodes and weight gain.5 it increases patient’s satisfaction and improved patients compliance leading to improved glycemic control 6,7 unfortunately its use was limited due to its potential to produce respiratory adverse effects such as increased bronchial reactivity, cough, dyspnea and bronchoconstriction.8 insulin has long been recognized as pro-inflammatory and procontractile hormone.9,10 the most likely mechanism of inhaled insulin induced bronchoconstriction is that insulin o r i g i n a l a r t i c l e 231 j i m d c 2 0 1 7 231 increases the mast cells degranulation and subsequently increased release of histamine and contractile prostaglandins are responsible for allergic inflammation of airways.11-13 it is well established from the review of literature that cromoglycate sodium exerts its anti-allergic and antiinflammatory effects due to its mast cell stabilizing activity. prophylactic use of sodium cromoglycate decreases the symptoms of airway hyper-reactivity induced by variety of allergens and chemicals. cromoglycate sodium has also shown to have weak bronchodilatory effects in guinea pig airway models.14 to our knowledge protective effects of sodium cromoglycate against inhalational insulin induced airway hyper-responsiveness have never been evaluated. insulin induced tracheal muscle contraction in guinea pig model described in this study closely resembles the bronchoconstriction produced by pulmonary delivery of inhaled insulin as high concentration of insulin get deposited in airway smooth muscles in both cases.15 based on the pharmacological effects of sodium cromoglycate the present study was designed to evaluate the efficacy of sodium cromoglycate against insulin mediated airway hyper-reactivity of guinea pig in vitro. s u b j e c t s a n d m e t h o d s this experimental study was conducted in pharmacology department in collaboration with centre for research in experimental and applied medicine (cream) army medical college rawalpindi from january 2012 to august 2012. total 12 healthy guinea pigs of either sex of dunkin hartely variety weighing 500-700g were used for current study.16 these guinea pigs were randomly divided into two groups; each group consists of 6 guinea pigs. all the protocols described in this study were approved by ethics commitee of centre for research in experimental and applied medicine (cream). they were sacrificed by cervical dislocation.17 the trachea was dissected out and tracheal chain was prepared with smooth muscle in the centre and cartilaginous portions on both sides. the tracheal strip was attached to the hook of oxygen tube of tissue bath containing oxygenated krebs-henseleit solution at 37o c.18 tracheal contractions were recorded with research grade isometric force displacement transducer harvard model no 72-4494 on four channel oscillograph harvard model no 50-9307.19 this research grade research grade isometric force displacement transducer harvard model no 72-4494 was extremely sensitive to force applied with very short amplitude. it has a minimum displacement of 0.1mm for a force application of 25 grams. 20 group 1: cumulative concentration response curve of insulin (10-7 to 10-3 m) cumulative dose response curves of insulin were constructed with varying concentrations (10-7 to 10-3m). when maximum response with 10-7 m concentration was obtained then the subsequent doses were added without washing the previous dose. 21 four channel oscillograph was used for recording tracheal muscle contraction. this group served as control group 1 and dose response curve of insulin pretreated with cromoglycate was compared with that of insulin alone. group 2: cumulative concentration response curve of insulin in the presence of fixed concentration (10-6 m) of sodium cromoglycate. cromoglycate sodium was added to the organ bath in a concentration of 10-6 m.14 after 15 minutes, the successive doses of insulin ranging from10-7 to 10-3 m were added into the organ bath in the presence of cromoglycate sodium. cumulative concentration response curves pretreated with cromoglycate sodium were constructed. statistical analysis the means of amplitudes of contractions and sems were calculated using spss version 16. student t test was applied to determine the significant difference between two observations. p-value of less than 0.05 was considered as statistically significant. r e s u l t s acute effects of insulin were studied on isolated tracheal smooth muscles of guinea pig by adding the successive doses of insulin ranging from 10-7 to 10-3 m. insulin induced contraction of tracheal smooth muscle was evident at a concentration of 10-7 m concentration. however, a significant enhancement of insulin-induced contractions was observed at 10-5 m, 10-4 m and 10-3 m concentration. (figure 1). 232 j i m d c 2 0 1 7 232 figure 1: comparison of semi log concentration response curve of group 1 and group 2 on isolated tracheal smooth muscle of guinea pig.  results are average of six separate experiments.  data is represented as mean ± standard error of means (sem) changes in tracheal smooth muscle contractions were measured by taking the amplitudes of tracheal smooth muscle contraction. amplitudes of contraction with maximum dose of insulin (10-3 m) was 35 ± 1.13mm (table 1). so insulin significantly enhanced the myogenic airway smooth muscle tone. this insulin induced tracheal smooth muscle contraction was significantly reduced in sodium cromoglycate treated group from 35 ± 1.13mm to 14.55 ± 0.62 mm. the means of amplitudes of contractions with varying doses of insulin when compared between group 1 and 2 were found to be statistically significant (table 1). our data showed that maximum constrictor response of insulin in the presence of cromoglycate was reduced by 41.57 percent as compared with insulin group (table 1). insulin concentration response curve in the presence of cromoglycate was shifted to the right and downwards indicating a profound inhibitory effect of cromoglycate sodium on airway hyper-reactivity induced by insulin (figure 1). d i s c u s s i o n the present study demonstrated that insulin induced airway smooth muscle contraction of guinea pigs in a concentration range of 10-7 m to 10-3 m. these contractions were reversible and sustained in nature. schaafsma et al also reported the acute contractile effect of insulin on isolated tracheal preparation of guinea pig but the concentration of insulin was in the range of 10-10 to 10-5 m. 21 our observations are also supported by in vivo studies in which treatment of diabetic rats with insulin resulted in airway hyper-reactivity and inflammation. this enhanced airway reactivity was due to the release of inflammatory mediators from mast cells under the influence of insulin. 22 when isolated tracheal muscle was pretreated with sodium cromoglycate, the maximum percent response of insulin in the presence of cromoglycate sodium was reduced to 41.57 percent of insulin control. so cromoglycate sodium significantly ameliorated the insulin mediated airway hyper-reactivity. the protection offered by cromoglycate is presumably through the inhibition of release of contractile prostaglandins and histamine from mast cells of isolated tracheal strip. our results are in accordance with other studies in which sodium cromoglycate has been shown to inhibit the bronchoconstrictor response to several kinds of challenges.23 table 1: comparison of responses of isolated tracheal muscle of guinea pig between two groups concentration of insulin (m) group 1 (n=6) amplitude of contraction (mm) (mean ± sd) group 2 (n=6) amplitude of contraction (mm) (mean ± sd) p-value percent response in group 1 from baseline to 10-3 m dose percent response in group 2 from baseline to 10-3 m dose (group 1) 10-7 8.167 ± 2.14 0 ± 0 .004* 23.34 0 10-6 16.16 ± 2.48 0.5 ± 0.837 .007* 46.17 1.43 10-5 26.1 ± 2.78 6.17 ± 1.169 0.000* 74.58 17.62 10-4 31.8 ± 2.04 10.33 ± 1.63 .003* 90.86 29.5 10-3 35 ± 2.76 14.55 ±1.52 .004* 100 41.57 233 j i m d c 2 0 1 7 233 c o n c l u s i o n this study provides us a clue that cromoglycate can attenuate the pro-contractile effect of insulin. so we suggest that pretreatment with cromoglycate may ameliorate respiratory adverse effects of inhaled insulin therapy in diabetic patients. further clinical trials are warranted to confirm whether the protection offered by cromoglycate in guinea pig model can translate to human airways. r e f e r e n c e s 1. ma z, parkner t, frystyk j, laursen t, lauritzen t, christiansen js. a comparison of pharmacokinetics and pharmacodynamics of insulin aspart, biphasic insulin aspart 70, biphasic insulin aspart 50, and human insulin: a randomized, quadruple crossover study. diabetes technology & therapeutics. 2012; 14(7):589-95. 2. mollema ed, snoek fj, heine rj, van der ploeg hm. phobia of self‐injecting and self‐testing in insulin‐treated diabetes patients: opportunities for screening. diabetic medicine. 2001; 18(8):671-4. 3. ulrich h, snyder b, garg ks. combining insulins for optimal blood glucose control in type 1 and 2 diabetes: focus on insulin glulisine. vasc health risk manag. 2007; 3(3): 245-254. 4. bellary s, barnett ha. inhaled insulin (exubera): combining efficacy and convenience. sage j. 2006; 3(3): 179-85. 5. de guadiana romualdo, l.g., morales, m.g., otón, m.d.a., garcía, e.m., gonzález, m.d.c.m.o., garcía, j.n. and santos, e.j.the value of hemoglobin a1c for diagnosis of diabetes mellitus and other changes in carbohydrate metabolism in women with recent gestational diabetes mellitus. endocrinología y nutrición (english edition), 2012; 59(6):362-366. 6. hermansen k, fontaine p, kukolja kk, peterkova v, leth g, gall ma. insulin analogues (insulin detemir and insulin aspart) versus traditional human insulins (nph insulin and regular human insulin) in basal-bolus therapy for patients with type 1 diabetes. diabetologia. 2004; 47(4): 622-29. 7. hollander ap, blonde l, rowe r, mehta ea, milburn lj. efficacy and safety of inhaled insulin (exubera) compared with subcutaneous insulin therapy in patients with type 2 diabetes. diabetes care. 2004; 27 (10): 2356-62. 8. rosenstock j, lorber ld, gnudi l, howard pc, bilheimer wd, chang cp, et al. prandial inhaled insulin plus basal insulin glargine versus twice daily biaspart insulin for type 2 diabetes: a multicentre randomized trial. the lancet. 2010; 375(9733): 2244-53. 9. ma yl, he qy. study of the role of insulin and insulin receptors in allergic airway inflammation of rats. zhonghua yi xue za zhi. 2005; 85(48): 3419-24. 10. kolahian s, asadi f, nassiri sm. reduces inflammatory parameters in airways of diabetic-antigen sensitized guinea pigs. european respiratory journal. 2011; 38(55):1789. 11. terzano c, morano s, ceccarelli d, conti v, paone g, petroianni a, et al. effect of insulin on airway responsiveness in patients with type 2 diabetes mellitus. j of asthma. 2009; 46 (7): 703-07. 12. martin jo, campos ac, cruz wj, manzolli s, alves av vianna e (2010). insulin modulates cytokine release and selectin expression in the early phase of allergic airway inflammation in diabetic rats. bmc. 2010; 10 (1): 39-46. 13. dekkers gb, bos ts, zaagsma j, meurs h. functional consequences of human airway smooth muscle phenotype plasticity. br j. pharmacol. 2012; 166 (1): 359-67. 14. van der wouden jc, uijen jh, bernsen r, tasche mj, de jongste jc, ducharme fm. inhaled sodium cromoglycate for asthma in children. the cochrane library. 2008; 4: 175-81. 15. douglas w, hay p. pharmacology of leukotriene receptor antagonist. chest. 1997; 111(2): 35-45. 16. hajare r, darrhekar mv, shewale a, patil v. evaluation of antihistaminic activity of piper betel leaf in guinea pig. ajpp. 2011; 5(2): 113-17. 17. noor a, najmi hm, bukhtiar s. effect of montelukast on bradykinin induced contraction of isolated tracheal smooth muscles of guinea pig. indian j pharmacology. 2011; 43(4): 445-49. 18. juskova m, franova s, sadlonova v. acute bronchodilator effect of quercetin in experimental allergic asthma. bratisi, lek listy. 2011; 112(1): 9-12. 19. dekkers gb, schaafsma d, tran t, zaagsma j meurs h. insulin-induced laminin expression promotes a hypercontractile airway smooth muscle phenotype. am. j. respir. cell mol. biol. 2009; 41(4): 494-504. 20. amira e, aziz ea, sayed en, mehran gl. anti-asthmatic and anti-allergic effects of thymoquinone on airwayinduced hypersensitivity in experimental animals. japs. 2011; 1(8): 109-17. 21. schaafsma d, gosens r, ris jm, zaagsma j, meurs h, nelemans sa. insulin induces airway smooth muscle contraction. br j pharmacol. 2007; 150(2): 136-42. 22. machado cs, lima tw, damazo sa, carralho fv, martins am, silva rm, et al. down regulation of mast cell activation and airway reactivity in diabetic rats: role of insulin. erj. 2004; 24 (4): 552-58. 23. mombeini t, anaraki zr, dehpour ra. effects of sodium cromoglycate on iranian asthmatic subjects without exposure to any bronchoconstrictor agent. ijpr 2012; 11(2): 549-57. j i m d c 2 0 1 7 182 182 open access f u l l l e n g t h a r t i c l e in-vitro toxicology approach to explore nicotine effects in oral mucosal culture muhammad nauman sheikh 1, sajid hanif 2, rabia sannam khan 3, zohaib khurshid 4, fatima ahmad 5, faisal rehan 6 1associate professor, department of oral pathology, college of dentistry 2 associate professor, department of oral pathology, sindh jinnah medical university karachi 3 senior lecturer. department of oral pathology, college of dentistry 4 lecturer, department of prosthodontics and implantology, college of dentistry, king faisal university, al-ahsa, ksa 5 sr. lecturer, department of oral pathology, college of dentistry, 6 assistant professor, department of oral pathology, college of dentistry (1,3,5 & 6 baqai medical university,karachi) a b s t r a c t objective: to measure the effect of in vitro nicotine on reconstituted oral mucosal culture and to study its effect after 5 minutes and 24 hours in normal healthy uninflammed oral mucosa. material and methods: this observational study was conducted at department of oral pathology, barts and london queen mary university london to measure the effect of in vitro nicotine on reconstituted oral mucosal model. the reconstituted human epithelium model was used and was supplied by skin ethic laboratories, nice, france. cells viability was assessed by mtt assay. working solutions (10μm, 100µm, 1mm, and 10mm) of nicotine were primed from 2.5m stock solution (sigma,uk). the effect of nicotine was studied after 5 minutes and 24 hours in normal healthy uninflamed oral mucosa. results: it was found that that application of nicotine after 5 minutes and 24 hours’ treatment on uninflamed oral mucosal model and did not significantly affect the viability at all concentrations used. conclusion: nicotine did not show any effect on uninflamed mucosa and also had no momentous effect after 5 minutes and 24 hours respectively. further workup on proteomics and genomics is suggested to confirm our observations. key words: nicotine, oral mucosa, tobacco, viability of cells. author`s contribution 1active participation in active methodology, interpretation and discussion 2synthesis and planning of the research, conception-, review the study, 3,4 review and paper writing address of correspondence rabia sannam khan email: rabia.sannam@baqai.edu.pk article info. received: may 21, 2017 accepted: august 20, 2017 cite this article. sheikh mn, hanif s, khan rs, khurshid z, ahmad f, rehan f. in vitro toxicology approach to explore nicotine effects in oral muscosal culture. jimdc. 2017: 6(3): 182-186 funding source: nil conflict of interest: nil i n t r o d u c t i o n tobacco use is regarded as a major cause morbidity and mortality and its extensive use has potentially significant and negative effects on oral and systemic health. the genus tobacco comes from a source named after jean nicot, a french ambassador that is being credited for the shipment of tobacco from portugal to paris in the year 1560.1 the prevalence of smoking in countries like western europe, australia, and the united states and the developing world is rising.2 mackay and eriksen in 2002 reported that tobacco smoking has serious and adverse health consequences in all of the countries of the world irrespective of socio-economic status.3 people consume variety of tobacco goods which can be either chewed, smoked or sniffed.4 products that are consumed could be o r i g i n a l a r t i c l e mailto:rabia.sannam@baqai.edu.pk j i m d c 2 0 1 7 183 183 smoked such as cigarettes, cigars, pipe tobacco or can be consumed smokeless as snuff and chewing tobacco.5 cigarette smoking and tobacco usage are also associated with the development of other cancers, including cancer of the oesophagus, and the lungs.6 fatal diseases such as respiratory heart disease, chronic obstructive lung disease, stroke, pneumonia, aortic aneurysm and ischaemic heart disease are also associated with smoking. non-fatal diseases like a peripheral vascular disease, cataracts, and periodontal disease are also suggested to be associated with smoking.7 both active and passive (environmental) cigarette smoking are the predisposing factors for cardiovascular morbidity and mortality.5 nicotine addiction results in exposure to various carcinogens and other bioactive compounds present in tobacco.8 the risk of renal cell carcinoma is increased with active smoking as compared to passive smoking.9 smoking during pregnancy is also associated spontaneous abortion, ectopic pregnancy and low birth weight babies limb reduction defects and various other congenital defects in children. nicotine (c10 h14 n2) is a naturally occurring alkaloid, obtained from the tobacco plant called nicotina tabacum present in the tobacco leaves and makes up about 5% of a tobacco plant by weight,10 and is highly addictive.11 it is now known that cigarette smoking is a result of addiction to nicotine and the amount of nicotine taken up by the people who use tobacco varies in each individual.12 nicotine, an important component of tobacco, is primarily. it is the addictive substance in tobacco and the main reason for the continuation of the use of tobacco-related products. oral snuff and pipe tobacco contain concentrations of nicotine similar to cigarette tobacco, whereas cigar and chewing tobacco have only about half of the nicotine concentration of the cigarette tobacco. an average tobacco rod contains 10 to 14 mg of nicotine, and on average, about 1 to 1.5 mg of nicotine is absorbed systemically during smoking. it is suggested that 0.0380.217m nicotine concentration is present in smokeless tobacco.13 cigarette smoking delivers rapid doses of nicotine into the brain, following each inhalation, 15-20 minutes is its distribution half-life with a terminal half-life of two hours in the blood. nicotine has a penetrating effect on brain neurochemistry causing activation of nicotinic acetylcholine receptors and releases dopamine in the nucleus accumbens.12 there are nicotinic acetylcholine receptors present in different regions of brain, autonomic ganglia, and the neuromuscular junction where from this nicotine acts and these are of two types, muscle and neuronal.13 nicotine is a type of psychomotor stimulant, and helps smokers to calm down when they are under stress and enables them to work more effectively and with a higher concentration.12 nicotine is linked with many lesions inside the oral cavity.2 it is recommended that nicotine could be correlated to the pathogenesis of oral white lesions.14 carcinogens in tobacco smoke are responsible for the development of oral diseases and cancer. nicotine adds to the risk factors for cancer when it is nitrosated and in turn, makes carcinogenic tobacco-specific nitrosamines.8 in vivo studies revealed that topical application of 0.216m of nicotine to oral mucosa for two hours resulted in alterations in epithelium such as nuclear shrinkage and acantholysis.15 in a study conducted by chen et-al it was evident that when 6% nicotine alone or in a combination of other tobacco-specific nitrosamines such as 0.01% nnn, 0.01% nnk was applied on hamster cheek pouch and gastric mucosal epithelium, it showed signs of hyperplasia, hyperkeratosis and also moderate dysplasia.16 they concluded that these changes may be associated with the development of squamous cell papillomas in animals. du et al revealed that nicotine is more rapidly and completely absorbed through the mucosal membrane of non-keratinized regions like floor of the mouth that is the most permeable region, than through other parts of the mouth.17 nicotine has also been shown to increase the permeability of oral mucosa to nnitrosonornicotine. nitrosonornicotine is known to be a tobacco-specific carcinogen and is also suggested that 0.2% nicotine significantly increases the permeability of oral mucosa to nnn and 2% nicotine causes a further increase to this permeability.17 m a t e r i a l a n d m e t h o d s this study was conducted at department of oral pathology, barts and london queen mary university of london. the reconstituted human epithelium model used in the study was supplied by skinethic laboratories, nice, france. the study focused on the effects of nicotine on an uninflamed stratified epithelial layer, when applied for a j i m d c 2 0 1 7 184 184 period of 5 minutes and over 24 hours respectively. tissue viability was assessed using a modified mtt assay. the reconstituted human epithelium is a threedimensional tissue culture model derived from a buccal carcinoma and obtained by culturing transformed oral keratinocytes (tr146). the cells were seeded and cultivated in a specific medium for 14 days. the consequential culture came out to be a stratified epithelium with 5-7 cell layers of epithelium. model cultures were transferred into a new 24 well culture plates (costar, uk) containing 500µl maintenance medium per well and incubated for 2 hours at 37ºc in 5% co2 in a humidified atmosphere. the cultures were transferred to a new 24 well plate containing fresh media for all experiments. working solution of nicotine + mtt assay: working solutions (10μm, 100µm, 1mm, and 10mm) of nicotine were set up from a 2.5m stock solution (sigma,uk) and before use it was diluted in phosphate buffered saline (pbs). viability assays were designed to quantify the proportion of cells that failed to survive under experimental conditions. in this study modified mtt assay was selected. the viability of exposed cultures was measured by the quantification of mitochondrial dehydrogenase activity using a modified mtt assay. mtt assay involves the use of a colour reaction as a measure of cell activity. mtt (3-(4, 5-dimethyl-thiazol-2-yl)-2, 5diphenyltetrazolium bromide) is a pale-yellow substrate, which is reduced to a dark blue insoluble formazan product when incubated with living cells. the amount of formazan uptake is measured using densitometry. at the end of the treatment period, the cultures were transferred into a new 24 well plate containing 300µl mtt solution (0.5mg/ml in pbs). the plate was wrapped in aluminium foil and incubated for 60 minutes at 37ºc in 5% co2 in a humidified atmosphere. after incubation, the cultures were transferred to a new 24-well plate containing 750µl isopropyl alcohol per well and 750μl of isopropyl alcohol applied to the epithelial surface. the plate was carefully sealed with parafilm®, to prevent evaporation, and then incubated for a further 2 hours at 37ºc to extract the formazan. the insert was then removed and any surface solution retained in the well. the plate was agitated gently in order to equilibrate the colour density. expended cultures were discarded. three 200µl aliquots from each well were transferred to a 96-well plate (costar uk) and the optical density (od) was determined using a titertek multiskan plus plate reader. epithelial viability was expressed as the absorbance at 570nm. the results for mtt assay were quoted as (mean ± standard deviation). r e s u l t s in this study, the tissue viability was assessed using a modified mtt assay. the results for mtt assay were quoted as (mean ± standard deviation) and it was observed that nicotine had no significant effect after 5 minutes on the viability of uninflamed stratified epithelial layer at 10µm (88.98 ± 20.14), 100µm (77.12 ± 16.15), 1mm (87.82 ± 12.28) and 10mm (97.70 ± 14.77) concentrations, when compared to pbs control (100 ± 6.45), (table 1). moreover, nicotine had no significant effect after 24 hours on the viability of uninflamed stratified epithelial layer at 10µm (111.72 ± 18.21), 100µm (110.10 ± 13.30), 1mm (96.90 ± 10.44) and 10mm (120.29 ± 13.99) concentrations, when compared to pbs control (100 ± 12.78 %), (table 2). table 1: mtt results after 5 minutes nicotine treatment on uninflamed tissue (n=4) treatment viability mean standard deviation nicotine (10µm) 88.98 20.14 nicotine (100µm) 77.12 16.15 nicotine (1mm) 87.82 12.28 nicotine (10mm) 97.70 14.77 phosphate buffered saline 100 6.45 table 2: mtt results after 24-hour nicotine treatment on uninflamed tissue (n=4) treatment viability mean standard deviation nicotine (10µm) 111.72 18.21 nicotine (100µm) 110.10 13.30 nicotine (1mm) 96.90 10.44 nicotine (10mm) 120.29 13.99 phosphate buffered saline 100 12.78 j i m d c 2 0 1 7 185 185 thus, results from mmt assay showed that application of nicotine after 5 minutes and 24 hours’ treatment on uninflamed oral mucosa did not significantly affect its viability at different concentrations used. d i s c u s s i o n smoking has been associated with diseases of the lung, pulmonary airways, and oral cavity. cytologic, genomic, and transcriptomic changes in oral mucosa correlate with oral preneoplasia, cancer, and inflammation (e.g. periodontitis). most of the studies also suggest that nicotine contributes to inflammatory processes in the oral cavity, and plays a critical role in the development of oral white pre-malignant lesions, and could be associated with the development of cancer in different regions of the oral mucosa. although this study provides an insight into the possible role of nicotine in the pathogenesis of tobaccorelated lesions in the oral cavity, there is a potential complexity which may limit the significance of the findings. in vivo, mucosa adjacent to nicotine is a stratified squamous epithelium and the results hence, presumes that nicotine has to saturate through epithelium to exert its effect. various studies have been conducted to understand the direct effects of nicotine on a reconstituted stratified squamous epithelium in vitro.18 recently, however, an in vitro reconstituted oral mucosa has become available. this system, thus, offers an alternative approach to evaluate the effect of nicotine on oral mucosa that may more closely reflect in vivo situation. the aim of this study was to explore the outcome of nicotine on an uninflamed reconstituted oral mucosa. the results from viability studies suggested that nicotine treatment of uninflamed reconstituted oral mucosa after 5 minutes and 24 hours had no significant effect on the viability of the cells, only a subtle change in membrane integrity and there were no morphological changes in the appearance of the epithelium. chang yc et al in their study showed that 4mm nicotine dose caused significant morphological alterations of microtubules and vimentin filaments which then lead to atypical changes and vacuoles formation within the oral fibroblasts.19 in a study conducted by schlage wk. et al, on oral organotypic epithelium models, after exposure to cigarette smoke (cs); cs was found to be associated with increased secretion of inflammatory mediators, induction of cytochrome p450s activity and overall weak toxicity. using microarray technology, they also identified cs impact on xenobiotic metabolism-related pathways and alteration in inflammatory processes. they supported the use of oral organotypical tissue models for an impact assessment.20 another study was conducted by filippo zanetti et al, in which human gingival epithelial organotypic cultures were repeatedly exposed (3 days) for 28 min to cs. they also found a significant association of cs with proinflammatory mediators.21 chang yc et al had also linked higher doses of nicotine to be responsible for causing irreversible changes in the morphological appearance of the cells.19 in the present study, it was not possible to quantify the amount of mitrochondrial disruption by nicotine at the concentration range used. further workup is required to confirm our observations. as no change in morphology was seen in these experiments, it might be better to look for electron microscopic changes. moreover, dna array technology can be used for effective detection of other cytokines release and any upregulated protein.22 through the genomic study, the indirect identification of protein products could be achieved by simply comparing normal/untreated tissue with diseased/treated tissue. c o n c l u s i o n nicotine concentration ranging from 10µm to 10mm had no significant effect on viability and morphology of the uninflamed oral mucosa. short exposure to nicotine causes it to reduce while long-standing exposure caused it to amplify. r e f e r e n c e s 1. shankar pr, upadhyay dk. book review: pharmacology by rang hp, dale mm, ritter jm and moore pk. churchill livingstone, edinburgh, iranian journal of pharmacology and therapeutics. 2005; 4(2):151. 2. edwards r. abc of smoking cessation: the problem of tobacco smoking. bmj: british medical journal. 2004; 328(7433):217. 3. eriksen m, mackay j, ross h. the tobacco atlas. american cancer society; 2013. 4. tanski se, prokhorov av, klein jd. youth and tobacco. minerva pediatrica. 2004; 56(6):553-65. 5. ambrose ja, barua rs. the pathophysiology of cigarette smoking and cardiovascular disease: an update. journal of the american college of cardiology. 2004; 43(10):1731-7. 6. weisburger jh, chung fl. mechanisms of chronic disease causation by nutritional factors and tobacco products and their prevention by tea polyphenols. food and chemical toxicology. 2002; 40(8):1145-54. j i m d c 2 0 1 7 186 186 7. wendell kj, stein sh. regulation of cytokine production in human gingival fibroblasts following treatment with nicotine and lipopolysaccharide. journal of periodontology. 2001; 72(8):1038-44. 8. hecht ss. tobacco carcinogens, their biomarkers and tobaccoinduced cancer. nature reviews. cancer. 2003; 3(10):733. 9. hu j, ugnat am, canadian cancer registries epidemiology research group. active and passive smoking and risk of renal cell carcinoma in canada. european journal of cancer. 2005; 41(5):770-8. 10. tomizawa m, casida je. neonicotinoid insecticide toxicology: mechanisms of selective action. annu. rev. pharmacol. toxicol.. 2005; 45:247-68.. 11. benowitz nl. nicotine addiction. new england journal of medicine. 2010; 362(24):2295-303.. 12. jarvis mj. abc of smoking cessation: why people smoke. bmj: british medical journal. 2004; 328(7434):277. 13. karlin a. emerging structure of the nicotinic acetylcholine receptors. nature reviews. neuroscience. 2002; 3(2):102-114. 14. greer ro. oral manifestations of smokeless tobacco use. otolaryngologic clinics of north america. 2011; 44(1):31-56. 15. boffetta p, hecht s, gray n, gupta p, straif k. smokeless tobacco and cancer. the lancet oncology. 2008; 9(7):667-75. 16. cheng ya, shiue lf, yu hs, hsieh ty, tsai cc. interleukin-8 secretion by cultured oral epidermoid carcinoma cells induced with nicotine and/or arecoline treatments. the kaohsiung journal of medical sciences. 2000; 16(3):126-33.. 17. dussor, g. o, leong sa, gracia bn, kilo s,† theodore j. price and hargeaves km et al. potentiation of evoked calcitonin gene-related peptide release from oral mucosa: a potential basis for the pro-inflammatory effects of nicotine eur j neurosci 2010; 18 (9): 2515–26 18. sinusas k, coroso jg. a 10-yr study of smokeless tobacco use in a professional baseball organization. medicine and science in sports and exercise. 2006; 38(7):1204-7. 19. chang yc, huang fm, tai kw, yang lc, chou my. mechanisms of cytotoxicity of nicotine in human periodontal ligament fibroblast cultures in vitro. journal of periodontal research. 2002; 37(4):279-85. 20. schlage wk, iskandar ar, kostadinova r, xiang y, sewer a and majeed s. et al. in vitro systems toxicology approach to investigate the effects of repeated cigarette smoke exposure on human buccal and gingival organotypic epithelial tissue cultures. toxicol mech methods, 2014; 24(7): 470–487 21. zanetti f, titz b, sewer a, sasso gl, scotti e and schlage wk et al. comparative systems toxicology analysis of cigarette smoke and aerosol from a candidate modified risk tobacco product in organotypic human gingival epithelial cultures: a 3day repeated exposure study. food and chemical toxicology 2017; 101: 15e35 22. patel v, ieethanakul c, gutkind js. new approaches to the understanding of the molecular basis of oral cancer. critical reviews in oral biology & medicine. 2001; 12(1):55 63. https://www.ncbi.nlm.nih.gov/pubmed/?term=leong%20as%5bauthor%5d&cauthor=true&cauthor_uid=14622152 https://www.ncbi.nlm.nih.gov/pubmed/?term=gracia%20nb%5bauthor%5d&cauthor=true&cauthor_uid=14622152 https://www.ncbi.nlm.nih.gov/pubmed/?term=kilo%20s%5bauthor%5d&cauthor=true&cauthor_uid=14622152 https://www.ncbi.nlm.nih.gov/pubmed/?term=price%20tj%5bauthor%5d&cauthor=true&cauthor_uid=14622152 https://www.ncbi.nlm.nih.gov/pubmed/?term=price%20tj%5bauthor%5d&cauthor=true&cauthor_uid=14622152 https://www.ncbi.nlm.nih.gov/pubmed/?term=hargreaves%20km%5bauthor%5d&cauthor=true&cauthor_uid=14622152 144 j i m d c 2 0 1 7 144 op e n ac c e ss f u l l l e n g t h a r t i c l e changes in lipid profiles according to body mass index in individuals coming to a tertiary care hospital saman waqar 1, haroon khan 2, rafi raza ahmed 3 1 assistant professor, department of chemical pathology, federal medical and dental college islamabad 2 professor, department of chemical pathology, pakistan institute of medical sciences, islamabad 3 post graduate resident, dept. of pediatric surgery, pakistan institute of medical sciences, islamabad a b s t r a c t objective: the aim of this study was to quantify dyslipidemia among people with different body mass index. patients and methods: this cross-sectional study was performed in the pathology department of pakistan institute of medical sciences, islamabad. a total of 198 participants were enrolled in the study. all the participants were above 20 years of age coming as caretakers to the patients coming to opd and indoor departments. people under 20 years, with cardiac diseases and those reluctant to give consent were excluded from the study. the outcomes were measured in the form of quantification of dyslipidemia among different classes of body mass index (bmi). results: the mean age of the participants was 34.9 + 9.4 years with predominance of male participants, 141 (71.2%). the overall frequency of dyslipidemia was 56.1%. it was observed that 51 (42.5%) individuals with normal bmi also had dyslipidemia. out of 38 overweight cases 32 (84.2%) were found to be associated with dyslipidemia (p-value = <0.001). conclusion: from the above study, it was found that dyslipidemia is not only associated with obese or overweight individuals, but also in individuals with normal bmi. this shows that normal bmi individuals are also at risk of developing cardiovascular disorders and should be routinely screened for dyslipidemia. keywords: bmi, cardiovascular disorders, dyslipidemia, lipid profile. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, active participation in data collection address of correspondence saman waqar email. samanwaqar@yahoo.com article info. received: july 25, 2017 accepted: august 11, 2017 cite this article: waqar s, khan h, ahmed rr. changes in lipid profiles according to body mass index in individuals coming to a tertiary care hospital nephrotic. jimdc. 2017; 6(2):144-147. funding source: nil conflict of interest: nil i n t r o d u c t i o n dyslipidemia means the abnormal quantity of lipid circulating in the blood. these lipids include triglycerides, phospholipids, and cholesterol. the most common dyslipidemia is hyperlipidemia, which is an elevation in the lipids in blood. two major contributing factors in this regard are diet and lifestyle.1 the commonly used classification of dyslipidemia is increased total cholesterol, increased low density lipids (ldl), increased triglycerides (tc) and decreased high density lipids (hdl).2 for the screening of dyslipidemia, a lipid profile is required which is a panel of blood tests that serve as a screening tool for abnormalities in total lipids and approximate risk of developing cardiovascular disease and other diseases.2 dyslipidemia is among the most common risk factors for atherosclerotic disease and cardiovascular diseases.2 dyslipidemia is very much o r i g i n a l a r t i c l e 145 j i m d c 2 0 1 7 145 prevalent in the region of south asia and this region is more prone to have increased levels of total cholesterol (tc), triglycerides (tg) and high density lipoprotein cholesterol (hdl-c).2,3 dyslipidemia is a common finding in obese population and increased levels of lipid parameters in blood are associated with atherosclerotic plaque formation.4 this study was planned to determine the changes in lipid profiles of healthy individuals coming as attendants with the admitted patients in pakistan institute of medical sciences, islamabad. the aim of the study was to categorize the population according to bmi and at the same time investigating their lipid profile to assess their association. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted in the department of pathology, pakistan institute of medical sciences, islamabad for the duration of 6 months. total 198 healthy individuals after taking informed consent were enrolled in the study. sample size was calculated through who calculator by using alpha error=5%, confidence level=95% and anticipated population=84.8%.2 sampling technique was non-probability consecutive sampling. all the adults, aged 20 or more and either gender, who came as caregivers with opd visiting patients were enrolled in the study. individuals less than 20 years, with known cardiac disease or other chronic morbidity and patients who refused to give the consent were excluded from the study. the blood samples were taken from study subjects under aseptic measures. lipid parameters including tc, ldl-c, hdl-c and tg were measured in the laboratory. the results were noted on the study performa. spss version 12.0 was used to enter and analyze the data. descriptive statistics were used to calculate mean and standard deviation from continuous variables like age, height, weight, bmi and lipid parameters. frequency and percentages were calculated for categorical variables like sex, family history of diabetes, hypertension, smoking habits and dyslipidemia. chi-square test was applied to find out the association of bmi with dyslipidemia. a pvalue of <0.05 was considered statistically significant. r e s u l t s a total of 198 healthy individuals were enrolled in this study to determine their lipid profile. the mean age of all the subjects was 34.9 + 9.4 years. most of the study participants 68 (34.3%) were between the age 31 to 40 years, followed by 46 (23.2%) between 26 to 30 years (table 1). table 1: demographic characteristics of participants (n=198) variables number percentage age (years) 20-25 36 18.2 26-30 46 23.2 31-40 68 34.3 41-50 33 16.6 51 or above 15 7.5 family h/o diabetes yes 63 31.8 no 135 68.2 family h/o hypertension yes 67 33.8 no 131 66.2 smoking yes 53 26.8 no 145 73.2 the predominant gender of this study was males i.e. 141 (71.2%) and females were 57 (28.8%). considering anthropometric measurements mean height was found to be 3.0 + 0.3 m2. the average weight came out to be 68.2 + 8.5 kg. using these parameters; the average bmi came out to be 22.6 + 2.5 kg/m2. among the study subjects, 63 (31.8%) patients had a family history of diabetes. hypertension was more prevalent i.e. 67 (33.8%) among patients. apart from these, there were 53 (26.7%) smokers in the study (table 1). the lipid profile of the patients was also analyzed. the mean ldl-c was 83.0 + 32.1 mg/dl. similarly, the average hdl-c was 39.4 + 8.8mg/dl and tg was 155.9 + 94.5 mg/dl. the total cholesterol was found to be 154.5 + 37.4 mg/dl. out of the total 198 cases, 14 (7.1%) had increased levels of ldl-c i.e. greater than 130mg/dl. a part of population also had decreased levels of hdl-c i.e. in 102 (51.5%) subjects having less than 40mg/dl of hdl-c. a total of 18 (9.1%) had raised levels of total cholesterol. increase in triglycerides level was observed in 80 (40.4%) individuals. considering the bmi of the study patients, out of the total 198 subjects, 120 (60.6%) had bmi within normal range (18.9 to 24.5%), 38 (19.2%) were overweight (24.6 to 30%) whereas 40 (20.2%) were obese (greater than 30%) in this study. it was noticed that out of 120 cases with 146 j i m d c 2 0 1 7 146 normal bmi, majority i.e. 69 (57.5%) had normal lipid levels. this shows that even the population with normal bmi may be at a risk of developing cvd. dyslipidemia was a common finding in overweight and in obese individuals (table 2). positive family history of diabetes, hypertension and smoking habit was significantly related to dyslipidemia. large number of smokers were also significantly found to be dyslipidemic (table 3). the overall prevalence of dyslipidemia collectively came out to be 56.1% with 111 cases being dyslipidemic. d i s c u s s i o n this study was conducted to find association of dyslipidemia in different bmi categories in order to assess the relative risk of developing cardiovascular disorders in our community. the region of south asia has been shown to be more susceptible to develop cardiovascular disorders. due to increased burden of cvd in population, we planned to assess the population at risk. it is a wellknown fact that a sufferers of dyslipidemia are at a great risk of developing cvd. the current study showed the average age of the participants was 34.9 + 9.4 years. more than 80% of the cases were between 20-40 years of age. a study done by sherpa ly et al3 reported mean age of their participants to be 48 years. this difference in the age presentation may be due to different geographical. regions according to developed and underdeveloped countries. in this study, we found that male gender was more prevalent i.e. 71.2% among the study subjects. humayun a et al6 found a similar trend in their study. the study by shah aza et al2 also showed this inclination towards the male gender. opposite finding i.e. female preponderance was seen in a study by sherpa ly et al3. the male dominance may be due to the fact that in majority of the cases, the attendants coming with the patients are usually male, so that may be the reason behind this. the overall prevalence of dyslipidemia was found to be in 56.1%. the most surprising fact about this study was that out of 120 individuals with normal bmi, 51 (42.5%) had dyslipidemia. this clearly shows that dyslipidemia may be seen in nonobese individuals and people with normal bmi may be vulnerable to dyslipidemia. in this study, about 32% of overweight individuals had dyslipidemia and 70.0% of obese participants had dyslipidemia. our findings are somewhat comparable to the findings of humayun a et al6 reporting in their study that a significant population of otherwise normal and healthy adults are at the verge of developing dyslipidemia. considering the lipid parameters and comparing it with other studies, decrease in hdl-c was observed in (51.5%) individuals as compared to shah sza et al who noted 46% individuals with decreased hdl-c, both these findings are comparable. the huge difference was seen in ldl-c levels, in our study, 7.1% of the individual had increased ldl-c levels whereas in shah sza et al study, almost one-third population had high ldl-c levels. so prevalent feature of dyslipidemia in this study was decreased hdl-c levels. similarly, mohanna et al12 also observed low hdl-c levels in 30.4% individuals and hypercholesterolemia in 34.3% cases. evidence from literature suggest that all these features of deranged lipid profile i.e. increased tg, ldl-c, tc and decreased hdl-c are atherogenic.13 thus in order to prevent cardiovascular diseases, these risk factors should be taken care of.14 bmi should be part of routine medical checkup which would give us an estimate of obesity in a population. studies have shown that obesity is related to dyslipidemia, which eventually leads to cardiovascular disorders.15 this study gives us alarming outcomes in table 3: predictors of dyslipidemia among participants (n=198) variables lipid profile p-value dyslipidemia (n=111) normal lipids (n=87) family h/o diabetes; n=63(31.8%) 43 (68.1) 63(31.8) <0.001 family h/o hypertension; n=67(33.8%) 48 (71.6) 67 (33.8) <0.001 smoking; n=53(26.7%) 41 (77.3) 53 (26.7) 53 (26.7) table 2: association of bmi categories with dyslipidemia among participants (n=198) bmi categories lipid profile p-value dyslipidemia n (%) normal lipids n (%) normal; n=120(60.6%) 51 (42.5) 120 (60.6) 0.01 over weight n=38(19.2%) 32 (84.2) 38(19.2) <0.001 obesity; n=40(20.2%) 28 (70.0) 40 (20.2) <0.001 147 j i m d c 2 0 1 7 147 which the normal bmi people are also found to be at risk of developing cvd. so, based on the findings of the current study, one can say that the lipid profile to assess dyslipidemia should be done in people irrespective of their bmi levels. chances of occult dyslipidemia may be there in otherwise healthy and even non-obese people. therefore, these people should be targeted for screening for dyslipidemia before development of heart diseases. c o n c l u s i o n dyslipidemia or deranged lipid profile is the most common risk factor for developing cvd. from this study, it was observed that 56.1% individuals who were otherwise healthy had dyslipidemia. it is not limited to obese and overweight individuals and a person with normal bmi can also present with dyslipidemia. the most common derangement observed was decreased hdl-c and increased tg. r e c o m m e n d a t i o n s people with normal bmi should also have routine checkup for lipid profile. the healthcare professionals should spread awareness about dyslipidemia in population. r e f e r e n c e s 1. medical definition of dyslipidemia [internet]. merriamwebster.com. 2016. 2. shah sza, devrajani br, devrajani t, bibi i. frequency of dyslipidemia in obese versus non obese in relation to body mass index (bmi), waist hip ratio (whr) and waist circumference (wc). pak j sci 2010; 62: 27-31. 3. sherpa ly, stigum h, chongsuvivatwong v, luobu o, thelle ds, nafstad p, bjertness e. lipid profile and its association with risk factors for coronary heart disease in the highlanders of lhasa, tibet. high altitude medicine & biology. 2011; 12(1):57-63. 4. flegal km, carroll md, ogden cl, curtin lr. prevalence and trends in obesity among us adults, 1999-2008. jama. 2010; 303(3):235-41. 5. finucane mm, stevens ga, cowan mj, danaei g, lin jk, paciorek cj, et al. national, regional, and global trends in bodymass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9· 1 million participants. the lancet. 2011; 377(9765):557-67. 6. humayun a, shah as, alam s, hussein h. relationship of body mass index and dyslipidemia in different age groups of male and female population of peshawar. j ayub med coll abbottabad 2009;21(2): 141-44. 7. national cholesterol education program (ncep) expert panel on detection, e. (2002). "third report of the national cholesterol education program (ncep) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii) final report". circulation 2002; 106: 3143–3421. 8. ito mk, mcgowan mp, moriarty pm. management of familial hypercholesterolemias in adult patients: recommendations from the national lipid association expert panel on familial hypercholesterolemia. j clin lipidol 2011;5(3):s38–45. 9. hooper l, summerbell cd, thompson r, sills d, roberts fg, moore hj, smith gd. reduced or modified dietary fat for preventing cardiovascular disease. sao paulo medical journal. 2016; 134(2):182-3. 10. jolliffe ja, rees k, taylor rs, thompson d, oldridge n, ebrahim s. exercise-based rehabilitation for coronary heart disease. cochrane database syst rev. 2001; 1(1). doi: 10.1002/14651858.cd001800 11. mckenney jm, davidson mh, jacobson ta, guyton jr. final conclusions and recommendations of the national lipid association statin safety assessment task force. am j cardiol 2006;97(suppl 8a):89c-94c. 12. mohanna s, baracco r, seclén s. lipid profile, waist circumference, and body mass index in a high altitude population. high altitude medicine & biology. 2006; 7(3):245-55. 13. howard bv, g ruotolo, dc robbins. obesity and dyslipidemia. endocrinol metab clin north am. 2003; 32:855-67. 14. toth, p.p. low-density lipoprotein reduction in highrisk patients: how low do you go? curr atheroscler rep. 2004; 6(5):348-52. 15. flegal km, carroll rj, kuczmarski, johnson cl. overweight and obesity in the united states: prevalence and trends, 1960-1994. int j obes relat metab disord. 1998; 22(1):39 47 1 j i m d c 2 0 1 8 1 address of correspondence: lawrence faulkner email: lawrence.faulkner@cure2children.org the rising global burden of hemoglobinopathies, a challenge and an opportunity for health care in pakistan lawrence faulkner medical coordinator, cure2children foundation, florence, itlay severe hemoglobinopathies, namely thalassemia major and sickle cell disease, are the most frequent lifethreatening non-communicable disease of children globally: a minimum estimate of 300.000 newborns yearly have some symptomatic globin disorder, these births occur largely in lowand middle-income countries (lmics) where prevention and management programs are often lacking or insufficient1,2. hematopoietic stem cell transplantation, also known as blood or marrow transplantation (bmt), is the only established curative modality with success rates over 85% in low risk children with a compatible sibling3–5, moreover, bmt can normalize long-term health-related quality of life (hrqol)6,7 and be highly cost effective8,9. however, there is a dire shortage of bmt centers in hemoglobinopathy-prone regions10 which often fall in the lowand middle-income country (lmic) strata, so that many families have to migrate to affluent countries seeking cure for their beloved ones; this not only aggravates misery, psychological and economical burden but perpetuates the hemorrhage of professional and financial resources to high-income countries (hic). within structured collaboration programs low-risk matched-related bmt can be associated with very good results even in startup centers directly in lmics11,12 and thus may provide a unique opportunity for saving lives, improve hrqol, decrease financial burden of disease and promote capacity-building, research & development, and health care strengthening13. bmt indications and outcomes: hics vs. lmics: the spectrum of bmt indications and procedures differ between west and east10: in north america and europe hematological malignancies are the most frequent indication and unrelated donors are often employed because of small average family size. in the middle east and asia non-malignant disorders, e.g. hemoglobinopathies and aplastic anemia, tend to be most common indications and matched related donors more frequently available14–16. moreover, in addition to financial and logistic issues, the very limited use of unrelated volunteer donors in the east is also due to the fact that non-malignant disorders require stringent hla matching and non-caucasian ethnicities are generally underrepresented in donor registries17. lastly, results using partially matched family doors for so called haploidentical transplantation, typically the mother or father, are increasingly encouraging18. there is no evidence that, at least for low-risk matched related bmts, outcomes are substantially different in hics compared to lmics. gliebel et al. assessed the impact of human development index (hdi) on bmt results in adults with acute leukemia and found that transplantations performed in countries with an upper hdi were associated with improved leukemia-free survival, this however was not due to higher transplant-related mortality (trm) but rather to higher relapse rates in lmics, suggesting that the survival differences were probably related to patient selection and residual disease assessment rather than the bmt procedure itself19, and thus may not apply to non-malignant disorders. in the experience of the cure2children foundation (c2c) in supporting the startup of centers in pakistan and india performing primarily low-risk matched-related bmts for severe thalassemia aided by a structured peer to peer collaborative platform20, outcomes where comparable to those obtained in western centers21. there is also no e d i t o r i a l 2 j i m d c 2 0 1 8 2 evidence that in lmics the spectrum of transplant-related infections is substantially different compared to the west22,23. cost issues bmt is one of the most expensive tertiary care procedures with costs generally above 150.000 usd in hics24. figure 1 compares the relative cost breakdown of bmt for adult leukemia in hics to the one for childhood thalassemia in lmics underlining several interesting points: a) the major difference is related to follow up costs, probably because chronic gvhd is far more common, and to some extend therapeutically desirable, in adult leukemia; b) the second major difference is in hospitalization charges, which are related mostly to differences in salaries but also to bmt units construction and maintenance, in fact, complex infection control environments may not be needed for low-risk matchedrelated bmt in children with non-malignant diseases who arrive to transplant with no prior exposure to chemotherapy, no previous prolonged neutropenia episodes, no infections and in good general conditions12; c) diagnostics are also much less expensive in bmt for thalassemia since, for example, residual leukemia quantification or frequent chimerism analysis post bmt are not an absolute requirement as long as transfusionindependency is achieved; d) drugs and transfusion support is also different because of patient size and complication frequency, particularly fungal infections, the treatment of which may substantially impact on final costs. in fact, in the c2c experience in pakistan and india the incidence of possible, probable or proven fungal infections25 in young thalassemic children undergoing matched-related bmt is less than 2%23. within an existing hospital facility, less than 100,000 usd where sufficient to renovate and fully equip a 4-bed start up bmt unit26. increasing evidence suggest that complex and costly infection control environments may not be required27–29 and established international guidelines do not call for stringent air control systems, at least for low-risk bmts30. the cure of severe hemoglobinopathies as a capacity-building opportunity optimal supportive care if often not available or not accessible in lmics so that most children with severe hemoglobinopathies do not survive beyond 20 years of age and the risk of blood-borne infections, primarily hepatitis c, is still substantial32. figure 1. cost breakdown comparison of matchedrelated bmt in hic (adult leukemia24) and lmic (children with thalassemia31); total cost $116,000* and $11,200 respectively (family support program not included) as paradoxical as it may seem, bmt may actually be the best option for many patients with thalassemia in developing countries: it is a one-time procedure not depending on long-term access to appropriate medical care and at the same time greatly improves the quality of life for both patients and families by decreasing medical, psychological and financial burdens6,7. buccal swab-based hla-typing technology has greatly facilitated centralized compatibility testing so that there is no need to set up hla laboratories locally, and patients can be easily typed worldwide and referred to bmt centers within south-south cooperation programs offering effective and cost-conscious bmt33. in the c2c-supported bmt network in pakistan and india hinging on focused training and intensive online cooperation, low-risk matched-related bmt in children younger than 15 years is currently delivered with more than 95% thalassemia-free survival, a result at least as good as that obtained in hic3, for an average cost of 12.000 usd per bmt4,31. the realistic prospect of a definitive cure also improved compliance with supportive care and engaged families in cascade screening and prevention programs, e.g. most mothers of thalassemic children accepted the offer of free prenatal diagnosis for subsequent pregnancies. because of large patient loads, there is great potential for expertise on specific disease curable by bmt, for 3 j i m d c 2 0 1 8 3 example, pakistan has at least 100 times the incidence of thalassemia compared to the west, and many cases have a compatible sibling donor due to large family size. as a result, many more transplants for young thalassemic children with a compatible donor are currently carried out in lmics compared to europe or north america34. however, to take advantage of this opportunity, increasing efforts will have to focus on quality assurance platforms20 and outcome reporting programs as a means of reassuring national and international patients, patient advocates, insurances and other sponsoring bodies. it seems reasonable to assume that if quality standards are assured, expertise is higher and costs are much lower, there might be the potential for patient attraction. why should an insurances or national health systems refuse to cover a patient willing, for example, to go from the uk to pakistan in centers that have much more experience on specific diseases, e.g. thalassemia, where appropriate quality standards are assured, outcome reporting is transparent and bmt costs are much less bmt for thalassemia offers several advantages for startup centers in lmics: a) it is the least expensive and simplest form of allogeneic bmt with relatively basic technology requirements; b) being a chronic disease there is enough time to adequately prepare patients in order to maximize initial success rates; c) high commitment and compliance of affected families; d) children generally enjoy high cure rates and excellent hrqol; e) high cost-effectiveness; f) potential for leading expertise and patient attraction. c o n c l u s i o n bmt consists of a wide array of procedures which have very different complexities, outcomes and costs. the one used to cure young children with severe hemoglobinopathies having a compatible sibling sits on the simplest side of this spectrum, it's far less expensive than long-term supportive care and can restore a normal quality of life in most patients. it does not require complex hospital environments or undue sophisticated technologies. it can save the life of many children while being a great opportunity for health care strengthening, professional motivation and higher medical education. bmt may have positive ripple effects on institutions taking over the challenge as well as on screening and prevention programs in lmics r e f e r e n c e s 1. modell, b. & darlison, m. global epidemiology of haemoglobin disorders and derived service indicators. (who website, 2009). 2. weatherall, d. j. the inherited diseases of hemoglobin are an emerging global health burden. blood 115, 4331–4336 (2010). 3. angelucci, e. hematopoietic stem cell transplantation in thalassemia. hematology 456– 462 (2010). doi:10.1182/asheducation-2010.1.456 4. mehta, p. a. & faulkner, l. b. hematopoietic cell transplantation for thalassemia: a global perspective. biol. blood marrow transplant. 19(1 suppl), s70-3 (2013). 5. bernaudin, f. et al. long-term results of related myeloablative stem-cell transplantation to cure sickle cell disease. blood 110, 2749–2756 (2007). 6. cheuk, d. k. l. et al. quality of life in patients with transfusion-dependent thalassemia after hematopoietic sct. bone marrow transplant. 42, 319–327 (2008). 7. la nasa, g. et al. long-term health-related quality of life evaluated more than 20 years after hematopoietic stem cell transplantation for thalassemia. blood 122, 2262–2270 (2013). 8. leelahavarong, p. et al. a cost-utility and budget impact analysis of allogeneic hematopoietic stem cell transplantation for severe thalassemic patients in thailand. bmc health serv res 10, 209–221 (2010). 9. ho, w.-l. et al. financial burden of national health insurance for treating patients with transfusiondependent thalassemia in taiwan. bone marrow transplant 37, 569–574 (2006). 10. gratwohl, a. et al. hematopoietic stem cell transplantation: a global perspective. jama 303, 1617–1624 (2010). 11. faulkner, l. b., uderzo, c. & masera, g. international cooperation for the cure and prevention of severe hemoglobinopathies. j. pediatr. hematol. oncol. 35, 419–423 (2013). 12. faulkner, l. et al. atg vs. thiotepa with busulfan and cyclophosphamide in matched-related bone marrow transplantation for thalassemia. blood advances 1, 792–801 (2017). 13. faulkner, l. setting up bone marrow transplantation for children with thalassemia may facilitate pediatric cancer care. south asian journal of cancer 2, 109– 112 (2013). 4 j i m d c 2 0 1 8 4 14. hajeer, a. h., algattan, m., anizi, a., alaskar, a. s. & jarrar, m. s. chances of finding a matched parentchild in hematopoietic stem cell transplantation in saudi arabia. am j blood res 2, 201–202 (2012). 15. klein, t. et al. extended family studies for the identification of allogeneic stem cell transplant donors in jewish and arabic patients in israel. pediatric transplantation 9, 52–55 (2005). 16. elbjeirami, w. m., abdel-rahman, f. & ayad ahmed hussein. probability of finding an hla-matched donor in immediate and extended families: the jordanian experience. biol. blood marrow transplant. 19, 221– 226 (2013). 17. switzer, g. e. et al. race and ethnicity in decisions about unrelated hematopoietic stem cell donation. blood 121, 1469–1476 (2013). 18. anurathapan, u. et al. hematopoietic stem cell transplantation for homozygous β-thalassemia and βthalassemia/hemoglobin e patients from haploidentical donors. bone marrow transplant 51, 813–818 (2016). 19. giebel, s. et al. association of human development index with rates and outcomes of hematopoietic stem cell transplantation for patients with acute leukemia. blood 116, 122–128 (2010). 20. agarwal, r. k. et al. a prospective international cooperative information technology platform built using open-source tools for improving the access to and safety of bone marrow transplantation in lowand middle-income countries. j am medical informatics association in press, (2014). 21. hussein, m. h. et al. bone marrow transplantation for thalassemia: a global perspective. thalassemia reports 3, 103–107 (2013). 22. george, b., mathews, v., viswabandya, a., srivastava, a. & chandy, m. infections in children undergoing allogeneic bone marrow transplantation in india. pediatr.transplant 10, 48–54 (2006). 23. soni, r. et al. infectious complications in 153 matched-related bmts performed without hepa filtration or positive pressure rooms in 3 bmt centres in south-east asia. in 21st asia-pacific bmt meeting 285 (2016). 24. blommestein, h. m. et al. real-world costs of autologous and allogeneic stem cell transplantations for haematological diseases: a multicentre study. ann. hematol. 91, 1945–1952 (2012). 25. ascioglu, s. et al. defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. clin. infect. dis. 34, 7–14 (2002). 26. ramprakash, s. et al. low-cost matched sibling bone marrow transplant for standard-risk thalassemia in a limited-resource setting. pediatric hematology oncology journal 107–113 (2017). doi:10.1016/j.phoj.2017.12.002 27. kumar, r. et al. allogeneic hematopoietic sct performed in non-hepa filter rooms: initial experience from a single center in india. bone marrow transplant 43, 115–119 (2009). 28. solomon, s. r. et al. outpatient myeloablative allosct: a comprehensive approach yields decreased hospital utilization and low trm. bone marrow transplantation 45, 468–475 (2010). 29. svahn, b.-m. et al. home care during the pancytopenic phase after allogeneic hematopoietic stem cell transplantation is advantageous compared with hospital care. blood 100, 4317–4324 (2002). 30. mcgrath, e. international standards for cellular therapy product collection, processing and administration accreditation manual, fact-jacie 6th edition. (2015). 31. faulkner, l. et al. transplantation in low resource countries. thalassemia reports 1, 30–33 (2011). 32. di marco, v. et al. management of chronic viral hepatitis in patients with thalassemia: recommendations from an international panel. blood 116, 2875–2883 (2010). 33. agarwal, r. k. et al. the case for high resolution extended 6-loci hla typing for identifying related donors in the indian subcontinent. biology of blood and marrow transplantation 23, 1592–1596 (2017). 34. sabloff, m. et al. hla-matched sibling bone marrow transplantation for β-thalassemia major. blood 117, 1745–1750 (2011) j islamabad med dental coll 2020 82 open access comparison of intravenous co-amoxiclav and benzyl penicillin in children with severe streptococcal tonsillitis sumera akram 1 , muhammad ahmed khan 2 , abdul rehman 3 , hassan bin usman 4 , ali abbas 5 1 assistant professor, department of pediatrics, mardan medical complex, kpk pakistan 2 ent specialist, combined military hospital, mardan, kpk pakistan 3 associate professor, department of pediatrics, bahawal victoria hospital, bahawalpur, pakistan 4 public health specialist, ministry of health, doha qatar 5 child specialist, combined military hospital, mardan, kpk pakistan a b s t r a c t background: streptococcal tonsillitis is a common pediatric ailment which is faced by physicians on a daily basis and is associated with disastrous complications if not treated adequately. the objective of this study was to compare the efficacy, safety and cost-effectiveness of intravenous co-amoxiclav with benzyl penicillin in the treatment of severe streptococcal tonsillitis in children. material and methods: this randomized controlled trial was carried out at cmh mardan, khyber pakhtunkhwa from january 2018 to november 2019. a total of 310 children with severe tonsillitis, aged between 5 to 15 years were selected from outpatient department of combined military hospital mardan. the cases were divided into two groups. injection co-amoxiclav was given to patients in group a (n=155) and injection benzyl penicillin was administered to patients in group b (n=155). both groups were compared in terms of effectiveness of treatment, safety and cost. all the data was assessed with help of spss (statistical package for social sciences) version 21. chi square and independent t-test were used with p-value < 0.05 taken as statistically significant. results: there were 310 children with severe tonsillitis, 155 in each group. mean age in group a was 9.35±3.17 years and in group b, 9.96±2.96 years, respectively. in group a, 2 cases developed hypersensitivity to injection co-amoxiclav after initial test dose as compared to 3 cases in group b. mean duration for complete resolution of symptoms (i.e. hospital stay) was 4.13±0.375 days for group a as compared to 4.09±0.377 days for group b (p=0.458). mean cost of antibiotic drugs for each child in group a was rs. 965.88 ± 298 and in group b was rs. 152.36±53. benzyl penicillin was found to be more cost effective as compared to co-amoxiclav (p=0.000). conclusions: both the drugs have similar efficacy and safety profile in the treatment of severe streptococcal tonsillitis in children. however, benzyl penicillin is more cost effective than co-amoxiclav in our study population. key words: co-amoxiclav, benzyl penicillin, efficacy, safety profile, streptococcal tonsillitis clinical trail registration: clinicaltrials.gov: nct04215770 authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; 4,5 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad ahmed khan email: akawan79@gmail.com article info: received: january 13, 2020 accepted: june 22, 2020 cite this article. akram s, khan ma, rehman a, usman hb, abbas a. comparison of intravenous co-amoxiclav and benzyl penicillin in children with severe streptococcal tonsillitis. j islamabad med dental coll.2020; 9(2): 82-87. doi: 10.35787/jimdc.v9i2.489 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 83 i n t r o d u c t i o n tonsillitis is defined as inflammation of pharyngeal tonsils, although infection may spread to lingual tonsils, adenoids and adjacent tissues. 1,2 it is mostly caused by viral or bacterial infections. group a streptococcal tonsillitis is also called ‘strept throat’.3 symptoms of tonsillitis include fever, pain throat, dysphagia, odynophagia, headache, chills, malaise, white pus-filled spots or membrane over tonsils and neck node enlargement. 4 pain of tonsillitis can also radiate to ears. the patient may also complain of fatigue, halitosis, anorexia, voice change etc. 3 most common cause of tonsillitis is viral, caused by adenovirus, rhinovirus, influenza, respiratory syncytial and coronavirus etc. 5 second common cause is bacterial tonsillitis. among bacterial microorganisms, group a β-hemolytic streptococcus (gas), streptococcus pyogenes is most frequently involved. 6,7 staphylococcus aureus (including methicillin-resistant staphylococcus aureus), streptococcus pneumoniae, mycoplasma pneumoniae, chlamydia pneumoniae, etc. can also be responsible infrequently. 8 clinically, streptococcal pharyngitis/tonsillitis is diagnosed with the help of characteristic clinical features along with throat swab culture, which is the gold standard diagnostic test. in literature, streptococcal tonsillitis, pharyngitis and pharyngotonsillitis have been used synonymously/interchangeably. 9,10 prevalence of acute streptococcal pharyngitis /pharyngotonsillitis caused by gas (streptococcus pyogenes) varies from 20 to 30% and is the commonest cause of bacterial tonsillitis requiring antibiotics. 11,12 the prevalence of acute streptococcal pharyngitis in pakistan has been reported as 25.3%. 13 streptococcal tonsillitis (tonsillitis or pharyngotonsillitis caused by gas) requires treatment with antibiotics as it is associated with not only local suppurative complications like peritonsillar abscess, otitis media, mastoiditis and pneumonia but can also cause non-suppurative complications like acute rheumatic fever, acute post-streptococcal glomerulonephritis, poststreptococcal reactive arthritis and pediatric autoimmune neuropsychiatric disorders. penicillins, macrolides, cephalosporins, and clindamycin are highly sensitive against the streptococci. 11,12 streptococcal tonsillitis can be confirmed in less than 10 minutes with 95% specificity and 80-90% sensitivity. 13 in our resource-constrained country, economic factors are very important with regards to the treatment of streptococcal tonsillitis. in the present study, we have compared coamoxiclav with benzyl penicillin for the treatment of children with acute streptococcal tonsillitis/pharyngotonsillitis in terms of efficacy, safety and cost-effectiveness. m a t e r i a l a n d m e t h o d s this randomized single-blinded clinical trial was carried out at combined military hospital mardan, khyber pakhtunkhwa pakistan from january 2018 to november 2019. permission was sought from the ethical review board of the hospital and informed consent was obtained from the parents/guardian at the start of the study. sample size was calculated with help of epitools online sample size calculator. prevalence of streptococcal pharyngitis was taken as 25.3%, 13 with a confidence interval of 95%, sample of 291 was calculated. children aged between 5 to 15 years, with a centor score for strep tonsillitis /pharyngotonsillitis of 3 or 4 and those who had a positive rapid antigen detection test (radt) for group a beta-hemolytic streptococci were included in the study. immunocompromised children, those with known allergy to penicillins (co-amoxiclav and benzyl penicillin), those on oral or parenteral antibiotics j islamabad med dental coll 2020 84 and with liver failure or renal impairment were excluded from the study. the cases were selected from outpatient department of combined military hospital mardan, kpk. a child was diagnosed as a case of streptococcal tonsillitis/pharyngotonsillitis on the basis of centor criteria, 14 which includes the following: fever >38.5ᵒc, anterior cervical lymphadenopathy, absence of cough and tonsillar exudate. children with a centor score of 4 or 3 were grouped as “severe tonsillitis”, those with a centor score of 2 were termed “moderate tonsillitis” and those with a centor score of 1 were called “mild tonsillitis”. the children were termed “healthy” when centor score was 0. a total of 310 children fulfilling the inclusion criteria were admitted indoor. the cases were divided randomly through random number tables into two groups, group a and group b. children in group a (n=155) were given injection co-amoxiclav 50 units/kg/day in 3 divided doses and those in group b (n=155) were given injection benzyl penicillin 25000 units/kg/day in 3 divided doses, intravenously. both these groups were compared in terms of efficacy of treatment, safety and cost effectiveness. efficacy was assessed through improvement/ decrease (reduction in fever, decrease in tonsillar exudates and settling lymphadenopathy) in centor criteria score on a daily basis. improvement/ decrease in centor criteria score was charted for all cases till they recovered. children were discharged after they had recovered fully and their centor score became zero/nil. group a children were prescribed syrup co-amoxiclav (50mg/kg/day divided in 3 doses) and group b, syrup penicillin v (25 mg/kg/day in 3 divided dosage) to complete the ten days antibiotics course. safety was assessed by recording the frequency of hypersensitivity reactions and serious side effects of antibiotics leading to the withdrawal of the offending injection/drug. children in both groups were administered a test dose of the antibiotic before injecting full dose of benzyl penicillin or coamoxiclav. the procedure of test dose comprised of giving 10% of antibiotic dose slowly intravenously over 5 minutes. the child was subsequently observed for any allergic reaction (urticaria, shortness of breath, angioedema, itching, nausea, vomiting, anaphylaxis, etc.) for 30 to 60 minutes. a trained nurse supervised the test dose and full dose administration. all the cases were also observed for any serious side effects of both antibiotics. in group a (co-amoxiclav group), children were observed for severe vomiting, diarrhea, abdominal pain and clinical jaundice. in group b (benzyl penicillin group), children were observed for seizures and blood dyscrasias. complete blood picture, liver and renal function tests were carried out every 48 hours to detect any serious side effect of the antibiotics being used. cost effectiveness was compared in terms of total cost of injections (co-amoxiclav versus benzyl penicillin), which were administered to the children of both groups. data was analyzed with help of spss (statistical package for social sciences) version 21. frequencies were expressed by percentages. chi square test was used to compare the qualitative variables, while independent t test was used to analyze quantitative variables. p-value < 0.05 was taken as statistically significant. clinical trial registration: clinicaltrials.govnct04215770. r e s u l t s there were 310 cases, 155 in each group. overall, there were 163 (52.58%) males and 147 (47.42%) females. the age range of patients was from 5 to 15 years with a mean age of 9.66 ± 3.08 years. both j islamabad med dental coll 2020 85 groups a and b were matched in terms of age and gender (table i). table i: baseline characteristics of group a and b (n=310) variables group a group b p-value* mean age (years) 9.35±3.17 9.96±2.96 0.083 male (n=163) 80 (51.61%) 83 (53.55%) 0.733 female (n=147) 75 (48.39%) 72 (46.45%) *p-value <0.05 was considered statistically significant group a-injection coamoxiclav; group b-injection benzyl penicillin centor score was evaluated and documented for each child on admission, then checked daily and recorded till the child recovered i.e. centor score was nil/zero. children were discharged from hospital when centor score became nil/zero. table ii shows mean centor score record of children on admission and subsequent days till recovery. mean duration for complete resolution i.e. hospital stay was 4.13+0.375 days in group a, and 4.09+0.377 days in group b (p=0.458). the overall frequency of allergic reactions to both penicillin group antibiotics was 1.61%. there were only 2 (1.29%) cases of allergic reactions in group a and 3 (1.94%) cases in group b, indicating that both antibiotics are safe for use in children (p=0.652). there were no serious side effects to any of these two antibiotics in our study, except the allergic (hypersensitivity) reactions. regular complete blood picture, liver and renal function tests in all cases were normal and did not show any blood dyscrasias, liver or renal compromise. mean cost of antibiotic drug for each child in group a was rs. 965.9 ± 298 and in group b, rs. 152.4 ± 52.8. there was significant difference in cost of both these injections, benzyl penicillin being more cost effective (p=0.000). price of one intravenous injection of amoxiclav 600mg was rs. 80 15 and that of benzyl penicillin 5 lac units was rs. 8, 16 respectively (table iii). table ii: comparison of both groups in terms of daily centor score day centor score recorded groups n mean centor score sd pvalue* admission day group a 155 3.96 0.195 0.768 group b 155 3.97 0.179 day 1 group a 155 2.97 0.396 0.340 group b 155 2.93 0.447 day 2 group a 155 2.12 0.419 0.054 group b 155 2.03 0.406 day 3 group a 155 1.11 0.390 0.472 group b 155 1.08 0.391 day 4 group a 155 0.14 0.352 0.632 group b 155 0.13 0.332 day 5 group a 155 0.01 0.081 0.559 group b 155 0.01 0.114 *p-value <0.05 was considered statistically significant. group a-children on injection coamoxiclav; group bchildren on injection benzyl penicillin; sd-standard deviation; n-number of children d i s c u s s i o n streptococcal tonsillitis/pharyngotonsillitis is one of the most common cause of hospital visits in children. it can cause serious complications including rheumatic heart disease and acute renal failure. 14 antibiotics have to be used to eradicate streptococcus pyogenes to prevent these complications which are serious health issues and cause of a worldwide economic burden. co-amoxiclav and benzyl penicillin both belong to the penicillin group of antibiotics. they are betalactam antibiotics with bactericidal action and are effective against streptococcus pyogenes. in literature, the allergic reactions of penicillins occur 1 in 5000 patients. 17 in pakistan, till date, no such study has been carried out to compare these two drugs for tonsillitis or pharyngotonsillitis. j islamabad med dental coll 2020 86 table iii: comparison of cost-effectiveness of group a and group b antibiotics groups antibiotics n mean cost (rs.) standard deviation total cost (rs.) p-value* a co-amoxiclav 155 965.88 297.99 147780.0 0.000 b benzyl penicillin 155 152.36 52.82 23160.0 total 310 560.46 460.19 170940.0 *p-value <0.05 was considered statistically significant baomah et al. compared co-amoxiclav with benzyl penicillin in the treatment of ludwigs angina in ghana, and found that both these drugs are equally effective. 18 agweyu et al. compared oral amoxycillin with benzyl penicillin in kenyan children with severe pneumonia and found no difference in their efficacy. 19 atkinson et al. compared oral amoxicillin with intravenous benzyl penicillin in patients of community-acquired pneumonia, and found equal efficacy of these two pharmacologic agents. 20 similarly, we found both these drugs safe and equally effective in treating severe tonsillitis or pharyngotonsillitis in children. however, there was significant difference in cost-effectiveness of both these drugs: benzyl penicillin being very cheap as compared to co-amoxiclav. as already mentioned, one injection of co-amoxiclav 600mg costs rs. 80.00 versus rs 08.00 of benzyl penicillin. 15,16 thus, there is significant difference of prices between the two drugs with similar efficacy and safety profile. 18 c o n c l u s i o n intravenous co-amoxiclav and benzyl penicillin have similar efficacy and safety profile in the treatment of severe streptococcal tonsillitis. however, benzyl penicillin is more cost effective than co-amoxiclav in our study population. r e f e r e n c e s 1. abraham zs, bazilio j, kahinga aa, manyahi j, ntunaguzi d, massawe er. prevalence and bacteriology of tonsillitis in patients attending otorhinolaryngology department at muhimbili national hospital, dar es salaam tanzania. tanzan med j. 2019; 46(1): 33-40. 2. alasmari nsh, bamashmous rom, alshuwaykan rma, alahmari mam, almubarak rm, mohammed aa, et al. causes and treatment of tonsillitis. egypt j hosp med. 2017; 69(8): 2975-80. doi: 10.12816/ 0042838 3. okoye el, obiweluozor cj, uba bo, odunukwe fn. epidemiological survey of tonsillitis caused by streptococcus pyogenes among children in awka metropolis (a case study of hospitals in awka community, anambra state). iosr j pharm biol sci. 2016; 11(3): 54-58. doi: 10.2139/ssrn.3448992 4. eisenberg mj. rheumatic heart disease in the developing world: prevalence, prevention, and control. eur heart j. 1993; 14(1): 122-8. doi: 10.1093/eurheartj/14.1.122 5. brook i. foot pa. isolation of methicillin resistant staphylococcus aureus from the surface and core of tonsils in children. int j pediatr otorhinolaryngol. 2006; 70(12): 2099-2102. doi: 10.1016/j.ijporl. 2006.08.004 6. najam y, walla fl, iqbal a. the efficacy and safety of cefaclor in respiratory infections amongst pakistani children. j pak med assoc. 2000; 50(9): 289-93. pmid: 11043017 7. siddiqui sj, awan a, ekangakic a, stocks jm, sheikh ja, ahmad tm, et al. an evaluation of cefaclor in pakistani children with pharyngotonsillitis. j pak med assoc. 2002; 52(10): 451-6. pmid: 12553673 8. van kempen mj, rijkers gt, van cauwenberge pb. the immune response in adenoids and tonsils. int arch allergy immunol. 2000; 122(1): 8-19. doi: 10.1159/000024354 9. farooqi ia, akram t, zaka m. incidence and empiric use of antibiotic therapy for tonsillitis in children. int j appl res. 2017; 3(12): 323-27. j islamabad med dental coll 2020 87 10. huovinen p. causes, diagnosis and treatment of pharyngitis. comp ther. 1999; 25(6-7): 326-9. doi: 10.1007/bf02944278 11. pichichero me. group a streptococcal tonsillopharyngitis: cost effective diagnosis and treatment. ann emerg med. 1995; 25(3): 390-403. doi: 10.1016/s0196-0644(95)70300-4 12. shulman st, bisno al, clegg hw, gerber ma, kaplan el, lee g, et al. clinical practice guidelines for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the infectious disease society of america. clin infect dis. 2012; 55(10): 1279-82. doi: 10.1093/cid/cis629 13. rathi sk, ahmed r. pakistan prevalence survey in acute pharyngitis. j pak med assoc. 2014; 64(8): 928-31. pmid: 25252520 14. orra m, naos m, ghanem s, mehri ba, rajab m. the diagnostic value of ‘centor criteria’ in children with group a beta hemolytic streptococcus tonsillopharyngitis. enr j biomed pharm sci. 2018; 5(8): 43-9. 15. https://dawaai.pk/benzyl-penicillin-500000-unit9231.html. 16. co-amoxiclavin; pharmaguide. 21st ed. page 610.available online @. www.epharmaguide.com/ online. 17. canzani d, aldeek f. penicillin g’s function, metabolites, allergy and resistance. j nutr hum health. 2017; 1(1): 28-40. doi:10.35841/nutritionhuman-health.1.1.28-40 18. baomah mo, saheeb bd, parkins ge, nuamah i, ndanu ta, blankson pw. a comparative study of the efficacy of intravenous benzylpenicillin versus intravenous augmentin in the empirical management of ludwig’s angina. ann afr med. 2019; 18(2): 65-9. doi: 10.4103/aam.aam_22_18 19. agweyu a, gathara d, oliwa j, muniga n, edwards t, allen e et al. oral amoxicillin versus benzyl penicillin for severe pneumonia among kenyan children: a pragmatic randomized controlled noninferiority trial. clin infect dis. 2015; 60(8): 1216-24. doi: 10.1093/cid/ciu1166 20. atkinson m, lakhanpaul m, smyth a, vyas h, weston v, sithole j. comparison of oral amoxicillin and intravenous benzyl penicillin for community acquired pneumonia (pivot trial): a multicenter pragmatic randomized controlled equivalence trial. thorax. 2007; 62(12): 1102-06. doi: 10.1136/thx. 2006.074906 j islamabad med dental coll 2019 203 open access breast feeding remains a strong protection against infant infections shagufta sohail1, kaneez fatima1, noshina riaz1 1assistant professor, department of paediatrics, yusra medical and dental college, islamabad a b s t r a c t background: breast feeding prevents infections in infants. bottle-fed infants who are partially breast-fed or never breast-fed at all are at higher. the objectives of this study were to record the effect of exclusive breast feeding versus partial and never breast feeding on infections in infants and also to find an association of infection with type of feed, gestation and vaccination status in infants till six months of age. material and methods: a total of 500 infants were included in this cross-sectional study. information regarding pattern of feeding and infections was obtained by verbal interview of mother and the questionnaire was filled by the study physician. the outcome evaluated was infections in infants till one year of age. categorical comparisons were made using chi square test. a ‘p’ value < 0.05 was considered statistically significant. results: out of 500 infants, 59.4% were males. about 59.6% were exclusively breast-fed till 6 months of age, 31.2% were partially breast-fed and 9.2% were never breast-fed. in exclusively breast-fed group, 29.5% infants reported infections as compared to 40.4% in partial breast-fed group and 65.2% in never breast-fed infants (p < 0.000). similarly, 40.6% of infants in exclusively breast-fed group, 55.1% in partial breast feed and 58.7% in the never breast-fed reported infections in 4-6 months of age, which was statistically significant (p = 0.003). there was no significant difference in infection rates among the three study groups in 7-9 (p=0.192) and 10 -12 months (p=0.42) of age. conclusions: exclusive breast feeding till six months of age significantly reduces the risk of infections in infancy. key words: exclusive breast feeding, infant infections, partial breast feeding authors’ contribution: 1-3 conception, synthesis, planning of research and manuscript writing interpretation, discussion, active participations in data collection data analysis. correspondence: shagufta sohail email: shaguftasohail2009@hotmail.com article info: received: june 6, 2019 accepted: november 19, 2019 cite this article. sohail s, fatima k, riaz n. breast feeding remains a strong protection against infant infections. j islamabad med dental coll.2019; 8(4): 203-207. doi: 10.35787/jimdc.v8i4.351 funding source: nil conflict of interest: nil i n t r o d u c t i o n breast milk is nature’s first gift to the newly born baby. world health organization (who) recommends breastfeeding within one hour after birth but currently only 50% of neonates are breast-fed in the first hour of life in the world.1,2 who recommends exclusive breast feeding till six months and it should be continued till two years of age as a part of mixed diet.3 however, only 37% of infants are exclusively breastfed till six months of age in developing countries.4 duration of breast feeding is even shorter in developed countries. there are more chances of morbidity and mortality from different infections in infants who are not breast fed or are partially fed. if babies are breast fed according to global recommendations, 823,000 children could be saved each year.4 breast feeding provides optimal nutrition to the growing infants in initial six months after birth.5 it helps in maturation of immune system and prevents infections.6 breast feeding has an immediate protective effect against upper and lower respiratory tract infections, otitis media, diarrhea and urinary tract infection.7 multiple studies in developing countries show that the risk of infections especially respiratory and diarrheal infections is increased with shorter duration of breast feeding. these studies considered different durations of exclusive breast feeding but did not study the duration and exclusiveness of breast o r i g i n a l a r t i c l e j islamabad med dental coll 2019 204 feeding together. the objectives of this study were to record the effect of exclusive breast feeding versus partial and never breast feeding on infections in infants and also to find an association of infection with type of feed, gestation and vaccination status in infants till six months of age. m a t e r i a l a n d m e t h o d s this was an observational cross-sectional study done in yusra general hospital at pediatrics department from november 2017 till october 2018. non-probability convenient sampling technique was used for sample collection. infants till two years of age reporting to the hospital with their mothers with various complaints were included. who calculator was used to calculate sample size of study. at 95% confidence interval, 5% absolute precision and anticipated population proportion assumed to be 50%, total sample size calculated was 384. however, data was collected from 500 subjects. informed consent was taken from the mother and information regarding type of feeding and infections was obtained by verbal interview and was noted by the principal investigators.6 infants with congenital anomalies, twin deliveries and those attending day care centers were excluded. the study was approved by the ethics committee of yusra medical and dental college and yusra general hospital. mothers were asked about their education status, gestation and mode of delivery of the infant. type of infant feeding till 6 months of age was categorized as ‘exclusive breast-fed’ for infants taking only breast milk. ‘partial breast-fed’ included infants on breast feed along with formula feed or any other milk and ‘never breast-fed’ included infants who had not been fed on breast milk at all. infants whose vaccination was complete according to expanded program of immunization (epi) were said to be ‘fully vaccinated’, if they had missed few vaccines were labelled as ‘partially vaccinated’ and if they had received no vaccine as ‘not vaccinated’. the outcome which was evaluated after different type of feeding was infections in infancy for which medical consultation was taken in first 3 months of life, at 4-6 months, 7-9 months and 10-12 months of age. data was analyzed using spss version 23. frequencies and percentages were calculated from descriptive variables. categorical comparisons were made using chi-square test with a p value < 0.05 considered statistically significant. r e s u l t s of the 500 infants enrolled in the study, 297(59.4%) infants were male, 433 (86.6%) were born at full-term and 448 (89.6%) were fully-vaccinated. about 215 (43%) of the mothers were educated up to 10th grade. table i shows the demographic characteristics of the study population. in this study, 298 (59.6%) infants were exclusive breast-fed while 156 (31.2%) were partial breast-fed. table i: demographic characteristics of study population variables n (%) gender of infant male 297(59.4) female 203 (40.6) education of mother illiterate 21 (4.2) matric 215 (43) intermediate 92 (18.4) graduate 102 (20.4) post graduate 70 (14) gestation pre-term 44 (8.8) term 433 (86.6) post-term 23 (4.6) vaccination status of infant fully 448 (89.6) partially 44 (8.8) none 8 (1.6) in exclusively breast-fed group, 29.5% infants reported infections compared with 40.4% in partial breast-fed group and 65.2% in never breast-fed infants in first 3 months. this difference was statistically significant with ‘p’ value of 0.000. similar high protection against infections was noticed in the exclusive breast-fed group during 4-6 months of age (table ii). although infection rates increased with increasing age of infants, they were considerably less in exclusive breast-fed group. our study showed that infants who were never breast fed reported highest infections during first 3 months of life (65.2%) and that pattern remained stable in the subsequent months of age with little decline (table ii). p values in table ii suggest that results were significant for exclusive and partial breast-fed group for all comparison from baseline indicating more children were likely to report infection during subsequent months of age. while the data showed j islamabad med dental coll 2019 205 table iii: association of infection with type of feed, gestation and vaccination in infants up to 3 months of age odds ratio 95 % confidence interval p value type of feed ebf reference ebf versus partial breast-fed 1.698 1.12 2.57 0.012 ebf versus no breast-fed 4.463 2.29 8.69 0.000* gestation preterm reference pre term versus term 0.358 0.18 68 0.002* preterm versus post term 0.609 0.22 1.72 0.351 vaccination fully vaccinated reference fully vaccinated versus partial vaccinated 1.283 0.668 2.468 0.453 fully vaccinated versus none 3.271 0.727 14.708 0.122 *p <0.05 considered statistically significant figure 1. association of infection with type of feed, gestation and vaccination in 4-6 months of age. odds ratio plot along with 95% confidence interval from binary logistic regression analysis p values a1=0.003, a2=0.031, b1=0.039 b2=0.874, c1=0.000 c2=0.244 table ii: association of type of feed with infection and age of infant infection 0-3 months a 4-6 months b 7-9 months c 10-12 months d exclusive no 210(70.5) 177(59.4) 147(49.3) 112(37.6) yes 88(29.5) 121(40.6) 151(50.7) 186(62.4) partial no 93(59.6) 70(44.9) 63(40.4) 59(37.8) yes 63(40.4) 86(55.1) 93(59.6) 97(62.2) none no 16(34.8) 19(41.3) 21(45.7) 22(47.8) yes 30(65.2) 27(58.7) 25(54.3) 24(52.2) p-value chi-square 0.000* 0.003* 0.192 0.420 post hoc hypothesis test ebf. 0.0001* partial 0.193 none: 0.000 ebf 0.000* partial 0.0124 none 0.0891 j islamabad med dental coll 2019 205 that for never breast-fed group, subsequent comparisons from baseline were not significant. the results of linear regression analysis showed that during first 6 months, breast feeding offered greater protection against infections during the first three months. the odds of having infection were 1.698 (95% ci 1.12---2.57; p value 0.012) times higher in partial breast-fed as compared to exclusive breast-fed infants. similar higher odds (or 4.463; 95% ci 2.29—28.69; p value 0.000) of infection were seen for never breast-fed group versus exclusively breast-fed group, when other variables entered in the model were held constant (table iii). from 4-6 months of age, the results showed higher odds for infection (or 1.827; 95% ci 1.22 --2.72; p value 0.003) for partial breast-fed infants versus exclusive breast-fed infants and similar higher odds of infection (or 2.036; 95% ci 1.068—3.88; p value 0.031) in never breast-fed group compared with exclusive breast-fed group (table iii). this shows that during first 6 months of life breast feeding offer greater protection against infections. d i s c u s s i o n this study done locally in a pakistani community emphasizes the effectiveness of breast feeding against infections in infancy. exclusive breast feeding for six months prevents infections in infants. even infants who are breast fed partially showed the protective effect by having lesser infections as compared to those who are never breast fed. the results of the study are similar to various studies done in different regions which have documented beneficial effect of breast feeding against common infections in infancy.8,9 in a cohort study done in united kingdom, quigley et al. concluded that there is an increased risk of infection in infants who are exclusively breast fed for less than four months or for four to six months or those who stop breast feeding by six months of age.8 similarly a study from bangladesh showed the beneficial effect of exclusive breast feeding for six months against infections.9 they suggested that exclusive breast feeding for six months prevents infants from fever, acute respiratory infections and diarrhea. 9 encouraging breast feeding exclusively for six months is an effective and inexpensive way for prevention of infections in infancy. it ultimately decreases the number of hospital visits and admissions. a scottish cohort study by ajetunmobi at el reported the protective effect of breast feeding in infants with the conclusion that there is a higher risk of hospital admissions for gastroenteritis and respiratory tract infections in formula-fed infants.10 similar results were seen is a study done in a rural area in india, which found a high incidence of diarrhea in non-breast-fed babies.11 breast feeding for six months or more was significantly associated with decreased risk of lower respiratory tract infections in preschool children till four years of age.12 protective effect of breast feeding against infections is not limited to infancy. its beneficial effects beyond infancy against respiratory tract infections were observed in the generation r study, which concluded that exclusive breast feeding for six months or more was significantly associated with decreased risk of lower respiratory tract infections in preschool children till four years of age.12 prolonged exclusive breast feeding for 6 months has a significant beneficial effect against infections especially in low to middle income countries. only 37% of infants younger than six months are breast fed exclusively in middle to low income countries.4 exclusive breast feeding for 6 months was observed in 59.6% of our study population as compared to 41.5% in a study done in faisalabad in working mothers, 66% in a study from ghana and only 9% in united states, showing a falling trend of exclusive breastfeeding in industrialized world.1315 two main factors which significantly predispose infants to infection are preterm delivery and lack of immunization. most of the late preterm infants in this study were exclusively breast fed by their mothers till six months of age and hence were protected against common infections in infancy by favorable effects of breast milk. similarly, immunization has protective role against respiratory and diarrheal infections. majority of infants despite their different feeding patterns were fully j islamabad med dental coll 2019 206 vaccinated according to epi schedule in this study conferring the protective effect of vaccination. the main limitation of this study was that the information included was obtained through interview of the mother, making it subjective and biased. c o n c l u s i o n exclusive breast feeding till six months significantly reduces the risk of infection in infancy. r e f e r e n c e s 1. phukan d, ranjan m, dwidevi lk. impact of timing of breastfeeding initiation on neonatal mortality in india. int breastfeed j. 2018; 13: 27. doi: 10.1186/s13006018-0162-0 2. ebmond k, newton s, hurt l, shannon cs, kirkwood br, taneja s, et al. timing of initiation, patterns of breast feeding, and infant survival: prospective analysis of pooled data from three randomized trials. lancet glob health. 2016; 4(4): e266-75. doi: 10.1016/s2214-109x(16)00040-1 3. who. the world health organization’s infant feeding recommendation, world health organization. 2016. http://www.who.int/nutrition/topics/infantfeeding recommendation/en/ 4. victora gg, bahl r, barros aj, franca gv, horton s, krasevec j, murch s, sankar mj, walker n, rollins nc. breast feeding in the 21st century: epidemiology, mechanisms, and lifelong effect .lancet. 2016; 387(10017): 475-90. doi: 10.1016/s01406736(15)01024-7. 5. martin cr, ling pr, blackburn gl. review of infant feeding: key features of breast milk and infant formula. nutrients. 2016; 8(5): e279. doi: 10.3390/nu8050279 6. butt ca, hedderley di, herath td, paturi g, glynjones s, wiens f et al. human milk composition and dietry intakes of breast-feeding women of different ethnicity from the manawatu-wanganui region of new zealand. nutrients. 2018; 10(9): e1231.doi: 10.3390/nu10091231. 7. frank nm, lynch kf, uusitalo u, yang j, lönnrot m, virtanen sm et al. the relationship between breastfeeding and reported respiratory and gastrointestinal infection in young children. bmc pediatr. 2019; 19(1): 339. doi: 10.1186/s12887-0191693-2 8. quigley ma, carson c, sacker a, kelly y. exclusive breastfeeding duration and infant infection. eur j clin nutr. 2016; 70(12):1420-27. doi: 10.1038/ejcn.2016.135 9. khan mn, islam mm. effect of exclusive breastfeeding on selected adverse health and nutritional outcomes: a nationally representative study. bmc public health. 2017; 17(1): 889. doi: 10.1186/s12889-017-4913-4 10. ajetunmobi om, whyte b, chalmers j, tappin dm, wolfson l, fleming m et al. breastfeeding is associated with reduced childhood hospitalization: evidence from a scottish birth cohort (1997-2009). j pediatr. 2015; 166: 620–5. doi: 10.1016/j.jpeds.2014.11.013 11. biswas a, mandal ak. a study on association between breast feeding and its protective role against diarrhea in under five children in a rural block of west bengal, india. int j community med public health 2016; 3(9): 2499-503. doi: 10.18203/23946040.ijcmph20163060 12. tromp i, kiefte-de jong j, raat h, jaddoe v, franco o, hofman a et al. breastfeeding and risk of respiratory tract infections after infancy: the generation r study. plos one. 2017; 12(2): e0172763. doi: 10.1371/journal.pone.0172763 13. sabin a, manzur f, adil s. exclusive breastfeeding practices in working women of pakistan: a cross sectional study. pak j med sci. 2017; 33(5): 11481155. doi: 10.12669/pjms.335.12827 14. asare by, preko jv, baafi d, dwumfour-asare b. breastfeeding practices and determinants of exclusive breastfeeding in a cross-sectional study at a child welfare clinic in tema manhean, ghana. int breast feed j. 2018; 13: 12. doi: 10.1186/s13006018-0156-y 15. nnene-agumadu uh, racine ef, laditka sb, coffman mj. association between perceived value of exclusive breastfeeding among pregnant women in the united states and exclusive breast feeding to three and six months postpartum: a prospective study. int breast feed j. 2016; 11: 8. doi: 10.1186/s13006-016-0065-x j islamabad med dental coll 2019 60 221 j i m d c 2 0 1 8 221 op e n ac c e s s c a s e r e p o r t diastematomyelia due to spinal intradural extramedullary teratoma in an adult huma mushtaq1, rayif rashid kanth2, saeed alam3 1 associate professor of pathology, 2assistant professor neurosurgery, 3professor of pathology (islamabad medical and dental college) a b s t r a c t teratomas are rarely found in the central nervous system and are approximately 2% of all other teratomas. spinal teratomas are extremely rare as compared to the teratomas that are found intracranially and are almost 0.1–0.5% of all tumors of spinal cord. these tumors are even more infrequent in adults. diastematomyelia, also known as split cord malformation causes complete or incomplete sagittal division of the neural axis and duplicates it. this condition is mostly accompanied by various malformations and in rare cases it is associated with intradural spinal teratoma. we report a case of 39 years old male who presented with complaints of severe pain in the left leg and weakness with power 2/5 in left leg and urinary obstruction. on evaluation, he was diagnosed as having diastematomyelia due to spinal intradural extramedullary teratoma. key words: diastematomyelia, spinal intradural teratoma, split cord malformation address of correspondence huma mushtaq email: dr_kat18@hotmail.com article info. received: august 2, 2018 accepted: september 12, 2018 cite this case report: mushtaq h, kanth rr, alam s. diastematomyelia due to spinal intradural extramedullary teratoma in an adult. jimdc. 2018; 7(3):221-224 funding source: nil conflict of interest: nil i n t r o d u c t i o n diastematomyelia, also known as split cord malformation causes complete or incomplete sagittal division of the neural axis and duplicates it.1 this condition is mostly accompanied by various malformations including skeletal and vertebral anomalies, meningocele, myelomeningocele, cutaneous changes, hydromyelia, hydrocephalus, klippel–feil syndrome, arnold–chiari malformation and in rare cases it is associated with intradural spinal teratoma.2 intradural spinal teratomas are very rare dysembriogenetic tumors 3 and are less common in adults.4 the first case of spinal teratoma was reported by virchow in 1863.5 among total spinal tumors, the incidence of intradural extramedullary spinal teratoma (iest) is only 0.150.18%.6 whereas in infants and children the incidence of spinal teratomas is comparatively higher and is approximately 5–10% of all spinal tumors.7 furthermore, the ratio among male to female is 3:1.6. intradural extramedullary spinal teratoma is mostly located in dorsolumber region and is associated with conditions like spinal dysraphism prior spinal surgeries and lumbar puncture (lp) .8 for iest, magnetic resonance imaging (mri) is the diagnostic modality of choice, whereas total surgical excision is the treatment modality of choice for it.9 teratomas are classified into mature, immature and malignant type, on the basis of histological characteristics and degree of differentiation.10 these tumors typically, but not always are composed of tissue derived from three germ cell layers’ ectoderm, mesoderm, and endoderm. in infancy, these tumors usually arise from sacrococcygeal region although it can arise from anywhere throughout the spinal canal in cases of adults, but in reported cases, there is predominance of thoracic and lumbar region and the most frequently involved site is conus medullaris.11. c a s e r e p o r t a 39 years old male presented via opd as a case of low back pain and left sided lower limb weakness since his c a s e r e p o r t 222 j i m d c 2 0 1 8 222 childhood with sudden onset of urinary symptoms ranging from dysuria to obstruction in the last 15 days. patient had multiple episodes of pain in his childhood, which improved with physiotherapy and medication. now the patient presented with severe pain in the left leg and weakness with power 2/5 in left leg and urinary obstruction. on examination, tuft of hairs in the lumbar region along with a dermal sinus without discharge was seen. his left leg had gross muscle atrophy in calf muscles measuring 3cm less than the right calf. patient had painful dorsiflexion, grade 4/5. power in the left lower limb was 4/5 and 5/5 in the right lower limb and the patient also had bilateral high arched feet. he was advised x-ray lumbosacral spine which showed spina bifida in the lower lumbar region. mri lumbosacral spine with contrast was done which showed features of diastometomyelia due to intradural space occupying lesion (sol), most likely dermoid cyst (figure 1). patient was counseled regarding the condition and surgical treatment. surgery was performed and excision of intradural mass was done and sent for histopathological examination. figure 1: mri showing diastematomyelia due to spinal intradural extramedullary teratoma. figure 2: gross appearance of spinal teratoma showing cystic and solid areas figure 3: histopathological examination showing various mature derivatives of germ layers fibroadipose tissue and small cystic areas lined by respiratory and stratified squamous epithelium. h&e, 400x on gross examination, the specimen comprised of a cystic mass, its cut surface showed cystic and yellowish white solid areas (figure 2). histopathological examination revealed various mature derivatives of germ layers, comprising of mature neural tissue, fibroadipose tissue, mature bone and small cystic areas lined by respiratory and stratified squamous epithelium. focal areas of calcification were also seen, whereas no immature derivatives were seen (figure 3). patient recovery was unremarkable except power of left lower limb of 3/5. d i s c u s s i o n teratomas are rarely found in the central nervous system (cns) and are approximately 2% of all other teratomas.12 most of the cns teratomas are seen intracranially and mainly involve the midline structures and are mostly seen in the pineal region, some in suprasellar compartment and rarely found in fourth ventricle, basal ganglia, posterior fossa and cerebral hemispheres.13 spinal teratomas are extremely rare as compared to the teratomas that are found intracranially and are almost 0.1–0.5% of all tumors of spinal cord.12 these tumors are even more infrequent in adults.14 in one study that was conducted by slooth et al. in 1964, out of 1322 spinal cord tumors only two were of spinal teratomas. in another series of neurosurgical biopsies conducted by al-sarraj et al, in a total period of 15 years there were 25,000 total cases, out of which only seven were of spinal teratomas.15 clinically, these spinal teratomas of adults present variably depending upon the location. symptoms of the patient depend on whether the 223 j i m d c 2 0 1 8 223 tumor is present in the cervical region, thoracic or in lumber region. the presentation also varies in cases of intramedullary, extramedullary, intradural or extradural teratomas. poeze et al. reviewed intramedullary teratomas (31 cases) out of which 22(71%) cases presented with motor dysfunction and that was the commonest complaint in those patients.15 the other complaints were of disturbance in reflexes seen in 16 (52%), and sensory changes seen in 14 (45%) cases. some cases (11, 35%) also presented with pain and urinary disturbance. other complaints that were only seen in one or two patients included disturbance in defecation, meningismus, visible tumor and sexual disturbance. in a study by tarantino et al, pain was the commonest symptom (47.7%) observed in 107 cases that presented with intradural, extramedullary tumors16 and other less common symptoms were of sensory deficits (15%) followed by motor deficits in 12% cases, sensorimotor deficit in 19.6% cases and sphincter dysfunction in 3.7% of cases.15 diastematomyelia also known as split cord malformation (scm) is accompanied by intradural teratoma in rare cases. scm is of two types. in case of type i scm, there are two hemicords each having its separate dural sheath and an osteocartilaginous septum separates the two hemicords. in type ii scms there are two hemicords but both have same dural envelope and a fibrous septum separates them.2 in our case, the patient was shown to harbor a type ii lesion. caruso, et al,3 reviewed 33 cases of intramedullary spinal teratoma out of which two cases presented with diastematomyelia. hader, et al.,4 reviewed 12 cases that presented simultaneously with intradural spinal teratoma and scm but out of these only two cases were found in adults.17 if an adult presents with spinal teratoma, radiological evaluation of whole spinal canal should be done to rule out dysraphic lesions in any spinal area. the most common symptom seen in adults that present with occult spinal dysraphism is pain which may be accompanied by neurological deficit. when teratoma and scm occur simultaneously, it usually increases neurological problems and may lead to a complex surgery.1 regarding the origin of intraspinal teratoma there are two different theories18, one theory is dysembryogenic theory and the other is misplaced germ cell theory. in case of dysembryogenic theory, spinal teratomas originate from pluripotent cells that differentiate chaotically and this occurs in a developmental environment that is locally disturbed. when this occurs in a caudal cell mass or primitive streak, it develops in to a spinal teratoma. the other theory is the misplaced germ cell theory in which some of the pluripotent primordial germ cells from the neural tube, while migrating from yolk sac to gonad get misplaced and in this way develop into spinal teratoma. this germ cell theory is more likely to be responsible for adult intraspinal teratomas and which normally do not lead to significant dysraphism.18 the gold standard technique used for the diagnosis of spinal teratomas is mri by which the location and the extent of involvement is revealed. the solid and cystic areas are also identified by this technique. but the definitive diagnosis can only be made by histopathological examination, which clearly confirms the presence of three germinal layers or two germinal layers (ectoderm, mesoderm, and endoderm).11 it is suggested that the tumor should be resected as much as possible keeping in mind that the surrounding neural tissue should be completely preserved. it should also be noted that while performing surgery, the content of cyst should never be spilled into the intradural space because it can cause chemical meningitis.19 regarding the treatment of spinal teratomas, the role of chemotherapy and radiotherapy for treating the residual portion of mature teratoma is not clearly evident, mainly due to its slow growth and rarity. however, in case of immature teratoma (malignant) it is controversial to use these techniques.6 in this case, only surgical excision was done and tissue was totally removed. there was no need of adjuvant therapy because on histopathology this tumor was diagnosed as non-malignant mature cystic teratoma. follow up of the patient is recommended by performing serial mri especially if the patient develops new neurological signs and symptoms, if the diagnosis is immature teratoma or if adjuvant therapy is used.9 c o n c l u s i o n only a few cases of intraspinal teratomas are reported in the literature and it is even more rare in adults. the presence of diastematomyelia along with spinal intradural teratoma in adults is very rare. among the imaging modalities, mri is very useful for identifying the location, 224 j i m d c 2 0 1 8 224 extent and determining solid or cystic composition. however, the final diagnosis depends on the histopathological examination. the main treatment of choice for these tumors is aggressive surgical resection but in cases of adhesion to the neurological components, subtotal resection is more appropriate in order to prevent from complications. r e f e r e n c e s 1. elmacı i̇, dağçinar a, özgen s, ekinci g, pamir mn. diastematomyelia and spinal teratoma in an adult: case report. neurosurgical focus. 2001; 10(1):1-4. 2. pang d. split cord malformations. part ii: clinical syndrome. neurosurgery 1992; 31:481–500 3. caruso r, antonelli m, cervoni l, salvati m. intramedullary teratoma: case report and review of the literature. tumori journal. 1996; 82(6):616-20. 4. hader wj, steinbok p, poskitt k, et al: intramedullary spinal teratoma and diastematomyelia. case report and review of the literature. pediatr neurosurg 1999; 30:140–145 5. virchow r. krankhaften geschwul ste. hirschwald, berlin. 1863;1:443. 6. khazendar a, ameen hm, jabbar ni, hasan so, ahmed ts, ali aa. upper lumbar mature cystic teratoma: a case report. world neurosurgery. 2016; 96:609-e7. 7. desousa al, kalsbeck je, mealey j, jr., campbell rl, hockey a. intraspinal tumors in children. a review of 81 cases. j neurosurg. 1979;51:437– 445. 8. borlot f, soares ms, espíndola aád, reed uc, matushita h, teixeira mj. intramedullary spinal teratoma: a rare condition with a good outcome. arq neuropsiquiatr. 2009;67:733–735. 9. pandey s, sharma v, shinde n, ghosh a. spinal intradural extramedullary mature cystic teratoma in an adult: a rare tumor with review of literature. asian j neurosurg. 2015;10:133–137. 10. li y, yang b, song l, yan d. mature teratoma of the spinal cord in adults: an unusual case. oncol lett. 2013;6:942– 946. 11. spinal intradural extramedullary mature cystic teratoma in young adult: a rare tumor with review of literature. agay ak, garg s, hedaooet k, int j res med sci. 2016;4(12):54815483 12. nonomura y, miyamoto k, wada e, et al. intramedullary teratoma of the spine: report of two adult cases. spinal cord 2002;40(1):40–3. 13. paterakis kn, karantanas ah, barbanis s, et al. cervical spinal cord intramedullary teratoma. clin neurol neurosurg 2006;108(5):514–7. 14. hejazi n, witzmann a. spinal intramedullary teratoma with exophytic components: report of two cases and review of the literature. neurosurg rev 2003;26(2):113–6. 15. schmidt rf, casey jp, gandhe ar, curtis mt, heller je. teratoma of the spinal cord in an adult: report of a rare case and review of the literature. journal of clinical neuroscience. 2017; 36:59-63. 16. tarantino r, donnarumma p, nigro l, et al. surgery of intradural extramedullary tumors: retrospective analysis of 107 cases. neurosurgery 2014;75(5):509–14. 17. koen jl, mclendon re, george tm: intradural spinal teratoma: evidence for a dysembryogenic origin. report of four cases. j neurosurg 89:844–851 18. alsarraj st, parmar d, dean af, phookun g, bridges lr. clinicopathological study of seven cases of spinal cord teratoma: a possible germ cell origin. histopathology. 1998;32:51-6. 19. sung ks, sung sk, choi hj, song yj. spinal intradural extramedullary mature cystic teratoma in an adult. j korean neurosurg soc. 2008;44:334–337. journal of islamabad medical & dental college (jimdc); 1211(1):6-9 6 original article clinical manifestations of acute myeloid leukemia naghmi asif* and khalid hassan** *assistant professor, department of pathology, islamabad medical and dental college, islamabad **head, department of pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) abstract background: acute myeloid leukemias (aml) affect preferentially adults. clinical manifestations are due to cytopenias and tissue infiltration. manifestations vary with certain subtypes e.g. bleeding and infections are common with aml-m3, tissue infiltration is more often seen in aml-4 and m5, and bone marrow fibrosis is seen in aml-m7. objective: to study demographic features and clinical manifestations of acute myeloid leukemia. patients & methods: a cross-sectional study was conducted at department of pathology, pakistan institute of medical sciences, islamabad from july 2007 to july 2009. all the cases of aml (diagnosed on bone marrow biopsy) belonging to all age groups and both sexes were included in the study. age at diagnosis, symptoms and clinical findings in aml and its various subtypes were noted. results were entered on spss version 14 for statistical analysis. results: in a total of 82 cases of aml, 55% were males and 45% females, with mean age of 27.5+19.9 years sd. the most common subtype was aml-m1 (33%) followed by m3 (22%) and m4 (18%), respectively. the common presenting symptoms were pallor, fever and bleeding. hepatomegaly, splenomegaly, lymphadenopathy and gum hyperplasia were also frequent. tissue infiltration was the commonest in aml-m5 and m4. conclusion: acute myeloid leukemia is the malignancy of adults; it is more common in males and manifestations vary with its subtype. key words: leukemia, clinical manifestations, aml, hematological malignancies introduction acute leukemias are highly malignant neoplasms and are responsible for a large number of cancer-related deaths.1 although the survival rates have improved remarkably in the younger age group, the prognosis in older patients is still poor. 2 acute myeloid leukemia is characterized by hemopoietic insufficiency (with or without leukocytosis) and infiltration of bone marrow and other tissues by myeloid cells. it is further classified into 8 subtypes. aml occurs at any age but is more common in adults (comprising about 80% of acute leukemias). symptoms related to aml are caused by replacement of bone marrow and failure of normal hemopoiesis, resulting in anemia, bleeding and increased risk of infections. these may be general or related to specific organ system. the most common complaint is nonspecific fatigue or malaise. fever is common and is the presenting feature in 15-20% patients. bleeding can occur from nose, gums, gastrointestinal tract or urinary tract, or more commonly as petechial rash or easy bruisibility. the severity correlates with degree of thrombocytopenia or presence of disseminated intravascular coagulation (dic), most commonly observed in aml-m3. bone pains occur in less than 20% of patients.3 leukemic blast cells circulate and infiltrate other tissues. extramedullary involvement is the most common in monocytic and myelomonocytic leukemias and usually involves tissues like liver, spleen lymph nodes, gums, skin and cns. palpable splenomegaly and hepatomegaly occur in about one third of patients. pustules or other major pyogenic infections of the skin and of minor cuts or wound common. with severe neutropenia after chemotherapy however, major bacterial, fungal or viral infections become frequent. myeloid (granulocytic) sarcoma is an extra medullary tumor that occurs in 2 to 14% of cases of aml.3 the tumors are usually localized; they often involve bone, periosteum, soft tissues, lymph nodes, or skin. common sites are orbit and paranasal sinuses, but other sites may be involved. testicular infiltration is less common in aml than in all, with an incidence of 1 to 8%.4 meningeal disease has been reported to develop in 5 to 20% of children and up to 16% of adults with aml.3 the cns disease is associated with young age (<2 years), hyperleukocytosis, and the aml-m0 variants. the diagnosis of acute leukemia is based primarily on welldefined morphologic criteria and findings of cytochemical stains. immunophenotyping is also very important particularly in characterizing morphologically poorly differentiated acute leukemias. cytogenetics provide an important prognostic information and are becoming vitally important in classifying these leukemias (who classification) and also determining the appropriate treatment protocol. molecular studies are also helpful in journal of islamabad medical & dental college (jimdc); 1211(1):6-9 7 defining prognosis, response to treatment and identification of minimal residual disease. a number of clinical and biologic factors affect the outcome and response to treatment in aml patients. the chance of cure for a specific patient depends on a number of prognostic factors.5 in aml some differences in prognosis are seen among the different fab categories. cases of m5, m6, and m7 generally have a worse prognosis than those of m1-m4, and aml m0 has the worst prognosis. cure rates for promyelocytic leukemia can be as high as 98%.6 conversely, evidence of maturation of leukemic cells, such as the presence of granules or auer rods, strong positivity of sbb and positive reactions for non-specific esterase, is associated with a more favorable prognosis. other adverse prognostic factors include an age over 60 years, poor performance score before treatment, aml resulting from prior chemotherapy or antecedent mds, and a white-cell count of more than 20,000 per cubic millimeter or an elevated serum lactate dehydrogenase level at presentation. patients with t15; 17, t8; 21, t16; 16, and inv 16 have good prognosis. cure rates in clinical trials have ranged from 20– 45%.7 the objective of this study was to look into demographic features and clinical manifestations of acute myeloid leukemia and its various subtypes. patients & methods this was a cross-sectional study conducted at the department of pathology, pakistan institute of medical sciences (pims), islamabad, from july 2007july 2009. inclusion criteria: all freshly diagnosed cases of acute myeloid leukemia from all age groups and both sexes were included in the study. exclusion criteria: patients already diagnosed as aml, and receiving cytotoxic therapy were excluded. a detailed clinical history of patients especially regarding age, sex, duration of symptoms, fever, pallor, bone pain, bleeding and other constitutional symptoms were entered in specially designed performa. physical examination was also performed especially pertaining to lymphadenopathy, hepatomegaly, splenomegaly, purpuric or petechial rash and gum hyperplasia etc. in every patient, about 2.5 ml blood sample was collected in edta containing tube. complete blood picture was done on an automated hematology analyzer, sysmex kx-21. peripheral blood smears were freshly made and stained by wright stain and two slides were made for reticulocyte count by brilliant cresyl blue. all the patients were subjected to bone marrow aspirations using disposable lumbar puncture needle size 16g. bone marrow smears were stained by wright stain. in all cases cytochemical stains (sudan black b, non-specific esterase and pas) were performed, according to requirement. statistical analysis: all the findings (including clinical features, peripheral film and bone marrow findings) were entered on spss version 14 for final analysis. results in a total of 82 patients of aml belonging to all age groups, 45 (55%) were males and 37(45%) were females with male to female ratio of 1.2:1. age ranged from 2 months to 79 years with a mean age of 27.5 + 19.92 sd years. among them 26 (38%) were below the age of 15 years and 56 (68 %) were more than 15 years with adult to children ratio of 2.2:1. table1: frequency of aml subtypes (n= 82) subtype n (%) aml-m1 aml-m2 aml-m3 aml-m4 aml-m5 aml-m6 aml-m7 aml-m0 27 (33) 12 (15) 18 (22) 15 (18) 06 (7.2) 02 (2.4) 01 (1.2) 01 (1.2) `table 2: clinical features in aml clinical feature n (%) pallor 71 (86.6) bleeding 43 (52.4) fever 68 (82.9) weakness 31 (38) palpitation 02 (2.4) weight loss 08 (9.8) bone pains 15 (18.3) the most common subtype (table 1) was aml-m1 (33%) followed by aml-m3 (22%), aml-m4 (18%), aml-m2 (14.6%) and aml-m5 (7.3%). aml-m0, m6 and m7 were relatively infrequent. table 3: physical findings in aml subtypes physical finding aml-m1 n:27 n (%) amlm2 n:12 n (%) aml-m3 n:18 n (%) aml-m4 n:15 n (%) aml-m5 n:06 n (%) pallor 24 (89) 10 (83.3) 14 (77.8) 13 (86.7) 06(100) lymphadenopathy 06 (29.6) 04(32.3) 05 (28) 06 (40) 05 (83.3) hepatomegaly 16 (59.3) 04 (13.3) 05 (27.8) 07(46.7) 06(100) splenomegaly 14 (52) 05 (41.7) 05 (27.8) 07(46.7) 05 (83.3) gum hyperplasia 0 (00) 0(00) 01(5.6) 03 (20) 03 (50) journal of islamabad medical & dental college (jimdc); 1211(1):6-9 8 the most common presenting symptoms were pallor, fever and bleeding seen in 87%, 83% and 52.4% patients, respectively (table 2). other symptoms which were observed less frequently were weight loss (9.8%), weakness (38%), dyspnea (12.2%), easy fatigability (29%) and palpitation (2.4%). bone pains were noted in 18.3% patients. among the physical findings pallor was the most frequent (87%). hepatomegaly, splenomegaly, lymphadenopathy and gum hyperplasia were observed in 48%, 45%, 38% and 9.8% cases respectively. hepatosplenomegaly in majority of cases was mild to moderate type. as shown in table 3, hepatosplenomegaly was the commonest in aml-m5, m4 and m1. gum hyperplasia was most frequent in aml-m4 and m5 (3 cases each). these findings show that tissue infiltration was most common in aml-m5 and m4 and least frequent in patients of amlm3. discussion aml accounts for approximately 25% of all leukemias in adults in the western world, and therefore is the most frequent form of leukemia in this age group. 8 in the present study among the total of 82 patients belonging to all age groups, male to female ratio was 1.2:1.the same frequency of gender distribution has also been reported in different international and local studies, e.g. 1.5:1. 1.2:1 and 1.7:1. 9-11 however one of the studies done by frederick r. et al (to look for changes in biological features with age) shows an equal distribution of aml in both males and females. a study done by kumar l et al on clinico morphological features of aml shows male to female ratio of 2:1. 12 aml is primarily a disease of adults. overall incidence of aml increases with age. 13 patients newly diagnosed with aml have a median age of 65 years. 14 in our study the mean age was quite low i.e. 27.5 + 19.92 sd years. these results are comparable with another local study done at agha khan university hospital karachi to see the frequency of aml subtypes in their population and they found that the mean age of their patients was 32 years (ranging between 6 months to 85 years). 9 in a study done by hassan et al in 1993 on fab subtypes and clinico-hematological features of aml the mean age was different for different fab subtypes; for example they found that the mean age of m1, m2, m3 and m5 cases was between 25 and 29 years, whereas in m4 patients it was 45.6 years. 15 almost similar observations were also made in our study. in a study done at armed forces bone marrow transplant centre, to evaluate outcome of treatment on patients of patients of denovo aml, the median age of patients was 21 years (ranging from 7 to 56 years).11 the median age for aml is quite high in west as compared to our studies. in one of the studies done in u.k. on aml patients from 26 hospitals in south and west region, the median age was 67 years. 16 in another study done in spain on cytogenetic abnormalities of aml, median age was 61 years. (range was between 1 month-94 years) 17 reports from japan and australia show a mean age of 51 and 52 years, respectively.18 the reasons for the difference between age at presentation in subjects from the various regions are not clear. whether this represents a true geographic/ethnic difference is difficult to ascertain. but higher mean age in the west is probably due to overall higher mean age in these countries as compared to east. disrupted hematopoiesis leads to the most common presenting manifestations, i.e. anemia, infection, and bleeding tendency. among our patients majority presented with pallor and fever. bleeding was also a common presenting feature. bleeding however was a prominent symptom in aml-m3. most common types of bleeding were epistaxis, gum bleeding and easy bruisibility. in aml-m3, there is also risk of bleeding from other sites and the bleeding diathesis is either due to thrombocytopenia alone or as a part of dic. other features included weakness, easy fatigability, dysnea, palpitation, bone pains and weight loss. similar findings have been reported in different studies. 12,19-21 in one of the local studies done by qazi et al on bleeding diathesis in acute myeloid leukemia it was noted that dic was the most frequent in aml m3 (69 %), followed by in m5 (40 %), m2 (23.1 %), m4 (18.2 %) and m1 (16.6 %), respectively. 22 ghosh et al from tata memorial hospital reported that majority of their patients presented with fatigue and pallor. they also reported that bleeding was most commonly seen in acute promyelocytic leukemia and monocytic leukemia. 23 hepatomegaly and splenomegaly were observed in 48% and 45% patients respectively in our study. majority had mild to moderate hepatosplenomegaly. lymph node enlargement was noted in 38% patients. gum hyperplasia was seen inonly 10% cases and majority of them belonged to fab types m4 and m5. almost similar observations were made by kumar et al in 2004 (42% patients and comparatively lesser number of patients having splenomegaly or lymphadenopathy, however gum hypertrophy was noted in 24% patients compared to 10% in our study. 12 another interesting point which should be noted regarding this study is that majority of their patients with tissue infiltration belonged to aml-m4, m5 and m1 subtypes, the finding comparable to our results. hoffman has reported the presence of splenomegaly in 50% of his cases. 24 in another study done by ghosh et al, hepatosplenomegaly in 68 patients (26.2%) and lymphadenopathy was seen in 36% patients.23 two patients with acute myelomonocytic leukemia presented with extramedullary leukemia. both these patients presented with orbital masses and belonged to the pediatric age group. we also had one patient with testicular swelling (he was a case of aml-m5) and the other one with bilateral proptosis. similarly one of our patients presented with testicular swelling and when we journal of islamabad medical & dental college (jimdc); 1211(1):6-9 9 looked into the frequency of these findings in aml subtypes it was noticed that hepatosplenomegaly, lymphadenopathy and gum hyperplasia was most frequent in aml4, m5. tissue infiltration is seen more with monocytic and myelomonocytic leukemia than with other subtypes of aml. boils and mouth ulcers were seen in 6 patients. geographic variations have been reported in the distribution of extramedullary leukemia and are more frequently reported from the african countries such as uganda, egypt and turkey. acute myeloblastic leukemia is the malignancy of adults and depending upon its subtype has variable manifestations. references 1. jemal a, siegel r, ward e. cancer statistics, 2006. ca cancer j clin. 2006; 56: 106–130 2. redaelli a, lee jm, stephens jm, pashos cl. epidemiology and clinical burden of acute myeloid leukemia, expert rev. anticancer ther. 2003; 3:695–710. 3. john p, greer m, maria r and marsha c. kinney. acute myeloid leukemia in adults. in: wintrobe's clinical hematology. lippincott williams & wilkins, a wolters kluwer company philadelphia 11th edition 2004; pp 2097-2142 4. wiernik ph. extramedullary manifestations of adult leukemia. in: american cancer society atlas of clinical oncology adult leukemias. london: bc decker inc, 2001:275-292 cited by john p, greer m, maria r and marsha c. kinney. acute myeloid leukemia in adults. in: wintrobe's clinical hematology. lippincott williams & wilkins, a wolters kluwer company philadelphia 11th edition 2004; pp 2097-2142 5. estey e. prognostic factors in acute myelogenous leukemia. leukemia2001; 15 (4): 670–2. 6. sanz ma, lo coco f, martín g. definition of relapse risk and role of nonanthracycline drugs for consolidation in patients with acute promyelocytic leukemia: a joint study of the pethema and gimema cooperative groups. blood 2000; 96 (4): 1247–53. 7. matthews jp, bishop jf, young ga. patterns of failure with increasing intensification of induction chemotherapy for acute myeloid leukaemia. br. j. hematol 2001;113 (3): 727–36. 8. ries lag hd, krapcho m, mariottoa . seer cancer statistics review, 1975–2003. bethesda, md: national cancer institute. based on november 2005 seer data submission, posted to the seer website, 2006.6 9. harani ms, adil sn, shaikh mu, kakepoto gn, khurshid m. frequency of fab subtypes in acute myeloid leukemia patients at aga khan university hospital karachi. j ayub med coll abbottabad. 2005 ; 17(1):26-29. 10. braham-jmili n, sendi-senana h, labiadh s and ben abdelali r. hematological characteristics, fab and who classification of 153 cases of myeloid acute leukemia in tunisia. ann biol clin (paris). 2006; 64(5):457-65. 11. khalil ullah, ahmed p, raza s, satti tm, et al. management of acute myeloid leukemia 5 years experience at armed forces bone marrow transplant centre. rawalpindi j pak med assoc 2007; 57 (9): 434-439 12. kumar l, menon h, sharma a, wadhwa j, kumar r and kochupillai k. acute myeloid leukemia (aml): a study of 516 patients. journal of clinical oncology 2004; 22 (14) : 6711 13. ries lag em, kosary cl, hankey bf. seer cancer statistics review, 1975–2000. bethesda, md: national cancer institute; 2003. 14. forman d, stockton d and moller h . cancer prevalence in the uk: results from the europreval study. ann oncol 2003; 14:648–654. 15. hassan k, qureshi m, shafi s, ikram n, akhtar mj. acute myeloid leukemia-fab classification and its correlation with clinico-hematological features. j pak med assoc 1993; 43 (10):200-3 16. rule s, poirer v, singer c. management of acute myeloid leukemia. a regional audit in the south and west of united kingdom, clinical medicine 2001; 1 (4):313-316. 17. magdalena s, alvaro a , odero m, dolores o, belen gm. geographic differences in the incidence of cytogenetic abnormalities of acute myelogenous leukemia (aml) in spain. leukemia research 2006; 30 (8) :943-948 18. nakase k, bradstock k, sartor m, gottlieb d, byth k, shiku h, kamada n & the japanese cooperative group of leukemia/lymphoma (2000). geographic heterogeneity of cellular characteristics of acute leukemia: a comparative study of australian and japanese adult cases. leukemia, 14: 163-168. 19. ikram n, hassan k, ramzan m, and tufail s et al, leukemia in children, j pak institute of medical sciences 2003; 14 (1): 728-734 20. rogers lr. cerebrovascular complications in patients with cancer. semin neurol 2004; 24: 453–460. 21. mukiibi jm, nyirenda cm, adewuyi jo.leukemia at queen elizabeth central hospital in blantyre, malawi. east africa medical journal 2001; 78 (7):349-354 22. qazi r. beena hameed. bleeding diathesis in acute myeloid leukemia: thrombocytopenia alone or in disseminated intravascular coagulopathy. j pak inst med sci dec 2002; 13 (2):682-5 23. ghosh s, shinde sc, kumaran gs, `et al. hematologic and immunophenotypic profile of acute myeloid leukemia: an experience of tata memorial hospital indian journal of cancer. 2003; 40 (2): 71-76 24. miller kb, daonst pr. clinical manifestation of acute myeloid leukemia. in: hoffman r. editor. hematology basic principles and practice. 3rd edn. pennsylvania: churchill livingstone; 2000. 125 j i m d c 2 0 1 7 125 op e n ac c e ss f u l l l e n g t h a r t i c l e role of cytogenetics in gender confirmation hamna alvi1, aftab ahmad khan 2, rizwan uppal 3 1 , associate pathologist, islamabad diagnostic centre, assistant professor pathology, alnafees medical college, islamabad 2 consultant pathologist, islamabad diagnostic centre, assistant professor pathology, alnafees medical college, islamabad 3 assistant professor medicine, alnafees medical college, islamabad a b s t r a c t objective: to determine the karyotype of referred cases of gender ambiguity through cytogenetic study. patients and methods: this cross-sectional study was carried out at islamabad diagnostic centre, islamabad from april 2010 to june 2017. a total of 72 cases of gender ambiguity aged 1day to 35 years were referred to idc for chromosomal analysis and karyotyping during above mentioned period. out of these 72 cases, 37 presented with somewhat male-like external genitalia and 35 with more of female-like external genitalia but clear-cut gender differentiation was not possible on external physical examination. hence cytogenetics was performed on peripheral blood to confirm their chromosomal makeup. results: out of the total 72 cases, 12 cases that were suspected to be female on external physical examination, turned out to have male karyotype (46, xy). conversely 7 cases that were suspected to be male on external physical examination, turned to have female karyotype (46, xx). twenty seven cases with male-like clinical gender were confirmed to have male karyotype (46, xy) and 22 cases with female-like clinical gender were confirmed to have female karyotype (46,xx). conclusion: cytogenetic study is essential in confirming the chromosomal makeup of individuals born with ambiguous gender. it should be carried out as early as possible in life for appropriate brought up and social adjustment of the affected individual. keywords: ambiguous genitalia, cytogenetics, gender confirmation, karyotype author`s contribution 1 data analysis, interpretation and manuscript writing, active participation in data collection 2 conception, synthesis, planning of research and manuscript writing 3. interpretation and discussion address of correspondence aftab ahmed khan email: ahmadaftab65@yahoo.com article info. received: july 6, 2017 accepted: august 9, 2017 cite this article: alvi h, khan aa, uppal r. role of cytogenetics in gender confirmation jimdc. 2017; 6(3):125-129. funding source: nil conflict of interest: nil i n t r o d u c t i o n it is a great blessing of god almighty to be born normal and with a clear gender either male or female. indeed, it is a big stress for parents if the newborn has some congenital anomaly or the gender is ambiguous due to malformed external genitalia. such cases of gender ambiguity are not rare. their incidence is approximately 1 per 4500 live births.1 gender differentiation is under a complex control of specific genes on chromosomes along with hormonal regulation.2 while many cases are the result of virilising effect of adrenal hormones in congenital adrenal hyperplasia (cah), a significant number is because of genetic abnormalities resulting in true hermaphroditism, gonadal dysgenesis and pseudohermaphroditism.3 a newborn with ambiguous genitalia o r i g i n a l a r t i c l e 126 j i m d c 2 0 1 7 126 requires urgent evaluation to detect life threatening conditions such as salt-losing crisis in congenital adrenal hyperplasia (cah) and also for early assignment of gender to minimize the stress of parents having a baby with unidentified sex.4 a thorough physical examination of the patient along with relevant imaging tests, hormonal assay, molecular and cytogenetic assay is essential to make a correct diagnosis, so as to properly counsel the parents. proper gender assignment should be done at the earliest so as to make use of various therapeutic options to enable the affected child to develop into a psychosocially stable individual.5,6 initially, both male and female embryos have two pairs of genital ducts: mesonephric (wolffian) ducts and paramesonephric (mullerian) ducts.7 sex differentiation is a complex process involving many genes. the key factor to sex differentiation is y chromosome which contains sry gene (sex determining region on y) on its short arm (yp11). its presence determines the fate and development of sexual organs. under the influence of sry gene male development occurs and its absence leads to female development.8 some individuals carry a y chromosome but are phenotypically female (46 xy). this could be due to loss of sry gene. some patients are phenotypically male but have female karyotype (46, xx). this is due to translocation of sry gene on an x chromosome or some autosome.3 the genetic sex of embryo is established at the time of fertilization whereas phenotypic sex development occurs during the period of organogenesis when the gonads develop. apart from sex specific genes on x and y chromosomes, other autosomal genes also play a role in sex determination.9 patients of gender ambiguity are evaluated with cytogenetic analysis for detecting x and y chromosomes and determining the exact karyotype of the individual. ideally the baby born with ambiguous genitalia should be managed in a tertiary care setup by a multidisciplinary team including pediatric endocrinologist and urologist, geneticist, gynecologists and clinical psychologist with access to specialist lab and radiology services.10 p a t i e n t s a n d m e t h o d s a total of 72 cases of gender ambiguity, aged 1 day to 35 years, were referred to islamabad diagnostic centre, islamabad from april 2010 to june 2017 for cytogenetic analysis and karyotyping. out of these 72 cases, 37 presented with somewhat male-like external genitalia and 35 with more of female-like external genitalia but clear cut gender differentiation was not possible on external physical examination. hence cytogenetics was performed on peripheral blood to confirm their chromosomal makeup. in all cases heparinized peripheral blood samples were subjected to 72 hours‟ culture at 370 c on pbmax medium with phytohaemagglutinin (pha) as a stimulant for lymphocytic cells division induction and mitosis. after colchicine treatment, harvesting was done as per standard protocol. upto 20 metaphases were analyzed microscopically in each case after giemsa trypsin banding. r e s u l t s the study included 72 cases of ambiguous gender referred for cytogenetic analysis and karyotyping to confirm chromosomal makeup. among these 72 cases of ambiguous genitalia 46 (63.9%) cases were aged 1 day to 3 years while 08 (11.1%) cases belonged both to 4 to 7 years and 8 to 11 years‟ age groups. four (5.6%) cases were between 12 to 15 years and 6 (8.3%) belonged to 16 to 35 years of age. (table 1) table 1: age presentation in 72 patients of gender ambiguity variable no. of cases percentage 1day to 3 years 46 63.9 4 to 7 years 08 11.1 8 to 11 years 08 11.1 12 to 15years 04 5.6 16 years and above 06 8.3 on detailed chromosomal analysis of the 72 cases (table 2), interestingly 12 cases with provisional gender of female on physical examination turned out to be cytogenetically male with 46, xy karyotype while 7 cases with provisional gender of male turned out to be cytogenetically female with 46, xx karyotype. twentyseven cases who were suspected to have male gender on clinical examination were confirmed to have 46, xy male karyotype. similarly, 22 cases with clinical suspicion of female gender were confirmed to have 46, xx female karyotype. additional karyotypic findings were also noted in 4 cases which included: 45, xo/46, xy (p-), 46, xy with 127 j i m d c 2 0 1 7 127 small y chromosome but intact „p” and „q” arms, 47, xyy /45, xo mosaic and 45, xo turner‟s syndrome. figure 1: 46, xy male karyotype figure 2: 46,xx metaphase female karyotype figure 3: 46,xy with a small chromosome figure 4: 45,xo turner’s syndrome table2. a summary of findings in 72 cases predominant physical presentation karyotype no of cases phenotypically males (n-37) 46, xy male karyotype 27 46, xx female karyotype 07 45, xo/46, xy (p-) absent/small y chromosome with deleted short arm 01 46, xy with unusually small y chromosome but intact short and long arms. 01 47, xyy/45xo 01 phenotypically females (n=35) 46, xx female karyotype 22 46, xy male karyotype 12 45, xo turner‟s syndrome 01 128 j i m d c 2 0 1 7 128 figure 5: 47,xyy karyotype figure 6: 46,xypdeleted short arm of y chromosome d i s c u s s i o n disorders of sex development (dsd), formerly termed “intersex” conditions, arise from numerous causes. congenital adrenal hyperplasia (cah), secondary to 21hydroxylase deficiency is the most common cause of dsd. sex chromosome disorders, including sex chromosome mosaicism, are the second most common cause of dsd.11 the main purpose of our study was the cytogenetic evaluation of patients with ambiguous genitalia. determination of chromosomal karyotype is very important for the appropriate counseling and effective management of patients with gender ambiguity.12 sex determination is based upon presence or absence of y chromosome. as a general rule, xy embryos are males whereas xx embryos are females. however, many a times, hormonal influences during gestational period results in babies born with ambiguous external genitalia. this leads to social stresses for the parents as to whether to declare the newborn as a girl or a boy. many worried parents seek consultation of pediatricians for this purpose who advise imaging, hormonal and cytogenetic testing to confirm the gender of these babies born with ambiguous external genitalia. sometimes the testing is quite delayed due to lack of awareness on the part of the individuals concerned. hence early physical/clinical examination, hormonal and cytogenetic analysis is essential in presumptive etiological diagnosis in cases of disorders of sexual development (dsd).13 in our study, out of 72 cases of ambiguous genitalia referred to our center, 46 (63.9%) cases were of 1 day to 3 years of age while 08 (11.1%) cases were of 4 to 7 years of age. this is comparable to the report by pandit et al 3 in which among 50 cases of ambiguous genitalia 27 (54%) cases were of 1 day to 3 years of age and 09 (18%) were of 4 to 7 years of age. in both studies, around 3 quarter of the cases were less than 7 years of age. in our study 12 cases who were thought to be physically female turned out to be cytogenetically male with 46xy karyotype while 7 cases that were physically suspected to be male conversely turned out to be cytogenetically female having 46,xx karyotype. this further signifies the importance of cytogenetic studies early on in life so that exact chromosomal /genetic gender is confirmed for initiation of any therapy needed and appropriate brought up of the affected kid. in another study 156 cases with varied abnormalities of sexual development had cytogenetic analysis between 1991 till 2001. out of these 68 had been raised as males (43.6%) and 88 as females (56.4%). on chromosomal analysis 4 out of the 68 raised as males were found to have 46 xx karyotype.14 in our study, out of the 72 cases of ambiguous gender, 27 cases who presented with somewhat male-like ambiguous external genitalia were confirmed to have male (46, xy) karyotype on cytogenetic study. similarly, 22 cases presenting with female-like ambiguous external genitalia were confirmed to have female (46, xx) karyotype on cytogenetics. in another study, chromosomal 40 cases with ambiguous genitalia was done.15 out of these 20 were reared as males and 20 as females. while 8 cases were below the age of one year, 18 (45%) were in the age bracket of 1-5 years. in these 40 cases, 21 had 46 xy karyotype, 13 had 46, xx karyotype, 2 cases showed true hermaphroditism i.e. 46, 129 j i m d c 2 0 1 7 129 xx/46 xy karyotype while 4 cases showed mosaic pattern with 46, xo/46, xy karyotype. c o n c l u s i o n cytogenetic study is a vital tool in confirming the gender of patients born with ambiguous external genitalia. the earlier this study is carried out, the better it is for appropriate counseling of parents and initiation of any therapy needed. delay in determining the gender of the individual leads not only to social stresses for the parents but also hampers the appropriate brought up of the individual with associated psycho-social effects and adjustment issues in later life. hence there is need to create awareness amongst the masses about the availability of genetic testing to know the exact gender of the individuals born with ambiguous external genitalia early on in their life. r e f e r e n c e s 1. al-agha ae, thomsett mj, batch ja(2001) the child of uncertain sex : 17 years of experience. j paediatric child health 37: 348 351. 2. frimberger d, gearhart jp (2005) ambiguous genitalia and intersex. urol int 75: 291-297. 3. pandit aa, akbar s, faheem s, malla tm, zargar mh et al. (2015) molecular and cytogenetic evaluation of gender in patients born with ambiguous genitalia from different regions of the valley of kashmir, north india. j genet syndr gene ther 6:261. doi:10. 4172/2157-7412.1000261. 4. al-mutair a, iqbal ma, sakati n, ashwal a. cytogenetics and etiology of ambiguous genitalia in 120 pediatric patients. ann saudi med. 2004; 24(5):368-72. 5. s.m.lambert, e.j.vilain, t.f.kolan .a practical approach to ambiguous genitalia in the newborn period. urol clin north am 2010; 37(2):195-205. 6. american academy of pediatrics. evaluation of the newborn with developmental anomalies of the external genitalia. paediatrics 2006; 106: 138-142. 7. langman‟s medical embryology. 12th edition; 246. 8. langman‟s medical embryology. 12th edition; 243. 9. damiani d, fellous m, mcelreavy k, barbaux s, barreto es et al. (1997) true hermaphroditism: clinical aspects and molecular studies in 16 cases. eur j endocrin 136: 201-204. 10. ogilvy-stuart al, brain ce. early assessment of ambiguous genitalia. archives of disease in childhood 2004; 89:401 407 11. lei zhang, linda d. cooley, sonal r. chandratre, atif ahmed, and jill d. jacobson, “a newborn with genital ambiguity, 45,x/46,xy mosaicism, a jumping chromosome y, and congenital adrenal hyperplasia,” case reports in endocrinology 2013, article id 747898. doi:10.1155/2013/7 47898 12. forest mg (1992) etiopathogenesis, classification, investigation and diagnosis in intersex. indian j pediat 59:475-485. 13. atta i, ibrahim m, prakash a, lone sw, et al. etiological diagnosis of undervirilized male/ xy disorder of sex development. journal of the college of physician and surgeons pakistan 2014; l.24 (10):714-718. 14. kaur a, mahajan s, singh jr (2004) cytogenetic analysis in cases with sex anomalies. int j hum genet, 4(3):167-171 (2004). 15. kumari va et al. ambiguous genitalia: a clinical and chromosomal study. int j res med sci. 2015; 3(12):3743 3748. https://www.ncbi.nlm.nih.gov/pubmed/?term=al-mutair%20a%5bauthor%5d&cauthor=true&cauthor_uid=15573851 https://www.ncbi.nlm.nih.gov/pubmed/?term=iqbal%20ma%5bauthor%5d&cauthor=true&cauthor_uid=15573851 https://www.ncbi.nlm.nih.gov/pubmed/?term=sakati%20n%5bauthor%5d&cauthor=true&cauthor_uid=15573851 https://www.ncbi.nlm.nih.gov/pubmed/?term=ashwal%20a%5bauthor%5d&cauthor=true&cauthor_uid=15573851 j islamabad med dental coll 2019 70 open access comparative study of conventional electrocautery versus ultrasonic dissector in laparoscopic cholecystectomy saad bin anis 1, pir muneeb rehman 2, farhan ahmad 3, umar farooq 4 1 resident, department of neurosurgery, agha khan university hospital, karachi 2 consultant, department of surgery, life care hospital, bahria town, lahore 3 resident, department of general surgery, jinnah hospital, lahore 4 resident, department of surgery jinnah hospital, lahore a b s t r a c t background: laparoscopic cholecystectomy (lc) is very commonly performed for removal of gallstones. in routine, ultrasonic devices are used for laparoscopy involving the deeper operating fields, while electrosurgical devices are preferred for lc. however, nowadays both of these devices are used for lc. the objective of this study was to compare the surgical outcomes of ultrasonic dissector over conventional electrocautery in patients planned for lc. material and methods: this non-randomized clinical trial was conducted in general surgery unit, jinnah hospital lahore. the study duration was 15th january 2015 to 31st december 2016. in group a (n=100), patients were operated through three-port standard laparoscopic cholecystectomy and conventional electrosurgical cautery was used for dissection. while in group b (n=50), patients were operated through single incision laparoscopic surgery (sils) and harmonic dissector was used for sealing of cystic artery and cystic duct. spss version 23 was used for data analysis. complications between electrocautery and ultrasonic dissector were compared using chi-square test/fischer exact test and operative time was compared using student’s t-test with p-value ≤ 0.05 considered as statistically significant. results: out of 150 patients planned for laparoscopic cholecystectomy, 33 (22%) were males and 117 (78%) females. the mean age was 40±6.45 years with an age range of 12-80 years. in group a, intraoperative gall bladder perforation was found in 5 patients whereas in group b, there was only one patient with perforation. a total of 4 cases were converted to open cholecystectomy in group a due to difficult dissection in calot’s triangle as compared to 1 case in group b. in group a, 3 cases had postoperative bile leakage in the drain. in two patients it settled over a period of 3 days. about 03 cases had wound infection in group a and 1 in group b. mean operative time in group a was 42.2±8.93 minutes versus 35.7±4.85 minutes in group b (p-value 0.001). conclusion: in this study, the rate of post-operative complications was similar between the two groups, but operative time was significantly shorter in the group b. harmonic dissector enabled easy dissection of tissues with good hemostasis and less trafficking of instrument, avoiding use of clips and sutures during minimal invasive surgery. key words: electrocautery, laparoscopic cholecystectomy, ultrasonic dissector authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3 interpretation, discussion, active participation in data collection 4 data analysis. correspondence: pir muneeb rehman email: dr_pm@outlook.com article info: received: january 8, 2019 accepted: april 19, 2019 cite this article. anis s, rehman pm, ahmad f, farooq u. comparative study of conventional electrocautery verses ultrasonic dissector in laparoscopic cholecystectomy. j islamabad med dental coll.2019; 8(2):70-73 funding source: nil conflict of interest: nil i n t r o d u c t i o n laparoscopic cholecystectomy (lc) is very commonly performed for removal of gallstones.1 ultrasonic and electrosurgical energy dissectors are commonly used dissection devices during lc.2 these high energy devices are used during surgical procedures to reduce blood loss intraoperatively and at the same time used to cut, o r i g i n a l a r t i c l e j islamabad med dental coll 2019 71 coagulate, desiccate or fulgurate the tissues. the conventional electrocautery uses electrical current for achieving these goals during surgery either open or laparoscopic. it is of two types, in unipolar the current goes through the patient to complete the current cycle and in bipolar cautery, the current flows through tissues between the electrodes of the instrument.3 however, its use during lc can cause damage to the adjacent organs such as common bile duct, stomach or intestines. it can also cause liver injury, loss of bile or gallbladder perforation.4 ultrasonic (harmonic) scalpel was developed to resolve this issue.5 harmonic dissector (hd) was introduced in 1992 by ethicon endo surgery usa, and surgeons have used this instrument in more than 14 million procedures worldwide. with this instrument ultrasonic vibrations are generated at the probe which generates friction. it produces vibrations in the range of 20,000 to 50,000 hz and this friction leads to denaturation of proteins, which leads to coagulation and as heat goes up to 200ºc, tissue is transected with minimal collateral damage. 6 ultrasonic dissectors are new addition in the instruments for laparoscopic procedures, and perform dissection and ligation of vessels by coaptation and cavitation. 7 in routine, ultrasonic devices are used for laparoscopy involving the deeper operating fields, while electrosurgical devices are preferred for lc.8 however, nowadays ultrasonic dissectors have also started being used during routine lc procedures.9,10 the present study was designed to compare the surgical outcomes of ultrasonic dissector with conventional electrocautery dissection used for laparoscopic cholecystectomy m a t e r i a l a n d m e t h o d s this non-randomized clinical trial was conducted at general surgery unit jinnah hospital lahore from 15th january 2015 to 31st december 2016. out of total 150 patients that were planned to undergo lc, 130 were admitted through opd and 20 patients through emergency. this study was approved by ethical review committee of jinnah hospital, lahore. patients fit for general anesthesia and willing for laparoscopic cholecystectomy were included, while patients with preexisting cardio respiratory comorbid factors, having more than one previous abdominal surgical scars, presenting after four days of acute cholecystitis or having choledocholithiasis along with gall stones were excluded from the study. after taking written informed consent, the principal investigator divided the patients into two groups. in group a (n=100), patients underwent standard three-port approach and conventional electrosurgical cautery was used for dissection. while in group b (n=50), patients were operated through single incision laparoscopic surgery (sils) and hd was used for sealing of cystic artery and cystic duct. after giving preoperative antibiotic, cephalosporin (1 gm) and general anesthesia, patients were prepared. pneumoperitoneum was created using co2 in all patients through veress needle. sils was done by giving a supraumbilical incision (ranging from 1.5-2.5cm). drains were placed in few cases of electrocautery group and no drain in harmonic dissector group. after lc, patients were kept in ward for 24-48 hrs. antibiotics, i/v fluids and analgesia was given according to the status of the patients. surgical outcomes were measured in terms of total procedural time and frequency of post-operative complications such as gall bladder perforation, conversion to open cholecystectomy, postoperative bile leak and wound infection. spss version 23 was used for data analysis. complications between electrocautery and ultrasonic dissector were compared using chi-square test/fischer exact test and operative time was compared using student’s t-test with p-value <0.05 considered as statistically significant. r e s u l t s out of 150 patients planned for laparoscopic cholecystectomy, there were 33 (22%) males and 117 (78%) females. age range of patients was 12-80 years with a mean age of 40±6.45 years. intraoperative gall bladder perforation and wound infection was more in group a and more cases were converted to open cholecystectomy due to difficult dissection in calot’s j islamabad med dental coll 2019 72 triangle. in group b, only 1 incision was extended as anatomy was not clear in calot’s triangle. in group a, out of 3 cases that had postoperative bile leakage in the drain, two patients settled down over a period of 3 days. endoscopic retrograde cholangio-pancreatography (ercp) was performed in one patient and accidental stone was found in common bile duct (cbd) which was retrieved by papillotomy. range of operative time in group a and b was 35-70 minutes and 33-40 minutes. mean operative time in group a was more as compared to group b (table i) table i. comparison of factors assessing surgical outcomes in patients undergoing laproscopic cholecystectomy variables group a (n=100) n (%) group b (n=50) n (%) p-value operative time (mins) mean±sd 42.2±8.9 35.7±4.9 0.0001 gall bladder perforation 5 (5) 1 (2) 0.37 conversion to open procedure 4 (4) 1 (2) 0.52 post-op bile leakage 3 (3) 0 (0.0) 0.55 wound infection 3 (3) 1 (2) 0.72 d i s c u s s i o n in gallbladder surgery, a decrease in operative blood loss, less local thermal damage to tissue, less gallbladder perforation and common bile duct injury, less intraoperative time and more cost effectiveness are the aims. this can be achieved when the equipment, technique, and experience reach the optimum level of requirement.11 we found that hd is multi-functional in performance as it is used for dissection, sealing of vessels and cystic duct and it obviates the exchange of instruments such as l hook. there is no smoke produced during its use which is inherent with electrocautery use. there is only snow falling effect which does not hinder the vision over the monitor and decreased the operative time. there is good securing of hemostasis during dissection and little need of irrigation. on the other hand, in electrocautery group there are problems during dissection, difficulty in securing hemostasis and because of smoke release vision was blurred. all these lead to an increase in the operative time, increased incidence of complications such as gall bladder perforation, postoperative drain placement, postoperative bile leakage and wound infection. these factors also lead to increased dose of analgesia in postoperative period in the ec group. a study by jain et al showed that use of hd during lc is associated with shorter procedural time, taking less time to remove gallbladder from its bed, low pain score and less blood loss. also, they reported shorter hospital stay with the use of hd but they did not report any incidence of major complications or bile leak during a 6-month followup period in either of the groups.6 another study from egypt reported operative time of 33.21+9.6 minutes in hd group as compared to 51.7+13.8 minutes in ec group. the authors also reported lower rate of conversion in hd group and no risk of bile leakage and very small amount of blood loss. these authors further concluded that hd provides complete hemobiliary stasis and is a safe alternative to standard clipping of cystic duct and artery. it provides a shorter operative duration, less incidence of gallbladder perforation, less postoperative pain, and less rate of conversion to open cholecystectomy.11 sanawan et al. found that blood loss and procedural time is reduced using hd during lc.10 ramzanali at al. also reported that multiple functions can be safely performed using harmonic scalpel such as cavitation, coaptation and cutting and is safer and reliable when compared with conventional electrocautery dissector.10 shabbir et al. and ali et al. found significantly higher gallbladder perforation rate using electrocautery when compared to harmonic scalpel during lc.12,13 outcome of our study in terms of operative time, gallbladder perforation, postoperative bile leakage, preoperative hemobilliary stasis, conversion to open cholecystectomy correlates with the above-mentioned studies. c o n c l u s i o n in this study, the rate of post-operative complications was similar between the two groups but operative time was significantly shorter in the group b in comparison with the j islamabad med dental coll 2019 73 conventional method. during surgery, it was observed that hd makes dissection of tissues easy with good securing of hemostasis, less trafficking of instruments and less use of clips and sutures. there were also minimal chances of injury to adjacent structures as compared to ec group. r e f e r e n c e s 1. agresta f, campanile fc, vettoretto n, silecchia g, bergamini c, maida p, et al. laparoscopic cholecystectomy: consensus conference-based guidelines. langenbeck's arch surg. 2015; 400(4): 429-53. doi: 10.1007/s00423-015-1300-4 2. alkatout i, schollmeyer t, hawaldar na, sharma n, mettler l. principles and safety measures of electrosurgery in laparoscopy. j soc laparoendosc surg. 2012; 16(1): 130. doi: 10.4293/108680812x13291597716348 3. lee c-l, huang k-g, wang c-j, lee p-s, hwang l-l. laparoscopic radical hysterectomy using pulsed bipolar system: comparison with conventional bipolar electrosurgery. gynecol oncol. 2007; 105(3): 620-4. doi: 10.1016/j.ygyno.2007.01.029 4. wolfe bm, gardiner b, frey cf. laparoscopic cholecystectomy: a remarkable development. j am med assoc. 2015; 314(13): 1406. doi:10.1001/jama.2014.12014 5. williams n, o'connell pr. bailey & love's short practice of surgery 26th ed: crc press; 2013. 6. jain sk, tanwar r, kaza rcm, agarwal pn. a prospective, randomized study of comparison of clipless cholecystectomy with conventional laparoscopic cholecystectomy. j laparoendosc adv surg tech. 2011; 21(3): 203-8. doi: 10.1089/lap.2010.0455 7. devassy r, hanif s, krentel h, verhoeven hc, torres-de la roche la, de wilde rl. laparoscopic ultrasonic dissectors: technology update by a review of literature. med devices (auckl). 2019; 12:1. doi: 10.2147/mder.s113262 8. park ae, mastrangelo jr mj, gandsas a, chu u, quick ne, editors. laparoscopic dissecting instruments. semin laparosc surg. 2001; 8(1): 42-52 pmid: 11337736 9. sanawan e, qureshi au, qureshi ss, cheema km, cheema ma. effectiveness of ultrasound shear for clipless laparoscopic cholecystectomy versus conventional unipolar electrocautery in patients with cholelithiasis. j coll phys surg pak. 2017; 27(10) :00. doi: 2719. 10. ramzanali sa, shah ssh. monopolar electrocautery versus ultrasonic dissection of the gallbladder from the gallbladder bed in laparoscopic cholecystectomy. j ayub med coll abbottabad. 2013; 25(3-4): 16-8. pmid: 25226730 11. kandil t, el nakeeb a, el hefnawy e. comparative study between clipless laparoscopic cholecystectomy by harmonic scalpel versus conventional method: a prospective randomized study. j gastrointest surg. 2010; 14(2): 323-8. doi: 10.1007/s11605-009-1039-8 12. shabbir a, hussain s. comparison of gallbladder perforation during dissection from liver bed in patients undergoing monopolar electrocautery with those undergoing ultrasonic dissection during lap. cholecystectomy. pak j med health sci. 2016; 10(4): 13902. 13. ali m, akbar a, khan mur, ullah mh. comparison of incidence of gallbladder perforation in laparoscopic cholecystectomy with harmonic scalpel vs electrocautery. pak j med health sci. 2015; 9(2): 511-3. j islamabad med dental coll 2020 4 ope n acce ss covid-19 pandemic: impact on countries with weak health systems muhammad ahmed abdullah1, farah rashid2 1assistant professor, department of community medicine, islamabad medical and dental college 2professor and head, department of community medicine, islamabad medical and dental college the whole world has swiftly been overtaken by the covid-19 pandemic within a short span of time. the total number of positive cases is 423,882 with 18,926 deaths globally1, on the day this manuscript was written. the disease rates blew up so rapidly with the help of technology. it spread from its epicenter through person to person contact,1 central heating and cooling systems in cruise ships, 2 and spread to other countries though planes and ships.3 it is further spreading within countries mostly though public transport and gatherings. we are constantly being told that things will get worse before they get any better. the situation in europe and america looks grave, while china, the origin of the infection seems to have controlled the outbreak through a robustly authoritarian approach. markets are plummeting and businesses around the world are going bankrupt.4 this is not the first time that humans have faced a pandemic of this proportion, but it is definitely the first time we are facing one, in a world controlled by technology. the world health organization had warned during the early period of this outbreak that this virus would have a devastating effect on the countries with weaker health systems.5 this has been proven true in the case of iran,6 however it also has far worse impacts on the countries with apparently the best healthcare systems of the world. italy, spain, united states of america and germany are struggling immensely and are deeply affected by constantly escalating mortality and morbidity caused by the virus.7 a multitude of factors can be associated with such an outcome. countries in south asia and africa have generally evaded the devastating effects of this virus. these countries share hotter and humid climates, the average hygiene level of the people exposes them to a large number of microorganisms on a daily basis. these countries also have shorter life expectancies and hence have a greater proportion of young people in their populations. herd immunity might also be playing a role in this regard, with the virus floating freely in the masses. the recent discovery that sars cov2 can be transmitted through saliva and fecal contact might also be loading the population with an immunizing dose unknowingly in a similar manner, as the polio virus does. in our part of the world, we have been bracing for impact for a few weeks now, after watching the developed world crumble in the face of this unseen enemy; an impact that might never appear. what happened in italy is unprecedented, supporting the general opinion that the virus apparently mutated into a much more aggressive strain when it landed in the country. italy has the highest geriatric population in europe with around 30% people above 60 years of age. thus the virus had enough vulnerable population to infect giving e d i tor i a l correspondence: muhammad ahmed abdullah email: drahmedabdullah83@gmail.com cite this editorial: abdullah ma, rahid f. covid-19 pandemic: impact on countries with weak health systems. j islamabad med dental coll. 2020; 9(1):4-5. doi: 10.35787/jimdc.v9i1.523 j islamabad med dental coll 2020 5 rise to a large number of highly symptomatic cases, who were shedding large doses of the virus through coughing and sneezing.7 this might have exposed other age groups to large doses of the virus as well, leading to the healthcare system on the verge of collapse under this burden of death and disease. the same model is being replicated in the rest of europe. lastly, we would like to state that unrealistic fears and phobias spread by the media and social media are not helping, as they are often not based on scientific evidence. fear reduces human immunity and makes people susceptible to a wide range of diseases and adverse outcomes. in this time of myths and fallacies, the media needs to play an extremely important role of awareness and health promotion based on scientific evidence . r e f e r e n c e s 1. paules ci, marston hd, fauci as. coronavirus infections—more than just the common cold. jama. published online january 23, 2020. doi:10.1001/jama.2020.0757 2. rocklöv j, sjödin h, wilder-smith a. covid-19 outbreak on the diamond princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. j travel med. 2020. doi:10.1093/jtm/taaa030 3. bogoch ii, watts a, thomas-bachli a, huber c, kraemer mu, khan k. potential for global spread of a novel coronavirus from china. j travel med. 2020; 27(2): taaa011. doi: 10.1093/jtm/taaa011 4. haushofer j, metcalf cj. combining behavioral economics and infectious disease epidemiology to mitigate the covid-19 outbreak. working paper, princeton university. 2020. 5. sohrabi c, alsafi z, o’neill n, khan m, kerwan a, al-jabir a, iosifidis c, agha r. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid19). int j surg. 2020; 76: 71-76. doi: 10.1016/j.ijsu.2020.02.034 6. arab-mazar z, sah r, rabaan aa, dhama k, rodriguez-morales aj. mapping the incidence of the covid-19 hotspot in iran–implications for travellers. travel med infect dis. 2020; 14: 101630. doi: 10.1016/j.tmaid.2020.101630 7. remuzzi a, remuzzi g. covid-19 and italy: what next?. the lancet. 2020. doi: 10.1016/s01406736(20)30627-9. j islamabad med dental coll 2021 56 open access histomorphometric alterations in hepatic tissue from malathion-induced toxicity: an experimental animal study shazia parveen channar1, nasreen qazi2, sajjad ali almani3, sehar gul memon4, mansoor mukhtar qazi5, rida qureshi5 1senior lecturer, department of pharmacology, isra university, hyderabad pakistan 2professor and chairperson, department of pharmacology & therapeutics, lumhs, jamshoro pakistan 3assistant professor, department of anatomy, dow medical university karachi pakistan 4lecturer, department of physiology, ghad college, riyadh, saudi arabia 5lecturer, department of anatomy, isra university, hyderabad pakistan a b s t r a c t background: malathion, a widely used insecticide readily absorbed through skin and seriously affects different tissues and organs of the body. the main objective of this study was to compare the histomorphometric alterations resulting from hazardous effects of different doses of malathion on hepatic tissue of male albino wistar rats. material and methods: this animal experimental study was conducted at the department of anatomy and postgraduate research laboratory at the isra university, hyderabad, sindh pakistan from february to july 2019. th irty male albino wistar rats between 250 -300 grams weight were distributed equally into group a (control), group b (low dose malathion group; 27mg/kg 1/50 of ld50), and group c (high -dose malathion group; 50mg/kg). bodyweight of all rats was taken twice, before and after the experiment. the liver was dissected out, washed and weighed. histopathological examination was done under the light microscope. grading was done for severity in histopathological changes in each group. data was analyzed using one -way anova and post-hoc tukey test for comparison with the level of significance set at p-value ≤ .05. results: statistically significant (p < .05) decline in body weight was observed in groups b and c in comparison with group a. the relative weight of the liver was increased significantly (p < .05) in the experimental groups, when compared with the control group. mild-to-moderate histopathological changes were observed in the low-dose malathion group (group b) while moderate -to-severe histopathological changes were demonstrated in the high-dose group (group c). conclusions: malathion is a potent toxic pesticide and its exposure can exhibit damage to the hepatic tissues in a dose dependent manner. key words: albino wistar rats, hepatotoxicity, malathion, pesticide. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; manuscript editing. correspondence: mansoor mukhtar qazi email: dr.lumhs119@yahoo.com article info: received: april 16, 2020 accepted: december 17, 2020 cite this article. channar sp, qazi n, almani sa, memon sg, qazi mm, qureshi r . histomorphometric alterations in hepatic tissue from malathion-induced toxicity: an experimental animal study. j islamabad med dental coll. 2021; 10(1): 56-61. doi: 10.35787/jimdc.v10i1.534 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2021 57 i n t r o d u c t i o n organophosphate compounds (op) like malathion are widely used around the globe as insecticides. op are routinely used for the eradication of household insects and ectoparasites, elimination of diseasecausing arthropods and to protect stored grains. 1,2 it is also used for eradication of the vectors of different vector-borne diseases in households as well as the agriculture sector.3 other than pests and insects, several animal species are affected by these toxic compounds and act as a source of toxicity for the human population.4 these compounds degrade in the atmosphere and cause diverse degrees of poisoning that not only dangerously affect the environment but also pose hazardous effects on crops, animal, and health of the humans. 3,5,6 in developing countries like pakistan, op compounds like malathion is the foremost reason of environmental poisoning.6,7 it is a topical agent and being lipophilic, gets rapidly absorbed through the skin. it can also be absorbed through nasal and oral routes. soon after the absorption, malathion disintegrates into a very toxic metabolite called malaoxon. this metabolite is sixty-one times more toxic than malathion. it is also lipophilic and directly interacts with the cellular plasma membrane resulting in lipid peroxidation and membrane damage.7,8 prolonged exposure to malathion through water and food products causes serious pathological effects including hepatotoxicity, nephrotoxicity, neurotoxicity, pancreatitis, hematological disorders, fertility issues, venous thrombosis as well as carcinomas.9 studies have reported harmful effects of these malathion-containing pesticides on human health ranging from mild headaches and body aches to respiratory distress, hormonal issues among women, hepatic issues and even death. 3,9 moreover, studies also reported the harmful effects of malathion on the different tissues and organs of the body of humans and animals.10,11 the liver is not only a vital organ but also a chief metabolizing site for the bio-transformation of malathion and its toxic metabolites. hepatic tissues are considered to be the most exposed tissues to malathion toxicity. 12,13 there is a significant knowledge gap regarding the dose-wise hazardous effects of commonly used pesticides like malathion on different organs of the body. therefore, the current study was designed to compare the hazardous effects of malathion, in different doses, on the hepatic tissue of male albino wistar rats. m a t e r i a l a n d m e t h o d s this animal experimental study was carried out in the department of anatomy and postgraduate research laboratory at the isra university, hyderabad, sindh from february 2019 to july 2019. the study was approved by the research and ethical review committee of isra university, hyderabad pakistan (ref no: iu/rr-10-irc-19/n/2019/1827). sample size was calculated using the standard method of power analysis for animal studies. 14 thirty male albino wistar rats were procured from the agriculture university of tando jam, sindh by nonrandom purposive sampling technique. male albino wistar rats, aged 8-10 weeks, weighing between 250 to 300 grams and without any disease or deformity were included in the study. the handling of all rats was as per the standard guidelines for animal studies. they were housed in a well-equipped and hygienic environment at an optimum temperature of 24-26℃ in a day-night cycle of 12/12 hours. before the initiation of the experiment, animals were acclimatized to the environment for ten days. rats were provided free access to chow diet and clean water ad libitum. j islamabad med dental coll 2021 58 all rats were equally divided (n=10 in each group) into, group a (control group and given a normal chow diet, clean water ad libitum daily for two weeks), group b (malathion low-dose experimental group, provided 27 mg/kg body weight/day malathion equivalent to 1/50 of ld50 for oral dose15 along with normal chow diet, clean water ad libitum daily for the same duration) and group c (malathion high-dose experimental group, provided 50 mg/kg body weight/day along with normal chow diet, clean water ad libitum daily for the same duration).16 soon after the acclimatization period, the bodyweight of all rats was measured twice, that is before initiation of the experiment and after completion of two weeks of the experiment using an electronic precision balance. after two weeks, all the rats were anesthetized (inj. sodium pentobarbital 40mg/kg intraperitoneally) and sacrificed by cervical dislocation. the liver was removed after dissection and weighed using the same balance and then washed with normal saline. hepatic tissue was fixed in 10% formalin and routinely processed for 4 µm thick sections and stained with hematoxylin and eosin stain. histopathological analysis of hepatic tissue was done by evaluating the degree of sinusoidal dilation, infiltration of inflammatory cells, vascular congestion, hemorrhage, necrosis, and vacuolar degeneration. the changes in severity were recorded using a graded scale used from a previous study.17 the grading scale consists of rankings according to tissue damage; none (0), mild (i), moderate (ii) and severe (iii). statistical analysis of data was performed using spss version 24. findings of measures like body and liver weights were expressed as mean and standard deviation while their comparison was analyzed by one-way anova and post hoc tuckey analysis. the level of significance was set at p-value ≤ .05. r e s u l t s the preand post-exposure body weight and weight of liver were compared between the different groups (a, b & c). a statistically significant decline in the bodyweight was found in group c in comparison with groups b and a. moreover, a significant decline in the relative weight of the liver was observed in group c as compared to groups b and a (table i). the light microscopic findings revealed the deleterious effects of malathion administration in different doses on the normal histology of rat hepatic tissues compared with the control group. the liver of control group rats showed evident sinusoids in most of the places, normally arranged hepatocytes with centrally placed nuclei, normally appearing vesicular as well as uniformly appearing cytoplasm (figure 1a). mild-moderate histopathological changes in the liver parenchyma included infiltration of mononuclear inflammatory cells around the central hepatic vein, hemorrhage, vascular congestion, and sinusoidal dilation. these changes were observed in the low-dose malathion group (group b) in comparison with the control group (figure 1b). moreover, moderate-severe histopathological alterations like more pronounced hepatocyte condensation with distorted plasmalemma, infiltration of mononuclear inflammatory cells and marked sinusoidal dilation was observed in the hepatic tissues of high-dose malathion group rats (group c). distorted pyknotic nuclei and hyalinized cytoplasm, marked vacuolar degeneration, hemorrhage and necrotic changes were also observed in this group (figure 1c). table ii demonstrates the grade -wise comparison summary of all the histopathological changes in hepatic tissues observed in each group under light microscopy (table ii). j islamabad med dental coll 2021 59 table i: preand post-malathion exposure mean body weight and mean relative weights of the liver in different groups group a group b group c p-value mean ± sd mean ± sd mean ± sd pre-exposure body weight (gm) 261.4±4.3 259.2±4.1 263.1±4.4 .38 post-exposure body weight (gm) 262.2±4.1b,c 222.8±3.8a,c 211.1±3.5a,b .001* relative weight of liver (gm/100 gm) 3.24±0.25 5.20±0.39 6.19±0.43 .001* * statistically significant difference between the groups on anova a,b,cdenote the statistically significant difference between control and malathion treated groups, resp ectively through post hoc tukey (p < .05). figure 1: histology of hepatic tissue of experimental animals (h&e; x400). a: photomicrograph showing the normal architecture of the liver (control group a). b: photomicrograph of section of liver showing the effect of malathion 27 mg/kg (low dose group b). c: photomicrograph showing more toxic effects of malathion 50mg/kg (high dose group c) on liver. table ii: grading-wise comparison of histopathological changes in hepatic tissues of rats groups cellular infiltration sinusoidal dilation hemorrhage vascular congestion vacuolar degeneration necrosis a 0 0 0 0 0 0 b i ii i ii 0 0 c iii iii iii ii ii iii group a-control group; group b-low dose malathion group; group c-high dose malathion group grading score follows: none (0), mild (i), moderate (ii) and severe (iii) d i s c u s s i o n the use of pesticides like malathion leads to its lingering effects in the environment for a variable span. this residue of malathion contaminates plants, crops, water as well as other food sources of humans and animals, and therefore considered an eminent chronic hazard to both.18 the current study compares the changes in the body weight, liver weight and the morphological changes in the liver of rats exposed to malathion with unexposed rats. there was a significant reduction in the body-weight gain of malathion-treated groups as compared with the control group, and more so in the group receiving high dose of the toxic agent. on the other hand, a significant increase in the relative weight of the liver in the treated groups was observed. these findings are consistent with selmi j islamabad med dental coll 2021 60 et al., who also demonstrated the alterations in morphometric parameters in their studies following malathion induction.19 these morphological variations may result from the characteristic of inhibition of acetylcholinesterase enzyme that includes the accumulation of acetylcholine resulting in stimulation of different receptors (nicotinic, cholinergic and muscarinic receptors) and neurological alterations in malathion treated group of rats.20n the main objective of the present study was to observe the hepatotoxic effects of different doses of malathion. none of the rats died during the duration of the experiment. we observed moderate to severe histopathological in the mentioned doses of malathion. different studies also observed the toxic effects of malathion on hepatic tissues of rats. a study conducted by hosseini et al. observed similar hepatotoxic changes in their experimental animals with the use of malathion.21 another study by gupta et al. reported disorganization of the normal hepatic architecture after malathion exposure.17 while severcan et al. observed the hepatic as well as biochemical alterations in their rats after giving malathion 100mg/kg, 200mg/kg and 400mg/kg.22 abdel salam et al. also demonstrated the deleterious effect of malathion on the liver primarily causing structural and functional disruption in hepatocytes.23 the present study did not observe the hematological effects of malathion on rat’s blood which is one of the limitations of this study. several other studies observed that malathion induction results in the alterations of hematological parameters in clinical cases as well as in the experimental animals. malathion induction results in leukocytosis which is directly linked with response to the state of stress by the immune system.12,17 findings of the present study support this possibility as histopathological analysis of our study also observed moderate -tosevere hemorrhages, infiltration of inflammatory cells, vascular congestions, and necrosis. the histopathological findings observed in the current study included inflammatory cell infiltrations, sinusoidal and vascular congestion, hepatocyte hypertrophy, vacuolization, nuclear pyknosis, the disintegration of the hepatocyte membrane and vascular hemorrhages. with regards to such histopathological analysis, our study findings are consistent with the study by hosseini et al, gupta et al., severcan et al. and abdel salam et al., who observed similar findings in the liver of their study animals following malathion induced hepatotoxicity.17,21,22 the foremost limitation was the constraint of time and resources. other parameters like hematological parameters, hepatic markers, and oxidative stress markers were not researched. c o n c l u s i o n based on the findings of the present study, it can be concluded that malathion is a potent toxic pesticide and exposure to it can result in dose dependent damage to hepatic tissues. r e c o m m e n d a t i o n further studies are recommended for a more detailed evaluation of the toxic effects of malathion on other organs as well as other parameters that may give more insight into the topic. r e f e r e n c e s 1. mulla si, ameen f, talwar mp, eqani sa, bharagav a rn, saxena g, et al. organophosphate pesticides: impact on environment, toxicity, and their degradation. bioremediation of industrial waste for environmental safety: springer; 2020. p. 265 -90. 2. ibrahim a. biochemical and histopathological response of oreochromis niloticus to malathio n hepatotoxicity. j royal sci. 2019; 1(1): 10 -5. j islamabad med dental coll 2021 61 3. ferreira rcb, papini s, luchini lc, vieira e. persistence of malathion used in dengue control on household surfaces. arq ins biol. 2019; 86. 4. lasram mm, annabi ab, el elj n, selmi s, kamoun a, el-fazaa s, et al. metabolic disorders of acute exposure to malathion in adult wistar rats. j hazard mater. 2009; 163(2-3): 1052-5. doi: 10.1016/j.jhazmat.2008.07.059. 5. azmi m, naqvi s, azmi m. pesticide residue in the blood of rural population from gadap, karachi and related health hazards. j exp zool. 2005; 8: 343 -51. 6. bhalli ja, khan q, haq m, khalid a, nasim a. cytogenetic analysis of pakistani individuals occupationally exposed to pesticides in a pesticide production industry. mutagenesis. 2006; 21(2): 143 8. doi: 10.1093/mutage/gel009. 7. walia a, sumal k, kumari s. effect of chlorpyrifos and malathion on soil microbial population and enzyme activity. acta sci microbiol. 2018; 1(4): 14-22. doi: 10.31080/asmi.2018.01.0033. 8. geng x, shao h, zhang z, ng jc, peng c. malathion induced testicular toxicity is associated with spermatogenic apoptosis and alterations in testicular enzymes and hormone levels in male wistar rats. environ toxicol pharmacol. 2015; 39(2): 659 -67. doi: 10.1016/j.etap.2015.01.010. 9. alsherbiny ma, abd-elsalam wh, taher e, fares m, torres a, chang d, et al. ameliorative and protective effects of ginger and its main constituents agains t natural, chemical and radiation-induced toxicities: a comprehensive review. food chem toxicol. 2019; 123: 72-97. doi: 10.1016/j.fct.2018.10.048. 10. abdel-daim mm, abushouk ai, bungău sg, binjumah m, el-kott af, shati aa, et al. protective effects of thymoquinone and diallyl sulphide agains t malathion-induced toxicity in rats. environ sci pollut res int. 2020; 27(10): 10228 -35. doi: 10.1007/s11356-019-07580-y. 11. yokota k, fukuda m, katafuchi r, okamoto t. nephrotic syndrome and acute kidney injury induced by malathion toxicity-case reports. bmj case rep. 2017: bcr-2017-220733. doi: 10.1136/bcr -2017220733. 12. aboubakr hm, elzohairy ea, ali aa, rashed la, elkady nk, soliman as. therapeutic effects of nacetylcysteine against malathion-induce d hepatotoxicity. egypt j forensic sci. 2019; 9(1 ): 34. doi: 10.1186/s41935-019-0142-6. 13. esen m, uysal m. protective effects of intravenous lipid emulsion on malathion-induced hepatotoxicity . bratisl lek listy. 2018; 119(6): 373 -8. doi: 10.4149/bll_2018_069. 14. charan j, kantharia n. how to calculate sample size in animal studies? j pharmacol pharmacotherap. 2013; 4(4): 303-06. doi: 10.4103/0976-500x.119726. 15. kalender s, uzun fg, durak d, demir f, kalender y. malathion-induced hepatotoxicity in rats: the effects of vitamins c and e. food chem toxicol. 2010; 48 (2): 633-8. doi: 10.1016/j.fct.2009.11.044. 16. elzoghby rr, ahlam fh, abdel-fatah a, farouk m. protective role of vitamin c and green tea extract on malathion-induced hepatotoxicity and nephrotoxicity in rats. american j pharmacol toxicol. 2014; 9(3): 177. doi: 10.3844/ajptsp.2014.177.188. 17. gupta vk, siddiqi nj, ojha ak, sharma b. hepatoprotective effect of aloe vera against cartap‐ and malathion‐induced toxicity in wistar rats. j cell physiol. 2019; 234(10): 18329 -43. doi:10.1002/jcp.28466. 18. salih si, karem kk, alhussain haaa, al-hindawi aa. protective effect of green tea against poisoning with malathion in adult rats. indian j pub health res dev. 2019; 10(2): 716-20. doi: 10.37506/ijphrd. v10i2.7714. 19. selmi s, rtibi k, grami d, sebai h, marzouki l. malathion, an organophosphate insecticide, provokes metabolic, histopathologic and molecular disorders in liver and kidney in prepubertal male mice. toxicol rep. 2018; 5: 189 -95. doi: 10.1016/j.toxrep.2017.12.021. 20. taherdehi fg, nikravesh mr, jalali m, fazel a. evaluating the protective effects of vitamin c on serum and erythrocyte cholinesterase activity of male rats exposed to malathion. electron physician. 2016; 8(7): 2633-8. doi: 10.19082/2633. 21. hosseini sa, ahmadipour a, soltani m, mehdipour m, mandegary a, karami-mohajeri s. malathion increased hepatotoxicity in diabetic rats. pharma biomed res. 2020; 6(1): 53-60. doi: 10.18502/pbr.v6i1.3428. 22. severcan ç, ekremoglu m, sen b, pasaoglu ot, akyurek n, severcan sm, et al. acute effects of different doses of malathion on the rat liver. clin exp hepatol. 2019; 5(3): 237-43. doi: 10.5114/ceh.2019.87637. 23. abdel-salam om, sleem aa, youness er, morsy fa. preventive effects of cannabis on neurotoxic and hepatotoxic activities of malathion in rat. asian pacific j trop med. 2018; 11(4): 272 -9. doi: 10.4103/1995-7645.231467. j islamabad med dental coll 2020 115 open access nasal colonization of methicillin-resistant staphylococcus aureus in patients' attendants in a tertiary care hospital of pakistan taaha muddassir mirza 1 , rimsha ali 1 , huma musarrat khan 2 1 house officer, medicine unit i, benazir bhutto hospital, rawalpindi, pakistan 2 professor, head, department of anatomy, foundation university medical college, islamabad, pakistan a b s t r a c t background: hospital associated methicillin-resistant staphylococcus aureus (mrsa) is a serious health concern, as its infection is associated with high rates of mortality and morbidity. health care professionals around the globe are concerned by the increased prevalence of these bacteria in the hospital environment. with this background in mind, this study was conducted to determine the frequency of nasal colonization of methicillin-resistant staphylococcus in attendants of admitted patients in a tertiary care hospital in pakistan. material and methods: a cross-sectional study was conducted in holy family hospital, rawalpindi, pakistan from 10 th may to 31 st august, 2016. attendants of sixty admitted patients were selected by simple random sampling. two nasal swabs samples were obtained from these attendants; the first at the beginning of the study with a hospital stay of less than 12 hours, and the second when their stay in the hospital had exceeded 48 hours. the samples were cultured on cystine lactose electrolyte deficient agar, mannitol salt agar, and nutrient agar. the colonies were subjected to gram staining, catalase test, coagulase test, and methicillin/oxacillin sensitivity using the kirby-bauer’s disc diffusion method. frequencies and percentages were calculated. chi-square test was applied and statistical significance calculated for the demographic data. results: the first culture report (at <12 hours hospital stay) showed that 46/60 (76.7%) attendants were not found to have any resistant strain of staphylococcus. these 46 attendants were then subjected to a second culture (after 48 hours hospital stay), which showed that 24/46 (52.2%) were now colonized with methicillin-resistant staphylococcus species (mrsa; n=7 and mr other than s. aureus; n=17). there was no statistically significant difference between colonization of isolates and relationship to gender, age, residence, and co-morbid conditions. conclusions: the frequency of colonization with resistant strains of staphylococcus aureus in attendants of admitted patients increased after being exposed to the hospital environment for more than forty-eight hours. key words: attendants, colonization, infection, mrsa, staphylococcus aureus authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: huma musarrat khan email: huma.anat@gmail.com article info: received: march 5, 2020 accepted: june 18, 2020 cite this article. mirza tm, ali r, khan hm. nasal colonization of methicillin-resistant staphylococcus aureus in patients' attendants in a tertiary care hospital of pakistan. j islamabad med dental coll.2020; 9(2): 115-122. doi: 10.35787/jimdc.v9i2.512 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 116 i n t r o d u c t i o n staphylococcus aureus (s. aureus) is a bacterium, that colonizes the anterior nares of 20-80% of the human population. 1-3 healthy individuals who are carriers of the organism have an increased risk of contracting an infection. 4 a resistant form of s. aureus called, methicillin-resistant staphylococcus aureus (mrsa) has also been isolated. it is a grampositive bacterium characterized by the presence of pbp-2a, a penicillin-binding protein encoded by meca gene, which makes it resistant to beta-lactam antimicrobials. 5 this resistant form was first isolated in a british study in 1960, and since then it has gone through speedy evolutionary changes and epidemiologic expansion. 6 on the basis of acquisition and genetics, two common varieties of this bacterium have emerged; community-associated mrsa (ca-mrsa) and the hospital-associated mrsa (ha-mrsa). 7 in the united states, the first case of ca-mrsa infection was reported in 1980s. 8 these infections commonly presented as skin and soft-tissue infections (ssti) of variable severity in previously healthy individuals. 9 hospital-acquired mrsa rates increased rapidly after the 1990s. mrsa is a common cause of lifethreatening infections that requires aggressive management and consumption of resources. 10 risk factors for ha-mrsa infections include prolonged antibiotic use, extended hospital stay, mrsa colonization and exposure to mrsa infections.5 studies report that community-associated mrsa (ca-mrsa) strains at times also spread into hospitals, causing life-threatening infections. this indicates that the genotypes of strains of staphylococcus aureus causing ha-mrsa infections are becoming more diverse. 11 the prevalence of mrsa infection varies in different parts of the world. studies show that in south-east asia, the incidence of mrsa ranges from 2.3% to 69.1% of s. aureus infections, which is a great healthcare concern. the pooled colonization of mrsa has been estimated to 1.3% of general population 12 and studies are showing an increase in this percentage. a study conducted in usa revealed that in females, the risk factors for colonization include 60 years of age or older, poor socioeconomic setup, and diabetes. whereas in males, exposure to healthcare institutes has been considered as the only major risk factor. 13 as colonization with mrsa significantly increases the risk of infection by this organism, it is essential to estimate the prevalence of its colonization in healthy individuals. 13 in pakistan, the attendants of the hospitalized patients are in close proximity of not only the patients, but also the doctors, healthcare staff and the hospital environment in general, and therefore at a risk of getting colonized or infected. 14 despite many studies outlining the prevalence of mrsa colonization in healthcare professionals and patients, little or no studies have been conducted on the attendants who are also exposed to this resistant bacterium. 15 with this background in mind, the current study was conducted to determine the frequency of colonization of mrsa (ha-mrsa) in attendants of patients admitted to a tertiary care hospital in pakistan. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in holy family hospital, rawalpindi, pakistan from 10 th may to 31 st august, 2016 after obtaining permission from the institutional research forum. the study was conducted on attendants accompanying admitted patients. total of 60 attendants were selected by simple random sampling. the sample included adult attendants of patients who had spent less than 12 hours in the hospital and whose total expected hospital stay would be more than 48 j islamabad med dental coll 2020 117 hours. exclusion criteria included attendants with a history of exposure to the hospital as a patient, patient’s attendant, or healthcare worker in the past 6 months. data was collected using a questionnaire. sampling was done in two stages. initially, a nasal swab (for primary culture) was taken from the patient’s attendants (n=60) when their stay in the hospital had not exceeded 12 hours. the attendants whose primary culture report was negative for resistant staphylococcus (n=46) were enrolled for a second nasal swab. these swabs were taken for a second culture after they had spent more than 48 hours in the hospital. after obtaining informed consent and basic demographic data of the attendants, samples were collected using sterile cotton swabs from both anterior nares of each of the participants. the samples were transported to the laboratory in sterile containers and processed immediately as the primary culture specimen. they were first cultured on cled agar (cystine lactose electrolyte deficient agar) and were incubated at 37°c for 24 hours. yellow-colored colonies obtained in the samples indicated likely presence of staphylococcus aureus. these colonies were then transferred to mannitol salt agar (msa), a medium selective for the identification of staphylococcus aureus. the plates were incubated for 37°c for 48 hours. the colonies that fermented mannitol appeared yellow or golden, indicating the presence of staphylococcus aureus. these colonies were then selected from the msa and were cultured on nutrient agar. the colonies subsequently obtained were subjected to gram staining, catalase test, and coagulase test to differentiate s. aureus from other species of staphylococcus. s aureus colonies were also tested for methicillin/oxacillin susceptibility. this was done using the kirby-bauer’s disc diffusion method. 2,13 the dose of oxacillin used was 5 µg/disc. the plates were incubated at 37°c for 24 hours and zones of clearance were measured around the disc. if the zone of clearance was <20mm, the organism was considered to be resistant to methicillin. subjects with a negative primary culture report for resistant bacteria (mrsa) were further investigated by taking a second swab. specimens from these subjects were collected again from both anterior nares (secondary culture specimen) after their hospital stay exceeded 48 hours, and processed by the same methodology. the data was analyzed using spss version 24. percentages and frequencies were calculated. chi-square test was applied to calculate statistical significance between male and female attendants, different age groups, place of residence, and any existing co-morbid. a p-value of <0.05 was taken as significant. r e s u l t s the total number of participants was 60, out of which 25 (41.7%) were males and 35 (58.3%) were females. approximately 34 (56.7%) of the attendants resided in rural areas and the rest in urban localities. out of the 60 attendants, 4 (6.67%) were diabetic and 14 (6.67%) were hypertensive. the rest (42; 70%) had no diagnosed co-morbid diseases. none of the subjects were on antibiotic therapy. the results of the first nasal swab culture report are given in tables i and ii. of the 60 subjects, 44 (73.3%) showed positive results for staphylococcus isolation, with the highest frequency for methicillin-sensitive staphylococcus species (30; 50%) (table i). attendants with methicillin-resistant staphylococci (n=14) were dropped out of the study (table i). the remaining 46 attendants were incorporated in the second stage of the study. the results of the second culture report are given in table i and iii. a total of 24/46 (52.1%) attendants were positive for colonization with methicillinresistant strains of staphylococcus (table i). j islamabad med dental coll 2020 118 table i: frequency distribution of isolates from nasal swab culture of patient’s attendants isolates first culture report (n=60) second culture report (n=46) frequency percentage frequency percentage methicillin sensitive staphylococcus species 30 50 11 23.9 methicillin-resistant staphylococcus species other than s. aureus 10 16.7 17 36.9 methicillin resistant staphylococcus aureus 4 6.7 7 15.2 none 16 26.7 11 23.9 table ii: basic demographic data and frequency of isolates of first nasal swab culture variables msss (n=30) mrss other than s. aureus (n=10) mrsa (n=4) none (n=16) p-value* gender (n=60) male (n=25) 12 (40%) 3 (30%) 3 (75%) 7 (43.8%) 0.484 female (n=35) 18 (60%) 7 (70%) 1 (25%) 9 (56.3%) age (years) (n=60) <30 (n=23) 12 (40%) 4 (40%) 2 (50%) 5 (31.3%) 0.643 30-55 (n=29) 16 (53.3%) 4 (40%) 2 (50%) 7 (43.8%) ≥55 (n=8) 2 (6.7%) 2 (20%) 0 (0%) 4 (25%) residence (n=60) urban areas (n=26) 14 (46.7%) 3 (30%) 2 (20%) 7 (43.8%) 0.817 rural areas (n=34) 16 (53.3%) 7 (70%) 2 (20%) 9 (56.3%) comorbidity (n=60) hypertension (n=14) 7 (23.3%) 1 (10%) 1 (25%) 5 (31.3%) 0.060 diabetes (n=4) 0 (0%) 3 (30%) 0 (0%) 1 (6.3%) none (n=42) 23 (76.7%) 6 (60%) 3 (75%) 10 (62.5%) *p<0.05 was considered statistically significant msss-methicillin sensitive staphylococcus species; mrss-methicillin-resistant staphylococcus species; mrsa-methicillin resistant staphylococcus aureus there was no significant statistical difference in the colonization of isolates related to gender, different age groups, place of residence, and any associated co-morbidity (table ii and iii). d i s c u s s i o n staphylococcus aureus colonizes the nares of a large proportion of the general population and poses a substantial threat as a serious pathogen. 16 in the present study, colonization of staphylococcus in apparently healthy attendants in the primary culture report was 73.3% and 76.1% in the secondary culture report when the attendants had been exposed to the hospital environment for more than 48 hours which is similar to the percentages observed in other related studies. 1 resistance to antimicrobials is a global health concern, and drug resistance of staph aureus is a serious threat. mrsa is generally associated with poor clinical outcomes. j islamabad med dental coll 2020 119 table iii: basic demographic data and frequency of isolates of second nasal swab culture variables msss (n=11) mrss other than s. aureus (n=17) mrsa (n=7) none (n=11) p-value* gender (n=46) male (n=19) 3 (27.3%) 7 (41.2%) 4 (57.1%) 5 (45.5%) 0.790 female (n=27) 8 (72.7%) 10 (58.8%) 3 (42.9%) 6 (54.5%) age (years) (n=46) <30 (n=17) 5 (45.5%) 7 (41.2%) 2 (28.6%) 3 (27.3%) 0.838 30 55 (n=23) 6 (54.5%) 8 (47.1%) 4 (57.1%) 5 (45.5%) ≥55 (n=6) 0 (0%) 2 (11.8%) 1 (14.3%) 3 (27.3%) residence (n=46) urban areas (n=21) 3 (27.3%) 9 (52.9%) 4 (57.1%) 5 (45.5%) 0.611 rural areas (n=25) 8 (72.7%) 8 (47.1%) 3 (42.9%) 6 (54.5%) comorbidity (n=46) hypertension (n=12) 2 (18.2%) 4 (23.5%) 3 (42.9%) 3 (27.3%) 0.305 diabetes (n=1) 0 (0%) 0 (0%) 0 (0%) 1 (9.1%) none (n=33) 9 (81.8%) 13 (76.5%) 4 (57.1%) 7 (63.6%) *p<0.05 was considered statistically significant msss-methicillin sensitive staphylococcus species; mrss-methicillin-resistant staphylococcus species; mrsa-methicillin resistant staphylococcus aureus it causes metastatic infections such as septic arthritis, infective endocarditis, osteomyelitis, and septic shock leading to high rates of mortality and morbidity. 17 the risk factors for mrsa infection include prolonged antibiotic use, extended hospital stays, mrsa colonization, and exposure to mrsa infection. there are two varieties of mrsa, the healthcare-associated mrsa and the communityassociated mrsa, both of which differ from each other in their clinical presentations and epidemiology. 18 however, the line between the two is blurred with a considerable overlap occurring between the two. 18 in the present study, 4/60 (6.7%) subjects were harboring resistant staphylococcus aureus on primary culture. this can be taken as ca-mrsa as these subjects had little or no exposure to a hospital set-up in the recent past. this percentage is lower than that reported by a study in a teaching hospital of nepal, which claimed a percentage of 13.1% of nasal colonization rate of mrsa in patient's attendants. 3 forty-eight hours after exposure to the hospital environment, the percentage of attendants with mrsa increased to 7/46 (15.21%), which can be considered as ha mrsa. other studies show variable percentages of mrsa in attendants. an indian study reported s. aureus colonization of 45.5% with mrsa carriage rate of 33.3% in attendant accompanying the patients. 19 in contrast, another study claimed this percentage to be as low as 8.2%, which is less than the present study. 3 recent studies have indicated that approximately 65% of all s. aureus isolated from icus are mrsa. 12,13 multiple studies have been done in pakistan and the world to check the prevalence of mrsa in the hospital settings. these researches have focused on health care professionals, patients, and laboratory cultures. a multicentered research done by hafiz and his colleagues indicated that mrsa was j islamabad med dental coll 2020 120 present in a wide range of 2 to 61% of the specimens collected by various laboratories in major cities of pakistan, varying from city to city.15another study conducted in peshawar showed that 62.7% of healthcare workers were colonized with mrsa. 20 this high percentage may be explained in light of the prolonged hospital exposure of health care providers in contrast to the brief 48 hours stay of attendants in the present study. the more alarming statistics are related to the nasal colonization of the resistant species of staphylococcus (mrsa) other than staph aureus. the primary culture report showed that 14 out of 60 (23.3%) attendants had resistant species of staphylococcus. after exposure to the hospital environment, this percentage increased to 17/46 (36.95%). this large number presents a challenge, as this resistant bacterium may be transmitted to patients and healthcare providers, thus causing severe infections in the already compromised patients. 21,22 in the present study no significant difference in age groups was observed in relation to colonization of staph aureus. however, a study on prevalence of mrsa in eritrea claimed a higher incidence of colonization of staph aureus in subjects less than 18 years of age. 23 unlike all the previous researches, the present study focuses on the attendants. in most of the general hospitals of southeast asia, the attendants give hands-on care and emotional support to the patient. 14 this can act as a double-edged weapon; not only can attendants with mrsa colonization infect the patients, but as our study has shown, attendants can also acquire mrsa and harbor it. these attendants thus act as vectors and further facilitate the spread of bacteria within the hospital and the community. it has been indicated by multiple studies that methicillin-resistant staphylococcus aureus (mrsa)is more virulent than methicillin-sensitive s. aureus (mssa) strains. 12 however, other studies have shown that due to the heterogenic nature of the resistant population, quantitative laboratory analysis of the virulence factors show conflicting results with some researches stating that mssa is more virulent. 24,25 in light of the present study, the need for regular screening is emphasized. it is proposed that the frequency of exposure of the attendants to the patients and the hospital environment should be decreased. all attendants intending to stay with the patient for longer than 48 hours should be screened on entry in the hospital and on their departure. those positive for resistant species of staphylococcus should not be allowed to stay in the hospital with their patient. all health care professionals should be made aware of the nosocomial transmission of bacteria and should be regularly screened. the doctors should take into account the nasal carriage rates of mrsa in their hospital while making therapeutic decisions. the main limitation of the present study is a small sample size confined to a single tertiary care hospital. moreover, due to limited number, the attendants were not categorized on the basis of wards (medicine, surgery, gynae & obstetrics etc.), icu and private rooms. therefore, these findings cannot be generalized to all the patient's attendants in the hospital. c o n c l u s i o n the frequency of colonization with resistant strains of staphylococcus aureus in attendants of admitted patients increases after being exposed to the hospital environment for more than forty-eight hours. r e f e r e n c e s 1. brown af, leech jm, rogers tr, mcloughlin rm. staphylococcus aureus colonization: modulation of host immune response and impact on human j islamabad med dental coll 2020 121 vaccine design. front immunol. 2014; 4(jan): 1–38. doi: 10.3389/fimmu.2013.00507 2. mehraj j, witte w, akmatov mk, layer f, werner g, krause g. epidemiology of staphylococcus aureus nasal carriage patterns in the community. curr top microbiol immunol. 2016; 398: 55–87. doi: 10.1007/82_2016_497 3. shakya b, shrestha s, mitra t. nasal carriage rate of methicillin resistant staphylococcus aureus among at national medical college teaching hospital, birgunj, nepal. nepal med coll j. 2010; 12(may 2008): 26–9. 4. stenehjem e, rimland d. mrsa nasal colonization burden and risk of mrsa infection. am j infect control. 2013; 41(5): 405–10. doi: 10.1016/j. ajic.2012.07.017. 5. choo ej. community-associated methicillinresistant staphylococcus aureus in nosocomial infections. infect chemother. 2017; 49(2): 158. doi: 10.3947/ic.2017.49.2.158 6. deresinski s. methicillin-resistant staphylococcus aureus: an evolutionary, epidemiologic, and therapeutic odyssey. clin infect dis. 2005; 40(4): 562–73. doi: 10.1086/427701 7. peng h, liu d, ma y, gao w. comparison of communityand healthcare-associated methicillinresistant staphylococcus aureus isolates at a chinese tertiary hospital, 2012-2017. sci rep. 2018; 8(1): 17916. doi: 10.1038/s41598-018-36206-5 8. bukharie ha. a review of community-acquired methicillin-resistant staphylococcus aureus for primary care physicians. j family community med. 2010; 17(3): 117–20. doi: 10.4103/1319-1683. 74320 9. stryjewski me, chambers hf. skin and soft‐tissue infections caused by community‐acquired methicillin‐resistant staphylococcus aureus. clin infect dis. 2008; 46(s5): s368–77. doi: 10.1086/ 533593 10. okwu mu, olley m, akpoka ao, izevbuwa oe. methicillin-resistant staphylococcus aureus (mrsa) and anti-mrsa activities of extracts of some medicinal plants: a brief review. aims microbiol. 2019; 5(2): 117–37. doi: 10.3934/microbiol. 2019.2.117. 11. joo e-j, chung dr, kim sh, baek jy, lee ny, cho sy, et al. emergence of community-genotype methicillin-resistant staphylococcus aureus in korean hospitals: clinical characteristics of nosocomial infections by community-genotype strain. infect chemother. 2017; 49(2): 109. doi: 10.3947/ic.2017.49.2.109. 12. hassoun a, linden pk, friedman b. incidence, prevalence, and management of mrsa bacteremia across patient populations—a review of recent developments in mrsa management and treatment. crit care. 2017; 21(1): 211. doi: 10.1186/s13054-017-1801-3 13. gorwitz rj, kruszon‐moran d, mcallister sk, mcquillan g, mcdougal lk, fosheim ge, et al. changes in the prevalence of nasal colonization with staphylococcus aureus in the united states, 2001–2004. j infect dis. 2008; 197(9): 1226–34. doi: 10.1086/533494 14. sultana r, rimi na, islam ms, nahar n, luby sp, gurley es. role of patients’ attendants in transmission and prevention of nosocomial infections in bangladeshi public hospitals. int j infect dis. 2008; 12: e369. doi: 10.1016/j. ijid.2008.05.979 15. hafiz s, hafiz an, ali l, chughtai as, memon b, ahmed a, et al. methicillin resistant staphylococcus aureus: a multicentre study. jpma. 2002; 52: 312–5. 16. haaber j, penadés jr ih. transfer of antibiotic resistance in staphylococcus aureus. format abstr trends microbiol. 2017; 25(11): 893–905. doi: 10.1016/j.tim.2017.05.011 17. van hal sj, jensen so, vaska vl, espedido ba, paterson dl, gosbell ib. predictors of mortality in staphylococcus aureus bacteremia. clin microbiol rev. 2012; 25(2): 362–86. doi: 10.1128/cmr.0502211 18. salmenlinna s, lyytikäinen o, vuopio-varkila j. community acquired methicillin resistant staphylococcus aureus, finland. emerg infect dis. 2002; 8(6): 602–7. doi: 10.3201/eid0806.010313 19. khan f, shukla i, rizvi m, sultan a, kumar p. screening for detection of mrsa in patients and hospital staff of a tertiary institutional hospital. int j curr microbiol app sci. 2013; 2(12): 569–74. j islamabad med dental coll 2020 122 20. asghar m, asghar n, mumtaz s, khan sa, ullah i, munir ah, et al. frequency of methicillin resistant staphylococcus aureus (mrsa) colonization amongst hospital staff in teaching hospitals of peshawar. j med sci. 2016; 24(4): 194–8. 21. kobayashi t, nakaminami h, ohtani h, yamada k, nasu y, takadama s, et al. an outbreak of severe infectious diseases caused by methicillin-resistant staphylococcus aureus usa300 clone among hospitalized patients and nursing staff in a tertiary care university hospital. j infect chemother. 2020; 26(1): 76–81. doi: 10.1016/j.jiac.2019.07.009 22. klevens rm, morrison ma, nadle j, petit s, gershman k, ray s, et al. invasive methicillinresistant staphylococcus aureus infections in the united states. jama. 2007; 298(15): 1763–71. doi: 10.1001/jama.298.15.1763 23. garoy ey, gebreab yb, achila oo, tekeste dg, kesete r, ghirmay r, et al. methicillin-resistant staphylococcus aureus (mrsa): prevalence and antimicrobial sensitivity pattern among patients— a multicenter study in asmara, eritrea. can j infect dis med microbiol. 2019; 2019: 1–9. doi: 10.1155/2019/8321834 24. rozgonyi f, kocsis e, kristóf k, nagy k. is mrsa more virulent than mssa? clin microbiol infect. 2007; 13(9): 843–5. doi: 10.1111/j.1469-0691. 2007.01780.x 25. mizobuchi s, minami j, jin f, matsushita o, okabe a. comparison of the virulence of methicillinresistant and methicillin-sensitive staphylococcus aureus. microbiol immunol. 1994; 38(8): 599–605. doi:10.1111/j.1348-0421.1994.tb01829.x 265 j i m d c 2 0 1 7 265 open access f u l l l e n g t h a r t i c l e mandibular third molars and lower anterior crowding: comparison of opinions of oral-maxillofacial surgeons and orthodontists muhammad azeem 1, muhammad mudassar saleem 2, sana mehmood qureshi 3, arshad mehmood 4, muhammad imran khan 5, awais ahmed 6 1 assistant professor of orthodontics, faisalabad medical university 2 assistant professor of oral and maxillofacial surgery, islamabad medical and dental college 3 assistant professor oral pathology, faisalabad medical university 4-6 postgraduate trainee, de’montmorency college of dentistry lahore a b s t r a c t objective: to compare the opinion of orthodontists and oral-maxillofacial surgeons on relation between erupting mandibular third molars and lower incisal crowding. patients and methods: this descriptive study involved 100 pakistani clinicians (50 orthodontists, 50 oralmaxillofacial surgeons) to answer online questionnaire regarding their opinions on link between erupting mandibular third molars along with their extraction opinion with reference to development and prevention of lower incisal crowding. data was analyzed using spss version 21.0. pearson's chi-square test was applied and statistical significance was defined at <=0.05. results: statistically insignificant differences were found between oral-maxillofacial surgeons and orthodontists regarding question of erupting mandibular third molars in causing lower incisal crowding. similarly, statistically insignificant differences between oral-maxillofacial surgeons and orthodontists were found regarding question of recommending preventive extraction of mandibular third molars for developing lower incisal crowding. conclusion: no opinion differences were observed between pakistani oral surgeons and orthodontists, regarding the link of lower third molar as a cause of lower incisal crowding. key words: crowding; orthodontists; third molars author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-6 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence muhammad azeem email: dental.concepts@hotmail.com article info. received: april 17, 2018 accepted: july 10, 2018 cite this article. azeem m, saleem mm, qureshi sm, mehmood a, khan mi, ahmed a. mandibular third molar and lower anterior crowding: comparison of opinions of oral maxillofacial surgeons and orthodontist. jimdc.2018; 7(4):265-264 funding source: nil conflict of interest: nil i n t r o d u c t i o n in orthodontics, one of the most explored topics is the role of dentofacial development and mandibular third molars (m3m) in lower incisal dental crowding.1,2 the proposed theory behind this association is, transmission of anterior component of force from erupting m3m to lower incisal region resulting in irregularity of lower anterior teeth.3 niedzielska,4 bergstrom5 and vego et al,3 concluded that when retro molar space is deficient, m3m exert anteriorly directed force from behind the arch. more recently, lindqvist also showed that m3m eruption would create anterior component of force toward the lower incisal teeth.6 however, evidence on the role of m3m as cause of lower anterior crowding is still lacking.7,8 a recently conducted randomized control trial (rct) by harradine et o r i g i n a l a r t i c l e 266 j i m d c 2 0 1 7 266 al. concluded that the extraction of m3m to treat or prevent lower incisal crowding could not be justified.9 they calculated lower incisal crowding, mandibular 33-43 width, and arch perimeter following orthodontic treatment randomly administered to m3m removal.9 as literature evidence on relation between m3m and lower incisal crowding has not yet been clarified,7,8 dental practitioners have always been divided in opinion on lower incisal crowding caused by erupting m3m. lindauer et al. in a survey found significant differences in the opinion of oral-maxillofacial surgeons (omfss) and orthodontists.10 laskin found that 65% of both orthodontists and omfss supported the idea that m3m do transmit an anteriorly directed pressure and should be extracted as prophylaxis management of developing lower incisal crowding.11 in view of the fact that opinion is divided among orthodontists and omfss, this study was designed with aim to compare the present opinion of pakistani orthodontists and omfss regarding the relation between erupting mandibular third molars and lower incisal crowding. p a t i e n t s a n d m e t h o d s this descriptive study was conducted after approval from institutional ethical committee and informed consent from the participants. in total 100 clinicians (50 orthodontists, 50 omfs), having at least 1-year experience as postgraduate student of orthodontics or oral surgery were involved to answer online questionnaire regarding their opinions on link between erupting mandibular third molars along with their extraction opinion in reference to development and prevention of lower incisal crowding. an electronic questionnaire was developed and was floated in social media groups of orthodontists and omfss. the key questions were:1. do you believe that the erupting m3m can cause lower incisal crowding, and no 2. do you recommend extraction of the m3m to prevent lower incisal crowding? pearson's chi-square test was applied to find out the opinion differences and to analyze whether there was link between opinions and clinicians’ experience. r e s u l t s a total of 100 pakistani clinicians (50 orthodontists, 50 omfs) completed the online survey. statistically insignificant difference was found between omfss and orthodontists regarding question of erupting mandibular third molar in causing lower incisal crowding. (p >0.21). similarly, statistically insignificant differences were found regarding question of recommending preventive extraction of mandibular third molar for developing lower incisal crowding. (p >0.22) (table 1). opinions were also analyzed according to clinicians’ experience. a total of 70 clinicians were postgraduate students, while 30 were postgraduate fellows having completed their postgraduate diplomas or degrees in respective fields. out of 50 omfss, 40 (80%) were postgraduate students and 10 (20%) were experienced fellows, while out of 50 orthodontists, 30 (60%) were students and 20 (40%) were experienced fellows. there were no statistically significant differences between the groups (p > 0.11) regarding influence of experience. d i s c u s s i o n it is generally advocated that mandibular wisdoms should be extracted when symptomatic because of any pathology,10 but in the absence of pathology reviewers suggest monitoring over time,.12,13 the suggestion of removal of asymptomatic wisdom teeth has been controversial for years.14-19 without proper scientific evidence for suggesting wisdom molar extraction,12,13 omfss might be more likely to recommend removal of erupting mandibular wisdoms.10 in the present study statistically insignificant differences were found between omfss (36%) and orthodontists (30%) in their opinion, that erupting mandibular third molar do cause lower incisal crowding. it is interesting to find such a consistent opinion matching on this wisdom molar topic, between the two specialist groups. table 1: opinion of orthodontists and oralmaxillofacial surgeons omfss (n=50) no (%) orthodontists (n=50) no (%) p value erupting mandibular third molar can cause lower incisal crowding yes 18 (36) 15 (30) 0.21 no 32 (64) 35 (70) do you recommend extraction of the mandibular wisdoms to prevent lower incisal crowding yes 17(34) 15(30) 0.22 no 33(66) 35(70) 267 j i m d c 2 0 1 7 267 results are not in accordance to a previously conducted study where percentages were 64% for omfss and 39% for orthodontists,10 but in agreement with study on italian clinicians where percentages were 36% for omfss but 47% for orthodontists, for the same question.20 similarly, statistically insignificant differences between omfss (34%) and orthodontists (30%) were found regarding opinion that preventive extraction of mandibular third molar should be recommended for developing lower incisal crowding, where oral surgeons were not more inclined towards suggesting removal of 3rd molars. results are in contrast to a previously conducted study where 65% of oral surgeons and orthodontists suggested extraction of lower wisdom molars to prevent anterior mandibular crowding.11 results are also in contrast to a previously conducted study where percentages were 57% for omfss and 35% for orthodontists,10 but in accordance with study on italian clinicians where percentages were 37% for omfss and 41% for orthodontists, for same question.20 there were no statistically significant differences between the two specialist’s groups regarding influence of experience. results are in contrast with study where fresh graduates suggested wisdom molar extraction to prevent lower incisal crowding.10 results are similar to study findings of italian clinicians where younger orthodontists do not differ from those of the older orthodontists; however, in contrast a significant difference between younger and older italian surgeons’ opinion has been reported in one study.20 there are certain limitations to our study, such as small sample size but still the findings of present study are valid and generalizable to some extent for omfs and orthodontists of pakistan. c o n c l u s i o n there were no statistical differences in the opinion of pakistani oral surgeons and orthodontists, regarding the link of lower third molar as a cause of lower incisal crowding. similar to oral surgeons, orthodontists, did not recommend the mandibular wisdom extraction to prevent developing lower incisal crowding. r e f e r e n c e s 1. karasawa lh, rossi ac, groppo fc, prado fb, caria ph. cross-sectional study of correlation between mandibular incisor crowding and third molars in young brazilians. medicina oral, patologia oral y cirugía bucal. 2013;18(3): e505. 2. barros se, chiqueto k, janson g. impact of dentofacial development on early mandibular incisor crowding. american journal of orthodontics and dentofacial orthopedics. 2016; 150(2):332-8. 3. vego l. a longitudinal study of mandibular arch perimeter. the angle orthodontist. 1962; 32(3):18792. 4. niedzielska i. third molar influence on dental arch crowding. the european journal of orthodontics. 2005; 27(5):518-23. 5. bergstrom k. responsibility of the third molar for secondary crowding. indent. abstr. 1961 (vol. 6, pp. 544-545). 6. lindqvist b, thilander b. extraction of third molars in cases of anticipated crowding in the lower jaw. american journal of orthodontics. 1982;81(2):130-9. 7. stanaitytė r, trakinienė g, gervickas a. do wisdom teeth induce lower anterior teeth crowding? a systematic literature review. stomatologija. 2014;16(1):15-8. 8. zawawi kh, melis m. the role of mandibular third molars on lower anterior teeth crowding and relapse after orthodontic treatment: a systematic review. the scientific world journal. 2014; 2014. 2014: 615429. doi: 10.1155/2014/615429 9. harradine nw, pearson mh, toth b. the effect of extraction of third molars on late lower incisor crowding: a randomized controlled trial. journal of orthodontics. 1998; 25(2):117-22. 10. lindauer sj, laskin dm, tüfekçi e, taylor rs, cushing bj, best am. orthodontists’ and surgeons’ opinions on the role of third molars as a cause of dental crowding. american journal of orthodontics and dentofacial orthopedics. 2007;132(1):43-8. 11. laskin dm. 9 evaluation of the third molar problem. the journal of the american dental association. 1971; 82(4):824-8. 12. song f, o’meara s, wilson p, golder s, kleijnen j. the effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth. health technol assess 2000;4: 1-55. 13. mettes tg, nienhuijs me, van der sanden wj, verdonschot eh, plasschaert aj. interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. cochrane database syst rev. 2005. https://dx.doi.org/10.1155%2f2014%2f615429 268 j i m d c 2 0 1 7 268 14. gavazzi m, de angelis d, blasi s. third molars and dental crowding: different opinions of orthodontists and oral surgeons. european journal of clinical orthodontics. 2014;2(3). 15. costa mg, pazzini ca, pantuzo mc, jorge ml, marques ls. is there justification for prophylactic extraction of third molars? a systematic review. brazilian oral research. 2013;27(2):183-8. 16. alves-pereira d, pereira-silva d, figueiredo r, gayescoda c, valmaseda-castellón e. clinician-related factors behind the decision to extract an asymptomatic lower third molar. a cross-sectional study based on spanish and portuguese dentists. medicina oral, patologia oral y cirugia bucal. 2017; 22(5):e609. 17. garrocho-rangel a, pozos-guillén a, noyola-frías má, martínez-rider r, gonzález-rivas b. prophylactic extraction of third molars: evidencebased dentistry. odovtos international journal of dental sciences. 2017; 19(3):10-5. 18. pithon mm, baião fc, de andrade sant li, da silva coqueiro r, maia lc. influence of the presence, congenital absence, or prior removal of third molars on recurrence of mandibular incisor crowding after orthodontic treatment: systematic review and metaanalysis. journal of the world federation of orthodontists. 2017; 6(2):50-6. 19. esan t, schepartz la. third molar impaction and agenesis: influence on anterior crowding. annals of human biology. 2017; 44(1):46-52. 20. gavazzi m, de angelis d, blasi s, pesce p, lanteri v. third molars and dental crowding: different opinions of orthodontists and oral surgeons among italian practitioners. progress in orthodontics. 2014; 15(1):60. j islamabad med dental coll 2019 101 open access antibiotic sensitivity patterns of uropathogens in children: the current trend sara najeeb 1, naima tariq 2, muniba kanwal 3, gul-e-rehan 4, m. usman sadiq 5, m. irfan sadiq 6 1 assistant professor, department of pathology, mohi-ud-din islamic medical college, mirpur azad kashmir 2 assistant professor, department of pathology, islamabad medical and dental college, islamabad. 3 consultant hematologist, pakistan thalassemia center, islamabad 4 consultant pathologist, nayab laboratories, islamabad 5 assistant professor, department of ophthalmology, mohi-ud-din islamic medical college, mirpur azad kashmir 6 assistant professor, department of ophthalmology, m. islam medical and dental college, gujranwala a b s t r a c t background: the emergence of antibiotic-resistant infections has led to increased health care costs and mortality among children. the purpose of this study was to determine the causative organisms responsible for urinary tract infection and their antibiotic sensitivity pattern among pediatric patients of rawalpindi/islamabad. material and methods: this cross-sectional study was carried out from june 2014 to june 2015, in the department of microbiology, army medical college, rawalpindi, affiliated with the military hospital, rawalpindi. about 270 urine samples of children with uti were analyzed through analytical profile index (api) 20e and biochemical test strips system. their antibiotic susceptibility was determined by using standard techniques. data were assessed and analyzed by spss version 17. results: most common uropathogen was escherichia coli (61.48%), followed by proteus (15.5), klebsiella (12.3%), pseudomonas (4.5%), enterococcus (3.7%) and enterobacter (2.5%). gram-negative rods, were most sensitive to imipenem (100%), gentamycin (86%) and amikacin (78.3%). they were least sensitive to ampicillin (4.2%) and norfloxacin (5.5%). gram-positive cocci showed highest sensitivity for vancomycin (100%) while displayed relatively less sensitivity for nitrofurantoin (61.2%) and gentamycin (48.7%). cephalosporins also showed increased resistance with only 14% of gram-negative rods showing sensitivity to cefotaxime. these organisms were highly resistant to penicillin, showing a sensitivity of only 12.4%. conclusion: decreased sensitivity against penicillin and cephalosporins is seen in uropathogens causing uti in children. high sensitivity towards nitrofurantoin makes this drug an empirical treatment in uti. regular surveillance of the developing resistance in uropathogens due to inappropriate use of antibiotic is necessary to reduce complication in children with urinary tract infection. key words: antibiotic resistance, bacterial sensitivity, cephalosporins, multi-drug resistance, urinary tract infection authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3,4 active participations in data collection 5,6 data analysis. correspondence: naima tariq email: dr_naima_tariq@yahoo.com article info: received: april 6, 2019 accepted: july 23, 2019 cite this article. najeeb s, tariq n, kanwal m, rehan g, sadiq mu, sadiq mi. antibiotic sensitivity patterns of uropathogens in children: the current trend. j islamabad med dental coll.2019; 8(3):101-106. doi:10.35787/jimdc.v8i3.415 funding source: nil conflict of interest: nil i n t r o d u c t i o n one of the most common infections among children is urinary tract infections (uti).1 if ignored or untreated it can lead to a number of complications including pyelonephritis, renal scarring, hypertension, and endstage renal disease. all these complications result in increased health care costs and mortality.2 uti mostly occurs during the first year of life, however in girls it can occur at any age1. timely diagnosis and prompt treatment are essential to reduce life-threatening complications.3 most common organisms in uti originate from intestine4, but causative agent is not limited to e. coli. proteus o r i g i n a l a r t i c l e j islamabad med dental coll 2019 102 species, pseudomonas, klebsiella, staphylococcus species, streptococcus species, chlamydia, neisseria gonorrhea, candida species and mycoplasma are also involved in urinary tract infections.5 this is an unquestionable fact that the use of antibiotic reduces the complications and mortality related to urinary tract infections in childhood. however, the overuse or misuse of antibiotics results in the antibiotic resistance in the urinary pathogens.6 widespread use of antibiotics has led to an alarming rise of resistance against thirdgeneration cephalosporins and aminoglycosides. sensitivity patterns of uropathogens to different commonly used antibiotics show great historical and geographical variation. the awareness and the knowledge of the sensitivity pattern of common uropathogens in children is necessary for selection of an appropriate antibiotic for empirical treatment.7 this is because resistant strains are becoming difficult to treat and will lead to therapeutic dead ends.8 antibiotic resistance in the treatment of uti is a hurdle for health physicians, mainly in the developing countries where there is frequent use of spurious drugs.9 such practices not only endanger the health of the patient but also increase bacterial resistance to certain drugs thus leading to less available option for treatment of utis.10 there are regional variations in drug resistance patterns.11 to reduce treatment failure and health care costs12 , it is important to understand the spectrum and resistance patterns, helping in effective empirical antibiotic therapies.13 the epidemiological data of empiric antibiotic therapy must be updated regularly for monitoring of bacterial antibiotic resistance.14 despite these regional variations, no country can save itself15 because resistant strains can be imported through travel and trade.16 moreover, bacteria are known to develop resistance against several antibiotics with time. thus, it is important to determine the new resistance pattern in urinary pathogens to facilitate efficient management of urinary pathogens as well as to reduce complications in pediatric patients.17 this study was undertaken to obtain current knowledge of the type of organisms responsible for utis among children in our population along with their antibiotic sensitivity patterns. we also explored age related gender variation among children presenting with uti. m a t e r i a l a n d m e t h o d s it was a cross-sectional study, carried out in the department of microbiology, army medical college, rawalpindi. sample size was calculated using who sample size calculator. keeping confidence interval at 95%, margin of error 5%, expected frequency of outcome factor as 82.3%, sample size was calculated to be 224.18 in order to minimize bias and increase the strength of study a total of 270 samples of urine were studied. the evaluation included 270 urine specimens of children aged between i month to 12 years, that showed more than 100,000 colony-forming units/ml of a single pathogen on urine culture. exclusion criteria was specimens showing multiple organisms on urine culture. all samples were cultured on cysteine lactose electrolyte deficient agar (cled) (oxoid uk) incubated at 37°c for 48 hours and bacteria were identified by standard biochemical methods. for antibiotic sensitivity, modified kirby bauer disc diffusion method was applied. a panel of antimicrobial agents depending on the identified causative organism was used and bacterial susceptibility zones against antibiotics were measured with help of clinical laboratory standards institute (clsi) guidelines. data were assessed and analyzed by spss version 17. chisquare test was applied to assess gender variation among different age groups in children suffering from uti. a p-value of <0.05 was considered significant. r e s u l t s in our study, the total number of urine samples evaluated were 270, of which 133 were of girls and 137 of boys. mean patient age was 41.11 ± 41.27 months. this study showed that the frequency of uti in children was highest during the first year of life, which progressively decreased with age. in infants, boys (28.51%) were affected more; in contrast to girls (14.07%). whereas between 1 to 5 years, a greater number of females were affected (1.28: 1). j islamabad med dental coll 2019 103 table i: comparison of age groups and gender distribution in children with uti gender ≤1 year n (%) >1-5 years n (%) >5-12 years n (%) total n (%) p-value male 77 (28.51) 35 (12.96) 25 (9.26) 137 (50.74) <0.001 female 38 (14.07) 45 (16.66) 50 (18.51) 133 (49.26) total 115 (42.59) 80 (29.62) 75 (27.77) 270 (100) this trend in uti frequency between the two genders continued till the 12th year of life. this variation in gender between the three age groups in children was found to be highly significant (p <0.001). (table i). among the positive urine culture, gram-negative bacilli were most frequently isolated accounting for 97% (n=263) of infections, whereas gram-positive cocci comprised only 3% (n=7) of cases. among the gram-negative rods, e. coli was the most frequently isolated pathogen followed by proteus and klebsiella. among the gram-positive cocci, enterobacter was the only pathogen isolated. (figure 1). figure 1: percentage distribution of uropathogens in children figure 2: antibiotic sensitivity pattern in gram-negative rods *amp, ampicillin; amk, amikacin; nor, norfloxacin; sxt, trimethoprim-sulphamethoxazole; nit,nitrofurantoin;gen, gentamicin;imp, imipenem; ofx, ofloxacin; dox, doxycycline; ctx, cefotaxime among the isolated gram-negative rods, all of them were sensitive to imipenem. greatest resistance was seen against ampicillin and only 4.2% of gram-negative rods were sensitive to this particular antibiotic. cephalosporins also showed increased resistance with only 14% of gramnegative rods showing sensitivity to cefotaxime (figure 2). gram-positive cocci were highly sensitive to vancomycin, followed by nit and gentamycin. these organisms were least sensitive to penicillin; showing a sensitivity of only 12.4%. (figure 3). figure 3: antibiotic sensitivity pattern in grampositive cocci *nit, nitrofurantoin; dox, doxycycline; nor, norfloxacin; gen, gentamicin; pen, penicillin; van, vancomycin d i s c u s s i o n in the present study, the local status of antimicrobial susceptibility pattern in uropathogens was determined. it was done with a view to offer assistance in monitoring the continuous changing environment of bacterial resistance and bring improvements in uti treatment. urinary tract infection is the most common cause of fever of unknown origin and is one of the leading cause of infection and hospitalization among children.19 to prevent potential sequels, like hypertension and recurrent or chronic pyelonephritis which results in renal scarring and renal j islamabad med dental coll 2019 104 damage that may develop to chronic renal failure, it is important to start empirical antibiotic treatment before culture results.3,15 culture needs 24 to 48 hours to give microbiological growth, dipstick method is a reliable and less time-consuming method to diagnose complicated and uncomplicated uti.10 antibiotic susceptibilities give direction for empirical treatment of urinary tract infection.20 awareness of the main uropathogens in the children and their antibiotic resistance patterns help in the selection of antibiotics.13 in our study, the most common pathogen isolated was escherichia coli (61.48%), followed by proteus (15.5%) and klebsiella (12.3%). parveen et al in a recent study at children hospital, lahore, observed that klebsiella (40.0%) was the most frequent pathogen followed by e.coli (26.0% )amongst children with complicated uti. 21 studies by kalsoom and bashir showed e. coli to comprise 46.98% and 66% of all bacteria causing uti respectively.22,23 a number of other studies conducted worldwide have also demonstrated e. coli to be the number one cause of urinary tract infections in children and adults alike. klebsiella was usually found to be the second most frequent uropathogen unlike our study in which proteus was more frequently isolated.2426 in our study, gram-negative rods demonstrated the highest resistance against ampicillin followed by norfloxacin. previous studies from pakistan have also demonstrated high resistance against ampicillin.22 however, a study by bashir et al in 2008 demonstrated intermediate-level resistance against third-generation cephalosporins (35-50%) and about 40% of gramnegative bacilli were still susceptible to second-generation cephalosporins.23 over the years, this resistance against antibiotics seems to have increased tremendously. the research by shahnaz et al published in 2016 concluded that about 80-90% of gram-negative rods were resistant to third-generation cephalosporins.21 this trend is supported by our study which showed that 86% of gramnegative pathogens were resistant to cefotaxime. similarly, resistance to quinolones has gone up from 62% in 200823 to 80% in 2011.22 in this study, we observed the resistance of more than 90% against norfloxacin which is quite alarming. researches conducted in south asia have also shown increasing trends of antimicrobial resistance among children with uti. research by ghorashi et al27 in 2011 showed a low level of resistance by e. coli against ciprofloxacin (14.5%) and intermediate-level resistance to third-generation cephalosporins, while they were strongly resistant to ampicillin, cotrimoxazole, and cephalexin. however, a later study conducted by sharan et al28 in india demonstrated markedly increased resistance by e. coli to third-generation cephalosporins (73%) and quinolones (63%). these uropathogens have, throughout the years, shown increased susceptibility to amikacin, nitrofurantoin, and imipenem, which is also supported by our study. 19,21,26 tseng et al29 who conducted his study in 1991-2000 and 2001-2005 in taiwan found that ampicillin resistance is increasing in children. this should be a matter of great concern especially in asian countries and adequate measures must be taken, including the prescription of over the counter medications, so that this resistance can be avoided in our country. as regards the gram-positive cocci, our study showed enterococci to be most susceptible to vancomycin, whereas greatest resistance was seen against penicillin. nitrofurantoin showed intermediate-level resistance of up to 40%. previous studies in pakistan have also shown increased sensitivity of enterococci to vancomycin.21 catal et al26 also showed that leading causative organism of urinary tract infection in children in istanbul was escherichia coli (81.7%). in his study, gram-positive cocci, e.g. enterococcus showed resistant to all antimicrobials but were sensitive to vancomycin. the latest study carried out in turkey showed that only 10% of enterococci were resistant to nitrofurantoin whereas in our study the resistance seen is up to 40%.30 our study has a few limitations. firstly, in vitro testing of antibiotics does not ensure similar results in patients. secondly, we are uncertain of the empirical or definite treatment offered to patients because there was no follow up. c o n c l u s i o n decreased sensitivity against penicillin and cephalosporins is seen in children with urinary tract infection. nitrofurantoin j islamabad med dental coll 2019 105 with a high sensitivity makes this drug an empirical treatment in uti. regular surveillance of the developing resistance in uropathogen due to inappropriate use of antibiotic is necessary to reduce complication in children with urinary tract infection. r e f e r e n c e s 1. pouladfar g, basiratnia m, anvarinejad m, abbasi p, amirmoezi f, zare s. the antibiotic susceptibility patterns of uropathogens among children with urinary tract infection in shiraz. medicine. 2017; 96(37): e7834. doi: 10.1097/md.0000000000007834 2. mitiku e, amsalu a, tadesse bt. pediatric urinary tract infection as a cause of outpatient clinic visits in southern ethiopia: a cross sectional study. ethiopian journal of health sciences. 2018; 28(2):18796. doi: 10.4314/ejhs.v28i2.10 3. bryce a, hay ad, lane if, thornton hv, wootton m, costelloe c. global prevalence of antibiotic resistance in paediatric urinary tract infections caused by escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis. bmj (clinical research ed). 2016; 352: i939. doi: 10.1136/bmj.i939. 4. forster cs, courter j, jackson ec, mortensen je, haslam db. frequency of multidrug-resistant organisms cultured from urine of children undergoing clean intermittent catheterization. j pediatric infect dis soc. 2017;6(4):332-8. doi: 10.1093/jpids/piw056 5. kenosi m, whitla l, khan n, carty e, coghlan d, nadeem m. interpretation of pyuria in children with urinary tract infection. acta paediatrica (oslo, norway: 1992). 2018; 107(2):358. 6. kutasy b, coyle d, fossum m. urinary tract infection in children: management in the era of antibiotic resistance-a pediatric urologist's view. european urology focus. 2017; 3(2-3):207-11. 7. sohail m, khurshid m, saleem hg, javed h, khan aa. characteristics and antibiotic resistance of urinary tract pathogens isolated from punjab, pakistan. jundishapur j microbiol. 2015; 8(7): e19272. doi: 10.5812/jjm.19272v2 8. polat m, kara ss. once-daily intramuscular amikacin for outpatient treatment of lower urinary tract infections caused by extended-spectrum betalactamase-producing escherichia coli in children. infection and drug resistance. 2017; 10: 393-9. doi: 10.2147/idr.s148703 9. chaudhari pp, monuteaux mc, bachur rg. should the absence of urinary nitrite influence empiric antibiotics for urinary tract infection in young children? pediatric emergency care. 2017. doi: 10.1097/pec.0000000000001344 10. suthar ks, vanikar av, nigam la, patel rd, kanodia kv, thakkar ug, et al. urinary screening for early detection of kidney diseases. indian j pediatr. 2018; 85(8):607-12. doi: 10.1007/s12098-017-2494-y 11. toubiana j, timsit s, ferroni a, grasseau m, nassif x, lortholary o, et al. community-onset extendedspectrum beta-lactamase-producing enterobacteriaceae invasive infections in children in a university hospital in france. medicine. 2016; 95(12): e3163. doi: 10.1097/md.0000000000003163 12. alsammani ma, ahmed mi, abdelatif nf. bacterial uropathogens isolates and antibiograms in children under 5 years of age. med arch (sarajevo, bosnia and herzegovina). 2014; 68(4):239-43. doi: 10.5455/medarh.2014.68.239-243 13. russell g. antibiotic resistance in children with e coli urinary tract infection. bmj (clinical research ed). 2016; 352: i1399. doi: 10.4172/2329-6887.1000215 14. trevino m, losada i, fernandez-perez b, coira a, pena-rodriguez mf, hervada x. surveillance of antimicrobial susceptibility of escherichia coli producing urinary tract infections in galicia (spain). rev esp quimioter: publicacion oficial de la sociedad espanola de quimioterapia. 2016; 29(2):86-90. pmid: 26964515 15. herrera c, navarro d, tager m. etiology and antimicrobial resistance profile of urinary tract infection in children, valdivia 2012. revista chilena de infectologia : organo oficial de la sociedad chilena de infectologia. 2014; 31(6):757-8. doi: 10.4067/s071610182014000600019 16. li s, guo l, liu l, dong f, liu g. clinical features and antibiotic resistance of escherichia coli bloodstream infections in children. zhonghua er ke za zhi = chinese journal of pediatrics. 2016; 54(2):150-3. 17. ali i, kumar n, ahmed s, dasti ji. antibiotic resistance in uropathogenic e. coli strains isolated from non-hospitalized patients in pakistan. jcdr. 2014; 8(9): dc01-4. doi: 10.7860/jcdr/2014/7881.4813 18. pouladfar g, basiratnia m, anvarinejad m, abbasi p, amirmoezi f, zare s. the antibiotic susceptibility patterns of uropathogens among children with urinary tract infection in shiraz. medicine (baltimore). 2017; 96(37): e7834. doi:10.1097/md.0000000000007834 j islamabad med dental coll 2019 106 19. yilmaz s, ozcakar zb, kurt sukur ed, bulum b, kavaz a, elhan ah, et al. vesicoureteral reflux and renal scarring risk in children after the first febrile urinary tract infection. nephron. 2016; 132(3): 17580. doi: 10.1159/000443536 20. kengne m, dounia at, nwobegahay jm. bacteriological profile and antimicrobial susceptibility patterns of urine culture isolates from patients in ndjamena, chad. the pan african medical journal. 2017; 28:258. doi: 10.11604/pamj.2017.28.258.11197 21. perveen s, hafeez f, akhtar n, bhati fa, rabbani ia, masood s. changing trend of uropathogens and antimicrobial sensitivity in complicated urinary tract infection in children. pak paed j. 2016; 40(1):54-8. 22. bano k, khan j, begum h, munir s, akbar n, ahmad ansari j, et al. patterns of antibiotic sensitivity of bacterial pathogens among urinary tract infections (uti) patients in a pakistani population. afr. j. microbiol. res. 2012; 6(2):414-20. doi: 10.5897/ajmr11.1171 23. bashir mf, qazi j, ahmad n, riaz s. diversity of urinary tract pathogens and drug resistant isolates of escherichia coli in different age and gender groups of pakistani. trop j pharm res. 2008; 7(3):1025–31. doi: 10.4314/tjpr.v7i3.14687 24. shrestha d, thapa p, bhandari d, parajuli h, chaudhary p, thapa k, et al. biofilm production and antimicrobial resistance among uropathogens in pediatric cases: a hospital based study. journal of nepal health research council. 2018; 16(2):178-83. doi: 10.3126/jnhrc.v16i2.20307 25. merga duffa y, terfa kitila k. prevalence and antimicrobial susceptibility of bacterial uropathogens isolated from pediatric patients at yekatit 12 hospital medical college, addis ababa, ethiopia. 2018; 2018:8492309. 26. catal f, bavbek n, bayrak o, karabel m, karabel d, odemis e, et al. antimicrobial resistance patterns of urinary tract pathogens and rationale for empirical therapy in turkish children for the years 2000-2006. int urol nephrol. 2009; 41(4):953-7. doi: 10.1007/s11255-008-9445-5 · 27. ghorashi z, ghorashi s, soltani-ahari h, nezami n. demographic features and antibiotic resistance among children hospitalized for urinary tract infection in northwest iran. infect drug resist. 2011; 4:171-6. doi: 10.2147/idr.s24171 28. sharan r, kumar d, mukherjee b. bacteriology and antibiotic resistance pattern in community acquired urinary tract infection. indian pediatr. 2013; 50(7):707. pmid: 23942441 29. tseng mh, lo wt, lin wj, teng cs, chu ml, wang cc. changing trend in antimicrobial resistance of pediatric uropathogens in taiwan. pediatr int. 2008; 50(6):797-800. doi: 10.1111/j.1442200x.2008.02738.x. 30. gunduz s, uludağ altun h. antibiotic resistance patterns of urinary tract pathogens in turkish children. glob health res policy. 2018; 3:10. doi: 10.1186/s41256-018-0063-1. http://www.pakmedinet.com/ppj 246 j i m d c 2 0 1 7 246 open access f u l l l e n g t h a r t i c l e apgar score of neonates born to anemic mothers versus non-anemic mothers tasleem bano1, bushra nazar2, muhammad raza tahir3 1 assistant professor, department of pediatrics, nawaz sharif medical college, gujrat 2 women medical officer, basic health unit jheuranawali, gujrat 3 medical officer, aziz bhatti shaheed teaching hospital gujrat a b s t r a c t objective: to determine the effect of maternal iron deficiency anemia on apgar score of neonates at one minute. patients and methods: this cross-sectional study was conducted at aziz bhatti shaheed teaching hospital gujrat from january 2017 to november 2017. in total 380 patients (50% anemic and 50% non-anemic mothers) were included in study. grouping into anemic and non-anemic groups was done, based on their hemoglobin level, mcv, mch and ferritin levels. apgar score at 1 minute was noted in neonates born to both groups. data was analyzed using spss 20.0. chi square test was applied to evaluate the difference of apgar score. results: mean age in anemic was 27+4.6 years and in non-anemic 26+5.1 years. the mean hemoglobin among anemic was 8.9+2.1 g/dl and among non-anemic 12.3+1.2 g/dl. mean mcv in non-anemic 85.7+3.8 fl, while among anemic was 62.4+4.1 fl mean ferritin levels among anemic were 7.4+1.1 ng/ml. neonates delivered by anemic mothers had mean apgar score of 6.5+0.2 and those delivered to non-anemic had 8.7+0.5. the apgar score of neonates delivered by anemic and non-anemic showed a significant difference (p-value 0.00). the relative risk of having low apgar score of infant in anemic compared to non-anemic mothers was 29.00 (95% ci, 13.1798-63.8098) with p<0.0001. conclusion: maternal anemia is significantly associated with poor apgar score in neonates. key words: apgar score, iron deficiency anemia, maternal anemia author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence tasleem bano email: banobaig3@gmail.com article info. received: december 20, 2017 accepted: july 10, 2018 cite this article. bano t, nazar b, tahir mr. apgar score of neonates born to anemic mothers versus non-anemic mothers. jimdc.2018; 7(4):246-249 funding source: nil conflict of interest: nil i n t r o d u c t i o n iron deficiency is a nutritional problem worldwide and considered as epidemic in many developing countries.1 iron absorption varies in male and female population depending upon their iron requirements. males require 1mg/day of iron, menstruating females require 1.5mg/day while pregnant females require higher levels i.e. 45mg/day.2 almost 50% of iron deficiency anemia cases in pregnancy are due insufficient iron intake and reduced stores.3 hemoglobin below 11gms/dl in pregnant women is considered abnormally low and anemia develops due to iron deficiency.4 the prevalence of iron deficiency anemia in pregnant women in different countries varies. in usa the prevalence on anemia in pregnant women is 18.6%, which ranges from 6.9% in the first trimester of pregnancy to 29.5% in the third trimester.5 another study conducted among pregnant patients in uganda showed prevalence of anemia to be 29.1%.6 another study conducted in southern iran shows the prevalence to be 28.5%.7 according to a survey the prevalence of iron deficiency anemia in india is 58.7% in pregnant women.8 one of the study carried out in pakistani population reported the prevalence of anemia in pregnant women to 90.5% 9 o r i g i n a l a r t i c l e 247 j i m d c 2 0 1 7 247 while another study conducted in swat district of kpk showed prevalence in first, second and third trimester to be 52%, 63.3% and 54% respectively.10 apgar score is a simple method proposed by dr. virginia apgar11 (table 1). despite the advancement in technology, the apgar score remains the best tool for the identification of neonates in need of resuscitation. maternal anemia is also considered a risk factor for poor perinatal outcome like low birth weight babies, low apgar scores at one min, meconium stained liquor and nicu admissions.12 studies conducted in nepal13, india,14 pakistan15 and iran16 showed a significant association of maternal anemia with low apgar score while some other studies did not show any significant correlation.17,18 the purpose of this study was to evaluate the association of maternal anemia with low apgar score in neonates at 1 minute after birth. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted at aziz bhatti shaheed teaching hospital gujrat from january 2017 to november 2017 after approval of ethical committee of hospital. sample size was calculated keeping the expected incidence among non-anemic to be 8.4% with 95% ci, 80% power of study and assuming relative risk of 3.? total 380 females aged 15-45 years with singleton pregnancy either having iron deficiency anemia or nonanemic delivered at full term were included in study using purposive non-probability sampling. anemic patients having multiple or twin pregnancy or preterm delivery and those having anemia due to hemoglobinopathies, thalassemia trait, red cell membrane defects, acute blood loss or anemia of chronic disease were excluded from study. after taking the informed consent, patients were equally divided in two groups, anemic group and nonanemic group having 190 patients each. complete blood count (cbc) and mean corpuscular volume (mcv) of both anemic and non-anemic group was noted. serum ferritin levels and reticulocyte count was noted only in anemic group having low mcv. a hemoglobin of < 11 g/dl was considered as anemia and patients with low mcv were considered to have iron deficiency which was further confirmed by serum ferritin levels. apgar score of all neonates, delivered by anemic and non-anemic females was calculated at one minute (table 1). score of ≤7 was considered abnormal while >7 was considered reassuring. data was collected using a predesigned performa. chi square test was applied to evaluate the difference in apgar score of neonates born to anemic mothers compared to non-anemic mothers and relative risk was calculated. p-value <0.05 was considered statistically significant. r e s u l t s out of 380 patients, 190 were anemic and 190 were nonanemic. mean age of both groups was almost same. mean hemoglobin and mcv levels in anemic group were less as compared to non-anemic group. mean ferritin levels among anemic were 7.4+1.1 ng/ml and mean reticulocyte count was 0.9+0.1%. total 190 neonates were delivered by anemic females. they had mean apgar score of 6.5+0.2 out of which 91.58% neonates had apgar score of ≤ 7 while 8.42% had apgar score of >7. the 190 neonates delivered to non-anemic females had a mean apgar score of 8.7+0.5 out of which 96.84% neonates had apgar score of >7 while 3.16% had score ≤7 (table 2). the apgar score of neonates delivered by anemic and non-anemic mothers showed a significant difference (table 3). the relative risk of having low apgar score of infant in anemic compared to nonanemic mothers was 29.00 (95% ci, 13.1798-63. 8098). table 1: apgar scoring sign score 2 1 0 a appearance (skin color) normal over entire body normal except extremities cyanotic or pale all over p pulse (heart rate) >100 bpm <100bpm absent g grimace response (reflexes) sneezes, coughs, pulls away grimaces no response a activity (muscle tone) active arms and legs flexed absent r respiration (breathing rate and effort) good, crying slow, irregular absent 248 j i m d c 2 0 1 7 248 table 2: characteristics of mothers and neonates participating in study (n=380) variables anemic mothers(n=190) mean + sd non-anemic mothers (n=190) mean + sd age (years) 27+4.6 26+5.1 hemoglobin (g/dl) 8.9+2.1 12.3+1.2 mean mcv (fl) 62.4+4.1 85.7+3.8 ferritin (ng/ml) 7.4+1.1 apgar score of neonates at 1 minute 6.5+0.2 8.7+0.5 d i s c u s s i o n this study shows a significant difference in apgar score of neonates delivered to anemic and non-anemic mothers. many studies have revealed a similar picture of the problem presented above. ghimire et al. conducted a study in nepal and concluded that anemia is a significant risk factor for worse outcome in mothers and neonates.13 in neonates it was significantly associated with low birth weight, low apgar score, small for gestational age, intrauterine death and perinatal death. the study correlates with our results of apgar score although they only enrolled mother with hemoglobin < 7g/dl as anemic compared to < 11 in our study and number of patients was less than our study group. akhtar et al. in study conducted in bangladesh showed that maternal anemia is directly associated with birth weight, placental weight and apgar score of neonates.20 kaul et al. and batar et al. demonstrated similar results in their studies conducted in jummu city and new delhi.12,14 similarly local studies conducted also showed a significant correlation of maternal anemia with low apgar score of neonates. lone et al. concluded that lower apgar score risk at birth was 1.8 times among anaemic mothers.21 ahmed et al demonstrated a linear relationship between maternal anemia and low apgar score at 1 and 5 minutes after birth.15 alizadeh et al. reported similar findings in his study conducted in iran.16 lelic et al conducted a study among sideroblastic anemic mothers compared to controls and found out that there was no significant difference in apgar score of neonates table 3: apgar score of neonates delivered by anemic and non-anemic mothers (n=380) group apgar score p-value ≤7 >7 anemic (n=190) 174 16 0.000 non-anemic (n=190) 6 184 delivered to anemic mothers compared to controls which is contrary to our results.17 however they had a small sample size compared to our study and included sideroblastic anemic mothers compared to iron deficient anemic mothers in our study. masukume et al concluded in their study that there is a significant correlation between maternal iron deficiency anemia and adverse pregnancy outcomes but not all outcomes including apgar score of neonates.18 they performed this study in a large multicenter nulliparous cohort. this is contrary to our results. they had a large sample size of 5690 patients with maternal anemia in only 2.2% of mothers. the association of maternal anemia with poor apgar score may be because of poor neonatal development in anemia, due to insufficient oxygen supply to fetus across the placenta as depicted in other studies.22 this can be prevented by iron supplementation in pregnant mothers which may prevent the maternal and fetal adverse outcomes.23 our study has few limitations. it includes small number of patients, fetal and maternal outcome variables were not determined except apgar score at 1 minute. mortality and morbidity in neonates should also be compared. the effect of iron supplementation to anemic mothers should be determined. however, this study suggests that decreased neonatal wellbeing is associated with low hemoglobin levels in mothers, which is a major concern. education of fertile women of childbearing age is very important in this regard. moreover, antenatal booking and follow up should be encouraged through community services and media. c o n c l u s i o n maternal anemia is associated with significantly low apgar score in neonates born to anemic mothers as compared to non-anemic mothers. r e f e r e n c e s 1. sirdah mm, yaghi a, yaghi ar. iron deficiency anemia among kindergarten children living in the 249 j i m d c 2 0 1 7 249 marginalized areas of gaza strip, palestine. rev bras hematol hemoter. 2014; 36(2):132-138. 2. penney ds, miller kg. nutritional counselling for vegetarians during pregnancy & lactations. j midwifery womens health 2008;53(1):37-44. 3. kassebaum nj, jasrasaria r, naghavi m, wulf sk, johns n, lozano r et al. a systematic analysis of global anemia burden from 1990 to 2010. blood. 2014;30(123):615-624 4. shill kb, karmakar p, kibria g, das a, rahman ma, hossain ms et al. prevalence of iron-deficiency anaemia among university students in noakhali region, bangladesh. j health popul nutr. 2014; 32(1):103-110. 5. mei z, cogswell me, looker ac, pfeiffer cm, cusick se, lacher da, et al. assessment of iron status in us pregnant women from the national health and nutrition examination survey (nhanes), 1999-2006. am j clin nutr. 2011; 93(6):1312-20. 6. baingana rk, enyaru jk, tjalsma h, swinkels dw, davidsson l. the aetiology of anaemia during pregnancy: a study to evaluate the contribution of iron deficiency and common infections in pregnant ugandan women. public health nutr. 2015; 18(8):1423–35. 7. karimi m, kadivar r, yarmohammadi h. assessment of the prevalence of iron deficiency anemia, by serum ferritin, in pregnant women of southern iran. med sci monit, 2002; 8(7): cr488-492 8. national family health survey (nfhs-3), 2005-2006 .2007; 1. 9. baig-ansari n, badruddin sh, karmaliani r, harris h, jehan i, pasha o, moss n, mcclure em, goldenberg rl: anaemia prevalence and risk factors in pregnant women in an urban area of pakistan. food nutr bull. 2008, 29 (2): 132-9. 10. attaullah, khan gn, ahmad b, iqbal n, ahmad n. in district swat khyber pakhtunkhwa pakistan anemia (iron deficiency) in pregnant women of different ages as a public health problem becomes a reality. j. entomol. zool. stud;2017; 5(2):1266-1269 11. apgar v. a proposal for a new method of evaluation of the newborn infant".curr. res. anesth. analg. 1953;32 (4): 260–267. 12. batar a, salvi a, saini l, agarwal s, rajoria l, mital p. maternal and perinatal outcome of pregnancy with severe anemia. int j biomed adv res. 2015;6(08):611-6. 13. ghimire rh, ghimire s. maternal and fetal outcome following severe anaemia in pregnancy:results from nobel medical college teaching hospital, biratnagar, nepal. j nobel med coll. 2013;2(3):22–26. 14. kaul i, sunil i, gupta a. maternal haemoglobin and perinatal outcome in a tertiary care hospital in jammu city, india. int j reprod contracept obstet gynecol. 2017 ;6(11):5060-5066. 15. ahmad mo, kalsoom u. effect of maternal anaemia on apgarscore of newborn. j rawalpindi med coll. 2015;19(3):239–242. 16. alizadeh l, raoofi a, salehi l, ramzi m. impact of maternal hemoglobin concentration on fetal outcomes in adolescent pregnant women. iran red crescent med j. 2014;16(8): e22761 17. lelic m, bogdanovic g, ramic s, brkicevic e. influence of maternal anemia during pregnancy on placenta and newborns. med arch. 2014;68(3):184187. 18. masukume g, khashan as, kenny lc, baker pn, nelson g, scope consortium. risk factors and birth outcomes of anaemia in early pregnancy in a nulliparous cohort. plos one. 2015;10(4): e0122729. 19. sample size calculator. http://epitools.ausvet.com.au/content.php?page=coho rtss&p1=0.08&rr=3&conf=0.95&power=0.8 last accessed on 30 june 2018. 20. akhter s, momen ma, rahman n, rahman s, karim r, selim s et al. maternal anemia and its correlation with iron status of newborn. birdem med j 2014; 4(1): 27-32 21. lone fw, qureshi rn, emmanuel f. maternal anemia and its effect on perinatal outcome in a tertiary care hoospital in pakistan. east mediterr health j. 2004:10(6);801-7. 22. malhotra m, sharma jb, batra s, sharma s, murthy ns, arora r. maternal and perinatal outcome in varying degrees of anemia. int j gynecol obstet. 2002; 79(2):93–100. 23. drukker l., hants y., farkash r., ruchlemer r., samueloff a. grisaru-granovsky s. iron deficiency anemia at admission for labor and delivery is associated with an increased risk for cesarean section and adverse maternal and neonatal outcomes. transfusion 2015; 55(12): 2799– 2806. j islamabad med dental coll 2019 135 open access use of zinc and oral rehydration solution in home management of diarrhea: knowledge of mothers attending a tertiary care hospital noshina riaz1, sidra tul muntaha1, maria qibtia2, shagufta sohail1 1assistant professor, department of pediatrics, yusra medical and dental college, islamabad 2 house officer, department of pediatrics, cantonment general hospital, rawalpindi a b s t r a c t background: diarrhea is the second leading cause of mortality in children below 5 years of age in pakistan. use of zinc and ors has been proven in clinical trials to be beneficial in reducing morbidity and mortality. poor knowledge regarding home management of diarrhea leads to mortality due to severe dehydration. the objective of this study was to assess the level of knowledge of mothers of under five-year-old children regarding, diarrheal home management in cantonment general hospital, rawalpindi. material and methods: this was an observational cross-sectional study carried out at department of pediatrics, cantonment general hospital, rawalpindi, from 1st august, 2017 to 31st january, 2018. about 400 mothers of under five-year-old children, coming to the outpatient department of the hospital were enrolled in this study. a self-designed structured and validated questionnaire was used to assess the level of knowledge of mothers regarding home management of diarrhea using oral rehydration solution (ors) and zinc. data was analyzed using spss version 23 with a p value < 0.05 considered statistically significant. results: about 91% (n=364) of mothers had awareness regarding use of ors as a means of diarrheal home management. regarding level of knowledge variable results were found. a good percentage of mothers had knowledge of the purpose of ors use (78.3%), administration (60%) and initiation of ors (68%), but only 20.8% mothers rightly answered the timing of ors administration. mothers knowledge about the use of zinc, daily administration and duration of administration (10-14 days) was 38.8% ,20.5% and 17.3% respectively. mothers who were more educated especially secondary and above and of the age group 22-31, had better awareness of ors than others, as p value is less than 0.05. among mothers who were aware of the use of ors, only 41.8% of them were also aware of the use of zinc. conclusion: a high awareness level regarding ors use in mothers was reflected fairly in terms of purpose, administration and initiation of ors but the knowledge of mothers regarding use of zinc and timing of ors administration, in home management of diarrhea is still lacking. key words: diarrhea, knowledge, mothers, oral rehydration solution, zinc authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3 active participations in data collection 4 data analysis. correspondence: noshina riaz email: noshi_17@hotmail.com article info: received: january 22, 2019 accepted: may 19, 2019 cite this article. riaz n, muntaha s, qibtia m, sohail s. use of zinc and ors in home management of diarrhea: knowledge of mothers attending a tertiary care hospital. j islamabad med dental coll.2019; 8(3):135-140. doi:10.35787/jimdc.v8i3.419 funding source: nil conflict of interest: nil i n t r o d u c t i o n diarrhea is the passage of three or more loose or watery stools in a 24-hour period. it can be an increase in daily stool fluidity, frequency or volume from what is considered to be normal for an individual.1 according to world health organization, under 5 mortality is 81.1/1000 live births in pakistan.2 this high mortality rate is attributable to diarrhea as the second leading cause of death in children after pneumonia.3 in pakistan, around 24 million children are under 5 year of age. an estimate of 3-4 episodes of diarrhea per year are suffered by children under 4 years of age, amounting to approximately 120 million episodes per year.4 o r i g i n a l a r t i c l e j islamabad med dental coll 2019 136 preventive measures can help reduce morbidity and mortality caused by diarrhea. primary prevention includes practicing proper hand washing, use of clean drinking water, exclusive breast feeding, immunization and good hygienic and sanitary practices. secondary prevention includes earlier recognition and treatment of dehydration by oral rehydration solution (ors), frequent feeding and zinc administration as advised by the integrated management of childhood illness (imci) strategy developed by who.5,6 in developing countries, less than 40% of children with diarrhea receive recommended treatment and not much has been done to improve this situation.7 since 2004, who and unicef has recommended zinc as the only treatment to be coupled with ors in all diarrheal episodes. zinc is essential for protein synthesis, cell differentiation and immune function.8 numerous clinical trials have proved that the use of zinc along with ors reduces the duration and severity of diarrhea and also decrease the incidence of diarrhea in the following 23 months.9 inadequate knowledge of mothers regarding management of diarrhea leads to mortality due to severe dehydration.10 misbah and rasheed carried out a study in military hospital, rawalpindi and reported that only 13.5% mothers were aware of zinc as a therapy in the management of diarrhea. however, ors was known to 77% of mothers while 60% were familiar with the correct purpose of ors use.11 macdonald et al conducted household surveys in six countries upon caregiver’s behavior about use of ors and zinc in paediatric diarrhea and found that only 12% mothers in pakistan were aware of the correct use of zinc.12 diarrhea starts at home and is first managed by mothers at home. inadequate knowledge may lead to delay in appropriate intervention. despite the efforts of who in educating mothers regarding management of diarrhea with the use of ors and zinc, our community in general is not aware of the benefits of combined use of ors and zinc. this study was conducted to assess the level of knowledge of mothers of under five-year-old children regarding diarrheal home management, a step towards reducing morbidity and mortality related to diarrhea in our set-up. m a t e r i a l a n d m e t h o d s this observational cross-sectional study was conducted at department of pediatrics cantonment general hospital, rawalpindi from 1st august 2017 to 31 january 2018. non-probability consecutive sampling technique was used for sample collection. all mothers of under fiveyear-old children coming to outpatient department in cantonment general hospital were included in study. informed written consent was taken from parents of participants. sample size was calculated by who sample size calculator, at 95% confidence level, 5% absolute precision and anticipated population proportion of 61.7%.13 although the calculated sample size was 364, in order to improve the validity of data a total of 400 mothers were enrolled in this study. this study was approved by the ethical review board of yusra medical & dental college, islamabad. a selfdeveloped structured questionnaire was used for data collection1 and validated for this study with a reliability of 0.78 cronbach alpha. this questionnaire was used to assess the level of knowledge of home management of diarrhea using ors and zinc. educational status, maternal age and source of information of mothers was noted. education was categorized into primary (until 8th grade), secondary (9-12 grades) and tertiary (graduate or above) levels. data was analyzed by using spss version 23. for descriptive variables like maternal age and educational level, frequencies and percentages were calculated. chi square test was used for categorical comparisons with a p value < 0.05 considered statistically significant. r e s u l t s major source of information for mothers were health workers (55.8%) followed by family members (27.3%) with media as a poor source of information (2.8%), while 14.3% of mothers had no information at all regarding diarrheal home management. the awareness and level of knowledge of mothers regarding use of oral rehydration solution is shown in table i. table ii states poor level of knowledge of mothers regarding use of zinc in home management of diarrhea. j islamabad med dental coll 2019 137 mothers knowledge about the use of zinc, daily administration and duration of administration (10-14 days) was 38.8%, 20.5% and 17.3% respectively. table i: awareness of mothers regarding use of ors in diarrheal home management yes no have you heard of oral rehydration solution as a means of managing childhood diarrhea at home? 364 (91%) 36 (9%) respondents’ knowledge of diarrheal home management: use of ors items variables n (%) the purpose of ors is to stop diarrhea 25(6.3) reduce the duration of diarrhea 12(3) replace the body salts, energy and water lost in diarrhea 313(78.3) prevents diarrhea 4(1) i don’t know 46(11.5) ors is given with feeding bottle 107(26.8) cup and spoon 240(60) by force feeding 20(5) i don’t know 33(8.3) how soon should the use of ors start? after two days of watery stool 44(11) after three days 11(2.8) soon after the first/second motion of watery stool noticed 272(68) i don’t know 73(18.3) timing of ors administratio n: it is given every hour 59(14.8) after each bowel motion 83(20.8) after vomiting 10(2.5) to prevent diarrhea before it starts 3(0.8) frequently 183(45.8) i don’t know 62(15.5) table ii. awareness of mothers regarding use of zinc in diarrheal home management items variables n(%) zinc tablet or suspension is used for children with diarrhea yes 155(38.8) i don't know 245(61.3) zinc is given daily 82(20.5) twice daily 31(7.8) thrice daily 27(6.8) four times daily 1(0.8) i don't know 259(64.8) zinc is given for duration of 3 days 10(2.5) 5 days 17(4.3) 7 days 29(7.3) 10-14 days 69(17.3) i don't know 275(68.8) mothers who were more educated especially secondary and tertiary level, with an age group of 22-31 years, had better awareness of ors than others (p < 0.05) (figures 1 and 2). the mothers who were aware regarding the use of ors for diarrhea, only 41.8% of them were also aware of the use of zinc (table iii). table iii. comparison of awareness level of ors and use of zinc in diarrheal home management use of zinc p-value yes i don't know awareness of ors yes 41.8% 58.2% 0.00 no 8.3% 91.7% figure 1: impact of educational status of mothers on awareness of ors use. figure 2: relation of age with awareness level of ors. d i s c u s s i o n our study reveals good awareness regarding use of ors amongst mothers of under five-year-old children, for diarrheal home management but the level of knowledge for the use of ors showed variable results. mothers had adequate knowledge of the purpose, administration and j islamabad med dental coll 2019 138 initiation of oral rehydration solution but less than one fourth of the mothers rightly stated the timing of ors administration. poor knowledge regarding the use of zinc, daily administration and duration of administration (10-14 days) was found in our study population. a study conducted in nigeria by olatona et al.8 showed consistent results with our study as far as awareness level of ors and knowledge of zinc is concerned. but the level of knowledge of ors use showed mix results. as in their study 51.4% mothers knew the purpose of ors as compared to 78.5% mothers in our study. knowledge about administration of ors in our study was found in 60% of mothers, in comparison to 80.9% mothers in the nigerian study. similarly, our study revealed a higher percentage of mothers (68%) with a sound knowledge on how soon ors should be administered as compared to the nigerian mothers (54.6%). knowledge regarding timing of ors use was poor in both studies.8 masiha et al in their study in holy family hospital, rawalpindi reported that 81.7% mothers were aware of ors use in diarrhea and 37.6% knew the correct timing in contrast to 91% and 20.8% respectively in our study.4 shahzad et al conducted a survey in three tertiary care hospitals of lahore and found management of diarrhea was greatly influenced by the information transferred by family members (64.30%). health care workers were a poor source (16.7%), while 14.3% were unaware of the management. these findings are contradictory to our results as major source was healthcare workers followed by relatives and then media. while similar percentage of mothers were unaware of the management in our study. correct timing of ors administration was almost similar in both studies, 29% in the former and 20.8% in the latter study, respectively.13 akhtaruzzaman et al.14 concluded in a study conducted in bangladesh that 90% mothers used ors while only 35.5% mothers used zinc in diarrheal episodes and these results are consistent with our study. contrasting results were found with a study conducted in chandragiri by maheswari et al., as 100% participants were aware of zinc supplementation.15 tariq et al found consistent awareness level of zinc use in diarrhea among mothers in peshawar (36.7% versus 38.8%).16 kalsoom et al found 61% mothers at fauji foundation hospital in rawalpindi were aware of correct timing of ors administration that is quite high compared to our study (20.8%).17 dhar et.al reported that only 1.9% of the respondents were aware of zinc use in diarrhea in a study conducted in india. this knowledge corresponded to the educational level of mothers as higher the level, more was the awareness observed.18 this finding was also consistent with our study. gwarzo conducted an awareness study of zinc use in north western nigeria and found that 55.7% mothers were well aware of it.19 this awareness level is higher than our study, most probably due to difference in the level of maternal education. health facilities were the main sources of information for 55.9% mothers as found in our study (55.8%).19 padhy et.al in southern odisha, india found that only 1% of mothers had good knowledge of zinc therapy.20 this level is very low as compared to our study. ogunrinde et al found comparable results of awareness level of zinc (32%) in northwestern nigeria, but the overall knowledge of home management of diarrhea was found to be less than 1%, that is quite low as compared to our study.21 mosweu conducted a survey in botswana and found that 84.5% of mothers were aware of ors use and 41.7% practiced zinc supplementation in home management of diarrhea respectively.22 these observations are comparable to our results. ali et.al assessed the effectiveness of the 7-point diarrhea control strategy of who and unicef in uttar pradesh, india and observed lower levels of awareness of use of ors and zinc for diarrhea. about 69.3% mothers knew about ors use and only 18.5% mothers had heard of zinc use in diarrhea.23 in a nutshell we need mass awareness campaigns regarding diarrheal home management, as knowledge will affect the behavior of masses. use of zinc still needs to be incorporated in our community as low awareness levels were found. j islamabad med dental coll 2019 139 c o n c l u s i o n a high awareness level regarding ors use in mothers was reflected fairly in terms of purpose, administration and initiation of ors, but the timing of ors administration and knowledge of mothers regarding use of zinc in home management of diarrhea is still lacking. r e f e r e n c e s 1. olopha oo, egbewale b. awareness and knowledge of diarrheal home management among mothers of under-five in ibadan, nigeria. universal j public health. 2017; 5(1): 40 5. doi: 10.13189/ujph.2017.050106 2. world health organization. global health observatory. geneva: world health organization; 2017. http://apps.who.int/gho/data/node.cco. 3. salmanuddin, shah i, arif s, ilyas a. mother’s knowledge and attitude associated with diarrhea in an urban area in karachi, pakistan. int j innov res dev. 2015; 4(5): 138-41. 4. masiha sa, khalid a, malik b, shah sma. oral rehydration therapyknowledge, attitude and practice (kap) survey of pakistani mothers. jrmc students supplement. 2015;19(s-1):51-54. 5. rokkappanavar kk, nigudgi sr, ghooli s.a study on knowledge and practice of mothers of under-five children regarding management of diarrhoea in urban field practice area of mrmc, kalaburagi, karnataka, india. int j community med public health. 2016; 3(3): 705-10. doi: 10.18203/2394-6040.ijcmph20160637 6. amare d, dereje b, kassie b,tessema m, mullu g, alene b , et al. maternal knowledge and practice towards diarrhoea management in under five children in fenote selam town, west gojjam zone, amhara regional state, northwest ethiopia. j infect dis ther. 2014 ;2(6): 182. doi:10.4172/23320877.1000182 7. hemant j,bamnawat s. knowledge and attitude towards oral rehydration therapy among mothers of under-five children of south rajasthan, india. int j contemp pediatr. 2016; 3(2): 394-397. doi: 10.18203/2349-3291.ijcp20161021 8. olatona fa, obrutu oe, adeniyi of.home management of childhood diarrhea including zinc supplementation among mothers attending primary health centers in an urban community in lagos. tjhs. 2016; 23 (2): 23-29. 9. omuemu vo, ofuani ij, kubeyinje ic. knowledge and use of zinc supplementation in the management of childhood diarrhea among health care workers in public primary health facilities in benin-city, nigeria. glob j health sci .2012; 4(2): 68-76. doi: 10.5539/gjhs.v4n2p68 10. mumtaz y, zafar m, mumtaz z. knowledge attitude and practices of mothers about diarrhea in children under 5 years. j dow uni health sci. 2014; 8(1): 3-6. 11. misbah s, rasheed k. maternal knowledge and management skills about diarrhea among children under 5 years of age. 2016 13th international bhurban conference on applied sciences and technology (ibcast), islamabad. 2016: 92-95. doi: 10.1109/ibcast.2016.7429860. 12. macdonald v, banke k, sanders e. encouraging caregiver use of zinc and ors for the treatment of pediatric diarrheas. ejnfs. 2015. http://www.journalejnfs.com/index.php/ejnfs/article/ view/27853 13. shahzad s, farooq sa, noor a, batool sf, alvi qa, amir t, et al. association of maternal knowledge and practices regarding prevention and care of diarrhea at home for children less than 5 years of age: a study conducted in tertiary level hospitals of lahore, pakistan. int arch biomed clin res. 2018; 4(2): 68-72. doi:10.21276/iabcr.2018.4.2.21 14. akhtaruzzaman m, hossain ma, khan rh, karim mr, choudhury am, islam ms, et al. knowledge and practices of mothers on childhood diarrhea and its management attended at a tertiary hospital in bangladesh. mymensingh med j. 2015; 24(2): 26975. pmid: 26007253 15. maheswari mu, sreelatha m, sudharani p. a study to assess the knowledge and practices regarding ort for acute diarrhea among mothers of under five children in rhc, chandragiri. jnmmh. 2016; 2(2): 75-80. doi: 10.21088/jnmmh.2454.7506.2216.6 16. tariq m, khanzada a, aram a, naeem a, ahmad b, rauf am, et al. diarrhea in children: health-seeking behavior of parents attending a rural community hospital of peshawar, khyber pakhtunkhwa, pakistan. j med students. 2015; 1(2): 26-32. 17. kalsoom u, amjad t, bairam s. assessment of knowledge about diarrhea and its home management in mothers of under five-year children attending a tertiary care hospital. pak armed forces med j. 2018; 68(3): 550-55. 18. dhar dk, majumder n, paul d. assessment of knowledge and practice of mothers of children under j islamabad med dental coll 2019 140 five regarding zinc therapy in childhood diarrhea. int j adv integ med sci.2016; 1(4): 169-172. doi: 10.5005/jp-journals-10050-10055. 19. gwarzo gd. mothers’ awareness and use of zinc in under-five children with diarrhea in north-western nigeria. niger j paediatr. 2018; 45 (2): 81 85. doi: 10.4314/njp.v45i2.2 20. padhy s, sethi rk, behera n. mother’s knowledge, attitude and practice regarding prevention and management of diarrhoea in children in southern odisha. int j contemp pediatr. 2017; 4: 966-71. doi: 10.18203/2349-3291.ijcp20171708 21. ogunrinde og, raji t, owolabi oa, anigo km. knowledge, attitude and practice of home management of childhood diarrhea among caregivers of under-5 children with diarrheal disease in northwestern nigeria. j trop pediatr. 2012; 58(2): 143-6. doi: 10.1093/tropej/fmr048 22. mosweu gj. knowledge, attitude and practices of caregivers (kap) on management of childhood diarrhea among children aged between 0-5 years attending child welfare clinic (cwc) in mogoditshane village, botswana. msc[dissertation]. johannesburg: university of the witwatersrand, johannesburg; 2018. uri: https://hdl.handle.net/10539/25229. 23. ali f, singh op, dutta a, haq zu, ghatak a, ashtankar t. assessing critical gaps in implementation of who and unicef's 7-point diarrhea control and prevention strategy in uttar pradesh, india. ann trop med public health .2017; 10: 571-9. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 116 original article revascularization of non-vital permanent teeth with open apices: a new treatment modality naila amir ali1 and anser maxood2 1. assistant prof, dhq hospital quetta 2. prof, dental department, pakistan institute of medical sciences, islamabad. abstract objective: to determine increase in root(s) length and thickness and closure of apical foramen in patients undergoing revascularization of immature, permanent, necrotic teeth material and methods: this study was conducted at outpatient department of operative dentistry, pakistan institute of medical sciences (pims), islamabad, from 22 nd january 2011 to 22 nd january 2013. all the patients were assessed with the detailed history and clinical examination. on the first visit, pulp chambers of the teeth were opened followed by minimal instrumentation. disinfection of the root canal was done with 2.5% sodium hypochlorite (naocl), saline, and 2% chlorhexidine (chx). then triple antibiotic paste (tap) was placed in the canal till next visit. in the next visit, in the absence of clinical signs and symptoms, under local anesthesia without vasoconstrictor, bleeding was induced in the root canal. blood clot was allowed to form beyond the level of cementoenamel junction (cej) which was then covered with non-setting formulation of calcium hydroxide{ca(oh)2}and bacteria tight coronal seal with glass ionomer cement or composite was made. patients were evaluated clinically and radiographically at 0, 3, 6, 12, 18 till 24 months. results: efficacy of revascularization was measured on 24 months follow up of patients having immature, permanent and necrotic teeth. out of 36 teeth, 34 (94.4%) showed increase in root length and whereas only 2 (5.6%) teeth showed no increase in root length. similarly, 33 (91.7%) teeth showed increase in root thickness and 3 (8.3%) patients showed no increase in root thickness. conclusion: on the basis of follow-up period of at least 24 months, the present study demonstrates favorable outcome of the revascularization procedure in terms of increase in root length and thickness in immature permanent necrotic maxillary anterior teeth. the cases remained successful even with the use of non-setting formulation of ca(oh)2 in place of mineral trioxide aggregate(mta). key words: immature teeth, calcium hydroxide, regenerative endodontics, revascularization. introduction trauma to anterior teeth, commonly found among young children, accounts for one third of all traumatic injuries in males and one fourth in females. in these cases of trauma, tooth fracture constitutes about 4 to 5% of the cases. 1 as root development takes place for almost two to three years after tooth eruption into oral cavity, an incompletely formed apex is most common feature seen in traumatized teeth which in turn poses many potential complications. for example, difficulty in cleaning and shaping of the wide canal, difficulty in disinfecting necrotic debris in wide root canal and absence of apical constriction against which obturation can be done etc. moreover, thin root canal walls render it susceptible to future fracture. 2 endodontic management of such teeth includes surgery and retrograde sealing, conventional ca(oh)2 induced apexification and placement of an apical plug of mineral trioxide aggregate (mta) followed by gutta percha obturation. but these procedures are not associated with more root development in terms of apical maturation and thickening of the dentinal walls and tooth will be more prone to further fracture due to being weak internally. 3,4 recently introduced regenerative endodontic procedures (e.g. revascularization) have the potential to allow for continuation of root development to reinforce dentinal walls and strengthen the tooth against future fracture and might therefore offer an alternative therapeutic approach in the management of immature permanent teeth with compromised integrity. 5,6 although no randomized controlled trial related to regenerative endodontic therapy has been conducted yet. however, current best available evidence undeniably allows clinicians to provide this treatment modality safely and successfully to the patients. present study was conducted to evaluate the effectiveness of revascularization procedure in terms of complete resolution of signs and symptoms and increase in root length and thickness and closure of apical foramen radiographically. material and methods this study was conducted at outpatient department of operative dentistry, pakistan institute of medical sciences (pims), islamabad, from 22 nd january 2011 to 22 nd january corresponding author: prof anser maxood email:ansermaxood@gmail.com received: august 11,2016; accepted: sept 16, 2016 mailto:ansermaxood@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 117 2013. all the patients were assessed with the detailed history and clinical examination. patients with immature necrotic teeth with at-least 1 mm wide open apex mesiodistally, teeth not needing future post and core restoration, physically and mentally healthy children of both genders and patients with age group between 9 to 14 years were included in the study. as root lengthening and apex formation are possibly related to vitality and interaction between hertwig epithelial root sheath and stem cells of apical papillae which could be threatened in case of longer lasting periapical infection, so to avoid this, the younger patients having plenty of vital stem cells with no history of longer lasting infection were selected. periapical radiographs were taken with the help of beam aiming device (endoray11, dentsply) by parallel angle radiographic technique for future comparison of radiographic findings. the study was approved by the ethical committee of pims. the parents of the patients were informed and explained about the whole procedure and informed consent in written was taken. on first visit, pulp chambers of the teeth were opened with round diamond bur of iso size 018 (mani diaburs, japan) under rubber dam isolation (safe touch, medicom, usa) followed by disinfecting the root canal(s) by using 2.5% sodium hypochlorite solution (pfizer), normal saline solution and 2% chlorhexidine (clinica, platinum). canals were dried with paper points. no instrumentation was done. then triple antibiotic paste (tap), consisting of equal amounts of ciprofloxacin, metronidazole and minocycline mixed with propylene glycol liquid was placed as intracanal medicament for at least one week and access cavities were resealed with cavit (provis, germany). on next visit, in case of infection free, dry root canals, local anesthesia without vasoconstrictor (plain lidocaine, huons co, ltd) was administered and rubber dam was re-applied. access cavities were re-entered followed by same irrigation protocol comprising of sodium hypochlorite, saline and chlorhexidine. then bleeding was induced in the root canal with 25 # or 30 # sterile k-file (mani, inc. japan) while going 2 to 3 mm beyond the measured working length. bleeding was controlled by sterilized cotton pellet by placing it for about 10 minutes beyond cej. after formation of blood clot, non-setting formulation of calcium hydroxide (hidroxido calcio. a, biodinemica) was applied over the blood clot. finally bacteria tight coronal seal with glass ionomer cement (kross fill, kross dent inc, usa) or composite was made (tgmicrohybrid, uk). (fig.1a-h). patients were evaluated clinically and radiographically with beam aiming deviceat 0, 3, 12, 18 till 24 months. who software was used for sample size calculation with confidence level: 95%, anticipated population proportion:70 % and absolute precision 15%. all collected data was entered on spss version 17.0. number and percentage was calculated for effectiveness, gender and increase in root length and thickness at 24 months. mean and standard deviation was calculated for age of patient. results according to inclusion criteria of our study, total 36 subjects (teeth) were included in our study from the outpatient department with detailed history and clinical examination for the duration of two years. age of our patients ranged from 8-14 years with mean age of 10.61+1.85 sd; 24 (67%) were males and 12 (33%) were females. patients were evaluated clinically and radiographically at 0, 3, 6 and 12 months till two years (24 months). on clinical examination at 24 months, number and percentages of ttp (tender to percussion) and sinus tract was 2 (5.6%) and 1 (2.8%), whereas only one patient was found without intact coronal seal. similarly, no patient was found with mobility, showing that revascularization is effective in terms of complete resolution of signs and symptoms clinically. efficacy of revascularization was also measured on 24 months follow up of patients having immature, permanent and necrotic teeth. about 34 (94.4%) out of 36 teeth showed increase in root length (fig 1a-f) and whereas only 2 (5.6%) teeth showed no increase in the root length. similarly, 33 (91.7%) patients showed increase in root thickness and 3 (8.3%) patients showed no increase in root thickness, revascularization is effective in terms of complete resolution of signs and symptoms clinically and also with an increase in root length and thickness of teeth radiographically which would help in preventing further root fracture as shown in table 1. table 1: frequency of clinical examination and efficacy of revascularization radiographically on 24 months. n (%) clinical examination ttp 02 (5.6) mobility 0 (0) sinus tract 01 (2.8) coronal seal (intact) 35 (97.2) efficacy root length increase 34 (94.4) no increase 02 (5.6) root thickness increase 33 (91.7) not increase 03 (8.3) journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 118 . fig 1a: pr-eop pa radiograph of maxillary left central incisor the 18months followup. fig 1b: pre-op. pa radiograph maxillary left central incisor the 12-months follow up fig 1c: preop. pa radiograph the 24months follow up. maxillary left central incisor fig 1e: pre-op. pa radiograph the 18months follow up maxillary rightcentral incisor fig 1d: pre-op. pa radiograph the 20months follow up maxillary right central incisor fig 1f: pre-op. pa radiograph the 12months follow up maxillary leftcentral incisor journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 119 discussion individuals between 6-16 years have sequential permanent tooth eruption and maturation of roots. any factor that interrupts the normal physiological process of pulp may arrest the root growth and prevents it from completion. 2 losing immature teeth is difficult to manage as the jaws are still developing and any restorative procedure is likely to be a temporary measure. 7 because of the important role of hertwig epithelial root sheath (hers) in continued root development, after pulp injury, every effort should be made to maintain its viability. 8 before applying any clinical approach to traumatized immature teeth, two clinical situations must be considered. first is dealing with immature teeth with vital pulp where apexogenesis can be attempted with high rate of success. second is immature teeth with non-vital pulp where apexification can be attempted. 9.10 but more recently introduced is revascularization/ maturognesis which can be applied on immature non-vital permanent teeth, whereby not only the apex is closed but entire root is allowed to mature. 11 regeneration of tissues rather than replacement with artificial substitutes is a novel and exciting field in the health sciences. 12 there has been great deal of discussion as to the correct terminology for what has been called pulp revascularization, 2 whether the correct term should be a revascularization, revitalization, regeneration or matuarogenesis? it would be difficult to impossible to assign a proper term unless complete histological analysis is performed of reformed/revascularized pulp tissue. a few histologic case reports have been published after completion of regenerative procedures. two reports found evidence of pulp-like loose connective tissue and one study reported an ingrowth of cementum, bone, and connective tissue. animal studies examining regeneration procedures have shown that the types of tissues found within the root are not pulp but consist of bone, cementum, and connective tissue. 13 our study population undergoing ‘revascularization’ comprised 36 subjects (teeth) of 24 patients with the age range of 8 to 14 years. all teeth being maxillary anterior teeth. all patients presented with non-vital teeth with or without periapical. necrosis of the teeth occurred secondary to coronal fracture with the exception of one patient in whom necrosis occurred due to enamel hypoplasia followed by bacterial invasion of root canal systems. periodontally all teeth were found to be sound with healthy gingiva and periodontal depth being ≤ 3 mm. radiographically teeth were immature (with open apices being at least 1mm wide mesiodistally upto being blunderbuss with thin and short radicular dentinal walls). a critical aspect prior to providing regenerative endodontic procedure to immature necrotic teeth is the size of the apical foramen. amazingly two of our subjects (teeth) of the same patient showed apical diameter of about less than 1mm or almost closed as detected radiographically but root canals being still wide. one tooth of the same patient was found to be involved in large periapical lesion that was diagnosed to be an infected cysticlike lesion, also involving adjacent lateral incisor and canine. these teeth underwent revascularization procedure. after period of 13 months, not only radiographic evidence of periapical healing was observed but amazingly teeth responded very strongly to cold and electric pulp test (ept) tests. these findings suggest that teeth with roots showing very narrow apical openings could be revascularized along with periapical healing (perhaps even of cyst, too). this finding may give two new prospects to think of applying regenerative procedure; first, revascularization procedure can be attempted on mature teeth with the hope that canal space will be re-occupied with healthy tissue carrying the immune cells to combat further bacterial invasion. this result is similar to the findings of case report of khimiya paryani who demonstrated the resolution of clinical signs and symptoms with complete periapical healing in mature permanent incisors with apical periodontitis after regenerative endodontic treatment. 14 second, revascularization procedure can be applied on immature/ mature necrotic permanent teeth involved in cyst-like lesion similar to the results of tarek mohamed who successfully revascularized two mature, permanent teeth with large cyst-like lesions. 7 it can be hypothesized that disinfection of the root canals with naocl, saline and chx and intracanal placement of triple antibiotic paste could eliminate the source of infection from the canal system thus providing suitable environment conductive for healing. 15 chx has been used along with gold standard naocl because of its antimicrobial properties, substantivity, low toxicity. this may be safe alternative if comes in contact with periapical tissues of immature teeth. 9 moreover stem cells of apical papillae (scaps) being supplied with collateral circulation survived even in necrotic condition of dental pulp thus ensuring the in-growth of the blood vessels fig 1g: pre-op. pa radiograph maxillary leftcentral incisor the 10-months follow up(resolution of pa radiolucency) journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 120 and regenerating tissue either from healing periapical tissue or periodontal ligament( pdl) with associated periodontal ligament stem cells ( pdlscs). 7 both points are not more than a hypothesis that require further investigation at molecular level. at the same time, the above described findings could be able to expand the inclusion criteria in selecting the cases for revascularization. although ca(oh)2 mixed with 2% chlorhexidine has been used successfully in place of triple antibiotic paste to disinfect root canal system, 15 our studies remained different from previously described studies on revascularization in that nonsetting formulation of ca(oh)2 was placed over blood clot below the level of cej (instead of mta used in previous studies). to the best of our knowledge, it is the first study in which ca(oh)2 has been used but surprisingly continued growth of the roots observed with positive responses to sensibility tests. although some cases underwent clinical and radiographic failures in terms of reinfection, pain and swelling and non-healing of periapical lesion respectively, but it is uncertain to say that only the use of ca(oh)2 is responsible for failure as previously reported studies done on revascularizations using mta also showed some failures. 16 but again this point opens the new field of research on the use of ca(oh)2 in place of mta where financial constraints limit the application of revascularization procedure. among the findings observed in revascularized teeth, one of the teeth showed complete root canal calcification and three teeth showed partial calcification starting coronally and progressing apically. partially calcified teeth responded negatively to cold test and electric pulp tester (ept). among two of the three partially calcified teeth, radiopaque masses or well demarcated calcified deposits on apical areas were detected on periapical radiographs along with the diffused haziness in coronal side extending apically. the hard tissue may begin as calcific particles originating or being associated with blood vessels and perineurium sheaths. interestingly these are also the locations where pulp stem cells are believed to exist i.e. the scaps. whether these stem cells are activated by low grade inflammation to undergo osteogenic differentiation is unclear at present. this finding is similar to a case report of maxillary incisor which underwent progressive calcific metamorphosis after being successfully revascularized. 17 as hypothesized previously, longer standing of an infection, and long term use of ca(oh)2 as an intra canal medicament, may be detrimental to the process of successful revascularization 18.19 but contrary to this hypothesis, one of the patients with the age of 14 years in our study presented with non-vital maxillary central incisors with periapical radiolucencies from last six years and had been attempted unsuccessfully for ca(oh)2 induced apexification before referral to us. the revascularization procedure was performed and after the period of 12 months, successful healing of periapical lesion and continued root growth was detected radiographically, although one of the teeth redeveloped infection so it was re-entered and re-apexified. this unique set of findings requires establishing strict evidence-based guidelines that teeth with which type of pulpal and periapical status (i.e. teeth with irreversible pulpitis, partially/completely necrotic pulp, with apical periodontitis/abscess or cyst-like large lesions) are best candidates for revascularization. moreover, it must be known that how long the placement of ca(oh)2 in the root canal and duration of infection will completely damage hertwig epithelial root sheath (her), stem cells of apical papillae(scaps) and dental pulp stem cells(dpscs) etc. as far as blood clotting is concerned after induction of bleeding in the canal system, we observed frequent bleeding, infrequent bleeding and very difficult to induce bleeding in different cases. we observed no significant increase in root length and thickness in cases despite of the fact that profused bleeding was induced at the bleeding induction phase. so at this time it is difficult to say that how much amount of the blood is sufficient to give adequate quantity of fibrin-rich clot that will be conductive for in-growth of new tissue. regarding response to sensibility tests (cold test and ept), although successfully revascularized cases showing increase in root length and root thickness radiographically, responded positively to sensibility tests but point of interest arises when revascularizing teeth responded positively to cold test but no response to ept or negative response to both tests. the lack of response might not even be related to the presence or absence of regenerated pulp nerve tissue, according to torabinejad et al, both the coronal level of regenerated tissue and thickness of coronal filling material placed over this tissue may affect the presence and absence of response to cold test or ept. 8 our study remained different in many aspects from previously described studies on revascularization in that; first, a large number of the patients were selected. second, ca(oh)2 was used instead of mta over blood clot, thirdly discoloration was taken as one of the clinical parameters. discoloration of the crowns of revascularized teeth increased over time in some cases. it may be due to residual tap left in the pulp chamber. two patients presented with pain and partially dislodged filling after being revascularized which subsided by prescribing non-steroidal anti-inflammatory drug (nsaids) and repairing the existing restoration. pain may be ascribed due to some inflammatory reaction in the canal system as a result of possible micro leakage from defective coronal restoration. one explanation of subsiding the pain may be related to age of the patient. as the patients were young and healthy with fully mature immune system and defense cells so repairing the restoration and administrating of non-steroidal antiinflammatory drug (nsaids) could subside inflammation and pain and immature teeth continued to develop their roots. 20 in the last if the objective of revascularization is to journal of islamabad medical & dental college (jimdc); 2016:5(3):116-121 121 achieve more clinical and radiographic success (rather than biological failure) in terms of healing of periapical tissue, no signs and symptoms, increase in root length and width and closure of apical foramen, then it can be claimed with certainty that present study succeeded to achieve that objective. conclusion our study showed that revascularization of immature necrotic permanent teeth is a clinical possibility with the benefits of revitalizing the teeth irrespective of the fact whatever the tissue inside the canal space because we were not focused primarily on histological findings in newly revascularized teeth. overall effects (clinically as well as radiographically) were more promising in terms of revitalizing teeth again. it can be hypothesized that revascularized/ regenerated tissue carrying the full range of immune cells can better fight against future microbial challenges just like the pulp tissue of healthy, vital and mature teeth. this treatment modality may explore the vast field of research on tertiary dentine formation capability of regenerated pulp in future in the same way as do vital, healthy and mature teeth. conflict of interest this study has no conflict of interest as declared by any author. references 1chen x, bao z, liu y, liu m, jin x, xu x. regenerative endodontic treatment of an immature permanent tooth at an early stage of root development: a case report. j endod. 2013;39(5):719-22. 2kontakiotis e, filippatos c, tzanetakis g, agrafioti a. regenerative endodontic therapy: a data analysis of clinical protocols. j endod. 2015;41(2):146-54. 3lin l, shimizu e, gibbs j, loghin s, ricucci d. histologic and histobacteriologic observations of failed revascularization / revitalization therapy: a case report. j endod. 2014;40(2):291-5 4kontakiotis e, filippatos c, tzanetakis g, agrafioti a. levels of evidence for the outcome of regenerative endodontic therapy. j endod. 2014;40(8):1045-53. 5wigler r, kaufman a, lin s, steinbock n, hazan-molina h, torneck c. revascularization: a treatment for permanent teeth with necrotic pulp and incomplete root development. j endod. 2013;39(3):319-26 6peter o. translational opportunities in stem cell-based endodontic therapy: where r we and what are we missing? j endod. 2014;40(4):s82-s5. 7saud t, sigurdsson a, rosenburg p, lin l, ricucci d. treatment of large cyst like inflammatory periapical lesion associated with mature necrotic teeth using regenerative endodontic therapy. j endod. 2014;40(12):2081-6. 8torabinejad m, milan m, shabahang s, wright k, faras h. histologic examination of teeth with necrotic pulps and periapical lesions treated with 2 scaffolds: an animal investigation. j endod. 2015;41(6):846-2. 9soares-ade a, lins ff, nagata jy, gomes bp, zaia aa, ferraz cc, et al. pulp revasculariztion after root canal decontamination with calcium hydroxide and 2% chlorhexidine gel. j endod. 2013;39(3):417-20. 10 scarparo r, dondoni l, bottcher d, grecca f, figueiredo j, kantarci a, etal. intracanal delivery of resolving e1 controls inflammation in necrotic immature rat teeth. j endod. 2014;40(5):678682. 11saud t, zaazou a, nabil a, moussa s, lin l, gibbs j. clinical and radiographic outcome of traumatized immature permanent necrotic teeth after revascularization/ revitalization therapy. j endod. 2014;40(12):1946 52. 12zhang d, chen x, bao z, chen m, ding z, zhong m. histologic comparison between platelet-rich plasma and blood clot in regenerative endodontic treatment: an animal study. j endod. 2014;40(9):1388-93. 13zhu w, zhu x, huang g, cheung gsp, dissanayaka wl, zhang c. regeneration of dental pulp tissue in immature teeth with apical periodontitis using platelet-rich plasma and dental pulp cells. int j endod. 2013;46(10):962-70. 14 paryani k, kim sg. regenerative endodontic treatment of permanent teeth after completion of root development: a report of 2 cases. j endod. 2013;39(7):929-34 15 diogenes a, ruparel n, teixeira f, hargreaves k. translational science in disinfection for regenerative endodontics. j endod. 2014;40(4):s52-s7. 16 nosrat a, li kl, vir k, hicks ml, fouad af. is pulp regeneration necessary for root maturation? j endod. 2013;39(10):1291-5. 17 thibodeau b, trope m. pulp revascularization of a necrotic infected immature permanent tooth: case report and review of literature. pediatr dentist. 2007;29(1):47-50. 18hargreaves km, diogenes a, teixeira fb. paradigm lost: a perspective on the design and interpretation of regenerative endodontic research. j endod. 2014;40(4):s65-s9. 19 fouad a, verma p. healing after regenerative procedures with and without pulpal infection. j endod. 2014;40(4):s58-s4. 20simon s, tomson p, berdal a. regenerative endodontics: regeneration or repair? j endod. 2014;40(4):s70-s5. . authorship contribution author1: active participation research, analysis and discussion author2: conception, planning and final review of article 46 j i m d c 2 0 1 8 46 open access f u l l l e n g t h a r t i c l e combined effect of alpha tocopherol and ascorbic acid on body weight of rats exposed to chronic restraint stress sadia moazzam 1, meena gul 2, shemaila saleem3 1 professor of physiology, fazaia medical college. 2associate professor, department of physiology, gkmc, swabi. 3associate professor, department of physiology, federal medical& dental college a b s t r a c t objective: this study was planned to determine the combined effect of ascorbic acid and alpha tocopherol on body weight of sprague dawley rats exposed to chronic restraint stress. materials and methods: the study was conducted in national institute of health (nih), islamabad. ninety male sprague dawley rats (mean wt 250 ± 50 grams) were used and divided into 3 groups. each group comprised of 30 rats. group i was taken as control. group ii was exposed to chronic stress, whereas group iii was given combined doses of ascorbic acid and alpha tocopherol prior to restraint stress. results: the comparison of weight gain by the different groups revealed that there was a significant decrease in weight gain of rats exposed to the chronic stress as compared to control group. combined supplementation with ascorbic acid and alpha tocopherol resulted in significant improvement of their eating habits. conclusion: chronic stress has a detrimental effect on weight. this effect can be minimized by the intake of sufficient amount of antioxidants. key words: ascorbic acid, alpha tocopherol, body weight, chronic stress. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence sadia moazzam email: sadiamoazzam1@yahoo.com article info. received: august 22, 2017 accepted: december 19, 2017 cite this article. moazzam s, gul m, saleem s. combined effect of alpha tocopherol and ascorbic acid on body weight of rats exposed to chronic restraint stress. jimdc.2018; 7(1):46-49 funding source: nil conflict of interest: nil i n t r o d u c t i o n stress is a widespread problem of today’s society where stressors are increasingly prevalent.1 best way to prevent stress in life is to live a healthy lifestyle which includes good nutrition, moderate exercise, adequate sleep, meaningful work.2 stress is commonly known to change body weight and food intake in animals. of the various stress methods available for the study of the effects of stress, the restraint stress model is most commonly used, as it effectively mimics physical and psychological stress.3 the restraint stress method has also been used as an animal model of depression. thus, many studies have shown that restraint stress suppresses food intake and body weight gain in rats.4,5 the central regulation of body weight and food intake occurs in the hypothalamus, which contains multiple neuronal systems, that play important roles in the regulation of energy homeostasis.6 the weight loss due to stress is dependent on the acute central release of corticotrophin-releasing factor (crf)7, but there is no sustained activation of this pathway to determine for the maintained suppression of body weight.8,9 crf activates hypothalamic-pituitary-adrenal (hpa) axis, the sympathetic nervous system, and catecholamine systems. all of these systems likely to inhibit food intake and reduce body weight, but none of them is activated o r i g i n a l a r t i c l e 47 j i m d c 2 0 1 8 47 significantly during the hours or days after exposure to repeated restraint. moreover, the preventive role of antioxidant in reducing weight loss is still unclear. several studies have documented the beneficial effects of ascorbic acid supplementation on stress induced changes. keeping in view the beneficial role of antioxidants, this study was designed to determine the role of combined supplementation of ascorbic acid and alpha tocopherol in preventing the decline in body weight due to chronic restraint stress. m a t e r i a l s a n d m e t h o d s total 90 sprague dawley healthy male rats weighing 250±50 grams, 60 days (8weeks) old were purchased from (nih), islamabad. female rats, diseased rats or rats who developed disease during the course were excluded from the study. rats were divided into 3 groups. each group comprised of 30 rats. group-one was considered as control group. rats in this group were fed with normal standard diet without any supplementation. they were supplied plain tap water for drinking. rats in group-two were given standard diet without any supplementations. however, these rats were exposed to daily stress for 15 days. rats of group 3 were supplemented with ascorbic acid in a dose of 500mg /l added in drinking water & alpha tocopherol 300mg/l supplement with soya bean oil for one month before and during chronic stress. rats of group 2 & 3 were exposed to chronic stress by keeping immobilized in a meshwire restrainer for 6 hours daily for 15 days.9 stress was determined by the serum cortisol level. samples were taken in the morning between 8.00 and 9.00 am, to avoid bias due to different levels of cortisol owing to the diurnal variations.11 composition of pelleted diet for rats ingredients weight 1 whea flour 2.85kg 2 wheat brawn 2.85kg 3 dried skimmed milk powder 2.00 kg 4 soya bean oil 0.50kg 5 mollasen 0.15kg 6 fish meat 0.15kg 7 salt (common) 0.05kg this diet was prepared at (nih), islamabad, according to the standard approved by the universities federation for animals welfare. eating habits and behavioral changes were also noticed throughout the duration of the study. for statistical analysis statistical package for social sciences (spss) version 15 was used. mean and standard deviation of body weight were calculated. one way anova was applied to calculate p-value r e s u l t s the rats remained healthy and active throughout the study. the average intake of feed by each rat was between 15-20 grams. if the rats took more than 20 grams of diet per day, it was considered ‘improved’ while less than 15 grams’ intake was considered ‘reduced’ (table 1). average weight of all rats at the beginning was 220 grams. the comparison of weight gains by the different groups shown in (table 2) revealed that there was a significant decrease in weight gain of rats exposed to the chronic stress as compared to control group. table 2: group wise comparison of body weight (kg) of rats during different weeks of the study (n=90) weeks group 1 (n= 30) group 2 (n= 30) group 3 (n= 30) p-value 9th 235.17±7.48 234.17±7.32 243.50±7.21 < 0.001 10th 261.00±6.07 261.67±7.11 286.00±7.24 < 0.001 11th 279.33±6.26 279.33±7.63 300.00±6.95 < 0.001 12th 300.00±5.72 299.50±7.70 322.50±6.53 < 0.001 13th 313.83±6.78 306.83±7.13 334.33±7.16 < 0.001 14th 320.17+6.83 309.50±7.58 369.57±6.03 < 0.001 nevertheless, combined supplementation with ascorbic acid and alpha tocopherol resulted in significant improvement of their eating habits. serum cortisol levels were highest in group 2 followed by group 3 and then group 1 (table 3) table 3: group wise comparison of serum cortisol (n=90) variable group1 (mean±sd) group 2 (mean±sd) group 3 (mean±sd) p-value cortisol (ng/ml) 21.4 ± 0.92 34.71± 1.45 24.17± 1.07 < 0.001 normal: daily dietary intake of each rat = 15-20 grams; reduced = dietary intake less than 15 grams/ day; improved = dietary intake more than 20 grams/day. 48 j i m d c 2 0 1 8 48 d i s c u s s i o n in the present study, we investigated the effects of combined supplementation of ascorbic acid and alpha tocopherol on the body weight and food intake of sprague dawley rats exposed to chronic restraint stress. several studies have tried to establish the fact that chronic exposure to restraint stress reduces the body weight and food intake of rats.12-14 however, the mechanisms underlying these restraint-induced changes in body weight and food intake remain to be clarified. our results have shown that restraint stress rapidly induce a marked decrease in body weight that may be due to a reduction of food intake. the stress-induced decrease in body weight may be due initially to an early decrease in food intake but then may be subsequently maintained by increases in energy expenditure and body temperature during restraint. increased serum cortisol levels suggest that physiological responses to repeated stress are associated with the activation of the hpa axis. results of study conducted by santos, support our results that chronic stress causes reduction in weight gain (2.0 ± 0.65 g/day)15, while dallman et has documented contradictory results and postulated that chronic stress resulted in increase in weight gain (2.5 ± .32g / day). it could be due to reduction in growth hormone secretion, reduced linear growth, and sympathetic neural outflow along with reduced fat mobilization, which led to obesity.16 moreover, this study also showed that, while exposure to restraint stress significantly decreased food intake, once the stress ended, the food intake of the stressed group returned to the normal level. in our study, serum corticosterone levels were increased by repeated restraint stress. effect of combined supplementation with ascorbic acid and alpha tocopherol has been documented by different studies as more potent as compared to their individual effects, in improving the immune status. fuente et al., documented that combined use of ascorbic acid and alpha tocopherol improved not only the immune status by decreasing serum cortisol level but also the body weight.17 the data of present study has revealed that stress; whether psychological or physical could lead to lower the immune status of the individual. stress is one of the major factors, which, in one way or the other, disrupts many physiological functions. higher the intensity or duration of stress, greater will be the disruption. the use of antioxidants supplements can be one of the means by which we can prophylactically protect our body from the harmful effects of stress. c o n c l u s i o n the results of this study showed that chronic restraint stress is responsible for elevated serum cortisol level, which directly or indirectly affect the food intake, and reduces the body weight. however, those rats who were given prior combined supplementation of ascorbic acid and alpha tocopherol did not show that reduction. r e f e r e n c e s 1. ablimit a, kühnel h, strasser a, upur h. abnormal savda syndrome: long-term consequences of emotional and physical stress on endocrine and immune activities in an animal model. chin j integr med. 2013;19(8):603–609.. 2. smith ap. effects of upper respiratory tract illnesses and stress on alertness and reaction time. psychoneuroendocrinology. 2013;38(10):2003–2009. 3. srinivasan s, loganathan s, wankhar w,rathinasamy s, rajan r. stress effect on humoral and cell mediated immune response: indispensible part of corticosterone and cytokine in neutrophil function.trials in vaccinology 2016; 5: 61-70. table 1: comparison of eating habits of rats in different group (n=90) groups 9th week 10th week 11th week 12th week 13th week 14th week group 1 (n=30) normal normal normal normal normal normal group 2 (n=30) normal normal normal normal reduced reduced group 3 (n=30) normal improved improved improved improved normal 49 j i m d c 2 0 1 8 49 4. loveless se, hoban d, sykes g, frame sr, everds ne. evaluation of the immune system in rats and mice administered linear amminium perfluorooctanoale.toxicological sc 2008 ;105(1): 8696. 5. belay t, woart a. cold-induced stress increases the intensity of chlamydia genital infection in mice. j microbiol immunol infect. 2013;46(5):330–337 6. zieziulewicz tj, mondal tk, gao d, lawrence da. stress-induced effects, which inhibit host defenses, alter leukocyte trafficking. cell stress chaperones. 2013;18(3):279–291 7. sarjan hn, yajurvedi hn. chronic stress induced duration dependent alteration in immune system. immunology letters 2018;75:1357–1368 8. liu n, wang lh, guo ll, wang gq, zhou xp, jiang y et al. chronic restraint stress inhibits hair growth via substance p mediated by reactive oxygen species in mice. plos one 2013; 8(4); e61574 9. hu gz, yang sj, hu wx , wen z, hu d, zeng lf, xiang q, wu xm et.,al. effect of cold stresson immunity in rats. exp ther med 2016; 11(1):3342. 10. everds ne, snydes pw, bailay kl, bolon b, creasy dm. intepreting stress responses during routine toxicity studies: a review of the biology, impact and assessment. toxicologic pathology2013; 41(4): 561614. 11. marti o, marti j, armario a. effects of chronic stress on food intake in rats:influence of stressor intensity and duration of daily exposure. physiol behav. 1994; 55(4):747-53. 12. harris rb, zhou j, youngblood bd, rybkin ii, smagi gn, ryan dh. effect of repeated stress on body weight and body composition of rats fed lowandhighfat diets. am j physiol 1998;275(6): 1928-1938. 13. gamaro gd, manoli lp, torres il, silveira r, dalmaz c. effects of chronic variate stress on feeding behavior and on monoamine levels in different rat brain structures. neurochem int. 2003;42(2):107 14. 14. santos j, benjamin m, yang pc, prior t, perdue mh. chronic stress impairs rat growth and jejunal epithelial barrier function: role of mast cells. am j physiol gastointest liver physiol 2000; 278(6): 84754. 15. dallman mf, pecoraro n, akana sf, , fleur sei, gomaz f, houshyar h . chronic stress and obesity: a new view of comfort food. proc natl acad sci usa 2003; 100(20): 11696701 16. fuenta mdi, ferrandoz md, burgos ms, solar a, prieto a, miquel j. immune function in aged women is improved by ingestion of vitamin c and e. can j physiol pharmacol. 1998; 76(4); 373-80. 17. ark pc, slominski a, theoharidestc, peters em, paus r. neuroimmunology of stress: skin takes centre stage. j invest dermatol 2006; 126(8): 16971704. journal of islamabad medical & dental college (jimdc); 2012(2):99-101 99 case report osteopetrosis, a rare cause for bone marrow failure naghmi asif*, khalid hassan**, urooj akram***, mohammad ashraf farooq**** * assistant prof pathology, islamabad medical & dental college ** prof & hod pathology, islamabad medical & dental college *** consultant pediatrician, department of pediatrics, social security hospital islamabad **** prof & hod radiology dept, islamabad medical & dental college, islamabad (bahria university, islamabad) abstract osteopetrosis is a rare genetic disorder characterized by functional defect of osteoclasts resulting in failure of bone resorption, increased bone sclerosis and bone marrow failure. patients present with stunted growth, skeletal changes, hepatosplenomegaly, features of pancytopenia and characteristic radiological changes. osteopetrosis has variable inheritance pattern. diagnosis is made on the basis of history with clinical findings, characteristic radiological and bone marrow findings. we present a case of a 10 years old female child with stunted growth, frontal bossing, teeth abnormalities and characteristic radiological and bone marrow findings. key words: osteopetrosis; marble bone disease; bone marrow failure introduction osteopetrosis (op) refers to a group of rare genetic disorder characterized by increased bone density on radiographs. the condition varies in presentation and severity ranging from neonatal onset with life threatening complications such as bone marrow failure to an incidental finding. the term osteopetrosis is derived from greek, osteo meaning bone and petros meaning stone. op is also known as marble bone disease and albers-scharberg disease, after the name of german radiologist who gave first description of disease.1 the primary underlying defect in all types of osteopetrosis is failure of the osteoclasts to reabsorb bone resulting in thickened sclerotic bones, which have poor mechanical properties. increased bone fragility results from a failure of the collagen fibers to connect osteons properly and from defective remodelling of woven bone to compact bone. 2 this leads to generalized sclerosis of bone with an increased skeletal mass due to abnormally dense bone. mutations in at least 10 genes have been identified. generalized osteosclerosis is apparent radiographically, often with a “bone within a bone” appearance.3 in severely affected patients, the medullary cavity is filled with endochondral new bone, with little space remaining for hematopoietic cells. this abnormality contributes to the brittleness of bone in osteopetrosis. the abnormal skeletal radiographs and microscopic appearance of bone can be reversed by hematopoietic stem-cell transplantation.4 overall, the incidence of the disease is estimated at 1 in 100,000500,000. however, the actual incidence is unknown because no large epidemiological studies have been conducted so far.5 the condition may be inherited as autosomal recessive, autosomal dominant or xlinked trait. autosomal op also known as malignant op is the most severe of all genetic variants and manifests classically in first few months of life. characteristic features include short stature, macrocephaly, frontal bossing, tooth eruption defects and dental caries. increased bone density can produce weakness of bones resulting in predisposition to fractures and osteomyelitis. the expanding bone can narrow nerve foramens resulting in signs of nerve compression such as blindness, deafness and facial palsy. these children are also at a risk of developing hypocalcaemia which may result in tetanic seizures and secondary hyper parathyroidism. hematological findings are due to obliteration of bone marrow cavity by bone, causing myelophthisic anemia, which manifests as a leukoerythroblastic picture on peripheral blood smear. the most severe complication of op is bone marrow suppression resulting in life threatening pancytopenia. hepatosplenomegaly is due to extra medullary hematopoiesis. thrombocytopenia, leukopenia and anemia may also occur due to hypersplenism. many patients of malignant recessive osteopetrosis become transfusion dependant. 6 variants of arop may have neurological and renal manifestations. autosomal dominant op typically have onset in late childhood and adolescence. patients classically have the radiographic signs of sandwich vertebrae, fractures, scoliosis, osteoarthritis and osteomyelitis particularly affecting mandible in association with dental caries and abscesses. x linked op is rare and is characterized by immunodeficiency with ectodermal changes. the diagnosis of op depends upon clinical, radiographic and bone marrow findings. the classic radiological features of osteopetrosis include diffuse sclerosis, affecting the skull, spine, pelvis and appendicular bones, bone modelling journal of islamabad medical & dental college (jimdc); 2012(2):99-101 100 defects, "bone-in-bone" appearance particularly in the vertebrae and phalanges and focal sclerosis of the skull base, pelvis and vertebral end plates giving "sandwich" appearance. bone marrow typically shows increased bone density with reduction or absence of medullary cavity and markedly decreased hematopoietic tissue. once the diagnosis of a primary osteopetrosis is made, it is important to distinguish between different subtypes as they have different responses to treatment, prognosis and recurrence risks. we present a case of a 10 years old female child who presented with anemia and thrombocytopenia and on radiological evaluation and bone marrow examination was diagnosed as a case of osteopetrosis. figure 1: patient of osteopetrosis showing: a. frontal bossing; b. dental abnormalities case report a ten years old female child presented in opd at social security hospital islamabad, with history of generalized bodyache and pain in legs for the past 4-5 years. she was the product of consanguineous marriage. there was no history of transfusion in the past. she was a short statured child and also had frontal bossing. on examination of oral cavity, dental caries was observed in many teeth. she was mildly pale. there was no lymphadenopathy or hepatosplenomegaly. her blood complete picture showed hb 8.4 gms/dl, tlc 8.4 x 106/l; platelet count 110 x 109/l, mcv 77.3 fl, mch 23.1 pg and mchc 29.9 g/dl. her biochemical profile showed serum calcium: 8.6 mg/dl, po4: 4.7 mg/dl and alkaline phosphatase: 559 iu/l. she was sent for radiological evaluation. x-rays of spine, skull, long bone and hands were taken. radiological evaluation showed increased bone density with increased thickening of bony cortices with diagnosis of osteopetrosis. she was referred to us for bone marrow biopsy. bony texture was stony hard. bone marrow aspirate was hypocellular with hypoplastic erythroid, myeloid and megakaryocytic series cells. no abnormal cells were found. histological section of trephine biopsy showed hypocellular bone marrow fragments with decrease in erythroid, myeloid and megakaryocytic series cells. bone marrow fragments were replaced by new bone formation (at different stages of ossification). final diagnosis was osteopetrosis. figure 2: sclerotic bones a. skull b. ulna & radius c. wrist and hand figure 3: trephine biopsy shows widening of bone trabeculae, and evidence of bone formation in the bone marrow fragments. bone has encroached into the bone marrow replacing normal marrow cells discussion osteopetrosis, also called marble bone disease, was first described by heinrich albers-schonberg in 1904 which is a heterogeneous group of heritable conditions in which there is a defect in bone resorption by osteoclasts. hallmark of disease is increased bone density on radiographs resulting from failure of osteoclast development or function, decreased bone resorption and thickened sclerotic bone. a b c a b journal of islamabad medical & dental college (jimdc); 2012(2):99-101 101 osteopetrosis varies in severity depending on mode of inheritance and time of presentation. based on the age, clinical, hematological and radiological features three distinct forms namely the infantile or ar, adult (ad) form, and intermediate op.7 the ar variety is also known as congenital or infantile or malignant op occurs in infancy and has a rapid downhill course due to severe bone marrow failure.8 features of infantile osteopetrosis include dense and deformed bones, growth failure, anemia, hypoplastic dentition, chronic infection, splenomegaly and neurological impairment. adult type of op has an autosomal dominant inheritance pattern and approximately one half of the patients are asymptomatic, and the diagnosis is made incidentally or is based on family history. autosomal recessive osteopetrosis may have less severe manifestations and is known as “intermediate” autosomal recessive osteopetrosis (in which bony changes are there but bone marrow failure is not prominent and it has poor prognosis).9 recently a case has been described with abnormal bone modelling, increased bone density and histological features of osteopetrosis in a 12-year-old boy with extended bisphosphonate therapy. this case suggests that agents that inhibit the recruitment and function of osteoclasts, when given over an extended period of time, may cause a clinical picture comparable to heritable osteopetrosis and has been designated as acquired osteopetrosis.10 we present a case of autosomal recessive osteopetrosis which is probably of intermediate severity as she is 10 years old girl and has presented with bony changes and anemia but there is no history of transfusion in past. her trephine showed sclerotic changes but there was still some residual marrow seen on bone marrow trephine. her two siblings however died at the age of 3 and 3.5 years with same disease probably having severe form of malignant osteopetrosis. osteopetrosis is a rare cause of anemia both in infantile and adult varieties, 11 due to replacement of hemopoietic tissue by bone marrow sclerosis. in a study done in india on clinical and laboratory features of 6 patients of infantile osteopetrosis in 5 years duration, increasing pallor and listlessness were the most common initial symptom. other features included abdominal distension, fever, frontal bossing, nasal block, anemia and thrombocytopenia. 12 the risk of developing hematological impairment in the first year of life is about 75% and its onset within 3 months of life is indicative of a poor outcome.13 infantile osteopetrosis requires treatment due to the adverse outcome associated with the disease. calcitriol may help by stimulating dormant osteoclasts and, thus, stimulating bone resorption. however it only produces a modest clinical improvement, which is not sustained after discontinuation of therapy.14 erythropoietin can be used to correct anemia. children with infantile osteopetrosis have disease-related complications that affect nutritional status. good nutritional support can provide nutrients needed for improved growth and response to treatment in these patients. recently, use of interferon gamma has been found to decrease the rate of infection and transfusion requirements after 24 months of therapy. the natural course of the disease results in survival of about 30% of patients at six years of age. some may live till 2nd or 3rd decade but the quality of life is mostly poor. bone marrow transplant is the only treatment that can be offered to cure the disease and has remarkably shown improvement in some cases of osteopetrosis. recipients of hla identical bmt have been reported to have 5 year survival of 79%.15 it can cure both bone marrow failure and metabolic abnormalities. however in adult op which has relatively normal bone marrow function no specific medical treatment exists. though rare, ar osteopetrosis should be considered in the differential diagnosis of an infant or young child presenting with anemia with or without hepatosplenomegaly. an accurate diagnosis is essential in view of availability of curative treatment and for genetic counseling. references 1. stark1 z and savarirayan r. osteopetrosis orphanet journal of rare diseases 2009; 4(5):1-12 2. sutton d. textbook of radiology and imaging.7th ed. edinburgh: churchill livingstone 2003:2; 1126-9. 3. shapiro f. osteopetrosis: current clinical considerations. clin orthop 1993:34-44. 4. jakub tola., steven l. teitelbaum, and paul j. orchard, m.d. osteopetrosis n engl j med 2004;351:2839-49. 5. chapman s. nakielwy r. aids to radiological differential diagnosis.4thed. edinburgh. saunders 2003:577-8. 6. wilson cj, vellodi a. autosomal recessive osteopetrosis : diagnosis, management and outcome. arch dis child 2000;83: 449-52. 7. saluja s, bhandari s, aggarwal s, kapoor s. osteopetrosis: a rare cause of anemia review of literature. indian journal of pathology & microbiology 2009;52(3):363-367 8. bodamer oa, braverman rm, craigen wj. multiple fractures in a 3-month-old infant with severe infantile osteopetrosis j pediatr child health 2001;37:520-2 . 9. shapiro f. osteopetrosis: current clinical considerations. clin orthop 1993:34-44. 10. whyte mp, wenkert d, clements kl, mcalister wh, mumm s. bisphosphonate induced osteopetrosis. n engl j med 2003; 349:457-63. 11. sreehari s, naik dr, eapen m. osteopetrosis: a rare cause of anemia. hematology reports 2011;3(1) 12. shubha r, gupta a, pahi j, pandey a and gautam p et al. malignant recessive osteopetrosis. indian pediatrics 1999;36:69-74 13. gerritsen eja, vossen jm, van loo ihg, hermans j, helfrich mh, griscelli c, fischer a. autosomal recessive osteopetrosis: variability of findings at diagnosis and during the natural course. pediatrics 1994; 93: 247253. 14. key ll, carnes d, cole s et al. treatment of congenital osteopetrosis with high dose calcitriol. n eng j med 1984; 310: 409-19 15. gerritsen eja, vossen jm, fasth a and friedrich w. et al. bone marrow transplantation for autosomal recessive osteopetrosis: a report from the working party on inborn errors of the european bone marrow transplantation group. j pediatr 1994; 125: 896901. j islamabad med dental coll 2020 73 ope n acce ss aggressive central giant cell granuloma: a case report jahangir hammad1, muhammad ayoub2, kashaf-ud-doja tariq2, farhat gul babar2 1 associate professor, department of oral and maxillofacial surgery, sandeman provincial hospital, bumhs, quetta 2 resident, department of oral and maxillofacial surgery, sandeman provincial hospital, bumhs, quetta a b s t r a c t central giant cell granuloma (cgcg) is a benign non odontogenic lesion of jaw that may show aggressive behavior. it is classified as aggressive and non-aggressive lesion on the basis of biological behavior and radiographic features. central giant cell lesion is more frequent in children and young adult before the age of 30 years with female predilection, with characteristic radiological and histopathological features. here we present a case of a 35 years old female with clinical and radiological diagnosis of central giant cell lesion in posterior mandible confirmed by histopathology. a surgical approach with regular follow up is the treatment of choice in most of the cases . key words: calcitonin, corticosteroid, curettage, enucleation, giant cell lesion correspondence: kashaf-ud-doja tariq email: memahmood1945@gmail.com article info: received: october 21, 2019 accepted: february 6, 2020 cite this case report: hammad j, ayoub m, tariq k, babar fg. aggressive central giant cell granuloma: a case report. j islamabad med dental coll. 2020; 9(1):.73-75. doi: 10.35787/jimdc.v9i1.428 funding source: nil conflict of interest: nil i n t r o d u c t i o n central giant cell granuloma (cgcg) is a giant cell lesion, that represents a benign proliferation of fibroblasts and multinucleated giant cells.1 kaban and colleagues formalized a classification system that provides a guide for treatment.2 the biological behavior can be aggressive or non-aggressive, in which aggressive form exhibits numerous symptoms whereas non aggressive is asymptomatic.1 the aggressive form has any three of the following criteria; greater than 5cm, painful, rapid growth, root resorption, tooth displacement, cortical bone thinning or perforation, extension into soft tissue, ulceration of overlying mucosa and recurrence. the non-aggressive lesion is relatively small, painless, exhibits few or no symptoms, grows slowly, and does not cause root perforation or root resorption.1 central giant cell granuloma mostly occurs in children and young adults with female predilection. the mandible is affected more frequently than maxilla (3:1), mostly anterior to the first permanent molar teeth. lesion may be seen crossing midline.1 central giant cell granuloma resembles other giant cell lesions so proper clinical examination, histological and radiographic analysis, helps to differentiate it from these lesions. 3 c a s e r e p o r t a 35 years old female came to oral and maxillofacial surgery department with complaint of pain and swelling on the right side of lower jaw, which appeared 6 months back. patient was referred by a general dentist. pain radiated to the head region and was only relieved by analgesics. swelling progressively increased in size due to which patient was unable to eat. it was not associated with fever, chills, rigors and lymphadenopathy. c a s e r e p or t j islamabad med dental coll 2020 74 past medical, surgical, drug and family history were unremarkable. patient was a housewife with 3 children and belonged to a middle -class family. she was well oriented in time place and person. there was no anemia, jaundice, cyanosis, clubbing or lymphadenopathy. on clinical examination, there was facial asymmetry due to swelling on right lower side of the face. mouth opening was adequate with a firm swelling of approximately 5cm, extending superiorly to occlusal level of teeth, inferiorly to buccal vestibule, anteriorly to first premolar and posteriorly to third molar region. the overlying mucosa was normal. teeth associated with swelling were mobile. baseline investigations were normal. orthopantomograph revealed radiolucent swelling 4cm×2cm in size on right posterior mandible with bone resorption and displacement of associated teeth (figure 1). on incisional biopsy, microscopic features such as few multinucleated giants in a background of plump proliferating mesenchymal cells along with red blood cells extravasation confirmed central giant cell granuloma (cgcg). surgery was performed under general anesthesia with enucleation (complete removal of lesion) and curettage, along with extraction of the associated teeth and peripheral ostectomy to prevent recurrence. first, incision was marked to ensure that it was placed over an area of sound bone that allow for adequate tissue closure as placement of incision over a bony defect may allow the wound to break down in to the lesion cavity. a small round bur was used for lateral corticotomy and sharp double end curette was used for enucleation. the sharp end of curette was used between the lesion and against the bone to allow proper enucleation of the lesion and minimize the occurrence of a tear. the cavity was then examined for any remnant. a peripheral ostectomy was completed with large round diamond bur with copious irrigation to remove 1-2 mm of surrounding bone until the cavity was completely cleared. post-removal examination of lesion was done (figure 2). written consent was signed by the patient in which the disease, complications of disease and surgery and prognosis of surgical treatment was clearly explained. patient was recalled weekly for follow-up. in each visit wound was examined carefully, irrigated, dressing was placed in the intraoral wound to promote healing. rehabilitation with prosthesis was planned after complete wound healing. figure 1: opg showing radiolucency on right posterior mandible with bone resorption and teeth displacement . figure 2: gross specimen of cgcg after enucleation and peripheral ostectomy d i s c u s s i o n world health organization classified central giant cell granuloma in 2005 as the rarely aggressive lesion of jaw that may be asymptomatic or present j islamabad med dental coll 2020 75 with pain, paresthesia and bone perforation. 4 jaffee (1953) considered this lesion as reparative reaction of bone.5,6 cossío et al suggested that trauma is the main cause of cgcg.7 soames and southam (1997) suggested that it could be a reaction to bone marrow hemodynamic disturbance .there are many orofacial giant cell lesions that have similar presentation so surgeon should have proper knowledge of histopathological and radiographic features to differentiate, diagnose and manage the lesion. cgcg is frequently reported in females less than 30 years of age with anterior mandible as the most commonly affected site.4 however, our case was a 35 years old female with the lesion in posterior mandible. medical treatment of this lesion includes intralesional corticosteroid injections for 6 weeks, subcutaneous calcitonin injections for 1 year, interferon alpha-2b subcutaneous injections or combination.8,9 surgical treatment options include curettage alone (with more chances of recurrence) or curettage with enucleation, resection and peripheral ostectomy as the best treatment option.4 intraoperative complications of these surgical procedures include damage to adjacent teeth and nerves, bleeding, and tearing of lesion lining. postoperative complications include infection, wound dehiscence, graft failure, facial asymmetry, and recurrence.10 c o n c l u s i o n central giant cell granuloma belongs to giant cell lesion group with unknown etiology. this pathological lesion is managed by taking proper history, examination, radiographic and, histopathological analysis that helps to differentiate it from other lesions. there are different treatment strategies for central giant cell granuloma with the choice depending upon patient's demand, medical condition of the patient, severity of the disease and surgeon experience. r e f e r e n c e s 1. kumar n, vande av, tewary s, zope sa. giant cell lesion and central giant cell granuloma. aabs. 2017; 4(1): 22-29. doi: 10.21276/aabs.2017.1315 2. kudva a, cariappa km, dhara v, solomon m. central giant cell granuloma: an uncommon presentation. oral maxillofac sur cases. 2018; 4(4): 135 -40. doi: 10.1016/j.omsc.2018.08.001 3. cavalcante rc, de lucas corso pf, dias tr, schramm e, de souza ph, rebellato nl, et al. central giant cell granuloma (cgcg) in childhood: surgical treatmen t by maintaining the tooth germs. rsbo revista sulbrasileira de odontologia. 2017; 14(1): 37-43. 4. buduruk k, podduturi sr, prakesh j. central giant cell granuloma: a case report and review. jiaomnr .2017 april; 29(2): 145. 5. sandhya t, avinash t, snehal d, neha t, uma m. multifocal central giant cell granuloma a case report. ijp. 2016;11(3):276. 6. kaur n, kohli t, chhina ak. central giant cell granuloma: a diagnostic predicament. j adv med dent scie res. 2016; 4(1): 90. 7. infante cossío p, martínez de fuentes r, carranza carranza a, torres lagares d, gutiérrez pérez jl. recurrent central giant cell granuloma in the mandible: surgical treatment and dental implan t restoration. med oral patol oral cir bucal (internet). 2007 may; 12(3):229-32. 8. el hadidi yn, ghanem aa, helmy i. injection of steroids intralesional in central giant cell granuloma cases (giant cell tumor): is it free of systemic complications or not? a case report. int j surg case rep. 2015; 8:166-70. doi: 10.1016/j.ijscr.2015.02.001 9. rachmiel a, emodi o, sabo e, aizenbud d, peled m. combined treatment of aggressive ce ntral giant cell granuloma in the lower jaw. j craniomaxillofac surg. 2012; 40(3): 292-7. doi: 10.1016/j.jcms.2011.04.002 10. bataineh ab, al-khateeb t, ma'amon ar. the surgical treatment of central giant cell granuloma of the mandible. j oral maxillofac surg. 2002 jul 1;60(7):756-61. j islamabad med dental coll 2019 88 open access effect of nigella sativa on oxidative stress in post-menopausal females shazo sana 1, muniza saeed 2, hafiz muhammad umair 3 1 demonstrator, department of physiology, fatima jinnah medical university, lahore 2 professor/head, department of physiology, postgraduate medical institute, lahore 3 senior demonstrator, department of hematology, fatima jinnah medical university, lahore a b s t r a c t background: the permanent cessation of menstrual periods in menopause causes a decline in estrogen levels and increased oxidative stress. both of these factors lead to menopausal symptoms, cardiovascular diseases and osteoporosis in the postmenopausal females that negatively affect the quality of their lives. antioxidant properties of nigella sativa are due to its natural ingredient “thymoquinone” and have been studied in various animal and human studies. this study was done to determine beneficial effect of nigella sativa. material and methods: thirty postmenopausal females were recruited in the study after taking consent. nigella sativa was administered at a dose of 1g/day for 2 months after breakfast. blood sample was taken for pre and post treatment glutathione (gsh) estimation. the spss version 21 was used to analyze the data. paired ttest was applied. p value of< 0.05 was considered significant. results: regarding the effect of the nigella sativa on oxidative stress, result indicated a highly significant increase from baseline (p<0.0001) after 8 weeks’ consumption of nigella sativa. the effect size was calculated both for biochemical parameter gsh and general parameter like weight and bmi. the result of the effect size calculation showed larger effect size for gsh levels (3.9) and moderate sized effect for weight and bmi. conclusion: nigella sativa showed beneficial antioxidant effects in post-menopausal females and might be responsible for a better quality of life in these women. key words: nigella sativa, menopause, oxidative stress authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3 active participations in data collection data analysis. correspondence: shazo sana email: shazirose2011@hotmail.com article info: received: january 8, 2019 accepted: april 19, 2019 cite this article. sana s, saeed m, umair hm. effect of nigella sativa on oxidative stress in post-menopausal females. j islamabad med dental coll.2019; 8(2):88-91 funding source: pgmi lahore conflict of interest: nil i n t r o d u c t i o n menopause is characterized by end of menstrual cycles in the absence of any pathological or physiological cause for at least 12 consecutive months. ovarian functions gradually decline as the females’ approach menopause resulting in decreased concentration of both estrogen and progesterone.1 the aging process involves increased oxidative stress that is caused by an imbalance between production of oxidants and their elimination by antioxidants.2 oxidative stress increases in postmenopausal females.3 this is because of decreasing levels of estrogens as it acts as direct scavenger of free radicals.4 the increased oxidative stress in postmenopausal females results in heart diseases, vasomotor disturbances and osteoporosis.5 at present, medicinal plants are used for treatment and prevention of many diseases due to easy availability, affordability and safety .6 among different medicinal herbs, nigella sativa (kalonji) is one miraculous herb o r i g i n a l a r t i c l e j islamabad med dental coll 2019 89 having historical and religious background.7there has been extensive research on the biological qualities and therapeutic properties of nigella sativa like use as antidiabetic, anticancer, antimicrobial, antipyretic, antiinflammatory and as analgesic.7 in addition to all these properties, nigella sativa has remarkable antioxidant properties.8 thymoquinone (tq) is the main active component of nigella sativa that has been found to scavenge all the reactive oxygen species (ros).9 an animal study showed the antioxidant property of tq as it protected the liver against oxidative stress caused by hepatic carcinogens.10 another study also showed significant reduction in cerebral oxidative stress by using tq in rats.11 likewise, tq increased the antioxidant enzymes significantly in animal model of colonic carcinogenesis proving excellent antioxidant properties.12thus in short, menopause results in increased oxidative stress. by administering nigella sativa can have beneficial effects for postmenopausal women by decreasing oxidative stress. m a t e r i a l a n d m e t h o d s this non-randomized clinical trial was conducted at this interventional study was conducted at post graduate medical institute, lahore. from feb. 2017 april, 2017. ethical approval was taken from ethical review board of post graduate medical institute (pgmi), lahore. a total of 30 post-menopausal females were inducted through non probability purposive sampling. inclusion criteria was healthy non obese postmenopausal females with age range 45-55 years. subjects consuming hormonal replacement therapy (hrt), phytoestrogens and antioxidant medications such as vitamin e and vitamin c were excluded from study. good quality nigella sativa seeds were brought from market and grinded with the help of electric grinder making a fine powder. empty capsules of 500 mg size were filled completely with powder manually. a total of 60 capsules were placed in each bottle and stored at room temperature. written informed consent was taken from every subject. general physical examination was done. total 5 ml of the blood was taken in the vacutainer for measuring gsh levels before the nigella sativa supplementation. serum was extracted by centrifuging the blood at 3000rpm for a period of 20 min. serum was stored at -20 ºc. study subjects were advised to take 1g of nigella sativa (2 capsules 500mg each) for 2 months daily after taking breakfast.14 a compliance tabulated sheet was provided to every subject and they were asked to write ‘yes’ after consuming daily dose. this sheet was reviewed after every 15 day follow up visit. after 2 months, blood was again collected for post treatment gsh levels. serum gsh was measured by gsh elisa kit (glory science co.). absorbance was read at 450nm. the detection range of the kit was 30-500 ng/l. data was entered and analyzed by spss version 21. the quantitative variables were expressed as mean± sd. the pre and post treatment means were compared by paired t-test. p value of < 0.05 was considered statistically significant. calculation of effect size was done by cohen’s d test and interpreted as up to 0.2 = small sized effect, up to 0.5 = moderate sized effect, 0.8 or more= large sized effect.15 r e s u l t s this study was conducted on 30 postmenopausal females. general characteristics of the study population are presented in table i. after administration of nigella sativa for 8 weeks, result showed a significant reduction in body weight (p= 0.012) and bmi (p=0.011) (table ii). table i: general characteristics of the study population parameters mean ± sd age (years) 49.8 ± 3.26 years being post-menopausal 1.66 ± 0.84 weight (kg) 59.9± 5.97 bmi (kg/m2) 25.7± 2.14 blood pressure (mmhg) 142.3 ±3.4 / 86.7± 5.38 pulse rate (beats/min) 86± 6.45 regarding the effect of the nigella sativa on oxidative stress, result indicated a highly significant increase from baseline (p<0.0001) after 8 weeks’ consumption of nigella sativa (figure 1). the effect size was calculated both for biochemical parameter gsh and general parameter like weight and bmi. the result of the effect size calculation showed larger effect size for gsh levels (3.9) and j islamabad med dental coll 2019 90 moderate sized effect for weight (0.5) and bmi (0.6) as given in table iii. table ii: comparison of general parameters of postmenopausal women before and after consumption of nigella sativa for 8 weeks (n=30) parameters before treatment (mean ± sd) after treatment (mean ± sd) p value weight (kg) 59.7± 2.67 57.8± 3.42 0.012* bmi (kg/m2) 25.5± 2.04 23.6± 6.44 0.011* systolic bp mmhg 142.6 ±5.34 139.2± 2.89 0.063 diastolic bp mmhg 88.7 ± 10.38 84.4 ± 6.73 0.074 pulse rate 86± 6.45 88±4.13 0.066 figure1: changes in the serum level of gsh after 8-week supplementation of nigella sativa table iii. effect size of change in biochemical parameters after nigella sativa supplementation (n=30) serum parameters effect size gsh 3.9* weight 0.5** bmi 0.6** *large effect size **moderate effect size d i s c u s s i o n menopause, a natural phase of reproductive aging is associated with decreased estradiol level and increased oxidative stress which is the main factor causing vasomotor symptoms, osteoporosis and heart diseases.5 the current study was conducted to assess whether nigella sativa supplementation (1g/day for 8 weeks) reduces oxidative stress in postmenopausal females. the results have shown that nigella sativa reduced oxidative stress in the study population as shown by significant increase in the serum gsh levels (p < 0.001) (effect size 3.9). this finding suggests that nigella sativa has antioxidant property due to the presence of tq that trap ros. thus, ros may be less available to convert gsh into its oxidized form resulting in increased gsh levels. our results are in line with animal study conducted by alothman et. al. in 2006. addition of oxidized corn oil to the rat chow was done in their study to produce oxidative stress; later on, nigella sativa supplementation greatly reduced oxidative stress indicated by significant increase in tissue gsh levels.16 similarly, tuluce et.al. (2008) have shown that 6-week supplementation of nigella sativa in the feed of broiler chicks significantly improved the erythrocyte gsh level and decreased malondialdehyde (mda) levels as compared to the chicks that were given the normal feed without nigella sativa supplementation.17 likewise, mostafa et. al. in 2013 assessed the antioxidative effect of nigella sativa and garlic.18 they administered 3g/day of nigella sativa along with garlic to 30 healthy postmenopausal females for 8 weeks and measured the plasma levels of mda, superoxide dismutase and glutathione peroxidase before and after supplementation. their results showed that consumption of 3 g /day of nigella sativa along with garlic reduced mda levels significantly (p<0.05) and increased the levels of superoxide dismutase and glutathione peroxidase significantly (p<0.05). our findings are similar to this study as gsh improved significantly in our postmenopausal females but our dose (1g/day) is much lower than used in their study (3g/day). this dose of 1g/day has also been used by ibrahim et. al. 2014 to prevent metabolic syndrome in postmenopausal females in a randomized control trial.14 they administered nigella sativa for 2 months to 19 and placebo to 18 postmenopausal females with metabolic syndrome. their results showed that this dose of nigella sativa was quite effective in reducing body weight, blood glucose level and improving lipid profile. although nigella sativa has been well tolerated in subjects of both the studies as well as in our study but it is highly important to take the proper dose of nigella sativa as zaghol et. al., 2012 have observed the toxic effects of nigella sativa on liver and kidney in high doses in rats (15-25ml of nigella sativa oil/kg).19in addition to decreasing oxidative stress, nigella sativa also decreased body weight and bmi in the current study. this j islamabad med dental coll 2019 91 protective effect has also been shown by shah et. al. 2012 that nigella sativa reduces body weight and bmi.20 thus, menopause results in increase in oxidative stress and oxidative stress result in menopausal symptoms. nigella sativa has improved gsh level indicating reduction in the oxidative stress, thus may help in improving in the quality of life of the postmenopausal females. the major limitation of the study was that no control group was included in the study. c o n c l u s i o n nigella sativa caused reduction in oxidative stress in postmenopausal females and might be responsible for a better quality of life. r e f e r e n c e s 1. huang y, malone ke, cushing-haugen kl, daling jr, li ci. relationship between menopausal symptoms and risk of postmenopausal breast cancer.cancer epidemiol biomarkers prev.2011;20(2):379–88. doi: 10.1158/10559965 2. ďurackova z. some current insights into oxidative stress.physiol res.2010; 59: 459-69.pmid: 19929132 3. martha asr, mariano zf, alicia ar, elsa cm, victor mn. menopause as risk factor for oxidative stress.menopause. 2012;19(3): 361-67.doi: 10.3390/ijms17091388 4. baltgalvis ka, greising sm, warren gl, lowe da. estrogen regulates estrogen receptors and antioxidant gene expression in mouse skeletal muscle, plos one. 2010; 5: e10164.doi: 10.1371/journal.pone.0010164 5. doshi sb, agrawal a. the role of oxidative stress in menopause. j mid-life health. 2013; 4(3): 140-46.doi: 10.4103/0976-7800.118990. 6. leong xf, rais mustafa m, jaarin k.nigella sativa and its protective role in oxidative stress and hypertension. evid based complement altern med. 2013; 2013:120732. doi: 10.1155/2013/120732. 7. ahmad a1, husain a, mujeeb m, khan sa, najmi ak, siddique na, et. al. a review on therapeutic potential of nigella sativa: a miracle herb. asian pac j trop biomed. 2013; 3(5): 337-52.doi: 10.1016/s2221-1691(13)60075-1 8. yoruk o, gur fo, uyanik h, yasar m, mutlu v, altas e, et. al. antioxidant effects of nigella sativa in the treatment of experimentally induced rhinosinusitis. maced j med sci. 2010;3(2): 132-37. doi:10.3889/mjms.18575773.2010.0101 9. mansour ma, nagi mn, el-khatib as, al-bekairi am. effect of thymaquinone on antioxidant enzyme activities, lipid peroxidation and dt-diaphorase in different tissues of mice: a possible mechanism of action. cell biochem funct. 2002; 20(2): 143-51.doi: 10.1002/cbf.968 10. elgendy s, hessien m, salam ia, moradm, magraby k el, ibrahim h.a, et. al. evaluation of the possible antioxidant effects of soybean and nigella sativa during experimental hepatocarcinogenesis by nitrosamine precursors. turk j biochem.2007; 32(1): 5-11. 11. sheikh by, mohamadin am. thymoquinone a potential therapy for cerebral oxidative stress. ajsc,2012; 1(2): 76– 92. 12. harzallah hj, grayaa r, kharoubi w, maaloul a, hammami m, mahjoub t. thymoquinone, the nigella sativa bioactive compound, prevents circulatory oxidative stress caused by 1,2-dimethylhydrazine in erythrocyte during colon post initiation carcinogenesis. oxid med cell longev.2012;2012:854065. doi:10.1155/2012/854065. 13. kanter m, coskun o, korkmaz a, oter s. 2004. effects of nigella sativa on oxidative stress and beta cell damage in streptozocin-induced diabetic rats. anat rec a discov mol cell evol biol. 2004; 279(1): 685-691. 14. ibrahim rm, hamdan ns, ismail m, saini sm, abd rashid sn, abd latiff l et. al. protective effects of nigella sativa on metabolic syndrome in menopausal women. apb. 2014; 4(1): 29-33.doi: 10.5681/apb.2014.005 15. kirkwood br, sterne jac. essential medical statistics. 2nd ed., london, w.j. elizebeth; 2002.doi:10.1002/sim.1961 16. al-othman am, ahmad f, al-orfs s, al-murshed ks, arif z. effect of dietary supplementation of ellataniacardanum and nigella sativa on the toxicity of rancid corn oil in rats. int j pharmocol.2006;2(1): 60-5. 17. tuluce y, özkol h, sogut b, çelik i. effects of nigella sativa l. on lipid peroxidation and reduced glutathione levels in erythrocytes of broiler chickens. j anim vet adv.2008;1(3): 95-9. 18. mostafa rm, moustafa ym, mirghani z, alkusayer gm, moustafa km. antioxidant effect of garlic (allium sativum) and black seeds (nigella sativa) in healthy postmenopausal women. sage open med.2013; 1: 2050312113517501.doi: 10.1177/2050312113517501. 19. zaghlola daa, kamelb es, mohammedc ds, abbasb nh.the possible toxic effect of different doses of nigella sativa oil on the histological structure of the liver and renalcortex of adult male albino rats.egypt j histol. 2012; 35(1): 127-36. doi: 10.1097/01.ehx.0000411396.11951.02 20. shah as, khan gm, badshah a, shah su et. al.nigella sativa provides protection against metabolic syndrome. afr j biotechnol.2012; 11(48): 10919-25.doi:10.5897/ajb-12890. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):126-130 126 original article use of gastrocnemius muscle and musculocutaneous flaps for coverage of soft tissue defects in leg muhammad naveed shahzad 1 , muhammad ayub 2 , muhammad afzal sajid 3 1 senior registrar plastic surgery, department of plastic surgery, nishtar hospital, multan 2 senior registrar surgery, department of general surgery, nishtar hospital, multan 3 emergency surgeon, department of general surgery, nishtar hospital, multan abstract objective: to share our experience of proximally based gastrocnemius flap use, recipient-site variables, donor-site management, complications, and outcomes. patients and methods: this retrospective study was conducted at pak italian modern burn center nishtar hospital multan from january 2009 to december 2014. the records of 139 patients were retrieved from the departmental medical record system and the required information regarding the demographic, diagnostic, and clinical data (like patients' particulars---age and sex, history of occupation, any previous surgery , causes of the defects , the extent and dimensions of the defects, time since injury, exposure of bone or tendons, presence of chronic osteomyelitis, , any co-morbid conditions, postoperative course regarding wound-healing difficulties, flap loss, postoperative palsy of the peroneal nerve after elevation of lateral gastrocnemius and walking limitations) were noted. pre and post-operative photographs and radiographs were also evaluated along with follow up of at least 6 weeks. results: out of 139 our 134 flaps survived with only 1 flap having partial necrosis and 4 flaps with marginal necrosis. the complication rate is low conclusion: gc is a robust flap and is number one choice in proximal tibial defects as even in extensive trauma this flap can be elevated and used safely. key words: proximal tibial defects. gastrocnemius muscle, musculocutaneous flap . introduction long bone fractures are seen in 11.5 per 100,000 persons per year and are more common in males. 1,2 the proximal tibia has been defined as the part of the tibia that extends from the knee joint distally for 1.5 times the medial to lateral joint width. 3 in this area fractures are grossly heterogeneous and their prognosis depends on intraarticular involvement, fracture comminution, condition of the soft-tissue, osteoporosis, patient’s age and comorbidities. 4 regardless of the pattern of a proximal tibia fracture, the soft tissues around the knee joint can be injured with variable severity. over the period of years, standards for the management of open fractures have evolved because of collaborations between orthopeadic surgeons and plastic surgeons. 5 the aim of plastic surgeon in the treatment of open fractures is to provide well vascularized soft-tissue coverage to the wound, so as to promote revascularization of injured bone and soft tissues, and to prevent late osteomyelitis and nonunion that may occur secondary to persistent bone ischemia. 6,7.8 defects surrounding the knee and proximal tibia result from trauma, tumor, or infection. both lateral and medial gastrocnemius flaps are used as a muscle or myocutaneous flap to cover defects surrounding the knee, lower thigh, patellar region and upper third of tibia. its consistent vascular anatomy and superficial location have made it a workhorse for coverage of defects in this area. transposition of one head of the gastrocnemius results in little or no functional deficit, provided, the soleus and the other head of the gastrocnemius are left intact and functioning. if necessary, subsequent bony procedures can be carried out by elevating the healed flap with the assurance of a good vascular supply. in this study we share our experience of proximally based (medial or lateral) gastrocnemius muscle or myocutaneous flap use, recipientsite variables, donor-site management, complications, and outcomes. patients and methods a retrospective clinical audit was done on 139 consecutive cases of gastrocnemius flap, with at least a six weeks follow up at the pak italian modern burn center nishtar hospital multan from january 2009 to december 2014. patients having small to medium sized defects surrounding the knee, lower thigh, patellar region and proximal tibia were included in the study. all these patients were referred to our department from orthopedic department after bony fixation. patients with extensive tissue loss, deep severe scarring or wounds on the popliteal area or the pedicle site were excluded from the study. corresponding author: muhammad naveed shahzad e-mail:drmuhammaad@gmail.com received: june 24,2016; accepted: sept 29,2016 mailto:drmuhammaad@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):126-130 127 the records of patients were retrieved from the departmental medical record system and the required information regarding the demographic, diagnostic, and clinical data (like patient`s age and sex, history of occupation, any previous surgery , causes of the defects , the extent and dimensions of the defects, time since injury, exposure of bone or tendons, presence of chronic osteomyelitis, any co-morbid conditions, postoperative course regarding wound-healing difficulties, flap loss, postoperative palsy of the peroneal nerve after elevation of lateral gastrocnemius and walking limitations) were noted. pre and post-operative photographs and radiographs were also evaluated. the preoperative management of open fractures involved stabilization of the patient, tetanus prophylaxis, and broadspectrum antibiotics. nonviable tissue required aggressive debridement. serial debridement was needed if tissue viability was uncertain. when the wound bed was clean, flap coverage was done, within 72 to 96 hours following initial injury in our setup. however, in some cases we had to perform flap at later dates because of unstable patient or unfavorable wound. during preoperative physical examination our main focus is determining the function of the remaining muscles of the leg to predict loss of plantar flexor following gastrocnemius flap. during vascular examination, we assessed for the patency of the popliteal artery and excluded the evidence of venous problems like dvt (deep venous thrombosis), though it was not an absolute contraindication in our series. in very few patients with a history of peripheral vascular disease or a history of popliteal arterial trauma, we requested for ct angiogram to confirm patency of the sural artery prior to surgery. all the patients who were booked for flap surgery, underwent preoperative anesthesia assessment and accordingly received either general or spinal anesthesia. patients were positioned in the prone position in almost all cases except in few cases we used supine position with the leg internally or externally rotated to facilitate exposure of the medial or lateral heads, respectively. tourniquet was applied in all the patients. after sterile preparation, the entire extremity was draped and fully exposed. in almost all the cases we used ipsilateral thigh for a skin graft donor site except in very rare cases where it was not available because of trauma. appropriate preoperative antibiotics were given prior to incision. the posterior dissection was generally done first through a posterior midline incision as the posterior anatomy was clear and very rarely damaged or obscured by the anterior trauma. two key landmarks, the sural nerve and lesser saphenous vein seen superficial to the muscle bellies helped to locate the natural cleavage between the two muscle bellies. according to the requirement, the flap elevated and donor site grafted if required. a suction drain was placed at the donor site; this was a mandatory step in order to obliterate the dead space created by the elevation of the flap. the drain was removed in couple of days however in one case we had to leave in place for 1 week. above knee pop slab was applied for one week in every patient to avoid skin graft loss because of underlying muscle movements. post operatively limb elevation 7 days to reduce pain and swelling. flap monitoring done according to our unit protocol. patients were discharged on 6th post-operative day. first follow up visit was one week after the discharge and then fortnightly. we encourage early mobilization of the ankle to avoid adhesions and stiffness along with gentle mobilization of the knee joint, after one week and full range of motion started within 4–6 weeks. results among 139 patients 105 (75.5%) were males and 34 (24.5%) females. age range of the study population was between 18 years to 55 years with the mean age of 30.05 years. size of the smallest wound was 3x3 cm and maximum was 20 x 9 cm. regarding site of the presenting wound in this series most of the defects were on proximal tibia. the largest number of our flaps were either muscle or musculocutaneous medial gc flap. about 134 flaps survived. in 12% cases flap infection was found that was managed with antibiotics. we were able to cover almost 2/3rd of upper tibia with transposition of medial musculocutaneous flap. there was no significant functional donor-site morbidity during level and uphill gait after a gastrocnemius harvest. few of our patients were dissatisfied of cosmetic outcome with a musculocutaneous flap that does not allow for primary closure of the donor site. infection of either donor site, flap, recipient site was big complication in our study but it was easily encountered by antibiotics. in almost all cases staphylococcus aureus was the culprit organism. early complication which may mimic venous thrombosis is a large hematoma in the posterior superficial compartment of the leg was absent in our series. one of our patient experienced persistence of a contraction of the flap at the recipient site, but it was not symptomatic and well managed by this patient. clinical and demographic data analysis is given in table 1 & 2 and postoperative complications are given in table 3. table 1: demographic data of patients (n=139) gender male female 105 (75.5 %) 34(24.5%) h/o any previous surgery yes no 12 (8.6%) 127(91.4%) age in years minimum age maximum age mean ±s.d 18 years 55 years 30.05 ±10.325 journal of islamabad medical & dental college (jimdc); 2016:5(3):126-130 128 figure 1a figure 1b figure 1c figure 1 (a, b, c): a 25-year-old man had wound involving upper third of tibia, medial musculocutaneous gc covered this huge area table 2: clinical data of patients (n=139) road traffic accident fall sports & recreational activities causes of the defects 119(85.6%) 14(10.1%) 6(4.3%) >10 x 5 cm >15x7cm >20 x 9.5cm defect extent & dimensions 86(61.9%) 40(28.8%) 12(8.6) time of flap coverage since injury 72-96 3-7days 7-21days 60(43.16%) 47(33.8%) 32(23%) site of defect upper tibia isolation knee isolation complex wound involving more than one area 96(69.06%) 40(28.77%) 3(2.16%) type of flap medical gc muscle medical gc musculocuta neous lateral gc muscle lateral gc musculocut aneous 64(46.04%) 51(36.69%) 12(8.6%) 12(8.6%) flap survival complete survival partial necrosis marginal necrosis 134(96.4%) 1(0.7%) 4(2.87%) bone exposure bone /or joint exposed no bone exposure 124(89.21%) 15(10.79%) postoperative palsy of the peroneal nerve (1 case in total of 24 lateral gastrocnemius flaps) table.3: postoperative course & complications postoperative course no (%) no complication 117(84.2) flap infection 11(7.91) hematoma 0(0) donor site infection 2(1.44) recipient site infection 6(4.32) venous congestion 0(0) wound dehiscence 1(0.7) superficial epidermolysis 2(1.4) discussion orthopedic surgeons seek help of reconstructive surgeon to cover the exposed bones/joints, obliterate the dead space, help eradicate the infection of chronic osteomyelitis and prepare and vascularize the wound for subsequent bone grafting. tibia on its anteromedial side is covered only by a thin layer of skin and subcutaneous tissue, making it vulnerable to high energy trauma that often results in open fractures and now a days its incidence is increasing in adults younger than 45 years of age. 9-10 open fractures mandate the need for coverage which enables the victims to ambulate early without bony complication. prime goal of a plastic surgeon working in third world, where health care facilities are not very much up to standards, is to provide least complicated and highly reliable flap coverage to a person with open fractures. microsurgical flaps although are ideal in most of that covers the defect successfully in a one-stage operation, however it requires a long operative time; experienced, skillful technique; and patent vascular status of the recipient site. free flap transfer to the lower limb in chronic post-traumatic conditions is known to have a higher complication rate with flap loss in up to 10% of cases, mainly due to the recipient vessel. the dissection of these vessels often leads to refractory spasm, due to the so-called post-traumatic vessel disease (ptvd). 11-12 ger first described the use of gastrocnemius flap and after that the flap gained worldwide popularity. 13-15 the gastrocnemius is the most superficial muscle of the posterior calf. the muscle has two heads arising from the medial and lateral condyles at the femur, and the adjacent capsule of the knee; these muscles then insert into the calcaneal tendon. gastrocnemius muscle (medial and or lateral) is a type i flap based on sural artery from the popliteal artery. the lateral head of the muscle, compared to the medial, is used more rarely in reconstructive surgery. the reasons for its restricted use are the size and the limited arc of rotation as well as the potential risk of peroneal nerve palsy of the muscle that might be caused by the surgical procedure itself. 16 the medial head of the gastrocnemius muscle, which is the part mostly used, meets all the requirements needed for a successful wound coverage. certainly there are journal of islamabad medical & dental college (jimdc); 2016:5(3):126-130 129 cases, when the application of the lateral head is preferred and that happens in cases of wounds in the proximal part of the tibia and the lateral surface of the knee. however, there are disadvantages associated with the application of the gastrocnemius flap such as deformation of the donor area. this study shows proportion of gender close to the distribution of gender in other studies. 16 however, unlike these studies we did not use the cross leg gastrocnemius muscle flap because of difficulties in postoperative immobilization and its attendant morbidity and in these cases where ipsilateral gastrocnemius muscle is not suitable for transfer, we used free flap coverage of the defect. we also provided excellent soft-tissue coverage of exposed or infected hard ware. gc muscle flap was the good local choice to cover them. regarding indications for flap coverage, exposure of the underlying bone is a major reason as skin grafting are not fruitful and are contraindicated in these situations. effectiveness of a flap is judged by various factors and survival of the flap is a major determinant of success of the procedure. in this study, complete survival rate of the flap was very high, partial necrosis and marginal necrosis in very few cases. statistically these results are better when compared to other studies, and complications in their study were mainly technical error, inadequate debridement, use of diseased and traumatized muscle and unrealistic objectives. 18-21 in our cases fewer complications were because of careful preoperative evaluation and surgical planning. we were able to cover up to upper 2/3 rd of tibia by only musculocutaneous flap. we experienced that with simple transposition or rotation of musculocutaneous gc flap, a large number of defects (up to half of tibia) can be addressed. except in one case where peroneal nerve damaged rest of flap, elevation and handling is easy to learn and execute. it is very interesting that despite of its superficial location we found that even in comminuted fractures this muscle was useable. in one case we experienced difficulty in elevation of medial head as almost half was fibrosed & this was speculated that compartment syndrome may be the reason in this case which was treated little later. in our study one case had partial necrosis in a musculocutaneous flap, we think that this was because of handling of flap and tight bandage. conclusion gastrocnemius flap is still one of the best available commodity to cover problem wounds in upper leg and knee wounds. due to its technical ease, low complication rate, easy learning curve, and low donor area morbidity, it is one of the best choices. we suggest that indications of musculocutaneous flap should be revised as this can be used up to upper 2/3 rd of tibia. even in extensive complicated trauma it is useable. its harvest does not involve sacrifice of major blood vessel and has no or little effect on gait. conflict of interest this study has no conflict of interest as declared by any author. references 1. court-brown cm, caesar b. epidemiology of adult fractures: a review. inj. 2006;37(8):691–7. 2. lindvall e, sanders r, dipasquale t, herscovici d, haidukewych g, sagi c. intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases. j orthop trauma. 2009;23(7):485-92. 3. casanova, olivier hulard, rémy zalta, jacques bardot, guymagalon d. management of wounds of exposed or infected knee prostheses. scand j plast reconstr surg hand surg. 2001;35(1):71-7. 4. charlson m, szatrowski tp, peterson j, gold j. validation of a combined comorbidity index. j clin epidemiol. 1994;47(11):1245–51. 5. conway jd, mont ma, bezwada hp. arthrodesis of the knee. j bone joint surg am. 2004; 86-a(4):835–48. 6. corten k, struelens b, evans b, graham e, bourne rb, macdonald sj. gastrocnemius flap reconstruction of softtissue defects following infected total knee replacement. bone joint j. 2013; =95-b(9):1217–21. 7. galat dd, mcgovern sc, larson dr, harrington jr, hanssen ad, clarke hd. surgical treatment of early wound complications following primary total knee arthroplasty. j bone joint surg am. 2009;91(1):48–54. 8. parrett bm, matros e, pribaz jj, orgill dp. lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. plast reconstr surg. 2006;117(4):1315-22. 9. kumar ar. standard wound coverage techniques for extremity war injury. j am acad orthop surg. 2006;14(10):s62-5. 10. hallock gg. getting the most from the soleus muscle. ann plastic surg. 1996;36(2):139-46. 11. parrett bm, matros e, pribaz jj, orgill dp. lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. plast reconstr surg. 2006;117(4):1315-22. 12. godina m. early microsurgical reconstruction of complex trauma of the extremities. orthop trauma direct. 2006;4(05):29-35. 13. hohmann e, wansbrough g, senewiratne s. medial gastrocnemius flap for reconstruction of the extensor mechanism of the knee following high-energy trauma: a minimum 5 year follow-up. inj. 2016;47(8):1750-5. 14. mathes sj, nahai f. clinical applications for muscle and musculocutaneous flaps. new york; cv mosby company publishers. 1982. 15. sanger jr, kao ds, hackbarth da. peroneal nerve compression by lateral gastrocnemius flap. j plast reconstr aesthet surg. 2009;62(8):280-2. 16. smith dj jr, loewenstein pw, bennett je. surgical options in the repair of lower-extremity soft-tissue wounds. j trauma. 2010;22(5):374-80. 17. salibian ah, meniak fj. bipedicle gastrocnemius musculocutaneous flap for defects of the distal one third of the leg. plast reconstr surg. 1982;70(1):17-23. 18. salibian ah, rogers fr, lamb rc. microvascular gastrocnemius muscle transfer to the distal leg using https://www.ncbi.nlm.nih.gov/pubmed/?term=hohmann%20e%5bauthor%5d&cauthor=true&cauthor_uid=27297707 https://www.ncbi.nlm.nih.gov/pubmed/?term=wansbrough%20g%5bauthor%5d&cauthor=true&cauthor_uid=27297707 https://www.ncbi.nlm.nih.gov/pubmed/?term=senewiratne%20s%5bauthor%5d&cauthor=true&cauthor_uid=27297707 https://www.ncbi.nlm.nih.gov/pubmed/27297707 journal of islamabad medical & dental college (jimdc); 2016:5(3):126-130 130 saphenous vein grafts. plastic and reconstructive surgery. 1984;73(2):302-7. 19. el-sherbiny m. pedicled gastrocnemius flap: clinical application in limb sparing surgical resection of sarcoma around the knee region and popliteal fossa.j egypt natl canc inst. 2008;20(2):196-207. 20. busfield bt, huffman gr, nahai f, hoffman w, ries md. extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty. clin orthop relat res. 2004;428:190-7. 21. patnaik s, nayak b, mishra l, sahoo ak. complex primary total knee replacement (tkr) using prophylactic gastrocnemius flap and rotating-hinge knee in posttraumatic, infective arthritis of the knee: a case report. j orthop case rep. 2015;5(4):40-3. . authorship contribution: author 1: concept and planning of research and final review of the article author 2: interpretation, analysis and discussion author 3: active participation in research 121 j i m d c 2 0 1 7 121 open access f u l l l e n g t h a r t i c l e leptin to adiponectin ratio as atherogenic index in ischemic heart disease patients muhammad kashif nisar 1, erum afaq 2, humera afaq 3, anila jaleel 4, adnan zuberi 5 1 associate professor, department of biochemistry, liaquat national hospital & medical college 2 assistant professor, department of physiology, liaquat national hospital & medical college 3 post graduate resident medical officer, internal medicine, abbasi shaheed hospital, karachi 4 professor &hod, department of biochemistry, fmh college of medicine and dentistry, lahore 5 professor, department of chemical pathology, ziauddin university a b s t r a c t objective: to determine plasma adiponectin and leptin levels in subjects with and without ischemic heart disease (ihd) and to find the correlation between leptin, adiponectin to the number of coronary vessels disease-using angiography. patients and methods: this is a cross-sectional study conducted ziauddin university. 80 subjects were recruited who were undergoing angiography. height, weight, waist and hip circumference were measured. bmi and whr were calculated accordingly. venous blood was drawn to measure adiponectin and leptin using elisa. results: leptin to adiponectin ratio (la ratio) was significantly increased in three and two vessel disease compared with single vessel and non-significant groups. conclusion: the study shows that adiponectin decreases and leptin increases in multivessel disease. la ratio has been found to correlate well in two and more than two vessel disease. key words: adeponectin, ihd, la ratio leptin author`s contribution 1-2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-5 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence muhammad kashif nisar email: dr.kashifnisar@gmail.com article info. received: april 16, 2018 accepted: july 10, 2018 cite this article. nizar mk, afaq e, afaq h, jaleel a, zuberi a. leptin to adiponectin ratio as atherogenic index in ischemic heart disease patients. jimdc.2018; 7(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n cardiovascular disease is the leading cause of death worldwide. genetic tendency, sedentary life style, age, hypercholesterolemia, insulin resistance, smoking, diabetes mellitus and hypertension are the most common determinants for these disorders.1an imbalance between oxygen demand and supply to myocardial vessels due to atherosclerosis results in coronary artery disease.2 according to who report, prevalence of cardiovascular disease is increasing in both developed and developing countries.3 by 2020, pakistan will be ranked 4th most heavily populated country in terms of diabetic patients and every 3rd person above 45 years of age will be hypertensive.4 since both are risk factors for ischemic heart disease, the burden of disease on our population can be easily foreseen. people from the asian subcontinent are especially prone to cardiovascular disease due to certain risk factors incurred with a variation in lifestyle including, lack of a balanced diet, health awareness, exercise, and inaccessibility to modernized health care.5,6 more specifically, the national health survey of pakistan showed that obesity, hypercholesterolemia, and atherosclerosis are the most important determinants of ischemic heart disease.7 it also indicated that increasing prevalence of obesity, o r i g i n a l a r t i c l e 122 j i m d c 2 0 1 7 122 hypertension, diabetes, and ischemic heart disease are not only due to diets rich in salt and sugar, but also due to the lack of recreational/physical activities.8 previously adipocytes were considered to be an inert storage site for triglycerides. in numerous studies adipocytes have now been demonstrated to have an endocrinological function by which they release two hormones notably, leptin and adiponectin, which are thereby termed as adipocytokines.9 these hormones are considered important in the regulation of cardiovascular function and homeostasis.10 leptin was one of the first adipocytokine discovered.11 leptin is a protein, containing 167 amino acid belonging to cytokine family, encoded by obesity gene at 7q31.3 locus.12 adiponectin is a 244-residue protein that is produced mainly by white adipose tissue.13 several studies demonstrated that high plasma leptin levels alone can indicate acute cardiovascular conditions, reocclusions after angioplasty, without association of traditional risk factors.14 in contrast to this, low levels of serum adiponectin levels (due to genetic and environmental causes) results in obesity, type 2 diabetes, metabolic syndrome and atherosclerosis. this paradox in leptin and adiponectin concentrations suggests that leptin may trigger the process of vascular injury while adiponectin have protective role in the development of atherosclerosis.11 more recently la ratio is recognized as an index of atherogenesis in diabetic patients.15 in this study would evaluate the role of la ratio in ischemic heart disease and its correlation with the extent of coronary artery disease. m: meter, kg: kilogram, cm: centimeter, bmi: body mass index, whr: waste hip ratio l/a ratio: leptin to adiponectin ratio table 1: descriptive characteristics of ischemic heart disease patients (n=80) variables mean±sd range age (years) 48.81±6.15 35-60 height (m) 1.64±0.98 1.45-1.82 weight (kg) 73.23±9.32 58-105 bmi (kg/ m2) 27.23±3.42 20.50-38.10 waist circumference(cm) 91.15±7.06 74-107 hip circumference(cm) 90.48±6.27 76-102 whr 1.01±0.08 0.87-1.20 figure-1: graphical distribution of pattern of extent of cad figure-2: graphical representation of mean leptin level according to multi vessel disease involvement figure-3: graphical representation of mean adeponectin level according to multi vessel disease involvement p a t i e n t s a n d m e t h o d s this cross sectional study was conducted at ziauddin university. study duration was 2 years. ethical approval was taken from ethical review committee of ziauddin university. individuals with age range between 40 -55 years from both genders diagnosed as a patient of cvd 123 j i m d c 2 0 1 7 123 on the basis of standard diagnosis protocol including ecg, cardiac enzyme and stress tests from angiography unit were inducted in the study. exclusion criteria was subjects with endocrine disorders or on anti-diabetics or lipid lowering drugs. sampling was done through nonprobability purposive sampling technique. written consent was taken. a detailed history was entered on a detailed prescribed study proforma. height, weight, waist and hip circumference were measured. bmi and whr were calculated by standard formulae. they were classified obese if bmi > 30 kg/m2 and non-obese if bmi <30 kg/m2.16 waist to hip ratio >0.95 in women and > 0.80 in men was considered obese.17 total 10 ml blood was taken by venipuncture at the time of angiography in a vacutainer tube. after centrifugation at 3000rpm for 15 minutes’ serum was stored at -70˚c for future use. samples were analyzed for leptin and adiponectin concentrations by using elisa immunoassay kits (drg diagnostics, germany). commercially available elisa kit (drg instrument gmbh, marburg, germany) was used to determine plasma adiponectin concentration. manufacturer instructions were followed strictly and all tests were performed in duplicate on 96 well plates. adiponectin values were expressed as µg/ml. angiography was performed on toshiba infinix 2000a. intra coronary guide wire was selected by the operator on the basis of coronary anatomy and morphology of the lesion. after crossing target lesion, the guide wire was fixed and appropriate sized balloon (balloon/artery ratio 1:1) was advanced to lesion site. after that balloon was inflated by inflation device filled with 50% mixture of contrast and saline. data analysis was performed by using spss (statistical program for social sciences) version-21.0. figure-4: graphical representation of mean l/a ratio according to multi vessel disease involvement for continuous variables like age, height, weight, bmi, waist circumference, hip circumference, whr, serum adiponectin, leptin and la ratio were presented by mean ± standard deviation. one-way anova and post hoc tukey hsd were performed to compare mean level among four study groups according to extent of cad. regression analysis was done to estimate relationship of serum levels with extent of cad. statistical significance was considered if p ≤ 0.05 r e s u l t s out of 80 subjects, large number of patients (37.5%) had one vessel followed by (30%) three vessels cad (figure 1). table 1 showed basic characteristics of all the participants expressed as mean and standard deviation. waist circumference and whr was significantly more in three vessels cad group (table 2). mean serum adiponectin level was significantly decreased in 2 & 3 vessels cad groups (p<0.001) compared with two other groups. high l/a ratio in 3-vessels cad was observed compared with the other three groups (table 3). positive significant correlation of serum leptin level was found with extent of cad (r = 0.298). regarding serum adiponectin levels, negative but significant correlation was present with extent of cad (r = -.496). la ratio also showed positive significant correlation (r = 0.498) (table 4). (figure 2) showed that serum leptin levels increased with progression of disease. figure 3 indicates low levels of adiponectin with the progression of multi vessels disease. l/a also increased as the disease advances from 1 vessels to 3 vessels stage (figure 4). d i s c u s s i o n our study is focused on the variations in leptin and adiponectin levels and the ratio of leptin to adiponectin with the extent of occlusion of coronary arteries. according to our data serum adiponecctin levels decreased significantly with the progression of disease that is two vessels or three vessel disease compared with one vessel and non-significant group (table-3). adiponectin has been anticipated to protect against cardiovascular diseases. adiponectin exerts strong antiinflammatory effects through nuclear factor κ-b pathway,18,19 down regulates adhesion molecules expressions on endothelial cells and enhances lipid 124 j i m d c 2 0 1 7 124 clearance.20,21 endothelial dysfunction is the first stage of atherogenesis.22 adiponectin holds protective actions on every stage of atherogenesis.23 no (nitric oxide) is the key endothelium derived relaxing factor which plays a central role in the regulation of vasomotor function and vascular tone. alteration in no levels in the endothelium mediates anti-inflammatory properties of adiponectin. in vitro, adiponectin induces no production in human aortic endothelial cells via activation of mapk(mitogen activated protein kinase) pathway and enhanced endothelial nitric oxide synthase mrna and protein expression10, 24 adiponectin is prone to suppress superoxide generation and enhances nitric oxide synthase activity in endothelial cells that are treated with oxidized ldl. adeponectin is reported to down regulate acetyl co a, cholesteryl acyltransferase-1 in macrophages, thereby reducing the formation of foam cells.25 our study shows that serum leptin concentration increases with the number of vessels involve. our data suggest that there is significant increase in two vessel disease and three vessel disease when compared with one vessel and non-significant diseases (p value of <0.001) leptin is secreted by white adipose tissues, the most frequent form of adipose tissues in mammals.26 cardiovascular risk is increasingly implicated by increased levels of leptin. increased leptin levels are well associated with obesity related cardiovascular diseases such as atherosclerosis.27, 28 leptin exerts atherogenic effects, including endothelial dysfunction,29 smooth muscle cell proliferation 30 generation of inflammatory mediators and platelet function modulation.31,32 the key event which contribute to the formation of atherogenic plaque is the formation of lipid laden macrophages.31 antagonism of leptin and adeponectin actions on cardiovascular system is shown above, there are evidences that high plasma leptin and low plasma adiponectin levels reflects poor cardiovascular outcome.33 kappelle et al proposed l:a ratio is a useful parameter to evaluate the cardiovascular event.34 according to norata et al, the l:a ratio can be used as a marker to predict thickness of intima media and its possible cardiovascular outcome.35 in one study it was found that increased peritoneal dialysis patients markedly elevated l: a ratio is consistent with high risk for cardiovascular disease.36 , table 2: characteristics of ischemic heart disease patients according to multi vessel disease involvement (n=80) hns group (n=14) mean±sd one vessel cad (n=30) mean±sd two vessels cad (n=12) mean±sd three vessels cad (n=24) mean±sd p-value age (years) 47.42±5.89 49.13±6.62 49.25±5.24 49.00±6.35 0.837 height (m) 1.61±0.10 1.62±0.09 1.71±0.09 1.65±0.08 0.024 weight (kg) 70.14±14.02 71.76±7.61 77.58±8.69 74.70±7.58 0.138 bmi (kg/ m2) 26.84±4.65 27.15±3.91 26.30±1.87 28.03±2.41 0.505 waist circumference(cm) 85.64±5.74 90.13±5.98 92.66±8.15 94.87±6.33 0.000 hip circumference(cm) 89.50±6.72 91.83±7.27 90.66±5.92 89.29±4.65 0.463 whr 0.94±0.06 0.98±0.07 1.06±0.04 1.07±0.05 0.000 table 3: plasma levels of adiponectin, leptin and l/a ratio according to functioning of multi vessel disease (n=80) variables hns group (n=14) mean±sd one vessel cad (n=30) mean±sd two vessels cad (n=12) mean±sd three vessels cad (n=24) mean±sd adiponectin (µg/ml) 5.36±2.41 5.13±3.42 2.96±1.05*,** 2.65±1.03*,** leptin (ng/ml) 9.89±5.53 11.69±9.05 12.55±4.67*,** 16.39±10.9*,**,*** l/a ratio 3.15±5.75 3.08±2.68 5.46±3.95*,** 7.81±6.29*,**,*** 125 j i m d c 2 0 1 7 125 post hoc tukey hsd was applied *p-value < 0.05 -significant compared with hemodynamically non-significant group **p-value < 0.05 significant compared with one vessel disease group ***p-value <0.05 significant compared with two vessels disease group table 4: spearman’s correlation of cad group with quantitative variables (n=80) variables correlation coefficient® p-value leptin (ng/ml) 0.298 0.007 age (years) 0.076 0.501 bmi (kg/ m2) 0.200 0.075 whr 0.558 0.000 adiponectin (µg/ml) -0.496 <.001 l/a ratio 0.498 <.001 c o n c l u s i o n la ratio may be used to assess the cardiovascular status of the subjects recommended for angiography by the cardiologist. r e f e r e n c e s 1. ignarro lj, balestrieri ml, napoli c. nutrition, physical activity, and cardiovascular disease: an update. cardiovascular research. 2007;73(2):326-40. 2. fauci a, kasper d, longo d, braunwald e, hauser s, jameson j. harrison's principles of internal medicine. 2008, single edition book isbn 978-0-07-159991-7: mhid 0-07-159991-6. 3. riley l, guthold r, cowan m, savin s, bhatti l, armstrong t, et al. the world health organization stepwise approach to noncommunicable disease risk-factor surveillance: methods, challenges, and opportunities. american journal of public health. 2016;106(1):74-8. 4. khealani ba, hameed b, mapari uu. stroke in pakistan. journal of the pakistan medical association. 2008;58(7):400. 5. joshi p, islam s, pais p, reddy s, dorairaj p, kazmi k, et al. risk factors for early myocardial infarction in south asians compared with individuals in other countries. jama. 2007;297(3):286-94. 6. bhardwaj r, kandoria a, sharma r. myocardial infarction in young adults-risk factors and pattern of coronary artery involvement. nigerian medical journal: journal of the nigeria medical association. 2014;55(1):44. 7. jafar th, haaland ba, rahman a, razzak ja, bilger m, naghavi m, et al. non-communicable diseases and injuries in pakistan: strategic priorities. the lancet. 2013;381(9885):2281-90. 8. yaseen f. association of resistin & interleukin 6 in ischemic heart disease and diabetic patients. pak j med dent. 2014;3(1):17-22. 9. zahorska-markiewicz b. metabolic effects associated with adipose tissue distribution. adv med sci. 2006;51(2):111-4. 10. szmitko pe, teoh h, stewart dj, verma s. adiponectin and cardiovascular disease: state of the art? american journal of physiology-heart and circulatory physiology. 2007;292(4):h1655-h63. 11. conde j, scotece m, gómez r, lópez v, gómez‐reino jj, lago f, et al. adipokines: biofactors from white adipose tissue. a complex hub among inflammation, metabolism, and immunity. biofactors. 2011;37(6):413-20. 12. al-jumaily ef, zgaer sh. a review ratical: leptin gene and obesity. world journal of pharmacy and pharmaceutical sciences. 2014;3(9). 13. oh dk, ciaraldi t, henry rr. adiponectin in health and disease. diabetes, obesity and metabolism. 2007;9(3):282-9. 14. beltowski j. leptin and atherosclerosis. atherosclerosis. 2006;189(1):47-60. 15. lópez-jaramillo p, gómez-arbeláez d, lópez-lópez j, lópez-lópez c, martínez-ortega j, gómezrodríguez a, et al. the role of leptin/adiponectin ratio in metabolic syndrome and diabetes. hormone molecular biology and clinical investigation. 2014;18(1):37-45. 16. banks wnd. global data base on obesity and body mass index (bmi) in adults.(accessed at htpp://www. who. int/nut/db_bmi. htm). august; 2002. 17. organization wh. waist circumference and waist-hip ratio: report of a who expert consultation, geneva, 8-11 december 2008. 2011. 18. wang x, chen q, pu h, wei q, duan m, zhang c, et al. adiponectin improves nf-κb-mediated inflammation and abates atherosclerosis progression in apolipoprotein e-deficient mice. lipids in health and disease. 2016;15(1):33. 19. pamukcu b, lip gy, shantsila e. the nuclear factor– kappa b pathway in atherosclerosis: a potential therapeutic target for atherothrombotic vascular disease. thrombosis research. 2011;128(2):117-23. 126 j i m d c 2 0 1 7 126 20. balsan ga, vieira jldc, oliveira amd, portal vl. relationship between adiponectin, obesity and insulin resistance. revista da associação médica brasileira. 2015;61(1):72-80. 21. ouedraogo r, gong y, berzins b, wu x, mahadev k, hough k, et al. adiponectin deficiency increases leukocyte-endothelium interactions via upregulation of endothelial cell adhesion molecules in vivo. the journal of clinical investigation. 2007;117(6):1718-26. 22. choi b-j, matsuo y, aoki t, kwon t-g, prasad a, gulati r, et al. coronary endothelial dysfunction is associated with inflammation and vasa vasorum proliferation in patients with early atherosclerosis. arteriosclerosis, thrombosis, and vascular biology. 2014:atvbaha. 114.304445. 23. verma s, anderson tj. fundamentals of endothelial function for the clinical cardiologist. circulation. 2002;105(5):546-9. 24. wang x, pu h, ma c, jiang t, wei q, duan m, et al. adiponectin abates atherosclerosis by reducing oxidative stress. medical science monitor: international medical journal of experimental and clinical research. 2014;20:1792. 25. motoshima h, wu x, mahadev k, goldstein bj. adiponectin suppresses proliferation and superoxide generation and enhances enos activity in endothelial cells treated with oxidized ldl. biochemical and biophysical research communications. 2004;315(2):264-71. 26. coelho m, oliveira t, fernandes r. state of the art paper biochemistry of adipose tissue: an endocrine organ. archives of medical science. 2013;9(2):191200. 27. wannamethee sg, tchernova j, whincup p, lowe gd, kelly a, rumley a, et al. plasma leptin: associations with metabolic, inflammatory and haemostatic risk factors for cardiovascular disease. atherosclerosis. 2007;191(2):418-26. 28. martin ss, qasim a, reilly mp. leptin resistance: a possible interface of inflammation and metabolism in obesity-related cardiovascular disease. journal of the american college of cardiology. 2008;52(15):120110. 29. morioka t, emoto m, yamazaki y, kawano n, imamura s, numaguchi r, et al. leptin is associated with vascular endothelial function in overweight patients with type 2 diabetes. cardiovascular diabetology. 2014;13(1):10. 30. huang f, xiong x, wang h, you s, zeng h. leptininduced vascular smooth muscle cell proliferation via regulating cell cycle, activating erk1/2 and nf-κb. acta biochim biophys sin. 2010;42(5):325-31. 31. maya-monteiro cm, almeida pe, d'ávila h, martins as, rezende ap, castro-faria-neto h, et al. leptin induces macrophage lipid body formation by a phosphatidylinositol 3-kinase-and mammalian target of rapamycin-dependent mechanism. journal of biological chemistry. 2008;283(4):2203-10. 32. schafer k, konstantinides s. mechanisms linking leptin to arterial and venous thrombosis: potential pharmacological targets. current pharmaceutical design. 2014;20(4):635-40. 33. li ac, glass ck. the macrophage foam cell as a target for therapeutic intervention. nature medicine. 2002;8(11):1235. 34. kappelle pj, dullaart rp, van beek ap, hillege hl, wolffenbuttel bh. the plasma leptin/adiponectin ratio predicts first cardiovascular event in men: a prospective nested case–control study. european journal of internal medicine. 2012;23(8):755-9. 35. norata gd, raselli s, grigore l, garlaschelli k, dozio e, magni p, et al. leptin: adiponectin ratio is an independent predictor of intima media thickness of the common carotid artery. stroke. 2007;38(10):28446. 36. park jt, yoo t-h, kim j-k, oh hj, kim sj, yoo de, et al. leptin/adiponectin ratio is an independent predictor of mortality in nondiabetic peritoneal dialysis patients. peritoneal dialysis international. 2013;33(1):67-74.. j islamabad med dental coll 2020 103 open access refractive errors: prevalence and pattern among rural population of islamabad, pakistan waseem akhter 1 , erum yousafzai 2 , afia matloob rana 3 , shakaib anwar 4 1 associate professor, department of ophthalmology, rawal institute of health sciences, islamabad, pakistan 2 assistant professor, department of ophthalmology, rawal institute of health sciences, islamabad, pakistan 3 assistant professor, department of ophthalmology, hbs general hospital, islamabad, pakistan 4 professor, department of ophthalmology, rawal institute of health sciences, islamabad, pakistan a b s t r a c t background: refractive error is the most common cause of correctable visual loss worldwide. decreased vision due to refractive error can be easily corrected with the help of spectacles, contact lenses and refractive surgery. however, there are 42% of uncorrected refractive errors all over the world. the present study aimed to evaluate different kinds of refractive errors, its prevalence and pattern in patients from rural areas who visited our hospital in the last five years. material and methods: this cross-sectional study enrolled 2,138 patients, who visited eye opd at rawal institute of health sciences, islamabad during a period of five years i.e. from september, 2013 to september, 2018. patients having only refractive error with an age of five years and above were included in the study. all patients had objective refraction with automated refractometer followed by subjective refraction. data was entered and analyzed in spss version 20.0. chi-square test was used for comparing groups with a p-value of <0.05 considered as statistically significant. results: compound myopic astigmatism was the most common error found in our study population (n=575; 26.9%). the second most frequent complaint was simple myopia (n=501; 23.4%) followed by presbyopia (n=441; 20.6%) and mixed astigmatism (n=235; 11%). patients with more than one refractive error included 178 (8.3%) with mixed astigmatism and presbyopia and 78 (3.6%) with simple myopia and presbyopia. compound myopic astigmatism was more prevalent in younger ages compared to older age groups (46.4% vs 19.9%) (p <0.001). mixed astigmatism (12.4% vs 8.9%), simple myopia (23.8% vs 22.9%) and presbyopia (21.3% vs 19.5%) were slightly greater in females than males (p=0.07), respectively. conclusions: the prevalence of myopia is significantly higher among female population and young individuals. mixed astigmatism combined with presbyopia is more common among elderly population. key words: astigmatism, hypermetropia, myopia, presbyopia, refractive errors authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; 4 data analysis; manuscript editing. correspondence: waseem akhter email: wsmakhter@yahoo.com article info: received: march 29, 2019 accepted: may 18, 2020 cite this article. akhter w, yousafzai e, rana am, anwar s. refractive errors: prevalence and pattern among rural population of islamabad, pakistan. j islamabad med dental coll.2020; 9(2): 103-108. doi: 10.35787/jimdc.v9i2.326 funding source: nil conflict of interest: nil i n t r o d u c t i o n refractive error is the most common cause of correctable visual loss worldwide and also in pakistan. 1,2 refractive error is a physiological deviation in which parallel light rays coming from o r i g i n a l a r t i c l e j islamabad med dental coll 2020 104 infinity do not focus on the retinal plane, when eye accommodation is fully relaxed. 3 vision is important for healthy life style while blurred vision leads to injuries, difficulties in driving and depression. 4 therefore, "vision 2020: the right to sight" program launched by who and the international agency for blindness prevention (iabp) in 1999 focused on the refractive errors as a priority area to prevent visual impairment that can be corrected. 5,6 generally refractive errors are myopia, hypermetropia, astigmatism and presbyopia. in myopia, light rays are focused in front of the retinal plane because of large axial length or abnormally high refractive power of eye. 7 in hypermetropic type refractive error, light rays are focused behind the retinal plane because of short axial length or abnormally low refractive power of eye. 8 while in astigmatism, there are more than one refractive foci because of abnormal meridians of refractive surfaces of eye. 9,10 decreased vision due to refractive error can be easily corrected with the help of spectacles, contact lenses and surgery. 11 the refractive correction clinical services are available all over country and worldwide. however, there are 42% of uncorrected refractive errors all over the world. 12 this study aims to evaluate different kinds of refractive errors, its prevalence and pattern in patients from rural areas of islamabad, pakistan, who visited rawal institute of health sciences, islamabad in the last five years. m a t e r i a l a n d m e t h o d s this cross-sectional study comprised of 2,138 patients from rural areas who visited eye opd at rawal institute of health sciences, islamabad during the period of september 2013 to september 2018. ethical approval was granted by the hospital ethics committee and patients filled a written informed consent at enrolment. patients five years of age and above with different kinds of refractive errors from rural areas of islamabad, which are marked by the islamabad capital territory administration 13 were included, while patients with any kind of ocular pathology e.g. cataract, keratoconus, ocular trauma and previous eye surgery were excluded. after taking written informed consent, patients were examined using slit lamp, applanation tonometer and 78d fundus lens. all the patients had objective refraction with automated refractometer followed by subjective refraction. data was collected and entered on a self-structured proforma. statistical analysis was performed through spss version 20.0. continuous variable like age was presented as mean and standard deviation. the categorical variables like gender and type of refractive errors were calculated as frequency and percentages, while comparison between the two groups was done using chi-square test. a p-value of <0.05 was taken as statistically significant. r e s u l t s a total of 2138 cases were included in this study. most of the patients (n=921; 43.1%) were between 31 and 45 years of age followed by patients aged 45 years or above (n=453; 21.2%). the mean age of patients was 36 ± 18.3 years with a female preponderance (n=1294; 60.5%) (table i). table i: frequency distribution of refractive errors according to age groups and gender (n=2138) no of cases age groups (years) n (%) up to 15 352 (16.5) 16 to 30 412 (19.3) 31 to 45 921 (43.1) 45 or above 453 (21.2) mean age ± sd 36.0 ± 18.3 gender male 844 (39.5) female 1294 (60.5) j islamabad med dental coll 2020 105 compound myopic astigmatism was the most common error found in this study (n=575; 26.9%). the second most frequent refractive error was simple myopia (n=501; 23.4%) followed by presbyopia (n=441; 20.6%) and mixed astigmatism (n=235; 11%). many patients were found to have more than one refractive error. there were 178 (8.3%) patients with mixed astigmatism and presbyopia. another 78 (3.6%) were found to have simple myopia and presbyopia. about 30 (1.4%) patients had simple hypermetropia and presbyopia, 27 (1.3%) had hypermetropia and presbyopia and only 6 (0.3%) had compound myopic astigmatism and presbyopia, respectively. table ii shows distribution and association of refractive errors with gender (p=0.07). males were more likely to get affected by compound myopic astigmatism (29.3% vs 25.3%). mixed astigmatism (12.4% vs 8.9%), simple myopia (23.8% vs 22.9%) and presbyopia (21.3% vs 19.5%) were slightly greater in females than males respectively (table ii). when refractive errors were analyzed according to age of patients, it was noted that compound myopic astigmatism was more prevalent in younger ages as compared to older age groups (46.4% vs 19.9%). mixed astigmatism (18.1% vs 6.3%) and mixed astigmatism combined with presbyopia (38.9% vs 0.7%) were found significantly more common in older ages. simple myopia was also found significantly greater in younger ages (43.7% vs 15.7%). overall, the association between different refractive errors and age was statistically significant (p <0.001) (table iii). table ii: association of refractive errors with gender female (n=1294) n (%) male (n=844) n (%) p-value* compound myopic astigmatism 328 (25.3) 247 (29.3) 0.07 compound myopic astigmatism + presbyopia 3 (0.2) 3(0.4) hypermetropia + presbyopia 17 (1.3) 10 (1.2) mixed astigmatism 160 (12.4) 75 (8.9) mixed astigmatism + presbyopia 95 (7.3) 83 (9.8) presbyopia 276 (21.3) 165 (19.5) simple hypermetropia 37 (2.9) 30 (3.6) simple hypermetropia + presbyopia 18 (1.4) 12 (1.4) simple myopia 308 (23.8) 193 (22.9) simple myopia + presbyopia 52 (4.0) 26 (3.1) *p-value <0.05 was considered statistically significant d i s c u s s i o n refractive error is the most common correctable cause of decreased vision in developing countries as well as in pakistan (43%). 14 a survey by signessoler et al in rural paraguay also listed refractive errors (58%) as the major cause of visual impairment followed by retinal problems. 15 according to world health organization bulletin 2010 world load of uncorrected refractive errorsrelated decreased vision (myopia, hypermetropia, astigmatism) is 103 million. 14 different factors effecting the prevalence of refractive errors include selected population (urban or rural), developed or developing country, quality of available eye services, tests and conditions used to evaluate the visual acuity, etc. the current study evaluated the prevalence of different type of refractive errors and their association with different age groups and gender. j islamabad med dental coll 2020 106 table iii: association of refractive errors with age age categories n (%) p-value* up to 15 (n=352) 16 to 30 (n=412) 31 to 45 (n=921) 45 or above (n=453) compound myopic astigmatism 113 (32.1) 191 (46.4) 183 (19.9) 88 (19.4) <0.001 compound myopic astigmatism + presbyopia 0 (0.0) 0 (0.0) 2 (0.2) 4 (0.9) hypermetropia + presbyopia 1 (0.3) 1 (0.2) 13 (1.4) 12 (2.6) mixed astigmatism 61 (17.3) 26 (6.3) 66 (7.2) 82 (18.1) mixed astigmatism + presbyopia 2 (0.6) 2 (0.5) 68 (7.4) 106 (23.4) presbyopia 2 (0.6) 3 (0.7) 358 (38.9) 78 (17.2) simple hypermetropia 28 (8.0) 8 (1.9) 16 (1.7) 15 (3.3) simple hypermetropia + presbyopia 0 (0.0) 1 (0.2) 18 (2.0) 11 (2.4) simple myopia 145 (41.2) 180 (43.7) 145 (15.7) 31 (6.8) simple myopia + presbyopia 0 (0.0) 0 (0.0) 52 (5.6) 26 (5.7) *p-value <0.05 was considered statistically significant there was a higher trend of myopia especially myopic astigmatism in our study. shah et al carried out a population survey on refractive errors in pakistan and reported myopia (36.5%) as the most common refractive error followed by hypermetropia (27.1%) and astigmatism (37%), respectively. 16 similarly a mexican study by gomezsalazar et al. also found myopia as the most common type of refractive error among younger population (10-29 years) and hypermetropia as more common in the older age group. 17 in our study the different types of myopia as well as hypermetropia were more common in females (60.5%) as compared to males (39.5%). these results are in accordance with a study carried out by you et al. in beijing, china. 18 other studies on prevalence of refractive errors in bangladeshi adults by bourne and colleagues, 19 south indian adult population by krishnaiah et al. 20 and a review by grzybowski et al. 21 showed that hypermetropic type of refractive error was more common among females. this is in contrast to our study as hypermetropia was more common among our female population. this difference in results can be attributed to factors affecting prevalence mentioned above, like urban vs rural, developed vs developing country or availability of eye services, etc. compound myopic astigmatism was more prevalent in younger ages as compared to older age groups (46.4% vs 19.9%). mixed astigmatism (18.1% vs 6.3%) and mixed astigmatism combined with presbyopia (38.9% vs 0.7%) were found significantly more common in older ages. simple myopia was also found significantly greater in younger ages as compared to older age groups (43.7% vs 15.7%). younger age myopia was also more prevalent (52.2%) in a study done by yingyan et al. 22 the uneven distribution of trained health services and institution among rural and urban population is a major challenge making it difficult for patients with refractive errors to approach these services. 23,24 world health organization in the global action plan of 2014-2019 for "universal eye health” also identified provision of resources and development of national policies for prevention of avoidable visual impairment, specifically refractive errors. 25 the major strength of this study was a large sample size and use of both objective and subjective refraction for testing of visual acuity. the main limitation of the study was that patients with j islamabad med dental coll 2020 107 refractive errors were enrolled from one institution only; therefore, findings cannot be generalized to the whole rural population of islamabad. c o n c l u s i o n the prevalence of myopia and hypermetropia is significantly higher among female population and younger individuals of rural area of islamabad while mixed astigmatism combined with presbyopic type of refractive error is more common among elderly population. r e f e r e n c e s 1. rensikoff s, pascolini d, mariotti sp, pokharel gp. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bull world health organ. 2008; 86(1):63-70. doi: 10.2471/blt .07.041210 2. solange rs, rafael wc, adriana b, luana m, célia r. nakanami, et al. prevalence and causes of visual impairment in low–middle income school children in são paulo, brazil. invest ophthalmol vis sci. 2008; 49(10): 4308–13. doi: 10.1167/iovs.08-2073 3. pirro gh, omar am, phillippa c, robert w, katie mw, terri ly, et al. common mechanisms underlying refractive error identified in functional analysis of gene lists from genome-wide association study results in 2 european british cohorts. jama ophthalmol. 2014; 132(1): 50–6. doi: 10.1001/ jamaophthalmol.2013.6022 4. john c, chiu-fang c, matthew mz, xinzhi z, kai mb, alan rm, et al. the association of health-related quality of life with severity of visual impairment among people aged 40–64 years: findings from the 2006–2010 behavioral risk factor surveillance system. ophthalmic epidemiol. 2016; 23(3): 145-53. doi: 10.3109/09286586.2016.1168851 5. van cl, kristen ae. vision 2020: the right to sight in 7 years? med hypothesis discov innov ophthalmol. 2013; 2(2): 26–9. pmid: 24600638 6. pizzarello l, abiose a, ffytche t, duerksen r, thulasiraj r, taylor h, et al. vision 2020: the right to sight. a global initiative to eliminate avoidable blindness. arch ophthalmol. 2004; 122(4): 615–20. doi: 10.1001/archopht.122.4.615 7. siegwart jt, norton tt. perspective: how might emmetropization and genetic factors produce myopia in normal eyes? optom vis sci. 2011; 88(3): 365–72. doi: 10.1097/opx.0b013e31820b053d 8. rafael i, hassan h, mehdi k, ian gm, emamian mh, shariati m, et al. hyperopia and lens power in an adult population: the shahroud eye study. j ophthalmic vis res. 2015; 10(4): 400–07. doi: 10.4103/2008-322x.158895 9. flitcroft di. emmetropisation and the aetiology of refractive errors. eye (lond). 2014; 28(2): 169–79. doi: 10.1038/eye.2013.276 10. stambolian d. genetic susceptibility and mechanisms for refractive error. clin genet. 2013; 84(2): 102–8. doi: 10.1111/cge.12180 11. ak sm, pourmazar r, gohary, i. awareness and attitude toward refractive error correction methods: a population-based study in mashhad. patient saf qual improv. 2013: 1(1):23-9. 12. suraj ss, praveen vn, sumit m, vasundhara m, bhardwaj a, vivek g. prevalence of visual impairment due to uncorrected refractive error: results from delhi-rapid assessment of visual impairment study. indian j ophthalmol. 2016; 64(5): 387–90. doi: 10.4103/0301-4738.185614 13. islamabad capital territory administration. archived 4th april 2011 at the wayback machine. ictadministration.gov.pk. retrieved on 14 june 2020. http://www.ictadministration.gov.pk/ 14. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96(5): 614–18. doi: 10.1136/bjophthalmol-2011-300539 15. signes-soler i, hernández-verdejo jl, lumeras ma, verduras et, piñero dp. refractive error study in young subjects: results from a rural area in paraguay. int j ophthalmol. 2017; 10(3): 467–72. doi: 10.18240/ijo.2017.03.22 16. shah sp, jadoon mz, dineen b, bourne rr, johnson gj, gilbert ce, et al. refractive errors in the adult pakistani population: the national blindness and visual impairment survey. ophthalmic epidemiol. 2008; 15(3): 183-90. doi: 10.1080/0928658080 2105822 j islamabad med dental coll 2020 108 17. gomez-salazar f, campos-romero a, gomezcampaña h, cruz-zamudio c, chaidez-felix m, leonsicairos n, et al. refractive errors among children, adolescents and adults attending eye clinics in mexico. int j ophthalmol. 2017; 10(5): 796–802. doi: 10.18240/ijo.2017.05.23 18. you qs, wu lj, duan jl, luo yx, liu lj, li x, et al. prevalence of myopia in school children in greater beijing: the beijing childhood eye study. acta ophthalmol. 2014; 92(5): 398–406. doi: 10.1111/ aos.12299 19. bourne rr, dineen bp, ali sm, huq dm, johnson gj. prevalence of refractive error in bangladeshi adults: results of the national blindness and low vision survey of bangladesh. ophthalmol. 2004; 111(6): 1150-60. doi: 10.1016/j.ophtha.2003.09.046 20. krishnaiah s, srinivas m, khanna rc, rao gn. prevalence and risk factors for refractive errors in the south indian adult population: the andhra pradesh eye disease study. clin ophthalmol. 2009; 3:17-27. pmid: 19668540 21. grzybowski a, kanclerz p, tsubota k, lanca c, saw sm. a review on the epidemiology of myopia in school children worldwide. bmc ophthalmol. 2020; 20(1): 27. doi:10.1186/s12886-019-1220-0 22. ma y, qu x, zhu x, xu x, zhu j, sankaridurg p, et al. age-specific prevalence of visual impairment and refractive error in children aged 3–10 years in shanghai, china. iovs. 2016; 57(14): 6188-96. doi: 10.1167/iovs.16-20243 23. gilbert ce, shah sp, jadoon mz, bourne r, dineen b, khan ma, et al. poverty and blindness in pakistan: results from the pakistan national blindness and visual impairment survey. bmj. 2008; 336(7634): 29–32. 24. wang w, yan w, müller a, keel s, he m. association of socioeconomics with prevalence of visual impairment and blindness. jama ophthalmol. 2017; 135(12): 1295–1302. 25. gupta n, kocur i. chronic eye disease and the who universal eye health global action plan 2014-2019. can j ophthalmol. 2014; 49: 403–4 130 j i m d c 2 0 1 7 130 op e n ac c e ss f u l l l e n g t h a r t i c l e vascular preoperative venous mapping decreases the frequency of negative exploration in arteriovenous fistula creation muhammad jamil 1, rashid usman 2, muhammad misbah 3 1 consultant vascular surgeon and associate professor of surgery, department of vascular surgery 2 consultant vascular surgeon and assistant professor of surgery, department of vascular surgery 3 consultant general surgeon, department of surgery (combined military hospital, lahore cantt) a b s t r a c t objective: to assess the impact of preoperative venous mapping on the incidence of negative exploration for arteriovenous fistula (avf) in patients requiring hemodialysis. patients and methods: this case control study was conducted in department of vascular surgery combined military hospital lahore and peshawar, from january 2016 to june 2016. a total of 200 consecutive patients fulfilling the inclusion criteria were divided into case (with preoperative mapping) and control (without mapping) groups. negative exploration rate along with fistula maturation rates were recorded and compared. results: in control group 24% patients had negative exploration when compared with 0% in case group (p-value 0.000). in case group, 16 % patients had change in type and site of avf based on the results of venous mapping hence bringing down the negative exploration rate to zero in this group. conclusion: routine preoperative venous mapping decreases negative exploration in avf creation and is helpful in deciding the best site and type of avf. keywords: arteriovenous, exploration, fistula, imaging, venous mapping author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence muhammad jamil jamilmalik13@yahoo.com article info. received: june 3, 2017 accepted: august 19, 2017 cite this article: jamil m,usman r,misbah m. vascular preoperative venous mapping decreases funding source: nil the incidence of negative exploration in arteriovenous fistula creation. jimdc.2017;6(3):130-133. conflict of interest: nil i n t r o d u c t i o n the population of patients with renal disease is progressively increasing worldwide and hemodialysis (hd) being patient’s ‘lifeline is one of the important developments for management of patients with esrd.1 it has been found that of the 3 types of hemodialysis vascular access, arteriovenous fistulae (avf) are the preferred access for hd. they have higher patency rates, lower infection rates and lower overall costs.1-3 however, with continuously increasing the number of patients on hd, complications following this procedure have been increasing as major causes of morbidity with subsequent hospitalization and increased the cost to hd patients. this repeated venous access causes superficial thrombophlebitis and segmental venous occlusion or stenosis when it is re-canalized.4 moreover, frequent phlebotomies and a high prevalence of comorbid conditions including diabetes, obesity, and vascular disease in this high-risk population may negatively affect the vasculature and contribute to early avf dysfunction. creating an avf in such patients may result in negative o r i g i n a l a r t i c l e mailto:jamilmalik13@yahoo.com 131 j i m d c 2 0 1 7 131 exploration when no suitable vein is found. avf failures have also been attributed to inadequate vessels used for surgery. consequently, the selection of suitable vessels by preoperative vascular mapping is recommended before avf creation for both pre-dialysis ckd and esrd patients on hemodialysis and measures to improve the durability of va are needed. preoperative evaluation with doppler ultrasonography (usg) is an excellent choice and may facilitate selection of suitable vessels and reduces avf failures. preoperative venous mapping not only provides a road map of upper limb superficial veins but also tells us about their diameters and patency which are very important in preventing perioperative and postoperative avf complications.4,5 we conducted this study to check whether the preoperative venous mapping is helpful in reducing the negative exploration rate. p a t i e n t s a n d m e t h o d s all consecutive patients from january 2016 to june 2016, reporting to vascular surgery clinic in combined military hospital lahore and peshawar for avf creation, were included in this study. patients with uncontrolled diabetes (fasting blood sugar of more than 120mg/dl), uncontrolled hypertension (blood pressure of more than 160/90 mmhg), unwilling to undergo mapping, severe congestive cardiac failure were excluded. after taking informed consent, patients were randomly divided into two groups by simple random draw method generated at the time of enrolment in clinic. group a (control) had all patients who had no preoperative venous mapping done and group b (case) had all patients who underwent venous mapping. all patients in this group underwent duplex scan to assess the preoperative venous diameter and patency of superficial veins and diameter of brachial and radial artery. magnetic resonance venogram (mrv) was performed only in patients with inadequate duplex findings. all patients underwent avf procedure by a consultant vascular surgeon who had a minimum of five years of experience of doing such procedure under local anaesthesia. in control group, based on clinical experience and patient’s examination, the operating surgeon made a decision to choose the type and site of avf creation. in group b, the type and site of avf was decided based on the findings of preoperative mapping. all patients were given oral antibiotics and analgesics on discharge. they were also provided with written instructions about hand and forearm exercises and general care of the avf. patients were regularly followed up in clinic at 2 weeks, 4 weeks, 2 months and 3 months. a functionally mature avf is defined as per kidney disease outcome quality initiative (kdoqi) guidelines as one that can be easily cannulated and has at least six successful consecutive dialysis sessions.6 negative exploration rate, fistula failure rate and other procedure-related complications were recorded. the data was analyzed using statistical package for social sciences (spss) version 22. the numerical outcomes e.g. age was calculated as mean and standard deviation. gender was recorded as frequency and percentage. chi square test was applied to assess qualitative variables such as failure of fistula and negative exploration rate. independent sample t-test was applied to assess quantitative variables like age. the results were considered statistically significant if the pvalue was found to be ≤ 0.05. r e s u l t s a total of 200 consecutive patients fulfilling the inclusion criteria were included in this study. the age range was from 19-55 years with mean age of 31.5±4.5 years. out of 200 cases, 142 (71 %) were males and 58 (29 %) were females. male to female ratio was 2.44:1. patients were divided into two equal groups depending upon whether they had a preoperative mapping done or not. group a (control; n=100) had all patients without preoperative mapping and group b (case; n=100) with venous mapping. in group b all patients underwent duplex scan however 18 patients underwent mrv also for full venous assessment. regarding age, gender, diabetes and hypertension; there was no statistically significant difference between two groups (table 1). in control group, 24% (n=24) patients had negative exploration however in case group the negative exploration rate was 0% (table 2). this difference between the two groups is statistically significant. in group b, the average preoperative diameter of the anastomotic vein in group b was 22±4 mm. in this group, we had to 132 j i m d c 2 0 1 7 132 change our initial plan of avf creation after mrv, and brachio-basilic avfs were created instead of brachiocephalic in 24% patients. in terms of fistula maturation; in group a, out of 76 patients who had avf created, only 52 got matured, hence maturation rate was 68.4%. while in group b, 21 avfs failed to mature hence the maturation rate was 79%. the difference in terms of maturation rate was again statistically significant. d i s c u s s i o n recent advances in medicine and improvement in general health measures have grossly decreased the morbidity and mortality in esrd patients on renal replacement therapy as maintenance haemodialysis.7-9 vascular access is required in these patients for hemodialysis to be done in the form of avf, arteriovenous graft (avg) or insertion of dialysis catheter.8,9 the first choice is creating a native avf and according to kdoqi guideline at least 50% of patients on chronic hemodialysis should have a functionally mature avf as it provides better long term patency as compared to avg and dialysis catheter.10,11 studies have suggested that 40-55% of avfs in unites states do not mature adequately 12,13 and in europe such rate is 7-10%.14,15 many factors has been blamed for this fistula failure including advanced age, female gender, diabetes, hypertension, smaller diameter of vein or artery, obesity, late avf creation and diseased vessels.13,16 repeated blood sampling and intravenous infusions in esrd patients cause superficial thrombophlebitis and segmental venous occlusion or stenosis after recanalization which clinically sometimes gives impression of the normal veins. creating avf in these patients may fail due to thrombosis or can result in rapid swelling of the upper limb due to proximal outflow obstruction. preoperative doppler scan and mrv as routine or on selective basis has decreased negative exploration and fistula failure rate.17 however, there has been systemic reviews, which suggest that preoperative mapping may not have a statistical impact on fistula failure. wong et al in 2013 concluded that preoperative mapping may help to improve the maturation rate but they failed to find a statistically significant impact.18 similarly bashar et al concluded that selective use of preoperative duplex increases the maturation rate of fistula however, routine use was not recommended by them.19 on the contrary, dageforde et al concluded that larger vein diameter on preoperative vein mapping are at lower risk for failure of fistula maturation and have increased long-term avf patency. they noted that one third of their fistulae with a venous diameter of less than 2.7mm failed to mature. hence, preoperative mapping is helpful in identifying such cases.20 in our series, we also found that the mean venous diameter was 22mm in the group with negative exploration and the maturation rate was 79% which was 10.5% more than the group where no mapping was done. to have a better idea about outline, diameter of superficial veins and patency of deep veins of upper limb; all 100 patients in case group underwent avf creation after having preoperative doppler scan as a routine and only 18% (n=18) out of these 100 had preoperative mr venography to further confirm the patency and diameter in patients with equivocal duplex scan findings. patel et al reported that 32% patients required mr venography in addition to doppler scan18. table 2: comparison of fistula maturation and negative exploration rates between two groups outcome variable group a (control) n = 100 group b (case) n = 100 p value fistula maturation n (%) 52/76 (68.4) 79/100 (79) 0.003 negative exploration (n) 24 0 0.000 table 1: comparison of baseline characteristics between control and case groups variable group a (control) n = 100 group b (case) n = 100 p value age (years); mean±sd 36.1±7.3 34.4±6.9 0.624 gender male (n) female (n) 67 33 75 25 0.914 0.817 diabetes mellitus (n) 80 91 0.668 hypertension (n) 55 60 0.562 133 j i m d c 2 0 1 7 133 use of selective mr venography helped us to change our initial plan for avf creation and instead of brachiocephalic, brachio-basilic avf were created. there was no negative exploration in our series. on the basis of our results and of the other studies, we can say that routine venous mapping of the upper limb in esrd patients results in marked increase in avf creation and decrease in the negative exploration for a suitable vein for avf. c o n c l u s i o n routine preoperative venous mapping decreases negative exploration in avf creation and is also helpful in deciding the best site and type of avf. r e f e r e n c e s 1. u.s. renal data system. usrds 2007 annual data report: atlas of end-stage renal disease in the united states. national institutes of health, national institute of diabetes and digestive and kidney diseases; bethesda, md: 2007. 2. pisoni rl, young ew, dykstra dm, et al. vascular access use in europe and the united states: results from the dopps. kidney int. 2002;61:305–316. 3. kalman pg, pope m, bhola c, et al. a practical approach to vascular access for hemodialysis and predictors of success. j vasc surg. 1999;30:727–733. 4. robbin l, gallichio h, deierhoi h, young j, weber m, allon m. us vascular mapping before hemodialysis access placement. radiology 2000; 217(1): 83-8. 5. allon m, lockhart e, lilly z, gallichio h, young j, barker j et al. effect of preoperative sonographic mapping on vascular access outcome in hemodialysis patients. kidney int 2001; 60(5):201320 6. rayner c, besarab a, brown w, disney a, saito a, pisoni l. vascular access results from the dialysis outcomes and practice patterns study (dopps): performance against kidney disease outcomes quality initiative (k/doqi) clinical practice guidelines. am j kidney dis 2004;44(5 suppl 2):22–6 7. parmley c, broughan a, jennings c. vascular ultrasonography prior to dialysis access surgery. am j surg 2002; 184(6):568-72. 8. efstratiadis g, platsas i, koukoudis p, vergoulas g. interventional nephrology: a new subspecialty of nephrology. hippokratia 2007; 11(1): 22–4. 9. jennings c, turman a, taubman e. arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site. j pediatric surg 2009; 44(7): 1377-81. 10. hogg rj, furth s, lemley kv, portman r, schwartz gj, coresh j, balk e, et al.. national kidney foundation’s kidney disease outcomes quality initiative clinical practice guidelines for chronic kidney disease in children and adolescents: evaluation, classification, and stratification. pediatrics. 2003; 111(6):1416-21. 11. pisoni l, young w, dykstra m et al. vascular access use in europe and the united state from the dopps. kidney int 2002; 61(1):305-16. 12. tordior m, rooyens p, dammers r, van der sande m, de haan m, yo i. prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis. nephrol dial transplant 2003; 18(2):378-83. 13. miller pe, tolwani a, luscy cp, deierhoi mh, bailey r, redden dt, allon m. predictors of adequacy of arteriovenous fistulas in hemodialysis patients. kidney international. 1999; 56(1):275-80. 14. koo l, burnapp l. contemporary vascular access surgery for chronic haemodialysis. j r coll surg edinb 1996; 41(3):164-9. 15. reilly t, wood f, bell r. arteriovenous fistulas for dialysis: blood flow, viscosity, and long-term potency. world j surg 1982; 6(5):628-33. 16. roa k, azin d, hood b, rowe l, kohl d, katz g et al. basilic vein transposition fistula: a good option for maintaining hemodialysis access site options. j vasc surg 2004; 39 (5):1043-7. 17. menegazzo d, laissy j, durrbach a, deray m, messin b, delmas v et al. hemodialysis access fistula creation: preoperative assessment with mr venography and comparison with conventional venography. radiology 1998; 209(3):723-8. 18. wong s, mcnicholas n, healy d, clark-moloney m, coffey c, grace a et al. a systematic review of preoperative duplex ultrasonography and arteriovenous fistula formation. j vasc surg. 2013; 57(4):1129-33. 19. bashar k, clarke-moloney m, walsh r. pre-operative ultrasonography and arteriovenous fistulae maturation. j vasc access. 2013; 15 suppl 7:s60-3. 20. dageforde a, harms a, feurer d, shaffer d. increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency. j vasc surg. 2015; 61(1):170-6. 21. patel t, hughes j, mills l. failure of arteriovenous fistula maturation: an unintended consequence of exceeding dialysis outcome quality initiative guidelines for hemodialysis access. j vasc surg 2003; 38(3):439-45. j islamabad med dental coll 2019 146 open access airway clearance in bronchiectasis: a randomized control trial with nacetylcysteine and 3% hypertonic saline muhammad imran shehzad1, muhammad atiq ul mannan2, masood alam3, abdul rauf4, muhammad imran sharif5 1 assistant professor, department of pulmonology, ch. pervaiz ellahi institute of cardiology, multan 2 senior registrar, department of pulmonology, nishtar medical university, multan 3 consultant pulmonologist, ch. pervaiz ellahi institute of cardiology, multan 4 assistant professor, department of pulmonology, dg khan teaching hospital, dera ghazi khan 5 consultant, department of pulmonology, tehsil head quarter hospital, shujabad a b s t r a c t background: n-acetylcysteine and 3% hypertonic saline are being used effectively for sputum clearance in chronic cases of bronchiectasis for quite some time. however, their use in acute condition of the disease seems to be underexplored. the objective of our study is to compare the role of nebulized n-acetylcysteine and 3% hypertonic saline in clearing the airway in patients with acute exacerbation of bronchiectasis. material and methods: a total of 136 confirmed cases of bronchiectasis were enrolled in this study. this randomized controlled trial was done in chest ward of nishtar hospital multan from january 2015 to march 2017. sampling was done by non-probability consecutive sampling and patients were divided into two groups a and b by lottery method. verbal informed consent was taken from all participants. group a participants received nebulization of n acetylcysteine mixed in normal saline for ten minutes, while group b participants were nebulized with 10ml of 3% hypertonic saline for ten minutes. group b was active control group in the study. data was collected on pre-designed proforma, and analyzed by spss version 22. numerical variables such as saturation, weight of sputum, age and blood pressure was analyzed by using t test. these were considered significant if the p value was equal or less than 0 .05. for qualitative variables chi square test was applied. results: the mean o2 saturation of group a, before and after treatment, was 92.11±3.07% and 94.47±2.18%, respectively. the difference was statistically significant (p value =0.001). the sputum weight of group a, before and after treatment, was 2.63±2.39 g and 7.41±1.38 g, respectively. the difference was statistically significant (p value =0.001). the frequency of rhonchi of group a, before and after treatment, was 52% and 76%, respectively. the difference was statistically significant (p value =0.003). while, for group b, the mean o2 saturation, before and after treatment, was 92.36±3.13% and 93.49±2.27%, respectively. the difference was statistically significant (p value =0.012). the sputum weight, before and after treatment, was 3.11±2.01 g and 5.56±1.02 g, respectively. the frequency of rhonchi, before and after treatment, was 45% and 74% respectively. again, the difference was statistically significant. conclusion: both nebulized n-acetylcysteine and 3% hypertonic saline cause airway clearance by enhancing sputum expectoration in patients with acute exacerbation of bronchiectasis equally. both these agents also improve oxygen saturation in acute exacerbation of bronchiectasis significantly. key words: bronchiectasis, hypertonic saline, n-acetylcysteine authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3,4 active participations in data collection 5 data analysis. correspondence: masood alam email: dr.masood174@gmail.com article info: received: february 3, 2019 accepted: august 23, 2019 cite this article. shahzad mi, atiq ul manana m, alam m, rauf a, sharif i. airway clearance in bronchiectasis: a randomized control trial with n-acetylcysteine and 3% hypertonic saline. j islamabad med dental coll. 2019; 8(3):146-150. doi: 10.35787/jimdc.v8i3.389 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2019 147 i n t r o d u c t i o n n-acetylcysteine is a mucolator and a drug with antioxidant qualities. both these qualities make it suitable for the treatment of chronic respiratory diseases, because there is excessive production of thick mucus. large amount of mucus production causes repeated infections, difficulty in breathing, excessive cough and other symptoms, and this can be treated with mucolator qualities of n-acetylcysteine. oxidative process has a major role in pathophysiology of many chronic respiratory diseases, and n-acetylcysteine reduces oxidant toxins.1 long term use of n-acetylcysteine has good safety profile with no major side effects. serious side effects are very rare.2,3 in many chronic respiratory diseases, clinical trials of n-acetylcysteine have been carried out and results have shown that it relieved symptoms and improved quality of life.4,5 hypertonic saline is salty water and is found to be beneficial when nebulized in many chronic respiratory diseases. it has various mechanisms of action; it produces osmotic pressure which causes addition of water to surface of airway and this rheological quality makes the mucus suitable for clearance through cough. it also causes disruption of bond in mucus gel and thus reduces viscosity and elasticity by reducing cross linking. it is said to have shown some anti-inflammatory properties as well by reducing the formation of bio-film by organisms. hypertonic saline increases the levels of thiols and behaves as anti-oxidants.6,7 in nebulized form, it is well tolerated and no adverse reactions are reported.8 in many chronic respiratory diseases, efficacy of hypertonic saline has been evaluated and is said to have shown improvement in quality of life by relieving symptoms.9,10 although the role of both these agents is well established in clearing airway during chronic bronchiectasis, but their action in acute exacerbation of the same disease seems to be underexplored. to the best of our knowledge no study has been carried out in this regard so far. therefore, we compared the efficacy of both nacetylcysteine and 3% hypertonic solution in clearing the airways in acute exacerbation of the disease and hope to provide some evidence-based data regarding their usefulness. m a t e r i a l a n d m e t h o d s after approval from ethical committee of nishtar hospital multan, a total of 136 participants were recruited for the study. all the participants were diagnosed cases of acute exacerbation of bronchiectasis and were admitted in the chest ward of nishtar hospital multan from january 2015 to march 2017 either through emergency or outpatient departments. acute exacerbation of bronchiectasis was defined as worsening of shortness of breath, fever or increased production of sputum. sample size was calculated by taking a reference study with power of study 80 and confidence interval 95% in which sputum expectoration was 2.65 +3.47 g and after treatment was 7.5 +6.29 g by using software www.openepi.com.11 sampling was done by non-probability consecutive sampling and patients were divided into two groups a and b by lottery method. verbal informed consent was obtained from all participants of the study. group a were given standard medical treatment for bronchiectasis with nebulization of n acetylcysteine mixed in normal saline for ten minutes while group b participants were nebulized with 10ml of 3% hypertonic saline also for ten minutes. group b in the study was considered as active control group. a focused history was taken from all the patients and detailed examination was done. the demographic information and the variables to be studied were recorded by the investigators on self-designed proforma. demographic variables included age, gender, blood pressure, smoking status, educational status, residential area and diabetes. chest was auscultated for wheeze, or rhonchi and findings were recorded. blood samples were drawn and baseline investigations were done. forty minutes before nebulization sputum samples were collected from every patient and their weight recorded. after that nebulization with assigned drug was started for each patient in both the groups. patients of both groups were nebulized three times in 24 hours. after 24 hours, sputum was collected again in calibrated containers and its weight measured. oxygen saturation was also measured. j islamabad med dental coll 2019 148 data was analyzed by spss version 22. numerical variables such as age, blood pressure, saturation, weight of sputum, were analyzed by t-test. these were considered significant if the p value was equal or less than 0.05. percentages of qualitative variables were calculated and chi square test was applied to test their significance. r e s u l t s table i presents the details of demographic data. there were more males affected by the acute exacerbation than females and more patients belonged to rural than urban areas. the percentage of smokers was greater in group a and those of non-smokers was greater in group b. comparison of parameters preand post-nebulization is shown in table ii. oxygen saturation improved after nebulization in both the groups (a and b) as apparent by the statistically significant difference of 0.001 and 0.012 respectively. sputum weight also increased after nebulization in both the groups significantly with p value of 0.001 in both the groups. similar is the case with frequency of rhonchi which increased after nebulization with both the drugs significantly with p value of 0.003 and 0.001 in groups a and b respectively. table i demographic characteristics of both groups variables group a n=68 group b n=68 mean age (years) 38.89±2.57 46.07±5.12 mean blood pressure (mm hg) 91.13±1.11 96.48±2.26 gender n (%) male 37 (54.4%) 47 (69.1%) female 31 (45.6%) 21 (30.9%) smoking n (%) yes 38 (55.9%) 27 (39.7%) no 30 (44.1%) 41 (60.3%) education status n (%) literate 41 (60.3%) 32 (47.1%) illiterate 27 (39.7%) 36 (52.9%) residential area n (%) rural 47 (69.1%) 41 (60.3%) urban 21 (30.9%) 27 (39.7%) diabetics n (%) 15 (22.1%) 10 (14.7%) table ii comparison of parameters in both groups before and after treatment variable before treatment after treatment p-value oxygen saturation (%) group a 92.11±3.07 94.47±2.18 0.001 group b 92.36±3.13 93.49±2.27 0.012 sputum weight (g) group a 2.63±2.39 7.41±1.38 0.001 group b 3.11±2.01 5.56±1.02 0.001 ronchi (%) group a 52% 76% 0.003 group b 45% 74% 0.001 d i s c u s s i o n patients of both groups showed significant improvement after nebulization three times in 24 hours. patients in both groups expectorated significantly greater amount of sputum post-nebulization thus improving symptoms. effects of n-acetylcysteine in clearing airway and sputum expectoration have been observed in various studies. outcomes of our study are consistent with most of the other researches. hirsch and kory demonstrated that nebulization with n-acetylcysteine caused thinning of sputum leading to increased expectoration.12 kory et al reported increase sputum expectoration when nacetylcysteine was combined with a bronchodilator in patients with chronic bronchitis.13 pavia et al reported significantly improved sputum expectoration after nebulization with hypertonic saline of 7.1%.14 however, nacetylcysteine when used in nebulization form for mechanically ventilated patients did not lead to significant improvement in airway clearance.15 improved airway clearance by mucolytic agents caused improved lung function and oxygen saturation by improving minimizing effects of atelectasis. ueno o. et al. demonstrated that nebulization of n-acetylcysteine in obstructive lung disease caused improved oxygenation and hypercapnia was relieved. n-acetylcysteine also caused improved gaseous exchange after bronchospasm caused by methacholine challenge test.16 hypertonic salines can be used to clear the airway by causing more hydration of the airway and electrostatic effects on respiratory secretions and also due to enhancing cough reflex and improved oxygenation.17 j islamabad med dental coll 2019 149 in a retrospective study, nebulization with hypertonic saline was used to treat acute exacerbation of cystic fibrosis, after which it caused bronchospasm.18 in a study by pappová et al showed that nebulization with nacetylcysteine caused bronchospasm by increasing airway reactivity.19 similarly, in our study nebulization with both 3% hypertonic saline and n-acetylcysteine caused increased airway reactivity and rhonchi. we recommend further research in this regard. limitations of the study were reduced sample size, one-center trial and no follow up after discharge. c o n c l u s i o n nebulization with both n-acetylcysteine and 3% hypertonic saline improves airway clearance by enhancing sputum expectoration in patients with acute exacerbation of bronchiectasis. both these agents improve/increase oxygen saturation and post expectoration weight of sputum significantly. r e f e r e n c e s 1. rushworth gf, megson il. existing and potential therapeutic uses for n-acetylcysteine: the need for conversion to intracellular glutathione for antioxidant benefits. pharmacol ther. 2014; 141(2): 150-9. doi: 10.1016/j.pharmthera.2013.09.006 2. kranzer k, elamin wf, cox h, seddon ja, ford n, drobniewski f. a systematic review and metaanalysis of the efficacy and safety of n-acetylcysteine in preventing aminoglycoside-induced ototoxicity: implications for the treatment of multidrug-resistant tb. thorax. 2015; 70(11): 1070-7. doi: 10.1136/thoraxjnl-2015-207245 3. dodd s, dean o, copolov dl, malhi gs, berk m. nacetylcysteine for antioxidant therapy: pharmacology and clinical utility. expert opin biol ther. 2008; 8(12): 1955-62. doi: 10.1517/14728220802517901 4. zheng jp, wen fq, bai cx, wan hy, kang j, chen p, et al. twice daily n-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (pantheon): a randomised, double-blind placebo-controlled trial. lancet respir med. 2014 mar;2(3):187-94. 5. pirabbasi e, shahar s, manaf za, rajab nf, manap ra. efficacy of ascorbic acid (vitamin c) and/nacetylcysteine (nac) supplementation on nutritional and antioxidant status of male chronic obstructive pulmonary disease (copd) patients. j nutr sci vitaminol (tokyo). 2016; 62(1): 54-61. doi: 10.3177/jnsv.62.54 6. jantrawut p, phongpradist r, muller m, viernstein h. enhancement of anti-inflammatory activity of polyphenolic flavonoid rutin by encapsulation. pak j pharm sci. 2017; 30(5): 1521-1527. pmid: 29084668 7. bedreag oh, rogobete af, sarandan m, cradigati ac, papurica m, et al. oxidative stress in severe pulmonary trauma in critical ill patients. antioxidant therapy in patients with multiple trauma—a review. anaesthesiol intensive ther. 2015; 47(4): 351-9. doi: 10.5603/ait.a2015.0030 8. reeves ep, williamson m, o'neill sj, greally p, mcelvaney ng. nebulized hypertonic saline decreases il-8 in sputum of patients with cystic fibrosis. am j respir crit care med. 2011; 183(11): 1517-23. doi: 10.1164/rccm.201101-0072oc 9. ros m, casciaro r, lucca f, troiani p, salonini e, favilli f, et al. hyaluronic acid improves the tolerability of hypertonic saline in the chronic treatment of cystic fibrosis patients: a multicenter, randomized, controlled clinical trial. j aerosol med pulm drug deliv. 2014; 27(2): 133-7. doi: 10.1089/jamp.2012.1034 10. baron j, el-chaar g. hypertonic saline for the treatment of bronchiolitis in infants and young children: a critical review of the literature. j pediatr pharmacol ther. 2016; 21(1): 7-26. doi: 10.5863/1551-6776-21.1.7 11. gallon am. evaluation of nebulised acetylcysteine and normal saline in the treatment of sputum retention following thoracotomy. thorax. 1996; 51(4): 429-32. doi: 10.1136/thx.51.4.429 12. hirsch sr, kory rc. an evaluation of the effect of nebulized n-acetylcysteine on sputum consistency. j allergy. 1967; 39: 265–73. doi: 10.1016/00218707(67)90090-1 13. kory rc, hirsch sr, giraldo j. nebulization of nacetylcysteine combined with a bronchodilator in patients with chronic bronchitis. a controlled study. dis chest. 1968; 54: 504–9. doi: 10.1378/chest.54.6.504 14. pavia d, sutton pp, lopez-vidriero mt, newman sp, clarke sw. drug effects on mucociliary function. eur j respir dis 1983; 64(suppl 128): 304–17. pmid: 6137400 https://www.ncbi.nlm.nih.gov/pubmed/?term=existing+and+potential+therapeutic+uses+for+n-acetylcysteine%3a+the+need+for+conversion+to+intracellular+glutathione+for+antioxidant+benefits. j islamabad med dental coll 2019 150 15. masoompour sm, anushiravani a, norouz at. evaluation of the effect of nebulized n-acetylcysteine on respiratory secretions in mechanically ventilated patients: randomized clinical trial. iran j med sci. 2015; 40(4): 309–315. pmid: 26170516 16. ueno o, lee ln, wagner pd. effect of nacetylcysteine on gas exchange after methacholine challenge and isoprenaline inhalation in the dog. eur respir j. 1989; 2(3): 238-46. pmid: 2659384 17. donaldson sh, bennett wd, zeman kl, knowles mr, tarran r, boucher rc. mucus clearance and lung function in cystic fibrosis with hypertonic saline. n engl j med. 2006; 354(3): 241-50. doi: 10.1056/nejmoa043891 18. pezzulo aa, stoltz da, hornick db, durairaj l. inhaled hypertonic saline in adults hospitalised for exacerbation of cystic fibrosis lung disease: a retrospective study. bmj open. 2012; 2(2): e000407. doi: 10.1136/bmjopen-2011-000407 19. pappová l, kazimierová i, kocmálová m. effect of inhaled and oral n-acetylcysteine on airway defense mechanism. eur pharmaceut j. 2017; 64(1): 17-21. doi: 10.1515/afpuc-2017-0002. j islamabad med dental coll 2020 95 open access diagnostic accuracy of sonographic septations in tuberculous and malignant pleural effusions abdul rasheed qureshi 1 , muhammad irfan 1 , zeeshan ashraf 2 1 assistant professor, gulab devi post graduate medical institute lahore, pakistan 2 lecturer, department of statistics, gulab devi educational complex, lahore-pakistan a b s t r a c t background: discrimination between tuberculous (tb) and malignant pleural effusions is a real practical challenge because both exist as exudative lymphocytic type. transthoracic ultrasonography not only identifies and quantifies pleural effusion but also displays sonographic septations, which are frequently seen in tb pleural effusions and can help in differentiation between tuberculosis and malignancy successfully, without any invasive procedure. we designed this study to determine the diagnostic usefulness of these septations for tuberculous and malignant pleural effusions. material and methods: this prospective study was conducted in the opd of gulab devi chest hospital lahore, pakistan, a 1500 bedded tertiary care hospital, from november 2016 to february 2018. total of 339 consecutive cases, aged 14-83 years with radiological evidence of pleural effusion were included in the study. after detailed history, thorough physical examination, radiological, haematological and biochemical findings were recorded. pleural fluid macroscopic, cytological, microbiologic and biochemical analysis results were also recorded. ultrasonography was done, septated and non-septated pleural effusions identified and findings were noted. spss-16 was used for statistical evaluation. fisher exact test was utilized for comparison between tb and malignant cases with p-value < 0.05 taken as significant. sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv), diagnostic accuracy and positive likelihood ratio were calculated. results: out of total 339 cases, 49 (14.45%) were malignant and 290 (85.55%) were non-malignant. in the malignant group, only 03 cases (6.12%) showed sonographic septations. in the non-malignant group, 259/290 (89.31%) cases showed tuberculous etiology and 187/259 (72.20%) of these cases displayed sonographic septations. by considering septations as predictor of tb, statistical analysis revealed a sensitivity of 79.23%, specificity of 92.85%, ppv of 98.42%, npv of 44.31% and diagnostic accuracy of 81.29%, respectively. conclusions: sonographic septations can be a valuable predictor of tuberculosis, in a population with high prevalence of the disease. we found it to be a useful feature in differentiating between a malignant and tuberculous etiology, in exudative lymphocytic pleural effusions. it can be used with confidence in patients who are unfit for interventional procedures. key words: pleural effusion, sonographic septations, transthoracic ultrasonography, tuberculosis authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad irfan email: irfan16d2@gmail.com article info: received: may 2, 2019 accepted: june 24, 2020 cite this article. qureshi ar, irfan m, ashraf z. diagnostic accuracy of sonographic septations in tuberculous and malignant pleural effusions. j islamabad med dental coll.2020; 9(2): 95-102. doi: 10.35787/jimdc.v9i2.339 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 96 i n t r o d u c t i o n a pleural effusion (pe) is always abnormal and indicates the presence of an underlying disease. many infective, neoplastic, inflammatory, metabolic or connective tissue disorders produce pleural effusions. it can be an exudate or transudate depending upon the protein content of the pleural fluid (pf). according to the global tuberculosis (tb) report by who, tb is endemic in pakistan, which occupies the fifth position among the high burden countries. 1 the incidence of tb is 497/100,000 in pakistan. tb is usually considered the sole cause of an exudative lymphocytic pleural effusion until proven by further work up. according to literature, tb is the most common cause of exudative pleural effusion. 2 malignancy and acute infections are also significant contributors. 3 the gold standard for tb diagnosis is capturing acidfast bacilli (afb) in pleural fluid, but the yield is less than 20%. 4,5 about 40-70% cases can be diagnosed by an invasive procedure like pleural biopsy followed by histopathology. 6-8 in spite of utilizing all these tools, 10-20% cases still remain undiagnosed. 9 similarly negative results on afb smear, culture and histopathology reports do not rule-out tb. the chest ultrasonography has been gaining popularity for the evaluation and management of lung cancer, consolidations, mediastinal tumors, and pleural diseases during the last decade. 10,11 it has emerged as an excellent imaging tool for assessing the quantity and nature of pleural effusions. sonographic septations are frequently present in exudates and very commonly found in tubercular pleural effusions. 12 current literature reports that tuberculous pleural effusions and empyema commonly have complex septated sonographic appearances. 13-15 pyogenic effusions (empyema and parapneumonic pe) can be isolated by typical clinicopathological findings but the discrimination between tb and malignancy still remains a practical challenge, because both exist as exudative-lymphocytic type of pe. the differentiation between tuberculosis and malignancy is made by pleural fluid cytology, adenosine deaminase levels and pleural biopsy. 16,17 pleuroscopic biopsy is the standard widely-used technique, but requires special equipment and expertise. 18 it has its own complications and lacks cost-effectiveness. 19 in this scenario, there is a need for a safe, readily available and cost-effective tool capable of discriminating tb from malignancy. this study was designed with the primary objective of evaluating the diagnostic usefulness of sonographic septations in predicting tuberculosis. in order to achieve this objective, we first diagnosed pleural effusions on the basis of pleural fluid analysis and laboratory investigations, then identified the sonographic patterns in different types of pes and finally compared the usefulness/efficacy of sonographic septations in differentiating between tb and malignant pe. m a t e r i a l a n d m e t h o d s this prospective study was conducted at pulmonology opd of gulab devi teaching hospital, lahore pakistan (a 1500 bed tertiary care hospital). ethical approval was obtained from the irb of the hospital (irb no. admin/gdec/18-549) prior to the commencement of the study. informed consent was taken from all the patients enrolled in the study. sample size was calculated using the openepi sample size formula for cross-sectional studies [(z1-a/2) 2 x p(1—p)/d2]. total of 339 consecutive patients, reporting from november 2016 to february 2018 (15-months period) were recruited. patients with undiagnosed pleural effusions (on laboratory investigations and ultrasound), aged 14-83 years and willing for pleural aspiration/biopsy were included. the j islamabad med dental coll 2020 97 exclusion criteria included minimal pe, pleural effusions with diagnosed etiology, previous pleural interventions and any contraindication to pleural aspiration. the diagnostic tools included chest x-ray posteroanterior (pa) and lateral views, and ultrasound examination (toshiba, japan) with 3.55.5 mhz convex probes. after a thorough history and physical examination, patients were evaluated with grey scale ultrasonography machine (toshiba, japan) using 3.5-5.5 mhz convex probes. anterior, posterior and lateral scans were obtained in sitting and supine positions. both hemithoraces were scanned systematically. pleural effusions, septations, loculations and pleural thickenings were diagnosed. four main sonographic patterns were recognized: 1. anechoic pattern having no echoes inside the effusion (simple effusion), 2. complex septated pattern with fibrous bands running inside the complex effusion, 3. complex non-septated pattern with effusion without any septation, 4. homogenous echogenic pattern with effusion consisting of homogenous bright echoes. ultrasound-guided pleural fluid aspiration was done and sent for biochemistry, cytology, afb smear, culture and sensitivity (c/s) and adenosine deaminase (ada) levels. cbc, esr, serum proteins, liver function tests (lfts) and renal function tests (rfts) were performed. pleural fluid analysis results including macroscopic findings, cytological, microbiological and biochemical analysis were recorded. exudates and transudates were classified by light’s criteria.20 exudates were further subclassified into neutrophilic and lymphocytic by differential leukocyte count (dlc). para-pneumonic effusions and empyema were diagnosed by typical short history, peripheral leukocytosis, neutrophilic exudate, homogenous echogenic pleural effusion, gram staining and c/s results. tuberculosis was diagnosed by history, pyrexia of unknown origin (puo), history of contact, lymphocytic exudates, caseating granulomas and by capturing afb. pleural fluid (pf) ada level with a cut-off value of 40 iu/l was used for diagnosis of tb. anti-tb treatment initiated according to dots protocol and response to treatment was considered for final diagnosis. patients were followed up for six months at least. all observations were recorded in a proforma. findings were tabulated, sonography patterns were compared with the final clinical diagnosis and statistical analysis was done. spss-16 software package was used for statistical evaluation. quantitative data was expressed as means with standard deviation and categorical variables were presented as percentages. fisher exact test was utilized for comparison between tb and malignant cases. p-value < 0.05 was considered significant. patients with disease and also having septations were considered true positive (tp), cases with disease but without septations were false negative (fn), cases without disease but with septations were false positive (fp) and patients without any disease and with no septation were defined as true negative (tn). sensitivity, specificity, ppv, npv, diagnostic accuracy and positive likelihood ratio were calculated. r e s u l t s total 339 cases were enrolled with 233 (68.73%) male and 106 (31.26%) female patients, respectively (male-to-female ratio of 2.2:1.2). about 339 (62.24%) pleural effusions were on the right side while 128 (37.75%) were on the left side. the mean age of the patients was 48.5 ± 21.6 years (age range 14-83 years). the mean age for tuberculous and pyogenic effusion was 28 years while for malignant group it was 41 years. fortynine cases (14.45%) were found with a malignant etiology. of the non-malignant (n=290; 85.55%) j islamabad med dental coll 2020 98 cases, 259/290 (89.31%) had tuberculous etiology, while 31/290 cases (11.96%) had a pyogenic cause (parapneumonic pe and empyema). regarding clinical presentation of the patients, 282 (83.18%) presented with chest pain, 264 (77.87%) with cough, 247 (72.86%) with fever, 210 (61.94%) with dyspnea, 200 (58.99%) with expectoration and 198 (58.4%) with loss of appetite, respectively. about 48 (14.15%) gave history of previous contact with tb patients, 36 (10.61%) cases had hemoptysis, 44 (12.97%) clubbing and 37 (10.91%) cases were found with known diabetes mellitus. table i: pleural fluid analysis and laboratory investigations for diagnosis of pleural effusions (n = 339) s no diagnosis of pe (n=339) pleural fluid analysis n (%) mean concentrations clot +ve mean protein gm/dl afb pyogenic culture infl cells (poly/ lymph) cancer cells serum protein (gm/dl) esr (mm/1 st hr) tlc /mm 3 hb (gm%) 1. *tb (n=259) 251 (97) 5.3 0.00 0.00 lymph 255 (98.43) 0.00 6.49 39.0 8,450 11.86 2. *pyogenic (n=31) 0.00 5.9 0.00 26 (83.9) poly 26 (82) 0.00 7.7 31.6 13,750 10.9 3. *malignant (n=49) 0.00 5.0 0.00 0.00 lymph 42 (85.71) 38 (77.55) 7.2 69 10,220 8.2 *percentages are calculated independently for each etiology. pe-pleural effusion; n-number of patients; +ve-positive; afb-acid-fast bacilli; esr-erythrocyte sedimentation rate; tlc total leukocyte count; hb-hemoglobin; infl cellsinflammatory cells; poly-polymorphonuclear leukocytes/neutrophils; lymph-lymphocytes table ii: frequency distribution of sonographic patterns in different types of pleural effusions (n = 339) s no. sonographic patterns of pe types of pleural effusions n (%) total cases n (%) tuberculous (n=259) malignant (n=49) para-pneumonic (n=31) 1. anechoic 23 (8.88) 5 (10.20) 2 (6.45) 30 (8.84) 2. complex septated 187 (72.2) 03 (6.12) 6 (19.35) 196 (57.81) 3. complex non-septated 49 (18.91) 39 (79.59) 7 (22.58) 95 (28.02) 4. homogenously echogenic 0.00 2 (4.08) 16 (51.61) 18 (5.3) the details of pleural fluid analysis and laboratory investigations for tuberculous, pyogenic and malignant pleural effusions are shown in table i. on cytology, 308/339 (90.85%) showed lymphocytic infiltration, 31/339 (9.14%) neutrophilic infiltration and 38/339 (11.20%) were found with malignant cells. about 76.4% cases with lymphocytic infiltration were of tuberculous etiology and 14.45% were found in malignant cases. table ii shows the distribution of sonographic patterns in different types of pleural effusions. there were 278 cases of complex pleural effusions, 190 patients with complex septated pe and 88 cases with complex non-septated pe. all these cases had a tb and malignant etiology. by considering complex septated pattern as predictor of tb diagnosis, 187 cases were tp, 3 cases were j islamabad med dental coll 2020 99 fp, 39 cases were tn and 49 cases were fn. statistical analysis revealed a sensitivity of 79.24% (95% confidence interval 73.5% to 84.23%), specificity of 92.86% (95% ci 80.52% to 98.5%), ppv of 98.42% (95% ci 95.44% to 99.46%), npv of 44.32% (95% ci 37.96% to 50.87%), diagnostic accuracy of 81.29% (95% ci 76.21% to 85.70%) and positive likelihood ratio of 11.09 (95% ci 3.72 to 33.07). similarly, sensitivity, specificity, ppv, npv, positive likelihood ratio and diagnostic accuracy were also determined for malignancy by using sonographic septations. comparative efficacy is depicted in table iii. by using sensitivity and specificity for tb and malignancy from table iii, the fisher exact test p-value is 0.0418 which is statistically significant. ppv: positive predictive value, npv: negative predictive value. *by using sensitivity and specificity for tb and malignant pe, p-value (by fisher exact test) is 0.0418 which is statistically significant. figure 1: transthoracic ultrasound image showing sonographic septations in tuberculosis pe. d i s c u s s i o n we aimed to evaluate the usefulness of sonographic septations for the diagnosis of tb pe and its comparative efficacy in differentiating tb from malignant pe. exudative lymphocytic pleural effusions are a diagnostic dilemma and tb is a common cause in high prevalence areas. that is why many undiagnosed patients with exudative lymphocytic pleural effusions are found on anti-tb drugs. 20 pyogenic infections and malignancy are also significant contributors to this type. 21 sonographic septations are found in all these entities (tb, pyogenic and malignant) but with different frequencies. this study showed a male to female ratio of 2.19:1, indicating a male predominance in our population. the mean age for our study population was 48.5 years with an inter-quartile range of 40, which is higher than that reported by hira et al. (48.5 vs 31.7 years). 8 the mean age for non-malignant group was 28 years. this group included pyogenic infections and mostly fresh cases of tuberculosis. the mean age for malignant group was 41 years. a small number of tb cases were also found in elderly age group, which comprised mostly of previously treated patients. these cases were either due to reinfection or reactivation of previously healed lesions, as shown by other authors as well. 22 chest pain, fever and cough were the predominant symptoms in this study, which are the usual, nonspecific respiratory complaints. dyspnea, expectoration and loss of appetite were also found in a significant number. these clinical features are consistent with the reports of light 2 and porcel et al. 3 the sudden onset pointed towards pyogenic infection, clubbing of finger suggested chronic suppurative processes like pyothorax and pyopneumothorax and positive history of contact with tb-patients raised a high index of suspicion for tuberculosis. table iii: comparative efficacy of sonographic septations in tb and malignant pe statistical test tuberculous pe n = 236 malignant pe n = 42 sensitivity 79.23% 7.14% specificity 92.85% 20.76% ppv 98.42% 1.57% npv 44.31% 55.68% positive likelihood ratio 11.15 0.089 diagnostic accuracy 81.29 % 18.70% j islamabad med dental coll 2020 100 maskell and butland also reported tuberculous effusions as a predominant cause, followed by malignant and parapneumonic effusions. 23 this high percentage for tb is due to the fact that our region is endemic for tuberculosis with pakistan ranked as fifth among the high burden countries with an annual incidence of 497/100000. 24 in short, tuberculosis is the commonest etiology, followed by malignancy and pyogenic infections (parapneumonic pe and empyema) which is compatible with reports from the current literature. 25 in this study, out of 339 cases, 196 had septations and 6/196 pyogenic cases were isolated easily by acute onset, high blood and pleural fluid tlc count, culture sensitivity findings and homogenous echogenic pattern. out of remaining 190 cases with septations, 3/190 (1.57%) were malignant while 187/190 (98.42%) had tb pleural effusion. current researchers have tried the application of intrapleural sonographic septations for early diagnosis of tuberculosis in exudative lymphocytic pleural effusions. 26 the intra-pleural fibrinous matrix formation is due to disordered fibrin turn-over. the dynamic equilibrium is lost and fibrin formation is up-regulated while fibrin dissolution is downregulated. furthermore, cytokines, such as tgf-β and tnf-α enhance the fibrin matrix formation. according to kunter et al., high levels of pleural fluid glucose, alpha-1 acid glycoprotein (aag) and c-reactive protein, seen in these patients might be responsible for pleural thickening. 27 philip-joet et al. and hua et al. displayed significantly higher levels of plasminogen activator inhibitor and von willebrand factor in patients with tuberculosis than in those with cancer. they also reported increased levels of tissue-type plasminogen activators in some malignant pleural effusions. these findings reveal that fibrinolytic activity is higher in malignant pleural effusions than tuberculous pleural effusions. 28,29 chen et al. also reported that complex septated pattern is a useful diagnostic tool for discriminating tuberculosis from lung cancer. 26 a number of authors reported pleural infections, including tuberculosis as a cause of intra-pleural fibrosis, in addition to other causes. in 1989 martinez et al. reported that winding bands were seen by ultrasonography in 38% patients with tb pleural effusion. 30 these facts further confirm our findings that fibrin strands were more common in tuberculous than cancer-related pleural effusions, hence septations are more commonly encountered in tuberculous pleural effusions. there were 190 cases of sonographic septations after excluding pyogenic cases (proven tb pe n=187; malignant pe n=3) the frequency of tb effusion was 98.42% and that of malignancy was 1.57% with a wide gap between the two entities. the fisher exact test was highly significant (p< 0.00001) and suggests that tuberculosis can be predicted with a high degree of confidence in complex, exudative lymphocytic pe just by finding sonographic septations, with no need for any invasive procedure. by group wise analysis, there were 3 cases of septated pleural effusions in 49 cases of malignancy, which is only 6.1% of total malignant group, indicating a very low chance of malignancy in septated pleural effusions. similarly, there were 187 cases (79.23%) of septated pleural effusions out of 236 complex tb-pleural effusions, indicating that by finding sonographic septations, chance of malignancy is only 6.1%, while for tuberculosis it is 79.23%. it means we can correlate sonographic septations with tuberculosis by high level of confidence in clinical suspects. conventionally, the differentiation between tb and malignant pleural effusion is made by pleural fluid cytology, pleural biopsy, histopathology and immuno-cytology, which are invasive, costly, timeconsuming and expertise-dependant procedures. furthermore, the availability of these facilities is also an issue in resource limited populations. on j islamabad med dental coll 2020 101 the other hand, sonographic septations do not have such disadvantages and can help in predicting tuberculosis immediately, without any delay, invasion and complication. in the light of this discussion, it can be said that the finding of sonographic septations is useful in clinical practice for differentiating tuberculous from malignant pleural effusions with confidence, in high prevalence populations. it can be very useful in those areas where facilities for invasive procedures are not available or in patients who are not fit for invasive procedures. the main limitation of our study was that this was a single centre study and the number of patients in malignant and pyogenic group was small as compared to tb group. this might be because the study is prevalence dependent. as 339 consecutive patients were included in the study, there is more probability of getting tb cases in larger number in an endemic population as compared to non-tb patients. c o n c l u s i o n sonographic septations are non-invasive, easily detectable, cost effective and valuable predictor of tb diagnosis in exudative lymphocytic pleural effusions, in high prevalence populations. it can be used with confidence for making differentiation between malignant and tb pes. furthermore, it can provide tremendous help for point of care diagnosis in non-ambulatory and serious patients. a c k n o w l e d g e m e n t the authors are thankful to mr. mehfooz ahmed and mr. tahir for their valuable cooperation during the study. r e f e r e n c e s 1. global tuberculosis report 2015. geneva: world health organization, 2015. available online: http://apps.who.int/iris/bitstream/10665/191102/1 /9789241565059_eng.pdf?ua=1, accessed 18 april 2016. 2. light rw. update on tuberculous pleural effusion. respir ology. 2010; 15(3): 451-8. doi: 10.1111/j.1440-1843.2010.01723.x. 3. porcel jm, esquerda a, vives m, bielsa s. etiology of pleural effusions: analysis of more than 3,000 consecutive thoracenteses. arch bronconeumol. 2014; 50(5): 161-5. doi: 10.1016/j.arbres.2013.11.007. 4. rauniyar s, agarwal a, bhattacharya s. comparison 1 of needle biopsy with pleural fluid analysis for the evaluation of pleural lesions. nepal med coll j. 2004; 6(2): 112-5. pmid: 16295740 5. liam ck, lim kh, wong cmm. causes of pleural exudates in a region with a high incidence of tuberculosis. respirology. 2001; 5 (1): 33-38. doi: 10.1046/j.1440-1843.2000.00223.x 6. avnon l, kalchiem-dekel o, gozlan-talmor a, shimonovitch f, shalev r, maimon n. the role of closed pleural biopsy in the diagnosis of tuberculous pleurisy in a population at-risk. harefuah. 2016; 155(2):110-4. pmid: 27215124 7. dixon g,fonseka d,maskell n. pleural controversies: image guided biopsy vs. thoracoscopy for undiagnosed pleural effusions. j thorac dis. 2015; 7(6): 1041–1051. doi: 10.3978/j.issn.20721439.2015.01.36 8. hira h, ranjan r. role of percutaneous closed needle pleural biopsy among patients of undiagnosed exudative pleural effusion. lung india. 2011; 28(2): 101–4. doi: 10.4103/0970-2113.80319 9. zarić b, kuruc v, milovančev a, markovic m, šarčev t, čanak v, et al. differential diagnosis of tuberculous and malignant pleural effusions: what is the role of adenosine deaminase? lung. 2008; 186(4): 233-240. doi: 10.1007/s00408-008-9085-7. 10. beckh s, bo pl, lessnau k-d. real-time chest ultrasonography: a comprehensive review for the pulmonologist. chest. 2002; 122(5): 1759-73. doi: 10.1378/chest.122.5.1759. 11. chian cf, su wl, soh lh, yan hc, perng wc, wu cp. echogenic swirling pattern as a predictor of malignant pleural effusions in patients with malignancies. chest. 2004; 126(1): 129-34. doi: 10.1378/chest.126.1.129 12. brogi e, gargani l, bignami e, barbariol f, marra a, forfori f, et al. thoracic ultrasound for pleural effusion in the intensive care unit: a narrative j islamabad med dental coll 2020 102 review from diagnosis to treatment. crit care. 2017; 21(1): 325. doi:10.1186/s13054-017-1897-5 13. bedawi eo, hassan m, harriss e, mccracken d, asciak r, mercer r, et al. s57 sonographic septations in pleural infection–what do they actually mean? thorax. 2018; 73(4): a35. 14. hassan wafaa a, alkarn atef f, kamel m. can chest ultrasonography differentiate between benign and malignant effusions? egypt j bronchol. 2015; 9(2): 165-9. doi: 10.4103/1687-8426.158061 15. vorster mj, allwood bw, diacon ah, koegelenberg cf. tuberculous pleural effusions: advances and controversies. j thorac dis. 2015; 7(6): 981-91. doi:10.3978/j.issn.2072-1439.2015.02.18 16. aggarwal an, agarwal r, sehgal is, dhooria s. adenosine deaminase for diagnosis of tuberculous pleural effusion: a systematic review and metaanalysis. plos one. 2019; 14(3): e0213728. doi:10.1371/journal.pone.0213728 17. zhai k, lu y, shi hz. tuberculous pleural effusion. j thorac dis. 2016; 8(7): e486-e494. doi: 10.21037/jtd.2016.05.87 18. zhou x, jiang p, huan x, li w, chen y, gao h, et al. ultrasound-guided versus thoracoscopic pleural biopsy for diagnosing tuberculous pleurisy following inconclusive thoracentesis: a randomized, controlled trial. med sci monit. 2018; 24: 7238-48. doi:10.12659/msm.912506 19. mohamed as, abo-sheisha dm, shamloula mm. exudative pleural effusions: comparative study of image assisted abram needle pleural biopsy and medical thoracoscopy. egypt j chest dis tuberc. 2014; 63(3): 625-8. doi: 10.1016/j.ejcdt.2014.02.014 20. light rw. pleural diseases. 6th ed. philadelphia: lippincott williams & wilkins, 2013.mayse ml. nonmalignant pleural effusions. in: fishman ap, editor. fishman's pulmonary diseases and disorders. new york: mcgraw-hill; pp. 1487–504. 21. valdes l, alvarez d, san jose e, penela p, valle jm, garcía-pazos jm, et al. tuberculous pleurisy: a study of 254 patients. arch intern med. 1998; 158(18): 2017-21. doi: 10.1001/archinte.158.18.2017 22. emad a, rezaian g. diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in 20 suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: a comparative, age-dependent study. respir med. 1998; 92(3): 488-92. doi: 10.1016/s0954-6111(98)90296-7 23. maskell n, butland r. bts guidelines for the investigation of a unilateral pleural effusion in adults. thorax. 2003; 58(suppl 2): ii8-17. doi: 10.1136/thorax.58.suppl_2.ii8 24. fatima r, harris r, enarson d, hinderaker s, qadeer e, ali k, et al. estimating tuberculosis burden and case detection in pakistan. int j tuberc lung dis. 2014; 18(1): 55-60. doi: 10.5588/ijtld.13.0198 25. hallifax rj, corcoran jp, ahmed a, nagendran m, rostom h, hassan n, et al. physician-based ultrasound-guided biopsy for diagnosing pleural disease. chest. 2014; 146(4):1001-06. doi: 10.1378/chest.14-0299 26. chen hj, hsu wh, tu cy, yu yh, chiu kl, hang lw et al. sonographic septation in lymphocyte-rich exudative pleural effusions: a useful diagnostic predictor for tuberculosis. j ultrasound med. 2006; 25(7): 857-63. doi: 10.7863/jum.2006.25.7.857 27. kunter e, ilvan a, kilic e, cerrahoglu k, isitmangil t, capraz f, et al. the effect of pleural fluid content on the development of pleural thickness. int j tuberc lung dis. 2002; 6(6): 516-22. doi: 10.5588/09640569513039. 28. philip-joet f, alessi m, philip-joet c, aillaud m, arnaud a, juhan-vague i. fibrinolytic and inflammatory processes in pleural effusions. eur respir j. 1995; 8(8): 1352-6. doi: 10.1183/09031936.95.08081352 29. hua cc, chang lc, chen yc, chang sc. proinflammatory cytokines and fibrinolytic enzymes in tuberculous and malignant pleural effusions. chest. 1999; 116(5): 1292-6. doi: 10.1378/chest.116.5.1292 30. martínez oc, serrano bv, rodr romero rí. real‐time ultrasound evaluation of tuberculous pleural effusions. j clin ultrasound. 1989; 17(6): 407-10. doi: 10.1002/jcu.1870170605 165 j i m d c 2 0 1 7 165 op e n ac c e ss f u l l l e n g t h a r t i c l e comparison of the efficacy of postoperative diclofenac suppository with intramuscular diclofenac in children undergoing inguinal hernia surgery aleena hussain 1, mustafa awais 2 momina awais 3 1-3 ex. house officers service institute of medical sciences lahore. a b s t r a c t objective: to compare the analgesic effect of postoperative diclofenac suppository with intramuscular diclofenac in children undergoing inguinal hernia surgery. patients and methods: this cross-sectional study was conducted at paeds surgery department of services hospital lahore, from august 2016 to march 2017. a total of 160 patients were included in the study and were divided into two groups, one receiving diclofenac suppository (group ds) and the other group di which received intramuscular diclofenac injection. numerical variables like age and weight were analyzed statistically by taking their mean and standard deviation while the outcome variable like the severity of pain was categorized as no pain, mild, moderate and severe pain in frequency percentage at 0, 2 and 4 hours’ interval. results: total 160 patients were divided into 2 groups equally, 80 in each (ds & di). there was no significant difference in the efficacy of diclofenac suppository and diclofenac intramuscular when calculated at 0, 2 and 4 hours’ interval. when chi-square was applied to determine the association, it was observed that pain severity was significantly associated with age. however, the association of pain severity with weight and with time intervals in two groups was not statistically significant. conclusion: there was no significant difference between the postoperative analgesic effect of either suppository or intramuscular diclofenac but suppository route has an advantage over intramuscular in that it is easier and safer, less prone to injury, easy to administer and has a longer duration of action, especially preferable in pediatric patients. keywords: children, diclofenac sodium, inguinal hernia, intramuscular, suppository. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence aleena hussain email. farmiali@hotmail.com article info. received: july 31, 2017 accepted: august 19, 2017 cite this article: hussain a, awais m, awais m. comparing the efficacy of postoperative diclofenac suppository with intramuscular diclofenac in children under going inguinal hernia surgery jimdc. 2017; 6(3):165-169. funding source: nil conflict of interest: nil i n t r o d u c t i o n the incidence of an inguinal hernia is almost 80,000 children in the world. it was found that the cumulative incidence of an inguinal hernia from birth to 15 years of age was 0.74% in females and 6.62% in males.1,2 while in the adult population almost all cases of sliding hernias are seen in men.3 the processus vaginalis is an embryonic developmental outpouching of peritoneum attached to the testicle. when obliteration of the processus vaginalis fails o r i g i n a l a r t i c l e 166 j i m d c 2 0 1 7 166 to occur, it results in an inguinal hernia. an inguinal hernia is an indication of elective herniotomy (in children) and herniorrhaphy (in adults), which prevents incarceration and subsequent strangulation. multiple factors contributing to chronic pain include a scrotal hernia, hernia repair or emergency recurrent hernia repair. postoperative pain may be less with laparoscopic procedures as compared to open procedures.4 pain caused by tension or compression may slowly diminish with time as a consequence of tissue reorganization.5 the quality and duration of analgesia provided by morphine remain without comparison.6 but due to the complications of opioids, in recent times, physicians have been paying attention to non-steroidal anti-inflammatory drugs (nsaids) for pain control.7 nsaid, diclofenac, which reduces inflammation and relieves pain, is used to treat dental pain, muscle aches, and athletic injuries. it is frequently used to treat the swelling, stiffness, and pain related to arthritis.8 perioperative analgesia in pediatrics herniotomies requires effective, safe and less invasive strategies. local infiltration with bupivacaine, caudal bupivacaine, and rectal diclofenac are widely used to alleviate the pain. hernia repair is an outpatient procedure. patients are usually a healthy and full-term child or infant. diclofenac restrains prostaglandin synthesis by lessening cyclooxygenase activity, which sequentially, reduces the formation of prostaglandin precursors. diclofenac suppository with local infiltration is an effective and less invasive alternative to caudal bupivacaine for postoperative pain relief in pediatric hernia repair. different studies have been performed on the efficacy of analgesics for the postoperative pain of an inguinal hernia but there is lack of studies for effect of route of administration of diclofenac. this study was planned to compare intramuscular and suppository route of administration of diclofenac to see which of these is more effective. p a t i e n t s a n d m e t h o d s this study was conducted at pediatric surgery department of services hospital lahore, from august 2016 to march 2017. children who presented for inguinal hernia repair were included in the study. the sample size was calculated using a reference from a previous study by saghar samimi sede et al.9 for which confidence interval was taken as 95 %, and a total of 160 patients were included in the study. we collected 160 patients’ data; authorization for the study protocol was obtained from the hospital ethical committee and informed written permission was obtained from the parents of all children. the randomized control trail non-probability sampling technique was used and patients were divided into two groups, one receiving diclofenac suppository (group ds) and the other group di receiving intramuscular diclofenac injection. children from age 5-15 years, who were operated for an inguinal hernia were included in the study. patients with a history of asthma, known allergy or contraindication for study drug, kidney or hepatic dysfunction, duration of surgery more than two hours or those who refused to give informed consent were excluded from the study. standard patient monitoring involved measurement of blood pressure, pulse oximetry, electrocardiograph, inhalation agents and capnography. general anesthesia was administered by inhalation of sevoflurane in oxygen or intravenously with 2.5-3.5 mg/kg propofol. a laryngeal mask airway was inserted after induction of anesthesia. all patients were administered 50 µg/kg midazolam immediately after induction of anesthesia and 60% nitrous oxide, 40% oxygen, and sevoflurane during their operation. the sevoflurane concentration (2.0%) was regulated to achieve optimum intraoperative hemodynamic measurements. intravenous fluids were administered in the operating room following standard guidelines (ringer's lactate solution at maintenance rates). postoperatively group ds received diclofenac suppository 2.5mg/kg and group di received intramuscular diclofenac 2mg/kg. patients were evaluated for severity of pain by a single autonomous observer 0, 2 and 4 hours after the return to the ward. the pain was evaluated using visual analogue score. the visual analogue scoring scale is a linear scale from 0-10 number, which shows the intensity of pain increases along with increasing number. according to this scale, no pain was labeled when vas 0, mild pain when vas 1-4, moderate pain when vas 5-8 and severe pain when the patient had vas 9-10. for continuous variables, mean and sd were calculated. while categorical variables were analyzed as number and percentage. chi-square test was applied to check effect 167 j i m d c 2 0 1 7 167 modification; independent sample t-test was applied to check the difference between the mean of both groups. pvalue ≤0.05 was considered statistically significant. r e s u l t s total 160 patients were included in the study and all were males. the mean age and weight of the patients were 10.94±2.55 years and 31.04±10.45 kg respectively (table 1). when patients were stratified into different age and weight groups, it was noted that 55.6% (n=89) were aged from 11 to 15 years. regarding weight, majority of the patients i.e. 62.5% (n=100) were between 26-48 kg (table 1). the mean age, weight and pain severity of the patients’ ingroup ds and group di have been mentioned in table 2. table 2: comparison of demographic variables and pain severity between groups (n=160) variables ds group (n=80) (mean±sd) di group (n=80) (mean±sd) p-value age (years) 10.85±2.72 11.03±2.37 0.583 weight (kg) 31.82±11.76 30.12±9.27 0.598 pain severity 1.89±1.03 2.00±1.006 0.486 statistical evaluation of these parameters revealed no significant difference between the two groups. table 3: association of pain severity with stratified age and weight (n = 160) \ pain severity p-value no mild moderate severe stratified age (years) 5-10 38 11 14 8 0.010 11-15 32 35 13 9 stratified weight (kg) 12-25 30 13 8 9 0.174 26-48 40 33 19 8 the severity of pain was notably associated with age (p value 0.010) but it was not considerably associated with weight (p-value 0.174) (table 3). the main outcome variable of this study was pain severity. the mean severity of pain was 1.89±1.03 and 2.00±1.006 for the groups ds and di respectively. it was observed that, in group ds, at 0-hour, the maximum number of patients 41.2% (n=33) were suffering from mild pain. while at 2 hours and at 4 hours’ majority of patients 50% (n=40) and 62.5% (n=50) respectively had no pain (table 4). it was noted that in group di also, at 0 hour, 46.2% (n=37) had mild pain while at 2 hours and 4 hours’ maximum number of patients 42.5% (n=34) and 53.7% (n=43) respectively had no pain (table 5). table 1: demographic variables of participants of study (n=160) characteristics mean sd age (years) 10.94 2.55 weight (kg) 31.04 10.45 stratified age (years) frequency percentage 5-10 71 44.4 11-15 89 55.6 stratified weight (kg) frequency percentage 12-25 60 37.5 26-48 100 62.5 table 4: severity of pain in group ds (n=80) group time levels of pain frequency percentage ds 0 hour no pain 23 28.7 mild 33 41.2 moderate 15 18.7 severe 9 11.2 2 hours no pain 40 50.0 mild 18 22.5 moderate 10 12.5 severe 12 15 4 hours no pain 50 62.5 mild 15 18.7 moderate 9 11.2 severe 6 7.5 table 5: severity of pain in group di (n=80) group time levels of pain frequency percentage di 0 hour no pain 18 23.1 mild 37 46.2 moderate 21 26.2 severe 4 5 2 hours no pain 34 42.5 mild 21 26.2 moderate 9 11.2 severe 16 20 4 hours no pain 43 53.7 mild 14 17.5 moderate 17 21.2 severe 6 7.5 168 j i m d c 2 0 1 7 168 d i s c u s s i o n the results of our study revealed that there is almost no difference between the effectiveness of both suppository and intramuscular diclofenac when given postoperatively. however, there is lower pain rating scale with suppository type of modality. moreover, suppository route is safer, less prone to injury, easy to administer and has longer duration of action. suppository route was introduced as a newer route to treat children in 21st century by vincent jannin et al.10 this comprehensive meta-analysis compared the rectal and oral routes for reducing fever. and it was concluded by the comparison of these two routes and it may change the recommendations of american academy of pediatrics, whose recommendation was, so far, to refrain rectal administration to children.11 diclofenac is used as an analgesic in preand postoperative pain management and illustrates excellent effectiveness by suppository administration alone, or in combination with other drugs.12 several studies have explored the use of paracetamol and diclofenac in pediatric patients. concurrent administration of diclofenac in children receiving patient-controlled analgesia (pca) morphine has a very considerable morphine-sparing effect, as demonstrated by morton and o'brien, although they were unable to explain any extra additive outcome of paracetamol.13 our study is concerned with postoperative use of diclofenac via rectal and intramuscular route while most of the previous studies were concerned with preoperative administration of diclofenac in children undergoing inguinal hernia. in a similar study by w riad and a moussa, preoperative diclofenac suppository in combination with paracetamol was used which showed that its use spared the post-operative use of morphine.14 sodium diclofenac is a non-steroidal anti-inflammatory drug, which shows analgesic affects in various conditions. a study suggests that sodium diclofenac presents the advantages that it could restrain prostaglandin biosynthesis by blocking the cyclo-oxygenase enzyme. by decreasing the production of prostaglandins, the feeling of pain may diminish in the peripheral nervous system; although a central anti-nociceptive effect has also been claimed for nsaids. opioids are usually unable to remove the chemical mediators of pain and by using meperidine, the patients still have a vague feeling of pain. furthermore, sodium diclofenac does not result in respiratory depression or any other meperidine side effects such as vomiting, nausea, respiratory depression, itching, decreased gastrointestinal motility, tachycardia, physical dependency and hemodynamic instability. sodium diclofenac similar to other nsaids has some gastrointestinal effects and there is a speculative risk of postoperative hemorrhage as it causes prolonged bleeding time and decreases platelet aggregation.15 in a preliminary study of the two-marketed formulations of diclofenac, intramuscular and suppository revealed that both preparations provided comparable analgesia but patients who received the suppository preparation were released earlier.16 in another study, conducted to compare intramuscular diclofenac with intravenous paracetamol in patients undergoing lower abdominal gynecological surgery, it was reported that im diclofenac appears to be a superior post-operative analgesic as compared to intravenous paracetamol, with no added advantage of their combination over intramuscular diclofenac, in terms of rescue analgesic requirements.17 diclofenac suppository is a superior choice for postoperative analgesia in pediatric patients going through tonsillectomy in comparison to bupivacaine infiltration as there were considerable variation in pain score (p<0.05) after two hours onwards postoperatively.18 another study, which compared the postoperative analgesic effect of suppository diclofenac with caudal bupivacane suggested that suppository diclofenac although provides comparable analgesic effect postoperatively but immediate pain relief is difficult by the use of suppository diclofenac.19 a study on comparison of efficacy of nsaids when given through different routes was performed which revealed that fastest and most effective analgesia was provided by intravascular route of administration. but other than that there was no significant difference in analgesic effect. in the same study it was shown that most side effects were through intramuscular and rectal routes i.e. discomfort at the site of injection (intramuscular route) and diarrhea, rectal irritation and non-retention of suppositories (rectal route).20 c o n c l u s i o n there is no significant difference between the postoperative analgesic effect of either suppository or 169 j i m d c 2 0 1 7 169 intramuscular diclofenac but suppository route has an advantage over intramuscular in that it is easier, safer, less prone to injury, easy to administer and has longer duration of action, especially preferable in pediatric patients. r e f e r e n c e s 1. chang sj, chen jy, hsu ck, chuang fc, yang ss. the incidence of inguinal hernia and associated risk factors of incarceration in pediatric inguinal hernia: a nation-wide longitudinal population-based study. hernia. 2016.; 20 (4):55963. 2. kelly kb, ponsky ta. pediatric abdominal wall defects. surgical clinics of north america. 2013 ;93(5):1255–1267 3. komorowski al, moran rodriguez j, kazi r, wysocki wm. sliding inguinal hernias. int j surg 2012;10(4):206-208 4. townsend cm, beauchamp rd, evers bm, mattox kl. textbook of surgery. stomach, 19th edn. elsevier, philadelphia. 2012:1182-226. 5. inaba t, et al. chronic pain and discomfort after inguinal hernia repair. surgery today. 2012; 42(9):825-829. 6. banik d, hye ma, akhtaruzzaman a, aziz l, yeasmeen s, iqbal k. effect of small dose intermittent iv pethidine in combination with diclofenac for post-operative pain relief. journal of the bangladesh society of anaesthesiologists. 2014;22(2):40– 47. 7. barkhori a, drodian mr, norozi m, hashemi shadmehri m, shabani m. a comparative study of the effect of diclofenac, indomethacin, naproxen, and acetaminophen rectal suppositories on post-cesarean pain. j birjand univ med sci. 2014; 20(4):338– 45. 8. crofford lj. use of nsaids in treating patients with arthritis. arthritis research & therapy. 2013; 15(3):s2. 9. sede ss, tanha fd, valadan m, modaressi z. comparison between preoperative rectal diclofenac plus paracetamol and diclofenac alone for postoperativepain of hysterectomy. journal of family & reproductive health. 2014; 8(3):91. 10. jannin v, lemagnen g, gueroult p, larrouture d, tuleu c. rectal route in the 21st century to treat children. advanced drug delivery reviews. 2014; 73:34-49. 11. prins sa, van dijk m, van leeuwen pi, searle s, anderson bj, tibboel d, mathot ra. pharmacokinetics and analgesic effects of intravenous propacetamol vs rectal paracetamol in children after major craniofacial surgery. pediatric anesthesia. 2008; 18(7):582-92. 12. adarsh es, mane r, sanikop cs, sagar sm. effect of preoperative rectal diclofenac suppository on post-operative analgesic requirement in cleft palate repair: a randomised clinical trial. indian journal of anaesthesia. 2012; 56(3):265. 13. morton ns, o'brien k. analgesic efficacy of paracetamol and diclofenac in children receiving pca morphine. br j anaesth 1999; 82(5):715–7. 14. riad w, moussa a. pre‐operative analgesia with rectal diclofenac and/or paracetamol in children undergoing inguinal hernia repair. anaesth. 2007; 62(12):1241-5. 15. alijanpour e, jabbari a, rabiea sm, tabasi s. suppository diclofenac instead of intravenous meperidine for postoperative management. caspian j intern med. 2012; 3(3):506. 16. pinto pl, chen d, clement y, simeon d. analgesic effects of diclofenac suppository and injection after preoperative administration. int j clin pharmacol res. 1999; 19(2):47-51. 17. pal a, biswas j, mukhopadhyay p, sanyal p, dasgupta s, das s. diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: a comparative study. anesth essays res. 2014; 8(2):192. 18. solanki ns, goswami m, thaker n. bupivacaine infiltration versus diclofenac suppository for post-tonsillectomy pain relief in paediatric patients. natil j med res. 2012; 2(1):5-7. 19. moores m, wandless j, fell d. paediatric postoperative analgesia a comparison of rectal diclofenac with caudal bupivacaine after inguinal herniotomy. anaesth. 1990; 45(2):1568. 20. tramŕr dm, williams j, carroll d, wiffen p, moore r, mcquay h. comparing analgesic efficacy of non‐steroidal anti‐inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review. acta anaesthesiologica scandinavica. 1998; 42(1):71-9. j islamabad med dental coll 2019 141 open access earthquake preparedness in schools of islamabad nadia tariq1, tamkeen jaffry1, sadaf khalid1 1 assistant professor, department of community medicine, islamabad medical and dental college a b s t r a c t background: pakistan is located in the himalayan region, which has the highest vulnerability to earthquakes. the islamabadrawalpindi area lies in a tectonically active zone, where earthquakes have been frequent in the recent geological past. earthquake preparedness in schools is relatively under studied area in pakistan. the objective of this study was to determine the level of preparedness of schools for earthquakes and to compare it between urban and rural, government and private schools in islamabad capital territory. material and methods: it was a cross-sectional comparative study. the study population was schools of islamabad capital territory. the total sample size was 74 and non-probability purposive sampling technique was used. data was collected through a structured questionnaire pretested on 5% of the sample size and respondents were administrative staff of schools. data was analyzed using spss version 21. data of the categorical variables was presented in the form of frequencies (percentages). statistical significance of association between school profile and level of preparedness was determined by using bivariate tabular association analysis (chi square). results: out of 74 schools, 61 were private and 14 were government schools. 46 schools were located in urban areas while 28 were in rural area of islamabad capital territory. out of the total schools, 66.2% had written preparedness plan for earthquake and 73% of the schools had a safety committee to lead disaster response planning. most of the schools (82.4%) had minimum of two exits in high occupancy rooms. there was significant association of location of school with preparedness plan for earthquake (p=0.009), and type of school with two evacuation drills annually (p=0.03). conclusion: private schools and those located in urban areas are better prepared for earthquakes as compared to government schools and the ones located in rural areas. key words: earthquake, emergency preparedness, schools authors’ contribution: 1conception, synthesis, planning of research and manuscript writing interpretation, discussion, active participations in data collection and data analysis. correspondence: nadia tariq email: nadia.tariq@imdcllege.edu.pk article info: received: june 26, 2019 accepted: august 19, 2019 cite this article. tariq n, jaffry t, khalid s. earthquake preparedness in schools of islamabad. j islamabad med dental coll.2019; 8(3):141-145. doi 10.35787/jimdc.v8i3.398 funding source: nil conflict of interest: nil i n t r o d u c t i o n natural disasters around the world kill an average of 74,000 and affect more than 230 million people annually.1 many natural disasters, earthquakes, tsunamis and hurricanes are the deadliest; responsible for loss of lives and damage to properties.1 they put a huge burden on the economy. there is a long history of catastrophic earthquakes throughout the world, which usually occur with little or no warning.2 united states and japan are most prone and have experienced frequent earthquakes in the last 20 years. 3 pakistan is located in a zone roughly 200 km north of the himalaya front. this region has the highest vulnerability to earthquakes.4 the resistance of the buildings determines amount of loss to a great extent. the poor standard of buildings in pakistan indicates a major seismic risk. seismic vulnerability manifests itself most intensely in building collapses, falling objects and inadequate emergency exits.5 the educational system of pakistan comprises of preprimary, primary, middle, high, high secondary schools, inter colleges and degree colleges. islamabad o r i g i n a l a r t i c l e j islamabad med dental coll 2019 142 has total of 1105 private and 348 government institutes from preprimary level till high school.6 a school is a foundation that houses a community’s future. the collapse of a school in a community has more psychological impact as compared to other buildings. school’s distinct structural and managerial characteristics make them vulnerable to earthquakes. the main causes behind the greater vulnerability of schools are poor building construction practices, lack of good supervision and quality control, lack of financial resources and lack of awareness and understanding about the risks and possibility of mitigation measures.7 the islamabad-rawalpindi area lies in a tectonically active zone, where earthquakes have been frequent in the recent geological past. on october 28, 2010 earthquake jolts were felt in different areas of khyber pakhtunkhwa, punjab, azad kashmir and islamabad.8 approximately, 1,500 people were rendered homeless. the 2005 pakistan earthquake resulted in extensive damage in azad jammu kashmir and eastern districts of khyber pakhtunkhwa. it killed more than 80,000 people in pakistan, resulted in the collapse of 8000 schools in the north-west part of the country taking an indescribable toll on children.9 each time a disaster occurs, a large number of school children are victimized. our children are the future; their school buildings must be safe in the face of natural hazards and children must be enabled with an understanding of natural hazards and actions they can take to be in a better position to face the next “incident”. with respect to natural hazards, educational institutions have a multiple role to ensure the safety of their students, teaching them about natural hazards and planning for disaster prevention in future.10 teachers are the first line responders in case of disaster. it is important to train school administrators to prepare for disaster in school with the defined role of each staff member during and after the event. in addition to that, there is a need to prepare disasters awareness programs for the community utilizing experiences of other developed countries in disasters and emergencies management especially for school.11 preparedness is a continuous cycle of planning, organizing, training, equipping, exercising, evaluating and taking corrective action.12 the rationale behind this study was earthquake preparedness in schools is relatively under studied area in pakistan. implementation of preparedness measures in schools can significantly reduce damage. objectives of this study were firstly to determine level of preparedness of schools for earthquakes and secondly to compare preparedness between urban/ rural and government/ private schools respectively. m a t e r i a l a n d m e t h o d s a cross sectional comparative study was carried out in schools of islamabad capital territory. out of total 1453 schools6 (government:348, private:1105), calculated sample size was 74 with 80% confidence level, absolute precision 5% and design effect of 0.5 13 sample size was calculated using the following formula (n = [deff*np(1-p)]/ [(d2/z21-α/2*(n-1) + p*(1-p)]). schools were selected on the basis of non-probability purposive sampling technique. inclusion criteria was preprimary, primary, middle and high schools (government and private) located in commercial as well as residential areas whereas madrassas, vocational institutes and tuition centers were excluded. study was carried out from july, 2018 till december, 2018. a self-designed structured questionnaire was used, pretested on 5% of the sample size and modified accordingly. the content of the questionnaire included information on school profile like location of the school, its general condition, type and educational level, conforming to standard building codes etc. in addition, there was a checklist of various measures related to preparedness for earthquakes.14-17 reliability analysis of questionnaire was carried out. cronbach’s alpha showed acceptable reliability at 0.79. respondents were the key informants assigned by the school administration. data was analyzed using spss version 21. data of the categorical variables was presented in the form of frequencies (percentages). statistical significance of association between school profile and level of preparedness was determined by using bivariate tabular association analysis (chi square). technical and ethical approval from institutional review board was taken. in addition, informed written consent from the school administrator/principal was taken and j islamabad med dental coll 2019 143 confidentiality was maintained throughout and after the study. r e s u l t s out of 74 schools, 61 were private and 14 were government. 46 schools were located in urban areas while 28 were in rural area of islamabad capital territory (ict). the level of 13 schools was pre-primary or primary while19 were middle and 42 were high schools. most of the schools had double (42.9%, n=24) or triple storey (23.2%, n=13) buildings. maximum (91.4%, n=64) number of the schools were built according to the standard building codes. remaining were either not built according to building codes or the informant did not have the information. most of the schools (66.2%, n=49) had written preparedness plan for earthquakes and staff was aware of their roles and responsibilities. about 73% (n=54) schools had a safety committee to lead disaster response planning. regular meetings in 54.1% schools (n=40) included staff as well as students. parents were not included in these meetings in most of the schools (74.3%, n=55) and community leaders were also not the part of the meetings in the majority of schools (73%, n=54). a detailed map of the school was displayed in only 39 school and building exit routes were marked in 40 schools. most of the schools (79.7%, n=59) did not have an automatic emergency lighting. high occupancy rooms had minimum of two exits in 82.4% (n=61) schools, while only 43 schools had exit doors that opened outwards. there was no separate route of evacuation for disabled students in 94.1% schools (n=64) (figure 1). awareness among teachers regarding measures to be taken before, during and after an earthquake is shown in table i. 42 schools had minimum of two building evacuation drills with each class annually. there was no trained staff for search and rescue in 52.7% (n=39) schools, while location of main gas, electricity and water shut off valves was known to staff of 83.8% (n=62) schools. evacuation plan was shared with nearest police station in 51 schools while 38 had shared it with nearest fire station and 36 schools with the nearest hospital, respectively. figure 1: earthquake preparedness measures observed in different schools. there was significant difference between urban and rural schools in display of map (p=0.00),having marked exit routes (p=0.00), having automatic emergency lighting (p=0.025), exit doors opening outwards (p=0.03), display of standard operating procedures (p=0.00),awareness of teachers about duck and cover action (p=0.00),having staff trained for search and rescue (p=0.03), sharing of evacuation plan with nearest police station (p=0.00) and having buildings built according to standard building codes (p=0.02). there was significant difference between government and private schools in level of preparedness as shown in table ii. d i s c u s s i o n this study done in schools of islamabad capital territory reveals, that most of the schools whether government or private have written preparedness plan for earthquakes and a safety committee to lead disaster response planning. table i: schools with awareness among teachers regarding measures to be taken before, during and after an earthquake (n=74) awareness among teachers about measures for earthquake preparedness yes no implementing duck and cover action 59 15 having emergency kit near students’ desk and release information near the desk 23 51 when to evacuate and when to remain in class room 63 11 how to administer first aid 56 18 working in buddy system 39 35 j islamabad med dental coll 2019 144 table ii: preparedness measures according to type of school variables government private p value yes (%) no (%) yes (%) no (%) schools in having written preparedness plan 33.3 66.7 70.8 29.2 0.02 display of map in schools 11.1 88.9 58.5 41.5 0.00 exit doors opening outwards 22.2 77.8 63.1 36.9 0.02 display of standard operating procedures 0 100 35.9 64.1 0.02 awareness of teachers regarding implementation of duck and cover action 33.3 66.7 86.2 13.8 0.00 having minimum of two evacuation drills annually 88.9 11.1 52.3 47.7 0.03 sharing of evacuation plan with nearest police station 11.1 88.9 78.1 22.9 0.00 sharing of evacuation plan with nearest hospital 11.1 88.9 54.7 45.3 0.01 this is in accordance with a study conducted in turkey18 where school administrators had pre-disaster plan for earthquakes with noticeable differences between the status of school preparedness and school type. high schools were better prepared than elementary schools. the schools located in cities were better prepared as compared to the ones located in villages. our study also showed significant difference between government/private and rural/urban schools in having preparedness plan for earthquakes. while there was no significant association between educational level of school and having earthquake preparedness plan. the results of this study show that the schools have minimum of two exit routes in high occupancy rooms with exit doors opening outwards, which is in accordance with the standard criteria16 but maps showing the exit routes are displayed in half of the total schools of our study. it is very important to display maps showing evacuation route at all the levels of the school building. for years, experts have said that if there is an earthquake, we should duck, cover and hold i.e. duck under something strong like a desk, then stay under cover and hold on until the shaking stops. our study results are encouraging showing almost 80% school teachers know about this measure. the official earthquake protection instructions for schools and kindergartens in israel have recently been updated from the traditional “drop, cover and hold on” approach to the “flee outside to an open space” approach.19 earthquake and safety drills have a good effect on enhancing preparedness at the time of earthquake and improving safety culture. as earthquakes come without warning, unpreparedness among teachers, students and other staff may result in trauma and casualties.20 this study shows almost half of the schools practice recommended two evacuation drills annually along with its evaluation at the end of the year. circumstances requiring medical attention are common at schools. according to a study conducted in south india, poor and moderate knowledge of first aid was observed among 13% and 87% teachers, respectively. in contrast, 75.7% schools included in this study had teachers who knew how to administer first aid to the seriously wounded, which is very important as teachers are often the first individuals to witness and handle situations requiring first aid and medical emergencies.21 c o n c l u s i o n majority of schools of islamabad, especially private and those located in urban areas are well prepared for earthquakes. government should take measures to strengthen it further in private schools; however major steps should be taken to improve earthquake preparedness in government schools, as well as those located in rural areas. r e f e r e n c e s 1. tuladharg, yatabe r, dahal rk, bhandary np. knowledge of disaster risk reduction among school students in nepal. geomatics, natural hazards and risk. 2013; 5(3): 190-207. doi: 10.1080/19475705.2013.809556 j islamabad med dental coll 2019 145 2. dixit am, yatabe r, dahal rk, bhandary np. public school earthquake safety program in nepal. geomatics, natural hazards and risk. 2014; 5(4): 293-319. doi: 10.1080/19475705.2013.806363 3. alex greer m s. earthquake preparedness and response: comparison of united states and japan. leadership and management in engineering. 2012; 12(3). doi:10.1061/(asce)lm.1943-5630.0000179 4. iqal a. pakistan in the most active quake zone, says us geological survey. dawn news. 2015. 5. rafi mm, lodi sh, ahmed m, kumar a, verjee f. development of building inventory for northern pakistan for seismic risk reduction. international journal of disaster resilience in the built environment. 2016; 7(5): 501-20. 6. pakistan education statistics. national education management information system. ministry of federal education. government of pakistan. 2015-16. http://library.aepam.edu.pk/books/pakistan%20educa tion%20statistics%202015-16.pdf last cited on 8-818. 7. rodgers je. why schools are vulnerable to earthquakes. in proceedings, 15th world conference on earthquake engineering, lisbon. 2012. (pp. 24-28). 8. m 7.7-61km nne of awaran, pakistan, 2013-09-24 11:29;47(utc).usgeologicalsurvey.earthquake.usgs .gov. accessed on 18-7-19. 9. rehman k. analysis of the devastating kashmir earthquake 2005 aftershocks. arabian journal of geosciences. 2016; 9: 379. doi: 10.1007/s12517016-2418-6 10. tuladhar g, yatabe r, dahal rk, bhandary np. knowledge of disaster risk reduction among school students in nepal, geomatics, natural hazards and risk.2013; 9(3): 190-207. doi: 10.1080/19475705.2013.809556 11. margolin g, ramos mc, guran el. earthquakes and children: the role of psychologists with families and communities. professional psychology: research and practice. 2010; 41(1): 1-9. doi: 10.1037/a0018103 12. park k. disaster management. preventive and social medicine.2014: 740-747. 13. kevin m. sullivan, john c. pezzullo, andrew g, roger a. mir. sample size calculator. open source statistics for public health. http://www.openepi.com/samplesize/sscohort.htm. accessed on 1-7-2018 14. disaster and emergency preparedness: guidance for schools. international finance corporation, world bank. 2010: 6-41. 15. tatebe j, mutch c. perspectives on education, children and young people in disaster risk reduction. international journal of disaster risk reduction.2015; 14(2): 108-114. doi: 10.1016/j.ijdrr.2015.06.011 16. twig j. disaster risk reduction. good practice review. 2015; 9: 2-17. 17. dixit a m, yatabe r, dahal r k bhandary,n p. public school earthquake safety program in nepal. geomatics, natural hazards and risk. 2014; 5(4). doi: 10.1080/19475705.2013.806363 18. ocal a, topkaya y. earthquake preparedness in schools in seismic hazard regions in the south-east of turkey. disaster prevention and management.2011; 20(3): 334-348. doi: 10.1108/09653561111141754 19. rapaport, c. and ashkenazi, i. "drop down or flee out?". international journal of disaster resilience in the built environment. 2019; 10(1): 52-64. https://doi.org/10.1108/ijdrbe-09-2018-0040 20. izadkhah yo, hosseini ka. an evaluation of disaster preparedness in four major earthquakes in iran. spring and summer.2010; 12(1): 62-75. 21. joseph n, narayanan t, zakaria sb, nair av. awareness, attitudes and practices of first aid among school teachers in mangalore, south india. journal of primary health care. 2015; 7(4): 274-281. j islamabad med dental coll 2019 57 correspondence: professor dr. naila irum hadi email: naila.irum@imdcollege.edu.pk o p e n ac c e s s evolution of breast cancer classification towards personalized medicine naila irum hadi professor, director research & development, islamabad medical and dental college breast cancer (bc) is a heterogenous disease, both genetically as well as clinically1 with need for a histological, molecular and functional classification system that can aid in devising an appropriate treatment and predicting clinical behavior.2 “histological classification” has been considered a valuable tool for classification of breast cancer subtypes for decades owing to its diagnostic as well as limited prognostic value. it characterizes different types on the basis of histological features like glandular/tubular formation, nuclear pleomorphism, and mitotic rate/10 hpf.2 luminal a, luminal b, basal-like, normal breast like and erbb2+/her2+3,4 and recently “claudin-low”5 have been identified as molecular subtypes of breast cancer on microarray-based gene expression and hierarchical clustering analysis; hence the evolution of “molecular classification” with great potential for predicting therapeutic response and a better ability to predict overall survival as well as disease-free survival and therefore make prognostic predictions.3,4 these gene expression patterns have been linked with variations in dna copy number and mrna. for example, estrogen receptor (er) positive tumors (luminal a and b) exhibited pik3ca (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) mutations and er/pr/her2 negative presented with p53 mutations.6 breast cancer researchers have developed pam50 (50gene signature using qrt-pcr),7 oncotype dx (21-gene recurrence score) and mammaprint (70-gene signature),8 of which the latter two have been approved by food and drug administration (fda) for use in united states. pam50, now named as prosigna breast cancer prognostic gene signature assay analyzes genes in early stage, er-positive bc, while oncotype dxtm (genomic health inc., redwood city, ca) gives information regarding recurrence as well as response to chemotherapy in early stage, er-positive bc. mammaprinttm (agendia, the netherlands) gene signature, also done in early stage bc gives information regarding low-/high-risk of development of metastasis, with the option of not administering chemotherapy to patients with low risk hence sparing them the harmful side effects of these drugs. cancer stem cells (cscs), an evolving area of cancer research with likely focus on targeted therapy, provides the “functional classification” for breast cancer based on the hypotheses that breast cancer heterogeneity is either due to oncogenic transformation of single mammary stem cell or due to transformation of mammary stem cells at various levels.9 cscs markers are used to quantify the percentage of these cells in a cancer patient, with high values indicating a poor prognosis. understanding the histological, molecular and functional characteristics of a tumor will be necessary as tools for individualized/personalized cancer therapy in the future.2 ambiguities in bc classification still exist, with clinical routine still relying primarily on er, pr and her2 immunohistochemistry as a basis for classification while numerous studies have been carried out on molecular characterization of bc. protein expression levels in bc and their role in classification has not been thoroughly investigated. recently mass spectrometry (ms) based proteomic studies have been carried out with this objective.10,11 in the clinical proteomic tumor analysis consortium (cptac) study,11 novel proteomic and phosphoproteomic e d i t o r i a l j islamabad med dental coll 2019 58 subgroups were identified through an unsupervised tumor classification. the three proteomic groups identified included one corresponding to the luminal cluster, second to the basal bc cluster and the third was named as stromal-enriched cluster composed of tumors from different subtypes.6 figure 1: evolution of breast cancer classification. luma/lumb: luminal a/b, tn: triple negative, ca: cancer revere-phase liquid chromatography-mass spectrometry (uhplc – thermo fisher scientific) was used for separation of peptides. raw ms data was analyzed by maxquant (version 1.5.3.16)12 and andomeda (an integrated peptide search engine).13 hierarchical clustering analysis was carried out using r environment (version 3.2.3) and consensusclusterplus package.14 for information regarding protein-protein interaction in each group, the statistically significant upregulated proteins in each cluster were applied to the string database (http://string-db.org). this was followed by centrality analysis (identification of central nodes i.e. nodes appearing in shortest path between two other nodes)6 employing/with cytonca plug-in and cytoscope.15 the cancer proteome atlas (tcpa) provided the cancer genome atlas reverse phase protein array (tcga rppa) data. the study by yanovich and colleagues for proteomic classification of bc has identified a novel luminal a subtype with an intrinsic er positive signature along with additional high expression of key signaling markers specific for tnbc.6 this finding suggests use of protein expression pattern for classification of luminal breast cancers, which might benefit treatment decision making. cancer proteomics is a robust high-throughput ‘omic’ technology, which can be used independently and also complementary to other ‘omics’ like genomics, transcriptomics and metabolomics. metabolomics is an “omics” science, a survey to identify and quantify low molecular weight metabolites that reflect alterations in energy metabolism. they are present downstream and are a reflection of the activity of genes, proteins and mrna upstream. high throughput analytical techniques like mass spectrometry (ms) or nuclear magnetic resonance (nmr) are used for metabolic characterization using untargeted or targeted approaches.16 metabolic profile can be obtained by analyzing the enormous raw data through specialized software with validation of the mass spectra obtained, with those available in the national institute of standards and technology (nist) mass spectral (wiley registry) and agilent fiehn metabolomics retention time locked (rtl) libraries. a number of studies aimed at identifying a metabolomic biomarker for breast cancer have been carried out,16-18 however validation studies combining different sample types (e.g. blood, tissue, urine etc.) might bring an understanding of the overall metabolome of bc. although cancer metabolomics has evolved over time, it is still lagging behind in clinical diagnostics.19 the integration of multiple ‘omics’, including genomics, transcriptomics, proteomics and metabolomics will provide information regarding tumor progression, distant spread, and response to therapy. these experiments can yield high-accuracy and more robust data, exploring the complex heterogeneity of bc, highlighting the importance of an in-depth multi-level point of view in bc research. this will also ensure tailored healthcare involving disease prevention, diagnosis, and treatment in this soon-to-come era of personalized medicine r e f e r e n c e s 1. stingl j, caldas c. molecular heterogeneity of breast carcinomas and the cancer stem cell hypothesis. nat rev cancer. 2007; 7: 791–9. doi:10.1038/nrc2212. j islamabad med dental coll 2019 59 2. malhotra gk, zhao x, band h, band v. histological, molecular and functional subtypes of breast cancers. cancer biol ther. 2010; 10: 955-60. doi:10.4161/cbt.10.10.13879 3. sorlie t, perou cm, tibshirani r, aas t, geisler s, johnsen h, et al. gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. proc natl acad sci usa. 2001; 98: 10869-74. 4. sorlie t, tibshirani r, parker j, hastie t, marron js, nobel a, et al. repeated observation of breast tumor subtypes in independent gene expression data sets. proc natl acad sci usa. 2003; 100: 8418-23. 5. prat a, parker js, karginova o, fan c, livasy c, herschkowitz ji, et al. phenotypic and molecular characterization of the claudin-low intrinsic subtype of breast cancer. breast cancer res. 2010; 12: 68. 6. yanovich g, agmo h, harel m, sonnenblick a, peretz t, geiger t. clinical proteomics of breast cancer reveals a novel layer of breast cancer classification. cancer res. 2018; 78(20): 6001–10. doi: 10.1158/0008-5472.can-18-1079. 7. parker js, mullins m, cheang mc, leung s, voduc d, vickery t, et al. supervised risk predictor of breast cancer based on intrinsic subtypes. j clin oncol. 2009; 27: 1160-7. 8. ross js, hatzis c, symmans wf, pusztai l, hortobagyi gn. commercialized multigene predictors of clinical outcome for breast cancer. oncologist. 2008; 13: 477-93. 9. visvader je. keeping abreast of the mammary epithelial hierarchy and breast tumorigenesis. genes dev. 2009; 3: 2563-77. 10. tyanova s, albrechtsen r, kronqvist p, cox j, mann m, geiger t. proteomic maps of breast cancer subtypes. nat commun. 2016; 7 10259. 11. mertins p, mani dr, ruggles kv, gillette ma, clauser kr, wang p, et al. proteogenomics connects somatic mutations to signalling in breast cancer. nature. 2016; 534(7605): 55–62. [pubmed: 27251275] 12. tyanova s, temu t, cox j. the maxquant computational platform for mass spectrometry-based shotgun proteomics. nat protoc. 2016; 11(12): 2301– 19. [pubmed: 27809316] 13. cox j, neuhauser n, michalski a, scheltema ra, olsen jv, mann m. andromeda: a peptide search engine integrated into the maxquant environment. j proteome res. 2011; 10(4): 1794–805. [pubmed: 21254760] 14. wilkerson md, hayes dn. consensusclusterplus: a class discovery tool with confidence assessments and item tracking. bioinformatics. 2010; 26(12): 1572–3. [pubmed: 20427518] 15. tang y, li m, wang j, pan y, wu fx. cytonca: a cytoscape plugin for centrality analysis and evaluation of protein interaction networks. biosystems. 2015; 127: 67–72. [pubmed: 25451770] 16. asiago vm, alvarado lz, shanaiah n, gowda ga, owusu-sarfo k, ballas ra et al. early detection of breast cancer using metabolite profiling. cancer res. 2010; 70 (21): 8309-18. doi: 10.1158/00085472.can-10-1319. 17. kanaan ym, sampey bp, beyene d, esnakula ak, naab tj, ricks-santi lj, et al. metabolic profile of triple-negative breast cancer in african american women reveals potential biomarkers of aggressive disease. cancer genomics and proteomics. 2014; 11(6): 279-94. 18. armitage eg, southam ad. monitoring cancer prognosis, diagnosis and treatment efficacy using metabolomics and lipidomics. metabolomics. 2016; 12: 146. 19. gunther ul. metabolomic biomarkers for breast cancer. pthobiology. 2015; 82: 153-65. doi: 10.1159/000430844. journal of islamabad medical & dental college (jimdc); 1211(1):10-13 10 original article correlation between salivary glucose level and gingivitis in patients with diabetes sadia iqbal*, saad asad**, farhat kazmi***, fareeha bokhari**** * assistant professor, department of oral pathology, lahore medical & dental college, lahore. **correspondence: assistant prof department of orthodontics, head of oral biology & tooth morphology, the university college of dentistry, the university of lahore. *** assistant professor & head of oral pathology, university college of dentistry, the university of lahore. ****assistant professor, department of orthodontics, the university college of dentistry, the university of lahore. abstract: introduction: type 1 diabetes has been linked with an increased risk of gingivitis and periodontal disease. patients with periodontal disease and/or diabetes show differences in the profile of constituents in whole saliva. this profile reflects the nature and amplitude of the host response to a periodontal microbial challenge and /or response to diabetes mellitus. objectives: tto compare gingival health between control group and patients with type i diabetes and to assess whether there is any association between gingivitis/periodontitis and salivary glucose level. patients & methods: study was conducted on 90 subjects; 30 control and 60 diabetics. gingival and periodontal status was assessed for both the groups clinically. then un-stimulated whole saliva samples from diabetics and control group were collected stored and frozen at -200 c. saliva samples were then thawed, centrifuged and its supernatant portion was analyzed by dimension clinical chemistry system for salivary glucose levels. spss 17.0 was used for statistical analysis. results: results showed that gingivitis was statistically significantly higher among the type i diabetic patients when compared with the control group p < 0.05. conclusion: it was concluded that gingival health was compromised in diabetic children. it was also concluded that salivary glucose levels were higher in the patients with type i as compared to control group key words: salivary glucose level, type i diabetes, gingivitis, periodontitis introduction diabetes mellitus (dm) is a common disease and has been linked with an increased risk of oral diseases.1 changed oral environment in diabetes causes increase in colonization of pathogenic bacteria which leads to destruction of hard and soft tissues of mouth. oral lesions associated to diabetes thus include gingivitis and periodontal disease, xerostomia and salivary gland dysfunction, increased susceptibility to bacterial, viral and fungal infections, dental caries, and periapical abscesses, loss of teeth, taste impairment, lichen planus and burning mouth syndrome.2 these findings are associated with excessive loss of fluids due to polyuria, altered response to infection, altered connective tissue metabolism, micro vascular changes and impaired saliva.3 gingivitis has been rated as sixth most common complication of diabetes mellitus. it is the most common oral complication associated with diabetes. firatli et al found that clinical attachment loss is more common in diabetic children and adolescents than in controls.4 bridges rb et al in their study concluded that diabetic men have poorer periodontal status than non-diabetic men 5. young diabetic patients have been reported to have significantly higher gingival inflammation scores than controls 6-8. diabetic patients aged 40-49 have more periodontal pockets ≥6 mm and more extensive alveolar bone loss than nondiabetic patients in the same age-group 9. there is more attachment loss among subjects with type i diabetes with poor metabolic balance and/or multiple complications, and probed pocket depth ≥4 mm often re-occurs faster after periodontal therapy.10 few studies however, have reported gingival inflammation & periodontal destruction to be equal in diabetic patients and controls. 11 the inconsistency in the results of these studies may be due to the differences in metabolic control, duration of diabetes and age of subjects between different study populations.12 there are several possible mechanisms involved in diabetes that mediate the increased risk for periodontal diseases. a prolonged hyperglycemic condition leads to no enzymatic formation of advanced glycation end products (ages), which affects the structure of many cells and tissue proteins, including collagen, predisposing the person to macroand micro vascular complications. there are reports of decreased collagen synthesis and increased collagen degradation, i.e. increased collagenase activity 13. the host response to local infection is inefficient in diabetic patients. disorders in neutrophil function together with age-related activation of inflammatory cells change the profile of cytokines and tissue growth factors. consequently, the inflammation response and tissue homeostasis are altered.14-16 two-way relationship between periodontal disease and diabetes journal of islamabad medical & dental college (jimdc); 1211(1):10-13 11 mellitus has been postulated by davies et al. 17 thus, periodontitis, as a chronic infection, may impair metabolic control and increase the need for insulin and hence have an influence on the systemic level. on the whole, knowledge is currently insufficient regarding the ability of periodontal therapy to improve the metabolic control of diabetes.18 diagnosis and monitoring of dm is based on serum glucose concentration or glycosylated hemoglobin concentration however in the recent past because of chances of cross infection, assessment of other body fluids as diagnostic tool has also increased.19 saliva has gained importance as a diagnostic tool because it is readily available; collection requires non-invasive approach, no chances of cross infection and above all being the representative of various changes occurring in the body.20 if diabetic patients could be screened by saliva with same level of accuracy as is assessed with blood or urine then it would be advantageous for not only dental patients but also for all diabetic patients.21,22 moreover researchers have gained interest in establishing the relationship between gingival health and salivary sugar levels: whether with increase in salivary sugar level the gingival health deteriorates or not? present study has been aimed at comparing gingival health between control groups and type 1 diabetic patient and to assess whether there is any association between gingivitis / periodontitis and salivary glucose level in the subjects under study. patients & methods the study was conducted on 90 children (3-14 years), out of whom 60 were diabetics (fasting blood sugar level >120mg/dl) 23-25, who were registered in the endocrinology department of shaikh zayed medical complex, lahore and 30 were normal non-diabetics (fasting blood sugar level between 70-120mg/dl), who were under treatment in dental/orthodontic department of faculty of dentistry, the university of lahore. un-cooperative patients, patients with any active systemic disease and patients with missing teeth were excluded from the study. consent was taken from the patients/parents and also control group. un-stimulated whole saliva from diabetic and control group was collected in sterilized plastic jars through spitting method and stored in freezer at -200c and then brought to the laboratory in an ice chilled box. saliva samples were thawed, centrifuged and its supernatant portion was used for analysis which was carried out by using auto analyzer (dimension clinical chemistry system). the glucose method used on the dimension® clinical chemistry system is an in vitro diagnostic test. the glucose method is an adaptation of the hexokinase-glucose-6-phosphate dehydrogenase method. for cases and controls percentage of subjects with reference to their gingival status was computed based on full mouth examination. table 1: salivary glucose levels among study groups study groups salivary glucose level mean ± sd control (n=30) fasting blood sugar level between 70-120mg/dl 7.33 ± 1.36 patients (n=60) fasting blood sugar level >120mg/dl 15.26 ± 2.52 table 2: comparison of gingival status among study group oral hygiene status controls (n=30) n (%) cases (n=60) n (%) p value healthy 16 (53.3%) 13 (21.7%) p < 0.05 gingivitis with or without calculus 14 (46.7%) 47 (78.3%) p < 0.05 table 3: correlation of salivary glucose level with gingival status among study group gingivitis status good (healthy) gingivitis/calculus salivary glucose 14.02 + 1.73 (mg/dl) 17.6 + 1.23 (mg/dl) spss 17.0 was used for statistical evaluation. descriptive statistics were calculated for each variable for each subject. chi-square test was applied to show the association of diabetes with the oral hygiene condition and p value was calculated. p value of < 0.05 was taken as statistically significant. student’s t-test was applied to show the difference between salivary glucose level for normal & diabetics was assessed and co-relation with gingivitis incidence was established. results glucose concentration (mg/dl) in saliva in patients with diabetes mellitus was compared with healthy population. as shown in table 1 the mean salivary glucose level in diabetic cases was 15.26 ± 2.52 ranging from 10.5 to 20.0 mg/dl and that of control was 7.33 ± 1.36 ranging from 3.0 to 9.0 mg/dl. comparison of gingival status among study groups showed that glucose concentration in saliva of diabetic patients was significantly higher as compared to healthy population (t =16.11, p = 0.001 < 0.05). it was also observed that there was a significant difference between case and control subjects in regard to gingival status. (table 2) table 3 shows that mean salivary glucose level among cases having good oral hygienic condition (healthy) was 14.02 + 1.73, while mean salivary glucose level among cases having poor oral health (gingivitis/ calculus) was 17.6 + 1.23. it was also observed that salivary glucose was significantly journal of islamabad medical & dental college (jimdc); 1211(1):10-13 12 higher in cases having poor hygiene status than having good oral health (p = 0.021 <0.05). discussion present study revealed that glucose levels in the unstimulated whole saliva of type 1 diabetic group were higher than in healthy subjects. the mean salivary glucose level in diabetic patients was 15.26 ± 2.52 and that of control was 7.33 ± 1.36mg/dl., so glucose concentration in saliva of diabetic patients was significantly higher as compared to healthy population (p = 0.001 < 0.05). these results are in agreement with reports of other researchers who found the same increased correlated levels of glucose in the saliva.26 in one of the studies, mean and standard deviation of glucose level in diabetic children was found to be 2.05±1.63 where as in non-diabetic children was 1.03±1.03, indicating that salivary glucose level was higher in diabetics.5 kjellman et al and thorstensson et al 27,28 reported significantly higher values of glucose in whole saliva in diabetics than in healthy controls. in contrast, other studies of diabetics and healthy individuals indicate that no such relationship exists.29 dm and periodontitis are common multigenic and multifactorial chronic diseases. both of the morbidities negatively affect periodontal health and systemic health, thus affecting the quality of life. an abundance of recent evidence has consolidated a bidirectional correlation between diabetes and periodontitis. while diabetes is an independent risk factor for periodontitis, periodontitis as a chronic inflammation has a negative impact on the metabolic control of diabetes. in particular, periodontitis ranks sixth among all complications of diabetes. the present study shows that there was a significant difference between case and control subjects in regard to healthy gums, gingivitis and calculus. there is a significant level (p < 0.05) of marginal gingivitis observed amongst diabetic children (78.3%). however, the percentage of calculus in diabetic children is comparable to that of healthy children and is not of much significant difference (p > 0.5). these results were supported by a previous study in which gingival health (bleeding on probing) and oral hygiene (plaque percent) were assessed in 2 groups of children and adolescents with insulin-dependent diabetes mellitus.30 in another study, diabetic children with poor metabolic control showed a clear tendency towards higher gingival index scores than nondiabetics. 31 in present study calculus among normal control and that of diabetic show no association. this is in contrast to the study which indicates that children with type 1 dm are more prone to calculus accumulation which seemed to be a predisposing factor in development of gingivitis in these individuals. 32 thus an increase in gingivitis in association with hyperglycemia suggests that hyperglycemia-associated biological alterations, which lower host resistance towards plaque, have apparently taken place. 33-35 conclusion it was concluded that salivary glucose levels were higher in the patients with type i diabetes as compared to control group and gingival health is compromised in diabetic children. though not all cases of gingivitis proceed into a destructive periodontal disease, prevention of plaqueinduced gingival inflammation should be emphasized, particularly in children and adolescents with poorly controlled diabetes. references 1. ira b et al. the relationship between oral health and diabetes mellitus. jada 2008; 139 (5): 19s-24s 2. awuti g et al. epidemiological survey on the prevalence of periodontitis and diabetes mellitus in uyghur adults from rural hotan area in xinjiang. exp diabetes res. 2012; published online 2011. 3. iqbal s et al. dental caries & diabetes mellitus. pak oral & dent j. 2011; 31(1): 60 -63 4. firatli e. the relationship between clinical periodontal status and insulin-dependent diabetes mellitus, results after 5 years. j periodontal 1997; 68: 136–40. 5. bridges rb, anderson jw, saxe sr, gregory k , bridges sr. periodontal status of diabetic and non-diabetic men: effects of smoking, glycemic control, and socioeconomic factors. j periodontal 1996; 67: 1185– 92. 6. novaes jr ab, pereira ala, de moraes n , novaes ab. manifestations of insulin-dependent diabetes mellitus in the periodontium of young brazilian patients. j periodontol 1991; 62: 116–22. 7. sandholm l, swanljung o, rytömaa i, kaprio ea , mäenpää j. periodontal status of finnish adolescents with insulindependent diabetes mellitus. j clin periodontol 1989;16: 617–20. 8. faulconbridge ar, bradshaw wcl, jenkins pa, baum jd. the dental status of a group of diabetic children. br dent j.1981; 151: 253–5. 9. thorstensson h, hugoson a. periodontal disease experience in adult long-duration insulin-dependent diabetics. j clin. periodontal 1993; 20: 352– 8. 10. tervonen t, karjalainen k. periodontal disease related to diabetic status. a pilot study of the response to periodontal therapy in type 1 diabetes. j clin periodontol 1997;24: 505–10 11. goteiner d, vogel r, deasy m, goteiner c periodontal and caries experience in children with insulin-dependent diabetes mellitus. j am dent assoc 1986; 113: 277–9. 12. bacic m, plancak d , granic m. cpitn assessment of periodontal disease in diabetic patients. j periodontol 1988; 59: 816–22. 13. reiser kmn. on enzymatic glycation of collagen in aging and diabetes. proc soc exp biolmed 1991; 196: 17–29. 14. vlassara h. recent progress in advanced glycation end products and diabetic complications. diabetes 1997; 46: 19–25. 15. sánchez ga, miozza v, delgado a, busch l. determination of salivary levels of mucin and amylase in chronic journal of islamabad medical & dental college (jimdc); 1211(1):10-13 13 periodontitis patients j periodontal res. 2011 apr;46(2):221-7. 16. koss ma, castro ce, salúm km, lópez me. changes in saliva protein composition in patients with periodontal disease. acta odontol latinoam. 2009; 22(2):105-12. 17. davies rc, jaedicke km, barksby he, jitprasertwong p, alshahwani rm, taylor jj, preshaw pm. do patients with aggressive periodontitis have evidence of diabetes? a pilot study. j periodontal res. 2011; 17 18. taylor gw. periodontal treatment and its effects on glycemic control. oral surg oral med oral pathos oral radiol endod 1999; 87: 311–6. 19. herenia p lawrence. salivary markers of systemic disease: non invasive diagnosis and monitoring of general health. j can dent assoc 2002; 68:170-74. 20. ahmadi motamayel, f. davoodi, p. dalband, m. hendi, s.s. saliva as a mirror of the body health .djh 2010; 1(2): 115 21. dale ag. salivary glands. in: ten cate a.r, editor. oral histology, development, structure and function. 7th ed. mosby; 2010.p. 315-316 22. lopez m e et al. a. salivary characteristics of diabetic children: brazilian dental journal. june 2003:14:1. 23. jawad m, shahid sm, qader sa, azhar a. dental caries in diabetes mellitus.vernillo a t. dental consideration for the treatment of patients with diabetes mellitus: role of salivary flow rate & minerals. j diabetes complications 2010;25(3):183 86. 24. vasconcelos ac et al. comparative study of the concentration of salivary and blood glucose in type 2 diabetic patients. j oral sci. 2010;52(2):293 8 25. jurysta c, et al. salivary glucose concentration and excretion in normal and diabetic subjects. j biomed biotechnol. 2009;:430426. 26. rodbard d. clinical interpretation of indices of quality of glycemic control and glycemic variability. postgrad med. 2011 jul;123(4):107-18 27. darwazeh amg et al. mixed salivary glucose levels and candidal carriage in patients with diabetes mellitus. j oral pathol med 1991; 20: 280– 83. 28. camp bell mja. glucose in the saliva of the non diabetic and the diabetic patient .archive of oral biology 1965; 10:197-205. 29. kjellman o. the presence of glucose in gingival exudates and resting saliva of subjects with insulin-treated diabetes mellitus. swede dent j 1970; 63: 11–19. 30. horstensson h et al. some salivary factors in insulindependent diabetics. acta odontol scand 1989; 47: 175– 83. 31. karjalainen km, knuuttila ml, kaar ml. salivary factors in children and adolescents with insulin dependent diabetes mellitus. pied .dent 1996; 18:306-11. 32. gislen g, nilsson ko, matsson l .gingival inflammation in diabetic children related to degree of metabolic control. acta odontol scand.1980; 38(4):241-6. 33. siudikienej, maciulskiene v, dobrovolskiene r, nedzeiskiene i .oral hygiene in children with type 1 dm. stomatologia 2005; 7(1); 24-7. 34. patino mn, loyola rjp, et al. effect of metabolic control in type diabetes patients and its association with periodontal disease .rev invest clin.2002 may-jun; 54(3):218-25. 35. marchisio o, esposito mr, genovesi a. salivary ph level and bacterial plaque evaluation in orthodontic patients treated with recaldent products. int j dent hyg. 2010 aug;8(3):232-36. j islamabad med dental coll 2019-student corner 159 op e n ac c e s s an unusual case of gallbladder carcinoma with pseudopancreatic cyst nahin akhtar1, huma mushtaq2, ahmad raza3 1 fourth year mbbs student, islamabad medical and dental college 2 associate professor, department of pathology, islamabad medical and dental college 3 associate professor, department of surgery, akbar niazi teaching hospital, islamabad a b s t r a c t generally, carcinoma of the gallbladder is an extremely unusual neoplasm, however, high incidence rates have been reported in certain parts of the world. the role of certain factors such as genetic susceptibility, lifestyle and infections of gallbladder in causing carcinogenesis is still not clearly understood. due to its early vague symptoms and lack of serosa in the gallbladder to slow its spread, gallbladder carcinoma typically presents at an advanced stage with a five-year survival rate of less than 5%. pseudopancreatic cyst is an uncommon but not a rare complication of acute pancreatitis and injury to the pancreas. however, it rarely presents with carcinoma of gallbladder. we present here an unusual case of gallbladder carcinoma with pseudopancreatic cyst in a 58-year old male. key words: gallbladder cancer, gallstones, pancreatitis, pseudo-pancreatic cyst correspondence: nahin akhtar email: nahinakhtar007@gmail.com article info: received: may 15, 2019 accepted: august 19, 2019 cite this case report: akhtar n, mushtaq h, raza a. an unusual case of gallbladder carcinoma with pseudopancreatic cyst. j islamabad med dental coll-student corner. 2019; 8(3):159-162. doi: 10.35787/jimdc.v8i3.401 funding source: nil conflict of interest: nil i n t r o d u c t i o n gallbladder cancer is an extremely rare neoplasm but shows a high incidence rate in certain parts of the world.1 role of infections, lifestyle, genetic susceptibility and other factors in the gallbladder carcinogenesis is still not clearly understood. the incidence rate of gallbladder cancer was 1 to 2.5 per 100,000 in united states.2 the incidence rate of gallbladder cancer among females was found to be 13.8/100,000 in karachi (pakistan), 21.5/100,000 in delhi (india) and 12.9/100,000 in quito (ecuador).3 the incidence ratio of female to male was generally found to be 3:1.3 gallbladder cancer typically presents at an advanced stage and carries a five-year survival rate of less than 5%. this is due to lack of serosa and early ambiguous symptoms of gall bladder cancer.4 the pathogenesis of this cancer follows the progression from metaplasia to dysplasia to carcinoma.5 important risk factor for gallbladder carcinoma is presence of gallstones and it is found in most (∼85%) of the patients that present with gallbladder carcinoma.6 chronic inflammations is also considered as a major factor for carcinogenesis and malignant transformation. the recurrence of chronic inflammation causes deoxyribonucleic acid (dna) damage and further provokes restoration of tissue proliferation. this also causes release of growth factors and cytokines, further predisposing the cells to oncogenic transformation.7 according to a new research, diabetes mellitus has also been considered as a risk factor of gall stone formation and this is also associated with the pathogenesis of gallbladder carcinoma.8 previous research has also shown that there is an important role of interaction between exposure to environmental risk factors and innate genetic predisposition in causing carcinoma of gallbladder. there is also an association with family history of gallbladder carcinoma, as the risk of carcinoma gallbladder increases in such cases.9 c a s e r e p o r t j islamabad med dental coll 2019-student corner 160 pseudo pancreatic cyst is a rare condition but it can present as a complication of acute pancreatitis and injury to the pancreas10 the cyst commonly arises after an episode of acute or chronic pancreatitis. according to literature, it is reported that the prevalence of pancreatic pseudocyst in cases of acute pancreatitis ranges from 6% to 18.5%11 and in chronic pancreatitis it ranges from 20% to 40%.12 it also arises in patients with alcoholic chronic pancreatitis (70% to78%). other causes include idiopathic chronic pancreatitis and biliary pancreatitis.13 it is very rare to find pseudo pancreatic cyst as a complication of gallbladder cancer with gallstones. we here present an unusual case of carcinoma of gallbladder with pseudopancreatic cyst. c a s e r e p o r t a 58 year old male, presented in the out patient department of surgery, akbar niazi teaching hospital (anth) with complaints of pain epigastrium and right hypochondrium for the last one month, associated with nausea and vomiting. there was no history of fever, jaundice, melena or clay coloured stools. ultrasound was advised and he was diagnosed with symptomatic gallstone disease. further workup was advised for gallstones but patient compliance was not good. about 6 weeks later, he presented with severe pain epigastrium, radiating towards the back. abdominal examination revealed a firm mass in the epigastrium, measuring 10x10 cm in diameter. ctscan revealed pancreatitis with pseudopancreatic cyst and gallstones in the gall bladder with thick irregular, enhancing walls in the fundus of gallbladder, abutting adjacent part of the liver (figure 1) two hypodense lesions in segment iv b of the liver with suspicion of malignancy were noted. pseudocyst was seen in the region of tail and adjacent part of body of pancreas. an open extended cholecystectomy was performed and specimen was sent for histopathological evaluation. gross examination revealed a mass lesion which comprised of two fragments of gallbladder. the larger fragment with tumor measured 5x4x2 cm in size. outer surface of gallbladder was ruptured. on cutting open, the larger fragment showed a fungating tumor diffusely involving the lumen and wall of the gallbladder (figure 2). tumor measured 4x4 cm in diameter. few calculi were also seen in the lumen. a portion of liver, measuring 2.6x2.3 cm in size, was seen attached with serosa. microscopic examination revealed a grade 3 poorly differentiated adenocarcinoma, extending beyond the serosa (figure 3). cystic duct margin was uninvolved. additional findings included cholelithiasis and extensive necrosis of gallbladder wall. figure-1(a, b): ct-scan showing pancreatitis with pseudopancreatic cyst and gallstones in gall bladder with thick irregular, enhancing walls in fundus of gallbladder, abutting adjacent part of liver. two hypodense lesions in segment iv b of liver with suspicion of malignancy are seen. pseudocyst is also seen in region of tail and adjacent part of body of pancreas. figure-2: showing gross specimen of gall bladder with a fungating tumor diffusely involving the lumen and wall of gallbladder. figure-3: showing infiltration by adenocarcinoma with cells having marked pleomorphism and vesicular nuclei (h&e x 400). j islamabad med dental coll 2019-student corner 161 d i s c u s s i o n a gallbladder cancer is an extremely rare malignancy with a high mortality rate.3 chronic inflammation of the gallbladder wall with subsequent cellular proliferation and large gallstones or chronic salmonella typhi infection are the common risk factors for gallbladder cancer. the high rates of local recurrence and micro-metastases even for those considered surgically curable malignant tumors, renders clinical management challenging. about 80%– 90% of malignancies are associated with cholelithiasis as a risk factor.14 pure cholesterol stones greater than 1.5 cm are associated with adenosquamous and squamous cell carcinomas while increased size of the calculi may increase the risk of malignant transformation.14 among the aggressive biliary tract malignancies, carcinoma of gallbladder is most common with the shortest median survival time mainly due to the lack of screening efforts.15 pancreatic duct disruptions due to trauma or pancreatitis followed by release of pancreatic secretions seems to play an important role in the formation of pseudopancreatic cyst.16 this cyst is mostly associated with acute pancreatitis. in the paediatric population, an association of this cyst was found with trauma, viral illness, biliary tract disease, states of intracranial hypertension and also with steroids. trauma is the most common cause of pancreatic pseudocysts in children.17 acute pancreatitis leads to necrosis of peri-pancreatic tissue or parenchyma which can cause liquefaction and subsequent organization resulting in pseudocysts.18 chronic pancreatitis leads to an acute exacerbation of pancreatitis or progressive ductal obstruction which can also lead to pseudocyst formation.18 there is no specific treatment for most of the pancreatic pseudocysts because it resolves spontaneously. however, drainage may be required when symptoms due to compression of adjacent organs appear or when complications like rupture, infection or bleeding arise.19 gallbladder carcinoma is associated with many diseases but association of pseudopancreatic cyst with gallbladder carcinoma and gallstones has never been investigated. c o n c l u s i o n carcinoma of gallbladder with pseudo-pancreatic cyst is an unusual presentation. the possibility of both pathologies in the same case is considered to be a rare and novel occurrence. r e f e r e n c e s 1. lazcano‐ponce ec, miquel jf, muñoz n, herrero r, ferrecio c, wistuba ii et al. epidemiology and molecular pathology of gallbladder cancer. ca: a cancer journal for clinicians. 2001; 51(6): 349-64. doi: 10.3322/canjclin.51.6.349 2. shaffer ea. gallbladder cancer: the basics. gastroenterol hepatol (ny). 2008; 4(10): 737-41. pmid: 21960896 3. randi g, franceschi s, la vecchia c. gallbladder cancer worldwide: geographical distribution and risk factors. ijc. 2006; 118(7): 1591-602. doi: 10.1002/ijc.21683 4. duffy a, capanu m, abou‐alfa gk, huitzil d, jarnagin w, fong y et al. gallbladder cancer (gbc): 10‐year experience at memorial sloan‐kettering cancer centre (mskcc). j. surg. oncol. 2008; 98(7): 485-9. doi: 10.14740/wjon951w 5. lewis jt, talwalkar ja, rosen cb, smyrk tc, abraham sc. prevalence and risk factors for gallbladder neoplasia in patients with primary sclerosing cholangitis: evidence for a metaplasiadysplasia-carcinoma sequence. am j surg pathol. 2007; 31(6): 907-13. doi: 10.1097/01.pas.0000213435.99492.8a 6. zatonski wa, przewozniak k, lowenfels ab, boyle p, maisonneuve p, bueno de mesquita hb et al. epidemiologic aspects of gallbladder cancer: a casecontrol study of the search program of the jnci. 1997; 89(15): 1132-8. doi: 10.1093/jnci/89.15.1132 7. rashid a, ueki t, gao yt, houlihan ps, wallace c, wang bs et al. k-ras mutation, p53 overexpression, and microsatellite instability in biliary tract cancers: a population-based study in china. clin cancer res. 2002; 8(10):3156-63. pmid: 12374683 8. lai hc, chang sn, lin cc, chen cc, chou jw, peng cy, et al. does diabetes mellitus with or without gallstones increase the risk of gallbladder cancer? results from a population-based cohort study. j gastroenterol. 2013;48(7):856–865. doi: 10.1007/s00535-012-0683-z j islamabad med dental coll 2019-student corner 162 9. dutta u, nagi b, garg pk, sinha sk, singh k, tandon rk. patients with gallstones develop gallbladder cancer at an earlier age. eur j cancer prev. 2005; 14(4): 381-5. pmid: 16030429 10. bahari hm, abdullah i. endoscopic transgastric drainage of pseudopancreatic cyst. med j malaysia. 1982;37(4):316-7. pmid: 7167081 11. imrie cw, buist lj, shearer mg: importance of cause in the outcome of pancreatic pseudocysts. am j surg 1988; 156: 159–62. doi: 10.1016/s00029610(88)80055-2 12. barthet m, bugallo m, moreira ls, bastid c, sastre b, sahel j: man-agement of cysts and pseudocysts complicating chronic pancreatitis. a retrospective study of 143 patients. gastroenterol clin biol.1993; 17: 270–6. pmid: 8339886 13. ammann rw, akovbiantz a, largiader f, schueler g: course and outcome of chronic pancreatitis. longitudinal study of a mixed medical surgical series of 245 patients. gastroenterol. 1984; 86:820–8. pmid: 6706066 14. hundal r., shaffer e.a. gallbladder cancer: epidemiology and outcome. clin. epidemiol. 2014; 6(5 pt 1): 99–109. doi: 10.2147/clep.s37357 15. zhu ax, hong ts, hezel af, kooby da. current management of gallbladder carcinoma. oncologist. 2010; 15(2): 168–181. doi:10.1634/theoncologist.2009-0302 16. habashi s, draganov pv. pancreatic pseudocyst. wjg. 2009; 15(1): 38. doi: 10.3748/wjg.15.38 17. tomar s, bakhshi s, kabra sk, arya ls. pancreatic pseudocyst complicating treatment of acute lymphoblastic leukemia. indian pediatric. 2003; 40(7): 670. doi: 10.1007/s13193-013-0250-y 18. udeshika wa, herath hm, dassanayake su, pahalagamage sp, kulatunga a. a case report of giant pancreatic pseudocyst following acute pancreatitis: experience with endoscopic internal drainage. bmc research notes. 2018; 11(1): 262. doi: 10.1186/s13104-018-3375-9 19. devangan m, sonkar sk, sharma s. a rare case of pancreatic pseudocyst involving liver and spleen. int j med sci res pract. 2015; 2:150-2. j islamabad med dental coll 2020 201 open access an experience of surgical management of peripheral vascular injuries at pakistan institute of medical sciences, islamabad muneeb ullah1, seemab niaz2, aabid ali3, arsalan4 1 senior registrar, maroof international hospital islamabad , pakistan 2 medical officer, ali medical hospital islamabad, pakistan 3 medical officer, polyclinic hospital islamabad, pakistan 4 medical officer, district headquarter hospital, miranshah north waziristan , pakistan a b s t r a c t background: peripheral vascular trauma is fairly common and its repercussions demand urgent management and multidisciplinary approach. we hereby evaluate d the presentation, management and outcomes of peripheral vascular injuries presenting in a tertiary care hospital in islamabad, pakistan . material and methods: this was a prospective clinical study conducted in the department of general surgery, pakistan institute of medical sciences (pims) hospital, islamabad pakistan from january 2016 to june 2018. a total of 60 patients with peripheral vascular extremity trauma were included in the study. initial assessment and resuscitation was done and patients with vascular injury were directly shifted to operating room for primary vascular repair (if defect size < 2 cm) or vein graft (great saphenous). fractures and nerve injuries were also treated. fasciotomies were performed where indicated. post-operative monitoring of limb was done for palpable pulses, temperature and color changes. collected data included age, gender, duration of injury, nature of injury, operative findings, other associated injuries, type of definitive repair, involvement of artery, complication s including amputations, infections, re -exploration, ligation or death. statistical package for social sciences (spss) version 23 was used to analyze data . results: out of total 60 patients, 53 (88.3%) were males and 7 (11.7%) were females , with a mean age of 27.8±14.1 years. most of the patients presented after 6 hours of trauma (n=36; 60%). blunt trauma accounted for 37 (61.7%) while penetrating trauma was seen in 23 (38.3%) patients. per operatively, 33 (55%) patients had intimal injury, 7 (11.7%) had partial tear and 20 (33.3%) had complete transection of artery. primary repair was performed in 9 (15%) patients and reverse vein graft in 51 (85%) patients. most commonly injured arteries were femoral (n=21; 35%), brachial (n=18; 30%) and popliteal (n=12; 20%) arteries, respectively. amputations were significantly related to presentation of patients later than 6 hours (p=0.035). conclusions: patients who present with vascular trauma need an early diagnosis, referral and timely management in order to save both limb and life of patients with special concern for good quality of life and cost-effective management . key words: blunt trauma, penetrating trauma, peripheral vascular injury, vascular trauma authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4data analysis; manuscript editing. correspondence: muneeb ullah email: muneebullah@gmail.com article info: received: september 22, 2019 accepted: september 23, 2020 cite this article. ullah m, niaz s, ali a, arsalan. an experience of surgical management of peripheral vascular injuries at pakistan institute of medical sciences, islamabad. j islamabad med dental coll. 2020; 9(3): 201-206. doi: 10.35787/jimdc.v9i3.411 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 202 i n t r o d u c t i o n overall, vascular trauma constitutes 3% of all traumatic injuries while in urban trauma centers, peripheral vascular injuries account for approximately 5% of all the major traumas. 1,2 the surgical management of extremity vascular injuries has evolved over time. in the civilian population, blunt trauma in road side accidents is more prevalent when compared with penetrating trauma, which is mostly related to warfare injuries.3 however, recently, due to an increase in urban violence, the patterns of vascular injuries are changing.4,5 major blunt trauma is associated with the transmission of force to the lower extremity that can lead to vascular, nerve, soft tissue and bone injury. neurovascular examination including ankle– brachial index should be assessed before and after reduction of fractures. major orthopedic injuries secondary to blunt trauma are associated with traction-type injuries, avulsions, or transections of the popliteal artery from the adjacent bone fragments.4,6 unfortunately, traumatic extremity vascular injury associated with concomitant fractures and major soft tissue loss results in a relatively high morbidity in terms of prolonged hospital stays and high amputation rates. 4,7,8 popliteal artery injuries are potentially devastating injuries with a relatively high morbidity, but are uncommon, accounting for 0.2% of all traumas.1 injury to the popliteal artery can occur in the form of transection, occlusion, intimal injury, pseudoaneurysm, or fistula formation.9,10 initial evaluation requires a thorough vascular and neuromuscular assessment.10 early recognition of lower limb vascular injuries can improve overall patient outcomes. immediate engagement of the trauma team is essential for early resuscitation and prevention of existing exsanguination. hard signs of vascular injury, including hemorrhage, expanding hematomas, pulsatile bleeding, presence of bruits or thrills, absent pulses and signs of distal ischemia require immediate surgical intervention.1,4,11 diagnostic procedures are frequently unnecessary and lead to delay in definitive care although information may be obtained through doppler, duplex ultrasound, or angiography as necessary. evidence of cyanosis, neurological deficit, and temperature change are reliable findings predictive of vascular compromise.1,11 to date, there are no well-defined guidelines for the management of extremity vascular trauma and optimum strategies are variable depending upon the local setup and expertise available.5 despite major efforts in establishing protocols and guidelines in the management of vascular trauma, optimal strategies of traumatic peripheral arterial injuries are still under investigation.12 an organized approach is of paramount importance in the expedited delivery of care by the trauma team leader, the nursing staff and subspecialties, such as interventional radiology, orthopedics, anesthesiology, emergency department personnel, and vascular surgeons.13 a stepwise multidisciplinary approach to manage traumatic injuries is associated with improved morbidity and decreased in-hospital mortality.14-16 this study was conducted to evaluate the presentations, management and outcomes of peripheral vascular injuries presenting in a tertiary care center of a developing country. m a t e r i a l a n d m e t h o d s this was a prospective clinical study, conducted in the department of general surgery, pims hospital, islamabad pakistan over a period of two and a half years i.e. from january 2016 to june 2018. a total of 60 patients were included in the study. all patients with vascular extremity trauma presenting in the emergency were included in the study. initial assessment and resuscitation were done by casualty medical officer followed by referral to the general j islamabad med dental coll 2020 203 surgical team. in cases presenting with fractures and dislocations, orthopedic department was involved. in patients less than 12 years of age, pediatric surgical team was contacted. patients having established gangrene, crush injuries with unsalvageable limb, extensive trauma leading to auto amputation, those who had amputations performed in periphery as lifesaving treatment or those presenting with severe visceral or brain injury were excluded from the study. ethical approval was taken from the pakistan institute of medical sciences (ref no: f51/2018 pg/gs). after initial resuscitation, patients with hard signs of vascular injury were directly shifted to operating room while those with soft signs were investigated further using one or more of the following: color doppler scan, x-rays for associated bone injuries and computerized tomographic angiograms. definitive vascular repair, either primary for defect size less than 2cm or vein graft (great saphenous) was used to restore circulation to the affected limb. after repair, flow was confirmed by using hand held doppler. associated fractures were reduced and immobilized with external fixator by the orthopedics team before definitive vascular repair. a nerve injury, if found, was either repaired after vascular injury or two ends were brought together and a marker was applied. fasciotomies were performed in all patients presenting more than 6 hours after injury or where clinically indicated. postoperatively patient was started on heparin infusion six hours after surgery if there were no contraindications and patient’s limb was monitored for palpable pulses, temperature and color changes. amputation was decided when there were no signs of perfusion and gangrene developed and patient became septic. relevant data was collected using a proforma which included age, gender, duration of injury, nature of injury, operative findings, other associated injuries, type of definitive repair, involvement of artery and postoperative complications. these postoperative complications/outcomes included amputations, wound/graft infections, re-explorations, ligation or death. statistical package for social sciences (spss) version 23 was used to analyze data. r e s u l t s total 60 patients were included in the study, with 53 (88.3%) males and 7 (11.7%) females and a mean age of 27.8 ± 14.1 years. table i shows the characteristics of patients presenting with vascular trauma. only 24 (40%) patients presented within 6 hours of trauma and 36 (60%) presented after 6 hours. of the latter, 23 (38.3%) patients presented between 6 to 12 hours of trauma and 13 (21.7%) patients presented after 12 hours of trauma. table ii shows the details of operative findings of the patients. intimal injury was the commonest type of arterial injury (n=33; 55%). primary repair was done in 9 (15%) patients and reverse vein graft was done in 51 (85%) patients. most commonly injured arteries were femoral (n=21; 35%) and brachial arteries (n=18; 30%). fasciotomy was performed in 51 (85%) patients. table iii shows the postoperative outcomes of patients who underwent vascular repair. postoperative wound infection occurred more commonly in patients presenting after 6 hours than table i: presenting characteristics of patients with vascular trauma characteristics results age in years mean + sd 27.8±14.1 range 5 to 72 gender n (%) male 53 (88.3) female 7 (11.7) duration of injury n (%) less than six hours 24 (40) more than six hours 36 (60) type of injury n (%) blunt injury 37 (61.7) penetrating injury 23 (38.3) j islamabad med dental coll 2020 204 those presenting within 6 hours (p=0.056). amputation was required post operatively in 6 (10%) patients and all of them presented after 6 hours (p=0.035). re-exploration was done with re anastomosis and ligation only in cases presenting after 6 hours. death occurred in 2 (3.3%) of the patients. none of the other factors like graft infection, graft thrombosis, hemorrhage and death were significantly related with time of presentation (p>0.05). d i s c u s s i o n a high index of suspicion should be kept for peripheral vascular injuries in patients with blunt and penetrating limb trauma. patient with hard signs of vascular injury should be immediately explored to prevent morbidity and mortality. in our study there was a male predominance (88.3%) which is also reported in other studies.17-19 mean age in our study was 27.8 ± 14.1 years which is comparable to another study (28.6 ± 14.5 years) conducted in level1 trauma centers in pakistan. this is probably because in our society males suffer more road traffic accidents as mostly automobiles are driven by them. penetrating vascular trauma patients are mainly involved in violence associated with poverty and lack of knowledge. blunt trauma is mostly associated with road traffic accidents and domestic assault cases. blunt trauma was present in 61.7% of the cases while 38.3% cases had penetrating trauma. similar incidence was reported in another study (65.4% blunt trauma and 34.6% penetrating trauma).17 the time of presentation since injury varied from less than 6 hours to more than 24 hours. this variation is probably because some patients are brought directly to the hospital, while others are brought from remote areas, referred from other setups for specialized care with missed injuries associated with blunt trauma. majority of the vascular injuries can be easily diagnosed clinically and presence of hard signs of vascular injury should be addressed with immediate exploration. 16 patients with soft signs of vascular injury can be evaluated using doppler and computerized tomography before intervention if or as required. arterial intimal injury was present in 55% of the cases followed by complete transection (33.3%) and partial tears (11.7%). intimal injury was usually associated with blunt trauma while tear and complete transection was associated with penetrating injury. primary repair was done in 15% patients which was also reported in another study, while reverse vein graft was done in a higher percentage of our patients table ii: operative findings of patients with vascular trauma operative findings frequency n (%) type of arterial injury intimal injury 33 (55) partial tear 7 (11.7) complete transection 20 (33.3) type of repair primary repair 9 (15) venous graft repair 51 (85) artery involved femoral 21 (35) brachial 18 (30) popliteal 12 (20) radial 5 (8.3) ulnar 2 (3.3) axillary 2 (3.3) associated injuries to limbs venous injury 14 (23.3) nerve injury 2 (3.3) fractures 35 (58.3) table iii: postoperative outcomes of vascular repair outcomes presentation < 6hrs (n=24) presentation > 6hrs (n=36) total (n=60) wound infection 2 (8.3) 8 (22.2) 10 (16.7) graft infection 1 (4.16) 4 (11.1) 5 (8.3) graft thrombosis 1 (4.16) 3 (8.3) 4 (6.67) hemorrhage 0 (0) 1 (2.7) 1 (1.67) reexploration 0 (0) 3 (8.3) 3 (5) amputation 0 (0) 6 (16.67) 6 (10) death 1 (4.16) 1 (2.7) 2 (3.3) j islamabad med dental coll 2020 205 (85% versus 60.5%).17 higher incidence of vein graft in our study is due to the fact that no prosthetic grafts were used at the time of repair as these grafts are associated with increased morbidity due to infection, graft thrombosis, long term patency and amputations. fasciotomy was done (in n=51; 85% patients) to prevent risk of compartment syndrome occurring after reperfusion injury. complications like postoperative wound infection, graft infection and rejection, re-explorations and amputations were all more common in patients presenting after six hours of injury. amputations were significantly associated with late presentations (p=0.035). two deaths occurred in our study, one in each group as patient went into multi organ failure due to sepsis. peripheral vascular trauma is a condition which if not properly addressed can lead to high morbidity and mortality. a multidisciplinary approach should be opted when dealing with polytrauma cases. training of surgeons working in remote areas regarding management of peripheral vascular traumas with a high index of suspicion must be initiated. r e c o m m e n d a t i o n s this study was conducted in a single tertiary care hospital of islamabad. a study with a larger sample size taking into account the management protocols of other tertiary care hospitals at national level is required to come up with uniform local guidelines for vascular injuries in our hospitals. there is a need to compare them with international guidelines to further improve patient outcomes in the local context. c o n c l u s i o n amputation rates in peripheral vascular injury increase significantly in patients presenting after six hours of injury. in a developing country with limited resources, an early diagnosis, referral and timely management of patient having a peripheral vascular trauma can save both limb and life of patient. a c k n o w l e d g m e n t the authors are thankful to prof dr. tanwir khaliq and dr. tariq abdullah for their valuable cooperation during the study. r e f e r e n c e s 1. sciarretta jd, perez-alonso aj, ebler dj, mazzini fn, petrone p, asensio-gonzalez ja. popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. eur j trauma emerg surg. 2012: 38(4): 373–391. doi: 10.1007/s00068-012-0217-7 2. feliciano dv, rasmussen te. evaluation and treatment of vascular injuries. in: browner bd, jupiter jb, kretteck c, eds. skeletal trauma. basic science, management and reconstruction. philadelphia: elsevier saunders, 2015: 423 -35. doi: 10.3400/avd. oa.18-00068 3. rozycki gs, tremblay ln, feliciano dv, mcclelland wb. blunt vascular trauma in the extremity: diagnosis, management, and outcome. j trauma. 2003; 55(5): 814-24. doi: 10.1097/01.ta.0000087807 .44105.ae 4. sciarretta jd, macedo fi, otero ca, figueroa jn, pizano lr, namias n, et al. management of traumati c popliteal vascular injuries in a level 1 trauma centre: a 6-year experience. int j surg. 2015; 18: 136 -141. doi: 10.1016/j.ijsu.2015.04.056 5. feliciano dv, moore ee, west ma, moore fa, davis jw, cocanour cs, et al. western trauma association critical decisions in trauma: evaluation and management of peripheral vascular injury, part ii. j trauma acute care surg. 2013:75(3):391 -397 doi: 10.1097/ta.0b013e3182994b48 6. trieman gs, yellin ae, weaver fa, s wang, n ghalambor, w barlow, et al. examination of the patient with knee dislocation. the case for selective arteriography. arch surg. 1992: 127(9): 1056 –1062. doi: 10.1001/archsurg.1992.01420090060009 7. hafez hm, woolgar j, robbs jv. lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. j vasc surg. 2001:33(6): 1212-19. doi: 10.1067/mva.2001.113982 8. kauvar ds, sarfati mr, kraiss lw. national trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. j vasc surg. 2011; 53(6): 1598-603. doi: 10.1016/j.jvs.2011.01. 056 j islamabad med dental coll 2020 206 9. abou-sayed h, berger dl. blunt lower -extremity trauma and popliteal artery injuries. arch surg. 2002; 137(5): 585–89. doi:10.1001/archsurg.137.5.585 10. teixeira pgr, dubose j. surgical management of vascular trauma. surg clin north am. 2017; 97(5): 1133-55. doi: 10.1016/j.suc.2017.05.001 11. feliciano dv. for the patient: evolution in the management of vascular trauma. j trauma acute care surg. 2017; 83(6): 1205 -12. doi: 10.1097/ta. 0000000000001689 12. fox n, rajani rr, bokhari f, chiu wc, kerwin a, seamon mj, et al. evaluation and management of penetrating lower extremity arterial trauma: an eastern association for the surgery of trauma practice management guideline. j trauma acute care surg. 2012; 73(5): s315-320. doi: 10.1097/ta.0b013 e31827018e4 13. d’amours sk, rstogi p, ball cg. utility of simultaneou s interventional radiology and operative surgery in a dedicated suite for seriously injured patients. curr opin crit care. 2013; 19(6): 587 -593. doi: 10.1097/mcc.0000000000000031 14. tubb cc, oh js, do nv, tai nr, meissel mp, place ml. trauma care at a multinational united kingdom-led role 3 combat hospital: resuscitation outcomes from a multidisciplinary approach. mil med. 2014; 179(11): 1258-62. doi: 10.7205/milmed-d-14-00042 15. bach ja, leskovan jj, scharschmidt t, boulger c, papadimos tj, russell set al. the right team at the right time: multidisciplinary approach to multi trauma patient with orthopedic injuries. opus 12 scientist. 2012; 6(1): 6-10. doi: 10.4103/ijciis. ijciis_5_17 16. georgiou a, lockey dj. the performance and assessment of hospital trauma teams. scan j trauma resusc emerg med. 2010: 18(1): 66. doi: 10.1186/ 1757-7241-18-66 17. usman r, jamil m, anwer mf. evaluation, surgical management and outcome of traumatic extremity , vascular injuries: a 5-year level-1 trauma centres experience. ann vasc dis. 2018: 11(3): 312 -17. doi: 10.3400/avd.oa.18-00068 18. khan ma, jamal s, khaliq t. a critical appraisal of management of extremity vascular trauma in civilian population: a pims experience. rawal med j. 2011: 36(3): 190-4. 19. nasim a, nisar m, bashir a. the outcome of surgery for vascular injuries in major limb trauma. j fati ma jinnah med univ. 2016; 10(4): 41 -48 microsoft word 12-metallo-_eta-lactamase detection comparative evaluation of double-disk synergy versus combined disk tests-converted 249 j i m d c 2 0 1 7 249 open access f u l l l e n g t h a r t i c l e naima mehdi 1, nadia aslam 2, muhammad saeed 3, abdul wadood khalid 4, saba riaz 5, mateen izhar 6 1 consultant pathologist, punjab institute of cardiology lahore pakistan 2 associate professor of pathology, rai medical college sargodha pakistan 3 medical lab technologist district head quarter hospital mandi bahauddin pakistan 4 senior consultant pathologist, punjab institute of cardiology lahore pakistan 5 assistant professor microbiology punjab university lahore pakistan 6 professor of pathology, sheikh zaid medical complex lahore pakistan a b s t r a c t author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3,4 data analysis, interpretation 5,6 manuscript writing, active participation in address of correspondence muhammad saeed email: mian.scientist@yahoo.com. article info. received: august 17, 2017 accepted: december 7, 2017 data collection cite this article. mehdi n, aslam n, saeed m, khalid a.w, riaz s, izhar m.metallo βeta lactamase detection comparative evaluation of double-disk synergy versus combined disk test . jimdc.2017;6(4): funding source: nil conflict of interest: nil despite of multiple solid steps taken to control drug resistance it is still emerging a dilemma of the civilized world. the emergence of drug resistance is credited to over and inappropriately use of antimicrobial drugs. i n t r o d u c t i o n objective: to establish (i) if carbapenemases are a major cause of carbapenem resistance in enterobacteriaceae and belong to metalloβ-lactamases (ii) which one is the best phenotypic method for the detection of metalloβ-lactamases. patients and methods: this cross-sectional study was conducted at pathology department, punjab institute of cardiology lahore. samples were randomly enrolled from daily lab work and analysed. during the period of september 2016 to january 2017, a total of 2970 clinical samples were enrolled and processed for bacterial culture. every isolate of enterobacteriaceae was processed for detection of carbapenem resistance and for the detection of carbapenemases producers by modified hodge test. metalloβ-lactamases detection (mbl) was done by three different phenotypic techniques, (i) combined disk technique (0.1 m edta), (ii) (0.5 m edta). (iii) double disk synergy technique (dsst). results: out of total n=2970 samples, 38.7% (n=1150) were culture positive of which 40.5% (n=550) were enterobacteriaceae. among these, 9.0 % (n=50) were carbapenem-resistant; 98% (49/50) were carbapenemase producers (modified hodge test -positive). according to (i) combined disk technique (0.1 m edta), 98% (48/49) were metalloβ-lactamases positive (ii) combined disk technique (0.5 m edta), 86% (42/49) were metalloβ-lactamases, 2% (1/49) were non-determinable (iii) double disk synergy technique (ddst) showed 100% (49/49) isolates were metalloβlactamases positive. chloramphenicol and tigecycline were found sensitive in 28% and 16% respectively; all other antimicrobials were highly resistant against carbapenem-resistant isolates. conclusion: carbapenemases are a major cause of carbapenem resistance in enterobacteriaceae. double-disk synergy technique is good for the detection of mbl as compared to other phenotypic methods. each carbapenem resistant isolate of enterobacteriaceae should be process for the detection of carbapenemase especially mbl. key words: combined disk technique, double disk synergy technique, metallo-β-lactamases. metallo-βeta-lactamase detection comparative evaluation of double-disk synergy versus combined disk tests original article 250 j i m d c 2 0 1 7 250 carbapenems are the most commonly used drugs against multi-drug resistant (mdr) and extended spectrum betalactamases (esbl) strains of enterobacteriaceae.1, 2 the emergence and spread of resistance in enterobacteriaceae are complicating the treatment of serious nosocomial infections and threatening to create species resistant to all currently available agents. the vast majority of enterobacteriaceae, including esbl producers, remain susceptible to carbapenems, and these agents are considered preferred empirical therapy for serious enterobacteriaceae infections. carbapenem resistance, although rare, appears to be increasing.3 carbapenemases (metallo ß-lactamases or mbls) have been emerged and spread from p. aeruginosa to enterobacteriaceae.4 better antibiotic stewardship and strict infection control programs are needed to prevent further spread of esbls and other forms of resistance in enterobacteriaceae throughout the world.3 resistance to carbapenems develops when bacteria acquire or develop structural changes within their penicillin binding proteins (pbp), when they acquire mbl that are capable of rapidly degrading carbapenems, or when changes in membrane permeability arise as a result of the loss of specific outer membrane porins.5 several resistance mechanisms occur to evade the efficacy of carbapenem and the carbapenemases are the most prominent enzymes that neutralize carbapenem.6 first, high-level production of chromosomal ampc cephalosporins combined with decreased outer membrane permeability due to loss or alteration of porins can result in carbapenem resistance. this has been shown for enterobacter cloacae, enterobacter aerogenes, proteus rettgeri, citrobacter freundii, escherichia coli and k. pneumonia. the second mechanism is the production of a β-lactamase, that is capable of hydrolysing carbapenems (e.g., imi-1, imp-1, nmc-a, sme-1, and cfia). the third mechanism of resistance involves changes in the affinity of the target enzymes, the penicillin-binding proteins, for carbapenems.7 the rapid global spread of k. pneumoniae that produces k. pneumoniae carbapenemase (kpc) is of major concern. the most common mechanism of resistance for the βlactam antibiotic in clinically important gram-negative bacteria is hydrolysis of this group by β-lactamases.8 carbapenemases are β-lactamases with versatile hydrolytic capacities. they have the ability to hydrolyse penicillins, cephalosporins, monobactams, and carbapenems. bacteria producing these β-lactamases may cause serious infections in which the carbapenemase activity renders many β-lactams ineffective. carbapenemases are members of the molecular class a, b, and d β-lactamases. class a and d enzymes have a serine-based hydrolytic mechanism, while class b enzymes are metallo-β-lactamases that contain zinc in the active site. 9 rapid detections of carbapenemases especially mbl producing gramnegative pathogens is crucial to prevent their widespread dissemination.10 kpc genes are typically located on mobile genetic elements, especially a particular transposon known as tn4401, which helps transfer between plasmids and across bacterial species. tn4401 and related transposons have been detected in many species from different continents.11 several methods including modified hodge test, double disc synergy method using imipenem-edta discs, edtaimpregnated imipenem disc and edta impregnated meropenem discs and imipenemedta impregnated etest strips have also been recommended.12, 13 as carbapenemase mediated carbapenem resistance is more of a challenge for infection control than other forms of carbapenem resistance in enterobacteriaceae, so this study will help in establishing a method for early detection of carbapenemase and this, in turn will lead to prompt measures to check their dissemination and will have a valuable importance in infection control. p a t i e n t s a n d m e t h o d s this cross-sectional analytical type of study was carried in the pathology department of punjab institute of cardiology lahore. samples were randomly enrolled from daily lab work during the period of january 2016 to january 2017 and analysed. a total of 2970 clinical samples were enrolled, every sample was processed for bacterial culture. bacterial identification was done by colonial morphology, gram stain and standard biochemical profile api-20 e. every enterobacteriaceae isolate was processed for antimicrobial susceptibility testing for the detection of carbapenem-resistant, and all those isolates that were carbapenem-resistant were further analyzed for the detection of carbapenemases 251 j i m d c 2 0 1 7 251 producers by modified hodge test (mht). moreover, every carbapenemase producer (mht-positive) isolate was tested for the detection of mbl produced by three different phenotypic methods. only carbapenem-resistant isolates of enterobacteriaceae were included. repeat isolates of enterobacteriaceae from all the specimens of the same patients were excluded. modified hodge test: a 0.5 mcfarland (1:10) dilution of e. coli atcc 25922 was prepared and inoculated on mueller hinton agar, a 10-µgram meropenem disk was placed in the centre and in a straight line, test organism was streaked from the edge of the disk to the edge of the plate and was incubated at 35+2 in ambient air for 16-24 hours. after incubation, the plates were examined for a cloverleaf-type indentation at the intersection of the test organism and the e. coli 25922, within the zone of inhibition of the carbapenem susceptibility disk. mht positive test had a clover leaf-like indentation of the e.coli 25922 growing along the test organism growth streak within the disk diffusion zone. while mht negative test had no growth of the e.coli 25922 along the test organism growth streak within the disc diffusion. for quality control purpose klebsiella pneumonia atcc® baa-1705 were used as positive control and klebsiella pneumonia atcc® baa-1706 were used as negative control. mbl detection: mbl detection was done by phenotypic techniques, using single agar plate (mueller-hinton agar) inoculated with test organism and comprised of three components. combined disk technique (0.1 m edta): two imipenem disks (10 µg), one containing 10µl of 0.1m (292µg) anhydrous edta, were placed 25 mm apart. 10 µl of 0.1 m (292 µg) edta was chosen, as higher concentration led to inhibitory effects with the edta alone. an increase in zone diameter of > 4mm around the ipm-edta disk compared to that of the ipm disk alone was considered positive for an mbl. combined disk technique (0.5 m edta): a 0.5 m edta solution was prepared (ph= 8.0). two disks of 10 µg imipenem were placed on mueller-hinton agar and to one of them, 4 µl of edta solution was added. one blank disk with edta was also added as an edta control. inhibition zones of imipenem alone and imipenem plus edta disks were read after 18-24 hours’ incubation at 350c. for mbl-positive organisms, addition of edta to the imipenem disk (imipenem plus edta) increased the inhibition zone by 8-15 mm (mean 10.5 mm), while the increase for mbl-negative isolates was 1-5 mm (mean) 3.8 mm double disk synergy technique: in ddst, an imipenem (10µg) disk was placed 20mm apart (center to center) from a blank disk containing 10µl of 0.1 m edta. enhancement of zone of inhibition in the area between two disks was considered positive for an mbl. statistical package for social sciences (spss) version 21.0 was used for statistical analysis of the data, descriptive statistics were applied. r e s u l t s out of total 2970 samples, 38.7% (n=1150) were culture positive of which 40.5% (n=550) were enterobacteriaceae. figure: 1. figure 1: breakup of culture positive isolates (n=2970) among this 9.0 % (n=50) were carbapenem-resistant isolates of which 98% (49/50) were found to be positive for carbapenemase production (mht-positive) figure: 2. figure 2: frequency of carbapenamases producers (n=50) 252 j i m d c 2 0 1 7 252 figure 3: breakup of three different modalities for the detection of mbl producers’ (n=49) table:1 antimicrobial resistant pattern of carbapenem resistant isolates antimicrobial drugs frequency percentage chloramphenicol 36 72 tigecycline 42 84 amikacin 47 94 nalidixic acid 49 98 ciprofloxacin 49 98 moxifloxacin 49 98 cefoperazone+sulbactam 49 98 co-trimaxazole 49 98 meropenem 50 100 imipenem 50 100 cefotaxime 50 100 ceftazidime 50 100 augmentin 50 100 cefepime 50 100 tazobactam+piperacillin, 50 100 tetracycline, 50 100 piperacillin+sulbactam, 50 100 ticarcillin+clavulanic acid 50 100 gentamicin 50 100 according to (i) combined disk technique (0.1 m edta), 98% (48/49) were mbl positive (ii) combined disk technique (0.5 m edta), 86% (42/49) isolates were found to be positive for mbl production, and 2% (1/49) were placed in a non-determinable category. (iii) double disk synergy technique (ddst)100% (49/49) isolates were found to mbl positive. figure:3 antimicrobial resistant pattern of carbapenem-resistant isolates is presented in table:1 d i s c u s s i o n the emergence of carbapenemases producers possesses alarming challenges as mdr infections around the globe. in the last 10 years, it has become a significant problem. these β-lactamases are able to hydrolyze the carbapenem and provide resistance to a broad spectrum of antibiotics. 9 carbapenems are commonly used to treat infections caused by multidrug-resistant enterobacteriaceae and they are one of the antibiotics of last resort for many bacterial infections, such as e. coli and k. pneumonia ,14 but now the clinical use of this group is under threat with the emergence of acquired carbapenemase, particularly ambler class b metallo-βlactamase (mbl) and worldwide spread of the resistance gene is becoming a potentially frightening scenario.15 the present study was planned to evaluate the major source of carbapenem resistance in clinical isolates of enterobacteriaceae, whether it is due to enzyme production or any other mechanism. detection of carbapenemase was carried out by modified hodge method according to the guidelines recommended by clsi-2016.16 the study further focuses on the detection of metallo-β-lactamase (mbl).three different methods were used for detection of metallo-β-lactamase (mbl) which included double disc synergy method, combined disc method by using two different concentration of edta. this is the simplest, highly sensitive and specific method used in a number of widely published studies. present study reported that of total n=2970 samples, 38.7% (n=1150) were culture positive, of which 40.5% (n=550) were enterobacteriaceae. among this 9.0 % (n=50) were carbapenem-resistant isolates of which 98% (49/50) were found to be positive for carbapenemase production (mhtpositive). according to (i) combined disk technique (0.1 m edta), 98% (48/49) were mbl positive (ii) combined disk 253 j i m d c 2 0 1 7 253 technique (0.5 m edta), 86% (42/49) isolates were found to be positive for mbl production, and 2% (1/49) were placed in a non-determinable category (iii) double disk synergy technique (ddst)100% (49/49) isolates were found to mbl positive. we suspect that the pre-dominant mbl among these isolates is most probably new delhi metallo-β-lactamase (ndm-1) a similar study from india 17 reported that 107 clinical isolates of gram negative rods (gnr) were processed for the detection of mbl, by using (edta) as mbl inhibitor. four phenotypic techniques were used (i) combined disk synergy test (cdst) with 0.5m edta (ii) cdst with 0.1 m edta (iii) ddst with 0.5m edta (iv) ddst with 0.1 m edta. out of 107 only 30 isolates were carbapenem resistant of which 21 (70%) isolates were mbl positive by cdst-0.1 m edta, 19 (63.3%) by cdst-0.5m edta, 17 (56.6%) by ddst-0.1 m edta, and 16 (53.3%) by ddst-0.5m edta. every mbl-producer isolate was resistant to ampicillin/sulbactam while polymyxin b was the only choice of drug with high sensitive rate. therefore, cdst0.1 m edta was reported as the best technique for the detection of mbl producers. furthermore sensitivity of cdst-0.1 m edta and ddst-0.1 m edta technique have reported 100% and 79% respectively.18 in our view, the best method to detect mbl production in enterobacteriaceae is double disk synergy method because this method detected all the mbl producers. if we are using combined disk method, then we should perform it by both methods by using two different concentrations of edta until and unless one of these is recommended as gold standard after confirmation by molecular genetic analysis. moreover, it is suggested that the method to be used as gold standard for detection of mbl should be confirmed by molecular genetic analysis of the mbl producers. in this study, we also tried to establish the sensitivity pattern of meropenem resistant enterobacteriaceae to alternative antibiotics. almost 20% isolates were found sensitive to chloramphenicol and 16% were susceptible to tigecycline. the sensitivity of all other antimicrobial tested in this study was poor against these organisms. present study reflects that once an isolate is declared as carbapenemase producer, we will be left with a very limited choice of antibiotics because genes encoding these enzymes are clustered with those encoding to resistance to aminoglycosides and fluoroquinolones, thus further compromising our antibiotic choice for these isolates.3 similarly walsh et al 15 mentioned very high resistant of mbl-producers against all beta-lactams, aminoglycosides, tetracycline, and fluoroquinolones group of antibiotics. moreover, present study strongly supports the inevitable need to differentiate carbapenemases producers enterobacteriaceae from other strains to limit their spread. clinical microbiology laboratories should be able to distinguish mbl producer strains because the uncontrolled spread of these organisms will result in treatment failure eventually. confirmation of these enzymes requires molecular analysis, by pcr or dna sequencing. at present, there is not enough data available from our country about the prevalence of carbapenemases including mbl. avoidance of unnecessary use of antimicrobials should be a part of the recommended drug therapy in hospitalized patients, especially in icu. regular surveillance programs should be conducted to check the drugs susceptibility, their usage pattern and resistance mechanism. molecular genetic analysis of these enzymes by dna probing and pcr is suggested for further studies. c o n c l u s i o n double-disk synergy technique is good method for the detection of mbl producers as compared to other phenotypic methods. making it highly applicable to routine clinical laboratories, each carbapenem-resistant isolate of enterobacteriaceae should be processed for the detection of carbapenemase especially mbl. r e f e r e n c e s 1. k. anderson, d. lonsway, j. rasheed, j. biddle, b. jensen, l. mcdougal, r. carey, a. thompson, s. stocker and b. limbago, journal of clinical microbiology.2007; 45 (8):2723-2725. 2. m. hindiyeh, g. smollen, z. grossman, d. ram, y. davidson, f. mileguir, m. vax, d. b. david, i. tal and g. rahav, journal of clinical microbiology.2008; 46 (9):28792883. 3. d. l. paterson, the american journal of medicine.2006; 119 (6):s20-s28. 4. v. gupta, indian journal of medical research. 2007; 126 (5): 417. 5. g. g. zhanel, r. wiebe, l. dilay, k. thomson, e. rubinstein, d. j. hoban, a. m. noreddin and j. a. karlowsky, drugs.2007; 67 (7):1027 1052. 254 j i m d c 2 0 1 7 254 6. p. nordmann and l. poirel, clinical microbiology and infection.2002; 8 (6):321-331. 7. h. yigit, a. m. queenan, g. j. anderson, a. domenechsanchez, j. w. biddle, c. d. steward, s. alberti, k. bush and f. c. tenover, antimicrobial agents and chemotherapy.2001; 45 (4):1151-1161. 8. k. bush and g. a. jacoby, antimicrobial agents and chemotherapy.2010; 54 (3):969-976. 9. a. merie queenan and k. bush, clin microbiol rev.2007; 20 (3):440-458. 10. s. irfan, a. zafar, d. guhar, t. ahsan and r. hasan, indian journal of medical microbiology.2008; 26 (3):243. 11. l. s. munoz-price and j. p. quinn, (the university of chicago press, 2009). 12. g. peirano, l. m. seki, v. l. val passos, m. c. f. pinto, l. r. guerra and m. d. asensi, journal of antimicrobial chemotherapy.2008; 63(2): 265-268. 13. r. c. picao, s. s. andrade, a. g. nicoletti, e. h. campana, g. c. moraes, r. e. mendes and a. c. gales, journal of clinical microbiology.2008; 46(6):2028-2037. 14. p. deshpande, c. rodrigues, a. shetty, f. kapadia, a. hedge and r. soman, journal of association of physicians of india.2010; 58 (3):147-149. 15. t. r. walsh, m. a. toleman, l. poirel and p. nordmann, clinical microbiology reviews.2005; 18 (2):306-325. 16. j. patel, f. cockerill, p. bradford, g. eliopoulos, j. hindler, s. jenkins, j. lewis ii and b. limbago, methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. approved standard m07-a10, wayne, pa.clinical and laboratary standared institue. 2015. 17. c. a. panchal, s. s. oza and s. j. mehta, journal of laboratory physicians.2017; 9(2):81. 18. c. franklin, l. liolios and a. y. peleg, journal of clinical microbiology.2006; 44(9):3139-3144. 225 j i m d c 2 0 1 8 225 op e n ac c e s s c a s e r e p o r t emphysematous cystitis along with emphysematous pyelonephritis in type ii diabetes: a case report awais saeed abbasi 1, zahid nabi 2 1 registrar, department of accident and emergency, dr. akbar niazi teaching hospital islamabad head department of nephrology, krl hospital islamabad a b s t r a c t emphysematous urinary tract infections (utis) are infections of the lower or upper urinary tract associated with gas formation. they may manifest as cystitis, pyelitis, or pyelonephritis. diabetes mellitus is a major risk factor for these infections. the diagnosis of gas-forming uti is usually made by plain films of the abdomen and/or computed tomography (ct). escherichia coli and klebsiella pneumonia are the predominant etiologic organisms. we present a rare case of emphysematous cystitis along with emphysematous pyelonephritis in a patient with poorly controlled diabetes. this patient underwent nephrectomy and 500 ml of puss was drained before nephrectomy. puss c/s showed growth of escherichia coli which was sensitive to pipercillin/tazobactam. we conclude that all female diabetic patients more than 60 years of age presenting with urinary symptoms, abdominal pain, fever and evidence of uti on urine routine examination should have at-least an ultrasound abdomen and kidney ureter bladder (kub) done and if presence of air is suspected, these patients should get ct scan kub done so that diagnosis of emphysematous uti be made and managed accordingly. key words: cystitis, diabetes, emphysematous cystitis, pyelonephritis address of correspondence awais saeed email: awais1357@yahoo.com article info. received: june 5, 2018 accepted: september 12, 2018 cite this case report: abbasi as, nabi z. emphysematous cystitis along with emphysematous pyelonephritis in type ii diabetes: a case report. jimdc. 2018; 7(3):225-228 funding source: nil conflict of interest: nil i n t r o d u c t i o n emphysematous urinary tract infections (utis) are infections of the lower or upper urinary tract associated with gas formation. they may manifest as cystitis, pyelitis, or pyelonephritis. diabetes mellitus is a major risk factor for these infections and is also associated with an increased risk of asymptomatic bacteriuria and certain symptomatic utis such as cystitis, renal and perinephric abscess, and candida infections.1-3 elevated tissue glucose levels in diabetic patients may provide a more favorable microenvironment for gas-forming microbes. however, bacterial gas production does not fully explain the pathologic and clinical manifestations of emphysematous utis.4,5 diabetes mellitus and urinary tract obstruction are the major risk factors for emphysematous urinary tract infections (utis). in different series, diabetes was present in more than 80 percent of patients with emphysematous pyelonephritis.4,6 the diagnosis of a gas-forming uti is usually made by plain films of the abdomen and/or computed tomography (ct). such radiographs reveal air in the renal parenchyma, bladder, or surrounding tissue in 50 to 85 percent of cases. ct scanning is more sensitive than plain films and may show the extent of gas formation and any obstructing lesions in the urinary tract.4,5,7 escherichia coli and klebsiella pneumoniae are the predominant etiologic organisms.8 treatment modalities include intravenous (i/v) antibiotics, percutaneous drainage (pcd) and nephrectomy. c a s e r e p o r t a 64-year-old female was admitted to intensive care unit (icu) via outpatient department (opd) with complaint of c a s e r e p o r t 226 j i m d c 2 0 1 8 226 fever, abdominal pain, vomiting and burning micturition. her fever was acute in onset, high grade, intermittent for last 2 days. her abdominal pain was described as ―achy,‖ 6/10, intermittent, and located in the right upper quadrant without radiation. she also had complaint of vomiting, 4 episodes in last 2 days, not containing blood and burning micturition along with mild dysuria. she was diagnosed diabetes mellitus (dm) 1 year back during a routine checkup and was started on oral hypoglycemics (ohgs). her blood sugar control was not adequate so 6 months later, she was started on humulin 70/30 (nph 70%/regular insulin 30%) with no regular follow ups. apart from dm she had no other comorbid condition. she denied ever having any surgeries. she used regular insulin, omeprazole and diclofenac in past. her family history was noncontributory, and she denied tobacco use. examination revealed a temperature of 100.6° f, respiratory rate of 16 breaths per minute, heart rate of 96 beats per minute, blood pressure of 110/60 mm hg, oxygen saturation of 98% at room air, and no edema was appreciated. her fasting capillary blood glucose was 385 mg/dl. she was oriented in time, person and place with a glasgow coma scale (gcs) score of 15/15. her pupils were equally reactive to light and accommodation. rest of the neurological examination was unremarkable. the cardiac exam was normal with audible 1st and 2nd heart sound respiratory examination revealed bilateral breath sounds with reduced breath sounds and vocal resonance at right base, trachea was central. the abdomen was soft with moderate tenderness to palpation in the right hypochondrium and lumbar region. there was no guarding or rebound tenderness. laboratory tests revealed the following: white blood cell (wbc) count, 9,100/mm3 with 85% neutrophils; hemoglobin, 13.1 g/dl; platelet count, 61,000/mm3; urea, 161 mg/dl; serum creatinine, 3.3 mg/dl; sodium, 130 mmol/l; potassium, 3.8 mmol/l; alanine transaminase, 10 iu/l; prothrombin time, 15.4/10.6 seconds (inr 1.4); activated partial thromboplastin time, 37.2/29 seconds; serum calcium, 9 mg/dl; serum phosphorus, 2.8 mg/dl; serum bicarbonate, 15.7 mmol/l; anti-hcv antibodies was positive. the urinalysis revealed protein 1+, red blood cells 10/hpf, and wbc numerous/hpf. urine culture/ sensitivity (c/s) was negative for any growth. ultrasound abdomen revealed enlarged hydronephrotic right kidney with few calculi at lower pole and few air loculi. irregular liver margins, right sided pleural effusion and mild ascites. non-contrast computed tomography (ct) scan of the abdomen was ordered. the ct scan revealed significant air in the bladder wall, consistent with emphysematous cystitis along with air in the right renal parenchyma extending to perinephric area consistent with emphysematous pyelonephritis. there were few calculi found at the lower pole as well. a diagnosis of emphysematous cystitis along with class 3a emphysematous pyelonephritis was made. she was managed with intravenous (i/v) antibiotics including pipercillin/tazobactam 2.25 gm 8 hourly initially, dose adjusted according to estimated gfr and later as the renal functions improved, full 4.5 gm 8 hourly dose was administered, moxifloxacin 400 mg once a day and metronidazole 500 mg 8 hourly. i/v normal saline was started. insulin regular was given according to sliding scale. ranitidine was given for ulcer prophylaxis and tramadol was given for pain. after ct report, urology consult was taken and unanimous decision of right nephrectomy was made. patient underwent nephrectomy under general anesthesia via right lumbar incision. 500 ml of puss was drained before nephrectomy. puss c/s showed growth of escherichia coli which was sensitive to pipercillin/tazobactam. patient was again started on i/v antibiotics with a plan to discharge patient on oral antibiotics. figure 1: (a) computed tomography (ct) image showing air level extending to right perinephric area. (b) showing air level involving right renal parenchyma. (c) ct image showing hydroaeric level and pneumobladder at the level of bladder wall. d i s c u s s i o n emphysematous pyelonephritis (epn) was first described in 1898, in association with pneumaturia as a result of gas forming pathogens.9 these bacteria ferment sugars within 227 j i m d c 2 0 1 8 227 the urine producing gases including nitrogen, hydrogen, carbon dioxide, and oxygen.10 epn occurs nearly exclusively (90%) in people with diabetes.11 the factors that predispose to epn in people with diabetes may include uncontrolled diabetes, high levels of glycosylated hemoglobin, and impaired host immune mechanisms caused by local factors such as renal tract obstruction (tumours or lithiasis).12 renal uss can confirm the presence of epn in approximately 80% of cases13, whereas ct is 100% sensitive.14 based upon the findings seen on ct scan, two classification systems have been proposed to estimate prognosis and guide therapy. one classification system divided emphysematous pyelonephritis into two types:15  type i — renal parenchymal necrosis with either absence of fluid collection or the presence of a streaky or mottled gas pattern  type ii — renal or perirenal fluid accompanied by a bubbly gas pattern or gas in the collecting system emphysematous pyelonephritis or pyelitis may be alternatively categorized into four prognostic classes based upon ct scan findings:11  class 1: gas in the collecting system only (ie, emphysematous pyelitis); this finding may be associated with severe obstruction at the site of the pyelitis in some patients  class 2: gas in the renal parenchyma without extension to the extrarenal space  class 3a: extension of gas or abscess to the perinephric space (defined as the area between the fibrous renal capsule and the renal fascia)  class 3b: extension of gas or abscess to the pararenal space (defined as the space beyond the renal fascia and/or extension to adjacent tissues such as the psoas muscle)  class 4: bilateral emphysematous pyelonephritis or a solitary functioning kidney with emphysematous pyelonephritis. treatment of these patients has always been tough and controversial as limited data has been published. patients with class 1 disease (pyelitis) who do not have abscess formation or obstruction can be treated with antibiotics alone.16 other patients with class 1 disease and patients with class 2 disease should be treated with antibiotics plus percutaneous catheter drainage (pcd) and, if present, relief of urinary tract obstruction.17 patients with class 3a or 3b disease at low risk (defined as none or one of the following risk factors: thrombocytopenia, acute renal failure, impaired consciousness, or shock) can initially be treated with antibiotics plus pcd and, if present, relief of urinary tract obstruction. however, given the lack of confirmatory evidence beyond the one study11, some urologists feel that early nephrectomy is warranted in all patients with class 3 disease. patients with class 3a or 3b disease with two or more of the above risk factors should be treated with antibiotics plus immediate nephrectomy. patients with class 4 disease (bilateral involvement or infection is a solitary functioning kidney) should initially be treated with antibiotics plus bilateral percutaneous catheter drainage and, if present, relief of urinary tract obstruction. nephrectomy is a last option. emphysematous cystitis is a lower urinary tract infection characterized by air within the bladder wall and lumen, usually occurring in elderly diabetic females, immunocompromised patients.18 multiple gas-forming microorganisms can cause emphysematous cystitis. it was reported that various bacterial and fungal organisms were isolated in urine culture with escherichia coli being the most prevalent, followed by klebsiella pneumonia.18,19 the treatment generally consists of antibiotics, bladder drainage, and glycemic control with correction of any underlying comorbid disorders. broad-spectrum antibiotics are used initially. the precise regimen is then tapered to the sensitivities of the urinary pathogens.18 when treated with antibiotics alone, epn is associated with a high mortality rate (40%).20 mortality rates were 15– 20% in two case series in which nephrectomy was the treatment of choice.21 in case of emphysematous cystitis, the overall mortality rate was 7%, which increased to 14% in patients who presented with combined emphysematous cystitis and pyelonephritis.22 c o n c l u s i o n female diabetic patients more than 60 years of age presenting with urinary symptoms, abdominal pain, fever and evidence of uti on urine routine examination should have at-least an ultrasound abdomen and kidney ureter bladder (kub) done and if presence of air is suspected, these patients should get ct scan kub so that diagnosis of emphysematous uti can be made early as the 228 j i m d c 2 0 1 8 228 treatment depends upon proper diagnosis. nephrectomy in class 3a epn along with emphysematous cystitis is the treatment of choice. r e f e r e n c e s 1. ronald a, ludwig e. urinary tract infections in adults with diabetes. international journal of antimicrobial agents. 2001; 17(4):287-92. 2. geerlings se, stolk rp, camps mj, netten pm, collet tj, hoepelman ai, diabetes women asymptomatic bacteriuria utrecht study group. risk factors for symptomatic urinary tract infection in women with diabetes. diabetes care. 2000; 23(12):1737-41. 3. boyko ej, fihn sd, scholes d, chen cl, normand eh, yarbro p. diabetes and the risk of acute urinary tract infection among postmenopausal women. diabetes care. 2002; 25(10):1778-83. 4. huang jj, tseng cc. emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. archives of internal medicine. 2000; 160(6):797-805. 5. grupper m, kravtsov a, potasman i. emphysematous cystitis: illustrative case report and review of the literature. medicine. 2007; 86(1):47-53. 6. pontin ar, barnes rd, joffe j, kahn d. emphysematous pyelonephritis in diabetic patients. br j urol 1995; 75(1):71-74. 7. chen mt, huang cn, chou yh, huang ch, chiang cp, liu gc. percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. j urol. 1997;157(5):1569. 8. bos d., patal p., ditullio s. emphysematous cystitis: an atypical multi-organism presentation. journal of the canadian urological association. 2014; 8(3-4): e210– e212. 9. kelly ha, maccallum wg. pneumaturia. jama. 1898;31(8):375–81. 10. huang jj, chen kw, ruaan mk. mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection.j urol.1991;146(1):148–51. 11. huang jj, tseng cc. emphysematous pyelonephritis: clinicoradiological classification, management, prognosis and pathogenesis. arch intern med.2000; 160(6):797– 805. 12. vollans sr, sehjal r, forster ja, rogawski k. emphysematous pyelonephritis in type ii diabetes: a case report of an undiagnosed ureteric colic. cases j.. 2008; 1(1): 192. 13. tang hj, li cm, yen my, chen ys, wann sr, lin hh, et al. clinical characteristic of emphysematous pyelonephritis. j microbiol immunol infect. 2001;34(2):125–30. 14. ahlering tc, boyd sd, hamilton cl, bragin sd, chandrasoma pt, lieskovsky g, et al. emphysematous pyelonephritis: a five year experience with 13 patients. j urol. 1985;134(6):1086–1088. 15. wan yl, lee ty, bullard mj, tsai cc. acute gasproducing bacterial renal infection: correlation between imaging findings and clinical outcome. radiology 1996; 198(2):433. 16. roy c, pfleger dd, tuchmann cm, lang hh, saussine cc, jacqmin d. emphysematous pyelitis: findings in five patients. radiology 2001; 218(3):647. 17. aswathaman k, gopalakrishnan g, gnanaraj l, chacko nk, kekre ns, devasia a. emphysematous pyelonephritis: outcome of conservative management. urology 2008; 71(6):1007-1009 18. thomas aa, lane br, thomas az, remer em, campbell sc, shoskes da. emphysematous cystitis: a review of 135 cases. british journal of urology.2007;100(1):17–20. 19. grupper m, kravtsov a, potasman i. emphysematous cystitis: illustrative case report and review of the literature. medicine.2007;86(1):47–53. 20. wan yl, lo sk, bullard mj, chang pl, lee ty. predictors of outcome in emphysematous pyelonephritis. j urol. 1998;159(2):369–73. 21. shokeir aa, el-azab m, mohsen t, el-diasty t. emphysematous pyelonephritis: a 15-year experience with 20 cases. urology. 1997;49(3):343–6. 22. yoshino t, ohara s, moriyama h. emphysematous cystitis occurred in the case treated with steroid for autoimmune hepatitis. case rep urol. 2013; 2013: 821780. https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/4 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/4 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/4 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/4 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/8 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/8 https://www.uptodate.com/contents/emphysematous-urinary-tract-infections/abstract/8 j islamabad med dental coll 2021 37 open access knowledge of otic barotrauma among air travelers in sialkot, pakistan muhammad saeed razi1, saleh muhammad2, asif javed3, javaid riaz qureshi4, miss mahnoor5, mujahid hussain6 1assistant professor, department of ent, sialkot medical college, sialkot, pakistan 2associate professor, department of medicine, sialkot medical college, sialkot, pakistan 3assistant professor, department of medicine, m. islam medical college, gujranwala, pakistan 4assistant professor, department of ent, khawaja m safdar medical college, sialkot, pakistan 5final year mbbs student, federal medical and dental college, islamabad pakistan 6assistant professor, department of biology, fg degree college (m), khari an cantt., pakistan a b s t r a c t background: otic barotrauma (obt) is defined as traumatic inflammation in human middle ear that occurs at the time of avian drop. however, it can be avoided using its adequate knowledge. the objective of present study was to evaluate the knowledge of the trauma among air travelers in sialkot city of punjab, pakistan . material and methods: this cross-sectional study enlisted male adult international air travelers (n=50) from sialkot city, pakistan between november 2018 and april 2019 using purposive sampling technique. a specially developed questionnaire (cronbach’s alpha = .82) having 12 close -ended items on barotrauma (total possible score 12) was administered to the participants at their home. level of knowledge was categoriz ed as inadequate (score 0-6), moderate (7-9) and adequate (10-12). pearson’s chi-squared test was used to see the association between adequate knowledge on the obt and sociodemographic variables using a p -value < .05 as statistically significant. results: mean age of the participants was 47.60±9.9 years. most of them (n=36; 72%) travelled for work reason. almost all i.e. 46 (92%) gave correct response against item 1 (information provider about air trauma) and 12 (treatment of otic barotrauma) of the administered questionnaire. the rate of adequate knowledge on obt was found to be higher among those having more than two-time travelling experience (82.9%, p = .02). however, there was no significant difference in knowledge of the barotrauma between people having less than or more than 12 years of science education (p = .59). all the business tourists (n = 5) had adequate knowledge of barotrauma followed by jobbers (n=25) and pilgrims (n=3), respectively. conclusions: business tourists have adequate knowledge on otic barotrauma associated with air travel than jobbers or hajj/umrah pilgrims. key words: air travel agents, international air travelers, otic barotrauma, pakistan . authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6data analysis; manuscript editing. correspondence: mujahid hussain email: hmujahid64@yahoo.com article info: received: october 11, 2019 accepted: february 22, 2021 cite this article. razi ms, muhammad s, javed a, qureshi jr, mahnoor m, hussain m. knowledge of otic barotrauma among air travelers in sialkot, pakistan. j islamabad med dental coll. 2021; 10(1): 37-43. doi: 10.35787/jimdc.v10i1.433 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2021 38 i n t r o d u c t i o n otic barotrauma (obt) also called acute aerotitis media1 is defined as traumatic inflammation in middle ear (me) followed by hearing discomfort on changes in atmospheric pressure inside the cabin of an airplane. at the time of airplane descent, atmospheric pressure increments in the cabin with a reduction in the middle ear (me). ultimately, a pressure difference of 60 mmhg approaches which hinders the eustachian tube (et). the blockage prevents passive entry of the air in me and causes hearing inconvenience. usually, the issue settles by ear maneuvering. however, chances of severe obt2,3 increases on further increase in the difference (≥90 mm of hg). this condition may lead to hyperemia of tympanic membrane or hemorrhage in me. like colonic barotrauma,4 obt warrants appropriate knowledge on prevention and treatment. knowledge-based practice of precautionary measures e.g., swallowing ensures equalization of pressure on both sides of the tympanic membrane. this facilitates re-entry of the air in et for hearing.3,5 similarly, anti-allergy2,6 or topical nasal/systemic decongestant(s) prophylaxis is advised for the pertinent patients. in case of mild trauma, practice of valsalva’s maneuver is effective. 7 knowledge of a problem is gauged in its vulnerable/affected population using easy to response study tool e.g., questionnaire. knowledge of an infectious disease among students, 8 or obt among air travelers can be cited in this context. in contrast to australia,9 researchers have no access to the respondents (air travelers) at airport domains of pakistan such as waiting lounge on account of legitimate boundaries. so, one has to recruit the subjects from civilian residential areas to know their unpleasant experiences in air traveling. online published literature is available on assessing the knowledge of the problem among flight crew members or air travelers at airport domains. 1,3,7,10 however, there is no precedence of recruiting air travelers from civil residential areas especially in pakistan. to address the gap, present study was designed. the objective of the study was to evaluate the knowledge on obt among air travelers in sialkot city of punjab, pakistan. it will not only help civil aviation authorities in revising travelers' guide but also air travel agents in reviewing information package for clients. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted between november, 2018 and april, 2019 in sialkot city, pakistan after getting permission from the ethics committee of rachna hospital, sialkot, pakistan. adult male residents of sialkot city (n=50), who had at least 12 years of academic education in science subjects and minimal two-times experience of international air travel, were included in the study. the purpose of travel might vary from business, to job, hajj/ umrah, medical treatment or recreational trip. the eligible individuals were recruited using chain referral sampling technique. the final enrollment was based on positive participation consent. those who had any severe physical or mental problems were excluded. a total of 492 air travelers (i.e., accessible population) were documented in a computergenerated table from administrative jurisdiction of sialkot city. whereas, sample size was found to be 50 (approximately 10% of the accessible population) following principles of sampling11,12 for pilot study on clinical issues. the 50 subjects were recruited from the accessible population using purposive sampling technique. j islamabad med dental coll 2021 39 during questionnaire development, a team of language (english) specialists and practicing psychologists having enough knowledge on obt set candidate questions in the questionnaire. the tool was administered to 15 air travelers (first focus group) for acceptability of the questions. the response-based revised version was given to the second group (n = 15) while next revised version was administered to the same-sized third group. so, a total of 45 individuals (selected from the accessible population) participated in the practice. however, these participants were not considered for giving responses in the present pilot study. after the three rounds, the questionnaire was subjected to techniques of development including reliability test (cronbach’s alpha = .82). at the end, there was an instrument with 12 close-ended items. item 1-4 (section-a) were on general information while 5-12 (section-b) were related to cause, predictors, prevention and treatment of obt. each item was followed by four response options. one mark was awarded if responder ticked the correct option against an item otherwise zero; hence, total possible scores were equal to 12. the degrees of knowledge were categorized as inadequate (0–6), moderately adequate (7–9) and adequate (score: 10–12) knowledge. nominal and continuous data were processed for percentage and mean values, separately. the association between adequate knowledge on obt and sociodemographic variables was seen using pearson’s chi-squared test in spss software version 25.0. in the test, a p-value less than .05 was taken as statistically significant. r e s u l t s all the 50 study subjects i.e., international air travelers, gave complete responses in the study tool for assessment of knowledge on obt (response rate = 100%). mean age of the participants was 47.60 ± 9.9 years with 56% (n=28) having more than 12 years of science education, 70% (n=35) with more than two-time experience of international air travel and 90% (n=45) obtained direct information from the travel agent. similarly, most of them (n=36; 72%) travelled for ex-pakistan job. others traveled for hajj/ umrah or business visits. however, not a single case of air travel with the purpose of medical treatment or recreational trip(s) was recorded. table i shows responses of subjects against each of the 12 items in the survey tool. forty-six (92%) subjects marked correct option against item no. 1 on obt-related information providing source in the administered questionnaire. the same rate (92%) of correct answers was also found against item no. 12 on consequences of obt. however, knowledge on medical insurance dealing agency (item no. 4) was evidently low with only 19 participants (38%) holding airline as the responsible party. table ii show association of the adequate level of the knowledge on obt with demographic variables. the rate of adequate knowledge on obt (score: 9-12 out of total possible 12) was found to be higher among travelers with more than two-time travelling experience (82.9%, p = .02). adequate knowledge showed insignificant association with age of the subjects or practice of direct information seeking from air travel agent (p = .30). figure 1 depict adequate knowledge in various categories of the participants in the study. in business tourists, the rate of the knowledge was 80% in section a (item: 1-4 pertaining to general knowledge on obt) and 100% in section b (item: 512 on obt specific knowledge) of the questionnaire. the pilgrims or jobbers likewise had highe r rate of information in section b as compared to a. j islamabad med dental coll 2021 40 table i. responses of subjects in questionnaire on otic barotrauma (n = 50) s.no items response options % (n) 1 this person/site informs about the incidence of trauma: a – air traveling agent 8 (4) b – waiting lounge for air passengers c – air attendant in the plane d – none of the above 92 (46) 2 gop have never ever launched a public awareness campaign on: a – air traveling ethics 10 (5) b – banned items in air traveling 2 (1) c – management of health issues in a flight 84 (42) d – rate of air fare 4 (2) 3 select the most efficient media for educating the youth about the trauma: a – newspaper (e.g., through columns) b – television (e.g., through drama) 4 (2) c – social media (e.g., facebook) 82 (41) d – pana flexes in main chowks of each city 14 (7) 4 claim amount of medical insurance on perforation in the air drum (after aerotitis) can be obtained from: a – air travel agent 20 (10) b – concerned air line 38 (19) c – government (to which airline belongs) 10 (5) d – civil aviation authority 32 (16) 5 otic barotrauma is a: a – sign of psychological problem 2 (1) b – result of physical tiredness 4 (2) c – indicator of decrease of air pressure within ear 74 (37) d – result of technical mishandling by aircrew 20 (10) 6 barotrauma generally occurs: a – before taking off the plane b – during taking off 20 (10) c – when the plane is at its maximum height 2 (1) d – on landing 78 (39) 7 a person with following problem is under high threat of barotrauma: a – obesity 12 (6) b – high blood pressure 8 (4) c – dust allergy 76 (38) d – mental depression 4 (2) 8 select a factor for barotrauma: a – position of the seat in the cabin 10 (5) b – altitude of the plane 86 (43) c – shape of the cabin d – susceptibility of the passenger to aerotitis 4 (2) 9 a person with following habit is under high threat of barotrauma: a – drinking alcohol 10 (5) b – smoking tobacco 82 (41) c – inhaling narcotics 8 (4) d – dieting 10 which practice cannot help in protecting from otic barotrauma? a – sleeping 78 (39) b – swallowing of food 10 (5) c – use of chew gum 8 (4) d – artificial yawning (opening of mouth) 4 (2) 11 severe prolonged barotrauma needs help of a: a – medical specialist 22 (11) b – ent specialist 76 (38) c – allergy specialist d – psychiatrist 2 (1) 12 usually otic barotrauma: a – lasts for some hours and recovers itself 2 (1) b – finishes on mild ear fingering 92 (46) c – results in hole in the air drum 6 (3) d – hits other ear problems correct options and relevant data are in bold letters; gop – government of pakistan j islamabad med dental coll 2021 41 table ii. demographic information versus level of knowledge on otic barotrauma (n = 50) demographic variables adequate knowledge % (n) x2 value p-value age (years) .734 .40 ≤48* 67.7 (21) >48 78.9 (15) science education (years) .284 .59 12 68.2 (15) >12 75.0 (21) experience of air travel .02** 2-times 46.7 (7) >2-times 82.9 (29) practice of direct information seeking from air travel agent .30 no 100 (5) yes 68.9 (31) *arithmetic mean of age; **exact significant two sided; x2 -chi-square p-value <.05 was considered as statistically significant. figure 1: adequate knowledge against three categories of the subjects (pilgrims = 9, jobbers = 36, and tourists = 5) . d i s c u s s i o n like navy divers, air travelers are vulnerable to obt.10,13,14 so, appropriate knowledge pertaining to barotrauma is essential for the travelers to avoid any complication. they can be accessed at the airport or home for assessment of the knowledge. in our study, 100% (n = 50) response rate reflects enthusiasm on part of the air travelers to participate in recording their responses candidly and with openness.15 similarly, comfortable feelings exist in j islamabad med dental coll 2021 42 patients of pulmonary barotrauma in the clinical settings.16 adequate knowledge (ak) on obt among older subjects (78.9% in >48 versus 67.2% in <48 years) is in line with the findings of a similar questionnairebased survey on 15-72 years old air travelers at two uk airports.3 knowledge in a particular area increases with advancing age.15 similarly, travelers’ awareness about prevention of obt is age dependent as spending more years in acquiring scientific academic education clarifies the scientific concepts. it was observed that educated study subjects had comparatively higher rate of adequate knowledge (ak) on barotrauma (75%), thus providing a physical demonstration of this education-consciousness coupling. significantly higher ak rate (. 82.9%) after more than two travel experiences is the result of experience – knowledge interactivity,8 indicating that experience enhances knowledge, cyclically. lower ak rate in information seekers from the travel agents contradicts a widely accepted perception that frequent contact with the agents enhances the level of knowledge in the passengers, especially of physically/mentally disabled categories.17 in kap (knowledge-attitude-practice), the knowledge and practice influence each other in a cyclic pattern.8,18,19 it is general practice of the air travelers to seek obt related information from the traveling agent(s). this is why substantially higher numbers of subjects (46 of 50) opted for the correct option against item no.1 of the study tool. however, correct response on obt-based insurance by just 19 people reflects general unawareness towards such essential matters. unfortunately, general insurance policies have no evident space in pakistan just like addis ababa,20 ethiopia. high rate of correct response for item 12 (i.e., simple ear fingering resolves mild obt) indicates adequate knowledge of the passengers regarding the unpleasant episode. fingering is an appropriate alternate to complex valsalva’s maneuver (a moderately forceful attempt of exhalation against a closed airway) at public place, provided there is no ent infections. 1,6,7,21,22 adequate level of knowledge in all the business tourists might be due to their interest in being updated on obt through internet facility, 23 literature survey, and peer to peer discussions. similarly, their strong socioeconomic background-derived trends might be responsible for ak on obt, just like better reading ability in a child24 of this class. pilgrims and foreign jobbers lack this dimension and have inadequate knowledge on the obt. inclusion of wide range of air passengers, their levels of knowledge on otic barotrauma, and emergence of predictors for the inadequate knowledge mark the strength of the present work. however, the study cannot be generalized due to bias related to a small sample size. c o n c l u s i o n the higher rate of adequate level of knowledge on obt was seen in business tourists followed by overseas jobbers and hajj/umrah pilgrims. r e f e r e n c e s 1. fyntanakii q, alevitsovitis g, angelakis l, moutevelis v. acute barotitis media in flight: pathophysiology , symptoms, prevention, treatment. balkan mil med rev. 2013; 16(1): 50-5. 2. mirza s, richardson h. otic barotrauma from air travel. j laryngol otol. 2005; 119(5): 366 -70. 3. mitchell-innes a, young e, vasiljevic a, rashid m. air travelers’ awareness of the preventability of otic barotrauma. j laryngol otol. 2014; 128(6): 494 -8. doi:10.1017/s 0022215114001145. 4. sheikh s, baig ma. colonic barotrauma causing tension pneumoperitoneum following jet air insufflation to the rectum. eurasian j emerg med. 2018; 17 (3): 133-5. doi: 10. 5152/eajem.2018.07769 . 5. smith me, scoffings dj, tysome jr. imaging of the eustachian tube and its function: a systematic review. neuroradiol. 2016; 58, 543-56. doi: 10.1007/s00234016-1663-4. j islamabad med dental coll 2021 43 6. fletc j. how to treat and prevent ear barotrauma [internet]. 2018. medical news today [cited 2019 july 11]. available from: https://www.medicalnewsto d ay . com/articles/ 322215.php. 7. ghosh s, kumar v. study of middle ear pressure in relation to eustachian tube patency. ind j aerospace med. 2002; 46(2): 27-30. 8. wang m, han x, fang h, xu c, lin x, xia s, yu w, he j, jiang s, tao h. impact of health education on knowledge and behaviors toward infectious diseases among students in gansu province, china. biomed res int. 2018; 2018: 1-12. doi: 10.1155/2018/6397340. 9. wiredja d, popovic v, blackler a. a passenger centered model in assessing airport service performance. j model manage. 2019; 14(2): 492 -520. doi: 10.1108/jm2-10-2018-0171. 10. sultani i, khayat sk, garout ir, alahmad ls, alzahrany aaa. the prevalence and risk factors of otic barotraumas among aircrew members. int j life sci pharma res. 2019; 9(2): 24-30. doi: 10.22376/ijpbs/lpr.2019.9.2.p24 -30. 11. treece ew, treece jw. elements of research in nursing (3rd ed.). 1982; st. louis, mo: mosby. 12. connelly lm. pilot studies. medsurg nursing. 2008; 17(6): 411-12. 13. wright t. middle-ear pain and trauma during air travel. bmj clin evid. 2015; 2015(1): 0501. pmid: 25599243. 14. rehman cm, zaheer s, rizvi f, afzal m. frequency of ear problems associated with diving and their prevention in pakistan. pak armed forces med j. 2010; 60(1): 135-9. 15. soederberg mlm. age differences in the effects of domain knowledge on reading efficiency. psychol aging. 2009; 24(1): 63-74. doi:10.1037/a0014586. 16. khan f, ahmad n. pneumoperitoneum following mechanical ventilation in a child. j coll phys surg pak. 2001; 11(8): 508-10. 17. mckercher b, packer t, yau m, lam p. travel agents: facilitators or inhibitors of travel for people with disabilities? tour manag. 2003; 24 (4): 465–74. 18. harackiewicz jm, smith jl, priniski sj. interest matters: the importance of promoting interest in education. policy insights behav brain sci. 2016; 3(2): 220-7. doi:10.1177/ 2372732216655542 . 19. dickens gl, ion r, waters c, atlantis e, everett b. mental health nurses’ attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings. bmc nursing. 2019; 18(1): 1. doi: 10.1186/s12912-0190339-x. 20. obse a, hailemariam d, normand c. knowledge of and preferences for health insurance among formal sector employees in addis ababa: a qualitative study. bmc health serv res. 2015; 15: 318. doi:10.1186/s12913-015-0988-8. 21. stefanescu cd, zainea v, hainarosie r. aerotitis media. rev air force aca. 2014; 3(27): 133 -6. 22. ayub f, haider i, saeed s, murtaza b, tariq, m. shortterm outcomes in patients undergoing mechanical ventilation in a tertiary care centre in sialkot. pak armed forces med j. 2018; 68(4): 1007-12. 23. el-ghitany em, mohamed abdelmohsen ma, farghaly ag, abd el-gawwad es, abd elwahab ew. travel health survey: risk perception, health-seeking behavior, and subjective evaluation of travel health services in egypt. int j travel med glob health.2018; 6(1): 16-24. doi:10.15171/ ijtmgh.2018.04 . 24. chen q, kong y, gao w, mo l. effects of socioeconomic status, parent-child relationship, and learning motivation on reading ability. front psychol. 2018; 9: 1297. doi:10.3389/ fpsyg.2018.01297. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):107-111 107 original article impact of gnrh agonists and gnrh antagonists on embryo quality, endometrial thickness and pregnancy rate in in-vitro fertilization haroon latif khan1, yousuf latif khan2, saba sardar3, abdul rahman khawaja4 1prof, embryologist & ceo, lahore institute of fertility and endocrinology (life) pakistan 2prof and consultant endoscopic surgeon, department of obstetrics & gynecology, hameed latif hospital, lahore 3assistant biostatistician, life research cell, hameed latif hospital, lahore pakistan 4 research consultant, life research cell, hameed latif hospital, lahore pakistan abstract objective: to compare the effects of gnrh agonists (long protocol) and gnrh antagonists (short protocol) on embryo quality, endometrial thickness (et) and pregnancy rate in human in vitro fertilization (ivf). subjects & methods: in this quasi experimental study 237 patients underwent short protocol and 175 long protocol of ivf. hcg was administrated when 2 or more follicles reached the size of 18mm. after 34-36 hours’ oocytes were retrieved transvaginally. et was carried out after 3-5 days under ultrasound guidance. rising β-hcg concentration confirmed the diagnosis of pregnancy. results: there was no significant difference in proportion of primary and secondary sub fertility between the two groups. regarding female age, embryo quality and endometrial thickness no significant difference was found between two groups. number of attempts, no of oocytes, fertilization & cleavage rate, maturation of oocytes and embryos transferred were significantly associated with both long and short protocols. conclusion: ongoing research in assisted reproductive technology has identified some issues which are important from the patient point of view such as ovarian hyper stimulation and safe successful pregnancy. this study shows that pregnancy rate is better with long protocol but that is not statistically significant. more studies should be designed with increase power for suitable comparison of long gnrh agonist protocols with short gnrh antagonist protocols. keywords: embryo quality, endometrial thickness, gnrh agonist (long), gnrh antagonist (short), oocytes, ovarian stimulation, pregnancy rate, uterine endometrium. introduction in the last 50 years, development of assisted reproduction and unprecedented success has given hope to couples who were considered sub-fertile and constituted 10-15% of the general population. in the developed nations 1% of the children are thought to be conceived with the help of assisted reproductive technology (art). 1 since the birth of louise brown, first "test tube baby” more than five million babies have been born worldwide with the help of art. 2 joint research and collaboration between diversified scientific fields like biology, physiology, endocrinology, embryology, laboratory science and clinical medicine resulted in development of art of today. 3 howard and jones in usa and trounson from australia pioneered coh (controlled ovarian hyperstimulation) by using gonadotropins derived from the urine and provided a useful tool for in vitro fertilization (ivf). 4-6 these injectable gonadotropins made it possible to expose ovarian follicles to higher hormonal levels and make a larger number of ovarian follicles to mature into oocytes which can be retrieved predictably in a large number from a single ivf cycle. 6 in order to suppress internal secretion of pituitary gonadotropin, gnrh agonists are used which help in revolutionizing the process and procedure of stimulation of the ovaries and prevention of lh (luteinizing hormone) surge. it is named as super ovulation. 7,8 when greater number of good quality embryos is needed for transfer into the uterus, higher number of pre-ovulatory follicles is required to be recruited to yield better quality oocytes. this is done by hyper stimulation of the ovaries by external recombinant gonadotrophins. 9,10 average number of follicles recruited in an ovarian stimulation cycle have risen to ten, twenty or more, which have led to the yield of enhanced number of oocytes per cycle. 11 higher number of oocytes retrieved has been linked with greater chances of pregnancy. 12 manipulation of menstrual physiology with the help of drugs and surgery is the key to success in art. 13 gnrh agonists utilize agonistic analogues of gonadotropins which have some amino acids substitutions in their amino acid sequence which happen to make them more competent corresponding author: dr abdul rehman khawaja email: arkhaja@gmail.com received: may11, 2016; accepted: october 21,2016 mailto:arkhaja@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):107-111 108 and enhance their half lives in comparison with the natural hormones. gnrh agonists provide continuous release of gonadotropin secretion. 14 gnrh antagonists cause sudden chemical suppression of the pituitary, thereby causing shutdown of lh (luteinizing hormone) and fsh (folliclestimulating hormone) secretion. 15 gnrh analogues are given to the women undergoing ovarian hyper-stimulation to obviate lh surge which may cause the follicles to ovulate prematurely. this helps the leading follicles to reach the optimum size. this is followed by injection of ovulation trigger which is hcg (human chorionic gonadotropin). history of the menstrual cycle provides information about the day of ovulation of the natural cycle which helps the clinician to schedule the visits of the patient for hormone tests and ultrasound examination. experienced clinician, after evaluating the situation of the patient, chooses the drugs, doses and time of ovulation induction from the available protocols. 16 so called long protocol consist of giving external recombinant gonadotropin along with gnrh agonists and causing suppression of pituitary fsh and lh. by this protocol cancellation rate is reduced and there is increase in recruitment of the follicles and getting larger number of oocytes. the incidence of premature surges of lh is also remarkably reduced. ovarian stimulation, through the use of gnrh agonists, helps to improve pregnancy rate as a result of ivf. 10 in the short protocol gnrh antagonists are used in art. they are highly potent and are effective in lower dosage. 17 suppression of anterior pituitary is more rapid in the short protocol thereby preventing lh release. the suppression is also easily and rapidly reversible. their mode of action is pharmacologically different from gnrh agonists. 14 gnrh antagonists are given in the mid-cycle which prevents an early lh surge. 18 no suppression occurs in the beginning of follicular phase which is an important time for recruitment of the follicles. ovarian stimulation by gnrh antagonist protocol is not only short but also cost effective. 17 perfect synchronization of female endocrines, endometrial physiology and embryonic factors form the basis of molecular communication between the uterine endometrium and upcoming embryo which helps in implantation and subsequent conception. 19 changes in morphology of the endometrium and hormonal secretion ensure proper embryo transfer and implantation capable of progression to pregnancy. 20 operational definitions embryo quality: embryo quality (eq) is based on division, age of embryo, day of embryo and degree of fragmentation or nucleation. and it is graded as grade 1, 2 or 3. endometrial thickness: thickness of lining of uterus, more than 8mm is considered for et. pregnancy rate:pregnancy rate is the success rate for getting pregnant. it is the percentage of all attempts that leads to pregnancy. chemical pregnancy:β-hcg level <10 iu/l for the first time. clinical pregnancy:β-hcg level testing >10 iu/l with pregnancy on ultrasound examination. long protocol: ovarian stimulation protocol using gnrh analogue in mid-leuteal phase of previous cycle is called long protocol (21 st day of cycle down regulation). antagonist protocol:ovarian stimulation protocols using gnrh antagonist is called antagonist protocol. subjects and methods in this quasi experimental study total number of 412 cases undergoing ivf were included who attended life art clinic at a private hospital in lahore from 1 st january to 30 th june 2015.this study was approved by life and hlh ethical committee. after taking approval from the institutional review board a specially designed questionnaire was used for data collection. the questionnaire was validated by life research cell biostatistician. patients who were not suitable for et were excluded from data. before signing the consent form, the couples were informed about the procedure and processes in detail. anonymization and de-identification of the couples was carried out prior to the analysis of the data. down-regulation was carried out in patients in the long protocol (n=175) group by starting the injection decapepyle1.0 mg-1.3 mg from day 21 of the menstrual cycle. serum level of e2 <30 pg/ml and lh <2 miu/ml confirmed full suppression of pituitary gland. recombinant fsh (gonal-f, puregon, follitropin) were also given on regular daily basis. ovarian response helped in adjusting the dosage of external fsh and lh. when 2 or more follicles reached the size of 18 mm recombinant hcg (pregnyl) was given. 34-36 hours after hcg administration oocytes were retrieved transvaginally. the patients on short protocol (n=237) gnrh antagonist (cetrotide, orgalutran) were started on 2nd day of the menstrual cycle and were continued till hcg administration. embryo transfer took place after three to five days under ultrasound guidance. fourteen days after embryo transfer, rising concentration of β-hcg confirmed pregnancy. data was entered on spss version 15.0 and analyzed. for continuous variables mean, sd and se were calculated. for categorical variables frequencies and percentages were calculated. chi-square test was used to check association for categorical variables and t-was used of continuous variables. multiple logistic regression was used to determine the relationship between pregnancy and factors that influence the outcome. results there was no significant difference in proportion of primary and secondary subfertility between two groups. there was also no significant difference between two groups in female journal of islamabad medical & dental college (jimdc); 2016:5(3):107-111 109 age, embryo quality, fsh (on day three) number of attempt, no of oocytes, fertilization, cleavage rate, maturation of oocytes and embryos transfer were significantly associated with both long and short protocol (table 1). in long acting gnrh group 1, fertilization rate was 62.74% and cleavage rate was 94.46% while in short acting gnrh group 2, fertilization rate was 61.89% and cleavage rate was 92.61%. in agonist (long protocol) had positive pregnancy test and (72%) had negative pregnancy test while in antagonist (short protocol) (24.1%) had positive pregnancy test and (75.9%) had negative pregnancy test. (table 2) rate of good quality embryos in long acting gnrh group was 28% and in short acting gnrh group was 24%. primary subfertility had 26.4 % while secondary subfertility had 17.6% rate of good embryo quality (table 3). female age and endometrial thickness were significantly associated with pregnancy outcome. pregnancy rate was improved as the endometrial thickness (p-value=0.05) increased. the estimated odds ratio (or) of positive pregnancy with female age was (1.075), type of infertility (1.454), endometrial thickness (0.868), no of embryo transfer (0.986) and protocol (1.066) respectively. (table 4) table 1: general characteristics of patients treated with the short and long protocol (gnrh) for ovarian stimulation variables longacting(n=175) short-acting(n=237) p-values female age (years) (mean±sd) 30.±4. 31.±5.1 0.071 proportion of primary subfertility n(%) 161(92) 217(92) 0.873 proportion of secondary subfertility, n(%) 14(8) 20(8) no of attempt (mean±sd) 1.1±0.5 1.2±0.529 0.034 no of oocytes (mean±sd) 11.±5.3 10.±5.232 0.004 fertilization rate, n(%) 1120/1785 (62.74) 1259/2034 (61.89) 0.009 cleavage rate, n(%) 1058/1120(94.46) 1166/1259 (92.61) 0.009 matured (mean±sd) 10.2000±4.8848 8.5641±6.0084 0.017 embryo transferred (mean±sd) 1.8092±0.7855 1.5511±0.6212 0.0001 on day 3 fsh [mlu/ml], (mean±sd) 7.5534±6.9503 7.1815±2.9639 0.106) on the day of hcg administration p4 [ng/ml], (mean±sd) 5.2232±2.1554 6.4222±3.9793 ns(0.414) endometrial thickness [mm], (mean±sd) 9.8573±1.6921 9.5574±1.6033 ns(0.635) table 2:association of long vs short protocol with respect to pregnancy test protocol p-value pregnancy agonist(long) (n=175) antagonist(short) (n=237) 0.356 positive n(%) 49 (28.0) 57(24.1) negative n(%) 126(72) 180 (75.9) table 3: association of ivf outcome predictors and embryo quality embryo quality variables good embryo quality(n) average embryo quality(n) rate of good embryoquality (%)% protocol long,gnrh(a) 49 126 28 short, gnrh(anta) 57 180 24 type of subfertility primary 100 278 26.4 secondary 6 28 17.6 table 4: association between pregnancy and factors that influence the outcome. variable b se wald d.f or 95% ci p-value female age 0.073 0.024 9.175 1 1.075 1.026 1.127 0.002 subfertility(primary, secondary) -0.374 0.476 0.618 1 1.454 0.572 3.697 0.432 endometrial thickness -0.142 0.075 3.55 1 0.868 0.748 1.006 0.05 number of embryo transfer -0.014 0.162 0.007 1 0.986 0.718 1.356 0.986 protocol (long, short) 0.063 0.238 0.071 1 1.066 0.669 1.698 0.79 discussion in our research primary and secondary subfertility, embryo quality, fsh (on day three), serum e2 and progesterone (p4) level on day of hcg injection and endometrial thickness had insignificant association with long and short protocol. female age, number of attempt, no of oocytes, fertilization, cleavage rate, maturation of oocytes and embryos transfer were significantly associated with long and short protocol. fertilization rate and cleavage rate was 63.79 % and 94.28% for long protocol; 64.53% and 92.47% for short protocol. percentage of good quality embryos in the long protocol was 28% and short protocol was 24%. the pregnancy rate with long protocol was 28.0% whereas 24.1 % with short protocol. age of the female and endometrial thickness showed a significant association with the pregnancy outcome in the logistic regression model. journal of islamabad medical & dental college (jimdc); 2016:5(3):107-111 110 primary and secondary subfertility had insignificant association with long and short protocol of ovarian stimulation in ivf/ icsi. main aim of assisted conception is to improve pregnancy rate in couples with subfertility. in vitro fertilization and embryo transfer in the subfertile females leading to clinical pregnancy became possible because of intelligent assessment of needs of individual patient and a personalized tailoring of coh and successful recruitment of adequate number of oocytes. 21 in many cases the response of the females to coh is not adequate and failure of treatment is imminent. these females are called poor responders who need an individualized ovarian stimulation protocol. 22 pregnancy rate after undergoing ivf got better because of using gnrh agonists for coh. untimely early lh surges were also lessened due to gnrh agonists. 11 gnrh antagonists have lesser side effects and also prevent early lh surges. 14 when gnrh antagonist suppresses the pituitary secretion of gonadotropins, it can be reversed rapidly. 23 short gnrh antagonist protocol is flexible, effective and easier to use and may become an alternative to the long protocol. 14 greenblatt, meriano and casper looked into type of coh protocols (both long and short) in 34 consecutive icsi cycles and their effect on oocyte maturity, rate of fertilization and cleavage. all these three parameters appeared to be better with the long protocol. more oocytes became mature (metaphase ii) as well as more cleaving embryos were seen with long gnrh protocol with a higher fertilization rate in comparison with short gnrh antagonist protocol. 24 successful ivf depends on maturation of adequate number of oocytes. chances of successful fertilization and subsequent clinical pregnancy are decreased when the retrieved oocytes are meiotically incompetent. 25 al-inany and aboulghar published a systematic review in 2002 in which long and short protocols were compared for efficacy in assisted reproduction by coh. short protocol was shown to have resulted in lesser number of clinical pregnancies (or 0.79; 95% ci 0.630.99). as far as premature lh surges’ prevention is concerned or was found to be 1.76 [95% confidence interval (ci) 0.75-4.16]. 24 malmusi et al., found that pregnancy rate was better with long protocol whereas implantation was similar in long and short protocol. retrieval of higher number of matured oocytes and greater number of good quality embryos were also shown in long protocol. 26 a prospective study was done on the data from 4 egyptian universities' "integrated fertility centers” by youssef et al. in 2008. women over the age of 40 were included who had a normal hormonal profile and no pelvic abnormality. women who received long protocol were 285 whereas 246 women received short protocol. standard icsi procedure was performed. pregnancy rate achieved by long protocol was 26.6 % and by short protocol was 10.2% (p <0.001). 27 mao et al. published retrospective analysis of comparison between long and short protocol in 2014, regarding thickness of the endometrium, quality of embryo and pregnancy rate. no significant differences were noted between long and short protocols for embryo quality, (63.16% vs. 66.26%, p> 0.05). pregnancy rate was higher with long protocol as compared to short protocol (59.60% vs. 43.42%, p < 0.05) type of subfertility and endometrial thickness had significant association with pregnancy success as shown by logistic regression analysis. 28 cheung et al. in 2005 published a randomized controlled trial comparing gnrh antagonist and long gnrh agonist protocol in women who underwent assisted reproduction (ivf) but were identified as poor responders. they were not able to find any significant differences in many important parameters like cancellation rates, stimulation duration, gonadotropins consumed, and average numbers mature follicles, oocytes, and number of embryos acquired. the antagonist group had higher number of embryos transferred, means and standard deviations being 2.32, 0.58 versus 1.50, 0.83 (p = 0.01). implantation rates were similar but pregnancy rates were higher for the antagonist group, though the difference was insignificant statistically. 29 ovarian response is categorized on the basis of levels of serum fsh and e2, number of oocytes, dose of gonadotropin and cycle cancellation rate. females with lower number of oocytes (>4) were labeled as poor responders and fsh higher than 300 iu was taken as no ovarian response. 15 conclusion in this study, pregnancy rate is better with long protocol but that was not statistically significant. more studies should be designed to compare long gnrh agonist protocols with short gnrh antagonist protocols with increase sample size for suitable comparison. conflict of interest this study has no conflict of interest a declared by any author. references 1. larcher v. the health of children conceived by assisted reproduction technologies. arch dis child. 2007;92(8):668-9. 2. qiao j, feng hl. assisted reproductive technology in china: compliance and non-compliance. transl pediatr. 2014;3(2):91-7. 3. feinberg ec, bromer jg, catherino wh. the evolution of in vitro fertilization: integration of pharmacology, technology, and clinical care. j pharmacol exp ther. 2005;313(3):93542. 4. trounson ao, leeton jf, wood c, webb j, wood j. pregnancies in humans by fertilization in vitro and embryo transfer in the controlled ovulatory cycle. science. 1981;212(4495):681-2. 5. brinsden pr, brinsden pr. thirty years of ivf: the legacy of journal of islamabad medical & dental college (jimdc); 2016:5(3):107-111 111 patrick steptoe and robert edwards. hum fertil (camb). 2009;12(3):137-43. 6. zhao y, brezina p, hsu cc, garcia j, brinsden pr, wallach e. in vitro fertilization: four decades of reflections and promises. biochimbiophysacta. 2011;1810(9):843-52. 7. ashkenazi j, dicker d, feldberg d, goldman ga, yeshaya a, goldman ja. the value of gnrh analogue therapy in ivf in women with unexplained infertility. hum reprod. 1989;4(6):667-9. 8. magon n. gonadotropin releasing hormone agonists: expanding vistas. indian j endocrinolmetab. 2011;15(4):261-7. 9. commenges-ducos m, tricaud s, papaxanthos-roche a, dallay d, horovitz j, commenges d. modelling of the probability of success of the stages of in-vitro fertilization and embryo transfer: stimulation, fertilization and implantation. hum reprod. 1998 ;13(1):78-83. 10. macklon ns, stouffer rl, giudice lc, fauser bc. the science behind 25 years of ovarian stimulation for in vitro fertilization. endocr rev. 2006;27(2):170-207. 11. edwards rg, lobo r, bouchard p. time to revolutionize ovarian stimulation. hum reprod. 1996;11 (5):917-9. 12. fleming r. time to revolutionize ovarian stimulation. ovarian stimulation. hum reprod. 1996;11(12):2579. 13. matzuk m & lamb dj.the biology of infertility: research advances and clinical challenges. nature medicine 2008. 14, 1197 1213 14. copperman ab, benadiva c. optimal usage of the gnrh antagonists: a review of the literature. reprod biol endocrinol. 2013;11:20. 15. shrestha d, la x, feng hl. comparison of different stimulation protocols used in in vitro fertilization: a review. ann transl med. 2015;3(10):137. 16. templeton a, morris jk, parslow w. factors that affect outcome of in-vitro fertilisation treatment. lancet. 1996;348(9039):1402-6. 17. depalo r, jayakrishan k, garruti g, totaro i, panzarino m, and giorgino f et al. gnrh agonist versus gnrh antagonist in in vitro fertilization and embryo transfer (ivf/et) reprod biol endocrinol. 2012; 10: 26. 18. gordts s, van turnhout c, campo r, puttemans p, valkenburg m, gordts s. a prospective randomised study comparing a gnrh-antagonist versus a gnrh-agonist short protocol for ovarian stimulation in patients referred for ivf. facts views vis obgyn. 2012;4(2):82-7. 19. cartwright je, fraser r, leslie k, wallace ae, james jl. remodelling at the maternal-fetal interface: relevance to human pregnancy disorders. reproduction. 2010;140(6):803-13. 20. gellersen b, brosens jj. cyclic decidualization of the human endometrium in reproductive health and failure. endocr rev. 2014;35(6):851-905 21. loutradis d, drakakis p, vomvolaki e, antsaklis a. different ovarian stimulation protocols for women with diminished ovarian reserve. j assist reprod genet. 2007;24(12):597-611. 22. shanbhag s, aucott l, bhattacharya s, hamilton ma, mctavish ar. interventions for 'poor responders' to controlled ovarian hyperstimulation (coh) in in-vitro fertilisation (ivf). cochrane database syst rev. 2007;(1):cd004379. 23. al-inanyh, aboulghar m. gnrh antagonist in assisted reproduction: a cochrane review. hum reprod. 2002;17(4):874-85. 24. greenblatt em, meriano js, casper rf. type of stimulation protocol affects oocyte maturity, fertilization rate, and cleavage rate after intracytoplasmic sperm injection. fertilsteril. 1995;64(3):557-63. 25. lee je, kim sd, jee bc, suh cs, kim sh. oocyte maturity in repeated ovarian stimulation. clinexpreprod med. 2011;38(4):234-7. 26. malmusi s, la marca a, giulini s, xella s, tagliasacchi d, marsella t, volpe a. comparison of a gonadotropinreleasing hormone (gnrh) antagonist and gnrh agonist flare-up regimen in poor responders undergoing ovarian stimulation. fertilsteril. 2005;84(2):402-6. 27. youssef h, el deebw,shawky o, metawe m, goda h. gnrh-along protocol versus semi-short protocol in women 40 years or more undergoing icsi: a multicenter study. middle east fertil soc j.2008;13 (1): 63–66. 28. mao gh, feng z, he y, huang yr. comparisons of the effects of long-acting and short-acting gnrh agonists on embryo quality, endometrial thickness and pregnancy rate in human in vitro fertilization. arch med sci. 2014;10(1):161-6. 29. cheung lp, lam pm, lok ih, chiu tt, yeung sy, tjer cc. et al. gnrh antagonist versus long gnrh agonist protocol in poor responders undergoing ivf: a randomized controlled trial. hum reprod. 2005;20(3):616-21. authorship contribution: author1:conception, plaining and final review of article. author2:active participation in research, interpretation, analysis and discussion author3:conception and plaining, active participation in research and final review of article author4:active participation in research and critical review of article https://www.ncbi.nlm.nih.gov/pubmed/?term=depalo%20r%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pubmed/?term=jayakrishan%20k%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pubmed/?term=garruti%20g%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pubmed/?term=totaro%20i%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pubmed/?term=panzarino%20m%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pubmed/?term=giorgino%20f%5bauthor%5d&cauthor=true&cauthor_uid=22500852 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3442989/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3442989/ j islamabad med dental coll 2020 303 open access effect of novel covid-19 infection on different organs of human body: a narrative review abdul qader hayat1, muhammad sajid hamid akash2 1student, department of pharmaceutical chemistry, government college university faisalabad, pakistan 2associate professor, department of pharmaceutical chemistry, government college university faisalabad, pakistan a b s t r a c t the covid-19 (corona virus disease-2019) infection produces detrimental effect on vital organs of the human body leading towards mild to severe organ damage. the most drastic effects associated with covid-19 infection include respiratory failure, cardiac arrest, liver injury and brain damage. the drugs which are used for the treatment of novel coronavirus are also associated with various side effects, which may prove fatal during treatment. this viral infection also reduces patients’ immunity by binding with ace2 (angiotensin-converting enzyme 2) receptors and modulates immune responses. older people are particularly at a greater risk. the literature selected for this narrative study was searched and collected from two databases, google scholar and pubmed by using specific key words, from march 2020 to june 2020. the objective of this study was to increase understanding about covid-19, particularly its effects on vital organs so that a better treatment strategy can be established. key words: angiotensin-converting enzyme 2, covid-19, immunity, organ damage authors’ contribution: 1-2conception; literature search; manuscript design and drafting; critical analysis and manuscript review; manuscript editing. correspondence: abdul qader hayat email: pharmacistqader316@gmail.com article info: received: april 16, 2020 accepted: december 25, 2020 cite this article. hayat aq, akash ms. effect of novel covid-19 infection on different organs of human body: a narrative review. j islamabad med dental coll. 2020; 9(4): 303-306. doi: 10.35787/jimdc.v9i4.532 funding source: nil conflict of interest: nil i n t r o d u c t i o n about 82% gene sequence of 2019 novel coronavirus or sars-cov-2 (severe acute respiratory syndrome-coronavirus 2) resembles sars-cov (severe acute respiratory syndromecoronavirus) and 50% with middle-east respiratory syndrome coronavirus (mers-cov).1 generally, covid-19 is a reversible disease with 0.1 to 25% case fatality ratio globally.2 in covid-19, death usually occurs due to massive alveolar destruction and respiratory failure.3 these patients suffer either a direct liver injury by viral invasion of cells or an indirect injury due to hepatotoxicity from drugs used in treatment.4 studies reveal that sars-cov2 has potentially deleterious effects on central nervous system as well.5 according to who, there have been about 21294845 confirmed covid-19 cases worldwide, including 761779 deaths till submission of this review. although this virus can infect all ages, but children, elderly and people with comorbidities are at greater risk.6 literature search for this narrative review was done mainly from two r e v i e w a r t i c l e j islamabad med dental coll 2020 304 databases (google scholar and pubmed) by using specific key words in english, from march 2020 to june 2020. key words/phrases used included “coronavirus”, covid-19”, “sars-cov”, “sars-cov2”, “organ damage in covid-19”, “liver and covid19”, “cvs and covid-19”, “respiratory system and covid-19”, “cns and covid-19”, and “angiotensinconverting enzyme 2”. the objective of this study was to increase understanding about covid-19, particularly its effects on vital organs so that a better treatment strategy can be established. cardiovascular system (cvs) novel coronavirus and mers-cov produce similar pathogenicity. cardiac injury produced by novel coronavirus infection was reported in 5 of 41 earliest patients in wuhan.3 according to nhc (nationalhealth commission, china), the coronavirus patients first complained about chest tightness and heart palpitations before the onset of typical symptoms such as shortness of breath, flu, cough, fever and sore throat. death in many covid-19 patients has been reported due to cardiac arrest and heart damage during hospitalization.7 a survey-based data collected from 25 patients, who had recovered from sars-cov-2 infection, showed cvs abnormalities in 44% patients. these patients exhibited an abnormal biochemical profile, indicating high levels of serum free fatty acids (ffa), lysophosphatidyl ethanolamine (lpe), lysophosphatidylcholine (lpc) and phosphatidylglycerol (pg) as compared to normal individuals.8 because the structure of sarscov-2 is similar to sars-cov, there is a possibility of similar behavior in affecting cvs. people with comorbidities of cvs are at a higher risk and the death rate is also found to be high in such patients. therefore, patients already suffering from cvs complications must be monitored carefully during treatment and given special care.7 during treatment, the administration of antiviral drugs should also be carefully monitored because these drugs can lead to arrhythmias, cardiac insufficiency and other related complications.9 liver the chances of hepatic disturbance due to covid-19 infection are high, probably due to the attack of sars-cov-2 on liver cells or adverse effects of the medicines taken by the patients.4 liver injury has been described in a patient infected with novel coronavirus.10 in another study, elevation of ast (aspartate aminotransferase), a biomarker of liver injury, was recorded in 8 of 13 patients infected with sars-cov-2 in the intensive care unit. it was observed that the severe cases are more prone to liver injury than milder ones.7 approximately 2–10% of patients with novel coronavirus infection present with diarrhea, and sars-cov-2 rna has been detected in stool and blood samples.11 however, the pathological investigation of hepatic tissues of a dead coronavirus patient showed no viral inclusions in the liver.11 drugs used in the treatment of covid-19 may also produce hepatotoxicity. in addition, the immunemediated inflammation, including pneumoniaassociated hypoxia and cytokine storm might also cause liver injury in corona patients.7 the medicines being used to combat novel coronavirus like lopinavir, oseltamivir, ribavirin, ritonavir, hydroxychloroquine sulfate, chloroquine phosphate, and azithromycin are metabolized within hepatic cells. the hepatotoxicity associated with coronavirus can disturb the metabolism of these drugs leading to their higher concentrations in plasma causing increased chances of toxicity.12 central nervous system (cns) many studies have shown the existence of sars-cov in cns, where most of the viral strains are found in nerves.13-15 an experimental study has also revealed that when sars-cov and mers-cov are given j islamabad med dental coll 2020 305 intranasally, these can enter into the brain via the olfactory nerves and spread rapidly to brain niches, specifically in the brainstem and thalamus.16 surprisingly the mers-cov strains were isolated from only brain (not in lungs), and the brainstem appeared to be the most prominent site of infection by sars-cov-2.16,17 the actual route of entry of viral strains into cns is still not clear, however some evidence suggests sars-cov strains first permeate into peripheral nerves, and then enter cns via synapse-connections.18,19 collectively, the neuroinvasive tendency is a common property of coronaviruses and due to similarity between sarscov2 and sars-cov, it is possible that sars-cov2 also possesses the same potential. thus, the virus enters into the brain and damages the medullary neurons. some neurological symptoms observed in patients of covid-19 in a study are headaches, loss of smell and taste, vomiting and nausea.5 respiratory system the novel coronavirus shows great resemblance with middle-east respiratory-syndrome (mers) and sars-cov infection.20 in a study the histological features exhibited bilateral alveolar damage and multinucleated-syncytial cells in alveolar spaces, which was a clear indication of viral infection.11 covid-19 infection and ace-2 receptor interaction angiotensin-converting enzyme 2 (ace2) is an aminopeptidase that plays a very important role in immune and cardiovascular system. ace2 has diverse functions. most importantly this enzyme participates in the regulation of heart functions and has been implicated as a key receptor for binding of covs (coronaviruses) such as sars-cov2 and sarscov. the sars-cov2 contains various proteins on its surface in a spike-like form and the infection of sars cov2 is stimulated when these viral proteins interact with ace-2. this interaction creates harmful effects on patients’ immune system and cvs.21 sars-cov2 mainly destroys alveolar cells which leads to respiratory symptoms.7. limitation: this review included studies till june 2020, a lot of research must have been available till the publication of this manuscript. the element of bias cannot be ruled out because of unsystematic selection procedure inherent of the narrative reviews. c o n c l u s i o n the current form of coronavirus is capable of destroying vital organs of human body. the heart, liver, cns and lungs are more prone to the attack of this virus. now, covid-19 infection has become a global threat and it has spread worldwide. the population of some countries is at greater risk because of low levels of immunity owing to poor socioeconomic conditions. in many countries the biological researchers are struggling to combat covid-19 infection. the pakistani researchers should also play their part and should present their research initiatives to the government. the government of pakistan needs to set up proper research centers for this purpose so that we may have better treatment options not only for local community but also for the world in future. r e f e r e n c e s 1. chau tn, lee kc, yao h, tsang ty, chow tc, yeung yc, choi kw, tso yk, lau t, lai st, lai cl. sars‐associated viral hepatitis caused by a novel coronavirus: report of three cases. hepatol. 2004; 39(2): 302-10. doi: 10.1002/hep.20111. 2. world health organization. who: estimating mortality from covid-19. [online]. available from: https://www.who.int/news-room/commentaries /detail/estimating-mortality-from-covid-19. 3. chan, j.f.w., yuan, s., kok, k.h., to, k.k.w., chu, h., yang, j., xing, f., liu, j., yip, c.c.y., poon, r.w.s. and tsoi, h.w., 2020. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet. 2020; 395(10223): 514-23. doi: 10.1016/s0140-6736(20)30154-9. j islamabad med dental coll 2020 306 4. zhang c, shi l, wang fs. liver injury in covid-19: management and challenges. lancet gastroenterol hepatol. 2020; 5(5): 428-30. doi: 10.1016/s24681253(20)30057-1. 5. li yc, bai wz, hashikawa t. the neuro-invasive potential of sars‐cov2 may play a role in the respiratory failure of covid‐19 patients. j med virol. 2020; 92(6): 552-5. doi: 10.1002%2fjmv.25728. 6. world health organization. coronavirus disease 2019 (covid-19): situation report, 146. https://apps.who.int/iris/handle/10665/332403. 7. zheng yy, ma yt, zhang jy, xie x. covid-19 and the cardiovascular system. nat rev cardiol. 2020; 17(5): 259-60. doi: 10.1038/s41569-020-0360-5. 8. wu q, zhou l, sun x, yan z, hu c, wu j, et al. altered lipid metabolism in recovered sars patients twelve years after infection. sci rep. 2017; 7(1): 1-2. doi: 10.1038/s41598-017-09536-z. 9. sakabe m, yoshioka r, fujiki a. sick sinus syndrome induced by interferon and ribavirin therapy in a patient with chronic hepatitis c. j cardiol cas. 2013; 8(6): 173-5. doi: 10.1016/j.jccase.2013.08.002. 10. yeo c, kaushal s, yeo d. enteric involvement of coronaviruses: is faecal–oral transmission of sarscov-2 possible? lancet gastroenterol hepatol. 2020; 5(4): 335-7. doi: 10.1016/s2468-1253(20)30048-0. 11. xu z, shi l, wang y, zhang j, huang l, zhang c, et al. pathological findings of covid-19 associated with acute respiratory distress syndrome. lancet respi medi. 2020; 8(4): 420-2. doi: 10.1016/s22132600(20)30076-x. 12. rismanbaf a, zarei s. liver and kidney injuries in covid-19 and their effects on drug therapy; a letter to editor. arch acad emerg med. 2020; 8(1): e17. http://journals.sbmu.ac.ir/aaem. 13. ding y, he l, zhang q, huang z, che x, hou j, et al. organ distribution of severe acute respiratory syndrome (sars) associated coronavirus (sars‐cov) in sars patients: implications for pathogenesis and virus transmission pathways. j pathol. 2004; 203(2): 622-30. doi: 10.1002/path.1560. 14. gu j, gong e, zhang b, zheng j, gao z, zhong y, et al. multiple organ infection and the pathogenesis of sars. j exp med. 2005; 202(3): 415-24. doi: 10.1084/jem.20050828. 15. xu j, zhong s, liu j, li l, li y, wu x, et al. detection of severe acute respiratory syndrome coronavirus in the brain: potential role of the chemokine mig in pathogenesis. clin infect dis. 2005; 41(8): 1089-96. doi: 10.1086/444461. 16. li k, wohlford-lenane c, perlman s, zhao j, jewell ak, reznikov lr, et al. middle east respiratory syndrome coronavirus causes multiple organ damage and lethal disease in mice transgenic for human dipeptidyl peptidase 4. j infect dis. 2016; 213(5): 712-22. doi: 10.1093/infdis/jiv499. 17. netland j, meyerholz dk, moore s, cassell m, perlman s. severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ace2. j virol. 2008; 82(15): 7264-75. doi: 10.1128/jvi.00737-08. 18. li yc, bai wz, hirano n, hayashida t, hashikawa t. coronavirus infection of rat dorsal root ganglia: ultrastructural characterization of viral replication, transfer, and the early response of satellite cells. vir res. 2012; 163(2): 628-35. doi: 10.1016/j.virusres.2011.12.021. 19. matsuda k, park ch, sunden y, kimura t, ochiai k, kida h, et al. the vagus nerve is one route of transneural invasion for intranasally inoculated influenza a virus in mice. vet pathol. 2004; 41(2): 1017. doi: 10.1354%2fvp.41-2-101. 20. ding y, wang h, shen h, li z, geng j, han h, et al. the clinical pathology of severe acute respiratory syndrome (sars): a report from china. j pathol. 2003; 200(3): 282-9. doi: 10.1002/path.1440 21. turner aj, hiscox ja, hooper nm. ace2: from vasopeptidase to sars virus receptor. trends pharmacol sci. 2004; 25(6): 291-4. doi: 10.1016/j.tips.2004.04.001. 178 j i m d c 2 0 1 7 178 op e n ac c e ss f u l l l e n g t h a r t i c l e effects of therapeutic ultrasound and manual physiotherapy in shoulder impingement syndrome in volleyball players muhammad imran 1, naveed arshad 2, shahbaz ibrahim 3, aqeel ahmed 4, muhammad tayyab minhas 5 1 consultant physiotherapist, dhq hospital sheikhpura 2 assistant professor, islamabad medical and dental college, islamabad 3 assistant professor, riphah international university, faisalabad campus 4 assistant professor, isra university islamabad campus 5 lecturer, riphah international university, faisalabad campus a b s t r a c t objective: to look into the effectiveness of ultrasound therapy in addition to physical therapy and exercises on relief of pain, increase in the range of movements and improvement in muscle power in patients of shoulder impingement syndrome (sis). patients and methods: a total of 30 patients, aged 18-30 years, of sis were randomly selected amongst volley ball players. they were divided by convenient sampling into two groups of 15 patients each: therapeutic ultrasound manual physiotherapy & exercise treatment (tumpet) group and manual physiotherapy exercise treatment (mpet) group; the latter served as the control group. both group were tested twice once before the start of treatment and once after completion of treatment. results: the measurement of shoulder rang of movement and muscle power show significant results in both control and treatment groups at the end of 14th week’s treatment period. in control group (group mpet) the range of motion degree scale has improved from 135.53±10.88 to 136.67±9.94 p-value 0.000 and muscle strength grades has improved from 3.33±0.49 to 4.00±0.000. in the interventional group (group tumpet) the range of motion degree scale has improved from 134.00±6.80 to 164.33±8.42 p-value 0.000 and muscle strength grades has improved from 3.47±0.52 to 5.60±0.50 p-value 0.000. conclusion: those individuals who received ultrasound treatment along with manual and exercises therapy showed significant improvement at fourteen weeks’ treatment. keywords: manual therapy, shoulder exercises, shoulder impingement syndrome, therapeutic ultrasound author`s contribution 1 conception, synthesis and planning of the research, active participation in data collection. 2 active participations in active methodology, interpretation, analysis and discussion. 3 data management. 4 analysis and discussion. 5 data management address of correspondence naveed arshad email. oliajann@gmail.com article info. received: june 12, 2017 accepted: august 10, 2017 cite this article: imran m, arshad n, ibrahim s, ahmed a, minhas mt. effects of therapeutic funding source: nil ultrasound and manual physiotherapy in shoulder impingement syndrome in conflict of interest: nil volleyball players..jimdc. 2017; 6(3):178-181. i n t r o d u c t i o n various studies have been conducted focusing on the clinical problem of shoulder impingement syndrome (sis), especially making an attempt to identify the causes of this problem and the damage it causes to a sport man. kibler argued that sportsmen, normally throwing athletes and swimmers, who experience the unpleasant effects of o r i g i n a l a r t i c l e 179 j i m d c 2 0 1 7 179 impingement disorder, are shown to have tear of the scapulothoracic muscles.1 the dynamic impact of the scapular muscles weakening is best shown when the serratus anterior muscle is involved.2 the failure of stretching the scapula offers ascent to scapula winging via raising the upper limb.3 weak muscles of scapula modify the scapulohumeral muscles and spot tension on gleno-humeral, which brings about auxiliary muscles outward the impingement. in the tendon of supraspinatus and sub acromial bursa, the painful condition is sub acromial impingement syndrome (sis) in the arch of coracoacromial and humeral head; this is a common cause of pain.4 the pain is felt severely and is caused by micro trauma, misuse or repetitive movements of the overhead position of the arm which is leading to deltoid and biceps area. it is presumed that the stiffness of coracoacromial ligament, the long head of biceps lesion, rotator cuff tear, partial or full thickness and sub acromial bursitis and abnormal biomechanical movements of scapula are the main causes of sub acromial impingement disorder.5 the literature shows the effectiveness of different physical therapy movements and manual therapy procedures on the management outcome.6 effectiveness of the use of ultrasound therapy for the management of sis is still inconclusive. several researches show that ultrasound for sis do not provide an extra advantage7; others show the usefulness of ultrasound in sis.8 sub acromial impingement might be treated by means of traditional treatment.9 for range of motion and muscular power to restore the mobility and stability of shoulder perform specific supervised exercises. therapeutic ultrasound is more common in physical therapy treatment and other electrotherapy treatments like tens and stimulator are also used. mulligan's theory on manuals therapy is that damage of joint or loss in function result in a chronic misaligns inside the joint and the procedures are used to straighten joint or re-establishing its alignment for decrease in pain, improve utility and improve dynamic range of movement in shoulder abduction.10 the rationale of this study was to evaluate, firstly, the impact of ultrasound treatment for impingement disorder in athletes and coaches. we are interested to increase muscle strength of shoulder joint by different shoulder exercises. p a t i e n t s a n d m e t h o d s a randomized control trial was done. a total of 30 male volley ball players with sis were enrolled in the study from different universities of lahore. they were allocated into two groups of 15 individuals each by non-probability convenience sampling; these groups were named as therapeutic ultrasound manual physiotherapy & shoulder exercise treatment (tumpet) group and manual physiotherapy shoulder exercise treatment (mpet) group. both group were tested twice once before the start of treatment and once after completion of treatment. the participants were separated into two assemblies via convenience sampling. the duration of the study was 14 weeks. the following two procedures were used for evaluation of the patients: abduction range of motion which was measured by the degree of range of motion and assessed by a goniometer. it consists of 4 degrees of shoulder abduction range of motion i.e., 40 – 60 degree, 61 – 100 degree, 101 – 150 degree and 151 – 180 degrees.12 muscle power which was measured by grading system of muscle power and assessed by using the 3 kg weight.12 it consists of 6 grades and has response as (grade 0: refers to non contractile and non-sensory in palm of the person. grade 1: the individual presently feels a contraction lacking the capability of hands to move. grade 2: the patient devoid of burdens raises hands by means of half of the range. grade 3: the person only with no weights can raise hands with full range. grade 4: person can lift weight up to three kg to partial range, 90 degrees. grade 5: the person can lift three kg with full range). demographic data included the following information: ages of the participants and difficulties in overhead activities. all participants completed the study and were included in the analysis. 15 individuals from mpet group completed the study that expected manual therapy and executed the exercises of shoulders. whereas 15 individuals of tumpet group as well completed the study that acknowledged ultrasound therapy, exercises of shoulders and manual therapy. the protocol for both the mpet and 180 j i m d c 2 0 1 7 180 tumpet groups involved the application of manual physical therapy and shoulder exercises for a total of 14 treatment sessions of 30 minutes, over a period of 14 consecutive weeks. at the beginning of the treatment, all participants were given a brief explanation of anatomy and biomechanics of the shoulder complex and a short description of the etiology and pathology of sis.the treatments aimed to prevent further damage and consisted of manual therapy techniques such as joint mobilization techniques and transverse friction massage and shoulder pendulum exercises. the treatments aimed at restoring the functional level by increasing rom, muscle strength and flexibility and consisted of rom exercises with rope and pulley, l bar exercises, selfcapsular stretching exercises, joint mobilization techniques and strengthening exercises with weights, therapeutic bands, springs and push-ups. the standard exercise protocol and manual therapy were given in order to restore muscular deficits in strength, mobility, and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements. and the participants were expected to return to their functional level without recurrence at the end of the treatment. participants in the tumpet group received continuous ultrasound for 5 minutes with a device that was operated at a frequency of 1.5 mhz, and an intensity of 1 w/cm2, the treating physical therapist, using the technique of slow circular movements, applied the transducer head over the superior and anterior periarticular regions of the participant's glenohumeral joint and on the shoulder trigger points. the treatment was continued from the first treatment session over the 15th treatment session period. all data was entered and analyzed carried out with spss statistical software (version 21). distributions of frequency and also standard deviations and means were utilized for expressive reasons. paired sample t-test to assess the difference of mean values, ± std. deviation and p value or not in 1st week range of motion and power of muscle and 14th-week range of motion and power of muscle within each group. independent sample t-test to assess dissimilarity of mean values, ± std. deviation and p value for significant or not in 1st-week range of motion and power of muscle and 14th-week range of motion and power of muscle in between groups. the p value was considered statically significant 0.05. r e s u l t s the mean range of ages and sports experience was calculated by mean values. the average age of both groups (mept and tumpet) was 24.57±2.54 and sports experience was 3.58±1.73 (table 1). paired sample t-test was applied for change in (group mpet & tumpet), 1st week range of motion and muscle power and 14th week rom and muscle power (table 2) compare the mean significant values in between the groups, independent sample t-test was used that indicated highly significant difference in rom and muscle power in impingement syndrome. it was hypothesized that ultrasound, manual therapy and physical therapy exercises are more effective in shoulder impingement syndrome in volleyball players. d i s c u s s i o n in this study, ‘the range of movements (rom) and muscle power’ in shoulder impingement syndrome were looked into before and after subjecting the affected joint to ultrasound therapy, manual therapy and physical exercises in an attempt to reduce the signs and symptoms and to increase the rom and muscle power of the shoulder joint. previously, a randomized control study has been published from turkey; it emphasized on the effectiveness of ultrasound versus physical therapy treatments and other measures in the management of shoulder problems.13 the study was conducted on 40 patients who had been recognized with the help of ultrasonography or mri to have a periarticular tender ailment of the shoulder and had been randomly selected. of these patients, one group obtained proper ultrasound (n=20, mean time and standard deviation=8.7±8.8 months and the range was 1 – 36) and the other group received fake ultrasound (n=20, imply time=8.1±10.8 months, and range=1-42). both groups were treated in 5 days a week with real or fake ultrasound for 10 minutes, superficial heat for 10 mins, electrical stimulation for 15 minutes, and exercise program for15 to 30 minutes for 3 weeks. the groups showed a reduction of pain, improved rom, shoulder incapacity annexure ratings, and fitness assessment rankings with treatment, but the changes 181 j i m d c 2 0 1 7 181 were not statistically significant between the groups. after findings finally they determined that the results cautioned that proper ultrasound as compared with fake ultrasound deliver in addition gain whilst implemented to different physical therapy treatment within the control of shoulder problems. different studies have determined that manual and exercise therapy appear to have a role in shoulder impingement.14 it is observed that a 4-week program along with motor management and strengthening exercises reduced shoulder pain and improved feature of individuals with shoulder impingement syndrome. the efficacy of ultrasound, laser, and exercises of shoulder impingement syndrome have been emphasized.4 in another study, a management plan of manual and exercise therapy was looked into for the efficacy of placebo treatment which was implemented through physical therapists to the patients with persistent rotator cuff syndrome. patients were selected randomly and blinded, placebo controlled trial was conducted. a program of manual therapy and domestic workout was no longer advised; further, instantaneous treatment for pain and functional ability was found to have benefits as compared with a practical placebo treatment that was given by therapists’ in elderly patients with chronic rotator cuff syndrome.15 some authors investigated and concluded that ultrasound is a diagnostic tool with high precision, safe and affordable, dynamic, and conservative treatment after two months resulted in improved treatment outcome.12 in the present study, the individuals who were subjected to manual and physical exercises therapy of shoulder as well as those who were subjected to ultrasound treatment in addition to manual and exercises therapy had significant improvement after fourteen weeks treatment. however, in the latter group, there was the statistically highly significant difference in the degree of range of motion of shoulder joints. there was also observed a significant difference in term of muscle strength grades in impingement syndrome. c o n c l u s i o n it is concluded that ultrasound therapy has benefit as compared to physical exercises of shoulder in treatment of shoulder impingement syndrome to reduce pain, increase rom and muscle power. r e f e r e n c e s 1. kibler, w.b. closed kinetic chain rehabilitation for sports injuries. phys med rehabil clin n am. 2000; 11(2): 369–384. 2. duke, p., & wallace, w.a. pathophysiology of impingement. in copeland s (ed) shoulder surgery. w.b. saunders company ltd, london. 1997; 1st ed: p. 171–178. 3. weiser, w.m., lee, t.q., mcmaster, w.c., mcmahon, p.j. effects of simulated scapular protraction on anterior glenohumeral stability. am j sports med. 1999; 27(6): 801–805. 4. aktas, i., akgun, k., cakmak, b. therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome. clin rheumatol. 2007; 26(8): 1234-9. 5. calis, h.t., berberoglu, n., calis, m. are ultrasound, laser and exercise superior to each other in the treatment of subacromial impingement syndrome? a randomized clinical trial. eur j phis retail med. 2011; 47(3):375-380. 6. lori, a., michener, matthew, k., walsworth, evie, n., burnet. effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. hand ther. 2004; 17(2):152–164. 7. celik, d., atalar, a.c., sahinkaya, s., demirhan, m. the value of intermittent ultrasound treatment in subacromial impingement syndrome. acta orthop traumatol turc. 2009; 43(3): 243-7. 8. santamato, a., solfrizzi, v., panza, f., tond, g., frisardi, v., leggin, b.g., ranieri, m., fiore, p. short-term effects of highintensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial. phys ther. 2009; 89(7): 643-52. 9. arcuni, s.e. rotator cuff pathology and subacromial impingement. nurse pract. 2000; 25(5): 58-61. 10. bang, m.d., deyle, g., d. comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome.j orthop sports physther. 2000; 30(3), 126–137. 11. thiruvasagar p. effectiveness of ultrasound therapy in combination with manual therapy and shoulder exercises for sub acromial impingement syndrome. international journal of scientific and research publications. february 2013; 3(2): 8. 12. alipour d., & goodarzi b, effect of 12 weeks selected physiotherapy programs on treatment of the shoulder impingement syndrome in volleyball players. asian journal of multidisciplinary studies. january 2015; 3(1): 194-195. 13. gursel yk, ulus y, bilgic a, dincer g, van der heijden gj. adding ultrasound in the management of soft tissue disorders of the shoulder: a randomized placebo-controlled trial. physical therapy. 2004; 84(4):336-43. 14. michener l.a., walsworth, m.k., burnet, e.n. effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. j hand ther. 2004; 17(2): 15264. 15. bennell, k., coburn, s., green, s., harris, a., staples, m., forbes, a., buchbinder, r. efficacy of standardized manual therapy and home exercise programme for chronic rotator cuff disease. bmj. 2010; 340, 27-56. j islamabad med dental coll 2019 74 open access effectiveness of tympanic thermometry for diagnosing acute otitis media muhammad zubair 1, ghulam saqulain 2, arfat jawaid 3 1 audiologist, isra university, islamabad 2 head, department of ent, cda capital hospital, islamabad 3 ent surgeon, department of ent, fc hospital, quetta a b s t r a c t background: acute otitis media (aom) is a common upper respiratory tract infection (urti) in children and usually presents with fever and otalgia. aom is characterized by congested tympanic membrane and possible increase in temperature, which might be picked up by infrared tympanic thermometry. the objective of this study was to compare the temperature difference of tympanic membrane of affected ear with the unaffected ear and axilla in unilateral acute otitis media, and compare it with the control group. material and methods: this case control study comprised of 200 cases of both genders, aged up to 5 years. they were divided into two groups; group a included 100 clinically diagnosed cases of acute otitis media (aom), who reported in the ent outpatient department (opd) and group b included 100 controls who presented in general filter clinic with no ear complaints. cases with chronic ear disease, ear discharge, and use of local drugs including ear drops, impacted ear wax, tragal tenderness and congenital malformations of the ear were excluded by taking a detailed history. clinical examination including otoscopy by an expert was done before subjecting patients to axillary and tympanic thermometry measurements and data recording. data was collected and tabulated using microsoft excel worksheet and analyzed by spss 16. qualitative data like gender were presented as percentage and ratio, while means and standard deviation were calculated for the quantitative data. difference between the means of experimental and control groups were analyzed by independent sample t-test and p value of less than or equal to 0.05 was taken as significant. results: this study included 100 cases of unilateral aom and 100 normal controls without aom. in patients with aom, the mean temperature difference between the affected ear and axilla was 1.41ºf as compared to 0.075ºf in controls (p=0.026). while the mean temperature difference between the affected ear and other ear was 0.65ºf as compared to 0.19ºf in controls (p=0.069). conclusion: in acute otitis media, the temperature of affected ear is significantly higher than axilla but was not significantly higher than the other ear. the finding may help establish thermometry as a diagnostic tool in clinics manned by doctors not competent to do otoscopy. key words: axillary temperature, infrared tympanic thermometer, otitis media, tympanic temperature authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussions, active participation in data collection 3 data analysis. correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: january 8, 2019 accepted: april 19, 2019 cite this article. zubair m, saqulain g, jawaid a. effectiveness of tympanic thermometry for diagnosing acute otitis media. j islamabad med dental coll.2019; 8(2):74-78 funding source: nil conflict of interest: nil i n t r o d u c t i o n ear temperature accurately reflects core body temperature1, since the eardrum shares blood supply with the thermostat in the hypothalamus. tympanic infrared thermometry is increasingly being used to rapidly measure body temperature. acute otitis media (aom) is a common upper respiratory tract infection urti in children2, with an incidence of 256/1000 person-years in europe3 and a high overall incidence per 1000 personyears of 138, 207, 105 and 99 respectively reported for pakistan, saudi arabia, oman, and turkey in a o r i g i n a l a r t i c l e j islamabad med dental coll 2019 75 multinational study by mustafa et al.4. aom usually presents with fever and otalgia. in a study by liese et al., earache was reported in 68.3%, redness of the tympanic membrane in 67.3%, ear discharge in 16.9% and spontaneous perforations in 7.1% of children presenting with aom.3 in young children, crying, rubbing and holding of the ear, may suggest earache, however it becomes difficult for the physician to know the exact cause of fever in children who are unable to share their complaints. diagnosis of aom in such cases would require otoscopy. aom is characterized by congested tympanic membrane and possible increase in temperature, which might be picked up by infrared tympanic thermometry. this study was conducted to see whether there is an increase in tympanic temperature as measured by tympanic thermometry in ears affected by acute otitis media, as compared to normal ear and temperature in axillary region. this will serve to see if tympanic thermometry can be used as a screening tool by nonotologists to diagnose aom especially in basic health units and in pediatric setups. the present study is important since no study has come up from pakistan and because our basic health units are devoid of personnel trained in otoscopy. m a t e r i a l a n d m e t h o d s this is a case control study in which clinically diagnosed children of aom of both genders, and up to 5 years of age, who presented in the ent outpatient department (opd) and general filter clinic of capital hospital, capital development authority (cda), islamabad from january 2014 to december 2016, were included. cases with discharging ears, those using local medications like ear drops, any ear disease, tragal tenderness, otitis externa, congenital deformities of ear and impacted wax were excluded from the study. patients were divided into two groups. group a (experimental group) comprised of 100 clinically diagnosed cases of acute otitis media who reported in ent opd, and group b (control group) included 100 cases who presented in filter clinic of outpatient. a detailed history including, chronic ear disease, ear discharge, use of ear drops was obtained by an otolaryngologist who also ruled out conditions like ear wax impaction, tragal tenderness etc., by otoscopy and confirmed presence of aom in the experimental group before the patient underwent axillary and tympanic thermometry measurements. in all the patients, axillary temperature (at) was noted at 3 minutes using a calibrated mercury thermometer and tympanic temperature was measured with the help of a calibrated infra-red thermometer (braun thermoscan irt4020) using a new lens filter for each measurement. for each recording, thermometer probe was gently but snuggly fitted in the ear canal ensuring its direction to the tm (avoiding any discrepancy in measurement).5 the data included qualitative variables like gender and quantitative variables like age, tympanic temperature right ear (ttr), tympanic temperature left ear (ttl) and axillary temperature. data was collected, tabulated and analyzed using microsoft excel worksheet. tympanic temperature minus axillary temperature was calculated for both experimental and control groups. temperature of affected ear minus other ear was calculated for patients of aom in experimental group while temperature difference of right and left ears was calculated for normal individuals in control group. data was collected and tabulated using microsoft excel worksheet and analyzed by spss 16. qualitative data was calculated and presented as percentage and ratio, while means were calculated for the quantitative data. difference between the means of experimental and control groups was analyzed by independent sample ttest and p value of less than or equal to 0.05 was taken as significant. the data was then compared with the literature available from different parts of the world and other parts of the country and deductions made and discussed. r e s u l t s the total study population analyzed (n= 200) was divided equally into two groups. group a (experimental group) included 58 (58 %) males and 42 (42%) females, with male to female ratio of 1.4:1. group b (control group) included 81 (81%) males and 19 (19%) females with male to female ratio of 4.3:1. in group a, age range of aom j islamabad med dental coll 2019 76 patients was from 4 months to 4 years with a mean age of 2.8 + 0.96 years and in group b, age range of the controls was from 1 year to 5 years with a mean age of 3 + 0.97 years (table i). table i: demographic data of the study population (n=200) group a group b gender n (%) male 58(58%) 81 (81%) female 42(42%) 19(19%) age (years) minimum 0.3 1.0 maximum 4.0 5.0 mean 2.8 3.0 median 3.0 3.1 mode 3 3 table ii shows the temperature difference between the ear and axilla in group a, mean temperature difference and standard deviation between the affected ear and axilla of 1.41 + 1.470f. while in group b, the mean temperature difference and standard deviation between the ear and axilla was 0.075 + 1.80f with p value less than 0.026, which is statistically significant. note: group a = experimental group, group b = control group pair 1: group a: tympanic temperature of affected ear minus axillary temperature group b: tympanic temperature of normal ear minus axillary temperature pair 2: group a: tympanic temperature of affected ear minus normal ear group b: tympanic temperature of right ear minus left ear in control regarding the temperature difference between both the ears, in group a, 77 out of 100 patients had unilateral aom. in these patients the mean difference and standard deviation between the temperature of affected ear and the other ear is 0.65 + 0.78 0f. while in the first 77 individuals in the control group the mean temperature difference and standard deviation, between the temperature of right and left ear is 0.19 + 0.650f. the observed difference is not statistically significant as the calculated p value is more than 0.05 (p=0.069). d i s c u s s i o n body core temperature is a vital sign with no test that can be labelled as gold standard for clinical temperature assessment. core temperature should actually be measured from the pulmonary artery 1, which is not accessible clinically. conventionally body temperature is measured by taking an intraoral sublingual, rectal, axillary and even skin temperature, usually with a mercury thermometer. however, a number of drawbacks made physicians stick to axillary temperature measurement since this is safe and easily accessible in children. however, doubts regarding accuracy of axillary temperature exist.6 tympanic temperature reflects core body temperature.1,7 advent of infrared tympanic thermometry has made this vital sign recording possible within seconds. acute otitis media (aom) being very common in childhood 3 and being an infective/ inflammatory condition, increase in temperature in the tympanic cavity is very likely. several authors have searched the effect of different pathologies of the ear on thermometry in a hope to use this vital sign for ear pathologies.8 13 robb and shahab, studied thermometry in otitis media with effusion (ome) with no effect on temperature.8 terndrup and wong found elevated rectal temperature in cases with acute otitis media,13 and aniutin et al., found increased difference between tympanic and axillary temperatures in exudative otitis media (eom).11 kelly and alexander did not find significant temperature difference in suppurative and nonsuppurative otitis media with either the other ear or oral and rectal temperatures.14 presence of wax may reduce the temperature measurement.12 in this study we found that the temperature of affected ear in acute otitis media was significantly higher than axillary temperature but was not significantly higher than the other ear, with mean temperature difference between the affected ear and table ii: independent sample test statistics for temperature difference between pair 1 and pair 2 variables temperature difference levene’s test for equality of variance t-test for equality of means p value pair 1 (mean + sd) (f, sig.) t group a: 1.41 + 1.47 .815, .374 2.344 .026 group b .075 + 1.80 pair 2: 0.65 + 0.78 .178, .676 1.880 .069 group a group b: 0.19 + 0.65 j islamabad med dental coll 2019 77 axilla being 1.41of as compared to 0.075of in controls (p=0.026). however, the mean temperature difference between the affected ear and other ear was 0.65of as compared to 0.19of in controls (p=0.069). similarly, dogan et al., found higher temperature in tympanic than axillary thermometry.9 brennan et al concluded in their study that tympanic thermometry was not useful for diagnosis of aom, when compared to reference temperatures without aom and the other ear in case of unilateral aom.10 we also did not find any significant difference between temperatures of the two ears in case of unilateral aom. therefore, increase in tympanic temperature compared to axillary temperature in patients with acute otitis media may be used in diagnosing in nonotologic setup. this could be especially helpful in young children who cannot volunteer a history. jolin et al., studied the utility of tympanic thermometry in diagnosing acute suppurative otitis media (asom) and found it useful.15 the mean temperature difference between the two ears for children with unilateral asom was 0.39o c ± 0.29oc in their study, while the mean temperature difference in control group was 0.23o ± 0.15oc. they concluded that tympanic thermometry may be useful in diagnosing asom when used with other clinical data. in our study, although the mean temperature of affected ear was 0.65°f higher than the other ear, but it was not statistically significant as a difference of 0.190f was found between the two ears in controls as well (p=0.069). we suggest that the temperature difference between the affected ear and axilla is more useful in diagnosing aom than the difference between the two ears. also, since aom is bilateral in many cases it will be missed if the two ears were compared. blood supply of the two tympanic membranes is centrally controlled, thus if inflammation causes congestion of one tympanic membrane then the blood supply of the other tympanic membrane may be increased sympathetically. furthermore, if we study the pathogenesis of aom then we see that upper respiratory tract infection is the leading cause of aom which can affect both the eustachian tubes and thus both the ears in many cases. jolin et al.15 studied patients of aom with suppuration and similarly aniutin et al.11 studied patients with exudative otitis media (eom). however, in our study we excluded patients with ear discharge, as discharge is a physical barrier and is likely to interfere with the detection of infra-red emission from the tympanic membrane. in addition, the diagnosis of aom in nonotologic setup is more difficult when there is no ear discharge, so tympanic thermometry if used as a diagnostic or screening tool for aom, will be more helpful in patients without ear discharge. brennan et al., found that in patients with unilateral aom, the infected ears were warmer than the uninfected ears however the difference was not statistically significant.10 this finding was also replicated in our study. c o n c l u s i o n in acute otitis media, the temperature of affected ear was significantly higher than axilla but was not significantly higher than the other ear. this finding may help establish thermometry as a diagnostic tool in clinics manned by doctors not competent to do otoscopy r e f e r e n c e s 1. el-radhi as, barry w. thermometry in paediatric practice. arch dis child 2006; 91(4):351-6. doi: 10.1136/adc.2005.088831 2. long ss, pickering ik, prober cg, “otitis media” in principles and practice of pediatric infectious diseases, 4th ed. usa.2012. 3. liese jg, silfverdal sa, giaquinto c, carmona a, larcombe jh, garcia-sicilia j. et al. incidence and clinical presentation of acute otitis media in children aged <6 years in european medical practices. epidemiol infect. 2014; 142(8): 1778-88. doi:10.1017/s0950268813002744. 4. mustafa g, al aidaroos ay, al abaidani is, meszaros k, gopala m, ceyhan m et al. incidence and economic burden of acute otitis media in children aged up to 5 years in three middle eastern countries and pakistan: a multinational, retrospective, observational study. j epidemiol glob health. 2017; 7(2): 123-30. doi: 10.1016/j.jegh.2016.12.004 5. mccarthy pw, heusch ai. the vagaries of ear temperature assessment. j med eng technol. 2006; 30 (4):241-51. doi: 10.1080/03091900600711415 6. haddock bj, merrow dl, swanson ms. the falling grace of axillary temperature. pediatr. nurs. 1996; 22:121–25. pmid: 8715845 7. childs c, harrison r, hodkinson c. tympanic membrane temperature as a measure of core temperature. arch. dis. child. 1999; 80(3):262-66. j islamabad med dental coll 2019 78 8. robb pj, shahab r. “infrared transtympanic temperature measurement and otitis media with effusion”. int. j. pediatr. otorhinolaryngol. 2001; 59(3):195-200. doi: 10.1016/s01655876(01)00482-7 9. doğan hh, sezer rg, kırkgöz t, bozaykut a. comparison of axillary and tympanic temperature measurements in children diagnosed with acute otitis media. int. j. pediatr. 2016. id 1729218. doi:10.1155/2016/1729218 10. brennan df, falk jl, rothrock sg, kerr rb. infrared tympanic thermometry in the evaluation of pediatric acute otitis media. acad emerg med. 1994; 1(4):354-9. doi: 10.1111/j.1553-2712. 1994.tb02643.x 11. aniutin rg, ivkina sv, dmitriev ns, mileshina na. tympanic thermometry in diagnosis of exudative otitis media in children. vestn otorinolaringol. 2004; (2):33-5. pmid: 15111947 12. hasel kl, erickson rs. effect of cerumen on infrared ear temperature measurement. j gerontol nurs. 1995;21(12):614. pmid: 8537621 13. terndrup te, wong a. influence of otitis media on the correlation between rectal and auditory canal temperatures. am j dis child. 1991; 145(1):75-78. doi:10.1001/archpedi.1991.02160010081020 14. kelly b, alexander d. effect of otitis media on infrared tympanic thermometry. clin pediatr (phila). 1991; 30(4): 468. doi: 10.1177/0009922891030004s13 15. jolin sw, howell jm, milzman dp, stair to, butzin ca. infrared emission detection tympanic thermometry may be useful in diagnosing acute otitis media. am j emerg med. 1995; 13(1): 6-8. doi: 10.1016/0735-6757(95)90230-9. 231 j i m d c 2 0 1 7 231 open access f u l l l e n g t h a r t i c l e immunohistochemical expression of epidermal growth factor receptor in different histopathological grades of muco-epidermoid carcinoma of salivary glands zainab niazi 1, shoaib naiyar hashmi 2, saadia muneer 3 1asistant professor, department of oral pathology, islamabad medical and dental college, saheed zulficar ali bhutto medical university, islamabad. 2consultant histopathologist, department of histopathologist, armed forces institute of pathology, rawalpindi. 3asistant professor, department of oral pathology, islamabad medical and dental college, saheed zulfiqar ali bhutto medical university, islamabad a b s t r a c t objective: to determine the immunohistochemical expression of epidermal growth factor receptor (egfr) in different histopathological grades of mucoepidermoid carcinoma (mec) in salivary glands. patients and methods: this cross-sectional study was conducted from august 2015 to september 2016 at armed forces institte of patholgy rawalpindi (afip), to determine the immunohistochemical expression of epidermal growth factor receptor (egfr) in different histopathological grades of mucoepidermoid carcinoma (mec) in salivary glands. thirty cases of mec were retrieved from record files along with their paraffin blocks at afip, rawalpindi. new histological diagnosis was made on freshly prepared hematoxylin and eosins section followed by application and analysis by immunostaining. chi-square test was used to find the effect of egfr on different grades of mec. results: out of 30 cases, 24 cases were positive for egfr. in case of low-grade mucoepidermoid carcinoma, 8 cases were weak positive, whereas remaining six were negative. out of eight cases of intermediate grade mucoepidermoid carcinoma, 3 were week positive, whereas remaining five are strong positive. in high grade mucoepidermoid out of eight cases seven were strong positive. p-value for egfr was calculated as .036. egfr expression increased with increase in grade of tumor. conclusion: the expression of egfr increased with increase in grade of tumor. key words: egfr, mucoepidermoid carcinoma, salivary glands author`s contribution 1-2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence zainab niazi email: dr.zainabniazi@gmail.com article info. received: september 16, 2018 accepted: november 10, 2018 cite this article. niazi z, hashmi sn, muneer s. immunohistochemical expression of epidermal growth factor receptor in different histopathological grades of muco-epidermoid carcinoma of salivary glands. jimdc.2018; 7(4): 231-234 funding source: nil conflict of interest: nil i n t r o d u c t i o n tumors of salivary glands have an important place in oral and maxillofacial pathology, having incidence of 5% around world.1 mucoepidermoid carcinoma (mec) is the most common malignant tumor of salivary glands, accounting for 15.3% of all tumors and 56.9% of malignant tumors .2 this tumor is composed of three intermixed type of cells: mucin-producing cells, intermediate cells or clear cells, and squamoid cells.3 mucoepidermoid carcinoma shows a variety of biological behavior that is correlated with histopathological grades of o r i g i n a l a r t i c l e 232 j i m d c 2 0 1 7 232 tumor.4 all treatment plans are based exclusively on histopathological grades. number of microscopic grading systems based on specific microscopic parameters have been described to find the grades of mucoepidermoid carcinoma.5 egfr is a “tyrosine kinase receptor” of erbb family. egfr is a membrane glycoprotein and has an extracellular ligand -binding domain, a transmembrane lipophilic part and an intracellular protein kinase domain. egfr is present on chromosome 7p12 and in many types of cancers. it is involved in proliferation, angiogenesis and metastasis of cancer cells. egfr encodes membrane glycoprotein that is activated by phosphorylation.6-8 in many cases of mec of salivary glands, egfr protein is strongly expressed.9 in high grade of mec, the oncogenic glycoprotein muc1 is greatly expressed.10 muc1 react with egfr and cause activation of mapk in mouse model. in mec of salivary glands, erk1/2 mapks expression is high in high grade mec. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted from august 2015 to september 2016 the study included thirty cases of mucoepidermoid carcinoma. the data was collected from clinical histories given with each case. blocks were cut and stained with hematoxylin and eosin stains. necrosed, scanty and autolysed tissue samples were excluded. after diagnosing on microscopy, histopathological grading was done according to auclair et al and goode criteria.11,12 expression of egfr on different grades of mec was calculated by evaluating the percent of positive stained cells under the objective lens of power 40 with microscope.12 positive staining appeared as a linear to finely granular pattern in cell membrane and adjacent cytoplasm. chi-square test was used to find out the association of egfr with different grades of tumor. p value >0.05 was taken as significant r e s u l t s among 30 cases, 23 patients were males and remaining 7 were females. anatomically, 22 patients had tumor in parotid glands, while 4 had in submandibular areas. other tumors were in palate, retromolor area, and in posterior 1/3 of tongue. most of patients had age between 40 to 60 years. immunohistochemical labeling patter:egfr was applied to all 30 cases of mucoepidermoid carcinoma. both membranous and cytoplasmic stainings were considered. among thirty cases eight cases were negative (-), while 24 were positive. out of 24 positive 16 were weak positive (+), while 8 were strong positive (++). the low grade mec was diagnosed in 14 cases, out of these 6 cases were negatively stained (-) and remaining 8 were weak positive (+). in intermediate grade mec, 3 cases were weak positive (+) while 5 cases were strong positive (62.5%), where as in high grade mec one case was weak positive (12.5%) while the rest 7 were strong positive (87.5%) chi-square test was applied to evaluate the association of egfr and grades of tumor. p value of .036 was calculated and was significant. (table 3). table 1: scoring system intra cystic component <20% 2 points neural invasion present 2 points necrosis 2 points mitosis (4 or more per 10 hpf) 3 points anaplasia 4 points the quantitative grading system by these scores is: low grade 0-4points intermediate grade 5-6points high grade 7-14points table 2:score assessment of immunoreactions score assessment negative <5% of positive cells week positive 5 -50%of positive cells strong positive >50% of positive score table 3: expression of egfr in different grades of tumors grades >50% (++) 5-50% (+) <5% (-) total pvalue low 0 8 6 14 0.036 intermediate 5 3 0 8 high 5 1 0 8 total 10 12 6 30 233 j i m d c 2 0 1 7 233 igure 1: strong membranous positivity of egfr in high grade mucoepidermoid carcinoma (40x100) figure: 2 high membranous positivity of egfr in high grade mec (10x10 magnification) d i s c u s s i o n the egfr/erbb1 is a gene located on chromosome 7p12. this gene encodes membrane glycoprotein that is activated by phosphorylation. this activation induces a downstream signalling transduction cascade.13 it is over expressed in many tumors like head and neck tumors, glioblastoma, lung, breast, ovaries and bladder. in the present study, we evaluated the expression of egfr on different histopathological grades of mec. there are few studies present in literature showing expression of egfr on mec. in study conducted by khiavi et al in 2012, out of 40 patients 2 were negative (4.3%), 12 week positive (26.1%) and 32 were strong positive (69.6%). the egfr expression was cytoplasmic that is contrary to present study, as it had both cytoplasmic and membranous expressions. in another study conducted by al-ani in 201214, out of seventeen patients all were egfr immunopositive. no statistical significant correlation was seen among marker and grading systems. according to above mentioned study, 9 cases were weak positive and remaining 8 cases were strong positive. egfr in this study showed membranous expression. in 2010, lujan et al conducted a study to check relation of egfr expression in salivary glands mec of high grade.15 out of 42 cases, 34(79%) cases were positive for protein expression. expression of egfr was high in high grade mec, so it was more positive in aggressive tumors. they considered only continuous membranous staining of egfr as strong positive. in contrast, we considered both cytoplasmic and membranous staining. in a study conducted by hoyek-gebeily et al in 2007, in which they checked the prognostic significance of egfr in mec of the salivary gland, 75% of cases are positive for egfr staining.16 they considered only membranous staining and found high expression of egfr in high grade so have poor prognosis. c o n c l u s i o n expression of egfr is strongly positive in high grade mec and in few cases of intermediate grade mec. in low grade mec, egfr has both negative and week positive expression. egfr showed both membranous and cytoplasmic expression. r e f e r e n c e s 1. neville bw, damm dd, allen cm, bouquot je. oral and maxillofacial pathology.3rded. elsevier health sciences; 2015 2. gill ms, muzaffar s, soomroi in, hussainy as, pervez s, hasan sh. morphological patterns of salivary glands tumors. j pak med assos 2001; 51(10):343-46. 3. bai s, clubwala r, alder e. salivary mucoepidermoid carcinoma: a multi institutional review of 76 patients. head and neck pathol 2001 ; 7(2): 105-112. 4. hoyek – gebeily j, nehme e, aftimos g, saderghorra c, sargi z, haddad a. prognostic significance of egfr, p53 and e-cadherin in mucoepidermoid cancer of salivary glands. j med liban 2007; 55(2):83-8. 5. auclair pl, goode rk, ellis gl. mucoepidermoid carcinoma of intraoral salivary glands evaluation and application of grading criteria in 143 cases. cancer. 1992;69(8):2021-30 6. seshacharyulu p, ponnusamy mp, haridas d. targeting the egfr signaling pathway in cancer 234 j i m d c 2 0 1 7 234 therapy. expert opinion ther targets 2012; 16(1):1531. 7. han w, wen h. landscape of egfr signaling network in human cancers: biology and therapeutic response in relation to receptor subcellular locations. cancer lett 2012; 318(2):124-134. 8. pai si, weftra wh. landscape of egfr signaling network in human cancers: biology and therapeutic response in relation to receptor subcellular locations. cancer left 2009; 318(2):124-134. 9. shang j, shui y, sheng l, wang k, hu q, wei q. epidermal growth factor receptor and human epidermal growth factor 2 expression in parotid mucoepidermoid carcinoma : possible implication for targeted therapy 2007; 19(2): 435-440. 10. alos l, castillo m, nadal a, caballero, mardesa a, mallofre c, palacin a, cardesa a. adenosquamous carcinoma of head and neck: criteria for diagnosis in a study of 12 cases. histopathology 2004; 44(6):570579. 11. handra luca a, lamas g, bertrand jc, fouret p. muc1, muc2, muc4, muc5ac expression in salivary gland mucoepidermoid carcinoma: diagnostic and prognostic implications. am j surg pathol 2005; 29(7): 881-889. 12. khiavi mm, vosouughhosseini s, saravani s, halimi m. immunohistochemical correlation of epidermal growth factor receptor and c-erb with histopathological grading of mucoepidermoid carcinoma. j. can. res. therp 2012; 8(4): 586-590. 13. klapper ln, kirschbaum mh, sela m, yarden y. biochemical and clinical implications of erbb/her signaling network of growth factor receptors. adv cancer res 1999; 77: 25-79. 14. alani, s a, abdullah bh. evaluation of epidermoid growth factor receptor (egfr), proliferation (ki67) and apoptosis (p53) in salivary mucoepidermoid carcinoma in relation to tumor grade. j bagh college dentistry 2012; 24(2): 43-47. 15. lujan b, hakim s, moyano s, nadal a, caballero m, diaz a, valera a. activation of the egfr/erk pathway in high-grade mucoepidermoid carcinoma of the salivary glands. british journal of cancer 2010; 103(4) :510-516. j islamabad med dental coll 2019 198 ope n ac cess mandibular reconstruction with free fibula flap: experience at hayatabad medical complex, peshawar syed asif shah1, irfanullah2, muhammad bilal2, mohammad hamayun shinwari2, adeeba ahmad3, ehsanullah3 1 associate professor, plastic surgery unit, hayatabad medical complex, peshawar 2 assistant professor, plastic surgery unit, hayatabad medical complex, peshawar 3 junior registrar, plastic surgery unit, hayatabad medical complex, peshawar a b s t r a c t background: mandibular defects may result from trauma, infections, cancer ablation or radiation necrosis. these defects may vary according to the content and nature of the tissues that require reconstruction. the objective of this study was t o evaluate the outcome of vascularised free fibula flap for mandibular reconstruction in terms of flap success rate and complications. material and methods: this prospective clinical study was carried out at department of plastic surgery, hayatabad medical complex, peshawar from january 2014 to december 2018. the study included patients of either gender who underwent mandibular reconstruction with free fibula oseteocutaneous flap during the study period. diabetic patients with underlying vascular pathologies and cachectic patients were excluded from the study. results: there were 56 patients with 38 males and 18 females. their age ranged from 24-66 years with a mean age of 36 years. the mandibular defects resulted from various etiologies and included: squamous cell carcinoma (n=27, 48.21%), giant cell granuloma (n=3; 5.35%), ameloblastoma (n=2; 3.57%), road traffic accidents (n=10; 17.85%), firearm injury (n=9; 16%), bomb blast injury (n=3; 5.35%) and osteoradionecrosis (n=2; 3.57%). primary reconstruction of the mandibular defects was performed in 44 patients, whereas delayed reconstruction was performed in 12 patients. out of the 56 flaps, 49 flaps survived completely. our share of complications was as follows: wound infections (n=13; 23.21%), skin graft loss at donor site (n=5; 8.95%), complete flap loss (n=4; 7.14%), orocutaneous fistulae (n=3; 5.35%), ankle instability (n=2; 3.57%), skin paddle necrosis (n=1; 1.78%) and sensory deficit distal to donor site (n=1; 1.78%). conclusions: microvascular free fibula is a reliable tool for mandibular reconstruction following tumor resection or trauma. the flap has a high success rate and relatively fewer complications. key words: mandibular defects, mandibular reconstruction, oseteocutaneous flap authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3-5 active participations in data collection 6 data analysis. correspondence: irfanullah email: drirfann@gmail.com article info: received: august 28, 2019 accepted: november 29, 2019 cite this article. shah sa, irfanullah, bilal m, shinwari mh, ahmad a, ehsanullah . mandibular reconstruction with free fibula flap: experience at hayatabad medical complex, peshawar. j islamabad med dental coll.2019; 8(4): 198-202. doi: 10.35787/jimdc.v8i4.374 funding source: nil conflict of interest: nil i n t r o d u c t i o n mandibular defects may result from trauma, infections, cancer ablation or radiation necrosis. these defects may vary according to the content and nature of the tissues that require reconstruction. sometimes the defects are simple and may require a single type of tissue to be restored; for instance, isolated bony defects. but at times complex defects may need reconstruction of multiple tissues, such as bone and soft tissues. in either case, the reconstructive surgeon faces a challenge to restore the anatomic, functional and aesthetic aspects of the damaged structures.1,2 trauma to facial region can result in distortion of anatomy and aesthetics of the region. the reconstruction of such defects and restoration to normal anatomy and function poses a challenge to the reconstructive surgeon. the facial region has certain discriminations in the structure of each anatomical part and it varies with individual patient. each case is different from the other and requires individual consideration for or i gi n a l a r ti c le j islamabad med dental coll 2019 199 proper management. certain procedures have been adopted for reconstruction of various simple and comp l e x defects of facial region. in the last three to four decades, microsurgical techniques have emerged as the standard techniques for the reconstruction of head and neck defects. vascularized free fibula has emerged as the workhorse flap in this regard.3,4 before the era of microvascular free tissue transfer, mandibular defects used to be reconstructed with metalli c plates, free bone grafts or combination of both. reconstruction with metallic plates resulted in complications like plate exposure, infection, plate fractu re and insufficient facial symmetry.4,5 a number of microvascular free flaps were invented for reconstruction of mandible but each has its limitations. free radial forearm flap was successfully employed wherein 10-12 cm of radius could be harvested for bone reconstruction. its frequent problem was the fracture of radius at donor site and the limitation of osteotomies in free radius. similarly, free subscapular flap has been used for restoration of mandibular defects, however the location o f the donor site hinders simultaneous harvest of the flap at the time of tumor resection. the use of iliac crest was abandoned due to the short length vascular pedicle and the lack of segmental perforating vessels for osteotomies.4-7 taylor in 1975 described the free fibula flap, while hidalgo described its use for mandibular reconstruction.8,9 since then, the fibula was chosen by various reconstructive surgeons and some of them were able to standardize its use for the restoration of oral cavity defects. advantages of using fibula as a donor site include available long length of bone and associated soft tissues, near anatomi c dimensions, ability to accept bicortical implants and relatively low donor site morbidity.4,8-12 the present study was designed to evaluate the outcome of mandible reconstruction using vascularized free fibula flap, in te rms of flap success rate and complications. m a t e r i a l a n d m e t h o d s this prospective clinical study was carried out at department of plastic surgery, hayatabad medical complex, peshawar from january 2014 to december 2018. patients of either gender, who underwent mandibular reconstruction with free fibula oseteocutaneous flap during the study period were included. diabetic patients with underlying vascular pathologies and cachectic patients were excluded from the study. the study protocol was approved by the hospital ethical committee. informed consent was taken from the participants. all the patients were admitted to the hospital. a detailed history of the illness was recorded. thorough clinical examination and relevant investigations were performed. prior to the surgical treatment, all the patients were counseled about the procedures along with the associated risks and benefits of the planned surgery. all the surgeries were performed under general anesthesia and tracheostomies were performed in patients requiring mandibular reconstruction. a hand-hel d doppler was used for identification of the perforating vessels supplying the fibula flap. these perforators were marked and the skin paddles were designed to inclu d e a t least one of the perforating vessels. a tourniquet was applied to the donor lower limb and inflated to create pressure 100 mmhg above the systolic pressure, over the main vessel supplying the lower limb. after cleaning and draping, skin incisions were made over the markings. retracting the skin and fascia, peroneus longus was retracted anteriorly and the fibula bone was identified. the fibula freed by dissecting from surrounding tissues. the pedicle of the flap was identified, dissected and preserved. the fibula was then harvested with the hel p o f an oscillating saw. at least 6 cm of bone was preserved proximally to prevent injury to peroneal nerve. about 8 cm of distal fibula was left intact for support of ankle. the length of bone needed for reconstruction was measured. multiple osteotomies were performed for contouring of th e bone before dividing the pedicle. after harvesting the fre e fibula, soft tissues were sutured and skin closure done. split thickness skin grafts were used where the wound could not be closed primarily. at the end of bone harvest, aseptic dressing of the wound with a posterior splint was applied. the bone was plated and inserted into the defect. the pedicle was positioned along the lingual aspect of the flap. anastomosis was then performed with standard j islamabad med dental coll 2019 200 microvascular techniques. at the end of surgery, a nasogastric tube was inserted for feeding. after the surgery, all patients were started on intravenous antibiotics, analgesics and fluids. heparin was given for three days and replaced by oral aspirin 75 mg twice daily for 2 weeks. postoperatively, the flap was clinically monitored. patients were encouraged to mobilize on the second postoperative day. the donor site dressing was changed on fifth post-operative day and were assessed for graft-take. the wounds were redressed and back slab reapplied. the patients remained hospitalized for 2-3 weeks. nasogastric feeding was carried out for 3 weeks. data were analyzed by spss version 20. the variables under study were age, sex, operative time, donor site morbidity, flap survival, duration of ng tube feeding and postoperative complications (infection, dehiscence, skin necrosis, delayed wound healing or fistula formation). r e s u l t s there was a total of 56 patients, with 38 (67.85% ) males and 18 (32.14% ) females. the mean age was 36±10.5 years with an age range of 24-66 years. the mandibular defects resulted from various etiologies: squamous cell carcinoma (27; 48.21% ), giant cell granuloma (3; 5.35 % ), ameloblastoma, (2; 3.57% ), road traffic accidents (10; 17.85% ), firearm injury (9; 16% ), bomb blast injury (3; 5.35% ) and osteoradionecrosis (2; 3.57% ). observed success rate of mandibular reconstruction and associated complications are given in table i. table i: success rate and complications observed in study participants undergoing mandible reconstruction using vascularized free fibula flap (n=56) variables number (%) success rate number of flaps survived completely 52(92.85) complication rate wound infections 13(23.21) skin graft loss at donor site 5(8.93) complete flap loss 4(7.14) orocutaneous fistulae 3(5.36) ankle instability 2(3.57) skin paddle necrosis 1(1.78) sensory deficit distal to donor site 1(1.78) out of the four flaps with complete necrosis, three had venous thrombosis, whereas one had anastomotic disruption due to persistent postoperative hypertension. patients with partial necrosis of skin paddle were managed with debridement and wound care that resu l te d in healing with secondary intention. patients with orocutaneous fistulae were managed with revisional surgery and repair. figure 1: female patient with post traumatic mandibular defect. (a) tracheostomy was performed to secure the airway preoperatively. (b) pre-operative orthopantomogram (opg) showing the skeletal defect. figure 2: (a) post-operative lateral view of the same patient. (b) post-operative opg of the same patient. d i s c u s s i o n defects arising at certain anatomic sites need to be reconstructed with appropriate tissue for a desirable outcome. mandibular defects are usually difficult to reconstruct primarily due to concerns regarding adequate restoration of function and aesthetics. the main objective in mandibular reconstruction is to repair the bony defects. the aim of management is to restore the stability of bone segment along with appropriate soft tissue coverage.2 j islamabad med dental coll 2019 201 mandible reconstruction is needed in cases of trauma, after tumor resection and necrosis of mandible as complication of radiation therapy to the region. 2-4 in the present study, it was observed that oncologic defects of the mandible were the leading cause that required reconstruction. while studying the indications for mandible reconstruction, sajid et al. and spzindor also reported this defect as the most common indication,13,14 while road traffic accidents and firearm injuries are also not uncommon mandibular defects indicating its restoration.15 certain congenital anomalies, like osteodytstrophy and osteoradionecrosis as a complication of radiation therapy, are also indications for mandible reconstruction.1 the free fibula flap was developed by taylor and colleagues in 1975.9 hidalgo described its use for mandibular reconstruction along with the defects of the floor of the mouth in 1989. three years later he recommended its use for majority of mandibular defects.9,10 fibula has the advantage of dual blood supply. it has got an endosteal and a periosteal blood supply th a t makes it a reliable option amongst other flaps. this pattern of blood supply to fibula makes it promising for multiple osteotomies to shape it as mandible.4,11 another advantage of fibula flap is the availability of long leng th o f the bone. almost 25 cm of fibula can easily be harvested, which provides sufficient amount of bone to reconstruct a mandible. the flap has an extended length and vessels have a large caliber (artery 2-3 mm and vein 3-4 mm). with large caliber vessels, vascular anastomosis can easily be performed even under the surgical magnifying loupes.4, 11-13 the various reconstructive options for mandibular defects include the use of neovascularized bone grafts, titanium reconstructive plates, bone grafts and microsurgical repair with vascularized free osseous and osteocutaneous flaps.1-4 we performed free osteocutaneous flaps for mandible reconstruction along with reconstruction plates in our patients. it was observed that among the 56 flaps performed, only four flaps could not survive yielding a success rate of 91% . this figure can be compared with the results reported by researchers in two separates studies. these studies have reported a success rate of 82.6% , 81.8% and 100% respectively.17,18 furthermore, they have reported venous thrombosis as a cause of flap failure which is in accordance with our results. reconstruction of both soft tissues and bone is necessary after the resection of tumors arising from the mandible. resections may sometimes include adjacent structures like the floor of mouth, tongue and cheek. in addition, a neck dissection in malignant cases may also result in larger defects and even exposure of the vessels. restoration of all types of tissue with like-tissue has always been challenging and the options for reconstruction are usually not totally satisfactory. reconstruction of the defects pertaining to the oral cavity along with the mandible are best reconstructed with free fibula osteocutaneous flaps that provide bone and soft tissues simultaneously.4,16-19 primary reconstruction of the mandibular defects has a major advantage over secondary reconstruction as it is carried out in virgin tissue that are infection free and not manipulated earlier. the tissues are clean and they have no scarring resulting in a reconstructive surgery with optimal functional and esthetic results for the patient. secondary reconstruction of mandibular defects is usually recommended in cases where there is persistent infectio n in the previously reconstructed tissue. execution of surgical procedures in a scarred bed is a tedious task tha t poses a challenge to the reconstructive surgeon and a l so badly affect the desirable outcomes.20,21 primary reconstruction of the mandibular defects is not only cost effective but it also result in early patient mobilization, decreased hospital stay and acceptable functional and aesthetic outcomes. vascularized free fibular flap has become the choice of reconstruction for defects of any etiology. this flap is well suitable for the bony defects requiring multiple osteotomies. the additional advantages of free fibula are its anatomic dimension, ability to accept bicortical implants and relatively low donor site morbidity.4,20 although the large bony defects need to be reconstructe d with free flaps, however nonvascularized bone grafts can be used for short bone defects in non-irradiated tissue or in patients not fit to bear the additional operative time required for a free flap reconstruction.17 patients with advanced tumor usually present with co-morbid conditions and selection of a specific procedure and operating time j islamabad med dental coll 2019 202 should be considered to reduce the morbidity and mortality in these selected patients.17 in the present study it took us five and half hours on average to complete the whole procedure of mandible reconstruction with free fibula flap. other surgeons have also reported almost same time duration for this procedure in their patients.18,21 c o n c l u s i o n microvascular free fibula is a reliable tool for mandibular reconstruction following tumor resection or trauma. the flap has high success rate and fewer complications. r e f e r e n c e s 1. kumar bp, ventakesh v, kumar kaj, yadav by, mohan sr. mandibular reconstruction: overview j maxillofac oral surg. 2016; 15(4): 425–41. doi: 10.1007/s12663-015-0766-5 2. goh bt, lee s, tideman h, stoelinga paul jw. mandibular reconstruction in adults: a review. int j oral maxillofac surg. 2008; 37(7): 597–605. doi: 10.1016/j.ijom.2008.03.002 3. maurer p, eckert aw, kriwalsky ms, schubert j. scope and limitations of methods of mandibular reconstruction: a long-term follow-up. br j oral maxillofac surg. 2010; 48(2): 100–104. doi: 10.1016/j.bjoms.2009.07.005 4. delacure m. reconstruction of the mandible. indian j plast surg. 2007; 40(supplement): 28-34. 5. peled m, el-naaj ia, lipin y, ardekian l. the use of free fibula flap for functional mandibular reconstruction. j oral maxillofac surg. 2005; 63(2): 220-24. doi: 10.1016/j.joms.2004.06.052 6. biglioli f, pedrazzoli m, autelitano l, colletti g, brusati r. the free fibula flap for treating benign mandibular lesions. minerva stomatol. 2007; 56(6): 349-58. pmid: 17625492 7. aydin a, emekli u, ere m, hafiz g. fibula free flap for mandibular reconstruction. kulak burun bogaz ihtis derg. 2004; 13(3-4): 62-6. pmid: 16055983 8. taylor gi, miller gd, ham fj. the free vascularized bone graft: a clinical extension of microvascular techniques. plast reconstr surg. 1975; 55(5): 533-44. doi: 10.1097/00006534-197505000-00002 9. hidalgo da. fibula free flap: a new method of mandible reconstruction. plast reconstr surg 1989; 84(1): 71-8. pmid: 2734406 10. hidalgo da. aesthetic improvements in free-flap mandible reconstruction. plast reconstr surg 1991; 88(4): 574-85. pmid: 1896529 11. ozalp t, masquelet ac, begue tc. septocutaneous perforators of the peroneal artery relative to the fibula: anatomical basis of the use of pedicled fasciocutaneous flap. surg radiol anat. 2006; 28(1): 54-8. doi: 10.1007/s00276-005-0059-7 12. shen y, guo xh, sun j, li j, shi j, huang w et al. double-barrel vascularised fibula graft in mandibular reconstruction: a 10-year experience with an algorithm. j plast reconstr aesthet surg 2013; 66(3): 364-71. doi: 10.1016/j.bjps.2012.10.005 13. sajid mah, warraich ra, abid h, ehsan-ul-haq m, shah kl, khan z. reconstruction of mandibular defects with autogenous bone grafts: a review of 30 cases. j ayub med coll abbottabad. 2011; 23(3): 825. pmid: 23272442 14. szpindor e. evaluation of the usefulness of autogenic bone grafts in reconstruction of the mandible. ann acad med stetin 1995; 41: 155–69. pmid: 8615541 15. kim mr, donoff rb. critical analysis of mandibular reconstruction using ao reconstruction plates. j oral maxillofac surg. 1992; 50(11): 1152–57. doi: 10.1016/0278-2391(92)90145-p 16. thoma a, levis c, young je. oromandibular reconstruction after cancer resection. clin plastic surg. 2005; 32(3): 361–375. doi: 10.1016/j.cps.2005.01.006 17. riaz n, warraich r. reconstruction of mandible by free fibular flap. j coll phy surg pak. 2010; 20(11): 723-27. doi: 11.2010/jcpsp.723727. 18. pieptu d, gogalniceanu d, getu n, grosu o, popescu s, costan v. mandibular reconstruction using the free fibula osteocutaneous flap. tmj. 2005; 55(1): 43-8. 19. nicolic z, jeremic j, milosavjevic r. use of free microvascular flaps in the management of the head and neck defects. vojnsanit pregl. 2006; 63(8): 71320. 20. rosenthal e, carroll w, dobbs m, wax m, peters g. simplifying head and neck micro-vascular reconstruction. head neck. 2004; 26(11): 930-36. doi: 10.1002/hed.20076 21. balaji sm. total reconstruction of mandible by transport distraction after complete resection for benign and malignanat tumors. indian j dent res. 2016; 27(2): 205-12 5 j i m d c 2 0 1 8 5 open access f u l l l e n g t h a r t i c l e frequency of helicobacter pylori infection in immune thrombocytopenia jamaluddin kakar 1 , sadia sultan 2 , syed muhammed irfan 3 1 department of hematology & blood bank, liaquat national hospital and medical college karachi 2 consultant hematologist, national medical centre, karachi 3consultant hematologist, liaquat national hospital, karachi a b s t r a c t objective: to accomplish the comparative analysis of clinical features and laboratory findings in helicobacter pylori positive and negative patients with immune thrombocytopenia. patients and methods: this cross sectional study was conducted from may 2013 to nov 2014 at hematology unit, liaquat national hospital, karachi. during the study duration, 59 adult patients, diagnosed as chronic immune thrombocytopenia were enrolled in the study. helicobacter pylori infection was documented by helicobacter pylori stool antigen (hpsa) enzyme immunoassay method (eia). frequencies were calculated. chi-square test and independent sample t test were used for comparison. p-value of less than 0.05 was considered statistically significant. results: helicobacter pylori infection was detected in 25 out of 59 cases of chronic immune thrombocytopenia. no statistically significant differences were seen in h-pylori positive and negative patients with respect to clinical features and laboratory findings except mean platelet count, which was lower (57.95±15.1) in helicobacter pylori negative as compared to positive patients (71.44±18.8). conclusion: we found no significant difference between the clinical and laboratory attributes in h pylori positive and negative cases. significant finding of high platelet count in helicobacter pylori positive patients, may perhaps narrate the possible association. key words: chronic immune thrombocytopenia, helicobacter pylori, platelet count. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence sadia sultan email: sadiasultan96@yahoo.com article info. received: august 10, 2017 accepted: december 24, 2017 cite this article. kakar j, sultan s, irfan sm. frequency of helicobacter pylori infection in immune thrombocytopenia. jimdc.2018; 7(1):5-11 funding source: nil conflict of interest: nil i n t r o d u c t i o n immune thrombocytopenic purpura (itp) is an acquired immune condition defined by a low platelet count secondary to rapid platelet destruction by autoantibodies against platelet.1, 2 itp is diagnosed as decreased platelets on the blood smear and the exclusion of other causes of thrombocytopenia.1, 2 as itp is caused by antiplatelet antibodies, the reason of the autoimmune disease remains enigmatic. several immunological studies have still not explained why some persons generate antiplatelet antibodies leading to itp, while the great majority of people do not. the yearly incidence of adult itp ranges 1.6-3.9 per 100,000 per year.2 the assessed female-tomale ratio ranges between 1.2-1.9.2 itp is classified based on the presence or absence of other underlying diseases (primary or secondary), patient age (adult or childhood itp) and duration of thrombocytopenia (acute, persistent or chronic).2 itp in adults commonly is chronic in nature and progresses o r i g i n a l a r t i c l e 6 j i m d c 2 0 1 8 6 insidiously, seen mostly in females and less likely resolves spontaneously.2 conversely adult itp commonly occurs without a clear provoking event and mostly leads to chronic disease and patient may present with moderate to severe bleeding 1. chronic itp is more commonly seen in older people being twofold greater in people older than 60 years, and rises with time.3 gender variance disappears with progression of age.3 immune thrombocytopenia may follow secondarily in certain infectious diseases, lymphoproliferative diseases, autoimmune disorders and drugs.4 among the infections, helicobactor pylori is an important etiological factor as its existence can cause the persistence of disease.5 the aim of this study was to determine the frequency of helicobacter pylori infection in adult itp patients and secondly to compare the clinical and laboratory aspects between positive and negative patients with itp. as local published data is limited on this disease and it may be anticipated that frequency might be different in our population as compared to international studies. study will be beneficial as patients could be offered eradication therapy if deemed appropriate. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted in hematology unit, liaquat national hospital, karachi. calculated sample size was 55 by using confidence interval 95%, precision 10% and prevalence 83%.7 to overcome the possibility of dropouts we enrolled 59 adult patients suffering from itp by non-probability consecutive technique. study duration was 19 months from may 2013 to nov 2014. patients with more than six months history of bleeding with thrombocytopenia or asymptomatic thrombocytopenia with platelet count below 150x109/l were enrolled. patients recently treated for h-pylori eradication therapy, history of malignancy or chronic liver disease and those who were on medication known to cause thrombocytopenia were excluded. bone marrow failure, disseminated intravascular coagulation and patients with hypersplenism were also excluded. an informed consent was taken from each enrolled patient. patient’s history and physical examination was conducted. after thorough clinical evaluation, stool samples were collected in a plain container. antigen of hpylori was detected from stool sample by immunoassay methodology. results were reported as positive or negative. the specificity and sensitivity of the test were 96% and 83% respectively. confounding variables and bias were controlled by following the strict exclusion criteria. data was compiled and analyzed through statistical package of social sciences (spss) version 13. mean±sd was calculated for the quantitative variables i.e. age, platelet count, hemoglobin, hematocrit, mcv, mpv and wbc count. frequency and percentages were calculated for qualitative variables i.e. gender and outcome (h-pylori antigen). chi-square test was used to analyze association between qualitative variables. independent t-test was used to determine significant difference in quantitative variables. p-value < 0.05 was considered as statistically significant. r e s u l t s out of 59 patients, 36 were females (61.0%) and 23 were males (39.0%), with mean age of 40.95±14.82 years. mean age of the h-pylori positive and negative patients was 42.83±14.5 years and 39.9±15.9 years respectively (p=0.4). total 25(42.3%) patients out of 59 were positive for h-pylori antigen. among the total patients, 28 (47.4%) cases were symptomatic and 31 (52.6%) were asymptomatic at the time of presentation. symptomatic patients had mild mucosal bleeds and none had visceral, intracranial or life threatening bleeds. table 1: comparison of clinical features between helicobacter pylori positive and negative patients with itp (n=59) parameters h pylori positive (n= 25) h pylori negative (n= 34) p value age (years) mean±sd 42.83 ± 14.5 39.9 ± 15.9 0.44 male; n (%) 9(36) 14(41) 0.25 female; n (%) 16(64) 20(59) 0.25 asymptomatic; n (%) 11 (44) 17 (50) 0.38 symptomatic; n (%) 14 (56) 17 (50) 0.38 dry purpura; n (%) 8 (32) 9 (26.5) 0.31 wet purpura; n (%) 6 (24) 8 (23.5) 0.21 7 j i m d c 2 0 1 8 7 the difference between the age, gender and clinical symptoms of h-pylori positive and negative group was statistically insignificant (table 1). regarding laboratory results, comparison of platelet count was statistically significant between positive and negative groups (table-2). d i s c u s s i o n helicobactor pylori association with immune thrombocytopenia was first time reported by gasbirrini et al from italy in 1998, in which significant increment in platelet count was observed, after bacterium eradication.6 afterwards many studies from italy and japan reported the causative role of h-pylori in itp and platelet augmentations were seen after eradication therapy.7-10 helicobacter pylorus is a gram-negative microaerophilic bacterium that inhabits the human stomach of more than 50% of the world population. h-pylori have evidently been occupied in the pathogenesis of gastric and duodenal ulcers, gastritis and gastric malignancy.11 numerous studies have proposed that h. pylori infection may be linked with various disorders, comprising pernicious anemia, autoimmune neutropenia, henoch-schoenlein purpura, membranous nephropathy, autoimmune thyroid disease and immune thrombocytopenic purpura (itp).12 various studies have shown the link among h-pylori and itp. with respect to itp, role of h-pylori as a causative agent has provided conflicting results. many reports mainly from japan show a strong association between the two. ando k et al reported 83% (50/61) of patients with hpylori infection in itp patients.7 some pakistani studies on itp have also found a strong association with h-pylori. shaikh et al reported 63% of h-pylori infection in chronic itp patients.13 however in american and french population the frequency seems to be low. michel et al reported 29% (15/51) positivity of h-pylori in chronic itp patients.14 h-pylori bacterium is easily eradicated and patients with positive h-pylori, itp may have recovery from thrombocytopenia by the short term eradication therapy. a local study from pakistan shows the association, where h-pylori infection was found high when compared with controls.13 this study reported 43.3% prevalence in general control population compared with 63.3% in diseased patients.13 some studies from turkey, iran and korea also favor this association.14-18 we could not establish a correlation of h-pylori infection in our itp patients, as the difference between h pylori positive and h pylori negative in chronic itp patients was statistically insignificant. the association between the two is also not seen in studies from france, spain and northern america, where the prevalence in general population is same as in chronic itp patients 14, 19, 20 the mechanism by which h-pylori can cause thrombocytopenia is unclear but the pathogenetic virulence factors of h pylori such as caga and vaca are known to play the main role.21-23 several hypotheses have been advanced regarding the mechanisms by which hpylori may cause itp. one of the mechanism is the molecular mimicry, according to this, h pylori could initiate antibody formation secondary to antigens that cross-react against various antigens of platelet glycoprotein.5 the important role of caga-positive h-pylori strains as a pathogenic bacterium for itp was recognized in molecular table 2: comparison of laboratory results between helicobacter pylori positive and negative patients with itp (n=59) parameters h. pylori positive patients (n= 25) mean±sd h. pylori negative patients (n= 34) mean±sd pvalue hemoglobin (gm/dl) 12.21± 1.47 gm/dl 11.98 ±1.82 >0.05 hematocrit (%) 38.23±1.78 37.53±2.37 >0.05 tlc (109 /l) 8.39 ± 2.86 7.63± 2.84 >0.05 mpv(fl) 10.80±1.42fl 9.63±0.95 >0.05 mcv (fl) 83.13± 8.74 fl 86.67 ±8.98 >0.05 platelets (µl) 71.44±18.8 57.95±15.1 0.03 8 j i m d c 2 0 1 8 8 table 3: brief overview of previous studies showing h-pylori positive itp patients authors total particip ants (n) male/ femal eratio infected persons n(%) age (years) of infected persons (mean±sd) or median(range) age (years) of non infected persons (mean±sd) or median(range) plate count(µl) of infected persons plate count (µl) of noninfected persons (mean±sd) gasbarrini et al. (1998)6 18 5/13 11 (61) 43±14 49±12 95±39 103±24 jarque et al. (2001)19 56 18/38 40 (71) 54(17-80) na 57±22a 58±23 kohda et al. (2002)27 40 12/28 25 (62) 54±14 48±13 67±54 na hino et al. (2003)8 30 8/22 21 (70) 55±15 51±17 38±20 22±12 hashino et al. (2003)30 22 9/13 14 (64) 53.2±12.9 41.8±18.6 61±26 63±20 ando et al. (2003)7 61 12/49 50 (82) 58±11 40±16 56±24 42±24 michel et al. (2004)20 74 21/53 16 (22) 52.5± 15.9 38.5±18.3 34 (mean) 43 (mean) takahashi et al. (2004)22 20 5/15 15(75) 54±13 46±18 40±27 39±22 sato et al. (2004)32 53 16/37 39 (74) 62 (37-87) 52 (39-77) 55 (19-99) 56 (20-97) ando et al. (2004)31 20 5/15 17 (85) 62 (38-83) na 48 (4–86) 41 (12–82) nomura et al. (2004)10 42 15/27 28 (66) na na 29±6 31±5 veneri et al. (2005)9 43 18/25 43 (100) 52 (28-78) na 54±29 na inaba et al. (2005)33 35 11/24 25 (71) 57 (25-82) 52±26f 40 na stasi et al. (2005)36 137 57/80 64 (47) 58±13 42±16 42±25 46±23 fujimura et al. (2005)38 435 120/31 5 300 (69) 59±14 47±16 na na suzuki et al. (2005)34 36 na 25 (69) na na na na suvajdzic et al. (2006)35 54 12/42 39 (72) 54±13 42±16 68±32 78±32 kodama et al. (2007)37 116 32/74 67 (58) 57.9±14.3 47.8±17.2 39±29 30±24 tag hs, et al (2010) 39 25 18/7 23(92) 55(35-76) na 78 (6-96) na gan gg,et al (2013) 40 50 12/38 11 (22) 50(19-71) 49(18-79) 58 (24-100) 52(8-97) hwang jj et al (2016)41 102 42/62 42(41) 52.9±19.3 53.0±11.1 43.2±29.1 43.1±28.9 sheema et al, (2017)42 85 37/62 34 (40) 43.89 ± 7.06 44.75 ± 7.91 12.3 ± 3.7 13.5 ± 4.1 present study 59 23/36 25 (42.3) 42.8(14.5) 39.9(15.9) 71.4 57.9 9 j i m d c 2 0 1 8 9 studies.5 they first reported a decrease in plateletassociated immunoglobulin-g in itp patients after h pylori eradication as well as the existence of a molecular mimicry between the platelet-associated antibodies and the cag-a protein.8 the second study stated that antibodies against cag-a cross-react with a peptide expressing on platelets of patients with itp.23 although the prevalence of h-pylori is much higher in developing countries including india, bangladesh and pakistan but we are not aware of the strain of bacterium in our population.24, 25 in our patients, no difference in maternal characteristics was seen in h-pylori positive and negative groups. findings of many related studies are similar to us but increased prevalence of h-pylori with increasing age is seen in some of the studies mainly from japan.7, 11, 26, 27 in japanese population, the h pylori was seen significantly in older patients and had more cases of hyperplastic megakaryocytes in the bone marrow compared to those patients without h pylori infection.28 an analysis of 20 reported series world-wide showed that 873 itp patients were h-pylori positive out of 1367 (64%) (table-3).the suspicions concerning the definite role of ordinary eradication treatment warranted a study in which 37 known itp patients of both h-pylori positive and negative were treated with triple regime therapy, 16 of 26 (62%) patients were responders who were h pylori positive, while in the h pylori negative patients none was responder.29 the improved platelet count in patients who took ppi single therapy could have been facilitated by a decrease in the amount of h pylori and a bacteriostatic influence of the treatment. limitations of the study: these include, small sample size and lack of a control group for comparison. another limitation of our study was inaccessibility of data concerning the bacterium strain identification and eradication therapy. a large sample size would be better indicator of comparison between h pylori positive and negative patients with itp. c o n c l u s i o n the frequency of h pylori infection in our itp patients was 42%. the comparative analysis of immune thrombocytopenic patients with h pylori positivity and negativity based on clinico-hematological features revealed no significant difference in the present study. future studies with larger sample size and association with eradication therapy will be required to confirm this finding. r e f e r e n c e s 1. lichtman ma, beutler e, seligsohn v, kaushansky k, kipps to. williams hematology. 7th ed. usa: mcgraw-hill medical;2008. 2. liebman ha, pullarkat v. diagnosis and management of immune thrombocytopenia in the era of thrombopoietin mimetics. hematology am soc hematol educ program. 2011; 2011:384-90. 3. george jn, woolf sh, raskob ge: idiopathic thrombocytopenic purpura: a guideline for diagnosis and management of children and adults. american society of hematology. ann med. 1998; 30(1):38-44. 4. kühne t, berchtold w, michaels la, wu r, donato h, espina b, et ql; intercontinental cooperative itp study group. newly diagnosed immune thrombocytopenia in children and adults: a comparative prospective observational registry of the intercontinental cooperative immune thrombocytopenia study group. haematological. 2011; 96(12):1831-7. 5. cines db, liebman h, stasi r. pathobiology of secondary immune thrombocytopenia. semin hematol. 2009; 46(1 suppl 2):s2-14. 6. gasbarrini a, franceschi f, tartaglione r, landolfi r, pola p, gasbarrini g. regression of autoimmune thrombocytopenia after eradication of helicobacter pylori. lancet 1998 12; 352(9131): 878. 7. ando k, shimamoto t, tauchi t, ito y, kuriyama y, gotoh a et al. can eradication therapy for helicobacter pylori really improve the thrombocytopenia in idiopathic thrombocytopenic purpura? our experience and a literature review. int j hematol 2003;77(3):239-44. 8. hino m, yamane t, park k, takubo t, ohta k, higuchi k, et al. platelet recovery after eradication of helicobacter pylori in patients with idiopathic thrombocytopenic purpura. ann hematol 2003; 82(1): 30–2. 9. veneri v, krampera m, franchini m. high prevalence of sustained remission of idiopathic thrombocytopenic purpura after helicobacter pylori eradication: a long-term follow-up study. platelets 2005;16(2):117–9. 10. nomura s, inami n, kanazawa s. the effects of helicobacter pylori eradication on chemokine production in patients with immune thrombocytopenic purpura. eur j haematol 2004;72(4): 304–5. http://www.ncbi.nlm.nih.gov/pubmed?term=1)%09george%20jn%2c%20woolf%20sh%2c%20raskob%20ge%3a%20idiopathic%20thrombocytopenic%20purpura%3a%20a%20guideline%20for%20diagnosis%20and%20management%20of%20children%20and%20adults.%20american%20society%20of%20hematology.%20ann%20med.%201998%3b30%3a38%2c http://www.ncbi.nlm.nih.gov/pubmed?term=%22ando%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22shimamoto%20t%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22tauchi%20t%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22ito%20y%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22kuriyama%20y%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22gotoh%20a%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22gotoh%20a%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/12731666## 10 j i m d c 2 0 1 8 10 11. suerbaum s, michetti p. helicobacter pylori infection. n engl j med 2002 10;347(15):1175-86. 12. emilia g, luppi m, zucchini p, morselli m, potenza l, forghieri f, et al. helicobacter pylori infection and chronic immune thrombocytopenic purpura. blood 2007; 12(110):3833-41. 13. shaikh kh, ahmed s, ayyub m, anwar j. association of helicobacter pylori infection with idiopathic thrombocytopenic purpura. j pak med assoc 2009;59(10):660-3. 14. michel m, khellaf m, desforges l, lee k, schaeffer a, godeau b et al. autoimmune thrombocytopenic purpura and helicobactor pylori infection. arch intern med 2002 13;162(9):1033-36. 15. kurtoglu e, kayacetin e, ugur a. helicobacter pylori infection in patients with autoimmune thrombocytopenic purpura. world j gastroenterol 2004;10(14):2113-15. 16. vakili m, faghihi kashani ah, zargar-koucheh a. recovery of thrombocytopenia after eradication of h. pylori infection in chronic idiopathic thrombocytopenic purpura. iran j med sci 2004; 29(3): 120-23. 17. azarm t, khami m. helicobacter pylori eradication can induce platelet recovery in chronic refractory idiopathic thrombocytopenic purpura. ijhobmt 2005;2(4):13-16. 18. tag hs, lee hs, jung sh, kim bk, kim sb, lee a, et al. effects of helicobacter pylori eradication in patients with immune thrombocytopenic purpura. korean j hematol 2010;45(2):127-32. 19. jarque i, andreu r, llopis i, de la rubia j, gomis f, senent l, et al. absence of platelet response after eradication of helicobacter pylori infection in patients with chronic idiopathic thrombocytopenic purpura. br j haematol. 2001;115(4):1002-3. 20. michel m, cooper n, jean c, frissora c, bussel jb. does helicobacter pylori initiate or perpetuate immune thrombocytopenic purpura? blood. 2004 1;103(3):890-6. 21. stasi r, provan d. helicobactor pylori and chronic itp. hematology am soc hematol educ program. 2008:20611. 22. takahashi t, yujiri t, shinohara k, inoue y, sato y, fujii y et al. molecular mimicry by helicobacter pylori caga protein may be involved in the pathogenesis of h. pyloriassociated chronic idiopathic thrombocytopenic purpura. br j haematol. 2004;124(1):91-96. 23. franceschi f, christodoulides n, kroll mh, genta rm. helicobacter pylori and idiopathic thrombocytopenic purpura. ann intern med. 2004 4;140(9):766-7. 24. hunt rh, xiao sd, megraud f, barua lr, bazzoli f, merwe sv, et al. helicobacter pylori in developing countries. world gastroenterology organisation global guideline. j gastrointestin liver dis. 2011;20(3):299-304. 25. rasheed f,ahmed t, bilal r. frequency of helicobacter pylori infection using 13c-ubt in asymptomatic individuals of barakaho, islamabad, pakistan. jcpsp. 2011; 21(6): 379-381. 26. tsumo c, tominaga k, okazaki h, tanigawa t, yamagami h, watanabe k, nakao t, et al. long term efficacy of helicobactor pylori eradication in patients with idiopathic thrombocytopenic purpura: 7-year follow-up prospective study. ann hematol. 2009;88(8):789-93. 27. kohda k, kuga t, kogawa k, kanisawa y, koike k, kuroiwa g, et al. effect of helicobactor pylori eradication on platelet recovery in japanese patients with chronic idiopathic thrombocytopenic purpura and secondary autoimmune thrombocytopenic purpura. br j haematol. 2002;118(2):584-88. 28. fujimura k, kuwana m, kurata y, imamura m, harada h, sakamaki h, et al. is eradication therapy useful as the first line of treatment in helicobacter pylori positive idiopathic thrombocytopenic purpura? analysis of 207 eradicated chronic itp cases in japan. int j hematol. 2005;81(2):162-168. 29. asahi a, kuwana m, suzuki h, hibi t, kawakami y, ikeda y. effects of a helicobacter pylori eradication regimen on antiplatelet autoantibody response in infected and uninfected patients with idiopathic thrombocytopenic purpura. haematologica. 2006;91(10):1436-37. 30. hashino s, mori a, suzuki s, izumiyama k, kahata k, yonezumi m et al. platelet recovery in patients with idiopathic thrombocytopenic purpura after eradication of helicobacter pylori. int j hematol. 2003 feb;77(2):18891. 31. ando t, tsuzuki t, mizuno t, minami m, ina k, kusugami k et al. characteristics of helicobacter pylori-induced gastritis and the effect of h. pylori eradication in patients with chronic idiopathic thrombocytopenic purpura.helicobacter. 2004 oct;9(5):443-52. 32. sato r, murakami k, watanabe k, okimoto t, miyajima h, ogata m, et al. effect of helicobacter pylori eradication on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura. arch intern med. 2004 sep 27;164(17):1904-7. 33. inaba t, mizuno m, take s, suwaki k, honda t, kawai k, et al. eradication of helicobacter pylori increases platelet count in patients with idiopathic thrombocytopenic purpura in japan. eur j clin invest. 2005;35(3):214-9. 34. suzuki t, matsushima m, masui a, watanabe k, takagi a, ogawa y et al. effect of helicobacter pylori eradication in patients with chronic idiopathic thrombocytopenic http://www.ncbi.nlm.nih.gov/pubmed?term=morselli%20m%5bauthor%5d&cauthor=true&cauthor_uid=17652264 http://www.ncbi.nlm.nih.gov/pubmed?term=potenza%20l%5bauthor%5d&cauthor=true&cauthor_uid=17652264 http://www.ncbi.nlm.nih.gov/pubmed?term=potenza%20l%5bauthor%5d&cauthor=true&cauthor_uid=17652264 http://www.ncbi.nlm.nih.gov/pubmed?term=forghieri%20f%5bauthor%5d&cauthor=true&cauthor_uid=17652264 http://www.ncbi.nlm.nih.gov/pubmed?term=%22shaikh%20kh%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22ahmed%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22ayyub%20m%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22anwar%20j%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=association%20of%20helicobactor%20pylori%20infection%20with%20idiopathic%20thrombocytopenic%20purpura%20kashif%20hafeez%20shaikh%2c%20suhaib%20ahmed## http://www.ncbi.nlm.nih.gov/pubmed?term=36.%09stasi%20r%2c%20provan%20d.%20helicobactor%20pylori%20and%20chronic%20itp.%20blood.%202008 http://www.ncbi.nlm.nih.gov/pubmed?term=inoue%20y%5bauthor%5d&cauthor=true&cauthor_uid=14675413 http://www.ncbi.nlm.nih.gov/pubmed?term=sato%20y%5bauthor%5d&cauthor=true&cauthor_uid=14675413 http://www.ncbi.nlm.nih.gov/pubmed?term=fujii%20y%5bauthor%5d&cauthor=true&cauthor_uid=14675413 http://www.ncbi.nlm.nih.gov/pubmed?term=fujii%20y%5bauthor%5d&cauthor=true&cauthor_uid=14675413 http://www.ncbi.nlm.nih.gov/pubmed?term=imamura%20m%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=harada%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=harada%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=sakamaki%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=hashino%20s%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=mori%20a%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=suzuki%20s%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=izumiyama%20k%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=kahata%20k%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=kahata%20k%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=yonezumi%20m%5bauthor%5d&cauthor=true&cauthor_uid=12627857 http://www.ncbi.nlm.nih.gov/pubmed/12627857 http://www.ncbi.nlm.nih.gov/pubmed?term=ando%20t%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=tsuzuki%20t%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=mizuno%20t%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=minami%20m%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=ina%20k%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=kusugami%20k%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=kusugami%20k%5bauthor%5d&cauthor=true&cauthor_uid=15361084 http://www.ncbi.nlm.nih.gov/pubmed/15361084 http://www.ncbi.nlm.nih.gov/pubmed?term=sato%20r%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=murakami%20k%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=watanabe%20k%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=okimoto%20t%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=miyajima%20h%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=miyajima%20h%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=ogata%20m%5bauthor%5d&cauthor=true&cauthor_uid=15451766 http://www.ncbi.nlm.nih.gov/pubmed?term=sato%20r%20et%20al.%20itp%20h%20pylori%20(2004) http://www.ncbi.nlm.nih.gov/pubmed?term=suwaki%20k%5bauthor%5d&cauthor=true&cauthor_uid=15733077 http://www.ncbi.nlm.nih.gov/pubmed?term=honda%20t%5bauthor%5d&cauthor=true&cauthor_uid=15733077 http://www.ncbi.nlm.nih.gov/pubmed?term=kawai%20k%5bauthor%5d&cauthor=true&cauthor_uid=15733077 http://www.ncbi.nlm.nih.gov/pubmed?term=suzuki%20t%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=matsushima%20m%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=masui%20a%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=watanabe%20k%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=takagi%20a%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=takagi%20a%5bauthor%5d&cauthor=true&cauthor_uid=15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=ogawa%20y%5bauthor%5d&cauthor=true&cauthor_uid=15929755 11 j i m d c 2 0 1 8 11 purpura-a randomized controlled trial. am j gastroenterol. 2005 jun;100(6):1265-70. 35. suvajdzic n, stankovic b, artiko v, cvejić t, bulat v, bakrac m, et al. helicobacter pylori eradication can induce platelet recovery in chronic idiopathic thrombocytopenic purpura. platelets. 2006;17(4):227-230. 36. stasi r, rossi z, stipa e, amadori s, newland ac, provan d. helicobacter pylori eradication in the management of patients with helicobacter pylori eradication in the management of patients with idiopathic thrombocytopenic purpura. am j med 2005 ;118(4):414-19. 37. kohda k, kuga t, kogawa k, kanisawa y, koike k, kuroiwa g, et al. effect of helicobactor pylori eradication on platelet recovery in japanese patients with chronic idiopathic thrombocytopenic purpura and secondary autoimmune thrombocytopenic purpura. br j haematol. 2002;118(2):584-88. 38. fujimura k, kuwana m, kurata y, imamura m, harada h, sakamaki h, et al. is eradication therapy useful as the first line of treatment in helicobacter pylori positive idiopathic thrombocytopenic purpura? analysis of 207 eradicated chronic itp cases in japan. int j hematol. 2005;81(2):162-168. 39. tag hs, lee hs, jung sh, kim bk, kim sb, lee a, lee js, shin sh, kim ys. effects of helicobacter pylori eradication in patients with immune thrombocytopenic purpura. korean j hematol. 2010; 45(2):127-32. 40. gan gg, norfaizal al, bee pc, chin ef, habibah ah, goh kl.helicobacter pylori infection in chronic immune thrombocytopenic purpura patients in malaysia. med j malaysia. 2013 ;68(3):231-3. 41. hwang jj, lee dh, yoon h, shin cm, park ys, kim n. the effects of helicobacter pylori eradication therapy for chronic idiopathicthrombocytopenic purpura. gut liver. 2016; 10(3):356-61. 42. sheema k, ikramdin u, arshi n, farah n, imran s. role of helicobacter pylori eradication therapy on platelet recovery in chronic immune thrombocytopenic purpura. gastroenterol res pract. 2017;2017: 9529752. http://www.ncbi.nlm.nih.gov/pubmed/15929755 http://www.ncbi.nlm.nih.gov/pubmed/15929755 http://www.ncbi.nlm.nih.gov/pubmed?term=imamura%20m%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=harada%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=harada%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=sakamaki%20h%5bauthor%5d&cauthor=true&cauthor_uid=15765787 http://www.ncbi.nlm.nih.gov/pubmed?term=gan%20gg%5bauthor%5d&cauthor=true&cauthor_uid=23749012 j islamabad med dental coll 2019 123 open access prevalence of cerebrospinal fluid leak in traumatic head injury at a tertiary care center muhammad junaid1, asad nabi2, muhammad aslam khan3, muhammad umair4 1 assistant professor, ent, head & neck surgery, khyber medical college, peshawar 2 clinical fellow, neurosurgery, addenbrooke’s hospital cambridge, uk 3 senior registrar, ent, hitec/ ims 4 core medical trainee, northern lincolnshire, uk a b s t r a c t background: cerebrospinal fluid circulates around the surface of brain and spinal cord and through the brain’s ventricles. csf leak is a condition that occurs when the csf leaks through a defect in the dura or skull and out through the ear or nose. the most common causes of csf leak include head injury, brain and sinus surgery. the objective of this study was to determine the frequencies of post-traumatic cerebrospinal fluid leak in traumatic head injury. material and methods: a descriptive case series was carried out in the department of neurosurgery, hayatabad medical complex, peshawar for a period of 1 year, from 1st february 2016 to 31st january 2017. a total of 422 patients presenting within 48 hours of acute trauma to the head were included in a consecutive manner and followed up till 7th day to determine the csf leak. results: the mean age group of our sample was 37.37 + 12.3 years of which 79.6% were male patients and 20.4% female patients. most of the patients (55.5%) were ≤ 40 years of age. csf leak was observed in 5.2% of patients, with otorrhea seen in 2.1% patients and rhinorrhea in 3.1% patients, respectively. conclusion: csf leak is quite common in our population after acute trauma to the head. the high prevalence may be due to high frequency of accidents in our society with high velocity impact and more commonly seen in the younger age group (≤ 40 years). key words: craniocerebral trauma, csf leak, otorrhea, rhinorrhea, traumatic head injury authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3 active participations in data collection 4 data analysis. correspondence: muhammad junaid email: drjunaident@gmail.com article info: received: june 26, 2019 accepted: august 19, 2019 cite this article. junaid m, nabi a, khan ma, umair m. prevalence of cerebrospinal fluid leak in traumatic head injury at a tertiary care center. j islamabad med dental coll.2019; 8(3):123-126. doi: 10.35787/jimdc.v8i3.416 funding source: nil conflict of interest: nil i n t r o d u c t i o n traumatic brain injury is the fourth largest cause of fatal trauma worldwide.1 the social and economic implications of traumatic brain injuries are immense whilst the physical and mental bearing upon the patient are devastating. injury to the head results in a wide spectrum of anatomic and physiologic disruptions which frequently needs expert neurosurgical care.1 trauma to the head might result in leakage of cerebrospinal fluid (csf) through dural tears in the skull base and at other fracture sites. the reported incidence of post-traumatic csf leaks is 2% among the head trauma patients.2 these leaks are frequently associated with basilar skull fractures and present as rhinorrhea, otorrhea and in rare cases as occulorrhoea.1,2 the csf leak may be acute, chronic, spontaneous, iatrogenic, infection/inflammation and tumor associated. acute or early csf leaks present within 24 to 48 hours of trauma while the chronic or late leaks present in a delayed fashion such as weeks, months or years later.3 most of the cases of traumatic csf leaks resolve spontaneously with simple conservative measures such as reclined bed position, blood pressure control, diuretics o r i g i n a l a r t i c l e j islamabad med dental coll 2019 124 and does not require repair of the dural and cranial defect.4 current guideline advises conservative treatment of posttraumatic csf leaks for 10 to 14 days. if the leak does not respond to conservative measures in two weeks, then it is imperative to intervene invasively.5-7 the common investigations performed to detect skull fracture and hence the suspected dural tear area by the high-resolution ct scan is seen with coronal and sagittal cuts. mri with t2 weighted images in prone position is also highly favored. radionuclide cisternography, metrizamide contrast test and intrathecal fluorescein dye test are other tests to confirm csf leaks. beta transferrin of the leaking fluid and its glucose levels are also helpful in differentiation between csf rhinorrhea from other causes. 7-9 complications of posttraumatic csf leaks include acute fulminant meningitis with a considerably higher mortality rate, repeated pneumocephalus with the possibility of tension pneumocephalus.9-12 bell et al13 has conducted a review of posttraumatic csf leaks and its management and has reported that these leaks are present in 4.6% of head trauma patients. however, the true prevalence is unknown because the csf leaks may appear years after initial dural tear. sometimes, patients may present with sudden onset acute meningitis which may appear months or years after the initial head injury.13 the rationale of this study was to observe frequency of early posttraumatic csf leaks at our institute. wide discrepancies exist in the observed frequencies of post traumatic csf leaks in different studies. by determining the frequencies of post-traumatic cerebrospinal fluid leak in traumatic head injury at our institution, the present study will be helpful to overcome that difference in the observed studies. furthermore, recording the associated morbidity will help us in delineating the management strategies according to our local expertise and availability of treatment options m a t e r i a l a n d m e t h o d s this study was conducted at neurotrauma ward, hayatabad medical complex peshawar. duration of the study was one year, from 1st february 2016 to 31st january 2017. the study design was descriptive case series in which non-probability consecutive technique was used for sample collection. patients presenting within 48 hours after the initial head trauma, both male and female, with age ranging from 18 to 65 years were included, while patients who developed post-operative cerebrospinal fluid leaks, those who presented with spontaneous cerebrospinal fluid rhinorrhea or otorrhea or those who developed inflammatory type of cerebrospinal fluid discharge were excluded. patients were divided into four different age groups (≤ 30 years, 31-40 years, 41-50 years and ≥ 51 years). all patients meeting inclusion criteria were included in the study through emergency and opd. detailed history, clinical examination and diagnosis was confirmed using high resolution ct and mri of brain, skull base, temporal region followed by routine investigations. patients were followed during their course of admission till the day of discharge and were assessed for the presence or resolution of the csf leak. post stratification was done through chi square test and pvalue less than or equal to 0.05 was considered significant. r e s u l t s the study was conducted on 422 patients presenting after acute trauma. the mean age of the sample was 37.4 + 12.4 years (table i). there were 79.6% male patients and 20.4% female patients (table i). csf leak was observed in 5.2% of patients (table ii). looking at the type of outlet of csf leak, we observed that 2.1% of patients had otorrhea, while 3.1% patients had rhinorrhea (table ii). we stratified the csf leak with regards to different age groups and observed that the difference was statistically significant with a p value of 0.000. (table iii). csf leak was also stratified with regards to gender however the difference was statistically insignificant (p = 0.793) (table iv). table i: frequency distribution of patients according to age groups (n = 422) age (years) frequency(n) percentage (%) ≤ 30 150 35.5 31 to 40 84 19.9 41 to 50 104 24.6 ≥ 51 84 19.9 total 422 mean ± sd 37.4 ±12.4 j islamabad med dental coll 2019 125 table ii: frequency distribution of types of csf leak (n = 422) type of csf leak frequency n percentage % otorrhea 09 2.1 rhinorrhea 13 3.1 total csf leaks 22 5.2 table iii: age wise stratification of patients with csf leak (n = 422) csf leak total yes n (%) no n (%) age groups ≤ 30 7 (4.7) 143 (95.3) 150 31 to 40 13(15.5) 71(84.5) 84 41 to 50 1(1.0) 103(99.0) 104 ≥ 51 1(1.2) 83(98.8) 84 total 22(5.2) 400(94.8) 422 p value 0.0001 table iv: gender wise stratification of patients with csf leak (n = 422) gender csf leak yes n (%) no n (%) total male (79.6%) 18 (5.4) 318 (94.6) 336 female (20.4%) 4(4.7) 82(95.3) 86 total 22(5.2) 400(94.8) 422 p value 0.793 d i s c u s s i o n nonsurgical trauma accounts for approximately 80% of csf leaks. this is in sharp contrast to 16% of csf leaks seen after surgical procedures and 4% due to nontraumatic causes. of the traumatic leaks, more than 50% are evident within the first two days of trauma, 70% within the first week, and almost all present within three months.14 csf traumatic leaks occur commonly in young males and complicate 2% of all head injuries, and 12% to 30% of all basilar skull fractures.11 adoga and colleagues15, in their study on otorhinolaryngological manifestations in head trauma found that majority of patients with head injury were male patients and the most affected population was below 40 years.15 we report comparable results, as in our study also, most of the patients with head trauma (79.6%) and csf leak (82%; 18/22) were male. similarly, majority of the patients (54.4%) were below 40 years of age. the common sites of csf rhinorrhea in cases of accidental trauma are the frontal sinus (30%), sphenoid sinus (30%) and cribriform/ ethmoid (23%).16 identifying the site of lesion in cases of csf leak is important and that can be done either through high resolution ct (hrct) scan or a cisternogram. localization of lesion is essential for appropriate management plan especially in cases of surgical intervention.11 ji-woong et al17 mentioned in his research article that for diagnosis, laboratory tests and radiological workup is mandatory, as physical examination is not reliable. furthermore, they added that radiologic findings are important in identification of leaking point and further decision making for management. the radiologic investigations may include plain radiograph of skull bones, high resolution computed tomography (hrct), ct cisternography, and magnetic resonance imaging (mri) with intrathecal contrast or cisternography. similarly, in a study by oakley18 and his colleagues, hrct is recommended as the first-line study for localization of csf leak while mr cisternography should be used for csf leak identification as a second line for each of these if beta-2 transferrin is not available or if hrct is not clear.18 in our study, we also used these modalities to locate csf leakage site i.e. hrct, ct/ mri cisternogram. csf leaks will usually resolve without surgical intervention in cases of trauma. in refractory cases, successful management often involves a combination of observation, csf diversion, and/ or extracranial and intracranial procedures.13 unilateral watery nasal discharge is the most common presenting symptom in skull base trauma cases.10 adoga et al, in a study found that common otorhinolaryngological presentations of csf leaks were rhinorrhea followed by otorrhea.15 contrary to this, yellinek and his colleagues in their study reported that otorrhea is more frequent then rhinorrhea in cases of csf leak secondary to traumatic brain injury.19 in our study, 22 patients had csf leaks out of total 422 patients i.e. 5.2% patients were diagnosed with csf leak, out of which 2.1% had csf otorrhea and 3.1% had rhinorrhea. anatomical differences in the skull base bone and dural structures seems to be the reason for above discrepancy. rhinorrhea is mostly associated with leaning forward or standing. other nasal conditions, like allergic rhinitis, perennial rhinitis and vasomotor rhinitis, are common, and may mimic the signs and j islamabad med dental coll 2019 126 symptoms of csf rhinorrhea or may occur simultaneously with a csf leak. if test is performed during the quiescent phase, there are chances of false-negative results on diagnostic testing. repeat testing and further follow-up is required in cases of high clinical suspicion.10,13 c o n c l u s i o n csf leak is common in our population after traumatic head injury. the high prevalence may be due to high number of accidents in our society with high velocity impact and more commonly seen in the age group less than 40 years. r e f e r e n c e s 1. algattas h, huang jh. traumatic brain injury pathophysiology and treatments: early, intermediate, and late phases post-injury. int. j. mol. sci. 2014; 15(1): 309-41. doi: 10.3390/ijms15010309 2. gray s.t, wu a.w. pathophysiology of iatrogenic and traumatic skull base injury. adv otorhinolaryngol. 2013; 74: 12–23. doi: 10.1159/000342264 3. posser jd, vender jr, solares ca. traumatic cerebrospinal fluid leaks. otolaryngol clin n am. 2011; 44(4): 857–73. doi: 10.1016/j.otc.2011.06.007 4. schoentgen c, henaux pl, godey b. management of post-traumatic cerebrospinal fluid (csf) leak of anterior skull base: 10 years’ experience. acta otolaryngol. 2013; 133(9): 944-50. doi: 10.3109/00016489.2013.793821 5. kumar br, sahu r, srivastava ak, nair ap, mehrotra a. surgically repaired posttraumatic csf rhinorrhea: an institutional experience and review of literature. indian j neurosurg 2012; 1(1): 23-7. doi: 10.4103/2277-9167.94366 6. kim sw, park hw, jeon sy. versatility of the pedicled nasoseptal flap in the complicated basal skull fractures. auris nasus larynx. 2013; 40(3): 3347. doi: 10.1016/j.anl.2012.07.013 7. tahir mz, khan mb, bashir mu, akhtar s, bari e. cerebrospinal fluid rhinorrhea: an institutional perspective from pakistan. surg neurol int. 2011; 2: 174. doi: 10.4103/2152-7806.90689 8. pease m, marquez y, tuchman a. diagnosis and surgical management of traumatic cerebrospinal fluid oculorrhea: case report and systematic review of the literature. j neurol surg rep. 2013; 74(1): 57-66. doi: 10.1055/s-0033-1347902 9. aurangzeb a, ahmed e, khan sa. outcome of transcranial repair of traumatic csf rhinorrhoea. j ayub med coll abbottabad. 2012; 24(2): 47-9. pmid: 24397051 10. bhatti sn, khan sa, shah r. transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea. j ayub med coll abbottabad. 2011; 23(2): 15-7. pmid: 24800333 11. luszczyk mj, blaisdell gy, wiater bp. traumatic dural tears: what do we know and are they a problem? spine j. 2014; 14(1): 49-56. doi: 10.1016/j.spinee.2013.03.049 12. chaudhary n, awan lm, niaz a. success determination of lumber drainage in cranial traumatic csf fistula. j spine neurosurg. 2013; 2(5). doi: 10.4172/2325-9701.1000121 13. bell rb, dierks ej, homer l, potter be. management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. j oral maxillofac surg. 2004; 62(6): 676-84. doi: 10.1016/j.joms.2003.08.032 14. kerman m, cirak b, dagtekin a. management of skull base fractures. neurosurg q. 2002; 12(1): 23–41. 15. adoga aa, ozoilo kn, iduh aa, mugu jg. otorhinolaryngological manifestations in head trauma: a prospective study of the epidemiology, clinical presentations, management, and outcomes. int j crit illn inj sci. 2017; 7(4): 231-35. doi: 10.4103/ijciis.ijciis_108_16 16. banks ca, palmer jn, chiu ag, et al. endoscopic closure of csf rhinorrhea: 193 cases over 21 years. otolaryngol head neck surg. 2009; 140(6): 826–33. doi: 10.1016/j.otohns.2008.12.060 17. oh jw, kim sh, whang k. traumatic cerebrospinal fluid leak: diagnosis and management. korean j neurotrauma. 2017; 13(2): 63–67. doi: 10.13004/kjnt.2017.13.2.63 18. oakley gm, alt ja, schlosser rj, harvey rj, orlandi rr. diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. int forum allergy rhinol. 2016; 6(1): 8–16. doi: 10.1002/alr.21637 19. yellinek s, cohen a, merkin v, shelef i, benifla m. clinical significance of skull base fracture in patients after traumatic brain injury. j clin neurosci. 2016; 25: 111-5. doi: 10.1016/j.jocn.2015.10.012. 274 j i m d c 2 0 1 7 274 open access f u l l l e n g t h a r t i c l e efficacy/ validity of neck dissection and radiotherapy for cervical nodal disease clinicopathological analysis mumtaz ahmad umar 1, jawwad ahmed 2, ghulam saqulain 3 1 ent specialist, shifa college of medicine, islamabad, pakistan 2 associate surgeon ent department, capital hospital, islamabad, pakistan 3 head of department of ent, capital hospital, islamabad, pakistan a b s t r a c t objective: to analyze treated head and neck malignancies with reference to frequency of cervical metastases and frequency of nodal recurrence following neck dissection and/ or radiotherapy for cervical metastases. patients and methods: this observational prospective study was conducted at ent department, pakistan institute of medical sciences, islamabad over a period of 16 months. study population was comprised of 15 cases of either gender and any age, with treated head and neck primary who developed metastatic neck disease and were included through non-probability sampling technique. patients with primary site recurrence or distant metastases were excluded from the study. they were treated with neck dissection, radiotherapy or both for neck disease and followed up for a 1 year. clinical data including age, gender, site and histopathology of treated primary tumor, nodal involvement both clinical and histopathological, treatment and post treatment result were recorded. data was collected, tabulated and analyzed using microsoft excel worksheet. results: out of total 15 cases, 17% patients were with n1 disease, 33% patients with n2a disease, and 50% were with n2b disease. total 3 (20%) patients received radiotherapy (2 being unfit for surgery and 1 due to refused consent) and 12 (80%) patients underwent surgery. out of these 12, 3 underwent rnd, 7 mrnd and 2 snd. total 20% (3) developed recurrence. conclusion: combination of rnd or mrnd and radiotherapy is highly effective in controlling neck disease in controlled primary tumors. key words: cervical nodal metastasis, neck dissection, radiotherapy author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence ghulam saqulain email: ghulam_saqulain@yahoo.com article info. received: june 20, 2018 accepted: november 10, 2018 cite this article. umar ma, ahmed j, saqulain g. efficacy/ validity of neck dissection and radiotherapy for cervical nodal disease clinicopathological analysis. jimdc.2018; 7(4):274279 funding source: nil conflict of interest: nil i n t r o d u c t i o n head and neck tumors are quite common,1, 2 majority being squamous cell carcinomas with laryngeal involvement being the commonest.3 in a local study variation in the prevalence was noted in different parts of the country.3 also presentation with metastatic neck disease is quite common.4 the status of cervical lymph nodes with primary head and neck malignancy has vital prognostic significance with increased incidence of distant metastases with nodal disease. 5 this demands workup for cervical lymph node metastasis and thorough management of cervical nodal disease. one of the most widely used procedure conventionally was radical neck dissection (rnd), however in recent years treatment of neck disease in head and neck malignancy has been o r i g i n a l a r t i c l e 275 j i m d c 2 0 1 7 275 widely debated. rnd, which was popularized by dr. hayes martin 6 involves unblock removal of lymph nodes of lateral neck along with superficial and deep layers of deep cervical fascia, including submandibular, deep cervical, posterior triangle and supraclavicular nodes and lymphatics along with sternomastoid muscle, internal jugular vein and accessory nerve.7 now surgeons are moving away from rnd for no and n1 neck, and started performing modifications by preserving the accessory nerve or other non-lymphatic structures. however, the question remains that for advanced neck disease are modifications like modified radical neck dissection (mrnd) with post-operative radiotherapy adequate. this has been agreed by some researchers 8 despite the bulk of literature available on the subject, lack of uniformity in connection with treatment strategies for neck disease still exist and also because there is dearth of such studies from this part of pakistan, therefore, the present study is important. p a t i e n t s a n d m e t h o d s this observational prospective study was conducted at department of otorhinolaryngology and head and neck surgery of pakistan institute of medical sciences, islamabad over a period of 16 months from february 2005 to june 2006. inclusion criteria was patients with controlled primary malignant tumor in the head and neck with cervical nodal metastases, of either gender and all age diagnosed and managed at the department. exclusion criteria include patients who had un-resectable primary tumor and cases of cervical metastases with recurrence at primary site. sampling was done through non-probability sampling technique. total15 patients who met the inclusion criteria were included in the study. chart reviews of these patients were done to acquire history and other clinical data including age, gender, site and histology of primary tumor. for neck metastases the level of lymph nodes, their size, mobility, whether ipsilateral, contralateral or bilateral was assessed and nodal status was recorded using uicc staging. 9 all patients underwent fnac examination to confirm metastases. ct scan was done in some patients to see the extent of the metastatic neck disease and treatment was planned accordingly. histopathology was confirmed by histopathology reports of the patients. out of total 15 patients, rnd was performed on 3 patients, 7 patients underwent mrnd and 2 patients underwent supraomohyoid neck dissection (snd), while another 3 patients were treated with radiotherapy. all the patients followed up after treatment for minimum up to 1 year with special attention to neck node palpation to detect any recurrence. data was collected, tabulated and analyzed using microsoft excel worksheet. gender was presented by frequency and percentage. mean, median and mode was calculated for age of patient at presentation. variables like site and histology of primary tumor site, nodal status including level, mobility, fnac, treatment and post treatment results were presented by frequency and percentage. r e s u l t s among total 15 cases, there was male preponderance with 11 males (73 %) and 4 females (27 %) with male to female ratio m: f = 2.75: 1. their age ranged from 45 to 75 years with mean age of 57.3 years (table 1). common tumor sites included larynx in 5 (33.3%) cases and tongue in 4 (26.7%) cases (table 2). examination revealed that most patients having nodal metastasis at level ii, followed by level iii. nodes were mostly mobile. fnac confirmed the presence of metastatic neck disease which was mainly squamous cell variety in 10 (83.4%) cases. total 12 (80%) patients underwent neck dissection. while 3 (20%) patients received radiotherapy (a dose of 66 gy each), among them 2 were unfit for surgery and 1 refused surgery. among surgical procedures mrnd was the most common procedure done 47% (table 2). table 1: demographic data of study population (n=15) gender male 11(73%) female 04 (27%) age (years) minimum 45 maximum 75 mean 57.3 median 55 mode 50.55 276 j i m d c 2 0 1 7 276 table 2: frequency of site involvement, level of lymph nodes, histology of primary tumor and treatment given for cervical metastasis in studied population (n=15) variables frequency (n) percentage (%) primary tumor site (n=15) larynx 5 33.3 tongue 4 26.7 lower alveolar ridge 2 13.3 submandibular gland 2 13.3 nasophrynx 1 6.7 skin 1 6.7 lymph node level (n= 15) level i 2 13.3 level ii 6 40 level i & ii 2 13.3 level iii 3 20 level ii & iii 1 6.7 level v 1 6.7 lymph node mobility (n=15) mobile 9 60 immobile 6 40 histopathology (n = 12) squamous cell carcinoma 10 83.4 adenoid cystic carcinoma 1 8.3 malignant melanoma 1 8.3 treatment (n=15) rnd 3 20 mrnd 7 47 snd 2 13 radiotherapy 3 20 post treatment result (n=15) no follow up 4 26 living without disease 8 54 regional recurrence 2* 13 primary site & regional recurrence 1 7 dead 1* 7 * this one patient with regional recurrence expired minimum follow up was maintained for a year. total 2(13%) patients developed recurrence in the neck (1 in mrnd group, and the other 1 in radiotherapy group who later expired) in the absence of recurrent primary disease. in 1(7%) patient, the recurrence in the neck was associated with recurrent primary disease as well. all these patients developed recurrence within first 6 months. therefore, total of 12 out of 15 necks (80%) were controlled and total 3 (20%) patients had recurrence. total 8 patients (54%) were living without loco regional disease with the longest follow up of 16 months for 1 patient, while 4 (26%) were lost to follow up after first 6 months. however, one of these lost patients came for follow up but after the mentioned study period i.e. of one year (table 2). total 11 patients received postoperative radiotherapy, with a mean dose of 55 gy (range 30-66 gy), only 2 patients received less than 50 gy. total 17% (2/12) of dissected necks were pathologically n1, 33% (4/12) were n2a and 50% (6/12) were n2b (table 3). d i s c u s s i o n head and neck cancers are common all over the world occupying 6th 1 and 8th position 2, among whole body cancers according to different authors, occurring in 560000 patients with 380000 deaths per year.10 these tumors being predominant in males are mostly seen between 50 to 70 years of age.4 squamous cell carinomas (ssc) with laryngeal involvement are the commonest.3 according to ridge ja et al, ssc account for > 90% head and neck tumors in the west 4 and in a local study, aziz f et al reported the frequency of scc being the commonest 45.8%, followed by lymphoma 277 j i m d c 2 0 1 7 277 (14.5%), basal cell carcinoma (bcc), thyroid carcinoma (10.5% each), salivary gland tumors (8.80%), others being infrequent. 3 in our study ssc topped the list (83.4%) followed by adenoid cystic carcinoma and malignant melanoma. site wise, laryngeal tumors are the commonest i.e., 53.5%, followed by pharynx 18.7%, tongue 10.71%, oral cavity 4.4% and skin 2.6%, being the least common.3 in the present study also larynx and tongue were the commonest sites with relative frequency of 33.3% and 26.7% respectively and skin being the least common with frequency of 6.7%. head and neck tumors show gross variations in incidence in different regions globally. aziz f et al noted variation in the prevalence in different parts of pakistan as well.3 metastatic neck disease is also very common with 43% showing involvement of regional nodes, 4 and this also drops survival by almost 50%. cervical nodal status with primary head and neck malignancy has vital prognostic significance demanding workup and thorough management of cervical nodal disease.11,12 rnd was the most widely used procedure to deal with neck metastasis, however this has been widely debated. rnd, which was popularized by dr. hayes martin 6, involves enblock removal of lateral neck nodes with superficial and deep layers of deep cervical fascia, including submandibular, deep cervical, supraclavicular and posterior triangle nodes and lymphatics along with sternomastoid muscle, internal jugular vein and accessory nerve 7. according to saurez, removal fibro fatty tissue of neck bearing lymph nodes, without sacrificing the non-lymphatic structures was oncologically sound.13 also, for no and n1 nodal status, surgeons have started modifications of the procedure by preserving the accessory nerve or other non-lymphatic structures to minimize morbidity but to maintain oncologic efficacy. however, the question still remains that for advanced cases i.e., n2 or n3 (stage iv) which have worst prognosis, is mrnd with post-operative radiotherapy adequate. this has been agreed by some researchers.8 it is important to note that modification with preservation of spinal accessory avoids the shoulder disability.14 leipzig et al.16 and sobel et al.14 have shown clear correlation between the amount of nerve dissection and degree of shoulder dysfunction. even lesser dysfunction was noted when all the three i.e., nerve, muscle and vein were preserved during snd and functional neck dissection.15 nerve sparing dissections result in significant, but temporary and reversible shoulder dysfunction, while rnd is followed by profound and permanent one.16 preservation of the spinal accessory nerve and if preserved along with sternocleidomastoid muscle, result in better shoulder function, protection of neck arteries and cosmesis.17,18 therefore surgeons try to preserve accessory nerve etc., when oncologially feasible. postoperative radiation therapy is recommended for cases with large nodal metastasis and extranodal spread. however, a high incidence of local recurrence and distant metastasis is noted in these cases. distant secondaries are seen in 10% cases of initial relapse, and 47 % in cases with more than three positive nodes.19 radiotherapy has also been claimed to have good results at some centers. in a study by bernier and bataini 20 achieved a 3-year nodal control rate for no tumours of 98 %; for n1, 90 %; for n2, 88 %; and for n3, 71% when the primary site remained controlled. our neck control rate was of 100% (3/3) for rnd and 86% (6/7) for mrnd that are comparable to the international studies and it also supports the approach to nerve preservation, even in bulky n2 or n3 disease. in our study, radiotherapy alone for the neck disease was not as effective as surgery followed by radiotherapy and 2 of 3 cases who received radiotherapy alone developed neck recurrence, one of these 2 also developed recurrence at primary site. studies by richards et al 21, santos et al 21, pathak et al 22, and leemans et al 23 as well as our study shows that comprehensive neck dissection (rnd & mrnd) and postoperative radiotherapy has a high likelihood of controlling disease in the ipsilateral neck, as long as disease remains controlled at the primary site. table 3: clinical versus pathological nodal staging clinical stage (n = 15) histo-pathological stage (n =12) number (n%) number (n%) n1 4(26.7) 2(17) n2a 8(53.4) 4(33) n2b 3(20) 6(50) 278 j i m d c 2 0 1 7 278 in correlating our clinical and pathological staging, a number of patients were found clinically n1 but pathologically n2a and clinically n2a but pathologically n2b. also around 50% of the necks are pathologically n2b, suggesting that by the time a solitary mass becomes clinically greater than 3 cm, probably metastasis to multiple nodes have already occurred. based on this experience, a comprehensive neck dissection for n2 or greater disease and postoperative radiotherapy seems logical. though in this study contralateral negative necks were treated with radiotherapy alone, however failure of control was not noted, indicating success of this approach. however, in contrast, richards et al 8, found contralateral neck failure in the absence of primary site disease in some patients and they suggested. snd of contra lateral negative neck follow up with evaluation by physician is essential 24 with special attention to neck palpation which has a sensitivity and specificity of 6070%, is essential element of management of these cases. unfortunately, 4 cases were lost to follow up in this study. this study has significant importance since there is dearth of such studies from this part of the world, though cervical recurrence in is quite common here. the study highlights the importance of various surgical, radiotherapeutic or combined strategies, which can be adopted for the treatment of cervical metastasis. c o n c l u s i o n combination of rnd and mrnd with radiotherapy is highly effective in controlling neck disease in the absence of persistent or recurrent local disease. also in our experience, mrnd appears to be as effective as rnd in controlling even advanced neck disease, which supports the preservation of the spinal accessory nerve whenever oncologically feasible. r e f e r e n c e s 1. siegel rl, miller kd, jemal a. cancer statistics, 2017. ca cancer j clin. 2017; 67(1):7-30 2. hakim m, billan, s, tisch u, peng g, dvrokind i, marom o et al. diagnosis of head-and-neck cancer from exhaled breath. br j cancer.2011; 104(10): 1649–55. 3. aziz f, ahmed s, malik a, afsar a, yusuf nw. malignant tumors of head and neck region a retrospective analysis. j coll physicians surg pak 2001; 11(5):287-90. 4. ridge ja, mehra r, lango mn, galloway t. head and neck tumors. in: pazdur r, wagman ld, camphausen ka, hoskins wj (eds),cancer management: a multidisciplinary approach medical, surgical and radiation oncology 12th edn., the oncology group: new york.2016 5. ferlito a, shaha ar, silver ce, rinaldo a, mondin v. incidence and sites of distant metastases from head and neck cancer. orl j otorhinolaryngol relat spec. 2001; 63(4):202-7. 6. martin h, del valle b, ehrlich h, cahan wg. neck dissection. cancer 1951; 4(3):441–99. 7. watkinson jc, gaze mn, wilson ja. neck dissection. in: stell and maran’s head and neck surgery. 4th ed. london: butterworthheinemann; 2000:215-32. 8. richards bl, spiro jd. controlling advanced neck disease: efficacy of neck dissection and radiotherapy. laryngoscope 2000; 110(7):1124 – 7. 9. tnm classification of malignant tumours sobin l h, gospodarowicz m k, wittekind ch international union against cancer. 7th ed. wiley-blackwell publishing, 2009. 10. global burden of disease cancer collaboration, fitzmaurice c, allen c, et al. global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disabilityadjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. jama oncol 2017; 3(4):524. 11. chen cc, lin jc, chen kw. lymph node ratio as a prognostic factor in head and cancer patients. radiat oncol. 2015; 10(1):181. 12. park jo, joo yh, cho kj, kim ms. lymph node density as an independent prognostic factor in nodepositive patients with tonsillar cancer. head neck. 2016;38(s1):e705-e711. 13. suarez, o. el problema de las metastasis linfáticas y alejadas en cancer de laringe e hipofaringe. rev otorrinolaring (santiago) 1963 ; 23: 83-89. 14. sobol s, jensen c, sawyer w, costiloe p, thong n. objective comparison of physical dysfunction after neck dissection. am j surg 1985;150(4): 503-09. 15. leipzig b, suen jy, english j, barnes j, hooper m. functional evaluation of the spinal accessory nerve after neck dissection. am j surg 1983;146(4): 52630. 16. remmler d, byers r, sheetz a. a prospective study of shoulder disability resulting from radical and 279 j i m d c 2 0 1 7 279 modified neck dissections. head neck surg 1986;8(4):280-86. 17. erisen l, basel b, irdesel j, zarifoglu m, coskun h, basut o. shoulder function after accessory nervesparing neck dissections. head neck 2004;26(11): 967-71. 18. cuccia g, shelley op, alcontres fs, giannitrapani m, soutar ds, camilleri ig. evidence of significant sternocleidomastoid atrophy following modified radical neck dissection type iii. plast reconstr surg. 2006; 117(1): 227-32. 19. leemans cr, tiwari r, nauta jjp, van der waal i, snow gb. regional lymph node involvement and its significance in the development of distant metastasis in head and neck carcinoma. cancer 1993; 71(2): 452-56. 20. bernier j, bataini jp. regional outcome in oropharyngeal and pharyngolaryngeal cancer treated with high dose per fraction radiotherapy: analysis of neck disease response in 1646 cases. radiother oncol 1986; 6(2):87-103. 21. santos ab, cernea cr, inoue m, ferraz ar. selective neck dissection for node-positive necks in patients with head and neck squamous cell carcinoma: a word of caution. arch otolaryngol head neck surg 2006;132(1):79-81. 22. pathak ka, das ak, agarwal r, talole s, deshpande ms, chaturvedi p, pai ps, chaukar da, d’cruz ak. selective neck dissection (i–iii) for node negative and node positive necks. oral oncology. 2006;42(8):83741. 23. leemans cr, tiwari r, van der waal i, karim abmf, nauta jjp, snow g. the efficacy of comprehensive neck dissection with or without postoperative radiotherapy in nodal metastasis of squamous cell carcinoma of the upper respiratory and digestive tracts. laryngoscope 1990;100(11): 1194-98. 24. agrawal a, desilva bw, buckley bm, schuller de. role of the physician versus the patient in the detection of recurrent disease following treatment for head and neck cancer. laryngoscope 2004; 114(2):232-35. j islamabad med dental coll 2020 249 open access nephroprotective effects of l-arginine against chemotherapy induced acute kidney injury in wistar rats kumayl abbas meghji,1 tariq feroz memon,2 imtiaz ahmed,3 sehar gul memon,4 naila noor,5 ali abbas6 1assistant professor, department of physiology, isra university, hyderabad pakistan 2assistant professor, department of community medicine, isra university, hyderabad pakistan 3assistant professor, department of biochemistry, suleman roshan medical college, tando ādam, pakistan 4lecturer, department of physiology, ghad college, riyadh, saudi arabia 5senior lecturer, department of physiology, isra university, hyderabad pakistan 6assistant professor, department of pharmacology, isra university, hyderabad pakistan a b s t r a c t background: l-arginine is a nitric oxide precursor that decreases oxidative stress and regulates the blood flow by modifying the tone of vessels and also prevent ischemic renal tissue injuries. the objective of this study was to evaluate the protective role of l-arginine in cisplatin-induced acute renal injury through assessment of renal, oxidative stress, and inflammatory markers in albino wistar rats. material and methods: a quasi-experimental study was conducted at the department of physiology and postgraduate research laboratory, isra university, hyderabad, pakistan from april to september 2019. thirty male albino wistar rats were selected through non-random purposive sampling and divided equally into three different groups: group a (control group), group b (cisplatin group), and group c (cisplatin plus arginine group). blood samples from rats were collected through cardiac puncture, followed by renal histopathological analysis under light microscope. the severity of tissue damage was observed using a graded scale from ‘0’ (no damage) to iii (severe damage). data was analyzed using spss version 24.0., with one-way anova and post hoc tukey analysis used for comparison of different variables. results: there was a statistically significant decline in the bodyweight and rise in absolute kidney weight of group b in comparison with the other two groups (p <.05). moreover, a significant rise in serum renal markers was observed in group b (p <.05), with a statistically significant decline in these markers in group c compared with group b (p <.05). marked histological alterations (glomerular and tubular damage) were observed in renal tissues of group b as compared to group c. conclusions: the present study concludes that l-arginine exerts anti-oxidative, anti-inflammatory, and nephroprotective effects against renal tissue damage caused by cisplatin. key words: acute kidney injury, antioxidant, cisplatin, l-arginine, oxidative stress authors’ contribution: 1conception; literature research; manuscript design and drafting; 2-6 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: tariq feroz memon email: drtariqferoz@gmail.com article info: received: june 19, 2020 accepted: december 7, 2020 cite this article. maghji ka, memon tf, ahmed i, memon sg, noor n, abbas a. nephroprotective effects of l-arginine against chemotherapy induced acute kidney injury in wistar rats. j islamabad med dental coll. 2020; 9(4): 249-255. doi: 10.35787/jimdc.v9i4.535 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 250 i n t r o d u c t i o n kidney disorders are recognized as a major public health concern as the number of such diseases is significantly increasing each year. according to reports, the prevalence of diseases related to kidneys has climbed up by 10% in the general population and up to 50% in high-risk subpopulations in the last 10 years.1 acute kidney injury (aki), previously known as acute renal failure is characterized by a sudden decline in renal function resulting in the accumulation of metabolic wastes such as urea and creatinine in the blood.2 although the etiology of aki is diverse (e.g., sepsis, ischemia/hypo-perfusion, etc.), nephrotoxic drugs including chemotherapeutic agents like cisplatin, are the main causative factors, as demonstrated in 19% to 25% of cases.3 cisplatin is a very common and effective antineoplastic drug used against a wide range of cancers. along with its effective use, it also poses many harmful effects on the tissues due to its reactive oxygen species (ros) generating capability that causes depletion of glutathione levels and inhibition of renal antioxidant enzymes resulting in nephrotoxicity. studies reported nephrotoxicity in 25% to 35% of patients who received a single dose of cisplatin.4,5 the pathogenesis of aki has been widely attributed to defects in the l-arginine: nitric oxide (no) pathway.6 l-arginine, a no precursor, is converted into no by the action of the enzyme no synthase (nos).7 no decreases oxidative stress as well as regulates blood flow by modifying the vascular tone.8 it prevents the ischemic tissue injuries of different organs like kidneys, heart, lungs, liver, and intestine of experimental animals. it also decreases neutrophil and leukocyte adhesion as well as decreases the secretion of pro-inflammatory cytokines, such as c-reactive protein (crp), which play an important role in causing tissue injury.8,9 the present study was designed with an objective to evaluate the protective role of l-arginine in cisplatininduced acute renal injury through assessment of renal, oxidative stress, and inflammatory markers in albino wistar rats. m a t e r i a l a n d m e t h o d s this quasi-experimental study was carried out in the department of physiology and postgraduate research laboratory, isra university, hyderabad, pakistan from april to september 2019. about thirty healthy, male albino wistar rats, aged 8-10 weeks and weighing between 250 to 300 grams, were procured from the agriculture university of tando jam, sindh by non-random purposive sampling technique. the sample size was calculated using the standard method of power analysis for animal studies.10,11 this study was approved by the ethics review committee of isra university, that is fully equipped to give permission for animal studies. all the animals were handled according to the guidelines of international research council for laboratory animals’ handling. before the initiation of the experiment, animals were kept for ten days of acclimatization in a wellequipped and hygienic environment at the postgraduate laboratory in isra university, hyderabad at the optimum temperature of 24-26℃ in a day-night cycle of 12/12 hours. to avoid any harm, animals were placed in plastic cages with water drinkers having stainless steel nozzles and feed containers. rats were provided free access to chow diet and clean water ad libitum. their bedding consisted of sawdust and was renewed daily. j islamabad med dental coll 2020 251 all rats were equally (n=10) divided into group a (control group, given a normal chow diet and clean water ad libitum), group b (single dose of cisplatin, 20mg/kg body weight, intraperitoneal), and group c (single dose of cisplatin, 20mg/kg + l-arginine, 10 mg/kg, body weight, intraperitoneal). arginine was crushed into powder and administered orally, mixed in diet, for 3 weeks. the level of the orally administered dosage of arginine (10 mg/kg) and the intraperitoneal dose of cisplatin (cisplatin 20mg/kg) was based on previous studies.12,13 soon after the acclimatization period, the bodyweight of all rats was measured twice i.e. before initiation of the experiment and after completion of three weeks of the experiment using an electronic precision balance. on completion of the experiment, all rats were given anesthesia (inj. sodium pentobarbital at 40mg/kg, intraperitoneal) and sacrificed by cervical dislocation. for analysis of oxidative and renal function markers, blood was collected by cardiac puncture. serum urea and creatinine were analyzed on hitachi roche automated chemistry analyzer (cobas c311) whereas serum glutathione peroxidase (gpx) was analyzed using bioassay technology elisa kit (catalog no: e1242ra) with the results read through dia source elisa plate reader (rt0931117dia) at diagnostic laboratory, isra university, hyderabad. the kidneys were dissected out and weighed on an electronic scale after which they were fixed in 10% buffered formalin. then, they were passed in xylene for clearing and embedded in paraffin wax. thin tissue sections, of up to 4-µm thickness were cut manually using rotary microtome, 290 and stained with hematoxylin and eosin (h&e) for examination under the light microscope (olympus bx51, tokyo, japan). histopathological analysis of renal tissue was done by evaluating the degree of infiltration of inflammatory cells, vascular congestion, hydropic change (swelling of epithelial cells), etc. the changes in severity of tissue damage were observed using a graded scale adopted from a previous study as: none (0), mild (i), moderate (ii), and severe (iii).14 statistical analysis of data was performed in spss version 24.0. findings of variables like body and kidney weights, oxidative, inflammatory, and renal function markers were expressed as mean and standard deviation while their comparison was analyzed by one-way anova and post hoc tukey analysis. the level of significance was set at p-value ≤ .05. r e s u l t s table i shows changes in the preand postexperimental body weights and absolute kidney weights of albino wistar rats. there was a statistically significant decline in the bodyweight of group b in comparison with groups a and c (p < .05). similarly, a significant rise in absolute kidney weight was observed in group b in comparison with groups a and c (p < .001). however, the difference between absolute kidney weights of groups a and c was nonsignificant (table i). the changes in markers of renal function, oxidative stress as well as inflammation are shown in table ii. there was a significant rise in serum urea, creatinine, and crp levels in group b in comparison with groups a and c. however, the experimental animals which received l-arginine only revealed markedly decreased blood urea, creatinine, and crp levels as compared to group b. similarly, there was a statistically significant decline in the serum glutathione peroxidase (gpx) levels of group b in comparison with groups a and c (table ii). figures 1, 2, and 3 demonstrate the photomicrographic findings of cut-sections of renal tissues of groups a, b, and c, respectively. prominent glomerular structure shrinkage, dilatation of the bowman’s capsule, peritubular fibrotic areas, and hydropic degeneration of the renal tubules was observed in group b. moreover, marked congestion j islamabad med dental coll 2020 252 was observed all over the renal tissues of the same group. while group c displayed significantly lesser glomerular and tubular damage as compared with group b. table iii demonstrates the grade-wise comparison summary of all the histopathological changes in renal tissues observed in each group under light microscopy. table i: difference in mean body weight and absolute kidney weight between experimental groups by post-hoc tukey test variables group a group b group c p-value initial body weight (gm) 262.7±3.8 259.3±2.4 261.1±3.1 0.38 final body weight (gm) 270.2±6.4b,c 221.9±4.1a,c 238.1±2.7a,b .001* absolute kidney weight (gm) 1.41±0.02 b 1.48±0.09 a,c 1.39±0.04b .001* * statistically significant difference between the groups on anova a, b, cdenotes the statistically significant difference between control and treated groups, respectively through post hoc tukey test (p < .05). table ii: difference in mean serum urea, creatinine, gpx, and crp between experimental groups by post-hoc tukey test mean serum levels group a group b group c p-value serum urea (mg/dl) 22.70±2.66b,c 57.27±3.65a,c 38.10±0.99a,b .001* serum creatinine (mg/dl) 0.45±0.05 b,c 0.78±0.09 a,c 0.58±0.16 a,b .001* serum gpx (ng/dl) 1.44±0.13 b,c 0.85±0.11 a,c 1.54±0.07 a,b .001* serum crp (mg/dl) 0.10 ± 0.11 b,c 0.81± 0.25 a,c 0.57± 0.15 a,b .001* *statistically significant difference between the groups on anova a, b, cdenotes the statistically significant difference between control and treated groups, respectively through post hoc tukey (p-value < .05) gpx-glutathione peroxidase; crp-c-reactive protein table iii: grade-wise comparison of histopathological changes in renal tissue of rats cellular infiltration peritubular fibrotic areas hydropic degeneration vascular congestion group a 0 0 0 0 group b *** *** *** *** group c * ** ** * grading score follows: none (0), mild (*), moderate (**) and severe (***) figure 1. a: control group shows normal glomerular and tubular architecture (h&e, 100x). b: nephrotoxic group shows shrinkage of glomeruli, dilatation of bowman’s slit, and congestion (h&e, 400x). c: l-arginine group shows near normal glomerular structure and comparatively less apparent renal congestion (h&e, 400x). j islamabad med dental coll 2020 253 d i s c u s s i o n the present study sought to investigate the nephroprotective effects of l-arginine exerted on cisplatin-induced aki in a rat model by examining different biochemical and histopathological parameters associated with kidney function of intoxicated and treated rats. significant alterations in kidney function and histopathological status were observed in experimental rats intoxicated with cisplatin. however, significant improvement was observed in body weight and all biochemical parameters related to kidney function causing significant reduction in serum creatinine, urea, c-reactive protein, and glutathione peroxidase levels as well as improving the renal histological architecture. these results show that l-arginine therapy can ameliorate cisplatin-induced nephrotoxicity by improving levels of endogenous antioxidants. being the excretory units of the body, the kidneys are exposed to numerous toxic substances causing the liberation of elevated quantities of free radicals which make the kidneys vulnerable to damage.15 cisplatin has been proven to be toxic to kidneys causing alterations in the parameters of renal function.16 cisplatin has also been shown to have a direct inflammatory effect on the kidneys as well as causing increased oxidative stress leading to depletion of vital anti-oxidant molecules like glutathione.17 in our experiment, administration of cisplatin was followed by a reduction in the weight of the experimental animals, which is consistent with previous findings.3 the animals receiving larginine therapy showed a much less reduction in their weights, which is consistent with the findings of eshraghi-jazi et al., who observed that arginine ameliorates cisplatin-induced weight loss in male rats.18 in this study, there was an increase in the blood urea and creatinine of all the animals receiving cisplatin as compared with the controls. these findings are similar to the results reported by wang et al. and adeneye and benebo.19,20 however, blood urea and creatinine levels in the rats receiving adjunct therapy of l-arginine were far less than those who received cisplatin alone which is consistent with the findings of başhan et al.21 saleh et al. also reported a significant rise in blood urea and creatinine levels in experimental animals which received cisplatin but the experimental animals receiving concomitant arginine therapy showed near normal levels, which is consistent with the current study.22 in this experiment, there was an increase in the crp levels and decrease in the serum gpx levels of cisplatin-treated rats denoting inflammation and oxidative stress, respectively. such changes were not observed in the control group as animals were not exposed to the nephrotoxic agent. however, arginine therapy prevented the change in the crp and gpx levels. these findings are in accordance with the findings of yu et al., who observed that consumption of arginine rich foods such as nuts was inversely associated with inflammatory biomarkers such as crp.23 hong et al. also observed arginine consumption was inversely related to crp levels but directly related to serum gpx levels in rats, which is consistent with the findings of our study.24 the positive effects of arginine on oxidative stress have also been studied by gharibi et al., who reported that l-arginine supplementation increased no concentration and significantly improved oxidative status.16 in our study, histological examination of the kidneys showed clear evidence of cisplatin-induced nephrotoxic injury manifested as marked tubular cell necrosis, vascular congestion, and tubular dilatation, which is consistent with previous findings.3 however, these changes were much less evident in the arginine treated animals. these findings are consistent with the findings of bashan and coworkers, who noted that histopathological j islamabad med dental coll 2020 254 changes were reversed in the nephrotoxic animals who received l-arginine as well.21 the main limitation of our study was lack of funds to assess further parameters of renal function, such as plasma and urinary albumin levels, serum electrolyte levels and urine analysis for further evaluating the renal damage and related complications due to cisplatin. c o n c l u s i o n the present study concluded that l-arginine exerts an anti-oxidative, anti-inflammatory, and nephroprotective effect against cisplatin-induced renal tissue damage. however, further studies should be carried out for a more detailed evaluation of the protective effects of arginine on other organs as well, to give more insight into the topic. r e f e r e n c e s 1. eckardt k-u, coresh j, devuyst o, johnson rj, köttgen a, levey as, et al. evolving importance of kidney disease: from subspecialty to global health burden. lancet. 2013; 382(9887): 158-69. doi:10.1016/s0140-6736(13)60439-0. 2. kianian f, seifi b, kadkhodaee m, sajedizadeh a, ahghari p. protective effects of celecoxib on ischemia reperfusion–induced acute kidney injury: comparing between male and female rats. iran j basic med sci. 2019; 22(1): 43-8. doi: 10.22038/ijbms.2018. 29644.7156. 3. meghji ka, talpur ra, uqaili aa, nizammani ym, kazi n, nizammani gs. resveratrol attenuates oxidative stress in chemotherapy induced acute kidney injury: an experimental rat model. kmuj. 2019; 11(2): 85-9. doi: 10.35845/kmuj.2019.19114. 4. martinho n, santos tc, florindo hf, silva lc. cisplatin-membrane interactions and their influence on platinum complexes activity and toxicity. front physiol. 2019; 9: 1898. doi:10.3389/fphys.2018. 01898. 5. yu w, chen y, dubrulle j, stossi f, putluri v, sreekumar a, et al. cisplatin generates oxidative stress which is accompanied by rapid shifts in central carbon metabolism. sci rep. 2018; 8(1): 1-12. doi:10.1038/s41598-018-22640-y. 6. schramm l, heidbreder e, lopau k, schaar j, zimmermann j, harlos j, et al. influence of nitric oxide on renal function in toxic acute renal failure in the rat. miner electrolyte metab. 1996; 22(1-3): 168-77. pmid: 8676813. 7. cherla g, jaimes ea. role of l-arginine in the pathogenesis and treatment of renal disease. j nutr. 2004; 134(10 suppl): 2801s-6s; discussion 18s-19s. doi: 10.1093/jn/134.10.2801s. 8. wink da, miranda km, espey mg, pluta rm, hewett sj, colton c, et al. mechanisms of the anti-oxidant effects of nitric oxide. antioxid redox signal. 2001; 3(2): 203-13. doi:10.1089/152308601300185179. 9. omi h, okayama n, shimizu m, fukutomi t, nakamura a, imaeda k, et al. cilostazol inhibits high glucose-mediated endothelial-neutrophil adhesion by decreasing adhesion molecule expression via no production. microvasc res. 2004; 68(2): 119-25. doi: 10.1016/j.mvr.2004.05.002. 10. charan j, biswas t. how to calculate sample size for different study designs in medical research? indian j psychol med. 2013; 35(2): 121-26. doi: 10.4103/0253-7176.116232. 11. hanif ms, baloch ms, meghji ka, abbas a, kashif s, qureshi r. histopathological changes in the gastric mucosa induced by carbaryl toxicity: an experimental rat model. kmuj. 2020; 12(2): 137-42. doi:10.35845/kmuj.2020.19896. 12. claybaugh t, decker s, mccall k, slyvka y, steimle j, wood a, et al. l-arginine supplementation in type ii diabetic rats preserves renal function and improves insulin sensitivity by altering the nitric oxide pathway. int j endocrinol. 2014; 2014: 171546. doi:10.1155/ 2014/17154.6 13. sahu bd, kumar jm, sistla r. baicalein, a bioflavonoid, prevents cisplatin-induced acute kidney injury by upregulating antioxidant defenses and down-regulating the mapks and nf-κb pathways. plos one. 2015; 10(7): e0134139. doi:10.1371/journal.pone.0134139 14. bazmandegan g, amirteimoury m, kaeidi a, shamsizadeh a, khademalhosseini m, nematollahi mh, et al. sumatriptan ameliorates renal injury induced by cisplatin in mice. iran j basic med sci. 2019; 22(5): 563-67. doi:10.22038/ijbms.2019 .33620.8020. 15. osman a-mm, telity sa, damanhouri za, al-harthy se, al-kreathy hm, ramadan ws, et al. chemosensitizing and nephroprotective effect of resveratrol in cisplatin–treated animals. cancer cell int. 2015; 15: 6. doi:10.1186/s12935-014-0152-2. 16. gharibi f, soltani n, maleki m, talebi a, nasiri m, shirdavani s, et al. the protective effect of l-arginine in cisplatin-induced nephrotoxicity in streptozotocin-induced diabetic rats. adv biomed res. 2017; 6: 100. doi:10.4103/2277-9175.212928. j islamabad med dental coll 2020 255 17. manohar s, leung n. cisplatin nephrotoxicity: a review of the literature. j nephrol. 2018; 31(1): 1525. doi:10.1007/s40620-017-0392-z. 18. eshraghi-jazi f, nematbakhsh m, nasri h, talebi a, haghighi m, pezeshki z, et al. the protective role of endogenous nitric oxide donor (l-arginine) in cisplatin-induced nephrotoxicity: gender related differences in rat model. j res med sci. 2011; 16(11): 1389. pmid:22973338. 19. wang h, jia z, sun j, xu l, zhao b, yu k, et al. nitrooleic acid protects against cisplatin nephropathy: role of cox-2 /mpges-1 /pge2 cascade. mediators inflamm. 2015; 2015: 293474. doi:10.1155/2015/293474. 20. adeneye aa, benebo as. chemopreventive effect of tadalafil in cisplatin-induced nephrotoxicity in rats. niger j physiol sci. 2016; 31(1): 1-10. 21. bashan i, bashan p, secilmis ma, singirik e. protective effect of l-arginine on gentamicin-induced nephrotoxicity in rats. indian j pharmacol. 2014; 46(6): 608-12. doi:10.4103/0253-7613.144915. 22. saleh s, el-demerdash e. protective effects of larginine against cisplatin-induced renal oxidative stress and toxicity: role of nitric oxide. basic clin pharmacol toxicol. 2005; 97(2): 91-7. doi: 10.1111/j.1742-7843.2005.pto_114.x. 23. yu z, malik vs, keum n, hu fb, giovannucci el, stampfer mj, et al. associations between nut consumption and inflammatory biomarkers. am j clin nutr. 2016; 104(3): 722-8. doi:10.3945/ajcn.116.134205. 24. hong my, beidler j, hooshmand s, figueroa a, kern m. watermelon and l-arginine consumption improve serum lipid profile and reduce inflammation and oxidative stress by altering gene expression in rats fed an atherogenic diet. nutr res. 2018; 58: 46-54. doi: 10.1016/j.nutres.2018.06.008. 235 j i m d c 2 0 1 7 235 open access f u l l l e n g t h a r t i c l e synovial lipomatosis; a clinicopathological study of a rare entity shaarif bashir 1, usman hassan 2, noreen akhtar 3, sajid mushtaq 4 department of pathology, shaukat khanum memorial cancer hospital and research centre, lahore, pakistan a b s t r a c t objective: this study was conducted to analyse the clinicopathological and radiological features associated with synovial lipomatosis. patients and methods: cases diagnosed as synovial lipomatosis from 2008 to 2018 were retrieved and clinical information and histology were reviewed. results: thirteen cases of synovial lipomatosis were diagnosed between 2008 and 2018. most common site was knee joint and mean age of presentation was 28.6. about 62% of subjects were males and mostly presented with joint pain and swelling. two of the subjects had significant history of trauma and disease was bilateral in one of the cases. microscopically, villous proliferation of synovium with infiltration of mature adipocytes was noted. focal synovial hyperplasia and inflammatory infiltrate were other findings in some of the cases. conclusion: synovial lipomatosis should be considered in the differential diagnosis of joint pain and swelling and should be distinguished from pigmented villonodular synovitis, synovial haemangioma and intra-articular synovial lipoma (iasl) using radiological and histological features. key words: synovial hyperplasia, synovial haemangioma, synovial lipomatosis author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence usman hassanjj email: drusmanhassan256@gmail.com article info. received: september 13, 2018 accepted: november 10, 2018 cite this article. bashir s, hassan u, akhtar n, mushtaq s. synovial lipomatosis, a clinicopathological study of a rare entity. jimdc.2018; 7(4):235-238 funding source: nil conflict of interest: nil i n t r o d u c t i o n synovial lipomatosis, also known as lipoma arborescens, is a rare pseudotumor, which arises from the synovial lining of the joints. it usually involves the knee joint, particularly the supra-patellar pouch, but can affect any joint in the body, even the tendon sheath and bursa, which have the synovial lining.1 the exact etiology is still unclear. peak incidence is between fifty and seventy years and there is a slight predilection for males.2 patients present with joint pain, swelling and effusion. synovial lipomatosis can be bilateral in some cases.3 radiologically, synovial lipomatosis presents as a frondlike mass along with joint effusion arising from the synovium with subcutaneous fat-equivalent signal on all pulse sequences of mri.3 histologically, there is synovial hyperplasia with synovial membrane lined villous structures infiltrated by mature adipocytes. mild chronic inflammation is present as well.4 treatment options include open and arthroscopic synovectomy.5-9 as it is a rare entity with less than 100 cases reported so far, the clinical, radiological and pathological data available is very limited and varied.3 the purpose of our study is to contribute to the literature the clinical details (age, gender, clinical presentation), radiological and o r i g i n a l a r t i c l e 236 j i m d c 2 0 1 7 236 histological features of the cases reported at our centre in the last decade and provide a better understanding of this condition to physicians, radiologists and pathologists. p a t i e n t s a n d m e t h o d s the cases of synovial lipomatosis, diagnosed on histological examination, between 2008 and 2018 at shaukat khanum cancer hospital and research centre were retrieved. all the relevant information e.g. age, gender, site, size, significant history and clinical findings were analysed. case slides were reviewed and pertinent histological findings were re-confirmed and additional findings like vascular proliferation, fibrosis and inflammation were looked for. all the biopsy proven cases of synovial lipomatosis were included in the study. cases like intra-articular synovial lipoma, pigmented villonodular synovitis and synovial heamangioma which may mimic synovial lipomatosis but do not fulfil the histological criteria were excluded from the study. r e s u l t s thirteen cases of synovial lipomatosis were diagnosed at our centre in the last decade from 2008 to 2018 (table 1). the age of presentation ranged from 10 years to 60 years with mean age of presentation 28.6 years. eight of the thirteen patients (61.5%) were males. knee joint was the site of involvement in 10 (76.9%) cases and wrist joint, ankle and dorsum of hand in the other three cases respectively. bilateral joint involvement was observed in only one case (7.7%). two of the thirteen patients (15.4%) had a history of trauma. presenting complaint of nine patients (69.2%) was swelling of the joint and seven (53.9%) amongst them felt pain as well. two cases (15.4%) had restriction of movement of joint, as a result of swelling and the pain. the size of the lesion ranged from 3 mm to 143 mm with mean size of 45mm. microscopic examination of the cases revealed villous proliferation of hyperplastic synovium with infiltration of mature adipocytes. d i s c u s s i o n synovial lipomatosis, also called as lipoma arborescens and hoffa disease, is a rare tumor-like condition of synovial lining of the joints characterized by villous proliferation of synovium with infiltration of mature adipose tissue. it was first described by albert hoffa in 1904, as a table 1: bio data and significant clinical details serial no age gender site laterality duration size (mm) significant history clinical presentation 1. 19 male knee bilateral 2 years 42 fever (on and off) pain and swelling 2. 60 female wrist left not known 30 not known ganglion on wrist 3. 26 female knee left 18 years 35 not known swelling 4. 20 male ankle right not known 20 not known not known 5. 60 male knee right not known 85 not known pain and swelling 6. 40 male knee right not known not known swelling 7 15 female dorsum of hand not known not known 18 not known swelling 8. 30 male knee left 6 months 3 trauma 3 years ago pain 9. 16 male knee left not known 55 not known pain and swelling 10. 10 female knee right 4 years 65 trauma 4 years ago pain, swelling and restricted mobility 11. 40 female knee right not known 11 not known pain 12. 15 male knee right not known 35 not known not known 13. 21 male knee left 9 years 143 not known pain and swelling 237 j i m d c 2 0 1 7 237 condition involving the infrapatellar fat pad of athletes, and later in more detail by arzimanoglu in 1957.1,3,7 less than 100 cases have been reported so far mostly as case reports.2 the exact etiology is unclear but association with trauma resulting in a reactionary inflammation and synovial hyperplasia has been proposed.1,3 moreover, association with inflammatory joint diseases like osteoarthritis, rheumatoid arthritis, psoriasis and uveitis has been reported in the literature.3,4 a peculiar association with short bowel syndrome was reported by siva et al in a case with multiple joints involvement of a patient with short bowel syndrome, suggesting that it results from abnormal deposition of fat in joints as a result of reduced fat absorption in resected small bowel.10 in our study, only two subjects had a history of trauma and that too more than 5 years ago. synovial lipomatosis occurs commonly between 50 to 70 years with mean age of 45.6 years and a predilection for male gender.1 in a study by rao s et al. of 8 cases, subjects ranged from 1 to 73 years with mean age 45.2.1 in our study, the mean age of presentation was 28.6 years and subjects ranged from 10 to 60 years. in both the studies, more than 60% of the patients were males. although, the lesion usually involves the knee joint but it can present in any joint of body, even the tendons and bursae as they are also lined by synovium.1 involvement of hip, elbow, wrist and shoulder joints has been noted as well. bilateral/multiple joint involvement is uncommon. knee joint was commonest site of involvement in our subjects (76.9%) and the rest had diseases of ankle, wrist joint and dorsum of hand. one patient had bilateral knee joint involvement as well. clinically, patient presents with pain and swelling of joint with limited mobility. joint effusion and crepitus are also noted sometimes.1,3 effusion causes pressure effect leading to the swelling and pain in the joint. the sign and symptoms in our study were almost the same as those reported in literature. swelling of the joint(s) was the most common presentation followed by pain and limited mobility of joint. the diagnosis of synovial lipomatosis requires a combination of radiology and histopathogical examination. magnetic resonance imaging (mri) remains the gold standard modality and shows an intra-articular frond-like synovial mass with fat equivalent high signal intensity (both t1 and t2) which is suppressed using fat suppressed sequences.4,6,11 other findings include joint effusion, bone erosions, synovial cyst and degenerative changes. arthroscopy of joint also reveals villous proliferation of the synovium. on gross examination, the lesion of synovial lipomatosis is pale yellow, soft to firm with villous architecture. microscopic examination is essential for definite diagnosis. histologically, there is villous proliferation of synovium with infiltration of mature adipocytes (fig 1a and 1b).1-3 synovial hyperplasia, mild inflammation, dilated blood vessels and fibrosis can be present.3,9 the differential diagnoses of synovial lipomatosis include synovial lipoma, pigmented villonodular synovitis, synovial haemangioma and intraarticular synovial lipoma (iasl). the later presents as a solitary nodular lesion in contrast to multiple villous projections in synovial lipomatosis. figure 1: biopsy from knee joint. (a) villous structure lined by synovial membrane infiltrated by mature adipocytes. (hematoxylin and eosin, 20x). (b) adipocytes and congested vessels in sub epithelial tissue. (hematoxylin and eosin, 20x) figure 2 (a) synovial tissue with infiltration of mononuclear inflammatory infiltrate and mature adipocytes. (hematoxylin and eosin 20x) (b) synovial lining of villi showing focal hyperplasia (arrow). (hematoxylin and eosin, 20x) 238 j i m d c 2 0 1 7 238 histologically, iasl is composed of manure adipose cells covered by thin fibrous layer. unlike synovial lipomatosis, villous proliferation of synovium is absent in intra-articular synovial lipoma.1,3,9 pigmented villonodular synovitis (pvns) is characterized by papillary projections of hyperplastic synovium composed of foamy cells and hemosiderin-laden macrophages. there are large pseudoglandular spaces lined by synovial cells, epithelioid cells and multinucleated giant cells. absence of hemosiderin laden macrophages is a major differentiating feature of synovial lipomatosis from pvns.1,3 synovial hemangioma shows synovium with dilated and congested vascular spaces. lack of fat infiltration, villous architecture and synovial hyperplasia separates it from synovial lipomatosis.3 the treatment of choice for synovial lipomatosis is arthroscopic synovectomy especially when the disease is limited to one compartment. larger lesion, however, requires open synovectomy. recurrence is uncommon after synovectomy.1,5,8,9 c o n c l u s i o n synovial lipomatosis is a rare psuedotumor, of unknown etiology, arising from synovial lining of joints characterized by villous proliferation of synovium with infiltration of adipocytes. clinical presentation can vary but mri and histopathological findings are characteristic and help in definite diagnosis. treatment by arthroscopic or open synovectomy is enough with very low rates of recurrence. r e f e r e n c e s 1. rao s, rajkumar a, elizabeth mj, ganesan v, kuruvilla s. pathology of synovial lipomatosis and its clinical signifcance. j lab physicians 2011;3(2):84-8. 2. das s, chattopadhyay p, ray a, sharma v. incidental diagnosis of bilateral synovial lipomatosis in long standing knee osteoarthritis. human pathology: case reports 2015; 2(4): 103-105 3. vleeschhouwer md, steen evd, vanderstraeten g, huysse w, neve jd, bossche lv. lipoma arborescens: review of an uncommon cause for swelling of the knee. case reports in orthopedics 2016.2016, article id 9538075, 5 pages. 4. natera, l, gelber, p.e, erquicia, j.i. et al. j orthopaed traumatol (2015) 16: 47. 5. beyth s, safran o. synovial lipomatosis of the glenohumeral joint. case reports in orthopedics 2016; article id 4170923. 6. miladore n, childs ma, sabesan vj. synovial lipomatosis: a rare cause of knee pain in an adolescent female. world j orthop. 2015;6(3):369-73 7. hoffa. the influence of the adipose tissue with regard to the pathology of the knee joint. the journal of the american medical association 1904; 43(12): 795–796 8. ji j-h, lee y-s, shafi m. spontaneous recurrent hemarthrosis of the knee joint in elderly patients with osteoarthritis: an infrequent presentation of synovial lipoma arborescens, knee surgery, sports traumatology, arthroscopy 2010; 18(10):1352– 1355 9. kamran f, kavin k, vijay s, shivanand g (2015) bilateral lipoma arborescens with osteoarthritis knee: case report and literature review. j clin orthop trauma. 2015; 6(2):131–136 10. siva c, brasinton r, totty w, sotelo a, atkinson j. syonovial lipomatosis (lipoma arborescens) affecting multiple joints in a patient with congenital short bowel syndrome. j rheumatol 2002;29(5):1088-92. 11. babar sa, sandison a, mitchell aw. synovial and tenosynovial lipoma arborescens of the ankle in an adult: a case report. skeletal radiol 2008; 37(1):75 7 50 j i m d c 2 0 1 8 50 open access f u l l l e n g t h a r t i c l e effect of zinc on serum testosterone level in albino rats mohammad sair1, mohammad nauman shad2, sana imran3, moosa khan 4 1 assistant professor, department of pharmacology and therapeutics, islam medical and dental college, pasrur road sialkot 2 associate professor, sahara medical college, narowal 3 assistant professor, jinnah sindh medical university, karachi 4 professor, shaheed zulfiqar ali bhutto medical university, islamabad a b s t r a c t objective: to study the effect of zinc on serum testosterone levels in albino rats. material and methods: this study was conducted in the department of pharmacology and therapeutics bmsi jpmc karachi. in this study 60 albino rats were divided into four groups, 15 rats in each group. group one was control group (normal diet was given to this group), group two was given indomethacin, group three was given zinc and group four was given combination of zinc and indomethacin. all the drugs were given for 12 weeks. serum testosterone level was checked at the end of study and finally data was analyzed statistically using spss version 18. results: in group 2, serum testosterone level (3.12±0.63) was low as compared with control (6.26±0.15). in group 3, mean testosterone was high (6.97±0.63) when it was compared with control (6.26±0.15). in group 4, mean testosterone was low (5.15±0.73) but not significant when compared with control (6.26±0.15). conclusion: zinc has a protective role on testes and it increases testosterone and fertility. key words: zinc, serum testosterone level, indomethacin, fertility. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 ,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence mohammad sair email: drsairkhan@hotmail.com article info. received: september 12, 2017 accepted: december 28, 2017 cite this article. sair m, shad mn, imran s, khan m. effect of zinc on serum testosterone level in albino rats. jimdc.2018; 7(1): 50-53 funding source: nil conflict of interest: nil i n t r o d u c t i o n zinc is an essential mineral and essential trace element present in more than 200 metallo enzymes.1 zinc deficiency leads to gonadal dysfunction, decreases testicular weight and causes shrinkage of seminiferous tubules.2 previously it was known as "white vitriol”. 3 zinc is available in the form of zinc oxide, zinc acetate, and zinc gluconate. 4 it is a constituent of enzyme superoxide dismutase, which protects cells from damage caused by free radicals. zinc reduces oxidative stress in developing sperm and improves sperm quality. 5 it possesses antioxidant properties 6 and is present in rich quantity in semen.7 testosterone is a steroidal androgenic hormone, it is the main male sex hormone and an anabolic steroid. 8 it is necessary for normal sperm development, it activates genes in sertoli cells and promotes differentiation of spermatogonia.9 by restricting zinc in diet, significant decrease in serum testosterone concentrations will occur, on the other hand zinc supplementation increases serum testosterone levels.10 indomethacin is a non-steroidal anti-inflammatory drug that is a nonselective inhibitor of cyclooxygenase (cox) 1 and 2. indomethacin produces toxic effect to testes. oligospermia and azoospermia have been reported after the use of indomethacin. 11 zinc is the second most abundant element in human and plays multifactorial role in sperm function,12 adult human body contains approximately 1-3 g of zinc and recommended daily allowance (rda) is 11-8 mg/day for men and o r i g i n a l a r t i c l e http://en.wikipedia.org/wiki/androgen http://en.wikipedia.org/wiki/male http://en.wikipedia.org/wiki/sperm http://en.wikipedia.org/wiki/spermatogonia 51 j i m d c 2 0 1 8 51 women respectively.13 zinc has many biologically significant interactions with hormones and has special role in production, storage and secretion of hormones. zinc deficiency has a major impact on testosterone, insulin and adrenal corticosteroids. 14 m a t e r i a l a n d m e t h o d s this experimental study was conducted in the department of pharmacology and therapeutics bmsi, jpmc karachi from 30th june 2013 to 30th december 2013. sixty male albino rats, 2.5 to 3.5-month old weighing 200 to 300 grams were taken from animal house. sample size of 60 rats was calculated by using computer program open epi version 2 with power of 80 of the test and 95% confidence interval (www.openepi.com/samplesize/sspropor.htm). zinc was obtained in the syrup form available as 20 mg /5ml. total 5 mg/kg was given orally for 12 weeks. indomethacin powder dissolved in distilled water was given orally with a dose of 10mg /kg to selected animals for 12 weeks. selected sixty albino male rats were divided into four equal groups, 15 animals in each group. group i (control group): the 15 albino rates of this group were kept on normal diet. group ii (indomethacin group): in this group 15 albino rats were treated with indomethacin. group iii (zinc group): the 15 albino rats in this group were given zinc. group iv (combination group): combination of zinc and indomethacin in their respective dose was given for 12 weeks. before starting the research, animals were kept in room temperature for one week for acclimatization. all the animals were observed daily for their physical activity and weighed weekly. medication was given to each rat in their proper doses for three months. at the end of study period, weight of albino rats was observed and then they were scarified. a mid line incision was made up to scrotum and extended upwards to the thoracic region. blood sample was taken from each animal by intra-cardiac puncture with the help of disposable syringe, for the detection of serum testosterone levels. blood was taken from rat heart and was shifted to plain glass tube and retained in standing position for one hour for clot formation. after that, the centrifugation was done. the separated serum was then shifted to small sterile plastic cups and was stored in laboratory refrigerator at -80°c. before estimation, the samples were drawn from refrigerator and were kept at room temperature for two hours. afterwards the serum testosterone levels were estimated. all data was analyzed with spss version 18. quantitative variables were expressed as mean±sd. statistical comparison between groups was done by analysis of variance (anova). in order to compare means, student t test was applied. p value ≤0.05 was considered as statistically significant. r e s u l t s albino rats which were given indomethacin 10mg/kg for 90 days, revealed an overall decrease in mean serum testosterone level as compared to control. decrease in mean serum testosterone level was highly significant (pvalue=0.0001) on day 90 as compared to control, with overall reduction of 34% (table 1). ** very low levels * slightly low levels albino rats given zinc 10 mg/kg revealed increase in mean serum testosterone level as compared to control. the increase in serum testosterone level was highly significant (p-value 0.001) on day 90 as compared to control, with overall increase of 6% (table 2; figure 1). albino rats were given combination of zinc and indomethacin 10mg/kg for 90 days with slight decrease in mean serum testosterone level as compared to control. the decrease in serum testosterone level was not significant on day 90 i.e.5.15±0.73 as compared to control 6.26±0.15, with overall decrease of 2%. albino rats given zinc 10mg/kg revealed increase in mean serum testosterone level as compared to indomethacin. the increase in serum testosterone level was highly significant (p-value 0.0001) on day 90 as compared to indomethacin 3.12±0.6, with overall increase of 38%. albino rats given table 1: mean serum testosterone levels within different groups in albino rats (n=60) groups serum testosterone level observed(ng/dl) mean±sd control group 6.26±0.15 indomethacin group 3.12±0.63** zinc group 6.97±0.63 zinc + indomethacin group 5.15±0.73* 52 j i m d c 2 0 1 8 52 table2: comparative effects of different drugs on mean serum testosterone level (ng/dl) in albino rats (n=60) groups animals (n) serum testosterone at day 90 p-value control vs indomethacin 15 6.26±0.15 vs 3.12±0.63 0.0001** control vs zinc 15 6.26±0.15 vs 6.97±0.63 0.0016** control vs indomethacin +zinc 15 6.26±0.15 vs 5.15±0.73 0.119 indomethacin vs zinc 15 3.12±0.63 vs 6.97±0.63 0.0001** indomethacin vs indomethacin +zinc 15 3.12±0.63 vs 5.15±0.73 0.0001** zinc vs indomethacin +zinc 15 6.97±0.63 vs 5.15±0.73 0.001** figure 1: comparing mean serum testosterone level in different groups g1= group 1 (control), g2 =group 2 (indomethacin), g3= group 3 (zinc), g4= group 4 (indomethacin+zinc) indomethacin + zinc 10mg/kg showed increase in mean serum testosterone level as compared to indomethacin. the increase in serum testosterone level was highly significant (p-value 0.0001) on day 90 as compared to indomethacin 3.12±0.6, with overall increase of 32%. albino rats given indomethacin + zinc for 90 days revealed slight decrease in mean serum testosterone level as compared to zinc. the decrease in serum testosterone level was highly significant (p-value 0.0001) on day 90 i.e. as compared to zinc, with overall decrease of 16%. (table 2; figure 1). d i s c u s s i o n zinc is essential for spermatogenesis. it causes induction of metallothionein which protect cells from toxicity caused by free radicles.13 zinc deficiency in rats causes changes in seminiferous tubules and in serum levels of testosterone.14 the results of present research indicate that administration of indomethacin in a dose of 10mg/kg suppresses synthesis of testosterone due to toxic effects of indomethacin on seminiferous tubules in testes. similar finding was reported previously by jahangir et al in 2009.15 seminiferous tubule atrophy was observed by administration of propoxur (ppx) by oyewopo et al in 2010. 16 the results of combination therapy showed the protective effects of zinc in presence of indomethacin. when combination therapy was compared with control, there was no significant difference. study conducted by falana et al observed similar findings, in which rats were divided in four groups and were treated for 30 days, group 1 was control group, group 2 received lead, group 3 received zinc and selenium, group 4 received lead with zinc and selenium. 17 after completion of study period, blood was taken, mean serum testosterone levels were significantly decreased in lead treated group compared with control. the administration of lead with selenium and zinc increased the serum levels of testosterone. the zinc and selenium treated group had significant increase (p˂0.05) in mean serum level of testosterone when value was compared with control. this is compatible with our study in which group 3 (zinc) showed increased mean serum testosterone (6.97±0.63). when it was compared with control (6.26±0.15) the result was highly significant (p˂0.001). similarly, in group 4 mean serum testosterone level was low but when compared with control it was not significant. c o n c l u s i o n synthesis of testosterone is inhibited by some drugs/ chemicals due to its toxic effects on seminiferous tubules. zinc plays protective a role on testes and increases production of testosterone to normal range. 53 j i m d c 2 0 1 8 53 r e f e r e n c e s 1. kumarn,vermar,singhl.effect of different level and sources of zinc supplementation on quantitative and qualitative semen attributes and serum testosterone level in crossbreed cattle,bulls.nutr.dev2006; 46(6).663-675 2. chiase,ongcn,chuallh.comparision of zinc concentration in blood and seminal plasma and various parameters between fertile and infertile men.j andr. 2000; 21(1):53-57 3. hambidge km and krebs nf.zinc deficiency a special challenge. j of nut. 2007;137 (4):1101-5 4. rasmussen jk,heilmann sm.in situ cyanosilylation of carbonyl compounds :0 –trimethylsilyl-4methoxymandelonitrile.organic syntheses1990;7:521 5. disilvestro, robert a.handbook of mineral as nutritional supplements 2004;135-155 6. afonne oj ,orisakwe oe,ekanem ia and akumka dd.zinc protects chromium induced testicular injury in mice.ind j pharmacol 2002; 34(1):26-31. 7. millbury, paul e,alice c. understanding the antioxidant controversy. greenwood publishing group 2008;99 8. berdanier, carolyn d,dwyer,johanna.nutritional science. handbook of nutrition and food 2007; 2.1200. 9. reed wl,clark me ,parker pg,raouf sa,arguedas.physiological effects on demography a long term experimental study of testosterone s effects on fitness. the american nutralist. 2006;167(5) 667683 10. mehtra ph,jones ac,josephs ra. the social endocrinology of dominance basal testosterone predicts cortisol changes and behavior following victory and defeat pers soc psychol 2008; 94(6)1078-1093 11. prasad as .zinc deficiency has been known of for 40 years but ignored by global health organizations.bmj 2003;326.419-10 12. zhaoj,dongx,longz,wangl.zinc levels seminal plasma and their correlation with male infertility.scirep. 2016; 6:22386 13. murarka s,mishra v,joshi p,kumar s. role of zinc in reproductive biology. ausj rep 2015;1-8 14. jn egwurugwu,cu ifedi,rc uchefuna,en ezekafor,ea alagwu.effects of zinc on male sex hormones and semen quality in rats.niger j phys sci. 2013;28(1):17-22 15. alam j, khatun m, begum m, hossain m, akhter j, paul uk and begum t. role of vitamin e on antispermatogenic effects of indomethacin on number of sperm containing seminiferous tubules of testes in long evans rats. bangladesh j anat 2009; 7(1):5 9. 16. oyewopo ao,saalu lc,osinubi aa.the attenuating effect of zinc on propoxur induced oxidative stress impaired spermatogenesis and deranged steroidogenesis in wistar rat.j of med and med sci. 2010;1(5):178-184 17. falana and oyeyipo.selinium and zinc attenuate lead induced reproductive toxicity in male sprague dawley rats res.j.med sci.2012; 6(2):66-70. summary journal of islamabad medical & dental college (jimdc); 2016:5(3):104-106 104 original article role of nigella sativa in carbon tetrachloride induced hepatotoxicity kashif shaikh1, majid ali hingoro2, amin fahim3 1assistant prof. pharmacology, muhammad medical college, mirpurkhas 2assistant prof. pharmacology, islamabad medical & dental college, islamabad. 3associate prof. histopathology, al-tibri medical college, karachi. abstract objective: to evaluate the protective role of nigella sativa in carbon tetrachloride induced hepatic changes in rabbits. material and methods: this case control experimental study was conducted at department of pharmacology, isra university hyderabad during july 2011 to november 2011. a total of 45 rabbits were divided into three groups consisting of 15 animals in each group a, b and c. each group was further divided into three sub groups. sub groups (a1,b1 and c1) received treatment for one week. sub groups (a2, b2 and c2) received treatment for two weeks. sub groups (a3, b3 and c3) received treatment for three weeks. the animals in group a (control) received normal saline. the animals in group b were treated with carbon tetrachloride. the animals in group c were treated with carbon tetrachloride and nigella sativa. result: in present study sinusoidal congestion, periportal inflammation, kupffer cell hyperplasia, steatosis, necrosis and fibrosis were seen in carbon tetrachloride intoxicated rabbits. these findings were less marked in rabbits treated with nigella sativa. conclusion: this study showed the hepatoprotective effects of nigella sativa in carbon tetrachloride induced hepatotoxicity. key words: carbon tetrachloride, hepatoprotective, hepatotoxicity, nigella sativa. introduction carbon tetrachloride (ccl4) has been used as a dry cleaning agent, fabric spotting fluid, solvent, reagent in chemical synthesis, fire extinguisher fluid and grain fumigant. 1,2 its primary use was observed in chlorofluorocarbon (cfc) production. 1, 3 in the 20th century ccl4 was widely used as a refrigerant and in lava lamps. 4 ccl4 is metabolized in the body primarily by the liver, but also in the kidney, lung and other tissues containing cytochrome p (cyp450). 5 as demonstrated in studies with cyp2e1 genetic knockout mice, this enzyme is required for the development of hepatotoxicity (as measured by elevated liver enzymes and liver histopathology) in mice exposed to ccl4. 6 in the liver the greatest accumulation of ccl4 metabolites occurs in the centrilobular region, which has high cyp450 levels. 7 zangar et al in a study measured ccl4 metabolic rate constants for human and animal hepatic microsomal preparations in vitro. results suggested that the metabolic rate in humans is more similar to the rate in rats than in other rodent species. 8 nigella sativa linn. (n. sativa) family ranunculaceae is commonly known as black seed or black cumin. original black cumin seed is carum bulbocastanum. in south asia it is known as kalonji. 9 it is found that n. sativa is an important medicinal herb; its oil is used as a natural remedy for a wide range of diseases including various allergies. it probably has an important role in the pharmacological effects. n. sativa possesses antioxidant property. 10 the pharmacological actions include protection against nephrotoxicity and hepatotoxicity induced by either disease or chemicals. the oil and certain active ingredients showed beneficial immunomodulatory properties, augmenting the t cell and natural killer cell mediated immune responses. most importantly, both the oil and its active ingredients expressed anti-microbial and anti-tumor properties toward different microbes and cancers. 11 thus the present study is conducted to evaluate the protective role of n. sativa in ccl4 induced hepatic changes in rabbits. material and methods this is a case control experimental study which was carried out in the department of pharmacology, isra university hyderabad in collaboration of lumhs hyderabad. sample size was 45 normal healthy rabbits of either sex with weight >1.5 kg. the animals were divided in to 03 groups each comprising 15 animals.  group a: served as a control group  group b: received ccl4  group c: received ccl4 + n. sativa corresponding author: dr. amin fahim e-mail: draminfahim@gmail.com received: may 6, 2016; accepted: june 11 ,2016 http://en.wikipedia.org/wiki/refrigerant http://en.wikipedia.org/wiki/lava_lamp mailto:%20draminfahim@gmail.com journal of islamabad medical & dental college (jimdc); 2016:5(3):104-106 105 each group were sub divided into 03 sub groups (a1, a2 and a3), (b1, b2 and b3) and (c1, c2 and c3) according to the period of administration of ccl4 alone and in combination. each subgroup comprised of 05 animals. five animals each of sub group (a1, b1 and c1) received treatment for one week and were sacrificed, five animals each of sub group (a2, b2 and c2) received treatment for two weeks and sacrificed while, five animals each of sub group (a3, b3 and c3) received treatment for three weeks. group a: (control group): all sub groups (a1, a2 and a3) were given 0.9% isotonic saline solution at a dose level 4 ml/kg on alternate day and were sacrificed at the end of their respective period of time and served as a control group. 12 group b: all sub groups (b1, b2 and b3) were given ccl4 dissolved in olive oil (1:1 ratio) at a dose level of 1.9 ml/kg orally on alternate day and were sacrificed at the end of their respective period of time. 12 group c: all sub groups (c1, c2 and c3) were given ccl4 dissolved in olive oil at a dose level of 1.9 ml/kg along with suspension of n. sativa (1.25 g powder of n. sativa + 100 ml isotonic saline) at a dose level of 4 ml/kg on alternate day and were sacrificed at the end of their respective period of time. 12 at the end of respective period of treatment, the animals were weighed and sacrificed. a mid line incision was given in the middle part of trunk and all the skin layers and fascia were opened and liver was identified and removed. the liver tissue was processed for histopathological examination followed by interpretation of results. the data was analyzed by spss version 16.0. the data was analyzed by applying the chi-square to compare the histomorphological findings in animals of group a, b and c. p value of <0.05 was considered to be significant. results histopathological examination of the liver tissue for gross and microscopic findings was carried out. there were no gross changes or no any findings supporting the liver cirrhosis were observed. 1.at 1st week: 15 rabbits were sacrificed, 5 rabbits from each sub group. histopathological findings of 5 rabbit’s liver which were given isotonic saline showed no changes with normal liver architecture. histopathological findings of 5 rabbit’s liver which were intoxicated with ccl4, 3 of them showed sinusoidal congestion and periportal inflammation and 2 of them sinusoidal congestion and periportal inflammation and kupffer cell hyperplasia. histopathological findings of 5 rabbit’s liver which were given ccl4 along with n. sativa, 3 of them showed no changes and 2 of them showed sinusoidal congestion and periportal inflammation (table 1). 2.at 2nd week: 15 rabbits were sacrificed, 5 rabbits from each sub group. histopathological findings of 5 rabbit’s liver which were given isotonic saline showed no changes or normal liver architecture. histopathological findings of 5 rabbit’s liver which were intoxicated with ccl4, 2 of them showed sinusoidal congestion, periportal inflammation and kupffer cell hyperplasia, 2 of them showed steatosis and 1 of them showed piece meal necrosis. histopathological findings of 5 rabbit’s liver which were given ccl4 along with n. sativa, 3 of them showed no changes and 2 of them showed sinusoidal congestion and periportal inflammation (table 2). 3.at 3rd week: 15 rabbits were sacrificed, 5 rabbits from each sub group. histopathological findings of 5 rabbit’s liver which were given isotonic saline showed no changes or normal liver architecture. histopathological findings of 5 rabbits liver which were intoxicated with ccl4, 1 of them showed steatosis, 1 of them showed piece meal necrosis, 2 of them showed bridging necrosis and 1 of them showed fibrosis. histopathological findings of 5 rabbits liver which were given ccl4 along with n. sativa, 2 of them showed no changes and 3 of them showed sinusoidal congestion and periportal inflammation (table3). table 1: histopathological findings of liver at 1st week r a b b it d is tr ib u ti o n n o f in d in g s s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n + k u p ff e r c e ll h y p e rp la si a s te a to si s p ie c e m e a l n e c ro si s b ri d g in g n e c ro si s f ib ro si s t o ta l p -v a lu e control 5 0 0 0 0 0 0 5 0.07 ccl4 0 3 2 0 0 0 0 5 ccl4 + n. sativa 3 2 0 0 0 0 0 5 total 8 5 2 0 0 0 0 15 table 2: histopathological findings of liver at 2 nd week r a b b it d is tr ib u ti o n n o f in d in g s s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n + k u p ff e r c e ll h y p e rp la si a s te a to si s p ie c e m e a l n e c ro si s b ri d g in g n e c ro si s f ib ro si s t o ta l p -v a lu e control 5 0 0 0 0 0 0 5 0.02 9 ccl4 0 0 2 2 1 0 0 5 ccl4 + n. sativa 3 2 0 0 0 0 0 5 journal of islamabad medical & dental college (jimdc); 2016:5(3):104-106 106 table 3: histopathological findings of liver at 3 rd week r a b b it d is tr ib u ti o n n o f in d in g s s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n s in u so id a l c o n g e st io n + p e ri p o rt a l in fl a m m a ti o n + k u p ff e r c e ll h y p e rp la si a s te a to si s p ie c e m e a l n e c ro si s b ri d g in g n e c ro si s f ib ro si s t o ta l p -v a lu e control 5 0 0 0 0 0 0 5 0.049 ccl4 0 0 0 1 1 2 1 5 ccl4 + n. sativa 2 3 0 0 0 0 0 5 total 7 3 0 1 1 2 1 15 discussion ccl4 is well-known for its hepatotoxic effects. it causes significant increases in absolute and relative liver weight, serum levels of alt, ast and alkaline phophatase, and centrilobular hepatocellular vacuolar degeneration and necrosis. 7 in the present study, sinusoidal congestion, periportal inflammation and kupffer cell hyperplasia were seen in ccl4 treated rabbits. these results are consistent with the findings of tien et al. 13 another study by de-groot and noll reported ccl4 produces necrosis and steatosis. this correlates with findings of the present study. 14 in current study, n. sativa proved to be hepatoprotective by reducing the toxic effects of ccl4. however in contrast to the findings of the present study tennekoon et al reported that there were no histological changes seen in animal model treated with n.sativa. 15 turkdogan et al have reported that n. sativa helps in the prevention of liver fibrosis in rabbits. 16 these findings are consistent with our present study, in which we also observed that n. sativa reduces steatosis, necrosis and fibrosis in liver. al-ghamdi has reported that n. sativa seeds appeared to be safe and possibly protective against ccl4 induced hepatotoxicity. 17 this study supports the findings of the present study. conclusion the present study has highlighted the important role of n. sativa which is directly related to the histological changes induced by ccl4 induced on liver morphology. this study showed the hepatoprotective effects of n. sativa in ccl4 induced hepatotoxicity. conflict of interest this study has no conflict of interest as declared by any author references 1. nlm (national library of medicine). carbon tetrachloride. hazardous substances data bank (hsdb). national institutes of health, u.s. department of health and human services, bethesda.2003 2. holbrook mt. carbon tetrachloride. in: kroschwitz, ji, howe-grant m, editors. kirk-othmer encyclopedia of chemical technology. 4th ed. john wiley and sons; 1993. p. 1062-72. 3. rossberg m. chlorinated hydrocarbons. in: gerhartz, w; yamamoto, ys; campbell, ft, editors. ullmann’s encyclopedia of industrial chemistry. 5th ed. (a6): vch publishers; 2002. 370-1. 4. doherty re. a history of the production and use of carbon tetrachloride, tetrachloroethylene, trichloroethylene and 1,1,1-trichloroethane in the united states: part 1—historical background; carbon tetrachloride and tetrachloroethylene. environ forensics. 2000;1(1):69–81. 5. jia r, du jl, cao lp, liu yj, xu p, yin gj. protective action of the phyllanthin against carbon tetrachloride-induced hepatocyte damage in cyprinus carpio. in vitro cell dev biol-anim. 2016;52(1):1-9. 6. teranishi y, matsubara t, krausz kw, le tt, gonzalez fj, yoshizato k, etal. involvement of hepatic stellate cell cytoglobin in acute hepatocyte damage through the regulation of cyp2e1-mediated xenobiotic metabolism. lab invest. 2015; 95(5): 515-24. 7. liu yj, du jl, cao lp, jia r, shen yj, zhao cy, et al. antiinflammatory and hepatoprotective effects of ganoderma lucidum polysaccharides on carbon tetrachloride-induced hepatocyte damage in common carp (cyprinus carpio l.). int immunopharmacol. 2015; 25(1):112-20. 8. zangar rc, benson jm, burnett vl, springer dl. cytochrome p450 2e1 is the primary enzyme responsible for low-dose carbon tetrachloride metabolism in human liver microsomes. chem biol interact. 2000;125(3):233-43. 9. ali bh, blunden g. pharmacological and toxicological properties of nigella sativa. phytother res. 2003;17(4):299– 305. 10. suboh sm, bilto y, abuarjai ta. protective effects of selected medicinal plants against protein degradation, lipid peroxidation and deformability loss of oxidatively stressed human erythrocytes. phytother res. 2004;18(4):280-84. 11. salem ml. immunomodulatory and therapeutic properties of the nigella sativa l. seed. int immunopharmacol. 2005;5(13-14):1749-70. 12. essawy ae, hamed ss, abdel-moneim am, abou-gabal aa, alzergy aa. role of black seeds (nigella sativa) in ameliorating carbon tetrachloride induced haematotoxicity in swiss albino mice. j med plants res. 2010;4(19):1977-81. 13. tien yc, liao jc, chiu cs, huang th, huang cy, chang wt, etal. esculetin ameliorates carbon tetrachloridemediated hepatic apoptosis in rats. int j mol sci. 2011;12(6):1-8. 14. de-groot h, noll t. the crucial role of low steady oxygen partial pressure in haloalkanes free radical induced lipid peroxidation. possible implications in haloalkane liver injury. biochem pharmacol. 1980;35(1):15-9. 15. hosseini m, mohammadpour t, karami r, rajaei z, sadeghnia hr, soukhtanloo m. effects of the hydro-alcoholic extract of nigella sativa on scopolamine-induced spatial memory impairment in rats and its possible mechanism. chin j integr med. 2015;21(6):438-44. 16. turkdogan mk, agaoglu z, yenerz, sekeroglu r, akkan ha, avci me. the role of antioxidant vitamins (c and e), selenium and nigella sativa in the prevention of liver fibrosis and cirrhosis in rabbits: new hopes. dtsch tieraztl wochenschr. 2001;108(2):71–3. 17. al-ghamdi ms. protective effect of nigella sativa seeds against carbon tetrachloride-induced liver damage. am j chin med. 2003;31(5):721–8. [ authorship contribution: author 1: interpretation, analysis and discussion author 2: concept, planning and interpretation, analysis and discussion author 3: concept and planning and active participation in research. j islamabad med dental coll 2020 23 open access antimicrobial susceptibility pattern among patients presenting with acute exacerbation of copd amer zohaib1, fahad aman khan2, imran khan2, mukhtar ahmad2, talha khalid1, tashia malik1, khawar siddique3, sidra munir4, muhammad saeed5 1senior registrar, department of medicine, jinnah hospital lahore 2assistant professor, department of medicine, allama iqbal medical college, lahore 3medical officer, jinnah hospital lahore 4postgraduate trainee, histopathology allama iqbal medical college lahor e 5manager pathology, medical lab technologist, dhq hospital, mandi bahauddin a b s t r a c t background: the irrational use of antibiotics in outpatient as well as indoor patients without studying the culture and sensitivity patterns may have led to resistance in common organisms causing acute exacerbation of chronic obstructive pulmonary disease. the objective of this study was to determine the culture and sensitivity patterns of bacteria in the sputum of patients presenting with acute exacerbation of chronic obstructive pulmonary disease (copd) in our population. material and methods: this cross-sectional study was conducted in the medicine department, jinnah hospital lahore from 1st january 2018 to 25th june 2018. a total of 215 patients with acute exacerbatio n of copd were collected through non-probability consecutive sampling technique. copd was diagnosed on the basis of history, examination, chest x-ray and spirometry. acute exacerbation was taken as an acute rise in one or more of the following; sputum volume and/or purulence, frequency and severity of cough and dyspnea. two sputum samples were collected from each patient. antimicrobial susceptibility testing was done as per clsi guidelines. data was analyzed by spss version 21.0. with p-value ≤ 0.05 considered as statistically significant. results: among 215 selected cases, 118 (54.88%) were male s and 97 (45.12%) were females. a total of 110 (51.16%) cultures were positive and 105 (48.84%) were negative for bacterial growth. klebsiella pneumoniae (n=69; 62.72%) was the most frequent microorganism in patient’s sputum followed by pseudomonas aeruginosa (n=21; 19.1%) and staphylococcus aureus (n=20; 18.2%). regarding sensitivity pattern, amikacin was found to be the most sensitive antibiotic against these organisms followed by gentamicin and ciprofloxacin. conclusion(s): klebsiella pneumoniae was the most common microorganism in the sputum of patients presenting with acute exacerbation of copd, while amikacin was reported to be most sensitive antibiotic against t he microorganism. key words: acute exacerbation, antimicrobial susceptibility pattern, copd authors’ contribution: 1-3conception; literature research; manuscript design and drafting; 4-6critical analysis and manuscript review; 7-9data analysis; manuscript editing. correspondence: muhammad saeed email: mian.muhsaeed@gmail.com article info: received: october 8, 2019 accepted: march 9, 2020 cite this article. zohaib a, khan fa, khan i, ahmad m, khalid t, malik t, siddique k, munir s, saeed m. antimicrobial susceptibility pattern among patients presenting with acute exacerbation of copd. j islamabad med dental coll.2020; 9(1): 23-27. doi: 10.35787/jimdc.v9i1.429 funding source: nil conflict of interest: nil i n t r o d u c t i o n chronic obstructive pulmonary disease (copd) is a lung disease categorized by the chronic obstructio n to lung airflow that affects normal breathing.1 it is emerging as the fourth communal reason of or i gi n a l a r ti c le j islamabad med dental coll 2020 24 morbidity and mortality around the world triggering more than 3 million deaths every year. 2 globally, it is predicted that in 2020 it will be the third common cause of death.3 currently the burden of this disease in asia is greater than that in the developed western world, both in terms of mortality and the morbidity.4 acute exacerbation of copd (aecopd) is a recurrent event throughout the chronic course of this sickness.5 aecopd is well-defined as an acute rise in one or more of the following; sputum volume and/or purulence, frequency and severity of cough and dyspnea.6 bacterial infections are considered to be causing 30-50% of acute exacerbations.7 the occurrence of copd is highest in elderly aged more than 65 years of age. antibiotics are considered to improve the outcomes in management of acute exacerbation of copd (aeocopd).8 but still there are many difficulties in the management of such patients. the problem is the emergence of resistance to antibiotics, used against common bacterial pathogens responsible for acute exacerbations. the most common cause of this problem is unnecessary use and excessive exposure of these bacterial organisms to antibiotics.9 a local study done in karachi revealed the emergence of resistance in isolates of klebsiella pneumoniae and pseudomonas aeruginosa again s t different quinolones.10 various studies carried out in different parts of the world have shown variatio n in the culture and sensitivity patterns in this group of patients. in our population, the irrational use of antibiotics in outpatient and indoor patients without studying the culture and sensitivity patterns may have led to resistance in common organisms causing aeocopd. there is scarcity of data regarding the issue especially in our set up. so, this study was designed to determine the most common microorganisms causing aeocopd in our population followed by finding the sensitivity patterns of these bacteria against various antibiotics. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted at medicine department of jinnah hospital lahore from 1st january 2018 to 25th june 2018. the sample size was calculated as 215 using 95% confidence level, 3.5% margin of error, and 7.3% as expected percentage of pseudomonas aeruginosa in patien ts with aeocopd.11 non-probability consecutive sampling technique was used. sputum samples were collected from 215 patients with acute exacerbation of copd, after rinsing the mouth twice with plain water. samples were collected in sterile jars, properly labeled with the name and registration number of the patient before sending to the pathology department of allama iqbal medical college, lahore. each sample was processed for bacterial culture and sensitivity as per standard microbiological techniques. antimicrobial susceptibility testing was done as per clsi guidelines. newly or previously diagnosed patients of copd both male and female , aged 25-80 years presenting in opd or emergency departments with acute exacerbations were included in study. copd was diagnosed on the basis of history, examination, and chest x-ray (pa) v ie w . post bronchodilator fev1/fvc ratio of <0.70 by spirometry was taken as confirmatory for copd. acute exacerbation was taken as an acute rise in one or more of the following; sputum volume and/or purulence, frequency and severity of co u gh and dyspnea. exclusion criteria included (i) all cases with evidence of pneumonia or bronchiectasis (based on history, examination, and cxr) developed as a sequela of other disease, pulmonary tuberculosis (determined by 3 early morning sputum samples for afb), cystic fibrosis (determined by ct chest) (ii) patients who were j islamabad med dental coll 2020 25 already on antibiotics (determined by taking drug history). (iii) patients with other chronic ailments like congestive cardiac failure, chronic kidney disease, chronic liver disease (based on history, examination, cxr, echocardiogram, ultrasound abdomen, renal function tests and liver function tests). patients were divided into two age groups; 25-50 years and 51-80 years. data was analyzed by spss v 21.0. mean and standard deviation was calculated for quantitative variables such as age. for qualitative variables like gender and microorganisms, frequency and percentages were analyzed. chi-square test was applied to find out the association of micro-organisms with age, gender and duration of disease. p-value ≤ 0.05 w as considered as statistically significant. r e s u l t s among 215 selected cases, 118 (54.88%) were male and 97 (45.12%) were female with a mean age of 53.98+10.29 years. there were 83 (38.6%) patients in 25-50 years age group and 132 (61.4%) in 51-80 years age group. regarding duration of disease, 139 (64.65%) patients had 1-6 months of disease history and 76 (35.35%) had history of more than 6 months of duration. a total of 110 (51.16%) cultures were positive and 105 (48.84%) were negative for bacterial growth. klebsiella pneumoniae (n=69; 62.72%) was the most frequent microorganism found in patient’s sputum followed by pseudomonas aeruginosa (n=21; 19.1%) and staphylococcus aureus (n=20; 18.2%). regarding sensitivity pattern, amikacin was found to be most sensitive antibiotic. amikacin and gentamicin showed highest sensitivity for pseudomonas aeruginosa followed by staphylococcus aureus and klebsiella pneumoniae (figure 1). ciprofloxacin exhibited maximum sensitivity for staphylococcus aureus followed by pseudomonas aeruginosa and klebsiella pneumoniae (figure 1). figure 1: frequency of antibiotics sensitivity pattern against common microorganisms (n=110). pseudomonas aeruginosa and staphylococcus aureus have no significant association with age, gender and duration of disease. klebsiella pneumonia was found to be more prevalent amon g males as compared to females. association of klebsiella pneumoniae with age and duration of disease was statistically insignificant (table i). d i s c u s s i o n infections are the main reasons for aecopd which result in significant mortality and morbidity.12 the present study determines the bacterial culture an d sensitivity patterns in the sputum of patients presenting with aecopd. in the light of this study we can find the most appropriate empirical antibiotic therapy for the management of such patients in future, as the choice of antibiotics should be modified according to local bacterial culture and sensitivity patterns. likewise, studies have shown different sensitivity patterns to most commonly used drugs including penicillin, macrolides and fluoroquinolones.13 the wide use of these antibiotics in our hospitals may lead to resistance and decreased response of lower respiratory tract infections which can result in problems managing these patients.14 j islamabad med dental coll 2020 26 + ve-positive for bacterial growth; ve-negative for bacterial growth moreover, the copd patients are likely to develop resistance to antibiotics over time, especially those with productive cough. it has been reported that 23.5% patients with copd will develop resistance to an antibiotic within the period of 28.4 months of follow-up, with sputum producers considered as having a higher risk.15 this emphasizes the significance of investigating sputum samples with determination of resistance patterns. our findings are supported by a study conducted in hyderabad india in which cultures were positive fo r gram-negative bacteria in 50% of the patie nts (n=81). the commonest bacteria were klebsiella pneumoniae (59%) followed by pseudomonas aeruginosa (15%), staphylococcus aureus (13.6%), streptococcus pneumoniae (6.8%) and streptococcus pyogenes (4.5%), respectively.16 similar findings reported by pradhan et al18 who isolated klebsiella pneumoniae in most of the culture-positive cases of chronic respiratory diseases. the gram-negative bacteria were sensitive to amikacin followed by gentamicin and ciprofloxacin. these drugs are available in most of the primary health care settings of our country and resistance could have developed by positive selection as copd patients take antibiotics often for their symptoms. sputum culture is a simple method to f ind the causative pathogen and bacterial sensitivity pattern for aecopd patients. it aids in screening drugresistant microbes and the selection of superior antibacterial drugs for treatment. the results of our study are primary in our population; larger trials should be conducted to validate our findings for authentication. limitation: this was a single center study with a small sample size, due to time constraints and funding limitations c o n c l u s i o n klebsiella pneumoniae followed by pseudomonas aeruginosa and staphylococcus aureus are the most common microorganisms in the sputum of patien ts presenting with an acute exacerbation of copd, while amikacin was found to be the most sensitive antibiotic against these microorganisms. r e c o m m e n d a t i o n sputum culture and sensitivity is highly recommended in patient presenting with copd. r e f e r e n c e s 1. vestbo j. copd: definition and phenotypes. clin chest med. 2014; 35(1): 1-6. doi: 10.1016/j.ccm.2013.10.010 2. soriano jb, abajobir aa, abate kh, abera sf, agrawal a, ahmed mb, et al. global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990–2015: a systematic analysis for the global burden of disease study 2015. lancet respir med. 2017; 5(9): 691-706. doi: 10.1016/s2213-2600(17)30293-x table i: association of micro-organisms with age, gender and duration of disease (n=110) variables klebsiella pneumoniae pvalue pseudomonas aeruginosa pvalue staphylococcus aureus pvalue + ve ve + ve ve + ve ve age (years) 25-50 24 59 0.42 8 75 1.0 10 73 0.27 51-80 45 87 13 119 10 122 gender male 47 71 0.007 2 106 0.82 11 107 1.0 female 22 75 9 88 9 88 duration of disease (months) 1-6 25 51 0.86 7 69 0.841 8 68 0.64 >6 44 95 14 125 12 127 j islamabad med dental coll 2020 27 3. mallia p, johnston sl. asthma-copd overlap syndrome: a review of current knowledge and future directions. malta med. j. 2017; 29(02): 182-89 4. landis sh, muellerova h, mannino dm, menezes am, han mk, van der molen t, et al. continuing to confront copd international patient survey: methods, copd prevalence, and disease burden in 2012–2013. int j chron obstruct pulmon dis. 2014; 9: 597-611. doi: 10.2147/copd.s61854 5. jinjuvadia c, jinjuvadia r, mandapakala c, durairajan n, liangpunsakul s, soubani ao. trends in outcomes, financial burden, and mortality for acute exacerbation of chronic obstructive pulmonary disease (copd) in the united states from 2002 to 2010. copd: copd. 2017; 14(1): 72-9. doi: 10.1080/15412555.2016.1199669 6. freeman cm, martinez ch, todt jc, martinez fj, han mk, thompson dl, et al. acute exacerbations of chronic obstructive pulmonary disease are associated with decreased cd4+ & cd8+ t cells and increased growth & differentiation factor-15 (gdf-15) in peripheral blood. respir res. 2015; 16(1): 94. doi: 10.1186/s12931-015-0251-1 7. anrıverdi h, örnek t, erboy f, altınsoy b, uygur f, atalay f, et al. comparison of diagnostic values of procalcitonin, c-reactive protein and blood neutrophil/lymphocyte ratio levels in predicting bacterial infection in hospitalized patients with acute exacerbations of copd. wien klin wochenschr. 2015; 127(19-20): 756-63. doi: 10.1007/s00508-014-0690-6 8. bope et, kellerman rd. conn's current therapy 2016: elsevier health sciences. 2015: 335-39. 9. lópez‐campos jl, tan w, soriano jb. global burden of copd. respirology. 2016; 21(1): 14-23. doi: 10.1111/resp.12660 10. nesar s, shoaib mh, rahim n, rehman r. emergence of resistance to fluoroquinolones among gram positive and gram negative clinical isolates. pak j pharm sci. 2012; 25(4): 223-27. pmid: 23010009 11. kulkarni g, chaudhary d, bhoyar a, dugad s. bacteriological profile in sputum and their antibiogram among the patients of acute exacerbation of copd. mvp j med sci. 2017; 4(2): 113-7. doi: 10.18311/mvpjms/2017/v4i2/11048 12. vogelmeier cf, criner gj, martinez fj, anzueto a, barnes pj, bourbeau j, et al. global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. gold executive summary. am j respir crit care med. 2017; 195(5): 557-82. doi: 10.1164/rccm.201701-0218pp 13. rakesh g, yuvarajan tks. bacterial agents causing acute exacerbations in chronic obstructive pulmonary disease (copd) patients, their antibiograms to extended spectrum beta-lactamases (esbl) production in a tertiary care hospital, india. int j curr microbiol app sci. 2013; 2(11): 273-82. https://www.ijcmas.com/vol-211/gerard%20rakesh,%20et%20al.pdf 14. ventola cl. the antibiotic resistance crisis: part 1: causes and threats. pharm ther. 2015; 40(4): 277-83. pmid: 25859123 15. nian l, liangyi x, gang j, wei l, yongliang j. analysis on constituents and drug resistance of pathogenic bacteria causing chronic obstructive pulmonary disease. biomed res. 2017; 28(19): 560-68. 16. madhavi s, rao r. bacterial etiology of acute exacerbations of chronic obstructive pulmonary disease. j microbiol biotechn res. 2012; 2(3): 440-4. 17. pradhan kc, kar s, nanda bk. bacteriology of chronic respiratory disease of non-tubercular origin. indian j pathol microbiol. 1979; 22(2): 133-138. pmid: 489083 255 j i m d c 2 0 1 7 255 open access f u l l l e n g t h a r t i c l e comparison of ranson’s score, bisap, and ctsi in predicting the severity of acute pancreatitis saad sarfraz janjua 1, fakhar zaman 2, tehmina qamar 3, fawad mirza 4, asaf alvi 5, muhammad hanif 6 1,2 postgraduate resident, bbh surgical unit rawalpindi 3 associate professor, department of biochemistry, rawalpindi medical university 4 senior registrar, bbh surgical unit rawalpindi 5 assistant professor, bbh surgical unit rawalpindi 6 professor, department of surgery, bbh surgical unit rawalpindi a b s t r a c t objective: to use of ranson’s, bisap and ctsi scoring system in predicting the severity and outcomes of patients with acute pancreatitis. patients and methods: one hundred and six (106) patients of acute pancreatitis were studied prospectively. data of patient’s baseline demographics, clinical and radiological investigation was collected. bisap score was calculated by obtaining data within 24 hours of admission, while ranson score was calculated at the time of admission and at 48 hours of admission. ctsi was based on findings from ct scan of selected patients. severity of acute pancreatitis was defined in terms of icu admission, development of associated complications and mortality. resultsout of 106 patients, 55.7% were females and 44.3% were male patients. regarding complications of acute pancreatitis, 9 (8.5%) patients were admitted in icu, complications occurred in 33 (31.1%) patients while mortality occurred in 9 (8.5%) patients. out of 106 patients 11 patients had ransons score greater than 3. 04(36.4%) patients required icu admission, 07(63.6%) patients developed complications and mortality of 5(45.5%) patients occurred. patients with bisap score greater 03, 6 (26%) patients required icu admission, 17 (74%) developed complications and mortality of 8(34.7%) patients occurred. 24 patients underwent cect abdomen and 4 patients had modified ctsi score of 8 to 10 (severe ap) out of which 4(100%) patients required icu admission, 4(100%) patients developed complications and mortality occurred in 4(100%) patients. conclusion: bisap score is a useful prognostic scoring system for predicting the severity of acute pancreatitis and can be a crucial aid in determining the group of patients that have a high chance of need for intensive care during the course of their illness and therefore need early resuscitation; especially in resource-limited developing countries. key words: acute pancreatitis, bisap score, modified ctsi score, ranson score author`s contribution 1-3 conception, synthesis, planning of research and manuscript writing interpretation and discussion 4-6 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence saad sarfraz janjua email: saadicarnot@hotmail.com article info. received: october 10, 2010 accepted: september 20, 2018 cite this article. janjua ss, zaman f, qamar t, mirza f, alvi a, hanif a. compaison of ranson’s score, bisap and ctsi in predicting the severity of acute pancreatitis. jimdc.2018; 7(4):255-259 funding source: nil conflict of interest: nil i n t r o d u c t i o n acute pancreatitis (ap) is inflammation of pancreas that sometimes may involve adjacent or remote body organs in severe cases.1 only 10 to 20% patients have mild inflammation and have good prognosis. but in severe o r i g i n a l a r t i c l e mailto:saadicarnot@hotmail.com 256 j i m d c 2 0 1 7 256 cases, patients present with pancreatic necrosis or with distant organ failure requiring intense medical management or surgical intervention with mortality risk of 40%. overall mortality risk is 5 to 10%.2 therefore, early detection and determination of severity of ap is very crucial for optimal management. because sometimes mild cases may progress to severe cases resulting in high mortality rates. unfortunately, no laboratory or diagnostic test is available for this and different risk scoring systems have been developed to determine the ap.3 out of various scoring systems, bisap (bedside index of severity in acute pancreatitis), ranson’s score and ctsi (computed tomography severity index) scoring system are commonly used for determining ap severity. ranson’s score include 11 variables, presence of 3 or >3 indicates severe ap.4 bisap score have 5 variables to determine severe ap (presence of age >60 years, pleural effusion, bun >25mg/dl, presence of sirs and impaired mental health).5,6 while modified ctsi is linked only with grading of pancreatic necrosis and extent of pancreatic necrosis.7 all of these scors have potential risk and benefits and have been used in routine practice. in present study, we aimed to determine the accuracy of bisap, ranson’s and ctsi scoring system in determining the severity of ap. p a t i e n t s a n d m e t h o d s one hundred and six (106) patients of acute pancreatitis of age 10 years to 90 years and any gender were studied prospectively. data of patient’s baseline demographics, clinical and radiological investigation was collected. approval of study was taken before starting data collection. mixed clinical and laboratory investigations data was used to confirm the diagnosis of ap (i.e. abdominal pain, increased serum amylase/lipase levels more than three folds, findings of ap on abdominal ultrasonography). after diagnosis of ap, these patients were informed about study purpose and protocols in the emergency department and informed consent was signed from them. patients with chronic pancreatitis were not included in the study. venous and arterial blood samples were taken and sent to the lab for measurements of patients’ blood gases, liver and renal function parameters and complete blood investigations. ct scan was performed in only selected patients and calculation of modified ctsi score was done on the basis of findings on ct scan. bisap score was calculated by obtaining data within 24 hours of admission, while ransons score was calculated at the time of admission and after 48 hours of admission. severity of ap was defined in terms of icu admission, development of associated complications and mortality. severity was noted at the time of discharge/death of patients. initial treatment of ap patients was resuscitation using fluids. inotropes were given if needed. urinary catheter and iv line was passed in all patients. urine output was noted on hourly basis. iv line was used for fluid resuscitation. prophylactic broadspectrum antibiotics were given. patients of severe ap who did not improved with medical therapy necrosectomy and open drainage was done in these cases. cholecystectomy was done either in same admission or in follow-up period. for data analysis, we used spss v23 software. chi-square test was used to compare complications and mortality on the basis of severity of scores. p-value <0.05 was taken as significant difference. table 1. baseline variables of patients (n=106) age of patients n(%) 10-20 6 (5.7) 21-30 24 (22.6) 31-40 20 (18.9) 41-50 22 (20.8) 51-60 12 (11.3) 61-70 16 (15.1) 71-80 5 (4.7) 81-90 1 (0.9) gender male 47 (44.3) female 59 (55.7) type of admission new 88 (83.0) follow-up 18 (17.0) cause of ap gallstones 73 (68.9) idiopathic 20 (18.9) hypertriglyceridemia 6 (5.7) alcohol induced 4 (3.8) post ercp 1 (0.9) drug induced 1 (0.9) corrosive intake 1 (0.9) 257 j i m d c 2 0 1 7 257 table 2. association of scoring systems in predicting complications and mortality in ap patients (n=106) scoring system icu admission complications mortality p-value yes no yes no yes no ranson’s score <3 5 (5.3) 90 (94.7) 26 (27.4) 69 (72.6) 4 (4.2) 91 (95.8) 0.006, 0.02, <0.0001 >3 4 (36.4) 7 (63.6) 7 (63.6) 4 (36.4) 5 (45.5) 6 (54.5) bisap score <3 3 (3.6) 80 (96.3) 16 (19.2) 67 (80.7) 0 (0) 83 (100) 0.47, 0.001, 0.001 >3 6 (26) 17 (74) 17 (73.9) 6 (26.08) 8(34.7) 15 (65.2) modified ctsi findings 0 -2 mild 0 (0.0) 10 (100) 7(70) 3(30) 0 (0) 10 (100) <0.001, <0.0001, <0.001 4-6 moderate 5 (50.0) 5 (50.0) 10(100.0) 0 (0.0) 2(20.0) 8 (80.0) 8-10 severe 4 (100) 0 (0) 4(100) 0 (0.0) 4 (100) 0 (0) r e s u l t s a total number of 106 patients of ap were studied. most of the patients 24 (22.6%) were in age group 21-30 years, 22 (20.8%) were in age group 41-50 years, 20 (18.9%) were in age group 31-40 years’ age group. there were 55.7% females and 44.3% male patients. there were 88 (83.0%) new admissions and remaining 18 (17.0%) were follow-up. most common cause of ap was gallstones in 73 (68.9%), idiopathic in 20 (18.9%) patients and hypertriglyceridemia in 6 (5.7%) patients (table 1). regarding complications of ap, 9 (8.5%) patients were admitted in icu, complications occurred in 33 (31.1%) patients while mortality occurred in 9 (8.5%) patients. most common complication in ap patients was pseudocyst occurred in 7 (6.6%) patients, ascites in 6 (5.7%), shock in 3 (2.8%) patients, while pleural effusion and acute renal failure occurred in 1 (0.9%), 1 (0.9%) cases only respectively. 11(10.4%) patients had multiple complications. regarding reliability of scoring systems in predicting severity and mortality due of ap. out of 106 patients, 11 patients had ransons score greater than 3, signifying severe pancreatitis. out of 11 patients 04(36.4%) patients required icu admission, 7(63.6%) patients developed complications due to pancreatitis and mortality of 5 (45.5%) patients occurred. whereas 95 patients had ransons score less than 03 and mortality of 4(4.2%) patients occurred in this group. out of all patients, 23 patients had bisap score greater than or equal to three, 6 (26%) patients required icu admission, 17 (74%) developed complications and mortality of 8(34.7%) patients occurred (table 2). mortality of patients with individual bisap score of 3 was 7.6 %, with bisap score 4 mortality rate was 50% and with bisap scores 5 and 6, mortality was 100 % (table 3). cect with pancreatic protocol was done for 24 patients. on the basis of findings on ct scan, modified ct severity index score was calculated. in patients having modified ctsi score equal to zero to two (mild ap), no patient required icu admission, 7(70%) patients developed complications and no mortality occurred. (table 2). in patients having modified ctsi score of 4 to 6 (moderate ap), 5(50%) patients required icu admission, 10(100%) patients developed complications and mortality of 2(20%) patient occurred. in patients having modified ctsi score of 8 to 10 (severe acute pancreatitis) 4(100%) patients required icu admission, 4(100%) patients developed complications and mortality of 4(100%) patients occurred (table 2). table 3. mortality with individual bisap score bisap score mortality yes (%) no (%) total 0 0 35 (100) 35 1 0 35 (100) 35 2 0 13 (100) 13 3 1(7.6) 12 (92.3) 13 4 3(50) 3 (50) 6 5 3(100) 0 3 6 2 (100) 0 2 total 09 97 106 258 j i m d c 2 0 1 7 258 table 4. mortality with individual ransons score. ransons score mortality yes (%) no (%) total 0.00 0 (0) 20 (100) 20 1.00 0 (0) 23 (100) 23 2.00 0 (0) 17 (100) 17 3.00 1 (7) 13 (93.0) 14 4.00 1 (6) 14 (94.0) 15 5.00 3 (33) 6 (67.0) 9 6.00 2 (33) 4 (67.0) 6 7.00 2 (100) 0 (0.0) 2 total 9 (8.4) 96 (91.6) 106 d i s c u s s i o n acute pancreatitis is one of the common presentations in medical emergency departments. due to high morbidity and mortality, early diagnosis and prediction of severity is very essential for optimal management of patients. in present study, we determined the accuracy of the ranson’s, bisap and modified ctsi scoring system in predicting the severity and associated mortality in ap patients. most of our patients (> 60%) were between 2150 years old and majority were females (55.7%). a study conducted by kumar et al. reported that mean age in their study was 48.42 years, and female population in their study was 66.0% (8). while in a study by yadav et al. mean age was 38.94+14.59 years, and female population was 70.6%.9 regarding etiology, the most common cause was gallstones, diagnosed in 68.9% patients. kumar et al. reported gallstones in 74.0% patients of ap followed by alcohol abuse in 18.0% patients.8 khanna and yadav et al. also reported gallstones as commonest etiology in ap patients.9,10i n present study, 8.5% patients were admitted in icu, complications occurred in 31.1% patients and mortality occurred 8.5% patients. yadav et al. reported mortality in 10.1% of the ap patients. while studies by bollen et al. and carnovale et al. reported mortality in only 3.5% and 4.8% patients respectively.11,12 regarding accuracy of different scoring systems, modified ctsi was the most accurate among all three scores. in patients having ctsi score >2 (>30 % necrosis), icu admissions occurred in 85.7% patients, complications in 100% patients and mortality in 57.1% patients. while ranson score and bisap score were important tool in risk stratification in patients with acute pancreatitis. in government setup, like ours due to very high patient load and limited facilities ransons score has a great role in predicting outcomes because it is easy to calculate and has very small financial burden on system. drawback of ransons score is that it takes 48 hours to calculate it. the advantage of bisap score is the relative ease with which data can be acquired and can be calculated within 24 hours of presentation. patients with a bisap score of equal to or greater than 4 have high mortality. kumar et al. conducted a study on comparison of apache ii, bisap, ranson’s score and modified ctsi score in predicting ap severity and mortality also reported that modified ctsi has highest accuracy in predicting icu admissions, complications and mortality in these patients. these authors found almost similar accuracy of bisap and ranson score.8 while a study by yang et al. comparing ranson, bisap, apache ii, and mctsi score in hyperlipidemia induced ap patients, reported that mctsi is outstanding in predicting complications, but is not good in predicting severity and mortality in these patients.13 studies by mortele et al. and banday et al. also reported ctsi as a simpler and best tool for predicting hospital stay, infections risk, organ failure risk and mortality in ap patients.14,15 c o n c l u s i o n modified ctsi is most accurate score in predicting icu admissions, complications and mortality in ap patients, however the bisap score represents a simple way of identifying patients at greater risk of dying and developing complications within 24 hours of presentation. also bisap score should be considered for risk stratification because as the bisap score increases, its accuracy in predicting table 5. mortality with overall ctsi score ctsi score mortality total yes (%) no (%) 00 0 (0) 4 (100) 4 2.00 0 (0) 6 (100) 6 4.00 1 (16) 5 (84.0) 6 6.00 1 (25) 3 (75.0) 4 8.00 4 (100) 0 (0.0) 4 total 6 (25.0) 18 (75.0) 24 259 j i m d c 2 0 1 7 259 mortality increases. ransons score was least accurate among bisap score and ctsi scoring system for predicting outcomes in ap patients. r e f e r e n c e s 1. brivet fg, emilie d, galanaud p. pro-and antiinflammatory cytokines during acute severe pancreatitis: an early and sustained response, although unpredictable of death. crit care med. 1999;27(4):749-55. 2. yang cj, chen j, phillips ar, windsor ja, petrov ms. predictors of severe and critical acute pancreatitis: a systematic review. digest liver dis. 2014;46(5):446-51. 3. shah ap, mourad mm, bramhall sr. acute pancreatitis: current perspectives on diagnosis and management. j inflamm res. 2018; 11:77-85. 4. di m-y, liu h, yang z-y, bonis pa, tang j-l, lau j. prediction models of mortality in acute pancreatitis in adults: a systematic review. ann intern med. 2016;165(7):482-90. 5. wu bu, johannes rs, sun x, tabak y, conwell dl, banks pa. the early prediction of mortality in acute pancreatitis: a large population-based study. gut. 2008;57(12):1698-703. 6. sanmugachandran v, othman h, wahab ma, jarmin r, zuhdi z. evaluation of the bedside index for severity in acute pancreatitis score (bisaps) in predicting disease severity, organ failure and mortality in acute pancreatitis. hpb. 2018;20: s523. 7. melkundi ss, patil s. acute pancreatitis, computed tomography, modified ct severity index. prospective study of ct in acute pancreatitis and its complications. jemds. 2015;73(4):12706-13. 8. harshit kumar a, singh griwan m. a comparison of apache ii, bisap, ranson’s score and modified ctsi in predicting the severity of acute pancreatitis based on the 2012 revised atlanta classification. gastroenterol rep. 2017;6(2):127-31. 9. yadav j, yadav sk, kumar s, baxla rg, sinha dk, bodra p, et al. predicting morbidity and mortality in acute pancreatitis in an indian population: a comparative study of the bisap score, ranson’s score and ct severity index. gastroenterol rep. 2015;4(3):216-20. 10. khanna ak, meher s, prakash s, tiwary sk, singh u, srivastava a, et al. comparison of ranson, glasgow, moss, sirs, bisap, apache-ii, ctsi scores, il-6, crp, and procalcitonin in predicting severity, organ failure, pancreatic necrosis, and mortality in acute pancreatitis. hpb surg. 2013;2013: 367581. 11. bollen tl, singh vk, maurer r, repas k, van es hw, banks pa, et al. comparative evaluation of the modified ct severity index and ct severity index in assessing severity of acute pancreatitis. am j roentgenol. 2011;197(2):386-92. 12. carnovale a, rabitti pg, manes g, esposito p, pacelli l, uomo g. mortality in acute pancreatitis: is it an early or a late event. jop. 2005;6(5):438-44. 13. yang l, liu j, xing y, du l, chen j, liu x, et al. comparison of bisap, ranson, mctsi, and apache ii in predicting severity and prognoses of hyperlipidemic acute pancreatitis in chinese patients. gastroenterol res pract. 2016;2016: 1834256. 14. mortele kj, wiesner w, intriere l, shankar s, zou kh, kalantari bn, et al. a modified ct severity index for evaluating acute pancreatitis: improved correlation with patient outcome. am j roentgenol. 2004;183(5):1261-5. 15. banday ia, gattoo i, khan am, javeed j, gupta g, latief m. modified computed tomography severity index for evaluation of acute pancreatitis and its correlation with clinical outcome: a tertiary care hospital based observational study. j clin diagnost res. 2015;9(8):tc01. j islamabad med dental coll 2019 92 open access association of serum psa levels with histopathological pattern of prostate lesions afra samad 1, nudrat fayyaz 2, ayesha siddiqa 3, naseem akhter 4, rabia saeed 5, maryam rafiq 6, aqsa ashraf bukhari 7, ayesha afzal 8 1 associate professor, department of pathology, multan medical & dental college, multan 2 assistant professor, department of chemical pathology, multan medical and dental college multan 3 consultant pathologist, district health authority, t.h.q. hospital, yazman, bahawalpur 4 assistant professor, department of hematology, ibn-e-sina hospital, multan 5 assistant professor., department of chemical pathology, combined military hospital, bahawalpur 6 assistant professor. department of chemical pathology, sahiwal medical college, sahiwal 7 microbiologist, multan medical and dental college, multan 8 phd scholar human genetics and molecular biology & lecturer, gc university, faisalabad a b s t r a c t background: pathological changes that mainly affect prostate gland are prostatitis, benign prostatic hyperplasia (bph) and cancerous lesions. digital rectal examination (dre), transrectal ultrasonography (tus), and prostate specific antigen (psa) followed by histopathological examination, are routinely used tests for diagnosis of prostate lesions. the aim of the present study is to determine the role of serum psa levels in differentially diagnosing the different types of prostate lesions. material and methods: this retrospective (observational) study was conducted in ibn-e-sina hospital multan. data of 2189 patients who were operated from 2007 to 2017 due to prostatic lesions were included in this analysis. patients with bph, prostatitis, prostate carcinoma and prostatic intraepithelial neoplasia (pin) were grouped according to serum psa levels (ranging from 0 to >100 ng/ml) into five groups. frequencies and percentages were calculated for different histopathological findings. association of psa levels with different histological patterns was determined with chi-square test with p-value < 0.05 taken as significant difference. results: mean age of patients was 62.45+10.64 years. on histopathology, bph was diagnosed in 1676 (76.56%) patients, prostatitis in 133 (6.07%), carcinoma in 378 (17.26%) and pin in 02 (0.09%) patients, respectively. serum psa levels of 4.01-10 ng/ml were found in 1050 (62.64%) bph patients and in 59 (44.36%) prostatitis patients. serum psa levels of 10.01-20 ng/ml were found in only 40 (2.4%) bph patients, 47 (35.33%) prostatitis patients, 22 (5.82%) carcinoma patients and in 1 (50.0%) pin patient. serum psa levels of 20.01-100 ng/ml were found in 32 (1.9%) bph patients, 11 (8.27%) prostatitis patients, 302 (79.89%) carcinoma patients, and in 1 (50.0%) pin patient. serum psa levels of >100 ng/ml were absent in patients with bph and pin, and present in 1 (0.75%) prostatitis and 54 (14.28%) carcinoma patients. conclusion: benign prostatic hyperplasia was the commonest lesion in our patients (76.56%) with serum psa levels >10 ng/ml reported in all patients with prostate carcinoma and prostatic intraepithelial neoplasia (pin) patients. key words: benign prostatic hyperplasia, prostate carcinoma, prostate specific antigen, prostatic intraepithelial neoplasia, prostatitis authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing 3,4 interpretation, 5-8discussion, active participation in data collection data analysis. correspondence: nudrat fayyaz email: nudrat_khan_07@yahoo.com article info: received: january 4, 2019 accepted: april 10, 2019 cite this article. samad a, fayyaz n, siddiqa s, akhter n, saeed r, rafiq m, bukhari aa, afzal a. association of serum psa levels with histopathological pattern of prostate lesions. j islamabad med dental coll.2019; 8(2):92-95 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2019 93 i n t r o d u c t i o n benign prostatic hyperplasia (bph), prostatitis and carcinoma are three most common prostate lesions with bph as the commonest lesion, affecting 210 million of the male population worldwide.1 bph is now considered a normal part of aging as it is present in 100% male population of age >80 years.1 cancer of prostate is ranked as the second most common cancer and fifth leading cause of death due to cancer in males.2 pathological changes that mainly affect prostate gland are prostatitis, benign prostatic hyperplasia (bph), pin and prostate cancer. there is an increasing incidence of prostate cancer and bph with increasing age, however bph is reported as the commonest lesion.3 histological findings of bph are present in 20% of males at the age of 40 years, in 70% at 60 years and in 90% by the time they reach 80 years of age.3 peak incidence is reported in the sixth decade of life in the pakistani population.4 while in some other countries the peak incidence is in the ninth decade of life.5 in addition to age, other risk factors of prostate lesions are those concerned with metabolic disorders such as diabetes, obesity, dyslipidemia and physical inactivity.4 digital rectal examination (dre), transrectal ultrasonography, and prostate specific antigen (psa) followed by histopathological examination are routinely used tests for the diagnosis of prostate lesions.6 psa is physiologically secreted in semen in high concentrations for liquefication of semen coagulum.7 psa is also found in human blood plasma/serum and is widely used for detection of prostate pathology since 1988. psa levels increase in proportion with disease severity and studies have found that a steep increase in psa level increases the likelihood of diagnosis of prostate cancer.8,9 serum psa levels <4.0 ng/ml in patients with prostate lesions are considered normal, 4-10 ng/ml are border line while >10 ng/ml are considered to have a high risk for malignancy. psa levels are only used to diagnose lesions and histopathological examination is needed to differentiate different types of lesions. the aim of the present study was to determine the role of serum psa levels in differentially diagnosing the different histopathological types of prostate lesions. m a t e r i a l a n d m e t h o d s this retrospective study was conducted in ibn-e-sina hospital multan. data of 2189 patients who were operated from 2007 to 2017 due to prostatic lesions were included in this analysis. patients with inadequate biopsy specimens were excluded. departmental and erb approval was taken before analyzing the data. patients with bph, prostatitis, prostate carcinoma and prostatic intraepithelial neoplasia (pin) were grouped according to serum psa levels (ranging from 0 >100 ng/ml) into five groups serum psa levels done before surgery were noted for each patient. biopsy specimens were brought to the histopathology laboratory in 10% formalin solution for confirmation of the diagnosis of prostate lesions. these sections were then stained with eosin and hematoxylin stain and slides were evaluated microscopically for determination of types of lesions. consultant histopathologist made the final diagnosis of prostate lesions. all the data was entered in spss version 21. frequencies and percentages were calculated for different histopathological findings. association of serum psa levels with different histopathological patterns was determined using chi-square test with p-value < 0.05 taken as a significant difference r e s u l t s mean age of all patients was 62.45+10.64 years. on histopathology, bph was diagnosed in 1676 (76.56%) patients, prostatitis in 133 (6.07%), carcinoma in 378 (17.26%) and pin in 02 (0.09%) patients only (table i). on comparison of serum psa levels with various types of histopathological lesions, almost all patients of bph, and about 55% patients of prostatitis had psa levels within the range of 0-10 ng/ml. j islamabad med dental coll 2019 94 table i. frequency distribution of histopathological lesions type of lesion frequency (n) percentage (%) bph 1676 76.56 prostatitis 133 6.07 acute prostatitis 26 1.18 chronic prostatitis 83 3.79 acute and chronic prostatitis 24 1.09 carcinoma 378 17.26 adenocarcinoma 364 16.62 transitional cell carcinoma 01 0.045 mucinous adenocarcinoma 02 0.09 adenoid basaloid tumor 01 0.045 rhabdomyosarioma 01 0.045 small cell tumor 01 0.045 squamous cell carcinoma 03 0.14 infiltration by tcc 02 0.09 large cell type 01 0.045 sarcomatoid varices 01 0.045 leiomyoma 01 0.045 pin 02 0.09 total 2189 100 about 50% patients of pin had psa levels in the range of 10-20 ng/ml, while more than 90% patients of prostate cancer had psa levels >20 ng/ml (table ii). d i s c u s s i o n bph and prostate carcinoma are very common in males especially in geriatric age and results in lower urinary tract symptoms. psa levels, dre, and transurethral usg and biopsy investigations are routinely used tests for diagnosing prostate lesions.10 mean age of all patients in the present study was 62.45±10.6 years. this is in agreement with the mean age reported by multiple studies including khant et al. (66.9 ± 9.4 years),10 josephine (65.5 years),11 and lakhey et al. (67.6 years)12 in indian and nepalese patients respectively. in comparison, jasani and colleagues reported mean age of 57.77±4.86 years for patients with bph and 65.82±5.6 years for patients with prostate cancer.13 in our study, bph was diagnosed in 1676 (76.56%) patients, prostatitis in 133 (6.07%), carcinoma in 378 (17.26%) and pin in 02 (0.09%) patients only. patel and surti reported bph in 68.75% patients, followed by carcinoma in 25% cases and prostatitis in only 1.8% patients.14 shetty et al. reported bph in only 36.6% patients, prostatitis in 30%, pin in 15.3% and carcinoma in 18% patients.15 gurumurthy et al. reported pin in 5.95% cases of prostatic lesions.16 horninger et al. reported frequency of pin in 2.91% patients and anderson-jackson et al. in 4.07% patients, respectively.17,18 all these studies report contrasting results, which are much different from our study. serum psa is the most widely used tumor marker but it cannot be used alone because it has low sensitivity and specificity, especially when the psa levels are low. elevation of psa level occur in conditions such as bph, prostatitis, prostatic infarct and especially in carcinoma of prostate. in the present study, we correlated the serum psa levels with histopathological diagnosis of prostate lesions. we found significant association of psa with carcinoma of prostate; psa levels were >10 ng/ml in all patients with prostate carcinoma and pin. in our study, psa levels <10.0 ng/ml were found in 76.65% of the patients. murthy et al. reported normal psa levels in more than 40% patients who underwent prostate biopsy.19 another study by el-imam et al. reported psa >4 to <10.0 ng/ml in >70% of sudanese patients.20 wadgaonkar et al. and gurumurthy et al. reported findings similar to our study with significant elevation in serum psa levels in pin and prostate carcinoma patients.21,16 serum psa levels more than 10 ng/ml is highly indicative of prostate cancer. so, patients having psa >10 ng/ml should be considered for surgical intervention as early as possible because of high probability of prostate carcinoma. the limitation of the present study is that we table ii. association of serum psa levels with common types of histopathological lesions psa (ng/ml) bph (n=1676) prostatitis (n=133) carcinoma (n=378) pin (n=02) p-value 0-4.0 554 (33.05%) 15 (11.27 %) 0 (0.0 %) 0 (0.0 %) <0.05 4.01-10 1050 (62.64 %) 59 (44.36 %) 0 (0.0 %) 0 (0.0 %) 10.01-20 40 (2.4 %) 47 (35.33 %) 22 (5.82 %) 1 (50.0 %) 20.01-100 32 (1.9 %) 11 (8.27 %) 302 (79.89 %) 1 (50.0 %) >100 0 (0.0 %) 1 (0.75 %) 54 (14.28 %) 0 (0.0 %) j islamabad med dental coll 2019 95 did not correlate the severity/grades of prostate cancer (gleason scores) with serum psa levels. c o n c l u s i o n in our study, benign prostatic hyperplasia was the commonest prostate lesion (76.56% of the patients) and serum psa levels of >10 ng/ml was found in all patients with prostate carcinoma and prostatic intraepithelial neoplasia (pin). r e f e r e n c e s 1. arya rc, minj mk, tiwari ak et al. pattern of prostatic lesions in chhattisgarh institute of medical sciences, bilaspur: a retrospective tertiary hospital based study. int j scientific study 2015;3(6):179-82. 2. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: cancer j clin. 2018; 68: 394424. doi: 10.3322/caac.21492. 3. kumar v, abbas ak, fausto n, aster jc. robbins and cotran pathologic basis of disease. philadelphia: elsevier saunders; 2005; 8 :208-21 4. aslam hm, shahid n, shaikh na, shaikh ha, saleem s, mughal a. spectrum of prostatic lesions. int arch medicine. 2013; 6(1): 36. doi: 10.1186/1755-7682-6-36 5. ojewola rw, oridota es, balogun os, alabi to, ajayi ai, olajide ta, et al. prevalence of clinical benign prostatic hyperplasia amongst community-dwelling men in a southwestern nigerian rural setting: a cross-sectional study. afr j urol. 2017;23(2):109-15. doi: 10.1016/j.afju.2016.02.004 6. heidenreich a, bellmunt j, bolla m, joniau s, mason m, matveev v, et al. eau guidelines on prostate cancer.part 1: screening, diagnosis, and treatment of clinically localised disease. eur urol. 2011; 59(1): 61-71. doi: 10.1016/j.eururo.2010.10.039 7. lee c, keefer m, zhao zw, kroes r, berg l, liu x, sensibar j. demonstration of the role of prostate‐specific antigen in semen liquefaction by two‐dimensional electrophoresis. journal of andrology. 1989 nov 12;10(6):432-8. 8. brawer mk, chetner mp, beatie j, buchner dm, vessella rl, lange ph. screening for prostatic carcinoma with prostate specific antigen. j urol. 1992; 147(3 part 2): 841-5. doi: 10.1016/s0022-5347(17)37401-3 9. gretzer mb, partin aw. psa levels and the probability of prostate cancer on biopsy. eur urol suppl. 2002; 1(6): 21-7. doi: 10.1016/s1569-9056(02)00053-2. 10. khant vs, goswami h, shah py. correlation of serum prostate-specific antigen level in various prostate pathology in elderly men. international j med sci public health. 2017; 6(2): 257-62. doi: 10.5455/ijmsph.2017.17072016588 11. josephine a. clinicopathological study of prostatic biopsies. j clin diagn res. 2014; 8(9): fc04-06. doi: 10.7860/jcdr/2014/8591 12. lakhey m, ghimire r, shrestha r, bhatta a. correlation of serum free prostate-specific antigen level with histological findings in patients with prostatic disease. kathmandu uni med j. 2010; 8(30): 158-63. pmid: 21209527 13. jasani jh, patel hb, gheewala b, vaishnani hv, bhuva k. diagnostic utility of prostate specific antigen for detection of prostatic lesions. int j biomed adv res. 2012; 3(4): 268– 72. doi: 10.7439/ijbar.v3i4.425. 14. patel sk, surti hb. analysis of prostatic biopsies in a tertiary care hospital in correlation with prostate-specific antigen levels: a clinicopathological study. int j med sci public health. 2017; 6(5): 842-6. doi: 10.5455/ijmsph.2017.1266106122016 15. shetty pp, singh bm, shetty t, bishnu a. correlation of prostate specific antigen level with histopathological findings in patients with prostatic disease. trop j pathol microbiol. 2016; 2(3): 152-8 16. gurumurthy d, maggad r, patel s. prostate carcinoma: correlation of histopathology with serum prostate specific antigen. int j sci technol soc. 2015; 4: 1-5. doi: 10.11648/j.sjcm.s.2015040401.11 17. horninger w, volgger h, rogatsch h, strohmeyer d, steiner h, hobisch a, et al. predictive value of total and percent free prostate specific antigen in high grade prostatic intraepithelial neoplasia lesions: results of the tyrol prostate specific antigen screening project. j urol. 2001; 165(4): 1143-5. doi: 10.1016/s0022-5347(05)66451-8. 18. anderson-jackson l, mcgrowder da, alexander-lindo r. prostate specific antigen and gleason score in men with prostate cancer at a private diagnostic radiology centre in western jamaica. asian pacific j cancer prev. 2012; 13(4): 1453-6. doi: 10.7314/apjcp.2012.13.4.1453 19. murthy d, ray u, morewaya j, sengupta s. a study of the correlation of prostatic pathology and serum prostatespecific antigen (psa) levels: a perspective from papua new guinea. papua n guinea med j. 1998; 41(2): 59-64. 20. mohammed el imam ma, higazi nz, abuidris do, idris aa, khalid ke, omran m, et al. prostate specific antigen versus digital rectal examination as screening for ca prostate in sudanese patients. sudan j public health. 2009; 4(2): 27881. 21. .wadgaonkar a, patil a, mahajan s, yengantiwar r. correlation of serum prostate specific antigen (psa) level in various prostate pathology in elderly men. int j basic applied med sci. 2013; 3(2): 274-8. j islamabad med dental coll 2020 65 open access transmission routes and infection control of novel coronavirus-2019 in dental clinics – a review sana ali1, uroosa zeb1, mashooq khan2, anees muhammad1 1college of medical technology, bacha khan medical college , mardan 2institute of paramedical sciences, khyber medical university, peshawar a b s t r a c t the novel coronavirus (2019-ncov) pandemic began in wuhan, china with severe acute respiratory syndrome ( sars) in december, 2019. the virus transmitted from china to other countries by traveling of the infected individuals. the number of infected populations with coronavirus is increasing day by day with an increased mortality rate. the signs and symptoms of the disease include fever, non -productive cough, dyspnea, and fatigue. the transmission routes of the virus include respiratory secretions or droplet infection and direct contact with the infected person. dentists are a group of professionals that are highly exposed to infectious diseases. the nco v-19 is transmitted from patient to dentist and dentist to patient mainly through aerosol and splatter produced by the dental procedure and saliva of an infected person. to avoid transmission of the virus from patient to dentist and from dentist to other p atients, screening tests should be done at dental setups. the use of gloves, face shields, masks, gowns, and antiseptic handwash are mandatory for the dentist. awareness programs should be conducted to prevent further transmission of the disease. we searched google, google scholar, who website for coronavirus and national institute of health website (nih.org.pk) for relevant literature by using various me sh terms including ‘2019-ncov’, ‘transmission of 2019ncov in dental clinics’, ‘dentistry and covid-19’ and ‘infection control’, etc key words: covid-19, dental clinics, infection control, transmission authors’ contribution: 1,2conception; literature search; manuscript design and drafting; critical analysis and manuscript review; manuscript editing. correspondence: anees muhammad email: aneesafridi15295@yahoo.com article info: received: march 15, 2020 accepted: march 17, 2020 cite this article. ali s, zeb u, muhammad a. transmission routes and infection control of novel coronavirus-2019 in dental clinics – a review. j islamabad med dental coll.2020; 9(1):65-72. doi: 10.35787/jimdc.v9i1.517 funding source: nil conflict of interest: nil i n t r o d u c t i o n coronaviruses are a group of rna viruses, singlestranded and enveloped, that can infect animals as well as human beings.1 the four genera of coronavirus are alpha, beta, gamma, and delta. six coronaviruses are recognized to infect human beings, with four from the alpha type of coronavirus and two from a beta type of coronavirus. the alpha coronavirus can cause mild upper respiratory illness that is “common cold” while the beta type leads to severe and serious illness.1,2 the sars-cov (severe acute respiratory syndrome-coronavirus) was reported between 2002-2003 in china, with infection in 8,098 and death in 774 affected individuals. the actual cause of the syndrome remained unclear but bats were considered to be the origin of this virus that r e v i e w a r ti c le j islamabad med dental coll 2020 66 transmitted to other mammals. after 2004, not even a single case of sars-cov was reported.1 the middle east respiratory syndrome coronavirus (mers-cov) emerged in saudi arabia in the year 2012.1,3-5 these cases of viral infection occurred at irregular intervals. the origin of the mers-cov is the same as sars-cov with infection in bats transmitted into camels with further transmission to humans.1,6,7 these viruses spread through air by sneezing or coughing of the infected person as w e ll as by bodily contact (i.e. handshaking etc.) with th e infected person. thus the transmission was airborne as well as through direct contact with the patient and the object that was contaminated with the virus.8 since 2012, about 2,494 cases have been reported by the world health organization (who) with 858 deaths and a mortality rate of 35%.1 more cases emerged from saudi arabia followed by the united arab emirates.8 awareness of the population and dental professionals regarding the spread of the disease is important.9 dentists might play a role in the spread of the infection because their work primarily involves the oral cavity and hence contact with saliva of different patients. some of the dentists do n o t u s e proper personnel protective equipment (gloves, gown, goggles, masks, hair and foot covers) during routine procedures, which is one of the possible way of transmitting various viral and bacterial infections. moreover, aerosol and splatter are produced during various dental procedures like scaling, polishing, cavity preparation and tooth cutting. these aerosol and splatter are mixed with oral fluids (i.e. saliva) of the patient, which beco m e air borne with the use of rotary hand pieces and thus can transmit the covid-19 disease to the dentists.9 this review article highlights possible high-risk transmission of the virus in dental clinics in the current pandemic of 2019-ncov. the main purpo s e is to increase awareness and prevent transmission of this virus among the dentists and their patients during dental practice. we searched google , google scholar, who website for coronavirus and national institute of health website (nih.org.pk) for related literature reported in english language. different ‘mesh’ terms were used, such as ‘2019ncov’, ‘transmission of 2019-ncov in dental clinics’, ‘dentistry and 2019-ncov’, ‘current status of 2019ncov’ and ‘infection control’, etc. articles related to previous pandemics due to coronavirus, current pandemic of 2019-ncov and dentistry were included. hence all relevant articles published in various international journals, government reports, world health organization reports, national institute of health (pakistan) reports about 2019ncov from december, 2019 to march, 2020 were retrieved. literature pertaining to previous epidemics and pandemics due to influenza and coronavirus was also included to give a historical perspective. recent outbreak of covid-19 in the early days of december 2019, the who office in china received reports of some cases of pneumonia having an unknown cause. the cases emerged in wuhan which is a city of hubei province in china. after a few weeks, the agent responsible for the disease was declared to belong to the family of coronavirus and hence named as 2019 novel coronavirus (2019-ncov). the 2019-ncov is currently named as sars-cov-2 and the disease caused by the virus as covid-19 has spread from wuhan (china) to several other countries with a variable number of cases and different rates of transmission.10,11 prevalence of covid-19 about 1,67,515 individuals have been infected with ncov-19 throughout the world with 6,606 deaths till march 16, 2020. the occurrence ratio is going to double every 6.4 days. till march 16, 2020 the number of cases in china reached up to 81,077 j islamabad med dental coll 2020 67 with 3,218 deaths. the total affected countries in the world are 150 in number. besides china, outbreak has also occurred in italy, iran, republic of korea, spain and france. the number of case s is abruptly increasing in italy with a high mortality rate of approximately 7.3%, the highest in the current outbreak.12 in pakistan, a total of 887 confirmed cases were detected in different regions, with 6 causalities reported till march 23, 2020. majority cases have been identified from sindh (karachi), followed by baluchistan, federal capital islamabad, gilgit baltistan, punjab, khyber pakhtunkhwa, merged areas (ex-fata), azad jammu and kashmir, respectively.13 it is estimated that cases in pakistan are imported from different countries especially pilgrims travelling from border city of taftan, iran. mode of transmission the ncov-19 is believed to be transmitted primarily through respiratory secretions and also from person to person contact. this virus is seen in the saliva of infected patients which means it can be transmitted through oral fluids of the infected person to others,14 through sneezing, coughing or talking. the airborne particles when inhaled have a high risk of transmission from one person to another.14,15 thus contact transmission, droplet transmission, and person to person transmission are different modes of transmission of 2019ncov.16 the sources for the airborne contamination in dentistry are dental instruments, saliva, respirato ry sources and the operative site.17 saliva and respiratory sources of contamination saliva continuously makes the oral environment wet. the fluid in the oral cavity is mostly contaminated with different pathogens including many types of bacteria and viruses. the plaque or calculus present on the tooth surface is the major source of these microorganisms, either supragingival or subgingival. apart from these, the oral cavity also serves to protect the nose, throat and respiratory system from entry of these pathogenic bacteria and viruses. dental procedures of any type that can aerosolize this saliva will lead to airborne contamination with organisms from any or all of these sources. the commonly present bacterium that has a serious threat to the dentist is mycobacterium tuberculosis which leads to tb and blood-borne viral diseases like hepatitis b, hepatitis c and hiv. the saliva and nasopharyngeal secretions also contain other pathogens and viruses like influenza, herpes virus, and the sars virus. airborne diseas e s have the ability to transmit to the dentist through dental procedures that produce aerosol and splatter.17 signs and symptoms of covid-19 a person infected with 2019-ncov will manifest lower respiratory tract illness, for example, dry cough (in 67-82% cases), shortness of breath that is dyspnea (in 38%), fever (in 83-99% of cases), kidney failure and eventually death.1,11,14 the least common features are headache, nausea, vomiting, diarrhea, nasal congestion and sore throat.16 an elevation of ast, ldh, d-dimer, and prolonged prothrombin time support the diagnosis of viral infection. findings of pneumonia through x rays or ct scans will be seen in all the 2019-ncov patients.1 diagnosis and treatment of covid-19 the 2019-ncov can be diagnosed with the help of reverse-transcription polymerase chain reaction (rt-pcr). the suspected person has to be analy z e d through rt-pcr of upper respiratory (nasal and pharyngeal swabs) or lower respiratory specimens (sputum, bronchoalveolar lavage, tracheal aspirate or bronchoscopic brush biopsy).18 the specimen of j islamabad med dental coll 2020 68 blood and feces may also be utilized for the analysis of 2019-ncov through rt-pcr. rt-pcr is the only available diagnostic procedure throughout the world. no serological or immunochromatography technique exist for detection of 2019-ncov.18 however, viral profile (hepatitis etc.), hematological tests and creatine kinase may be performed for suspected or confirmed covid-19 patients. imaging techniques may also be helpful in diagnosis of 2019-ncov.30 nucleic acid amplification is also utilized to diagnose sars-cov through saliva and sputum.31,32 the availability of salivary tests at the dental setup also helps in the diagnosis of any infectious virus. 32 the treatment of ncov-19 is mainly supportive with use of hydroxychloroquine and azithromycin, as option for these patients. however, some antiv iral drugs (e.g. oseltamivir) that were used for treatment of the initial cases did not give beneficial effects against 2019-ncov. in china, drugs commonly used to treat human immune de ficiency virus, for example, ritonavir-boosted lopinavir, are going to be assessed for covid-19 infection. it is also planned to use remdisivir as a treatment option against 2019ncov, as it has shown high efficacy against merscov and sars-cov in the past. the who and cdc do not recommend the use of corticosteroids in the treatment of 2019-ncov infection. vaccine for the control of 2019-ncov is also under investigation.30 covid-19 and its risk for dental professionals there are many microbiological risk factors in dentistry including prions, viruses, bacteria, protozoa, and fungi. the routes may be bloodborne, saliva droplet infection and direct contact with an infected person. the droplet aerosol from an infected patient, the aerosol that comes out of the handpiece that contains 2019-ncov and table i: previously reported global epidemics and pandemics of inf luenza and coronaviruses year type of virus disease place of origin important characteristics of virus epidemic/ pandemic references 1918 h1n1 influenza (spanish flu) us 20-50 million deaths, lethal in young adults pandemic 19 1957 h2n2 influenza (asian flu) china 2 million deaths, lethal in elderly pandemic 20 1968 h3n2 influenza (hong kong flu) hong kong 1 million deaths, lethal in elderly (>65 years) pandemic 21 1977 h5n1 influenza (bird flu) hong kong 352 deaths, linked to poultry, human-human transmission rare pandemic 22 2002 sars-cov sars china 774 deaths epidemic 23 2009 h1n1 influenza (swine flu) mexico 18000 deaths, combination of a eurasian swine flu virus with another strain (mix of bird, swine and human flu virus) pandemic 24,25 2012 mers-cov mers saudi arabia 700 deaths epidemic 26,27 2013 h7n9 influenza (avian flu) china 295 deaths, mostly affected old adults ≥60 years epidemic 28 2019 ncov-19 covid-19 china 16,565 deaths till now pandemic 29 j islamabad med dental coll 2020 69 contaminated instruments can lead to infection in the dental professionals.33 aerosol and splatter in dentistry micik and colleagues were the first to use the term aerosol and splatter at the time when they were working on aerobiology. the term aerosol is defined as those particles which have lesser than 50um diameters. these are small enough to stay in the air before settling down or entering the respiratory tract. pneumonic plague, influenza, legionnaires’ disease, and severe acute respiratory syndrome are transmitted through aerosol. o n th e other side, the term splatter is defined as those particles that have a diameter greater than 50um. these particles are larger in size and are unable to stay in the air. so, the greater chances of crossinfection in dentistry are through aerosol which is airborne and can enter the respiratory tract. however, splatters are also a threat to pass infection from patients to the dentist. tb is transmitted through the droplet nuclei produced during coughing or sneezing of an infected individual or from the splatter of the ongoing dental procedure. thus splatter and droplet nuclei also transmit infectious diseases from patients to dental professionals like measles, herpes, and sars.17 approaches to minimize the risk of covid-19 in dental clinics the most important control measure for 2019ncov-19 infection is hand hygiene. as the dentis t is in direct contact with the patients so he/she has to use hand sanitizers/ antiseptics before and after finishing the dental procedure. this will help in prevention of transmission of ncov -19 infection to the dentist as well as the patient.2,18,34 the dentist should provide oxidative mouth w ash to the patient before starting the dental proced u re to prevent the transmission of 2019-ncov from th e saliva of an infected patient.35 sterilized instruments for each patient should be used and the area surrounding the patient should be disinfected before starting with the next patient. one hand technique for recapping needle sh ould be applied with use of sharps container for used needles and surgical blades.34 dentists and other staff must wear personal protective equipment (ppe) like surgical gloves, n95 masks, long sterilized gowns and eye protectors with face shields when performing dental procedures that produce aerosol and splatter. 36-39 awareness among general population visiting dental-setup before going to dental setups, people should have all the related information about ncov -19. they should be aware of the cause, signs and symptoms , and safety measures of ncov-19 infection. seminars and workshops should be arranged for the awareness of general public regarding transmission of ncov-19 and their respective preventive measures. people should be asked to avoid unnecessary visits to crowded areas and medical health care and dental setups. if the visit is absolutely necessary, then use of masks should be promoted. they should avoid contact with individuals who show signs and symptoms of ncov 19 or flue and cough. after the dental procedure, the patient, as well as the dentist, should wash their hands with antiseptics. recommendations for dentists in current scenario dentists should be aware of the patient's recent travel history, the incubation period of the diseas e , isolation protocol of the dental procedure and appropriate disposal of used instruments. 40 strict preventive measures should be employed f o r ncov-19 infection while working in their dental setups. screening tests should be available at the j islamabad med dental coll 2020 70 dental setup and if any patient shows positive result for the virus, he should be referred to the medical health facilities identified for screening and treatment. dentists should search for latest information about 2019-ncov infection and keep themselves updated from reliable national and international sources to better handle cases with this pandemic infection. c o n c l u s i o n the novel coronavirus is transmitted through direct person to person contact and re spiratory droplet infection. the dental staff is at a higher risk for ncov-19 infection as they are exposed to the aerosol and splatter produced during a dental procedure. the risk of transmission can be reduce d by taking some precautions. these include the use of antiseptic hand wash, rubber dam isolation, and mouth rinse for patient before dental procedure, gloves, protective eye wears, gowns, and masks. moreover, it is necessary to arrange seminars and awareness programs for the dentist regarding dental practice during this outbreak. appropriate precautionary measures can play an important role in reducing transmission and further spread of ncov-19 infection. a c k n o w l e d g m e n t we are thankful to all the staff of college of medical technology, especially project director, dr. abdul jamil, dr. nasir ali, miss areena khan, mr. hidayat khan and muhammad owais for their support and suggestions. r e f e r e n c e s 1. crawford b, kasmidi m, korompis f, pollnac rb. factors influencing progress in establishing community-based marine protected areas in indonesia. coastal management. 2006; 34(1): 39-64. doi:10.1080/08920750500379300 2. mirza mb, bhagat tv, inderjit mg, aljeaidi za. middle east respiratory syndrome and precautions to be taken by dental surgeons. jhs. 2016; 4(2): 105. doi: 10.4103/1658-600x.179821 3. al mohaissen m. awareness among a saudi arabian university community of middle east respiratory syndrome coronavirus following an outbreak. east mediterr health j. 2017; 23(5): 351-60. 4. baseer ma, ansari sh, alshamrani ss, alakras ar, mahrous r, alenazi am. awareness of dr oplet and airborne isolation precautions among dental health professionals during the outbreak of corona virus infection in riyadh city, saudi arabia. j clin exp dent. 2016; 8(4): e379. doi: 10.4317/jced.52811 5. althomairy sa, baseer ma, assery m, alsaffan ad. knowledge and attitude of dental health professionals about middle east respiratory syndrome in saudi arabia. j int soc prev community dent. 2018; 8(2): 137. doi: 10.4103/jispcd.jispcd_9_ 18 6. elrggal me, karami na, rafea b, alahmadi l, al shehri a, alamoudi r, et al. evaluation of preparedness of healthcare student volunteers against middle east respiratory syndrome coronavirus (mers-cov) in makkah, saudi arabia: a cross-sectional study. z gesundhwiss. 2018; 26(6): 607-12. doi: 10.1007/s10389-018-0917-5 7. kharma my, alalwani ms, amer mf, tarakji b, aws g. assessment of the awareness level of dental students toward middle east respiratory syndromecoronavirus. j int soc prev community dent. 2015; 5(3): 163. doi: 10.4103/2231-0762.159951 8. hoda j. identification of information types and sources by the public for promoting awareness of middle east respiratory syndrome coronavirus in saudi arabia. health educ res. 2016; 31(1): 12-23. doi: 10.1093/her/cyv061 9. jeon mh, kim th. institutional preparedness to prevent future middle east respiratory syndrome coronavirus-like outbreaks in republic of korea. infect chemother. 2016; 48(2): 75-80. doi: 10.3947/ic.2016.48.2.75. 10. perrella a, carannante n, berretta m, rinaldi m, maturo n, rinaldi l. editorial–novel coronavirus 2019 (sars-cov2): a global emergency that needs new approaches?. eur rev med pharmaco sci. 2020; 24(4): 2162-4. doi: 10.26355/eurrev_202002_20396 11. del rio c, malani pn. 2019 novel coronavirus— important information for clinicians. jama. 2020 doi:10.1001/jama.2020.1490. 12. world health organization. coronavirus disease 2019 (covid-19). 2020; situation report – 46. accessed on 16th march 2020. j islamabad med dental coll 2020 71 13. ministry of national health services, regulations and coordination. daily situation report – pakistan covid-19. 2020. accessed on 16th march 2020 14. sabino-silva r, jardim ac, siqueira wl. coronavirus covid-19 impacts to dentistry and potential salivary diagnosis. clin oral investig. 2020. doi: 10.1007/s00784-020-03248-x. 15. omrani as, al-tawfiq ja, memish za. middle east respiratory syndrome coronavirus (mers-cov): animal to human interaction. pathog glob health. 2015; 109(8): 354-62. doi: 10.1080/20477724.2015.112285 2 16. harrel sk, molinari j. aerosols and splatter in dentistry: a brief revie w of the literature and infection control implications. j am dent assoc. 2004; 135(4): 429-37. doi: 10.14219/ jada.archive.2004.0207 17. corstjens pl, abrams wr, malamud d. saliva and viral infections. periodontol 2000. 2016; 70(1): 93110. doi: 10.1111/prd.12112. 18. corstjens pl, abrams wr, malamud d. detecting viruses by using salivary diagnostics. j am dent assoc. 2012 ;143: 12s-8s. doi: 10.14219/ jada.archive.2012.0338 19. johnson np, mueller j. updating the accounts: global mortality of the 1918-1920" spanish" influenza pandemic. bull hist med. 2002: 76(1): 105-15. doi:10.1353/bhm.2002.0022 20. andrewes ch. epidemiology of influenza. bull world health organ. 1953;8(5-6):595. 21. lina b. history of influenza pandemics. in paleomicrobiology 2008 (pp. 1 99-211). springer, berlin, heidelberg. 22. bean a, baker m, stewart c, cowled c, deffrasnes c, wang lf, et al. studying immunity to zoonotic diseases in the natural host − keeping it real. nat rev immunol. 2013; 13: 851-61. doi: 10.1038/nri3551 23. guan y, zheng bj, he yq, liu xl, zhuang zx, cheung cl, et al. isolation and characterization of viruses related to the sars coronavirus from animals in southern china. science. 2003 oct 10;302(5643):276-8. doi:10.1126/science.1087139 24. bautista e, chotpitayasunondh t, gao z, harper sa, shaw m, uyeki tm, et al. writing committee of the who consultation on clinical aspects of pandemic (h1n1) 2009 influenza. clinical aspects of pandemic 2009 influenza a (h1n1) virus infection. n engl j med. 2010; 362(18): 1708-19. doi: 10.1056/nejmra1000449 25. hsieh mc, tsou tp, chen wc, kuo sh. the response to novel influenza a (h1n1) epidemic in taiwan and analysis of the initial 61 confirmed cases. epidemiology bulletin. 2009; 25(8): 556-67. 26. oboho ik, tomczyk sm, al-asmari am, banjar aa, almugti h, aloraini ms, et al. 2014 mers-cov outbreak in jeddah—a link to health care facilities. n engl j med. 2015 feb 26;372(9):846 -54. doi: 10.1056/nejmoa1408636. 27. widjaja i, wang c, van haperen r, gutiérrez-álvarez j, van dieren b, okba nm, et al. towards a solution to mers: protective human monoclonal antibodies targeting different domains and functions of the mers-coronavirus spike glycoprotein. emerg microbes infec. 2019; 8(1): 516-30. doi:10.1080/22221751.2019.1597644 28. zhang j, li y, jin z, zhu h. dynamics analysis of an avian influenza a (h7n9) epidemic model with vaccination and seasonality. complexity. 2019; 2019: 4161287: 15. doi.org/10.1155/2019/4161287 29. munster vj, koopmans m, van doremalen n, van riel d, de wit e. a novel coronavirus emerging in china—key questions for impact assessment. n engl j med. 2020; 382(8): 692-4. doi: 10.1056/nejmp2000929 30. massachusetts general hospital. covid-19 treatment guidance. version 1.0 3/17/2020 31. slots j, slots h. bacterial and viral pathogens in saliva: disease relationship and infectious risk. periodontol 2000. 2011; 55(1): 48-69. doi: 10.1111/j.1600-0757.2010.00361.x 32. corstjens pl, abrams wr, malamud d. detecting viruses by using salivary diagnostics. j a m dent assoc. 2012; 143: 12s-8s. doi: 10.14219/ jada.archive.2012.0338 33. harte ja. standard and transmission-based precautions: an update for dentistry. j am dent assoc. 2010; 141(5): 572-81. doi: 10.14219/ jada.archive.2010.0232 34. samaranayake lp, peiris m. severe acute respiratory syndrome and dentistry: a retrospective view. j am dent assoc. 2004; 135(9): 1292-302. doi: 10.14219/jada.archive.2004.0405 35. ashok n, rodrigues jc, azouni k, darwish s, abuderman a, alkaabba aa, et al. knowledge and apprehension of dental patients about mers-a questionnaire survey. journal of clinical and diagnostic research: jcdr. 2016; 10(5): zc58. doi: 10.7860/jcdr/2016/17519.7790 36. scully c, kirby j. statement on mouth cancer diagnosis and prevention. br dent j. 2014; 216(1): 37-8. doi: 10.1038/sj.bdj.2013.1235 37. smales fc, samaryanka lp. maintaining dental education and specialist dental care during an outbreak of new coronavirus infection. part 1: a deadly viral epidemic begins. br dent j. 2003; 195(10):557-61. doi:10/sj.bdj.4810723 https://doi.org/10.1126/science.1087139 j islamabad med dental coll 2020 72 38. ibrahim nk, alwafi ha, sangoof so, turkistani ak, alattas bm. cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in king abdulaziz university hospital, jeddah, saudi arabia. j infect public health. 2017; 10(4): 438-45. doi: 10.1016/j.jiph.2016.06.002 39. al-sehaibany fs. middle east respiratory syndrome in children: dental considerations. saudi med j. 2017; 38(4): 339. doi: 10.15537/smj.2017.4.15777 40. monaghan np. emerging infections–implications for dental care. br dent j. 2016; 221(1):13. doi: 10.1038/sj.bdj.2016.486. . j islamabad med dental coll 2019 84 open access frequency of different groove patterns on the occlusal surface of mandibular second premolars muhammad abul hasan ali 1, maham niazi 2, sania saqib 3, ahmed younas 4, najeeb khan 5 1 post graduate resident, department of oral medicine, islamabad medical and dental college 2 associate professor, department of oral biology, islamabad medical and dental college 3 assistant professor, department of oral biology, islamabad medical and dental college 4 ,5 ex-house surgeons, islamabad dental hospital a b s t r a c t background: the mandibular second premolar has commonly three different type traits depending on the occlusal groove patterns. in addition to that they are also recognized on the basis of number of cusps. the objectives of the study were to determine the frequency of different occlusal groove patterns of mandibular second premolars and to acquire base line data for future studies in this population and field of research. material and methods: this study was conducted in islamabad dental hospital (idh), from september 2017 to december 2017. a total of 600 patients (1200 teeth) with fully erupted mandibular second premolars of normal occlusal morphology, in age group of 15 years and above were screened in the out patient department (opd). groove patterns on occlusal surfaces and their anatomical variations on both sides i.e. right and left, were observed and noted in a proforma. data was analyzed using spss version 22. results: three different patterns of occlusal grooves (y, u and h) were found in our study population. y groove pattern was observed in 364 teeth (30.33%), u pattern in 447 teeth (37.25%) and h pattern was noted in 389 (32.41%) teeth. among males, u pattern was predominant (43.84%) followed by h and then y pattern. in females, h pattern grooves was found mostly (34.41%), followed by y and u pattern. conclusion: the most frequent occlusal groove pattern observed in our population was u followed by h and y type. key words: grooves, mandibular, occlusal surface, premolar authors’ contribution: 1, conception, synthesis, planning of research and manuscript writing 2,3 interpretation, discussion, 4,5active participation in data collection and data analysis. correspondence: maham niazi email: maham.niazi@iideas.edu.pk article info: received: january 12, 2019 accepted: april 17, 2019 cite this article. ali mah, niazi m, saqib s, younas a, khan n. frequency of different groove patterns on the occlusal surface of mandibular second premolars. j islamabad med dental coll.2019; 8(2):84-87 funding source: nil conflict of interest: nil i n t r o d u c t i o n human teeth have always been known for morphological variations in both crown and the root structures.1 the coronal morphological variations can be in the form of extra cusp/cusps, missing cusp/cusps or variations in groove patterns.2 these structural variations in teeth are the part of dental anthropological system and should be determined in different populations and/or races, as it can be of great help in identifying the age, gender or race of a deceased individual or cultural practices, habits or anomalies prevalent in a population.1 the developmental, structural and restorative dental work accounts for ante mortem dental records, which can be of significant importance for forensic dentists in identifying victims in mass disasters, like for 2001 world trade center attack and 2004 phuket tsunami.1,3 the fifth tooth from midline in both lower quadrants is mandibular second premolar. it erupts at the age of 11-12 years when its predecessor tooth, deciduous second molar sheds.2 this tooth, mesially, has a contact with the mandibular first premolar and on the distal aspect with the o r i g i n a l a r t i c l e j islamabad med dental coll 2019 85 permanent mandibular first molar.4 the second premolar has generally a larger crown, and slightly wider and longer root than the first premolar.5,6 the function of second premolar is to assist molars in mastication as opposed to the first premolar which functions much like the canine.4 the mandibular second premolar can be observed as either a bicuspid or a tricuspid but variations in its occlusal groove patterns may exist. there are three different observed patterns of occlusal grooves. y shape pattern is related mostly to three cusps type variety while u and h shape patterns are associated with bicuspid premolars.4 if the central groove is a horizontal line between the mesial and distal pits, this pattern is known as h type but if it is crescent shaped it is a u type occlusal groove pattern.4 clinically, the rare discrepancy in the leeway space because of difference in mesio-distal width of two and three cusps type can lead to prediction of slight crowding or spacing and can be helpful in orthodontic treatment planning.6 three-cups type can be the tooth of choice in extraction cases, as it will give more space for proper alignment.7 on the other hand where mild crowding is present or where space is remaining at the end of the treatment, the two-cusp type can undergo a buildup to close the extraction space.7,8 the coronal morphology of tooth sculpts an outline of the radicular morphology including the configuration and the number of root canals. anomalous coronal morphological features like supplemental cusps, tubercles, deep occlusal grooves or altered mesio-distal dimension could be complemented by anomalous endodontic morphology which compounds the struggle for clinicians. updated knowledge and thorough clinical examination can aid an endodontist in quality and satisfying practice.8,9 dental morphology including occlusal groove patterns, missing teeth, dental restorations, crowding or wear pattern of teeth and other unusual dental variances give every individual a distinctive identity. the records of these characters can help in identification of a deceased individual and so are employed in the field of dental anthropology and forensic dentistry.1 studies among different populations showed that u/crescent shaped occlusal grooves pattern is predominant in south indian (45.2%)10 and pakistani (54%)7 subjects while singaporean chinese population exhibited h-shaped pattern (75.9%).11 the purpose of the present study was to investigate the prevalence of various groove patterns seen on occlusal surface of mandibular second premolars in patients reporting to islamabad dental hospital, so we could gather a baseline data of this variation in the said population. m a t e r i a l a n d m e t h o d s this descriptive cross-sectional study was conducted in islamabad dental hospital, bhara kahu with the permission of institutional review board (irb) and written informed consent of the participants. a total of 600 patients of age 15 years and above regardless of gender were selected for the study. fully erupted mandibular second premolars with normal morphology were included and any lower second premolar with restoration, decay, trauma or fracture were excluded from the study. all the participants were examined in the outpatient department (opd), readings were noted down in a proforma and data was analyzed using spss version 22.0 r e s u l t s a total of 1200 teeth from 600 subjects were examined. among them 340 (56.7%) were females and 260 (43.3%) were males. most frequent occlusal groove pattern observed was u shaped in 447 teeth (37.25%) followed by h in 389 teeth (32.41%) and y in 364 teeth (30.33%). (table i) among males, the most predominant groove pattern was u/crescent shaped on both left (46.53%) and right (41.15%) quadrants followed by h and then y pattern. table i: distribution of different occlusal groove patterns in the study population groove pattern total number of teeth n (%) right side left side u shaped 447 (37.25%) 217 230 h shaped 389 (32.42%) 199 190 y shaped 364 (30.33%) 184 180 total 1200 600 600 j islamabad med dental coll 2019 86 in female participants the most frequent pattern was h type both on left (34.70%) and right (34.11%) sides, followed by y and u pattern. (table ii) (graphs i & ii). table ii: gender-wise distribution of different occlusal groove patterns gender u pattern h pattern y pattern total number of teeth n (%) female 219 234 227 680 (56.7) male 228 155 137 520 (43.3) total 447 389 364 1200 graphs i & ii: gender-wise distribution of occlusal grooves in right and left quadrant d i s c u s s i o n in different populations, the mandibular second premolar exists with different morphological features, so in order to clinically identify and differentiate its variants, a complete knowledge regarding its type traits is essential to the task at hand.9 clinically it has two types, bicuspids and tricuspids. the tricuspid type is overall larger than the usual bicuspid premolar and is also known as a mini molar or the transitional tooth with some of its features resembling a canine, for instance a single root or having multiple cusps such as those of molars. on the basis of occlusal morphology/anatomy it has further three types because of the configuration of primary grooves.7 in the current study, the most frequently observed occlusal groove pattern was u/crescent shaped i.e. 37.25% followed by h (32.41%) and y shaped grooves (30.33%). crescent/u shaped grooves were predominant in bicuspid type as compared to the h pattern which is more frequent in chinese and europeans and is consistent with the work done by ahmed and colleagues who conducted the study in school going children in lahore7 and sunil and gopakumar who studied mandibular premolars in kerala population.10 however our results are contrary to the findings of hong yoo and colleagues who reported the y pattern to be predominant in the korean population.12 gender predilection is different for groove patterns; in females’ h shaped pattern was most frequent (34.41%) as compared to males who mostly showed u/crescent grooves (43.84%). but overall, the most pronounced pattern in this population was u shaped occlusal groove pattern, similar to what was observed by mosharraf and hajian in iran, where it was found to be 44%.13 the frequency observed in our study is analogous to the study by ahmed et al., who also reported the same distribution of occlusal grooves pattern generally as well as for both genders independently.7 loh in a study on singaporean chinese population demonstrated that 66.3% exhibited bicuspid variety whereas 25.4% showed tricuspid premolars.11 in a local study conducted by ahmed et al.7 in different schools of lahore, pakistan the frequency of 2-cusps and 3-cusps variety was found to be 37.5% and 62.4% respectively, which is contrary to the figures presented by bath balogh and fehrenbach,14 who reported it to be 45% (2-cusp) and 55% (3cusp) individually. c o n c l u s i o n dental morphological studies are important for anthropological research, forensic dentistry and clinical sciences. the results of our study can contribute to all of the aforementioned. further studies based on these baseline statistics, involving larger population are expected to assess gender preference and incidence more proficiently. j islamabad med dental coll 2019 87 r e f e r e n c e s 1. krishan k, kanchan t, garg ak. dental evidence in forensic identification– an overview, methodology and present status. open dent j. 2015; 9: 250-6. doi: 10.2174/1874210601509010250 2. coro jc, velasquez rl, coro im, wheeler tt, mcgorray sp. relationship of maxillary 3-dimensional posterior occlusal plane to mandibular spatial position and morphology. am j orthod dentofacial orthop. 2016; 150(1):140-52. doi: 10.1016/j.ajodo.2015.12.020. 3. kolude b, adeyemi bf, taiwo jo, sigbeku of, eze ann uo. the role of forensic dentist following mass disaster. ib postgrad med. 2010;8(2):111-7. pmid: 25161478 4. fuller, jl. denehy ge, schulein tm. concise dental anatomy and morphology. 4th ed. iowa, university of iowa college of dentistry. 2013:86-98. 5. gunduz k, avsever h, orhan k, canitezer g, acikgoz a, oz u. a multi-center evaluation of multiple supernumerary premolar prevalence. aust orthod j. 2015;31(2):149-56. pmid: 26999887 6. allen tr, trojan tm, harris ef. evidence favoring a secular reduction in mandibular leeway space. the angle orthodontist. 2017;87(4):576-82. doi: 10.2319/091416688.1 7. ahmed a, iqbal n, baig mz. frequency of type traits of mandibular second premolars a study. podj. 2016;36(3):430-2. 8. habib aa, kalaji mn, j. al saysd t, al jawfi ka. root canal configurations of the first and second mandibular premolars in the population of north syria. journal of taibah university medical sciences, 2015;10(4):391-5. doi: 10.1016/j.jtumed.2015.02.011 9. farooq j, ahmed i, gul-e-erum, iqbal sn. relationship between tooth dimensions and malocclusion. j pak med assoc. 2014; 64(6): 670-4. pmid: 25252487 10. sunil s and gopakumar d. prevalence of the two variants of mandibular second premolars in kerala population. int. j odontostomat. 2012; 6(3): 375-7. 11. loh hs. coronal morphology of the mandibular second premolar in the singaporean chinese. aust dent j. 1993; 38(4): 283-86. pmid: 8216036 12. yoo hi, park hy, kim sh. occlusal surface analysis of mandibular premolars in koreans. korean j phys anthropol. 2015. 28(3):145-153. doi: 10.11637/kjpa.2015.28.3.145 13. mosharraf r and hajian f. occlusal morphology of the mandibular first and second premolars in iranian adolescents. j dent anthropol. 2004;13(5):94-6. 14. bath-balogh m, fehrenbach mj. occlusion in dental embryology, histology, and anatomy. 3rd ed. philadelphia: wb saunders. 2011: 198-205. 291 j i m d c 2 0 1 8 291 open access f u l l l e n g t h a r t i c l e vitamin d deficiency in patients with diabetic peripheral neuropathy hameedullah khan1, ihsanullah rajar2 , abdul rauf memon3 , nadeem naeem4 1 assistant professor, neuro surgery department of indus medical college tando muhammad khan 2 senior registrar, department of medicine, lumhs, nawabshah 3 senior registrar, department of neurosurgery, lumhs, nawabshah 4 fellow, diabetes, endocrinology and metabolism, baqai institute of diabetology and endocrinology karachi a b s t r a c t objective: to determine the frequency of vitamin d deficiency in patients presenting with diabetic peripheral neuropathy patients and methods: this cross sectional study was carried out in department of medicine and neurology indus medical college, tando muhammad khan. from march 2017 to august 2017. total 74 cases of diabetes mellitus presenting with peripheral diabetic neuropathy were selected for the study. evolution of degree of neuropathy was based on tcss score as: {no neuropathy: ≤5, severe: ≥12, moderate: 9-11 and mild: 6-8}. vitamin d level was categorized as (deficiency (0-20 ng/ml), insufficiency (21-30 ng/ml) sufficiency (>30 ng/ml), excess (>50 ng/ml) and toxicity (>100 ng/ml). all the data was entered in spss. results: total 74 patients with diabetic neuropathy were studied. vast majority of patients 36(48.6%) were found in age group 51-60 years, majority were males 45(60.8%). most of the cases 35(47.3%) were with 1-3 years duration of neuropathy. majority of patients 42(56.8%) were found with mild peripheral neuropathy. vitamin-d deficiency was present in 2(43.2%) cases and insufficiency was observed in 27(36.5%) cases. no significant association was found between vitamin d deficiency and severity of neuropathy. conclusion: vitamin d deficiency was found (43.2%) in patients of diabetic peripheral neuropathy. vitamin screening and intake of supplement is necessary, will help to decrease the complication of peripheral neuropathy in diabetic cases. key words: diabetes, peripheral neuropathy, vitamin d author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence hamidullah khan email: dr.2581hameedkhan @gmail.com article info. received: june 13, 2018 accepted: august 16, 2018 cite this article. khan h, rajar i, memon ar,naeemn. vitamin-d deficiency in patients with diabetic peripheral neuropathy. jimdc.2018; 7(4):291-294 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus type 2 is a chronic metabolic syndrome characterized by abnormal blood glucose levels. about 170 million people are affected with type 2 diabetes globally and the figures will increase to 370 million in 2030 and 642 million in 2040.1,2 as per a pakistani survey, incidence of currently diagnosed diabetes was 6.8% in females and 5.1% in males.3 neuropathy is a commonest complication of diabetes mellitus and diabetes is the commonest factor of neuropathy in the united states, affecting around 50% of cases with diabetes mellitus. symptoms generally involve weakness, pain, tingling, and numbness.4,5 diabetic peripheral neuropathy is a frequent problem that affects these patients and is a key factor of elevated mortality as well as morbidity.6 diabetic neuropathy is much challenging problem of diabetes, correlated with vast economic burden. it is reported to o r i g i n a l a r t i c l e 292 j i m d c 2 0 1 8 292 table 1: demographic characteristics of patients (n=74) basic characteristic frequency percentage age groups (years) 40 -50 27 36.5 51-60 36 48.6 >60 11 14.9 total 74 100.0 gender female 29 39.2 male 45 60.8 total 74 100.0 duration of neuropathy (years) 1-3 35 47.3 4-5 24 32.4 >5 15 20.3 total 74 100.0 peripheral neuropathy mild 42 56.8 moderate 24 32.4 severe 8 10.8 total 74 100.0 have an incidence of 39.6% within karachi.7 it is essential to explain the potential risk factors for diabetic peripheral neuropathy. as widely accepted, diabetic peripheral neuropathy is raised with age and duration of diabetes. current studies suggest that level of vitamin d contributes tremendously in influencing the generation as well as progression of diabetes mellitus in addition to complications related to it.8 vitamin d is a vital fat-soluble vitamin, which is strongly associated with human health. deficiency of vitamin d can lead to several health complications for example distinguished osteoporosis during adulthood.9 numerous articles reported that vitamin d can possibly contribute its therapeutic role remarkably through immuno-modulatory mechanism. in addition, vitamin d contributes significantly in preserving pancreatic β-cell functions by affecting several channels. several studies have highlighted the potential relationship of diabetic peripheral neuropathy and deficiency of vitamin d.10-13 in the meantime, therefore, deficiency of vitamin d can lead to the diabetes risk and its complications involving neuropathy, however because of the study design table 2: levels of vitamin d in studied population (n=74) presentation frequency (%) levels of vitamin d (ng/ml) deficiency (0-20) 32(43.2) insufficiency (21-30) 27(36.5) sufficiency (>30) 12(16.2) excess (>50) 03(04.1) difference, small sample size, regions and population of studies, there is yet no evident conclusion regarding the relationship amid diabetic peripheral neuropathy and vitamin d within diabetic cases. currently in a study carried out, meta-analysis and systematic review to discover the effect of vitamin d levels in the diabetic peripheral neuropathy development within type ii diabetic mellitus, concluded that deficiency of vitamin d are 1.22 folds to be influenced by dpn contrasted to normal vitamin d levels within asian and suggested more research on this event.14 therefore this study has been planned to evaluate the deficiency of vitamin d in diabetic peripheral neuropathy patients in our population. p a t i e n t s a n d m e t h o d s this cross sectional study was carried out in department of medicine and neurology at indus medical college tando muhammad khan. study duration was 6 months from march 2017 to august 2017. total 74 cases of diabetes mellitus presenting with peripheral diabetic neuropathy were selected for the study. sample size was calculated by raosoft software by taking proportion of diabetic peripheral neuropathy 36.6% with 10% margin of error and 95% confidence level.21 neuropathy degrees were based on toronto clinical scoring system (tcss) score applied within an earlier study as, no neuropathy: ≤5, mild:6-8, moderate: 9-11, severe: ≥12.15 complete medical history including duration of diabetes, duration of neuropathy and clinical examination were carried out. patients with history of smoking, alcohol, obesity, anemia and uncontrolled hypertension were excluded. total 5cc intravenous blood sample was taken to analyze vitamin d levels. vitamin d level was categorized as, deficiency: 0-20 ng/ml, insufficiency: 21-30 ng/ml, sufficiency: >30 ng/ml, excess: >50 ng/ml and toxicity: >100 ng/ml. all the data 293 j i m d c 2 0 1 8 293 table 3: degree of peripheral neuropathy according to vitamin d levels vitamin d level (ng/ml) neuropathy mild n(%) moderate n(%) severe n(%) total p-value deficiency (0-20) 17(53) 12(38) 03(09) 32 0.507 insufficiency (21-30) 13(48) 10(37) 04(15) 27 sufficiency (>30) 09(75) 02(17) 01(08) 12 excess (>50) 03(100) 00(00) 00(00) 03 were entered on predesigned proforma. spss was used for data analysis, frequency and percentage were computed for qualitative variable. mean and standard deviation were computed for quantitative variable. chisquare test was applied to assess the association of vitamin d level with severity of neuropathy. p-value less than 0.05 was taken as statistically significant. r e s u l t s total 74 patients with diabetic neuropathy were studied. mean age of patients was 52.8 + 5.44 years. majority of patients (48.6%) were found in age group 51-60 years. gender wise distribution showed that males (60.8%) were in majority. out of total 74, most patients (47.3%) presented with in 1-3 years of duration of neuropathy followed by 4-5 years (32.4%). majority of patients (56.8%) were found to have mild peripheral neuropathy (table 1). out of overall 74 patients, vitamin-d deficiency was found in 43.2%. excess levels of vitamin d were present only in 4.1% (table 2). degree of peripheral neuropathy was insignificantly associated with vitamin d levels. out of 32 patients suffering from vitamin d deficiency, 53% presented with mild neuropathy. in vitamin d insufficiency group, 48% had mild neuropathy. in vitamin d sufficiency proportion of mild neuropathy was 75% (table 3). d i s c u s s i o n in this study there is high frequency of vitamin d deficiency in diabetic patients. peripheral neuropathy findings of our study underline the importance of screening for vitamin d deficiency in diabetic patients because vitamin d contributes significantly in diminishing the risk of several chronic disorders, like cancers, infections and cardiovascular diseases.15 this is particularly pertinent for diabetic patients who are at increased risk for acquiring these conditions as compared to the general population and therefore can possibly advantage from increased levels of vitamin d.16-18 there are both in vivo and in vitro evidence of vitamin-d for being a neurotrophic substance and that it modulates neuromuscular functions as well as differentiation and neuronal growth. peripheral neuropathy is a distressing and frequently a painful condition. autoimmune disorders, infections, alcoholism, diabetes or trauma are potential cause. peripheral neuropathy can cause infection or numbness in affected limb. adequate vitamin-d can assist in keeping the nervous system strong, and can possibly contribute in diminishing the peripheral neuropathy symptoms. in our study, out of 74, most of the cases 35(47.3%) were with 1-3 years of duration of neuropathy, 24 cases (32.4%) with 4-5 years and just 15 cases (20.3%) were found with >5 years of duration of neuropathy. greater part of patients 42(56.8%) were found with mild peripheral neuropathy, followed by moderate and sever, 24(32.4%) & 8(10.8%), respectively. in comparison to this, study conducted by sheikh a et al 17 reported that a substantial proportion of diabetic patients in karachi are deficit in vitamin d. this can possibly explain a significant relationship between the peripheral diabetic neuropathy severity and vitamin d levels, have been reported. in our study, out of total cases of diabetic peripheral neuropathy, vitamin d deficiency was prevalent as 32(43.2%). in comparison to our study, diaz va et al 19 reported in their study that, 30.7% of diabetic adults had nephropathy, 48.9% were deficit in vitamin d and 36.6% had insufficiency of vitamin d. one more study of soderstrom lh et al 11 exhibited that insufficiency of vitamin d was correlated with symptoms of self-stated peripheral neuropathy. 50% reported numbness (paresthesia) or pain within their feet 294 j i m d c 2 0 1 8 294 or hands; 37% reported tingling or pain within feet or hands; and 38% reported loss of feeling or numbness in feet or hands. another study conducted by shehab d et al also documented that deficiency of vitamin d is an independent risk factor for diabetic peripheral neuropathy.18 c o n c l u s i o n vitamin d deficiency was seen in 43.3% in diabetic peripheral neuropathy cases, vitamin screening and supplementation will help to decrease the complication of peripheral neuropathy in diabetic cases. r e f e r e n c e s 1. olt s. relationship between vitamin d and glycemic control in patients with type 2 diabetes mellitus. intj clin expmed. 2015;8(10):19180 2. saleem s, siddiqui a, iqbal z. vitamin d deficiency in patients of type 2 diabetes. pakistan journal of medical & health sciences. 2017; 11(4):1324-6 3. qidwai w, ashfaq t. imminent epidemic of diabetes mellitus in pakistan: issues and challenges for health care providers. jlumhs 2010; 9(3);112-113 4. ishaq m, khan gj, ur rahman s, zulfiqar s. prevalence of complications in type 2 diabetes mellitus patients. pakistan journal of physiology. 2013;9 (2):35-7. 5. argoff c.e., cole b.e., fishbain d.a., irving g.a. diabetic peripheral neuropathic pain: clinical and quality-of-life issues. mayo clin proc. 2006;81(4 suppl): s3–s11 6. ahmed u. prevalence of chronic complications and associated factors in type 2 diabetes. j pak med assoc. 2004; 54:54–59 7. penckofer s., kouba j., wallis d.e., emanuele m.a. vitamin d and diabetes: let the sunshine. diabetes educ. 2008;34(6) 939-940 8. smith tj, lanham-new sa, hart kh. vitamin d in adolescents: are current recommendations enough? the journal of steroid biochemistry and molecular biology. 2017; 173:265-72 9. benrashid m, moyers k, mohty m, savani bn. vitamin d deficiency, autoimmunity, and graft-versushost-disease risk: implication for preventive therapy. exp hematol 2012;40(4):263–7 10. bell ds. reversal of the symptoms of diabetic neuropathy through correction of vitamin d deficiency in a type 1 iabetic patient. case rep endocrinol 2012;2012: article id:165056: 3 11. soderstrom lh, johnson sp, diaz va, mainous ag. association between vitamin d and diabetic neuropathy in a nationally representative sample:results from 2001–2004 nhanes. diabet med 2012;29(1):50–5 12. putz z, martos t, németh n, körei ae, szabó m, vági oe, et al. vitamin d and neuropathy. orv hetil 2013;154(51):2012–5 13. qu gb, wang ll, tang x, wu w, sun yh. the association between vitamin d level and diabetic peripheral neuropathy in patients with type 2 diabetes mellitus: an update systematic review and metaanalysis. journal of clinical & translational endocrinology. 2017; 9:25-31 14. inoue m, iwasaki m, otani t, sasazuki s, noda m, tsugane s. diabetes mellitus and the risk of cancer: results from a large-scale population-based cohort study in japan. arch intern med 2006;166(17):1871– 7 15. grundy sm, howard bs, sidney er jr, robert r, rita bonow ro. prevention conference vi: diabetes and cardiovascular disease: executive summary: conference proceeding for healthcare professionals from a special writing group of the american heart association. circulation 2002; 105:2231–9. 16. bertoni ag, sayda s, brancati fl. diabetes and the risk of infectionrelated mortality in the us. diabetes care 2001; 24(6):1044–9 17. sheikh a, saeed z, jafri sa, et al. vitamin d levels in asymptomatic adults—a population survey in karachi, pakistan. plos one 2012; 7(3): e33452 18. shehab d, al-jarallah k, mojiminiyi oa, et al. does vitamin d deficiency play a role in peripheral neuropathy in type 2 diabetes? diabet med 2012; 29(1):43–9 19. diaz va, mainous ag, carek pj, wessell am, everett cj. the association of vitamin d deficiency and insufficiency with diabetic nephropathy: implications for health disparities. the journal of the american board of family medicine. 2009 sep 1;22(5):521 7 case image kauser rehana 1, muhammad mudassir shafiq 2 department of pulmonology, pakistan institute of medical sciences islamabad. figure 1:a) chest xray pa view showing air shadow in cardiac area representing pneumopericardium. b) ct scan chest with contrast coronalview showing rim of air around whole heart shadow. c) axial view showing thick rim of air surrounding cardiac shadow. d) sagittal view showing pneumopericardium. r e f e r e n c e s 1. lee yj, jin sw, jang sh, jang ys, lee ek, kim yj, lee my, park jc, rho th, kim jh, hong sj, choi kb. a case of spontaneous pneumomediastinum and pneumopericardium in a young adult. korean j intern med. 2001;16(3):205–209. 2. mullens w, dupont m, de raedt h. pneumopericardium after pericardiocentesis. int j cardiol. 2007;118(2): e57. 3. choi wh, hwang ym, park my, lee sj, lee hy, kim sw, jun by, min js, shin ws, lee jm, koh ys, jeon hk, chung ws, seung kb. pneumopericardium as a complication of pericardiocentesis. korean circ j. 2011;41(5):280–282. 4. brander l, ramsay d, dreier d, peter m, graeni r. continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review. heart. 2002;88(4): e5 a 13 years old girl referred from rawalpindi institute of cardiology, where she was admitted with a diagnosis of pericardial effusion that was exudative and predominantly lymphocytic. pigtail catheter was inserted for pericardiocentesis and after drainage of 1 liter she was shifted to pulmonolgy pims with suspicion of tuberculous pericardial effusion and she was on att with steroid at that time. cardiology team was consulted here; catheter was removed as no evidence of collection on echocardiography. post extubation x-ray chest showed air shadow in mediastinum. ct scan chest was done that revealed mediastinal widening and proved this shadow to be pneumopericardium, likely traumatic keeping history in view. she had palpable cervical lymph nodes, biopsy was planned. pneumopericardium common causes are spontaneous pneumopericardium without underlying cause in healthy adult or trauma1. pneumopericardium after pericardiocentesis is even rarer and has been attributed either to an air leakage to the pericardial drainage system or to a direct pleuro-pericardial communication.2-4 latrogenic pneumopericardium requires no specific therapy most of the time but in some patients, life-threatening complications (pericardial tamponade) can occur and require urgent recognition and immediate managements.3,4 it is relatively easy to diagnose pneumopericardium by chest radiographs which shows lucent outline separating the pericardium from the heart.3 c a s e i m a g e j islamabad med dental coll 2019 181 ope n ac cess frequency of noise induced hearing loss among traffic wardens of lahore salman shahid1, hina majid2, khalid ismail3, sohail safdar4, syed bilal hassan5 1 mph trainee, university institute of public health, university of lahore 2 demonstrator, department of anatomy, postgraduate medical institute, lahore 3 assistant professor, university institute of public health, university of lahore 4 associate professor, university institute of public health, university of lahore 5 demonstrator, faculty of allied health sciences, university of lahore a b s t r a c t background: noise-induced hearing loss (nihl) is a major cause of disability throughout the world. it is the most common irreversible job-related hazard in the world with a higher burden in the developing countries. certain occupations are at high risk for nihl. traffic wardens could be considered highly vulnerable group as they are exposed to long hours of traffic noise. the objective of this study was to determine the frequency of noise induced hearing loss among traffic wardens of lahore city. material and methods: it was a cross-sectional, descriptive study, carried out from 1st december 2018 to 31st may 2019, in which 329 traffic wardens appointed in 34 beats/sectors of lahore city were included. data was collected through a structured questionnaire, followed by pure tone audiometry (pta) of all the subjects. results: a total of 329 traffic wardens were selected for this study. mean age of the traffic wardens was 35.35 ± 1.21 years. nihl was present in 174 (52.9%) traffic wardens, out of which, 138 (79.3%) had mild, 32 (18.4%) moderate, and 4 (2.3%) had moderately severe degree of hearing loss. among the 329 traffic wardens, 165 (50.2%) had exposure to noise between 7am to 3pm (morning shift) and 42 (12.8%) had some problem with their hearing. only 12 (3.6%) had ringing in the ears or tinnitus, 140 (42.6%) wore any hearing protection during duty hours and 42 (12.8%) said they had difficulty in hearing and frequently asked people to repeat themselves. conclusion: in this study a high frequency of noise induced hearing loss was reported among traffic wardens of lahore city with most of them having mild to moderate degree of hearing loss. key words: hearing impaired, noise-induced hearing loss, pure tone audiometry, traffic wardens authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3,4 ,5active participations in data collection, data analysis. correspondence: salman shahid email: salmanshahid95@gmail.com article info: received: july 16, 2019 accepted: november 27, 2019 cite this article. shahid s, majid h, ismail k, safdar s, hassan sb . frequency of noise induced hearing loss among traffic wardens of lahore. j islamabad med dental coll.2019; 8(4): 181-185. doi: 10.35787/jimdc.v8i4.380 funding source: nil conflict of interest: nil i n t r o d u c t i o n noise is defined as an unwanted sound which is unpleasant, or disruptive to hearing.1 noise-induced hearing loss (nihl) is a global occupational health hazard in industrialized countries. after presbycusis, it is the second most frequent form of sensorineural hearing loss.2 hearing impairment (audiometric notch) with a threshold frequency of 4000 hz is the characteristic feature of onse t of nihl.3 generally, nihl is bilateral and in both ears demonstrates the same pattern.4 noise is associated with many psychological problems that can contribute to stress.5 the adverse effects of noise are auditory (damage of hearing) and non-auditory such as impulsive behavior, depression, fatigue and p o o r concentration.6 nihl occurs due to repeated and sustained exposure to high levels of sound. any kind of noise exposure with enough strength and time can ca u se nihl.7 or i gi n a l a r ti c le j islamabad med dental coll 2019 182 outer hair cells (ohcs) of cochlea are main site of hearing impairment, and their damage is irreversible. when two supporting hair cells die, their apical domain expands rapidly leading to compression of hair cell beneath its apical domain.8 occupational safety & health association (osha) has set 90 decibels as time weighted average (twa) for eight-hour daily work exposure to sound,9 while this limit is 85 decibels as per national institute of occupational safety & health (niosh).10 the mechanism of damage includes accretion of the reactive oxygen genus and stimulation of the intracellular stress pathway, that leads to cell death.11 hearing loss due to cochlear dysfunction also changes the organization of the central auditory pathway.12 varying degrees of permanent deafness occurs due to damage to inner ear. occupational nihl is a major cause of disability throughout the world.13 as per who, 360 million individuals worldwide have hearing impairment.14 in america, most common reasons of hearing impairment for adults are noise, ear infection and age.15 nihl is one of the most common problems seen among the individuals working in noisy environment. it is a sensorineural hearing loss (shl), which may be occupational or non-occupational.16 vehicle noise is a main contributor.17 the rapid growth of many cities in developing countries like pakistan increases the use and ownership of motor vehicles18, thereby increasing the level of noise pollution.19 it is a notable problem of urban areas of the country, including the populous city of lahore.20 people residing in lahore remain under constant threat of noise pollution. as per a survey report, on any given day in karachi, lahore, peshawar, rawalpindi and quetta, the noise produced by vehicles i s about 95db + 5db, with auto rickshaw producing a noise up to 100-110db.21 among professionals, the traffic wardens are the ones who are under a constant threat of becoming hearing impaired due to heavy traffic noise in the city.23 most of them are unaware of effects of noise on their hearing capability because it takes quite long to become overt.23 in lahore, there are almost 3000 traffic wardens, working in three shifts of eight hours. 24 the city of lahore is divided into 34 beats/areas for traffi c management. two senior traffic wardens are appointed i n every beat/sector, one in morning shift and one in evening shift. this study can be beneficial in creating awareness among traffic wardens about nihl and necessity of precautionary measures to avoid it. m a t e r i a l a n d m e t h o d s it was a cross-sectional, descriptive study in which 329 traffic wardens appointed in 34 beats/sectors of lahore city were included. ethical approval was taken from the institutional review board of university of lahore. written informed consent was taken from all the traffic wardens included in the study. non probability purposive sampli n g technique was used. the sample size was calculated with who sample size calculator, taking the expected prevalence of nihl in pakistan at 69% 25, confidence interval at 95% and absolute precision at 5% . the study was carried out from 1st december 2018 to 31st may 2019. only male traffic wardens aged between 22 to 40 years working in this profession for at least 10 years were included. while traffic wardens having any middle ear disease like otitis media were excluded from the study. data was collected through a structured pre-tested questionnaire, followed by pure tone audiometry (pta) of all the 329 traffic wardens and entered into computer using spss version 24.0. frequencies and percentages were calculated and data was presented in tables and figures. r e s u l t s among 329 traffic wardens, 194 (59% ) were up to 35 years old while 135 (41% ) were more than 35 years old. the mean age of traffic wardens included in the study was 35.35 ± 1.21 years. about 165 (50.2% ) traffic wardens had exposure to noise between 7am to 3pm (morning shift), 163 (49.5% ) between 3pm to 11pm (evening shift) and only 1(0.3% ) traffic warden had exposure to noise between 11pm to 7am (night shift) (figure 1). j islamabad med dental coll 2019 183 figure 1: distribution of traffic wardens in different shifts to noise exposure table i: epidemiological and clinical characteristics of traffic wardens (n=329) frequency percentage age groups <35 years 194 59.0 >35 years 135 41.0 total 329 100.0 mean + sd 35.35 + 1.21 use of hearing protection during duty hours yes 140 42.6 no 189 57.4 total 329 100.0 nihl according to pta yes 174 52.9 no 155 47.1 total 329 100.0 degree of hearing loss (n = 174) mild 138 79.3 moderate 32 18.4 moderately severe 4 2.3 total 174 100.0 nihl-noise induced hearing loss, ptapure tone audiometry regarding hearing impairment, 42 (12.8% ) traffic wardens had problem with their hearing, including visit to a doctor/audiologist while majority 287 (87.2% ) said they did not have any problem. only 12 wardens (3.6% ) had ringing in the ears or tinnitus, while majority (n=317; 96.4% ) never faced this problem. about 140 traffic wardens (42.6% ) wore hearing protection during duty hours. nihl was not present in any of the 140 traffic wardens who wore hearing protection. of those wardens with impaired hearing, 42 (12.8% ) said they frequently asked people to repeat themselves while 287 (87.2% ) wardens did not have such difficulty. pure tone audiometry test revealed that more than half (n=174; 52.9% ) of the traffic wardens had noise induced hearing loss while 155 (47.1% ) had no nihl. out of those 174 traffic wardens who had noise induced hearing loss, 138 (79.3% ) had mild, 32 (18.4% ) had moderate while only 4 (2.3% ) traffic wardens had moderately severe hearing loss (table i). d i s c u s s i o n the current study was conducted to know the frequency of noise induced hearing loss among traffic wardens of lahore city. regarding hearing impairment, only 12.8% traffic wardens had problem with their hearing especially those in the morning or evening shifts. however, pure tone audiometry test revealed that more than half (n=174; 52.9% ) of the traffic wardens had noise induced hearing loss with about 20% suffering from moderate to moderately severe degree of hearing loss. most of the traffic wardens (59% ) were up to 35 years old with a mean age of 35.35 ± 1.21 years. the findings of a study carried out in ambala city (india) by singh and coworkers (2015) were different from our study as majority of traffic wardens (78% ) were more than 35 years old.17 similarly, another study by venkatappa and colleagues (2018) reported that mean age of the traffic wardens was 42.46 ± 6.78 years.23 constant exposure to heavy noise is dangerous for traffic wardens especially those who work eight hours daily during morning and evening shifts, when noise level is too high. the results of this study also confirmed that almost all the traffic wardens (99.7% ) had high level of noise exposure because they were working in morning and evening shift and only one traffic warden was working in night shift when exposure to noise is low. only a few of the traffic wardens included in this study had problem with their hearing and visited a doctor/audiologist, with only 3.6% traffic wardens complaining of ringing in the ears or tinnitus. the results of our study exhibited a better scenario than a study carried out by sreenivasulu who reported 40% of traffic wardens with complaint of ringing in the ears or tinnitus.26 use of hearing protection tools during duty hours, for example, ear muffs and ear plugs prevent traffic wardens from hearing loss. it is significant to mention that 42.6% traffic wardens used hearing protection devices but such j islamabad med dental coll 2019 184 protective measures should be followed by all traffic wardens. contrasting results have been reported by different researchers in this aspect. the results of a study undertaken by singh and coworkers in ambala india, reported only 2% traffic wardens using hearing protecti ve equipments.17 in our study only 12.8% traffic wardens “frequently asked people to repeat themselves” due to hearing loss, while gupta et al. found that 35.5% traffic wardens “asked people to talk loudly” in their study.19 when noise induce d hearing loss was evaluated using pure tone audiometry, nihl was found prevalent among more than half of the traffic wardens (n=174; 52.9% ) with 79.3% having mild, 18.4% moderate and 2.3% moderately severe degree of hearing loss. in contrast, venkatappa et al. reported only 26.7% traffic wardens with noise induced hearing loss in which 62.5% had mild and 37.5% had severe degrees of hearing loss.23 another study carried out by sreenivasulu showed the frequency of nihl at 38.3% among traffic wardens, with 43.5% having mild, 21.7% moderate and 34.8% moderately severe degree of hearing loss.26 the limitation of the study is that many traffic wardens refused to participate in this study, therefore, it may not be representative of the general traffic warden community. also, there may be information errors, as traffic wardens may falsely report on good habits such as use of ear protection during duty hours, and they may be misreporting on certain unacceptable habits, such as double duty shifts c o n c l u s i o n there was a high frequency of noise induced hearing loss among traffic wardens of lahore city with most of them having mild to moderate degree of hearing loss. further studies should be conducted on a large scale to asse ss th e frequency of noise induced hearing loss among traffic wardens and devise preventive strategies that are effective in the long run. r e f e r e n c e s 1. islam mt, nahar n, islam mj, islam ma, hossen ma. traffic induced noise pollution and its impact on human health in chittagong city corporation. j. environ. sci. nat. resour. 2015; 8(2): 37-40. doi: 10.3329/jesnr.v8i2.26862 2. lavinsky j, crow al, pan c, wang j, aaron ka, ho mk, et al. genome-wide association study identifies nox3 as a critical gene for susceptibility to noiseinduced hearing loss. plos genet. 2015; 11(4): e1005094. doi: 10.1371/journal.pgen.1005094 3. ristovska l, jachova z, atanasova n. frequency of the audiometric notch following excessive noise exposure. arch acoust. 2015; 40(2): 213–21. doi: 10.1515/aoa-2015-0024 4. maci l, belvis ad, assennato ac, pagano v, tavolar m. bilateral hearing asymmetry and lateral differences in susceptibility to noise damage. pulsus j of surg res. 2017; 1(1): 15-16. 5. daiber a, kröller‐schön s, frenis k, matthias oelze m, kalinovic s, et al. environmental noise induces the release of stress hormones and inflammatory signaling molecules leading to oxidative stress and vascular dysfunction—signatures of the internal exposome. bio factors. 2019; 45 (4): 495–506. doi: 10.1002/biof.1506 6. himanshu ks, mohit sg. are bullet riders at risk of noise induced hearing impairment? otolaryngol open access j. 2018; 3(1): 000166. 7. alvarado jc, fuentes-santamaría v, maría gabaldón-ull c, juiz jm. age-related hearing loss is accelerated by repeated short-duration loud sound stimulation. front neurosci. 2019; 13: 77. doi: 10.3389/fnins.2019.00077 8. goutman jd, elgoyhen ab, gomez-casati me. cochlear hair cells: the sound-sensing machines. febs lett. 2015; 589(22): 3354–61. doi: 10.1016/j.febslet.2015.08.030 9. occupational safety and health administration (osha). osha fact sheet: laboratory safety noise. washington, dc: osha. 2011. 10. carroll yi, eichwald j, scinicariello f, hoffman hj, deitchman s, radke ms et al. vital signs: noiseinduced hearing loss among adults — united states 2011–2012. mmwr. 2017; 66(5): 139–144. 10.15585/mmwr.mm6605e3 j islamabad med dental coll 2019 185 11. kurabi a, keithley em, housley gd, ryan af, wong acy. cellular mechanisms of noise-induced hearing loss. hearing res. 2017; 349: 129-37. doi: 10.1016/j.heares.2016.11.013 12. fetoni ar, troiani d, petrosini l, paludetti g. cochlear injury and adaptive plasticity of the auditory cortex. front aging neurosci. 2015; 7: 1-5. doi: 10.3389/fnagi.2015.00008 13. indora v, khaliq f, vaney n. evaluation of the auditory pathway in traffic policemen. int j occup environ med. 2017; 8: 109-16. doi: 10.15171/ijoem.2017.913 14. world health organization (who). who global estimates on prevalence of hearing loss: mortality and burden of diseases. geneva: who. 2012. 15. masterson ea, tak s, themann cl, wall dk, groenewold mr, et al. prevalence of hearing loss in the united states by industry. am j ind med. 2013; 56(6): 670-81. doi: 10.1002/ajim.22082 16. dhinakaran n, karthikeyan bm. prevalence of noise induced hearing loss among police personnel in madurai city. int j adv res. 2017; 5(8): 410-6. doi: 10.21474/ijar01/5075 17. singh a, bansal a, goel s, goel pk, chhikara p, singh nk. a rapid appraisal of traffic policemen about auditory effects of traffic noise pollution from ambala city. med j dy patil univ. 2015; 8: 12-5. doi: 10.4103/0975-2870.148826 18. sanju hk, kumar p. self-assessment of noiseinduced hearing impairment in traffic police and bus drivers: questionnaire-based study. indian j otol. 2016; 22: 162-7. doi: 10.4103/0971-7749.187971 19. gupta s, mittal s, kumar a, singh kd. selfassessment of hearing quality and noise-related attitudes among traffic policemen of patiala, india. int j prev med. 2014; 5: 511-5. pmid: 24829741 20. khan hu, khan s, ali si. evaluation of road traffic noise pollution in quetta (pakistan). am j modern phys. 2014; 3(2): 29-36. doi: 10.11648/j.ajmp.20140302.11 21. khan mw, memon ma, khan mn, khan mm. traffic noise pollution in karachi, pakistan. jlumhs. 2010; 9(3): 114-20. 22. gupta m, khajuria v, manhas m, gupta kl, onkar s. pattern of noise induced hearing loss and its relation with duration of exposure in traffic police personnel. indian j comm health. 2015; 27(2): 276-80. 23. venkatappa kg, shankar v, sparshadeep em. effect of road traffic noise on auditory threshold in traffic policemen. int j curr res biol med. 2018; 3(6): 12-7. doi: 10.22192/ijcrbm.2018.03.06.004 24. traffic police information, cplc lahore, home department, govt. of punjab, 2010. 25. tabraiz s, ahmad s, shehzadi i, asif mb. study of physio-psychological effects on traffic wardens due to traffic noise pollution; exposure-effect relation. journal of environmental health science and engineering. 2015; 13(1): 30. doi: 10.1186/s40201015-0187-x 26. sreenivasulu m. survey and cross-sectional study on noise induced hearing loss of police constables and officers working in heavy traffic areas-an indian perspective. tjprc: ijohns. 2016; 1(2): 17-20. tjprc: ijohnsdec20165 journal of islamabad medical & dental college (jimdc); 2012(2):56-61 56 original article role of female age in determining causes of infertility and predicting outcome of in vitro fertilization salma kafeel*, wajiha mahjabeen** and saeed alam*** **consultant gynaecologist and obstetrician, salma & kafeel medical centre, islamabad **assistant professor, department of pathology, islamabad medical and dental college, islamabad ***professor, department of pathology, islamabad medical and dental college, islamabad (**’***bahria university, islamabad) abstract objective: to look into various causes of infertility according to increasing age, differences in percentage of pregnancy rate after ivf in different age groups and role of various infertility parameters in determining pregnancy rate among these patients patients and methods: a total of 206 infertile couples were selected and divided into two groups according to female age: group i (<35 years, n=108) and group ii (≥35 years, n=98). diagnostic hysterosalpingography or laproscopy was done in order to rule out the tubal blockage and endometriosis. ovarian dysfunction was excluded on the basis of hormonal analysis. ivf treatment following a long protocol for use of gnrh agonist was given to infertile couple. analysis was done using spss 19 and medcal software 12. results: male causes were frequent in both groups without any significant difference (33%; p=0.882). tubal factor was significantly raised in older group (33%; p=0.000), whereas ovarian dysfunction was significantly higher in younger patients (33%; p=0.000). number of embryos transferred and pregnancy rate after ivf were significantly decreased in older couples (p≤0.05). age of patient and serum fsh levels (p=0.02) have relatively better predictive capability of pregnancy outcome regarding ivf treatment as compared to duration of infertility (p=0.04). conclusion: information of infertility factors can help clinician in estimating the chances of pregnancy rate before suggesting art in old age couples. keywords: infertility, advance reproductive age, ivf, tubal factor, ovarian dysfunction introduction infertility is described as inability of a couple to conceive despite twelve months of regular sexual activity, in the absence of contraceptives.1 failure of a couple to have child is termed as primary infertility while secondary infertility is defined as inability of a parous women to have additional live births.2 it is a universally recognized dilemma. in more developed countries, about 3.5% to 16.7% prevalence of infertility is estimated, while in less developed nations estimated ratio is about 6.9% to 9.3% with an estimated overall median prevalence of 9%. as far as medical care is concerned approximately similar pattern is noted in less and more developed countries. the proportion of infertile couples not seeking medical treatment in all countries is about 45%, with a sensible range from 30% to 60%.3 in pakistan situation is worse due to combined effects of increase prevalence of infertility that is 27.9% and decreased awareness of proper treatment facilities.4,5 etiology of this problem is recognized in both male and female at approximately equivalence rate.6 female age is most important parameter in case of fertility. age 35 is considered as cut-off point. there is a general conception that beyond this age the chances of conception decrease.7,8 multiple factors are responsible for deliberate delay by women to get conceived. these factors are carrier oriented approach, increased desire to get higher education or late marriages.9,10 it is recommended that women more than 35 years of age should consult doctor for further investigations and treatment.11 infertility evaluation is beneficial in women more than 35 years of age after 6 cycles of unprotected intercourse.12 there are multiple treatment options for infertile couples like intrauterine insemination (iui), ovulation induction either alone or in combination and in vitro fertilization (ivf).13 it is generally accepted that pregnancy outcome relatively decreases in women in their late 30’s even after using these artificial reproductive techniques (arts).8,14 however, some studies have shown that there are other factors beside female age that affects the pregnancy rate in infertile couples using these arts. these factors include type and duration of infertility, number of induced follicles journal of islamabad medical & dental college (jimdc); 2012(2):56-61 57 and spermatozoa count.15 in these patients multiple markers like serum follicle stimulating hormone (fsh), antimullerian hormone (amh), antral follicle count (afc) and others can be used as predictive tools to assess pregnancy output of arts. some researchers did not favor the idea of using these tests as part of routine diagnostic panel.16 contrary to this, few studies support this idea.17 in pakistan some work has been performed regarding diagnostic approach to infertility.18 moreover pregnancy rate of arts and factors affecting the treatment outcome have also been studied.19 but the comparative data that explain all of these factors in younger versus older age group is still lacking. therefore, this study was conducted in order to compare different causes of infertility with respect to different age groups (younger and older) and type of infertility (primary and secondary). this study also evaluates the difference of ivf outcome (number of embryos transferred and pregnancy rate) in younger versus older ages. besides this the capability of different parameters of infertility to predict pregnancy outcome regarding ivf in different age groups is also analyzed. patients and methods this retrospective study was conducted at salma and kafeel hospital islamabad from august to december 2011. couples having history of more than one year of regular unprotected intercourse, presenting with primary or secondary infertility and were advised to take ivf treatment were included in the study. a total of 206 infertile couples were recruited. they were further divided into two age groups. group i consisted of 108 infertile women < 35 years of age, while 98 women ≥35 years were included into group ii. investigations were performed in order to rule out the etiology of infertility. diagnostic hysterosalpingography or laproscopy was performed in order to rule out the tubal blockage and to diagnose endometriosis. in order to exclude the ovarian dysfunction, hormonal analysis was performed. sperm concentration > 20×106/ml, percentage of motile sperm > 50%, and normal sperm morphology (14%) were used to exclude the diagnosis of male infertility.20 mixed causes were labeled due to presence of more than one etiology in single couple. unexplained infertility was diagnosed after exclusion of male causes, ovulatory dysfunction, tubal blockage and endometriosis.21 for hormonal analysis early follicular phase serum fsh, lh and estrogen were analyzed on day 3 of pre stimulation cycle in both young and old infertile women. these hormones were measured using a specific immunometric assay kit (immulite; diagnostic products corporation, los angeles, ca, usa). after the baseline analysis and determination of etiology of infertility, ivf treatment following a long protocol for use of gonadotropin releasing hormone (gnrh) agonist was given to infertile couple.26 good quality embryos were selected during the procedure according to criteria defined by van royen.23 statistical analysis: in order to compare the mean between two age groups independent-t test was applied for parametric measurements. in case of non parametric data mann-whitney utest was used. percentage data was compared by continuity correction chi square test. statistical package for social sciences 19 (spss 19) was used in order to analyze the data. predictive capability of different parameters regarding pregnancy outcome was measured by receiver operating curve (roc). medcalc software version 12 was used for this analysis. comparison between areas under curve (auc) in two age groups was made in order to estimate the relative ability of these infertility parameters. p≤0.05 was considered significant. results the infertile couples who participated in the study were segregated into group i (108 couples) and group ii (98 couples) two groups. mean + sd age of females and males in group i was 27.38 ± 2.71 years and 33.39 ± 5.32 years respectively. in group ii, mean + sd age of female and male partners was 36.94 ± 2.27 and 41.05 ± 5.39 years, respectively. duration of infertility in group i and ii was 5.10 ± 2.67 and 7.91 ± 5.22 years. base line fsh and lh levels in group i and ii were 6.14 ± 2.26, 7.51 ± 2.74 iu/l and 8.10 ± 4.62, 8.81 ± 5.90 iu/l, respectively. baseline estrogen level measured in group i and ii was 84 (59.50124.75) and 64.19 (50.36-89.75) pg/ml. there is statistically significant increase (p≤0.01) in duration of infertility, serum fsh and estrogen levels in older age patients. the difference in lh levels in two groups was insignificant (p=0.803). the overall percentage of primary and secondary infertility in our patients was 61% and 39%, respectively. we further analyzed the date according to groups. in group i, 85 women presented with history of primary infertility while 23 female gave the history of secondary infertility. in group ii number of women with history of primary and secondary infertility was 40 and 58 respectively. analysis also revealed the statistically significant difference (p≤0.01) in proportion of these two types of infertility in older versus younger age group. regarding etiology of infertility, over all prevalence of male factor among all patients (n=206) was the highest (33%); percentage of other causes was as follows: tubal factor 20%, ovarian dysfunction 22%, endometriosis 5%, mixed 09% and unexplained 11%. when we compare the etiology of infertility in two age groups (table 1), difference in proportion of male factor was insignificant. but the overall percentage of male cause was very high in both groups. tubal factor was significantly raised in older group in comparison with ovarian dysfunction that was significantly higher in younger group (p≤0.01). difference among other journal of islamabad medical & dental college (jimdc); 2012(2):56-61 58 etiologies like endometriosis, mixed causes and unexplained reasons in two groups was insignificant. table 1: etiology of infertility in two age groups (n=206) participating in study diagnostic category age <35 yrs n=108 (%) age ≥35 yrs n=98 (%) p value male factor 36 (33) 32 (33) 0.882a tubal factor 09 (08) 32 (33) 0.000ab ovarian dysfunction 36 (33) 10 (10) 0.000ab endometriosis 08 (07) 03 (03) 0.215a mixed 12 (11) 06 (06) 0.217a unexplained 07 (06) 15 (15) 0.114a a continuity correction chi square test, b p≤0.05 considered significant table 2: diagnostic category according to primary and secondary infertility etiological causes primary infertility (n=83) secondary infertility (n=55) age <35 years n=57 (%) age≥ 35 years n=26 (%) p value age < 35 years n=15 (%) age ≥ 35 years n=40 (%) p value tubal factor 07(12) 09(35) 0.05a 02(13) 23(58) 0.02ab ovarian dysfunction 29(51) 05(19) 0.008a 07(47) 05(13) 0.006ab endometriosis 07(12) 2(08) 0.72a 01(07) 01(05) 0.97a mixed 08(14) 02(08) 0.57a 04(27) 04(10) 0.15a unexplained 06(11) 8(31) 0.07a 01(07) 07(18) 0.70a acontinuity correction chi-square test, b p≤0.05 considered significant how ever, the trend of unexplained infertility was increasing in older age group. while high percentage of endometriosis and mixed causes were found in females less than 35 years of age. when we analyze the data according to type of infertility (primary and secondary), similar pattern was noted (table 2). percentage of tubal causes was significantly higher in secondary infertility (p≤0.05). in case of ovarian dysfunction, significantly increased proportion was noted in case of primary infertility (p≤0.01). results of ivf treatment were also analyzed according to younger and older groups (table 3). total number of transferred embryos and number of good embryos transferred were significantly decreased in older age groups as compare to younger ones (p≤0.01). pregnancy rate after ivf treatment was also significantly higher in younger age group (p≤0.05). predictive capability of different factors of infertility regarding pregnancy rate after ivf treatment was analyzed with the help of roc curves (table 4). increased area covered by age of patients, duration of infertility and serum fsh levels revealed significantly high predictive power of these parameters in older ones (p≤0.05). on comparison between younger and older age groups, it was observed that females’ age and serum fsh levels had significantly better predictive capability of pregnancy rate than duration of infertility after ivf treatment (p≤0.05). table 3: outcome of ivf treatment in patients of two age groups (n=206) age<35 years (n=108) age ≥ 35 years (n=98) (p value) number of total embryos transferred (mean±sd) 3.39±0.61 2.64±0.75 0.000ac number of good embryos transferred (mean±sd) 2.47±0.62 2.15±0.60 0.000ac pregnancy rate (%) 30.1 17.48 0.05bc a independent t test, b continuity correction chi-square test, c p≤0.05 considered significant table 4: comparison between areas under roc curves of different parameters of infertility to pregnancy rate in two age groups parameters age<35 years (n=108) age ≥35 year (n=98) p value* auc (ci) pvalue auc(ci) p-value age 0.504 (0.404-0.604) 0.9485 0.715 (0.618-0.800) 0.000a 0.02a duration of infertility 0.523 (0.422-0.622) 0.7083 0.713 (0.615-0.798) 0.003a 0.04a fsh 0.502 (0.402-0.603) 0.9688 0.723 (0.626-0.806) 0.003a 0.02a estrogen 0.526 (0.425-0.625) 0.6852 0.550 (0.449-0.648) 0.500 0.80 roc curve: receiver operating curve, auc(ci): area under curve (95% confidence interval), *p-value by comparison of areas under respective roc curves in two age groups, a p≤0.05 was considered significant. discussion age is considered as an important factor regarding infertility. our study demonstrated that male factor remains an important cause in all age groups. regarding females, etiology of infertility varies according to increasing age. in younger group ovarian dysfunction plays an important role while in older patients tubal factor is mainly responsible to cause infertility. among other etiologies, percentage of endometriosis and mixed causes of infertility are slightly more frequent in younger group. on the other hand, unexplained infertility is found slightly increase in older patients. when we analyzed the data according to primary and secondary infertility similar trend was noted. our results are in accordance with study carried out by maheshwari et al.24 they conducted study on large sample size and journal of islamabad medical & dental college (jimdc); 2012(2):56-61 59 concluded that with age the chances of tubal factor and unexplained infertility decreases by two fold, while one third rise in ovulatory dysfunction was noted in female more than 35 years of age. this study also explains that although all these changes are more marked at the age of 35 years, but the trend can be visualized after 30 years of age. that is why the cut off age of 35 years regarding infertility should be reassessed. reason of diagnosing increase ovarian dysfunction in younger patients was perhaps due to increase query of younger ones about irregular cycles. however, high chances of pelvic infections with increasing age enhance the percentage of tubal factors in older age group.25 our data revealed that infertile couples more than 35 years of age have increased duration of infertility as compared to younger ones. secondary infertility was also significantly raised in these older couples. this can be explained in this way that couples having one child with them have potential to wait for a longer time as compared to couples having no child with them. this is the reason that these couples came late in clinics for their infertility evaluation.24 ovarian aging can be assessed by different ovarian reserve markers. our data revealed that serum fsh and estrogen levels are significantly affected with aging. in women more than 35 years of age these markers are significantly raised as compare to younger age groups. these results are in accordance with study conducted by kim et al. they conducted the study in normal ovulatory women of younger and older age groups. elevated fsh levels in older age group prove this marker as best predictor of age. this trend was also noted in case of estrogen levels.26 in 2009 similar pattern of fsh was analyzed in infertile couples of two age groups.17 after analysis of data related to ivf treatment given, we demonstrated that outcome of art also affects by increasing age of infertile couple. the outcome variables like number of transferred embryos and good embryos transferred were significantly decreased in group more than 35 years of age. this explains the decrease pregnancy rates even after using art in women with increasing age. in 2004 rizvi demonstrated that ivf/icsi treatment shows better results in women with good quality of embryos transferred.19 similar results were demonstrated in two age groups by lee.17 there was significant difference in number of total embryos and good quality embryos transferred in women more than 35 years of age. as we have demonstrated that age is a basic parameter that affects the outcome of ivf. other factors like duration of infertility, serum fsh and estrogen levels are also significantly varied in older age group as compare to younger ones. in order to confirm our data we perform roc analysis and determine the predictive power of these parameters regarding pregnancy outcome. increased area was covered by age of patients, duration of infertility and serum fsh levels in older age group. data revealed that these factors have significant predictive power of pregnancy rate after arts only in patients more than 35 years of age. comparison among roc analysis done in two age groups showed that age of patients and serum fsh levels have relatively better predictive capability as compare to duration of infertility. our results are in accordance with discussion done by lee. he concluded that different ovarian reserve markers have better predictive capability in females with increasing age.17 conclusion according to age of patient a clinician can make a differential diagnosis of infertility. moreover, information of other factors like duration of infertility and levels of different hormones can help clinician to estimate the chances of pregnancy rate before suggesting art in old age couples. limitation of study we conducted study on small sample size, and did not analyze the some factors like role of amh and afc etc in art regarding different age groups. that’s why more studies are needed in pakistan to further elaborate factors affecting outcome of art in different age groups. references 1. evers jl, de haas hw, land ja, dumoulin jc and dunselman ga. treatment-independent pregnancy rate in patients with severe reproductive disorders. hum reprod 1998;13, 1206–120 2. stirrat gm. recurrent miscarriage i: definition and epidemiology. the lancet. 1990; 336(8716): 673-675. 3. boivin j, bunting l, collins ja, nygren kg. international estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. hum rep. 2007; 22(6): 1506–1512. 4. unfpa. pakistan population assessment. government of pakistan. 2003. 5. talib w, ikram m, hafeez m, saeed m. infertile female; laproscopic evaluation. professional med j. 2007; 14: 562566. 6. omu ae, ismail aa, al-qattan f. infertility in kuwait. int j gynaecol obstet. 1999; 67:113–4 7. templeton a, morris j, parslow w. factors that affect outcome of in-vitro fertilisation treatment. lancet. 1996; 348: 1402–1406. 8. the practice committee of the american society for reproductive medicine. aging and infertility in women. fertil steril. 2006a; 86(suppl 4): s248–s252. 9. schoen r, canudas-romo v. timing effects on first marriage: twentieth-century experience in england and wales and the usa. popul stud (camb). 2005; 59: 13546. 10. botting b, dunnell k. trends in fertility and contraception in the last quarter of the 20th century. nat stat popul trends. 2003;100 :32–39. 11. national institute of clinical excellence, nice. fertility— assessment and treatment for people with fertility problems. clinical guideline number 11, nice uk. 2004. produced by national collaborating centre for women’s and children’s health. journal of islamabad medical & dental college (jimdc); 2012(2):56-61 60 12. gnoth c, godehardt e, frank-herrmann p, friol k, tigges j, freundl g. definition and prevalence of subfertility and infertility. hum reprod. 2005; 20:1144-7. 13. goverde aj, mcdonnell j, vermeiden jp, schats r, rutten ff, schoemaker j. intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost effectiveness analysis. lancet. 2000; 355: 13-8. 14. padilla sl, bayati j, garcia je. prognostic value of the early serum estradiol response to leuprolide acetate in in vitro fertilization. fertil steril. 1990; 53: 288-94. 15. ibérico g, vioque j, ariza n, lozano jm, roca m, llácer j, bernabeu r. analysis of factors influencing pregnancy rates in homologous intrauterine insemination. fer ster. 2004; 81(5): 1308-1313. 16. broekmans fj, kwee j, hendriks dj, mol bw, lambalk cb. a systematic review of tests predicting ovarian reserve and ivf outcome. hum reprod update. 2006; 12(6): 685–718. 17. lee t, liu c, huang c, hsieh k, lin p, lee m. impact of female age and male infertility on ovarian reserve markers to predict outcome of assisted reproduction technology cycles. reprod biol endo. 2009; 7: 100. 18. haider g, rani s, talpur s, zehra n, munir a. laparoscopic evaluation of female infertility. j ayub med coll. 2010; 22(1). 136-138. 19. rizvi jh, zuberi nf, bhatti s, bana m, virk s, nadir s, kidwai a, tahir n. assisted reproductive technology : experience with ivf / icsi. j coll physicians surg pak. 2004; 14(5):270-3. 20. world health organization. who laboratory manual for the examination of human semen and sperm-cervical mucus interaction, 4th edn. cambridge: cambridge university press. 1999; pp. 128. 21. the practice committee of the american society for reproductive medicine. aging and infertility in women. fertil steril. 2006b; 22. lee th, liu ch, huang cc, wu yl, shih yt, ho hn, yang ys, lee ms: serum anti-mullerian hormone and estradiol levels as predictors of ovarian hyperstimulation syndrome in assisted reproduction technology cycles. hum reprod. 2008; 23:160-167. 23. van royen e, mangelschots k, de neubourg d, valkenburg m, van de mm, ryckaert g, eestermans w, gerris j: characterization of a top quality embryo, a step towards single-embryo transfer. hum reprod. 1999; 14: 2345 2349. 24. maheshwari a, hamilton m, bhattacharya s. effect of female age on the diagnostic categories of infertility. hum rep.2008; 23(3): 538–542. 25. bewley s, davies m, braude p. which career first? the most secure age for child bearing remains 20–35. bmj. 2005; 331:588–589. 26. kim yk, wasser sk, fujimoto vy, klein na, moore de, soules mr. utility of follicle stimulating hormone (fsh), luteinizing hormone (lh), oestradiol and fsh:lh ratio in predicting reproductive age in normal women. hum reprod. 1997; 12:1152-1155. j islamabad med dental coll 2020 298 open access mucoepidermoid carcinoma: a demographic and histopathological profile zainab niazi1, imran khan2, farah farhan3, maria ilyas4, misbah ali5, syeda rabbab hasan1 1assistant professor, islamabad medical and dental college, islamabad pakistan 2associate professor, islamabad medical and dental college, islamabad pakistan 3assistant professor, foundation college of dentistry, rawalpindi pakistan 4senior lecturer, baqai dental college, karachi pakistan 5assistant professor, margalla institute of health sciences, rawalpindi pakistan a b s t r a c t background: mucoepidermoid carcinoma (mec) is the most common malignant tumor of salivary glands, with a variable prevalence (9.5%-25.6% in pakistan) and clinicopathological presentation. the objective of this study was to find out the frequency and clinicopathological presentation of mucoepidermoid carcinoma at armed forces institute of pathology, rawalpindi pakistan. material and methods: this descriptive cross-sectional study was carried out at armed forces institute of pathology, rawalpindi between june 2016 to september 2017. all the malignant salivary gland tumors fulfilling the diagnostic criteria for mec were included and the frequency of mucoepidermoid carcinoma was calculated. age, gender, histopathological grading and anatomical site of tumor were also evaluated. results: a total of 30 patients of mucoepidermoid carcinomas, 23 (76.66%) males and 7 (23.33%) females, with a mean age of 44.9±19.2 years and age range of 6 to 88 years were reported. regarding anatomical site, majority of the patients (73.3%) had tumor in the parotid gland, 13.3% in submandibular gland and 13.3% had tumor in palate, retromolar area and posterior one third of the tongue. according to histopathological grading, 26.6% mec were high-grade, 26.6 % intermediate-grade and 36.6% were low-grade tumors. conclusions: mucoepidermoid carcinoma was more common in males, in the third decade with parotid gland as the most common site for this tumor. on histopathology, low grade mec on auclair et al. grading had the highest frequency in our study cohort. key words: auclair grading system, mucoepidermoid carcinoma, salivary gland tumors. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: zainab niazi email: dr.zainabniazi@gmail.com article info: received: november 12, 2019 accepted: november 12, 2020 cite this article. niazi z, khan i, farhan f, ilyas m, ali m, hasan sr. mucoepidermoid carcinoma: a demographic and histopathological profile. j islamabad med dental coll. 2020; 9(4): 298-302. doi: 10.35787/jimdc.v9i4.460 funding source: nil conflict of interest: nil i n t r o d u c t i o n salivary gland tumors are about 5% of all tumors of the head and neck region.1 of these, mucoepidermoid carcinoma is the most common malignant tumor accounting for 56.9% of all o r i g i n a l a r t i c l e j islamabad med dental coll 2020 299 malignant salivary gland tumors.2,3 the prevalence of mucoepidermoid carcinoma in pakistan is 9.5%25.6% and an overall worldwide incidence of 12-40% has been reported.4 the most common site for mec carcinoma is major salivary glands (mostly parotid gland), where 60% to 90% of such lesions are present.5 in minor salivary glands, it accounts for 22.9%-37.1%. mec is more common in females (75%), with a female to male ratio of 3:1.6 the prevalence of mucoepidermoid carcinoma is highest in third to fifth decade of life. mecs consist of three cell types in differing proportions: mucous cells, epidermoid cells with squamoid differentiation and undifferentiated small cells. mec is typically classified into 3 histologic grades (low, intermediate and high) based on a compilation of characteristics including necrosis, mitoses, atypical nuclei and size of the cystic component.7 low-grade (grade 1) mucoepidermoid carcinoma usually does not metastasize and is often cured by appropriate surgery. patients with highgrade (grade 3) mec are at significant risk for presenting with positive lymph nodes and developing disease-progression and possibly disease-related mortality. the biological potential of intermediate-grade (grade 2) mec lies somewhere in the spectrum between grade 1 and 3 tumors. the most commonly involved sites are parotid gland, palate, retromolar trigone, buccal and submandibular glands.8 mec presents as firm, painless, and fixed swellings. the tumors in sublingual gland have pain in spite of small size. mec of minor salivary glands, especially in the palate are papillary. symptoms of mec include pain, bleeding, dysphagia, trismus, and facial nerve palsy.8 auclair et al. divided mec histologically into three grades depending on parameters like intracystic component, mitosis, anaplasia, neural invasion and necrosis. hence low grade tumors have a score of 0-4, intermediate grade, 5-6 and high grade tumors 7-14, respectively.9 unlike squamous cell carcinoma, in which tnm staging is applied uniformly, there is no consensus over staging of mec. there are also other grading systems like afip grading, modified healy system and brandwein grading system. afip grading system was initially discovered for mec of minor salivary glands.10 auclair et al. gading system is useful in determining the biological behavior of mec.9,10 here we present the clinicopathological characteristics of mec in patients presenting at a tertiary care hospital in rawalpindi, pakistan. m a t e r i a l a n d m e t h o d s this descriptive cross-sectional study was carried out at armed forces institute of pathology, rawalpindi between june 2016 to september 2017. a total of 30 patients of malignant salivary gland tumors were included. all the pathology slides were reviewed and only tumors with adequate histological features fulfilling the diagnostic criteria for mec of salivary gland tumors were included in the study. necrosed, scanty and autolyzed tissue samples and incomplete records were excluded from the study. the sample size was calculated by using the formula n = z2 × p (1-p) / d2, whereas estimated proportion was 2%, margin of error 5%, confidence level 95% and prevalence was 25%.11 the proposal was reviewed and approved by the ethical review committee of armed forces institute of pathology, rawalpindi. mucoepidermoid carcinoma was diagnosed on the basis of characteristic histopathological patterns on hematoxylin and eosin-stained slides. the data regarding gender, age and anatomic location of tumors were collected from the patients’ records. patients’ age was stratified into three categories; 630 years, 31-60 years and ≥ 60 years, respectively. mec were assessed by auclair et al. grading system (low, intermediate and high grade)9 based on a compilation of histological characteristics including necrosis, mitoses, atypical nuclei and size of the j islamabad med dental coll 2020 300 cystic component. the collected data was analyzed by using spss version 22.0. r e s u l t s a total of 30 patients of mucoepidermoid carcinoma, 23 (76.66%) males and 7 (23.33%) females, with a mean age of 44.9±19.2 years and age range of 6 to 88 years were reported. the mean age of male patients was 48.4±18.1 years, while mean age of female patients was 30.7±14.37 years. majority of the patients were between 31 to 60 years (56.7%) followed by 6 to 30 years (26.7%), while patient above 60 years were less in number (16.6%) (table i). with regards to gender, mec was more common in males as compared to females (table i). regarding anatomical site, majority of the patients (73.3%) had tumor in the parotid gland, 13.3% in submandibular gland and 13.3% had tumor in palate, retromolar area and posterior one third of the tongue (table i). according to histopathological grading, 26.6% mec were high-grade, 26.6 % intermediate-grade and 36.6% were low-grade tumors (table i). table i: demographic characteristics of mec (n = 30) gender number of cases percentage male 23 76.6 female 7 23.4 age groups (years) 6 to 30 years 8 26.7 31 to 60 years 17 56.7 above 60 years 5 16.6 site of mec parotid 22 73.2 submandibular 4 13.3 posterior 1/3rd of tongue 1 3.3 retromolar area 1 3.3 palate 2 6.6 grades of mec high 8 26.7 intermediate 8 26.7 low 14 46.6 figure 1: high grade mec with predominant epidermoid cells (h&e, 40x). figure 2: low grade mec showing cystic areas and mucus cells (h&e, 40x) d i s c u s s i o n mucoepidermoid carcinoma accounts for one third of all malignant tumors of major and minor salivary glands. it shows different biological behavior depending on histopathological grade of the tumor.11 however this aspect can only be proved in studies with larger sample size. mec was found mostly between 40 to 60 years of age in our patients with a mean age of 44 years as reported by many other studies.2-4,12 qureshi et al., compared ages of patients with grades of mec and observed that patients with increasing age are more susceptible to malignant tumors than patients in the younger age groups.4 there was a male predominance in the present study with a male to female ratio of 3:1. unlike oral cancer, we could not identify any specific etiological factor for the male predominance of mec. this is j islamabad med dental coll 2020 301 similar to studies conducted by khiavi et al.12 and rapidis et al.13 however, rapidis et al. observed that history of radiotherapy might be regarded as a causative factor in males.13 a study conducted by lujan et al.14 reported contrasting results with mec more common in females as compared to males. similarly, bell et al.15 and bai et al.3 reported male to female ratios of 1:1.2 and 1:3, respectively. parotid gland was the most common site of tumor followed by submandibular gland and palate. our results correlate with studies conducted by lujan et al.14 and bai et al.3 in a study conducted by al-ani et al.16 in baghdad, iraq on 17 cases of mec, submandibular salivary gland (n=5) was the most common site for mec, closely followed by parotid gland (n=4). since mec was first discovered, different grading systems have been used for classification of this entity. some pathologists have used two-tiered grading systems, while we used three-tiered grading system according to auclair et al. low grade mec was the most common histopathological variant of tumor in our study, followed by intermediate and high grade mec, respectively. this is in agreement with kokemueller and okabe,17 who also reported that mec of major salivary glands have less aggressive behavior as compared to mec of minor salivary glands. similarly, in our study 73% of cases of mec were in the parotid gland. according to khiavi et al., high grade mec was the most common variant (41%) followed by low grade (31%) and intermediate grade (13%), respectively.12 another study conducted by bai et al. also reported high grade mec as the most common tumor.3 c o n c l u s i o n mucoepidermoid carcinoma was more common in males, in the third decade with parotid gland as the most common site for this tumor. on histopathology low grade mec on auclair grading had the highest frequency in our study cohort. r e f e r e n c e s 1. neville bw, damn dd, allen cm, bouquot je. oral and maxillofacial pathology. 3rded. elsevier health sciences; 2015. 2. gill ms, muzaffar s, soomroi in, hussainy as, pervez s, hasan sh. morphological patterns of salivary glands tumors. j pak med assoc. 2001; 51(10): 343-6. 3. bai s, clubwala r, alder e, sarta c, schiff b, smith rv, et al. salivary mucoepidermoid carcinoma: a multiinstitutional review of 76 patients. head neck pathol. 2013; 7(2): 105-12. doi: 10.1007/s12105-012-0405-0. 4. qureshi sm, janjua os, janjua sm. mucoepidermoid carcinoma: a clinico-patholological review of 75 cases. int j oral maxillofac pathol. 2012; 3: 5-9. 5. regezi ja, sciubba jj, jordan rck. oral pathology, clinical pathological correlation. 5thth edition. u.p: saunders-elsevier; 2009. 6. ozawa h, tomita t, sakamoto k, tagawa t, fujii r, kanazaki s. mucoepidermoid carcinoma of the head and neck: clinical analysis of 43 patients. japan j clin oncol. 2008:414-8 7. deihimy p, mahzoomi p, torabinia n. study of myoepithelial cell markers in pleomorphic adenoma and mucoepidermoid carcinoma of salivary glands. dent res j. 2006;3(2):1-8. 8. chen mm, roman sa, sosa ja, judson bl. histologic grade as prognostic indicator for mucoepidermoid carcinoma: a population‐level analysis of 2400 patients. head neck. 2014; 36(2): 158-63. 9. auclair pl, goode rk, ellis gl. mucoepidermoid carcinoma of intraoral salivary glands evaluation and application of grading criteria in 143 cases. cancer. 1992; 69(8): 2021-30. 10. goode rk, el nagger ak. mucoepidermoid carcinoma. in: barnes l, eveson jw, reichart p, sidransky d, editors. world health organization classification of tumors: pathology and genetics of head and neck tumours. lyon: iarc press; 2005. p. 219-20. 11. niazi z, hashmi sn, muneer s. immunohistochemical expression of epidermal growth factor in different grades of mucoepidermoid carcinoma of salivary glands. jimdc. 2018; 7(4): 231-34. 12. khiavi mm, vosouughhosseini s, saravani s, halimi m. immunohistochemical correlation of epidermal growth factor receptor and c-erb with histopathological grading of mucoepidermoid carcinoma. j can res therp. 2012; 8(4): 586-90. 13. rapidis ad, givalos n, gakiopoulou h, stavrianos sd. mucoepidermoid carcinoma of the salivary glands. review of the literature and clinicopathological analysis. oral oncol. 2007; 43(2): 130-6. j islamabad med dental coll 2020 302 14. lujan b, hakim s, moyano s, nadal a, caballero m, diaz a, valera a. activation of the egfr/erk pathway in high-grade mucoepidermoid carcinoma of the salivary glands. br j cancer. 2010; 103(4): 510-16. 15. bell d, el-naggar ak. molecular heterogeneity in mucoepidermoid carcinoma: conceptual and practical implications. head neck pathol. 2013; 7(1): 23-7. 16. al-ani sa, abdullah bh. evaluation of epidermoid growth factor receptor (egfr), proliferation (ki-67) and apoptosis (p53) in salivary mucoepidermoid carcinoma in relation to tumor grade. j bagh coll dent. 2012; 24(2): 43-7. 17. kokemueller h, brueggemann n, swennen g, eckardt a. mucoepidermoid carcinoma of the salivary glandsclinical review of 42 cases. oral oncol. 2005; 41: 3-10x 134 j i m d c 2 0 1 7 134 open access f u l l l e n g t h a r t i c l e pattern of dyslipidemias and their association with ischemic and hemorrhagic stroke muhammad saeed aslam 1, khalid mahmood nasir 2, hajra hussain 3, muhammad saeed 4, muhammad salman walayt 5, waqas ahmad6, muhammad usman shabbir7 1,5 registrar, medicine unit 1, jinnah hospital lahore 2 assistant professor of medicine, medicine unit 1, jinnah hospital lahore 3 house officer king edward medical university &amp; mayo hospital lahore 4 medical lab technologist, head pathology lab, health care dep govt of punjab, dhq hospital mb-din 6 ph.d scholar (biochemistry; molecular biology), university of gujrat 7 head blood bank, primary & secondary health care department govt of punjab, dhq hospital mb-din a b s t r a c t objective: to find out the association between dyslipidemias and ischemic and hemorrhagic stroke. patients and methods: this cross-sectional study was conducted in medical unit i, jinnah hospital lahore (jhl) from 1st january 2015 to 30th jun 2015. a total of 420 cases of stroke were included via nonprobability consecutive sampling technique. the sample size was calculated with 95% confidence level, 2% margin of error. at the time of admission, every patient underwent ct scan in the radiology department of jhl, fasting blood samples were taken, on next day of admission. every sample was processed for lipid profile in pathology department of allama iqbal medical college, (aimc) lahore. based on ct scan findings, patients were labelled as ischemic or hemorrhagic stroke. demographic details, bmi, blood pressure and diabetic status were also recorded. results: out of 420 study participants, 47.6% (n=200) were male and 52.4% (n=220) were females, the mean age was 39.29 + 11.82 years, mean bmi was 39.29 + 11.82 kg/m2. history of hypertension (htn) was most frequent risk factor seen in 82.6% (n=347) followed by diabetes mellitus (dm) 49.8% (n=209) and smoking found in 32.1% (n=135) cases. frequency of hypercholesterolemia (>200 mg/dl) was observed in 26.2% (n=110) and hypertriglyceridemia (>150 mg/dl) in 7.9% (n=33) patients. high ldl (>130 mg/dl) levels were observed in 5.7% (n=24), high vldl (>35 mg/dl) in 6.9% (n=29) patients, while low hdl (<35 mg/dl) was noticed in 17.1% (n=72) patients. there was significant association between type of stroke & hypercholesterolemia as well as low hdl levels (p-value<0.05). while insignificant association was found between type of stroke & hypertriglyceridemia and high vldl (p-value>0.05). effect modifiers i.e.; age, bmi, gender, history of smoking, htn and dm were not significantly associated with type of stroke (p-value >0.05). conclusion: hypercholesterolemia & hdl levels are significantly associated with type of stroke, whereas serum hypertriglyceridemia, high ldl and high vldl were not significantly associated with type of stroke. key words: dyslipidemia, hemorrhagic stroke, ischemic stroke, stroke. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence muhammad saeed aslam email: m.saeed.aslam@gmail.com article info. received: feb 23, 2017 accepted: august 9, 2017 cite this article. aslam ms, nasir km, hussain h,saeed m,walayt ms, ahmad w,shabbir mu. pattern of dyslipidemias and their association with ischemic and hemorrhagic stroke.jimdc.2017;6(3):134-139 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e 135 j i m d c 2 0 1 7 135 i n t r o d u c t i o n stroke is the commonest neurological cause of morbidity and mortality all over the world and the third leading cause of death. evaluation of various risk factors for a population is not only helpful for identification of risk factors but this will be a great help for health care providers for management of these patients. cerebrovascular accident is global health problem. a recent international survey has estimated about 15 million people worldwide suffer from nonfatal stroke annually and 33% being permanently disabled.1 about 80% of all stroke deaths are registered in lower and middle-income countries.2 an estimated annual incidence of stroke in pakistan is 250/100,000 with an estimate of 350,000 new cases every year.3,4 stroke is a multifactorial disease; some of them are called primary, while the cause for others are uncertain and secondary. among the latter, hyperlipidemia plays a significant role. as the acute stroke management is expensive and stroke itself is associated with significant morbidity and mortality, the saying that “prevention is better than cure” holds a special meaning here. it is apparent from different studies that stroke can be significantly reduced by taking measures for control of modifiable risk factors. the modifiable risk factors of stroke are similar to western population and comprise of hypertension, cardiac disease, diabetes mellitus and dyslipidemia. hyperlipidemia causes hardening of the arteries with plaque formation and increases the risk of atherosclerosis.5 lipids and other components of blood are the sources of plaque formation. plaque formation is a cause of narrowing and hardness of blood vessels. as result, there is reduced blood flow, increasing the risk of stroke. unfortunately, there are no symptoms for hyperlipidemia, and lipid profile in fasting is the only method to reveal lipid levels. the desired lipid levels include; total cholesterol levels < 200 mg/dl, low-density lipoprotein (ldl) also known as "bad cholesterol" should be < 130mg/dl, high-density lipoprotein (hdl) also called “good cholesterol" should be >40mg/dl and 50mg/dl for males and females respectively. triglycerides levels should be <200 mg/dl.2 once the person is diagnosed with hyperlipidemia, the next step is to consult a physician who may prescribe treatment or discuss lifestyle and diet plan depending upon the results.6 as cholesterol levels increases, the risk of hemorrhagic stroke decreases and the risk of ischemic stroke increases. stroke mortality is lowest at cholesterol levels between 180mg/dl and 200mg/dl. mortality increases substantially above 240mg/dl. mortality is highest from 160mg/dl to 300mg/dl and above. diet high in polyunsaturated fat and low in antioxidants can make ldl-cholesterol within the blood vulnerable to oxidation. oxidized ldl can play a role in the development of stroke.7 stroke, also known as cerebral vascular accident (cva), is a second leading cause of death and disabilities around the globe.8 alarming symptoms include numbness, weakness (often on one side), confusion, visual problems, slurred speech, trouble walking, dizziness, loss of balance loss of coordination and severe headache.9 there are two categories of stroke, ischemic & hemorrhagic, both are entirely conflicting to each other. ischemic stroke is a most common entity, with numerous pathophysiologic mechanisms, results from blockage of a blood vessel supplying the brain, while the more damaging hemorrhagic stroke results from rupture of such a vessel.10 hypertension is another significant contributor to stroke, hypercholesterolemia may be an important factor leading to hypertension.11 polyunsaturated fat and carbohydrates are associated with a higher risk of stroke. exercise, stress management, proper control of oral or systemic infections, and adequate nutrition can lower the risk of stroke.12 important protective nutrients include magnesium, potassium, antioxidants and adequate proteins. modified lifestyle and timely medical management can treat hyperlipidemia, a major risk factor for stroke. statins have been shown to decrease lipids and exert a pleiotropic effect on the intracranial vasculature and inflammatory modulators, leading to neuroprotection. lower low-density lipoprotein and higher high-density lipoprotein levels are associated with decreased risk of stroke. despite screening guidelines and evidence of the efficacy of statins, there are numerous barriers to maintaining adequate control of lipids.13 therefore evaluation of dyslipidemia is significantly important. the present study was planned to evaluate spectrum and association of hyperlipidemia 136 j i m d c 2 0 1 7 136 among patients presenting with ischemic & hemorrhagic stroke. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at medical unit, jinnah hospital lahore. during the period of six months from january 1 to june 30, 2015. all patients presenting with the acute first episode of stroke within one week of onset of symptoms were included while all of the following were excluded, i.e. (1) history of known secondary dyslipidemia, (2) patients on lipid lowering therapy, (3) patients with recurrent stroke or cerebrovascular accident (on history). a total of 420 stroke cases were included via non-probability consecutive sampling technique. at the time of admission, every patient was processed for ct scan in the radiology department of jinnah hospital lahore (jhl). blood samples were taken by using aseptic measures and standard procedure after an 8 hour of overnight fasting on next day of admission. every sample was processed for lipid profile in pathology department (chemical pathology section) of allama iqbal medical college, (aimc) lahore. lipid abnormalities were labelled as hypercholesterolemia (>200 mg/dl), hypertriglyceridemia (>150 mg/dl), increased low-density lipoproteins (ldl) (>130 mg/dl), increased very lowdensity lipoproteins (vldl) level (>35 mg/dl), decreased hdl (<35 mg/dl). based on ct scan findings, patients were labelled as ischemic or hemorrhagic stroke as followed. ischemic stroke: a stroke was labelled as the ischemic stroke if there was the presence of a hypodense area reported as ischemia on ct scan. hemorrhagic stroke: a stroke was labelled as hemorrhagic stroke in case of presence of a hyperdense area reported as hemorrhage on ct scan. data analysis: numerical variables were analyzed as mean and sd. frequency and percentage was calculated for categorical variables. cross tabulation was done between abnormal lipid profile level and type of stroke. data were stratified by age, gender, bmi, type of stroke, smoking, htn and dm. post-stratification chi-square test was applied. a p-value < 0.05 was considered as statistically significant. r e s u l t s out of 420 study participants, 47.6% (n=200) were male and 52.4% (n=220) were females. the mean age of the patients was 39.29 +11.82 years, mean bmi was 39.29 + 11.82 kg/m2, mean cholesterol level was 171.45 + 32.7 mg/dl, mean triglycerides level was 133.01 + 15.39 mg/dl, mean ldl level was 116.87 + 12.78 mg/dl, mean vldl level was 21.88 + 10.93 mg/dl, mean hdl level was 43.41 + 15.13 mg/dl. patients suffering from ischemic and hemorrhagic stroke were 42% and 58% respectively (figure1). figure 1: frequency distribution of strokes (n=420) figure 2 represents frequency of different risk factors for stroke. as shown in the figure, history of hypertension was the most frequent risk factor seen in 82.6% (n=347) cases followed by diabetes mellitus in 49.8% (n=209) cases and smoking in 32.1% (n=135) cases. figure 2: frequency distribution of risk factor associated with stroke (n=420) frequency of hypercholesterolemia was observed in 26.2% (n=110) cases and hypertriglyceridemia was seen in 7.9% (n=33) cases. high ldl levels were observed in 137 j i m d c 2 0 1 7 137 5.7% (n=24), high vldl in 6.9% (n=29) patients, while low hdl was noticed in 17.1% (n=72) patients (figure 3). figure 3: frequency distribution of study participants with abnormal lipid profile (n=420) as shown in table 1, there was a significant association between type of stroke & hypercholesterolemia as well as low hdl levels (p-value<0.05). other factors like age, bmi, gender, history of smoking, htn and dm were not significantly associated with type of stroke (table 2). d i s c u s s i o n stroke is a major public health problem that ranks in the top four causes of death in most countries. dyslipidemias including high-density lipoproteins are the major risk factor for coronary heart disease, cerebrovascular disease, atherosclerosis, thrombosis, and stroke. the present study reported that females were more vulnerable to stroke as compared to males with earlier mean age of presentation (39.29 + 11.82 years) & mean bmi 39.29+11.82 kg/m. however, majority of studies showed a male predominance in their studies with presentation at a later age. bain lk et al, in their study reported that male suffered more than female with m:f ratio of 1.73:1 in ischemic group and 1.42:1 in hemorrhagic group.11 according to present study, hypercholesterolemia was observed in 26.2%, hypertriglyceridemia was noticed in 7.9% (n=33) cases, high ldl levels were observed in 5.7% (n=24), high vldl in 6.9% (n=29) patients, while low hdl was noticed in 17.1% (n=72) patients. our results are slightly different, but supported by the previous study table :2 association of type of stroke with other factors hemorrhagic stroke n=178 ischemic stroke n=242 p-value gender male 79 121 0.255 female 99 121 age-groups (year) < 40 83 126 0.271 > 40 95 116 bmi (kg/m2) < 29 93 111 0.196 > 29 85 131 history of smoking (n) yes 48 87 0.051 no 130 155 history of hypertension (n) yes 142 205 0.187 no 36 37 history of diabetes mellitus (n) yes 89 120 0.933 no 89 122 table 1: association of type of stroke with dyslipidemias variable results hemorrhagic stroke n=178 ischemic stroke n=242 p-value hyper-cholesterolemia (n) yes 26 84 0.000 no 152 158 hyper-triglyceridemia (n) yes 9 24 0.097 no 169 218 high-ldl (n) yes 9 15 0.676 no 169 227 high-vldl (n) yes 11 18 0.699 no 167 224 low-hdl (n) yes 10 62 0.000 no 168 180 138 j i m d c 2 0 1 7 138 conducted on 100 patients of ischemic stroke patients. according to this study, the mean age of patients with stroke at presentation was 64.2±12 years with a male to female ratio of 3.6:1. they also reported that hypercholesterolemia was seen in 42.0%, hypertriglyceridemia in 4.0%, high ldl-cholesterol in 5.0%, and vldl-cholesterol in 7.0% patients. low serum hdl-cholesterol was observed in 31.0% cases of ischemic stroke. on the other hand, serum total cholesterol and triglycerides was raised in 05 patients each, ldl-cholesterol in 09 and vldl-cholesterol in 03 patients of hemorrhagic stroke. serum hdl-cholesterol was below normal in 04 patients of hemorrhagic stroke. they also reported that there was a significantly greater number of patients with raised serum cholesterol and low hdl-cholesterol in ischemic stroke than hemorrhagic stroke (p < 0.05), the finding similar to our results.14 a greater number of patients in the recent study presented with ischemic stroke (58 %) while hemorrhagic stroke was observed in (42.4%) cases. in one study among 540 study participants (49.4% females) 19.1% (n=104) were observed to have a prior stroke while tia was found in 9.7% (n=53). history of smoking hypertension and diabetes mellitus were 32.1%, 82.6%, 49.8% respectively.13 aquil mentioned that out of the 100 patients with acute ischemic stroke, mean age at presentation was 63.5 years.15 risk factor distribution included hypertension 85.0%, diabetes mellitus 49.0%, ischemic heart disease 30.0%, dyslipidemia 22.0%, smoking 9.0%, atrial fibrillation 5.0%, and previous history of stroke in 29.0% cases. according to them, various subtypes of acute ischemic stroke were lacunar infarct seen in 43%, large artery atherosclerosis in 31.0%, cardio embolic type in 8.0%, and stroke of undetermined etiology in 18.0% cases.15 chaudhury reported that `fasting serum lipid profile analysis of 50 ischemic stroke patients revealed raised serum total cholesterol in 42.0% patients with the mean serum cholesterol of 190±35mg/dl whereas only 5 patients among hemorrhagic cva showing raised serum cholesterol with the overall mean of 151±29mg/dl. serum hdl was found to be low in 16 (32.0%) patients of ischemic stroke with a mean value of 42.4±6mg/dl whereas only 6.0% of hemorrhagic stroke patients showed low serum hdl with a mean value of 45.4±5mg/dl. abnormal serum triglyceride level was found to be distributed similarly in ischemic & hemorrhagic stroke with the mean value of 137±30mg/dl & 125±30mg/dl respectively. high serum ldl was found in 6.0% & 4.0% of ischemic & hemorrhagic stroke with mean value of 102±21mg/dl & 93±17mg/dl respectively. hypercholesterolemia and low hdl-cholesterol was seen significantly more in ischemic cva group as compared to those with hemorrhagic disease.16 mahmood et al from pakistan also reported that there were significantly greater number of patients with raised serum cholesterol and low hdl-cholesterol in ischemic stroke than hemorrhagic stroke (p < 0.05). no statistical significance was found on comparing serum values of ischemic and hemorrhagic stroke for triglycerides, ldl-cholesterol and vldl-cholesterol. ischemic stroke patients had high serum total cholesterol and lower hdl-cholesterol levels as compared to hemorrhagic stroke.14 according to zhang et al, factors which are significantly associated with ischemic stroke as opposed to hemorrhagic stroke were family history of stroke, obesity, atherosclerotic plaque of the common carotid artery, atrial fibrillation, hyperfibrinogenemia, transient ischemic attack (tia), atherosclerotic plaque of the internal carotid artery, coronary heart, lower high-density lipoproteins (lower hdl), increasing age, diabetes mellitus, and male gender. hypertension and family history of hypertension were the significant factors associated with hemorrhagic stroke versus ischemic stroke. smoking, alcohol intake, kidney diseases and lower hdl-c were the significant factors contributing to ischemic stroke in man. obesity, family history of hypertension, family history of stroke, hypercholesteremia and myocardial ischemia were the significant factors for females with ischemic stroke.17 osama a et al in their study, conducted on patterns of dyslipidemias in patients of ischemic stroke reported that high ldl and lipoprotein a were more frequent finding in ischemic stroke than other patterns of dyslipidemia.18 in their study, they observed that hypertension was the most frequent risk factor (74.3%) followed by hyperglycemia(64%) then dyslipidemia (57.1%) then smoking (53.3%), and these results are almost comparable with our results. however, they also reported that prevalence of dyslipidemia in males was 68.4%, which was significantly higher than in females (43.8%), and according to them prevalence of dyslipidemia was 139 j i m d c 2 0 1 7 139 more in the age group>65 years (63.2%) than in the age group≤ 65 years (53.7%), the findings are not comparable with our results. one of the local study conducted by khan et al reported, that of 55 patients of ischemic stroke studied, 78% were males and 22% were females, the finding not comparable with our results. they also reported that hypertension (65%), dyslipidemia (32.7%), diabetes mellitus (36.3%) and smoking was found in 32% cases of ischemic stroke patients. (18) meta-analysis of some studies shows that higher the level of total cholesterol (tc), greater the risk of cva and higher the high-density lipoprotein cholesterol (hdlc), lower the risk and each being an independent risk factor. moreover, tc to hdl ratio is better predictor of ischemic cva and is considered a useful clinical tool. the contribution of various risk factors for stroke may be different in different ethnicities.19 c o n c l u s i o n ischemic stroke was more frequent as compared to hemorrhagic stroke. serum total cholesterol level and serum hdl level were significantly associated with a type of stroke whereas serum triglyceride level, serum ldl, and serum vldl did not have significant association with type of stroke. r e f e r e n c e s 1. go as, mozaffarian d, roger vl, benjamin ej, berry jd, blaha mj, etal. american heart association. stroke statistics subcommittee 2014 update: a report from the american heart association. circulation. 2014. 21;129(3):e28. 2. hoffman a, dervish murad, van dui gin cm, france o h et al. the rotterdam study 2014 objectives and design update. eur.j. epidemio.2013; 28(11):889-926. 3. khatri ia, wasay m. can we stop the stroke epidemic in pakistan? jcpsp.2011; 21(4):195-6 4. taj f, zahid r, murtaza m, ahmed s, kamal ak. risk factors of stroke in pakistan: a dedicated stroke clinic experience. canadian journal of neurological sciences. 2010; 37(2):2527. 5. gusev v, lvova o, votty m. 15. risk factors for stroke/prognosis dyslipidemia as the possible risk factor for arterial ischemic stroke in young. international journal of stroke. 2015;10:246. 6. barkas f, milionis h, mozaffarian d, benjamin e, go a, tell g, et al., editors. treating dyslipidemia for the primary and secondary prevention of stroke. seminars in neurology thieme medical publishers. 2017; 37(3):286-293. 7. bain lk, myint pk, jennings a, lentjes ma, luben rn, khaw k-t, et al. the relationship between dietary magnesium intake, stroke and its major risk factors, blood pressure and cholesterol, in the epic-norfolk cohort. international journal of cardiology. 2015;196:108-14. 8. feigin vl, forouzanfar mh, krishnamurthi r, mensah ga, connor m, bennett da, et al. global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010. the lancet. 2014; 383(9913):245-55. 9. everson-rose sa, roetker ns, lutsey pl, kershaw kn, longstreth w, sacco rl, et al. chronic stress, depressive symptoms, anger, hostility, and risk of stroke and transient ischemic attack in the multi-ethnic study of atherosclerosis. stroke. 2014:strokeaha. 114.004815. 10. thigpen jl, dillon c, forster kb, henault l, quinn ek, tripodis y, et al. validity of international classification of disease codes to identify ischemic stroke and intracranial hemorrhage among individuals with associated diagnosis of atrial fibrillation. circulation: cardiovascular quality and outcomes. 2015;8(1):8-14. 11. canoy d, cairns bj, balkwill a, wright fl, khalil a, beral v, et al. hypertension in pregnancy and risk of coronary heart disease and stroke: a prospective study in a large uk cohort. international journal of cardiology. 2016;222:1012 8. 12. american diabetes association. standards of medical care in diabetes.2014;37(3):887. 13. al-rubeaan k, al-hussain f, youssef am, subhani sn, alsharqawi ah, ibrahim hm. ischemic stroke and its risk factors in a registry-based large cross-sectional diabetic cohort in a country facing a diabetes epidemic. journal of diabetes research. 2016. article id 4132589, 9 pages http://dx.doi.org/10.1155/2016/4132589 14. mahmood a, sharif ma, khan mn, ali uz. comparison of serum lipid profile in ischaemic and haemorrhagic stroke. j coll physicians surg pak. 2010;20(5):317-20. 15. aquil n, begum i, ahmed a, vohra ea, soomro ba. risk factors in various subtypes of ischemic stroke according to toast criteria. j coll physicians surg pak. 2011;21(5):2803. 16. chaudhury sr, ghosh s, kar d. comparative lipid profile study between ischemic and hemorrhagic stroke. j chem pharm res. 2014;6(11):20-7. 17. zhang j, wang y, wang g, sun h, sun t, shi j, et al. clinical factors in patients with ischemic versus hemorrhagic stroke in east china. world journal of emergency medicine. 2011;2(1):18-23. 18. osama a. khalil, fayrouz o. selim, hazem m. el-a. prevalence and pattern of dyslipidemia in acute cerebral infarction in medical intensive care in egypt. british journal of science 2013;10 (1): 51-66. 19. khan ni, naz l, mushtaq s, rukh l, ali s, hussain z. ischemic stroke: prevalence of modifiable risk factors in male and female patients in pakistan. pakistan journal of pharmaceutical sciences. 2009; 22(1):62-67. j islamabad med dental coll 2019 112 open access frequency of surgical impactions of mandibular third molar in orthodontic patients with different antegonial notching muhammad azeem1, muhammad mudassar saleem2, zubair hassan awaisi3, muhammad imran saleh4, naeem murtaza5, syeda rabbab hasan6 1 assistant professor, department of orthodontics, de’montmorency college of dentistry lahore 2 assistant professor, department of oral and maxillofacial surgery, islamabad medical and dental college 3 associate professor, department of orthodontics, nishter institute of dentistry, multan 4 assistant professor, department of oral and maxillofacial surgery, de’montmorency college of dentistry lahore 5 senior demonstrator, department of orthodontics., faisalabad medical university 6 assistant professor, department of orthodontics, islamabad medical and dental college a b s t r a c t background: few studies have been reported so far on the frequency of lower third molar impactions in patients with different morphological characteristics. our aim in this study was to find out the frequency of impacted lower third molars in orthodontic patients with different antegonial notch depths. material and methods: this cross-sectional research was conducted at orthodontics department of dental section, faisalabad medical university, faisalabad, and de’montmorency college of dentistry, lahore, pakistan from june 2017 to june 2019. a total of 60 orthopantomograms (opgs) of patients with impacted lower third molars were included. the depth of antegonial notch was calculated on all the selected opgs by measuring distance between the deepest area of the notch cavity and the tangent on the inferior border of the mandible. the patients with depth of antegonial notch of 1 mm or less were labeled as having shallow antegonial notch, while those with 3 mm or more were considered as having deep antegonial notch. percentages and mean + sd were calculated for different variables. depth of antegonial notching was compared between genders using anova with p-value <0.5 considered as significant. results: of 60 orthodontic patients, there was an equal number of male and female patients (n=30). the average age of the patients was 25.5±4 years. overall frequency of impactions was similar in both the genders and frequency of impacted lower third molars was found to be greater in patients with deeper antegonial notches. conclusion: mandibular third molar impactions were most frequent in orthodontic patients with deep antegonial notches. key words: antegonial notch, mandibular, orthodontics, third molars authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3-6 active participation in data collection data analysis. correspondence: muhammad azeem email: dental.concepts@hotmail.com article info: received: july 11, 2019 accepted: august 9, 2019 cite this article. azeem m, saleem mm, awaisi zh, saleh mi, murtaza n, hasan sr. frequency of surgical impactions of mandibular third molar in orthodontic patients with different antegonial notching. j islamabad med dental coll.2019; 8(3):112-116. doi: 10.35787/jimdc.v8i3.343 funding source: nil conflict of interest: nil i n t r o d u c t i o n mandibular third molars impactions are the most common impactions. this is when they fail to erupt in the normal functional position in the oral cavity beyond the expected developmental time, until and unless treated by orthodontics or oral surgery.1-2 there are different etiological factors reported in literature regarding impactions which include barriers in the form of soft and hard tissue, lack of arch perimeter, lack of retromolar space, lack of guidance, genetics, over-retention of primary teeth, and vertical facial morphology.3-7 the o r i g i n a l a r t i c l e j islamabad med dental coll 2019 61 vertical facial pattern can influence the eruption of mandibular third molars by altering the alveolar bone density, changing the strength of orofacial muscles and by influencing the retromolar space.6,7 there are two types of mandibular growth patterns; vertical and horizontal. in the vertical growth pattern, mandible goes downward and backward, that leads to more bone deposition under the angle of mandible and more bone resorption at symphysis. this results in formation of notch at lower border of mandible which is known as pregonial or antegonial notching.8-10 patients with deep antegonial notching are found to have disturbances of condylar and mandibular growth and it is more common with the patients having vertical growth pattern.11-13 shallow antegonial notching is usually seen in patients with horizontal growth pattern where orofacial muscular forces are strong.12 different studies have been conducted so far on finding out the frequency of lower third molar impactions and its pattern in different populations.9,10 however few studies have been reported on the frequency of lower third molar impactions in patients with different morphological characteristics. to our knowledge, this is the first study aimed at determining the frequency of impacted lower third molars in orthodontic patients with different antegonial notch depths. this will allow the orthodontists and oral surgeons to do early interceptive management of lower third molars for avoiding future impactions. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted at orthodontics department of dental section, faisalabad medical university, faisalabad, and de’montmorency college of dentistry, lahore, pakistan from june 2017 to june 2019. ethical approval was obtained from irb of both institutes. the sample size was calculated with the help of g* power software version 3.0.10. thirty patients were required to provide an 80% power with α of 0.05 and effect size of 0.582 calculated after obtaining the data from previous study.14 after taking informed consent, orthopantomograms (opgs) with impacted lower third molars of 60 patients with age range of 25-35 years were included to record the depth of antegonial notches. the third molars with completed root formation and which were not still in its normal functional occlusion position in the mandible were declared as impacted. both male and female patients of ages between 25-35 years with impacted lower third molars and erupted lower second molars having good readable opgs were included in the study. patients with hypodontia involving lower third or second molars, un-erupted lower second molars, angulated lower second molars, history of trauma, history of orthodontic or surgical treatment, craniofacial syndromes including clefts, and lower third molars with ongoing root formation were excluded from the study. the depth of antegonial notch was calculated on all the selected opgs by measuring distance between the deepest area of the notch cavity to the tangent on the inferior border of the mandible.15,16 the patients with depth of antegonial notch 1 mm or less were considered as shallow antegonial notch patients, and those with 3 mm or more were considered as deep antegonial notch patients.15 (figure 1). figure 1: opg showing antegonial notch depth to rule out the risk of inter-examiner errors, all measurements were done by a single expert orthodontist and 25 opgs were reevaluated later at interval of two weeks to rule out the risk of intra-examiner errors, which was found to be 7.9%. data was analyzed, age and depth of antegonial notching was presented in form of mean and standard deviation while gender and frequency of impacted lower third molars was presented as proportions and percentages. the depth of antegonial notching was compared between both the genders using anova test j islamabad med dental coll 2019 62 and p value of <0.05 was considered as statistically significant. r e s u l t s out of 60 orthodontic patients, an equal number of male and female patients were present (30 in each group) which shows that overall frequency of impaction was similar in both genders. the mean age of the patients was 25.5±4 years. the mean age of male patients was 25.2±4.5 years, and that of female patients was 25.7±4.4 years. the age and gender distribution are shown in table i. table i: age and gender distribution (n=60) gender frequency (%) mean age (years) male 30 (50) 25.2±4.5 female 30 (50) 25.7±4.4 total 60 (100) 25.5±4.1 patients with deep antegonial notches had greater number of impacted lower third molars (45%) than the ones with shallow notches (26.6%) as shown in table ii. there was no significant difference observed among male and female patients regarding antegonial notch depths in the study, please refer to table iii. table ii: frequency of mandibular third molar impactions in different antegonial notch depths (n=60) antegonial depth frequency of impactions percentage of impactions normal (1-3 mm) 17 28.3 shallow (≤1mm) 16 26.6 deep (≥3mm) 27 45.0 total 60 100.0 table iii: gender distribution in different antegonial notch depths (n=60) antegonial depth male n (%) females n (%) normal(1-3mm) 8 (13.33%) 9 (15.5%) shallow (≤1mm) 8 (13.33%) 8 (13.33%) deep (≥3mm) 14 (23.33%) 13 (21.66%) total 30 (50%) 30 (50%) p value 0.555 d i s c u s s i o n previous studies have shown the frequency of lower third molar impactions in various patients with different craniofacial morphological characteristics,4,17-18 but our study is unique in observing the frequency of impacted lower third molars in orthodontic patients with different antegonial notch depths. we used opg radiographs to find out the depth of antegonial notches, which avoided the radiation exposure of lateral cephalometric radiographs; this is in accordance with the previously conducted studies.15,16 in our study the frequency of lower third molar impaction was same in both genders. these findings are similar to results of hatem et al, who did not find any difference in sex distribution of impacted third molars in the libyan population.19 kumar et al too did not find predilection towards any of the genders in third molar impaction cases in eritrean population.20 however, there are studies with findings showing impacted third molars are more common in one of the two sexes. ayaz and rehman while studying the third molar impaction in the population of peshawar, pakistan found out that males were affected more than females.21 similarly, shahzad et al studied the patterns and pathologies associated with third molar impactions in lahore, pakistan and concluded that it was more common in females as compared to males.22 overall, frequency of impacted lower third molars was found to be greater in patients with deep antegonial notches (45%). this can be linked to the fact that deep antegonial notches are found more in patients with increased vertical facial pattern, which in turn leads to decreased retromolar space. the reason of decreased retromolar space is because of decreased resorption of anterior border of mandibular ramus resulting in higher number of molar impactions.23 skadu et al. too had similar findings when they studied the crowding of teeth in relation to growth of facial skeleton. they concluded that impaction frequency of lower third molars was greater in patients with vertical growth pattern also called dolichofacial (long faced) patients.24 nanda too while investigating patterns of vertical facial growth had similar observations about the third molar impaction.25 breik and grubor had comparable results when they explored the incidence of mandibular third molar impactions in various j islamabad med dental coll 2019 63 kinds of facial skeleton. they concluded that the incidence of impaction was less in brachyfacial (shortfaced) patients.26 they argued that these findings can be due to the reason that brachyfacial pattern leads to increased retromolar space because of increased amount of resorption of anterior border of ramus.26 we believe this is one of the pioneer studies in orthodontics to explore the frequency of impacted lower third molars in relation to antegonial notch depth. this study is a useful addition to the growing body of literature, as it will help in practicing evidence-based medicine by helping practitioners in early interceptive management of lower third molar impactions. the few limitations of our study were small sample size, lack of blinding and randomization. c o n c l u s i o n lower mandibular third molar impactions were found to be most frequent in orthodontic patients with deep antegonial notches. r e f e r e n c e s 1. mcardle lw, andiappan m, khan i, jones j, mcdonald f. diseases associated with mandibular third molar teeth. british dent j. 2018;224(6):434. doi: 10.1038/sj.bdj.2018.216 2. pilloud ma, heim k. a test of age estimation methods on impacted third molars in males. j forensic sci. 2019;64(1):196-200. doi: 10.1111/15564029.13860 3. becker a, chaushu s. etiology of maxillary canine impaction: a review. am j orthod dentofac orthop. 2015;148(4):557-67.doi: 10.1016/j.ajodo.2015.06.013 4. santosh p. impacted mandibular third molars: review of literature and a proposal of a combined clinical and radiological classification. ann med health sci res. 2015;5(4):229-34. doi: 10.4103/2141-9248.160177 5. niu q, zhang l, dai j, li f, feng x. orthodontic management with traction and asymmetric extraction for multiple impacted permanent maxillary teeth–a case report. open dent j. 2016; 10:553. doi: 10.2174/1874210601610010553 6. sajnani ak. permanent maxillary canines–review of eruption pattern and local etiological factors leading to impaction. j invest clin dent. 2015;6(1):1-7. doi: 10.1111/jicd.12067 7. kaczor-urbanowicz k, zadurska m, czochrowska e. impacted teeth: an interdisciplinary perspective. advan clinc exper med. 2016;25(3):575-85. doi: 10.17219/acem/37451 8. gupta s, dhingra ps, chatha s. a study of comparison and correlation between antegonial notch depth, symphysis morphology, and ramus morphology among different growth patterns in angle's class ii division 1 malocclusion. indian j dent sci. 2018;10(1):21. doi: 10.4103/ijds.ijds_109_17 9. priya b, pandian s. assessment of ramus notch depth in different skeletal malocclusion. drug inven today. 2019;12(3): 480-4 10. kar b, aggarwal i, mittal s, bhullar m, singla d, sharma a. antegonial notch and mandibular symphysis as indicators of growth pattern. dent j adv stud. 2016;6(02/03):080-8. doi: 10.1055/s-00391677777 11. porwolik m, porwolik k, domagała za, woźniak s, dąbrowski p, kacała r, kordecki h, chmielewski p, faraj sa, gworys b. typology of the antegonial notch in the human mandible. folia morphologica. 2015;74(3):365-71. 12. cotrim-ferreira fc, do valle-corotti km, lopes pd, junqueira th, stocco jr. association between respiratory pattern and mandibular morphology. revista de odontologia da universidade cidade de são paulo. 2017;21(1):18-23. 13. tung k, lagravère mo. skeletal and dental relationships in vertical/non-vertical growers using cbct. inter orthod. 2019;17(1):123-9. doi: 10.1016/j.ortho.2019.01.007 14. cerqueira pr, vasconcelos bc, bessa-nogueira rv. comparative study of the effect of a tube drain in impacted lower third molar surgery. j oral maxillofac surg. 2004;62(1):57-61. doi: 10.1016/s02782391(03)00675-x 15. lambrechts ah, harris am, rossouw pe, stander i. dimensional differences in the craniofacial morphologies of groups with deep and shallow mandibular antegonial notching. angle orthod. 1996;66(4):265-72. doi: 10.1043/00033219(1996)066<0265:dditcm>2.3.co;2 16. singer cp, mamandras ah, hunter ws. the depth of the mandibular antegonial notch as an indicator of mandibular growth potential. am j orthod dentofacial orthop. 1987 ;91(2):117-24. pmid: 3468794 j islamabad med dental coll 2019 64 17. carter k, worthington s. predictors of third molar impaction: a systematic review and meta-analysis. j dent res. 2016;95(3):267-76. doi: 10.1177/0022034515615857 18. vigneswaran at, shilpa s. the incidence of cysts and tumors associated with impacted third molars. j pharm bio sci. 2015; 7(suppl 1): s251. doi: 10.4103/0975-7406.155940 19. hatem m, bugaighis i, taher em. pattern of third molar impaction in libyan population: a retrospective radiographic study. saudi j dent res. 2016;7(1):7-12. doi: 10.1016/j.sjdr.2015.04.005 20. kumar vr, yadav p, kahsu e, girkar f, chakraborty r. prevalence and pattern of mandibular third molar impaction in eritrean population: a retrospective study. j contem dent prac. 2017;18(2):100-6. doi: pmid: 28174361 21. ayaz h, rehman a. pattern of impacted mandibular third molar in patients reporting to department of oral and maxillofacial surgery khyber college of dentistry peshawar. jkcd 2012; 2 (2): 50-53 22. shahzad m a, marath a m, chatha r m, sohail a. evaluation of patterns of mandibular third molar impactions and associated pathologies. pak oral dent j. 2016: 36 (2):192-196. 23. eroz ub, ceylan i, aydemir s. an investigation of mandibular morphology in subjects with different vertical facial growth patterns. aust orthod j. 2000; 16(1): 16-21. pmid: 11201956 24. sakuda m, kuroda y, wada k, matsumoto m. changes in crowding of teeth during adolescence and their relation to the growth of the facial skeleton. trans eur orthod soc.1976: 93-104. 25. nanda sk. patterns of vertical growth in the face. am j orthod dentofac orthop. 1988; 93(2): 103-16. doi: 10.1016/0889-5406(88)90287-9 26. breik o, grubor d, the incidence of mandibular third molar impactions in different skeletal face types. australian dent j. 2008; 53(4): 320-24. doi: 10.1111/j.1834-7819.2008.00073.x 148 j i m d c 2 0 1 7 148 op e n ac c e ss f u l l l e n g t h a r t i c l e demographic determinants of physical injuries in rawalpindi: role of rescue 1122 muhammad arshad arain 1, ahsan waqas khan niazi 2, rana muhammad aatif 3, waqar ahmed 4 1 consultant paediatrician, benazir bhutto hospital, rawalpindi 2 medical officer, thq hospital kallar syedan, rawalpindi 3 medical officer, thq hospital sharaqpur, sheikhupura 4 deputy medical superintendent, thq hospital kallar syedan, rawalpindi a b s t r a c t objective: to determine demographic characteristics, patterns and causes of physical injuries encountered in rawalpindi. 2. to access the utilization status of publically available free of cost emergency medical service system of rescue 1122. patients and methods: this cross-sectional study was conducted from november 2016 to march 2017. data was collected from rescue 1122 and emergency departments of government hospitals. there were total 2556 reported injured, with no age or gender discrimination. in order to collect the information, briefly designed performas in urdu language were circulated among the attendants of the injured and sometimes to the injured individuals. results: out of 2556 injuries reported during the study period, 1464 (57.30%) were due to fall from heights while 319 (12.5%) accidents were because of road crashes. among the road crashes, the highest incidence rate for injuries was due to bikes (n=166). as evident from the study that minor injuries; mostly abrasions were most frequent compared with the rest of the types of injury. out of 2556 cases, only 2.6% (n=67) were transported through rescue 1122. majority of the sufferers (27%) had to arrange a private transport to rush to the hospital. cars were used by 18% and private ambulances by 21% to transport the injured from accident site. conclusion: roadside accidents comprise a significant cause of injury. in view of provision of services at the time of these mishaps, rescue 1122 service, though available free of cost, is underutilized. keywords: hospitals, injuries, rescue 1122, wounds. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, active participation in data collection address of correspondence ahsan waqas khan niazi email: ahsanniazi99@gmail.com article info. received: june 1, 2017 accepted: august 29, 2017 cite this article: arain ma, niazi ahsan wk, aatif ra, ahmed w. demographic determinants of funding source: nil physical injuries in rawalpindi: role of rescue 1122. jimdc. 2017; 6(3):148-152. conflict of interest: nil i n t r o d u c t i o n globally about 5 million people die per annum because of injury, and the 15-44year people are affected mostly.1,2 the leading mechanisms of injury are road traffic crash (rtc), inter personal violence, self-harm, war, drowning and fire. people with lower socioeconomic strata are more vulnerable because of unsafe living and working environment.3 rtcs are significant public health issue globally and countries who prioritize human wellbeing have taken remedial measures. low income countries and medium income countries having the 48% of global registered vehicles do face more than 90% of death toll by rtcs. “vulnerable road users” are pedestrians, cyclists, o r i g i n a l a r t i c l e 149 j i m d c 2 0 1 7 149 riders and passengers of two-wheel vehicles are more prone to injury and comprise 46% global death toll (who).2 this figure is higher in under developed countries. in developing world, the cost of injury is estimated at 65 billion dollars and global figure rises up to 230 billion annually.4 history of injuries by fire, drowning, fall and ipv dates back from the early ages of human. however, the pattern of injuries is changing but still trauma remains on the top.3 a cyclist in new york city was reported to be first trauma sufferer on 30 may 1896 followed by a pedestrian facing fatal injury in london.5 about 7000 people lose their life in pakistan annually as an outcome of rtc.6 about 2 million rtc were reported in 2006 by national road safety.7 cost of 2 million rtcs in 2006 was estimated to be 1.14 billion dollars that had to bear by pakistani nation.7 first national injury survey of pakistan stated incidence of physical injury as 41 per 1000 individual, of which more than 1/3 were road traffic crashed.4 another cause of injury; intimate partner violence, is found to be as 44% in married women as marital physical abuse.8 blast injuries are the outcome of terrorist activities in various countries over the world especially in pakistan since recent past. to address the burden of mortality and severe distorting disability; 58 bomb blasts resulted in 689 injured and 164 ended up to death.9 a public private partnership between heart file and government of pakistan had been launched in april 2003.the partnership is nap-ncd to address determinants, and to develop strategies to address the causes of road traffic crashes, occupational injuries, falls, burns, intimate partner violence, fire and other unusual causes of injury.10 emergency medical services organizations are the direct providers of pre-hospital care in many developed countries. some of them have attained the service coverage to 70% of population. the examples are usa, uk, canada, australia and sweden. until a few years ago, pakistan had no emergency medical services.11 rescue 1122 is, claimed to be the first and only search and rescue service in public sector of punjab province; providinga pre-hospital care and rescue services to the victims of almost all types of injury by trained emergency medical technician. it was started under punjab emergency ordinance in 2004.11 it is further claimed that rescue 1122 has set an economical and effective system of pre-hospital care.11 moreover, it is claimed to be following the who guidelines.12 all the above claims are not supported by any prospective or retrospective clinical trials and supporting evidence. edhi foundation is another rescue ambulance service. they have the largest fleet of ambulance in pakistan but they do primarily transfer the injured to hospitals and do not provide pre-hospital care to the injured victims. 13 p a t i e n t s a n d m e t h o d s it was a cross sectional study conducted from november 2016 to march 2017. all the injured persons were included in the study irrespective of their injury type, mode of injury and gender. data was collected from central data bank records of rescue 1122 and from emergency departments of main tertiary care hospitals i.e. benazir bhutto hospital and holy family hospital present in district rawalpindi. in order to collect the information, briefly designed performas in urdu language were circulated among the attendants of the injured and sometimes to the injured themselves. all the data was analyzed using statistical package for the social sciences (spss) version 17.0. all the qualitative variables were expressed in the form of frequency and percentage. r e s u l t s out of 2556 injured people, 65.7% were male. most of participants belonged to 31-40 years of age with monthly income between 15,000-30,000 rupees (table 1). table 1: demographic characteristics of participants (n=2556) variables frequency percentage age (years) 1-10 185 7.2 11-20 429 16.8 21-30 468 18.3 31-40 559 21.9 41-50 469 18.3 > 50 446 17.4 gender male 1679 65.7 female 877 34.3 economic status (rupee) < below 15,000 649 25.4 15,000– 30,000 1622 63.5 31,000– 70,000 274 10.7 >70,000 11 4 illiterate 1727 67.6 primary 773 30.2 150 j i m d c 2 0 1 7 150 educational status matriculation 21 0.8 intermediate 20 0.8 graduate 12 0.5 post graduate 3 0.1 occupation businessman 9 0.3 driver 1 0.0001 farmer 1 0.0001 government employee 1 0.0001 house wife 8 0.3 laborer 17 0.7 private employee 16 0.6 student 718 28.1 un employed 10 0.4 others (beggers, drug addicts, toddlers) 1773 69.3 main cause of injury (57.28%) was fall from height. while only 12.5% injuries were because of road crashes. minor injuries; mostly abrasions (32.6%) were most frequent observed followed by punctured wounds (26.3%) (table 2). table 2: causes, types of injuries and conscious level reported among participants (n=2556) variables frequency percentage cause of injury road crash 319 12.48 violence 4 0.16 sports 11 0.43 industrial 1 0.04 fall from heights 1464 57.28 others 757 29.62 type of injury abrasion 832 32.6 punctured wound 671 26.3 lacerated wound 434 17 wound > 5cm 34 1.3 joint dislocation 132 5.2 single fracture 99 3.9 multiple fracture 5 0.2 spinal injury 2 0.1 head injury 37 1.4 chest injury 2 0.1 abdomen injury 5 0.2 poly trauma 303 11.9 conscious level conscious 2276 89 semiconscious 198 7.7 unconscious 80 3.1 dead 2 1 among the road crashes the highest incidence rate for injuries was due to bikes (6.5%) followed by pedestrians (4.5%). most of the people were not provided first aid at the site of injury (91.7%). majority of them were carried to hospitals through rickshaw (27.46%) or private ambulances (21%). rescue 1122 services were provided to only 2.62% injured people (table 3). table 3: facilities provided to participants after getting injury (n=2556) variables frequency percentage first aid not given 2345 91.7 ambulance 68 2.7 govt. hospital 113 4.4 private hospital 30 1.2 treatment treated & discharge 2230 87.2 emergency treatment & admitted 325 12.7 emergency surgery 1 0.01 mode of transportation rickshaw 702 27.46 private ambulance 537 21 private car 466 18.23 taxi cab 387 15.14 bike 266 10.41 lift (people carrying the injured to the hospital) 127 4.97 rescue 1122 67 2.62 walkin 4 0.16 among those who used rescue 1122 services, majority (86%) were highly satisfied, remaining 15% also gave good comments (figure 1). figure 1: satisfaction level among injured persons (n=2556) 151 j i m d c 2 0 1 7 151 d i s c u s s i o n as shown by the above-presented data analysis, there were more male victims (65.7%) than females. this is because of the social fact that males are more out-in-town for domestic and financial (bread & butter earning) activities so, being more vulnerable to road-crashes and occupational trauma. mostly reported cases (57%) were of fall from heights while only 12.5% were due to road crashes. among the road crashes the highest incidence rate for injuries were of bikes 6.5% followed by pedestrians (4.5%). increasing number of four-wheeled small vehicles is clearly in-line with the expectation of involvement of cars in the accidents but recorded data has shown more involvement of the bikes in the roadcrashes. unauthorized commercial transport, lacking routine safety evaluation, long driving hours, overspeeding are the one aspect, mass-transit vehicles are potentially liable for the injury-proneness however. education status, though not a direct indicator of driving skills but following the traffic rules and being able to drive and act safe has strong impact. more a person is literate less he or she is prone to accident either because of the relevant knowledge or just being a law-abiding citizen. as the data showed, there were only 0.1% of people with highest qualification had been the sufferers while maximum frequency (67.6%) belonged to the category of illiterates. poor being more prone to the road, occupation and other work-related injuries are also indicative of the results of this provided data as 63.5% of entries belonged to the economical group of average monthly income of 15000-30000 pkr, which is the second lowest category. geographically evident areas of saturated traffic pose more threat to the people on the road mostly for their routine. as evident from the data the following areas; satellite town, raja bazar and peer wadhai have shown increased record of trauma, mostly rtcs, because of high urbanization and vehicle-motorization. dropping at and picking kids from the schools, locations of offices and banks, catchment areas of commercial markets are most observed accident-prone areas. as evident from the study, minor injuries mostly abrasions are most frequent comparing with the rest of the types of injury. evidence of poly-trauma has been found for 11% of the total recorded cases. keeping in view the fact that the provided data and its employed collection tool is deficient in highlighting the outcome of all the injured taken to the hospitals. this is more of value for those who had been labeled as major and severe injured. evacuation and transportation of injured from the site of incident to the nearest medical facility is an important aspect of the rescuing. though maximum part of the golden hour is potentially consumed in the arrangement of transport and getting through the heavy and disorganized traffic, much of the potential morbidity has been averted (53% of injured) as the facility was nearest (2-5 km) while few (about 4%) had to travel more than 50 km. the deficiencies in the data-collecting tool pose difficulty and getting desired correlation of various social and demographic factors, which could be conclusive for potential improvements and policy-making regarding achievement of safe roads and safe occupations.14 as rescue 1122 being the only publically launched rescue service in punjab about a decade back has its own limitations out of which many are not even mentioned or reported rather than addressed. limited coverage area, lack of utilization is clearly highlighted as evidenced by only 2.6% of the injured being transported through rescue 1122. majority of the sufferers 27% had to arrange a private transport to rush to the hospital. cars and motor-bikes, each carrying 18% and 21% of the injured from incident site. among the injured who has been transported to nearest facilities by rescue 1122, the satisfaction level was seen up to 90% despite of the fact that a majority i.e. 97.3% of the respondents were transported by other means to the nearest hospital. fall from height has been observed more commonly associated mode of injury among males. comparable ratios of male to female are high in all categories of mode of injury but the most commonly observed injury mode was the same. among the most commonly involved victim’s vehicle i.e. bike has been observed to be the most commonly employed vehicle for the mode of hospital transportation. second most common victim’s category was pedestrian being transported to hospital mostly through taxi/cab. the unconscious status of the victims has been more commonly observed among age group 41-50 years. bikes are the most commonly involved as primary vehicle and in 152 j i m d c 2 0 1 7 152 maximum situations it struck with some object or slipped. almost all of the cars stuck also with some objects according to the data while pedestrians have been mostly hit by bikes. c o n c l u s i o n although rescue 1122 is publically available free of cost service, it is currently underutilized. extending the coverage of rescue 1122 up to 36 districts of punjab is a worth praising step but lack of awareness in general public is a major obstacle in reduction of mortality and morbidity. hence, promoting public awareness about rescue 1122 can improve effectiveness of this service. r e f e r e n c e s 1. lopez ad, mathers cd. measuring the global burden of disease and epidemiological transitions: 2002-2030. ann trop med parasito, 2006; 100(56):481-99. 2. world health organization. injuries. geneva, world health organization. 2008. 3. beuran m, negoi i, paun s, runcanu a, gaspar b. history of trauma care. chirurgia (bucur), 2010; 106(5):573-80. 4. ghaffar a, hyder aa, masud ti. the burden of road traffic injuries in developing countries: the 1st national injury survey of pakistan. public health, 2004; 118(3):211-17. 5. world health organization, road traffic accident global impact, www.who.int/roadtrafficaccidents. 6. farooq u, bhatti ja, siddiq m, majeed m, malik n, razzak ja, khan mm. road traffic injuries in rawalpindi city, pakistan. eastern mediterranean health journal, 2011; 17(9):647-53 7. ahmed a. road safety in pakistan. islamabad: national road safety secretariat. 2007. available at http://ae.linkedin.com/pub/ aizaz-ahmed/34/114/17a. 8. fikree ff, jafery sn, korejo r, afshan a, durocher jm. intimate partner violence before and during pregnancy: experience of postpartum women in karachi, pakistan. j pak med assoc, 2006; 56(6):252-7. 9. mehmood a, razzak j, khan sj. blast injuries in karachi. in: health sciences research assembly 2007. the agha khan university, karachi, pakistan; 2007. 10. nishtar s, mohamud kb, razzak ja, ghaffar a, ahmed a, khan sa, mirza ya. injury prevention and control: national action plan of ncd prevention, control and health promotion in pakistan. jpma, 2004; 54:57-68. 11. waseem h, naseer r, razzak ja. establishing a successful prehospital emergency service in a developing country: experience from rescue 1122 service in pakistan. emerg med j, 2011; 28(6): 513-5. 12. varghese m, sasser s, kellermann a, lormand jd. world health organization. prehospital trauma care systems. geneva, world health organization; 2005. 13. edhi foundation. edhi foundation services. field ambulance services 2010. available from url: http://www.edhifoundation.com/edhi-foundationservices.asp#06. 14. trickey aw, fox ee, junco d, ning j, holcomb jb, brasel kj, cohen mj, et al. the impact of missing trauma data in predicting massive transfusion. the journal of trauma and acute care surgery, 2013; 75: s68.–s74. doi:10.1097/ta.0b013e3182914530 http://www.edhifoundation.com/edhi-foundation-services.asp#06. http://www.edhifoundation.com/edhi-foundation-services.asp#06. j islamabad med dental coll 2020 12 open access assessment of complete coverage of expanded program on immunization in children at mayo hospital lahore, pakistan qurat ul ain khalid1, imran mahmood khan2, wajeeha amber1, aqmal laeeq chishti3, khawaja amjad hassan4 1senior registrar, department of pediatric, islamabad medical and dental college, islamabad 2assistant professor, department of pediatric, islamabad medical and dental college, islamabad 3professor, department of pediatric, king edward medical university, lahore 4associate professor, department of pediatric, king edward medical university, lahore a b s t r a c t background: the primary goal of the expanded program on immunization (epi) is to ensure full immunization of children under one year of age to globally eradicate poliomyelitis, tetanus, me asles-related deaths and to extend all new vaccines and preventive health interventions to children in all parts of the world. demographic and health survey 2012-13 showed that in pakistan complete immunization coverage is very low (54%) to achieve this goal. the objective of this study was to assess any improvement in terms of vaccination coverage in pakistan in the last 3 -4 years. material and methods: this descriptive cross-sectional study was carried out at outpatient department of pediatric medicine of mayo hospital lahore from may, 2016 till november, 2016 . the non-probability purposive sampling technique was used to include patients after taking informed consent. demographic details were collected and parents were questioned about different vaccinations received and confirmed through vaccination card. data analysis was done through spss version 20 and results were presented as frequencies and percentages. chi-square test was applied for association among categorical variables. results: complete coverage of expanded program on immunization was achieved in 86% children. a statistically significant difference was noted between mother’s education and immunization coverage of children (p-value 0.013). conclusion(s): education of mother and socioeconomic status were significant factors affecting immunization coverage. in order to meet target of 95% immunization coverage rate set by who, more awareness should be created among people with low socioeconomic status along with improvement of immunization facilities in these areas. key words: children, expanded program on immunization, immunization coverage authors’ contribution: 1-3conception; literature research; manuscript design and drafting; 4,5critical analysis and manuscript review; data analysis; manuscript editing. correspondence: imran mahmood khan email: lifesaverforu@yahoo.com article info: received: december 27, 2018 accepted: march 14, 2020 cite this article. khalid q, khan im, amber w, chishti al, hassan ka. assessment of complete coverage of expanded program on immunization in children at mayo hospital lahore, pakistan. j islamabad med dental coll.2020; 9(1): 12-16. doi: 10.35787/jimdc.v9i1.501 funding source: nil conflict of interest: nil i n t r o d u c t i o n the expanded program on immunization (epi) is a world health organization (who) program with the goal to make vaccines available to all children throughout the world. who initiated the epi in may 1974 with the objective to vaccinate children throughout the world. ten years later, in 1984, the who established a standardized vaccination schedule for the original epi vaccines: bacillus or i gi n a l a r ti c le j islamabad med dental coll 2020 13 calmette-guerin (bcg), diphtheria-pertussistetanus (dpt), oral polio, and measles. increased knowledge of the immunologic factors of disease led to development of new vaccines which were subsequently added to the epi’s list of recommended vaccines: hepatitis b (hep b) and hemophilus influenzae type b (hib) vaccines (in 2009) and pentavalent pneumococcal vaccine (in 2013) in countries with high burden of disease.1 the current goals of epi are to ensure full immunization of children under one year of age to globally eradicate poliomyelitis, reduce tetanus and measles-related deaths. it also encompasses prevision of new vaccines and preventive health interventions to children in all parts of the world.1,2 according to the demographic and health survey (pdhs) of 2012-13, overall vaccination status of pakistan is 54%, which is quiet low. 3 according to who, immunization coverage should be at least 95% to provide herd immunity to those individuals who are not immunized. immunization coverage varies in different regions of pakistan. it is 64.2% in peshawar,4,5 45% in karachi6 and 77.4% in nurpur shahan village near islamabad.7 in bangladesh, demographic and health survey 2014 showed that 84 percent of children aged 1223 months were fully vaccinated, 14% children were partially vaccinated and only 2% children had not received any vaccinations.8 according to indian national family health survey 2015-16, 62% of children aged 12-23 months received all basic vaccinations, 32% were partially vaccinated and 6% children received no vaccinatio n at all.9 a study conducted in angola, a country of south central africa showed that only 37% children completed the vaccination schedule, while 52% did not receive any vaccination.10 full immunization rate in england is 86.2% according to 2016-17 survey.11 centers for disease control (cdc) statistics of 2017-18 showed that usa is close to who target of complete vaccination coverage having immunization rate of near 95%.12 as pakistan demographic and health survey ( pdhs) statistics (2012-13) for complete immunization coverage in children are very low as compared to other countries of the world as well as who target, the present study was conducted to assess any improvement in terms of vaccination coverage in pakistan in the last 3-4 years. m a t e r i a l a n d m e t h o d s after seeking permission from institutional ethics review board of mayo hospital lahore, this crosssectional study was conducted at the outpatient department (opd) of pediatric medicine, mayo hospital lahore from may, 2016 till november, 2016. children of both genders, from 16 months to 5 years of age, presenting in the opd for the treatment of various diseases were included in th is study. those children whose vaccination cards were misplaced and parents were unable to recall the vaccination status were excluded from the study. a total of 300 children were included in the study. sample size was calculated by using who sample size calculator with following values of calculations; 95% confidence level, 5.5% margin of error and expected percentage of complete epi coverage as 64.2% in children presenting in a tertiary care hospital.4 these patients were recruited through non-probability, consecutive sampling and informed consent was taken from the parents. demographic details (name, age, sex, anthropometric measurements, education of mother and income level of families) were collected by treating physicians in opd on pretested questionnaire. mothers were divided into two categories based on the level of education; under matric and matric and above. income level was divided into three categories; low (monthly inco m e less than rs. 20,000), middle (monthly income rs. 20,000 to rs. 60,000) and high (monthly income j islamabad med dental coll 2020 14 more than rs. 60,000). parents were asked about different epi vaccinations like tuberculosis, poliomyelitis tetanus, measles, diphtheria, pertussis (whooping cough), hepatitis b, hib and pneumococcal. number of vaccination shots were confirmed through vaccination card of the child. data analysis was done using spss version 20. quantitative variables such as age, height and weight were presented as means and standard deviation. qualitative variables such as gender and complete epi coverage were presented as frequencies and percentages. data was stratified for gender, socioeconomic status and educational status. chi-square was used to compare the stratified groups. p-value ≤0.05 was considered as statistically significant. r e s u l t s in this study, a total of 300 children were enrolled with a mean age of 36.39 ± 12.39 months and 56% male and 44% female children (table i). the male to-female ratio of the patients was 1.27:1. mean values of height and weight of children, mother’s education and family’s income level are shown in table i. full epi coverage was achieved in 86% and not achieved in 14% of children (table i) . the difference between income level of families and epi coverage (p-value 0.000) as well as between the mother’s education and epi co v e rage of the children was statistically significant (p-value 0.013), while there was no association between gender and epi coverage in children (p-value 0.86) logistic regression was applied to check the combined effect of effect modifiers on epi coverage. three effect modifiers were identified i.e. mother’s education, gender of child and income level of families. among these variables, only mother’s education had significant impact on epi coverage, while the gender of child and income level of families did not show significant impact (table ii). the final model was: epi coverage = 19.946 – 0.899 (mother’s education). table i: characteristics of children, mother’s education and family’s income level characteristics mean ± sd age (months) 36.39±12.39 height (feet) 3.01±0.48 weight (kg) 13.96±4.88 variables n (%) gender male 168 (56%) female 132 (44%) mother’s education under matric 126 (42%) matric or above 174 (58%) income level low 165 (55%) middle 111 (37%) high 24 (8%) full epi coverage yes 258 (86%) no 42 (14%) d i s c u s s i o n infant and under-five mortality rates in pakistan are alarmingly high. the most recent data show that out of 1,000 live births, 74 infants and 89 children under five die before their first and fifth birthdays, respectively.3 a significant proportion of these deaths are preventable by immunizing pregnant mothers and children. since 1978, the epi has been responsible for the nationwide immunization of children in pakistan. in the early phase of the program, less than 2 percent of pakistani children were fully immunized in 1982. this figure quickly rose to 59 percent in 1984. another milestone was achieved with the introduction of gavi support of two new vaccines in the late 1990s and in 2001, the hep-b and hib vaccines. in 2008, the program introduced the pentavalent vaccine, which simplifies the schedule for full vaccination to five visits during the child’s first year of life. 13 in the present study, the epi coverage was achieved in 86% children which is quite encouraging. statistically significant difference was noted j islamabad med dental coll 2020 15 *p-value of chi-square test; $b: beta value; #p-value for logistic regression; constant=19.946 between mother’s education and epi coverage of the children (p-value 0.013). our results showed that 165 children belonged to low income level families in which epi coverage was achieved in 123 cases, 111 children belonged to middle income level families in which epi coverage was achieved in all cases. similarly, 24 children belonged to high income level families in which epi coverage was achieved in all cases. a study conducted in peshawar in 2010 showed similar results. the low polio vaccination coverage in peshawar is mainly due to low awareness amon g people, poor socioeconomic conditions and poor salaries, insecurity and transport problems faced by the immunization staff.4 a study done in lahore (2011) in labor community showed 59% children received full course of vaccination which is consistent with our results of low immunization coverage (74.5%) among children belonging to low socioeconomic conditions. so, efforts should be intensified to reach poor child re n living in far off areas.14 in a study conducted in karachi (from 2014-2016), a total of 51.8% children were completely vaccinated, 41.6% were incompletely vaccinated and 6.6% were unvaccinated. these results of complete vaccinations are considerably lower than our study as well as pdhs statistics of 2012-13. the drop-outs to the subsequent vaccines needs to be controlled immediately to prevent this alarming situation. 15 a study done in abbottabad (in 2015-16) reported 84.4% of the children as fully vaccinated with majority of these children having educated mothers. these results are comparable to our study and higher than those of pdhs statistics of 2012-13 which is very motivating indeed.16 studies from other counties also showed similar results to our study. a study in angola, a southcentral african country found that higher level of maternal education would facilitate increased vaccination coverage and low family income lead to behaviors where preventive activities are not considered family priorities.10 likewise, a study conducted in bangladesh sho w e d that mother’s level of education is strongly associated with polio vaccination coverage.17 c o n c l u s i o n our study results showed that the epi coverage was 86% which is encouraging and higher than pdhs statistics of 2012-13. education of mother and socio-economic status of people are two significan t factors that plays an important role in the epi coverage. in order to meet who target of 95% immunization rate, more epi awareness should be created in people with low socioeconomic status table ii: comparison of epi coverage in children with gender, mother’s education and income levels and logistic regression to check combined effect of factors on epi coverage epi coverage total *p-value logistic regression yes (%) no (%) $b #p-value gender male 145 (86.3) 23 (13.7) 168 0.86 -0.03 0.932 female 113 (85.6) 19 (14.4) 132 mother’s education under matric 101 (80.2) 25 (19.8) 126 0.013 -0.89 0.014 matric and above 157 (90.2) 17 (9.8) 174 income level low 123 (74.5) 42 (25.5) 165 0.000 -19.61 0.995 middle 111 (100) 0 111 high 24 (100) 0 24 j islamabad med dental coll 2020 16 along with availability of better epi facilities in such areas. a c k n o w l e d g m e n t we are thankful to all children and their parents who participated in our study. r e f e r e n c e s 1. khowaja ar, khan sa, nizam n, omer sb, zaidi a. parental perceptions surrounding polio and selfreported non-participation in polio supplementary immunization activities in karachi, pakistan: a mixed methods study. bull world health organ. 2012; 90(11): 822-30. doi: 10.2471/blt.12.106260 2. arooj s, ali s, baber n, abbasi a, ali m. socioeconomic factors effecting polio vaccination in pakistan. health2013; 5(5): 892-897. doi: 10.4236/health.2013.55117 3. national institute of population studies [pakistan] and icf international. pakistan demographic and health survey 2012-13 4. naeem m, adil m, abbas sh, khan mz-i, naz sm, khan a, et al. coverage and causes of missed oral polio vaccine in urban and rural areas of peshawar. j ayub med coll abbottabad.2011; 23(4): 98–102. pmid: 23472426 5. ahmad n, akhtar t, roghani mehr taj. immunization coverage in three districts of north west frontier province (nwfp). jpma. 1999; 49(12): 301–5. pmid: 10695282 6. iddiqi n, khan a, nisar n, siddiqi a -e-a. assessment of epi (expanded program of immunization) vaccine coverage in a peri-urban area. jpma. 2007; 57(8): 391–5. pmid: 17902521 7. ahmad r, alvi s, hassan m. availability of expanded programme of immunization services provided to children in a rural pakistani village. jpma. 2011; 61(4): 415–8. 8. iftekharuddin km, awwal a. field guide to image processing. 2012; 96 9. international institute for population sciences (iips) and icf. national family health survey (nfhs-4) 201516 india. iips. 2017 10. oliveira mfs de, martinez ez, rocha jsy. factors associated with vaccination coverage in children &lt; 5 years in angola. rev saude publica. 2014; 48(6): 90615. doi:10.1590/s0034-8910.2014048005284 11. charlton e. immunisation statistics. british society for immunology. 2017 12. mellerson jl, maxwell cb, knighton cl, kriss jl, seither r, black cl. vaccination coverage for selected vaccines and exemption rates among children in kindergarten — united states, 2017–18 school year. mmwr morb mortal wkly rep. 2018; 67(40): 1115 – 22. doi: 10.15585/mmwr.mm6740a3 13. haque mu, waheed m, masud t, malick ws, yunus h, rekhi r, et al. the pakistan expanded program on immunization and the national immunization support project : an economic analysis. 2016; 1–66 14. shaheen a, batool s, khan f, awan m, siddique a. vaccination status of children aged 1-5 years in labour community. esculapio j serv inst med sci. 2011; 7(3): 30–1 15. siddiqui s, akbar m, mehtab a, zafar m, shahid s, ahmad s, et al. frequency of immunisation of children upto five years of age according to vaccination card in karachi a multicentre study. ann abbasi shaheed hosp karachi med dent coll. 2017; 22(1): 12–9 16. zeb j, zeeshan m, kamal m, saleem m, shah t. effects of mother`s literacy on child health assessed by personal hygiene, nutritional and vaccination status. pak j physiol. 2017; 13(1): 22–5 17. biswas sc, darda ma, alam mf. factors affecting childhood immunisation in bangladesh. the pakistan development review. pakistan institute of development economics, islamabad. 2001; 40: 57 –70 j islamabad med dental coll 2019 60 open access teratogenic effect of sodium phenytoin on limb development in chick embryos is time-mediated as evident by stereomicroscope hamd binte shahab syed 1, m. yunus khan 2, ruqqia shafi minhas 3 1 assistant professor, department of anatomy, cmh institute of medical sciences, multan 2 professor/head, department of anatomy., cpsp regional center, islamabad. 3 assistant professor, department of anatomy, fazaia medical college, air university, islamabad a b s t r a c t background: women suffering from seizure-related illnesses are prescribed phenytoin during pregnancy if the benefits outweigh the risks. but the teratogenic effect of this drug on limb development needs exploration. this study was designed to investigate the time-mediated teratogenic effect of sodium phenytoin on limb development of chick embryos on days 04 and 09 of development using the stereomicroscope and at the time of hatching. material and methods: this randomized control trial comprised of two main groups of fertilized chicken eggs (egyptian fayoumi breed), control group a and experimental group b, each having 90 eggs. each experimental egg was injected with sodium phenytoin (3.5 mg, teratogenic dose) just before incubation. both the groups were divided into three subgroups each a1, a2, & a3/b1, b2 & b3. stereomicroscope was used to observe the limb buds and cartilaginous elements in subgroups 1 and 2 on days 04 and 09 of development respectively. the embryos of subgroups 3 were assessed for gross limb deformities on hatching. survival was noted in all the subgroups. results: the difference in limb bud size between experimental and controls was statistically insignificant. there was no variation or deformity in the bones. the experimental group 3 had gross limb defects on hatching and the difference in survival was also statistically significant in subgroups 3. conclusion: prenatal administration of sodium phenytoin induces limb defects in chick embryos as evident after hatching but limb anomalies are not observed on days 04 and 09 of development as investigated by stereomicroscope. we conclude that the teratogenic effect of phenytoin is time-mediated. key words: chick embryos, phenytoin, teratogen authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3 active participation in data collection 4 data analysis. correspondence: hamd binte shahab syed email: hamdsyed@hotmail.com article info: received: january 8, 2019 accepted: april 19, 2019 cite this article. syed hbs, khan my, minhas rs. teratogenic effect of sodium phenytoin on limb development in chick embryos is time-mediated as evident by stereomicroscope. j islamabad med dental coll.2019; 8(2):60-64 funding source: nil conflict of interest: nil i n t r o d u c t i o n nearly 50% patients prescribed anti-epileptic medications in pakistan are females.1 one of such medications, sodium phenytoin is a drug commonly prescribed to pregnant women for seizures and related illnesses if the therapeutic benefit outweighs the potential risk.2 babies born to such mothers are at an increased risk for the fetal hydantoin syndrome in which birth defects of the limbs is a consistent feature. the limb defects include digital hypoplasia, a ‘finger-like’ thumb, polydactyly, syndactyly, absence of palmar creases and positional limb defects (club feet).3,4 the precise mechanism of phenytoin-induced limb defects is still unclear and several hypotheses have been proposed.5 similar to humans, limbs appear in chick embryos as small elevations (buds) from the ventrolateral o r i g i n a l a r t i c l e j islamabad med dental coll 2019 61 body wall composed of undifferentiated mesenchyme (lateral plate mesoderm) with an epithelial covering (ectoderm). the ectoderm at the distal border of the limb bud is thickened to from the apical ectodermal ridge (aer) which exerts an inductive influence on the underlying mesenchyme causing it to remain as a population of undifferentiated rapidly proliferating cells called the progress zone (pz). as the limb bud grows the cells farther from the influence of the aer leave the pz and differentiate into cartilage and muscle, therefore the fate of the mesodermal cells is determined by the length of time spent in the pz during limb growth.6 the current study was aimed at investigating the timemediated teratogenic role of phenytoin keeping in mind the interplay of the progress zone and aer regarding outgrowth and development of cartilaginous structures in the developing limbs. the stereomicroscope (olympus model sz 40) was chosen for qualitative assessment of these parameters as it provides increased depth perception and structures can be visualized in threedimensional form.7 m a t e r i a l a n d m e t h o d s this research was carried out in the research laboratory of the department of anatomy located at the regional center of college of physicians and surgeons islamabad pakistan, from january 2014 to january 2015. ethical approval was given by the research advisory/evaluation committee of cpsp for basic medical sciences. a total of 180 freshly laid fertilized chicken eggs belonging to ‘egyptian fayoumi’ breed was obtained from the poultry research institute (pri), rawalpindi. cracked and dirty eggs were not included. all selected eggs were counted, numbered and were randomly distributed to control group (a) and experimental group (b) 90 eggs each, using the random selection table. these groups were further subdivided into subgroups 1, 2 and 3 each comprising 30 eggs. each egg of experimental group b was administered 3.5 mg sodium phenytoin by injection into egg albumen8 while each egg of control group was injected with equal volume of normal saline. dosage of sodium phenytoin was calculated by using the reference from study by singh and shah9 and by conducting a series of pilot experiments with several preliminary doses at our laboratory. injections were given with an insulin syringe (needle size 30-gauge x 8mm) and eggs were transferred to the incubator. temperature of the incubator was kept at 38±0.5°c, relative humidity was maintained between 60-70% and an uninterrupted electrical supply to the incubator was ensured. the eggs were rotated ½ turn twice daily for adequate gaseous exchange and uniform distribution of heat.10 on day 04 of incubation, the embryos were gently extracted from eggs of subgroups a1 and b1. each embryo was placed in a petri dish containing 70% isopropanol (2-propanol) and inspected under the stereomicroscope for the qualitative assessment of the external form and size of the limb buds. the limb bud size was recorded as small, moderate or large on the basis of hamburger and hamilton staging of chick embryo development.11 the observations were compared with controls and analyzed by chi-square test according to the statistical package of social sciences (spss), version 16. a p-value of ≤ 0.05 was considered statistically significant. on day 09 of incubation, the embryos from the eggs of subgroups a2 and b2 were extracted. the cartilaginous elements were selectively stained with methylene blue and observed under the stereomicroscope to check for anomalies like duplication, truncation etc. the number of bones was counted in the proximal, middle and distal segments including the number of phalanges in the digits to check for any missing or malformed bones. the qualitative data was noted on observation sheets using the hamburger and hamilton staging system as a reference guide.11 the chicks belonging to subgroups a3 and b3 were allowed to hatch by themselves till day 22 of incubation or assisted in hatching after day 22. the chicks of subgroup b3 were observed for gross abnormalities, lack of mobility and any abnormal behavior. survival was noted in all the subgroups. r e s u l t s on observation of the chick embryos of subgroup a1 under the stereomicroscope and incident illumination, each embryo was arched and had a brain (telencephalon, j islamabad med dental coll 2019 62 diencephalon, mesencephalon, metencephalon, myelencephalon), developing eyes, somites and heart. the developing limb buds for the wings and legs were clearly visible. the forelimb bud was identifiable as a protruding mound of tissue next to the beating heart at the level of the thoracic somites. the early hindlimb bud was also visible as a similar mass opposite the lumbosacral somites. the stereomicroscopic features of subgroup b1 were similar to that of the controls (figure.1). the size of the limb buds was observed to be moderate in majority of the specimens and the difference in limb bud size between subgroups a1 and b1 was found to be statistically insignificant (p 0.737) (table i). *statistically significant the cartilaginous pattern of the wings and legs of embryos of subgroups a2 and b2 was observed under the stereomicroscope. the methylene blue stained skeleton appeared homogeneous and well demarcated at this stage. the soft tissues were visible as translucent masses surrounding the skeletal framework. there was no duplication, truncation or missing bones. the bone count in the experimental group matched that of controls and there was no variation or deformity (figure.2). survival was less in the experimental chicks as compared to the controls. this difference was statistically significant between subgroups a3 and b3 (p 0.010) (table i). out of the alive chicks from experimental subgroup b3, nine had wings which appeared to be smaller in size in comparison to the wings of control animals, one had abnormally positioned feet with malformed toes spread out asymmetrically and one chick showed tremors in the legs accompanied by neck torsion. all the chicks were weak and unable to stand or walk properly (figure.3). all the dead chicks belonging to subgroup b3 exhibited a gross reduction in size whereas four of them had abdominal wall defects and one had inverted feet with malformed toes. all the chicks of control subgroup a3 were alive and active without any obvious deformity. figure 1: photomicrograph through stereomicroscope of 04-day old chick embryo of subgroup b1; developing wing(w) and leg buds(l), telencephalon(t), diencephalon(d), mesencephalon (ms), metencephalon (mt), myelencephalon (my), atrium (at), allantois (al) figure 2: photomicrograph through stereomicroscope of methylene blue stained 09-day old chick embryo of subgroup b2. leftdeveloping wing; humerus (h), radius (r), ulna (u), carpus (c), and phalanges in digits 1-3, right-developing leg; femur (fm), tibia (t), fibula (fb), metatarsus (m) and phalanges (p). table i: comparison of limb bud size (observed under stereomicroscope) between subgroups a1 and b1 and survival between all subgroups subgroups a1 b1 a2 b2 a3 b3 1: limb bud size (%age) small 4 4 moderate 85 88 large 11 8 p value 0.737 2. number of surviving embryos 30 29 30 26 30 24 p value 0.491 0.112 0.010* j islamabad med dental coll 2019 63 figure 3: photograph of newly hatched chicks belonging to experimental subgroup b3 and control subgroup a3. the one in the photograph also had inverted feet with malformed toes (arrow). d i s c u s s i o n the congenital limb defects observed in the experimental chicks in this study involved both upper and lower limbs. the live chicks showed weakness in the legs. there was a wide spectrum of limb anomalies including smaller wing size, inverted feet and malformed toes. this correlates with previous research that establishes phenytoin as a wellrecognized teratogenic agent that induces skeletal dysplasia and limb anomalies in human newborns.2-4 limb development in human embryos begins near the end of the 4th week of intrauterine life. the critical period of limb development is from 24 to 36 days’ post fertilization.12 this critical period of limb development in human embryos is represented by corresponding hamburger-hamilton stages 17-23 of development in the chick embryos. therefore, day 04 of incubation (96 hours of age) which corresponds to hamburger-hamilton stage 23 was chosen for observation of the external form and size of the chick limb bud under the stereomicroscope in this study.11 day 09 of incubation was chosen for observation of the cartilaginous elements in developing chick limbs because this time period corresponds to hamburger and hamilton stage 35 of chick development when the cartilaginous skeleton has been completely formed and can therefore, be observed for any abnormalities.11 the teratogenic effects of phenytoin have been documented in studies previously conducted on laboratory animals. our observations are consistent with the study by singh and shah9 who observed the teratogenic effects of sodium phenytoin on chick embryos and found out reduced body weight, abdominal wall defects and limb defects including shortening of the wings and hypoplasia of the digits. however, the serial observation of embryos at two points before hatching is an important aspect of our research which clearly shows that the deleterious effect of phenytoin is timemediated. it does not affect the earlier or differentiation phases of development but the later stages of growth. previously conducted prospective case-control cohort study by waters13 and colleagues showed the association of maternal intake of phenytoin with an increased incidence of fetal death and anomalies. in our study, survival was less in the experimental chicks as compared to the controls. also, the number of surviving embryos gradually decreased in the experimental groups as days of development advanced. this difference was statistically significant between the chicks of subgroups a3 and b3 further supporting the time-mediated teratogenicity of phenytoin. studies14 have shown that limb skeletal elements are laid down in a proximodistal sequence with the proximal elements beginning differentiation earlier than the more distal ones. the ‘progress zone model’ was proposed by researchers to explain skeletal patterning in vertebrate limbs. their research describes a layer of rapidly proliferating mesenchymal cells approximately 300 µm wide adjacent to and directly under the influence of the aer. once the aer is established, it produces fibroblast growth factors (fgf4 and fgf8) which maintain the progress zone. as the limb bud grows, cells in the proximal part of the pz escape its influence and form cartilage and muscle. the cells remaining longer in the progress zone give rise to distal elements. thus, cells residing in the pz have some sort of autonomous timing mechanism.15 our study seems to support this hypothesis that the undifferentiated zone of the limb bud are more prone to teratogenic effects of phenytoin as evident by the distal limb defects in the b3 experimental group. j islamabad med dental coll 2019 64 in our study, upon close inspection with the stereomicroscope, the cartilage pattern and number of bones was normal with no missing or duplicated pieces in the experimental chick embryos of subgroup b2. a possible explanation for this may be that the dose of phenytoin administered in this study was insufficient to produce any visible anomaly at this earlier stage of differentiation. similar to limb bud size, the cartilage pattern did not show any irregularities further supporting the conclusion that the teratogenic effect of sodium phenytoin must be time mediated. this study warrants precaution in administering sodium phenytoin and similar antiepileptic medications to pregnant ladies as the birth defects particularly limb anomalies might not be evident until much later stages of development. the main limitation of our study was that the stereomicroscope allows viewing a relatively large object in three dimensions, but provides low magnification. c o n c l u s i o n exposure of chick embryos to sodium phenytoin produces visible limb defects after hatching. no abnormality of limb morphogenesis is observed during developmental days 04 and 09 when inspected under the stereomicroscope. therefore, we conclude that the teratogenic effect of sodium phenytoin is time-mediated and the limb defects were induced at the maturation stage instead of differentiation. r e f e r e n c e s 1. mazhar f, shamim s, malhi sm. drug utilization evaluation of antiepileptics in three selected multidisciplinary teaching hospitals of pakistan. int j pharm pharm sci 2014; 6(5): 5966. 2. tomson t, battino d. teratogenic effects of antiepileptic drugs. the lancet neurol 2012; 11(9): 803-13. doi: 10.1016/s1474-4422(12)70103-5 3. singh r, kumar n, arora s, bhandari r, jain a. fetal hydantoin syndrome and its anaesthetic implications: a case report. case rep anesthesiol 2012. doi: 10.1155/2012/370412 4. singh a, bhatia hp, mohan a, sharma n. fetal hydantoin syndrome: a case report. j indian soc pedod prev dent. 2016 ;34(1):92-5. 5. etemad l, moshiri m, moallem sa. epilepsy drugs and effects on fetal development: potential mechanisms. j res med sci 2012; 17(9): 876–81. pmid: 23826017 6. sadler tw. langman’s medical embryology. 12th ed. philadelphia: lippencott william and wilkins 2012. 7. jia s, chen d, wang d, bao x, tian x. comparing marginal microleakage of three different dental materials in veneer restoration using a stereomicroscope: an in vitro study. bdj open. 2017; 3: 16010. doi: 10.1038/bdjopen.2016.10 8. ahangari yj, hashemi sr, akhlaghi a, atashi h, esmaili z, ghorbani m, et al. effect of in ovo injection of royal jelly on posthatch growth performance and immune response in broiler chickens challenged with newcastle disease virus. iran j appl anim sci 2013; 3(1): 201-06. 9. singh m, shah gl. teratogenic effects of phenytoin on chick embryos. teratology. 1989;40(5):453-8. 10. tona k, onagbeasan o, bruggeman v, mertens k, decuypere e. effect of turning duration during incubation on embryo growth, utilization of albumen and stress regulation. poult sci. 2005; 84(2): 315-20. 11. hamburger v, hamilton hl. a series of normal stages in the development of the chick embryo. 1951. dev dyn. 1992; 195(4): 231-72. doi: 10.1002/aja.1001950404 12. moore k. l, t.v.n persaud, torchia m. g. the developing human: clinically oriented embryology. 10th ed. philadelphia, pa: elsevier 2016. 13. waters ch, belai y, gott ps, shen p, de giorgio cm. outcomes of pregnancy associated with antiepileptic drugs. arch neurol. 1994;51(3):250-53. 14. fernandez-teran m, ros ma. the apical ectodermal ridge: morphological aspects and signalling pathways. int j dev biol. 2008; 52(7): 857-71. doi: 10.1387/ijdb.072416mf 15. molineux ac, maier ja, schecker t, sears ke. exogenous retinoic acid induces digit reduction in opossums (monodelphis domestica) by disrupting cell death and proliferation, and apical ectodermal ridge and zone of polarizing activity function. birth defects res a clin mol teratol. 2015;103(3):225-34. 217 j i m d c 2 0 1 8 217 open access f u l l l e n g t h a r t i c l e school health services and its practices in public and private schools of rawalpindi district sidrah nasim 1, sana bilal 2, fazal mehmood 3 1 postgraduate trainee, department of community medicine, rawalpindi medical university 2 assistant professor, department of community medicine, rawalpindi medical university 3associate professor, department of community medicine hbs medical college islamabad a b s t r a c t objective: to assess the school health services in public and private schools of rawalpindi district. subjects and methods: a comparative cross-sectional study was conducted in 50 public and private schools of rawalpindi district for a period of 3 months. consecutive sampling was done with inclusion criteria of only those teachers who had minimum two years of teaching experience in that particular school were included in the study. participants were interviewed using a structured, interviewer administered questionnaire and a checklist. data were entered and analyzed on spss version 20.0. results: among 50 selected schools, 10% were pre-schools, 28% primary schools and 68% were high schools. regarding clean drinking water, 64% schools were using filtered water, 14% unfiltered, and 2% mineral water. in 60% schools, water was chlorinated. first aid provision in case of emergency was available in 96% of schools. only in 24% of schools, sick room was available. first aid was given by teachers in most of the schools. conclusion: adequate health education on different aspects including nutrition is provided by most of schools. majority schools provide health services including provision of first aid but there is lack of placement of health professionals and periodical inspection of students. maximum number of schools have congested classrooms, uncomfortable seating and shortage of washrooms. key words: healthy environment, medical assessment, private schools, public schools, school health services author`s contribution 1, conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence sidrah nasim email: sidrah_nasim2002@yahoo.com article info. received: julyl 17, 2018 accepted: august 10, 2018 cite this article. nasim s, bilal s, mehmood f. school health services and its practices in public and private schools of rawalpindi district. jimdc.2018; 7(3):217-220 funding source: nil conflict of interest: nil i n t r o d u c t i o n many schoolchildren face significant health challenges resulting from familial, environmental or risk-taking behaviors. these health risks are often interrelated and may share common underlying determinants that can adversely affect the child’s ability to learn. thus, there is need for comprehensive health services within premises of schools.1 school health services is a branch of preventive medicine which deals with medical inspection of school children and their health protection, primarily in the environment of school.2 medical inspection in school was first instituted in france in 1837 and this was followed by other countries.3 who global school health initiative o r i g i n a l a r t i c l e 218 j i m d c 2 0 1 8 218 was launched in 1995.4 who promotes school health programs as a strategic measure to prevent important health risks among youth and to engage the education sector in efforts to change the educational, social, economic conditions that affect risk.5 an international study showed that school health services are existent, but its implementation is suboptimal in both private and public schools. significantly more private schools had treatment facilities within school premises (p=0.001).6 a study in nigeria showed that 36.4% schools had health personnel, 98.5% schools performed routine inspection of the students, and 18.2% schools requested pre-admission medical examination. about 75.8% schools administered first aid to injured /ill children, health records were present in 15.1% schools. there was no school nutrition program in any of the schools. only 32% schools had been visited by the school health team in the preceding year.7 the concept of health services in schools in pakistan originated in 70s. recently, school health program has been launched in pakistan, which has four basic pillars: school health environment, school health education, school health services, school nutrition program.8 an effective school health programme can be one of the most cost-effective investments, a nation can make to simultaneously improve education and health. the present study was planned to assess the school health services present in different schools of rawalpindi district. the results of this study will help the concerned authorities to bring about the change in the current scenario, as health of school children though not directly related to main reason of child mortality but significantly affect child morbidity. s u b j e c t s a n d m e t h o d s a comparative cross-sectional study was conducted in 50 schools (34 private, 15 governments and one semi government schools) of rawalpindi district for the duration of 3 months. consecutive sampling was done including those teachers who had minimum of two years of teaching experience in that particular school. principals /coordinators of school were excluded as their response could be biased. participants were interviewed using a structured, interviewer administered questionnaire and an observational checklist. informed consent was taken prior to answering questionnaire. anonymity was ensured to the participants. data were computed, processed and analyzed on spss version 20. r e s u l t s among total of 50 schools, 10% were pre-schools, 28% primary schools and 68% were high schools. there were up-to 1500 students in 66% schools, 1501-3000 in 20% schools and more than 3000 in 14% schools. in 42 out of 50 schools, playgrounds were present. space per capita & number of students to washroom ratio is shown in figure 1 and figure 2 respectively. in 88% of school’s source of light in classroom was both from tube lights and sunlight and in rest 12% only tube lights. seating arrangement of classroom showed that plus desk was noted in 32% cases, minus desk in 34% and zero desk in 34%. windows was the medium of ventilation in most of the schools (32%) followed by combination of windows and exhaust fans (28%). regarding clean drinking water, filtered water was being used in 32 of the schools, while 14% & 2% were using unfiltered and mineral water respectively. in routine, 60% schools water chlorination was done before consumption. first aid box availability was observed in majority (96%) of schools, while sick room existed in only 24% of schools. in most of the schools 1st aid was given by teachers (as shown in figure 3). availability of transport in case of emergency was observed in most (98%) of the schools. significant association was found between health education on different issues and schools.(p=0.043). figure 1: space per capita in each classroom 219 j i m d c 2 0 1 8 219 according to the survey, large number of schools educate their students on various health issues along with the promotion of healthy food eating behaviors. general hygeine of students was regularly checked in 96% schools. as a matter of concern more than half of the schools have never done medical inspection of students, however in 8% of schools medical assessment was done only at the time of admission, showing significant association between medical inspection of students and type of school (p=0.009). figure 2: ratio of students to washroom figure 3: first aid provider in case of emergency d i s c u s s i o n the significance of a good and well-designed school health program (shp) as an element of primary health care in the general development of children and the citizenry of a state cannot be over emphasized. school health services make one of the key constituents of the shp and upkeep the wellbeing of the schoolchildren. effective school health services enable early detection and diagnosis with quick intervention with the intention of preventing mortality and lessen morbidity. our research showed that 84% schools have playground which is compared to another study conducted in bangladesh revealing that 86% of schools hold playground.9 this result shows that school administrations are aware of the importance of the fact that healthy body is directly related to healthy mind which can be facilitated only by providing proper play areas for physical activity. majority of schools in our study had the facility of first aid, and only 26% of schools had sick room. in case of emergency, first aid is provided by teachers in 66% of schools, by doctor in 8%, by dispenser in about 2%, and by others in 18%, 6% had no provision of first aid in case of emergency. parallel findings were reported in a study in new zealand where there was 100% availability of first aid in schools, and they had a bigger figure (20%) of health professional e.g. doctor for medical care provision.10 lack of health professionals in our school setups indicates that we being developing country have less resources so most of the schools are unable to provide a full time doctor on regular basis in schools. in our study, it was illustrated that all schools had adequate lighting through bulbs and tube lights, and most of the schools had windows too, which served as an additional source of light. comparable results were noticed in a study conducted in hyderabad reporting that 97.4% of schools were provided with electricity.11 this shows the consensus of all school administrations on the fact that provision of light is the basic necessity for quality reading and writing in the classrooms; and most of them had windows too, so in case of load shedding, sunlight can be used for this purpose. it was revealed in this study that only 46% of schools provide one washroom for up to 50 students, 82% of schools provide one washroom for up to 100 students. median student to toilet ratio is 55 in our study. similarly, a study in nicaragua shows median student to toilet ratio 73 in urban areas.12 according to who recommendations, these should be at-least one washroom for 50 students.13 these results indicate lack of proper planning before construction along with the fact that toilet facility was neglected, or may be because most 220 j i m d c 2 0 1 8 220 of the private schools buildings are not primarily meant for school purpose, these are taken on rent and converted into schools, so the number of classes and students increase but number of toilets remain the same as their construction require proper water supply and drainage system. about 82% respondents of our study belonged to coeducated schools; among these 68% have genderseparated toilets. corresponding results were appreciated in the study in nicaragua, where the percentage was 49% in urban areas.12 a significant proportion of schools still do not have gender-separate toilets which could be due to lack of awareness or ignorance of owners and administration, it is highly recommended to have separate washrooms to avoid many social problems. conferring to our research, 84% of schools provided filtered drinking water, 2% used mineral water. contrary to this, a study conducted in government schools of sindh showed that only 21% of schools provided filtered water to students.11 this difference could be because of the fact that majority of the schools in our study were private as compared to government schools, where school administration receives heavy fees from students and in return at-least provide safe drinking water so as to ensure good health of students. our study shows that 38% of schools provide periodical medical inspection of students, and 8% at the time of admission. a study in nigeria showed 12% (7%public, 17% private) of schools arrange for periodical medical inspection.14 again the reason could be the lack of resources to afford a school health team to inspect schoolchildren. c o n c l u s i o n most of the schools provide health services including provision of first aid and conveyance to health care facility in case of emergency but there is lack of placement of health professionals and periodic assessment of students. majority schools have congested classrooms, uncomfortable seating and shortage of washrooms. qualified persons should provide professional development opportunities for physical education, nutrition services and mental health of students. adequate health education on different aspects including nutrition is provided by most of school. r e f e r e n c e s 1. chidiebere od, thomas uo, joy e, stanley ok, ikenna nk, uchenna e, is an.the status of school health services: a comparative study of primary schools in a developing country. american journal of public health research.2016;4(2):42-46. 2. iliyas m, khan i. community medicine & public health. karachi, pakistan: time publisher, medical division; 2003; 6th ed: 745-753. 3. schwab n, gelfman m, tirozzi g. legal issues in school health services. new york: authors choice press; 2005.: 7. 4. world health organization. global school health initiatives: achieving health and education outcomes. geneva: who document production services; 2015. 2 5. world health organization 2015. school and youth health: what is a health promoting school? available from http://www.who.int/school_youth_health/gshi/hps/en/. 6. small ml, majer ls, allensworth dd, farquhar bk, kann l, pateman bc. school health services. journal of school health. 1995; 65(8):319-26. 7. toma o, tinuade oo, gabriel io, agaba e. school health services in primary schools in jos, nigeria.open science journal of clinical medicine.2014; 2(3):83-88 8. ministry of education, government of pakistan, in collaboration with unesco. school health programme: a strategic approach for improving health and education in pakistan. islamabad: curriculum wing; 2010. 9. sharif s. school playground: its impact on children’s learning anddevelopment. theme: ecd on the global agenda: building partnerships for sustainability and harmony. 2014:17 10. denny s, grant s, galbreath r, clark tc. health services in new zealand secondary schools and the associated health outcomes for students. university of auckland, faculty of medical and health sciences; 2014. 11. khowaja da, munshi p, akhtar sh. an analysis the different health and hygiene conditions of government primary schools in the province of sindh (pakistan). asian journal of multidimensional research. 2013; 2(6). 12. jordanova t, cronk r, obando w, medina oz, kinoshita r, bartram j. water, sanitation, and hygiene in schools in low socio-economic regions in nicaragua: a crosssectional survey. international journal of environmental research and public health. 2015; 29;12(6):6197-217. 13. unicef. wash for school children, provisional draft. khatmandu: format printing press pvt. ltd; 2012 p. 15 14. kuponiyi ot, amoran oe, kuponiyi ot. school health services and its practice among public and private primary schools in western nigeria. bmc research notes. 2016 ;9(1):203. http://www.who.int/school_youth_health/gshi/hps/en/ 304 j i m d c 2 0 1 7 304 op e n ac c e s s c a s e r e p o r t multiple cranial neuropathies involvement in varicella zoster virus infections qamar zaman 1, wasim tariq malik 2, ehsan ul haq 3, muhammad farhan khan 4 1 assistant consultant, department of neurology, shifa international hospital, islamabad 2 associate consultant, department of neurology, shifa international hospital, islamabad 3 postgraduate assistant consultant, department of neurology, shifa international hospital, islamabad 4 assistant consultant, department of neurology shifa international hospital, islamabad (shifa tameere millat university, islamabad) a b s t r a c t unlike the children, varicella zoster virus (vzv) rarely cause disseminated infection of the cns except those who have immunocompromised state in the form of hiv infection or using immunosuppressents. however, it may cause focal root infection in the form of shingles and rarely as an involvement of the cranial nerves. infection involving the multiple cranial nerves has been observed only in some case reports. it is usually a self-limiting disease however early diagnosis and timely treatment may help in quick recovery. we are reporting an interesting case of vzv infection having typical rash and multiple cranial neuropathies. key words: immunocompromised, meningoencephalitis, postherpetic neuralgia, radiculopathy, rash, address of correspondence qamar zaman email: qamar_zaman1400@yahoo.com article info. received: november 9, 2018 accepted: november 22, 2018 cite this case report: zaman q, malik wt, ehsan-ul-haq, khan mf. multiple cranial neuropathies involvement in varicella zoster virus(vzv) infections: a casre report. jimdc. 2018; 7(4):304--306 funding source: nil conflict of interest: nil i n t r o d u c t i o n varicella zoster virus (vzv) infection commonly affects the central and peripheral nervous system, the commonest presentation being meningoencephalitis causing vasculitic arteriopathy and acute cerebellitis in children1. however, it may affect the peripheral nervous system in the form of acute radiculopathy or neuropathy. shingles refers to the local vzv infection resulting from reactivation of dormant virus commonly after lapses in immunity of the individual. it may affect various dermatomes and myotomes, most commonly the thoracic and lumbar regions but also rarely the cervical roots2. cranial nerves commonly affected are trigeminal and facial nerves referred as (ramsay hunt syndrome), other cranial nerve involvement is rare2. we are reporting a patient with multiple cranial neuropathies having contralateral superior oblique weakness resulting from left trochlear nerve palsy and associated lesions of right trigeminal and vestibulocochlear nerves. she responded to treatment with antivirals and recovered significantly on follow up c a s e r e p o r t a 24-year-old lady who had no previous co-morbids or any history of immunosuppressive illness (like hiv or diabetes) and was not taking any medication causing immunosuppression. she presented with 5 days’ history of rash in the right auricular canal and around the ear followed by fever, sore throat and right ear pain. it was followed shortly by double vision maximum on looking to the right side and downward with nausea, vomiting, vertigo and imbalance on walking. her symptoms gradually worsened over 2 days and she had to visit hospital. there was no history of headache or visual blurring but had pain involving right half of the face.there was no speech or swallowing difficulty, no weakness of arms or legs, no paraesthesias or numbness involving the c a s e r e p o r t 305 j i m d c 2 0 1 7 305 limbs. on examination she had normal higher mental functions and speech, normal vision and fundi. pupils were bilaterally equal and reactive. she had left superior oblique palsy andthe rest of the ocular movements were normal. she had vesicular rash involving the right ear and decrease sensation on the right half of the face. both sides of the face were symmetrical; the patient had normal hearingand tongue and pharyngeal movements. rest of the neurological examination including sensory,motor andcerebellar examination was normal, but had some ataxia on tandem walking.mri brain showed contrast enhancement of the right 8th nerve (figure 1). her csf showed 10 cells, with 70 % neutrophils,30% lymphocytes,proteins were 59 mg/dl and csf glucose was 61 mg/dl with serum glucose level of 75 mg/dl. mtb pcr was done to rule out tuberculosis as it is another common cause of such presentation. it was found to be negative, and esr was 14.other causes were ruled out. she was treated with acyclovir orally and her symptoms improved in a week. on followup, diplopia had markedly improved as well as ataxia, facial pain and rash. figure 1: t1weighted image with contrast showing contrast enhancement of the 8th nerve d i s c u s s i o n herpes zoster virus is a dna virus, commonly transmitted through direct spread and hematogenous route. it commonly affects the children and cause meningoencephalitis resulting in vasculitic arteriopathy and as acute cerebellitis. besides cns it also affects various systems of the body and may cause disseminated systemic infection. sometimes infection may be subclinical and virus may become dormant in the dermatomes of cranial and spinal nerves. reactivation of the virus commonly occurs in the immune deficiency states like hiv,hematological malignancies and use of immunosuppressant drugs3. it commonly affects the thoracic dermatomes followed by lumbar and cervical dermatomes causing pain and rash. it can affect the myotomes resulting in atrophy and weakness and can cause urine and bowl incontinence by affecting the sacral dermatomes. cranial nerves most commonly affected are trigeminal nerve and facial nerve where it causes auricular rash and lower motor neuron facial palsy. other cranial nerves affected include 3rd,4th,6th,8thand lower cranial nerves have been reported rarely.the reported incidence of extraocular muscle palsies has ranged between 7% and 31%4. in some reported cases there were multiple cranial neuropathies without the signs of meningoencephalitis and various mechanism have been proposed which include cytopathic/allergic, occlusive vasculitis and myositic processes affecting eye muscles. csf usually shows lymphocytic pleocytosis with mildly raised proteins, however monocytic or neutrophilic picture can also be seen. according to a case series of vzv patients, lymphocytic predominance was observed in 52% of patient cases, while monocytes predominated in 26% and neutrophils in 22%5. brain imaging may show contrast enhancement of the affected nerves6. investigations are needed to rule out immune deficiency states especially hiv infections and immune malignancies7. it is mostly self-limiting condition and improves significantly within 2 months in many cases8. however, it has been reported that the duration of diplopia can vary from 2 to 23 months8. long term squeal include post herpetic neuralgias and atrophy involving the distribution of affected nerves, systemic involvement may occur with wide spread dissemination. early treatment with antivirals may hasten the recovery and prevent complications7. c o n c l u s i o n herpes zoster virus infection should be suspected in patients presenting with multiple cranial neuropathies, especially in immunocompromised patients. early treatment with antiviral medications help to treat and prevent complications of herpes zoster viral infection r e f e r e n c e s 1. soares bp, provenzale jm. imaging of herpesvirus infections of the cns. american journal of roentgenology. 2016; 206(1):39-48. 306 j i m d c 2 0 1 7 306 2. sampathkumar p. herpes zoster and post-herpetic neuralgia. current geriatrics reports. 2016; 5(1):915. 3. levin mj, bresnitz e, popmihajlov z, weinberg a, liaw kl, willis e, curtis jr. studies with herpes zoster vaccines in immune compromised patients. expert review of vaccines. 2017; 16(12):1217-30. 4. johnson rw, alvarez-pasquin mj, bijl m, franco e, gaillat j, clara jg, labetoulle m, michel jp, naldi l, sanmarti ls, weinke t. herpes zoster epidemiology, management, and disease and economic burden in europe: a multidisciplinary perspective. therapeutic advances in vaccines. 2015; 3(4):109-20. 5. pahud ba, glaser ca, dekker cl, arvin am, schmid ds. varicella zoster disease of the central nervous system: epidemiological, clinical, and laboratory features 10 years after the introduction of the varicella vaccine.j infect dis. 2011;203(3):316-23 6. kikuchi h1, yoshimura t, hara h, mihara f, kobayashi t. .a case of multiple cranial neuropathy due to varicella-zoster virus infection: detection of involvement of cranial ganglia with mri .1995; 35(7):814-6 7. hoang-xuan t, büchi er, herbort cp, denis j, frot p, thénault s, et al. oral acyclovir for herpes zoster ophthalmicus. ophthalmology. 1992; 99:1062–1071 8. chang-godinich a, lee ag, brazis pw, liesegang tj, jones db. complete oph thalmoplegia after zoster ophthalmicus. j neuroophthalmol. 1997; 17:262–265.. http://www.ncbi.nlm.nih.gov/pubmed/?term=kikuchi%20h%5bauthor%5d&cauthor=true&cauthor_uid=8777811 j islamabad med dental coll 2020 190 open access comparison of auramine phenol and zn staining in diagnosis of pulmonary tuberculosis with genexpert mtb/rif as gold standard naureen saeed1, fatima-tuz-zuhra2, nadeem ikram3, farhana shaukat4, fareeha sardar5 1 associate professor, department of pathology. shalimar medical college lahore, pakistan 2 assistant professor, department of pathology, rawalpindi medical university rawalpindi, pakistan 3 associate professor, department of pathology, rawalpindi medical university rawalpindi, pakistan 4 medical technologist, district head quarter hospital rawalpindi, pakistan 5 demonstrator, rawalpindi medical university rawalpindi, pakistan a b s t r a c t background: pakistan faces an immense burden of pulmonary tuberculosis (tb) due to large number of cases and limited resources. despite the recent advancement in the diagnostic techniques for pulmonary tb, smear microscopy is still a useful technique for the diagnosis of this disease. this study was conducted in order to compare the diagnostic value of auramine stain with the conventional ziehl-neelsen (zn) stain on the sputum smear for the diagnosis of pulmonary tb, keeping genexpert mtb/rif as the gold standard . material and methods: this cross-sectional study was conducted on 356 suspected patients of pulmonary tb referred to the pathology laboratory from tb ward and opd of district head quarter (dhq) teaching hospital rawalpindi , pakistan. sputum specimen were collected and two smears wer e prepared from each sputum sample on which auramine phenol and ziehl-neelsen staining were carried out as per who recommendations. all these samples were further tested using gene xpert mtb/rif technique. the sensitivity, specificity, positive predictive value (ppv) and negative predictive values (npv) of zn and auramine stain were calculated and compared with genexpert mtb/rif technique. results: out of the total 356 samples, 64 (18%) were positive and 291 (82%) were negative by genexpert which was taken as the gold standard. on comparison with genexpert, percentage of true positive was greater in case of auramine than zn stained samples (16.29% versus 12.92%), while the percentage of false positive was same for both staining techniques (0.28%). there were lesser false negative cases observed in samples stained by auramine as compared to the ones stained by zn (1.68% versus 5.05%). the sensitivity, specificity, positive predictive value and negative predictive values were 97.87%, 94.17%, 71.88 and 99.66%, r espectively for the zn staining and 98.31%, 97.98%, 90.63% and 99.66% respectively, for the auramine phenol staining. conclusions: smear microscopy using auramine phenol stain is a useful technique for the diagnosis of pulmonary tb. the auramine phenol staining with fluorescent microscopy is found to be superior to zn staining because of higher sensitivity and specificity. key words: auramine phenol, fluorescence microscopy, genexpert, mycobacterium tuberculosis, ziehl -neelsen authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3,4 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: fatima-tuz-zuhra email: fatizuhra2@gmail.com article info: received: october 15, 2019 accepted: september 15, 2020 cite this article. saeed n, zuhra f, ikram n, shaukat f , sardar f. comparison of auramine phenol and zn staining in diagnosis of pulmonary tuberculosis with genexpert mtb/rif as gold standard. j islamabad med dental coll. 2020; 9(3): 190-194. doi: 10.35787/jimdc.v9i3.435 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 191 i n t r o d u c t i o n pulmonary tb, caused by mycobacterium tuberculosis (mtb) is a contagious disease that involves the lungs, and may spread to other organs.1 tuberculosis is a worldwide health problem and one of the leading causes of death even in the present era, despite the fact that the disease is preventable and curable. in the year 1993, world health organization (who) declared tb as a global emergency. in spite of the efforts made for its control and treatment, pulmonary tb is still a worldwide health problem, especially in the developing countries. in the year 2012, who estimated 8.6 million people infected with tb and 1.3 million deaths from the disease. moreover, a large number of people developed multidrugresistant tuberculosis (mdr-tb), which remains one of the biggest medical challenge to date.1 pulmonary tuberculosis is an important health problem in pakistan, with an estimated 510,000 new cases emerging each year and approximately 15,000 developing drug resistant tb.2 each active, sputum positive case of pulmonary tuberculosis can infect 10-15 people in a year. however, for effective management and disease control, an early and accurate diagnosis of tb and mdr-tb is crucial.3 diagnosis of pulmonary tb is usually based on positive family history, presence of classical clinical features (weight loss, cough, hemoptysis), positive findings on x-rays and purified protein derivative (ppd) results.4 nevertheless, the final diagnosis is based on laboratory results of sputum examination.5 for decades, direct microscopy of sputum smear of susceptible cases has been widely used for the diagnosis of tb. ziehl-neelsen and auramine phenol are the two most commonly used stains for the detection of acid-fast bacilli (afb) in the sputum of patients with pulmonary tb. zn staining of sputum smear is in use since 1882 and is an economical method of diagnosis of pulmonary tb. 5 fluorescence staining was introduced in 1978 for sputum examination.6 in 2011, who introduced genexpert mtb/rif assay for the detection of mycobacterium tuberculosis. it is an automated real time pcr (rt-pcr) which utilizes a dna-pcr technique.7 it also has provision of nucleic acid extraction, amplification, an advantage of bacterial lysis and minimum biosafety requirements.8 since its introduction genexpert has revolutionized the detection of mycobacterium tb in all kind of difficult to diagnose cases. 9 in this study we compared the diagnostic accuracy of the two conventional sputum staining methods with genexpert as gold standard in diagnosing pulmonary tb. m a t e r i a l a n d m e t h o d s this cross-sectional study was carried out at the department of pathology, district head quarter hospital rawalpindi, pakistan for a duration of 6 months, from 1st january to 30th june 2019. a total of 356 sputum samples were included in the study. all the samples were taken from patients with a strong clinical suspicion of pulmonary tb referred from opd and tb ward of dhq hospital rawalpindi. strong clinical suspicion was based on cough, weight loss, and hemoptysis, positive ppd results and positive chest x-ray findings. samples with insufficient volume or contaminated with food particles were excluded. the study was approved by the institutional review board (irb) of dhq hospital, rawalpindi. each sputum sample was divided into three parts; one used for zn smear, second for auramine phenol smear and the third part for genexpert testing. the sputum smear prepared for zn staining was flooded with carbol fuchsin and the slide was heated j islamabad med dental coll 2020 192 for 3-5 minutes and then rinsed again with water, decolorized and dried. microscopic examination was done at 100x for at least 5 minutes. each staining batch included a positive and negative slide for quality control. interpretation of zn staining was done as per revised national tuberculosis program (rntcp) guidelines. slides with red stained rods against blue background were labeled positive, whereas those without any rods seen on microscopy were labeled negative. for auramine phenol staining, the smear was prepared, dried and 0.1% auramine phenol was poured on the slide for 20 minutes, washed with water, decolorized with acid-alcohol and counterstained with methylene blue. the stained slides were examined under led fluorescent microscope at 20x for at least 3 minutes by scanning the slide from one side to the other. this was equivalent to one length or 100 high-power fields. the smears were graded according to who recommendations as 3+, 2+, 1+, doubtful and negative. for genexpert 0.5 ml of sputum sample was transferred to a sterile tube, 1.5 ml sample reagent was added and allowed to stand at room temperature for 15 minutes. then 2 ml of the mixture was transferred to the test cartridge and placed in the genexpert device. the results of the tests were noted and interpretation was done after 2 hours. statistical analysis was done using spss software version 22 (chicago il). the sensitivity, specificity, positive predictive values (ppv) and negative predictive values (npv), for zn and auramine phenol staining techniques were calculated. r e s u l t s of the total 356 samples, 64 (18%) were positive and 291 (82%) were negative by genexpert, which was taken as the gold standard. on comparison with genexpert, percentage of true positive samples was greater in case of auramine-stained than zn-stained samples (16.29% versus 12.92%), while the percentage of false positive was same for both staining techniques (0.28%). similarly, few false negative cases were observed in samples stained by auramine as compared to the ones stained by zn (1.68% versus 5.05%) (table i). table i: results of ziehl-neelsen and auramine phenol staining methods compared with genexpert (n=356) staining methods genexpert positive n (%) negative n (%) zn stain positive 46 (12.92) tp 1 (0.28) fp negative 18 (0.28) fn 291 (81.74) tn auramine stain positive 58 (16.29) tp 1 (0.28) fp negative 6 (1.68) fn 291 (81.74) tn tp-true positive; fp-false positive; tn-true negative; fnfalse negative auramine staining was found to be more sensitive and specific than ziehl-neelsen stain in detecting mycobacterium tuberculosis (98.31% versus 97.87% and 97.98% versus 94.17%). it also has much higher positive predictive value (90.63% versus 71.88%) than zn staining (table ii). table ii: sensitivity, specificity and predictive values for ziehl-neelsen and auramine phenol staining methods (n=356) staining methods zn stain auramine stain sensitivity (%) 97.87 98.31 specificity (%) 94.17 97.98 ppv (%) 71.88 90.63 npv (%) 99.66 99.66 ppv-positive predictive value ; npv-negative predictive value j islamabad med dental coll 2020 193 d i s c u s s i o n in developing countries like pakistan, microscopy of sputum smear for the detection of afb is still used for the diagnosis of pulmonary tb since it is a reliable, economical and rapid method of detection.10 in the present study two staining techniques, zn and auramine phenol were compared with genexpert as a gold standard. the results were in favor of auramine phenol and showed that it is better in terms of sensitivity, specificity and positive predictive value than zn staining technique. these results are in-line with the findings of many other studies. chhina et al. found higher values for sensitivity, specificity, ppv and npv of auramine staining (100%, 99.8%, 99.5% and 100% respectively), as well as zn staining (85.58%, 100%, 100% and 96.3% respectively).11 similarly, another study by hooja et al. showed 55.55% and 71.85% sensitivity values for zn and auramine stains respectively. the sensitivity of afb smear was further increased by 27.41% when both methods were combined.12 habeenzu et al. found 152 sputum specimens positive with auramine staining and 66 with zn staining method.13 ulukanligil et al. also found higher sensitivity of auramine stain (85.3%) as compared to zn stain (76.6%) in their study. 10 our findings showed that both zn and auramine staining techniques can be effectively utilized for the diagnosis of pulmonary tb. however, auramine stain is more sensitive in detecting lesser number of bacilli in smears which may remain undetected with zn staining.10 these findings are corroborating the results of studies by ulukanligill et al. and murray et al.10,14 murray and colleagues compared the sensitivity of auramine phenol and zn staining at all of the five stages of sample preparation and declared auramine phenol stain to be more sensitive and reliable than zn staining in detection of acid-fast bacilli (afb).14 lack of requirement of flame for slide fixation and examination of larger slide area at lower magnification and in lesser time, are the other advantages of auramine staining over zn staining. 6 we acknowledge that the results of these staining techniques are influenced by multiple factors like skill at staining, quality of stains, expertise of examining slides and adherence to the standard guidelines. however, we believe that despite the availability of advanced techniques such as genexpert, there is still an advantage of performing sputum smear microscopy. this is because a patient established tb-positive by both methods is likely to be more infectious than the one who is smearnegative but positive on genexpert.15 the costeffectiveness also makes it a preferable method for health care settings facing budget constraints and having large number of samples for pulmonary tb screening. c o n c l u s i o n smear microscopy using auramine phenol stain is a useful technique for the diagnosis of pulmonary tb and is superior to zn staining in terms of sensitivity and specificity. r e f e r e n c e s 1. zumla a, george a, sharma v, herbert n, baroness masham of ilton. who's 2013 global report on tuberculosis: successes, threats, and opportunities. lancet 2013; 382(9907): 1765 -7. doi: 10.1016/s0140-6736(13)62078-4. 2. world health organization. global tuberculosis report 2018. world health organization. 2018. http://www.who.int/iris/handle/10665/274453 3. agrawal m, bajaj a, bhatia v, dutt s. comparativ e study of genexpert with zn stain and culture in samples of suspected pulmonary tuberculosis. j clin diagn res. 2016; 10(5): dc09-12. doi: 10.7860/jcdr/2016/18837.7755. 4. waard jh, robledo j. conventional diagnostic methods. in: palomino jc, leão sc, ritacco v (eds). j islamabad med dental coll 2020 194 tuberculosis (www.tuberculosistextbook.c o m) 2007; 12: 401-24. 5. centers for disease control and prevention (cdc). updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. mmwr morb mortal wkly rep. 2009; 58: 7 -10. 6. balakrishna j, shahapur pr, chakradhar p, hussain saheb s. comparative study of different stainin g techniques ziehlneelsen stain, gabbet’s stain , fluorochrome stain for detecting of mycobacterium tuberculosis in the sputum. j pharm sci & res. 2013; 5(4): 89-92. 7. li s1, liu b1, peng m1, chen m1, yin w1, tang h. diagnostic accuracy of xpert mtb/rif for tuberculosis detection in different regions with different endemic burden: a systematic review and meta-analysis. plos one. 2017; 12(7): e0180725. doi: 10.1371/journal.pone.0180725 8. saeed m, iram s, hussain s, ahmed a, akbar m, aslam m. genexpert: a new tool for the rapid detection of rifampicin resistance in mycobacterium tuberculosis. j pak med assoc. 2017; 67(2): 270-74. 9. rakotoarivelo r, ambrosioni j, rasolofo v, raberahona m, rakotosamimanana n, andrianasolo r. evaluation of the xpert mtb/rif assay for the diagnosis of smear-negative pulmonary and extrapulmonary tuberculosis in madagascar. int j infect dis. 2018; 69: 20-25. doi: 10.1016/ j.ijid.2018.01.017 10. ulukanligil m, aslan g, tasci s. a comparative study on the different staining methods and number of specimens for the detection of acid-fast bacilli. mem inst oswaldo cruz. 2000; 95: 855 -58. 11. chhina d, gupta r, chawla a. comparison of ziehl neelsen (zn) and auramine phenol (ap) stainin g method to detect acid-fast bacilli in sputum smear. ijrhs. 2018; 6(1): 1-5. 12. hooja s, pal n, malhotra b, goyal s, kumar v, vyas l. comparison of ziehl neelsen & auramine o stainin g methods on direct and concentrated smears in clinical specimens. indian j tuberc. 2011; 58(2): 72 -6. pmid: 21644393 13. habeenzu c, lubasi d, fleming af. improved sensitivity of direct microscopy for detection of acid fast bacilli in sputum in developing countries. trans r soc trop med hyg. 1998; 92(4): 415 -16. doi: 10.1016/s0035-9203(98)91071-9 14. murray sj, barrett a, magee jg, freeman r. optimization of acid-fast smears for the direct detection of mycobacteria in clinical samples. j clin pathol. 2003; 56(8):613-15. doi: 10.1136/jcp. 56.8.613 15. rachow a, zumla a, heinrich n, rojas-ponce g, mtafya b, reither k. rapid and accurate detection of mycobacterium tuberculosis in sputum samples by cepheid xpert mtb/rif assay -a clinical validatio n study. plos one. 2011; 6(6): e20458. doi: 10.1371/journal.pone. 0020458. 121 j i m d c 2 0 1 7 121 open access f u l l l e n g t h a r t i c l e outcome of chipping method in complex non-union of long bones abdul samad khan1, muhammad shoaib 2, javedullah khan 3, haider darain4, aatik arsh5 1 junior registrar orthopedic department, khyber teaching hospital kpk 2 orthopedic department, khyber teaching hospital kpk 3 post graduate resident, orthopedic department, khyber teaching hospital kpk 4assistant professor, institute of physical medicine and rehabilitation khyber medical university, kpk 5 physical therapist paraplegic centre, kpk (1-4 khyber medical university, peshawar) a b s t r a c t objective: to determine the outcome of chipping method in the treatment of long bones complex non-union with autologous bone graft. patients and methods: this interventional study was conducted in orthopedics and trauma department khyber teaching hospital, peshawar. duration of this study was january 2015 to january 2016. the consecutive nonprobability technique was used to collect the samples and twenty-one patients were managed with chipping method for complex non-union of long bones. all the patients were treated by appropriate fracture fixation, including revision of implants. and followed for at least 06 months postoperatively. results: a total of 21 patients were included in the study among which 14(66.67%) were males and 7(33.33 %) were females. mean age of the patients was 44 years (range 20 to 80 years). among them 13 patients had femoral shaft fracture non-union,5 patients had tibial shaft fracture non-union, 2 patients had humerus fracture non-union and one had radius/ulna fracture non-unions. mean duration from trauma to non-union was 15 months (range 6 months to two years). all the patients were treated with this method, using an autologous bone graft from the iliac crest and followed for at least six months postoperatively. twenty patients obtained bony union successfully. one patient failed to get a union, requiring the second operation, three patients got ipsilateral knee stiffness and three patients got limb length discrepancy less than 2cm. conclusion: chipping method with autologous bone grafting is easy to perform and is an encouraging approach for enhancing bone healing in long bones complex non-union. keywords: autologous bone graft, chipping method, non-union. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence haider darain email: haider.kmu@hotmail.com article info. received: may 2, 2017 accepted: august 10, 2017 cite this article. khan as, shoaib m, khan j, darain h, arsh a. outcome of chipping method in complex non-union of long bones.jimdc.2017;6(3):121-124. funding source: nil conflict of interest: nil i n t r o d u c t i o n nonunion is a failure of bone union following a fracture of bone that needs further treatment before healing can occur.1 the exact length of time needed to determine whether a fracture is nonunion is not well defined, nevertheless, previous studies reported that fracture that doesn’t heal completely in 9 months is considered as nonunion.2,3 nonunion is a common complication following long-bone fracture, with a prevalence ranging o r i g i n a l a r t i c l e 122 j i m d c 2 0 1 7 122 from 2.5–46%.3-6 risk of nonunion increases in the presence of open fractures, extensive soft tissue injury and vascular injuries.7,8 nonunion of fractures of long bones represent a significant clinical challenge and is associated with high complication rates.6,9 challenges associated are to obtain union, restore alignment and leg length along with good range of motion joint above and joint below the non-union or delayed union site.9-12 conventionally, treatment of nonunion of bone has involved acquiring mechanical stability through internal fixation, with or without the use of bone graft in an attempt to improve healing.1,13 judet and patel’s decortication technique is also one of the good techniques for managing nonunion of long bones but difficult to reproduce in the same way as described in the original report.14,15 autologous bone graft is considered to be the gold standard for supplementing bone defects and for enhancing bone healing in non-unions and delayed unions.1 bed preparation is necessary for bone grafting and the method needs to be described in detail as no detail description is existing. chipping method is a new technique for the management of complex non-union of long bones. the literature review identified two studies which used chipping technique.16,17 matsushita and watanabe used chipping and lengthening technique in 6 patients for the management of non-union of long bones16, while hattori et al. presented a case report in which they used chipping and lengthening technique to treat proximal tibial pseudoarthrosis.17 both studies reported good results with chipping methods.16,17 current study was designed to further evaluate the effectiveness of chipping method in the treatment of long bones complex non-union with autologous bone graft. p a t i e n t s a n d m e t h o d s this interventional study was conducted in orthopedics and trauma department khyber teaching hospital, peshawar from january 2015 to january 2016. consecutive nonprobability sampling technique was used. a total of 21 patients were managed with chipping method for complex non-union of long bones and followed for at least 06 months postoperatively. total 13 femur,5 tibia,2 humerus and one radius/ulna having aseptic non-unions and previously treated with implants were included in the study. gap non-union of more than 4 cm gap and medically unfit patients were excluded. all the patients were treated by appropriate fracture fixation, including revision of implants. the radiographic evaluation included standard anteroposterior and lateral preoperative x-rays of the non-union site including joint above and joint below. intraoperatively, the non-union site was exposed without periosteal stripping to preserve the blood supply. the previously implanted plate or nail was removed if needed, fibrous tissue was removed from the non-union site and both ends of the fracture fragments were chipped into small pieces, using small sharp osteotome and a small hammer, producing pathways into the bone marrow. the osteotome was inserted into the bone parallel to the bone axis but not parallel to the fracture line. the autologous cancellous bone graft was taken from the iliac crest and grafted into the gap and chipped ends of both segments appropriate fixation was performed. the extent of bone chipping was adjusted according to the size of the fractured bone. chipping was done very carefully, avoiding detachment of small bone pieces from soft tissue. if the intramedullary nail was used for appropriate fixation of the non-union, chipping was done from anterior, lateral and posterior sides of the ends of both fragments. r e s u l t s a total of 21 patients were included, among these 14 (66.67%) were males and 7 (33.33 %) were females with an average age of 44 years (range 20 to 80 years). in total 13 patients had femoral shaft fracture non-union, 5 patients had tibial shaft fracture non-union, 2 patients had humerus fracture non-union and one had radius/ulna fracture non-union. mean duration from trauma to nonunion was 15 months (range 6 months to two years). all the patients were treated with chipping method. mean follow up time was 09 months (range 06-12 months). knail was used for 5 patients who had femoral fracture while plates were used for 9 patients having different fracture sites (4 femoral fractures, 2 tibial fractures, 2 humeral fractures, and 1 radial/ulnar fractures) (table 1). distal femoral locking plate was used in chipping method for 6 patients having femoral fractures while locking plate was used for 6 patients having different fracture sites (3 femoral fractures, 2 tibial fractures, and 1 humeral fracture) (table 2). bony union was obtained successfully 123 j i m d c 2 0 1 7 123 in 20 patients and one patient required second surgery for union due to type 2 diabetes mellitus and past smoking history. table 1: use of multiple treatment modalities in different types of bones treatment modalities types of bones total femur tibia humerus radius/ ulna k-nail 5 0 0 0 5 interlocking nailing (iln) 2 1 0 0 3 plates 4 2 2 1 9 dynamic hip screw (dhs) 2 0 0 0 2 externalfixation 0 2 0 0 2 total 13 5 2 1 21 table 2: outcome of chipping method (n=21) outcome number (percentage) successful bone union 20 (95) second surgery for union required 01 (05) knee stiffness 03 (14) limb length discrepancy 03 (14) table 3: use of different types of implants in chipping method implants used types of bones femur tibia humerus radius/ulna inter locking nailing 2 0 0 0 locking plate 3 2 1 0 conventional plate 1 0 1 1 proximal femoral locking plate 2 0 0 0 distal femoral locking plate 6 0 0 0 ilizarov external-fixator 0 1 0 0 condylar blade plate 1 0 0 0 total 3 (14.3%) patients got knee stiffness and 3 (14.3%) patients got limb length discrepancy less than 2cm (table 3).no donor site morbidity or infection was detected. mean duration from surgery to successful union was 13 weeks (range12-16 weeks) in femur and humerus, 16 weeks (12-20 weeks) in tibia and 14 weeks in radius/ulna. d i s c u s s i o n the objective of current study was to determine the outcome of chipping method in the treatment of long bones complex non-union with autologous bone graft. in chipping method, the surgeons chip the ends of both fragments of the non-union, producing pathways into the bone marrow. autologous cancellous bone graft is taken from iliac crest and grafted in the non-union site and the prepared apertures of the chipped bone. this technique allows the bone marrow stem cells to be mobilized and the bone morphogenic proteins in the bone matrix to induce osteoinduction thus enhancing bone healing in non-union.1,18 the chipping method appears similar to judet and patel’s decortication technique, however in judet and patel’s decortication technique, only surface of the bone is chipped off,14,15 whereas in the chipping technique the entire thickness of bone is chipped, making intramedullary channels. in this technique, it is hypothesized that stem cells with ostegenic capacity migrate from bone marrow and bone morphogenic proteins, existing in the bone extracellular matrix, introduce into the fracture site and participate in the healing process.18 matsushita and watanabe used chipping and lengthening technique in delayed union and non-union with shortening or bone loss.16 they used external fixator for lengthening without using autologous bone graft. in the current study, autologous bone grafting and internal or ilizarov external fixation are used along with the chipping of non-union. results of the current study showed that out of total 21 patients, bony union was obtained successfully in 20 patients while only one patient required a second surgery for the union. one patient in which chipping method was not successful had type 2 diabetes mellitus and also had past smoking history. similar results were also reported by previous studies, which used chipping technique.16,17 matsushita and watanabe reported that five out of six nonunion with shortening or bone loss were successfully united by using chipping method.16 chipping technique is usually indicated in atrophic or oligotrophic aseptic nonunion with gap less than 4 cm because it gives good results and very less complications in these biologically less active non-unions. it is very easy to perform and provides enhanced bone healing. bone morphogenetic protein-7 has very good 124 j i m d c 2 0 1 7 124 results in terms of bone healing in non-union19,20 but autologous bone grafting is still gold standard, useful and frequently used tool.10,12 bone autograft is the only graft material that has osteogenic, osteoinductive, and osteoconductive properties, which makes it an ideal graft material.7,13 the iliac crest is the most common donor site for obtaining autogenous bone.21 though the majority of studies reported good results with autologous bone graft but it is associated with donor-site morbidity.1,16 major complications have been reported in approximately 10% of iliac crest harvest procedures,8,22, however, no such donor site morbidity or infection was detected in current study. in current study, 14.3% patients (n=3) got knee stiffness after surgery, while the previous study which used ilizarov fixator for the management of complex non-union of long bones reported knee stiffness was observed in 6% patients.11 the high prevalence of knee stiffness in the current study can be explained by the fact that all these 3 patients who got knee stiffness were having poor compliance towards physiotherapy. despite these complications, chipping method with autologous bone grafting is easy to perform and is an encouraging approach for enhancing bone healing in long bones complex non-union. c o n c l u s i o n chipping method with autologous bone grafting is easy to perform and is an encouraging approach for enhancing bone healing in long bones complex non-union. r e f e r e n c e s 1. sen m, miclau t. autologous iliac crest bone graft: should it still be the gold standard for treating nonunions? injury. 2007;38(1):s75-s80. 2. metsemakers w, kuehl r, moriarty t, richards r, verhofstad m, borens o, et al. infection after fracture fixation: current surgical and microbiological concepts. injury. int j. care injured 2016. 3. oktas b, aslan a, daglar b, çirpar m, türker m, durusoy s. t1. 8 humerus shaft nonunions treated with expandable nail: a series of 5 cases. injury. 2013;44:s3. 4. furlan d, pogorelić z, biočić m, jurić i, budimir d, todorić j, et al. elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures. scandinavian journal of surgery. 2011;100(3):208-15. 5. dimitriou r, mataliotakis gi, angoules ag, kanakaris nk, giannoudis pv. complications following autologous bone graft harvesting from the iliac crest and using the ria: a systematic review. injury. 2011;42:s3-s15. 6. tzioupis c, giannoudis pv. prevalence of long-bone non-unions. injury. 2007;38:s3-s9. 7. phieffer ls, goulet ja. delayed unions of the tibia. j bone joint surg am. 2006;88(1):205-16. 8. watanabe y, matsushita t. femoral non-union with malalignment: reconstruction and biological stimulation with the chipping technique. injury. 2016;47:s47-s52. 9. lynch jr, taitsman la, barei dp, nork se. femoral nonunion: risk factors and treatment options. journal of the american academy of orthopaedic surgeons. 2008;16(2):88 97. 10. chen cm, su yp, hung sh, lin cl, chiu fy. dynamic compression plate and cancellous bone graft for aseptic nonunion after intramedullary nailing of femoral fracture. orthopedics. 2010;33(6):393-. 11. khan ms, raza w, ullah h, khan as, siraj m, askar z. outcome of ilizarov fixator in complex non-union of long bones. jpma the journal of the pakistan medical association. 2015;65(11 suppl 3):s147-51. 12. lin c-l, fang c-k, chiu f-y, chen c-m, chen t-h. revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture. journal of trauma and acute care surgery. 2009;67(6):1393-6. 13. panagiotis m. classification of non-union. injury. 2005;36(4):s30s7. 14. judet pr, patel a. muscle pedicle bone grafting of long bones by osteoperiosteal decortication. clinical orthopaedics and related research. 1972;87:74-80. 15. tall m, bonkoungou d, sawadogo m, da s, toe m, bone, et al. treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication. orthopaedics & traumatology: surgery & research. 2014;100(6):s299-s303. 16. matsushita t, watanabe y. chipping and lengthening technique for delayed unions and nonunions with shortening or bone loss. journal of orthopaedic trauma. 2007;21(6):404 -6. 17. hattori y, kida d, kanda h, mori k, sato s, maeda m, et al. chipping and lengthening technique for reconstruction of nonunion proximal tibial fracture: a case report. journal of orthopaedic science. 2016. 18. reddi ah. morphogenetic messages are in the extracellular matrix: biotechnology from bench to bedside. portland press limited; 2000; 28(4):345-349. 19. friedlaender ge, perry cr, cole jd, cook sd, cierny g, muschler gf, et al. osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. j bone joint surg am. 2001;83(1 suppl 2):s151-s8. 20. dohin b, dahan-oliel n, fassier f, hamdy r. enhancement of difficult nonunion in children with osteogenic protein-1 (op-1): early experience. clinical orthopaedics and related research®. 2009;467(12):3230. 21. khan sn, cammisa jr fp, sandhu hs, diwan ad, girardi fp, lane jm. the biology of bone grafting. journal of the american academy of orthopaedic surgeons. 2005;13(1):77 86. 22. niikura t, miwa m, lee sy, oe k, iwakura t, sakai y, et al. technique to prepare the bed for autologous bone grafting in nonunion surgery. orthopedics. 2012;35(6):491 5. j islamabad med dental coll 2020 145 op e n ac c e s s van der knaap disease in a 3-year-old male child: a case report imran mahmood khan 1 , asma shabbir 2 , sadaf naz 3 , rubina zulfqar 4 1 associate professor, pediatric department, islamabad medical and dental college, islamabad pakistan 2 associate professor, pediatric department, fazaia medical college, islamabad, pakistan 3 consultant radiologist, radiology department, islamabad diagnostic center, islamabad, pakistan 4 professor, pediatric department, islamabad medical and dental college, islamabad, pakistan a b s t r a c t van der knaap disease or megalencephalic leukoencephalopathy with subcortical cysts is a leukodystrophy with autosomal-recessive inheritance caused by mutation in the gene mlc1 which is localized on chromosome 22q. it is characterized by macrocephaly, motor developmental delay, seizures, spasticity, ataxia, and mild mental deterioration. on neuroimaging, involvement of cerebral white matter along with subcortical cysts in frontal and temporal lobes are hallmarks of the disease. there is no definite treatment of this disease. we report a case of van der knaap disease in a 3-year-old male child who presented with seizures and delayed developmental milestones. key words: degenerative brain disease, leukodystrophy, macrocephaly, megalencephaly, subcortical cysts, van der knaap disease correspondence: imran mahmood khan email: lifesaverforu@yahoo.com article info: received: april 18, 2020 accepted: june 16, 2020 cite this case report: khan im, shabbir a, naz s, zulfqar r. van der knaap disease in a 3-yearold male child: a case report. j islamabad med dental coll. 2020; 9(2):.145-148. doi: 10.35787/jimdc.v9i2.537 funding source: nil conflict of interest: nil i n t r o d u c t i o n van der knaap disease or megalencephalic leukoencephalopathy (mlc)with subcortical cysts is a leukodystrophy with autosomal-recessive inheritance. 1 it is characterized by early-onset macrocephaly, motor developmental delay, seizures, spasticity, ataxia, and mild mental deterioration. 2 this disease is present globally but occurs most commonly in the aggarwal community of india with a high frequency of consanguineous marriages. 3 due to rarity of this disease, exact incidence is not known. so far, in pakistan only one case has been reported in the literature. 4 here we report the case of a child with delayed developmental milestones, who was brought by his parents to pediatric opd with main complaint of a seizure one month back. he was finally diagnosed as a case of a very rare disease (van der knaap disease) with no specific treatment. c a s e r e p o r t a 3-year-old male child, resident of neelam valley, azad kashmir, pakistan, presented in the opd with complaints of nystagmus, seizures and delayed milestones. according to the parents, the child developed nystagmus at the age of 6 months. so far, he had only one episode of seizures one month back, which was generalized tonic clonic type, lasting for 2 to 3 minutes and stopped spontaneously. the child was not taking any antiepileptic drug. he was a product of nonconsanguineous marriage with one younger and two elder sisters. he was born at term through c a s e r e p o r t j islamabad med dental coll 2020 146 spontaneous vaginal delivery without any antenatal, natal or postnatal complications. his developmental milestones were delayed with neck holding achieved at 7 months of age and sitting at 12 months. he started walking at 2 years of age with history of frequent falls during walking. his vision, hearing, speech and cognition were appropriate for his age. on physical examination, his weight was 11.2 kg and height were 85 cm, both were less than 5th percentile for his age. his anterior fontanelle was open and head circumference was 53 cm which was above 97th percentile. he had hypertonia and hyperreflexia in both lower limbs. he had no dysmorphic features or visceromegaly. rest of the physical examination was unremarkable. his baseline investigations like cbc, esr, serum electrolytes, calcium and magnesium were normal. on the basis of large head, open anterior fontanelle and other symptoms, provisional diagnosis of hydrocephalous was made and ct scan brain was advised. however, ct scan brain showed significant diffuse hypodensity of the cerebral white matter, predominantly of the frontal, temporal and parietal lobes. this was associated with thinning of the cortex and bilateral temporal and left parietal subcortical cysts suggestive of megalencephalic leukoencephalopathy with subcortical cysts (figure 1). the hallmarks of the disease were quite evident on ct brain, so it was decided that mri brain the gold standard for diagnosis of van der knaap disease, was no more needed. syrup sodium valproate was started for the control of seizures and multivitamins prescribed to increase his growth. parents were counselled that no specific treatment was available for this slowly progressive inherited disease with 25% chances of occurrence in every pregnancy. as they had no wish to have more children, they refused genetic testing. follow-up visit after one month revealed a stable condition with no seizure during this period. figure 1a: ct scan image showing diffuse hypodensity of cerebral white matter predominantly of frontal, temporal and parietal lobes associated with thinning of the cortex as shown with arrow. 1b: ct scan image showing bilateral temporal subcortical cysts as shown with arrows. d i s c u s s i o n megalencephalic leukoencephalopathy was first described by the indian neurologist bhim sen singhal in 1991 in the agarwal community. 5 later in 1995, dutch neurologist marjo van der knaap described the series of cases in 8 children and the disease was referred to as van der knaap disease. 6 it is characterized by macrocephaly, delayed milestones and seizures, which start in early infancy and has slow progressive neurodegenerative course. 6 seizures are easily controlled by common antiepileptic drugs. 7 there are also extrapyramidal abnormalities with dystonia and athetosis along with spasticity and ataxia which usually develop by 5 years of age. cognitive delay is milder and occurs later than motor delay. 8 mlc result from defect in brain ion and water homeostasis resulting in chronic cerebral white matter edema and vacuole formation. 9 it is an autosomal recessive disease resulting from mutation in mlc1 gene on chromosome 22q leading to an imbalanced intracellular ion concentration and astrogliosis. 9 j islamabad med dental coll 2020 147 mri brain is superior to ct brain due to its ability to depict anatomy in greater detail and hence can differentiate between various differential diagnoses. mri of the brain in van der knaap disease show’s increased characteristic diffuse supratentorial white matter signal intensity on t2weighted images, decreased signal intensity on t1weighted images with relative sparing of grey and deep white matter structures such as corpus collosum, internal capsule and brain stem. cysts are present in the anterior temporal area and often in the frontoparietal area. 10 later in life, white matter swelling decreases and cerebral atrophy comes into the picture. 8 main differential diagnoses are alexander’s disease, infantile-onset gm1 and gm2 gangliosidosis and canavan’s disease. all these diseases have rapidly progressive course with almost 100% mortality in early childhood or adolescence. in contrast, mlc has a milder course despite highly abnormal ct/mri findings and life expectancy is up to 3rd and 4th decade of life. 2,4 mri in infantile gm1 and gm2 gangliosidosis and canavan’s disease shows involvement of the globus pallidus, basal ganglia and thalamus which are spared in mlc, in addition to the white matter abnormalities. in alexander disease, white matter involvement is predominant in frontal regions and shows contrast enhancement which is usually absent in mlc. 4,11 currently there is no definite treatment of mlc, although trials of gene therapy are going on. 12 treatment is only symptomatic for complications in the form of antiepileptic drugs and physiotherapy. 2,3 the best strategy is prevention of this disease in affected families by avoiding consanguineous marriages and providing prenatal diagnosis of future pregnancies through amniocentesis and chorionic villus sampling. 4,11 c o n c l u s i o n mlc should be included in the differential diagnosis of macrocephaly and seizures. imaging studies of brain are sufficient to make the diagnosis in the presence of particular symptoms. genetic testing for prenatal diagnosis should be done to identify the particular mutations in future pregnancies. affected families should be educated and counselled regarding risks of consanguineous marriages in order to decrease genetic diseases in the community. r e f e r e n c e s 1. lópez-hernández t, ridder mc, montolio m, capdevila-nortes x, polder e, sirisi s, et al. mutant glial cam causes megalencephalic leukoencephalopathy with subcortical cysts, benign familial macrocephaly, and macrocephaly with retardation and autism. am j hum genet. 2011; 88(4): 422–32. doi: 10.1016/j.ajhg.2011.02.009 2. sardana v, bhattiprolu rk. van der knaap disease: a case report. indian j case reports. 2018; 4(5): 375– 6. 3. singhal bs. leukodystrophies: indian scenario. indian j pediatr. 2005; 72(4): 315–8. doi: 10.1007/bf 02724013 4. bokhari m, inayat f, sardar j, bokhari r. van der knaap disease. j coll physicians surg pakistan. 2018; 28(11): 888–90. doi: 10.29271/jcpsp.2018.11.888 5. singhal bs, gursahani rd, udani vp, biniwale aa. megalencephalic leukodystrophy in an asian indian ethnic group. pediatr neurol. 1996; 14(4): 291–6. doi: 10.1016/0887-8994(96)00048-3 6. van der knaap ms, barth pg, stroink h, van nieuwenhuizen o, arts wfm, hoogenraad f, et al. leukoencephalopathy with swelling and a discrepantly mild clinical course in eight children. ann neurol. 1995; 37(3): 324–34. doi: 10.1002/ana. 410370308 7. batla a, pandey s, nehru r. megalencephalic leukoencephalopathy with subcortical cysts: a report of four cases. j pediatr neurosci. 2011; 6(1): 74–7. doi: 10.4103/1817-1745.84416 j islamabad med dental coll 2020 148 8. dash pk, raj dh, sahu h. megalencephalic leucoencephalopathy with subcortical cysts: subcortical diffuse leuco-encephalopathy associated with white matter cystic degeneration. bmj case rep. 2015; bcr2015211921. doi: 10.1136/bcr-2015211921 9. van der knaap ms, boor i, estévez r. megalencephalic leukoencephalopathy with subcortical cysts: chronic white matter oedema due to a defect in brain ion and water homoeostasis. lancet neurol. 2012; 11(11): 973–85. doi: 10.1016/ s1474-4422(12)70192-8 10. reis f, yoshio r, kido z, mesquita ja, oshima mm, montenegro ma. megalencephalic leukoencephalopathy with subcortical cysts a case with clinical and magnetic resonance imaging dissociation. arq neuropsiquiatr. 2015; 73(2): 171– 2. doi: 10.1016/s1474-4422 11. roy u, joshi b, ganguly g. van der knaap disease: a rare disease with atypical features. bmj case rep. 2015; bcr2015209831. doi:10.1136/bcr-2015209831 12. van der knaap ms, schiffmann r, mochel f, wolf ni. diagnosis, prognosis, and treatment of leukodystrophies. lancet neurol. 2019; 18(10): 962– 72. doi: 10.1016/s1474-4422(19)30143-7 j islamabad med dental coll 2019 96 op e n ac c e s s a huge lipoma involving left cheek region: a case report muhammad jamal 1, kaleem ullah 2, laiba saher 3 1 assistant professor, department of oral and maxillofacial surgery, islamabad medical and dental college 2 consultant, department of oral and maxillofacial surgery, krl hospital, islamabad 3 postgraduate resident, department of oral and maxillofacial surgery, islamabad medical and dental college a b s t r a c t lipomas are very common benign lumps that can be encountered in any part of the body but a small proportion present in the head and neck region. in this case report we have discussed the diagnosis and surgical treatment of an asymptomatic huge lipoma of left cheek. the patient had this swelling present for the last 5 years. initially there was a slight increase in the size of the swelling but since the last 3 years there is no change in size. there was no history of associated pain and tenderness. the patient had esthetic concerns because of which the lesion was excised. these lipomas continue to grow slowly, showing variable signs including dysphagia, dyspnea, and dysphonia due to the compressing effect on surrounding structures. it can also be a matter of cosmetic concern. with this case report, authors will also highlight the diagnostic modalities and treatment for lipomas occurring in unusual areas in the body. it is a rare finding that occurs anterior to parotid but can be treated successfully by current surgical approach. key words: cheek swelling, esthetics, lipoma correspondence: muhammad jamal email: jamal_kcd@hotmail.com article info: received: february 15, 2019 accepted: march 19, 2019 cite this case report: jamal m, kaleem ullah, saher l. a huge lipoma involving left cheek region: a case report. j islamabad med dental coll. 2019; 8(2):96-98 funding source: nil conflict of interest: nil i n t r o d u c t i o n in head and neck region, lipoma is one of the most common forms of benign neoplasm arising mostly in the posterior cervical triangle of the neck. it can occur in and around the parotid gland or the parapharyngeal space in the head and neck territory. presence of a lipoma should be included in the differential diagnosis of swellings of parotid gland. a thorough preoperative clinical, radiological and cytological examination should be performed to further investigate the swelling. c a s e r e p o r t a 42 years old male patient reported to oral & maxillofacial surgery clinic with a cheek swelling on the left side of face since last 5 years. initially there was a slight increase in the size of swelling but for the part last 3 years, there was no change in size. there was no history of associated pain and tenderness. the patient wanted removal of the lesion for esthetic reasons. on clinical examination there was localized, mobile, firm swelling involving the left cheek region, measuring approximately 3x3 cm in size. (figure 1) the overlying skin was of normal color and texture and not fixed to the lesion. there was no associated neurological deficit. ultrasound examination revealed well defined hyper echoic area measuring 1.8x1.6 cm in size, suggestive of lipoma. color doppler ultrasound revealed normal blood flow in the area with normal adjacent structures. fine needle aspiration cytology (fnac) showed hemorrhage, fused stromal cells and lipocytes. ct scan revealed a well-defined hypodense oval lesion on the left side of the face, just anterior to, but distinctly separate from the left parotid gland. the lesion measured 4.6x3.3 cm and had diffuse fat density. there was no mass affect due to the lesion on the surrounding structures. the ct findings were suggestive of a lipoma lying anterior to left parotid gland (figure 2). the patient was informed about the lesion and was advised for excision under general anesthesia (ga). under aseptic measures and standard surgery protocol, c a s e r e p o r t j islamabad med dental coll 2019 97 extended sub-mandibular incision was made 2cm below the lower border of the left mandible and dissection performed in the sub-platysmal plane to prevent damage to marginal mandibular branch of facial nerve. (figure 3) the lesion was dissected from the surrounding tissue without damaging the parotid fascia and was removed. hemostasis was achieved and the wound was closed using 3/0 vicryl while the skin incision was closed using 3/0 proline. the excised specimen was sent for histopathological examination. the patient was examined post operatively for any neurological deficit, which was not present. histopathology report confirmed the diagnosis of lipoma in the left cheek region measuring 5x5x3 cm in dimensions. on follow-up visits, no neurological deficit was noted and the wound healed satisfactorily without any post-operative complaint figure 1: preoperative pictures showing left cheek swelling figure 2: axial view of a pre-operative ct scan showing a well defined hypo-dense oval lesion just anterior to the left parotid gland figure 3: extended submandibular incision during surgery (a), exposure and removal of the lesion (b), excised lipoma (c), and surgical incision closed with sutures (d) d i s c u s s i o n lipoma, the most common benign mesenchymal neoplasm of soft tissue (15–20%), account for only 1–4% of all neoplasms arising in the oral cavity. roux in 1848 gave details of an oral lipoma for the first time, and named it as a “yellow epulis”.1 lipomas are most common in fifth to the sixth decades of life and males are more affected than females.2 heredity, obesity, diabetes, radiation, endocrine disorders, insulin injection, corticosteroid therapy and trauma are among the multiple causes of lipoma. trauma leads to formation of hematoma and lymphatic effusion and fat necrosis which results in lipoma formation.3 lipomas are present in the subcutaneous tissues where they grow slowly. they are nearly always benign masses of adipose tissue arranged in lobules and many times have a fibrous capsule.4 lipomas can be singular or multiple and are asymptomatic, unless they are large in size and compressing neurovascular structures. large lipoma can lead to facial asymmetry and aesthetic consequences besides exerting pressure on surrounding structures.5 lipomas are classified into multiple types namely simple lipoma, fibrolipoma, chondroid lipoma, myxolipoma, angiolipoma, angiomyolipoma, spindle cell lipoma, j islamabad med dental coll 2019 98 myelolipoma, sialolipoma, pleomorphic lipoma and atypical lipoma.6 diagnostic imaging like ultrasonography, ct scan or mri have an important role in diagnosing lipomas. benign lipomas in ct scan images appear as hypoattenuated homogeneous masses without contrast enhancement, while in mri images they tend to have high signal intensity in t1-weighted images with progressive decrease in signal intensity in t2-weighting.7 it has been shown by several studies that fnac also aids in diagnosis of lipoma.8,9 elliptical mass parallel to the skin surface that is hyper echoic relative to adjacent muscle and that contains linear echogenic lines at right angles to the ultrasound beam is appreciated on a sonogram.10 treatment of choice of lipomas is definitely surgical excision. surgery is opted for esthetic reasons, pressure symptoms due to enlarged size and malignancy. recurrence occurs commonly so proper excision is required to prevent incomplete removal of this lesion.5 c o n c l u s i o n an appropriate clinical evaluation can lead to a diagnosis of lipoma. it is a rare finding that occurs anterior to parotid but can be treated successfully by current surgical approach. r e f e r e n c e s 1. kaur r, kler s, bhullar a. intraoral lipoma: report of 3 cases. dental res j. 2011; 8(1): 48. pmid: 22132015 2. paparo f, massarelli m, giuliani g. a rare case of parotid gland lipoma arising from the deep lobe of the parotid gland. ann maxillofac surg. 2016; 6(2): 308. doi: 10.4103/2231-0746.200335 3. dispenza f, de stefano a, romano g, mazzoni a. posttraumatic lipoma of the parotid gland: case report. acta otorhinolaryngol ital. 2008; 28(2): 87. pmid: 18669074 4. el-monem mh, gaafar ah, magdy ea. lipomas of the head and neck: presentation variability and diagnostic work-up. j laryngol otol. 2006; 120(1): 47-55. doi: 10.1017/s0022215105004597 5. rana d, raychaudhuri s, arora s. a case of lipoma in lateral anterior neck: a common entity at an uncommon location. int j sci rep .2017; 3(6):182-4. doi: 10.18203/issn.2454-2156 6. sathyaki dc, roy ms.lipomas of head and neck. int j otorhinolaryngol head neck surg. 2018; 4(2): 368-71. doi: 10.18203/issn.2454-5929.ijohns20180521 7. najaf y, cartier c, favier v, garrel r. symptomatic head and neck lipomas. eur ann otorhinol head neck ds. 2019; 136(2): 127-9. doi: 10.1016/j.anorl.2018.12.001 8. fakhry n, michel j, varoquaux a, antonini f, santini l, lagier a. et al. is surgical excision of lipomas arising from the parotid gland systematically required? eur arch otorhino-l. 2012; 269(7):1839-44. doi: 10.1007/s00405-0111843-0. 9. demir d, eraslan ö, güven m, kösem m. rare cases of benign tumors of the head and neck: lipoma of larynx and sternocleidomastoid muscle. kulak burun bogaz ihtis derg. 2016; 26(2):118-22. doi: 10.5606/kbbihtisas.2016.92155 10. ahuja at, king ad, kew j, king w, metreweli c. head and neck lipomas: sonographic appearance. am j neuroradiol. 1998; 19(3): 505-8. pmid: 9541308. j islamabad med dental coll 2019 127 open access role of magnetic resonance imaging and spinal tap in early diagnosis of tuberculous meningitis salma haji assistant professor, department of neurology, jinnah postgraduate medical center, karachi a b s t r a c t background: tuberculous meningitis (tbm) is difficult to diagnose in early stages due to nonspecific symptoms. there should be high index of suspicion to diagnose tbm at an early stage. the objective of the study was to find out the role of magnetic resonance imaging (mri) and spinal tap in early diagnosis of tuberculous meningitis. material and methods: a cross sectional study was conducted from july 2015 till july 2018 at neuromedicine ward, jinnah postgraduate medical centre (jpmc), karachi. all patients above 12 year of age, both male and female with nonspecific symptoms like headache, malaise and drowsiness or suspicion of tbm (stage i, ii, and iii according to british medical research council tbm staging criteria) were included in the study. patients diagnosed with other cns disease like encephalitis, malaria and acute bacterial meningitis were excluded. magnetic resonance imaging (mri) of the brain and early spinal tap for cerebrospinal fluid (csf) analysis were used to diagnose tbm and findings were noted. results of mri and csf analysis were analyzed by spss version 24. results: a total of 110 patients of tbm, with 60 (54.5%) male and 50 (45.5%) female patients were included in the study. most of the patients belonged to a younger age group of 12-40 years (81.8%), while 18.2% were above 40 years of age. about 90% patients were diagnosed in stage i tbm and 10% in stage ii and iii. mri brain findings included meningeal enhancement (60%), hydrocephalus (41.81%) cerebral edema (82.73%), tuberculoma (19%) and infarct (14.5%), respectively. csf analysis showed low protein in 80%, low glucose in 91.8% and lymphocytic pleocytosis in 97.2%, respectively. conclusion: both mri brain and spinal tap with csf analysis played a role in the early diagnosis of tbm, which is important to prevent the lethal complications associated with late diagnosis of this disease. key words: brain, cerebrospinal fluid, magnetic resonance imaging, tuberculous meningitis authors’ contribution: conception, synthesis, planning of research and manuscript writing interpretation, discussion, active participation in data collection data analysis. correspondence: salma haji email: salmahajineuro@gmail.com article info: received: september 4, 2018 accepted: july 11, 2019 cite this article. haji s. role of magnetic resonance imaging and spinal tap in early diagnosis of tuberculous meningitis. j islamabad med dental coll.2019; 8(3):127-130. doi 10.35787/jimdc.v8i3.417 funding source: nil conflict of interest: nil i n t r o d u c t i o n tuberculous meningitis (tbm) is difficult to diagnose in early stages due to nonspecific symptoms. there should be a high index of suspicion to diagnose tbm at an early stage. history of bcg vaccination does not rule out tbm. in stage i, tbm patients can usually present with nonspecific symptoms like fever, headache, drowsiness, confusion, malaise and fatigue.1 duration of symptoms may be from days to many months. patients sometimes present with visual symptoms and wrong diagnosis can be made. tbm patients can also present with monoplegia, hemiplegia, aphasia, tetraplegia, cranial nerve palsies in stage ii disease and with coma in stage iii disease1.definitive diagnosis of tbm can be made by finding tubercle bacilli in csf by culture.1 large volume (10ml) is required to find tubercle bacilli in culture especially in ventricular fluid. pcr is 98% specific for diagnosis of tbm performed on csf.1 tuberculin skin test is not specific or sensitive for diagnosis of active tbm. patients with tbm should be preferably evaluated with contrast enhanced ct imaging and it can diagnose early tbm and hydrocephalus due to tbm. choroid o r i g i n a l a r t i c l e j islamabad med dental coll 2019 128 plexuses enhancement with ventricular enlargement is suggestive of diagnosis of tbm.2 mri reveals diffuse thick meningeal enhancement. cerebral infarct can also be seen in mri brain. basal enhancement hydrocephalus and infarction are diagnostic for tbm.3 contrast enhanced mri is generally considered best diagnostic test for tbm. tbm is usually secondary to pulmonary tb so chest x-ray is also important for diagnosis of tbm. serial transcranial doppler ultrasonography with blood flow velocity and pulsatility index measurement can be used to find out the prognosis of tbm and to find out the infarct resulting in permanent neurological deficit or death.4 the rationale of this study was early diagnosis of tuberculous meningitis to prevent complications associated with late stage disease. by avoiding early use of mri and spinal tap, we can delay the diagnosis of tbm which leads to increase in mortality and morbidity, when infarct and hydrocephalus develops. so even with mild symptoms, mri and early spinal tap can detect the tbm in stage i. therefore, the present study was conducted to find out the role of mri and spinal tap in diagnosing early stage tbm m a t e r i a l a n d m e t h o d s this was a cross sectional observational study conducted at neuromedicine ward, jinnah postgraduate medical center (jpmc) karachi, from july 2015 to july 2018. patients with a clinical suspicion of tbm, of both gender (male and female) and above 12 years of age were included. patients presenting with fever, headache, drowsiness, confusion, malaise, myalgia, fatigue, visual loss, coma and atypical symptoms like monoplegia, tetraplegia, hemiplegia neck stiffness, afebrile fits or cranial nerve palsy were investigated for tbm. patients diagnosed with other diseases of cns like encephalitis bacterial meningitis, viral meningitis, subarachnoid hemorrhage and cerebral malaria were excluded. tbm patients with nonspecific symptoms like fever, headache and vomiting were classified as stage i tbm, those presenting with altered consciousness as stage ii tbm and patients with coma were classified in stage iii tbm, according to the criteria of tbm severity outlined by british medical research councill.2 bcg vaccination history was taken if family history of tuberculosis was found positive, and suspicion of tbm was made even with mild nonspecific symptoms. laboratory investigation like cbc, urea, creatinine, random blood sugar, liver function tests and specific investigations like mantoux test and x-ray chest were carried out. fundoscopy was also done. spinal tap was done and csf analysis with afb staining and culture was performed. mri brain was carried out in all equivocal patients to diagnose the tbm in stage i. mri findings like meningeal enhancement, hydrocephalus, cerebral edema, tuberculoma and infarct were noted. csf findings like raised proteins, low glucose and lymphocytic pleocytosis were also recorded. data was analyzed using spss version 24. r e s u l t s a total of 110 patients of tbm above 12 years of age with 60 (54.5%) males and 50 (45.5%) females were included in the study. most of the patients (n=99; 90%) presented in stage i, while the remaining (n=11; 10%) were stage ii and/or stage iii patients. about 90 (81.86%) patients were between 12-40 years of age and 20 (19.19%) patients were above 40 years of age. complications included death due to tbm in 11 patients (10%) and hydrocephalus, cranial nerve palsies, hyponatremia in 33 patients (30%). other tbm patients (n=66; 60%) recovered uneventfully. about 33 patients (30%) were diagnosed with associated pulmonary tuberculosis, and 44 (40%) with associated tb abdomen and tb lymph node. mri findings were significant even in patients with nonspecific symptoms like basilar meningeal enhancement. mri and csf findings are given in tables i and ii, respectively. table: i mri findings in tbm patients mri brain findings no. of patients (n=110) percentage meningeal enhancement 66 60 hydrocephalus 46 41.8 cerebral edema 91 82.7 tuberculoma 21 19 infarct 16 14.5 j islamabad med dental coll 2019 129 table: ii csf findings in tbm patients csf findings no. of patients (n=110) percentage raised protein 88 80 low glucose 101 91.8 lymphocytic pleocytosis 107 97.2 almost all the patients except one (n=109; 99.09%) had mri findings suggestive of tbm with further confirmation on csf analysis. d i s c u s s i o n tbm patient can present with early or late symptoms. early diagnosis of the condition is important to prevent death or disability. in stage i of tbm, patients usually presented with non-specific symptoms like headache, vomiting, fever, myalgia and lethargy. in stage ii of tbm, patients presented with altered level of consciousness and focal deficits, while in stage iii of tbm, patients with coma and focal neurological deficit were included. to prevent brain infarction or hydrocephalus which leads to death or disability, it is important that early mri should be done to diagnose tbm, so that anti-tubercular treatment (att) can be started in initial stages of tbm. early lumbar puncture for csf analysis and mri brain should be done for diagnosis of tbm. mri brain shows diffuse basilar meningeal enhancement and cerebral infarct can be seen in 30% of tbm patients.5 a study conducted in south africa reported that combination of basilar enhancement, hydrocephalus and infarction was 100% specific and 41% sensitive for diagnosis of tbm.6 in this study, meningeal enhancement was present in 60%, tuberculomas in 19%, while infarct was found only in 14.5% of tbm patients. tuberculoma and infarcts are usually present in stage ii and stage iii of tbm disease. most of our patients were diagnosed in tbm stage i, so tuberculoma and infarcts were less common in this study. brain edema was the most common finding because of the early presentation of majority of tbm patients in this study. imaging studies, especially mri has an important role in diagnosing tbm, because clinical diagnosis is often difficult.7 spinal tap carries the risk of tonsillar herniation in patients with raised intracranial pressure. tuberculin skin testing also has limited value because patients vaccinated with bcg also turn out to be positive. however, in spite of the associated risk, the procedure of spinal tap must be performed for diagnosis of tbm.8 csf finding in this study revealed raised protein in 80%, low glucose in 91.8% and lymphocytic pleocytosis in 97.27%. almost similar values for csf analysis have been reported in another study.9 adenosine deaminase levels in csf (csf ada) greater than 6 strongly suggest the diagnosis of tbm. most guidelines for diagnosis of tbm agree on simple csf analysis such as low glucose, low protein and presence of lymphocytic pleocytosis. but this investigation has limitation when antibiotic has been already given. therefore, adjuvant mri brain can diagnose the tbm earlier.10 in this study we attempted to diagnose tbm in early stage to avoid lethal complications like hydrocephalus, hyponatremia, cranial nerve palsy, stroke and death from tbm, and to start disease eradication by att therapy. mri brain is not available in primaryand secondary-care centers, so physicians should refer the tbm patient to the tertiary-care center for csf analysis and mri scan for early diagnosis and to prevent lethal complications of the disease. in this study, we carried out mri brain in all patients with clinical suspicion of tbm presenting with non-specific symptoms and were able to diagnose tbm in stage i in 90% of our patients. computerized tomography (ct) findings in tbm do not corroborate the clinical presentation, while mri has the potential to diagnose with more sensitivity than ct scan, especially in detecting basal enhancement and infarcts,11 both in brain and spine.12,13 therefore mri is superior to ct scan for diagnosing tbm.11 rapid diagnoses of tbm is crucial and delay in diagnosis is associated with poor prognosis. laboratory diagnosis of tbm also has low sensitivity, so early mri brain is mandatory because once the neurological symptoms are advanced and patient presents in coma or with neurological deficit, then diagnosis is obvious, but the prognosis is poor. according to who “end tb strategy” program, 80% reduction in tb incidence by 2030 and 90% reduction in tb-related deaths can be achieved through early diagnosis (e.g. csf analysis, mri etc.) and appropriate treatment (att).14 j islamabad med dental coll 2019 130 meningitis is most common in children15 and adolescent mainly due to hematogenous spread with the primary focus mostly present in the lungs. jpmc is a public sector hospital which caters to the treatment of adult population while children are referred to the nearby national institute of child health (nich). therefore, we excluded children from our study, which was also a limitation. another limitation was non-availability of diffusion weighted mri, which can detect infarction in hyper acute stage. c o n c l u s i o n both mri brain and spinal tap with csf analysis played a role in the early diagnosis of tbm, which is important to prevent the lethal complications associated with late stage disease. r e f e r e n c e s 1. m.f torok. tuberculosis meningitis: advance in diagnosis and treatment of tbm; br med bull. 2015; 113(1): 117-131. doi: 10.1093/bmb/ldv003 2. thwaites ge, bang nd, dung nh, quy ht, oanh dtt, thoa ntc, et al. dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. n engl j med. 2004; 351: 1741-51. doi: 10.1056/nejmoa040573 3. namani s, dreshaj s, berisha az. tuberculous meningoencephalitis associated with brain tuberculomas during pregnancy: a case report. j med case rep. 2017 11:175. doi: 10.1186/s13256-017-1347-7 4. trivedi r, saksena s, gupta rk. magnetic resonance imaging in central nervous system tuberculosis. indian j radiol imaging. 2009; 19(4): 256-65. doi: 10.4103/09713026.57205 5. ros k l. pearl and pitfall in diagnosis and management of central nervous system infectious disease. semin neurol. 1998; 18(2): 185-96. doi: 10.1055/s-2008-1040872 6. andronikog s, smith b, hathushill m, douis h, wiliamhust j. definite neuroradiological diagnostic features of tuberculosis meningitis in children. pediatr radiol. 2004: 34(11): 876-85. doi: 10.1007/s00247-004-1237-1 7. medscape.https://emedicine.medscape.com/article/344862overview 8. tarakad s, ramachandral. tuberculosis meningitis workup; neurology. 2017 medscape. https://emedicine.medscape.com/article/1166190-workup 9. qamar fn, rahman aj, iqbal s, humayun k. comparison of clinical and csf profiles in children with tuberculous and pyogenic meningitis; role of csf protein: glucose ratio as diagnostic marker of tuberculous meningitis. j pak med assoc. 2013; 63(2): 206-10. pmid: 23894896 10. solari l, soto a, agapito jc, acurio v, vargas d, battaglioli t.et al validity of csf parameters for diagnosis of tbm: int j infect dis. 2013; 17(12): e1111-5. doi: 10.1016/j.ijid.2013.06.003 11. pienaar m, andronikou s, van toorn r. mri to demonstrate the diagnostic feature and complication of tbm not seen with ct; childs nerve syst. 2009; 25(8): 941-947. 12. verdon r, chevret s, laissy jp, wolff m. tuberculosis meningitis in adult, a view of 48 cases: clin infect dis. 1996; 22(6): 982-8. doi: 10.1093/clinids/22.6.982 13. hernaldiz, albaujar s, andres jr, roya a, gorzalez, jarcia jj, panajal, vazkuez. tuberculosis radiculomyelitis complicating tuberculosis meningitis; a case report: clin infect dis. 2011; 53(9): 915–926. doi: 10.1086/313821 14. world health organization. global tuberculosis report 20th edition. world health organization, geneva; 2015 15. sanei taheri m, karimi ma, haghighatkhah h, pourghorban r, samadian m, delavar kasmaei h. central nervous system tuberculosis: an imaging focus review of reemerging disease: radiol res pract. 2015; 2015: 202806. doi: 10.1155/2015/202806. https://doi.org/10.1093/bmb/ldv003 summary journal of islamabad medical & dental college (jimdc); 2016:5(3):122-125 122 original article management of ingested foreign bodies muhammad asad chughtai 1 , safdar nawaz malik 2 , imran ul haq 3 , muhammad jamal ullah 4 1. assistant professor, department of ent, wah medical college 2. associate professor, department of ent, islamabad medical and dental college 3. associate professor/hod, department of anesthesia, wah medical college 4. professor, department of ent, al-nafees medical college and hospital, islamabad abstract objective: to determine the likelihood of spontaneous passage of esophageal coins in stomach, to see the effect of initial coin location on spontaneous passage and to design management strategies. material and methods: this prospective interventional study was conducted from march 2011 to march 2016, in the department of ent pof hospital wah cantt.in all patients of coin ingestion history and radiological findings were recorded. they were evaluated after 24 hours for either spontaneous passage of coin to stomach or needed surgical intervention with either magill forceps or oesophagoscopy. base line investigations and repeat x-ray were done before surgical procedure. results: out of 25 patients of coin ingestion, 60% (n=15) were boys and 40% (n=10) were girls with age range from 2 to 6 years. total 84% patients (n=21) had coin at cricopharyngeus level, while 8% (n=2) at mid esophagus and 8% (n=2) at lower esophagus level. after 24 hours, total of 36% (n=9) patients had spontaneous passage of coin. among them two patients were with coin at lower esophageal level while two and five patients were with coin at middle esophagus level and at cricopharyngeus level respectively. among the remaining 16 patients only 20% (n=5) needed to go for esophagoscopy and rest 44% (n=11) had removal of coin by using direct laryngoscopy and magill forceps. conclusion: a trial of 24 hours for spontaneous passage of coin irrespective of the site of impaction is recommended. if the coin does not pass spontaneously, then upper esophageal level coins should be attempted with magill forceps. for left over cases oesophagoscopy should be done. key words: coins, direct laryngoscopy, esophagus, magill forceps. introduction foreign body (fb) ingestion is a common ent emergency, occurring mostly in children. most of these fbs are coins while less common are buttons, bone pieces and pins. 1 fb ingestion in usa accounts for over 100, 000 cases per year. 2 its peak incidence in pediatric population is between 6 months to 3 years. 3,4 in addition to young children, mentally retarded patients and developmentally delayed individuals are also at greater risk. presently a vast variety of coins of different sizes, ranging from 4 mm to 85 mm are in use all over the world. 5 mostly they are made of silver or zinc and are not causing much of the fb reaction. there are three notorious sites for impaction of fb in esophagus. first and most common one is level of cricopharyngeus which is at the level of sixth cervical vertebra. this place offers maximum resistance for passage of fbs. second less common site is the mid esophagus, in the region where the aortic arch and carina overlap the esophagus. the third site is the lower esophageal sphincter that is at gastroesophageal junction. 6 in addition, obstruction may also occur at pathologically narrowed parts of the esophagus like stricture, tumor etc. coin impaction in esophagus is not life threatening condition. it can easily be removed by simple procedure. successful removal depends upon many factors, including its location, size, experience of physician, patient cooperation, and equipment available. mostly watchful waiting is fruitful. since majority of the esophageal coins in children pass spontaneously to the stomach which may ultimately eliminate the need for any invasive procedures. 7,8 once the coin gets impacted in the upper esophagus then it’s become necessary to remove it. prolong retention may end up with complications like mediastinitis, perforation, mucosal ulceration, extra luminal coin migration, pneumonia mediastinum and very rarely fatal complication like aortoesophageal fistula. though minor problem like esophageal edema has also been noted with coin ingestion even with duration of impaction less than 24 hours. 9 dominant signs and symptoms of impaction are dysphagia, increased salivation, vomiting and regurgitation. a thorough history coupled with plain radiography is sufficient to diagnose all coins and most of other fbs. different methods are in practice for removal of fb esophagus. the classical method of removal of fb with rigid endoscopy still remains the gold standard procedure. 10 it is done under general anesthesia and is the most favorite procedure done by otorhionlaryngologist. other commonly practiced procedure is flexible endoscopy which is done corresponding author: dr muhammad asad chughtai e-mail:doctorasad.chughtai@yahoo.com received: august 15, 2016; accepted: sept 23, 2016 mailto:doctorasad.chughtai@yahoo.com journal of islamabad medical & dental college (jimdc); 2016:5(3):122-125 123 without general anesthesia, and is preferred by medical specialist. magill forceps is also used as alternative methods of fb removal. magill forceps is commonly used for coins which are placed at cricopharyngeus. this procedure is preferred by anesthetists. 11,12 foley’s catheter has also been used for removal of coin from esophagus. it has the advantage of being done without general anesthesia, and is more simple and economical. 13 coins impacted at distal end of esophagus has also been removed successfully with the use of snares and protective endoscopy cover. 14 bougies has also been used to advance the coin into the stomach. 15 conservative management that includes waiting for spontaneous passage is worth mentioning. when more than one option is available, selection for an appropriate treatment option becomes difficult. the aim of our study is to share our experience of removal of coin from esophagus. in all cases first step was to wait for 24 hours for spontaneous removal of coin, followed by removal of coin with magill forceps. rigid oesophagoscopy was reserved for failure cases. material and methods this prospective study was carried out in the department of ent pof hospital wah cantt, from march 2011 to march 2016. we included 25 cases having coins impacted in the esophagus. pof hospital is a tertiary care teaching hospital which provides health care to the employees of pof and their families as well as the private patients. patient with positive history of coin ingestion having duration less than 24 hours were included in the study. after the initial examination; patients with history of any esophageal disease, previous history of coin impaction and those who underwent earlier attempts of removal of coin, were excluded from the study. age, sex, time of occurrence, location of the fb and treatment option used were recorded. in all patients, x-ray neck (ap and lateral view) was performed. the fb locations were marked as pharyngeal, proximal esophagus, middle and distal esophagus. most common presenting symptoms were refusal to take food, vomiting, neck or chest pain, drooling of saliva, dysphagia and cough. x-ray was repeated in every case before taking the patient to operation theatre (ot), to see the latest location of impacted coin. three step treatment was planned for all patients. in first stage all cases were kept waiting for 24 hours. if no spontaneous passage of coin was observed than in second phase they were taken to ot for removal with magill forceps. in third phase all left over cases were given general anesthesia for esophagoscopy. all the patients were briefed about the advantages and possible complications (rare) of 24 hours wait. informed written consent was obtained from parents on a printed paper. patients were kept nil per oral till coin removal. vital signs observation was done 8 hourly. patients were given i/v fluid for 24 hours. after 24-hour, fresh x-rays were done to see the change of position of coin. all the cases with spontaneous passage of coin were discharged with proper informative briefing and reassurance. rest were taken to ot for removal of coin. the patients were sedated with injection propofol 2mg/kg body weight. they were ventilated on spontaneous breathing with hundred percent oxygen via face mask. laryngoscope was passed in sniff’s position where coin edge was visible at cricopharyngeal level. it was grasped and removed with the magill force. in cases were edge of coin was not visible and cricopharyngeal opening was found close, magill forceps was inserted gently in esophagus with blades/prongs close while prongs of forceps were kept horizontal. immediately after introducing the magill forceps with close prongs in cricopharyngeus, prongs were opened while moving it forward, coin was grasped by closing the blades and then removed. in case of failure second attempt was made and coin was removed. in case of failure with second attempt, patients were intubated after giving the muscle relaxant. rigid endoscopy was then the option left. after removing the coin second look oesophagoscopy was performed in all cases. every patient was kept nil by mouth till fully conscious. there was no anesthesia related complications. data analysis was done by using spss version 20. variables were categorized, compiled and represented on tables, pie charts. results total 25 cases of fb (coin) ingestion were managed. out of 25 children, 84% (n=21) had coin at first narrowing, followed by the 8% (n=2) at second level and rest 8% (n=2) with coin at lower esophageal level, among them 60%(n=15) were male and 40% (n=10) were female. the age range of the patients was 2 to 6 years with mean age of 4 years. five-rupee coin was most commonly found in our study. five-rupee coin was impacted in 48% (n=12), tworupee coin in 32% (n=8) and one-rupee coin in 20% (n=5) (table 1). age of patients at which coin impaction occur is shown in fig 1, site of coin impaction in fig 2 and common symptoms like dysphagia, refusal to take food, neck/chest pain, vomiting and drooling in fig 3. final radiography was done in all case before taking the patient to ot. spontaneous passage of the coin to the stomach noted in 36% (n=9) patients. total 44% (n=11) patients had coin removal successfully with the help of magill forceps. coins edge was visible on laryngoscopy in 28% cases (n=7). rest 20% (n=5) patients had removal of coin with esophagoscopy under general anesthesia. mean post op stay in the hospital was 6 hours and ranged from 4 to 10 hours. there were no complications of anesthesia and the procedures adopted. journal of islamabad medical & dental college (jimdc); 2016:5(3):122-125 124 table i: types of coin removed (n=25) type of coins number % 5 rupee 12 48 2 rupee 8 32 1 rupee 5 20 fig i: age of patients showing coin impaction (n=25) 84% 8% 8% 0 5 10 15 20 25 cricopharyngeus level mid oesophagous level lower oesophageal… fig 2: site of coin impaction (n=25) 8% 12% 16% 52% 40% 0 5 10 15 20 25 pain neck pain chest doorling of dsaliva refusal tomtake food vomiting fig 3: symptoms of coin impactions (n=25) discussion fb ingestion is a common problem in children. coins are the most common fb ingested in the esophagus in pakistan. 16,17 the incidence of ingestion of fb in children is high. it could be due to their natural propensity to gain the knowledge by putting things in the mouth, inability to masticate well and inadequate control of deglutition. the majority of the pediatric patient had foreign body lodge at the level of cricopharynx, which is the narrowest part of the pediatric gastrointestinal tract and is the site where a significant number of ingested fbs lodge. we divided our patients in three groups depending upon the location of coin in esophagus. all individuals with positive history of ingestion and with positive radiological finding were included in the study. in our study we have 84% of coin at the level of the cricopharyngeus, 8% at the level of the aortic cross over and 8% were found at of the lower esophageal level. kay m et al mentioned almost similar results. 18 vivek v et al also found coin as the commonest fb and cricopharynx was the commonest site of impaction in children. 19 besides history and physical examination, radiology is a very important diagnostic tool for identification of the nature of the fb and its location. in pediatric population, 60-80% of objects caught at the level of the cricopharyngeus muscle in the proximal esophagus, 10-20% become trapped at the level of the aortic cross over and 520% were found at the level of the lower esophageal sphincter. tadesse a et al in their study showed 78.8% impaction in proximal esophagus and 12.9% in mid esophagus. however, they did not have any individual with fb in distal esophagus. 20 digoy gp and conners et al also found most of their cases with impaction of coin at first narrowing of the esophagus, which is similar to our finding. 21 in our study of 25 cases, 36% (n=9) patient had their coin passed spontaneously to the stomach. among them 5 patients found fb at upper esophagus and 02 at middle and 02 at lower esophagus. this showed that the initial location of the coin in the esophagus did not affect the spontaneous passage of coin. robert e etal recommended a repeat radiograph immediately before the endoscopy, because up to one fourth of esophageal coins pass spontaneously within 8 to 16 hours. 22 most fbs leave the body spontaneously without leading to any mortality or morbidity. 23 stringer et al found that 33% of esophageal coins passed spontaneously to the stomach which is more close to over results. study conducted by conners etal revealed that coins impacted at distal location (60%) passed spontaneously and patients (48%) in which coin found at proximal or middle esophagus did not show spontaneous passage of the coin. 8 they recommended a 12 to 24 hour wait and see period, in patients with coins lodged at distal esophagus only. their results differ with our study in respect to location of coin. in our study spontaneous passage of coin was observed irrespective of site of location of coin. chua ah in his study found spontaneous passage of 27 out of 136 coins in pediatric patients with radiographic evidence of a round radio-opaque (coin) fb. 24 in our study 44% of patients had removal of coin with the help of magill forceps, and 20% with oesophagoscopy. nasser ahmad et al in their study removed 80% coins with magill forceps in first attempt. 25 refusal to take food and dysphagia was presenting symptom in 13 children (52%), which is similar to what journal of islamabad medical & dental college (jimdc); 2016:5(3):122-125 125 other researchers has mentioned. 25 in our study doodling of saliva was observed in only 4 (16%) children. pain was presenting complaint by 20% of patients. in most of cases it was in neck or in upper chest. ahmad n et al found 90% patient with difficulty in swallowing and excessive salivation while remaining 10% having vomiting and cough. 25 although this is generally agreed that chance of coin impaction is directly proportional to its size and inversely to the age of child. there are many unanswered and debatable questions on the topic of coin impactions and its managementlike which coin size is risky and what should be the criterion to wait for spontaneous passage. on completion of our study we are confidant to document that coins below 20 mm in size pass spontaneously and rarely need endoscopic removal. obtaining second x-ray just before operation in coins above 20mm in size is wasting of time and economy. conclusion all the cases of coin impaction should be offered wait and see policy for spontaneous passage for 12-24 hours. if the coin does not pass spontaneously, the upper esophageal level coins may be safely and quickly removed under direct vision by mcgill’s forceps using mcintosh laryngoscope. rest of the cases should be offered oesophagoscopy under g/a. further study involving a large number of patients, is needed before this regime can be generally recommended. print and electronic media can be used to educate the masses about the hazards of coin handling by kids. conflict of interest this study has no conflict of interest as declared by any author. references 1. abdulaziz aa, ali am. foreign bodies of the esophagus: twoyear prospective study. ann saudi med. 2000;2:25-62. 2. uyemura mc. foreign body ingestion in children. am fam physician. 2005;72 (2):287-92. 3. mcneill mb, sperry sl, crockett sd, miller cb, shaheen nj, dellon es. epidemiology and management of esophageal coin impaction in children. dig liver dis. 2012;44(6):4826. 4. waltzman ml. management of esophageal coins. curr opin pediatr. 2006;18(5):571–4. 5. raahat zm, nusrat r, adnan su. coin impaction at upper end of esophagus: wait or intervene. pak j otolaryngol. 2013;29:77-9. 6. ratcliff km. esophageal foreign bodies. am fam physician. 1991;44(3):824-31. 7. chaikhouni a, kratz jm, crawford fa. foreign bodies of the esophagus. am surg.1985;51(4):173-9. 8. conners gp, chamberlain jm, ochsenschlager dw. conservative management of pediatric distal esophageal coins. j emerg med. 1996;14(6):723-6 9. ahmed l, kumar s, ashraf p, laquee s. endoscopic esophageal foreign body retrieval: a single center experience. asian j pharm clin res. 2012;5(2);49 51. 10. khan c, hameed a, choudhry aj. management of foreign bodies in esophagus. j coll physicians surg pak. 2004;14(4):218-20 11. mahafza tm. extracting coins from the upper end of the esophagus using a magill forceps technique. int j pediatr otorhinolaryngol. 2002;62(1):37-9. 12. janik je, janik js. magill forceps extraction of upper esophageal coins. j pediatr surg. 2003;38(2):227-9. 13. digoy gp. diagnosis and management of upper aero digestive tract foreign bodies. otolaryngol clin north am. 2008;41(3):485-96. 14. hameed k, hassan mk, rehman s, khan d, khan im, khattak ak. management of foreign body in the upper gastrointestinal tract with flexible endoscope. jpmi. 2011; 25(1):29-34. 15. emslander hc, bonadio w, klatzo m. efficacy of esophageal bougienage by emergency physicians in pediatric coin ingestion. ann emerg med. 1996;27(6):726-9. 16. magsi pb, sangi ha, jamro b. experience of foreign bodies in aero-digestive tract at tertiary care hospital sukkur, pakistan. rmj. 2011;36(4):277-80 17. asif m, haroon t, khan z, muhammad r, malik s, khan f. foreign body esophagus: types and site of impaction. gomal j med sci. 2013:11:163-6. 18. kay m, wyllie r. pediatric foreign bodies and their management. curr gastroenterol rep. 2005;7(3):212 8. 19. harkare vv, khandakkar sp, deosthale nv, dhoke pr, dhote ks, banerjee m, etal. ingested foreign body in pharynx and oesophagus: comparison between adult and pediatric population, j evidence based med hlthcare. 2015; 2(44):8060-5. 20. tadesse a, feyo a. management of ingested foreign bodies in pediatric patients: an experience from a tertiary hospital in ethiopia. east cent afr j surg. 2014;19(1):11-6. 21. digoy gp. diagnosis and management of upper aerodigestive tract foreign bodies. otolaryngol clin north am. 2008;41(3):485-96. 22. kramer re, lerner dg, lin t, manfredi m, shah m, stephen tc, et al. management of ingested foreign bodies in children: a clinical report of the naspghan endoscopy committee. jpgn. 2015; 60:562-74. 23. sugawa c, ono h, taleb m, lucas ce. endoscopic management of foreign bodies in the upper gastrointestinal tract: a review. world j gastrointest endosc. 2014; 6(10):475-81 24. chua ah. spontaneous passage of ingested coin in children. philippine j otolaryngol head neck surg; 2015;30(2): 30-3 25. ahmad n, niamatullah, yousaf m, javaid m, ullah i. removal of coin from upper oesophagus under local anesthesia. jpmi. 2007;21(2):109-12. authorship contribution author1: active participation planning and final review of article author2: active participation in research, analysis and discussion author3: conception and planning, active participation in research author4: active participation in research, analysis and critical view of article j islamabad med dental coll 2019 117 open access association of clinicopathological features of cholecystitis with helicobacter pylori infection in gall bladders saleha anjum khan1, huma mushtaq2, ahmad raza3, mohammad nauman mustafa4, saeed alam5 1 assistant professor, department of surgery, akbar niazi teaching hospital, islamabad 2 associate professor of histopathology, department of pathology, akbar niazi teaching hospital, islamabad 3 associate professor, department of surgery, akbar niazi teaching hospital, islamabad 4 professor, department of surgery, frontier medical and dental college, abbottabad 5 professor of histopathology, department of pathology, akbar niazi teaching hospital islamabad a b s t r a c t background: helicobacter pylori (h. pylori) have been associated with gastritis, but its presence in other parts of the gastrointestinal system has not been studied much. few previous studies have identified “h. pylori” in gallbladder and found its association in causing cholecystitis and gallstones, but there is limited data showing a significant association in pakistan. this study was designed to identify h. pylori microorganism in cholecystitis patients and find its association with the morphological changes seen in the affected gall bladders. material and methods: all patients with acute and chronic cholecystitis admitted in akbar niazi teaching hospital (anth) between the ages of 18 and 80 years from january 2017 till march 2019, who underwent cholecystectomy, were included in the study. gall bladder specimens were sent to pathology department, anth after surgery and were analyzed for the presence of h pylori bacteria using hematoxylin and eosin and giemsa staining. signs of inflammation, hyperplasia, metaplasia, mucosal atrophy or erosion, lymphoid infiltration, fibrosis, cholesterolosis or any other morphological changes were also noted. association of h. pylori with cholecystitis and other morphological changes were assessed by chi square analysis. p value less than 0.05 was considered statistically significant. results: chronic cholecystitis was present in 91% cases and acute cholecystitis in 9%. other histological findings were hyperplasia (10%), metaplasia (15%), fibrosis (79%), cholesterolosis (19%) and ulcerations (36%). h pylori was found in 17% of gall bladders and all the cases were of chronic cholecystitis, with 11.7% males and 88% females. gallstones were present in 76.4% cases and were more common in 41-60 years’ age group (64.7%). other histological findings seen in h. pylori positive cases were; hyperplasia in 11.7% cases, metaplasia in 17.6%, fibrosis in 94.1%, cholesterolosis in 23.5% and ulcerations in 17.6% cases. association of h. pylori with gender, cholecystitis, gall stones, histological features and age distribution was non-significant. conclusion: although h. pylori infection has been found in cases of chronic cholecystitis and gall stone formation, its association with cholecystitis and other morphological changes could not be proved. hence, it is uncertain whether h. pylori eradication in patients with gastritis can prevent cholecystitis or gall stones formation. key words: cholesterolosis, cholecystitis, gall stones, h. pylori authors’ contribution: 1 conception, synthesis, planning of research. 2 data analysis, manuscript writing interpretation, and discussion, 3-5 active participations in data collection correspondence: huma mushtaq email: huma.mushtaq@imdcollege.edu.pk article info: received: april 20, 2019 accepted: august 30, 2019 cite this article. khan sa, mushtaq h, razza a, mustafa mn, alam s. association of clinicopathological features of cholecystitis with helicobacter pylori infection in gall bladders. j islamabad med dental coll.2019; 8(3):117-122. doi: 10.35787/jimdc.v8i3.403 funding source: nil conflict of interest: nil i n t r o d u c t i o n gallstone disease is the most commonly occurring disease in surgical practice with a prevalence of 10-15% in european population and 3-5% in asian and african population.1 internationally the reported prevalence of gallstone disease was 9.2% for italy, 9.7 % for spain, o r i g i n a l a r t i c l e j islamabad med dental coll 2019 61 28.5% for chile and 3.1% for thailand.2 in pakistan, the incidence reported in previous years was 9.03%.2,3 all over the world surgical units are managing many patients with gallstones every year and with cholecystectomy as one of the most common elective surgical procedure.1 in our setup in anth bara kahu, since last one-year (2017-2018), number of surgeries performed for gallstones have been at the top of the list i.e. 22% of all general surgical procedures (62 /286). hyperlipidemia, sedentary lifestyle, low fiber, high fat diet, metabolic syndrome and diabetes are the commonest causative factors of gallstone formation leading to cholecystitis.4 in recent years, few studies from middle east5 and asia (china,4,6,7, iran,8,9, india10,11) have identified a new causative agent “h pylori” which plays a role in gall stone formation leading to cholecystitis. the initial study dates back to 1996 by kawaguchi et al.12 who incidentally discovered a microorganism resembling h pylori from a cholecystectomy specimen. since then many researches have been performed, but still this association has not been widely accepted due to the lack of proper evidence. despite an overall percentage of approximately 20% being detected in gallbladder mucosa, according to various studies4, its eradication has not been practiced or proposed for cholecystitis. the prevalence of this bacteria is more in asian population but only a few studies have been performed in pakistan that have shown a significant association.3 therefore further studies are required, to elucidate the role of helicobacter in hepatobiliary diseases in our setup. this gram-negative rod has previously been associated with gastritis and acid peptic disease8 for decades and studies have been carried out to show its association with gallstones, cholecystitis13,14 and gall bladder cancer.15 many serological and histological methods16,17 have been used to detect its presence in gall bladder mucosa and bile including giemsa staining, h&e, pcr, urease test, warthin-starry18 test etc. out of these giemsa and h&e are considered the simplest, cheapest and most specific methods.2 few studies have detected h. pylori in gallstones but that cannot establish its association with cholecystitis. some of the studies conducted in germany19, brazil20 and iran21 statistically show no significant association between h pylori and cholecystitis, but these studies were performed more than ten years back. symptoms of acid peptic disease and cholecystitis are related and confusingly similar most of the time. in this cross-sectional study, we aimed to identify the association of h. pylori with cholecystitis ending up in cholecystectomy. if there is a significant evidence showing this relationship, this condition can be treated more conservatively. with the discovery of proton-pump inhibitors (ppis) and triple therapy for h pylori infection, many gastric surgeries like billroth i and ii have become almost obsolete. therefore, in the present study we looked for the presence of this microorganism in cholecystitis patients and its association with the morphological changes seen in gall bladders. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted by the departments of surgery and pathology of akbar niazi teaching hospital (anth) bara kahu, islamabad. ethical approval was taken from institutional review board of islamabad medical and dental college. sample collection was done using non probability convenience sampling. after taking informed consent, all patients with acute and chronic cholecystitis admitted in anth between the ages of 18 and 80 years from january 2017 till march 2019, who underwent cholecystectomy, were included in the study. patients with gall bladder tumors, hemolytic disease, patients who took triple regime antibiotic therapy for h. pylori eradication for gastritis were excluded from the study. data was collected from a total of 100 patients by using hims (hospital information management system). it included patient’s demographics i.e. age, gender, weight, residence and clinical data including; presenting complains, associated gastritis, comorbidity like diabetes, total leukocyte court (tlc), liver function tests (lfts). ultrasonographic findings of presence or absence of gall stones, gall bladder wall inflammation (edematous or wall thickness) and presence of pericholecystic fluid were also noted. j islamabad med dental coll 2019 62 gall bladder specimens were sent to pathology department, anth after surgery and specimens were analyzed for the presence of h pylori bacteria using h&e and giemsa staining22. signs of inflammation, hyperplasia, metaplasia, mucosal atrophy or erosion, lymphoid infiltration, fibrosis, cholesterolosis or any other morphological changes were noted. result of categorical variables were presented as frequency and percentages. continuous variables were expressed as mean and standard deviation. association of h.pylori with cholecystitis, morphological changes and other variables was checked by chi square test. p ≤ 0.05 was considered statistically significant. patients identity was not disclosed. r e s u l t s a total of 100 patients underwent cholecystectomy. according to age, most of the patients (n=52) were in 4160 years’ age group, followed by 20-40 years (n=38), and 61-80 years age group (n=10). female predominance was observed with 88% females (n=88) and 12% males (n=12). all the patients had symptoms of upper abdominal pain and dyspepsia. chronic cholecystitis was the most common presenting feature (91%) followed by gall stones (75%) and a few cases of acute cholecystitis (9%). other histological findings were hyperplasia (10%), metaplasia (15%), fibrosis (79%), cholesterolosis (19%) and ulcerations (36%). histological appearance of cholesterolosis is shown in figure 1. h. pylori was seen in mucosa of gall bladders of 17 patients (17%) (figure 2). among those patients, male/female ratio was 1:7.5. most of the patients were in the 41-60 years’ age group. chronic cholecystitis was present in all cases followed by gall stones. fibrosis was the most common histological feature. association of h-pylori with gender, cholecystitis, gall stones, histological features and age distribution was non-significant (table i). figure 1: section showing cholesterolosis (lipid laden histiocytes) in lamina propria of gallbladder (h&e x 100) table i: association of h-pylori with study variables features h pylori +ve n (%) h pylori –ve n (%) p-value gender 0.97 1 males 2(11.7) 10(83) 2 females 15(88) 73(82) diagnosis 0.56 1 chronic cholecystitis 17(100) 83(91) 2 acute cholecystitis 0(0) 9(100) presence of gallstones 1 gall stones 13(76.4) 62(82) 0.87 2 no gallstones 4(23.5) 21(84) histological features 0.59 1 hyperplasia 2(11.7) 8(80) 2 metaplasia 3(17.6) 12(80) 3 fibrosis 16(94.1) 63(79.7) 4 cholesterolosis 4(23.5) 15(98.9) 5 erosions/ ulcerations 3(17.6) 33(91.6) age distribution (years) 0.59 1 2 3 20-40 41-60 61-80 6(35.3) 11(64.7) 0(0) 32(84.2) 41(78.8) 10(100) j islamabad med dental coll 2019 63 figure 2: histological section from gallbladder showing h. pylori in the mucosa (giemsa stain x 400). d i s c u s s i o n h pylori has been mostly associated with gastritis but its presence in other parts of gastrointestinal system has not been studied much. it was first detected in gall bladder by kawaguchi in 1996, which opened the door to further research.12 the epithelial cells of human gallbladder can be damaged by h. pylori leading to cholecystitis. a metaanalysis of previous researches show association between gallbladder diseases and helicobacter infection.3 it is also believed that chronic inflammation is an underlying cause of development and progression to cancers. previous research has also shown that helicobacters release metabolites and several toxins that are carcinogenic.23 so far, no definite association has been established between h. pylori infection and cholecystitis. also, there is no evidence of the exact pathway by which h. pylori bacteria reaches the hepatobiliary system.4 risk factor such as age and gender play an important role in formation of gall stones but their role in chronic cholecystitis is still not clear. according to a study by bohr et al, all female patients above 65 years of age had an association with gallstone formation. another study by bulajic, et al showed association of h. pylori infection in bile with age but no association was seen with gender. in that study, more frequency of h. pylori infection was present in patients above 70 years of age.4 our study showed presence of h. pylori in 17% of the gall bladder specimens with majority being females (88%) with gallstones (76.4%) and all of them having chronic cholecystitis. the most commonly involved age group was 41-60 years (64.7%). two studies conducted in pakistan (abro et al3 and yakoob et al13) reported presence of h. pylori in 55% and 25% patients respectively which is much higher than our patients (17%). all the patients in our study had symptoms of upper abdominal pain and dyspepsia and no difference was found in both the groups. in all h pylori positive cases, chronic cholecystitis was present (100%), although a significant percentage of h pylori negative cases (91%) also showed chronic inflammation. some of the studies have also shown an association of h pylori infection in gall bladders with gall bladder cancer. in a study by bulajic et al, h. pylori was found 9.9 times more frequently in cases of gallbladder carcinoma when compared with normal controls and it was found 3.5 times more frequently in cases with gallstones.24 in another study, presence of helicobacter pylori and helicobacter bilis was confirmed in bile as well as gallbladder of patients having gallbladder carcinoma and chronic cholecystitis. it was observed that h. pylori was present in more than 75 % of patients with gallbladder cancer and it was present in more than 50 % of patients having chronic cholecystitis.25 in our study, we did not find any such evidence but metaplasia was noted in 17.6 % of the patients with h pylori infection and in 88% patients without h pylori infection. in a study by hassan et al, metaplasia was found in 28% of the patients with h pylori infection and only 4% in patients without h pylori infection. therefore, in their study there was a statistically significant difference between the two groups (p=0.049) regarding mucosal metaplasia.16 regarding association of h. pylori infection with gall stones, it was more common in h. pylori negative cases (82%) as compared to h pylori positive cases (76%). the results were similar to that of another study in which the prevalence of gallstones in h pylori positive cases was lower than in the h pylori-negative cases (odds ratio, 0.653)11 in our study, fibrosis was present in most of the h pylori positive cases (94%) whereas it was less (79%) in non j islamabad med dental coll 2019 64 infected patients proving its association with chronic cholecystitis. in another study, 36% cases of h pylori positive group had fibrosis but the same frequency was also seen in h pylori negative group and therefore no statistically significant difference was noted regarding fibrosis between both the groups16 when analyzed statistically, comparison of patients with h pylori positive and h pylori negative was not found significant in any of the findings. in another study, regarding gender, mean age, type of inflammation and stone formation, no statistically significant difference was noted between the two groups of h pylori positive and negative cases.16 similarly in another study, similar results were found.26 it is still not known how these bacteria find their way into the gall bladder, but most probable theory is that it travels from stomach to duodenum and through sphincter of odi enters the biliary system and resides in gall bladder. c o n c l u s i o n h pylori infection has been found in cases of chronic cholecystitis and cholelithiasis, its association with cholecystitis and other morphological changes could not be proved. hence, it is uncertain whether h pylori eradication in patients with gastritis can prevent cholecystitis or gall stones formation. further studies are required with higher number of patients and different histological methods to prove this association. r e f e r e n c e s 1. tazuma s. gallstone disease: epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). best pract res clin gastroenterol. 2006; 20(6): 1075-83. doi: 10.1016/j.bpg.2006.05.009 2. channa na, khand fd, bhanger mi, leghari mh. surgical incidence of cholelithiasis in hyderabad and adjoining areas (pakistan). pak j med sci. 2004; 20: 13–7. 3. abro ah, haider iz, ahmad s. helicobacter pylori infection in patients with calcular cholecystitis: a hospital-based study. j ayub med coll abbottabad. 2011; 23(1): 30-3. pmid: 22830140 4. cen l, pan j, zhou b, yu c, li y, chen w, shen z. helicobacter pylori infection of the gallbladder and the risk of chronic cholecystitis and cholelithiasis: a systematic review and meta‐analysis. helicobacter. 2018; 23(1): e12457. doi: 10.1111/hel.12457 5. fatemi sm, doosti a, shokri d, ghorbani-dalini s, molazadeh m, tavakoli h et al. is there a correlation between helicobacter pylori and enterohepatic helicobacter species and gallstone cholecystitis? middle east j dig dis. 2018; 10:24-30. doi: 10.15171/mejdd.2017.86 6. getachew a. epidemiology of gallstone disease in gondar university hospital, as seen in the department of radiology. ethiopia j health dev. 2016; 22(2). doi: 10.4314/ejhd.v22i2.10074 7. gunasekaran p, vinson i. helicobacter pylori colonization of gallbladder in patients with symptomatic cholelithiasis. int surg j. 2017; 4: 21946. doi: 10.18203/2349-2902.isj20172765 8. javaherzadeh m, shekarchizadeh a, sabet b, mousavi-almaleki sa, mirafsharieh a. simultaneous helicobacter pylori infection in gastric mucosa and gallbladder mucosa in patients with cholecystitis; is there any relationship? ajs. 2016; 3(1-2): 12-4. 9. kheirmand f, valadi f, dolatshahi k. the presence of helicobacter pylori in gallbladder mucosa of patients with chronic cholecystitis. feyz. 2016; 20 (5): 454-60. 10. athavale vs, khandalkar sn, bhide pc, shetty i, lad a. a study of association of h. pylori infection and cholelithiasis. isj. 2018; 5(2): 701-4. doi: 10.18203/2349-2902.isj20180377 11. xu my, ma jh, yuan bs, yin j, liu l, lu qb. association between helicobacter pylori infection and gallbladder diseases: a retrospective study. j gastroenterol hepatol. 2018; 33(6): 1207-12. doi: 10.1371/journal.pone.0221076 12. kawaguchi m, saito t, ohno h, midorikawa s, sanji t, handa y et al. bacteria closely resembling helicobacter pylori detected immunohistologically and genetically in resected gallbladder mucosa. j gastroenterol. 1996; 31(2): 294-8. doi: 10.3748/wjg.v13.i10.1608 13. yakoob j, khan mr, abbas z, jafri w, azmi r, ahmad z et al. helicobacter pylori: association with gall bladder disorders in pakistan. br j biomed sci. 2011;68(2):59-64. pmid: 21706915 14. guraya sy, ahmad aa, el-ageery sm, hemeg ha, ozbak ha, yousef k et al. the correlation of helicobacter pylori with the development of https://www.ncbi.nlm.nih.gov/pubmed/?term=haider%20iz%5bauthor%5d&cauthor=true&cauthor_uid=22830140 https://www.ncbi.nlm.nih.gov/pubmed/?term=ahmad%20s%5bauthor%5d&cauthor=true&cauthor_uid=22830140 https://www.ncbi.nlm.nih.gov/pubmed/22830140 file://///pubmed/%253fterm=yakoob%252520j%25255bauthor%25255d&cauthor=true&cauthor_uid=21706915 j islamabad med dental coll 2019 65 cholelithiasis and cholecystitis: the results of a prospective clinical study in saudi arabia. eur rev med pharmacol sci. 2015; 19(20): 3873-80. pmid: 26531273 15. kountouras j, tsiaousi e, trigonis s, zavos c, kouklakis g. helicobacter pylori infection in a greek cohort with biliary disease. br j biomed sci. 2014; 71(4):178-9. pmid: 25562997 16. hassan eh, gerges ss, el-atrebi ka, el-bassyouni ht. the role of h. pylori infection in gall bladder cancer: clinicopathological study. tumour biol. 2015;36(9):7093-8. doi: 10.1007/s13277-015-3444-9. 17. lee jy, kim n. diagnosis of helicobacter pylori by invasive test: histology. ann transl med. 2015; 3(1): 10. doi: 10.3978/j.issn.2305-5839.2014.11.03. 18. patnayak r, reddy v, jena a, gavini s, thota a, nandyala r et al. helicobacter pylori in cholecystectomy specimens-morphological and immunohistochemical assessment. journal of clinical and diagnostic research: jcdr. 2016; 10(5):ec01. doi: 10.7860/jcdr/2016/14802.7716 19. takahashi y, yamamichi n, shimamoto t, mochizuki s, fujishiro m, takeuchi c, et al. helicobacter pylori infection is positively associated with gallstones: a large-scale cross-sectional study in japan. j gastroenterol. 2014; 49(5): 882-9. doi: 10.1007/s00535-013-0832-z 20. bohr ur, kuester d, meyer f, wex t, stillert m, csepregi a et al. low prevalence of helicobacteraceae in gall-stone disease and gallbladder carcinoma in the german population. clinical microbiology and infection. 2007; 13(5): 525-31. doi: 10.1111/j.1469-0691.2007.01690.x 21. sherafat sj, tajeddin e, majidi mr, vaziri f, alebouyen m, alizade ah. lack of association between helicobacter pylori infection and biliary tract diseases. pjm. 2012; 61(4): 319-22. pmid: 23484417 22. silva cp, pereira-lima jc, oliveira ag, guerra jb, marques dl, sarmanho l et al. association of the presence of helicobacter in gallbladder tissue with cholelithiasis and cholecystitis. journal of clinical microbiology. 2003; 41(12): 5615-8. doi: 10.1128/jcm.41.12.5615-5618.2003 23. jergens ae, wilson-welder jh, dorn a, henderson a, liu z, evans rb, et al. helicobacter bilis triggers persistent immune reactivity to antigens derived from the commensal bacteria in gnotobiotic c3h/hen mice. gut. 2007; 56: 934–40. doi: 10.1136/gut.2006.099242 24. bulajic m, maisonneuve p, schneider‐brachert w, müller p, reischl u, stimec b et al. helicobacter pylori and the risk of benign and malignant biliary tract disease. cancer: 2002; 95(9): 1946-53. doi: 10.1002/cncr.10893 25. murphy g, michel a, taylor pr, albanes d, weinstein sj, virtamo j, et al. association of seropositivity to helicobacter species and biliary tract cancer in the atbc study. hepatology. 2014; 60(6): 1963–71. doi: 10.1002/hep.27193 26. motie m, rezapanah a, abbasi h, memar b, arianpoor a. the relationship between cholecystitis and presence of helicobacter pylori in the gallbladder, zahedan j res med sci. 2017; 19(7): e9621. doi: 10.5812/zjrms.9621. https://www.ncbi.nlm.nih.gov/pubmed/?term=hassan%20eh%5bauthor%5d&cauthor=true&cauthor_uid=25877756 j islamabad med dental coll 2020 17 open access clinical risk factors and angiographic pattern of coronary artery disease in young females hadi yousuf saeed1, fawad qadir1, muhammad shahid1, muhammad tahir mohyudin2, abu bakar ali saad3, zahid iqbal4 1senior registrar, department of cardiology, cpe institute of cardiology, multan 2associate professor, department of cardiology, cpe institute of cardiology, multan 3assistant professor, department of cardiology, cpe institute of cardiology, multan 4senior registrar, department of cardiology, dg khan medical college/hospital, dg khan a b s t r a c t background: coronary artery disease (cad) is associated with the highest mortality in women around the world. the objective of this study was to compare the clinical risk factors and angiographic pattern of coronary artery disease in young versus old age females having cad. material and methods: this cross-sectional study was conducted at the department of cardiology, chaudhry pervaiz elahi (cpe) institute of cardiology multan, pakistan from april 2018 to december 2018. all females with diagnosis of angina and consistent ischemic changes on ecg were enrolled in the study. a total of 230 females were included with 123 patients aged <45 years and 107 patients aged >45 years. comparison of patient characteris tics, clinical risk factors and angiographic pattern in young and old age females was done by using spss version 21 statistical software . results: prevalence of hypertension (p=0.001), dyslipidemia (p=0.06) and diabetes mellitus (p=0.007) was significantly higher in females of older age group (>45 years). similarly, a larger number of older age females (32; 29.9%) presented with st-elevation myocardial infarction (stemi) as compared to young female patients (22; 17.88%) ( p=0.03). regarding angiographic patterns of cad, there was no difference in the prevalenc e of single vessel disease (svd), double vessel disease (dvd) and triple vessel disease (tvd) between the groups. normal angiogram was found in 13 (12.3%) old age females versus 35 (28.8%) young females, respectively (p=0.002). conclusions: the risk factors profile and clinical presentation of cad is different in young female patients with cad. there is an essential need to determine the coronary atherosclerosis factors in young females and these women should be treated more aggressively to prevent adverse cardio-vascular outcomes. key words: angiographic pattern, coronary artery disease, clinical pattern, young females authors’ contribution: 1-3conception; literature research; manuscript design and drafting; 4-6critical analysis and manuscript review; data analysis; manuscript editing. correspondence: hadi yousuf saeed email: doc.cpeic@gmail.com article info: received: july 14, 2019 accepted: march 16, 2020 cite this article. saeed hy, qadir f, shahid m, mohyudin mt, saad aa, iqbal z. clinical risk factors and angiographic pattern of coronary artery disease in young females . j islamabad med dental coll.2020; 9(1): 17-22. doi: 10.35787/jimdc.v9i1.377 funding source: nil conflict of interest: nil i n t r o d u c t i o n coronary artery disease (cad) is associated with the highest mortality in women around the world. at present, in usa one out of every three women dies of cad, accounting to about 50% of deaths due to any cause.1 south asia including pakistan has th e highest prevalence of cad, ranging from more th an 50% to 300% than the rest of the world.2 in pakistan, nearly 30% females of age >45 years are or i gi n a l a r ti c le j islamabad med dental coll 2020 18 affected by cad in contrast to only 23.7% males. 3 a study conducted in karachi reported that from 1970 the prevalence of cad in urban community has doubled to this time.4 cad mostly affects men and usually it affects the women after menopause.5 recent studies have reported a prominent increase in mortality in premenopausal women due to cad. 5 it is still unclear how the menopause e ffects cad. moreover, due to lower prevalence of cad in young females, they are not properly educated about preventive factors of cad. 6 due to low awareness regarding cardiovascular diseases in younger age group, they remain under-diagnosed and untreated in many of the patients. in a study conducted by dave et al among rural indian females undergoing coronary angiography (cag), there was a higher proportion of triple vessel disease (39.6%) than double vessel disease (12. 9% ) or single vessel disease (15.8%), with normal coronaries in only 30.7% female patients. 7 this study aimed to compare the clinical presentation and angiographic pattern of coronary artery disease among young females aged <45 years and older females aged > 45 years. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted at the department of cardiology, cpe institute of cardiology multan, pakistan. it was conducted ove r a period of eight months, from april 2018 to december 2018. all females complaining of angina with a positive stress test or consistent ischemic changes in ecg (such as consistent st elevation or significant st depression) were included in the study. female patients with valvular heart disease, congenital heart disease (chd), pregnancy and renal failure were excluded. a cut-off value of 45 years of age was used (<45 years – young females versus >45 years – older females). sample size for this study was calculated by taking estimated prevalence of cad in female patients as 69.3% 7 who underwent cag and level of significance at 6.0%. the calculated sample size was 228 patients and was rounded off to 230 patients. all patients were followed till they underwent coronary angiography. elective coronary angiogram (cag) was performed through femoral artery or radial approach. interpretation of cag report was performed by senior cardiologists. cad was defined as stenosis of >50% in epicardial coronary segment in more than one major coronary artery, while <50% was considered as non-significant stenosis. they were into classified into single vessel disease (svd), double vessel disease (dvd) and triple vessel disease (tvd) depending on the significant stenos is of the major coronary artery. more than 50% stenosis in left main coronary artery was considered as left main disease (lmd). comparison of clinical and angiographic pattern in young and old age females was performed by usin g spss version 21 statistical software using chi-square and independent sample t-test with p-value of <0.05 considered as statistically significant. r e s u l t s a total of 230 females (mean age 49.3±6.8 years) underwent coronary angiography in the cardiac catheterization (cath) lab. the baseline characteristics and risk profile are shown in table i. there were 123 female patients aged <45 years (mean age 40.4±4.3 years) and 107 patients aged >45 years (mean age 56.3±5.2 years) (p <0.0001). frequency of hypertension (p=0.001), dyslipid e m ia (p=0.06) and diabetes mellitus (p=0.007) was significantly higher in females of older age group (>45 years). prevalence of non-st elevation myocardial infarction (nstemi) and unstable angina (usa) was similar in both groups while only 22 j islamabad med dental coll 2020 19 table i: base line characteristics and risk factors profile of females undergoing coronary angiogram patient characteristics total n=230 younger female n=123 older females n=107 p-value age (years) 49.3 ± 6.8 40.4 ± 4.3 56.3 ± 5.2 <0.0001 family history of heart disease 34 19(16.18%) 15(14.1%) 0.76 diabetic mellitus 105 46 (37.39%) 59 (55.14%) 0.007 hypertension 152 68 (55.28%) 82 (76.63%) <0.001 dyslipidemia 76 34 (27.64%) 42 (39.25%) 0.06 pre-menopausal 34 28 (22.76%) 3(2.8%) <0.0001 typical angina 168 73 (59.34%) 52 (89.71%) 0.10 stemi 54 22 (17.88%) 32 (29.90%) 0.03 nstemi 16 9 (7.31%) 7 (6.5%) 0.81 usa 35 19 (15.44%) 16 (14.95%) 0.91 treadmill stress test-positive 66 38 (30.89%) 28 (26.16) 0.42 stemi st elevation myocardial infarction; nstemi non-st elevation myocardial infarction; usa unstable angina table ii: comparison of angiographic pattern of young versus old aged females coronary lesions total n=230 younger females n=123 older females n=107 p-value left main disease 4 1 (0.8%) 3 (2.8%) 0.24 single vessel disease 42 20 (16.2%) 22(20.7%) 0.39 double vessel disease 34 14(11.4%) 20(18.7%) 0.11 triple vessel disease 54 26 (21.4%) 28(26.1%) 0.36 non-significant stenosis 48 27(21.4%) 21(19.4%) 0.66 normal coronaries 48 35(28.8%) 13(12.3%) 0.002 (17.88%) young females and 32 (29.90%) old age females presented with stemi (p=0.03) (table i). regarding angiographic patterns, svd was diagnosed in 20 (16.2%) young females as compared to 22 (20.7%) females in the older age group (p=0.39). similarly, there was no difference in the prevalence of dvd and tvd between the two groups. however, normal angiogram was found in only 13 (12.3%) females in older age group as compared to 35 (28.8%) young females ( p=0.002) (table ii). d i s c u s s i o n this study aimed to compare the clinical presentation and angiographic pattern of coronary artery disease among young females aged <45 years and older females aged >45 years. other studies have also used 45 years as a cut off value to j islamabad med dental coll 2020 20 define young age.8,9 however, a study by christus et al used the cut off value of 35 years to define young age in females.10 cad is a well-established cause o f mortality in female population. a multi-country based interheart study involving 52 thousand patients of cad concluded that although the prevalence of cad in females is approximately 10 years later as compared to males, mortality is rapidly increasing in the female population.11 global use of strategies to open occluded coronary arteries in acute coronary syndromes (gusto iib) investigators and thrombolysis in myocardial infarction (timi iiib) trial investigators found that women present more frequently with unstable angina and nstemi, while men prese nt more frequently with stemi and reperfusion therapy is more frequent in females than males. 12,13 moreover atypical presentation in females with vague and more generalized signs and symptoms make the diagnosis more difficult.14,15 lack of proper knowledge regarding risk factors of cad and clinical presentation may delay the presentation in women with cad attack.16 prevalence of cad in young females is much higher (12-16%) in asian countries than the western countries (5%).17 in the present study, there was no significant difference in risk factors of cad in young females as compared to older ones. we found diabetes mellitus in 37.39% young females versus 55.14% old age females, hypertension in 55.28% in young versus 76.63% old age females, and dyslipidemia in 27.64% young females and 39.25% old age females. prevalence of family history of heart disease was also similar in both groups. similar findings have been reported in other studies. soman et al. conducted a study on young (aged 30-40 years) and older (aged 41-50 years) females with cad. they also reported a higher frequency of hypertension (young 20%; old 51.78%) and diabetes (young 10%; old 48.21%) in older aged females.18 another study by ezhumalai et al also reported higher prevalence of diabetes and dyslipidemia in old age females as compared to th e younger ones.19 kher et al. conducted a comparative study between young male and female patients to study the risk factor profile and type of cad. the authors found higher prevalence of hypertension and diabetes in young females as compared to the young males. however, incidence of stemi and nstemi was higher in young males as compared to females. 20 in our study, frequency of nstemi and usa was higher in younger females, while incidence of stemi was higher in older age female patients w ith cad. these results are comparable to those reported by soman et al who also found higher incidence of nstemi and usa in young female patients.18 we did not find any difference in the incidence of severity of cad in both young and old age female patients. ezhumalai et al found higher incidence of dvd (19.7% versus 15.2%) and tvd (16.5% versus 7.8%) in old age females as compared to the young age females.19 the virgo study emphasized on the importance o f risk identification, and education of young females at all levels of health care management systems. 21 since the risk profile is different in young females, so there is a need to re-evaluate the diagnostic an d management options in these patients with early implementation of preventive strategies to prevent the occurrence of cad in these patients. c o n c l u s i o n the risk factors profile and clinical presentation of cad in young female patients is different from older age female patients with cad. there is an essential need to determine the risk factors for coronary atherosclerosis in young females so that they should be treated more aggressively to j islamabad med dental coll 2020 21 prevent adverse cardio-vascular outcomes and to improve long term prognosis. r e f e r e n c e s 1. mozaffarian d, benjamin ej, go as, arnett dk, blaha mj, cushman m, et al. heart disease and stroke statistics-2016 update: a report from the american heart association. circulation. 2016; 133(4): e38 360. doi: 10.1161/cir.0000000000000350 2. volgman as, palaniappan ls, aggarwal nt, gupta m, khandelwal a, krishnan av, et al. atherosclerotic cardiovascular disease in south asians in the united states: epidemiology, risk factors, and treatments: a scientific statement from the american heart association. circulation. 2018; 138(1): e1-34. doi: 10.1161/cir.0000000000000580 3. jafar th, jafary fh, jessani s, chaturvedi n. heart disease epidemic in pakistan: women and men at equal risk. american heart journal. 2005; 150(2): 221-6. doi: 10.1016/j.ahj.2004.09.025 4. aziz ku, faruqui a, patel n, jaffery h. prevalence and awareness of cardiovascular disease including life styles in a lower middle class urban community in an asian country. pak heart j. 2012; 41(3 -4): 11-20. 5. gyarfas i, keltai m, salim y. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries in a case -control study based on the interheart study. orv hetil. 2006; 147(15): 675-86. pmid: 16734179 6. garcia m, mulvagh sl, bairey mcn, buring je, manson je. cardiovascular disease in women: clinical perspectives. circ res. 2016; 118(8): 1273-93. doi: 10.1161/circresaha 7. dave th, wasir hs, prabhakaran d, dev v, das g, rajani m, et al. profile of coronary artery disease in indian women: correlation of clinical, non-invasive and coronary angiographic findings. indian heart j. 1991; 43(1): 25-9. pmid: 1894297 8. konishi h, miyauchi k, kasai t, tsuboi s, ogita m, naito r, et al. long-term prognosis and clinical characteristics of young adults (</=40 years old) who underwent percutaneous coronary inte rvention. j cardiol. 2014; 64(3): 171-4. doi: 10.1016/j.jjcc.2013.12.005 9. van loon je, de maat mp, deckers jw, van domburg rt, leebeek fw. prognostic markers in young patients with premature coronary heart disease. atherosclerosis. 2012; 224(1): 213-7. doi: 10.1016/j.atherosclerosis.2012.06.067 10. christus t, shukkur am, rashdan i, koshy t, alanbaei m, zubaid m, et al. coronary artery disease in patients aged 35 or less a different beast? heart views. 2011; 12(1): 7-11. doi: 10.4103/1995705x.81550 11. yusuf s, hawken s, ounpuu s, dans t, avezum a, lanas f, et al. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case -control study. lancet. 2004; 364(9438): 937-52. doi: 10.1016/s0140-6736(04)17018-9 12. hochman js, tamis je, thompson td, weaver wd, white hd, van de werf f, et al. sex, clinical presentation, and outcome in patients with acute coronary syndromes. global use of strategies to open occluded coronary arteries in acute coronary syndromes iib investigators. n engl j med. 1999; 341(4): 226-32. doi: 10.1056/nejm199907223410402 13. hochman js, mccabe ch, stone ph, becker rc, cannon cp, defeo-fraulini t, et al. outcome and profile of women and men presenting with acute coronary syndromes: a repor t from timi iiib. timi investigators. thrombolysis in myocardial infarction. j am coll cardiol. 1997; 30(1): 141-8. doi: 10.1016/s0735-1097(97)00107-1 14. rubini gimenez m, reiter m, twerenbold r, reichlin t, wildi k, haaf p, et al. sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. jama intern med. 2014; 174(2): 241-9. doi: 10.1001/jamainternmed.2013.12199 15. mehta ls, beckie tm, devon ha, grines cl, krumholz hm, johnson mn, lindley kj, vaccarino v, wang ty, watson ke, wenger nk. acute myocardial infarction in women: a scientific statement from the american heart association. circulation. 2016; 133(9): 916-47 doi: 10.1161/cir.0000000000000351. 16. lichtman jh, leifheit-limson ec, watanabe e, allen nb, garavalia b, garavalia ls, et al. symptom recognition and healthcare experiences of young women with acute myocardial infarction. circulation cardiovascular quality and outcomes. 2015; 8(2-s 1): s31-8. doi: 10.1161/circoutcomes.114.001612 17. enbergs a, burger r, reinecke h, borggre fe m, breithardt g, kerber s. prevalence of coronary artery disease in a general population without suspicion of coronary artery disease: angiographic analysis of subjects aged 40 to 70 years referred for catheter ablation therapy. european heart journal. 2000; 21(1): 45-52. doi: 10.1161/circoutcomes.114.001612 18. soman b, rahaman ma, rajan r, vijayaraghavan g. risk factor profile and disease pattern in premenopausal and postmenopausal indian women presenting with acute coronary syndrome. j clin j islamabad med dental coll 2020 22 prevent cardiol. 2016; 5(3): 78-83. doi: 10.4103/2250-3528.191098 19. ezhumalai b, jayaraman b. angiographic prevalence and pattern of coronary artery disease in women. indian heart j. 2014; 66(4): 422-6. doi: 10.1016/j.ihj.2014.05.009 20. kher m, sathyanarayan bc. coronary artery disease in young females: current scenario. ind j car dis wom. 2017; 2(03): 39-43. doi:10.1055/s-00371607040 21. leifheit-limson ec, d'onofrio g, daneshvar m, geda m, bueno h, spertus ja, et al. sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: the virgo study. j am coll cardiol. 2015; 66(18): 1949-57. doi: 10.1016/j.jacc.2015.08.859 j islamabad med dental coll 2020 212 open access a review of child sexual abuse in pakistan based on data from “sahil” organization muhammad abdullah avais1, hamida narijo2, mike parker 1 ph.d. scholar, department of sociology, university of sindh jamshoro, pakistan 3 assistant professor, department of sociology, university of sindh jamshoro, pakistan 3 medical statistician a b s t r a c t child sexual abuse (csa) is an unrevealed but an alarming issue in every civilized society. this paper examines the reported incidents of child sexual abuse in pakistan. its primary goal is to assess the currently available data on incidents of csa in pakistan from 2010 to 2016, while the specific objective is to understand the magnitude, as well as nature and context of the problem. data on csa from 2010 to 2016 were collected from the "annual cruel numbers" of the "sahil" organization, which revealed that incidents of csa have increased in pakistan since 2010. the data show that 2,252 incidents of csa (boys 606 and girls 1,646) occurred in 2010 and a larger number, 4,139 incidents (boys 1,729 and girls 2,410), occurred in 2016. most of the survivors belonged to the punjab province of pakistan (1,723 out of 2,252 in 2010 and 2,676 out of 4,139 in 2016). most abusers were acquaintances of their victims (3,964 in 2010 and 1,829 in 2016). the majority of incest cases were observed in 2012 (144 cases). the victim's home was a place of abuse in most incidents (306 incidents in 2010 and 594 in 2016). government, as well as non -governmental organizations, should raise awareness of csa. furthermore, religious leaders must play their role to curb occurrence of csa by preaching about its religious implications. key words: children, incest, incidents, pakistan, sahil organization, sexual victimization authors’ contribution: 1-3conception; literature search; manuscript design and drafting; critical analysis and manuscript review; manuscript editing. correspondence: muhammad abdullah avais email: abdullahawais77@yahoo.com article info: received: october 5, 2019 accepted: september 25, 2020 cite this article. avais ma, narijo h, parker m. a review of child sexual abuse in pakistan based on data from “sahil” organization. j islamabad med dental coll. 2020; 9(3): 212-218. doi: 10.35787/jimdc.v9i3.412 funding source: nil conflict of interest: nil i n t r o d u c t i o n half of the children across the world are exposed to violence every year.1 the culprit's violence and survivor's trauma, along with its consequences, are commonly obscured from the public view. 2 child sexual abuse (csa) is an unrevealed but an alarming issue in every civilized society.3 in this era of globalization, there is a need for designating time to educate and empower the most vulnerable in society against abuse from strangers and their teachers and relatives.4 the frequency of such offenses are increasing. there are daily reports, in either local or national newspapers, about different types of child abuse. some of these stories seem r e v i e w a r ti c le j islamabad med dental coll 2020 213 improbable because of the cruelty and inhumane torture described. it can seem unbelievable that some fathers are found to be involved in abusing their own children, that teachers harass their students, that women batter boys, and that employees try to hire uneducated, unskilled young children below the age of maturity. these types of child abuse have not been reported for multiple reasons, such as family pressure, poverty, negligence of parents, social barriers, and political influence of offenders.5,6 south asia has 23% of the world's population and is also known as the world's most impoverished region. in many countries of south asia, such as pakistan, india, bhutan, nepal, and bangladesh, child labor, child trafficking, child prostitution, and child sexual abuse are common problems.7 there are many forms of violence against children; psychological, sexual, emotional, and physical abuse. physical anger directed towards a child by an adult is an example of physical abuse.8 child sexual abuse (csa) is a form of child abuse in which an adult or older adolescent sexually stimulates a child. 9 child sexual abuse consists of different forms, such as forcing a child to be engaged in sexual activities, showing pornographic material to a child, sexual intercourse/attempted intercourse with a child, viewing of the child's genitalia with or without physical contact, or using a child for prostitution or pornography.8-10 in 2011, 50 police officials were found to be perpetrators of csa in pakistan, and 10 of them used official residential quarters of police for their offenses. similarly, 155 officials were involved in csa in 2012, and 13 cases were committed in police stations, with five children being sexually abused in police lockups in 2013.11 depression, unemployment, physical and mental illness, poor socialization or trouble in socialization are common factors seen in perpetrators.12-14 different taboos such as the claimed curative powers of virgins are often reasons stated or believed by perpetrators for the csa.13,15,16 this paper examines the reported incidents of child sexual abuse in pakistan. its primary goal is to assess the currently available data on incidents of csa in pakistan from 2010 to 2016, while the specific objective is to understand the magnitude, as well as nature and context of the problem. the research employs an exploratory approach using secondary data. the data for csa from 2010 to 2016 were obtained from "sahil" organization, a nongovernmental organization working on creating a society free from all forms of violence, especially child sexual abuse. the sahil organization is functional through its head office in islamabad, the capital of pakistan and has four regional offices. through the monitoring of 91 local and national newspapers at its head and regional offices, along with help from volunteers, the organization collects the data of csa on an annual basis and, after compilation at its head office, sahil publishes a report on "cruel numbers" on an yearly basis. d i s c u s s i o n according to the world health organization (2006), csa is "the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violates the laws or social taboos of society."32 commonly, the perpetrators of sexual abuse are predominantly male.33 in 2006, a report on the prostitution of pakistani boys at lahore and peshawar recognized that society strongly condemned the relationship between a male and female without marriage, while affection between males, either social or physical, was socially tolerated.34 there are no accurate statistics regarding csa in pakistan, but it is estimated that sexual abuse mostly affects girls j islamabad med dental coll 2020 214 (19%) compared to boys (14%).35 in india, 52% of school-going children were sexually abused, and 89% of perpetrators were family members. 36,37 in 2017, sahil ngo computed 3445 cases of csa from 91 national and local pakistani newspapers.38 in rawalpindi/islamabad, 17% of 300 school-going children were survivors of csa (1 in 7 girls and 1 in 5 boys), and the majority of victims (72%) were below the age of 13 years.38 close acquaintances of the victims were found to be involved in 80% of csa cases.39,40 across the globe, regardless of religion and culture, 40-60% of known sexual assaults were committed by family members, and the victims were girls belonging to the age group 15 years or younger.41 in pakistan, like other south asian countries, child mobility, poverty, inadequate education, weak rule of law, and child labor are common factors behind the csa or child exploitation.42 child sexual abuse is probably a less acknowledged and less explored form of abuse in pakistan because people hesitate to open a pandora's box of problems. nevertheless, child sexual abuse has been present in pakistan since the date of its national independence since 1947. these incidents produce long-lasting effects on both society and victims. although child sexual abuse exists in pakistani society, it is nevertheless a taboo subject. in pakistan, it is easy to talk about sex, but talking about sexuality is regarded as immoral. the number of survivors of csa is increasing day by day, and from january 2010 to december 2016, a total of 21,760 cases of csa were reported. the number of reported incidents of child sexual abuse in pakistan from 2010 to 2016 showed an upward trend with increase in number of cases from 2010 to 2016 (figure 1). the number of cases in the year 2010 was 2,252, with 2,303 incidents reported in 2011, 2,788 incidents in 2012, 3,002 incidents in 2013, 3,508 incidents in 2014, 3,768 incidents in 2015, and 4,139 incidents in 2016. the gender-specific distribution of reported cases of csa from 2010 to 2016 is shown in figure 2. the number of abused girls was approximately 2.5 times more than boys from 2010 to 2013, however the number of boys increased steadily from 2014 to 2016. figure 1: number of csa incidents from 2 010 to 2016 figure 2: grouping of survivors by gender figure 3 shows the distribution of incidents of csa by province, with the majority of cases taking place in punjab. the actual figure may be higher than those reported since, due to honor and to avoid defaming a whole family, parents try not to share the incident with anyone. therefore, sometimes they blame the survivors. similarly, due to fear, sometimes survivors do not share the details of incidents with their parents, so these cases go j islamabad med dental coll 2020 215 unreported. these figures are indicative of the values of any civilized society. figure 3: province wise distribution of survivors althugh most of csa cases were register with the police, it failed to decrease the number of cases reported annually (figure 4). incidents occurred at victims' homes, with nearly as many incidents occurring at acquaintances' homes also (table i). figure 4: status of police registration of sexual abuse cases table ii is presenting the abuser profiles. majority of abusers were acquaintances, with strangers being in a close second place. compared to strangers, most perpetrators are known to their victims or at least to relatives of the survivors.43 the issue of csa must be addressed as a priority by religious leaders, parents, civil society, policymakers, law enforcement agencies, and social scientists. moreover, the outcome of different ngos working on child rights and awareness of csa needs to be evaluated by concerned authorities. the major determinants of csa in pakistan are poverty, illiteracy, and various unacceptable taboos regarding sexual health. the government should provide basic health needs and education to all children. in addition to this, it is the prime duty of the government to raise awareness in law enforcement agencies on how to address victims of csa. sahil collects csa data from a compilation of 84 national and local newspapers, which may not represent the magnitude of severity. thus, the government must collect the data of survivors of csa at the national level for policymakers and social scientists, because ngos cannot engage in this role as effectively as government agencies. furthermore, the government should develop a national action plan against child sexual abuse/exploitation. limitation: this study was solely based on a secondary source of data collected from the “cruel numbers” of sahil organization from 2010 to 2016, therefore, some data may be missing because of not ever being reported to the sahil organization. c o n c l u s i o n in pakistan, children are exposed to sexual abuse everywhere–in markets, at schools, in hospitals/clinics, at madrasa and police stations, and even their own homes. the analysis of the data demonstrated that the number of csa cases was increasing gradually year by year in pakistan. although some ngos are working to raise awareness of csa in society, the topic of csa remains a taboo subject for discussion in pakistan. r e c o m m e n d a t i o n s • government, civil society, and religious leaders should recognize csa as a major threat to the fabric of society, that is intolerable at any cost. therefore, the government should address this issue as a crime against humanity at the national level. j islamabad med dental coll 2020 216 • the increasing incidents of csa are questioning the prestige of the traditional and religious family system in pakistan. policymakers, sociologists, and criminologists should seriously take up this table i: yearly distribution of cases according to probable location for sexual abuse place of incident 2010 2011 2012 2013 2014 2015 2016 number of incidents n (%) victim’s home 306(7.6) 1042(26.0) 566(14.1) 492(12.3) 475(11.8) 539(13.4) 594(14.8) acquaintance's home 369(8.4) 809(18.5) 648(14.8) 630(14.4) 653(14.9) 689(15.7) 578(13.2) school 18(7.1) 24(9.4) 60(23.6) 43(16.9) 52(20.5) 26(10.2) 31(12.2) shop 23(18.4) 14(11.2) 17(13.6) 0(0.0) 19(15.2) 12(9.6) 40(32.0) haveli 18(4.2) 19(4.5) 7(1.6) 9(2.1) 20(4.7) 302(71.1) 50(11.8) medical centre/hospital 5(7.0) 8(11.3) 8(11.3) 12(16.9) 16(22.5) 10(14.1) 12(16.9) police station 2(7.7) 0 13(50.0) 5(19.2) 1(3.8) 1(3.8) 4(15.4) field/jungle 172(8.4) 148(7.2) 225(11.0) 211(10.3) 534(26.1) 383(18.7) 372(18.2) street 68(5.0) 76(5.6) 165(12.2) 148(10.9) 199(14.7 414(30.5) 287(21.1) madrassa 0 0 0 0 27(35.1) 13(16.9) 37(48.1) table ii. yearly distribution of cases according to various categories of sexual abusers abuser categories 2010 2011 2012 2013 2014 2015 2016 number of incidents n (%) acquaintance 3964 (23.19) 2805 (16.41) 2780 (16.26) 1548 (9.06) 1856 (10.86) 2310 (13.52) 1829 (10.70) stranger 728 (8.93) 1315 (16.23) 2172 (26.63) 1067 (13.08) 1246 (15.28) 829 (10.17) 798 (9.79) relative 114 (11.53) 388 (39.23) 189 (19.11) 85 (8.59) 60 (6.07) 77 (7.79) 76 (7.68) incest 24 (5.33) 56 (12.44) 144 (32.00) 70 (15.56) 62 (13.78) 72 (16.00) 22 (4.89) molvie/ faith healer 18 (6.21) 30 (10.34) 66 (22.76) 28 (9.66) 43 (14.83) 49 (16.90) 56 (19.31) teacher 22 (7.61) 91 (31.49) 38 (13.15) 26 (9.00) 20 (6.92) 55 (19.03) 37 (12.80) shopkeeper 3 (8.57) 0 0 0 4 (11.43) 12 (34.29) 16 (45.71) not mentioned 0 0 0 110 (11.65) 148 (15.68) 295 (31.25) 391 (41.4 2) jirga 0 0 0 15 (28.30) 8 (15.09) 30 (56.60) 0 j islamabad med dental coll 2020 216 • issue because it is a challenge for societal values and a sign of abnormality in our moral standards. • incidents of csa are a violation of the basic rights of children. the government should introduce special courts to address cases of child sexual abuse at district levels. moreover, severe and swift punishment will be helpful to create a deterrence against csa in the community. • the government, as well as non-governmental organizations and health departments, should introduce courses for the people who are directly involved, from treatment programmes to the investigation of victims of csa. • the government, as well as non-governmental organizations and civil society, should launch awareness campaigns for parents to sensitize and educate them on the prevalence of csa. r e f e r e n c e s 1. hillis s, mercy j, amobi a, kress h. global prevalence of past-year violence against children: a systemati c review and minimum estimates. pediatrics. 2016; 137(3):e 20154079. doi: 10.1542/peds.2015 -4079 2. mercy ja, hillis sd, butchart a, bellis ma, ward cl, fang x, et al. interpersonal violence: global impact and paths to prevention. injury prevention and environmental health. 3rd ed. 2017. 3. johnston h. the bravehearts toolbox for practitioners: working with child sexual assault. 2nd ed. 2014. 4. tshabalala t, khosa mt. awareness of various forms of child abuse: pupils' attributions–a case study of gomadoda cluster. ajssms. 2014; 1(1): 23 -8. 5. taylor c, steward w. women and child abuse. london: hertman (pvt) ltd. 2011. 6. paolucci eo, genuis ml, violato c. a meta-analysis of the published research on the effects of child sexual abuse. j psychol. 2001; 135(1): 17 -36. doi: 10.1080/00223980109603677. 7. venkateswarlu d, kasper j, mathews r, reis c, iacopino v, wise p. child labour in india: a health and human rights perspective. the lancet. 2003; 362: s32-3. 8. hosin aa. responses to traumatized children: springer; 2007. 9. gorey km, leslie dr. the prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. child abuse negl. 1997; 21(4): 391-8. doi: 10.1016/s0145-2134(96) 00180-9 10. krug eg, mercy ja, dahlberg ll, zwi ab. the world report on violence and health. lancet. 2002; 360(9339): 1083-8. doi: 10.1016/s0140-6736(02) 11133-0 11. khoso a, yew vw. recognizing invisible structural violence on juveniles: a case of pakistan. mediterr j soc sci. 2015; 6(4): 141. doi:10.5901/mjss.2015. v6n4s3p141 12. oyemade ad. child abuse and neglect: a global phenomenon. afr j med med sci. 1991; 20(1): 5 -9. pmid: 1905471 13. kisanga f, mbwambo j, hogan n, nystrom l, emmeli n m, lindmark g. perceptions of child sexual abuse —a qualitative interview study with representatives of the socio-legal system in urban tanzania. j child sex abuse. 2010; 19(3): 290-309. doi: 10.1080/10538 711003789031 14. veenema tg, thornton cp, corley a. the public health crisis of child sexual abuse in lowand middleincome countries: an integrative review of the literature. int j nurs. 2015; 52(4): 864 -81. doi: 10.1016/j.ijnurstu.2014.10.017 15. smith k, bryant-davis t, tillman s, marks a. stifled voices: barriers to help-seeking behavior for south african childhood sexual assault survivors. j child sex abuse. 2010; 19(3): 255-74. doi: 10.1080/105387 11003781269 16. meursing k, vos t, coutinho o, moyo m, mpofu s, oneko o, et al. child sexual abuse in matabeleland , zimbabwe. soc sci med. 1995; 41(12): 1693 -704. doi: 10.1016/0277-9536(95)00130-y 17. verelst a, de schryver m, broekaert e, derluyn i. mental health of victims of sexual violence in eastern congo: associations with daily stressors, stigma, and labeling. bmc women's health. 2014; 14(1): 106. doi: 0.1186/1472-6874-14-106 18. fontana vj. introduction-the maltreatme n t syndrome of children. pediat ann. 1984; 13(10): 736. 19. james m. child abuse and neglect [series of two parts] part 1: redefining the issues. trends and issues in crime and criminal justice/australian institute of criminology. 2000; 146: 1. j islamabad med dental coll 2020 217 20. tang cs. childhood experience of sexual abuse among hong kong chinese college students. child abuse negl. 2002; 26(1): 23-37. doi: 10.1016/s01452134(01)00306-4 21. kellogg n. the evaluation of sexual abuse in children. pediat. 2005; 116(2): 506-12. doi: https://doi.org/10. 1542/peds.2005-1336 22. finkelhor d, turner ha, shattuck a, hamby sl. prevalence of childhood exposure to violence, crime, and abuse: results from the national survey of children's exposure to violence. jama pediatr. 2015; 169(8): 746-54. doi: 10.1001/jamapediatrics.2015. 0676 23. sharma br, gupta m. child abuse in chandigarh , india, and its implications. j clin foren med. 2004; 11(5): 248-56. doi: 10.1016/j.jcfm.2004.01.009 24. csorba r, tsikouras p, lampé r, póka r. the sexual abuse of female children in hungary: 20 years’ experience. arch gynecol obstet. 2012; 286(1): 161 6. doi: 10.1007/s00404-012-2282-x 25. davies ea, jones ac. risk factors in child sexual abuse. j forensic leg med. 2013; 20(3): 146 -50. doi: 10.1016/j.jflm.2012.06.005 26. zhai f, gao q. child maltreatment among asian americans: characteristics and explanatory framework. child maltreat. 2009; 14(2): 207 -24. doi: 10.1177/1077559508326286 27. london k, bruck m, ceci sj, shuman dw. disclosure of child sexual abuse: what does the research tell us about the ways that children tell?. psychology, public policy, and law. 2005; 11(1): 194. doi: 10.1037/10768971.11.1.194 28. wyatt ge, loeb tb, solis b, carmona jv, romero g. the prevalence and circumstances of child sexual abuse: changes across a decade. child abuse negl. 1999 jan 1;23(1):45-60. doi: 10.1016/s01452134(98)00110-0 29. finkelhor d, ullmann e, hilweg w. childhood and trauma: separation, abuse, war. 1999. 30. finkelhor d. child sexual abuse: challenges facing child protection and mental health professionals. childhood and trauma: routledge; 2019. p. 101 -16. 31. smallbone s, wortley rk. child sexual abuse in queensland: offender characteristics and modus operandi: queensland crime commission and queensland police service brisbane, australia; 2000. 32. organization wh. preventing child maltreatment: a guide to taking action and generating evidence. 2006. 33. snyder hn. sexual assault of young children as reported to law enforcement: victim, incident, and offender characteristics: diane publishing; 2010. 34. muhammad t, zafar n, raghuvanshi a. situtation al analysis report on prostitution of boys in pakistan (lahore and peshawar). bangkok: ecpat international in collaboration with pakistan pediatrics association. 2006. 35. reproductive a. sexual health: an explorationof trends in pakistan. pakistan voluntary health and nutrition association (pavh na). 2000.. 36. srivastava r, seth r, van niekerk j. child abuse and neglect: challenges and opportunities: jp medical ltd; 2013. 37. maiti kd. ministry of women and child development, government of india. retrieved from january. 2016. 38. mehnaz a. child abuse in pakistan-current perspective. njhs. 2018;3(4):115. 39. kane j. sold for sex: arena; 1998. 40. tufail m. commercial sexual exploitation of children: a situation analysis of pakistan. save the children sweden. 2005. 41. fathalla mf. the girl child. int j gynaecol obstet. 2000;70(1):7-12. doi: 10.1016/s0020-7292(00)00219 -8 42. frederick j. sexual abuse and exploitation of boys in south asia: a review of research findings, legislation , policy and programme responses. 2010. 43. fergusson dm, horwood lj, lynskey mt. childhood sexual abuse and psychiatric disorder in young adulthood: ii. psychiatric outcomes of childhood sexual abuse. j am acad child adolesc psychiatry. 1996; 35(10): 1365-74. doi: 10.1097/00004583199610000-00024. j islamabad med dental coll 2020 269 open access nosocomial blood stream infections in pediatric intensive care unit of fauji foundation hospital, rawalpindi pakistan iqra ayaz1, hira hameed1, wajeeha amber1, talal zafar2 1 senior registrar, department of pediatrics, islamabad medical and dental college, islamabad pakistan 2 senior registrar, department of pediatrics, hbs medical and dental college, islamabad pakistan a b s t r a c t background: nosocomial blood stream infections with bacterial organisms are one of the most common problems faced by health care professionals in admitted patients, since these infections complicate the treatment and affect the outcome. the objective of this study was to determine the frequency of most common bacterial organisms in nosocomial blood stream infections in children admitted in pediatric intensive care unit of a tertiary care hospital at rawalpindi, pakistan. material and methods: this cross-sectional study was carried out from 6th july 2017 to 6th january 2018 in the pediatric intensive care unit (icu), fauji foundation hospital, rawalpindi, a tertiary care hospital. a total of 385 patients, aged 14 days to 12 years, admitted in the icu were monitored from the time of admission till their blood culture reports were positive for bacterial growth along with signs of clinical sepsis blood samples for culture were collected aseptically and the bottles were incubated for 7 days. patients were monitored from time the blood culture yielded growth of bacterial pathogens till final blood culture report with antibiotics sensitivity against the pathogen became available. data was analyzed using spss version 20. effect modifiers like age, duration of admission and gender were controlled by stratification and chi-square test was applied for comparison with p-value less than .05 considered as statistically significant. results: pseudomonas aeruginosa and salmonella typhi were the most common bacterial organisms (n=83; 21.6% each) causing nosocomial blood stream infection, followed by escherichia coli (n=77; 20%) and klebsiella (n=67; 17.4%), respectively. effect modifier, like gender (stratified and compared by chi-square test) had a statistically significant relationship with frequency of most common bacterial organisms in nosocomial blood stream infections (p=.001). however, effect modifiers like age and duration (hours) of admission to picu had a non-significant relationship with frequency of bacterial organisms in nosocomial blood stream infections (p>.05). conclusions: there is a high frequency of common bacterial organisms in nosocomial blood stream infections in children with predominance of gram-negative bacteria including pseudomonas aeruginosa and salmonella typhi. thus, early initiation of appropriate antibiotic therapy can help in decreasing mortality, significantly in hospitalized patients. key words: children, gram-negative bacteria, intensive care unit, nosocomial blood stream infections authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: hira hameed email: hira.hameed@imdcollege.edu.pk article info: received: april 16, 2020 accepted: september 25, 2020 cite this article. ayaz i, hameed h, amber w, zafar t. nosocomial blood stream infections in pediatric intensive care unit of fauji foundation hospital, rawalpindi pakistan. j islamabad med dental coll. 2020; 9(4): 269-274. doi: 10.35787/jimdc.v9i4.533 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 270 i n t r o d u c t i o n nosocomial bloodstream infections (nbsis) are an important cause of morbidity and mortality and are the most frequent type of infections in pediatric patients. the prevalence of health care associated infections is 4.2%.1 most common type of infections in children are blood stream infections (45%). other common infections include lower respiratory tract infections (22%), gastrointestinal infections (8%), eye, ear, nose, and throat infections (7%), urinary tract infections (5%), and surgical site infections (4%), respectively.1 among admitted patients, there is highest prevalence of infections in pediatric (picu) and neonatal intensive care units (nicu) (15.5% and 10.7% respectively).1 nosocomial bsis in picu are a common but preventable complication in critically ill patients and has a negative impact on patients’ outcome2. most of the common bacterial organisms causing nbsis show a high resistance to commonly used antibiotics including third generation cephalosporins.2 icu acquired infections increase mortality and duration of hospital stay.2 there are multiple studies on frequency of bsi, their etiology, common pathogens involved and recommended treatment guidelines.3-5 a study by mitt et al. in january 2004 to december 2008 in mixed pediatric population showed very high rates of blood stream infections. most common pathogen were coagulase-negative staphylococci (43%) and serratia marcescens (14%).4 a multicenter study was done in spanish picu in year 2008 to 2012, which concluded that common nbsi were central lineassociated nosocomial infections, ventilator associated pneumonia and catheter associated urinary tract infections. common microorganisms involved were gram-negative organisms, grampositive organisms and candida species.5 a study was conducted to determine the impact of an extended infection control training program in university malaya medical centre, malaysia which concluded that education of medical interns on infection control, a relatively low-cost intervention, resulted in a substantial reduction in the incidence of picu-acquired bsis.6 a study done in karachi, pakistan to determine frequency of bsi in adult population with febrile neutropenia showed that frequency of staphylococcus aureus was 16%, e. coli 14.5%, pseudomonas 8.5% and klebsiella 15.5 %.7 another study done at agha khan university hospital, karachi from 2013 to 2017 concluded that most common pathogen of bsi is staphylococcus non-aureus species (33.3%).8 it has been observed that frequency and types of nosocomial infections and pathogens causing bsi show demographical variation.9 there is limited date available regarding frequency of common pathogens in nosocomial bsis in children in punjab. the purpose of this study was to determine frequency of most common bacterial organisms in nbsis in children in a tertiary care hospital of rawalpindi, so that early initiation of appropriate antibiotic therapy can be implemented, which will contribute significantly towards decrease in mortality rates in our setup. m a t e r i a l a n d m e t h o d s this cross-sectional study was carried out at the department of pediatric medicine, fauji foundation hospital, rawalpindi pakistan in pediatric intensive care unit (picu) over a period of 6 months, from 6th july, 2017 to 6th january, 2018. sample size was calculated by using who calculator. the anticipated population proportion was 9.2% with level of significance 95% and absolute precision 2.9%.10 a total of 385 patients, aged 14 days to 12 years were enrolled by consecutive non probability sampling. j islamabad med dental coll 2020 271 the patients enrolled in the study had picu stay of more than 48 hours and they developed signs of clinical sepsis according to their age. children less than one year of age with either fever more than 38o c or hypothermia less than 37o c were defined as having clinical sepsis. children already admitted with nosocomial infections acquired from picu were excluded. bloodstream infection that occurred after more than 48 hours of admission to picu or within 48 hours after discharge was defined as nosocomial infection. ethical approval was taken from institutional ethical review committee. informed verbal and written consent were obtained from parents regarding use of data for research and publication. specimens were collected according to the protocol of the microbiology laboratory. blood samples for culture were collected aseptically from fresh peripheral venous pricks and inoculated into blood culture bottles that were incubated for 7 days. all patients at picu were monitored from the time of admission till they showed sign of infections, based on standard definitions. a microbiology resident and a nursing staff member were specifically given the task of following up all patients from the time the blood culture yielded growth till the report became available. data was collected on a predesigned proforma. confidentiality of patients was maintained during the study. the data was analyzed using spss version 20. descriptive statistics were calculated for both qualitative and quantitative variables. frequencies and percentages were calculated for qualitative variables like gender and bacterial organism. mean and standard deviation were used for quantitative data like age, duration of admission, blood pressure, heart rate and temperature. effect modifiers like age, duration of admission, gender was controlled by stratification. post stratification chi-square test was applied and a p-value of less than .05 considered statistically significant. r e s u l t s out of 385 patients, 231 (60%) were male while 154 (40%) were females with maximum stay at hospital being 72 hours (table i). pseudomonas aeruginosa and salmonella typhi were the most common bacterial organisms (n=83; 21.6% each) causing nosocomial blood stream infection (figure 1). gender, an effect modifier was stratified and compared with frequency of most common bacterial organisms in nosocomial blood stream infections. there was predominance of salmonella typhi and pseudomonas aeruginosa in males while mycobacterium tuberculosis was more frequent in females. chi-square test was used to compare gender stratification with frequency of most common bacterial organisms in nosocomial blood stream infections which was statistically significant (p=.001) (table ii). figure 1: frequency of bacterial organisms in nosocomial blood stream infections similarly, effect modifiers like age and duration (hours) of admission to picu were also compared with frequency of most common bacterial organisms in nosocomial blood stream infections. each of the above effect modifiers were divided into two groups (table ii). chi-square test was used to compare the frequency of different bacterial organisms between the two age groups as well as between two cut-off values for duration of stay in j islamabad med dental coll 2020 272 picu. the results showed that there was no association between patients’ age group and presence of different bacterial organisms. similarly, there was no statistically significant difference between duration of admission to picu and infection with different bacterial organisms (p > .05) (table ii). table: i descriptive statistics of patients (n=385) gender male 231 (60%) female 154 (40 %) category minimum maximum mean standard deviation age 0.038 12 3.19 2.09 duration of stay in picu (hours) 48 72 55.85 8.38 bp (mmhg) systolic 109 125 119.17 2.8 diastolic 41 80 58.11 10.29 heart rate 90 115 103.08 9.92 *p-value < .05 was considered statistically significant e. coli-escherichia coli; p. aeruginosa-pseudomonas aeruginosa; m. tuberculosis-mycobacterium tuberculosis; s. typhisalmonella typhi d i s c u s s i o n our study reports a high frequency of common bacterial organisms in nosocomial blood stream infection in children admitted to pediatric icu, with a predominance of gram-negative bacteria including pseudomonas aeruginosa and salmonella typhi. gender of the patients was an effect modifier with a significant relationship with frequency of most common bacterial organisms in nosocomial blood stream infection. nosocomial infections (ni) are a common problem, especially in intensive care units (icu). morbidity and mortality are high in patients with nbsis in both developing and developed countries.11,12 failure of the immune system to contain infection at a focal site and consequent dissemination, are a major cause of high morbidity and mortality.13 the frequency of these infections, their epidemiology, and the invading organisms keep on changing along with evolving medical environment. the immunocompromised hospitalized patients who are often heavily dependent on medical support and indwelling devices are especially prone to these infections.14,15 table ii: comparison of effect modifiers with frequency of bacterial infection bacterial organisms n (%) gender e. coli p. aeruginosa m. tuberculosis s. typhi klebsiella male 53 (68.8) 70 (84.3) 15 (20.0) 72 (86.7) 21 (31.3) female 24 (31.2) 13 (15.7) 60 (80.0) 11 (13.3) 46 (68.7) p-value* .077 .001 .001 .001 .001 age groups ≤ 6 years 73 (94.8) 76 (91.6) 70 (93.3) 79 (95.2) 65 (97) 7 12 years 4 (5.2) 7 (8.4) 5 (6.7) 4 (4.8) 2 (3.0) p-value* .826 .228 .228 .692 .29 duration of admission to picu (hours) 48-60 hours 58 (75) 68 (81.9) 58 (77.3) 74 (89.2) 49 (73.1) 61-72 hours 19 (24.7) 15 (18.1) 17 (22.7) 9 (10.8) 18 (26.9) p-value* .281 .576 .576 .563 .139 j islamabad med dental coll 2020 273 a study conducted by kasmi et al. showed an incidence of 22.8% of nosocomial infections with a rate of 30 per 1000 patients. according to this study, common nbsi included lower respiratory tract infection (10.5%), with ventilator associated pneumonia (vap) (6.8%), catheter associated uti (7.1%) and blood stream infection (bsi) (4.2%), with central line-associated bsi (clabsi) (2.4%).16 this study highlights the incidence of device associated nosocomial infections, while in our study frequency of common bacterial organisms causing nosocomial infection was observed based on blood culture reports. our study showed gram-negative bacteria as the commonest micro-organisms involved in nbsi with predominance of pseudomonas aeruginosa and salmonella typhi. a study carried out in egypt by elsahrigy et al. showed staphylococcus aureus, acinetobacter and klebsiella as the commonest microorganism among picu patients.17 in this study common infections were respiratory tract infections due to which staphylococcus was the commonest microorganism, while our study focused on hospital acquired blood stream infections. geographical difference may also be a reason for this variation in results. in our study, the mean age was 3.19 years while a study conducted by almuneef et al. from riyadh saudi arabia, reported a mean age of 2.6 years.18 this difference in mean age between the two studies may be due to the reason that majority of the patients included in study by almuneef et al. were suffering from congenital diseases, in which incidence of infections is usually high. there were 60% male and 40% female patients in our study, whereas a study conducted in picu of a tertiary care hospital of north india reported 76.92% male and 23.08% female patients.19 there is predominance of male gender in this study as well as in our study, however the difference between the two studies is difference in sample size. the indian study included only 20 children with hospitalacquired infection out of a total of 119 admitted to picu.19 an increase in sample size might affect the ratio of gender involvement. in our study, the mean duration of admission to picu was 55.85 hours, while almuneef and colleagues found that the mean picu stay was 30.20 days (720 hours) for catheter related bsi patients and 6.35 days (151 hours) for non-bsi patients (p<0.0001).18 these prolonged hours of picu stay in this study may be attributed to catheter insertion in all the enrolled patients, which was not the case in our study. blood pressure and heart rate of the patients were calculated and compared with age-specific review charts for early identification of clinical sepsis, as both these parameters are used as an important “pediatric severe sepsis screening tool”.20 our study highlights the current trends of bacterial organisms causing nbsi in picu which would be helpful in timely administration of antibiotics against common pathogens, hence reducing morbidity and mortality. c o n c l u s i o n there is a high frequency of common bacterial organisms in nosocomial blood stream infections in children, with a predominance of gram-negative bacteria including pseudomonas aeruginosa and salmonella typhi. r e c o m m e n d a t i o n s we recommend early identification of nosocomial infections in admitted patients, especially those with a hospital stay of more than 48 hours, so that morbidity and mortality rates due to blood stream infections can be minimized. j islamabad med dental coll 2020 274 a c k n o w l e d g m e n t we are thankful to all children and their parents who participated in our study. r e f e r e n c e s 1. zingg w, hopkins s, gayet-ageron a, holmes a, sharland m, suetens c, et al. health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the european centre for disease prevention and control point-prevalence survey. lancet infect dis. 2017; 17(4): 381–9. doi: 10.1016/s1473-3099(16)30517-5. 2. tauhid sa, chowdhury ma, hoque mm, kamal m, haque e. nosocomial bloodstream infections in children in intensive care unit: organisms, sources, their sensitivity pattern and outcome of treatment. j bangladesh coll physicians surg. 2017; 35(3): 115– 22. 3. haque a, ahmed sa, rafique z, abbas q, jurair h, ali sa. device-associated infections in a paediatric intensive care unit in pakistan. j hosp infect. 2017; 95(1): 98–100. 4. mitt p, metsvaht t, adamson v, telling k, naaber p, lutsar i, et al. five-year prospective surveillance of nosocomial bloodstream infections in an estonian paediatric intensive care unit. j hosp infect. 2014; 86(2): 95–9. doi: 10.1016/j.jhin.2013.11.002. 5. jordan gi, esteban te, bustinza aa, de carlos vjc, garcía sp, concha tja, et al. trends in nosocomial infections and multidrug-resistant microorganisms in spanish pediatric intensive care units. enferm infecc microbiol clin. 2016; 34(5): 286–92. doi: 10.1016/j.eimc.2015.07.010. 6. ng yy, abdel-latif mea, gan cs, siham a, zainol h, lum lcs. impact of infection control training for interns on picu-acquired bloodstream infections in a middle-income country. singapore med j. 2015; 56(9): 506–12. 7. siddiqui b, azmat r, tikmani ss, rafi s, syed b, khan mt, et al. frequency of bloodstream infection in febrile neutropenic patients, experience from a developing country. ann med surg. 2018; 34: 71–4. 8. qureshi s, fatima p, mukhtar a, zehra a, qamar fn. clinical profile and outcome of antibiotic lock therapy for bloodstream infections in pediatric hematology/oncology patients in a tertiary care hospital, karachi, pakistan. int j pediatr adolesc med. 2019; 6(1): 25–8. 9. somroo t, tikmani ss, ali sa. frequency and etiology of community-acquired bloodstream infection in hospitalized febrile children. j med diagnostic methods. 2016; 5(3). 10. altun o, botero-kleiven s, carlsson s, ullberg m, özenci v. rapid identification of bacteria from positive blood culture bottles by maldi-tof ms following short-term incubation on solid media. j med microbiol. 2015 nov 1; 64(11): 1346–52. 11. obeiro cw, seale ac, berkley j. empiric treatment of neonatal sepsis in developing countries. pediatr infect dis j. 2015; 34(6): 659-61. doi: 10.1097/inf.0000000000000692 12. riaz s, jamal m. surveillance of hospital acquired infections in newborn: a challenge in developing countries. j islamabad med dental coll. 2016; 5(1): 59-62. 13. denstaedt sj, singer bh, standiford tj. sepsis and nosocomial infection: patient characteristics, mechanisms, and modulation. front immunol. 2018; 9: 2446. doi: 10.3389/fimmu.2018.02446 14. esfahani bn, basiri r, mirhosseini smm, moghim s, dolatkhah s. nosocomial infections in intensive care unit: pattern of antibiotic-resistance in iranian community. adv biomed res. 2017; 6. 15. deng s, feng s, wang w, zhu h, gong y. bacterial distribution and risk factors of nosocomial blood stream infection in neurologic patients in the intensive care unit. surg infect. 2019 jan 1; 20(1): 2530. 16. kasmi i, sallabanda s, kasmi g. nosocomial infections in a pediatric intensive care unit in albania. int j sci res. 2013; 5(1): 1570-6. 17. el-sahrigy saf, shouman mg, ibrahim hm, abdel rahman amo, habib sa, khattab aa, et al. prevalence and anti-microbial susceptibility of hospital acquired infections in two pediatric intensive care units in egypt. maced j med sci. 2019; 7(11): 1744-9. doi: org/10.3889/oamjms.2019.485 18. almuneef ma, memish za, balkhy hh, hijazi o, cunningham g, francis c. rate, risk factors and outcomes of catheter-related bloodstream infection in a paediatric intensive care unit in saudi arabia. j hosp infect. 2006; 62(2): 207–13. doi: 10.1016/j.jhin.2005.06.032 19. sodhi j, satpathy s, sharma dk, lodha r, kapil a, wadhwa n, et al. healthcare associated infections in paediatric intensive care unit of a tertiary care hospital in india: hospital stay & extra costs. indian j med res. 2016 apr 1; 143: 502–6. 20. sepanski rj, godambe sa, mangum cd, bovat cs, zaritsky al, shah sh. designing a pediatric severe sepsis screening tool. front pediatr. 2014; 2: 56. doi: 10.3389/fped.2014.00056 121 j i m d c 2 0 1 7 121 open access f u l l l e n g t h a r t i c l e comparison of ciprofloxacin and amoxicillin/clavulanic acid in the treatment of chronic rhinosinusitis zaimal shahan 1, ghulam saqulain 2, jawwad ahmed 3 1 post-graduate trainee, 2 surgeon & head of department of ent, 3 associate surgeon (department of ent, capital hospital, cda, islamabad, pakistan) a b s t r a c t objective: to compare ciprofloxacin with amoxicillin/ clavulanic acid in the treatment of chronic rhinosinusitis (crs) in terms of frequency of improvement in symptom score. patients and methods: this randomized control trial was conducted at department of otorhinolaryngology, capital hospital islamabad, from march 2015 to march 2016. study population included 190 cases of chronic rhino sinusitis (crs) of either gender, aged 18 to 50 years and excluding confounders, divided in two groups. group a received ciprofloxacin 500 mg bd and group b received amoxicillin/ clavulanic acid 625 mg tds for 10 days. symptom score was recorded at start of treatment and finally at 16th week. data analysis was done by spss 17.0. chi square was used to compare improvement of two groups. p-value ≤ 0.05 was considered significant. results: the sample population comprised of 190 cases of crs aged 18 to 50 years with mean and standard deviation of 31.85 ± 10.07 years. improvement in symptom score was in the range of 1 28, with mean and standard deviation of 10.52 ± 3.94. male population was 54.7% (104/190) while females 45.3% (86/190). a significant association of treatment group on symptom score having p-value = 0.001 was found. ciprofloxacin group showed higher improvement (90.53%) compared to amoxicillin/ clavulanic acid group (71.58%). conclusion: ciprofloxacin showed significantly better results than amoxicillin/ clavulanic acid in the treatment of crs in terms of frequency of improvement in symptom score. key words: amoxicillin/ clavulanic acid, chronic rhinosinusitis, ciprofloxacin, symptoms score author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence ghulam saqulain email: ghulam_saqulain@yahoo.com article info. received: january 22, 2017 accepted: july 10, 2018 cite this article. shahan z, saqulain g, ahmed j. comparison of ciprofloxacin and amoxicillin/clavulanic acid in the treatment of chronic rhinosinusitis. jimdc.2018; 7(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n multidisciplinary expert panels have defined chronic rhinosinusitis (crs), as inflammatory disease of sinonasal mucosa lasting 12 weeks or longer including objective evidence of mucosal inflammation, despite attempts at medical management.1,2 the signs/ symptoms of crs are taken as diagnostic criteria, which include two or more symptoms, of which one should be either blockage of nose/ obstruction, congestion or discharge (anterior/ posterior), + facial pain or pressure and + loss/ reduction of smell.3 this should also include either endoscopic signs including mucopurulent discharge and/or nasal polyps, and/or oedema in middle meatus. in leu of endoscopic signs mucosal changes within the ostiomeatal complex and/or sinuses on ct scanning is also acceptable.3 prevalence of crs varies significantly, 2% to 16% in the united states 4,5 and 7% to 27% in o r i g i n a l a r t i c l e 122 j i m d c 2 0 1 7 122 european, south africa and caribbean region.6-8 crs is typically diagnosed among young or middle-aged 9 with mean age of 39 years with women disproportionately affected 4,8 and it also results in loss of work days.10 aim of treatment is to maintain nasal patency, reduce inflammation and eliminate pathogens. the pathogenesis is uncertain, however polymicrobial biofilms can contribute.11-13 therefore, antibiotics are indicated.13 in a local study cephalosporin (cefuroxime) was found to be more frequently prescribed than amoxicillin in treatment of crs.14 however, treatment also includes antihistamines, analgesics, decongestants, corticosteroids and mucolytic with antihistamines being commonly prescribed.14 nasal septal deviations are commonly seen in crs 15 so are nasal polyps16, therefore surgery is reserved for such cases and when abscess is revealed on ct and if it shows clinical deterioration.13 ct may also be helpful in the diagnosis of fungal infection involving paranasal sinuses.17 antibiotics are used against common isolates including staphylococcus aureus and anaerobes, including beta lactam producing organisms, pseudomonas aeruginosa and facultative gram-negative rods. therefore, the spectrum of antibiotic should include these organisms.18 a number of antibiotics are used in crs especially in acute exacerbations including amoxicillin and clavulanic acid combinations and fluoroquinolones. in a local study efficacy for resolution of signs and symptoms of crs with both amoxicillin-clavulanate and levofloxacin was found similar 19, however, no local study is available comparing the efficacy of amoxicillin-clavulanate and quinolones for crs. the objective of this study was to compare ciprofloxacin with amoxicillin/ clavulanic acid in the treatment of chronic rhinosinusitis (crs) in terms of frequency of improvement in symptom score. p a t i e n t s a n d m e t h o d s this randomized control trial was conducted at the ent department, capital hospital islamabad, from march 2015 to march 2016, after approval from the institutional ethical committee. other ethical issues were taken into account. presence of female attendant in cases of females being examined was made mandatory. the sample size was 190 cases calculated with 5% level of significance, 80% power of test, and anticipated population proportion of 83.3% in group a and 67.6% in group b with minimum sample size of 95 in each group. non-probability consecutive sampling technique was used. all the diagnosed cases of crs who consented for the study were included in the study. these included cases of both genders aged 18 to 50 years. cases which could act as confounders, were excluded from the study. these included cases with previous sinus surgery/fess, or nasal lavage within a week of presentation; cases with allergic rhinitis, allergy to test drugs, fungal sinusitis, nasal deformities and nasal polyposis. moreover, cases who used antibiotics within the last one week before presentation, those with chronic use of steroids or immunosuppressive cases with co morbidities, and pregnant females were also excluded from the study. patients with crs fulfilling the selection criteria were selected from ent outpatient’s department of capital hospital. informed consent was taken and patients were randomly divided into two groups (group a and group b), by balloting. patients were diagnosed as crs clinically by the research supervisor. this included nasoendoscopy and where required ct scanning was performed. performa was filled by the patient and symptom score calculated by the researcher. all 13 symptoms (major symptoms: nasal obstruction, post nasal discharge, nasal discharge, facial pain or pressure, hyposmia / anosmia, nasal congestion, headache; minor symptoms: halitosis, fever, fatigue, dental pain, cough, ear pain or fullness) were scored. each symptom was scored on the following scale: none = no symptom = 0 mild = symptom occurs in/ or continues for less than 6 hours. = 1 moderate = symptom recurs in/ or continues for 6 to 12 hours. = 2 severe = symptom recurs in/ or continues for more than 12 hours = 3 as, all 13 symptoms were scored the maximum score was 39 (13 x 3). group a patients were given ciprofloxacin 500 mg twice daily and group b cases were given amoxicillin/ clavulanic acid 625 mg thrice daily. treatment was instituted for 10 days. patients in both groups were also instituted xylometazoline nasal spray, tab. loratadine 123 j i m d c 2 0 1 7 123 10mg once daily and saline nasal douches thrice daily. symptom score was recorded at first visit and final outcome was measured at 16th week. follow up was ensured by taking contact number and address. data collected included medical record number, age, sex and contact detail and sinus score at first visit and at 16th week. the data collected was recorded, organized and analyzed on spss 17.0. qualitative variables like gender were measured in terms of frequency and percentage. quantitative variables like age and symptom score were measured in terms of mean and standard deviation. chi square was used to compare improvement of two groups. p ≤ 0.05 was significant. effect modifier like age and gender were controlled by stratification. post stratification chi square was applied. r e s u l t s among the 190 patients included in the study, 104 (54.7%) were males while 86 (45.3%) were females with a male to female ratio of 1.2:1. the patient age range was from 18 to 50 years with mean and standard deviation of the age as 31.85 ± 10.07. the range of improvement in symptom score following treatment ranged from 1-28, with mean and standard deviation of 10.52 ± 3.94. among males, a significant association was found between treatment group and improvement in symptom score, with p-value of 0.002 while no significant association between treatment group and improvement in symptom score was found in females with p-value of 0.118. in < 35 years of age group, significant association was found between treatment group and improvement in symptom score with p-value 0.003 while no significant association was found in patients > 35 years of age group, between treatment group and improvement in symptom score with p-value 0.095 (table 1). overall, the treatment group has shown significant association on symptom score having p-value = 0.001. it was noted that after instituting 10 days’ treatment and recording the symptom score on 16th week, ciprofloxacin group showed more improvement [n = 86 (90.53%)] compared to amoxicillin/ clavulanic acid group [n=68 (71.58%)] as shown in (table 2). table.2: comparison of improvement in both groups (n = 190) treatment group improvement total pvalue yes no ciprofloxacin treatment 86 (90.53%) 9 (9.47%) 95 0.001 amoxicillin treatment 68 (71.58%) 27 (28.42%) 95 total 154 36 190 table.1: stratification of gender and age stratification treatment group improvement total p-value yes no male (n=104) group a: ciprofloxacin 49 (90.74%) 5 (9.26%) 54 0.002 group b: amoxicillin/clavulanic acid 33 (66%) 17 (34%) 50 total 82 22 104 female (n=86) group a: ciprofloxacin 37 (90.24%) 4 (9.76%) 41 0.118 group b: amoxicillin/clavulanic acid 35 (77.78%) 10 (22.22%) 45 total 72 14 86 < 35 years (n= 118) group a: ciprofloxacin 55 (91.67%) 5 (8.33%) 60 0.003 group b: amoxicillin/clavulanic acid 41 (70.69%) 17 (29.31%) 58 total 96 22 118 >35 years (n = 72) group a: ciprofloxacin 31 (88.57%) 4 (11.43%) 35 0.095 group b: amoxicillin/clavulanic acid 27 (72.97%) 10 (27.03%) 37 total 58 14 72 124 j i m d c 2 0 1 7 124 d i s c u s s i o n since crs is an inflammatory disease of sinonasal mucosa lasting 12 weeks or longer 1,2, the aim of treatment in crs include steps to eliminate infection, reduce sinonasal inflammation, and maintain patency of sinonasal passage to facilitate drainage. management of precipitating risk factors is also recommended 20, in addition to antibiotics for the short-term treatment of crs with exacerbations.3 a number of antibiotics are in use. amoxicllin/ clavulanic acid combinations have increased effectiveness against b-lactamase producing bacteria.21 also, fluoroquinolones including ciprofloxacin have good activity against most of gram -ve and gram +ve organisms.22 a number of studies comparing different drugs for the treatment of crs have been documented.2325 namyslowski et al,24 compared cefuroxime axetil with amoxicillin/ clavulanic acid with no significant difference in clinical response and bacterial eradication. zaman et al., in a local study found that in context with resolution of signs and symptoms of crs efficacy of both amoxicillinclavulanate and levofloxacin was similar.19 legent f et al., compared the ciprofloxacin with amoxicllin/ clavulanic acid in terms of cure rate with assessment done on 40th day 23. in slight contrast, the objective of our research was to compare ciprofloxacin with amoxicillin/ clavulanic acid in the treatment of chronic rhinosinusitis (crs) in terms of frequency of improvement in symptom score at 16th week. for this we conducted a randomized control trial in which one hundred and ninety patients of crs were included which fulfilled the selection criteria by using, nonprobability consecutive sampling. these included patients aged 18 years to 50 years, with mean and standard deviation of the age as 31.85 ± 10.07 years. in our study males were 104/190 (54.7%) while females were 86/190 (45.3%). the minimum symptom score was 1 and maximum score was 28 with mean and standard deviation as 10.52 ± 3.94. several organisms (both aerobes and anaerobes) associated with chronic rhinosinusitis have been isolated, 26,27 which strengthens the role of antibiotics. role of amoxicillin/ clavulanic acid 2,24, ofloxacin, and erythromycin 25 is there. piromchai p et al., concluded in a small study to support the use of systemic antibiotics for the curative treatment of chronic rhinosinusitis in adults and there is limited evidence in support of use of antibiotics and that further good quality trials, with large sample sizes, are needed to evaluate the use of antibiotics in chronic rhinosinusitis.28 however, due to emerging resistance ciprofloxacin is proving to have a pivotal role in treatment,23 but not many studies have been conducted to prove its role. legent f.et al.23 reported in their study that after 9 days’ treatment, nasal discharge disappeared in 71/118 (60.2%) patients of the ciprofloxacin group and in 69/123 (56.1%) of those in the amoxycillin/clavulanic acid group. the clinical cure and bacteriological eradication rates were 58.6% versus 51.2% and 88.9% versus 90.5% for ciprofloxacin and amoxycillin/clavulanic acid, respectively. these differences were not significant, however, amongst patients who had a positive initial culture and who were evaluated 40 days after treatment. ciprofloxacin recipients had a significantly higher cure rate than those treated with amoxycillin/clavulanic acid (83.3% vs. 67.6%, p = 0.043). our treatment groups have shown significant association of symptom score with p-value of 0.006. after instituting 10 days’ treatment and recording symptom score at 16th week, ciprofloxacin group revealed a higher improvement (90.53%) in symptom score compared to amoxicillin/ clavulanic acid group (71.58%). thus ciprofloxacin has shown to be a better antibiotic, in terms of improvement, in symptom score. however, more studies need to be conducted to further strengthen its role in crs. c o n c l u s i o n ciprofloxacin shows significantly better results than amoxicillin/ clavulanic acid in the treatment of chronic rhinosinusitis, in terms of improvement in symptom score. also treatment group was significantly associated with improvement in symptom score in males and in less than 35 years of age group. r e f e r e n c e s 1. meltzer eo, hamilos dl, hadley ja, lanza dc, marple bf, nicholas ra, et al. rhinosinusitis: establishing definitions for clinical research and patient care. j allergy clin immunol 2004; 114(6):155-212 2. slavin rg, spector sl, bernstein il, kaliner ma, kennedy dw, virant fs, et al. the diagnosis and management of sinusitis: a practice parameter update. j allergy clin immunol 2005; 116(6):s13-47. 125 j i m d c 2 0 1 7 125 3. fokkens wj, lund vj, mullol j, bachert c, alobid i, baroody f. epos 2012: european position paper on rhinosinusitis and nasal polyps 2012. a summary for otorhinolaryngologists. rhinology. 2012;50(1):1-12. 4. shashy rg, moore ej, weaver a. prevalence of the chronic sinusitis diagnosis in olmsted county, minnesota. arch otolaryngol head neck surg. 2004; 130(3):320-23 5. blackwell dl, collins jg, coles r. summary health statistics for u.s. adults: national health interview survey, 1997. vital health stat 10. 2002; 205:1-109. 6. hastan d, fokkens wj, bachert c, newson rb, bislimovska j, bockelbrink a et al. chronic rhinosinusitis in europe--an underestimated disease. a galen study. allergy 2011; 66(9):1216-23. 7. ahsan sf, jumans s, nunez da. chronic rhinosinusitis: a comparative study of disease occurrence in north of scotland and southern caribbean otolaryngology outpatient clinics over a two-month period. scott med j. 2004; 49(4):130-33. 8. pilan rr, pinna fr, bezerra tf, mori rl, padua fg, bento rf, et al. prevalence of chronic rhinosinusitis in sao paulo. rhinology. 2012; 50(2):129-38. 9. lusk r. chronic rhinosinusitis: contrasts between children and adult patients. clin allergy immunol. 2007; 20:287-98. 10. bhattacharyya n. functional limitations and workdays lost associated with chronic rhinosinusitis and allergic rhinitis. am j rhinol allergy 2012; 26(2):120. 11. costerton jw, stewart ps, greenberg ep. bacterial biofilms: a common cause of persistent infections. science. 1999;284(5418):1318-22. 12. wood aj, fraser jd, swift s, patterson-emanuelson ea, amirapu s, douglas rg. intramucosal bacterial microcolonies exist in chronic rhinosinusitis without inducing a local immune response. am j rhinol allergy. 2012; 26(4):265-70. 13. masud-ul-haq m, hussain s. bony complications of chronic sinusitis. pak j med sci 2009;25(2):308-312. 14. mahmood kt, younas a, rasheed m. treatment and prevention of sinusitis. j. pharm. sci. & res. 2011; 3(1):1019-24 15. s.madani sa,hashemi sa, modanluo m.the incidence of nasal septal deviation and its relation with chronic rhinosinusitis in patients undergoing functional endoscopic sinus surgery. j pak med asso. 2015; 65(6):612-16 16. gohar ms, niazi sa, niazi sb. functional endoscopic sinus surgery as a primary modality of treatment for primary and recurrent nasal polyposis. pak j med sci. 2017;33(2):380-82 17. iqbal j, rashid s, darira j, shazlee mk, ahmed ms, fatima s. diagnostic accuracy of ct scan in diagnosing paranasal fungal infection. j coll physicians surg pak. 2017;27(5):271-74. 18. brook i. microbiology of chronic rhinosinusitis. eur j clin microbiol infect dis. 2016;35(7):1059-68. 19. muhammad r, zaman a, raza a, khan z. comparison of efficacy of amoxicillin clavulanate and levofloxacin in treatment of acute bacterial sinusitis. j. med. sci. 2015; 23(2): 77-81 20. piromchai p, kasemsiri p, laohasiriwong s, thanaviratananich s. chronic rhinosinusitis and emerging treatment options. international journal of general medicine. 2013; 6:453-64. 21. todd pa, benfield p. amoxicillin/clavulanic acid. an update of its antibacterial activity, pharmacokinetic properties and therapeutic use. drugs. 1990; 39(2):264-307. 22. chin nx, neu hc. post-antibiotic suppressive effect of ciprofloxacin against gram-positive and gramnegative bacteria. the american journal of medicine. am j med. 1987; 82(4a):58-62 23. legent f, bordure p, beauvillain c, berche p. a double-blind comparison of ciprofloxacin and amoxycillin/clavulanic acid in the treatment of chronic sinusitis. chemotherapy 1994; 40 (1): 8-15 24. namyslowski g, misiolek m, czecior e, malafiej e, orecka b, namyslowski p, et al. comparison of the efficacy and tolerability of amoxycillin/clavulanic acid 875 mg b.i.d. with cefuroxime 500 mg b.i.d. in the treatment of chronic and acute exacerbation of chronic sinusitis in adults. j chemother 2002; 14(5):508. 25. husfeldt p, egede f, nielsen pb. antibiotic treatment of sinusitis in general practice. a double-blind study comparing ofloxacin and erythromycin. eur arch otorhinolaryngol 1993; 250 (1):s23-5. 26. finegold sm, flynn mj, rose fv, jousimies-somer h, jakielaszek c,mcteague m et al. bacteriologic findings associated with chronic bacterial maxillary sinusitis in adults. clin infect dis 2002; 35:428-33 27. brook i, frazier eh, foote pa. microbiology of the transition from acute to chronic maxillary sinusitis. j med microbiol 1996; 45:372. 28. piromchai p, thanaviratananich s, laopaiboon m. systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults. cochrane database syst rev 2011; 11(5): 1-27. j islamabad med dental coll 2022 30 o p e n a c c e s s prophylactic use of amiodarone in coronary artery bypass graft patients with less ejection fraction shumaila ali rai1, chaudhry amjad ali2, muhammad arsalan qureshi3 1senior registrar, ch. pervaiz elahi institute of cardiology, multan 2classified anesthetist, combined military hospital kharian cantonment, gujrat 3medical officer, ch. pervaiz elahi institute of cardiology, multan a b s t r a c t background: dysrhythmias like atrial fibrillation are most common in post-cabg patients, with an incidence of around 40%. prophylactic amiodarone treatment decreases the occurrence of dysrhythmias in low ejection fraction patients. some studies have reported that the benefit of giving amiodarone is more in high-risk patients such as those having older age, higher angina class, diabetes, and severe coronary artery disease (cad). this study aims to determine the role of amiodarone prophylaxis in the prevention of dysrhythmias following cabg in patients with low ejection fractions. methodology: in this non-randomized study, we included150 patients who underwent cabg at multan institute of cardiology from jan-2019 to aug-2019, having ef ≤35%. in the amiodarone group (n=75), 3 mg/kg of amiodarone was given through cpb machine after removal of the x-clamp and before weaning from cardiopulmonary bypass. while in the remaining 75 patients, no anti-arrhythmic drug treatment was given during the peri-operative period. the occurrence of postoperative arrhythmia during the primary hospital stay after surgery was a primary study endpoint. results: there was no significant difference between patients' mean age, gender, bmi, and the number of grafts in the amiodarone group 3.9±0.53 and control group 3.04±0.50 (p-value 0.20). the frequency of post operative atrial fibrillation (poaf) was significantly different in both groups. in the amiodarone group, 13 (17.3%) patients developed poaf, and in the control group, poaf occurred in 25 (33.3%) patients (p-value 0.024). conclusion: amiodarone prophylaxis significantly lowers the incidence of poaf after cabg in low ef patients. keywords: amiodarone prophylaxis, coronary artery bypass grafting (cabg), post-operative atrial fibrillation (poaf). authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: shumaila ali rai email: drshumailarai@yahoo.com article info: received: january 15, 2021 accepted: march 29, 2022 cite this article. rai sa, ali ca, qureshai ms. prophylactic use of amiodarone in coronary artery bypass graft patients with less ejection fraction. j islamabad med dental coll. 2022; 11(1): 30-34. doi: 10.35787/jimdc.v11i1.490 funding source: nil conflict of interest: nil i n t r o d u c t i o n dysrhythmias like atrial fibrillation (af) and atrial flutter are most common in post coronary artery bypass graft (cabg). the incidence rate is around 40% to 60%,1,2 the incidence of af is increasing in cardiac surgery gradually as compared to the past. these arrhythmias usually occur on the 3rd to 5th postoperative day.3 atrial fibrillation and atrial flutter may cause post-operative stroke, heart failure, myocardial infarction, re-intubation and increase the length of hospital stay. 4dysrhythmias are independent risk factors of deterioration in the post-cardiac surgery period and cause long term morbidity and mortality.5,6,7 there have been some pharmacological and nonpharmacological techniques recommended for post operative atrial fibrillation (poaf) after cabg.8,9 o r i g i n a l a r t i c l e j islamabad med dental coll 2022 34 amiodarone is categorized as a class iii agent (vaughn-williams classification), which combines anti –beta-adrenergic effects with sodium, potassium, and calcium channel blocking properties10,11,12. amiodarone prolongs the av nodal refraction and conduction time due to calciumchannel blockade. at a constant dose, bradycardia could happen. at a low dose, amiodarone blocks the sodium channel. it may also reduce automaticity by diminishing voltage-dependent inward current, it decreases the phase4 slopes of an action potential. long-term therapy prolongs the refractory periods of the atrium and ventricles. 13 patients with low ejection fraction are more prone to dysrhythmias in comparison to normal ejection fraction patients. the occurrence of dysthymias is a significant contributor to morbidity and mortality in these patients. therefore, in the present study, we investigated the role of amiodarone as a prophylactic drug in the prevention of dysrhythmias following cabg in patients with low ef. m e t h o d o l o g y in this non-randomized comparative study, we included patients who underwent cabg at multan institute of cardiology for 07 months from jan-2019 to july-2019. patients planned for elective isolated cabg were included in this analysis. patients who were diagnosed with having any arrhythmia on admission such as atrial fibrillation or flutter, or any ventricular arrhythmia, those having a previous history of use of anti-arrhythmic drugs, or the patients who have received amiodarone before going on bypass were excluded. patients having severe pulmonary dysfunction requiring hospital admission were also excluded. all patients signed a written consent before being included in this study. we also took approval from the hospital institutional review board before starting the recruitment of patients. one day before surgery, data regarding baseline demographics such as age, gender, bmi, presence of co-morbid diseases, and severity of cad was taken. the sample size for this study was calculated using the results of a study by tokmakoglu et an l.14 they reported poaf in 8.3% of patients who received amiodarone prophylaxis versus in 33.6% of patients in the place group, taking (1-β) 80% and (α) 5.0%, the sample size was 47 patients in each group. we took 75 patients in each group making a total number of 150 patients being included in the study. in group i, peri-operative amiodarone was given to 75 patients, while in the remaining 75 patients no antiarrhythmic treatment was given during the perioperative period. in the intervention(amiodarone) group, 3 mg/kg of amiodarone was given through cpb machine ,after removal of the x-clamp and before weaning from cardiopulmonary bypass. the occurrence of postoperative arrhythmia (poaf and bradycardia) during the primary hospital stay after surgery was the primary study objective. for data interpretation and analysis, we used spss v23 software. for comparison of continuous variables, sample t-test statistics were used. while for comparison of qualitative variables, the chisquare test was used. p-value ≤0.05 was taken as statistically significant. r e s u l t s there were 75 patients in each group. there was no significant difference between the mean age and gender of patients in the two groups. the mean body mass index (bmi) was not different between the two groups of patients. there was also no significant difference in pre-surgery canadian cardiovascular society (ccs) class and ef between the groups. detailed information is given in table i. regarding per-operative data, there was no significant difference in the number of grafts in the amiodarone group 3.9±0.53 and the control group 3.04±0.50 (p-value 0.20). cardiopulmonary bypass j islamabad med dental coll 2022 34 (cpb) time and cross-clamp (x-clamp) time in both groups were also almost the same. intra-aortic balloon pump (iabp) was insertion was done in 10 (13.3%) patients in the amiodarone group and in 08 (10.7%) patients in the control group (p-value 0.80) (table-ii). the frequency of poaf was significantly different in both groups. in the amiodarone group, 13 (17.3%) patients developed poaf and in the control group, poaf occurred in 25 (33.3%) patients (p-value 0.024) (table-iii). table-i: baseline characteristics of patients. characteris tics amiodaron e group control group pvalue number,(n) 75 75 age (years) 55.44+_10. 78 57.90+_9.6 0.14 gender (male/fem ale) 58(77.3%)/ 17(22.7%) 59(78.7%)/16 (21.3%) 0.84 bmi(kg/m2) 26.76±4.94 26.57 0.81 canadian cardiovascular society class (ccsc), n (%) i 10 (13.5%) 9(12.7%) 0.73 ii 1 (1.3%) 2 (2.7%) iii 60 (80.0%) 57 (76%) iv 4 (5.3%) 7 (9.3%) ejection fraction (%) 33.13±2.82 32.44±3.2 0.16 major additional diseases hypertensi on, n (%) 40(55.6%) 32(44.4%) 0.14 diabetes mellitus, n (%) 35(54.7%) 29(45.3%) 0.40 table-ii: operative values of patients amiodaro ne control p-value number (n) 75 75 number of grafts 3.9 ± 0.53 3.04±0.50 0.20 cpb time (min) 117 ± 29.9 116±29.6 0.91 x-clamp time 66 ± 21.85 66.56±18.0 0.98 iabp, n (%) 10 (13.3%) 08 (10.7%) 0.80 table-iii. comparison of study endpoints. amiodarone control p-value af after surgery, n (%) 13 (17.3 %) 25 (33.3%) 0.024* symptomatic bradycardia after surgery 07(9.3%) 04 (5.3%) 0.34 p<0.05 * d i s c u s s i o n prophylactic amiodarone treatment decreased the occurrence of dysrhythmias (af) in low ejection fraction patients.15,16 some studies have reported that the benefit of giving amiodarone is more in high-risk patients such as those having older age, higher angina class, diabetes, and severe cad.17,18 in the present study, we included only high-risk patients; those having low ef (≤35%). moreover, different regimens have been described in the literature, in the present study we gave amiodarone through a cardiopulmonary bypass circuit after removing the x-clamp. studies have also reported variability in outcomes using peri-op iv administration followed by oral administration of amiodarone.19 a study by moroi et al. compared the iv amiodarone administration followed by 5 days of oral amiodarone with a j islamabad med dental coll 2022 34 placebo drug after cabg surgery, the authors reported supraventricular arrhythmias in 8.0% of patients in amiodarone versus in 20% of patients in the placebo group. while ventricular arrhythmias occurred in 15.0% of patients in amiodarone versus 33.0% of patients in the placebo group.18 a study by thanavaro et al. compared the prophylactic amiodarone administration with the control group. the authors reported a significantly lower incidence of postop af, 17.0% in the amiodarone group versus 25.9% in patients who did not receive amiodarone.20 another study by esmail et al. also reported similar results. in their study, poaf occurred in 16.1% of patients in whom amiodarone was given versus in 33.9% of patients in whom it was not given.21 the major difference between these studies and the present study is that these authors included all patients planned for cabg and we only included patients with low ef. in the present study, af occurred in 17.3% of patients in the amiodarone prophylaxis group versus in 33.3% of patients without prophylactic amiodarone. in our comparative study, the amiodarone treatment was well tolerated and it reduced the significant occurrence of post-operative af. amiodarone treated group patients had a low number of side effects without a significant difference compared with the control group patients, a more prophylactically effective amiodarone concentration among all low ejection fraction patients should reduce the onset of af after cabg. amiodarone didn’t build the operative complications. the prophylactic amiodarone treatment of high-risk patients was not associated with pro-arrhythmia or reduced ef. there are limitations of this study, the sample size of this study was small and we only took patients who underwent on-pump cabg. the role of amiodarone for patients undergoing off-pump cabg, and those undergoing valvular heart surgeries need to be evaluated further. c o n c l u s i o n amiodarone prophylaxis significantly lowered the incidence of poaf after cabg in patients with low ef. amiodarone is easy to administer and is a valuable adjuvant for the prevention of postoperative dysrhythmias. acknowledgment: thank you to dr. muhammad imran khan for the final editing and critical review for the submission of the manuscript. conflict of interest: none r e f e r e n c e s 1. shaker eh, hussein k, reyad em. levosimendan for patients with heart failure undergoing major oncological surgery: a randomized blinded pilot study. indian journal of anesthesia. 2019 dec; 63(12):1001.doi.10.4103%2fija. ija_548_18 2. omae t, candiotti ak, koh k, kumemura m, sakuraba s, iwatsubo c, et al . perioperative management of hypertrophic cardiomyopathy for patients undergoing noncardiac surgery―perioperative management of hcm―. 循環制御. 2021; 42(1):1729. doi.10.11312/ccm.42.17 3. brown pf, miller c, di marco a, schmitt m. towards cardiac mri based risk stratification in idiopathic dilated cardiomyopathy. heart. 2019 feb 1; 105(4):270-5. doi.10.1259/bjr.20210259 4. kovacs b, reek s, saguner am, krasniqi n, eriksson u, duru f. outcomes during and after the use of the wearable cardioverter-defibrillator in a tertiary-care and a regional hospital in switzerland. swiss medical weekly. 2019 nov 4; 149:w20136. doi: 10.4414/smw.2019.20136 5. poole je, olshansky b, mark db, anderson j, johnson g, hellkamp as, et al. long-term outcomes of implantable cardioverter-defibrillator therapy in the scd-heft. journal of the american college of cardiology. 2020 jul 28; 76(4):405-15. doi:10.1016/j.jacc.2020.05.061 6. sohns c, zintl k, zhao y, dagher l, andresen d, siebels j, et al. impact of left ventricular function and heart failure symptoms on outcomes post ablation of atrial fibrillation in heart failure: castle-af trial. circulation: arrhythmia and electrophysiology. 2020 oct;13(10):e008461. https://doi.org/10.1161/circep.120.008461 7. maisch b, alter p. treatment options in myocarditis and inflammatory cardiomyopathy. herz. 2018 https://dx.doi.org/%2010.4103%2fija.%20ija_548_18 https://doi.org/10.11312/ccm.42.17 https://doi.org/10.1259/bjr.20210259 https://doi.org/10.4414/smw.2019.20136 https://doi.org/10.4414/smw.2019.20136 https://www.jacc.org/doi/abs/10.1016/j.jacc.2020.05.061 https://doi.org/10.1161/circep.120.008461 j islamabad med dental coll 2022 34 aug;43(5):423-30. https://doi.org/10.3389/fped.2019.00342 8. notaristefano f, ambrosio g. defibrillator and nonischaemic dilated cardiomyopathy: a never ending story. european heart journal supplements. 2019 mar 1;21(supplement_b):b5-6. doi:10.1093/eurheartj/suz005 9. stolfo d, albani s, savarese g, barbati g, ramani f, gigli m, et al. risk of sudden cardiac death in new york heart association class i patients with dilated cardiomyopathy: a competing risk analysis. international journal of cardiology. 2020 may 15;307:75-81. https://doi.org/10.1016/j.ijcard.2020.02.025 10. sarullo fm, schembri g, nugara c, sarullo s, vitale g, corrao s. mutual relationship between heart failure and atrial fibrillation. monaldi archives for chest disease. 2020 nov 20;90(4). doi: 10.4081/monaldi.2020.1264 11. gatzoulis ka, tsiachris d, arsenos p, antoniou ck, dilaveris p, sideris s, et al. arrhythmic risk stratification in post-myocardial infarction patients with preserved ejection fraction: the preserve ef study. european heart journal. 2019 sep 14;40(35):2940-9. doi:10.1093/eurheartj/ehz260 12. schiau c, leucuța dc, dudea sm, manole s. magnetic resonance assessment of ejection fraction versus echocardiography for cardioverter-defibrillator implantation eligibility. biology. 2021 nov;10(11):1108. https://doi.org/10.3390/biology10111108 13. srinivasan nt, schilling rj. sudden cardiac death and arrhythmias. arrhythmia & electrophysiology review. 2018 jun;7(2):111. doi:10.15420%2faer.2018%3a15%3a2 14. savarese g, stolfo d, sinagra g, lund lh. heart failure with mid-range or mildly reduced ejection fraction. nature reviews cardiology. 2021 sep 6:1-7. doi: 10.1038/s41569-021-00605-5 15. sharma s, angral r, saini h. effect of prophylaxis of amiodarone and magnesium to prevent atrial fibrillation in patients with rheumatic valve disease undergoing mitral valve replacement surgery. anesth essays res. 2020;14(2):189-193. doi:10.4103/aer.aer_63_20 16. deckers jw, arshi b, van den berge jc, constantinescu aa. preventive implantable cardioverter defibrillator therapy in contemporary clinical practice: need for more stringent selection criteria. esc heart failure. 2021 oct;8(5):3656-62. doi:10.1002/ehf2.13506 17. reiffel ja. reduced-dose antiarrhythmic drugs: valuable or valueless?. j innov card rhythm manag. 2020;11(4):4063-4067. doi:10.19102/icrm.2020.110404 18. moroi mk, ruzieh m, aboujamous nm, ghahramani m, naccarelli gv, mandrola j, et al. dataset for amiodarone adverse events compared to placebo using data from randomized controlled trials. data in brief. 2020 feb 1;28:104835. doi:10.1016/j.dib.2019.104835 19. quinto l, sanchez-somonte p, alarcón f, garre p, castillo à, san antonio r, et al. ventricular tachycardia burden reduction after substrate ablation: predictors of recurrence. heart rhythm. 2021 jun 1;18(6):896-904. doi:10.1016/j.hrthm.2021.02.016 20. mattsson g, magnusson p. long‐term follow‐up of implantable cardioverter defibrillator patients about appropriate therapy, complications, and mortality. pacing and clinical electrophysiology. 2020 feb;43(2):245-53. doi:10.1111/pace.13869 21. thanavaro j, taylor j, guignon ms, vitt l. prophylactic amidarone treatment for atrial fibrillation after coronary artery bypass surgery. j nurse pract. 2017;13(6):433-40. doi:10.4037/aacnacc2019470 https://doi.org/10.3389/fped.2019.00342 https://doi.org/10.1093/eurheartj/suz005 https://doi.org/10.1016/j.ijcard.2020.02.025 https://doi.org/10.4081/monaldi.2020.1264 https://doi.org/10.4081/monaldi.2020.1264 https://doi.org/10.1093/eurheartj/ehz260 https://doi.org/10.3390/biology10111108 https://dx.doi.org/10.15420%2faer.2018%3a15%3a2 https://doi.org/10.1038/s41569-021-00605-5 https://doi.org/10.1038/s41569-021-00605-5 https://doi.org/10.1002/ehf2.13506 https://doi.org/10.1016/j.dib.2019.104835 https://doi.org/10.1016/j.hrthm.2021.02.016 https://doi.org/10.4037/aacnacc2019470 269 j i m d c 2 0 1 7 269 open access f u l l l e n g t h a r t i c l e causes of gross hematuria in patient at a tertiary care hospital nizam ud din 1, ahmed sajjad 2, saadat hassan hashmi 3, masroor hussain malik 4, zein-el-amir 5, zeeshan qadeer 6 1 assistant professor (urology) department of urology, saidu group of teaching hospital swat 2,3 consultant urologist, department of urology, benazir bhutto hospital rawalpindi 4,5 assistant professor urology, department of urology, rawalpindi medical university 6 senior registrar, department of urology, benazir bhutto hospital rawalpindi a b s t r a c t objective: to determine the causes of hematuria in patients coming to a tertiary care hospital. patients and methods: this cross-sectional study was carried out at pakistan institute of medical sciences (pims), islamabad, pakistan. data was collected over a period of six months (june 2016 to december 2016). data of all the adult male and female patients presenting with complaint of gross hematuria during the period were gathered and analyzed for etiological profile. results: in the study the most common cause was urological malignancy, which was present in 29 (58%) of patients. this includes all the urological cancers. among other causes, 11 (22%) patients had urolithiasis while 5 (10%) patients had gross hematuria due to trauma to renal tract. 3 (6%) males had hematuria due to enlarged vascular prostate and only 2 (4%) females had gross hematuria due to urinary tract infection. conclusion: urological malignancy was the most common cause of gross hematuria, which is associated with male gender, older age and history of smoking. other causes were urolithiasis, trauma, bph and uti. we recommend screening for malignant disease of all the patients presenting to the departments of urology with the complaint of gross hematuria. key words: hematuria, urolithiasis, urological malignancy author`s contribution 1-2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-6 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence ahmed sajjad email: drahmedsajjad@hotmail.com article info. received: april 16, 2018 accepted: july 10, 2018 cite this article. nizam-ud-din, sajjad a, hashmi sh, malik mh, zein-el-amir, qadeer z. cause of gross hematuria in patient at a tertiary care hospital. jimdc.2018; 7(4):269-273 funding source: nil conflict of interest: nil i n t r o d u c t i o n hematuria is defined as the presence of more than five red blood cells/hpf in three consecutive urine samples, taken at least one-week apart.1 hematuria that is not explained by an obvious underlying condition is commonly seen in urological practice. in many such patients, particularly young adult patients, the hematuria is transient and with no consequence. on the other hand, there is an appreciable risk of malignancy particularly in older patients (eg, over age 35 years) with hematuria, even if transient.2 presentation of gross hematuria can be overtly bloody, tea colored, smoky or microscopic.3 urinary tract malignancies (bladder, ureter and kidney) are distinct clinical entities. hematuria is a common presentation in all these diseases.2 condition can be asymptomatic or symptomatic, transient or persistent; it may or may not be associated with proteinuria or other o r i g i n a l a r t i c l e 270 j i m d c 2 0 1 7 270 abnormalities.2-5 evaluation of the hematuria involves a detailed history, physical evaluation and imaging studies.6 presence of the clots in the urine is suggestive of extraglomerular cause.5 fever, abdominal pain and dysuria is associated with uti. recent abdominal injury may point towards hydronephrosis.3 glomerular disease presentation is early morning periorbital puffiness, weight gain, dark colored urine, edema and hypertension. hematuria with glomerular causes is painless.7 a recent history of skin or throat infection may suggest post infection glomerulonephritis .8 among adult’s, joint pains, skin rash and prolonged fever are suggestive of collagen vascular diseases. in case of anemia, hematuria cannot be the sole cause, in such cases other factors must be counted on. in henoch-schonlein purpura and systemic lupus erythematosus, arthritis and rashes are a common presentation. information regarding exercises, menstruation, and bladder catheterization, recent intake of drugs or toxins or passage of a calculus may be helpful in differential diagnosis. further family history of the alports syndrome, cvd, polycystic disease and urolithiasis is critical for differential diagnosis.9 other denominators in the diagnosis of hematuria are age, sex and race. hematuria is a sign and not a disease, though it may be an early presentation of urinary tract cancers, so clinicians should focus on the root cause identification and eradication.10 currently, there is very limited data on etiological profile of hematuria in pakistani population. present study was designed to gather data from urology department of tertiary care hospital. as there is an appreciable risk of malignancy particularly in older patients, the study will table 1: baseline characteristics of study population baseline characteristics number (n) percentage (%) age (mean 44.8 ±17.2 years; range:17-78 years) upto 30 years 15 30 31-50 years 14 28 > 50 years 21 42 total 50 100 gender males 40 80 females 10 20 total 50 100 m:f 4:1 h/o smoking smokers 24 48 non-smokers 26 52 total 50 100 co-morbids no comorbid 31 62 hypertension 7 14 diabetes 5 10 hypertension+ diebetes 4 8 cva 2 4 asthma 1 2 total 50 100 duration of hematuria (mean 33.1 ±35.3 days; range:3-120 days) upto 2weeks 19 38 2-4 weeks 13 26 > 4 weeks 18 36 total 50 100 271 j i m d c 2 0 1 7 271 help in devising departmental guidelines in order to identify those high risk patients at an earlier stage. our main objective was to determine the causes of hematuria in adult pakistani population. p a t i e n t s a n d m e t h o d s this cross-sectional study was carried out at pakistan institute of medical sciences (pims), islamabad. data was collected over a period of six months (june 2016 to december 2016). study design was approved by the hospital ethical committee and informed consent was obtained from all study participants. data of all the adult male and female patients coming to urology outpatient and emergency department of pims with the complaint of gross hematuria was gathered and analyzed for etiological profile. the patients underwent a comprehensive protocol of investigations. these include complete blood count, esr, complete urine examination. renal function was assessed with serum creatinine, blood urea, and serum electrolytes including potassium, sodium, calcium and phosphate. results of urine cytology, urine culture, imaging studies and cystoscopy was also evaluated. statistical software spss 22 was used for data analysis. r e s u l t s in this study we included 50 patients with gross hematuria, 40 (80%) patients were male and 10 (20%) were female, with a male to female ratio of 4:1. age ranged from 17 years to 78 years with median 41.5 years. in the total sample size of 50, fifteen (30%) patients were less than 30 years while twenty-one (42%) were more than 50 years of age (table 1). in the study most common cause was urological malignancy which was present in 29 (58%) of patients. this includes all the urological cancers. table 2: causes of hematuria in study population causes n(%) urological malignancy 29(58%) urolithiasis 11(22%) uro-trauma 5(10%) bph 3(6%) urinary tract infection 2(4%) table 3: gender based stratification causes male (n=40) n (%) female (n=10) n (%) urological malignancy 26 (89.7) 3 (10.34) urolithiasis 4 (80) 1 (20) uro-trauma 7 (63.6) 4 (36.4) urinary tract infection 0 (0) 2 (100) bph 3 in total, 11 (22%) patients had urolithiasis while 5 (10%) patients had gross hematuria due to trauma to renal tract, 3 (6%) males had hematuria due to enlarged vascular prostate and only 2 (4%) females had gross hematuria due to urinary tract infection (table 2). urological malignancy was significantly associated with history of smoking; it was observed that 62.1% of the participants with urological malignancy were smoker while 37.9% were nonsmoker. gender based stratification showed patients with urological malignancy were mostly males (n=26/29, 89.7%). patients with uro-trauma and urolithiasis were also mostly males and patients with uti were all females (table 3). age based stratification showed that most patients with urological malignancy were >50 years of age (n=17/29, 58.6%) and all patients with bph (benign prostatic hyperplasia) were also >50 years of age, most of the patients with uro-trauma were < 30 years of age (n=4/5, 80%) and all patients with uti were < 30 years of age (table 4). d i s c u s s i o n in our study the most common cause was urological malignancy which was present in 29 (58%) of patients. this included all urological cancers. the urological malignancy remains the most common cause of gross hematuria in adults. patel jv in a similar study reported that the most common differential diagnosis for both microscopic and gross hematuria in adults includes infection, malignancy, and urolithiasis.11 our study results reveal similar information. in another study on patients with asymptomatic microscopic hematuria, yamamoto m, et al reported that of 236 patients over the age of 40, 272 j i m d c 2 0 1 7 272 table 4: age based stratification causes up to 30 years (%) 31-50 years (%) >50 years (%) total (n) urological malignancy 1 (3.4) 11 (37.9) 17(58.6) 29 urolithiasis 8 (72.2) 3 (27.3) 0 11 uro-trauma 4 (80) 0 1 (20) 5 bph 0 0 3 (100) 3 urinary tract infection 2 (100) 0 0 2 6.8% were found to have a genitourinary cancer, while 27.5% had other significant urologic disease. however, 52.1% of the patients had unknown etiology of microscopic hematuria and 13.6% had insignificant urologic lesions. of the 72 patients under the age of 40 a positive diagnosis was made in 16 patients (22.2%).12 the apparent differences in the rates of urological malignancy in their study (6.8%) and present study (58%) may be attributed to different patient inclusion criteria. they analyzed patients with asymptomatic microscopic hematuria while we analyzed patients with gross hematuria. considering high level of malignancy rate in our study, we can safely assume, it may be the result of late presentation of the patients at our facility, where most of the time, the cases are referred from remote areas, when symptoms are aggressive and failure of standard symptomatic treatments at gp clinics. there can be a role of socio-economic situations in the country and current practicing trends can be a major factor, thus we recommend that in future these factors should be considered along with standard parameters so that a clearer and multidimensional picture can be assessed. in another local study conducted in department of urology, mayo hospital, lahore it was concluded that 54% patients with gross hematuria had malignancy.13 a study conducted in srilanka by goonewardena sa et al showed that bladder cancer (urological malignancy) remains the commonest cause of gross hematuria in patients above 40 years of age.14 our results are quite comparable with these national and international studies as we have also concluded that the urological malignancy remains the common cause of the gross hematuria in our setup (58%). in the study of society statistics of hematuria done in 2002-2003, in hospital episode statistic department of health, england 2002-2003, 65% men and 35% women consulted for management of gross hematuria. in hospital episode statistic, department of health england 20022003, hematuria occurred in 15-59 years old group in about 44% of the patients and in the same study 24% of the people were above 75 years of age.15 among total 29 (58%) patients having urological malignancy, 26 (89.7%) were males and only 3 (10.3%) were females. in a study conducted in wine wells hospitals and medical school and university of dundee, scotland, uk it was concluded that 25% of patients presenting with frank hematuria had malignancy and in the same study, it was also concluded that males were more likely than females to have malignancy.16 studies conducted at mc gill university, canada and in usa, showed that primary health care providers are over using routine urine analysis in the absence of clear indications. while at the same time referral ratio for specialist investigation is lower. these studies concluded that cases of hematuria shall be looked carefully and possibility of the serious conditions like urological malignancy should not be ignored.17,18 contrary to above mentioned studies, a large scale study showed that microscopic hematuria among patients of age < 40 can be first assessed by nephrologist due to low risk of malignancy.19 a retrospective study concluded that patient above age 40 and >25 rbc’s/hpf are at greater risk of urological malignancy.19 the cigarette smoking has got a definite relationship with urinary tract malignancies. in our studies, 29 (58%)of the patients and urological malignancy among them 18 (62.1%) patients were smokers. smoking is the most common and important cause of urological malignancy. the study conducted by amlung cl.20 it was proven that cigarette smoking remains the most important cause of bladder cancer. in another study, the cigarette smoking was found as single most important cause of urinary bladder. our study results showed that the second common cause was urolithiasis, which was found in eleven (22%) patients. similar findings were reported by irfan et al13 and goonewardena et al14. our study results show that the third common cause was urological trauma found in 4/5 (80%) of males and 1/5 (20%) of females. the trauma 273 j i m d c 2 0 1 7 273 was common in younger age group. similar findings were reported by tarik k 21 that gross hematuria is present in all patients having renal trauma. shabir m 22 reported that renal trauma was more common in 21-40 years of age and among males (78%), which is similar to our study results. c o n c l u s i o n urological malignancy is the most common cause of gross hematuria, which is associated with male gender, older age and history of smoking. other causes include urolothiasis, trauma, bph and uti. r e f e r e n c e s 1. higashihara e, nishiyama t, horie s.et al. hematuria: definition and screening test methods. int j urol. 2008;15(4):281-4 2. nielsen m, qaseem a. hematuria as a marker of occult urinary tract cancer: advice for high-value care from the american college of physicians. ann intern med. 2016; 164(7):488-97 3. brannigan re. urology. med clin north am. 2018;102(2):17-9 4. tu wh, shortliffe ld. evaluation of asymptomatic, a traumatic hematuria in children and adults. nat rev urol. 2010; 7(4):189-94 5. crompton ch, ward pb, hewitt ik. the use of urinary red cell morphology to determine the source of hematuria in children. clinnephrol. 1993;39(1):44 9 6. lisanti cj, toffoli tj, stringer m. ct evaluation of the upper urinary tract in adults younger than 50 years with asymptomatic microscopic hematuria: is iv contrast enhancement needed? ajr am j roentgenol 2014; 203(3):615 7. kincaid-smith p, fairley k. the investigation of hematuria. semin nephrol. 2005;25(3):127-35 8. cybulsky av, walsh m, knoll g, hladunewich m, bargman j, reich h, et al. canadian society of nephrology commentary on the 2012 kdigo clinical practice guideline for glomerulonephritis: management of glomerulonephritis in adults. am j kidney dis. 2014;63(3):363-77 9. kashtan ce. familial hematuria. pediatrnephrol. 2009;24(10):1951-8 10. nielsen m, qaseem a. high value care task force of the american college of physicians. ann intern med. 2016;164(7):488-97 11. patel jv, chambers cv, gomella lg. hematuria: etiology and evaluation for the primary care physician. can j urol. 2008;15(1):54-61 12. yamamoto m, hibi h, miyake k. etiology of asymptomatic microscopic hematuria in adults. kiyo k. 1993;39(5):413-7 13. ahmed i, sheikh na. evaluation of patients with hematuria in district general hospital. ann king edward med coll. 1999;5(3,4):238-9 14. goonewardena sa, abeygunasekeraam. haematuria as the presenting symptom: experience from a tertiary referral centre in sri lanka. the ceylon medical journal. 1998;43(3):156-8 15. hospital episode statistics, department of health, england, 2002-03. canadian urological association journal. 2014;8:e481-5 16. ali s, byrne d, goodman m. hematuria investigation based on a standard protocol: emphasis on the diagnosis on urological malignancy. jr coll surgery edin. 2002; 47(1):771-2 17. yafi fa, aprikian ag, tanguay s, kassouf w. patients with microscopic and gross hematuria: practice and referral patterns among primary care physicians in a universal health care system. canadian urological association journal. 2011;5(2):97-101 18. nieder am, lotan y, nuss gr, langston jp, vyas s, manoharan m, soloway ms. are patients with hematuria appropriately referred to urology? a multiinstitutional questionnaire based survey. in urologic oncology: seminars and original investigations. 2010;28(5):500-3 19. kotb af, attia d. high-grade microscopic hematuria in adult men can predict urothelial malignancy. canadian urological association journal. 2014;8(78): e481-5 20. amlung cl. diagnosis and management of superficial bladder cancer. curr probl cancer. 2001; 25(4):21928 21. tarik k, fossi j, sadiq a. complications of renal trauma. . ann urol (paris). 2000;34:249-53 22. sabir m, babar am. epidemiology and management of renal injuries. pakistan j surgery. 2002;18(2):1720. 224 j i m d c 2 0 1 7 224 open access f u l l l e n g t h a r t i c l e spectrum of malignant and non-malignant hematological disorders in a tertiary care centre muhammad ihtesham khan 1, nuzhat yasmeen 2, syeda hina fatima 3 1,3 department of pathology, khyber medical college, peshawar 2 oncology department, children hospital, pakistan institute of medical sciences, islamabad a b s t r a c t objective: to analyze the spectrum of malignant and non-malignant hematological disorders in our setup. patients and methods: this cross-sectional study was done in the department of pathology, khyber teaching hospital, peshawar, from 1st january -2016 to 30th december-2016. a total 352 patients underwent bone marrow biopsy during study period. about 15 patients had inadequate aspirate samples that were unfit for opinion. so these were excluded from the study. the remaining of 337 patients were included in the study. all patients of both sexes and all ages were included in the study. bone marrow aspiration and biopsy was done, the slides were stained, examined and diagnosis was recorded. data was analyzed by spss version 16 and results were drawn accordingly. results: among total 337 patients, there were 185 (55%) male and 152 (45%) females. male to female ratio was 1.2:1. the median age of participants was 26 years and range was 9 months -72 years, (mean age was 36±17.8 years). regarding pattern of hematological illnesses, commonest non-malignant disorder was megaloblastic anemia. among malignant hematological illnesses, frequent disorder was acute lymphoblastic leukemia. conclusion: megaloblastic anemia, hemolytic anemia, and aplastic anemia are common non-malignant hematological disorders in our setup. acute lymphoblastic leukemia, acute myeloid leukemia and multiple myeloma are common malignant hematological disorders in our set up. key words: acute leukemia, anemia; bone marrow biopsy, megaloblastic anemia; multiple myeloma. author`s contribution 1, conception, synthesis, planning of research and manuscript writing 2,3 interpretation and discussion data analysis, interpretation, manuscript writing and active participation in data collection address of correspondence muhammad ihtesham khan email: ihteshamkhan9@yahoo.com. article info. received: november 4, 2017 accepted: december 7, 2017 cite this article. khan m.i, yasmeen n, fatima s.h. spectrum of malignant and nonmalignant hematological disorder in a tertiary care centre. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n hematological disorders are quite common in general poplation. 1 these disorders range from simple conditions like iron deficiency anemia to life threatening conditions like carcinomas involving bone marrow.1-6 most of the hematological disorders present with vague symptoms.6 thus, they create a diagnostic problem for the clinicians.1,6 such cases need the bone marrow examination to reach the final diagnosis and help clinician decide further management.1,6 relevant medical history, clinical examination, and review of already performed laboratory investigations is necessary before performing the bone marrow biopsy.1,7 interpretation of bone marrow aspirate findings is carried out in the light of patient's history, examination and laboratory findings; and final diagnosis is made accordingly .2 megaloblastic anemia, leukemia, aplastic anemia, idiopathic thrombocytopenia purpura are commonly seen hematological disorders.1,6 in megaloblastic anemia, there is low hemoglobin level and raised mean cell volume of above 100 fl.1 the most common cause of megaloblastic o r i g i n a l a r t i c l e 225 j i m d c 2 0 1 7 225 anemia is nutritional deficiency of vitamin b-12 and folate.1,8,9 in idiopathic thrombocytopenic purpura, there is an autoimmune destruction of platelets in the spleen.1 the platelet count is low but bone marrow megakaryocytes are increased in such patients.1,3 patients with fever, pallor, and enlarged liver or spleen usually have some underlying malignancies like leukemia.1 leukemia is common hematological malignant disorder in children and bone marrow examination is necessary for making its diagnosis. 6 worldwide, the commonest non-malignant hematological disorders are iron deficiency anemia while commonest malignancies are acute lymphoblastic leukemia in children and acute myeloid leukemia in adults. however, the pattern of hematological disorders is different in the western countries and the developing world.6 so, the data regarding pattern of hematological disorders in the developed countries may not be representative of our population. this study was conducted with the aim to determine the pattern of hematological disorders in our setup. p a t i e n t s a n d m e t h o d s this cross-sectional study was performed at the department of pathology, khyber teaching hospital, peshawar, from 1st january 2016 to 31st december 2016. sample size was calculated by using the sample size formula: z2 x p (1-p) n = ________________ d2 where: z (level of confidence) =1.96; p (prevalence of megaloblastic anemia) = 16.6% 1, d (precision)= 0.05; sample size turned out to be 213. we inducted 337 patients through non probability purposive sampling technique to further strengthen the data. patients of all ages and both sexes, for them bone marrow biopsy was advised by their consultants were included in the study. patients whose bone marrow samples were inadequate and final diagnosis could not be reached were excluded from the study. demographic data of patients was noted. bone marrow aspiration was done. slides were stained and examined under microscope. mean and standard deviation were calculated for quantitative variables e.g. age. frequencies and percentages were calculated for qualitative variables like diagnosis and gender. data was analyzed using spss version 16. r e s u l t s among total of 337 samples, 185 (55%) were males and 151 (45%) were female patients. the median age of participants were 26 years, ranging from 9 months to 72 years (mean age 36 years ±17.8 sd). the bone marrow aspiration/biopsy showed the commonest hematological malignancy was acute lymphoblastic leukemia, that was seen in 31 (9%) patients, followed by acute myeloid leukemia, which was seen in 26 (7.7%) cases. multiple myeloma and mononuclear infiltration was seen in 17 (5%) patients each. chronic lymphocytic leukemia was seen in 10 (2.9%) cases. (table 1) table 1: malignant hematological disorders in study participants (n=109) malignant disorders (n=109) n (%) gender male n(%) female n(%) acute lymphoblastic leukemia 31(9.1) 18(5) 13(4.1) acute myeloid leukemia 26(7.7) 12(3.5) 14(4.2) multiple myeloma 17(5) 15(4.4) 2(0.6) mononuclear infiltration 17(5) 14(4) 3(1) chronic lymphocytic leukemia 10(2.9) 6(1.8) 4(1.1) chronic myeloid leukemia 8(2.4) 5(1.5) 3(0.9) the commonest non-malignant hematological disorder was megaloblastic anemia, seen in 37(10%) cases, followed by hemolytic anemia and aplastic anemia which was seen in 20(5.9%) and 18(5.3%)cases respectively. anemia of chronic disorder was seen in 16(4.7%) cases. idiopathic thrombocytopenic purpura was seen in 12 (3.6%) patients. iron deficiency anemia was seen in 11 (3.3%) patients. mixed deficiency anemia in 9 (2.7%), 226 j i m d c 2 0 1 7 226 myelodysplasia in 6 (1.7%), malaria in 5(1.5%), and niemann pick in 4 (1.2%) patients. gaucher disease and visceral leishmania was seen in 2 (0.6%) patients each. histiocytic lymphohistiocytosis and chediak hegashi syndrome was seen in 1 (0.3%) patients each. (table 2). d i s c u s s i o n the spectrum of hematological disorders is very wide, ranging from anemias to leukemias.10,11 bone marrow aspiration and biopsy are very helpful in diagnosing the hematological disorders.6 it not only helps in giving final diagnosis but also helps the clinicians to decide which further tests should be performed.1 in certain cases, patient cannot be managed further until bone marrow report gives conclusive diagnosis.1,2 interpretation of bone marrow findings is tailored to the patient's clinical history, clinical examination and other laboratory results in order to make final diagnosis. in the present study, the commonest non-malignant hematological disorder was megaloblastic anemia, which was seen in 37 (10.9%) patients. similar findings are presented by shasri sm from india, in which megaloblastic anemia was the commonest anemia found in 59% patients.10 similar findings were reported in local studies done by rahim f and anjum.11,12 megaloblastic anemia was commonest disorder in studies done by gautam r and atla bl13,14 in another local study done by munir and colleagues, megaloblastic anemia was seen in 16.6% of patients.1 in another study done by shiddappa, megaloblastic anemia was present in 27% of the patients.15 these values are high as compared to the present study. in another study done by khan a, megaloblastic anemia was present in 14.6% of the cases.6 this figure is somewhat close to the one in the present study. in addition to poor dietary meat intake, factors like chronic diarrhea, worm infestations, and malnutrition are responsible for causing vitamin b12 deficiency in our setup.6 the diagnosis of excessive peripheral destruction was made in 32 (9.4%) patients. excessive peripheral destruction of hematopoietic cells is often due to enlarged spleen, causing removal of cells from circulation at a much faster rate.16 in a local study done by munir and collegues, excessive peripheral destruction was seen in 3.2% of the patients.1 in a study done in king fahad hospital saudi arabia, 4.4% of the patients were diagnosed as having excessive peripheral destruction.17 normal bone marrow was seen in 31 (9.1%) cases. in a table 2: pattern of non-malignant hematological disorders in study participants (n=228) non-malignant disorders (n=228) n (%) gender male n(%) female n(%) megaloblastic anemia 37(10.9) 21(6.2) 16(4.7) excessive peripheral destruction 32(9.4) 25(7.3) 7(2.1) normocellular marrow 31(9.1) 17(5) 14(4.1) hemolytic anemia 20(5.9) 8(2.4) 12(3.5) aplastic anemia 18(5.3) 8(2.4) 10(3) anemia of chronic disorder 16(4.7) 7(2) 9(2.7) idiopathic thrombocytopenic purpura 12(3.6) 5(1.5) 7(2.1) iron deficiency anemia 11(3.3) 5(1.5) 6(1.8) mixed deficiency anemia 9(2.7) 7(2) 2(0.7) myelodysplastic syndrome 6(1.7) 4(1.2) 2(0.5) polycythemia vera 6(1.7) 4(1.2) 2(0.6) essential thrombocythemia 5(1.5) 2(0.6) 3(0.9) myelofibrosis 5(1.5) 2(0.6) 3(0.9) hypereosinophilic syndrome 5(1.5) 3(0.9) 2(0.6) malaria 5(1.5) 2(0.6) 3(0.9) nieman pick disease 4(1.2) 1(0.3) 3(0.9) gaucher disease 2(0.6) 1(0.3) 1(0.3) visceral leshmeniasis 2(0.6) 2(0.6) chediak hegashi syndrome 1(0.3) 1(0.3) hemophagocytic lymphohistiocytosis 1(0.3) 1(0.3) 227 j i m d c 2 0 1 7 227 study done by addo and collegues in ghana, about 8.75% of the patients had a normal bone marrow.2 in a study done by anjum et al in abottabad, about 8.3% patients had normal bone marrow.11 this is quite close to the figure in the present study. in another study by atla bl, about 16.8% patients had normal marrow.14 hemolytic anemia was seen in 20 (5.9%) cases in the present study). in a study done by munir and collegues in peshawar, about 10.8% patients showed hemolytic anemia.1 this is much higher than that reported in the present study. atla bl found a higher prevalence of about 46% in his study.14 in hemolytic anemia, there is increased red blood cell destruction and bone marrow fails to form new red blood cells at the same rate. 1 in order to know the cause of hemolysis, investigations like g6pd level, osmotic fragility test, and coomb’s test are done.1 aplastic anemia was seen in 18 (5.3%) cases in the present study. atla bl showed the prevalence of 19% in his study which is much higher than the present study.14 aplastic anemia may be congenital or acquired.1,18 failure of the bone marrow causes decreased production of blood cells.18 such patients present with pallor, fever and bruises all over the body.6 viral infections and drugs are common causes of acquired aplastic anemia.19 hepatitis is a common cause of aplastic anemia in our society.19 anemia of chronic disorder was seen in 16 (4.7%) cases in the present study. treating the underlying chronic disease would cure the anemia in such cases.19,20 idiopathic thrombocytopenic purpura (itp) was seen in 12 (3.6%) cases in the present study. it was common in females. in one study done by munir and colleagues, itp was seen in 16.6% of patients.1 this is much higher than that reported in the present study. similar findings were presented by other local and international studies.3,6,21,22 patients with itp present with epistaxis and bruises all over body and a trial of corticosteroids usually improve the condition.23 iron deficiency anemia (ida) was seen in 11 (3.35%) cases. it was common in females (table.1). microcytic hypochromic red blood cells with absent bone marrow iron stores is suggestive of iron deficiency anemia.24,25 in a study conducted in peshawar, about 5.7% patients referred for bone marrow biopsy, had iron deficiency anemia.1 this figure is somewhat close to the present study. in another study done by khan a., about 7.6% patients had iron deficiency anemia6. similar data was presented in a study of ikram n. from islamabad. 26 commonest cause of iron deficiency anemia is worm infestations and nutritional deficiency of iron. 1 myelofibrosis was seen in 5 (1.5%) cases. in a study done by munir and colleagues, myelofibrosis was seen in only 0.6% of the patients1. in a study conducted in ghana, myelofibrosis was present in 2.5% of the patients.2 this figure is somewhat close to that in the present study. visceral leishmaniasis was diagnosed in 2 (0.6%) cases by bone marrow aspirate examination. higher incidence of 6.6% was reported in two local studies.5,6 in a study done in peshawar, only 0.5% patients had visceral leishmaniasis .1 in a similar study done by niazi m at lady reading hospital peshawar, only 0.2% patients had visceral leishmaniasis.27 this is in accordance with the present study. patients suspected of having visceral leishmaniasis present with pallor, fever and visceromegaly.28 bone marrow examination establishes final diagnosis in such cases. 28 in the present study, the commonest malignant hematological disorder was acute lymphoblastic leukemia (all), which was seen in 31 (9.1%) cases. similar findings were reported in a local study done by rahim f in which all was the commonest hematological disorder.12 acute myeloid leukemia (aml) was seen in 26 (6.6%) cases in the present study. thus, it was second commonest leukemic disorder next to all in the present study. similar findings are presented by anjum in his study in which all is the commonest malignancy followed by aml.11 similar results are reported in another studies done in peshawar.1,5,29 in a study done by shastry in india, aml was the commonest leukemia seen in about 3.6% cases.10 all is the commonest malignant disorder of childhood.6 multiple myelomas was seen in 17(5%) cases in the present study. so it was common malignancy next to acute leukemias. similar findings were presented by anjum in a study from abbottabad in which 10% patients had multiple myeloma and was common next to acute leukemias. 11 mononuclear infiltration was seen in 17 (5%) cases. in a study done in peshawar, only 2% patients had metastatic cells in the bone marrow.1 in a study done in india by atla bl, about 4% patients showed infiltration in bone marrow.14 spread of tumor cells to the bone marrow 228 j i m d c 2 0 1 7 228 points to poor prognosis of the disease.30 chronic lymphocytic leukemia (cll) was seen in 10 (2.9%) cases. in a study done in ghana, about 10% patients had cll.2 atla bl has shown incidence of 2.9% in his study which is same as in the present study.14. c o n c l u s i o n megaloblastic anemia was the commonest non-malignant hematological disorders in our setup. acute lymphoblastic leukemia was the most common malignant hematological disorders, followed by acute myeloid leukemia. proper education and awareness of population regarding the causation, prevention and treatment of these diseases may improve health of community and reduce morbidity. r e f e r e n c e s 1. munir ah, qayyum s, gul a, ashraf z. bone marrow aspiration findings in a tertiary care hospital of peshawar . j postgrad med inst 2016; 29(4): 297-300. 2. addo gb, amoako ya, bates i. the role of bone marrow aspirate and trephine samples in haematological diagnoses in patients referred to a teaching hospital in ghana. ghana med j. 2013 ;47(2):74-8. 3. padasaini s, parsad kbr, rauniyar sk, shrestha r, gautam k, pathak r, et al. interpretation of bone marrow aspiration in hematological disorders. j pathol nepal 2012; 2(4): 309-12. 4. syed nn, moiz b, adil sn, khurshid m. diagnostic importance of bone marrow examination in nonhematological disorders. j pak med assoc 2007; 57(3):123-5. 5. stiffer s, babarovic e, valkovic t, seili-bekafigo i, stemberger c, nacinovic a, et al. combined evaluation of bone marrow aspirate and biopsy is superior in the prognosis of multiple myeloma. diagn pathol 2010; 5(1):30. 6. khan a, aqeel m , khan ta, munir a. pattern of hematological diseases in hospitalized paediatric patients based on bone marrow examination. jpmi.2011;22(3):196-200. 7. bain bj. bone marrow aspiration. j clin pathol 2001; 54(9):657-63. 8. jauhar s, balckett a, srireddy p, mckenna p. pernicious anemia presenting as catatonic without signs of anemia or macroytosis. br j psychiatry 2010; 197(3): 244-5. 9. shinwari n, raziq f, khan k, uppal ft, khan h. pancytopenia: experience in a tertiary care hospital of peshawar, pakistan. rawal med j 2012; 37(4):370-3. 10. shastry sm, kolte ss. spectrum of hematological disorders observed in one-hundred and ten consecutive bone marrow aspirations and biopsies. med j dy patil univ 2012; 5(2):118-21. 11. anjum mu, shah sh, khaliq ma. spectrum of hematological disorders on bone marrow aspirate examination. gomal j med sci 2014; 12(4):193-6. 12. rahim f, ahmad i, islam s, hussain m, khattak ta, bano q. spectrum of hematological disorders in children observed in 424 consecutive bone marrow aspirations/biopsies. pak j med sci 2005; 21(4):433-6. 13. gautam r. ikram a, nath d, omhare a. pattern of hematological disorders diagnosed through bone marrow examination. national journal of medical and allied sciences 2016; 5(2):109-111 14. atla bl, anem v, dasari a. prospective study of bone marrow in haematological disorders. int j res med sci 2017;3(8):1917-21. 15. shiddappa g, mantri n, antin ss, dhananjaya. megaloblastic anemia secondary to vit b-12 and folate deficiency presenting as acute febrile illness and p.u.o: a prospective study from tertiary care hospital. sch j app med sci 2014; 2(id):422-5. 16. erwa e. hypersplenism. j biol, agricul health care 2012; 2(10):98-9. 17. bashawri la. bone marrow examination, indication and diagnostic value. saudi med j 2002; 23(2):191-6. 18. biswajit h, pratim pp, kumar st, krishna gb, aditi a. aplastic anemia a common hematological abnormality. n am j med sci 2012; 4(9):384-8. 19. rauff b, idrees m, shah sa, butt s, butt am, ali l, hussain a, ali m. hepatitis associated aplastic anemia: a review. virology journal. 2011; 8(1):87. 20. weiss g, goodnough lt. anemia of chronic disease. n engl j med 2005; 352(10): 1011-23. 21. muhury m, mathai am, rai s, naik r, muktha r, sinha r. megakaryocytes alteration in thrombocytopenia: bone marrow aspiration study. indian j pathol microbiol 2009; 52(4): 490-4. 22. jubelirer sj, harpold r. the role of bone marrow examination in the diagnosis of itp: case series and literature review. clin appl thromb hemost 2002; 8(1):73-6. 23. jan ma. thrombocytopenia in children. j postgrad med inst 2011; 18(3): 353-8. 24. akhtar s, ahmed a, ahmad a, ali z, riaz m, ismail i. iron status of the pakistan -current issues and strategies. asia pac j clin nutr 2013; 22(3): 340-7. 25. okinda na, riyal ms. bone marrow examination at agha khan university hospital nairobi. east afr med j 2010; 87(1):4-8. 229 j i m d c 2 0 1 7 229 26. ikram n. hassan k, bukhari k. spectrum of hematologic lesions amongst children,observed in 963 consecutive bone marrow biopsies. j pak inst med sci 2002; 13(2): 686-90. 27. niazi m, raziq f. the incidence of underlying pathology in pancytopenia an experience of 89 cases. j postgrad med inst 2011; 18(1):76-9. 28. piaroux r, gambarelli f, dumon h, fontes m, dunan s, mary c, et al. direct examination of bone marrow aspiration, myeloculture and serology for diagnosis of visceral lieshmaniasis in immunocompromised patients. j clin microbiol 1994; 32(3):746-9. 29. hamayan m, khan sa, muhammad w. investigation on the prevalence of leukemia in nwfp of pakistan. turk j cancer 2005; 35(3): 119-22. 30. braun s, pantel k. clinical significance of occult metastasis in the bone marrow of breast cancer patients. oncologist 2001; 6(2):125-32. j islamabad med dental coll 2020 149 op e n ac c e s s intestinal malrotation with midgut volvulus leading to small bowel obstruction in a young adult: a case report junaid zia hashmi 1 , talha kareem 1 , masood ur rauf khan 2 1 post graduate resident, nishter hospital multan, pakistan 2 professor, head of department, surgical unit iv, nishter hospital multan, pakistan a b s t r a c t the developing intestine rotates around the superior mesenteric vessels during physiological herniation from 6 th to 10 th weeks of embryogenesis. intestinal malrotation leading to midgut volvulus and small bowel obstruction is a rare condition. patients who develop this condition usually present in the first year of their life. intestinal malrotation is characterized by right sided duodenojejunal junction, caecum in left iliac fossa and a narrow mesentery. ladd’s procedure is the treatment of choice which is done to restore the normal anatomy. we report the case of an 18-yearold male patient, who presented with intestinal malrotation in emergency department of nishtar hospital, multan. it is an uncommon age for presentation of this anomaly. the patient had fecal peritonitis due to caecal perforation. he underwent ladd’s procedure in which ileocolostomy was made after right hemicolectomy. the patient had an uneventful recovery after the surgery and had no complaints on follow up visit one week after the discharge. key words: intestinal malrotation, midgut volvulus, right hemicolectomy, small bowel obstruction correspondence: junaid zia hashmi email: juneehashmi@yahoo.com article info: received: march 23, 2020 accepted: june 12, 2020 cite this case report: hashmi jz, kareemt, khan mr. intestinal malrotation with midgut volvulus leading to small bowel obstruction in a young adult: a case report. j islamabad med dental coll. 2020; 9(2):.149-152. doi: 10.35787/jimdc.v%vi%i.520 funding source: nil conflict of interest: nil i n t r o d u c t i o n obstruction of intestines is either due to a mechanical or a dynamic cause. among adults, hernia and adhesions are the two most common causes. 1 presentation of small bowel obstruction due to intestinal malrotation usually presents during infancy, therefore cases appearing later in life cause difficulties in diagnosis. 2 during normal fetal development midgut rotates around the superior mesenteric artery up to 270 o in anticlockwise direction. following this rotation, the bowels return to the abdominal cavity, with fixation of the duodenojejunal loop to the left of the midline and the cecum in the right lower quadrant. 3 congenital malrotation develops when there is either partial or no rotation of the returning gut. interruption of normal intestinal rotation and fixation can occur at a wide range of locations which leads to different acute and chronic presentations of the disease. 4 the most common presentation is incomplete rotation leading to midgut volvulus in infants and requires immediate surgical intervention. the clinical condition of small bowel obstruction due to congenital malrotation of gut was first described by william e ladd, a pediatric surgeon, who also described the corrective surgical procedure in 1932. 4 this procedure still remains the cornerstone of practice nowadays. according to a study, 90% of patients who present with malrotation are infants. 2 patients who remain c a s e r e p o r t j islamabad med dental coll 2020 150 asymptomatic in initial years, present as a case of intestinal obstruction later in their lives and are frequently misdiagnosed. intestinal malrotation leading to mid gut volvulus in older age group accounts only for 0.2-0.5% of cases. 5-7 here, we report an unusual case of caecal volvulus due to intestinal malrotation leading to caecal perforation in an 18-year-old male patient. c a s e r e p o r t an 18-year-old male, resident of dera ismail khan, khyber pakhtunkhwa, pakistan presented to the emergency department of nishtar hospital multan on 24 th august, 2019. he complained of generalized abdominal pain for the last 7 days, and vomiting, constipation and abdominal distention for 02 days. there was no history of fever, weight loss, or any previous abdominal surgery. there was no history of pulmonary tuberculosis. patient was a nonsmoker and not addicted to anything. systemic history was non-significant. clinical examination revealed a lean young boy of normal built and height. pulse rate was 108/min, blood pressure 100/70 mmhg, respiratory rate 22/min and temperature 101 o f. abdomen was distended, tense, mildly tender, hernial orifices were intact and no lymph nodes were palpable. bowel sounds were absent. digital rectal examination revealed empty rectum with no palpable mass. laboratory workup showed hemoglobin 14.2g/dl and tlc count 13,000/mm 3 . renal and liver function tests were normal. abdominal erect x-ray showed dilated jejunal and ileal gut loops. chest xray was unremarkable. ultrasound abdomen revealed gut loops with absent peristalsis and free fluid in the peritoneal cavity. exploratory laparotomy was done, which revealed intestinal malrotation leading to midgut volvulus, caecal perforation and fecal peritonitis (figure 1). ladd’s procedure was carried out to restore the normal anatomy. prolonged obstruction caused caecal perforation, so right hemicolectomy was done and an ileocolostomy was made. patient was allowed liquid and soft diet on 3 rd post-operative day. the patient had an uneventful recovery after the surgery and had no complaints on follow up visit one week after the discharge. figure 1: picture showing intestinal malrotation. dudenojejunal junction shown on right side (black arrow) and ileocecal junction on left side (red arrow). d i s c u s s i o n during the sixth week of embryological development, the rapid growth of the midgut renders it too large to be accommodated in the abdominal cavity. this leads to physiological herniation of the gut loops into the umbilical cord. subsequently a 270-degree counterclockwise rotation of the gut occurs around the superior mesenteric artery. malrotation of gut is a congenital defect caused by the incomplete or absent rotation of the gut. this leads to abnormal placement of the gut and various forms of clinical presentations. midgut volvulus is more common in the first few days of life with the presenting complaint of bilious vomiting. any irritable child with bilious emesis should be immediately evaluated for volvulus due to malrotation of midgut. the incidence of midgut volvulus due to intestinal malrotation is rare in j islamabad med dental coll 2020 151 adults with the rate approximately being 0.2%0.5%. 3,8 this patient presented to the emergency with the presenting complaints that were suggestive of acute intestinal obstruction. there was generalized abdominal pain for past one week with abdominal distension and absolute constipation for last 2 days. this presentation is quite different to that of an infant, who presents with irritability and bilious vomiting with bloody stools, if left untreated. this can further progress to circulatory shock leading to death of the infant. 9 adults on the other hand can have an acute or a chronic presentation. usually a chronic presentation is more common and results in frequent visits to the hospital with crampy abdominal pain and vomiting not subsiding with conservative measures, thus posing a challenge for the surgeon. 3 acute presentation, though uncommon, may present with intestinal ischemia and gangrene which has disastrous consequences. 10 in adults, the diagnosis requires a high index of suspicion because timely recognition is the key to survival. plain abdominal radiographs have not been helpful and the condition is best diagnosed by upper gastrointestinal series that show the displacement of duodenojejunal flexure to the right. 9 the findings suggestive of malrotation of gut include a corkscrew effect indicating a volvulus or a complete duodenal obstruction. in other cases, the entire bowel presents on the right side. in addition, there is a whirled appearance of the vessels entering the volvulus, hence named as the “whirlpool” sign.6 recent trends are suggesting an increasing use of ct scan with or without upper gi contrast studies with diagnostic accuracy ranging up to 80%. 11,12 once the patient has presented to the hospital and has been diagnosed, surgical intervention is the best option with ladd’s procedure as the treatment of choice. the procedure involves division of any bands between cecum and abdominal wall and between duodenum and terminal ileum. this procedure has the benefit of splaying the superior mesenteric artery and subsequently helping in bringing duodenum in right lower quadrant and cecum in left lower quadrant. procedure is concluded with appendectomy to avoid any confusion in diagnosis later in life. 8 however, this procedure is not done if there is severe ischemia at presentation. the volvulus is reduced without ladd’s procedure and reassessed after 24-36 hours. c o n c l u s i o n small bowel obstruction due to congenital malrotation of gut usually presents during the first year of life. although obstructed hernia and adhesions are the most common causes of bowel obstruction in adults, congenital malformation should be kept in mind as a differential diagnosis. this is important as early surgical intervention can decrease the morbidity and mortality. r e f e r e n c e s 1. rami reddy sr, cappell ms. a systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. curr gastroenterol rep. 2017; 19(6): 28. doi:10.1007/s11894-017-0566-9 2. vukie z. presentation of intestinal malrotation syndromes in older children and adults: report of three cases. croat med j. 1998; 39(4): 455–57. 3. bhatia s, jain s, singh cb, bains l, kaushik r, gowda n s. malrotation of the gut in adults: an often forgotten entity. cureus. 2018; 10(3): e2313. doi: 10.7759/cureus.2313 4. hmadeh h, saliba c, raka m, farhat ha, dabbous a, diab s, et al. an unusual case of intestinal malrotation causing duodenal obstruction by a looped appendix. am j case rep. 2018; 19: 136265. doi: 10.12659/ajcr.913039 5. fung at, konkin de, kanji zs. malrotation with midgut volvulus in an adult: a case report and review of the literature. j surg case rep. 2017; 2017(5): rjx081. doi: 10.1093/jscr/rjx081 6. low sf, ngiu cs, sridharan r, lee yl. midgut malrotation with congenital peritoneal band: a rare j islamabad med dental coll 2020 152 cause of small bowel obstruction in adulthood. bmj case rep. 2014; 2014: bcr2013202690. doi:10.1136/bcr-2013-202690 7. torres a., ziegler m. malrotation of the intestine. world j surg. 1993; 17: 326–331. 8. kache sa, sale d, yusuf n, makama jg. malrotation with midgut volvulus and bowel gangrene in a 45year-old man. arch med surg. 2017; 2: 29-31 9. smink ds. schwartz's principles of surgery. ann surg. 2015; 261(5): 1026. 10. asma h, khalid r, abdelouahed l, benasser f. midgut volvulus: acute abdomen in an adult patient. jucms. 2017; 14: 246-247. doi: 10.17265/1548-6648/2017.06.005 11. narayanasamy sn, manoharan gv, padmanaban n. reverse rotation of gut with small bowel volvulus. int surg j. 2015; 2: 295-9. 12. lai yk, mahmood rd. clinics in diagnostic imaging (168). singapore med j. 2016; 57(5) 274-78. doi:10.11622/smedj.2016093. pmid: 27212130 153 j i m d c 2 0 1 7 153 open access f u l l l e n g t h a r t i c l e role of pre-medicational ondansetron and ketamine to prevent shivering during spinal anaesthesia: a comparative study tabish hussain 1, khan karim afridi 2, asifa anwar mir 3, arshad siddique malik 4, jawad zahir 5, pervaiz minhas 6 1,3 department of anesthesia, critical care and pain medicine, fauji foundation hospital, kallar kahar, pakistan. 2 department of surgery, type d hospital, katlang, mardan 4 department of surgery, fauji foundation hospital, kallar kahar 5,6 department of anesthesia, intensive care and pain medicine, holy family hospital, rawalpindi a b s t r a c t objective: shivering is a common problem during anesthesia. ketamine has been used for preventing shivering during anesthesia. ondansetron (8 mg) has been recently evaluated for its peri-operative anti-shivering effect in patients undergoing spinal anesthesia. the objective of my study is to compare low dose ondansetron with low dose ketamine among patients undergoing spinal anesthesia in elective surgery in terms of frequency of shivering. patients and methods: patients undergoing elective general surgical procedures at department of anesthesiology, holy family hospital, rawalpindi, were inducted in the study. the study design was a randomized control trial and conducted from jan 2016 to june 2016. patients were included through a consecutive non-probability sampling. after spinal anaesthesia, patients were randomly assigned to receive ketamine 0.25 mg/kg (group a) or ondansetron 4mg (group b) by lottery method. during surgery, shivering was recorded at 10 min interval and recorded in terms of frequency. results: out of the total 256 study participants, 128 patients in each group received the study drug (ondansetron/ ketamine) before surgery for prevention of shivering. overall, there were 158 male and 98 female patients. the mean age of study population was 36 ± 11 yrs (range 21–40 yrs). shivering occurred in 11 (4.3%) patients only. there was no significant difference between the gender distributions between the two groups (p=0.16). patients pre-treated with ketamine significantly experienced lesser shivering episodes than ondansetron group (2 (1.6%) vs. 9 (7%), p=0.03). conclusion: the findings of our study suggest that the prophylactic administration of low dose ketamine (0.25 mg kg-1) and ondansetron (4mg) produces anti-shivering effect in patients undergoing spinal anaesthesia. ketamine (0.25 mg/kg) is significantly more effective than ondansetron (4mg) during spinal anaesthesia. key words: ketamine, ondansetron, spinal anesthesia, shivering. author`s contribution 1active participation in active methodology, interpretation and discussion 2synthesis and planning of the research, conception-, review the study, 3,4 review and paper writing address of correspondence tabish hussain email: drtabish@hotmail.com article info. received: may 21, 2017 accepted: august 20, 2017 cite this article: hussain t,rizvi syed sz, afridi kk, mir aa, malik as, zahir j,minhas p. role of pre-medicational ondansetron and ketamine to prevent shivering during spinal anaesthesia: a comparative study.jimdc.2017;6(3):153-156. funding source: nil conflict of interest: nil i n t r o d u c t i o n shivering is very unpleasant, physiologically stressful for the patient after surgery, and some patients feel the accompanying cold sensation to be worse than the surgical pain. though the mechanism of origin of shivering is not clear, various hypotheses have been proposed to explain its occurrence.1 shivering occurs as a thermoregulatory response to hypothermia or muscle activity with tonic or clonic patterns, and various frequencies have been noticed. however, in the postoperative period, muscle activity may be increased even with normothermia, suggesting that mechanisms other than heat loss with subsequent decrease in the core o r i g i n a l a r t i c l e 154 j i m d c 2 0 1 7 154 temperature contribute to the origin of shivering. these may be uninhibited spinal reflexes, sympathetic overactivity, postoperative pain, adrenal suppression, pyrogen release and respiratory alkalosis.2 post anesthesia shivering (pas) occurs in 40% of patients recovering from spinal anesthesia. most of the times, it is preceded by central hypothermia and peripheral vasoconstriction indicating that it is almost always thermoregulatory mechanism, which even today is ill understood. some shivering may not be thermoregulatory, thus making the management of pas complex. the prime objective of this study was to understand physiology of pas, organization of the thermoregulatory mechanism, and various measures for its prevention3. shivering is an involuntary, repetitive activity of skeletal muscles mainly caused by intraoperative heat loss, increased sympathetic tone, pain, and systemic release of pyrogens. the median incidence of shivering related to regional anesthesia observed in a review of 21 studies is 55%.4 shivering increases oxygen consumption, lactic acidosis, carbon dioxide production, and metabolic rate by up to 400%. therefore, shivering may cause problems in patients with low cardiac and pulmonary reserves. the best way to avoid these intraoperative and postoperative shivering-induced increases in hemodynamic and metabolic demands is to prevent shivering in the first place.4 post anesthetic shivering may cause discomfort to patients, and aggravate wound pain by stretching incisions and increase intracranial and intraocular pressure. regional anesthesia produces vasodilatation, which facilitates core-to-peripheral redistribution of heat and the cool periphery is warmed at the expense of the core compartment. thus, hypothermia from epidural anesthesia results from redistribution of heat from the core to the periphery.5 ondansetron, 5-ht3 receptor antagonist, is used antiemetic drug. it causes inhibition of serotonin reuptake on the pre-optic anterior hypothalamic region which might influence both heat production and heat loss pathways. ketamine has sympathomimetic activity thus may contribute towards heat preservation model and thus prevent shivering. spinal anaesthesia is widely used as a safe anaesthetic technique for both elective and emergency operations. shivering is known to be a frequent complication, reported in 40 to 70% of patients undergoing surgery under regional anaesthesia. shivering is a potentially serious complication, resulting in wound infection; increased surgical bleeding; and morbid cardiac events.6 p a t i e n t s a n d m e t h o d s this randomized trial was conducted at holy family hospital, rawalpindi for a period of 6 months from jan 2016 to june 2016. a total of 256 elective general surgical patients, aged 20-40 years, having mild systemic diseases with no functional limitations were included in the study by consecutive non-probability sampling technique. patients with concomitant co-morbid conditions like diabetes mellitus, hypertension, ischemic heart diseases, pulmonary, hepatic or renal diseases diagnosed on history and clinical examination were excluded from the study. similarly, individuals suffering from illnesses in which regional anesthesia were contraindicated like coagulopathies, infection at injection site, hypovolemia and having history of allergic reactions/hypersensitivity for using ondansetron and ketamine were not included in the study. after taking approval from hospital ethical committee, patients were assessed for anaesthesia fitness a day before surgery and no oral intake was advised for at least 8 hrs before surgery. written informed consent was taken. patients were randomly divided into group a and b of 128 individuals each by lottery method. all the patients were given premedication with 0.25mg alprazolam oral tablet at night before surgery. in the operating room, routine standard monitoring protocols were followed in all patients. the temperature of operating room was maintained at 24-26°c with the help of air conditioner temperature setting. before spinal anaesthesia, each patient was preloaded with 10-15 ml/kg of the ringer lactate solution. subarachnoid block was instituted at either l3-l4 interspace with 2 ml of 0.75% hyperbaric bupivacaine in sitting position. axillary temperature was measured with the help of axillary thermometer every 20 minutes till end of the surgical procedure. the intravenous fluid at room temperature (24°c26°c) was infused and all the patients were covered with standard sterile surgical drapes. just after the intrathecal injection, one of the study drugs (ondansetron 4 mg/ ketamine 0.25 mg/kg) was given as iv bolus. shivering 155 j i m d c 2 0 1 7 155 was measured as significant or not at 10 min interval peroperatively and recorded in terms of frequency. data was entered and analysed in spss (17.0). mean ± standard deviation was calculated for quantitative variables like age & bmi. frequency and percentages were calculated for qualitative variables like gender and shivering. chisquare or fishers exact test was used to compare shivering in both groups. p<0.05 was taken as level of significance. r e s u l t s out of the total 256 study participants, 158 were male and 98 were female. mean age of study population was approximately 36 ± 11yrs (range 21-40yrs) (table 1). patients were divided into two groups, 128 in each group. one group was given ondansetron and second group was provided ketamine before surgery for prevention of shivering. there were 58 (36.7%) males in ketamine group in comparison to 100 (63.3%) males in ondansetron group. similarly, the female proportion in the study patients was 28.6% in ondansetron group and 71.4% in ketamine group. the mean age (yrs) was not significantly different between the two groups. patients pre-treated with ketamine significantly experienced lesser shivering episodes than ondansetron group; 2 (18.2%) vs. 9 (81.8%), p=0.03 (table 2). d i s c u s s i o n very few studies are available till date in relation to use of ketamine for prevention of shivering during general or regional anaesthesia probably because of its undesirable side effects like too much sedation, hallucination, nausea and vomiting. 10 in our study, very low dose of ketamine (0.25mg/kg) was used to minimize the side effect and we found that it was significantly effective and the shivering was observed only in 2 patients out of 40 (1.6%). in one study dal et al. compared placebo, meperidine and ketamine 0.5 mg/kg for prevention of shivering after general anesthesia and found ketamine 0.5 mg/kg to be effective.8 although our study was performed on the patients to observe incidence of shivering after prophylactic use of ketamine during spinal anesthesia as compared to patients undergoing general anesthesia in dal et al. study, our study is better because: first, a lower dose of ketamine (0.25 mg/kg) was used as compared to 0.5 mg/kg ketamine. in addition, in comparison to 30 patients who were given ketamine in this study we gave ketamine to 128 study participants. shivering was graded using a scale that was validated by gangopadhyay s et al.9 the prophylactic drug was considered ineffective if the patient shivered to grade 3 and pethidine 0.5mg kg-1iv was given to control the shivering. sagir et al 10 and shakya et al 7 used same protocol in their study. ondansetron, which is a specific 5-ht3 receptor antagonist, influence both heat production and heat loss pathways.11 the recommended dose of ondansetron for prevention of postoperative nausea & vomiting is 4-8 mg in adult patients.12 kelsaka et al13 compared the 8mg ondansetron with pethidine for prevention of shivering and found the same anti-shivering effect and the incidence of shivering was 8% in ondansetron group. in study by shakya et al 7, low dose of ondansetron (4mg) was used and the incidence of shivering was only 10% in the ondansetron group. in our study, shivering occurred in almost same frequency as given in literature i.e. 7% patients pre-medicated with ondansetron in a dose of 4mg. in present study, despite a higher age group in ketamine treated patients, when the effectiveness of ondansetron and ketamine was compared, ketamine was found to be more effective in prevention of shivering. 9 (7%) vs. 2 (1.6%), p=0.03). the side effects of the drugs, which table 1: baseline characteristics of study population total patients (n) 256 patients in each group (n) 128 gender; n (%) males 158(61.72) females 98(38.28) age (years); mean±sd 36 ± 11 (range 21-40) shivering frequency; n (%) 11 (4.3) table 2: comparison of pre-operative ketamine and ondansetron in prevention of post-operative shivering (n=256) variables ketamine (n=128) ondansetron (n=128) pvalue gender; n (%) males 58 (36.7) 100 (63.3) 0.16 females 70 (71.4) 28 (28.6) mean age (years); mean ± sd 30.02 ± 05.54 29.93 ± 05.80 0.9 shivering; n (%) present 2 (18.2) 9 (81.8) 0.004 absent 126 (51.4) 119 (48.6) 156 j i m d c 2 0 1 7 156 although are not part of our study objectives, were also no more in ketamine group as expected from its known pharmacologic properties. c o n c l u s i o n the findings of our study suggest that the prophylactic administration of low dose ketamine (0.25 mg kg-1) and ondansetron (4mg) produces anti-shivering effect in patients undergoing spinal anaesthesia. ketamine (0.25 mg/kg) is significantly more effective than ondansetron (4mg) during spinal anaesthesia. r e f e r e n c e s 1. torossian a. perioperative thermal management in children. anesthesiol intensivmed notfallmed schmerzther. 2013; 48(4):278-80. 2. pazderska a, o'connell m, pender n, gavin c, murray b, o'dowd s. insights into thermoregulation: a clinico-radiological description of shapiro syndrome. j neurol sci. 2013; 329(1):66-8. 3. crowley lj, buggy dj. shivering and neuraxial anesthesia. reg anesth pain med. 2008; 33(3):241–252. 4. lenhardt r. the effect of anesthesia on body temperature control. front biosci (scholar ed). 2010; 2:1145 54. 5. pitoni s, sinclair hl, andrews pj. aspects of thermoregulation physiology. curr opin crit care. 2011; 17(2):115-21. 6. bilotta f, pietropaoli p, la rosa i, spinelli f, rosa g. effects of shivering prevention on haemodynamic and metabolic demands in hypothermic postoperative neurosurgical patients. anaesthesia. 2001; 56(6):519. 7. shakya s, chaturvedi a, sah bp. prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia. j anaesthesiol clin pharmacol. 2010; 26(4):465-9. 8. dal d, kose a, honca m, akinci sb, basgul e, aypar u. efficacy of prophylactic ketamine in preventing postoperative shivering. br j anaesth. 2005;95(2):189–92. 9. gangopadhyay s, gupta k, acharjee s, nayak sk, dawn s, piplai g. ketamine, tramadol and pethidine in prophylaxis of shivering during spinal anaesthesia. j anaesth clin pharmacol.2010; 26(1):59–63. 10. sagir o, gulhas n, toprak h, yucel a, begec z, ersoy o. control of shivering during regional anaesthesia: prophylactic ketamine and granisetron. acta anaesthesiol scand. 2007; 51(1):44–49. 11. ryan kf, price jw, warriner cb, choi pt. persistent hypothermia after intrathecal morphine: case report and literature review. can j anaesth. 2012; 59(4):384-8. 12. elvan eg, oç b, uzun s, karabulut e, coşkun f, aypar u. dexmedetomidine and postoperative shivering in patients undergoing elective abdominal hysterectomy. eur j anaesthesiol. 2008 ; 25(5):357-64. 13. kelsaka e, baris s, karakaya d, sarihasan b. comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. reg anesth pain med. 2006; 31(1):40-5. 295 j i m d c 2 0 1 7 295 open access f u l l l e n g t h a r t i c l e seroprevalence of rubella igg in pregnant females huda rana1, rijja chaudhary2, saeed alam3, wajiha mahjabeen 1,2 student mbbs, 2 professor, department of pathology,3 associate professor, department of pathology islamabad medical and dental college, islamabad a b s t r a c t objective: to find out the seropositivity of igg rubella in pregnant women in pakistan, to assess the prevalence of infection and to estimate the requirement of vaccination. patients and methods: in this retrospective cross sectional study total 730 females who visited salma kafeel fertility clinic (rawalpindi) for antenatal checkup were inducted. their age range was 18-45 years. the study was carried out from 2011-2016. elisa serological testing was used to check the seroprevalence of rubella igg. results: in total the 730 subjects were included in the study and divided in four groups according to their ages. the results were as follows: group 1(18-20yrs) 100% positive, group 2 (21-30yrs) 90.5% positive, group 3 (31-40yrs) 93.5% positive and lastly group 4 (>40yrs) 95%positive. overall 92.32 % seropositivity was seen while 7.70% were found at risk of developing infection. conclusion: there is a high prevalence of rubella in females of child bearing age in pakistan. this is alarming as it can result in high risk of crs in newborns and fetal death. therefore, women planning to become pregnant, who do not have natural immunity to rubella should be vaccinated at least 4 weeks prior to conception. key words: igg, rubella, seropositivity author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence wajiha mahjabeen email: doctor_wajeeha@yahoo.com article info. received: december 13, 2017 accepted: july 10, 2018 cite this article. rana h, chaudary r, alam s, mahjabeen w. seroprevalence of rubella lgg in pregnant women in pakistan. jimdc.2018; 7(4):295-298 funding source: nil conflict of interest: nil i n t r o d u c t i o n rubella (german measles) is an acute, contagious viral infection. it is a generally mild condition in children, but may have serious consequences in pregnant women causing fetal deaths, or congenital defects known as congenital rubella syndrome (crs). the most common birth defects from crs can include deafness, cataracts, heart problems, mental retardation, and cerebral palsy. late onset manifestations of crs include glaucoma, thyroiditis, and diabetes mellitus.1 in 1981-1983, the incidence of crs in america was 0.9-1/1000.2 however, since 2012, only six babies with crs have been reported.3 infection with rubella is most severe when the mother is infected during the first trimester of pregnancy. according to a study conducted in 1987, 72% of the married women, 77% of the pregnant females, and 51.75% of the pre-pubertal females were immune to rubella in pakistan.4,5 rubella infections can be easily prevented if the adult women of child bearing age are vaccinated before they become pregnant. according to the centers for disease control and prevention, before the introduction of the measles vaccine in 1963, 4 babies in every 1000 live o r i g i n a l a r t i c l e 296 j i m d c 2 0 1 7 296 births were born with crs. large scale vaccinations over the past decade have almost eliminated rubella and crs in the developed countries as well as in many developing countries. who region of the america became the first in the world to be declared free of endemic transmission of rubella in 2015.6 in pakistan rubella vaccination is not the part of national expanded program of immunization (epi). data regarding prevalence of rubella antibodies among females of reproductive age is also insufficient. the current study is planned in order to find out seroprevalence of rubella antibodies and to high light the importance of vaccination in this population. p a t i e n t s a n d m e t h o d s the retrospective cross sectional study was carried out at salma & kafeel fertility clinic, islamabad. sample size was calculated by using open epi calculator, and parameters were based on 83.4% seroprevalence found in reproductive age with 99.9% confidence levels.7 calculated sample size was 600 individuals. it was a single center study that’s why we inducted 730 subjects to further strengthen our data statistically through non probability convenient sampling. data of total 730 pregnant females who visited the clinic from year 20112016 for antenatal checkup was analyzed. enzyme linked immunosorbent assay (elisa) was performed to determine the presence of rubella specific immunoglobulin g (igg). data was entered as number and percentage. chi square test was applied to determine the association of rubella infection with age. r e s u l t s total 730 subjects with age range 15-45 years were divided in four groups according to their ages; group 1 (17-20 years), group 2 (21-30 years), group 3 (31-40 years) and group 4 (40 years & above). group 1 showed 100% positivity while in group 2, 3 and 4 there were 90.5%, 93.5% and 95% patients positive for rubella igg, respectively. rubella igg positivity shows that the women already had gained immunity to the infection, either because of previous infection or due to vaccination. the overall seropositivity was 92.3%, indicated the presence of immunity for rubella infection and the remaining 7.70% females were at risk for developing rubella infection. table 1: association of rubella infection with age (n=730) age (years) patients (n) positive igg n(%) negative igg n(%) pvalue 17-20 19 19(100) 0(0) 0.000 21-30 349 316(90.5) 33(9.5) 31-40 319 298(93.4) 21(6.6) above 40 43 41(95) 2(5) d i s c u s s i o n rubella, also known as german measles, is a contagious viral disease. it is a highly infectious disease, spread via air through coughs of infected people. in non-pregnant women, it causes relatively mild symptoms such as coryza, low grade fever, mild redness of the eye, and an associated characteristic exanthematous rash. infections in the pregnant women especially during the first trimester of pregnancy can be transmitted to the fetus, causing congenital rubella syndrome. congenital rubella syndrome is a major cause of several preventable life threatening disabilities. ophthalmic defects, mental retardation, heart anomalies, sensorineural deafness are some common manifestations.8 there is insufficient data about the current immune status of pregnant women against rubella in our country. we carried out a study to assess the seroprevalence of rubella igg in pregnant females. igg serology testing can be done to diagnose immunity to rubella.9 rubella virus infection confers lifelong immunity but it may also be achieved through vaccination. therefore, this study also helps us to estimate the need for rubella vaccination among women in pakistan as the mmr vaccine is not yet a part of the national epi program. although it is ideal that every woman of child bearing age should also be tested for rubella infection and be vaccinated accordingly, at the very least these measures should be carried out in women referring to an infertility clinic. we collected data from 730 women seeking antenatal treatment at salma and kafeel medical center and infertility services in islamabad, pakistan. our results cannot represent the immune status of the entire female population of pakistan, but it serves as a template for similar studies to be carried out in the more rural areas. the seroprevalence of rubella antibodies among our study population was 297 j i m d c 2 0 1 7 297 positive for 92.32% with the remaining 7.6% testing negative and therefore susceptible to rubella. the highest degree of susceptibility was among women of ages 21-30 years with a seronegativity of 4.52%, then susceptibility decreases with age. this means that in the best reproductive age (20-30 years ) considerable number of women if start reproduction without being immunized prior to conception can have a chance of getting crs. a pakistani study carried out in 2006 estimated 3 in 100 infants as confirmed cases of rubella. 10 our results are quite similar to a study conducted at multan, pakistan in females of reproductive age. their study revealed 93.33% seropositivity while 5% females were seronegative and 3% were in intermediate range. 11 our results were also in concordant to a study conducted in 2016 at kerala, india where 94.3% females were igg positive. the mean age of the subjects (n=70) was 24.7±4.3 years and data collection was done by elisa. 12 however, a cross sectional study carried out between 2012-2014 in the district of bijapur, showed only 31.66% being seropositive.13 total 88.2% of the females, in a study population of 339, in egypt were positive for rubella antibodies. immunity was higher in the 25-30 age group as compared to the younger 20-25 age group. 14 in shiraz, a city in southern iran, a study was conducted to find out the seroprevalence of anti rubella and anti measles igg in pregnant women. the results showed that 96% were positive and immune to rubella with mean geometric concentration being 14.9 iu/ml.15 this helps us compare our country’s immune status to other developing countries with an aim to collectively raise the immune status of these countries like that of the developed countries. the reported cases of rubella in pakistan have increased from 282 in 2015 to 648 in 2016. the reported cases in the united states was 5 in 2015 and 0 in 2016. 16 this remarkable contrast is due to the efficient vaccination programs in usa. in children, the first recommended dose is given at 12 months of age and the second at 4 years. women planning to become pregnant should be vaccinated at least 4 weeks prior to conception. 17 since the introduction of rubella vaccine in the canadian vaccination program in 1969, the incidence of rubella has had a considerable decrease with the exception of some outbreaks over the years. in a retrospective observational study conducted in alberta in 2002-2005, 91% subjects tested positive. there was an increase in seronegativity from 8.2% in 2002 to 9.9% in 2005.18 one limitation of this study was convenience sampling from single center in main city islamabad. that’s why results may not fully represent the whole population. in future, further multi center studies with appropriate age and pregnancy duration stratification should be planned to overcome the bias. c o n c l u s i o n the study concludes that 7.70% females of child bearing age are at risk for developing rubella infection in pakistan. this is alarming as it can result in high risk of congenital rubella syndrome in newborns and fetal deaths. it is suggested that women planning to become pregnant and don’t have natural immunity to rubella should be vaccinated at least 4 weeks prior to conception. r e f e r e n c e s 1. robertson se, featherstone da, gacic-dobo m, hersh bs. rubella and congenital rubella syndrome: global update. revista panamericana de salud publica. 2003;14(5):306-15. 2. control cfd. rubella and congenital rubella--united states, 1980-1983. mmwr morbidity and mortality weekly report. 1983;32(39):505. 3. mclean h, redd s, abernathy e, icenogle j, wallace g. congenital rubella syndrome. manual for the surveillance of vaccine-preventable diseases. 2012. 4. ishtiaq a. rubella susceptibility; a study of 200 college students and hospital employees. pharma news. 1987. 5. azmi f, iqbal j, rab a, khan m, amin a. prevalence of anti-rubella antibodies in pregnant and prepubertal females--a preliminary study. jpma the journal of the pakistan medical association. 1987;37(1):6. 6. watson jc, hadler sc, dykewicz ca, reef s, phillips l. measles, mumps, and rubella-vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the advisory committee on immunization practices (acip). vol. 47/no. rr-8. centers for disease control atlanta ga, 1998. 7. ali s, khan fa, mian aa, afzal ms. seroprevalence of cytomegalovirus, herpes simplex virus and rubella virus among pregnant women in kpk province of 298 j i m d c 2 0 1 7 298 pakistan. the journal of infection in developing countries. 2014;8(03):389-90. 8. imam h, yasmin m, ahsan cr, nessa j. pregnant women in and around dhaka city: are their children at risk of developing congenital rubella syndrome? indian journal of microbiology. 2010;50(4):443-8. 9. roush sw, beall b, cassiday p, gentsch j, icenogle j, mayer l, oberste sm, payne dc, rota p, schmid ds, shaw m. laboratory support for the surveillance of vaccine-preventable diseases. vpd surveillance. manual. 1999. 10. hussain n, jaffery g, hasnain s, anwar k. seroprevalence of rubella igg and igm antibodies in infants suspected of having rubella infection. biomedica. 2006;22:25-30. 11. quddusi h, sultana h, sajid km, sabih d, akhtar ms. seroprevalance of rubella antibodies among women of reproductive age: a study at nishtar hospital multan. annals of king edward medical university. 2016;12(4). 12. jayakrishnan t, murkoth a, george b, rao b, vidya k. sero prevalence of rubella immunity in pregnant women in kerala, india. international journal of medicine and public health. 2016;6(4). 13. shilpi g, praveen r, manpreet k. seroprevalence of rubella antibodies in women of reproductive age group. national j lab med. 2015;4:9-12. 14. gadallah m, el sayed n, kandeel a, moussa i, mohsen a, dewedar s. seroprevalence of rubella antibodies among adult egyptian females aged 20-30 years. is there a need for rubella vaccination? central european journal of public health. 2014;22(4): 282. 15. honarvar b, moghadami m, moattari a, emami a, odoomi n, lankarani kb. seroprevalence of antirubella and anti-measles igg antibodies in pregnant women in shiraz, southern iran: outcomes of a nationwide measles-rubella mass vaccination campaign. plos one. 2013;8(1): e55043. 16. who. who vaccine-preventable diseases: monitoring system. 2017 global summary. incidence time series for pakistan (pak) 2017 [updated updated 2017 sept 6]. available from: http://apps.who.int/immunization_monitoring/globalsu mmary/incidences?c=pak. . 17. national center for immunization and respiratory diseases (ncird) dovd. rubella (germam measles, three day measles); 2017. 18. kearns mj, plitt ss, lee be, robinson jl. rubella immunity among pregnant women in a canadian provincial screening program. canadian journal of infectious diseases and medical microbiology. 2009;20(3):73-7. 260 j i m d c 2 0 1 7 260 open access f u l l l e n g t h a r t i c l e comparison of 3% ciprofloxacin-1% dexamethasone and 10% ichthammol glycerin for control of pain due to acute otitis externa sadaf raffat mustafa assistant professor, department of ent, railway hospital, rawalpindi a b s t r a c t objective: to compare the efficacy of 10% icthammol glycerin and 3% ciprofloxacin-1% dexamethasone for controlling pain associated with acute otitis externa. patients and methods: this cross-sectional study conducted at the ent department of railway hospital, rawalpindi from 1st march to 1st december 2017. sixty (n=60) patients of both gender between age 12-60 years, diagnosed with moderate to severe acute otitis externa were enrolled and were randomly divided into two groups using lottery method. group a patients were administered 3% ciprofloxacin-1% dexamethasone wick in auditory canal and group b patients were administered 10% icthammol glycerin wick. the treatment was considered efficacious if there was marked reduction in pain (pain score decreased to ≤ 4 points from baseline on visual analog score on day 3). results: baseline characteristics were similar in both groups. mean vas was 6.67 ± 1.18sd in group a and 6.57 ± 1.16sd in group b (p=0.743) at baseline and was 2.43 ± 1.16sd and 3.50 ± 2.16sd, respectively on day 3 (p=0.028). efficacy was significantly better in group a patients as compared to group b (76.7%, n=23/30 versus 43.3%, n=13/30; p =0.008). conclusion: treatment with 3% ciprofloxacin-1% dexamethasone was found to be significantly better than 10% icthammol glycerin in patients with acute otitis externa in terms of associated pain control. key words: % ciprofloxacin-1% dexamethasone, 10% ichthammol glycerin author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion, data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence sadaf raffat mustafa email: drsadafrafat@yahoo.com article info. received: december 20, 2017 accepted: july 10, 2018 cite this article. mustafa sr. comparison of 3% ciprofloxacin, 1% dexamethasone and 10% ichthammol glycerine for control of pain due to acute otitis externa. jimdc.2018; 7(4):260264 funding source: nil conflict of interest: nil i n t r o d u c t i o n otitis externa is a common ear condition that affects individuals of all ages.1 it occurs in approximately 10% of the population, especially in warm and damp climates or in swimmers (swimmer's ear). other predisposing factors include, local trauma, maceration, external devices, anatomic abnormalities, dermatitides and canal obstruction, which might make the canal epithelium susceptible to infections.2 both external auditory canals are affected in approximately 10% of cases. otitis externa can be secondary to dermatitis (eczema) only, with no microbial infection or can be caused by active bacterial or rarely fungal/viral infection. pseudomonas aeruginosa and staphylococcus aureus are the two most commonly isolated organisms.3 management depends on severity of disease. mild disease is characterized by minor discomfort and pruritus with minimal canal edema and is usually treated with an acidifying agent and a glucocorticoid (acetic acid with hydrocortisone). topical antibiotic are usually not recommended. moderate disease is characterized by an intermediate degree of pain and pruritus with canal may be partially occluded and treatement by a topical preparation combination that is o r i g i n a l a r t i c l e 261 j i m d c 2 0 1 7 261 acidic and contains an antibiotic, an antiseptic, and a glucocorticoid is usually preferred. the antibiotic should have coverage against staphylococcus aureus and pseudomonas aeruginosa. cipro hc (ciprofloxacin and hydrocortisone) and cortisporin (neomycin, polymyxin, and hydrocortisone) are good first-line agents. severe disease is characterized by intense pain, and canal is completely occluded due to edema. fever, peri-auricular erythema, and regional lymphadenopathy may be present. for patients with severe disease, management includes topical therapy, wick placement, and, if there is evidence of deep tissue infection, oral antibiotics are recommended. 4 various studies reported the use of topicalglycerol/ichthammolwick, eomycin/betamethasone wick,5 3% ciprofloxacin 1% dexamethasone6 oral ciprofloxacin 500 mg 7 for the treatment of bacterial otitis externa in terms of relief of pain. there is still no agreement upon the use of prescribed drugs in the treatment of acute otitis externa and no drug is considered as the drug of choice. present study is designed to evaluate two different kinds of treatments in our local population. this will help the ent surgeons in offering the better one in those patients. patients will be benefited in terms of better pain control which is quite disturbing and effects the overall quality of life. the primary aim of present study was to compare efficacy of 10% ichthammol glycerin and 3% ciprofloxacin 1% dexamethasone in treatment of moderate to severe acute otitis externa in terms of pain reduction. p a t i e n t s a n d m e t h o d s it was a randomized controlled trial cross-sectional descriptive study conducted at the ent department of railway hospital, rawalpindi. study was conducted for a period of nine months from 1st march 2017 to 1st december 2017. sample size was calculated by taking level of significance as 5%, power of test as 80%, anticipated population proportion 1 as 76%, anticipated population proportion 2 as 38%.6 patients of both gender between ages 12 to 60 years, who were diagnosed with moderate to severe acute otitis externa were enrolled in the study. otitis externa was diagnosed on history and clinical examination, a characteristic history of excruciatingly severe pain, ≥ 5 on visual analogue scale in the ear, which was exacerbated by tragal pressure and when the auricle was pulled superiorly. on otoscopy, the tympanic membrane was only partially visible due to edema of external auditory canal. ottitis media was excluded by otoscopy, no fluid was seen and tympanic membrane was normally moving on gentle puffing of air. patients with a history of acute/chronic suppurative otitis media, patients suffering from local allergic conditions like eczema and psoriasis, patients with bilateral otitis externa and patients using hearing aids were excluded from the study. severity of pain was recorded twice, baseline pain score on the first day and follow up pain score three days after intervention by using visual analog score 0-10. patients needing aural packing were randomly divided into two groups using lottery method. group-a patients were administered 3% ciprofloxacin-1% dexamethasone and group-b patients were administered 10% icthammol glycerin. all the enrolled patients were inquired about history for pain, discharge, use of hearing aid, diabetes and nay sort of allergy. patients were then examined for tragal tenderness and presence of discharge/debris. after necessary suction clearance topical 3%ciprofloxacin1%dexamethasone wick was placed in auditory canal of group-a patients and icthammol glycerine wick was placed in group-b. same dose of analgesics was given to both groups of patients (mefenamic acid 500mg tds). the baseline pain score was determined using vas. as per the treatment protocol oral antibiotic (co-amoxiclav) was also prescribed to patients in both groups, follow up visits was made on 3rd day after starting the treatment. on first follow up visit (3rd day) after necessary suction clearance new wicks were placed and patients were inquired about the severity of pain which was scored using vas. the treatment was considered efficacious if there was marked reduction in pain (pain score decreased to ≤ 4 points from baseline on visual analog score (vas) on day 3). all the demographic data recorded on the predesigned proforma and statistical analysis of data was performed using statistical software spss-version 22. descriptive statistics were used to calculate mean and standard deviation for quantitative variables like age and pain scores at baseline and at day 3 after treatment. frequencies and percentages were presented for qualitative variable like gender and efficacy. efficacy in both groups was compared using the chi-square test and 262 j i m d c 2 0 1 7 262 p ≤0.05 was considered statistically significant. mean vas at baseline and at day 3 was also compared in both groups by applying student t-test for independent samples p-value ≤0.05 considered as significant. r e s u l t s a total of sixty (n=60, 30 in each group) patients were included in the study. baseline characteristics were similar in both groups. age and gender distribution is presented in table 1. mean baseline vas was also similar in both groups with 6.67 ± 1.18sd in group a and 6.57 ± 1.16sd in group b (p=0.743). after three days of intervention significance difference was noted in vas with group-a showing mean score of 2.43 ± 1.16sd and group-b showing a mean score of 3.50 ± 2.16sd (p=0.028). vas results are tabulated in table 2. efficacy as per our operational definition (pain score decreased to ≤ 4 points from baseline vas on day 3) was significantly better in patients treated with 3% ciprofloxacin-1% dexamethasone (group a). a total of 76.7% (n=23/30) patients in group a reported treatment was efficacious as compared to 43.3% (n=13/30) in group b (p=0.008). efficacy results are tabulated in table 3. table1: age and gender distribution in both groups group gender 3% cipro-1% dexa 10% icthammol glycerin males 21(70%) 20(66.7%) females 9(30%) 10(33.3%) total 30(100%) 30(100%) mean age (years±sd) 42.5±12.1 41.2±12.1 table 2: vas in both groups (baseline and at day 3) vas group mean+sd p-value baseline 3% cipro1%-dexa 6.67+ 1.184 0.743 10% icthammol glycerin 6.57+1.165 day-3 3% cipro1%-dexa 10% icthammolglycerin 2.43+1.43 3.50+2.16 0.028 table 3: efficacy of treatment in both groups efficacy group p-value 3% cipro-1% dexa 10% icthammol glycerin present 23976.7%) 13(43.3%) 0.008 absent 7(23.3%) 17(56.7%) total 30(100.0%) 30(100.0%) d i s c u s s i o n acute otitis externa (infection of external ear) is most often infectious in origin, and can be easily treated with a combination of topical antibiotic and steroid preparations.8 there is no definite agreement upon the use of prescribed drugs.9 cleaning of the meatus by an ent specialist and local application of a broad-spectrum antibiotic or an antiseptic is all what required for treating an uncomplicated infection.10 pain associated with acute ottitis externa is bothersome for patients. different therapies are being used for pain control. present study results showed that pain control was significantly better in patients treated with 3% ciprofloxacin-1% dexamethasone as compared to patients treated with 10% icthammol glycerin (p<0.743). our results are similar with a recent study in local population. abid et al compared the efficacy of topical glycerol/ichthammol wick (group a) with neomycin/betamethasone wick (group b) in treatment of bacterial otitis externa in terms of relief of pain. they demonstrated that pain relief was better in group a (19.8% no pain, 48.1% mild pain) as compared to group b (15.4% no pain, 24.7% mild pain) patients on the third day of treatment (p<0.05).5 in another recent study, jamalullah et al compared the efficacies of 3% ciprofloxacin 1% dexamethasone (group a) and 10% icthammol glycerine (group b) in treatment of otitis externa in terms of pain relief. they reported that on third day in group a, 76% (n=38) patients had marked, 14% (n=7) had moderate and 10% (n= 5) had mild reduction of pain. on the other hand, group b patients reported marked pain reduction in 38% (n=19) moderate reduction in 30% (n= 15) and mild pain in reduction 32% (n=16).6 adhikari et al compared 10% icthammol glycerin wick with steroid antibiotic wick in treatment of otitis externa in 263 j i m d c 2 0 1 7 263 children. they reported that use of steroid antibiotic pack resulted in earlier relief of pain as well as significantly lesser number of visits (p<0.05).10 masood and colleagues studied triadcortyl with icthammol glycerin in treatment of otitis externa. they demonstrated that both treatment modalities were efficacious in the treatment of severe acute otitis externa and there was a statistically significant improvement of pain parameters in the triadcortyl group.11 the lower efficacy of icthymol glycerin is attributed to its lower antimicrobial activity against gram negative organisms. ahmed et al studied antimicrobial activity of icthammol against otitis externa pathogens measured by a growth inhibition test and a modified cidal assay. they reported that inhibition of selected gram positive organisms (streptococcus pyogenes and staphylococcus aureus) by icthammol and glycerineicthammol combination, but only negligible antibacterial activity against pseudomonas aeruginosa and escherichia coli.12 candida albicans was also weakly inhibited. authors suggested that due to minimal activity against gram negative organisms, incorporation of an anti-gram negative antibiotic such as gentamicin in the glycerine-ichthammol compound to enhance its antibacterial spectrum. mösges et al compared the efficacy of treatment using a ciprofloxacin 0.2% solution with other therapeutic options. the research groups consistently observed high in vitro activity of ciprofloxacin against pseudomonas aeruginosa, confirms the hypothesis of superior efficacy of ciprofloxacin in the treatment of otitis externa, in terms of the cure rate and microbial eradication.13 in a comprehensive systematic review of literature, rosenfeld et al compared antimicrobial versus placebo; antiseptic versus antimicrobial; quinolone antibiotic versus nonquinolone antibiotic; steroid-antimicrobial combination versus antimicrobial alone and antimicrobial-steroid combination versus steroid alone for controlling pain due to acute ottitis externa. they found that compared with placebo, antimicrobials (neomycin/methylprednisolone and acetic acid/glyceryl triacetate) were associated with a significant increase in clinical cure rate at 3 to 10 days (rd 0.46, 95% ci: 0.29, 0.63, p<0.001; 2 rcts, n=89) and bacteriological cure rate (rd 0.61, 95% ci: 0.46, 0.76, p<0.001; 2 rcts, n=112). they also highlighted that quinolone antibiotics (ofloxacin, ciprofloxacin with and without dexamethasone or hydrocortisone) were associated with a significant increase in bacteriological cure rate compared with nonquinolone antibiotics (gentamicin, tobramycin, polymyxin/hydrocortisone plus neomycin and oxytetracycline), (rd 0.08, 95% ci: 0.006, 0.16, p=0.035; 6 rcts, n=980).14 in our study we did not evaluate bacteriological cure rate yet clinical cure rate was significantly better with3% ciprofloxacin-1% dexamethasone. kaushik v, et al in another systematic review assessed the effectiveness of different interventions for acute otitis externa. nineteen randomized controlled trials with a total of 3382 participants were included. authors summarized that topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. in most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. patients who are prescribed with antibiotic/ steroid drops can expect their symptoms to last for approximately six days after treatment has begun. patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management should be initiated.15 in summary, based on present study results and on the relevant literature review the evidence is convincing that steroid-antibiotic wick is better in pain control associated with acute ottitis externa when compared to antiseptic wick alone. outcomes of the study serve as an understanding of two different treatment options for the management of pain associated with acute otitis externa in our population. we recommend further randomized controlled trials with larger sample size to extend the validity of results to the general population. c o n c l u s i o n treatment with 3% ciprofloxacin-1% dexamethasone was found to be significantly better than 10% icthammol glycerin in patients with acute otitis externa in terms of associated pain control. outcomes of the study do serve as an understanding of two different treatment options for 264 j i m d c 2 0 1 7 264 the management of pain associated with acute otitis externa. we recommend further randomized controlled trials with larger sample size to extend the validity of results to general population. r e f e r e n c e s 1. jill g. otitis externa. j amer acad of pas. 2018;31(2):47–8. 2. schaefer p, baugh rf. acute otitis externa: an update. am fam hysician. 2012;86(11):1055-61. 3. llor c, mcnulty ca, butler cc. ordering and interpreting ear swabs in otitis externa. bmj. 2014;349: g5259-63. 4. prentice p. american academy of otolaryngology: head and neck surgery foundation clinical practice guideline on acute otitis externa 2014. arch dis child educ pract ed. 2015;100(4):197-205. 5. abid o, khan z, hakim a, alam a. comparison of efficacy of topical glycerol/ icthammol wick with neomycin/betamethasone wick in bacterial otitis externa. j med sci 2012; 20:108-11. 6. jamalullah m, rafique a, ahmed r. comparison of efficacies of 10% ichthammolglycerine and 3% ciprofloxacin 1% dexamethasone by means of sustained release of drug by wick method in treatment of otitis externa. isra medical journal 2011; 3(3):94-96. 7. gurov av, kriukov a, kunelskaya vy, isotova gn, shadrin gb, luchsheva yv, et al. evaluation of the efficacy and tolerability of oral ciprofloxacin used in the comprehensive treatment of external bacterial otitis: an observational prospective study. int arch otorhinolaryngol. 2017;21(4):329-35. 8. wipperman j. otitis externa. prim care. 2014; 41(1):1-9. 9. adhikari p, bhatta r, bhandari s, pyakurel bhatta m.comparison of steroid antibiotic pack and 10% ichthammol glycerine pack in relieving pain of acute otitis externa in children. int j pediatr otorhinolaryngol. 2011;75(4):500-3. 10. rosenfeld rm1, schwartz sr, cannon cr, roland ps, simon gr, kumar ka, et al. clinical practice guideline: acute otitis externa. otolaryngol head neck surg. 2014; 150(1 suppl):s1-24. 11. masood a, moumoulidis i, ray s, chawla o, panesar j. a randomised controlled trial comparing triadcortyl with 10% glycerineichthammol in the initial treatment of severe acute otitis externa. eur arch otorhinolaryngol. 2008;265(8):881-5. 12. lutz jk, lee j. prevalence and antimicrobialresistance of pseudomonas aeruginosa in swimming pools and hot tubs. .int j environ res public health. 2011;8(2):554-64. 13. mösges r, nematian-samani m, eichel a. treatment of acute otitis externa with ciprofloxacin otic 0.2% antibiotic ear solution ther clin risk manag. 2011; 7:325-36. 14. rosenfeld rm, singer m, wasserman jm, stinnett ss. systematic review of topical antimicrobial therapy for acute otitis externa. otolaryngol head neck surg. 2006;134: s24–48. 15. kaushik v, malik t, saeed sr. interventions for acute otitis externa. cochrane database syst rev.2010; 1:cd004740. https://www.ncbi.nlm.nih.gov/pubmed/23198673 https://www.ncbi.nlm.nih.gov/pubmed/20091565 radiological images comminuted left acetabular fracture department of radiology, islamabad medical and dental college acute pancreatitis acute pancreatitis type 1 choledochal cyst: fusiform dilatation of cbd type 1 choledochal cyst: fusiform dilatation of cbd septic cavitating pulmonary emboli: case of i/v drug abuser having infective endocarditis and vegetations on tricuspid valve j islamabad med dental coll 2021 1 ope n acce ss premature ovarian insufficiency: an important yet neglected health condition syeda batool mazhar1,2, zahra muslim3 1professor & head department of obstetrics & gynecology, mch centre, pims, islamabad pakistan 2pro vice chancellor, shaheed zulfiqar ali bhutto medical university, islamabad pakistan 3fcps resident, department of obstetrics & gynecology, mch centre, pims, islamabad pakistan menopause is defined to occur retrospectively at the completion of 12 months after the last reported menstrual period. this is due to ovarian follicular depletion along with estrogen deficiency.1 the average age at menopause is variously reported between 47 52 years in different populations worldwide. almost 10% women report early or premature menopause before 45 years. another 1% have premature ovarian insufficiency (poi) under the age of 40 while about 1 in 1000 women have poi under the age of 30 years.2 the women with poi report vasomotor symptoms like hot flushes and night sweats affecting their quality of life. menopause at an early age has long term adverse cardiovascular outcomes associated with increasing central obesity, atherogenic lipid profile and glucose intolerance.3,4 other health concerns in poi include fertility, contraception, neurological, psychological, psychosexual function and bone health. every year, 18th october is celebrated as world menopause day and the theme for the year 2020 is poi. poi can present either as primary or secondary amenorrhea. the etiology of premature ovarian insufficiency is classified broadly as autoimmune, non immune and iatrogenic. a reliable diagnostic test for autoimmune poi is not available and treatment strategies for autoimmune poi lack expert consensus. nonimmune conditions are often due to genetic mutations involved in the in-utero ovarian development sequence. this may result in delayed puberty, primary amenorrhea, or premature ovarian insufficiency (poi) as seen typically in turner’s syndrome and gonadal dysgenesis. young cancer patients in modern oncology practice have up to 75% long term survival. chemotherapy and or radiation therapy can affect the hpg axis at different levels related to the chemotherapeutic drug type and the field of irradiation. alkylating agents like cyclophosphamide are most gonadotoxic with high incidence of follicular depletion in females due to destruction of oocytes. radiation is particularly harmful for the germ cells of the gonads. brain tumors requiring cns irradiation often results in pituitary hormone deficiencies including gonadotropin deficiency which may occur many years post cns irradiation entailing long term follow up in young cancer survivors. bone marrow transplant for various hematologic disorders and inherited metabolic disorders also results in delayed puberty. counseling the parents for fertility preservation is very important for pediatric patients with cancer. gonadal protection from chemotherapy can be achieved to some extent by ovarian suppression with gnrh agonist injections and or radiation protection by gonadal shielding and surgical transposition of ovaries out of pelvis. oocyte preservation is usually not feasible in majority of e d i tor i a l correspondence: syeda batool mazhar email: batoolmazhar@yahoo.com cite this editorial: mazhar sb, muslim z. premature ovarian insufficiency: an important yet neglected health condition. j islamabad med dental coll. 2021; 10(1): 1-3 doi: 10.35787/jimdc.v10i1.664 j islamabad med dental coll 2021 2 cases due to prohibitive costs and limited availability in pakistan. while taking informed consent for any medical or surgical intervention likely to result in poi, counseling of the patient and her family is very important. in girls with delayed puberty, medical history for anosmia, eating disorders, chronic inflammatory bowel disease, malabsorption syndromes and hemoglobinopathies should be elicited and investigated based on clinical features. any family history of involuntary subfertility and delayed puberty is noted. physical examination for height, weight, bmi, breast development, axillary and pubic hair is essential. to exclude chronic disorders, inexpensive investigation like erythrocyte sedimentation rate, renal function tests and urinalysis can be used for screening. hormone assays include serum lh, fsh, dehydroepiandrosterone sulfate (dheas), estradiol (e2), testosterone, prolactin, tsh and anti-mullerian hormone levels. ultrasonography pelvis and abdomen remains the first line imaging modality. the bone age should be assessed with x ray study of the limb bones while more advanced imaging like brain mri remains limited to specific indications. elevated gonadotropin concentrations suggest primary gonadal failure especially when skeletal maturation is more than 11 years. if gonadotropin concentrations are elevated, chromosomal analysis should be performed in all women with non iatrogenic poi especially for turner’s syndrome and gonadal dysgenesis. gonadectomy is recommended for women with detectable y chromosomal material. genetic testing for autosomes is done if history and examination indicates a specific mutation.6 after excluding pregnancy as the cause of amenorrhea, progesterone withdrawal can be performed to assess effects of endogenous estrogen on uterus as well as patency of the genital outflow tract. implications for siblings or other relatives needs due consideration. currently there is no established predictive test for poi or e stablished prevention measures to offer to female relatives of poi women. serum fsh (>25 miu/ml) and e2 level (< 30 pg/ml) repeated 4 weeks apart are used to diagnose poi in clinical practice. serum amh (<1.0 ng/ml) levels are also suggestive. for puberty induction in girls with primary poi, low dose oral estrogen in gradually increasing doses given over the next three years. cyclical progestogens are added after minimum two years of estrogen. the oral contraceptive pill is not recommended for hormone replacement to induce puberty. a woman's health and wellbeing are affected by her environment and cultural influences, not merely the age at menopause. the management options range from lifestyle interventions to hormonal and nonhormonal treatments with specific benefits and risks. women at risk of poi should be advised to stop smoking, maintain optimal weight with a balanced diet and regular exercise of 120-150 min per week. adequate intake of calcium and vitamin d with supplementation as indicated needs to be ensured. women with poi have about 5% chance of spontaneous pregnancy. no effective fertility interventions to increase natural conception rates are available. anecdotal experience with dhea 25 mg, 8-12 hourly for 6 months is reported in literature with conflicting results. stem cells in the form of prp injections to ovaries as well as in vitro activation of primordial follicle for poi patients are being researched.7 oocyte donation is recommended for fertility in women with poi but is not legal in pakistan. this needs to be revisited by the national legal, medical and religious experts. decisions about hormone replacement therapy for poi are based on separate evidence and recommendations compared to women with age more than 45 years at menopause.6 early initiation of hormone replacement therapy (hrt) is j islamabad med dental coll 2021 3 recommended in women with poi for optimal health outcomes and it should be continued “at least until the average age of natural menopause”. there is no risk of increased breast cancer associated with hrt in the women with poi. annual monitoring of blood pressure and weight is however recommended as a good practice point. increasing awareness of condition of poi with optimal management can go a long way to improve quality of life of this group of women with re duction in long term morbidities and better health outcomes. r e f e r e n c e s 1. davis sr, lambrinoudaki i, lumsden m, mishra gd, pal l, rees m, et al. menopause. nat rev dis primers. 2015; 1: 15004. doi.org/10.1038/nrdp.2015.4. 2. albright f, smith p, fraser r. a syndrome characterized by primary ovarian insufficiency and decreased stature. am j med sci. 1942; 204: 625 -48. 3. anagnostis p, christou k, maria artzouchaltzi a, gkekas nk, kosmidou n, siolos p, et al. early menopause and premature ovarian insufficiency are associated with increased risk of type 2 diabetes: a systematic review and meta-analysis. eur j endocrinol. 2019; 180: 41-50. doi: 10.1530/eje-180602. 4. muka t, oliver-williams c, kunutsor s, laven js, fauser bc, chowdhury r, et al. association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality : a systematic review and meta-analysis. jama cardiol. 2016; 1(7): 767-76. doi: 10.1001/jamacardio.2016.2415. 5. kirshenbaum m, orveito r. premature ovarian insufficiency (poi) and autoimmunity-an update appraisal. j assist reprod genet. 2019; 36(11): 2207 15. doi: 10.1007/s10815-019-01572-0. 6. webber l, davies m, anderson r, bartlett j, braat d, cartwright b, et al. eshre guideline: management of women with premature ovarian insufficiency. hum reprod. 2016; 31(5): 926 -37. doi: 10.1093/humrep/dew027. 7. lee hn, chang em. primordial follicle activation as new treatment for primary ovarian insufficiency. clin exp reprod med. 2019; 46(2): 43 -9. doi: 10.5653/cerm.2019.46.2.43. j islamabad med dental coll 2020 195 open access prevalence of speech sound disorders among primary school children iqra aslam1, nazia mumtaz2, ghulam saqulain3 1 speech language pathologist, paf school for persons with special needs, paf base mushif, sargodha , pakistan 2 head, department of speech language pathology, riphah international university, islamabad, pakistan 3 head, department of otorhinolaryngology & head and neck surgery, capital hospital pgmi, islamabad, pakistan a b s t r a c t background: communication disorders are common and affect individual’s abilities to comprehend, detect and use language and speech, with speech sound disorders (ssd) being the most common communication issue of the youth. ssd is a disorder of development with difficulty in articulation and phonology affecting understanding and intelligibility of speech of a child. it affects the scholarly accomplishment in school as well. the objective of this study was to determine the prevalence of speech sound disorders among primary school going children . material and methods: this was a cross-sectional study, recruiting a sample of 377 children through probability sampling technique from may 2018 to december 2018. students of both genders, aged 4 to 8 years, were enrolled from government primary schools of mandi bahauddin distr ict, punjab pakistan. students from private and special schools were excluded. tool for assessment of articulation and phonology in urdu (taapu) was used to collect data, followed by data analysis using spss version 20 . results: of 377 primary school children, 167(44.3%) were males and 210 (55.7%) were females with a male to female ratio of 1:1.26. speech sound disorder was detected in 5 (1.3%) children, 4 males and only 1 female. of these 5 cases with ssd, 3 (60%) males suffered from substitution and 1(20%) from omission, while 1 (20%) female child suffered from substitution disorder. conclusions: the prevalence of speech sound disorders in primary school children is very low being 1.3%, with significantly higher prevalence in males aged 61 -72 months. “substitution” of sounds is more common compared to “omission”. key words: articulation disorder, communication disorder, prevalence, primary school children, speech sound disorder authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: february 4, 2019 accepted: september 15, 2020 cite this article. aslam i, mumtaz n, saqulain g. prevalence of speech sound disorders among primary school children. j islamabad med dental coll. 2020; 9(3): 195-200. doi: 10.35787/jimdc.v9i3.283 funding source: nil conflict of interest: nil i n t r o d u c t i o n communication disorders (cd) are deep rooted issues. they influence social and emotional wellbeing, cognition and conduct and are also related to poor school performance, psychosocial, language or i gi n a l a r ti c le j islamabad med dental coll 2020 196 and literacy problems.1 speech sound disorder (ssd), voice disorders and fluency disorders (stuttering) are the three cd’s traditionally referred to as speech disorder, with ssd being the most prevalent compared to other cds.2 ssd is a disorder of development with difficulty in articulation and phonology which also affects understanding and intelligibility of child’s speech, though there is no associated structural, motor, cognitive and affective deficits with the child.3 according to tkach et al. ssd results from deficiency of phonological memory,4 and is a risk factor for language and a problem for literacy in later life.5 most children in the process of child development commit errors as they figure out how to say new words,2 with ssd occurring when this continues past a particular age i.e. the inability or difficulty of the child to use speech sounds which are appropriate according to age for an individual dialect.6 ssds include four broad categories including, “omission”, in which sounds/ syllables are missed out by the child; “additions” or “commissions”, in which child adds an extra syllable or sound; “distortions”, in which though the child pronounces the word properly, however one of the sound is not correct and; “substitution”, in w hich child substitutes a sound for another sound. controversies on the classification of ssd in children still exist with proposed systems based on approaches including etiological, descriptive linguistic and processing.7 communication disorders like ssd have immediate and delayed consequences for the child, which may include poor scholastic accomplishment in school years and other social and psychological consequences with an effect on professional decisions later in adulthood.8 no recommendation exists for formal screening to detect speech and language disorder in children through 5 years of age. according to sui, there is no sufficient evidence for benefit of screening in 5 years and younger children for speech language delay.9 however, arshad et al. concluded in a local study at mayo hospital lahore, that family history as well as socioeconomic status were risk factors for speech and language disorders and recommended further research.10 similarly wallace et al. in their review noted deficiencies in the research base and highlighted the varieties of studies needed. 11 therefore, the current study was conducted to determine the prevalence of speech sound disorder among primary school children. this study is important since there is dearth of literature available from this part of the world on this important issue. this information might also be important for rehabilitation by early identification and timely intervention. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted to determine the prevalence of speech sound disorders (ssd) in students attending primary schools of mandi bahauddin using probability sampling technique over a period of eight months from may 2018 to dec 2018. this study was approved by the advance studies and research committee (asrc), isra institute of rehabilitation sciences (iirs), isra university islamabad. after calculating sample size using raosoft software, the study enrolled 377 students of both genders, aged 4 to 8 years, studying in nine government primary schools of mandi bahauddin district, punjab pakistan. informed consent was obtained from parents of children prior to inclusion in the study. approval was also sought from the institutional heads/administrations of all the nine primary schools included in this study. cases from private and special schools and those with any other disability were excluded. basic demographic sheet was used to collect data like age, gender, birth order, family system, number of siblings, class, and institution, while for the assessment of articulation and phonological disorders (apd) in regional language urdu, tool for assessment of articulation and phonology in urdu (taapu) 12,13 was used. taapu is a locally developed j islamabad med dental coll 2020 197 tool and contains 60 colorful pictures for assessment. it uses a response sheet to record the response of children on a phonological sheet, listing the sounds in urdu along with their phonetic transcription in english like /k/ /g/ /t/ /d/ /f/ /v/ etc. errors in speech sounds generation is known as articulation error while phonological disorder is a patterned modification of speech system. for instance, fronting is process in which back sounds like /k/ and /g/ normally produced by tongue moving up in the back, get replaced with front sounds /t/ and /d/ produced by the tongue coming up in the front. other features of ssd’s include omission and deletions, where child omit or delete certain sounds like “cu” for “cup”, substitution in which sounds are substituted like “thing” for “sing” and additions, where sounds are added like “buhlack” for “black”. after approval from institutional heads and consent of parents, children were evaluated for ssd using taapu, by a senior speech therapist and responses recorded on the response sheet. data was evaluated using spss version 21. gender was presented in frequency and percentage, while age and taapu score was presented in mean and standard deviation. r e s u l t s of 377 primary school children, 167(44.3%) were males and 210 (55.7%) were females with a male to female ratio of 1:1.26. a low prevalence of ssd was noted in our study (n=5; 1.3%) (figure 1). of these 5 cases with ssd 4 (80%) were males with 3 (60%) suffering from substitution and 1(20%) from omission, while 1 (20%) was a female child suffering from substitution (table1). the mean age of sample population was 72.50±23.50 months, mean birth order (mean of birth order of the affected child) was 1.12±0.58 and siblings (mean of number of siblings) were 1.41±0.58. figure i: prevalence of speech sound disorders (ssd) (n=377) statistical analysis revealed statistically significant difference between age groups and ssd and between gender and ssd with p-value of 0.025. the most common type of ssd in primary school children noted in the study was substitution (80%), followed by omission (20%) (figure 2). figure 2: frequency of different speech sound disorders (ssd) (n= 5) table ii shows the speech sound errors and their levels with one case substituting /k/ sound with /g/ at initial level, the other substituted /t/ with /d/ at mid-level and third substituted /f/ with /v/ at initial level. one case omitted /t/ at all levels and the other omitted /g/ sound at mid-level. j islamabad med dental coll 2020 198 table i: relationship of demographic characteristics with speech sound disorders (n=377) demographic variables speech sound disorders (ssd) (n=5) variable sample (n=377) n (%) sub n (%) omi n (%) del n (%) add n (%) total n (%) *p-value gender male: 167 (44.3) female: 210 (55.7) 3 (60) 1 (20) 1 (20) 0 0 0 0 0 4 (80) 1 (20) 0.025 age 49m60m: 150 (39.8) 61m72m: 74 (19.6) 73m84m: 93 (24.7) 84m96m 60 (15.9) 0 2 (40) 1 (20) 0 1 (20) 1 (20) 0 0 0 0 0 0 0 0 0 0 1 (20) 3 (60) 1 (20) 0 0.025 birth order 1-4: 238 (63.1) 5-8: 120 (31.8) 9-12: 19 (05.0) 2 (40) 1 (20) 1 (20) 1 (20) 0 0 0 0 0 0 0 0 3 (60) 1 (20) 1 (20) siblings 14: 238 (63.1) 58: 120 (31.8) 912: 19 (5.0) 2 (40) 1 (20) 1 (20) 1 (20) 0 0 0 0 0 0 0 0 3 (60) 1 (20) 1 (20) family system nuclear: 197 (52.3) joint: 180 (47.7) 1 (20) 3 (60) 1 (20) 0 0 0 0 0 2 (40) 3 (60) sub-substitution; omi-omission; del-deletion; add-addition *p-value <0.05 was considered statistically significant table ii: case wise distribution of type of ssd, sound error and level distribution (n=5) case ssd type sound level original substituted 1 substitution /k/ /g/ initial 2 substitution /t/ /d/ middle 3 substitution /f/ /v/ initial 4 omission /t/ all levels 5 omission /g/ middle d i s c u s s i o n the current study revealed the prevalence of ssd in public school children of mandi bahauddin district of punjab, pakistan. out of a sample population of 377 students, aged 4-8 years, the prevalence of ssd was 1.3% (n=5). different studies in the past have come up with widely variable prevalence rates.14 this might be due to variations in studies with regards to data collection tools; age groups; clinical versus non clinical setting; whether study was based on teacher, parent or speech language pathologist’s report; cohort versus other studies and possible etiological factors. in majority, the possible etiology of ssd cannot be determined. also the role of family history and recurrent otitis media with effusion in the early years of life as risk factors, has not been validated.15 law et al., in a systematic review comprising of most studies from the west, noted a wide range of prevalence of ssd in 5 to 7 year old children ranging from 2 to 25%.14 wren et al. in a cohort study in 8 year old children reported a low prevalence of 3.5%,16 while another cohort study also reported a lower range of 3.4%.6 eadie et al., in a large australian community cohort study reported an ssd prevalence of 3.4% in 4 year old children.17 in contrast, a high prevalence rate of 17.6% was noted in a local school-based study on children aged 8 to j islamabad med dental coll 2020 199 12 years evaluated using articulation cards and checklists.18 similarly, two iranian studies revealed a high prevalence of 14.8% 19 and 9.5%.20 while in another iranian study, abbastabar et al., report a prevalence of 2 per 1000 people .21 in a school based study, ceron et al., reported a prevalence of 15.26% phonological disorders.22 gender wise, in the current study the prevalence rate was high in males (4; 80%) as compared to females (1; 20%), with a male to female ratio of 4:1. similarly a higher prevalence in males was noted in other studies as well.16, 21 also a prevalence of 16.7% in males as compared to 12.7% in females was reported in an iranian study.19 genetic influence,23 gender, family history, mother’s vocabulary, and socio-economic condition can predict development of ssd.17 also, it is more common in rural residents compared to urban. 21 in the current study, substitution was the commonest ssd with a frequency of 4(80%), followed by omission in 1 (20%). similarly, in another local study by azmat et al. substitution was most prevalent (92%) followed by omission in 6.25% and distortion in 1.7%.18 similarly, in a study conducted in clinical setups of rawalpindi islamabad region, by noveen et al. substitution was the commonest variety noted 12 while 33% substitution, 60% distortion, 3% omission were reported in another local study.13 though the prevalence of ssd is grossly variable, there is no recommendation of universal screening for primary speech language delay.24 there were several limitations of this study. the sample size was small, study was done in a government school setting with only 4 to 8 years old students included in the study. all these factors made generalization of our findings to other children of this age group and those studying in private schools, difficult. lack of resources also limited the scope of this study as the research was self-funded. c o n c l u s i o n the prevalence of speech sound disorders in primary school children is very low being 1.3%, with significantly higher prevalence in males, 5-6 years of age. “substitution” of sounds is more common compared to “omission” in the affected children. r e f e r e n c e s 1. lewis ba, freebairn l, tag j, ciesla aa, iyengar sk, stein cm, et al. adolescent outcomes of children with early speech sound disorders with and without language impairment. am j speech lang pathol. 2015; 24(2): 150-63. doi: 10.1044/2014_ajslp-140075. 2. mckinnon dh, mcleod s, reilly s. the pr evalence of stuttering, voice, and speech-sound disorders in primary school students in australia. lang speech hear serv sch. 2007; 38(1): 5-15. 3. shriberg ld. diagnostic markers for child speechsound disorders: introductory comments. clin. linguist. phon. 2003; 17: 501–05. doi: 10.1080/ 0269920031000138150 4. tkach ja, chen x, freebairn la, schmithorst vj, holland s k, lewis b a. neural correlates of phonological processing in speech sound disorder: a functional magnetic resonance imaging study. brain lang. 2011; 119: 42–49. doi: 10.1016/j.bandl.2011 .02.002 5. lewis ba, freebairn l, tag j, ciesla aa, iyengar sk, stein cm, et al. adolescent outcomes of children with early speech sound disorders with and without language impairment. am j speech lang pathol. 2015; 24(2): 150-63. 6. american psychiatric association. diagnostic and statistical manual of mental disorders (dsm-5®). 5th ed. arlington, va: american psychiatric association; 2013. pp. 44-47. 7. waring r, knight r. how should children with speech sound disorders be classified? a review and critical evaluation of current classification systems. int j lang commun disord. 2013; 48(1): 25–40. j islamabad med dental coll 2020 200 8. johnson c, beitchman j, brownlie e. twenty-year follow-up of children with and without speech language impairments: family, educational , occupational, and quality of life outcomes. am j speech lang pathol. 2010; 19(1): 51–65. 9. siu al. screening for speech and language delay and disorders in children aged 5 years or younger: us preventive services task force recommendatio n statement. pediatrics. 2015; 136(2): e474-81. 10. arshad h, ghayas ms, madiha, ghayas r, ul ain q, shabbir m. patterns and risk factors associated with speech sounds and language disorders in pakistan . ann king edw med univ. 2013; 19(3): 226 -30. 11. wallace if, berkman nd, watson lr, coyne -beasley t, wood ct, cullen k, et al. screening for speech and language delay in children 5 years old and younger: a systematic review. pediatrics. 2015; 136(2): e448e462. doi:10.1542/peds.2014-3889 12. noveen s, butt ak, alam mb. development of a test for articulation and phonological disorders in urdu speaking children. jrcrs. 2017; 5(2): 89-93. 13. noveen s, ullah sh, alam b. correlation between articulation disorders and oral motor mechanism. ann king edw med univ. 2018; 24(1): 653-58. 14. law j, boyle j, harris f, harkness a, nye c. prevalence and natural history of primary speech and language delay: findings from a systematic review of the literature. int j lang commun disord. 2000; 35(2): 165-88. 15. wertzner hf, francisco dt, pagan-neves lo. causal factors and application of complementary tests in speech sound disorders. rsbf. 2012; 17(3): 299 -303. 16. wren y, miller ll, peters tj, emond a, roulstone s. prevalence and predictors of persistent speech sound disorder at eight years old: findings from a population cohort study. j speech lang hear res. 2016; 59(4): 647-73. 17. eadie p, morgan a, ukoumunne oc, ttofari eecen k, wake m, reilly s. speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children. dev med child neurol. 2015; 57(6): 578-84. doi: 10.1111/dmcn.12635 18. azmat r, khan ms, manzoor t, ibrahim m, tahira s, pervaiz s. prevalence of articulation disorder in school going children between ages of 8 to 12 years. int. j rehabil. sci.2014; 3: 32-36. 19. karbasi sa, fallah r, golestan m. the prevalence of speech disorder in primary school students in yazd iran. acta medica iranica. 2011; 49(1): 33-7. 20. hatami g, heidaritash h, firouzbakht s, motamed n. [the frequency of speech disorders and its relationship with nutritive and non-nutritiv e sucking behaviors in 3-5 years old children in bushehr, city, iran (persian)]. arch rehabil. 2018; 19(3): 238-49. doi: 10.32598/rj.19.3.238 21. abbastabar h, alizadeh a, darparesh m, mohseni s, roozbeh n. spatial distribution and the prevalence of speech disorders in the provinces of iran. j med life. 2015; 8(spec iss 2): 99-104. 22. ceron mi, gubiani mb, de oliveira cr, gubiani mb , soares mk. prevalence of phonological disorders and phonological processes in typical and atypical phonological development. codas 2017; 29(3): e20150306 doi: 10.1590/2317-1782/20172015306 23. stein cm, millard c, kluge a, miscimarra le, cartier kc, freebairn la, et al. speech sound disorder influenced by a locus in 15q14 region. behav genet. 2006; 36(6): 858-68. 24. law j, boyle j, harris f, harkness a, nye c. the feasibility of universal screening for primary speech and language delay: findings from a systemati c review of the literature. dev med child neurol. 2000; 42(3): 190-200. j islamabad med dental coll 2019 151 open access comparison of efficacy of laryngeal mask airway and intersurgicalgel supraglottic airway device during general anesthesia in a tertiary care hospital muhammad saqib butt1, noor un nisa2, ghulam mustafa1, hasham khan3 1 senior registrar, department of anesthesia, dr. akbar niazi teaching hospital, islamabad 2 senior registrar, department of anesthesia, shaikh zayed hospital, lahore 3 senior registrar, department of urology, dr. akbar niazi teaching hospital, islamabad a b s t r a c t background: upper airways collapse during anesthesia is a common issue faced by anesthetists. air way maintenance is an essential component of general anesthesia. laryngeal mask airway and intersurgical-gel (i-gel) air way devices are new advances in general anesthesia. present study aims to compare the ease of insertion and hemodynamic response of i-gel supraglottic and laryngeal mask airway (lma). material and methods: a randomized clinical trial was conducted at the department of anesthesia, shaikh zayed hospital, lahore. study duration was 6 months (june 2014december 2014). a total of 60 patients were selected through non-probability consecutive sampling. ethical approval was taken from ethical review board of sheikh zayed hospital and informed written consents were taken from all the participants. patients were randomly divided into two groups using lottery method. group a was given laryngeal mask airway device while group b patients were provided with i-gel supraglottic device during anesthesia. patients were compared for ease of insertion and hemodynamic parameters. data was analyzed using spss version 24. chi-square and t-test were applied and p-value ≤0.05 was considered statistically significant. results: a total of 60 patients were included in study. mean age of patients was 35.2±11.7 years in lma group and 36.7±13 years in i-gel group. group b had lower number of insertion attempts (p=0.01) and high insertion satisfaction (p=0.4) as compared to group a. however, process failure and bleeding rate was found to be slightly higher in group b (16% and 13% respectively) as compared to group a (p>0.05). conclusion: i-gel supraglottic device is a successful alternative option in terms of ease of insertion and less hemodynamic response as compared to laryngeal mask airway during general anesthesia. key words: general anesthesia, laryngeal mask airway, i-gel supraglottic device authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3, active participations in data collection and data analysis. correspondence: muhammad saqib butt email: drsaqibbutt@hotmail.com article info: received: april 16, 2019 accepted: august 23, 2019 cite this article. butt ms, noor un nisa, mustafa g, khan h. comparison of efficacy of laryngeal mask airway and intersurgical-gel supraglottic airway device during general anesthesia in a tertiary care hospital. j islamabad med dental coll.2019; 8(3):151-155. doi: 10.35787/jimdc.v8i3.331 funding source: nil conflict of interest: nil i n t r o d u c t i o n upper airways collapse during anesthesia is a common issue faced by anesthetists, worldwide.1 proportions of deaths associated with airways complication during anesthesia are increasing significantly from 1990.2 royal college of anesthetists and difficult airway society reported that airway related deaths are 7/1,000,000 in united kingdom (uk).3 mortality rate due to air ways collapse during anesthesia is 2.6% in togo.4 prevalence of anesthesia related complications in pakistan is 5.5% with more than 30% attributed to respiratory o r i g i n a l a r t i c l e j islamabad med dental coll 2019 61 complications.5 upper airway obstruction hallmark includes diminished or absent airflow (presence of continued respiratory effort). air way obstruction could be complete or partial. literature reports that patients with supralaryangeal obstruction had snoring as most common sign while patients with perilaryngeal obstruction had inspiratory stridor as a common sign.6 prevention and management of upper airway obstruction include anatomical positioning and posture, continuous positive airway pressure (cpap), heliox, tracheal tubes and airways aids.7 i-gel supraglottic airway is anatomically designed as a mask (composed of gel like thermoelastic elastomers). this single used device is featured for separation of respiratory and gastrointestinal tract. the device allows gastric tubes to pass in stomach. stability of device during insertion is associated with tensile properties of i-gel bowel. i-gel becomes narrow and longer upon sliding under pharyngo-epiglottis folds. proximal bowl ridge catches tongue base and helps to prevent device from moving upward out of position.8 a laryngeal mask airway (lma) is another supraglottic airway device initially developed by dr. archi brain (british anesthesiologist).9 lma is shaped like an endotracheal tube at the proximal end and this tube connects to an elliptical mask at the distal end. lma attributes to less gastric distention and reduce risk of aspiration.10 revi et al reported that i-gel is a successful alternative to lma in terms of shorter duration of insertion and less hemodynamic response during general anesthesia.11 radhika et al reported that lma and i-gel did not cause any significant change in hemodynamic status of patients. however, i-gel insertion is easier and rapid as compared to lma.12 limited data is available on efficacy of i-gel and lma efficacy in pakistan. the objective of the present study was to compare the ease of insertion and hemodynamic response of i-gel supraglottic device and laryngeal mask airway (lma). m a t e r i a l a n d m e t h o d s a randomized clinical trial was conducted at department of anesthesia shaikh zayed hospital, lahore. study duration was 6 months from november 2015 to april 2016. sample size was calculated with 80% power of study, confidence interval 95%, μ1=27.1 ± 16.7, μ2= 14.93 ± 4.6, standard deviation 16.7 using sample size calculation formula for clinical trials.13,14 calculated sample size was 30 patients in each group. recruitment of patients was done through non probability consecutive sampling. patients with age 18-70 years, both genders, weighing 30-100 kg, american society of anesthesiologists (asa) i and ii, mallampati grades (i and ii), patients undergoing elective surgery (under general anesthesia ≤30 minutes), fasting patients (>6 hours’ solids and > 2 hours’ liquids other than milk) and patients with non-symptomatic regurgitation were included in the study. exclusion criteria included obesity, pregnancy, history of cardiovascular and renal diseases, gastroesophageal reflux diseases, chain smokers (>40 cigarettes/day), drug abusers, trauma (thoracic, abdominal, orofacial, head and neck) and anticipated difficult intubation. ethical approval was taken from ethical review board. consent forms were taken from all the participants. patients were randomly divided into two groups using lottery method. in group a, laryngeal mask airway and in group b,i-gel was used for intraoperative maintenance of airway. the patients were pre-medicated with midazolam 2.5mg intravenous (i/v) 15 minutes before shifting to operation theatre. patients were preoxygenated for three minutes with 100% oxygen. propofol 1% 2mg/kg i/v were given at induction. igel and lma was lubricated with distilled water. after 1 minute of ventilation with oxygen and sevoflurane using a face mask, lma or an i-gel was placed in peri laryngeal area. anesthesia was maintained with o2, sevoflurane and with intermittent positive pressure ventilation (ippv). injection tramadol 1.5mg/kg was given for analgesia. group a and b were assessed for ease of insertion and hemodynamic status of lma and i-gel. ease of insertion was measured in terms of mean insertion time, insertion attempts, bleeding and failure status. hemodynamic response was measured through physical assessment with asa grading, airways assessment through mallampatti class (mpc) grading, mean heart rate, mean systolic and diastolic blood pressure and mean arterial pressure. data was analyzed using spss version 24. descriptive statistics, mean ± standard deviation and frequency and j islamabad med dental coll 2019 62 percentages were calculated. independent t test and chisquare test were applied for comparison. p-value ≤0.05 was considered statistically significant. r e s u l t s a total of 60 patients were included in the study (1:1 randomization, 30 patients in each group). mean age of patients in group a was 35.2 ±11.7 years and mean age of patients in group b was 36.7±13 years. there were 15 (50%) males and 15 (50%) females in group a. there were 10 (33%) males and 30 (67%) females in group b. asa grading and mpc grading were different in group a and group b. number of 2 insertion attempts were significantly lower in group b as compared to lma patients (10% versus 23%, p=0.01) (table i). insertion satisfaction was higher in group b (93%, p=0.424). moreover, failure and bleeding rate were slightly high (16% and 13%)in group b, however no statistical significance was found (p>0.05) (figure 1). figure 1: comparison of failure rate, bleeding episodes and insertion satisfaction rate between two groups (n=60). table i: comparison of asa, mpc grading and number of attempts in lma and igel group (n=60) asa grading group a n=30 n(%) group b n=30 n(%) total n(%) pvalue asa grade i 10(33) 20(67) 30(50) 0.01 asa grade ii 20(67) 10(33) 30(50) mpc grading grade i 12(40) 18(60) 30(50) 1.00 grade ii 18(60) 12(40) 30(50) number of attempts one attempt 23(77) 27(90) 50(83) 0.01 two attempts 7(23) 3(10) 10(17) total 30(50) 30(50) 60(100) insertion time was significantly low in group b (p=0.02). no statistical difference was found in hemodynamic parameters including heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure between groups a and b (table ii). variables group a (n=30) lma group b (n=30) i-gel t value p value mean±sd mean±sd ease of insertion insertion time; (seconds) 10.67±1.6 9.5±0.7 2.18 0.02 hemodynamic response heart rate; beats/min 80.9±14.9 78.17±11.2 1.23 0.72 systolic blood pressure (mmhg) 114.4±16.9 111.40±18.4 2.15 0.83 diastolic blood pressure (mmhg) 65.4±12 63±11.6 1.98 0.88 mean arterial pressure (mmhg) 83.5±11 81.10±9 2.16 0.83 d i s c u s s i o n adequate ventilation availability is a major responsibility of anesthesiologist. several supraglottic devices are available but most common are laryngeal mask airway and i-gel supraglottic airway.15 these devices are used in surgeries requiring general anesthesia and are used to avoid changes in hemodynamic responses due to endotracheal intubation in patients undergoing airway maintenance during anaesthesia.16 majority of group b (i-gel) patients in our study had grade i asa scores as compared to group a (lma) patients. reza et al also reported that reduction in asa grading was found in i-gel supraglottic patients as compared to patients treated with lma (p=0.00).17 in the present study, most of the patients in lma group (60%) had mpc grade ii for air way maintenance, however, in i-gel group majority of patients (60%) had mpc grade i for airway maintenance (p=0.60). an et al.18 and kapoor et al.19 reported findings contrasting to our study. they reported majority of patients with mpc i for airway maintenance in i-gel group as compared to lma group. j islamabad med dental coll 2019 63 in the present study, number of insertion attempts were significantly lower in i-gel group as compared to lma patients (10% versus 7%, p=0.01). other researchers have reported much higher percentages of success in their studies. for example, fujiwara et al reported that success rate in first attempt with i-gel was 100%, however, success rate in first attempt with lma was 84%.20 similarly, acharya et al reported that ease of insertion is higher in i-gel tm as compared lma classic tm (p<0.05).21 in the current study, among all patients in i-gel group, insertion time was found to be lower (9.5sec±0.7sd) as compared to patients in lma group (10.67sec±1.6sd) (p=0.02). hayashi et al reported that lma classic tm had significant higher duration of insertion as compared to igel.22 atef et al reported significant difference in median insertion time of i-gel and lma with significantly lower time in i-gel group (16 seconds). moreover, they reported that no cuff inflation was required by patients in i-gel group. they did not require any introducer and the device could be easily pushed into place.16 an insignificant difference between heart rate, systolic and diastolic b.p and mean arterial pressure in both groups was found in this study. atef et al reported that lma was associated with significant increase in heart rate and blood pressure (p=0.01).23 however, ali et al conducted a similar study in lahore and reported no significant difference in hemodynamic parameters after one minute of device insertion in both i-gel and lma group (p>0.05).24 this study was conducted at a single center that limits generalizability of the study. furthermore, air way placement position was not assessed by flexible intubating fiberscope. c o n c l u s i o n i-gel supraglottic device is a successful alternative option in terms of ease of insertion and less hemodynamic response as compared to laryngeal mask airway during general anesthesia. surgeons and anesthesiologists should be very careful during application of these devices to avoid upper airway obstruction. further research is required to evaluate minute details regarding efficacy of i-gel and lma. r e f e r e n c e s 1. janjua s, adnan a, zaidi ah, bilal ms, afridi ja. tracheomalacia as an unusual cause of upper airways obstruction leading to cardiac arrest. pak. armed forces med. j. 2015; 65(5): 714–5. 2. wong p, wong j, mok mus. anaesthetic management of acute airway obstruction. singapore med j. 2016; 57(3): 110–7. doi: 10.11622/smedj.2016050 3. cook t.m, davis m.s.r. complications and failure of airway management. bja. 2012; 109(1): i68-i85. doi: 10.1093/bja/aes393. 4. gavel g, walker rw. laryngospasm in anaesthesia. contin educ anaesth crit care pain. 2014; 14(2): 47– 51. doi: doi:10.1093/bjaceaccp/mkt031 5. siddiqui as, dogar sa, lal s, akhtar s, khan fa. airway management and postoperative length of hospital stay in patients undergoing head and neck cancer surgery. j anaesthesiol clin pharmacol. 2016; 32(1): 49–53. doi: 10.4103/0970-9185.173341 6. polat r. aydin b.g, ergil j, sayin m, kokulu t, ozturk i. comparison of the i-gel™ and the laryngeal mask airway classic™ in terms of clinical performance. braz j anesthesiol . 2015; 65(5): 343-348. doi: 10.1016/j.bjane.2014.02.009 7. batuwitage b, charters p. postoperative management of the difficult airway. bja educ. 2017; 17(7): 235–41. doi: 10.1093/bjaed/mkw077 8. chauhan g, nayar p, seth a, gupta k, panwar m, agrawal n. comparison of clinical performance of the i-gel with lma. proseal. j anaesthesiol clin pharmacol. 2013; 29(1): 56–60. doi: 10.4103/09709185.105798 9. singh j, yadav mk, marahatta sb, shrestha bl. randomized crossover comparison of the laryngeal mask airway classic with i-gel laryngeal mask airway in the management of difficult airway in post burn neck contracture patients. indian j anaesth. 2012; 56(4): 348–52. doi: 10.4103/0019-5049.100815. 10. pratheeba n, ramya gs, ranjan rv, remadevi r. comparison of i-geltm and laryngeal mask airway classictm in terms of ease of insertion and hemodynamic response: a randomized observational study. anesthesia, essays and researches. 2016; 10(3): 521. doi: 10.4103/0259-1162.180780 11. revi n, harikishore, puthur b, ershad. a comparative study on cardiovascular response and ease of insertion in classical laryngeal mask airway, proseal laryngeal mask airway and i-gel during surgery under j islamabad med dental coll 2019 64 general anaesthesia. j evid based med healthcare. 2015; 2(20): 3039–46. 12. radhika ks, sripriya r, ravishankar m, hemanth kumar vr, jaya v, parthasarathy s. assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: a prospective randomized trial. anesth essays res. 2016; 10(1): 88–93. doi: doi: 10.4103/0259-1162.167849 13. hashemian .r.m.s, nouraei n, razavi s. s, zaker e, jafari a, eftekhari p et al. comparison of i–gel™ and laryngeal mask airway in anesthetized paralyzed patients. int j crit illn inj sci. 2014; 4(4): 288–292. doi: 10.4103/2229-5151.147520 14. sakpal vijay tushar. sample size estimation in clinical trial. prespect clin res. 2010; 1(2): 67-69. pmid: 21829786 15. saran s, mishra sk, badhe as, vasudevan a, elakkumanan lb, mishra g. comparison of i-gel supraglottic airway and lma-proseal™ in pediatric patients under controlled ventilation. j anaesthesiol clin pharmacol. 2014;30(2):195–8. doi: 10.4103/0970-9185.130013 16. helmy am, atef hm, ei-taher em, henidak am. comparative study between i-gel, a new supraglottic airway device and classical laryngeal mask airway in anaesthetized spontaneously ventilated patients. saudi j anaesth. 2010; 4(3): 131–6. doi: 10.4103/1658-354x.71250 17. reza hashemian sm, nouraei n, razavi ss, zaker e, jafari a, eftekhari p, et al. comparison of i-gel™ and laryngeal mask airway in anesthetized paralyzed patients. int j crit illn inj sci. 2014; 4(4): 288–92. doi: 10.4103/2229-5151.147520 18. an j, nam sb, lee js, lee j, yoo h, lee hm, et al. comparison of the i-gel and other supraglottic airways in adult manikin studies: systematic review and metaanalysis. medicine. 2017; 96(1): e5801. doi: 10.1097/md.0000000000005801 19. kapoor s, jethava d.d, gupta p, jethava d, kumar a. comparison of supraglottic devices i-gel ® and lma fastrach ® as conduit for endotracheal intubation. ija. 2014;58(4): 397-402. doi: 10.4103/00195049.138969 20. fujiwara a, komasawa n, nishihara i, miyazaki s, tatsumi s, nishimura w, et al. muscle relaxant effects on insertion efficacy of the laryngeal mask proseal ® in anesthetized patients: a prospective randomized controlled trial. j anesth. 2015; 29(4): 580–4. doi: 10.1007/s00540-015-1982-3 21. acharya r. dave n.m. comparison between i-gel airway an the proseal laryngeal mask airway in pediatric patients undergoing general anesthesia. paccj. 2016; 4(2): 97-102. doi: doi:10.14587/paccj.2016.20 22. hayashi k, suzuki a, kunisawa t, takahata o, yamasawa y, iwasaki h. [a comparison of the singleuse i-gel with the reusable laryngeal mask airway proseal in anesthetized adult patients in japanese population]. masui. 2013; 62(2): 134–9. pmid: 23479911 23. atef hm, fattah sa, gaffer me, al rahman aa. perfusion index versus non-invasive hemodynamic parameters during insertion of i-gel, classic laryngeal mask airway and endotracheal tube. indian j anaesth. 2013; 57(2): 156–62. doi: 10.4103/00195049.111843 24. ali a, ali l, sheikh na, siddique sa. airway device; comparison of i-gel supraglotic with laryngeal mask airway for ease of insertion. professional med j dec. 2010; 17(4): 643–7. j islamabad med dental coll 2021 133 open access effects of dried aloe vera gel and diclofenac on sodium and potassium homeostasis: an experimental study on hypertensive rats nadeem yaqoob1, abdul qudoos arain2, mufakhara fatimah3, samina kausar4, sadia chiragh4 1associate professor, pharmacology, niazi medical and dental college, sargodha 2professor, pharmacology, hbs medical and dental college, islamabad 3assistant professor, pharmacology, sahara medical college, narowal 4professor, pharmacology, al-aleem medical college, lahore a b s t r a c t background: anti-inflammatory role of aloe vera gel is well established. diclofenac is extensively used for acute and chronic inflammation. the present study was conducted to compare dried aloe vera gel and diclofenac effects on sodium and potassium balance in hypertensive rats. material and methods: this experimental study was conducted at sargodha medical college from may to november 2016. twenty-four healthy male sprague dawley rats 7-8 weeks of age were included in study. any unhealthy-looking rat was excluded from the study. rats were equally and randomly divided into four groups normal control (group a), model control (group b), aloe vera (group c) & diclofenac (group d). hypertension was induced by a 20 % sucrose diet in all groups except group a in 8 weeks’ time. group b, c & d received distilled water and aloe vera dried gel 400 mg/kg & diclofenac powder 12 mg/kg body weight respectively orally between 8 to 10 weeks. serum and urine analysis was performed for hematocrit, sodium, and potassium concentrations at zero, eight and ten weeks. twentyfour-hour urinary sodium excretion was calculated. data was analyzed using graph pad prism version 6. result: after 2-week administration of aloe vera and diclofenac powder, serum potassium significantly decreased in group c (p <0.001) while increased in group b and d (p <0.001) as compared to group a. urinary sodium concentration and excretion increased significantly in group c (p <0.01) as compared to group a whereas result of group d was insignificant. no significant change in serum sodium and hematocrit of any group was observed. conclusion: aloe vera causes less sodium retention than diclofenac but decreases serum potassium contrary to the effect of diclofenac in hypertensive rats. keywords: aloe vera, diclofenac, electrolyte, hematocrit, hypertension authors’ contribution: 4conception; literature research; manuscript design and drafting; 1,2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: abdul qudoos arain email: qudoospk@gmail.com article info: received: january 5, 2021 accepted: august 30, 2021 cite this article. yaqoob n, arain aq, fatimah m, kausar s, chiragh s. effects of dried aloe vera gel and diclofenac on sodium and potassium homeostasis: an experimental study on hypertensive rats. j islamabad med dental coll. 2021; 10(3): 133-139. doi: 10.35787/jimdc.v10i3.658 funding source: pgmi conflict of interest: nil i n t r o d u c t i o n nsaids are the most prescribed agents in pakistan for controlling inflammation, pain and fever. the main action of these agents is to suppress prostaglandin (pg) synthesis; by inhibiting the enzyme cyclooxygenase (cox-i&ii). cox-i enzyme of kidneys plays a physiological role and controls hemodynamic and glomerular filtration rate (gfr), while cox-ii is an inducible enzyme responsible for o r i g i n a l a r t i c l e j islamabad med dental coll 2021 134 cell injury or inflammation. this enzyme is also present in kidneys and affects electrolytes and water excretion hence regulates intravascular volume. decreased activity of cyclooxygenase enzymes by nsaids causes hyperkalemia and sodium and water retention that causes edema hypertension, and kidney damage.1,2 nsaids other than affecting the kidneys also cause gastric and duodenal ulceration, exacerbate asthma symptoms, and increase bleeding tendency. nsaids like diclofenac have more potential to harm older people due to renal and cardiovascular risk. they carry a threat of chronic decrease of gfr as well as acute kidney damage.3 according to liew.et al., continuous use of nsaids is associated with the risk of hypertension in 12 percent of individuals as compared to non-use or limited use of nsaids.4 aloe vera, a water-storing and drought-tolerant plant has many therapeutic effects including antiinflammatory, immunomodulatory, hypoglycemic, anticancer, gastro-protective and antimicrobial properties. due to these vast pharmacological effects; aloe vera has been employed for several commercial applications.5it can be separated into two basic products; latex, a bitter yellow exudate derived from the outer skin of the leaves which occupy approximately 20–30% of the weight of the whole leaf, and gel, which is a transparent mucilage material derived from the pulp of the leaves.6 this mucilaginous part of aloe vera is traditionally used in different inflammatory disorders.7 the anti-inflammatory activity of this medicinal plant justifies its use in dermal inflammatory disorders and joint diseases, particularly in elderly patients. in this age group, the use of nsaids is limited because of their documented adverse effect on sodium & water retention and electrolyte imbalance. there is insufficient data on safety of aloe vera regarding sodium and potassium homeostasis especially in hypertensive subjects. the purpose of this study is to evaluate the use of aloe vera and its comparison with diclofenac on the hematocrit and electrolyte (sodium and potassium) balance of hypertensive rats. this research can provide data on safety profile of aloe vera to be used for future human studies on hypertensive patients. m a t e r i a l a n d m e t h o d s after approval from the ethical committee, this animal experimental study was conducted at sargodha medical college between may and november 2016. twenty-four sprague dawley rats weighing between 235–380 g, according to inclusion criteria of 7-8 weeks age and male gender were obtained from the university of agriculture faisalabad. unhealthy-looking rats were excluded. rats were randomly divided by lottery method into four equal groups: normal control (group a), model control (group b), aloe vera group (group c) and diclofenac group (group d). they were kept in the college animal facility in iron cages for two weeks for acclimatization. room temperature was maintained at 25±5°c. a light and dark cycle of 12 hours was followed, and animals were given free access to food and water. rats in group a were given normal rat chow throughout the study period, whereas all the other groups were given normal rat chow containing sucrose (20% w/w)to induce hypertension,8 which was induced in all three groups in eight weeks. systolic blood pressure ≥ 140 mm hg was considered hypertension9. after induction of hypertension at 8th week, group b was given distilled water 0.5ml, and group c was given aloe vera gel powder 400 mg/kg body weight,10 and group d was given diclofenac powder 12 mg/kg body weight by the oral route as a single morning dose for two weeks.11 plants were purchased from a local nursery and identified by the botany department of sargodha university. after washing the aloe vera leaves and draining the yellow juice, the pulp was removed, mixed in a blender, filtered, air-dried and the resultant dried gel was stored at 4°c.10. yield with reference to the whole leaf was 0.14%. the fresh j islamabad med dental coll 2021 135 solution was prepared daily by dissolving 400 mg in 5 ml distilled water. the body weight and blood pressure of animals were recorded at baseline and then weekly throughout the study. systolic blood pressure was measured by tail-cuff,8 using a non-invasive blood pressure controller (ml125r) attached to the computer-based data recording system (power lab). twenty-four-hour urine was collected in a glass container by keeping each animal in a separate cage at 0, 8, and 10 weeks. urine sodium concentration and volume were measured and 24hour urinary excretion was calculated. after urine collection, two ml of blood was drawn through cardiac puncture; one ml blood was put in edta for determination of hematocrit and one ml in gel & clot activator vacutainer. to separate serum, blood was centrifuged at 5000 rpm for three minutes. serum sodium and potassium levels were estimated by a flame photometer (seac p-10) and hematocrit by a hematology analyzer (sysmex kx21). data was analyzed using graph pad prism version 6. normality was tested by the shapiro-wilk normality test and data was presented as mean ± sd. normally distributed data was compared using anova. changes in parameters at different times in each group were compared by t-test. post hoc tukey's test was applied for comparison among groups. a p-value of ≤0.05 was considered significant. r e s u l t s during the first 8 weeks, body weight, as well as systolic blood pressure, increased significantly (p value< 0.001) in groups receiving sucrose diet (b, c & d) as compared to group a while after two weeks, blood pressure increased by 2, 4, 3 and 17 mm hg in groups a, b, c and d respectively. however, no significant change was seen in hematocrit of any group during the study period (table 1). serum sodium concentration remained within the normal range with non-significant differences in readings throughout the study serum potassium concentration: analysis by t-test within each group between 8 to 10 weeks revealed that serum potassium significantly decreased in aloe vera group (group c) and increased in diclofenac (group d) and model control (group b) groups with p-values ˂ 0.001, ˂ 0.001 and 0.008 respectively. at the end of study, serum potassium was significantly higher in model control and diclofenac groups as compared to normal control, while that of aloe vera group was significantly lower versus all other groups as calculated by tukey's test (figure 1). table i: effect of aloe vera gel and diclofenac on hematocrit, serum sodium and urine volume of hypertensive rats (n=6) groups hematocrit (%) serum na (meq/l) urine vol. (ml) 0 week 8 weeks 10 weeks 0 week 8 weeks 10 weeks 0 week 8 weeks 10 weeks mean ±sd mean ±sd mean ±sd mean ±sd mean ±sd mean ±sd mean ±sd mean ±sd mean ±sd normal control(a) 37.83±3 .06 38±3.9 38.5±3.7 3 120.83±1 4.2 118.17± 8.38 123±12. 17 5.77±1. 05 5.83±0. 41 5.87±0. 60 model control(b) 37.67±2 .8 39±3.29 38.5±2.4 3 117.83±3 .37 116.67± 16.94 117.67± 6.62 5.72±1. 80 5.70±0. 28 5.77±0. 23 aloe vera (c) 36.67±3 .39 39.33±6 .22 38.67±4. 27 119.33±7 .31 107.33± 30.16 124.33± 38.73 5.40±2. 69 5.50±0. 35 5.40±0. 94 diclofenac (d) 37.17±2 .93 39.5±3. 45 37.17±2. 48 125.17±1 1.07 118±4.2 4 115.83± 13.14 5.63±2. 37 5.60±0. 51 5.17±0. 59 anova 0.909 0.934 0.850 0.612 0.685 0.884 0.990 0.518 0.234 j islamabad med dental coll 2021 136 figure 1: effect of aloe vera gel and diclofenac on serum potassium concentration (mean±sd) of hypertensive rats (n=6). significance between groups calculated by tukey's test. *** p value <0.001 versus normal control group (a) ** p value <0.01 versus normal control group (a) ••• p value <0.001 versus model control (b) &diclofenac group (d) urinary sodium concentration: analysis by t-test within each group between 8 to 10 weeks revealed that urinary sodium concentration increased significantly in model group only (p-value 0.038). at the end of study, urinary sodium concentration was highest in model group, followed by aloe vera, diclofenac and normal group (figure2). figure 2: effect of aloe vera gel and diclofenac on urinary sodium concentration (mean±sd) of hypertensive rats (n=6) significance between groups calculated by tukey's test. *** p value <0.001 versus normal control (a) & diclofenac group (d) * p value <0.01 versus normal control (a) & model control group (b) urinary volume was statically similar in all groups at all reading times (table 1) twenty-four hour urinary sodium excretion: results were parallel to urinary sodium concentration, i.e., a significant increase from 8-10 weeks period in model group with p-value 0.016(ttest). at end of 10th week, it was highest in model group followed by aloe vera, diclofenac and normal group (figure 3). figure 3: effect of aloe vera gel and diclofenac on urinary sodium excretion (mean±sd) of hypertensive rats (n=6) significance between groups calculated by tukey's test. *** p value <0.001 versus normal control (a) & diclofenac group (d) * p value <0.01 versus model control group (b) d i s c u s s i o n nonsteroidal anti-inflammatory drugs like diclofenac are the most commonly used and prescribed drug in our society. nsaids are being prescribed in our routine medical practice as analgesics, antipyretics and anti-inflammatory agents.2the pharmacological effects of nsaids on body organs depend upon the concentration and the time-duration of their use. the most affected organ is kidney, and therefore high doses or prolonged treatment can increase morbidity, especially in geriatric patients, as they already have declined renal functions. moreover, these drugs disturb the normal electrolyte balance and affect the response of some diuretics which is expressed j islamabad med dental coll 2021 137 as chronic retention of sodium and potassium. according to aljadheyet al., nsaid use is linked with a small increase in systolic blood pressure in hypertensive patients.12 the role of aloe vera gel as an anti-inflammatory agent is well established. aloe vera controls inflammatory reactions through different mechanisms. one of these mechanisms is closely associated with nsaids, i.e., inhibition of arachidonic acid pathway.13 this study was designed with an objective to compare the effects of aloe vera gel and diclofenac on electrolyte balance in a hypertensive rat model. for this purpose, 20% sucrose diet was given to the rats, which successfully induced hypertension within the desired period of eight weeks. the results of this study clearly indicate that aloe vera causes potassium loss paradoxical to the effect of diclofenac which causes potassium retention. furthermore, it causes less sodium retention than diclofenac. diclofenac increases serum potassium concentration, possibly by inhibiting prostaglandin synthesis, resulting in decreased renin secretion, which reduces the level of aldosterone in the blood.14 another mechanism of elevated serum potassium could be decreased synthesis of pgi2 which stimulates renal juxtaglomerular cells to release renin and consequently aldosterone. the inhibition of pgi2 by nsaids also causes decreased distal renal tubular flow and hyperkalemia.2an increase in the model control group may be linked to decreased sodium reabsorption as compensatory mechanism leading to increased potassium reabsorption in exchange. aloe vera group exhibited a significant decrease in serum potassium from 8-10 weeks. saka et al. expressed an insignificant decrease in serum potassium level when aloe vera was given to healthy rats for 28 days,15 while higher dose, i.e., 800 mg/ kg of chloroform extract of aloe vera gel, significantly decreased serum potassium in healthy rats.16 this decrease in serum potassium may be an aldosterone-like effect of aloe vera gel sterols. contrary to these results, six weeks of treatment with 600 mg/kg dose of aloe vera gel has shown to produce no change in serum potassium of normal rats and increase in serum potassium of salt-loaded rats,17 which was considered to be due to increased exchange with sodium. the present research shows an insignificant decrease in serum sodium level of diclofenac group during 8-10-week period. another study has shown similar results in which 15 mg/kg dose of diclofenac given for five days did not produce any significant change in serum sodium concentration of wistar rats.18 serum sodium level of aloe vera group showed a non-significant rise which is supported by another study in which chloroform extract of aloe vera has shown an insignificant rise in serum sodium after 14 days of treatment which became significant after 28 days.19 saka et al. showed the opposite effects of aloe vera extract, which significantly decreased serum sodium concentration when given for 28 days.15 these studies were performed on healthy rats; no study is available for effect of aloe vera on hypertensive rats. urinary sodium concentration and 24-hour excretion increased in all groups during the 8-10week period, but this increase was significant only in the model control group and numerically negligible in the diclofenac group. at 10th-week, urinary sodium concentration and excretion were significantly higher in the model control group than all other groups which seems to be a normal compensatory mechanism, which is blunted with diclofenac treatment due to inhibition of renal prostaglandins.20 aloe vera caused less blunting of this compensatory mechanism. the reason may be lesser inhibition of prostaglandins by aloe vera as compared to diclofenac which acts mainly by inhibition of cox, while the anti-inflammatory activity of aloe vera is due to multiple mechanisms.21 j islamabad med dental coll 2021 138 the hematocrit of hypertensive groups decreased insignificantly from 8th to 10th week of the experiment, but this decrease was numerically more in diclofenac-treated rats. aycan et al. made the same observation when forty male wistar rats were treated with diclofenac (9mg/kg) intravenously, daily for five days.22 sodium and fluid retention by diclofenac may be the reason for hematocrit decrease. aloe vera did not affect hematocrit significantly in this study; obeten et al. reinforced these effects of aloe vera on hematology of wistar rats.23 to sum up the results, serum potassium was significantly higher in diclofenac group and significantly lower in aloe vera group. moreover, there was more decline in urinary sodium concentration and excretion with diclofenac than with aloe vera, although difference between the two was statistically insignificant. so ultimately these parameters show that diclofenac has the tendency to cause more salt and water retention than aloe vera. this is one of few studies on the effect of aloe vera on electrolyte balance and first one on hypertensive rats. the study has limitations that doses of aloe vera gel and diclofenac were selected from two different studies. the anti-inflammatory effect of these doses was not compared in the present research. one would have been more confident in declaring aloe vera a better anti-inflammatory option; had it been done. administration of experimental drugs for two weeks is a short duration and another limitation. long-term use of aloe vera may reveal more sodium retention, or further lowering of serum potassium may be more harmful than sodium retention. examination of histological effects may give a more clear picture. c o n c l u s i o n aloe vera causes less sodium retention than diclofenac but decreases serum potassium contrary to the effect of diclofenac in hypertensive rats. no significant effect on hematocrit was seen. further studies with different doses of aloe vera and longer duration of intervention, as well as interaction with drugs, need to be conducted. a c k n o w l e d g m e n t we appreciate dr. alamgeer, who allowed using the facility of power lab in the department of pharmacy, university of sargodha. we are grateful to mr. samiullah, the lecturer university of sargodha for providing help in statistical analysis. disclaimer current manuscript is part of the mphil thesis research funding disclosure post graduate medical institute (pgmi), lahore r e f e r e n c e s 1. abiola ts, adebayo oc, babalola o. diclofenacinduced kidney damage in wistar rats: involvement of antioxidant mechanism. journal of biosciences and medicines. 2019;7(12):44. doi: 10.4236/jbm.2019.712005 2. lucas gnc, leitão acc, alencar rl, xavier rmf, daher edf, silva junior gbd. pathophysiological aspects of nephropathy caused by nonsteroidal antiinflammatory drugs. brazilian journal of nephrology. 2019;41(1):124-30. doi: 10.1590/2175-8239-jbn2018-0107 3. modig s, elmståhl s. kidney function and use of nonsteroidal anti-inflammatory drugs among elderly people: a cross-sectional study on potential hazards for an at risk population. int j clin pharm. 2018;40(4):870-7. doi: 10.1007/s11096-018-0598-8 4. liew jw, ward mm, reveille jd, weisman m, brown ma, lee m, et al. nonsteroidal antiinflammatory drug use and association with incident hypertension in ankylosing spondylitis. arthritis care res (hoboken). 2020;72(11):1645-52. doi: 10.1002/acr.24070 5. maan aa, nazir a, khan mki, ahmad t, zia r, murid m, et al. the therapeutic properties and applications of aloe vera: a review. journal of herbal medicine. 2018; 12:1-10. doi: 10.1016/j.hermed.2018.01.002 6. minjares-fuentes r, femenia a. nonvitamin and nonmineral nutritional supplements: academic j islamabad med dental coll 2021 139 press; 2019. p. 145-52. doi: 10.1016/b978-0-12812491-8.00020-5 7. sánchez m, gonzález-burgos e, iglesias i, gómezserranillos mp. pharmacological update properties of aloe vera and its major active constituents. molecules. 2020;25(6):1324. doi: 10.3390/molecules25061324 8. yaqoob n, fatimah m, naqvi f, sarfraz j, mushtaq s, chiragh s. comparative evaluation of aloe vera and diclofenac on body weight, blood pressure and renal function of hypertensive rats. 2021;35(1):39-44. doi: 10.47489/p000s351z7821-6mc 9. chobanian av. time to reassess blood-pressure goals. n engl j med. 2015;373(22):2093-5. doi: 10.1056/nejmp1513290 10. shahriari m, khaksari m, bibak b, ramshini a, shahabi a: the effects of aloe vera extract on brain edema and blood-brain barrier permeability after traumatic brain injury. the neuroscience journal of shefaye khatam. 2017 10;5(2):50-50. 11. breganó jw, barbosa ds, kadri mze, rodrigues ma, cecchini r, dichi i. comparison of selective and nonselective cyclooxygenase 2 inhibitors in experimental colitis exacerbation: role of leukotriene b4 and superoxide dismutase. arq gastroenterol. 2014;51(3):226-34. doi: 10.1590/s0004-28032014000300012 12. aljadhey h, tu w, hansen ra, blalock sj, brater dc, murray md. comparative effects of nonsteroidal anti-inflammatory drugs (nsaids) on blood pressure in patients with hypertension. bmc cardiovasc disord. 2012;12(1):93. doi: 10.1186/1471-2261-1293 13. rahmani ah, aldebasi yh, srikar s, khan aa, aly sm. aloe vera: potential candidate in health management via modulation of biological activities. pharmacogn rev. 2015;9(18):120-6. doi: 10.4103/0973-7847.162118 14. krishnan sk, lepor ne. acute and chronic cardiovascular effects of hyperkalemia: new insights into prevention and clinical management. rev cardiovasc med. 2016. doi: 10.3909/ricm17s1s0002 15. saka w, akhigbe r, popoola o, oyekunle o. changes in serum electrolytes, urea, and creatinine in aloe vera-treated rats. j young pharm. 2012;4(2):78-81. doi: 10.4103/0975-1483.96620 16. arain aq, hussain m, chiragh s. effect of different doses of aloe vera versus indomethacin on sodium and water retention in healthy rats. jpmi. 2017;31(3): 286-91. 17. udefa al, archibong an, akwari aa, leilei sa. effect of aloe vera gel on some haematological parameters and serum electrolytes in high salt loaded wistar rats. micromedicine. 2018;6(2):69-77. doi: 10.5281/zenodo.1318287 18. barbosa cm, sakate m, camplesi ac, vailati mdcf, moraes lf, takahira rk. evaluations hematological and biochemical by the use of sodium diclofenac, meloxicam and firocoxib in rats. braz j vet res anim sci. 2010:118-26. 19. arain a, hussain m, muneer a, chiragh s. effect of chloroform extract of aloe vera jell on sodium and water retention in rats. biomedica. 2016;32(2):8992. 20. ahmed an and daniel ef. nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, nonopioid analgesics, & drugs used in gout; basic & clinical pharmacology. 14th ed. new york: katzung bg mcgraw hill education; 2018. chapter 36: 642-666. 21. gebremeskel l, bhoumik d, sibhat gg, tuem kb. in vivo wound healing and anti-inflammatory activities of leaf latex of aloe megalacantha baker (xanthorrhoeaceae). evid based complement alternat med;2018. doi: 10.1155/2018/5037912 22. aycan i̇ö, elpek ö, akkaya b, kıraç e, tuzcu h, kaya s, et al. diclofenac induced gastrointestinal and renal toxicity is alleviated by thymoquinone treatment. food and chemical toxicology. 2018; 118:795-804. doi: 10.1016/j.fct.2018.06.038 23. obeten ce, ani ej, ime au, kokelu an, edet o. thermoxidized palm oil diet (tpo)-induced haematological derangements in rats is ameliorated by aloe vera and garlic. the journal of phytopharmacology.2018;7(4):353-9. issn 2320480x https://doi.org/10.47489/p000s351z7821-6mc https://doi.org/10.47489/p000s351z7821-6mc 307 j i m d c 2 0 1 7 307 op e n ac c e s s c a s e r e p o r t successful pregnancy outcome in unicornuate uterus: a case report feriha fatima khidri 1, faiza kamran ali 2, hafsa shabir ahmed 3 1 lecturer, department of biochemistry, liaquat university of medical and health sciences, jamshoro 2 postgraduate trainee department of gynaecology and obstetrics, liaquat university of medical and health sciences, jamshoro 3 postgraduate trainee department of gynaecology and obstetrics, dow university of health sciences ojha campus a b s t r a c t pregnancy with a unicornuate uterus is an infrequent obstetrical presentation. unicornuate uterus leads to various complications, including infertility and poor pregnancy outcomes. it may be asymptomatic and remain undiagnosed till the woman is unable to conceive or present with a bad obstetric history. here we present a case report of a patient with unicornuate uterus diagnosed during caesarean section along with delivery of alive baby. key words: outcome, pregnancy, unicornuate uterus address of correspondence fariha fatima email: ferihafatima@yahoo.com article info. received: november 9, 2018 accepted: november 22, 2018 cite this case report: khidri ff, ali fk, ahmed hs. successful pregnancy outcome in unicornuate uterus: a casre report. jimdc. 2018; 7(4):307-308 funding source: nil conflict of interest: nil i n t r o d u c t i o n congenital uterine anomalies are rare and unicornuate uterus is one of the infrequent presentations among uterine anomaly. the prevalence of a unicornuate uterus is found to be 0.3% among the general population, whereas it remains a cause of infertility in about 0.6% of the infertile women.1,2 it usually remains undiagnosed till patient undergo certain surgical procedures or present with gynaecological, reproductive and obstetrical complications. it increases risks for abortion, infertility, preterm birth, premature rupture of membranes, abnormal lie, abnormal placental localization and intrauterine growth restrictions.3 c a s e r e p o r t a 30-year-old multigravida presented at the liaquat university of medical and health sciences hospital with 8 months’ gestational amenorrhea and preterm premature rupture of membranes (pprom). she had regular menstrual cycles and presented with history of recurrent fetal loss. the patient had one preterm baby delivered spontaneously vaginally, but the baby died in the early neonatal period, followed by two miscarriages at 2.5 months, two miscarriages at 4 months and one miscarriage at 4.5 months. after her last miscarriage, patient did not conceive for two years. on the advice of the local doctor, she took medications for ovulation induction and conceived after six months. at eight months of pregnancy she reported to a tertiary care hospital with complain of leaking. she received intramuscular dexamethasone cover at 33 weeks of gestation. her baseline investigations were normal. she had normal vitals with reactive cardiotocography (ctg) on admission. after 48 hours, baseline rate dropped to 80 bpm, demonstrating pathological ctg for over 15 minutes. caesarean section was performed due to fetal distress. while performing a caesarean section it was observed that the uterus was shifted from midline. semilunar incision was given in the lower portion of the uterus and alive baby boy delivered in cephalic presentation. placenta was expelled in 1 min and apgar score was observed as 7 in one minute and 8 in 5 minutes. on examination unicornuate uterus was found with right fallopian tube normally located whereas left fallopian tube was located abnormally on the lower portion of the uterus c a s e r e p o r t 308 j i m d c 2 0 1 7 308 (figure 1). left sided fallopian tube was thicker and originated anterioinferiorly on the lower portion of the uterus. right side ovary was enlarged 7×6 cm containing cyst whereas the left side ovary was normal in size but firm in consistency. figure 1a & 1b: unicornuate uterus presentation in reported case d i s c u s s i o n uterine anomalies are related to adverse pregnancy outcome and infertility. in the present case in spite of patient’s bad obstetric history and hospitalization patient was unaware of structural anomaly and reasons for miscarriage. although with the advancement in ultrasound technology, structural anomalies are easier to detect and diagnose, though it requires competent and experienced ultrasonologist and advanced ultrasound imaging and mri technology. a normal ultrasound usually fails to rule out unicornuate uterus. laparoscopy and hysteroscopy can detect unicornuate uterus; though, in this patient they were not advised, in spite of bad obstetric history. in the current case, uterine anomaly was diagnosed at the time of caesarean section, as only one ultrasound scan at the time of admission at 33 weeks’ gestation was available; which did not detect anomaly. heinonen pk in his retrospective study of uterine anomalies found right unicornuate uterus with non-communicating rudimentary horn as frequent type of presentation among uterine anomalies.4 another research comprising 20 studies on the outcome of pregnancy in patients with unicornuate uterus revealed its incidence to be 1 in 4020 pregnancies.5 unicornuate uterus predisposes women to greater risks for infertility, ectopic pregnancy, abortions, preterm delivery and intrauterine fetal death; where, only 50% of women are found to deliver alive babies.5 it is therefore suggested that women with bad obstetrical history and infertility should be considered for detailed anatomical evaluation of the uterus. later these patients on conceiving should be considered high risk patients and managed accordingly. r e f e r e n c e s 1. ombelet w, verswijvel g, vanholsbeke c, schobbens jc. unicornuate uterus and ectopic (undescended) ovary. facts views vis obgyn. 2011;3(2):131-134. 2. rani a, kumari m, shipra. a case of noncommunicating uterine horn containing functional endometrium. gynecology & obstetrics. 2015;5(9):320. 3. caserta d, mallozzi m, meldolesi c, bianchi p, moscarini m. pregnancy in a unicornuate uterus: a case report. j med case rep. 2014;8(1):130. 4. heinonen pk. unicornuate uterus and rudimentary horn. fertil steril. 1997;68(2):224-230. 5. reichman d, laufer mr, robinson bk. pregnancy outcomes in unicornuate uteri: a review. fertil steril. 2009;91(5):1886-1894.. j islamabad med dental coll 2020 48 open access impact of endoscopic retrograde cholangiopancreatography on laparoscopic cholecystectomy ramlah ghazanfor1, sara malik2, maham tariq2, mehwish changeez2, javaria malik3, khawaja rafay ghazanfor4, khadija ghulam2, syed waqas hasan2, jahangir sarwar khan5 1senior registrar, surgical unit 1, holy family hospital, rawalpindi 2post graduate trainee, surgical unit 1, holy family hospital, rawalpindi 3senior registrar, medical unit, dhq hospital, rawalpindi 4medical student, c.m.h lahore 5professor and head, department of surgery, holy family hospital, rawalpindi a b s t r a c t background: for common bile duct (cbd) stones an endoscopic retrograde cholangiopancreatography (ercp) is done prior to cholecystectomy. however, the ideal timing of cholecystectomy following ercp is still a matter of debate. the aim of the present study was to observe the possible impact of ercp on subsequent laparoscopic cholecystectomy. material and methods: this case control study was carried out in the department of surgery unit 1, holy family hospital, rawalpindi, from january 2018 to march 2019 . a total number of 300 patients of symptomatic gallstones presenting to outpatient department were enrolled. two groups, a (control group) and b (case group) were made on the basis of absence or presence of cbd stones, respectively. group a underwent laparoscopic cholecystectomy within three working days of admission. in group b, ercp was performed prior to cholecystectomy. primary operating surgeon filled structured questionnaires for each patient immediately after surgery to compare operative differences between both groups. the baseline demographic details, clinical characteristics, laboratory investigations and perioperative findings of both groups were recorded. means and percentag es were calculated with p value <0.05 regarded as statistically significant. results: majority of patients in this study were females (81%) of middle age group (42.5+15 years). biliary colic was most common presenting complaint in both groups (33%). dissec tion in triangle of calot (p=0.00) and removal of gallbladder from liver bed (p=0.00) was significantly more difficult in group b than a. intra-abdominal lavage was also done more often in post ercp group (p=0.00). however procedural time did not vary between the two groups (p=0.19). conclusion(s): preoperative ercp increases difficulty in laparoscopic cholecystectomy but does not prolong procedural time. key words: choledocholithiasis, endoscopic retrograde cholangiopancreatography, laparoscopic cholecystectomy authors’ contribution: 1conception; 2-3literature research; manuscript design and drafting; 4critical analysis and manuscript review; data analysis; 7,9manuscript editing. correspondence: sara malik email: saramalik087@gmail.com article info: received: july 18, 2019 accepted: march 18, 2020 cite this article. ghazanfor r, malik s, tariq m, changeez m, malik j, ghazanfor kr, ghulam k, hasan sw, khan js. impact of endoscopic retrograde cholangiopancreatography on laparoscopic cholecystectomy. j islamabad med dental coll.2020; 9(1): 48-53. funding source: nil conflict of interest: nil i n t r o d u c t i o n gallbladder stones are one of the commonest ailment of our times with an almost 20 million affected annually in united states.1 although initially asymptomatic, 1% of all these will become or i gi n a l a r ti c le j islamabad med dental coll 2020 49 problematic, hence mandating cholecystectomy.2 choledocholithiasis is one of the sequelae of gallstone disease with a prevalence of 15%. this if left untreated might lead to pancreatitis, cholangitis or simple obstructive jaundice with its associated complications of hepatorenal shutdown or encephalopathy.3 currently two step approach of ercp (endoscopic retrograde cholangiopancreatography) followed by laparoscopic cholecystectomy is considered gold standard treatment modality for common bile duct (cbd) stones.4 approximately 500,000 ercps are performed annually in the united states.5 various techniques like sphincterotomy, needle knife sphincteroplasty, and balloon sweep and occlusion cholangiogram are performed as a part of this procedure.5 although evading the hazards of open or laparoscopic cbd exploration, ercp is still an invasive procedure. post ercp cholecystectomy is mandatory to avoid recurrence.6,7 the time interval between ercp and laparoscopic cholecystectomy (lc) is a matter of debate. it can be performed during index admission or after interval of few weeks. intervening early will be cost-effective for both the patient and hospital as it will reduce chances of recurrent stones. a directly applicable original health economic model analysis with minor limitations suggests that early laparoscopic cholecystectomy following ercp for common bile duct stones is cost effective compared with delayed laparoscopic cholecystectomy. in fact, offering early cholecystectomy may reduce the number of readmissions, emergency operations, and length of stay.8 the other school of thought believes that ercp being an invasive procedure causes inflammation in triangle of calot. thus, early laparoscopic cholecystectomy after ercp can have higher chances of complications like uncontrolled hemorrhage and bile ducts or, duodenal injuries. it can also increase time of surgery and rates of conversion into open procedure. in this context, our study compared operative findings of laparoscopic cholecystectomy in patients who had or had not undergone ercp prior to surgery. m a t e r i a l a n d m e t h o d s a total number of 300 patients presenting to the outpatient department of surgical unit 1, holy family hospital, rawalpindi were prospectively enrolled in this study by simple consecutive sampling during january 2018 to march 2019. patients were between 15-70 years of age and all had ultrasonic evidence of gallstones. they were divided into two groups. group a (n=150) consisted of patients who had simple gallstone disease with no history of obstructive jaundice. their liver functions tests and cbd diameters on ultrasound were normal. while group b (n=150) patients had choledocholithiasis established on either ultrasound or magnetic resonance cholangiopancreatography (mrcp). lft’s were either norm al or deranged in this group but did not affect diagnosis. all patients were admitte d and allotted into respective groups by same team of qualified general surgeons. anesthesia fitness and baseline investigations were done in all patients. those falling outside the defined age group, with decapacitating comorbidities (active myocardial infarction, uncontrolled copd, super-obese) and not undergoing laparoscopic cholecystectomy (perforated gall bladder, empyema, cholecystoduodenal fistula etc.) were excluded from the study. after admission, group a underwent elective cholecystectomy within three working days. g ro u p b followed a two-step course. initially ercp was performed followed by laparoscopic cholecystectomy within next 48 hours. all ercps were performed by a single qualified gastroenterologist. sphincterotomy and balloon sweep was done to clear cbd. normal occlusion j islamabad med dental coll 2020 50 cholangiograms were confirmed at the end of all procedures. those cases where ercp failed to cle ar bile were treated by open cbd exploration and cholecystectomy. they were henceforth excluded from study. during surgery lc standard four port technique was used in all cases. all surgeries were performed by qualified laparoscopic surgeons of same seniority. society of american gastrointestinal endoscopic surgeons ( sages) guidelines for laparoscopic cholecystectomy were followed for dissection of triangle of calot and duplex view was achieved before ligating cystic duct and artery with titanium clips. gall bladder fossa was dissected using monopolar electrocautery mounted on an l hook. post operatively, both groups received intravenous injections of ceftriaxone 1 gram (three doses) and injection ketorolac 10 mg (two doses). all except those converted into open procedures got discharged early next morning after removal of drains. for data collection, structured questionnaires were filled for each patient immediately after surgery by primary operating surgeon. the baseline demographic details, clinical characteristics, laboratory investigations and perioperative findings of both groups were recorded. means and percentages were calculated with p value <0.05 regarded as statistically significant. r e s u l t s total number of 300 patients were included in our study. majority of them were females and belonged to the middle age group (table i). most have been symptomatic for more than one year. all patients had various presenting complaints related to underlying gallstones summarized in table ii. preoperative laboratory investigations and ultrasound were performed in all patients as per hospital protocol. serum amylase levels were checked to rule out active pancreatitis (table ii). table i: baseline demographic and clinical characteristics of cases and controls characteristics group a group b mean age (years) 44+12.4 41.32+17.77 gender n (%) male 20 (11.9) 57 (37.5) female 148 (88.1) 95 (62.5) mean duration of gallstone disease (years) 1.9±2.9 1.8±2.33 chief presenting complaints (n) biliary colic 55 45 acute cholecystitis 29 15 previous history of pancreatitis 19 21 chronic cholecystitis 45 35 history of jaundice 2 34 table ii: list of comorbidities, laboratory findings and asa levels of both groups group a group b preoperative lab values tlc 8.9±2.81 8.5±2.48 stb 1.02±0.5 0.83±0.29 alt 33.65±19.65 33.65±19.65 alkaline phosphatase 207.86±75.59 207.86±75.59 comorbidities hypertension 46 (27.40%) 39 (25.7%) diabetes mellitus 26 (15.5%) 9 (5.9%) copd 6 (3.6%) 10 (6.6%) bmi class 1 140 (83.3%) 124 (81.6%) class 2 24 (14.3%) 47 (36.9%) class 3 3 (24%) 19 (12.5%) asa level grade 1 88 (52.4%) 86 (52.4%) grade 2 56 (33.3%) 47(30.9%) grade3 24 (14.3%) 19 (12.5%) cardiac issues 16 (9.5%) 10 (6.6%) tlc–total leukocyte count; stb–serum total bilirubin; alt– alanine transaminase; copd–chronic obstructive pulmonary disease; bmi–body mass index; asa–american society of anesthesiologists primary operating surgeon was required to answer several questions regarding difficulty in perform in g cholecystectomy and answers were recorded as “yes” or “no” (table iii). j islamabad med dental coll 2020 51 table iii: list of important perioperative findings in both groups group a n (%) group b n (%) p value* difficulty in dissecting triangle of calot 66 (33.3) 104 (68.4) 0.00 difficulty in dissecting gallbladder from liver bed 77(45.8) 104 (68.4) 0.00 gall bladder fossa bleeding after cholecystectomy 79 (59.5) 95 (62.5) 0.129 need to wash 55 (32.7) 104 (68.4) 0.00 conversion to open procedure 6 (4.2) 0 0.01 mean of total time in minutes$ 41.16±16.69 43.65±17.35 0.19 *p value <0.05 was taken as statistically significant $from insertion of umbilical port to retrieval of gallbladder from same site d i s c u s s i o n laparoscopic cholecystectomy is the gold standard for treatment of symptomatic gallstones owing to lesser post-operative pain, earlier return to work and early mobility along with the additional benefits of better and magnified view.9 however, rate of operative complications if high will obviously nullify the benefits of minimally invasive technique.10 currently sages is working on development of “culture of safety in cholecystectomy”. their goal is to develop laparoscopic cholecystectomy as a procedure in which neither the patient (iatrogenic injury) nor the doctor (litigation) suffers.10 any ongoing inflammation in triangle of calot can obviously increase the risk of procedural complications.11 this is especially relevant in cases where prior ercp is performed for concomitant choledocholithiasis. although minimally invasive, ercp acts like a twoedged sword. maneuvers like sphinteroplasty, cbd cannulation, balloon sweeps and dormia basket retrieval can clear stones from cbd, but induce surrounding inflammation, edema and adhesions formation. they can also trigger pancreatitis and peri-portal inflammation.7,8 hence ercp can potentially obscure normal anatomy. several studies support that post-ercp laparoscopic cholecystectomies are usually difficult because of the need for adhesiolysis and inflammation in calot’s triangle.6 according to multiple studies this can lead to longer operating time and higher risk of conversion to open surgery.9,10 a questionnaire was designed in this study to establish whether various steps were easy or difficult to perform during laparoscopy. it was answered by primary surgeon at end of every procedure. researchers were well aware that perception of difficulty varies between different surgeons and those lacking necessary expertise will grade even a simple case as difficult one. to mitigate this bias, maximum surgeries were done by high volume laparoscopic surgeons (defined as > 15 cases/ year).12 in group b (ercp), significant difficulty was faced in dissecting triangle of calot and in separating gallbladder from liver bed. post cholecystectomy lavage was also performed more frequently in group b than a. surprisingly, there was no significant difference in procedure time in both groups. few international studies quote ercp as one of the predisposing factors of conversion of laparoscopic to open procedure.13-15 in our study, conversion to an o p e n procedure was done only in 3 cases with empye m a in one and perforated gall bladder in two cases. some authors state that rate of conversion to op e n surgery wasn’t affected by cholecystectomy following ercp but by number of ercps a patient had undergone concluding that multiple ercps lead to higher chances of conversion to open procedure.11 thus, the results of our study showed that prior ercp can adversely influence dissection during lc. j islamabad med dental coll 2020 52 this is in contrast with few recent studies. in 2018, fris et al published a meta-analysis in scandinavian journal that recommended early surgery post ercp declaring it safe. the systemic review of data pooled from 14 studies showed that postponing surgery up to 6 weeks post ercp almost tripled the chances of conversion into open procedure.8 similar conclusion was drawn by several other studies as well.16 in our study total hospital stay in both groups was between 4.5 to 7.4 days respectively. this was understandable as in addition to surgery, group b patients had to wait for appointments with gastroenterology department as well, which in tu rn depended upon the availability of endoscope. laparoscopic-endoscopic rendezvous can be one way to shorten the length of this stay. although no t available in our setup, this technique has been proved to be safe and effective world-wide.15-17 another alternative is same-day two-stage approach where both ercp and lc are performed within 24 hours of each other at the index admission. when done in suitable patients, this also improved patients’ quality-of-life, prevented recurrence with a significant cost abatement.17 thus in essence, those who endorse ercp follow e d by laparoscopic cholecystectomy deem it safe and effective12 while the opponents claim that previo u s ercp leads to a more complicated and lengthier cholecystectomy similar to the results of our study.13 c o n c l u s i o n preoperative ercp within 48 hours of laparoscopic cholecystectomy was associated with increased difficulty in dissecting triangle of calot and liver bed but was not associated with longer procedural tim e or conversion to open surgery. r e f e r e n c e s 1. zheng y, xu m, heianza y, ma w5, wang t3,4, sun d, et al. gallstone disease and increased risk of mortality: two large prospective studies in us men and women. j gastroenterol hepatol. 2018, 33(11): 1925-31. doi: 10.1111/jgh.14264 2. zaliekas j, munson jl. complications of gallstones: the mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of “lost” gallstones. surg clin north am. 2008, 88(6): 1345-68. doi:10.1016/j.suc.2008.07.011 3. portincasa p, ciaula ad, bari o, garruti g, palmieri vo, wang dq. management of gallstones and its related complications. expert rev gastroenterol hepatol. 2016, 10(1): 93-112. doi: 10.1586/17474124.2016.1109445 4. wang cc, tsai mc, wang yt, yang tw, chen hy, sung ww et al. role of cholecystectomy in choledocholithiasis patients underwent endoscopic retrograde cholangiopancreatography. scientific reports. 2019 feb 18;9(1):1 -7. doi: 10.1038/s41598 018-38428-z 5. guda nm, freeman ml. overview of ercp complications: prevention and management. inercp and eus. springer, new york, ny. 2015: 37 -56. 6. boerma d, rauws ea, keulemans yc, janssen im, bolwerk cj, timmer r et al.wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. lancet. 2002; 360(9335):761-5. doi: 10.1016/s0140-6736(02)09896-3 7. friis c, rothman jp, burcharth j, rosenberg j. optimal timing for laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography: a systematic review. scand j surg. 2018, 107(2): 99-106. doi: 10.1177/1457496917748224 8. ghadhban br. assessment of the difficulties in laparoscopic cholecystectomy among patients at baghdad province. ann med surg. 2019, 41: 16-9. doi: 10.1016/j.amsu.2019.03.008 9. gupta v, jain g. safe laparoscopic cholecystectomy: adoption of universal culture of safety in cholecystectomy. world j gastrointest surg. 2019, 11(2): 62-84. doi: 10.4240/wjgs.v11.i2.62 10. kama na, doganay m, dolapci m, reis e, atli m, kologlu m. risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery. surg endosc. 2001; 15: 965-68. doi: 10.1007/s00464-0010008-4 11. csikesz ng, singla a, murphy mm, tseng jf, shah sa. surgeon volume metrics in laparoscopic j islamabad med dental coll 2020 53 cholecystectomy. dig dis sci. 2010; 55(8): 2398-405. doi: 10.1007/s10620-009-1035-6 12. chauhan s, masood s, pandy a. preoperative predictors of conversion in elective laparoscopic cholecystectomy. saudi surg j. 2019; 7(1): 14-19. doi: 10.4103/ssj.ssj_37_18 13. ercan m, bostanci eb, teke z, karaman k, dalgic t, ulas m, et al. predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy. j laparoendosc adv surg tech. 2010; 20(5): 427-34. doi:10.1089/lap.2009.0457 14. loor mm, morancy jd, glover jk, beilman gj, statz cl. single-setting endoscopic retrograde cholangiopancreatography (ercp) and chole cystectomy improve the rate of surgical site infection. surg endosc. 2017; 31(12):5135-42. doi:10.1007/s00464017-5579-9 15. rosen m, brody f, ponsky j: predictive factors for conversion of laparoscopic cholecystectomy. am j surg. 2002; 184(3):254-8. doi: 10.1016/s00029610(02)00934-0 16. vettoretto n, arezzo a, famiglietti f, cirocchi r, moja l, morino m. laparoscopic‐endoscopic rendezvous versus preoperative endoscopic sphincterotomy in people undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct. cochrane database syst rev. 2018; 4: cd010507. doi: 10.1002/14651858.cd010507 17. borreca d, bona a, bellomo mp, borasi a, de paolis p. “ultra-rapid” sequential treatment in cholecystocholedocholithiasis: alternative same -day approach to laparoendoscopic rendezvous. updat surg. 2015; 67(4):449-54. doi: 10.1007/s13304-015 0339-7 j islamabad med dental coll 2020 109 open access combined effect of nicotine and caffeine on orthodontic tooth movement in rats naeem murtaza 1 , ahmad shamim 2 , shabbir hussain 3 , muhammad nauman sadiq 2 , muhammad azeem 2 , waheed ul hamid 4 1 assistant professor, department of orthodontics, dental section, faisalabad medical university, faisalabad, pakistan 2 assistant professor, department of orthodontics, de'montmorency college of dentistry, lahore, pakistan 3 assistant professor, department of orthodontics, rashid latif medical & dental college, lahore, pakistan 4 professor/principal, department of orthodontics, de'montmorency college of dentistry, lahore, pakistan a b s t r a c t background: the individual effects of nicotine and caffeine have been reported in previous studies but their combined effect on tooth movement needs to be elucidated. the objective of this study was to evaluate the combined effect of nicotine and caffeine on the magnitude of orthodontic tooth movement (otm) in rats. material and methods: this experimental study was conducted on sprague-dawley rats (animal house and pathology laboratory; post graduate medical institute, lahore) in the department of orthodontics, de’montmorency college of dentistry, lahore from 8 th july 2014 to 8 th january 2015. forty male sprague-dawley rats were divided into four equal groups: control group (cr), nicotine group (nt), caffeine group (cf) and combined nicotine and caffeine group (cnc). closed coil nickel titanium (niti) spring was placed between incisor and maxillary molar. nicotine group (nt) was treated by intraperitoneal injections of nicotine. caffeine was given to caffeine group and combined nicotine and caffeine group (cnc) was treated in the same way as individual nicotine and caffeine groups daily for 14 days. all the rats were sacrificed on 15th day. magnitude of the orthodontic tooth movement was measured using digital vernier caliper. means and standard deviation were calculated for orthodontic tooth movement. one-way anova was used to determine the mean difference in otm. post hoc tukey test was used for multiple comparisons among the groups. results: the mean orthodontic tooth movement (otm) was 0.32 mm ± 0.05 in control group, 0.56 mm ± 0.04 in nicotine group, 0.52 mm ± 0.034 in caffeine group and 0.8 mm ± 0.06 in combined nc group, respectively. the difference between mean otm among the groups was statistically significant (p-value <0.001). the mean otm in cnc group was significantly higher as compared to other groups (cr, nt, cf, nt) (p-value <0.001). conclusions: in rats, the combined use of nicotine and caffeine results in greater orthodontic tooth movement as compared to their individual use. key words: bone remodeling, caffeine, nicotine, orthodontic tooth movement authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; 4-6 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: muhammad azeem email: dental.concepts@hotmail.com article info: received: november 17, 2019 accepted: june 14, 2020 cite this article. murtaza n, shamim a, hussain s, sadiq mn, azeem m, hamid w combined effect of nicotine and caffeine on orthodontic tooth movement in rats. j islamabad med dental coll.2020; 9(2): 109-114. doi: 10.35787/jimdc.v9i2.462 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 110 i n t r o d u c t i o n the orthodontic tooth movement (otm) is based on periodontal ligament (pdl) and alveolar bone remodeling which is a complex process depending upon multiple biological mediators, intercellular and cell to matrix interactions. 1 the applied mechanical force is converted into molecular events that lead to otm through multifold networked reactions in alveolar bone and pdl cells. 2 any change in the biological response may lead to alteration in bone remodeling process and ultimately otm. 3 a number of studies have shown the influence of nicotine on the bone metabolism through its effects on bone remodeling process. 4 nicotine stimulated differentiation of osteoclasts in a porcine marrow cell model. 5 in a rat study, nicotine increased the bone resorption by induction of interleukin -1, a bone resorbing cytokine. 6 similarly a significant increase in the serum levels of bone resorbing cytokines, interleukin-1 (il-1) and interleukin-6 (il-6) after administration of nicotine to sprague-dawley male rats has also been reported. 6,7 investigations on human gingival fibroblasts have shown that nicotine increases the release of prostaglandin e2 (pge2) by increasing the expression of cyclooxygenase-2 (cox-2) which influence bone resorption. 8 on the other hand, it is reported that nicotine decreases the production of type 1 collagen and alkaline phosphatase (alpase) by osteoblasts and suppresses osteogenesis in cultured human osteosarcoma cells. 9 the use of nicotine resulted in significant acceleration in the rate of orthodontic tooth movement in rats. 10 similarly, several studies have demonstrated the effect of caffeine on bone metabolism. caffeine intake is reported to enhance otm in rats through its effect on alveolar bone remodeling. 11 researchers have found association between reduced bone mineral density and caffeine intake in their experiments on rats. 12 otm may be enhanced by daily coffee intake through its effect on bone mineral density. 13 a significant negative relationship between otm and trabecular bone mass is also demonstrated by hashimoto et al. in their study on rats. 14 on the other hand, caffeine is reported to affect the osteoblast function by decreasing 1,25-dihydroxyvitamin d3 stimulated alkaline phosphatase activity, which is an important marker of osteoblastic activity in human osteoblast cells. 15 caffeine is commonly used psychoactive agent by the children and adults because its use is socially acceptable and it is easily available. 16 carbonated and energy drinks, chocolates and coffee are rich sources of caffeine. 17 similarly, nicotine is found in many plants as naturally occurring alkaloid. tobacco and other products like nicotine containing gums are the available sources of nicotine. 18 out of thousands of drugs that are made in the laboratory or found in nature, caffeine and nicotine are among the most widely used legal drugs worldwide. 19 although alterations in otm through changes in bone remodeling process by the individual effects of nicotine and caffeine have been reported in previous studies but their combined effect on otm is not reported so far. many of the young orthodontic patients are simultaneously exposed to nicotine and caffeine thus warranting the need for this study. the null hypothesis was that combined use of nicotine and caffeine increases the orthodontic tooth movement in a rat model. m a t e r i a l a n d m e t h o d s this experimental study was conducted on male sprague-dawley rats, 10-12 weeks old weighing 200gm (±20) in the department of orthodontics, j islamabad med dental coll 2020 111 de’montmorency college of dentistry (dcd), lahore and pathology laboratory, post graduate medical institute, lahore from 8 th july 2014 to 8 th january 2015. all steps described herein conform to the ethical principles for animal research adopted by the us national institutes of health and were approved by ethical review committee of dcd and post graduate medical institute, lahore (protocol number 4320/19.9.2019). the sample size of 40 rats was calculated keeping the power of study at 80% and level of significance to 5%. 10 the 40 rats were randomized by lottery method into 4 groups with 10 rats in each group i.e. control group (cr), nicotine group (nt), caffeine group (cf) and combined nicotine and caffeine group (cnc). the rats were housed in the same room and placed in 8 plastic cages (5 per cage), and acclimated to a 12-hour light/dark cycle for 1 week. they had free access to water and standard laboratory rat chow at a temperature of 21°c and humidity of 55%. nicotine group (nt) was treated by intraperitoneal injections of nicotine, 1mg/1000gm body weight (nicotine tartrate salt, merck, darmstadt, germany, dissolved in normal saline solution). 10 caffeine was given to the caffeine group (cf) as 2.5mg/100gm body weight in drinking water. 11 combined nicotine and caffeine group (cnc) was treated in the same way as individual nicotine and caffeine groups daily for 14 days. before placement of an orthodontic appliance, rats were sedated with intramuscular injection of 1.8 mg/kg ketamine and 1.1 mg/kg xylazine, and distance between distal surface of right maxillary first molar and mesial surface of right maxillary second molar was measured. this was followed by ligation of orthodontic appliance between incisor and right maxillary first molar by laceback wire (morelli, são paulo, sp, brazil), using light cure composite adhesive (transbond xt; 3m/unitek, monrovia, calif) after drilling the tooth surface. 10 this appliance comprised of a nickel titanium (niti) closed coil spring (sentaloy ® , gac, ny) delivering a force of 20 cn, measured using a dynamometer tension gauge (medkraft orthodontics, usa). 6,10 all the rats were sedated at 15th day after the placement of appliance with the help of 5.4 mg/kg ketamine to measure the orthodontic tooth movement. this was measured as the distance between distal surface of right maxillary first molar to mesial surface of right maxillary second molar, using calibrated digital vernier caliper (fowler high precision, newton, mass). data was analyzed using spss version 20. means and standard deviation were calculated for orthodontic tooth movement. one-way anova was used to determine the mean difference in otm. post-hoc tukey test was used for multiple comparisons among the groups. a pvalue ≤0.05 was considered as statistically significant. r e s u l t s the mean orthodontic tooth movement (otm) in cr, nt, cf and cnc groups was 0.32 mm ± 0.05, 0.56 mm ± 0.04, 0.52 mm ± 0.034 and 0.8 mm ± 0.06, respectively. one-way anova was applied to compare the mean otm among groups, which was found to be statistically significant (p-value < 0.001) (figure 1). figure 1: comparison of mean orthodontic tooth movement among different groups for multiple comparisons, post hoc tukey test was used which showed that mean orthodontic tooth j islamabad med dental coll 2020 112 movement in cnc group was significantly greater as compared to other groups (cr, nt, cn) (table i). table i: pair wise comparison of mean orthodontic tooth movement in mm among groups s. no. gp i gp j md (i-j) se pvalue* 1 cr nt -.23900* .02005 < 0.001 cf -.20300* .02005 < 0.001 cnc -.48100* .02005 < 0.001 2 nt cf 0.03600 .02005 0.292 cnc -.24200* .02005 < 0.001 3 cf cnc -.27800* .02005 < 0.001 *p value ≤ 0.05 was considered statistically significant gp-group; md-mean difference; se-standard error d i s c u s s i o n numerous studies have been conducted in the past in order to monitor the effects of different drugs and surgical procedures on otm. 4-6 some of these studies reported that several agents, drugs and surgical procedures enhanced the otm, while other studies proved that the process of otm is slowed down by different stimuli. 7,8 the combined effects of nicotine and caffeine on otm need to be investigated. most of the young smokers exposed to nicotine are simultaneously exposed to caffeine in the form of coffee, chocolates and energy drinks. 19 we selected nicotine and caffeine the two psychoactive agents which are amongst the most extensively used stimulant drugs in the world. 20 one of the main reasons for excessive use is that in most of the countries these drugs are legal even if not freely accessible to everyone. 19 comparatively there is limited knowledge available about the combined effects of these two agents. 21 in this study, rats were used as a model for otm. for the placement of an orthodontic appliance, rats are the preferred choice because mice are too small for an orthodontic appliance to be placed accurately. 22 at present several methods including elastic power chains, other elastic modules and niti springs are being used for application of orthodontic force. however, in case of active modules and elastic chain there is considerable force decay with time which is a potential disadvantage. niti springs are considered an alternative, and are used extensively because these springs have advantage of delivering more consistent force for a longer period of time. 23 for experimental research in the field of orthodontics, application of continuous low force is recommended. 22,24 niti closed coil spring was also used in this study for delivering continuous orthodontic force of 20cn measured with a tension gauge. the experimental animals were sacrificed on the 15th day of administration of combined caffeine and nicotine, to measure the otm. several phases of otm have been established by the past clinical and animal research. 25 in this study the difference in the mean orthodontic tooth movement in all groups was statistically significant (p<0.001), with greater orthodontic tooth movement noted in cnc group and least in cr group in comparison to other groups. the variation in the underlying biological process is accountable for the difference in amount of otm. 15 henemyre et al. investigated the effect of nicotine on calcium and phosphate resorption of porcine osteoclasts and concluded that nicotine enhanced the resorptive function as well as the number of osteoclasts. 5 this effect of nicotine may have contributed to an increase in otm. rapuri et al. reported that caffeine dose dependently decreased the expression of vitamin d receptors and the activity of enzyme alkaline phosphatase in human osteoblasts. 15 this explains the possible mechanism by which bone metabolism is affected by caffeine intake. in our study, the greatest amount of otm was found in cnc group, which was treated with both nicotine and caffeine. however, combined effects of nicotine and caffeine on amount of otm did not turn out as the summative effect of j islamabad med dental coll 2020 113 individual drugs. these two drugs may have variable physiological effects when used in combination. clinical and epidemiological studies suggest a potential interaction between caffeine and nicotine. 26-28 it has long been observed by the orthodontists that response to orthodontic treatment is variable in different individuals in terms of rate of tooth movement. this difference in rate of tooth movement is due to the change in the process of bone remodeling which is induced by the various drugs and other systemic factors. the implication of this study is that a thorough medical history is imperative as a large fraction of young and adult population is exposed to these agents. consequently, it is essential that the orthodontist should pay attention to the social history of every patient to plan the best strategy for treatment including appointment intervals, force level control and duration of treatment for each class. the findings of this study establish that for increased amount of orthodontic tooth movement, the combination of nicotine and caffeine are recommended. the positive effect of combined nicotine and caffeine is an increase in the rate of orthodontic tooth movement, but a negative effect is that it may cause harm to underlying alveolar bone and orthodontic stability in presence of certain medical conditions. 18,19 there are certain limitations of this study. it is an experimental animal study with a limited sample size. findings of an animal study have to be validated through human studies. a limited sample size of animals is an ethical requirement of animal research, which allows researchers to use a minimum number of animals in an experiment. moreover, effect on bone resorption was not investigated. our recommendation is that human studies with larger sample size should be conducted to find out the effect of these agents on orthodontic tooth movement and bone resorption. c o n c l u s i o n in this animal study, the combined use of nicotine and caffeine resulted in greater orthodontic tooth movement as compared to their individual use. it is recommended that human studies with larger sample size should be conducted to further find out the effect of these agents on orthodontic tooth movement. r e f e r e n c e s 1. meikle mc. the tissue, cellular, and molecular regulation of orthodontic tooth movement: 100 years after carl sandstedt. eur j orthod. 2006; 28(3): 221-40. doi: 10.1093/ejo/cjl001 2. masella rs, meister m. current concepts in the biology of orthodontic tooth movement. am j orthod dentofacial orthop. 2006; 129(4): 458-68. doi: 10.1016/j.ajodo.2005.12.013 3. diravidamani k, sivalingam sk, agarwal v. drugs influencing orthodontic tooth movement: an overall review. j pharm bioallied sc. 2012; 4(suppl 2): s299. doi: 10.4103/0975-7406.100278 4. hermizi h, faizah o, ima-nirwana s, ahmad nazrun s, luke da, norazlina m. nicotine impaired bone histomorphometric parameters and bone remodeling biomarkers in sprague–dawley male rats. ann microsc. 2007; 7: 10-24. 5. henemyre cl, scales dk, hokett sd, cuenin mf, peacock me, parker mh, et al. nicotine stimulates osteoclast resorption in a porcine marrow cell model. j periodontol. 2003; 74(10): 1440-6. doi: 10.1902/jop.2003.74.10.1440 6. nozrazlina m, hapidin h, othman f, norliza m, shuid an, soelaiman in. vitamin e reversed nicotine-induced toxic effects on bone biochemical markers in male rats. arch med sci. 2010; 6(4): 505– 12. doi: 10.5114/aoms.2010.14460 7. hapidin h, othman f, soelaiman in, shuid an, luke da, mohamed n. negative effects of nicotine on bone-resorbing cytokines and bone histomorphometric parameters in male rats. j bone j islamabad med dental coll 2020 114 miner metab. 2007; 25(2): 93-8. doi: 10.1007/s 00774-006-0733-9 8. nakao s, ogata y, sugiya h. nicotine stimulates the expression of cyclooxygenase-2 mrna via nfκb activation in human gingival fibroblasts. arch oral bio. 2009; 54(3): 251-7. doi: 10.1016/j.archoral bio.2008.11.006 9. tanaka h, tanabe n, suzuki n, shoji m, torigoe h, sugaya a, motohashi m, et al. nicotine affects mineralized nodule formation by the human osteosarcoma cell line saos-2. life sci. 2005; 77(18): 2273-84. doi: 10.1016/j.lfs.2005.02.022 10. sodagar a, donyavi z, arab s, kharrazifard mj. effect of nicotine on orthodontic tooth movement in rats. am j orthod dentofacial orthop. 2011; 139(3): e261-5. doi: 10.1016/j.ajodo.2010.08.018 11. peng s, chun hy. effect of caffeine on alveolar bone remodeling during orthodontic tooth movement in rats. j tongji med univ. 2011;3. 12. lacerda sa, matuoka ri, macedo rm, petenusci so, campos aa, brentegani lg. bone quality associated with daily intake of coffee: a biochemical, radiographic and histometric study. braz dent j. 2010; 21(3): 199-204. doi: 10.1590/s0103-6440201 0000300004 13. yi j, zhang l, yan b, yang l, li y, zhao z. drinking coffee may help accelerate orthodontic tooth movement. dent hypotheses. 2012; 3(2): 72. doi: 10.4103/2155-8213.100391 14. hashimoto m, hotokezaka h, sirisoontorn i, nakano t, arita k, tanaka m, et al. the effect of bone morphometric changes on orthodontic tooth movement in an osteoporotic animal model. angle orthod. 2013; 83(5): 766-73. doi: 10.2319/111312869.1 15. rapuri pb, gallagher jc, nawaz z. caffeine decreases vitamin d receptor protein expression and 1, 25 (oh) 2d3 stimulated alkaline phosphatase activity in human osteoblast cells. j steroid biochem mol biol. 2007; 103(3-5): 368-71. doi: 10.1016/j.jsbmb. 2006.12.037 16. temple jl. caffeine use in children: what we know, what we have left to learn, and why we should worry. neurosci biobehav rev. 2009; 33(6): 793-806. doi: 10.1016/j.neubiorev.2009.01.001 17. babu km, church rj, lewander w. energy drinks: the new eye-opener for adolescents. clin ped emerg. 2008; 9(1): 35-42. doi: 10.1016/j.cpem. 2007.12.002 18. yildiz d. nicotine, its metabolism and an overview of its biological effects. toxicon. 2004; 43(6): 619-32. doi: 10.1016/j.toxicon.2004.01.017 19. jerome h, koobgf. substance abuse and addiction. dana guide. 2007. 20. crocq ma. alcohol, nicotine, caffeine, and mental disorders. dialogues clin neurosci. 2003; 5(2): 175. pmid: 22033899 21. johnson mw, strain ec, griffiths rr. effects of oral caffeine pretreatment on response to intravenous nicotine and cocaine. exp clin psychopharmacol. 2010; 18(4): 305. doi: 10.1037/a0020509 22. ren y, maltha jc, kuijpers-jagtman am. the rat as a model for orthodontic tooth movement—a critical review and a proposed solution. eur j ortho. 2004; 26(5): 483-90. doi: 10.1093/ejo/26.5.483. 23. dixon v, read mj, o'brien kd, worthington hv, mandall na. a randomized clinical trial to compare three methods of orthodontic space closure. j orthod. 2002; 29(1): 31-6. doi: 10.1093/ortho/ 29.1.31 24. van leeuwen ej, maltha jc, kuijpers‐jagtman am. tooth movement with light continuous and discontinuous forces in beagle dogs. eur j oral sci. 1999; 107(6): 468-74. doi: 10.1046/j.0909-8836. 1999.eos107608.x 25. proffit wr, fields hw, sarver dm. contemporary orthodontics, mosby, st. louis, mo, usa. 2000. 26. jones he, griffiths rr. oral caffeine maintenance potentiates the reinforcing and stimulant subjective effects of intravenous nicotine in cigarette smokers. psychopharmaco. 2003; 165(3): 280-90. doi: 10.100 7/s00213-002-1262-4 27. gilbert dg, dibb wd, plath lc, hiyane sg. effects of nicotine and caffeine, separately and in combination, on eeg topography, mood, heart rate, cortisol, and vigilance. psychophysio. 2000; 37(5): 583-95. 28. blank md, kleykamp ba, jennings jm, eissenberg t. caffeine's influence on nicotine's effects in nonsmokers. am j health behav. 2007; 31(5): 47383. doi: 10.5555/ajhb.2007.31.5.473 j islamabad med dental coll 2022 96 open access future trends in the treatment of mrsa in pakistan zarafsahn badar1, muhammad noor ul amin2,ayesha janjua3, azhar iqbal4, sobia humerah5, pakeeza arzoo shaiq6. 1,3associate professor, department of pharmacology, foundation university islamabad. 2medical technologist, department of pathology, rawalpindi institute of cardiology, rawalpindi. lab technician, department of pathology, holy family hospital, rawalpindi. 5associate professor, department of physiology, alnafees medical college, isra university, islamabad. 6assistant professor, university institute of biochemistry and biotechnology, pmas arid agriculture university, rawalpindi. a b s t r a c t background: the methicillin resistant staphylococcus aureus (mrsa) is accountable for community and hospital acquired infections. due to over and misuse of antibiotics, mrsa isolates are becoming multidrug resistant even with linezolid and vancomycin. the objective of this study was to determine recent antimicrobial profile of mrsa, isolated from different clinical samples and current treatment options for mrsa, other than vancomycin and linezolid. methodology: this cross-sectional study was conducted at foundation university medical college from jan 2019 to dec 2020. total 918 samples of blood, pus swab, throat swab, tracheal swab, wound swab, endotracheal tube (ett) tips, catheter tips, axillary swab and suction tips received by using aseptic techniques, for culture and sensitivity in different hospitals of rawalpindi and islamabad, were taken. isolated pathogens were identified using standard protocols and susceptibility testing was done by kirby-bauer disc diffusion method. results: out of 918 samples, mrsa was isolated in 96 (10.4%) samples and most frequently observed in 27% (n=26) blood samples. the mean age of enrolled patients was 52.02 (sd±16.1) years, the infection was largely seen in age group 46-55(24%) and in 57% (n=52) male population. mrsa showed higher resistance to levofloxacin 78.1% (n=75), ciprofloxacin 75% (n=72), erythromycin 70.8% (n=68) and gentamycin 62.5% (n=60). the susceptibility of older drug chloramphenicol and trimethoprim-sulfamethoxazole was found 61% & 49% respectively. mrsa isolates were highly susceptible to vancomycin (96.8%), linezolid (89.5%) and teicoplanin (70.85%). alarmingly, 2.1% (n=2) mrsa isolates showed resistance to vancomycin. conclusion:vancomycin resistant mrsa is a matter of great concern, because of unawareness among health administrative departments and public, self-medication, lack of surveillance system and non-availability of antibiotic policy. keywords: antibiotics, mrsa, vancomycin, chloramphenicol authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; 6manuscript editing. correspondence: muhammad noor ul amin email: noorulaminamin@yahoo.com article info: received: september 18, 2021 accepted: june 9, 2022 cite this article.badar z, amin n, janjua a, iqbal a, humaira s, shaiq pa. future trends in the treatment of mrsa in pakistan. j islamabad med dental coll. 2022; 11(2):96-102. doi: https://doi.org/10.35787/jimdc.v11i2.672. funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2022 96 i n t r o d u c t i o n surprisingly not long after the historical development of penicillin, the adaptive power of staphylococcus has led to the dawn of the era of methicillin resistant staphylococcus aureus (mrsa) infections. mrsa is notorious for developing resistance in treatment of infections ranging from minor skin infections to life-threatening full-blown sepsis.1 by and large, the problem of antibiotic resistance is on the rise due to extensive and irrational use of antibiotics along with self-medication and its impact is more, in low and middles income countries where infection rates are high due to unhygienic environment and poor health facilities.1,2 misuse and overuse of the antibiotics also helps in natural bacterial evolution and selection which becomes resistant to wide range of antibiotics.2 nosocomial mrsa infections are more prevalent and reluctant although the incidence of community acquired mrsa is also escalating. healthcareassociated mrsa is a truly opportunistic pathogen, which causes infection in otherwise seriously ill patients, or those who have undergone major surgery, patients on hemodialysis, and with an indwelling catheters and bed sores. the bug is also inhabitant of nursing homes. moreover, healthcareassociated infections caused by mrsa significantly increase the costs of hospital treatment.3 as limited numbers of antibiotics are effective against this super-bug, the mainstay of treatment is vancomycin. recently the development of resistance against the glycopeptide, vancomycin is of concern and poses a challenge in the treatment of resilient mrsa infections. decline in the development of new antibiotics in the setting of rapidly developing resistance against the existing ones make the circumstances worse.4,5 the consequential rise in the incidence of nosocomial infections due to mrsa poses a great threat to indoor patients and the medical personnel. this necessitates us to determine a standard empirical therapy depending upon the sensitivity of the organism to various drugs at a particular place. targeting the bacteria early in a course of infection can improve survival, prevent complications and reduce the health care cost. to accomplish this goal, a standard empirical therapy from time to time by scrutinizing sensitivity pattern in a health care facility is essential.6 therefore, this study was designed to determine the current antimicrobial profile of mrsa isolates, obtained from patients who visited hospitals of twin cities. the main objective of this study was to find out current treatment options for mrsa other than vancomycin, linezolid (oral), telavancin and ceftaroline (intravenous). m e t h o d o l o g y this cross-sectional study was conducted at department of pharmacology, foundation university medical college, rawalpindi after the acceptance from ethical committee. a total of 918 (calculated by raosaft sample size calculator) samples of blood, pus swab, throat swab, tracheal swab, wound swab, endotracheal tube (ett) tips, catheter tips, axillary swab and suction tips received by using aseptic techniques, for culture and sensitivity in different hospitals of rawalpindi and islamabad, during study period from january 2019 to december 2020 were taken. all submitted specimens except blood were inoculated on blood agar, macconkey agar and chocolate agar (oxoiduk) according to specimen type and incubated at 35±2oc for 24 hours. blood samples were inoculated into bact alert (biomerieux) and bactec (bd) at 37oc for 5 to 7days. bacterial isolates were identified by using standard identification protocols which includes colony morphology, gram staining and biochemical tests j islamabad med dental coll 2022 97 such as catalase test, slide and tube coagulase test, deoxy ribonuclease activity and api staph.7 the confirmed s. aureus isolates were processed further for antimicrobial susceptibility testing by kirby-bauer disc diffusion method as per clinical laboratory standard institute (clsi) guidelines. the antibiotics included ampicillin, amoxicillin, amoxicillin + clavulanic acid, erythromycin, levofloxacin, ciprofloxacin, amikacin, tigecycline, gentamicin, rifampicin, teicoplanin, linezolid, sulfamethoxazole + trimethoprim, fosfomycine, vancomycin, quinupristin/dalfopristin, doxycycline, chloramphenicol, nitrofurantoin and mrsa was confirmed by applying cefoxitin (30 µg) discs on muller hinton agar and incubating at 37oc for 24 hours. the zone sizes of all antibiotics including cefoxitin were measured and according to clsi standards (clsi m100-s25) the categorization of isolates as susceptible, intermediate, or resistant was done. the staphylococcus aureus isolates with zone size of cefoxitin< 21 mm were considered as mrsa.7 r e s u l t s out of 918 samples, mrsa were isolated in 96 (10.4%) samples. mrsa were largely isolated in blood samples followed by pus and urine samples with the frequency of 26 (27.0%), 22 (23.0%) and 14 (14.6%) respectively (table 1). in our study population, the frequency of mrsa infection was found in 55 (57.3%) males and 41 (42.7%) female population (figure 1). the mean age of enrolled patients was 52.02 years (sd±16.1) ranging from 06 to 85 years. the staphylococcus aureus infection was seen in all age groups but largely in age group 46-55 years with the percentage of 24.0% (n=23) (table 2). the drug resistant pattern according to clsi (2017) standards other than cefoxitin is given in table 3. it clearly shows that vancomycin resistant strains are only 2% whereas linezolid resistance is 8%. 61% of the strains are susceptible to older drug chloramphenicol and 49% to trimethoprimsulfamethoxazole. it was found that quinolones antibiotics (levofloxacin and ciprofloxacin) are highly resistant to mrsa 78.1% and 75.0% respectively (table 3). mrsa isolated from urine samples was highly sensitive to nitrofurantoin (71.5%). hvs= high vaginal swab table i: distribution of mrsa in different types of specimen specimen frequency (percentage %) blood 26 (27.0) urine 14 (14.6) catheter tip 5 (5.2) fluids 8 (8.4) throat swab 3(3.1) hvs 4 (4.2) pus 22 (22.9) sputum 3 (3.1) wound swab 9 (9.4) tissue 2 (2.1) total 96 (100) table ii: age wise distribution of mrsa age group (years) frequency (percentage %) 06-15 5 (5.2) 16-25 09 (9.4) 26-35 13 (13.5) 36-45 10 (10.4) 46-55 23 (24.0) 56-65 17 (17.7) 66-75 15 (15.6) 76-85 04 (4.2) total 96 (100) j islamabad med dental coll 2022 98 figure 1: gender distribution of mrsa positive patients. table iii: sensitivity pattern of mrsa isolates name of antibiotic susceptible frequency (%) resistant frequency (%) intermediate frequency (%) ampicillin 0 96 (100) 0 oxacillin 0 96 (100) 0 amoxicillin and clavulanate 0 96 (100) 0 erythromycin 24 (25.0) 68 (70.8) 04 (4.2) levofloxacin 16 (16.7) 75(78.1) 05 (5.2) ciprofloxacin 19 (19.8) 72 (75.0) 05 (5.2) amikacin 43(44.8) 50 (52.0) 03 (3.2) t i g e c y c l i n e 57 (59.4) 35 (36.5) 02 (2.1) gentamicin 30 (31.2) 60 (62.5) 06 (6.3) rifampicin 66 (68.8) 24 (25.0) 06 (6.2) teicoplanin 68 (70.8) 24 (25.0) 04 (4.2) linezolid 86 (89.5) 08 (8.4) 02 (2.1) trimethoprimsulfamethoxazole 47(49.0) 42 (43.7) 07 (7.3) vancomycin 93 (96.8) 02 (2.1) 01 (1.1) quinupristin /dalfopristin 59 (61.4) 28 (29.2) 09 (9.4) doxycycline 49 (51.0) 40 (41.7) 07 (7.3) chloramphenicol 59 (61.4) 30 (31.2) 07 (7.3) fosfomycin 08 (57.2) 05 (35.7) 01 (7.1) nitrofurantoin 10 (71.5) 03 (21.4) 01 (7.1) j islamabad med dental coll 2022 1 d i s c u s s i o n misuse and overuse of the antibiotics helps in natural bacterial evolution and selection which becomes resistant to wide range of drugs. today staphylococcus aureus is one of the most common causes of healthcare-associated infections, causing 40-70% of infections of intensive care units and quite a few of them are mrsa.8 in this study, mrsa was isolated in 10.4% population, mainly from admitted patients in surgical units of different hospital of twin cities. the epidemiology of mrsa is increasing yearly and the incidence of mrsa in different cities of pakistan varies from 2% to 60% due to difference in clinical practices and adherence to standard infection control guidelines. 9,10 it was found that all mrsa isolated in this study were resistant to beta-lactam antibiotics (amoxicillin, ampicillin, oxacillin and amoxicillin/clavulanate). high resistance of mrsa was seen to erythromycin, levofloxacin and ciprofloxacin with the frequency of 68 (70.8%), 75 (78.1%) and 72 (75.0%) respectively. the resistant frequencies of erythromycin (70%, 69.1% & 65%) reported in previous studies is in line with our results which is 70.8%. the ciprofloxacin resistance (33.7% and 47%) was lower in these studies as compared to our study (75%).9,11,12 in present study, mrsa resistance to gentamicin was found to be 62.5%, while the studies conducted in lahore and peshawar reported higher resistance 97.6% and 100% respectively.9,10 mrsa resistance to rifampicin was found 25.0 %, while low resistance of rifampicin such as 18.8%, 14.0% and 7.0 % reported in previous studies.13,14. siddique et al 2017 demonstrated slightly higher resistance (28.0%) of mrsa towards rifampicin as compared to the present study.9 the present study has reported 31.2% resistance of mrsa against chloramphenicol which was in accordance with the study of khan et al 2014 who had reported 29.41% resistance.10 the study conducted in karachi reported (5.3%) low resistance of mrsa to chloramphenicol.9 in this study we documented that 49% isolated mrsa were sensitive to trimethoprim-sulfamethoxazole which were higher than what was reported (3.9%) in 2011.9 other studies conducted in pakistan reported 51% & 54.17% sensitivity of mrsa to cotrimoxazole which were slightly higher than this study.10,14 the studies conducted in nigeria, jordan and iran reported co-trimoxazole sensitivity 56.9%, 58.4% and 73.5% respectively.14,15 due to the neglected use of co-trimoxazole, bacteria may now have been susceptible. this can mark resurgence in the use of this inexpensive easily available oral antibiotic. isolated mrsa showed high sensitivity to vancomycin, linezolid, nitrofurantoin (for urine isolates), teicoplanin, rifampicin, chloramphenicol, quinupristin/dalfopristin, tigecycline fosfomycine while intermediate sensitivity was seen with cotrimoxazole and amikacin in our study. vancomycin showed complete resistance to 2.1% of the isolates and intermediate resistance to 1.1% of cases. this is less than that reported in a similar study in ethopia.16 a retrospective study done in 2017 showed 5% resistance to vancomycin whereas comparable studies in the past also showed lesser resistance which is consistent with our study.14,17 interestingly, mrsa is still reported to be 100% susceptible to vancomycin in a recent study done in afghanistan.18 although, vancomycin remains the drug of choice for mrsa infections; the augmentation in development of resistance to vancomycin by mrsa in recent years is in the background of escalating incidence of mrsa infections and continued use of the glycopeptide itself.19 this has also been emphasized in a systematic review published by abubakar and sulaiman.20 j islamabad med dental coll 2022 100 linezolid (lzd) is broad-spectrum oxazolidinone effective against central nervous system infections, mrsa acute bacterial endocarditis and mrsa hospital-acquired pneumonia. oral administration coupled with a favorable side-effect not only provides economic benefits but is also contributing to the rapid development of resistance against this valuable armor. in our study,89.5% of the isolates were susceptible to lzd.20 the findings are consistent with those reported from lahore in which 90% were sensitive to lzd.21 from various areas of india, lzd resistance reported in literature ranges from 2-20%.22 however, resistance to lzd has been reported as high as 48% in a study conducted in pakistan.23 c o n c l u s i o n vancomycin resistant mrsa is a matter of great concern, because of unawareness among health administrative departments and public, shortage of funds, lack of surveillance system and research concerning mrsa infections. r e c o m m e n d a t i o n an important aspect highlighted from our study is that we can advocate the use of inexpensive and older drugs like co-trimoxazole and chloramphenicol in multidrug resistant mrsa infections. it is also recommended that administration of glycopeptides should be based on the sensitivity pattern and local epidemiology. sale of drugs over the counter, including antibiotics round the clock to the public, self-medication, wide spread quackery and over prescription of antibiotics by doctors to patients is few of the major causes of high resistance to infections. hence awareness can be generated through campaigns. being health personnel, we must use antibiotics judiciously and within our limited resources we must maintain a system of scrutiny in all hospitals. r e f e r e n c e s 1. kashef n, hamblin mr. can microbial cells develop resistance to oxidative stress in antimicrobial photodynamic inactivation? drug resistance updates. 2017 mar 1;31:31-42. doi: 10.1016/j.drup.2017.07.003 2. gurung rr, maharjan p, chhetri gg. antibiotic resistance pattern of staphylococcus aureus with reference to mrsa isolates from pediatric patients. future science oa. 2020 feb 24;6(4):fso464. doi: 10.2144/fsoa-2019-0122. 3. ayukekbong ja, ntemgwa m, atabe an. the threat of antimicrobial resistance in developing countries: causes and control strategies. antimicrobial resistance & infection control. 2017 dec;6(1):1-8. doi: 10.1186/s13756-017-0208-x 4. alseqely m, newton-foot m, khalil a, el-nakeeb m, whitelaw a, abouelfetouh a. association between fluoroquinolone resistance and mrsa genotype in alexandria, egypt. scientific reports. 2021 feb 19;11(1):1-9. doi: 10.1038/s41598-021-83578-2 5. blaskovich ma, hansford ka, butler ms, jia z, mark ae, cooper ma. developments in glycopeptide antibiotics. acs infectious diseases. 2018 jan 24;4(5):715-35. doi: 10.1021/acsinfecdis.7b00258 6. wangai fk, masika mm, maritim mc, seaton ra. methicillin-resistant staphylococcus aureus (mrsa) in east africa: red alert or red herring?. bmc infectious diseases. 2019 dec;19(1):1-0. doi: 10.1186/s12879-019-4245-3 7. becker k, skov rl, von eiff c. staphylococcus, micrococcus, and other catalase‐positive cocci. manual of clinical microbiology. 2015 may 15:35482. doi: 10.1128/9781555817381 8. avershina e, shapovalova v, shipulin g. fighting antibiotic resistance in hospital-acquired infections: current state and emerging technologies in disease prevention, diagnostics and therapy. frontiers in microbiology. 2021:2044. doi 10.3389/fmicb.2021.707330 9. siddiqui t, muhammad in, khan mn, naz s, bashir l, sarosh n, et al. mrsa: prevalence and susceptibility pattern in health care setups of karachi. pak j pharm sci. 2017 nov 1;30(suppl 6):2417-21. doi: emr-190229 10. khan at, jamil k, farooqi n, bilal m, hussain i. frequency of methicillin resistant staphylococcus aureus in patients referred from other specialties and its antimicrobial susceptibility and resistance https://doi.org/10.1016/j.drup.2017.07.003 https://doi.org/10.1186/s13756-017-0208-x https://doi.org/10.1038/s41598-021-83578-2 https://doi.org/10.1021/acsinfecdis.7b00258 https://doi.org/10.1186/s12879-019-4245-3 j islamabad med dental coll 2022 101 pattern. journal of medical sciences. 2014 mar 3;22(1):28-31. 11. de jonge s, boldingh q, solomkin j, dellinger p, egger m, salanti g, et al. conference on prevention & infection control (icpic 2019). antimicrobial resistance and infection control. 2019;8(1):148. doi: 10.1186/s13756-019-0567-6 12. brohi na, noor aa. frequency of the occurrence of methicilin resistant staphylococcus aureus (mrsa) infections in hyderabad, pakistan. pakistan journal of analytical & environmental chemistry. 2017 jun 22;18(1):84-90. doi: 10.21743/pjaec/2017.06.08 13. mir f, rashid a, farooq m, irfan m, ijaz a. antibiotic sensitivity patterns of staphylococcal skin infections. journal of pakistan association of dermatology. 2016 nov 22;25(1):12-7. 14. motamedi h, asghari b, tahmasebi h, arabestani mr. identification of hemolysine genes and their association with antimicrobial resistance pattern among clinical isolates of staphylococcus aureus in west of iran. advanced biomedical research. 2018;7. doi: 10.4103/abr.abr_143.18 15. al-zoubi ms, al-tayyar ia, hussein e, al jabali a, khudairat s. antimicrobial susceptibility pattern of staphylococcus aureus isolated from clinical specimens in northern area of jordan. iranian journal of microbiology. 2015 oct;7(5):265. doi: pmid-26719783 16. dilnessa t, bitew a. prevalence and antimicrobial susceptibility pattern of methicillin resistant staphylococcus aureus isolated from clinical samples at yekatit 12 hospital medical college, addis ababa, ethiopia. bmc infectious diseases. 2016 dec;16(1):1-9. doi: 10.1186/s12879-0161742-5 17. hanif e, hassan sa. evaluation of antibiotic resistance pattern in clinical isolates of staphylococcus aureus. pak j pharm sci. 2019 may 1;32(4):1749-53. doi: 31680068. 18. naimi hm, rasekh h, noori az, bahaduri ma. determination of antimicrobial susceptibility patterns in staphylococcus aureus strains recovered from patients at two main health facilities in kabul, afghanistan. bmc infectious diseases. 2017 dec;17(1):1-7. doi: 10.1186/s12879017-2844-4. 19. morrisette t, alosaimy s, abdul-mutakabbir jc, kebriaei r, rybak mj. the evolving reduction of vancomycin and daptomycin susceptibility in mrsa—salvaging the gold standards with combination therapy. antibiotics. 2020 nov;9(11):762. doi: 10.3390/antibiotics9110762 20. abubakar u, sulaiman sa. prevalence, trend and antimicrobial susceptibility of methicillin resistant staphylococcus aureus in nigeria: a systematic review. journal of infection and public health. 2018 nov 1;11(6):763-70. doi: 10.1016/j.jiph.2018.05.013. 21. markwart r, willrich n, eckmanns t, werner g, ayobami o. low proportion of linezolid and daptomycin resistance among bloodborne vancomycin-resistant enterococcus faecium and methicillin-resistant staphylococcus aureus infections in europe. frontiers in microbiology. 2021;12. doi. 10.3389/fmicb.2021.664199 22. azhar a, rasool s, haque a, shan s, saeed m, ehsan b,et al. detection of high levels of resistance to linezolid and vancomycin in staphylococcus aureus. journal of medical microbiology. 2017 sep 1;66(9):1328-31. doi: 10.1099/jmm.0.000566. 23. shariq a, tanvir sb, zaman a, khan s, anis a, khan ma,et al. susceptibility profile of methicillinresistant staphylococcus aureus to linezolid in clinical isolates. international journal of health sciences. 2017 jan;11(1):1. doi: pmid. 2293153. http://dx.doi.org/10.21743/pjaec/2017.06.08 https://dx.doi.org/10.1186%2fs12879-016-1742-5 https://dx.doi.org/10.1186%2fs12879-016-1742-5 187 j i m d c 2 0 1 7 187 op e n ac c e ss c a s e r e p o r t chronic gallstone disease presenting as cholecystoduodenal fistula sajid ali 1, mohammad zarin 2 1 post graduate resident, department of surgery, khyber teaching hospital peshawar 2 associate professor department of surgery khyber teaching hospital peshawar (khyber teaching hospital peshawar) a b s t r a c t cholecystoduodenal fistula (cdf) is the most common cholecystoenteric fistula. it is a late complication of gallbladder disease with calculus and is mainly encountered in the elderly and females. we report the case of a 60 years’ female patient with cholecystoduodenal fistula and gallstones. she had recurrent attacks of abdominal pain with anorexia and vomiting. ultrasound abdomen demonstrated air in the biliary system. computed tomography abdomen revealed pnemobilia and cdf tract. we did cholecystectomy and repair of cdh tract through modified graham’s repair. this case report suggests the importance of knowing the biliary anatomy through pre-op magnetic resonance cholongio pancreatography (mrcp) or mri abdomen and planning definitive procedure for bilioenteric fistulas. the patient’s clinical features and operative management are presented and discussed with current literature. key words: bilioenteric fistula, cholecystoduodenal fistula, chronic cholecystitis. address of correspondence sajid ali email: dralisajid89@gmail.com article info. received: august 24, 2017 accepted: september 12, 2017 cite this case report: ali s, zarin m. chronic gallstone disease presenting as cholecystoduodenal fistula.. jimdc;6(3):187-189. funding source: nil conflict of interest: nil i n t r o d u c t i o n cholelithiasis is a common health condition and only few patients (around 1–3%) develop rare complications such as choledochoduodenal fistulas.1 chronic cholecystitis with gallstones is the primary etiology in as many as 75% of cdf patients.3 the formation of biliroenteric fistula is initiated when the walls of the gallbladder and adjacent bowel are chronically inflamed and adherent. increasing intraluminal pressure caused by obstruction leads to local ischemia and necrosis and ultimately communication.2 cholecystoduodenal fistula is a difficult problem usually diagnosed intra-operatively and is the most common indication of conversion from laparoscopic to open surgery. a high degree of suspicion is mandatory in difficult cases during surgery to prevent complications. the treatment for cdf is cholecystectomy and closure of fistulous communication. the laparoscopic stapling technique has been reported as feasible and safe methods to treat such fistula. endostapler device is easy to use and is effective. the fistulous tract should be dissected clearly to demonstrate all-around anatomy and create adequate space to apply the endostapler.3 c a s e r e p o r t s a 60 years old non-diabetic non-hypertensive patient presented to our ward with 40 days’ history of pain in abdomen associated with anorexia and vomiting. she also gave a history of chronic constipation for which she was using on/off sodium picosulfate. there was no history of fever, jaundice or weight loss. on examination, she was found to have tender right hypochondrium and epigastric region and distended abdomen. vitals were bp: 130/80 mmhg, pulse 90/min, rr 18/min, and temperature: 990f. ultrasound abdomen and pelvis showed thickened irregular gallbladder with a gallstone which was 7.8mm. total leukocyte count was 11300/ cmm, hb 8.7gm/dl, platelets count 432000cmm, serum c a s e r e p o r t 188 j i m d c 2 0 1 7 188 amylase 50u/l, total bilirubin 0.47mg/dl, serum alkaline phosphatase 285u/l (up to 275), alt 42u/l, urea 63.5mg/dl, creatinine 1.43mg/dl, albumin 1.61mg/dl (3.56.5),s globulin 3.08 (1.8-3.6), serum calcium 8.7mg/dl. esr was 120mm 1st hour. she was started on conservative management with iv fluids, iv cefuroxime figure 1: abdominal ct scan showing pnemobilia and fistulous communication between gallbladder and duodenum 1.5gm b.d, painkillers and ppis, but patient did not improve clinically and ct abdomen and pelvis was done which showed pnemobilia and fistulous communication. one day before surgery her investigations were: hb 11.5gm/dl after two units of blood transfusions. tlc 15500cmm, platlets count 361000cmm, s bilirubin 0.91mg/dl, salpo4 265u/l (upto 275), alt 20u/l (10-40), urea 19mg/dl, creatinine 0.96mg/dl, pt control: 13sec, patient: 15sec, aptt control 28sec, patient 28sec.exploratory laparotomy was done through an upper midline incision and the following findings were noted • perforated gallbladder • cholecystoduodenal fistula • and gross ascites procedure done was • gallbladder resected • duodenal defect closed with omentum (modified grahams repair) • thorough wash and suction done • two drains placed one in right side of subhepatic space and second in left side in pelvis the patient was shifted to surgical intensive care unit for post-operative care. where she spent 2 weeks before fully stabilized and then was shifted to parent surgical e ward where she spent another week and was discharged successfully. the patient had no complications during 6months of follow-up. d i s c u s s i o n cholelithiasis is a common problem and cholecystoduodenal fistula is a rare complication of chronic gallstone disease.1,3 cholecystoduodenal type accounts for as many as 80% of cholecystoenteric fistulas.4 cholecystoduodenal fistula is generally considered a relative contraindication to laparoscopic cholecystectomy because of difficulties in its management intra-operatively. they are of two types non-obstructive and obstructive type, the former can present with cholangitis, weight loss and malabsorption syndrome while the latter with gallstone ileus or bouveret syndrome, hematemesis or melena. mri abdomen and mrcp should be ordered pre-operatively to delineate anatomy of biliary channels. diagnosis can be a challenge and preoperative ultrasound, as well as ct scan of abdomen, may reveal pneumobilia.5-7 a cholecystoduodenal fistula is generally considered to be a relative contraindication to laparoscopic cholecystectomy because of difficult anatomy and risk of injuries to the duodenum and surrounding structures intra-operatively but studies have shown that laparoscopic technique can be implied if expertise are available with same principles of the careful release of adhesions cholecystectomy and closure of fistulous track with endostapling device.8,9 careful preoperative workups for such patients should be done in order to plan definite treatment i.e. cholecystectomy and closure of fistulous tract.3,4 c o n c l u s i o n a cholecystoduodenal fistula is a rare complication of chronic gallstone disease and therefore there should be a 189 j i m d c 2 0 1 7 189 high index of suspicion of biliary enteric fistula in chronic gallstone disease when patients present with the bizarre clinical picture. r e f e r e n c e s 1. thomson wl, miranda s, reddy a. an unusual presentation of cholecystoduodenal fistula: vomiting of gallstones. bmj case reports. 2012; bcr2012007009. 2. nickel f, müller-eschner mm, chu j, von tengg-kobligk h, müller-stich bp. bouveret’s syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy. bmc surgery. 2013; 13(1) :33. 3. col nd. successful laparoscopic management of four cases of cholecystoduodenal fistula. medical journal armed forces india. 2012; 68(1):88-9. 4. constant e, turcotte jg. choledochoduodenal fistula: the natural history and management of an unusual complication of peptic ulcer disease. annals of surgery. 1968; 167(2):220. 5. hill bc, burke lh, ertl cw. cholecystoduodenal fistula in a patient post-roux-en-y gastric bypass. bmj case reports. 2013; bcr2013200562. 6. arfin sq, haqqi sa, shaikh h, wakani aj. bouveret's syndrome: successful endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone. journal of the college of physicians and surgeons pakistan. 2012; 22(3):174-5. 7. derici h, kara c, bozdag ad, nazli o, tansug t, akca e. diagnosis and treatment of gallbladder perforation. world journal of gastroenterology: wjg. 2006; 12(48):7832. 8. faridi ms, pandey a. mirizzi syndrome type ii with cholecystoduodenal fistula: an infrequent combination. the malaysian journal of medical sciences: mjms. 2014; 21(1): 69. 9. cahow jr ce, glenn f. sequelae attributed to delayed surgical treatment of gallstones. annals of surgery. 1965; 161(1):21. j islamabad med dental coll 2019 99 o p e n a c c e s s maternal health in pakistan: where do we stand? farah rashid1, sara makhdoom2 1 professor and head, department of community medicine, islamabad medical and dental college 2 fellow of college of family physicians, canada pakistan ranked amongst sixth most populous country in the world given the current rates; it will be the fifth most populous country globally by 2050.1 this rapid population growth leads to poor literacy and high fertility which translates into high morbidity and mortality, where women being the most vulnerable fragment in health especially.1,2 maternal mortality and morbidity are a major challenge that shows health inequalities and social injustice. in this modern era of medicine, almost all maternal deaths should have been prevented. pakistan is one of the six countries which together contribute to 50% of global maternal deaths.2 high maternal mortality (177/100,000 live births) in pakistan indicates neglect of women health as well as in-effective and insufficient obstetric services at the primary care level.3 the most significant approach to improve maternal health involves training and availability of skilled birth attendant in both public and private sector. data retrieved from developing countries show that only 44% of deliveries in rural areas and 75% in urban areas were attended by skilled personnel.4 world bank in 2015 reported a negligible maternal mortality ratio in developed countries. these include 3/100,000 live births in greece, 4/100,000 in austria, 5/100,000 in japan, 6/100,000 in germany, 7/100,000 in canada, and 9/100,000 live births in uk, respectively.5 now question arises what miracle industrialized world has done to achieve the optimum level of maternal health. research shows mnch has been a priority public health problem for decades. since 1990’s, the industrialized nation has adopted important strategies to reduce maternal and childhood morbidity and mortality,6 these are in line with the renewed global strategy for women’s, children’s and adolescents’ health (2016–2030).6 initially the main initiative has focused on access to health care services and enhancing the number of births in health facilities, at the same time increasing the births attended by skilled health care professionals. moreover, access to vibrant primary health care with wellestablished and effective linkages with tertiary care services for provision of quality obstetric care at the time of need, thus giving importance to the quality of care received.7 in pakistan, lady health worker program (lhwp), was launched during early 1990s, with community involvement and awareness regarding basic issues of health and family planning. this program strengthened the primary care facility and had significantly improved maternal neonatal, and child health (mnch) status.2,3 according to a recent survey in pakistan, 86% of women received antenatal care from a skilled provider, 51% of women had at least four antenatal care visits, 69% women were protected against neonatal tetanus, 69% of deliveries were conducted by skilled birth attendants, and 66% of deliveries took place in a health facility.3 in spite of all these efforts, pakistan was held up behind in achieving the health-related millennium development goals (mdgs),7 particularly goals 4 and 5. being a signatory of the sustainable development goals (sdgs) 2015-2030, which would need even greater efforts than those employed for the mdgs, the government of pakistan developed a monitoring and evaluation mechanism for the national health vision 2016-2025.. the resulting agenda and plan is linked and collaborated with the planning commission of pakistan for sdg reporting, through a hierarchy based reporting system which is fed by the provincial and local health departments for translation of policies to action.8 e d i t o r i a l j islamabad med dental coll 2019 100 the urge to improve maternal, newborn and child health in pakistan is only fulfilled successfully when the senior leadership is mindful about the significance of these investments for national progress. moreover evidence shows the key to success is provision of timely quality obstetric care through empathetic and compassionate health care professionals.6, 8 it is a serious matter that requires urgent attention and action through concentrated and direct efforts, enhancing multi-sectoral collaboration, acquiring commitment from the elected representatives, the civil society, researchers, clinicians and public health experts. all stakeholders will have to play a significant role in improving the current maternal health situation in the country. r e f e r e n c e s 1. national institute of population studies. population projections, 2015. http://www.nips.org.pk/news_details.php?news=mje 2. syeda batool mazhar. obstetric services in pakistan: where are we and what is the way forward? rmj. 2013; 38(1): 1-2. 3. national institute of population studies (nips) [pakistan] and icf. 2019. pakistan demographic and health survey 2017-18. islamabad, pakistan, and rockville, maryland, usa: nips and icf. 4. pakistan demographic and health survey (preliminary report), federal bureau of statistics, statistics division, 2012-13. 5. who, unicef, “unfpa, world bank group and united nation population division. trends in maternal mortality: 1990-2015. estimates by who, unicef.” (2015): 599-620. url: data.worldbank.org/indicator/sh.sta.mmrt 6. world health organization. the global strategy for women’s, children’s and adolescents’ health (2016 2030). united nations. 2015. http://www.who.int/lifecourse/partners/global-strategy/ewec-globalstrategyreport200915.pdf?ua=1. 7. millennium development goals database: goal 5. improved maternal health statistics pakistan. (online) 2013 url: http://data.un.org.html. 8. government of pakistan. 2016a. national health vision pakistan. 2016-2025 http://www.nationalplanningcycles.org/sites/default/files/plan ning_cycle_repository/pakistan/national_health_vision_201 6-25_30-08-2016.pdf. https://jpma.org.pk/%22http:/data.un.org.html./%22 j islamabad med dental coll 2020 6 open access accuracy of multi-detector computed tomography in detection of esophageal varices in chronic liver disease syeda zakia shah1, umair ajmal2, shahabuddin siddiqui2 1assistant professor, department of radiology, pakistan institute of medical sciences, islamabad 2post graduate resident, department of radiology, pakistan institute of medical sciences, islamabad a b s t r a c t background: patients with chronic liver disease should undergo screening endoscopy, but this approach places a heavy burden upon endoscopy units along with other limitations. the aim of this study was to determine the diagnostic accuracy of multi-detector computed tomography scan in detecting esophageal varices taking endoscopy as gold standard. material and methods: this cross-sectional study was done from 1 st jan 2018 to 31st dec 2018 at department of radiology, pims hospital islamabad. a total of 180 patients of both gender with chronic liver disease for at least 12 months were included in this study with an age range of 25-65 years. patients with active gastrointestinal hemorrhage, hypersensitivity to iodinated contrast agent, chronic renal failure, claustrophobic and pregnant females were excluded. all the patients underwent endoscopy and computed tomography of lower chest and the upper abdomen before and after intravenous contrast administration. multi detector computed tomography (mdct) scan findings for esophageal varices were compared with endoscopy findings. results: in mdct positive patients (n=102), 98 were true positive and 04 were false positive. among 78 mdct negative patients, 07 were false negative, whereas 71 were true negative. overall sensitivity and specificity were 93.33%, and 94.67% respectively. the positive and negative predictive values were 96.08% and 91.03% respectively, while diagnostic accuracy of mdct in detecting esophageal varices in chronic liver disease patients was 93.89%, taking endoscopy as gold standard. conclusions: multi-detector computed tomography scan is a highly sensitive and accurate non -invasive modality for detecting esophageal varices in chronic liver disease patients. key words: accuracy, chronic liver disease , esophageal varices, multi-de tec tor computed tomograph y authors’ contribution: 1-3conception; literature research; manuscript design and drafting; critical analysis and manuscript review; data analysis; manuscript editing. correspondence: syeda zakia shah email: sphoolsh@gmail.com article info: received: may 29, 2019 accepted: february 20, 2020 cite this article. shah sz, ajmal u, siddiqui s. accuracy of multi-detector computed tomography in detection of esophageal varices in chronic liver disease . j islamabad med dental coll.2020; 9(1): 6-11. doi: 10.35787/jimdc.v9i1.346 funding source: nil conflict of interest: nil i n t r o d u c t i o n portal hypertension is a serious complication of cirrhosis. it is defined as a hepatic venous pressure gradient (hvpg) above 5 mm hg. development of significant complication of portal hypertension i.e. ascites and esophageal and gastric varices results when hvpg increase s above 10 mmhg.1 commonest lethal complication of portal hypertension is variceal bleeding. gastroesophageal varices are the most common porto-systemic collaterals and their rupture or i gi n a l a r ti c le j islamabad med dental coll 2020 7 results in dangerous variceal bleeding. 2 the gold standard for identifying the presence and size of varices is esophagogastroduodenoscopy (egd). current guidelines recommend egd to be performed in all patients with cirrhosis at the time of diagnosis and subsequently every 1-2 years, depending on the findings of the first examination and on the severity of cirrhosis.3 egd has high sensitivity and specificity for the presence and grade of varices due to its ability to insufflate air and perform retroflexion in the gastric cardia and fundus. disadvantages include the need for intravenous sedation, relatively high cost and complications related to its invasive nature. 4 many non-invasive or minimally invasive methods have been proposed as alternatives to egd for screenin g of varices. the most promising ones are the platelet count (plt) to spleen diameter ratio, transient elastography, computed tomography (ct), and video capsule endoscopy.5,6 in a study carried out on liver cirrhosis patients, esophageal varices were found in 63.16% patients and mdct was accurate in detecting esophageal varices with a sensitivity o f 86.1% and specificity of 57.1%.7 ct is a non-invasive imaging modality and can be used routinely in general practice for detecting esophageal varices and for selection of timely and proper treatment option in order to reduce the morbidity and mortality of these patients. since there was controversy in the available literature o n diagnostic accuracy of computed tomography scan in detecting esophageal varices,5 so this study was conducted to determine the diagnostic accuracy of mdct in our set up, taking endoscopy as gold standard. m a t e r i a l a n d m e t h o d s this cross-sectional study was done from 1st january 2018 to 31st december 2018 at department of radiology, pims hospital islamabad after approval from institutional ethical committee was taken. a total of 180 patients of both gender with chronic liver disease for at least 12 months were included in this study with an age range of 25-65 years. patients with active gastrointestinal hemorrhage, hypersensitivity to iodinated contras t agent, chronic renal failure, claustrophobic and pregnant females were excluded. sample size was calculated by using sensitivity and specificity calculator (mohd. ayub sadiq, school of dental sciences, univerasiti sains malaysia), by taking 95% confidence level with expected prevalence of esophageal varices as 63.16%,5 12% desired precision for sensitivity of 86.1% and 12% for specificity of 57.1% of mdct scan in detecting esophageal varices.7 after taking informed consent, computed tomography of lower chest and the upper abdomen was performed after intravenous contrast administration on multislice mdct scanner (aquilion toshiba). three sets of images were acquired in a craniocaudal direction at 25, 65, and 180s after injection of the contrast medium. the first acquisition was used for hepatic arterial phase imaging, the second for portal venous phase imaging, and the 3rd acquisition to image the hepatic venous phase. images were obtained during single breath holding. each mdct scan were looked for esophageal varices by an experienced consultant radiologist (experience o f at least 5 years). esophageal varices were considered to be present when enhancing vascular structures within the wall of the esophagus projected into the lumen measuring ≥5 mm. all patients then underwent endoscopy in the gastroenterology department of pims by the same consultant. cherry red and dark red spots on the mucosa of the lower esophagus on endoscopy was taken as positive for esophageal varices. mdct scan findings were compared with endoscopy findings. all this data including the demographic data was recorded on a pre -design e d j islamabad med dental coll 2020 8 proforma and analyzed through computer software spss version 20.0. mean and standard deviation were calculated for quantitative variables i.e. age. frequency and percentage were calculated for qualitative variables i.e. gender and esophageal varices on mdct scan and endoscopy. a 2×2 contingency table was used to calculate sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of mdct scan in detecting esophageal varices, taking endoscopy as gold standard. r e s u l t s patients included in the study had a mean age of 47.57 ± 10.56 years and an age range from 25-65 years. majority of the patients (52.78%) were between 4665 years of age. regarding gender distribution, 100 (55.56%) were males and 80 (44.44%) were females with a male -tofemale ratio of 1.25:1. all the patients were subjected to multidetector computed tomography scan with the diagnosis of esophageal varices in 102 (56.67%) patients and no esophageal varices in 78 (43.33%) patients (figure 1). endoscopy findings confirmed esophageal varices in 105 (58.33%) patients and no esophageal varices in 75 (41 .67%) patients. in mdct positive patients, 98 (true positive) had esophageal varices and 04 (false positive) had no esophageal varices on endoscopy. among 78 mdct negative patients, 07 (false negative) had esophageal varices whereas 71 (true negative) had no esophageal varices on endoscopy (table i). overall, there was a high sensitivity (93.33%), specificity (94.67%), positive predictive value (96.08%), negative predictive value (91.03%) and diagnostic accuracy (93.89%) of multidetector computed tomography scan in detecting esophageal varices in chronic liver disease patients, taking endoscopy as gold standard (figure 2). table i: sensitivity and specificity of multi-detector computed tomography scan and endoscopy in detecting esophageal varices. result on endoscopy (n) total positive negative patients with positive result on mdct 98 (tp) 04 (fp) 102 patients with negative result on mdct 07 (fn) 71 (tn) 78 total 105 75 180 tp-true positive; fp-false positive; tntrue negative; fnfalse negative figure 1: appearance of esophageal varices on ct. arrow points to enhancing vascular structures within the wall of the esophagus projecting into the lumen figure 2: diagnostic accuracy of mdct scan in percentages ppv-positive predictive value; npv-negative predictive value j islamabad med dental coll 2020 9 d i s c u s s i o n early diagnosis of gastroesophageal varices before the onset of first bleed is highly recommended as many studies showed that the risk of variceal bleeding can be reduced from 50% to 15% for large esophageal varices.8 esophagogastroduodenoscopy (egd) is the gold standard in the diagnosis of gastroesophageal varices. however, due to its invasiveness, expense, need for sedation, and patient’s poor acceptance of the procedure, the use of endoscopy as a method of screening is limited.9,10 we conducted this study to determine the diagnostic accuracy of multi -detector computed tomography scan in detecting esophageal varices in chronic liver disease patients, taking endoscopy as gold standard. in our study the overall sensitivity and specificity of computed tomography scan in detecting esophageal varices in chronic liver disease patients, taking endoscopy as gold standard was 93.33% and 94.67% respectively. in a study performed by kammash et al, the overall sensitivity and specificity of mdct to detect esophageal varices were 99.40% and 99.60% respectively.11 the sensitivity and specificity of triphasic ct enterography with ingestion of neutral oral contrast material were 42% and 100% respectively in the detection of acute gi bleeding in a recent study by hara et al.12 in a study by scheffel et al, multidetector ct with arterial and portal phases of contrast enhancement and with no oral contrast material was able to show the bleeding source prospectively in 83% of patients.13 ct can be a good alternative for the detection of varices in cirrhotic patients with hcc, already undergoing local regional treatments. the effectiveness of the treatment and the presence of recurrence are evaluated by ct in these patients and kim et al14 showed high sensitivity (91.9%) and specificity (92.2%) for the detection of esophageal varices without alteration of the ct protocol. the efficacy of standard thick-slice ct, especially for the detection of large varices, was demonstrated by two studies,15,16 without thin slice reconstruction adding accuracy. in addition, like ultrasonography, ct is also an operator-dependent method, but radiologist residents and endoscopists showed similar performance to specialized abdominal radiologists in the detection of large varices. abdominal radiologists were more efficient in the detection of small varices compared to residents and endoscopists.17 ct scan is an excellent method for detecting moderate to large esophageal varices and for evaluating the entire portal venous system. it is a minimally invasive imaging modality that involves the use of only a peripheral intravenous line; therefore, it is a more attractive method than angiography or endoscopy in the evaluation of the portal venous system. in the only study directly comparing ct with the platelet/spleen diameter ratio, ct proved to have higher sensitivity and specificity.7 this method is better tolerated than endoscopy and more readily accepted by patients even in studies where air insufflation was used before performing ct.18 moreover, ct can be simultaneously used as a screening method for hcc and varices in cirrhotic patients. the main disadvantage of ct is the radiation dose, although, considering the high mean age of cirrhotic patients, the benefits are likely to outweigh the risk of radiation-induced carcinogenesis.19 the cost of the method is high e r compared to other non-invasive methods, but lower compared to endoscopy.20 several studies have compared ct and endoscop y findings. a cut off point of 5 mm was previously shown to have approximately 90% sensitivity and 50% specificity for large varices.21, another study j islamabad med dental coll 2020 10 used a 3-mm threshold for varices on ct to accurately predict the presence of large varices on egd.22 according to deng and his colleagues, the sensitivity and specificity of contrast enhanced ct (cect) scan were 95.56% and 71.43%, respectively. they concluded that cect scans have a moderate diagnostic accuracy for esophageal varices in liver cirrhosis. cect scan might be useful to decrease the use of upper gastrointestinal endoscopy in clinical practice.23 ct is an imaging modality that is quite precise in visualization of esophageal varices. ct could detect early hcc and hence is useful in the holistic management of cirrhotics. it is of paramount importance to underline the diagnostic value of ct in early detection of varices. radiologists should comment on incidental findings of varices even when it is done for other reasons. limitation: intravenous contrast is required for diagnosis of esophageal varices, which may be contraindicated in patients with impaired renal function or allergy to iodine. c o n c l u s i o n this study concluded that multi-detector computed tomography scan is a highly sensitive and accurate non-invasive modality in detecting esophageal varices in chronic liver disease patients. it has not only dramatically improved our ability to accurately diagnose esophageal varices but also contributed to patients’ care with timely and proper treatment. endoscopy might be reserved mainly for therapeutic purposes. although this appeared unrealistic a few years ago, advances in technology and more prospective studies could make it feasible in the future. r e c o m m e n d a t i o n s we recommend that multi-detector computed tomography (mdct) should be used routinely as a prime modality for detecting esophageal varices in chronic liver disease patients and in patients not willing for endoscopy. it will result in proper and timely management and will reduce the morbidity and mortality of these patients. ct can be a good alternative for the detection of varices in cirrhotic patients with hcc, already undergoing loco regional treatments. the effectiveness of the treatment and the presence o f recurrence is evaluated by ct in these patients. r e f e r e n c e s 1. salzl p, reiberger t, fe rlitsch m, payer ba, schwengerer b, trauner m. et al. evaluation of portal hypertension and varices by acoustic radiation force impulse imaging of the liver compared to transient elastography and ast to platelet ratio index. ultraschall med. 2014; 35(6): 528-33. doi: 10.1055/s-0034-1366506 2. masalaite l, valantinas j, stanaitis j. endoscopic ultrasound findings predict the recurrence of esophageal varices after endoscopic band ligation: a prospective cohort study. scand j gastroenterol. 2015; 50(11): 1322-30. doi: 10.3109/00365521.2015.104 3640 3. binţinţan a, chira ri, mircea pa. non-invasive ultrasound-based diagnosis and staging of esophageal varices in liver cirrhosis. a systematic review of the literature published in the third millenium. med ultrason. 2013; 15(2): 116 -24. doi: 10.11152/mu.2013.2066.152.ab1ric2 4. bonilha dq, lenz l, correial m, rodrigues ra, depaulo ga, ferrari ap, et al. propranolol associated with endoscopic band ligation reduces recurrence of esophageal varices for primary prophylaxis of variceal bleeding: a randomized controlled trial. eur j gastroenterol hepatol. 2015; 27(1): 84 -90. doi: 10.1097/meg.0000000000000227 5. de franchis r, dell'era a. invasive and noninvasive methods to diagnose portal hypertension and esophageal varices. clin liver dis. 2014; 18(2): 293 302. doi: 10.1016/j.cld.2013.12.002 6. lipp mj, broder a, hudesman d, suwandhi p, okon sa, horowitz m, et al. detection of esophageal j islamabad med dental coll 2020 11 varices using ct and mri. dig dis sci. 2011; 56(9): 2696-700. doi: 10.1007/s10620-011-1660-8 7. karatzas a, triantosb c, kalafatelib m, marzigieb m, labropoulou-karatzac c, thomopoulos k, et al. multidetector computed tomography versus platelet/spleen diameter ratio as methods for the detection of gastroesophageal varices. ann gastroenterol. 2016; 29(1): 71 -8. pmid: 26751694 8. assy n, rosser bg, grahame gr, minuk gy. risk of sedation for upper gi endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis. gastrointest endosc. 1999; 49(6): 690–94. doi: 10.1016/s0016-5107(99)70283-x 9. vasudevan ae, goh kl, bulgiba am. impairme nt of psychomotor responses after conscious sedation in cirrhotic patients undergoing therapeutic upper gi endoscopy. am j gastroenterol. 2002; 97(7): 1717– 721. doi: 10.1111/j.1572-0241.2002.05831.x 10. eisen gm, baron th, dominitz ja, faigel do, goldstein jl, johanson jf. complications of upper gi endoscopy. gastrointest endosc. 2002; 55(7): 784– 793. doi: 10.1016/s0016-5107(02)70404-5 11. kammash tel, elfiky i, zaiton f, khorshed se. diagnostic performance of multidetector computed tomography in the evaluation of esophageal varices. egyptian j radiol nuclear med. 2016; 47(1): 43-51. doi: 10.1016/j.ejrnm.2015.11.003 12. hara ak, walker fb, silva ac, leighton ja. preliminary estimate of triphasic ct enterography performance in hemodynamically stable patients with suspected gastrointestinal bleeding. ajr am j roentgenol. 2009; 193(5): 1252–260. doi: 10.2214/ajr.08.1494 13. scheffel h, pfammatter t, wildi s, bauerfeind p, marincek b, alkadhi h. acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row ct. eur radiol. 2007; 17(6): 1555–565. doi: 10.1007/s00330-006-0514-9 14. kim h, choi d, gwak gy. high-risk esophageal varices in patients treated with locoregional therapies for hepatocellular carcinoma: evaluation with regular follow-up liver ct. dig dis sci. 2009; 54(10): 2247-52. doi: 10.1007/s10620-008-0606-2 15. yu nc, margolis d, hsu m, raman ss, lu ds. detection and grading of esophageal varices on liver ct: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy. ajr am j roentgenol. 2011; 197(3): 643 -49. doi: 10.2214/ajr.10.5458. 16. park hs, kim yj, choe wh, ko sy, bak sh, il jung s, et al. diagnosis of esophageal varices on liver ct: is thinsection reconstruction necessary? hepatogastroenterol. 2015; 62(138): 333 -40. pmid: 25916059 17. kim h, choi d, gwak gy. evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists. j gastroenterolhepatol. 2009; 24(9): 1534 -540. doi: 10.1111/j.1440-1746.2009.05849.x 18. kim sh, kim yj, lee jm, choi kd, chung yj, han jk, et al. esophageal varices in patients with cirrhosis: multidetector ct esophagography—comparison with endoscopy. radiol. 2007; 242(3): 759 -68. doi: 10.1148/radiol.2423050784 19. d’amico g, garcia-tsao g, pagliaro l. natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. j hepatol. 2006; 44(1): 217-31. doi: 10.1016/j.jhep.2005.10.013 20. lotfipour ak, douek m, shimoga sv. the cost of screening esophageal varices: traditional endoscopy versus computed tomography. j comput assist tomogr. 2014; 38(6): 963-67. doi: 10.1097/rct.0000000000000147 21. perri re, chiorean mv, fidler jl. a prospective evaluation of computerized tomographic (ct) scanning as a screening modality for esophageal varices. hepatol. 2008; 47(5): 1587–594. doi: 10.1002/hep.22219 22. kamath ps, wiesner rh, malinchoc m, kremers w, therneau tm, kosberg cl et al. a model to predict survival in patients with end-stage liver disease. hepatol. 2001; 33(2): 464–70. doi: 10.1053/jhep.2001.22172 23. deng h, qi x, zhang y, peng y, li j, guo x. diagnostic accuracy of contrast-enhanced computed tomography for esophageal varices in liver cirrhosis: a retrospective observational study. j evid based med. 2017; 10(1): 46-52. doi: 10.1155/2019/670467 j islamabad med dental coll 2022 194 o p e n a c c e s s challenges for infection prevention and control practices in hospital naghmi asif1, khalid hassan2 1head and professor of pathology, islamabad medical & dental college. 2professor of pathology and editor-in-chief, journal of islamabad medical and dental college. infection prevention and control (ipc) is the foremost component in the delivery of patient care and safety in health care setting. major impact of implementation of infection control practices is not only on the safety of patients, but also safety of health care providers and patients’ attendants. due to ineffective implementation of ipc practices, patients may acquire nosocomial infections (also called health care associated infections), resulting in increased morbidity and mortality, longer hospital stay, increased resistance to antimicrobial and high financial burden on health care system and patients’ families. with inadequate ipc practices in health care system, hais are the most frequent adverse event in hospital settings, affecting hundreds of millions of people globally. at least one in 10 patients acquire an infection whilst receiving care in health facilities in low-and-middle-income-countries. this is because in many health care settings, resources are limited and infrastructure and practices both are neglected. among health care associated infections, (which include catheter associated infections, ventilator associated pneumonia, blood stream infections and surgical site infections) blood stream infections and correspondence: naghmi asif email: naheed.naghmi@imdcollege.edu.pk cite this editorial: asif n, hassan k. challenges for infection prevention and control practices in hospital. j islamabad med dental coll. 2022; 11(4)194-195 doi: https://doi.org/10.35787/jimdc.v11i4.936 catheter related infections comprise the leading cause, particularly in intensive care units. various factors such as adequate knowledge, development and stringent implementation of policies and guidelines, essential environmental health conditions, appropriate infrastructure, antibiotic stewardship, continuous surveillance and periodic audits etc. all play a vital role in implementation of ipc practices. establishment of ipc committee with well-defined tors, is an essential first step for successful ipc program. many studies have proven that inadequate hospital infrastructure and resources, shortage of staff, inadequate knowledge and training of health care providers. ineffective surveillance, large number of visitors and overcrowding are the main barriers to ipc in any health care setting. improperly built and poorly maintained buildings, such as damaged surfaces, walls and floors, improper doors and windows, lack of isolation rooms and cohorting areas, and non-availability of space and facilities in case of disease outbreaks, non-availability of proper waste segregation and incineration facilities have been identified as barrier to effective ipc practices. moreover, non-availability of handwash stations is a critical factor for ipc practice especially in critical areas like icus, where patients are under care for multiple problems and most of them are critically ill. continuous education, training, behavior change and monitoring are crucial to ipc practices. this is especially important in e d i t o r i a l mailto:naheed.naghmi@imdcollege.edu.pk j islamabad med dental coll 2022 195 relevance to hand washing practices, good hand hygiene practices and use of ppes. waste management, disinfection and regular monitoring of culture reports are some additional areas that need continuous surveillance and monitoring. role of microbiologist and ipc committee in this regard are of vital importance. housekeeping staff should always be included in ipc training programs. continuous education, training plus availability of relevant printed material in local language as well as in english should be available for house-keeping staff. lack of implementation and compliance to the visitor’s policy and large number of visitors (especially in critical areas) is another challenge to ipc. overcrowding is recognized as a risk factor for hais. with large number of visitors, it is difficult to clean the environment and provide proper care to the patients, since visitors do not understand the importance of hand hygiene practices, waste disposal and factors affecting transmission of diseases. lack of knowledge and training of hospital staff stands a major challenge to ipc. moreover, there is a lack of understanding and motivation to implement recommended ipc practices. shortage of ppes and disinfectants in resource limited setting is another challenge to ipc. however, in resource limited arears rational use of ppes should be monitored and policies should be devised accordingly. keeping under consideration all these factors, the following recommendations are made: a. every hospital must have an active ipc committee. b. ipc policies, its tors and sops must be properly displayed and strictly followed; these may be periodically revised according to need. c. hospital must have stringent waste management program.regular refreshment programs should be in place for training on hand hygiene, good hand hygiene practices, use of ppes, prevention of needle stick injuries, etc. 1 j i m d c 2 0 1 7 1 address of correspondence: dr sadaf t khalid email: sadaf.khalid@imdcollege.edu.pk school health services sadaf t. khalid1 and abdul majid rajput2 1 senior lecturer, department of community medicine, islamabad medical & dental college 2 prof and head of department, department of community medicine, islamabad medical & dental college school health service is defined as ‘a service concerned with the early detection of health and social problems in school children and their subsequent treatment and surveillance’1 or ‘coordinated system that ensures a continuum of care from school to home to community health care provider and back’.2 historically, the concept of school health services evolved in colonial american era by benjamin franklin who advocated a ‘healthful situation’ and promoted the primary subject of physical education in schools. later, this concept gained major attention as a mean to promote public health and prevent disease after the report of the ‘sanitary commission of massachusetts’, headed by lemuel shattuck in 1850.3 soon after shattuck report, the medical and public health sectors began to recognize the role that schools could play in controlling communicable diseases with their captive audience of children and young people. on realization of school’s role in the prevention of public health problems, in 1995 who launched ‘global school health initiative’. the aim of this program was to mobilize and strengthen health promotion and education activities at the local, national, regional and global levels4. this initiative was designed to improve the health of students, school personnel, families and other members of the community through ‘health promoting schools’.5 under this program, who developed ‘mega country health promotion network’ in 11 most populous countries in the world which constitute over 60% of world population. these countries were bangladesh, brazil, china, india, indonesia, japan, mexico, nigeria, pakistan, russian federation and the united states of america. all of the participating countries agreed upon the importance of addressing school health as specialized area and its implementation on large scale. a systematic review of nine studies on the effectiveness of health promoting schools6 suggests that school can successfully initiate efforts to transform themselves into health promoting schools but need the support of appropriate policies. although, this review concluded that published studies on the subject did not provide strong evidence for the efficacy of health promoting schools on the health of students, staff, and community, and on the school ethos and environment. this conclusion could be because of the absence of clear consensus on methods for evaluating health promoting schools7 and hence suggested the need to develop clearly defined, valid, and feasible indicators to evaluate the process, output, and outcome. however, another systematic review on implementation and effectiveness of school-based nutrition promotion programmes using health-promoting schools approach8 suggested the efficacy of this intervention, satisfaction of students and community engagement. it was evident in this review that this approach can not only increase participant’s consumption of high-fibre foods, healthier snacks, water, milk, fruit and vegetables but also reduce participant’s habit of breakfast skipping, eating disorders and intake of unhealthy diets. another research9 showed an association of safe and positive school environments with improved health behaviors and achievement. engaging families and community members in schools also had a positive effect on students' health and achievement. being signatory of alma-ata declaration, pakistan school health services remained part of health service delivery, however in 1980 this service was extended by appointing dedicated physicians and healthcare professionals, but program lacked comprehensive approach. punjab health sector reforms program (phsrp) developed school e d i t o r i a l mailto:sadaf.khalid@imdcollege.edu.pk 2 j i m d c 2 0 1 7 2 health program in 2008, to promote health through screening of students, capacity building of teachers and training school children as ‘change agent’ for disseminating health and hygiene message to their community.10 in addition to this, national commission for human development has launched school health program11 in 17 districts of pakistan with funding from bill and melinda gates foundation with the prime which focus only on health screening of students. in 2010, another initiative on school health program was initiated by pakistan federal ministry of education in collaboration with united nations educational, scientific and cultural organization (unesco).12 components of the program were: school health environment; school health education; school health services and school nutrition programme. mostly being donor-funded initiatives; long-term sustainability of these projects were questionable. hence, school health promotion program in pakistan is still in its infancy state12. a critical review on school health promotion13highlights that little attention has been paid to explore school’s role in the context of child health promotion activities, even fewer efforts are done in systematic documenting the current status of school health promotion in pakistan. in pakistan, 41.1614 million children between 3-18 years (pre-nursery to intermediate level) are attending schools; and not forgetting 21% of the un-enrolled number of children represent nearly one-fourth of the population. there is a dire need to formulate and enforce evidencebased program involving stakeholders from the public, private sectors as well as civil society to ensure sustainable ownership of the program. the tripartite partnership of education sector (owner of the program) with lead technical role being assigned to health sector (pmdc and medical institutions both at undergraduate & post graduate levels) is required to fulfill the social responsibility. strong oversight and sustainable support by csos and international bodies such as who, unicef and unesco may offer a way forward to achieve the long awaited unaccomplished mission. r e f e r e n c e s 1 school health service. a dictionary of nursing. retrieved april 10, 2017. http://www.encyclopedia.com/caregiving/dictionariesthesauruses-pictures-and-press-releases/school-healthservice 2 school health services small 1995 journal of school health wiley online library. http://onlinelibrary.wiley.com/doi/10.1111/j.1746 3 programs i of m (us) c on csh, allensworth d, wyche j, lawson e, nicholson l. the evolution of school health programs [internet]. national academies press (us); 1995 https://www.ncbi.nlm.nih.gov/books/nbk231148/ 4 who | global school health initiative [internet]. [cited 2017 http://www.who.int/school_youth_health/gshi/en/ 5 who | what is a health promoting school? http://www.who.int/school_youth_health/gshi/hps/en 6 mũkoma w, flisher aj. evaluations of health promoting schools: a review of nine studies. health promot int. 2004;19(3):357–68. 7 speller v, learmonth a. and harrison d. the search for evidence of effective health promotion. british medical journal. 1997: 361–363. 8 wang d, stewart d. the implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review. public health nutrition. 2013;16(06):1082-100. 9 michael, s. l., merlo, c. l., basch, c. e., wentzel, k. r. and wechsler, h. (2015), critical connections: health and academics. j school health, 85: 740–758. doi:10.1111/josh.12309 10 punjab health sector reforms programme (phsrp) http://phsrp.punjab.gov.pk/shns.asp 11 school health program www.nchd.org.pk/ws/index.php?option=com_content&view =article&id=65&itemid=33 12 moe and unesco. school health programme: a strategic approach for improving health and education in pakistan. ministry of education, curriculum wing, government of pakistan and united nations educational, scientific and cultural organization 2010. 13 prasla m, prasla sa. school health promotion-international perspectives and role of health care professionals. j ayub med coll abbottabad. 2011;23(1):150–3. 14 pakistan economic survey.2014-2015. retrieved from http://www.finance.gov.pk/survey/chapters_16/10_educati on.pdf http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/school-health-service http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/school-health-service http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/school-health-service https://www.ncbi.nlm.nih.gov/books/nbk231148/ j islamabad med dental coll 2021 181 open access oral manifestations of a patient suffering from a rare gilbert’s syndrome: a case report hira abbasi1, abhishek lal2, rizwan jouhar3 1fcps part ii trainee, department of operative dentistry, altamash institute of dental medicine, karachi 2bds, department of operative dentistry, altamash institute of dental medicine, karachi 3assistant professor, department of restorative dentistry and endodontics, king faisal university, al-ahsa, saudi arabia a b s t r a c t gilbert's syndrome is a rare genetic disorder characterized by abnormal glucuronidation of bilirubin in the liver, presenting as unconjugated hyperbilirubinemia in the absence of hepatocellular injury or hemolysis. diagnosis of this pathology is primarily made during routine examination described as the presence of a yellowish tinge in the eyes and skin in general. normally, the oral manifestations of gilbert's syndrome are present but mostly go unnoticed as the teeth are minimally affected which are visible to the patient and surrounding mucosa in the oral cavity, where yellow discoloration can be appreciated. dental treatments are smoothly carried out for such patients like extractions, root canal treatment, cleaning prophylaxis. the patient in this case safely underwent the root canal treatment after being diagnosed with irreversible pulpitis without any unusual discomfort. local anesthesia can also be safely administered to such patients such as infiltration and inferior alveolar block anesthesia. keywords: gilberts syndrome, oral, manifestations cite this case report: abasi h, lal a, jouhar r. oral manifestations of a patient suffering from a rare gilbert’s syndrome: a case report. j islamabad med dental coll. 2021; 10(3): 181-185. doi: 10.35787/jimdc.v10i3.706 funding source: nil conflict of interest: nil i n t r o d u c t i o n gilbert’s syndrome (gs) is a rare autosomal recessive genetic disorder characterized by abnormal metabolism (glucuronidation) of bilirubin in the liver, presenting as unconjugated hyperbilirubinemia in the absence of hepatocellular injury or hemolysis.1 normally patients do not report any symptoms that might hinder their daily lives so this pathology is mostly diagnosed during a routine examination. generally, it manifests as neonatal jaundice, abdominal pain, fatigue, loss of appetite, nausea, irritable bowel syndrome, and brain fog. symptoms worsen when the bilirubin levels tend to increase above 7mg/dl. about its prevalence, gilbert’s syndrome has been reported to vary amongst different populations between 4%-16%.2 moreover, during adolescence, there is a change in steroids concentration which tends to affect the metabolism of bilirubin that then leads to increased bilirubin levels. gilbert’s syndrome further is most commonly found in males as compared to females, primarily due to the greater daily production of bilirubin in males.3 although the pathology itself is harmless for the patient, symptoms that get the patient’s attention tend to increase anxiety amongst them so psychological counselling becomes an important part of the treatment plan. so, the diagnostic criteria to achieve a definitive diagnosis of gilbert’s syndrome include an assessment of bilirubin levels as part of the liver function test. moreover, mildly correspondence: hira abbasi email: drhirabbasi@gmail.com article info: received: april 19, 2021 accepted: august 31, 2021 c a s e r e p o r t j islamabad med dental coll 2021 182 elevated bilirubin levels alongside normal serum liver transaminases, red blood cell count, and biliary damage markers may indicate the presence of gilbert’s syndrome. furthermore, mildly elevated unconjugated bilirubin in gs is associated with the presence of reduced prevalence of chronic diseases, like cardiovascular diseases particularly, and type 2 diabetes along with its risk factors.4 the most characteristic feature that can be clinically appreciated in such patients is the yellow tinge of the skin and the eyes particularly.5 skin and mucosa of the body are affected to various degrees along with these manifestations found in the oral cavity. very scarcely, studies report the prevalence of oral manifestations of patients suffering from gs, mainly due to its signs been overlooked in the oral cavity and more conspicuous signs being focused upon by the treating physician. although the oral manifestations of gs if present are still harmless and a patient can undergo any dental treatment, the presence of such signs in the oral cavity should be searched for. c a s e r e p o r t a 35 years old female presented to the outpatient department of operative dentistry of altamash institute of dental medicine (karachi, pakistan). earlier 1 month ago, the patient developed severe throbbing pain in the lower left side of the jaw, unable to point out the tooth from where the pain was originating. the pain was persistently present, not completely relieved by self-medication as reported in the chief complaint of the patient. furthermore, the patient had difficulty in eating with the pain radiating to the neck and temporal regions of the head of the affected side that awakened her in the middle of the sleep and aggravated especially during sleeping hours. previously before visiting the dentist for treatment, the patient reportedly took some painkillers to relieve the pain but the effect was mild and still being bothersome for the patient, mandating a visit to the outpatient department. regarding medical history, the patient had been diagnosed with gilbert’s syndrome a couple of years back for which she had not been prescribed any medicines. other than that, the patient had no significant medical and family history, along with dental and social history. no allergies to drugs were reported by the patient. previously, the patient had undergone dental treatment such as extractions which were recommended to her without any unfortunate events during the perioperative and postoperative phases, as per the patient’s own words. the patient was diagnosed with irreversible pulpitis with the lower-left 1st molar being the offending tooth, for which non-vital therapy i.e., a pulpectomy (root canal treatment) had been suggested by the doctor as confirmed by intraoral, extraoral, and radiological examinations, respectively. as the patient reportedly suffered from gilbert’s syndrome, upon intraoral examinations some remarkable features were noted. the patient had a deep palate with a yellow tinge mainly limited to the hard palate and fading away towards the soft palate as shown in figure 1. furthermore, on examining the floor of the mouth, a similar yellow color was noted with the mucosa along sublingual folds, lingual frenum, and sublingual caruncle as shown in figure 2. regarding the appearance of the tongue, the size of the tongue was unremarkable with a normal shape although a smooth appearance was noted around the tip of the tongue and anterolateral parts of the tongue as shown in figure 3. the lower lip when being everted for examination was found to have a yellowish appearance diffusely present all around as shown in figure 4. the patient had normal teeth with some missing due to caries and trauma with slight paleness around the free and attached gingiva generalized around all of the teeth, and generalized spacing too, as shown in figure 5. while performing an extra-oral examination, the patient had normal j islamabad med dental coll 2021 183 temporomandibular joint movements, normal mouth opening, anatomy of the lips was unremarkable and no other remarkable features were found on the facial aspect of the patient. lastly, the most obvious clinical finding in this patient was yellow discoloration of the eyes. no other remarkable features were noted in the rest of the body. fig 1: hard and soft palate fig 2: floor of the mouth fig 3: tongue fig 4: everted lower lip fig 5: teeth and gingiva d i s c u s s i o n gilbert’s syndrome is a rare genetic disorder, which although alerts the patient when looked upon, but is harmless in general. normally the patients do not report any disturbing signs and symptoms in general and in regards to the oral cavity. the clinical manifestations only become more noticeable in certain situations such as fatigue, exercise, febrile illness, fasting, and alcohol ingestion especially in older patients.6 in our case report, it was found that the patient showed a yellow tinge as oral manifestation in the lower lip, hard palate, the floor of the mouth, gingiva, and tongue. no abnormalities were noted regarding teeth such as number, shape, or size. moreover, the patient also had yellow discoloration in the eyes and on the skin in general. sometimes as the literature states, crigler-najjar syndrome j islamabad med dental coll 2021 184 also manifests similarly to gilbert’s syndrome, so it's important to reach a definitive diagnosis correctly for the proper management of the patient.7 keeping in mind the oral manifestations of gilberts syndrome, patients normally do not notice these signs and symptoms for consultation from a physician or a dentist. brushing is the primary focus of the patients and since this pathology hasn’t been reported to affect the teeth as such in the literature, other signs go unnoticed. most commonly, it’s the general body symptoms that alert the patients suspected of suffering from gs that make them visit the doctor. in regards to the dental procedure, patients suffering from gs normally do not suffer from any discomfort in any of the dental procedures required although literature reports some patients did develop jaundice following oral surgery procedures.8 moreover, as local anesthesia was used in the patient being treated in our outpatient department, no difficulties for the doctor as well as the patient were reported till the next visit of the patient which was 1 week later. however, studies report problems with regional and general anesthesia for patients suffering from gs so the administering agents should be carefully selected as the hepatic dysfunction is present and it is the liver where the drugs metabolize.9,10 the patient in our case safely went through the entire root canal treatment from chamber opening, pulpectomy, cleaning and shaping, obturation, core build-up, crown prep, and finally cementation. no unusual discomfort was reported by the patient other than the normal sensations felt during any dental procedure by every normal and healthy patient such as pressure sensations. c o n c l u s i o n although a rare syndrome and being harmless in general, gilbert's syndrome until not being diagnosed does raise some anxiety in the sufferers. so, assurance along with necessary treatments must be offered to such patients with dietary guidance too. concerning the dental part of the syndrome, although yellow discoloration is present in the oral cavity, it's mostly harmless and patients safely undergo different dental treatments along with administration of local anesthesia with no reported side effects. r e f e r e n c e s 1. kamal s, abdelhakam s, ghoraba d, massoud y, aziz ka, hassan h, hafez t, sallam aa. the frequency, clinical course, and health related quality of life in adults with gilbert’s syndrome: a longitudinal study. bmc gastroenterology. 2019; 19(1):1-4. doi: 10.1186/s12876-019-0931-2 2. zaman s, fukushima h, suzuki r, hawlader md, yoshimatsu s, kanai y, ahsan gu, fukushima t. prevalence of gilbert syndrome in bangladesh. open journal of blood diseases. 2018; 8(01):1. doi: 10.4236/ojbd.2018.81001 3. creeden jf, gordon dm, stec de, hinds jr td. bilirubin as a metabolic hormone: the physiological relevance of low levels. am. j. physiol. endocrinol. metab. 2021; 320(2):e191-207. doi: 10.1152/ajpendo.00405.2020 4. english e, lenters-westra e. hba1c method performance: the great success story of global standardization. crit rev clin lab sci. 2018; 55(6):408-19. doi: 10.1080/10408363.2018.1480591 5. qian jd, hou fq, wang tl, shao c, wang gq. gilbert syndrome combined with prolonged jaundice caused by contrast agent: case report. world j gastroentero. 2018; 24(13):1486. doi: 10.3748/wjg.v24.i13.1486 6. tzoneva d, aleksiev e, michova k, stanimirov p. perioperative management and anaesthetic considerations for adult patients with gilbert’s syndrome and oral cancer: review and case report. biotechnol biotechnol equip. 2019; 33(1):1182–6. doi: 10.1080/13102818.2019.1649987 7. stanley la. drug metabolism. inpharmacognosy 2017: (pp. 527-545). academic press. doi: 10.1016/b978-0-12-802104-0.00027-5 8. quinn nw, gollan jl. jaundice following oral surgery: gilbert's syndrome. br j oral maxillofac surg. 1975;12(3):285-8. doi: 10.1016/0007117x(75)90059-1 9. nag d, sinha n, samaddar d, mahanty p. general anesthesia in a patient with gilbert′s syndrome. j anaesthesiol clin pharmacol. 2011;27(2):253. doi: j islamabad med dental coll 2021 185 10.4103/0970-9185.81836 10. ranjan rv, ramachandran tr, veliath dg, coelho d. perioperative management of a patient with gilberts syndrome and rheumatic heart disease. saudi j anaesth.. 2012;6(3):289. doi: 10.4103/1658354x.101225 j islamabad med dental coll 2020 28 open access perceptions of fellowship trainees in public and private tertiary care hospitals of karachi sadaf zia1, maisam abbas onali2, hina yousuf3, aria masoom4, asna shahab5, nabiha amjad6 1assistant professor, department of ent, head and neck surgery, dow international medical college , karachi 2assistant professor, department of ent, head and neck surgery, jinnah medical and dental college , karachi 3assistant professor, department of pediatric surgery, liaquat national hospital and medical college, karachi 4assistant professor, department of ent, bolan university of medical and health sciences , quetta 5house officer, dow university hospital, karachi 6house officer, national institute of child health, karachi a b s t r a c t background: the issues pertaining to postgraduate medical education have been debated for long but there has been little contribution to this literature from developing countries. therefore, a need to make an accurate assessment regarding current status of postgraduate training in pakistan was felt and feedback from residents is the cornerstone of such an assessment. the objective of our study was to document perceptions of fcps trainees of medical and surgical disciplines in private and public tertiary care hospitals of karachi, pakistan . material and methods: this was a cross sectional survey of the medical and surgical fcps trainees in three hospitals (1 public and 2 private) of karachi pakistan, conducted over a period of two months (1 st november 2018 to 31 st december 2018). a total of 32 5 participants selected by convenient sampling technique were included in the stu dy. data was collected through structured self-developed questionnaire and analyzed by spss version 16.0 . results: the percentage of postgraduate trainees in private hospitals working for more than 80hours/week is higher than those working in public sector hospitals (59.4% versus 42.4%). topic presentation and academic meetings (conferences, workshops and cmes) were the most preferred teaching strategies in postgraduate trainin g (77.4% and 77.5%). about 62.7% of the residents believed that their program was in line with cpsp guidelines. public sector hospitals were better in terms of medical benefits giving partial cover (62.8%) than private sector ( p-value <0.001). majority of trainees at private sector hospitals seemed satisfied with their working environment than at public hospital (77.5% versus 12.5%) (p-value <0.001). trainees perceived that the security arrangements at both public and private hospitals were not adequate, but in case of emergency private hospitals seemed to have better security response as compared to public hospitals (89% versus 23%) with a significant difference of <0.001 . conclusion(s): perception of most of the postgraduate trainees is that they are being adequately trained for the challenges of an independent physician or surgeon . key words: postgraduate training programs, medical education, trainees perception authors’ contribution: 1-3conception; literature research; manuscript design and drafting; 3-6critical analysis and manuscript review; data analysis; manuscript editing. correspondence: sadaf zia email: sadaf.zia@duhs.edu.pk article info: received: august 3, 2019 accepted: march 7, 2020 cite this article. zia s, onail ma, yousaf h, masoom a, shahab a, amjad n. perceptions of fellowship trainees in public and private tertiary care hospitals of karachi. j islamabad me d dental coll.2020; 9(1): 28-34. doi: 10.35787/jimdc.v9i1.392 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2020 29 i n t r o d u c t i o n effective teaching and training requires not only a well-motivated and a dedicated trainee but also demands a vigorous teaching faculty who help guarantee a vibrant environment for residents education and research.1-3 college of physicians and surgeons of pakistan (cpsp) is the leading institute awarding fellowships to trainees in various disciplines through structured guidelines and continuous surveillance.4 during postgraduate training of a doctor, it is expected that their existing clinical knowledge and skills will be improved, they will be exposed to a broad range of procedures and will benefit from mentoring by leaders in their respective fields.1 to assess such parameters, the accreditation council for graduate medical education (acgme) of usa identified six learning outcomes for postgraduate medical education.5-7 these include patient care, medical knowledge, interpersonal communication skills, professionalism, practice -based learning, an d system-based practice. in this perspective, every postgraduate institute has to provide a detailed list of training objectives in a particular field and explain how they will be delivered, monitored and measured. moreover, regular feedbacks from the trainees regarding their satisfaction with training and supervision, working hours and work environment must be made part of the program.8 we believe that there are many areas of concerns in the current fellowship training across the country and these need to be dealt individually. trainees seem dissatisfied with their training structures and long tiring working hours.9 lack of financial support, inadequate infrastructure and security concerns are also major problems. these are further aggravated if the faculty is also unable to provide a conducive learning environment. unfortunately, in pakistan majority of the institutes where postgraduate training programs are being conducted lack uniformity in structure and therefore fail to monitor and measure the progress and performance of the trainees according to the laid protocol.10 the issues pertaining to postgraduate medical education have been debated for long in developed countries, however, there has been little contribution to this literature from developing countries.11,12 therefore, there is a need to make an accurate assessment regarding current status of postgraduate training program in pakistan with perceptions/feedbacks from the re sidents (fcps trainees) in private and public hospitals of karachi, as the cornerstone of such an assessment. m a t e r i a l a n d m e t h o d s this was a cross-sectional survey of the medical and surgical fcps trainees in three hospitals of karachi pakistan, conducted over a period of two months (1st november 2018 to 31st december 2018). one public-sector hospital (dow university of health sciences) and two private-sector hospitals (liaquat national hospital and jinnah medical college hospital) were included. data was collected through self-developed structured questionnaire. informed consent was obtained from all the participants. confidentiality and anonymity of the participants was ensured. ethical approval for the study was obtained from the ethical review and research committee of jinnah medical and dental college, karachi. all trainees registered with cpsp as fcps ii train e e s in medicine and surgery were included in the study. a sample size of 268 was calculated by openepi calculator with 5% margin of error and 95% confidence interval. data was analyzed in spss version 16.0. chi-square test was applied to test significance and p-value ˂0.05 was taken as significant. variables of interest included working hours, teaching strategies and satisfaction of trainees with j islamabad med dental coll 2020 30 their training program. satisfaction with training program was measured in terms of alignment with cpsp guidelines, working environment, medical benefits, interaction with supervisor and guidance for research etc. trainees were also surveyed for provision of security on daily basis as well in case o f emergency. r e s u l t s a total of 325 participants were included in the study, out of which 103 (31.7%) trainees were doing residency in a private teaching hospital and 222 participants (68.3%) belonged to a public sector training hospital. about 195 (60%) residents were enrolled for fcps in medicine and allied and 130 (40%) were enrolled for fcps in surgery and allied. most of the employees were getting monthly stipend of rs. 65,000. according to our data 66.8% of the residents believed that their program was in line with cpsp guidelines while 33.2% thought it was partially or not in line with cpsp guidelines. percentage of trainees in private hospitals working for more than 80 hours/week was higher than those working in public sector hospitals (59.4% versus 42.4%), however the difference was not statistically significant (table i). data regarding the frequency of postgraduate teaching methods showed that “topic presentation” and “academic meetings” (conferences, workshops and cmes) were the most preferred teaching strategies in postgraduate training (77.4% and 77.5% respectively). “teaching rounds” and “topic presentation” were equally preferred in public and private medical institute. long case discussion was employed m o re in private hospital than public hospitals (44% versus 30%) (table ii). however, trainees in private hospital got significantly greater opportunities to attend “morbidity mortality meetings” and “conferences and workshops” than the residents in public sector hospitals (p-value <0.001) (table ii). table i: distribution of working hours of postgraduate trainees in public and private sector hospitals average working hours / week total >80 hours/week 80 hours/week <80 hours/week private hospitals 18 28 56 102 17.6% 27.5% 54.9% 100% public hospital 44 85 94 223 19.7% 38.1% 42.2% 100% total 62 113 150 325 19.1% 34.8% 46.2% 100% table ii: teaching strategies of postgraduate trainees in public and private sector hospitals public hospital private hospital pvalue teaching round yes 125(38.4%) 55(16.9%) 0.624 no 97(29.8%) 48(14.7%) topic presentation yes 158(48.6%) 80(24.6%) 0.218 no 64(19.6%) 23(7.07%) long case discussion yes 66(20.30%) 46(14.1%) 0.008 no 156(48%) 57(17.5%) morbidity and mortality meetings yes 62(19.07%) 77(23.69%) <0.001 no 144 (44.30%) 41(12.61%) academic meeting* yes 84(25.84%) 79(24.30%) <0.001 no 40(12.30%) 9(2.76%) st$ 97(29.84%) 15(4.61%) *academic meetings included conferences, cme, workshop $st-sometimes trainees at public sector hospitals recorded that they were being partially covered (62.8%) in terms of medical benefits while most of the trainees in private sector hospital believed that their institute had no such policy (81.4%) (p-value <0.001). a greater number of trainees at private sector hospital seemed satisfied with their working environment than at public hospitals (77.5% versus 12.5%) (p-value <0.001). they also documented that they received regular feedback from their supervisors (private 53.9% versus public 31.8%), had exposure to proper assessment techniques (private 62.7% versus public 32.3%) and were j islamabad med dental coll 2020 31 satisfied that they will be adequately trained by th e end of training (private 46.1% versus public 29.6%) (table iii). trainees perceive that the security arrangements at both public and private hospitals were not adequate but in case of emergency, private hospitals seem to have better response in term of security as compared to public hospitals (89% versus 23%) (p <0.001) (table iii). d i s c u s s i o n this study showed that there is a need to make an accurate assessment of current status of postgraduate training program in pakistan with perceptions of the residents (fcps trainees) in private and public sector hospitals of karachi, as the cornerstone of such an assessment. table iii: level of resident satisfaction with their residency programs (n=325) public hospital n=223 private hospital n=102 p-value medical benefits yes 7(3.1%) 6(5.9%) <0.001 no 76(34.1%) 83(81.4%) partially 140(62.8%) 13(12.7%) working environment adequate 27(12.1%) 79(77.5%) <0.001 not adequate 117(52.5%) 22(21.6%) none 76(35.4%) 01(1.0%) is the workload equally distributed among residents? yes 71(31.8%) 34(33.3%) 0.258 no 56(25.1%) 33(32.4%) partially 96(43.0%) 35(34.3%) reimbursement of workshops yes 37(16.7%) 18(17.6%) <0.001 no 67(30.3%) 79(77.5%) partially 117(52.9%) 5(4.9%) at the end of training has the resident done all the procedure as per cpsp guidelines yes 71(31.8%) 27(26.5%) 0.619 no 38(17.0%) 19(18.6%) partially 114(51.1%) 56(54.9%) do you get regular feedback from your supervisor? yes 71(31.8%) 55(53.9%) 0.001 no 53(23.8%) 20(19.6%) partially 99(44.4%) 27(26.5%) is there a proper assessment conducted by the supervisor? yes 72(32.3%) 64(62.7%) <0.001 no 53(23.8%) 19(18.6%) partially 98(43.9%) 19(18.6%) is there enough guidance/assistance given for medical research? yes 70(31.4%) 53(52.0%) 0.002 no 52(23.3%) 19(18.6%) partially 101(45.3%) 30(29.3%) level of satisfaction of the residents that they would be adequately trained by the end of the training program yes 66(29.6%) 47(46.1%) 0.005 no 33(14.8%) 17(16.7%) partially 124(55.6%) 38(37.3%) availability of security on daily basis prompt 34(10.4%) 67(20.6%) <0.001 adequate 81(24.9%) 16(4.9%) no 19(5.8%) 107(32.9%) response of security in case of emergency prompt 11(4.9%) 28(27.5%) <0.001 adequate 43(19.3%) 64(62.7%) no 169(72.8%) 10(9.8%) j islamabad med dental coll 2020 32 an interesting finding in our study was that more residents of medical and allied specialty were working more than 80 hours/week as compared to surgical specialties (p <0.001). this is in contrast to a study done by sameer-ul-hassan which showed the surgical trainees to be working more than their colleagues in medicine.12 this discrepancy could be because most of our study participants belonged to medicine and allied specialty. the reduction in training hours has a direct impact on the quality and exposure of trainees to difficult clinical problems. this has been widely discussed in the literature and the satisfaction level of trainees w ith their training programs has been reported to drop internationally.13-15 our study gives a satisfaction level that once they qualify, the residents would be capable enough to deal with all major medical and surgical problems independently (p-value 0.005). public and private sector trainees are confident that they would have an adequate training by the end of their training period. however, the trainees of public sector hospitals showed less confidence for the level of training for surgical procedures as compared to private hospital residents who had a slightly better confidence level for procedures. this is in contrast to widely held view that government institutes are better for postgraduate training owing to bulk of patients coming to these hospitals.10 according to the residents’ perceptions, academic teaching has a good format and is structured in both public and private teaching hospitals with teaching ward round and topic presentations bein g the most widely used method of teaching. long case presentation, morbidity and mortality meetings and conferences are less frequently u s e d for training. many teaching programs are trying new innovation methods of teaching and learning to improve quality of postgraduate medical training.16,17 in our study, residents at both public (125; 56.4%) and private sector (55; 54.9%) hospitals revealed that teaching ward rounds and topic presentations are used equally. this was followed by long case discussion and morbidity an d mortality meetings. only 32.4% of the public sector trainees believed that proper assessment was being conducted, 43.69% believed that it was being done only partially in contrast to private hospital trainees (62.1% and 27.1%). the student teacher interactio n has an important impact on the teaching and learning process. in case of regular feedback, the private hospital trainees were again at advantage than public hospital trainees. the private sector residents were being more regularly given feedbacks on their performance (p-value <0.001). the support and guidance which is required f or medical research was given more promptly in private sector hospitals than government hospital (p-value 0.002). tabassum et al emphasized the importance of giving timely feedback which most faculty members might not be able to give becau s e of time constraints faced during patient care.8 adequate facilities for on-call trainees are important for creating a good working environment. the work environment includes provision of room, access to reading materials and computers, clean water and cafeteria. these were either not present or were inadequate in public sector hospital. in contrast, private sector hospital are providing for the basic necessities of the postgraduate trainees (p-valve <0.001).1 the importance of working environment was also emphasized by weigl et al 18 and the inadequacy o f provisions for the trainees highlighted by biggs and khaloon le respectively.4,19 provision of safety and security for an on-call trainee doctor is of utmost concern and should be present at all times in the hospital. it is noted with concern that 84% of public hospital residents did not have comprehensive security arrangements. i n private hospital despite the presence of security j islamabad med dental coll 2020 33 arrangements, the response of security was inadequate (meaning that when called for help by the doctor they either did not reach the venue at all or were very late). this was a major source of concern for the trainees (p-value <0.001).19 a good salary package also plays an important role in the overall well-being and capacity for learning of a trainee. in our study this was an important factor. this observation has also been noted by hameed et al in a study performed on 99 surgical post graduate trainees. they found that salary was also one of the factors leading to job dissatisfaction an d lesser appreciation of wellbeing in trainees,20 an observation similar to our study. limitation: a larger sample comprising of fcps trainees of medicine and surgery all over the pakistan would give a more complete picture of the present situation of postgraduate training in the country. c o n c l u s i o n most of the postgraduate trainees perceive that they are being adequately trained for the challenges of an independent clinical practice . a c k n o w l e d g m e n t we are grateful to syed fida hussain for his help in data management. r e f e r e n c e s 1. holmboe es. faculty and the observation of trainees’ clinical skills: problems and opportunities. acad med. 2004; 79(1): 16-22. doi: 10.1097/00001888-200401000-00006 2. dyrbye l, shanafelt t. a narrative review on burnout experienced by medical students and residents. med educ. 2016; 50(1): 132-49. doi: 10.1111/medu.12927 3. yousuf a, ishaque s, qidwai w. depression and its associated risk factors in medical and surgical post graduate trainees at a teaching hospital: a cross sectional survey from a developing country. j pak med assoc. 2011; 61(10): 968-73. pmid: 22356028 4. biggs jsg. postgraduate medical training in pakistan: observations and recommendations. jcpsp. 2008; 18(1): 58-63 5. chapman dm, hayden s, sanders ab, binder ls, chinnis a, corrigan k, et al. integrating the accreditation council for graduate medical education core competencies into the model of the clinical practice of emergency medicine. ann emerg med. 2004; 43(6): 756-69. doi: 10.1016/s0196064403013532 6. dyne pl, strauss rw, rinnert s. systems-based practice: the sixth core competency. acad emerg med. 2002; 9(11): 1270 -7. doi: 10.1111/j.15532712.2002.tb01587.x 7. swing sr. assessing the acgme general competencies: general considerations and assessment methods. acad emerg med. 2002; 9(11): 1278-88. doi: 10.1111/j.1553-2712.2002.tb01588.x 8. zehra t, tariq m, ali sk, motiwala a, boulet j. challenges of providing timely feedback to residents: faculty perspectives. j pak med assoc. 2015; 65(10): 1069-74. pmid: 26440835 9. kasi pm, khawar t, khan fh, kiani jg, khan uz, khan hm, et al. studying the association between postgraduate trainees’ work hours, stress and the use of maladaptive coping strategies. j ayub med coll abbottabad. 2007; 19(3): 37-41. pmid: 18444589 10. saaiq m, khaleeq-uz-zaman. residents' perceptions of their working conditions during residency training at pims. j coll physicians surg pak. 2010; 20(6): 400 4. doi: 06.2010/jcpsp.400404 11. haney em, nicolaidis c, hunter a, chan bk, cooney tg, bowen jl. relationship between resident workload and self-perceived learning on inpatient medicine wards: a longitudinal study. bmc med edu 2006; 6: 35. doi: 10.1186/1472-6920-6-35 12. sameer-ur-rehman, kumar r, siddiqui n, shahid z, syed s, kadir m. stress, job satisfaction and work hours in medical and surgical residency programmes in private sector teaching hospitals of karachi, j pak med assoc. 2012; 62(10): 1109 -12. pmid: 23866463 13. liptrot s. problems in medical training won’t be solved by working time opt-outs. bmj. 2014; 349: g5431. doi:10.1136/bmj.g5431 14. ahmed n, devitt ks, keshet i, spicer j, imrie k, feldman l, et al. a systematic review of the effects of resident duty hour restrictions in surgery. impact on resident wellness, training, and patient outcomes. ann surg. 2014; 259(6): 1041 -53. doi: 10.1097/sla.0000000000000595 15. williams n, beamish a, foster cbea, hopson c, royles d, hamilton-fairley d, et al. report of the independent working time regulations taskforce. the implementation of the working time directive, j islamabad med dental coll 2020 34 and its impact on the nhs and healthcare professionals. rcs publications, 2014. www.rcseng.ac.uk/policy/documents/wtd-taskforcereport-2014 16. sandhu d. postgraduate medical education – challenges and innovative solutions. med teacher.2018; 40(6): 607-609. doi: 10.1080/0142159x.2018.1461997 17. murnaghan ml, forte m, choy ic, abner e. innovations in teaching and learning in the clinical setting for postgraduate medical education. members of the fmec pg consortium; 2011. 18. weigl m, hornung s, angerer p, siegrist j, glaser j. the effects of improving hospital physicians working conditions on patient care: a prospective, controlled intervention study. bmc health services research 2013; 13(1): 401. doi: 10.1186/1472 -6963-13-401 19. kahloon le. trainees’ perception of learning environment in public teaching hospitals of rawalpindi: a mixed methods study. pak armed forces med j. 2018; 68 (2): 404 -411. 20. hameed t, zia n, khan hs, zia a, ahmed r, hameed a, et al. analysis of level of satisfaction of postgraduate trainees on surgical floor. j ayub med coll abbottabad. 2019; 31(2): 207 -213. j islamabad med dental coll 2020 1 correspondence: memoona rasheed email: memoona_rasheed@hotmail.com cite this editorial: rasheed m. next generation sequencing as an emerging technology in rare disease genetics. j islamabad med dental coll. 2020; 9(1):1-3. doi: 10.35787/jimdc.v9i1.521 ope n acce ss next generation sequencing as an emerging technology in rare disease genetics memoona rasheed senior lecturer, department of allied health sciences, islamabad medical and dental college the dna sequencing techniques became available in 1970s. the technique developed by sanger and colleague, referred to as sanger sequencing, became the most widely used method in dna sequencing projects including the most famous human genome project (hgp).1 the first draft human genome sequence was published separately by a public sector group, international human genome sequencing consortium (ihgsc), in nature and by a private sector group, celera genomics, in science in 2001.1 the estimated cost for hgp was 3 billion usd over a span of 15 years but this cost and time reduced to 300 million in 2 years due to the rapid technical advancements.2 in 2004, the national human genome research institute (nhgri) started a funding program aimed to reduce the sequencing cost to 1000 usd which paved the path for development of the next generation sequencing (ngs) technologies, also known as h igh throughput sequencing technologies. 1 the first ngs technology was introduced by 454 life sciences (now roche) in 2004 which utilized pyrosequencing method. illumina sequencing platform and sequencing by oligo ligation detection (solid) by applied biosystems (now life technologies) were commercialized in 2006 and 2007, respectively.3 other ngs methods are also available like ion torrent, pacific bioscience and oxford nanopore but so far, illumina holds the major market share due to availability of wide range of cost effective platforms. 2 the illumina’s recently introduced novaseq 6000 system (www.illumina.com) has the capability of generation of 6 terabyte data per run with fastest run time of 1-2 days with much reduced price but their promise of reducing sequencing cost per genome to 100 usd is still to be fulfilled. the rapid drop in sequencing prices paved the path for clinical implementation of ngs technology. ngs has been used in cancer genomics, personalized medicine, forensic science, hla typing and organ transplantation, clinical microbiology, prenatal diagnostics, new born screening and in identification of genetic players in rare disorders (figure 1). rare disorders, although individually uncommon but collectively affect millions of people worldwide. these disorders occur due to mutation s in single gene affecting its function and so far, 7000 rare disorders are known to occur with almost 15000 genes being involved.4 for molecular diagnosis of rare disorders, ngs based targeted gene panels are most commonly used for identification of mutation in genes already known to cause a disease.5 whole exome sequencing (wes), which targets only protein coding portion o f the genome (~1%), is the second best option for identification of pathogenic mutations in already known and novel genes4 identification of disease gene will help to unravel the molecular pathways which will be helpful in exploring therapeutic options. currently, direct therapeutic approaches e d i tor i a l j islamabad med dental coll 2020 2 such as dna replacement by gene therapy, prote i n /enzyme replacement therapy, transcriptional downregulation by antisense oligonucleotides or rna interference and disease gene correction by using genome editing techniques are in clinical or pre-clinical trials. beside these, rapid low cost and low risk therapies for rare diseases is also practiced such as dietary substrate omission or supplementation as in case of phenylketonuria, maple syrup urine disease and some other metabolic disorders.4 figure 1: clinical applications of next generation sequences in pakistan, 17-38% marriages are consanguineous which have been long known to increase the risk o f congenital disorders among children. 6 large scale genetic studies have been conducted on pakistani families affected with various rare disorders by using next generation sequencing technologies which has led to identification of several novel genes and novel mutations in already known genes. genetic analysis of 23 family affected with autosomal recessive primary microcephaly revealed that most of the disease-causing mutations were harbored by aspm and wdr62.7 a study conducted on 60 families affected with intellectual disability (id) by using whole exome sequencing helped in identification of 30 novel candidate disease causin g genes.8 in another study, 192 id affected consanguineous families, belonging to pakistan and iran were studied which helped in identification of 26 new id causing genes.9 targeted ngs on 12 pakistani families affected with syndromic or non-syndromic hearing loss helped in identification of 8 novel disease causing variants in known genes. 10 in another study, whole exome sequencing help e d in developing molecular diagnosis for almost half of the cases in familial cohort inheriting retinal degeneration.11 thus implementation of ngs technology in clinical practice for rare disease diagnosis by designing population specific gene panels or by whole exome sequencing are the two cost effective approaches which will not only shorten the time for disease diagnosis but will also help in deciding therapeutic options available to the patient. r e f e r e n c e s 1. chan ey. advances in sequencing technology. mutat res. 2005; 573(1-2): 13–40. doi: 10.1016/j.mrfmmm.2005.01.004 2. timmerman, l. dna sequencing market will exceed $20 billion, says illumina ceo jay flatley. forbes [online],https://www.forbes.com/sites/luketimmerm an/2015/04/29/qa-with-jay-flatley-ceo-of-illuminathe-genomics-company-pursuing-a-20bmarket/#6b80ba6c42e7 (29 apr 2015) 3. van dijk el, auger h, jaszczyszyn y, thermes c. ten years of next-generation sequencing technology. trends genet. 2014; 30(9): 418-26. doi: 10.1016/j.tig.2014.07.001 4. boycott km, vanstone mr, bulman de, mackenzie ae. rare-disease genetics in the era of nextgeneration sequencing: discovery to translation. nat rev genet. 2013; 14(10): 681-91. doi: 10.1038/nrg3555 5. rehm hl. disease-targeted sequencing: a cornerstone in the clinic. nat rev genet. 2013; 14(4): 295-300. doi: 10.1038/nrg3463 6. hamamy h, antonarakis se, cavalli-sforza ll, temtamy s, romeo g, kate lp et al. consanguineous marriages, pearls and perils: geneva international j islamabad med dental coll 2020 3 consanguinity workshop report. genet med. 2011; 13(9): 841–47. doi: 10.1097/gim.0b013e318217477f 7. wang r, khan a, han s, zhang x. molecular analysis of 23 pakistani families with autosomal re cessive primary microcephaly using targe ted next-generation sequencing. j hum genet, 2017; 62(2): 299–304. doi: 10.1038/jhg.2016.128 8. riazuddin s, hussain m, razzaq a, iqbal z, shahzad m, polla dl, et al. exome sequencing of pakistani consanguineous families identifies 30 novel candidate genes for recessive intellectual disability. molecular psychiatry, 2017; 22(11): 1604–14. doi: 10.1038/mp.2016.109 9. harripaul r, vasli n, mikhailov a, rafiq ma, mittal k, windpassinger c, et al. mapping autosomal recessive intellectual disability: combined microarray and exome sequencing identifies 26 novel candidate genes in 192 consanguineous familie s. mol psychiatry. 2018; 23(4): 973-84. doi: 10.1038/mp.2017.60 10. wang r, han s, khan a, zhang x. molecular analysis of twelve pakistani families with nonsyndromic or syndromic hearing loss. genet test mol biomarkers. 2017; 21(5): 316-21. doi: 10.1089/gtmb.2016.0328 11. maranhao b, biswas p, gottsch adh, navani m, naeem ma, suk j, et al. investigating the molecular basis of retinal degeneration in a familial cohort of pakistani decent by exome sequencing. plos one, 2015; 10(9): e0136561. doi: 10.1371/journal.pone.0136561 . j islamabad med dental coll 2019 131 open access comparison of safety and efficacy of potassium hydroxide versus combination of salicylic and lactic acid for molluscum contagiosum durre-shehwar arshad pirzada1, sumaira abdullah2, qurat-ul ain zia3, syed afaq ahmed4, hamid ali5 1 private practitioner in abbotabad 2 senior registrar, department of dermatology, akbar niazi teaching hospital 3 senior lecturer, department of biochemistry, islamabad medical & dental college 4 head, department of dermatology, dr. akbar niazi teaching hospital 5 head, department of medical lab technology, dr. akbar niazi teaching hospital a b s t r a c t background: molluscum contagiosum (mc) is a contagious cutaneous infection caused by mc virus, affecting mainly the pediatric population. it is characterized by flesh-colored umbilicated papules occurring on the skin surface. potassium hydroxide (koh) and salicylic acid plus lactic acid combination being keratolytic agents, are effective treatment options. the objective of the study was to compare the efficacy and safety of 10% koh solution versus salicylic acid/ lactic acid combination in treating molluscum contagiosum in pediatric population. material and methods: a total of 80 children (age range 1-13 years) with molluscum contagiosum lesions were selected from the dermatology out-patient department, and were randomly allocated into two groups by lottery method. group a was given topical 10% koh solution and group b was given salicylic plus lactic acid preparations for topical application. patients were followed after two weeks to see regression in size of the lesion, and development of any side-effects. final visit was scheduled at 6 weeks. statistical analysis was carried out using spss (version 16) with p value less than 0.05 considered as statistically significant. results: patients with mc (n = 80) were equally divided into group a (treated with 10% koh) and group b (treated with combination of salicylic acid and lactic acid). after 6 weeks, complete remission from molluscum contagiosum virus was seen in 29 (72.5%) patients of group a and 34 (85%) patients of group b. there were 12 (30%) patients in group a who developed local irritation and 4 (10%) developed local erythema after 6 weeks. none of the patients of group b had any such side effects. conclusion: 10% koh solution is as effective as the combination of salicylic and lactic acids for treatment of molluscum contagiosum in pediatric population, however it is associated with side effects of local irritation and erythema. key words: molluscum contagiosum; potassium hydroxide; salicylic acid, lactic acid combination; topical authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3-5 active participations in data collection data analysis. correspondence: qurat-ul-ain zia email: quratulain_imdc@yahoo.com article info: received: december 6, 2018 accepted: may 10, 2019 cite this article. pirzada da, abdullah s, zia q, ahmed sa, ali h. comparison of safety and efficacy of potassium hydroxide versus salicylic acid and lactic acid combination for treatment of molluscum contagiosum. j islamabad med dental coll.2019; 8(3):131-134. doi: 10.35787/jimdc.v8i3.418 funding source: nil conflict of interest: nil i n t r o d u c t i o n molluscum contagiosum (mc) is a common viral infection in children caused by mc virus, a member of pox virus family, belonging to genus molluscipoxvirus.1 mc presents as pearly white papules with central depression, they can affect any part of the skin surface.1 a casecontrol study, compiling data for infected children (<5 years old) at an indian health service (ihs) outpatient clinic in the united states reported an overall incidence of o r i g i n a l a r t i c l e j islamabad med dental coll 2019 61 68.5 per 10,000 children.2 this viral infection spreads by scratching, sharing towels/clothing or using community swimming pools.2 molluscum contagiosum is a selflimiting condition, and spontaneous resolution occurs within 6-18 months. the need for treatment arises as the lesions are very contagious and a source of embarrassment both for the patient and parents.3 various treatments are available, aimed at destroying the infected tissue with the virus including curettage, electrocoagulation, topical keratolytic therapies like salicylic acid, koh, or tretinoins and oral drugs like cimetidine and isotretinoin.4 a comparative study on the effect of 10% koh and combination of salicylic plus lactic acid in treating childhood mc concluded that 83.3% of patients treated with koh and 100% patients treated with salicylic and lactic acid combination showed complete resolution with minimal side effects.5 koh solution is a cheap chemical and is freely available, while salicylic acid and lactic acid combination is also available as an over-the-counter drug. however, less data is on record regarding their safety and efficacy profile. this study helped us in determining the safety and efficacy profile of these drugs, thus finding a cost-effective and safer treatment option for molluscum contagiosum in pediatric population. m a t e r i a l a n d m e t h o d s this randomized control trial (rct) was carried out at dermatology outpatient department, pakistan institute of medical sciences (pims), islamabad from february, 2015 to august, 2015. sample size was calculated with the help of who calculator. level of significance was kept as α = 5%, power of the study 80%, p1=83.3%5 and p2 = 100%5 calculated sample size was 40 patients in each group. a total of 80 patients were recruited by consecutive nonprobability sampling. patients from 1-13 years of age suffering from molluscum contagiosum presenting to dermatology outpatient department, pakistan institute of medical sciences, islamabad were included. all immunocompromised patients (congenital or acquired) and patients having other topical treatment within the last month were excluded from study. the study commenced after approval from the hospital’s ethical review board. written informed consent was taken from the parents of the patients registered for study. confidentiality was maintained throughout the study. all enrolled patients were divided into group a and group b randomly by lottery method. single blinded protocol was followed by concealing any information about their allotment group from the patient/parents. group a was given 10% koh solution once a day, and group b was prescribed salicylic acid and lactic acid combination (active control) to be applied on mc lesions once a day. parents were instructed to apply these drugs on the lesions. either of the treatment regimens was discontinued, if the patient developed any of the side effects like erythema, ulceration, scaling and hyperpigmentation. all patients were asked to follow-up fortnightly, and at each visit lesions were examined for decrease in size and development of any side effects. final visit was scheduled at 6 weeks. no patient was lost to follow up. safety is defined in terms of absence of erythema, ulceration, scaling and hyperpigmentation, and efficacy is defined in terms of complete resolution of lesions in six weeks. all statistical calculations were performed using spss version 16. mean and standard deviation were calculated for age and duration of the disease. frequency and percentages were calculated for categorical variables such as gender, efficacy and safety. chi square test was used to compare categorical variables. p value of less than 0.05 was considered statistically significant r e s u l t s the demographic characteristics of participants of both groups are shown in table i. regarding efficacy, a greater number of patients (n=34) in group b using salicylic acid and lactic acid combination had complete remission as compared to patients in group a (n=29) using koh therapy, but the difference was statistically nonsignificant. however, 30% of patients in group a developed local irritation and 10% developed erythema and the difference was statistically significant (table ii). j islamabad med dental coll 2019 62 table i: demographic characteristics of participants of study no. of patients (80) group a (40) group b (40) mean age (years) 5.28 4.68 mean duration of disease (months) 3.83 3.63 males n (%) 19 (47.5) 18 (45) females n (%) 21 (52.5) 22 (55) table ii: comparison of efficacy and safety in both the groups (n=80) variables (after 06 weeks) group a n (%) group b n (%) p-value efficacy complete mc remission 29 (72.5) 34 (85.0) 0.274 safety local irritation 12 (30.0) 0 (0) 0.000* erythema 04 (10.0) 0 (0) 0.040* ulceration 0 (0) 0 (0) na hyperpigmentation 0 (0) 0 (0) na *p-value < 0.05 statistically significant d i s c u s s i o n molluscum contagiosum is a viral infection usually occurs in childhood but is also observed in adults especially those who are immunocompromised.1 it is usually a selflimiting condition but the need for treatment arises when the lesions disseminate, become pruritic or become a cause of discomfort for the patient. various treatment options are available which range from destructive modalities like curettage, surgical excision or cryotherapy to milder forms like application of topical agents.6,7 in the present study, the mean age was 5.28± 3 years in group a and 4.68 ± 3.3 years in group b. comparative figures for mean age of the patients (5.38 years) has been reported in a randomized controlled trial by marsal on efficacy and tolerance of topical application of potassium hydroxide (10% and 15%) in treatment of molluscum contagiosum.4 a systematic review on epidemiology of molluscum contagiosum in children by olsen et al. also showed that it was most common among children between 0 and 14 years of age8. in this study, female gender was predominantly affected by molluscum contagiosum lesions. however, a study done by laxmisha et al, opposes these findings and observed that more male children were affected by molluscum contagiosum as compared to female children.9 in the present study 85% of patients with molluscum contagiosum using salicylic acid and lactic acid combination and 72.5% of patients using 10% koh solution showed complete remission and the difference was statistically significant. this finding is supported by the work done by köse et al 5. a study done to evaluate the efficacy and safety of 10% potassium hydroxide solution in the treatment of pediatric patients with molluscum contagiosum also showed that 10% potassium hydroxide solution is safe, effective, inexpensive and noninvasive alternative treatment for molluscum contagiosum.10 they reported that 92.5% of patients receiving topical 10% potassium hydroxide solution had complete remission of the lesions in an average duration of 4 weeks. local side effect of hypopigmentation was observed in 32.4% of patients.10 similarly, a study done by sequeira et al also found 10% potassium hydroxide solution to be an effective and safe treatment modality for the pediatric patients with molluscum contagiosum.11 the present study showed no statistically significant difference in the side effects in both the groups after stratification of patients according to number of lesions. this finding is also supported by the study results of kose et al 5 and can et al.10 contrary to this, a study showed side effects of mild pain in 55% of patients, mild burning sensation in 20% of patients and secondary bacterial infection in 10% of patients, but in this study topical potassium hydroxide was used in a higher concentration of 20% instead of 10%. therefore, it can be inferred that topical potassium hydroxide when used in higher concentration can be associated with local side effects.12 the limitations of this study were small sample size that reduced the power of the study and inability to confirm diagnosis of mc by microscopy of skin scrapings, especially in cases with doubtful clinical diagnosis. c o n c l u s i o n 10% koh solution is as effective as combination of salicylic and lactic acids for treatment of molluscum contagiosum in pediatric population, however it is associated with side effects of local irritation (30%) and erythema (10%) in a fraction of treated patients. j islamabad med dental coll 2019 63 r e f e r e n c e s 1. jang hs, kim mr, oh sh. unusual manifestation of molluscum contagiosum: eruptive papules on the face and neck of an immunocompetent patient. ann dermatol. 2013; 25(3): 398-9. doi: 10.5021/ad.2013.25.3.398 2. mccollum am, holman rc, hughes cm, mehal jm, folkema am, redd jt et al. molluscum contagiosum in a pediatric american indian population: incidence and risk factors. plos one. 2014; 9(7): e103419. doi: 10.1371/journal.pone.0103419 3. marsal jr, cruz i, teixido c, diez o, martinez m, galindo g et al. efficacy and tolerance of the topical application of potassium hydroxide (10% and 15%) in the treatment of molluscum contagiosum: randomized clinical trial: research protocol. bmc infect dis. 2011; 11(1): 278. doi: org/10.1186/1471-2334-11-278 4. sherwani s, farleigh l, agarwal n, loveless s, robertson n, hadaschik e et al. seroprevalence of molluscum contagiosum virus in german and uk populations. plos one. 2014; 9(2): e88734. doi: 10.1371/journal.pone.0088734 5. köse o, özmen i̇, arca e. an open, comparative study of 10% potassium hydroxide solution versus salicylic and lactic acid combination in the treatment of molluscum contigiosum in children. j dermatology treat. 2013; 24(4): 300-4. doi: 10.3109/09546634.2011.649690 6. nguyen hp, tyring sk. an update on the clinical management of cutaneous molluscum contagiosum. skin therapy lett. 2014; 19(2):5-8. pmid: 24740746 7. forbat e, al-niaimi f, ali fr. molluscum contagiosum: review and update on management. pediatric dermatology/ 2017; 34(5): 504-15. doi: 10.1111/pde.13228 8. olsen jr, gallacher j, piguet v, francis na. epidemiology of molluscum contagiosum in children: a systematic review. fam pract. 2014; 31(2):130-6 9. laxmisha c,thappa dm and jaisankar tj. clinical profile of molluscum contagiosum in children versus adults. dermatol online j.2003; 9(5): 1. pmid: 14996374 10. can b, topaloglu f, kavala m, turkoglu z, zindanci i, sudogan s. treatment of pediatric molluscum contagiosum with10% potassium hydroxide solution. j dermatolog treat 2014; 25 (3): 246-8. doi: 10.3109/09546634.2012.697988 11. sequeira ff, bala nk, hundi gk, martis j. a study on the efficacy of topical 10% potassium hydroxide in the treatment of molluscum contagiosum. muller j med sci res 2016; 7:1-3. doi: 10.4103/0975-9727.174604 12. maluki ah, kadhum qj. treatment of molluscum contagiosum by potassium hydroxide solution 20% with and without pricking and by pricking alone: a comparative study with review of literature. int j dermatol clin res 2015; 1(2): 031-041. 140 j i m d c 2 0 1 7 140 op e n ac c e ss f u l l l e n g t h a r t i c l e comparison of mean lipid profile in calcific aortic stenosis cases and controls erum afaq1, syed hafeezul-hassan2, muhammad kashif nisar3, humera afaq4, kishwar naheed5 1 assistant professor physiology, liaquat national hospital and medical college, karachi 2 head/professor physiology, liaquat national hospital and medical college, karachi 3 associate professor biochemistry, jinnah medical & dental college, karachi 4 post graduate resident medical officer, internal medicine, abbasi shaheed hospital, karachi 5assistance professor, anatomy, liaquat national hospital and medical college, karachi a b s t r a c t objective: this study was aimed to compare the mean lipid profile in calcific aortic stenosis patients and control group. patients and methods: total 202 individuals, 101 cases and 101 controls visiting national institute of cardiovascular disease and various tertiary care hospitals of karachi from january 2012 to december 2012 were included in this study. calcific as patients having the age of ≥60 years fulfilling the inclusion criteria were selected from echocardiography department and opd from nicvd. age and gender match controls were selected from opd. lipid profile was done in ddrrl, ojha campus. lipid profile estimates were carried out on hitachi 902 analyzer using photometry technique. results: nonparametric mann-whitney test showed increase level of triglyceride in calcific as patients. conclusion: calcific as patients showed altered lipid profile as compare to control group so dyslipidemia may be involved in its pathogenesis. keywords: calcific aortic stenosis, cholesterol, dyslipidemias, high density lipoprotein, low density, lipoprotein, triglyceride. author`s contribution 1 conceived the topic of research, designed the study, data collection, literature review and manuscript writing 2 discussion, critical review, 3 data analysis, 4 critical review, 5 compiling results, address of correspondence erum afaq email. doc_erum@yahoo.com article info. received: may 31, 2017 accepted: july 9, 2017 cite this article: afaq e, hassan h, nisar mk, afaq h, naheed k. comparison of mean lipid profile in calcific aortic stenosis cases and controls.jimdc. 2017; 6(3):140-143 funding source: nil conflict of interest: nil i n t r o d u c t i o n severe calcific aortic stenosis (as) is one of the most commonly encountered valvular pathologies requiring surgery in developed countries.1 it is postulated that an early lesion in as is characterized by subendothelial thickening on the aortic side of the leaflet because of accumulation of cellular lipid infiltration and extracellular mineralization, accompanied by a proliferation of smooth muscle cells and lipid-laden foam cells resembling atherosclerotic plaques.2 there are similarities between risk factors for coronary atherosclerosis and the development of as, which suggests that the atherosclerotic process involving aortic valve leaflets eventually brings about or accelerates the thickening of the leaflet structure, leading to significant as.3-5 in patients with familial hypercholesterolemia, high cholesterol concentrations are associated with the development of as.6,7 many cardiovascular studies have proved that there is a link between atherosclerotic risk o r i g i n a l a r t i c l e 141 j i m d c 2 0 1 7 141 factors and the factors associated with the prevalence and progression of calcific as.8 that includes elevated ldl cholesterol, lipoprotein (a), hypertension, male gender and smoking.9 this information can leads the way as lipid lowering drugs may be the treatment of choice for prevention and delay the progression of calcific as.10,11 in pakistan no such data is available. we designed this retrospective case-control study to evaluate the relationship between altered lipid profilein echocardiographically diagnosed patients with calcific as, who referred to echocardiography department and opd for further evaluation and to compare the mean values of lipid profile in calcific as patients and controls. p a t i e n t s a n d m e t h o d s this study was conducted in national institute of cardiovascular disease (nicvd) and ddrrl, ojha campus dimc, dow university of health sciences (duhs). study was approved by ethical review committee of nicvd and duhs. patients were selected from echocardiography department and opd from nicvd. a detailed history was taken and elderly patients (age≥60 years) having calcific as were included in the study. for controls, age and gender matched persons without calcific as were inducted. patients having severe aortic regurgitation, history of endocarditis, rheumatoid arthritis, rheumatic fever or rheumatic heart disease and echocardiographic evidence of rheumatic valvular stenosis, chronic renal failure, familial hypercholesterolemia (total cholesterol >300 mg/dl in adults), cancer, prosthetic valves or patient taking lipid lowering drugs were excluded from the study. the patients were documented brased on their written consent on a detailed prescribed performa. study was completed in 2 years after approval from board of advanced scientific research (basr) and funding committee of dow university of health science. sample size was calculated with the help of open epi (http://www.openepi.com/samplesize/ssmean.htm) by taking mean total cholesterol in as patients as 211±43 mg/dl, mean total cholesterol in patients without aortic stenosis as 193±48 mg/dl,12 power of 80% and confidence interval of 95%. the calculated sample size was 202 patients, 101 in each case and control groups. non-probability purposive sampling technique was used. fasting blood samples were collected from both the case and control groups for lipid profiling. lipid profile estimates were carried out on hitachi 902 analyzer using photometry technique in ddrrl, ojha campus. data was entered in microsoft excel and analyzed using spss version 21. descriptive analysis was done according to the type of variable. numeric data was analyzed by calculating mean and standard deviation (sd). frequencies and percentages were calculated for categoric variables. as the data was nonparametric, median and range were taken. the nonparametric mannwhitney test was used to compare the two groups. pvalue less than 0.05 was considered to be statistically significant. r e s u l t s a total of 202 individuals were recruited in our study. total 101 elderly people as calcific as cases and 101 age and gender matched controls. the age and gender distribution among two groups is presented in table i. the mean age and standard deviation for the cases was 67.09±5.04 and the mean age and standard deviation for controls was 66.72±3.68. there were 63 (62.4%) males and 38 (37.6%) females in the case group and 67 (66.3%) male and 34 (33.7%) females were included in control group. histogram and shapiro-wilk test were applied to check the normality. as the variables are violating the assumption of normality therefore nonparametric mannwhitney test was used to compare both cases and controls. triglyceride level showed significant difference between both the groups as mentioned in table 2. table 1: demographic profile in cases and controls variables cases controls age (years) mean 67.09 66.72 sd 5.04 3.68 gender males n (%) 63 (62.4) 67 (66.3) female n (%) 38 (37.6) 34 (33.7) table 2: descriptive statistics of lipid profile in both groups lipid profile (mg/dl) cases controls p-value median (range) median (range) triglyceride 114 (421) 140 (356) <0.001 total cholesterol 160 (177) 152 (218) 0.739 hdl 39 (40) 40 (34.8) 0.524 ldl 93 (119) 88 (118) 0.087 d i s c u s s i o n multiple studies have shown many similarities in the histopathologic features of atherosclerosis and calcific as.3,13,14 there is also an overlap in the risk factors of 142 j i m d c 2 0 1 7 142 calcific as and atherosclerosis, among them one is dyslipidemia. 8,15,16 in this study fasting lipid profile was done among calcific as cases and controls. there was a difference in the mean triglyceride level in cases and controls with significant p-value <0.05. these findings are in contrast to peltier et al 2003, who showed a higher level of triglyceride in as cases.12 in our study, the cause of triglyceridemia may be due to the presence of coronary artery disease in controls.17 mean total cholesterol showed the insignificant difference in both groups. this finding is consistent with the findings of a study conducted by ortlepp 2006 and in contrast to the study conducted by peltier et al who found that there is hypercholesteremia in patients of calcific as. 18 models of atherosclerotic disease in rabbits and rats have also been used to determine the effects of hypercholesterolemia on the aortic valve morphology and function.19 insignificant values in our study may be due to presence of comorbidities in both groups. hdl-cholesterol showed insignificant p-value but hdl cholesterol was decreased in both the groups. the casecontrol study conducted by park et al. 2013, showed that decrease in hdl-cholesterol was associated with the as and its progression.20 novaro et al. 2003, showed an insignificant association of hdl-cholesterol with cases and controls. however, in his work patients had a normal level of hdl-cholesterol.21 in our study, insignificant pvalue for hdl-cholesterol might be due to the fact that both groups included female participants above sixty years of age and in females, hdlcholesterol decreases as age increases. regarding mean ldl-cholesterol, our study showed nonsignificant p-value. the study was consistent with the results of novaro et al. 2003, who showed insignificant pvalue of ldl cholesterol between cases and controls. 21 however, moura et al 2007 showed higher level of ldl cholesterol in calcific as patients. 22 in humans, a strong influence has been observed of the ldl cholesterol levels on the progression of as, as quantified by electron beam tomography using a volumetric score.23 c o n c l u s i o n calcific as is a multifactorial disease. the present study concluded that calcific as patients have altered lipid profile as compared to control group so dyslipidemia may be involved in its pathogenesis. however, in some patients, the presence of coronary artery disease may have produced symptoms, predominantly angina, which incited investigation and hence resulted in bias towards finding an association between aortic stenosis and altered lipid profile. a c k n o w l e d g m e n t authors acknowledged muhammad irfan and hira fatima waseem bio-statisticians in the department of statistics, liaquat national hospital and medical college, for their guidance in statistical analysis of the data. r e f e r e n c e s 1. heistad dd, shanahan c, demer ll. introduction to the compendium on calcific aortic valve disease. circulation research. 2013;113(2):176-8. 2. parisi v, leosco d, ferro g, bevilacqua a, pagano g, de lucia c, filardi p, caruso a, rengo g, ferrara n. the lipid theory in the pathogenesis of calcific aortic stenosis. nutrition, metabolism and cardiovascular diseases. 2015;25(6):519-25. 3. kamath ar, pai rg. risk factors for progression of calcific aortic stenosis and potential therapeutic targets. international journal of angiology. 2008;17(02):63-70. 4. rosenhek r, baumgartner h. aortic sclerosis, aortic stenosis and lipid-lowering therapy. expert review of cardiovascular therapy. 2008;6(3):385-90. 5. wierzbicki as, viljoen a, chambers jb. aortic stenosis and lipids: does intervention work? current opinion in cardiology. 2010;25(4):379-84. 6. retterstol k, mundal l, igland j, tell gs, holven k, veierod mb, leren tp. incidence of various types of atherosclerotic disease in patients with genotyped familial hypercholesterolemia. atherosclerosis. 2017;263:e26. 7. dutta b, islam a, ullah m, zaman a, karmakar k, rahman m, et al. homozygous familial hypercholesterolaemia with valvular aortic stenosis and significant coronary artery disease: a case report. cardiovascular journal. 2014;6(2):180-3. 8. ljungberg j, johansson b, engström kg, albertsson e, holmer p, norberg m, berqdahl ia, et al. traditional cardiovascular risk factors and their relation to future surgery for valvular heart disease or ascending aortic disease: a case–referent study. journal of the american heart association. 2017;6(5):e005133. 9. sathyamurthy i, alex s, kirubakaran k, sengottuvelu g, srinivasan k. risk factor profile of calcific aortic stenosis. indian heart journal. 2016;68(6):828-31. 10. rossebo ab, pedersen tr, allen c, boman k, chambers j, egstrup k, gerdts e, et al. design and baseline characteristics of the simvastatin and ezetimibe in aortic stenosis (seas) study. the american journal of cardiology. 2007;99(7):970-3. 11. shabiti a, aibibula a, tuerxun a, wufuer h. therapeutic effect and mechanism of action of abnormal savda munziq in development of degenerative atherosclerotic aortic valve disease. medical science monitor. 2017;23:4431-9. 12. peltier m, trojette f, sarano me, grigioni f, slama ma, tribouilloy cm. relation between cardiovascular risk factors and nonrheumatic severe calcific aortic stenosis among patients with a three-cuspid aortic valve. the american journal of cardiology. 2003;91(1):97-9. 143 j i m d c 2 0 1 7 143 13. liberman m, bassi evo, martinatti mk, lario fbc, wosniak jo, pomerantzeff pma, laurindo fr. oxidant generation predominates around calcifying foci and enhances progression of aortic valve calcification. arteriosclerosis, thrombosis, and vascular biology. 2008;28(3):463-70. 14. rajamannan nm, evans fj, aikawa e, grande-allen kj, demer ll, heistad dd, simmons ca, masters ks, mathieu p, o'brien kd, schoen fj. calcific aortic valve disease: not simply a degenerative process. circulation. 2011; 124(16):1783 91. 15. o’brien kd. pathogenesis of calcific aortic valve disease a disease process comes of age (and a good deal more). arteriosclerosis, thrombosis, and vascular biology. 2006;26(8):1721-8. 16. freeman rv, otto cm. spectrum of calcific aortic valve disease. circulation. 2005;111(24):3316-26. 17. do r, willer cj, schmidt em, sengupta s, gao c, peloso gm, et al. common variants associated with plasma triglycerides and risk for coronary artery disease. nature genetics. 2013;45(11):1345-52. 18. ortlepp jr, pillich m, mevissen v, krantz c, kimmel m, autschbach r, langebartels g, erdmann j, hoffmann r, zerres k. apoe alleles are not associated with calcific aortic stenosis. heart. 2006;92(10):1463-6. 19. le quang k, bouchareb r, lachance d, laplante m-a, el husseini d, boulanger mc, fournier d, et al. a. early development of calcific aortic valve disease and left ventricular hypertrophy in a mouse model of combined dyslipidemia and type 2 diabetes mellitus significance. arteriosclerosis, thrombosis, and vascular biology. 2014;34(10):2283-91. 20. park jy, choi jw, ryu sk, song cs. the impact of low level of high density lipoprotein cholesterol on adverse clinical outcomes in patients with mild to moderate aortic stenosis. the american journal of cardiology. 2013; 111(7):103b. 21. novaro gm, sachar r, pearce gl, sprecher dl, griffin bp. association between apolipoprotein e alleles and calcific valvular heart disease. circulation. 2003;108(15):1804-8. 22. moura lm, ramos sf, zamorano jl, barros im, azevedo lf, rocha-gonçalves f, rajamannan nm. rosuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis. journal of the american college of cardiology. 2007;49(5):554-61. 23. kizer jr, gefter wb, delemos as, scoll bj, wolfe ml, mohler 3rd e. electron beam computed tomography for the quantification of aortic valvular calcification. the journal of heart valve disease. 2001;10(3):361-6. 157 j i m d c 2 0 1 7 157 open access f u l l l e n g t h a r t i c l e comparison of effect of losartan with pioglitazone on β-cell function in a rat model of type 2 diabetes mellitus muhammad nauman shad 1, hina aslam 2, muhammad omar shamim 3, sadia chiragh 4, zeeshan ahmad 5 1 associate professor of pharmacology, sahara medical college narowal 2 assistant professor of pharmacology, islamabad medical & dental college, islamabad 3 associate professor of physiology, islam medical college, sialkot 4 retired professor of department of pharmacology, pgmi, lahore 5 phd research scholar, department of pharmacology, faculty of pharmacy, university of sargodha a b s t r a c t objective: to find out the effect of losartan in comparison with pioglitazone on β-cell function in a type 2 diabetic rat model. patients and methods: this was a randomized control trial study and was carried out at postgraduate medical institute (pgmi), lahore from june to august 2011. in this study 45 sprague-dawley rats of 5 weeks of age were randomized into three groups. all the rats were fed with a high fat and sucrose diet. pioglitazone or losartan were given along with this diet to the rats in-group hfd-pio and hfd-los respectively, while group hfd was kept under control. body weight and fasting blood glucose levels were determined weekly. at the end of 12 weeks, blood glucose and serum insulin levels were determined. a marker of β-cell function, homa-β, was also calculated. results: at the end of study period, body weight, fasting blood glucose, serum insulin, and homa-β levels were significantly lower in the hfd-pio and hfd-los groups as compared to the control hfd group. the difference in these parameters between the hfd-pio and hfd-los groups was not significant. conclusion: losartan is significantly comparable to pioglitazone in improving β-cell function. key words: β-cell function, homa-β, losartan, pioglitazone. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence muhammad nauman shad email: mnauman2002saj@yahoo.com article info. received: april 25, 2017 accepted: august 17, 2017 cite this article. shad mn, aslam h, shamim mo, chiragh s, ahmad z. comparison of effect of losartan with pioglitazone on β-cell function in a rat model of type 2 diabetes mellitus.jimdc;6(3):157-160. funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus, one of the most common noncommunicable diseases has become a worldwide epidemic. this disease is the fourth most common cause of death globally and is expected to affect 450 million people by the year 2030.1 insulin resistance and β-cell dysfunction plays a major role in the pathogenesis of type 2 diabetes mellitus. defects in insulin secretion predisposes to type 2 diabetes mellitus. studies have shown that individuals genetically predisposed to develop type 2 diabetes mellitus, when exposed to chronically increased levels of free fatty acids (for example in obesity or due to high-fat diet) may be prone to lipotoxicity that results in decreased insulin secretion through beta cell apoptosis. the resulting hyperglycemia and decreased insulin leads to glucotoxicity (glucose toxicity) that further decreases insulin secretion and predisposes to insulin resistance. lipid-induced beta-cell dysfunction may precede the decrease in beta cell mass.2 o r i g i n a l a r t i c l e 158 j i m d c 2 0 1 7 158 β-cell dysfunction is a key feature of development of type 2 diabetes mellitus.3 drug research has focused on developing drugs that improve β-cell function, including insulin secretagogues like the sulfonylureas and glinides, incretin analogs like dpp-4 inhibitors and glp-1 analogs, as well as insulin itself.4 thiazolidinediones (glitazones) are a group of drugs used for treatment of type 2 diabetes which have shown to preserve beta cell function by protecting the beta-cell from lipotoxicity. β-cell stress is reduced with thiazolidinedione therapy, but enhanced with sulfonylurea therapy.5 thiazolidinediones mediate their actions through ppar-γ receptors. ppar-γ activation acts to maintain β cell function.6 renin angiotensin aldosterone system (raas) is also implicated in the development of β-cell dysfunction. evidence suggests that the raas affects insulin secretion. angiotensin ii impairs insulin biosynthesis and promotes beta cell apoptosis possibly due to long-term vasoconstrictioninduced restricted blood flow to the pancreas.7 hence, pharmacologic inhibition of this system would be useful in preserving beta cell function. from the present research point of view and the most studied among inhibitors of raas are the selective at1 receptor blockers (arbs). development of arbs began in 1990 with the synthesis of losartan, an orally active, non-peptide angiotensin ii receptor antagonist. since then several others have been synthesized including valsartan, irbesartan, telmisartan, candesartan, eprosartan and olmesartan.8 arbs including telmisartan, irbesartan and losartan have shown to possess ppar-γ agonist activity.9 beneficial effect of ppar-γ agonist activity on improving insulin secretion has been mentioned. this provides a strategic rationale and pharmacological platform for the study of dual arb/ppar-γ agonist losartan on β-cell function in a rat model of β cell dysfunction. p a t i e n t s a n d m e t h o d s this was a randomized control trial and was carried out at postgraduate medical institute (pgmi), lahore. spraguedawley rats of 4 weeks of age were purchased from the university of veterinary & animal sciences, lahore and kept in the animal house of pgmi in iron cages under hygienic conditions. room temperature was maintained at 25+ 2c under natural day/night cycle with free access to rat chow and water. they were allowed one week to acclimatize. from 5 weeks of age, rats were fed on high fat diet containing 30% beef fat and 10% sucrose.10 animals were divided randomly into 3 groups of 15 animals each. all three groups were fed with high fat and sucrose diet throughout study period of 12 weeks. first group was given distilled water daily orally as a single morning dose and labeled as hfd (high-fat diet) group. the second group was given pioglitazone in dose of 10mg/kg body weight daily orally as a single morning dose for 12 weeks and labeled as hfd-pio group.11 third group was given losartan in dose of 10mg/kg body weight1 daily orally as a single morning dose for 12 weeks and labeled as hfd-los group.12 follow up body weight of rats: each rat was weighed initially and after every week. measurement of fasting blood glucose: fasting blood glucose level was measured every week using a glucometer (accuchek) using a drop of blood obtained from the tail vein. blood sampling: after 12 weeks, rats were kept on 12 hours fast and blood was collected by cardiac puncture. samples were then centrifuged at room temperature at 3000-4000 rpm for 5 minutes. serum was stored at –20°c until being analyzed for serum insulin determination. biochemical methods / measurement of serum insulin: serum insulin was estimated using insulin elisa (enzyme-linked immunosorbent assay) kit (novatecimmundiagnostica gmbh). calculation of index of β cell function: homestatic model assessment of β-cell function (homaβ) is a surrogate marker of β-cell function. many investigators have demonstrated strong relationships between this surrogate marker and responses measured with clamp procedure. homaβ was calculated as follows.13 homaβ = 360 x insulin glucose 63 drugs: pioglitazone and losartan were obtained from mass pharmaceuticals the data were entered and analyzed using spss 17.0. mean ± s.d was calculated for quantitative variables like fasting blood glucose levels, fasting insulin levels and 159 j i m d c 2 0 1 7 159 homaβ values. one-way anova was applied to compare the above variables among the groups. bartlett’s test was applied to see whether variances were significantly different. r e s u l t s mean body weight at beginning of study was 82±8, 79±7 and 81±5 g in group hfd, hfd-pio and hfd-los respectively. the body weight increased in all groups over 12-week study period but weight gain in rats of hfd-pio and hfd-los group was significantly less as compared to those of hfd group with p-value ‹0.05. as shown in table 1, the difference between hfd-pio and hfd-los group was not significant according to the mean fasting blood glucose level of animals at the start of study was 92±9, 87±7 and 91±7 mg/dl in-group hfd, hfd-pio and hfd-los. fasting blood glucose level increased in all groups over the study period. at 12 weeks, fasting blood glucose level was significantly less in hfd-pio and hfd-los group as compared to that of hfd group with p-value < 0.001. difference between hfd-pio and hfd-los group was not significant (table: 1). serum insulin level was measured at end of 12-week study period and it was observed that level was significantly lower in hfd-pio and hfd-los group as compared to that of hfd group with p-value 0.001 and 0.004 respectively. difference between hfd-pio and hfd-los group was not significant. barlett’s test was applied to assess for statistical significance of these results (table 1). homa-β calculated at end of study revealed significantly lower values in hfd-pio and hfd-los group as compared to that of hfd control group with p-value < 0.01 and < 0.05 respectively. (table 1). d i s c u s s i o n in the present study, the role of losartan in improving βcell function was evaluated in high fat fed diabetic rats in comparison with pioglitazone. for this purpose, 45 sprague-dawley rats of 5 weeks of age were randomized into three groups. all the rats were fed with a high fat and sucrose diet. such an animal model is the best model to study the human metabolic syndrome. numerous studies have shown that a diet rich in saturated fatty acids and refined carbohydrates increases the risk of diabetes.14 pioglitazone and losartan was given along with this diet to the rats in-groups hfd-pio and hfd-los respectively, while group hfd was kept as control. body weight and fasting blood glucose levels were determined weekly. at the end of 12 weeks, serum insulin levels were determined. a marker of β-cell function, homeostatic model assessment of β-cell function (homa-β), was also calculated at the end. mean body weight of animals at the start of study was around 80 grams which increased steadily in all study groups during the study period but increase was more in hfd group as compared to hfd-los and hfd-pio groups. as the increase in body weight is associated with type 2 diabetes, both groups treated with drugs along with a high-fat diet showed significantly less increase in body weight. a similar effect on body weight of rats was observed in one study using telmisartan and candesartan.15 mean fasting blood glucose level was significantly low in both experimental groups as compared to that of control. difference between hfd-los and hfdpio was not significant. chu et al also demonstrated a decrease in blood glucose level with losartan in a dosedependent manner in a genetic diabetic mice model.12 serum insulin levels were measured at the end of the study period (12 weeks) and they were found to be significantly raised in the hfd group as compared to hfd-pio and hfd-los groups. hyperinsulinemia with fasting and basal hyperglycemia have been observed in some models of type 2 diabetes due to high fat diet.10 homa-β is an index of β-cell function insulin.13 decrease in homa-β by losartan, an angiotensin receptor blocker, in the present study is supported by other studies on table 1: body weight and metabolic characteristics of hfd fed rats at end of 12-weeks study period group body weight (g) mean + sd blood glucose (mg/dl) mean + sd serum insulin (µiu/ml) mean + sd homa-β mean + sd hfd 382 ± 48 152 ± 12 23.20 ± 5.52 89.83 ± 3.948 hfd-pio 345 ± 45* 123 ± 17*** 12.07 ± 6.82*** 72.47 ± 3.617** hfd-los 342 ± 38* 132 ± 17*** 14.13 ± 8.83** 66.942 ± 6.943* *p-value ≤ 0.05, **pvalue ≤ 0.01, *** p value ≤ 0.001 as compared to group hfd bartlett’s test applied 160 j i m d c 2 0 1 7 160 diabetes. homa-β decreased in a human study with the use of losartan during 24 weeks follow up in hypertensive.17 various other angiotensin receptor blockers also showed the same results. in one study, twenty-six weeks of treatment with valsartan increased glucose-stimulated insulin release and insulin sensitivity in normotensive subjects with impaired glucose metabolism.18 possible mechanisms of improvement of β-cell function by losartan include that a decrease in activity of the reninangiotensin aldosterone system by arbs has been observed to cause significant reductions in reactive oxygen species, protein kinase c and nadph oxidase activities in pancreatic islet cells. this has led to enhanced  cell survival. increase in  cell mass also results from a protective effect by arbs against harmful effects of inflammatory and oxidative stress. enhanced  cell survival & an increase in  cell mass has seen to increase insulin secretion and improve glucose tolerance.19 the primary target for insulin action & an important determinant of glucose uptake is skeletal muscle blood flow. ace inhibitors & arbs cause vasodilation in peripheral blood vessels, which leads to an increase in skeletal muscle blood flow. this is by increasing the surface area for glucose exchange between the vascular bed & skeletal muscles. this action also facilitates an increase in blood flow to the pancreatic islet cells, thus further increasing insulin secretion.19 c o n c l u s i o n the results of present study indicate that losartan improves β-cell function, which is significantly comparable to that of pioglitazone. r e f e r e n c e s 1. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clinpract. 2010; 87 (1): 4-14. 2. giacca, a., xiao, c., oprescu, al., carpentier, ac., lewis, gf. lipid-induced pancreatic -cell function: focus on in vivo studies. am j physiol endocrinol metab.2011; 300 (2): e255 e262. 3. cerf me. beta cell dysfunction and insulin resistance. frontiers in endocrinology. 2013; 4: 37 4. saisho y. importance of beta cell function for the treatment of type 2 diabetes. journal of clinical medicine. 2014; 3(3):923-43. 5. hanefeld m. pioglitazone and sulfonylureas: effectively treating type 2 diabetes. international journal of clinical practice. 2007; 61(s153):20-7. 6. gupta d, kono t, evans‐molina c. the role of peroxisome proliferator‐activated receptor γ in pancreatic β cell function and survival: therapeutic implications for the treatment of type 2 diabetes mellitus. diabetes, obesity and metabolism. 2010; 12(12):1036-47. 7. ernsberger p, koletsky rj. metabolic actions of angiotensin receptor antagonists: ppar-γ agonist actions or a class effect? current opinion in pharmacology. 2007; 7(2):140-5. 8. atlas sa. the renin-angiotensin aldosterone system: pathophysiological role and pharmacologic inhibition. journal of managed care pharmacy. 2007; 13(8 supp b):9-20. 9. rossi, g. losartan metabolite exp3179: an at1-receptor– independent treatment strategy for patients with the metabolic syndrome? hypertension. 2009; 54(4): 710-712. 10. panchal sk, brown l. rodent models for metabolic syndrome research. j biomed biotechnol, 2011:351982. 11. koufany, m., moulin, d., bianchi, a., muresan, m., sebillaud, s., netter, p., weryha g., jouzeau, j. anti-inflammatory effect of antidiabetic thiazolidinediones prevents bone resorption rather than cartilage changes in experimental polyarthritis. arthritis res ther.2008; 10 (1): r6. 12. chu, k., lau, t., carlsson, p. and leung, p. angiotensin ii type 1 receptor blockade improves beta-cell function and glucose tolerance in a mouse model of type 2 diabetes. diabetes, 2006; 55 (2): 367-74 13. kamar, m, said, n, salem, i, abd-elrahman, a and azab, m, the effect of ramadan fasting on beta cell secretory efficiency in a sample of egyptian diabetic patients. british journal of science. 2014; 10 (2):10-19 14. gastaldelli a. abdominal fat: does it predict the development of type 2 diabetes? am j clin nutr. 2008; 87(5):1118-9. 15. muller-fielitz h, landolt j, heidbreder m, werth s, vogt fm, johren o, et al. improved insulin sensitivity after long-term treatment with at1 blockers is not associated with ppargamma target gene regulation. endocrinology, 2012; 153(3):1103-15. 16. sarafidis pa, lasaridis an, nilsson pm, pikilidou mi, stafilas pc, kanaki a, et al. validity and reproducibility of homa-ir, 1/homa-ir, quicki and mcauley's indices in patients with hypertension and type ii diabetes. j hum hypertens. 2007; 21(9):709-16. 17. madhukar, s. and sing, n. effect of losartan and atenolol on insulin sensitivity in nondiabetic hypertensive patients. j pharmacol pharmacother. 2016; 7(2): 80–86. 18. nynke, j., chantalle, c., gijs h., marc, m., ellen, e. and michaela, d.valsartan improves β-cell function and insulin sensitivity in subjects with impaired glucose metabolism. diabetes care. 2011; 34(4): 845-851. 19. lardizabal, j. and deedwania, p. the role of renin-angiotensin agents in altering the natural history of type 2 diabetes mellitus. curr cardiol rep. 2010; 12 (6):464-471. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4936083/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4936083/ j islamabad med dental coll 2020 207 open access frequency of neck and upper extremity musculoskeletal disorders in dentists sidra sarwar1, sarah khalid2, tahir mahmood3, hadeeq jabeen4, shahid imran5 1 demonstrator, department of physiotherapy, bahawalpur medical and dental college, pakistan 2 physiotherapist, children hospital & institute of child health lahore, pakistan 3 lecturer, department of physiotherapy, agile institute of rehabilitation sciences bahawalpur, pakistan 4 physiotherapist, rising sun institute for special children lahore, pakistan 5 senior physiotherapist, children hospital & institute of child health lahore, pakistan a b s t r a c t background: musculoskeletal disorders are not only becoming prevalent among health care professionals in our country but are affecting their health and performance adversely. they are caused by poor ergonomics and awkward posture during work activities. the purpose of this study was to determine the frequency of neck and upp er limb musculoskeletal disorders in dentists of lahore, pakistan. material and methods: this cross-sectional study was conducted from october 2017 to march 2018. the data was collected using convenient sampling technique from 162 dentists including 52 males and 110 females of children hospital lahore, punjab dental hospital and fatima memorial hospital, lahore. data was collected by usi ng mangalore questionnaire for identification of musculoskeletal disorders. descriptive analysis of the data was done using spss version 22.0. results: of 162 dentists, 115 (71%) suffered from musculoskeletal disorders. shoulder was the most commonly affec ted region (30.9%) followed by neck (25.9%), arm (6.2%), wrist (4.3%), elbow (3.1%) and forearm (0.6%). pain (45.7%) was found to be the most common complaint followed by muscle weakness (20.4%), paraesthesia (3.7%) and swelling (1.2%). conclusions: it was concluded that majority of the dentists were suffering from musculoskeletal disorders with shoulder as the most affected region and pain as the most frequent complaint. key words: dentists, musculoskeletal disorders, neck pain, upper extremity authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; manuscript editing. correspondence: tahir mahmood email: tahirmahmoodphysio@gmail.com article info: received: september 2, 2019 accepted: september 26, 2020 cite this article. sarwar s, khalid s, mahmood t, jabeen h, imran s. frequency of neck and upper extremity musculoskeletal disorders in dentists . j islamabad med dental coll. 2020; 9(3): 207-211. doi: 10.35787/jimdc.v9i3.404 funding source: nil conflict of interest: nil i n t r o d u c t i o n musculoskeletal disorders (msds) are conditions or injuries of the muscles, nerves, tendons, joints, cartilage and supporting structures. these are caused and exacerbated by sudden exertion or prolonged exposure to physical factors such as repetitive use, force, exertion, vibration and or i gi n a l a r ti c le j islamabad med dental coll 2020 208 awkward postures.1 work related msds include all musculoskeletal disorders that are caused or aggravated by activities at workplace. dental work includes various repetitive tasks, awkward postures, high force activities and static positions of joints and body for prolonged time. static position is essential for high degree of concentration and precision during dental procedures. deterioration of these abilities affects the practitioner’s performance. 2 therefore, working posture of dentists is the major cause of msds. the usual posture of a dentist during patient examination and procedural activities is a slightly forward bend of the body with the neck and head tilted in an effort to get a better view, while the arms are elevated and unsupported. the most common symptoms of musculoskeletal disorders in dental practitioners are pain, fatigue, numbness, joint stiffness, shoulder pain, hand and wrist problems including carpel tunnel syndrome. the upper fibres of the trapezius muscles are responsible for elevating the shoulders and rotating the neck.3 in rounded shoulder posture, these fibres along with neck muscles largely support the arm’s weight, increasing muscular strain on the neck and shoulders. in this way “trapezius myalgia” is caused by static, prolonged elevation of the shoulders, continuous mental stress, infrequent breaks and poor head posture in dentists.4 other musculoskeletal complaints like numbness and tingling sensation (upper extremity paraesthesia) are caused by nerve compression in the neck or at the wrist. 5 simone de and colleagues studied ergonomic risk and preventive measures of musculoskeletal disorders in dentistry environment and found out that static posture is the biggest cause of msds in dentists. he identified excessive forward flexion of head and neck, trunk rotation to one side and raising one or both shoulders as most reported uncomfortable postures in dentists. 6 batham and yasobant from india reported that the main risk factors for msds identified by dentists themselves were of finger pinch grip, repeated bending of elbow and shoulder joints and fixed posture adopted during work.7 patricia and her colleagues used rula (rapid upper limb assessment) method to measure the risk of developing upper limb msds in dental students. they concluded that dental students were at high risk of developing upper limb msds in future.8 this study was designed to determine the common work-related upper limb msds among dentists. we expect that our study will be helpful in creating awareness about the magnitude of the problem and will draw attention towards management of these issues in healthcare settings. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted from october 2017 to march 2018 at the dentistry department of children hospital & institute of child health, lahore, punjab dental hospital, fatima memorial hospital and lahore medical and dental college, lahore, pakistan. the study participants were dentists 40-60 years of age, both males and females, with 15-35 years of experience and recruited through convenient sampling. dental practitioners who suffered musculoskeletal injury during last 6 months or had systemic illness which can cause musculoskeletal pain or discomfort were excluded from the study. sample size was calculated as 162 with the help of the formula n=z2p/d; where ‘n’ is sample size, ‘z’ is confidence interval (95%), ‘d’ is precision (5%) and ‘p’ is prevalence (88%).9 a selfgenerated questionnaire, adapted and modified from mangalore questionnaire, was used for data collection.10 the questionnaire was designed to explore the symptoms of msd and the part of upper limb affected by msd. participants were instructed to fill this self-reporting and content validated questionnaire regarding their musculoskeletal problems. j islamabad med dental coll 2020 209 ethical approval was obtained from the institutional review committee of the school of allied health sciences, children hospital & institute of child health, lahore (ref 1116/sahs). participant personal information was kept confidential. statistical package for social sciences (spss) version 22.0 was used to calculate frequencies and percentages of the collected data. r e s u l t s the percentage of female participants was greater than the male participants in the study (67% vs 32%) and majority was suffering from upper limb msds (71%). most of the participants admitted to maintaining a static posture during work (72%) (table i). the most frequently occurring symptom of msd in our study participants was pain (45.7%) followed by upper limb weakness (20.4%) (table ii). table ii: frequency of various symptoms for musculoskeletal disorders musculoskeletal symptoms frequency (%) pain 74 (45.7) weakness 33(20.4) burning sensation 6(3.7) swelling 2(1.2) none 47(29.0) it was also observed that most affected parts of the body by msd were shoulders (30.9%) followed by neck (25.9 %) and the least affected part was forearm (table iii). table iii: parts of the upper limb affected by msds among dental practitioners region frequency (%) neck 42 (25.9) shoulder 50(30.9) arm 10(6.2) elbow 5(3.1) forearm 1(6) wrist 7(4.3) none 47(29.0) d i s c u s s i o n this study conducted on dentists reports that 71% of the participants with work-related musculoskeletal disorders experienced pain as the most frequent symptom (45.7%) followed by muscle weakness (20.4%). the most commonly affected upper limb areas were shoulder (30.9%) followed by neck (25.9%), respectively. our findings are in line with the observations of hassan and colleagues. they reported a prevalence of 75.8% msds among the dental surgeons of karachi, which is very close to our findings (71%). 11 in another survey by rabia et al. the main symptom of msds in dentists was observed to be pain, most commonly felt in the neck region (96%), followed by shoulder (90%) and upper limb (82%). 12 our findings are comparable to rabia and colleagues in terms of pain being the most reported symptom, although there is a slight difference regarding the most affected part, which is shoulder (30.9%) in our study followed by neck (25.9%). our findings are also similar to those reported by alali and colleagues related to occupational health problems of dentists in united arab emirates.13 the most common health problem they found was musculoskeletal pain (68%). similarly, haye et al. in their study concluded that the prevalence of musculoskeletal pain ranges between 64% to 93% table i: frequency distribution of gender, upper extremity musculoskeletal disorders and maintenance of static posture (n=162) variables frequency (%) gender male 52 (32.1) female 110 affected by upper limb msds yes 115 no 47 maintenance of static posture during work yes 117 no 45 j islamabad med dental coll 2020 210 among dentists.14 they observed that the most commonly affected body parts, in order of frequency, were back and neck. the results of the study conducted by chamani et al. are also comparable to our findings. they did a comparison of msds among dentists and office workers in kerman, iran by using nordic questionnaire and concluded that the frequency of msds affecting neck region was much higher in dentists as compared to office workers (46.4% vs 24.5%).15 muralidharan and colleagues used nordic questionnaire to explore the incidence of msds among dentists of south india. they observed that 78% of the participants were having work-related msds and most commonly effected areas of the body in order of magnitude were neck, low back and shoulders.2 their results are comparable to our findings in terms of prevalence of msds which is 71% in our study, however our participants had shoulder as the most commonly affected area of the body. morse et al studied risk factors and self -reported pain of msds in dental hygienists and found out a step-wise progressive pattern in students, assistant and practitioner hygienists, both in terms of risk factors and msd pain. they observed that neck pain was the most common symptom of msd followed by shoulder pain; this is in contrast to our finding where we had shoulder as the most affected area followed by neck. they also found out that excessive flexion of the neck and static posture were two common practices of dental hygienists, which might have led to these findings.16 in our study too, most of the dentists have stated that they maintain a static posture (72%). prolonged fixed or awkward postures lead to sustained muscle contraction that results in ischemia and muscle necrosis thus causing musculoskeletal disorders. the results of previous studies support the findings of the current study, that working postures of dentists in lahore are affecting their health and leading to development of different musculoskeletal disorders among these professionals. however, due to small sample size and collection of data from only 3 settings of a single city, these findings cannot be generalized to all the dentist community. c o n c l u s i o n it was concluded that majority of the dentists were suffering from musculoskeletal disorders with pain as the most frequent complaint. most affected part of the body was found to be shoulder. it was related to the maintenance of static posture for long periods of time. r e c o m m e n d a t i o n future studies should aim at assessing awareness/education about good working posture, workplace ergonomics and other factors responsible for msds in dental professionals. r e f e r e n c e s 1. tinubu bm, mbada ce, oyeyemi al, fabunmi aa. work-related musculoskeletal disorders amon g nurses in ibadan, south-west nigeria: a cross-sectional survey. bmc musculoskelet disord. 2010;11(1):12. doi: 10.1186/1471-2474-11-12 2. muralidharan d, fareed n, shanthi m. musculoskeletal disorders among dental practitioners: does it affect practice? epidemiol res int. 2013; 2013. doi: 10.1155/2013/716897 3. valachi b, valachi k. mechanisms leading to musculoskeletal disorders in dentistry. j am dent assoc. 2003; 134(10): 1344 -50. doi: 10.14219/jada. archive.2003.0048 4. fernández-de-las-peñas c, ge h-y, arendt-nielsen l, cuadrado ml, pareja ja. the local and referred pain from myofascial trigger points in the temporali s muscle contributes to pain profile in chronic tension type headache. clin j pain. 2007; 23(9): 786 -92. doi: 10.1097/ajp.0b013e318153496a 5. rehn b, nilsson t, järvholm b. neuromusculoskeletal disorders in the neck and upper extremities amon g j islamabad med dental coll 2020 211 drivers of all-terrain vehicles–a case series. bmc musculoskelet disord. 2004; 5(1): 1. doi: 10.1186/ 1471-2474-5-1 6. de sio s, traversini v, rinaldo f, colasanti v, buomprisco g, perri r, et al. ergonomic risk and preventive measures of musculoskeletal disorders in the dentistry enviroment: an umrella review. peerj. 2018: 6e4154. doi: 10.7717/peerj.4154 7. batham c, yasobant s. a risk assessment study on work-related musculoskeletal disorders amon g dentists in bhopal, india. indian j dent res. 2016; 27(3): 236. doi: 10.4103/0970-9290.186243 8. garcia ppns, pinelli c, dos reis derceli j, campo s jádb. musculoskeletal disorders in upper limbs in dental students: exposure level to risk factors. brazilian j oral sci. 2012; 11(2): 148 -53. doi: 10.20396 /bjos.v11i2.8641448 9. george b. sample size estimation and power calculation-a guide to biomedical researchers. pulmon. 2013; 15(3): 25-34. 10. lahoti s, narayan a, ottayil zc, bhaskaran u. prevalence of musculoskeletal disorders amon g doctors in mangalore: a cross-sectional survey. int j health allied sci. 2014; 3(3): 204 -07. doi: 10.4103 /2278-344x.138609 11. hameed mh, ghafoor r, khan fr, bada sb. prevalence of musculoskeletal disorders among dentists in teaching hospitals in karachi. jpma. 2016; 66(10): s36. pmid: 27895349 12. khan rs, ahmad f, merchant ms. prevalence of work related musculoskeletal disorders (msd) amon g dentists. int j contemporary med res. 2017; 4(5): 1208-11. 13. al‐ali k, hashim r. occupational health problems of dentists in the united arab emirates. int dent j. 2012; 62(1): 52-6. doi: 10.1111/j.1875-595x.2011.00091.x 14. hayes m, cockrell d, smith d. a systematic review of musculoskeletal disorders among dentists. int j dent hyg. 2009; 7(3): 159-65. doi: 10.1111/j.16015037.2009.00395.x 15. chamani g, zarei mr, momenzadeh a, safizadeh h, rad m, alahyari a. prevalence of musculoskeletal disorders among dentists in kerman, iran. j musculoskelet pain. 2012; 20(3): 202 -7. doi: 10.3109/10582452.2012.704138 16. morse t, bruneau h, michalak-turcotte c, sanders m, warren n, dussetschleger j, et al. musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students. j am dent hyg. 2007; 81(1): 10-14. pmid: 17362608 3 j i m d c 2 0 1 7 3 op e n ac c e ss f u l l l e n g t h a r t i c l e isolated amoebic abscess of spleen saira bano1, manal niazi2, naushaba malik3, muhammad ashraf farooq4 1resident radiology. social security hospital islamabad 2associate professor radiology, islamabad medical and dental college 3assistant professor radiology. islamabad medical and dental college, social security hospital islamabad 4professor/hod, department of radiology, islamabad medical and dental college, islamabad a b s t r a c t amoebic liver abscess is the most common extra intestinal manifestation of amebiasis. amoebic abscess of spleen is a rare disease and cases of isolated abscess of spleen have rarely been reported in literature. we report a case of 52-year female, who presented with history of high grade fever, weight loss and malaise. her ultrasound a showed a welldefined, thin-walled hypoechoic lesion in spleen and high dose contrast enhanced computer tomography(cect) abdomen revealed a well-defined cystic lesion within the spleen with thin enhancing rim. ultrasound guided aspiration of splenic abscess was done and showed clusters of trophozoites in the wall of the cavity. she received treatment for amebiasis for one month and reported with resolution of symptoms. post treatment repeat ultrasound also revealed resolution of abscess. key words: abscess, entameoba histolytica, extraintestinal amebiasis, spleen, trophozoites. address of correspondence dr. manal niazi. drmanalniazi@hotmail.com article info. received: feb 11, 2017 accepted: mar 7, 2017 cite this article: bano s, niazi m, malik n, farooq ma. isolated amoebic abscess of spleen. jimdc. 2017; 6(1):3-8. funding source: nil conflict of interest: nil i n t r o d u c t i o n each year about 50 million patients develop amoebic dysentery from entamoeba histolytica infections; 40,000 to 110,000 die of the disease annually.1 amoebic liver abscess is the most common extraintestinal manifestation of amebiasis. extrahepatic amoebic abscesses have occasionally been described in the lung, brain, and skin and presumably result from hematogenous spread. abscess of the spleen is a rare disease. isolated amoebic abscess of spleen has been reported scarcely in literature and remains a diagnostic dilemma.2 the presentation is nonspecific and diagnosis is often delayed. the timely and widespread use of imaging methods facilitates early diagnosis and guides treatment, thus improving the prognosis. most of the patients have associated recognized risk factors that compromise the immune system, trauma and intravenous drug abuse in addicts. the surgical treatment by splenectomy is usually the first choice of treatment.3 c a s e r e p o r t a 52-year female presented with history of high grade fever, weight loss and malaise for 1 month. she was a known case of diabetes mellitus for the past 16 years and hypertension for 6 years. she had past history of stroke 6 months back. general examination showed high grade fever (1030 f) and weakness of right side of the body. abdominal examination was unremarkable. her baseline laboratory (complete blood count, renal and liver function tests) were normal except for low haemoglobin (9 g/dl) ultrasound abdomen was done which showed a welldefined, thin-walled hypoechoic lesion in spleen. it measured 3.0 x 3.2 cm with few internal echoes and thin septations. cect abdomen showed a well-defined cystic c a s e r e p o r t mailto:drmanalniazi@hotmail.com 4 j i m d c 2 0 1 7 4 lesion within the spleen with thin enhancing rim. ultrasound guided aspiration of splenic abscess was done with a specimen taken from the margin of the cavity. it showed anchovy sauce colored fluid which was sent for histopathology and culture and sensitivity. the fluid culture was negative for the microorganism but clusters of trophozoites were seen embedded in the wall of the cavity. she received treatment for amebiasis for 1month. after resolution of symptoms and completion of medical treatment, her ultrasound was repeated. it showed normal spleen with resolution of abscess. d i s c u s s i o n amoebiasis is an infection, usually of the colon, caused by entamoeba histolytica. it is endemic in all parts of the world where sanitation is poor. amoebic dysentery is the usual consequence of infection and amoebic liver abscesses, not uncommon and usually result from haematogenous spread of parasite along the portal vein. amoebic abscesses of the spleen, however, have only been rarely reported. they result from direct or haematogenous spread of pathogens, or when a haematoma becomes infected.4 most of the patients present with recognized risk factors including conditions that compromise the immune system, such as endocarditis, diabetes mellitus, congenital or acquired immunodeficiency and the administration of immunosuppressive medication. trauma and intravenous drug abuse in addicts are additional predisposing factors for splenic abscesses solitary splenic abscess, however, with lack of any obvious risk factors is very rare. the clinical manifestations of splenic abscesses usually include left upper abdominal pain, fever, nausea, vomiting and anorexia. splenic abscess is a rare entity, with a reported frequency of 0.14-0.7% in autopsy series. its reported mortality rate is still high, up to 47%, and can potentially reach 100% among patients who do not receive antibiotic treatment. appropriate management can decrease the mortality to 14%. 3 the timely and widespread use of imaging methods facilitates early diagnosis and guides treatment, thus improving the prognosis. ultrasound is used as a preliminary diagnostic modality, which is often followed by ct scan. however, ultrasonography cannot discriminate between abscess and infarct in some cases, while computed tomography is the modality of choice.2 splenic abscesses appear as focal areas of low attenuation with no inflammatory rim traditional treatment for splenic abscess has been splenectomy and antibiotic therapy but image-guided percutaneous aspiration and drainage can also be considered. us-guided percutaneous aspiration of splenic abscesses is a safe and effective procedure. it can be used as a bridge to surgery in patients who are critically ill or have several comorbidities. percutaneous aspiration may allow complete non-operative healing of splenic abscesses or temporize patients at risk for surgery.5 while many advocate image-guided drainage, several publications suggest splenectomy having a better outcome than percutaneous drainage or intravenous antibiotics alone.6 r e f e r e n c e s 1. stanley sl jr. amoebiasis. lancet. 2003;361:1025–1034. 2. kaushik m, mahajan s, raina r, babu s, raghav s and sood s. et al. isolated amoebic abscess of spleen. online journal of health and applied sciences. 2014; 12(1):40-3. 3. aly saber. multiple splenic abscesses in a rather healthy woman: a case report. biomed central, 2009; 2(1):7340. 4. elphick da, elphick hl. amoebic spleen abscess. continuing medical education. 2007 ;25(4):194. 5. zhou x, rothstein tl, carroll mc. bibliography current world literature. current opinion in immunology. 1997;9:133-74. 6. giovanna ferraioliin,enrico brunetti,rosario gulizia, giuseppe mariani, piero marone,carlo filice. international journal of infectious diseases.2008; 8:024. javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); j islamabad med dental coll 2020 89 open access clinical presentation and outcome of covid-19 infection in patients undergoing maintenance hemodialysis muhammad ali1, shafique ahmed2, abdul manan junejo3, ayesha ejaz4, hina iram5, heer gul6 1assistant professor, department of nephrology, fazaia ruth pfau medical college, karachi, pakistan. 2,5,6registrar, department of nephrology, jinnah postgraduate medical center, karachi, pakistan. 3professor, department of nephrology, jinnah postgraduate medical center, karachi, pakistan. 4assistant professor, department of nephrology, jinnah postgraduate medical center, karachi, pakistan. a b s t r a c t background: who declared covid-19 a pandemic disease; although 80% of patients with cov-2 infection have no or mild symptoms, the remaining 20% of patients develop complications. in patients undergoing dialysis, mortality could be higher than that in the general population. this study was conducted to assess the frequency, clinical presentation, and outcome of covid-19 infection in patients of end-stage renal disease (esrd) on maintenance hemodialysis. methodology: this cross-sectional study was conducted at department of nephrology, jinnah postgraduate medical centre, karachi, from april to september 2020. this study included 130 patients of either gender of end-stage renal disease on maintenance hemodialysis for at least 3 months. two samples for covid-19 pcr were taken through nasal swab. blood samples were collected for hemoglobin level, total and differential leucocyte count, platelet count, intact parathyroid hormone, vitamin d level, urea, creatinine, ferritin, transferrin saturation, procalcitonin, d-dimer, creactive proteins, and lactate dehydrogenase. radiological assessment was done by x-ray chest. urea reduction ratio and single pool kt/v was used for assessment of adequacy of hemodialysis. results: out of 130 patients on hemodialysis, covid-19 was detected in 52 patients, of which males were 69.2% and females were 30.8%. the most common presentation was shortness of breath (28.8%), followed by cough (19.2%). home isolation was advised to 38.5% while noninvasive ventilation was given to 34.6%. mechanically ventilated patients were 26.9%. there were 63.5% patients who recovered and were discharged from the hospital or home-isolated, while 19 patients died (36.5%). conclusion: covid-19 pandemic has high chances of infection with increased mortality in people with chronic diseases, especially those having esrd on hemodialysis. this spread of infection can be hampered with standard measures of disinfection in centers, social distancing in patients, and the use of a face mask. keywords: covid-19, cough, hemodialysis, home isolation, ventilation authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3critical analysis and manuscript review; 4,5data analysis; manuscript editing. correspondence: muuhammad ali email: maunar2002@gmail.com article info: received: march 15, 2021 accepted: may 13, 2022 cite this article. ali m, ahmed s, junejo a m, ejaz a, iram h, gul h. clinical presentation and outcome of covid-19 infection in patients undergoing maintenance hemodialysis. j islamabad med dental coll. 2022; 11(2):89-95. doi: https://doi.org/10.35787/jimdc.v11i2.694. funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2020 90 i n t r o d u c t i o n in december 2019, a new viral infection emerged from the wuhan city of china by causing severe acute respiratory syndrome (sars). novel coronavirus (covid-19) is a new strand of the coronavirus family (sars-cov-2) that came out as a new challenge for humanity. it was declared as a pandemic by the world health organization on 11th march 2020. up till now, millions of people have been affected by the pandemic directly and as of now (22nd january 2021), around 96 million people have been diagnosed with covid-19 worldwide. out of them, two million deaths have been reported. in pakistan, this counts to 52,9000 cases, with around 11,000 deaths.1,2 covid-19, is usually asymptomatic (60-80%), but may present with pneumonia (15%), or respiratory distress leading to intensive care admission (3-5%).3 some documented symptoms include fever, sore throat, body aches, cough, shortness of breath, pulmonary hemorrhages, and multi-organ failure. when severe, it leads to sepsis, sars, and cytokine release syndrome (a fatal condition that leads to death with a mortality rate of around 1.4-8%).4 currently, the gold standard test for diagnosis is real-time pcr (reverse transcription polymerase chain reaction) that detects viral rna, by taking upper respiratory tract swabs. however, multiple laboratory tests (like c-reactive protein, d-dimer, procalcitonin, ferritin, lactate dehydrogenase) and radiological investigations (like x-ray, ultrasonography, and high-resolution computerized tomography) are carried out to assess the disease severity and outcomes.5 the old-age population, especially those with comorbid conditions (like diabetes mellitus, chronic kidney disease, ischemic heart diseases, chronic lung diseases, obesity, and hypertension) are at a higher risk of being infected, and that too with poor prognosis.6,7 further, patients undergoing maintenance hemodialysis are at a greater risk of infection as compared to general population due to in-center dialysis or frequently traveling to hemodialysis centers, and lack of social distancing.8,9 moreover, patients with end-stage renal disease (esrd) are immunocompromised and their comorbidities (like diabetes mellitus, hypertension, ischemic heart diseases, renal stone diseases, or multiple myeloma), put them at higher risk.10 the largest data from wuhan by xiong f et al. included 7154 patients undergoing hemodialysis, of which 154 had laboratory-confirmed covid-19. cardiovascular disease and hypertension were the most common comorbid conditions (68.7%) among those patients. only 51.9% of patients manifested with fever, while 21.4% remained asymptomatic.11another study from china by wun j et al. stated that fatigue was the most common symptom (59%) in hemodialysis patients with covid-19, followed by dry cough (49%) and fever (47%) respectively.12 covid-19 in-patients with esrd undergoing hemodialysis have a variable presentation and mortality. in europe, reported mortality is around 15 to 20%, highest in italy 23.6%, while in spain mortality rate is 12.8%13 and 28% mortality reported in the united states of america.14 this study will give the baseline information about the frequency, clinical presentation, and outcome of covid-19 infection in patients of end-stage renal disease (esrd) on maintenance hemodialysis in our setting. further, the findings will help to evaluate the preventive measures for covid-19 taken among high-risk patients and help the policy makers in devicing strategies. m e t h o d o l o g y this crosssectional study was conducted at the department of nephrology, jinnah postgraduate medical centre, karachi, pakistan from april to september 2020. ethical approval was taken from the institutional ethical review board and patients j islamabad med dental coll 2020 91 were enrolled in this study from the dialysis unit of the department after taking informed written consent. all the male and female patients with esrd on regular hemodialysis, at least once a week for at least three months and aged between 14 years to 70 years were included. patients of acute kidney injury were excluded from the study. the calculated sample size was 130 by open epi version 3 at 95% confidence level and anticipated frequency 50%. the patients’ information regarding primary cause of renal failure and comorbid conditions was noted. clinical signs and symptoms like fever, cough, sore throat, body aches, and shortness of breath were assessed and marked on a pre-designed performa. blood samples were collected for hemoglobin level, intact parathyroid hormone, vitamin d, urea and creatinine, ferritin, transferrin saturation, procalcitonin, d-dimer, c-reactive protein, and lactate dehydrogenase. radiological imaging was done with an x-ray chest ap view only due to the limitation of access for computed tomography (ct). adequacy of hemodialysis was calculated as urea reduction ratio (urr) and single pool (sp) kt/v (where kt/v shows dialysis adequacy by incorporating dialyzer clearance of urea-k, dialysis time-t, and volume of distribution of urea-v). dialysis weekly schedule, duration, and the access used were also noted. after the diagnosis of covid-19 infection, in the first patient, at our hemodialysis center, with persistent shortness of breath, a strict screening and triage system was implemented. patients were screened for symptoms of covid-19 before initiating hemodialysis. a mandatory checking of body temperature was also done before shifting the patient for hemodialysis in unit. overall, screening by nasopharyngeal swab was carried out after the diagnosis of two other patients. a total of 130 patients of esrd on hemodialysis were assessed for clinical features of covid-19. two samples were taken as swabs from the nasopharynx for rt-pcr and covid-19 was diagnosed as per results. management details were listed as home isolation, hospitalization, and mechanical ventilation according to the severity of clinical features. during the home isolation, no specific treatment was given but family was counselled for close observation of any worsening of symptom. while, outcome parameters were noted as discharge from the hospital (according to the hospital’s discharge protocol and asymptomatic) and death. data was analyzed with ibm spss version 21. continuous variables like laboratory parameters and dialysis parameters were recorded as mean with standard deviation, while categorical variables like causes, co morbidity, clinical features, radiological findings, weekly schedules, dialysis access, management plans, and outcomes were recorded in frequency and percentages. cross-tabulation was done to find the outcome according to the different variables. chi square test was applied to find significant association between categorical variables while student t-test was used to compare means of different continuous variables. statistical significance was set at a p-value less than 0.05. r e s u l t s in total of 130, covid-19 was confirmed in 40% (n=52) patients, out of them males were 69.2% (n=36) and females were 30.8% (n=16) with a mean age of 45.90 ±14.33 years. diabetes mellitus (dm) was found to be the most common cause of esrd (40.4%), followed by hypertension (19.2%). shortness of breath was the most common active complaint in these patients (28.8%), followed by cough (19.2%) and sore throat (17.3%). x-ray chest revealed bilateral ground-glass opacification in 28.8%, local patchy shadow in 28.8% and bilateral patchy shadow in 25% patients, while x-rays were normal in 17.3% (table 1). j islamabad med dental coll 2020 92 table i: causes of the end-stage renal disease and clinical features of covid-19 (n=52) frequency percentage primary cause of esrd diabetes mellitus 21 40.4% hypertension 10 19.2% chronic glomerulonephritis 8 15.4% bilateral small size kidneys 7 13.5% renal stone 4 7.7% multiple myeloma 1 1.9% contrast induced nephropathy 1 1.9% symptoms shortness of breath 15 28.8% fever 11 21.2% cough 10 19.2% sore throat 9 17.3% none (asymptomatic) 6 11.5% diarrhea 1 1.9% radiological findings (x-ray) bilateral groundglass opacification 15 28.8% local patchy shadow 15 28.8% bilateral patchy shadow 13 25% normal 9 17.3% patients’ hemodialysis characteristics are given in table 2, while the laboratory investigations are listed in table 3. table ii: patient hemodialysis characteristics (n=52) frequency percentage session-week thrice per week 29 55.8% twice per week 20 38.5% once per week 3 5.8% access for hemodialysis arteriovenous fistula 35 67.3% tunnel catheter 7 13.5% non tunnel catheter 6 11.5% av graft 4 7.7% mean standard deviation hemodialysis adequacy parameters duration (years) 3.75 1.466 urea reduction ratio (%) 66.345 4.057 sp kt/v 1.155 0.125 abbreviations: sp kt/v: single pool kt/v where kt/v shows dialysis adequacy by incorporating dialyzer clearance of urea (k), dialysis time (t), and volume of distribution of urea (v) table iii: laboratory tests (n=52) mean ± standard deviation lactate dehydrogenase (u/l) 596.269 ± 273.091 c-reactive protein (mg/l) 106.794 ± 50.833 procalcitonin (ng/ml) 2.991± 2.458 d-dimer (µg/ml) 2.5173± 1.905 creatinine (mg/dl) 7.35 ± 1.833 albumin (mg/dl) 2.898 ±0.238 intact parathyroid hormone (pg/dl) 692.63 ± 559.98 vitamin d (ng/dl) 17.041 ± 6.643 ferritin (ng/ml) 665.26 ± 468.433 hemoglobin (g/dl) 10.1758 ± 1.480 wbc (x109/l) 14.53 ± 5.42 platelets (x109/l) 211.53 ± 83.13 lymphocytes (x109/l) 1.38 ± 0.692 aspartate aminotransferase (u/l) 36.50 ± 10.85 alanine transaminase (u/l) 39.21 ± 11.569 j islamabad med dental coll 2020 93 there was significant association between gender and outcome with more females being discharged and males expired. there was significant association between primary cause of esrd and outcome of the patient with more deaths reported among those having contrast induced nephropathy and renal stone being primary cause of esrd. home isolation was advised to 20 (38.5%) patients, while noninvasive ventilation was given to 18 (34.6%). mechanically ventilated patients were 14 (26.9%). out of them, 33 (63.5%) patients recovered. while nineteen patients expired (36.5%), all those patients who were mechanically ventilated (n=14) expired, and there was significant association between action taken and outcome of the patient. more deaths reported among those who were mechanically ventilated as compared to noninvasive ventilation and home isolation.(p=0.001) d i s c u s s i o n although the coronavirus family, i.e. sars-cov-2, sars-cov, and mers-cov, have caused major health issues in this century, covid-19 (sars-cov-2) proved most serious of all.15 hemodialysis patients are at an increased risk of infection. however, data about these patients is limited. in our study, among 130 patients on maintenance hemodialysis,40% were found to have covid-19 infection, out of which 36.5% expired. in our study, diabetes mellitus was the most common primary cause of end stage renal disease and possibly a risk factor for covid-19 (40.4%), followed by hypertension (19.2%), while chronic glomerulonephritis was found in 13.4%. in comparison, a multicenter study from china reported unknown etiology in 29.4%, chronic glomerulonephritis in 21.6%, and hypertension in 21.6%.16 moreover, the chinese centers of disease control and prevention estimated the mortality rate of covid-19 patients with cardiovascular disorders, diabetes, chronic respiratory disease, and hypertension as 10.5%, 7.3%, 6.3%, and 6.0% respectively.17 shortness of breath was the main clinical presentation in our study population (28.8%), this may be due to covid-19 pneumonia superimposed on damaged or lungs with recurrent volume overload. it was also reported as the most common symptom from spain by goicoechea m et al.3 other clinical symptoms in our study like cough and sore throat were found in 22.2% each, while fever was found in 18.6%. a multicenter study from italy by alberici f et al. reported fever (68%) as most common symptom, followed by shortness of breath in 25%, and cough in 23%.18 on radiological investigation with x-ray chest, we found bilateral ground-glass opacification as the most common finding (28.8%), followed by local patchy shadow (28.8%), while in 17.3% of patients, imaging was normal. goicoechea m et al. from italy table iv: association of outcome according to various factors and action taken (n=52) outcome total pvalue discharge (n=33) expired (n=19) gender male 21 15 36 0.249 female 12 4 16 primary cause of esrd diabetes mellitus 10 11 21 0.06 hypertensi on 9 1 10 chronic glomerulo nephritis 6 2 8 bilateral small size kidneys 6 1 7 renal stone 1 3 4 multiple myeloma 1 0 1 contrast induced nephropat hy 0 1 1 j islamabad med dental coll 2020 94 reported bilateral peripheral ground-glass opacification in 61%, unilateral lung involvement in 19%, and normal radiology in 19%. similarly, wu j et al. when assessed the covid-19 patients on hemodialysis, quoted that on ct, there was bilateral ground-glass opacification in 82%, unilateral lung disease in 10%, and normal imaging in 8%.12 most of the patients with mild disease were advised home isolation (38.5%). intensive care unit admission with mechanical ventilation was given to 26.9%, while the remaining (34.6%) were hospitalized with noninvasive positive pressure ventilator support. in wuhan, results showed that most patients (84%) were on simple oxygen therapy, 25% received noninvasive ventilation, while mechanical ventilation was given to 6%.12 as for an outcome of covid-19 positive hemodialysis patients in our study, 63.5% were discharged after becoming asymptomatic and rtpcr negative. the 36.5% patients expired, most of them were on mechanical ventilation in intensive care units. in results by la milia v et al. from lombardy italy, 13 patients out of 25 expired (52%), while 28% were discharged and sent home asymptomatic.12 similar results were given by jiah ng, who reported 31.7% in-hospital mortality of covid-19 hemodialysis population19. they also found that hypertension and medications for hypertension are associated with increased mortality. we have found higher mortality in patients who required mechanical ventilation (p=0.000), while there was no significant association noted with other factors like crp, lymphopenia, ldh or ferritin level as found in other studies from turkey20 and by anthony in columbia university hospital.21 our study is limited by small sample size, singlecenteredness, and lack of hrct chest facility. large multicenter studies are required to find out the clinical and laboratory effects of covid-19 in this specific population. c o n c l u s i o n population with end stage kidney disease is susceptible to covid-19 infection with high rates of morbidity and mortality compared with general population. recommendations strict adherence to the preventive measures is necessary in order to halt the transmission of covid19 infection in end stage kidney disease patients, like use of personal protective gear for hemodialysis staff and patients, keeping one patient from other patient at a safe distance during hemodialysis, routine screening of the patients and medical staff, proper isolation and management of covid-19 pcr positive patients and hemodialysis of covid 19 esrd patients in isolated and specific area reserved for these patients. r e f e r e n c e s 1. rolling updates on corona virus disease (covid-19) [internet]. world health organization. 2020 [cited2021 jan 14]. available from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019/events-as-they-happen 2. covid-19 health advisory platform by ministry of national health services regulations and coordination [internet]. 2020 [cited 2021 jan 14]. available from https://covid.gov.pk 3. goicoechea m, sánchez cámara la, macías n, muñoz de morales a, rojas á g, bascuñana a, et al. covid19: clinical course and outcomes of 36 hemodialysis patients in spain. kidney int. 2020;98(1):27-34. doi: 10.1016/j.kint.2020.04.031 4. madjid m, safavi-naeini p, solomon sd, vardeny o. potential effects of coronaviruses on the cardiovascular system: a review. jama cardiology. 2020;5(7):831-40. doi: 10.1001/jamacardio.2020.1286. 5. konrad r, eberle u, dangel a, treis b, berger a, bengs k, et al. rapid establishment of laboratory diagnostics for the novel coronavirus sars-cov-2 in bavaria, germany, february 2020. euro surveill. 2020;25(9) doi: 10.2807/1560-7917.es.2020.25.9.2000173 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://covid.gov.pk/ https://doi.org/10.1016/j.kint.2020.04.031 https://dx.doi.org/10.2807%2f1560-7917.es.2020.25.9.2000173 j islamabad med dental coll 2020 95 6. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020;382(8):727-33 doi: 10.1056/nejmoa2001017 7. wynants l, van calster b, collins gs, riley rd, heinze g, schuit e, et al. prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal. bmj. 2020;369:m1328. doi: https://doi.org/10.1136/bmj. m1328 8. corbett rw, blakey s, nitsch d, loucaidou m, mclean a, duncan n, et al. epidemiology of covid-19 in an urban dialysis center. jasn. 2020;31(8):1815-23. doi 10.1681/asn.2020040534 9. li j, xu g. lessons from the experience in wuhan to reduce risk of covid-19 infection in patients undergoing long-term hemodialysis. cjasn. 2020;15(5):717-9. doi: https://doi.org/10.2215/cjn.03420320 10. ajaimy m, melamed ml. covid-19 in patients with kidney disease. cjasn. 2020;15(8):1087-9. doi: 10.2215/cjn.09730620 11. xiong f, tang h, liu l, tu c, tian jb, lei ct, et al. clinical characteristics of and medical interventions for covid-19 in hemodialysis patients in wuhan, china. jasn. 2020;31(7):1387-97. doi: 10.1681/asn.2020030354. 12. wu j, li j, zhu g, zhang y, bi z, yu y, et al. clinical features of maintenance hemodialysis patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. cjasn. 2020;15(8):1139-45. doi: 10.2215/cjn.04160320 13. la milia v, bacchini g, bigi mc, casartelli d, cavalli a, corti m, et al. covid-19 outbreak in a large hemodialysis center in lombardy, italy. kidney int rep. 2020;5(7):1095-9. doi: 10.1016/j.ekir.2020.05.019 14. fisher m, yunes m, mokrzycki mh, golestaneh l, alahiri e, coco m. chronic hemodialysis patients hospitalized with covid-19: short-term outcomes in the bronx, new york. kidney360. 2020;1(8):755 doi: 10.34067/kid.0003672020 15. rabaan aa, al-ahmed sh, haque s, sah r, tiwari r, malik ys, et al. sars-cov-2, sars-cov, and merscov: a comparative overview. le infezioni in medicina. 2020;28(2):174-84. doi https://doi.org/10.1186/s12941-020-00414-7 16. xu x, nie s, sun j, kong y, liang m, li d, et al. the cumulative rate of sars-cov-2 infection in chinese hemodialysis patients. kidney int rep. 2020;5(9):1416-21. doi: 10.1016/j.ekir.2020.07.010 17. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china]. zhonghua liu xing bing xue za zhi = zhonghua liuxingbingxue zazhi. 2020;41(2):145-51. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003 18. alberici f, delbarba e, manenti c, econimo l, valerio f, pola a, et al. a report from the brescia renal covid task force on the clinical characteristics and shortterm outcome of hemodialysis patients with sarscov-2 infection. kidney int. 2020;98(1):20-6. doi: 10.1016/j.kint.2020.04.030 19. ng jh, hirsch js, wanchoo r, sachdeva m, sakhiya v, hong s, et al.northwell covid-19 research consortium and the northwell nephrology covid-19 research consortium. outcomes of patients with endstage kidney disease hospitalized with covid-19. kidney int. 2020 dec;98(6):1530-1539. doi: 10.1016/j.kint.2020.07.030. 20. aydin bahat k, parmaksiz e, sert s. the clinical characteristics and course of covid-19 in hemodialysis patients. hemodial int. 2020 oct;24(4):534-540. doi: 10.1111/hdi.12861. 21. valeri am, robbins-juarez sy, stevens js, ahn w, rao mk, radhakrishnan j, et al.presentation and outcomes of patients with eskd and covid-19. j am soc nephrol. 2020 jul;31(7):1409-1415. doi: 10.1681/asn.2020040470. https://doi.org/10.1136/bmj.m1328 https://doi.org/10.1136/bmj.m1328 https://doi.org/10.1681/asn.2020040534 https://doi.org/10.2215/cjn.03420320 https://doi.org/10.2215/cjn.09730620 https://doi.org/10.2215/cjn.04160320 https://dx.doi.org/10.1016%2fj.ekir.2020.05.019 https://dx.doi.org/10.34067%2fkid.0003672020 https://doi.org/10.1016/j.ekir.2020.07.010 https://doi.org/10.3760/cma.j.issn.0254-6450.2020.02.003 https://dx.doi.org/10.1016%2fj.kint.2020.04.030 j islamabad med dental coll 2023 1 open access establishing and sustaining a pediatric bone marrow transplant program in developing countries aliya batool1, sadaf khalid2 1assistant professor pathology, department of hematology, oncology and bmt unit, akbar niazi teaching hospital, pakistan 2assistant professor community medicine, department of hematology, oncology and bmt unit, akbar niazi teaching hospital, pakistan bone marrow transplantation (bmt) is an established treatment modality for various pediatric malignant and nonmalignant hematological diseases such as leukemia, thalassemia major, sickle cell disease and bone marrow failure syndrome1. for low-risk patients of sickle cell anemia and thalassemia, bmt can cure 85% of the cases and improve the long term health related quality of life,2,3 whereas for high risk malignancies and marrow failure syndromes, bmt is the only lifesaving option. thalassemia major patients would die without transfusions or bmt. however, long term transfusion and optimized chelation therapy is highly challenging for many developing countries, where this disease is prevalent causing unsustainable health burden. bone marrow transplantation should be considered the primary treatment of choice in the presence of suitable donor4patient’s condition at the time of transplant is a major determinant of outcome, therefore close association between referral centers and bmt services is necessary.5 correspondence: aliya batool email: aliya.batool@imdcollege.edu.pk cite this editorial: batool a, khalid s. establishing and sustaining a peadiatric bone marrow transplant program in developing countries. j islamabad med dental coll. 2023;12(1): 1-3 doi: https://doi.org/10.35787/jimdc.v12i1.974 offering free or subsidized hla typing for identification of suitable transplant donor in communities with high consanguinity rate is also helpful for patients registered in thalassemia centers or other institutes providing supportive care to these patients6 there is a gross disparity between the requirement for transplant and existing facilities in pakistan.7 for a self-sustainable bmt program financial constraints and professional expertise are two main challenges in developing countries like ours,8 support and commitment of governmental and nongovernmental organizations for the nonaffording patients can help running such programs.9 the recognition of minimum to ideal requirement as well as clinical, technical, and financial consideration for the establishment of new bone marrow transplant (bmt) by wbmt will be helpful in limiting the initial program cost.10 developing countries are deprived of essential human resources due to their migration in developed countries, therefore human resource capacity building through trained and dedicated health care professional is the next challenge in proper functioning of a bmt center. international cooperation and twining with other institutions in developed countries through information technology platform could be very helpful.11 traveling of expert bmt physicians and nurses to e d i t o r i a l j islamabad med dental coll 2023 2 new bmt sites for supervision and on-site training of local bmt team when all basic requirement are in place is more cost effective than sending few physicians and nurses to established transplant centers. on-site training should be followed by interactions via web-based electronic medical record system and teleconferencing experienced nurses are critical component of any bmt program, recommended optimum nurse to bed ratio per shift is 1:2.12 professional development plan and suitable salary prevents the nursing shortage and turnover. bmt unit for low-risk patients can be established within an existing hospital facility with relatively less cost, for them high-efficiency particulate air filtration and positive pressure is not mandatory requirement according to international guidelines13 moving on to the challenges during the various phases of transplant, they can be in the form of availability of chemotherapeutic drugs, access to certain mandatory laboratory services like drug levels, viral pcrs, chimerism testing, blood bank facilities for irradiated blood products and specialized radiological testing. collaboration with institutes for outsourcing of tests like cmv pcr, peripheral chimerism, irradiation of blood products and preparation of single donor platelets can smooth line issues to quite an extent. management of post transplant complications including gvhd, vasoocclusive disease, intracranial hemorrhage, septicemia low risk transplants studies have shown that major complication is septicemia and no extensive chronic gvhd is observed in such cases.14 a multidisciplinary approach in the management of complications and strengthening of existing facilities can be helpful in most of the cases. in summary, structured collaborative program, commitment, and team work can make a difference in offering this treatment modality and bringing about the difference in the lives of patients and families suffering from such diseases. r e f e r e n c e s 1. snowden, j.a., sánchez-ortega, i., corbacioglu, s. et al. indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in europe, 2022. bone marrow transplant 57, 1217– 1239 (2022). https://doi.org/10.1038/s41409-02201691-w 2. faulkner l, uderzo c, khalid s, marwah p, soni r, yaqub n, et al. atg vs. thiotepa with busulfan and cyclophosphamide in matched-related bone marrow transplantation for thalassemia. blood adv. 2017;1:792–801. 3. la nasa g, caocci g, efficace f, dessì c, vacca a, piras e, et al. long-term health-related quality of life evaluated more than 20 years after hematopoietic stem cell transplantation for thalassemia. blood. 2013;122:2262–70 4. mohammad sy. thalassemia major: transplantation or transfusion and chelation. elsevier. 2017;10(4):290-298. https://doi.org/10.1016/j.hemonc.2017.05.022. 5. faulkner, l., verna, m., rovelli, a. et al. setting up and sustaining blood and marrow transplant services for children in middle-income economies: an experience-driven position paper on behalf of the ebmt pdwp. bone marrow transplant 56, 536–543 (2021). https://doi.org/10.1038/s41409-020-0983-5 6. agarwal rk, kumari a, sedai a, parmar l, dhanya r, faulkner l. the case for high resolution extended 6loci hla typing for identifying related donors in the indian subcontinent. biol blood marrow transplant. 2017;23:1592–6. 7. zaidi u, shamsi ts, farzana t, ansari sh, borhani m, munzir s, samad s, parveen k, anjum n, mirza ig, safdar d, naseem r, bukhari na, mazari m, jamil h, yousuf r, khan ia, rasheed k, mir ma. capacity building of stem cell transplantation facilities in pakistan: joint efforts of nibd, government, and private-sector institutions. blood adv. 2019 dec 6;3(suppl 1):41-44. doi: 10.1182/bloodadvances.2019gs121552. pmid: 31809547; pmcid: pmc7034115. 8. yeh ac, khan ma, harlow j, et al. hematopoietic stem-cell transplantation in the resource-limited setting: establishing the first bone marrow https://doi.org/10.1038/s41409-022-01691-w https://doi.org/10.1038/s41409-022-01691-w https://doi.org/10.1016/j.hemonc.2017.05.022 https://doi.org/10.1038/s41409-020-0983-5 j islamabad med dental coll 2023 3 transplantation unit in bangladesh. j glob oncol. 2018;4:1-10. doi:10.1200/jgo.2016.006460 9. rivera franco mm, leon rodriguez e. importance of nongovernmental organizations for the establishment of a successful hematopoietic stemcell transplantation program in a developing country. j glob oncol. 2018 sep;4:1-8. doi: 10.1200/jgo.17.00091. pmid: 30241235; pmcid: pmc6223420. 10. aljurf m, weisdorf d, hashmi s, nassar a, gluckman e, mohty m, et al. worldwide network for blood and marrow transplantation recommendations for establishing a hematopoietic stem cell transplantation program in countries with limited resources, part ii: clinical, technical, and socioeconomic considerations. biol blood marrow transplant. 2019;25:2330–7. 11. agarwal rk, sedai a, dhimal s, ankita k, clemente l, siddique s, et al. a prospective international cooperative information technology platform built using open-source tools for improving the access to and safety of bone marrow transplantation in low and middle-income countries. j am med inform assoc. 2014;21:1125–8. 12. day s, hollis r, challinor j, bevilacqua g, bosomprah e, siop podc nursing working group. baseline standards for paediatric oncology nursing care in low to middle income countries: position statement of the siop podc nursing working group. lancet oncol. 2014;15:681–2. 13. ebmt. 7th edition of fact-jacie standards. ebmt. https://www.ebmt.org/ebmt/news/7thedition-fact-jacie-standards-released. 14. faulkner l, setting up low-risk bone marrow transplantation for children with thalassemia may facilitate pediatric cancer care. south asian j cancer.2013;2(3):109-112. https://www.ebmt.org/ebmt/news/7th-edition-fact-jacie-standards-released https://www.ebmt.org/ebmt/news/7th-edition-fact-jacie-standards-released j islamabad med dental coll 2021 35 o p e n a c c e s s ototoxic hearing loss in the multidrug resistant tuberculosis laraib bakhat1, nazia mumtaz2, ghulam saqulain3 audiology technologist, civil hospital, bhawalpur head of department, speech and language pathology, riphah international university, lahore head of department, otorhinolaryhgology, capital hospital pjmi, islamabad a b s t r a c t background: the recommended treatment of mdr tb lasts for 20 months following therapy with second line antituberculosis drugs (slds) which carry the risk of adverse effects including hearing loss. the objective of this study was to determine the frequency of hearing loss and its association with demographic and clinical variables in multidrug resistant tuberculosis patients on second line drugs. methodology: this cross-sectional study was carried out at the audiology department of the civil hospital bahawalpur, over a period of 6 months, from 1st may 2019 to 31st october 2019. the study included 65 diagnosed cases of tuberculosis, aged 12-70 years, of either sex, who were on second line antituberculous therapy. non-probability purposive sampling technique was used for patient selection. screening was performed using medical history sheet, otoscopy and hearing assessment. data was entered and analyzed using spssversion 21. results: among a total of 65 patients,43 (66.2%) were males and 22(33.8%) were females. mean age of study population was 35.87±9.35 years. hearing loss was seen in 14(21.5%) cases, with mild hearing loss in 15.4% cases and moderate hearing loss 6.2%. hearing loss was associated with type of drug used, its duration and associated symptoms of tinnitus and vertigo (p=0.000). conclusion: it was found that hearing loss is quite frequent (21.5 %) with multidrug resistant anti-tuberculous therapy in this region and is significantly associated with the type of drug used and its duration. majority of affected cases were seen with the use of streptomycin. keywords: aminoglycosides, hearing loss, multi-drug resistant tuberculosis, ototoxicity, tuberculosis authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing.5,6 correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: february 21, 2021 accepted: march 28, 2022 cite this article. bakhat r, mumtaz n, saqulain g. ototoxic hearing loss in the multidrug resistant tuberculosis. j islamabad med dental coll. 2022; 11(1):35-41. doi: 10.35787/jimdc.v11i1.683. funding source: nil conflict of interest: nil i n t r o d u c t i o n normal hearing is the mainstay of human communication, in the absence of which an individual can suffer from serious loss in social, psychological and professional life.1 in developing countries like pakistan, tuberculosis including multidrug resistant tuberculosis (mdr-tb) is on the rise. mdr-tb is an aftermath of a strain of mycobacterium tuberculosis (mtb) which develops resistance to at least two of the most powerful anti tb drugs i.e., isoniazid (inh) and rifampicin (rmp).2 an ethiopian study revealed that tb infected cases do not disclose their condition to their relatives, thus contributing to development of mdr-tb.3 the level and prevalence of ototoxicity due to antituberculosis therapy (att) for mdr-tb has not been fully evaluated because of lack of ototoxicity monitoring.4 mdr-tb being resistant to rifampicin and isoniazid, is a growing clinical and health problem with high prevalence of adverse events.5,6 drugs used for treatment of mdr-tb are often very o r i g i n a l a r t i c l e j islamabad med dental coll 2022 41 toxic with 62% patients having residual side effect at the end of treatment. these may be gastrointestinal and psychiatric problems, arthralgia, central nervous system complications, hearing and balance issues, neuropathy of peripheral nerves, menstrual disturbances, liver, ophthalmic, kidney and thyroid problems in decreasing order of frequency, with hearing loss being an important issue.7-9 according to a who report in 2020, approximated tb prevalence was 5.8 million with majority of cases reported in south-east asia.10 the estimated incidence of tb in india was found to be approximately 2.79 million with 40% of population infected with tuberculous bacilli.11 high prevalence of mdr-tb has also been reported from central asian region.10 noncompliance to att in our country and neglect are resulting in mdr tb with a high prevalence of 69% in patients reporting to tertiary care centers in pakistan.12 with the resurgence of tuberculosis and the prevalence of mdr-tuberculosis in pakistan4, the emphasis has shifted to treatment using second line drugs, which carry the risk of adverse effects like hearing loss (hl).13 the present study was thus conducted to determine the prevalence of hearing loss and its association with demographic and clinical variables in mdr-tuberculosis patients using second line drugs. m e t h o d o l o g y this cross-sectional study was conducted in the audiology department of the civil hospital, bahawalpur, from may 1, 2019 to october 31, 2019. in total 65 diagnosed cases of tuberculosis, both genders, aged 12 to 70 years and on 2nd line antituberculosis therapy (att) were included in the study. patients were recruited using non-probability purposive sampling technique. cases with symptoms of ear disease prior to administration of att, with incomplete data or cases in which tests could not be conducted because of any reason were excluded from the study. sample size was calculated using the formula n= z2a/2xpx(1-p) x deff/d,2 taking a prevalence of mdr tb as 4.6% 14, estimated effective size (deff) of 1, at level of confidence of 95% and 5% absolute precision. participants were screened using medical history sheet, ear examination and hearing assessment. all cases were diagnosed by medical specialist. history was taken in a confidential setting and included questions regarding auditory and vestibular disorders with presence of vertigo, tinnitus, and exposure to agents harmful to hearing such as occupational or leisure noise and ototoxic drugs. hearing of all cases was assessed by pure tone audiometer model audio lab v-3. both ears were tested using the method of ascending pure tones at frequencies of 0.25, 0.5, 1, 2, 4, 6, 8 and 16 khz before descending to 1 and 0.5 khz. hearing measurements were performed in a soundproof audiometry booth that met the american national standards institute (ansi).15 data was entered and analyzed using spss version 21. mean and percentages were calculated. chisquare test was used to observe association of hearing loss with demographic and clinical variables. variables included for association with hl were age, gender, associated symptoms, ototoxic drugs administered, drug duration and smoking. p value of < 0.05 was considered statistically significant. r e s u l t s among total of 65 cases, hearing loss (hl) was seen in 14 (21.5%). demographic and clinical characteristics revealed that 43(66.2%) were males and 22(33.8%) were females with a male to female ratio of 1.95:1 (table 1). majority of patients, 26(40%) were between 31-40 years of age. there was no significant association of hl with gender (p value: 0.149) and age (p value: 0.069). there was however significant association of hl with associated symptoms (p=0.000) with 6 out of 8 cases of vertigo having hl and 4 out of 8 cases of tinnitus having hl. a significant (p=0.000) association of hl was also observed with drug used, it j islamabad med dental coll 2022 41 was found that 28(43.1%) cases in whom amikacin was used there was no hl while out of the 13(20%) cases in which streptomycin was used, 11 developed hl. moreover, only one case out of 12(18.5%) in which both amikacin and streptomycin were used developed hl. hl was also significantly associated with duration of drug use, with hl noted in 2 out of 2 cases at 2 months duration, and 6 out of 10 cases at 8 months duration, while only 4 out of 32 cases and 2 out of 21 cases developed hl at 6 and 7-months duration respectively, indicating that the drug actually caused hl at initiation of treatment. the study, however, revealed no significant association of hl with smoking. with reference to frequency of degree of hl of both ears, the sample population revealed a similar picture with 10(15.4%) cases with mild hl and 4 (6.2%) cases with moderate hl in both ears. the remaining sample did not reveal any hl. as far as configuration of audiogram was concerned, a flat curve was noted in 6 (9.2%) of right ears and 8 (12.3%) of left ears, while high frequency steeply sloping audiogram was noted in 5(7.7%) of right and 6(9.2%) of left ears. mean hearing threshold of cases which developed hl, increased from 26.43 +15.86 db to 35.36 + 16.34 db from 250 hz to 8 khz for right ear and from 26.78+12.18 to 37.50 + 12.36 db from 250 hz to 8 khz for left ear. however, the difference of mean thresholds at each frequency from 250 to 8 khz from both ears was not significant (table iii). table ii: characteristics of hearing loss. (n=65) variable frequency group characteristi cs (n) % hl normal hearing 51 78.5 hearing loss 14 21.5 mild 10 15.4 table i: demographic and clinical characteristics: descriptive statistics. (n=65) variable hearing status category characteristics n (%) normal n=51 affected n=14) x2 p-value) age group 10-20 3 (4.6) 1 2 8.71 (0.069) 21-30 16 (24.6) 12 4 31-40 26 (40) 24 2 41-50 16 (24.6) 12 4 51-60 4 (6.2) 2 2 gender males 43 (66.2) 36 7 2.08 (0.149) females 22 (33.8) 15 7 assoc. symptoms no 49 (75.38) 45 4 23.53 (0.000) vertigo 8 (12.31) 2 6 tinnitus 8 (12.31) 4 4 drugs amikacin 28 (43.1) 28 0 36.69 (0.000) streptomycin 13 (20) 2 11 both amikacin & streptomycin 12 (18.5) 11 1 others 12 (18.5) 10 2 drug duration (months) 2 2 (3.1) 0 2 19.38 (0.000) 6 32 (49.2) 28 4 7 21 (32.3) 19 2 8 10 (15.4) 4 6 smoking yes 10 (15.38 8 2 0.02 (0.898) no 55 (84.62) 43 12 j islamabad med dental coll 2022 41 degree of hl right ear moderate 4 6.2 normal 51 78.5 degree of hl left ear mild 10 15.4 moderate 4 6.2 normal 51 78.5 configuration audiogram right ear flat curve 6 9.2 high frequency steeply sloping curve 5 7.7 total 11 16.9 configuration audiogram left ear flat curve 8 12.3 high frequency steeply sloping curve 6 9.2 total 14 21.5 duration of hl no hearing issue 50 76.9 2-months 4 6.2 3-months 4 6.2 4-months 3 4.6 5-months 4 6.2 table iii: hearing threshold and paired sample t-test statistics. (n=14) ear freque ncy ra ng e min . ma x. mea n sd righ t 250hz 60 10 70 26.4 3 15.86 500hz 65 10 75 28.2 1 17.82 1khz 55 15 70 30.7 1 15.67 2khz 55 15 70 32.1 4 14.77 4khz 55 20 75 33.5 7 14.99 8khz 60 15 75 35.3 6 16.34 left 250hz 40 10 50 26.7 8 12.18 500hz 35 15 50 28.9 3 12.58 1khz 45 10 55 30.0 0 12.25 2khz 35 20 55 33.5 7 12.62 4khz 45 10 55 35.3 6 12.47 8khz 50 10 60 37.5 0 12.36 paired differences frequen cy me an sd std. error mean tvalu e pvalue right ear left ear 250 250 0.2 3 8.72 1.08 0.21 0.83 500 500 0.3 8 9.93 1.23 0.31 0.76 1000 1000 0.3 1 8.79 1.09 0.28 0.78 2000 2000 0.6 2 8.64 1.07 -0.57 0.57 4000 4000 0.6 9 10.49 1.30 -0.53 0.60 8000 8000 0.0 8 11.09 1.38 -0.06 0.96 d i s c u s s i o n aminoglycosides are responsible for permanent hl, which affects quality of life with susceptibility of patients varying significantly. hence, ways to identify high-risk cases are essential so that protective strategies and alternate treatment may be considered.16 the present study revealed a prevalence of hl of 21.5% (n=14) among mdr-tb cases on ototoxic att. results of a study from sogebi et al are comparable to our results with 22.9% cases of mdr-tb patients showing hl.17 in another study conducted by bhardwaj et al. prevalence of side effects of mdr-tb was 83.33% of which hl was present in 22%.7 in contrast haris et al. in a study conducted at cape town, reported a high prevalence of aminoglycoside induced hl of 57% 18 and saqwa et al. reported a prevalence of 58%.19 in our study, we found no significant association of hl with gender (p=0.149). however, nhokwara et al and sogebi oa et al reported significant association j islamabad med dental coll 2022 41 of hl with gender, with males more frequently affected than females.19,20 the mean age of our study population was 35.87 +9.35 years with maximum cases of hl noted in the age group 21-30 and 41-50 years however the age association was not statistically significant (p=0.069). in contrast, in a study by nhokwara et al, a statistically significant increase in cases of hl was noted with increasing age.19 in our study, 8 cases developed tinnitus and 8 cases reported vertigo and there was a significant association of hl with these associated symptoms (p=0.000). while in another study, 36% cases reported associated symptoms of vertigo and tinnitus, with the most common symptom being tinnitus in 75% of the cases.21 a significant (p=0.000) association of hl was also noted with drug used, with higher frequency of hl due to streptomycin. another study, using kanamycin for mdr tb, reported 75% of cases with hl.22 amikacin is an important part of botswana's mdr-tb treatment, recommended by who in most countries. a study by modongo c et al reported an increase in the risk of hl as the duration and dosage per weight per month increased.23 the current study revealed, a significant association (p=0.000) with higher frequency of cases affected at 2 months and at 8 months. more than one mechanism is responsible for this, including higher doses, genetic idiosyncrasy, and ischemia resulting in early hl .24jayakumar et al noted no hl before two months, while 27% & 20% cases in right and left ear developed hl at 2 months and 39% & 27 % developed hl at 3 months.21 similarly, in another study, 22% cases developed hl at 2 months.22 sogebi et al also reported that, ototoxicity with hl developed with treatment from 4 to 17 (mean 9.4 + 3.4) weeks with the use of aminoglycosides.17 saqwa et al. in a comparative study between amikacin and kanamycin, reported higher and more severe hl in cases of amikacin.20 in another study, 55% developed ototoxicity and this was 5 times more likely to develop with amikacin compared to capreomycin.25 this finding was in contrast to our study, where streptomycin was the major culprit. this indicates that in addition to the ototoxic drug, certain risk factors might be involved resulting in inconsistent results in different studies. regarding degree of hl in both ears, 10 (15.4%) cases reported mild hl and 4 (6.2%) moderate hl in both ears. in contrast, a study by jayakumar et al, mild hl was reported in 75% cases, moderate in 9.1%, moderately severe hl in 9.1%, severe hl in 4.5% and profound hl in 2.3% cases.21 saqwa et al reported severity of hl with 32% having mild hl, 23% moderate, 16% moderate to severe, 10% severe and 15 with profound hl. 20. in another study, prevalence of mild hl was 58.1%, moderate hl 30.6% and severe loss was seen in 11.3% cases.19 in the current study both ears revealed increase in mean thresholds from 250 hz to 8 khz, however the difference between right and left ear was not significant. however, according to a study reported by jayakumar et al, ototoxic hl in mdr-tb involving both ears was present in 63.63% cases, and unilateral involvement in 36.36% cases.21 current study revealed flat hl in 9.2% & 12.3% right and left ears respectively, while steeply sloping high frequency loss was noted in 7.7% & 9.2% of right and left ears respectively. however, hl was more frequently seen at higher frequencies but in 30.5%, it occurred at < 2000 hz.22 in contrast in a study by sogebi et al ,out of 16 cases who developed hl, 7 (43.8%) developed low frequency hl while high frequency loss was noted in 4 (25%) cases.17 a much higher percentage of high frequency hl of 57% was noted in a study by harris et al with higher prevalence in hiv positive cases.18 this indicates that the frequency and level of hl is inconsistent with studies, again indicating some risk factors might be responsible. according to sogebi et al, age, diabetes mellitus, retroviral status were all significantly associated with hl, while gender, previous drug regimen failure showed no association with hl.17 some studies have j islamabad med dental coll 2022 41 also reported association of hiv positive status, and low body weight with hl.18.20 considering the results of various studies, it is suggested that a control audiogram at the initiation of the treatment for mdr-tb followed by an audiogram every month for six months and then three monthly till treatment is completed is essential for prevention and mitigation of hl associated with ototoxic att, and is recommended for all cases of mdr-tb.21 limitation of study: our study had the limitation of a small sample size with only one audiologist to perform the testing. c o n c l u s i o n s frequency of hearing loss with multidrug resistant tuberculosis treatment was high and significantly associated with the drug used, its duration. majority of cases were observed with use of streptomycin. disclaimer this research is part of the main research of m phil (hearing sciences) thesis project. r e f r e n c e s 1) idstad, m., tambs, k., aarhus, engdahl bl. childhood sensorineural hearing loss and adult mental health up to 43 years later: results from the hunt study. bmc public health. 2019; 19:168. doi: 10.1186/s12889-019-6449-2. 2) krishnamurthy s. drug-resistant tuberculosis a ticking time bomb! perspect clin res. 2018;9(4):153154. doi: 10.4103/picr.picr_116_18. 3) gobena d, ameya g, haile k abreha g, worku y, debela t. predictor of multidrug resistant tuberculosis in southwestern part of ethiopia: a case control study. ann clin microbiol antimicrob. 2018;17(1):30. doi: 10.1186/s12941-018-0283-8. 4) javaid a, khan ma, khan ma, mehreen s, basit a, khan ra et al. screening outcomes of household contacts of multidrug-resistant tuberculosis patients in peshawar, pakistan. asian pac j trop med. 2016;9(9):909-12. doi: 10.1016/j.apjtm.2016.07.017. 5) avong yk, isaakidis p, hinderaker sg, van den bergh r, ali e, obembe bo, et al. doing no harm? adverse events in a nation-wide cohort of patients with multidrug-resistant tuberculosis in nigeria. plos one. 2015;10(3):e0120161. doi: 10.1371/journal.pone.0120161. 6) lange c, abubakar i, alffenaar jw, bothamley g, caminero ja, carvalho ac, et al. management of patients with multidrug-resistant/extensively drugresistant tuberculosis in europe: a tbnet consensus statement. eur respir j. 2014; 44(1): 23–63. doi:10.1183/09031936.00188313 7) bhardwaj p, deshkar am, verma r. side effects encountered in treatment of multidrug-resistant tuberculosis: a 3-year experience at first dots plus site of chhattisgarh. international journal of scientific study. 2015;3(5):104-7. 8) modongo c, sobota rs, kesenogile b, ncube r, sirugo g, williams sm, et al. successful mdr-tb treatment regimens including amikacin are associated with high rates of hearing loss. bmc infect dis. 2014;14:542. doi: 10.1186/1471-2334-14-542. 9) amin s, mishra v, mira d, rajesh s. pattern of adverse drug reactions and its potential impact on drug resistant tuberculosis patients at a tertiary care teaching hospital in western india. clin j pharmacol pharmacother. 2018; 1(1):15-20. 10) world health organization. global tuberculosis report 2021 [internet]. geneva: world health organization; 2021. available from: https://www.who.int/teams/global-tuberculosisprogramme/tb-reports/global-tuberculosis-report2021 11) pattnaik s. analysis of tuberculosis case report in hyderabad district of telangana state. j family med prim care. 2018;7(3):561-564. doi: 10.4103/jfmpc.jfmpc_110_18. 12) akhtar am, arif ma, kanwal s, majeed s. prevalence and drug resistance pattern of mdr tb in retreatment cases of punjab, pakistan. j pak med assoc. 2016; 66(8):989-93. 13) khan ra, shaikh aa, bulaadi gq. incidence of multidrug-resistant tuberculosis in sindh, pakistan. cureus. 2019;11(4):e4571. doi:10.7759/cureus.4571 14) jabbar a, khan ta, rahman h, khan as, ahmed s, khan sn. burden of drug resistant tuberculosis in newly diagnosed tuberculosis patients of khyber pakhtunkhwa, pakistan. j pak med assoc. 2021; 1-10. doi:10.47391/jpma.08-926 15) walker jj, cleveland lm, davis jl. audiometry screening and interpretation. am fam physician. 2013 jan 1;87(1):41-47 16) lanvers-kaminsky c, ciarimboli g. pharmacogenetics of drug-induced ototoxicity caused by aminoglycosides and cisplatin. pharmacogenomics. 2017;18(18):1683-95. 17) sogebi oa, adefuye bo, adebola so, oladeji sm, adedeji to. clinical predictors of aminoglycosidej islamabad med dental coll 2022 41 induced ototoxicity in drug-resistant tuberculosis patients on intensive therapy. auris nasus larynx. 2017; 44(4):404-410. doi: 10.1016/j.anl.2016.10.005. 18) harris t, bardien s, schaaf hs, petersen l, de jong g, fagan jj. aminoglycoside-induced hearing loss in hivpositive and hiv-negative multidrug-resistant tuberculosis patients. s afr med j. 2012;102(6). 3636 19) nhokwara pt. factors that influence the utilisation of ototoxicity monitoring services for patients on treatment for drug-resistant tuberculosis. university of cape town; 2015. 20) sagwael ,ruswa n , mavhunga f , rennie t , leufkens hg , mantel-teeuwisse ak . comparing amikacin and kanamycin-induced hearing loss in multidrugresistant tuberculosis treatment under programmatic conditions in a namibian retrospective cohort. bmc pharmacoltoxicol. 2015; 16:36. doi: 10.1186/s40360-015-0036 21) jayakumar n, krishnamoorthy k, mathan e, sangamithra g, hameed rs. incidence of kanamycin induced toxicity among drug resistant tuberculosis patients attending tirunelveli medical college hospital, dots plus centre, tamilnadu, paripex indian j res. 2018; 7(9): 62-64. 22) heysell sk, ahmed s, rahman mt, akhanda mw, gleason at, ebers a,et al. hearing loss with kanamycin treatment for multidrug-resistant tuberculosis in bangladesh. eur respir j. 2018;51(3):1701778. doi: 10.1183/13993003.017782017. 23) modongo c, sobota rs, kesenogile b, ncube r, sirugo g, williams sm, et al. successful mdr-tb treatment regimens including amikacin are associated with high rates of hearing loss. bmc infectious diseases. 2014;14(1):542. doi: 10.1186/1471-2334-14-542 24) lin cd, kao mc, tsai mh, lai ch, wei ih, tsai mh, et al. transient ischemia/hypoxia enhances gentamicin ototoxicity via caspase-dependent cell death pathway. lab invest. 2011;91(7):1092-106. doi: 10.1038/labinvest.2011.69. 25) arnold a , cooke gs , kon om , dedicoat m , lipman m , loyse a, et al. adverse effects and choice between the injectable agents amikacin and capreomycin in multidrug-resistant tuberculosis. antimicrob agents chemother. 2017;61(9). pii: e02586-16. doi: 10.1128/aac.02586-16 j islamabad med dental coll 2022 216 open access effect of depression on serum levels of follicular stimulating hormone and luteinizing hormone in male population of military hospital, rawalpindi nasar abbas shamsi1, shazia ali2, shazadi ambreen3, hira ayaz4, sobia waqas5, sidra arshad6 1,4assistant professor, physiology, foundation university islamabad, pakistan. 2professor, physiology, islamic international medical college, islamabad, pakistan. 3senior lecturer, physiology, shifa tameer e millat university islamabad, pakistan 5assistant professor, physiology, fazaia medical college islamabad, pakistan. 6associate professor,physiology, rawal institute of health sciences, islamabad, pakistan. a b s t r a c t background: depression is a psychiatric illness that affects the overall life quality of an individual. in depression along with other symptoms, one of the features affecting the personal life of individuals is loss of libido which is influenced by the hypothalamic-pituitary-testicular axis. this study was aimed to determine the serum levels of follicular stimulating hormone (fsh) and luteinizing hormone (lh) in depressed male patients. methodology: this comparative cross sectional study was done at islamic international medical college and armed forces institute of mental health, military hospital rawalpindi after being approved by ethical review committee. after informed consent, 96 male individuals having 18 – 60 years of age participated in the current study. participants were segregated into groups a and b. gender and age-matched healthy subjects in a quantity of 24 were taken in group a whereas group b consisted of 72 male depressed patients. serum gonadotropins levels of both groups were compared by using an independent student t-test in spss 21. results: serum fsh (2.66 ± 0.34 miu/ml) and lh (2.67 ±0.18 miu/ml) levels of group a have shown no significant difference as compared to serum fsh (3.32 ± 0.43 miu/ml) and lh (3.12 ± 0.19 miu/ml) levels of group b. conclusion: it is concluded from the study that serum fsh and lh levels were not significantly decreased in individuals with depression. keywords: depression, follicle stimulating hormone, luteinizing hormone authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3, 4 critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: nasar abbas shamsi email: n.abbas@fui.edu.pk article info: received: october 19, 2021 accepted: december 27, 2022 cite this article. shamsi n a ,ali s, ambreen s, ayaz h, waqas s, arshad s. effect of depression on serum levels of follicular stimulating hormone and luteinizing hormone in male population of military hospital, rawalpindi. j islamabad med dental coll. 2022; 11(4): funding source: nil conflict of interest: nil 216-221 doi: https://doi.org/10.35787/jimdc.v11i4.797 i n t r o d u c t i o n depression is a psychiatric illness which has deleterious effects on feelings, thought process and overall behavior of an individual1. in depression, cognitive and behavioral abnormalities are accompanied by an important manifestation which o r i g i n a l a r t i c l e j islamabad med dental coll 2022 217 is the loss of sexual desire and challenges to maintain intimate sexual relationships2. reduced sexual activity badly affects the individual’s family life and leads to severe depression which ultimately hindered the management of illness. the complex neuroendocrine network of hypothalamic pituitary testicular axis plays a central role in controlling the sexual activities of an individual3. the hypothalamus plays a pivotal role in hypothalamic-pituitary-testicular axis by secreting gonadotropin-releasing hormone (gnrh) which will affect the secretions of pituitary gland3. gnrh is a decapeptide synthesized by specialized neurons of the arcuate nucleus and preoptic area of hypothalamus4. pathologies involving hypothalamus especially those having underlying dysfunction of hypothalamic pituitary adrenal axis and suprachiasmatic nucleus have been seen to be involved in the development of mood disorders5. release of gnrh in pulsatile form by the hypothalamus will cause stimulation of pituitary gland which will ultimately secrete follicle stimulating hormone (fsh) and luteinizing hormone (lh)6,7. upon binding of fsh to its receptors in testis, there will be release of factors like p-450 aromatase, growth factors, inhibin and androgen-binding protein (abp) along with anti-mullerian hormone from the sertoli cells of testes. synthesis and action of certain steroid hormones is dependent on these factors8. antimullerian hormone released from testes promotes brain development and cognition9. lh released from pituitary gland causes testosterone production in males10. a wide range of functions in males is exerted by testosterone which includes spermatogenesis, secondary sexual traits development and behavioral characteristics like sexual motivation, libido and aggression11. in addition, testosterone is also important for brain development and cognitive processes of the brain12. fsh and lh are also associated with central nervous system functions like regulation of cognition and mood. low levels of fsh and lh have been observed in diseases that affect the cognitive behavior of an individual13, 14. it has also been observed that the response of gonadotropins to gnrh is reduced in case of psychiatric illness like depression and mood disturbances15. the present research is planned to determine fsh and lh levels in serum of male individuals with depression which can be considered while addressing treatment protocol for patients. m e t h o d o l o g y this comparative cross sectional study was conducted in islamic international medical college in collaboration with armed forces institute of mental health, from 2nd january 2018 to 23rd april after approval by the ethical review committee. informed consent was taken from 96 males which were considered to be participating in the study. age of these males was from 18 to 60 years. sample size was calculated by taking prevalence 4.2 % of depression using raosoft sample size calculator at 95% confidence level and standard error 5% 16. two groups were made from participants. group a, comprised of age-matched 24 healthy male individuals without depression while group b, comprised of 76 patients with depression diagnosed by using the siddiqui shah depression scale (ssds). the ssds was developed by dr. salma siddiqui and dr. syed ashiq ali shah and it consists of 36 items in which each item can be scored from 0-4 with range of total scores of 0-108. scores of 26 or above is considered to be an indication of depressive illness17. inclusion criteria includes male gender, body mass index (bmi) < 30 with no chronic illness or physical anomaly. individuals with depression but under electroconvulsive therapy (ect), alcohol or drug abusers, having bmi >30, and patients with other obvious physical deformities and chronic illness were not included in the current study. body mass index (bmi) and age of all participants j islamabad med dental coll 2022 218 along with the duration of illness of depressive individuals was recorded. blood sampling was done from medial cubital veins by considering aseptic measures. separated serum obtained after centrifugation at 3000 rmp for 10 minutes was stored at the temperature of -20 °c. serum gonadotropins (follicular stimulating hormone and luteinizing hormone) levels were determined by elisa kits which are manufactured by bios usa. analysis of data was done with the help of statistical package for social sciences version 21 (spss 21). all the results deduced were reported in the form of mean ± sem. serum gonadotropins (ng/ml) levels of group a and group b were compared by employing independent sample t-test. p-value of ≤ 0.05 was considered as significant. r e s u l t s in this study, 96 male participants were divided into 2 different groups: group a and b. group a served as the control group while group b was having diagnosed patients with depression. table 1 is depicting the age and body mass index (bmi) of all participants. comparison of mean ± sem of the age of group a (34.12 ± 1.49 years) and group b (35.19 ± 1.18 years) showed no significant difference. mean ± sem of bmi of group a (25.02 ± 0.23) was compared with that of group b (23.85 ± 0.25) and no significant difference was observed 1.60 ± 0.17 years was the duration of depression of group b. table i: mean ± sem of age (years), bmi, and duration of depressiion (years) of both groups parameter group a (controls) (n=24) group b (depressed patients) (n=72) age (years) 34.12 ± 1.49 35.19 ± 1.18 body mass index (bmi) 25.02 ± 0.23 23.85 ± 0.25 duration of disease (years) 1.60 0.17 serum follicle-stimulating hormone levels (miu/ml) no significant difference (p = 0.39) was observed on comparing follicle-stimulating hormone (fsh) levels (miu/ml) of group a (2.66 ± 0.34 miu/ml) with fsh levels of group b (3.32 ± 0.43 miu/ml). serum fsh levels of group a and b are shown in graph 1. figure i: comparison of mean ± sem of serum fsh levels (miu/ml) of group a (controls) with group b (depressed male patients). p<0.05 was considered significant in statistical analysis. serum luteinizing hormone levels (miu/ml) 0 1 2 3 4 a b groups controls depresse d j islamabad med dental coll 2022 219 figure ii: comparison of mean ± sem of serum lh levels (miu/ml) of group a (controls) with group b (depressed male patients). p<0.05 was considered statistically significant. d i s c u s s i o n this research project was planned out to evaluate the association of gonadotropins with depression in male patients. we have inferred from data of the present study that there is no significant variation in serum fsh and lh levels in depressive male individuals as compared to healthy individuals which are in concurrence to findings of a prospective cohort study conducted by prasad et al. in which they included normal women having age of 18-44 years and observed that fsh and lh concentration in women having or not having depressive symptoms had shown no significant difference18. observation made in another study was contrary to our results. in their study, they incorporated the women who came for follow-up at 6 weeks after delivery and they observed female individuals with postpartum depression had increased levels of serum fsh levels, decreased levels of serum lh, and low lh/fsh ratio19. a study was done on females with major depressive disorder (mdd) to explore the link between suicide and hormones of the female reproductive system20. they observed significantly lower levels of serum fsh in mdd patients having suicidal ideation or attempt in comparison to mdd patients not having these types of ideations or attempts. they concluded that fsh may serve as a biological indicator of current suicidality. these findings are contrary to our results but it could be due to the reason that none of our patients was having suicidal ideations or reported suicidal attempts. another study demonstrated that no statistically significant difference was present in serum fsh and lh levels of males having age 50-70 years with and without depressive symptoms which is in accordance with our findings21. in a metaanalysis, seventeen studies were identified and reviewed to know about the status of hormones of the hypothalamic-pituitary-gonadal (hpg) axis in male patients of depression which showed that fsh and lh did not differ between patients and controls22. 0 1 2 3 4 a b groups controls depresse d j islamabad med dental coll 2022 220 c o n c l u s i o n in brief, it is obvious from the outcomes of the present study that fsh and lh were different in depressive male patients as compared to healthy individuals but this dissimilarity was not significant statistically. however this fact cannot be ignored that all patients included in our project were already taking the treatment for depression. in order to validate the results patients without antidepressants treatment should be included. r e c o m m e n d a t i o n s newly diagnosed depressive patients without treatment may be included in further studies. in future, studies involving the magnetic resonance imaging (mri) can be carried out for analysis of the hippocampal volume. estimation of gonadotropinreleasing hormone (gnrh) may be considered to have a better understanding of hypothalamicpituitary-testicular axis and neurogenesis in depression. r e f e r e n c e s 1. lima imm, peckham ad, johnson sl. cognitive deficits in bipolar disorders: implications for emotion. clin psychol rev. 2018;59:126-36. doi: 10.1016/j.cpr.2017.11.006. 2. steinke ee, mosack v, hill tj. depression, quality of life, physical activity, and the impact of drugs on sexual activity in a population-based sample, ages 2059 years. issues ment health nurs. 2018;39(6):527-32. doi: 10.1080/01612840.2017.1413463. 3. kaprara a, huhtaniemi it. the hypothalamus-pituitarygonad axis: tales of mice and men. metabolism. 2018;86:3–17. doi: 10.1016/j.metabol.2017.11.018. 4. cimino i, casoni f, liu x, messina a, parkash j, jamin sp, et al. novel role for anti-müllerian hormone in the regulation of gnrh neuron excitability and hormone secretion. nat commun. 2016;7(1):1–12. doi: 10.1038/ncomms10055. 5. bao am, swaab df. the human hypothalamus in mood disorders: the hpa axis in the center. ibro rep. 2019;6:45-53. doi: 10.1016/j.ibror.2018.11.008. 6. lunenfeld b, bühler k. the neuro control of the ovarain cycle a hypothesis. gynecol endocrinol. 2018;34(4):278-82. doi: 10.1080/09513590.2017.1405933. 7. plant dt, pariante cm, sharp d, pawlby s. maternal depression during pregnancy and offspring depression in adulthood: role of child maltreatment. br j psychiatry. 2015;207(3):213–20. doi: 10.1192/bjp.bp.114.156620. 8. bhattacharya i, basu s, pradhan bs, sarkar h, nagarajan p, majumdar ss. testosterone augments fsh signaling by upregulating the expression and activity of fshreceptor in pubertal primate sertoli cells. mol cell endocrinol.2019;482:7080.doi:10.1016/j.mce.2018.12.012. 9. morgan k, ruffman t, bilkey dk, mclennan is. circulating anti-müllerian hormone (amh) associates with the maturity of boys' drawings: does amh slow cognitive development in males? endocrine. 2017;57(3):528-34. doi: 10.1007/s12020-017-1333-2. 10. o'hara l, curley m, tedim ferreira m, cruickshanks l, milne l, smith lb. pituitary androgen receptor signalling regulates prolactin but not gonadotrophins in the male mouse. plos one. 2015;10(3):e0121657. doi: 10.1371/journal.pone.0121657. 11. celec p, ostatníková d, hodosy j. on the effects of testosterone on brain behavioral functions. front neurosci. 2015;9:12. doi: 10.3389/fnins.2015.00012. 12. corona g, guaraldi f, rastrelli g, sforza a, maggi m. testosterone deficiency and risk of cognitive disorders in aging males. world j mens health. 2021;39(1):9-18. doi: 10.5534/wjmh.200017. 13. crawford ed, schally av, pinthus jh, block nl, rick fg, garnick mb, et al. the potential role of folliclestimulating hormone in the cardiovascular, metabolic, skeletal, and cognitive effects associated with androgen deprivation therapy. urol oncol. 2017;35(5):183-91. doi: 10.1016/j.urolonc.2017.01.025. 14. kim gw, park k, jeong gw. effects of sex hormones and age on brain volume in post-menopausal women. j sex med. 2018;15(5):662-70. doi: 10.1016/j.jsxm.2018.03.006. 15. henningsson s, madsen kh, pinborg a, heede m, knudsen gm, siebner hr, et al. role of emotional processing in depressive responses to sex-hormone manipulation: a pharmacological fmri study. transl psychiatry. 2015;5(12):e688. doi: 10.1038/tp.2015.184. 16. raosoft i. sample size calculator by raosoft, inc 17. siddiqui s, ali shah sa. siddiqui-shah depression scale (ssds): development and validation. psychology and developing societies. 1997 sep;9(2):245-62. doi:10.1177/097133369700900205. 18. prasad a, schisterman ef, schliep kc, ahrens ka, sjaarda la, perkins nj, et al. depressive symptoms and their relationship with endogenous reproductive hormones and sporadic anovulation in premenopausal women. ann epidemiol. 2014;24(12):920-4. doi: j islamabad med dental coll 2022 221 10.1016/j.annepidem.2014.10.005. 19. ramachandran pillai r, sharon l, premkumar nr, kattimani s, sagili h, rajendiran s. luteinizing hormonefollicle stimulating hormone ratio as biological predictor of post-partum depression. compr psychiatry. 2017;72:25-33. doi: 10.1016/j.comppsych.2016.09.001. 20. kim b, kang es, fava m, mischoulon d, soskin d, yu bh, et al. follicle-stimulating hormone (fsh), current suicidal ideation and attempt in female patients with major depressive disorder. psychiatry res. 2013;210(3):951-6. doi: 10.1016/j.psychres.2013.08.057. 21. liu zy, zhou ry, lu x, zeng qs, wang hq, li z, et al. identification of late-onset hypogonadism in middleaged and elderly men from a community of china. asian j androl. 2016;18(5):747-53. doi: 10.4103/1008682x.160883. 22. fischer s, ehlert u, castro ra. hormones of the hypothalamic-pituitary-gonadal (hpg) axis in male depressive disorders–a systematic review and metaanalysis. frontiers in neuroendocrinology. 2019 oct 1;55:100792. doi: 10.1016/j.yfrne.2019.100792. j islamabad med dental coll 2022 152 open access mitotic index and immunohistochemical expression of ki-67 in pleomorphic adenoma of salivary glands sultan muhammad wahid1, faiz rasul2, zainab rizvi3, umnah sultan4 , muhammad talha haseeb5, khurram nadeem6 1senior demonstrator, department of oral pathology, de’montmorency college of dentistry, lahore 2demonstrator, department of oral pathology, de’montmorency college of dentistry, lahore. 3associate professor, department of oral pathology, de’montmorency college of dentistry, lahore. 4house officer, sharif medical & dental college, lahore. 5postgraduate resident, internal medicine sheikh zaid hospital, lahore. 6 associate professor, oral medicine department, lahore medical & dental college. a b s t r a c t background: pleomorphic adenomas (pas) are the most common type of salivary gland tumors (sgts) which may undergo malignant transformation to carcinoma ex pa (caexpa). the purpose of this study was to determine mitotic index (mi) and expression of ki-67 in pleomorphic adenomas of salivary gland tumors. methodology: this study was carried out on sixty patients of pleomorphic adenoma. slides with specimens were stained with hematoxylin & eosin to count mitotic index. labeling index (li) of ki-67 was determined immunohistochemically. mitotic figures (mf) were counted in 10 hpf selected in the proliferative area. mi was scored as 1 (0 to 4 mf per 10 hpf); 2 (5-9 mf per 10 hpf) and 3 (> 9 mf per 10 hpf). immunoexpression of ki-67 was scored as ‘0-negative’ when <5% of neoplastic cells stained, ‘1-weak positive’ when 5-19% of neoplastic cells were stained, ‘2-moderate positive’ when 20-49% of neoplastic cells were stained, and ‘3-strong positive’ when >50% of neoplastic cells were stained with ki-67. data were analyzed by spss 21. results: mean age was 38.7 ± 12.86 years. out of 60 cases, 26 (43.33%) were of males while 34 (56.67%) were of females. expression of ki-67 was negative in 50% while remaining were weak positive. only score 01 of mi was observed. conclusion: ki-67 is more sensitive marker than mitotic index in pleomorphic adenomas even in small sized tumors and it can help in detection of malignant transformation of pas. keywords: adenomas, immunohistochemistry, ki-67 antigen, parotid neoplasms, pleomorphic cite this article. wahid m s, rasul f, rizvi z, sultan u, haseeb t m, nadeem k.mitotic index and immunohistochemical expression of ki-67 in pleomorphic adenoma of salivary glands. j islamabad med dental coll. 2022; 11(3): 152-157 doi: https://doi.org/10.35787/jimdc.v11i3.777 funding source: nil conflict of interest: nil i n t r o d u c t i o n pleomorphic adenoma is the most common salivary gland tumor, also named as mixed tumor. it is reported in both minor and major salivary glands. more commonly it is reported in 4th to 5th decades of life and involves females more than males. it mainly involves parotid salivary (psg) but can also be present in submandibular salivary gland (smsgs). clinically when it involves parotid gland, it typically presents as a slow growing swelling in front of the ear which is difficult to differentiate clinically from other sgts. swelling is initially mobile and not fixed to underlying tissue, without pain and palsy of 7th authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: faiz rasul email: bayfaiz871@gmail.com article info: received: september 4, 2021 accepted: september 20, 2022 o r i g i n a l a r t i c l e mailto:bayfaiz871@gmail.com j islamabad med dental coll 2022 153 cranial nerve. 1, 2, 3 when it involves minor sgs, most commonly it occurs at palate followed by upper lip and buccal mucosa accounting approximately for 50%, 27% and 17% of intraoral tumors respectively. pas which are present on palate are not mobile; however those which occur on lip or buccal mucosa are moveable. 4microscopically, pa is a biphasic tumor which possesses epithelial and mesenchymal components. typically, it is a well circumscribed, encapsulated tumor; however it maybe incompletely and partially infiltrated by tumor cells. intraoral tumors particularly palatal pas lack complete capsule. glandular epithelial and myoepithelial tumor cells present against the background of mesenchymal like tissue with variable proportion. in various tumors, connective tissue stroma is far more as compared to epithelial components. some tumors may consist almost entirely of background “stroma”. certain tumors are highly cellular in nature with little background alteration. pa which contains abundant cellularity is called cell rich type and if it contains high amount of connective tissue, it is called stroma rich type.5,6 epithelial component may be arranged in ducts and cystic shape or may occur as islets or sheets of cells. it may also show squamous cells keratinization. mucous producing cells are also observed. other type of cells which may give diversity to this tumor are myoepithelial cells. these cells often make up a large percentage of the tumor cells in pas. these cells have a variable morphology as angular or spindle shaped. in some tumors, myoepithelial cells appear round like plasma cells. presence of both types of cells help in diagnosis of pas.7 histopathological diagnosis becomes difficult in certain cases of pas. it is particularly true when biopsy is small and tissue possesses diversity because of pleomorphism and heterogeneity.2 due to this pleomorphism it may look like chondroid, osteoid and plasmacytoid like tissue. diagnosis further becomes difficult due to variation in capsule thickness which is difficult to detect, especially in pas with mainly mucous parts. its transformation into carcinoma (caexpa) further augments difficulty in diagnosis of pas due to presence of focal necrosis, extensive hyalinization, vascular or capsule invasion, hypercellularity and atypical mitosis. its conversion to caexpa is about 5 to 10 %. recurrent cases may create difficulty on histopathological diagnosis particularly in cases where stroma is rich and capsule is infiltrated.8 lastly, it also gives challenge due to resemblance to other sgts like low-grade adenocarcinoma (lgadc), adenoid cystic carcinoma (adcc), basal cell adenoma (bca) and epithelialmyoepithelial carcinoma (emc).2, 3 ki-67 is a protein (antigen) which is observed in all proliferating cells in active phases of cell cycle except g0. this antibody reacts selectively with the nuclei of the proliferating cells. it is used as a marker of nuclear proliferation. literature revealed role of ki67 in pleomorphic adenoma and its variable expression.9, 10, 11, 12 the biological behavior of pa is variable in few cases due to its transformation into caexpa. its diagnosis is usually made by conventional histopathological examination and potential malignant transformation is determined by counting mitotic activity however role of immunohistochemistry i.e. ki-67 need to be investigated. earlier changes of its transformation into malignancy can be detected with the help of ki67 expression, so the aim of this study was to determine mitotic count and expression of ki-67 in pleomorphic adenoma, to find percentage of mitotic figures in conventional histopathological examination on h&e staining and percentage of cells showing positive expression of ki-67 on immunohistochemistry. m e t h o d o l o g y this descriptive study was conducted in three hospital settings in lahore from january 2019 to december 2020 after taking ethical permission from institutional review board (irb) de’montmorency college of dentistry, lahore. a total of 60 cases from j islamabad med dental coll 2022 154 the department of surgery, lahore general hospital/post graduate medical institute, department of oral and maxillofacial surgery, mayo hospital, lahore were included after taking consent from the patients. sample size was based on a previous study conducted by muhammad et al. 11 non probability purposive sampling was used for data collection. recurrent cases of pa (carcinoma ex pleomorphic adenoma), patients on radiotherapy and chemotherapy were excluded from this study. demographic characteristics such as age, gender, and occupation, along with clinical information such as size of tumor, site (intraoral and extraoral), and type of biopsy of each individual were recorded in a proforma. gross examination of specimens of pas were performed in histopathology department of lgh/pgmi and information such as size, color and consistency were recorded as per protocol. routine h&e and immunohistochemistry were performed. two histopathologists examined pas for their histological characteristics using olympus bh-2 microscope and (×40) objective using this equipment, one high power field visualizes an area of 0.14 mm.2 mitotic figures were counted in 10 high power field (hpf) selected in the active proliferative area. scoring was done as score 1 (0 to 4 mitotic figures per 10 hpf); score 2 (5 to 9 mitotic figures per 10 high power field) and score 3 (> 9 mitotic figures per 10 hpf). scoring of ki-67 was done as negative or positive. its expression was taken as 0-negative when neoplastic cells were less than 5 (<5%). positive expression was taken as ‘1-weak positive’ when neoplastic cells ranged from 5 to 19% (5-19% of neoplastic cells), ‘2-moderate positive’ when neoplastic cells ranged from 20 to 49% (20-49% of neoplastic cells), and ‘3-strong positive’ when neoplastic cells were more than 50% (>50% of neoplastic cells). data was entered in spss 21. numerical variables like mitotic index (mi) and cells stained with ki-67 labelling index (li) were described in terms of mean and standard deviation. categorical variables like intensity of mitotic index and expression of ki-67 were presented as frequencies and percentages. r e s u l t s the clinicopathological features of pleomorphic adenoma and immunohistochemical expression of ki-67 and mitotic index in pleomorphic adenoma are given in table 1 & 2 respectively. *mean age (38.7 ± 12.86 years) table i: clinicopathological features of pleomorphic adenoma (n=60) variables sub variables n (%) age in years 2040 44 (73.34) 41-60 4 (6.66) 61-80 12 (20) gender male 26 (43.33) female 34 (56.67) occupation industry 6 (10) farmer 6 (10) labor 34 (56.67) office job 0 (0) household 14 (23.33) site parotid gland (pg) 38 (63.33) submandibular sg (smsg) 16 (26.67) sublingual sg (slsg) 0 (0) palate 6 (10) tongue 0 (0) labial mucosa 0 (0) buccal mucosa 0 (0) laterality right 28 (46.67) left 32 (53.33) size <1cm 0 (0) 1-2cm 0 (0) 2-5cm 60 (100) > 5 cm 0 (0) j islamabad med dental coll 2022 155 d i s c u s s i o n pleomorphic adenomas are seen more commonly in females. findings of this study are consistent with this fact and similar results are reported in other studies.4,6 size of tumor is a predictive factor for complication however, in current study it was consistently found to be 2 to 5cm.13 mean age was 38.7 ± 12.86 years which shows that pas are more frequently found in young age, this is also reported in other studies like hussain et al., who reported mean age of pleomorphic adenoma to be 30.36 ± 4.838 years in their study and khan et al (2017) who reported mean age of pleomorphic adenoma to be 34 years in population of lahore. 14,15 diaz et al., reported male predominance as compared to females. the mean age was 43.1 ± 18.0 years (ranging from 13 to 84 years). pas mainly affected parotid gland followed by submandibular gland. comparing the results with current study, mean age of subjects with pas was 38.7 ± 12.86 (ranging from 20 to 80 years). out of 60 pleomorphic adenomas, 38 (63.33%) were located in parotid, 16 cases (26.67%) in submandibular gland and 6 (10%) cases were found on the palate. in diaz et al study, the average tumor size was 1.6 cm, ranging from 0.8 to 2.4 cm. the mean percentage of ki‐67 immunostaining of pa was 0.06%, ranging between 0 and 0.40% while in this study all 60 cases of pleomorphic adenomas (100%) were 2-5 cm in diameter which is greater in diameter reported by diaz et al. 50% of pas were negative while remaining had weak scores for ki-67. all pas had 0-4 mitotic figures/hpf. further, it is also note-worthy that 30 (50%) cases of pleomorphic adenomas (out of 60) also had weak positive scores for ki-67 which is quite higher than diaz study. this difference may be due to difference in methodology because they excluded weak nuclear staining during cell count however we included it in our study.16 raja et al., reported that ki-67 li was more expressed in cell rich type as compared to stroma rich type 2.49± 1.5 and 1.19± 1.8 respectively however in this study we did not measure separately in cell rich type and stromal rich type.17 cunha et al also reported that ki-67 li was less expressed in pas compared to caexpa.18 ki-67 li expressed moderate positive in pa in a study by omitola and iyogun however there was only one case of pleomorphic adenoma. in another study, ki-67 li in benign sgts ranged from 0.76% to 13 % with highest reported in recurrent pleomorphic adenoma of the palate of cell rich type. the mean value in pas was 4.60 with range 1.2 to 13.19 in another study, the mean ± sd of ki-67 li (%) in normal salivary gland parenchyma was 0.27 ± 0.31%, range (0–0.88%) while in benign salivary gland tumors (15 case out of which 11 were pas) mean ± sd of ki-67 li was 0.76 ± 2.02%, and there was negligible proliferative activity in pleomorphic adenoma however in this study, 30 cases of pas expressed weak positive expression.20 higher values of ki67 were found among cases with larger size (p = 0.0061) and showing greater cellularity (p =0.0004).21 in another study, expression of ki-67 was not observed in benign mixed sgts however in current study, 50% cases expressed weak positive (5 to 19 cells) and 50% expressed negative.22 finding of another local study showed that mean age of patients of pas was 34.13 years with male predominance contrary to our study and most common site was parotid salivary glands similar to current study.23 table ii: immunohistochemical expression of ki-67 and mitotic index in pleomorphic adenoma (n=60) sr. no score cases n (percentage) ki-67 expression 0-negative 30 (50) 1-weak positive 30 (50) 2moderate positive 0 (0) 3-strong positive 0 (0) mitotic index score 1 (0-4 mf/ 10 hpf)* 60 (100) score 2 (5 to 9 mf/10 hpf 0 (0) score 3 (> 9 mf/ 10 hpf) 0 (0) j islamabad med dental coll 2022 156 another histopathological study of pa concluded that the pathogenesis and progression of pleomorphic adenoma to caexpa can be observed on routine h&e section by counting mitotic figures along with metaplasia, pseudopodia, cholesterol crystals, hyalinization, and lymphoid tissue. however still it should be confirmed by applying immunomarkers.24 this finding is consistent with the current study that ki-67 expression in pa determines certain areas which expressed more than others. markkanen’s study reported ki-67 in pas, recurrent pas and caexpas. expression of ki-67 was increased in recurrent pas and caexpas than pas. mitotic activity (0-2) in pas was low in 25 cases (out of 26) while increased mitotic activity (>3) was observed in caexpas. findings regarding mitotic activity in pas are similar to our study however ki-67 expression is high in our study in contrast to their study. the majority of studies reported ki-67 expression is negative to weak positive and some studies reported moderate to strong positive.11, 12, 16,17,18,19,20, 21, 25 the results of these studies indicate that biological behavior of pas is different in cases which recur and transform to malignancy and also show high expression of ki-67. during routine histopathological examination of pas when mitotic figures are observed more, then ki-67 expression may be suggested to observe its early transformation to malignancy (caexpas). one of the limitations of the study is that small sized pas were included in the study, whereas in literature it was observed that with large size tumors ki-67 was expressed more, so a large size of pas may be included in another study to find out a relationship between size of the tumor and ki-67 expression. another limitation of this study is that the period of existence of pleomorphic adenomas was not correlated with the expression of ki-67. c o n c l u s i o n ki-67 is more sensitive marker than mitotic index in pleomorphic adenomas even in small sized tumors and it can help in detection of malignant transformation of pas. a c k n o w l e d g e m e n t special thanks to amin and sohail for helping in histopathology lab in grossing, processing and immunostaining. r e f e r e n c e s 1. matsumiya-matsumoto y, morita y, uzawa n. pleomorphic adenoma of the salivary glands and epithelial–mesenchymal transition. j. clin. med. 2022 jul 20;11(14):4210. https://doi.org/10.3390/jcm11144210 2. pérez-de-oliveira me, leonel acl da s, de castro jfl, carvalho ej de a, vargas pa, perez de da c. histopathological findings of intraoral pleomorphic adenomas: a retrospective study of a case series. int j surg pathol [internet]. 2019;27(7):729–35. available from: http://dx.doi.org/10.1177/1066896919854181 3. khan mn, raza ss, hussain zaidi sa, haq iu, hussain ak, nadeem md, et al. pleomorphic adenoma of minor salivary glands. j ayub med coll abbottabad. 2016;28(3):620–2. 4. akhtar zm, sipra mw, ahmad s, saeed h, saeed f. histopathological analysis of salivary gland tumors at pathology department of king edward medical university lahore. j fatima jinnah med univ. 2018;12(1):28–32. 5. das d, saha s. histopathologic spectrum of salivary gland neoplasm. int j healthcare and biomed res. 2016;4(2):48–55. 6. hussain s, naseem n, anjum r, nagi a. histopathological spectrum of pleomorphic adenoma reported at tertiary care hospitals in lahore. pak oral dental j. 2016 dec 1;36(4). 7. badam r k, kanth s, raju s, kotha s k, rao m, chandrak l. current concepts of salivary gland tumors. j. orofac. sci. 2015; 7(1): 76-79. doi: 10.4103/09758844.169751 8. vasconcelos a c, nor f, meurer, l, salvadori g, de souza, l b, vargas p a, et al. clinicopathological analysis of salivary gland tumors over a 15-years period. braz. oral res. 2016; 30(2e): 1-7. 9. mansour ghoneim da, raslan h, ramadan o, zeitoun i. expression of il-10 and ki-67 in some benign and malignant salivary gland tumors. alex. dent. j. 2022 apr 1;47(1):62-9. 10. mariano f v, costa a f, gondak r o, martins a s, negro, tincani a j, et al. cellular proliferation index https://doi.org/10.3390/jcm11144210 http://dx.doi.org/10.1177/1066896919854181 j islamabad med dental coll 2022 157 between carcinoma ex-pleomorphic adenoma and pleomorphic adenoma. brazilian dent. j. 2015; 26(4): 416-421. 11. muhammad l, mousa c, abdulqadir h. proliferative potential in benign mixed salivary gland tumors, using ki-67 marker in relation to different clinicopathological parameters. zanco j. med. sci. 2016; 20(1): 1241-1248. 12. kaza s, rao t j m, mikkilineni a, ratnam g v, rao d r. ki-67 index in salivary gland neoplasm. int. j. phonosurg. larngl 2016; 6(1): 1-7. 13. farooq ms, altaf r, qureshi au, naumeri f, ali aa. outcome of parotid gland surgery in terms of complications especially the facial nerve palsy at mayo hospital, lahore. ann. king edw. med. univ. 2017; 23 (3): 343-6. doi: https://doi.org/10.21649/akemu.v23i3.2018 14. hussain s, sahaf r, siraj mr, rehman f, anjum s. immunohistochemical expression of vascular endothelial growth factor-c (vegf-c) in salivary gland tumours. int j curr med & pharma res. 2018; 6(1): 1112 15. khan hu, khalid k, yousuf ei. spectrum of salivary gland disorders at a tertiary care hospital in central lahore. j fatima jinnah med univ. 2017;11(3): 7-13 available from: https://jfjmu.com/index.php/ojs/article/view/46 16. díaz kp, gondak r, martins ll, de almeida op, león je, mariano fv, et al. fatty acid synthase and ki‐67 immunoexpression can be useful for the identification of malignant component in carcinoma ex‐pleomorphic adenoma. j. oral pathol. med. 2019; 48(3):232-8. 17. raja r, shetty dc, juneja s, tandon a, gulati n. mcm3 proliferative index is worthier over ki-67 in the characterization of salivary gland tumors. indian j pathol microbiol. 2021 jan 1;64(1):22 18. cunha jl, morais tm, de cáceres cb, de almeida op, carlos r, altemani am, et al. immunohistochemical expression of metabolic markers in pleomorphic adenoma and carcinoma ex pleomorphic adenoma. oral surg. oral med. oral pathol. oral radiol. 2020 sep 1;130(3):e265-6. 19. omitola og, iyogun ca. immunohistochemical study of salivary gland tumors in a tertiary institution in south-south region of nigeria. j. oral maxillofac. pathol. 2018 may;22(2):163. 20. živković n, kostić m, cvetanović a, milentijević mj, spasić m, petrović m, et al. differential challenges in salivary gland neoplasms. arch. biol. sci. 2021 mar 19;73(1):65-72. 21. de rosa f, pignatiello s, sibillo mc, guadagno e. proliferation in pleomorphic adenoma: lights and shadow on this parameter, in a neoplasm showing unpredictable behavior. an immunohistochemical study and review of the literature. pathol. res. pract. 2021 dec 23:153748. 22. khaleel ak. the differences between benign mixed tumor and papillary cystadenoma lymphomatosum in proliferative, apoptotic, and antiapoptotic activity. ann. trop. med. public health. 2019 dec;22:120-6. 23. raza sh, ahmed s, zafar m. spectrum of biopsied oral and maxillofacial lesions in a tertiary care hospital of karachi, pakistan. j fatima jinnah med univ. 2021 dec 7;15(2):81-6. doi.org/10.37018/mtrk523 24. syafriadi m, ummah dz, muna ai, surya me. progressivity analysis of pleomorphic adenoma toward carcinoma ex pleomorphic adenoma. dent j. maj. dokter gigi. 2022 jan 31;55(1):1-6. doi: 10.20473/j.djmkg.v55.i1.p1–6 25. markkanen a, aro k, laury ar, mäkitie aa, haglund c, atula t, et al. increased mib-1 expression in salivary gland pleomorphic adenoma that recurs and undergoes malignant transformation. sci. rep. 2022 may 30;12(1):1-0. | https://doi.org/10.1038/s41598022-13082-8 https://doi.org/10.21649/akemu.v23i3.2018 280 j i m d c 2 0 1 7 280 open access f u l l l e n g t h a r t i c l e patterns of traumatic brain injuries in patients presenting at a tertiary care unit pir saad 1, muhammad shehzad khan wazir 2, dawood sohail 3, shahbaz ali khan 4, atif ibrahim 5, muhammad waqas 6 1 polio eradication officer world health organization, united nation 2 mbbs, ayub medical and dental college abbatabad 3 trainee medical officer, north west hospital peshawer 4 associate professor, department of neurosergery ayub medical and dental college abbatabad. 5 trainee medical officer, rehman medical institute peshawer. 6 demonstrator, rehman medical institute peshawer a b s t r a c t objective: the purpose of this study was to evaluate the distribution of traumatic brain injuries. patients and methods: questionnaire based data was collected from an inpatient population of patients who presented to the neurosurgical unit of ayub teaching hospital with traumatic brain injuries. cat scan (computerized automated tomography scan) was used as the imaging modality for preliminary diagnosis. the data was collected over a period of three years. non-probability purposive sampling was used as the sampling technique. patients of both sexes and all ages were included in the study. results: out of a total of 1938 patients, 1470 (75.9%) were males and 468 (24.1%) were females. patients from 20 to 40 years’ age group (38.1%) represented the greatest number. fall (52.6%) was found to be the most common external cause of traumatic brain injury, followed by road traffic accidents (34.1%). most of the patients (42.4%) had a gcs score falling between 8 and 12. no lesion was found at the initial cat scan in most of the patients (27.2%). depressed skull fracture (21.4%) was the most common abnormal finding in initial imaging. conservative (78.3%) treatment was provided to most of the patients keeping in view the appropriate management requirements. 97.8% of the patients were treated successfully. conclusion: the quality of care at neurosurgery ayub teaching hospital was found to be up to the mark for traumatic brain injuries patients. however, the standard of care at kashmir and balakot needs to be re-evaluated. key words: extradural hematoma, glasgow coma scale, intracranial bleed, trauma, subdural hematoma, subarachnoid hemorrhage author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence pir saad email: saad.tyap@gmail.com article info. received: april 28, 2018 accepted: july 10, 2018 cite this article. saad p, wazir msk, sohail d, khan sa, ibrahim a, waqas m. patterns of traumatic brain injuries in patients presenting at a teriary care unit. jimdc.2018; 7(4):280284 funding source: nil conflict of interest: nil i n t r o d u c t i o n a traumatic brain injury can be defined as a no degenerative, noncognital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.1 traumatic brain injury is a o r i g i n a l a r t i c l e 281 j i m d c 2 0 1 7 281 substantial contributor of mortality and morbidity throughout the world.2 traumatic brain injuries cost an average of $56 billion annually in u.s 1 while in europe, approximately 1.6 million people are admitted to the hospital every year with traumatic brain injuries.4 in pakistan, the number of deaths attributed to traumatic brain injuries is increasing day by day.5 the annual incidence of traumatic brain injuries in pakistan has been estimated to be 50/100,000 with bread earning youth contributing the most to this figure.6 the situation in pakistan is particularly alarming because with the greater increase in the number of road traffic accidents and violence gaining its hold in the society, trauma patients are increasing in number substantially.7 a world bank study established the fact that each year almost four percent of pakistan’s total population is pushed below poverty due to health shocks.8 social re-emergence of a traumatic patient, both physically as well as mentally is a big problem in our setup.9 the prognostic model of traumatic brain injuries for a developing country like pakistan differs significantly from the developed world and hence based on epidemiological studies more valid and suitable prognostic and management models should be come up.10 the purpose of this study was to bring into light the distribution of traumatic brain injuries and to come up with recommendations to enrich research, ameliorate patient care and improve prevention of trauma. the pattern of traumatic brain injuries was followed in a number of variables like age, gender, area of residence, type of trauma, glasgow coma scale (gcs), preliminary diagnosis, management and outcome. keeping all these factors this study was conducted at ayub teaching hospital, abbottabad, which is a 1000 bed tertiary care hospital. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at the neurosurgery unit of ayub teaching hospital in three years’ time. one thousand nine hundred and thirty-eight patients were included in the study. non-probability purposive sampling was used as the sampling technique. neurosurgical in-patients who presented with brain injury secondary to trauma and only those patients who had no abnormality or a single abnormality on imaging out of the predefined lesions were included in the study. outdoor patients were excluded from the study. a detailed questionnaire that was filled after taking informed consent from the patients or their attendants was used as the data collection tool. preliminary diagnosis was made by cat scan as the imaging modality. glasgow coma scale (gcs) score was used as a mode of estimation of consciousness of the patients and the extent of their brain damage. the data was processed by using spss-16. descriptive statistics were calculated as frequency and percentages. r e s u l t s out of a total of 1938 patients, 1470(75.9%) were males and 468(24.1%) were females, 624 (32.2%) were less than 13 years of age, 318 (16.4%) between 13 and 19 years of age, 738 (38.1%) 20 to 40 years old while 258(13.3%) patients were more than 40 years old. the vast majority of patients i.e. 810(41.8%) were from district abbottabad. patients from swat, afghanistan and balakot contributed the least to the figure with 12(0.6%) from each of these areas. there were 132(6.8%) patients from district haripur, 468(24.1%) from district mansehra, 228(11.8%) from batagram, 48(2.5%) from northern areas including gilgit baltistan and 216(11.1%) from kashmir.fall was found to be the most frequent contributor to traumatic brain injuries i.e. 1020(52.6%) patients presented with a history of fall. this was followed by road traffic accidents contributing a total of 660(34.1%) patients, 204(10.5%) patients had a history of assault while only 54(2.8%) patients had firearm injury as the cause of traumatic brain injury. (table 1) on glasgow coma scale, 660(34.1%) patients scored from 13 to 15. table:1 cause of trauma cause of trauma frequency(%) cumulative percent fall 1020(52.6) 52.6 road traffic accident 660(34.1) 86.7 assault 204(10.5) 97.2 firearm injury 54(2.8) 100.0 total 1938 282 j i m d c 2 0 1 7 282 table:2 glasgow coma scale at the time of presentation (n=1938) glasgow coma scale frequency(%) cumulative percent 13-15 660(34.1) 34.1 8-12 822(42.4) 76.5 5-7 444(22.9) 99.4 3-4 12 100.0 table:3 preliminary diagnosis on cat scan preliminary diagnosis on cat scan frequency(%) cumulative percent no lesion 528(27.2) 27.2 extra dural hematoma 258(13.3) 40.6 subdural hematoma 54(2.8) 43.3 intracranial bleed 234(12.1) 55.4 linear skull fracture 294(15.2) 70.6 depressed skull fracture 414(21.4) 92.0 subarachnoid hemorrhage 156(8.0) 100.0 management conservative 1518(78.3) 78.3 operated 420(21.7) 100.0 outcome alive 1896(97.8) 97.8 dead 42(2.2) 100.0 total 1938 most of the patients had gcs between 8 and 12 i.e. 822(42.4%) patients fell in this category at the time of their presentation. 444(22.9%) patients had a gcs score of 5 to 7 while 12(0.6%) patients were graded as 3 to 4 on glasgow coma scale at the time of their presentation. (table 2). patients with no lesion i.e. 528(27.2%) had the lion’s share. this was followed by depressed skull fracture i.e. 414(21.4%) patients out of the total had a depressed skull fracture. 258(13.3%) patients were found to be positive for an extra dural hematoma while only 54(2.8%) patients had a subdural hematoma as their diagnosis on cat scan. 234(12.1%) patients had an intracranial bleed, 294(15.2%) linear skull fracture and 156(8%) patients had subarachnoid hemorrhage as their preliminary diagnosis. 1518(78.3%) of the patients were treated conservatively while 420(21.7%) had to be operated on as part of their management. the outcome was found to be exceptionally good with 1896(97.8%) being treated successfully while a meager number of 42(2.2%) out of 1938 could not make it back to life. (table 3) d i s c u s s i o n a physical injury to the living tissue caused by an external source is called a trauma.11 traumatic brain injury is therefore a physical injury to the brain that is not caused by a progressive process, is acquired and is caused by an external mechanical insult that may cause a long term or short term abnormality of behavioral, physical, social and/or psychological functions with an associated impaired consciousness.12 age was found to be an important factor while taking into consideration the epidemiology of traumatic brain injuries. majority of the patients were found to be below 40 years of age. this is in consistence with a study performed by john bruns et al.13 as most of the patients were relatively young, the outcome was positive for majority of the patients. this is in accordance with the study done by hilaire j et al.14 as per this study, majority of the patients were found to be males. this is in agreement with a study performed in 2004 in which 121 previous studies were critically studied for the prevention, incidence and risks of traumatic brain injuries.15 the finding of males being more sufferers of traumatic brain injuries is also strongly supported by the center for disease control and prevention (cdc), usa, according to which traumatic brain injuries rates are higher in males in every age group as compared to females.16 a study conducted by kraus j. et al also supports this statistical outcome.17 men below 40 years of age are more vulnerable to traumatic brain injuries.18 other studies have also reported male predominance, when it comes to contribution to the number of total tbi patients.19 despite the weak practical translation of healthcare hierarchy in pakistan20, it can be assumed that our tertiary care unit had a much lesser load of tbi patients because majority of the patients were being treated at their respective areas local healthcare facilities. however, tbi patients from kashmir and balakot surpassed the rest of the areas in number taking into 283 j i m d c 2 0 1 7 283 account the relative distances and the time that it takes to reach our healthcare unit from the different areas studied. as far as time of the day that has the greatest load of tbi patients is concerned, the outcome is dispersed. however, evening and night timings are definitely ahead of morning timings in numbers as evident by the data. fall was found to be the most frequent external source of injury in our setup followed by road traffic accidents and assault. surprisingly our region shared the trend with usa as the same distribution was found by a survey conducted from 2002-2006 at usa by the center for disease control and prevention.21 fall was also found to be the most frequent contributor to traumatic brain injuries by a survey conducted at tennessee and the number was found to be on the rise from 1996-2010.22 however, by comparison and contrast of different studies, it can be concluded that the external source of tbi varies depending on the geography and a fixed or nearly consistent pattern cannot be established between two different geographical regions or even within the region. glasgow coma scale (gcs) for majority of the patients was found to be more than 8 and that had an impact on the positive outcome of majority of the patients. this is consistent with a study performed by cisu d.23 linear skull fracture was found to be the most frequent finding on cat scans of patients presenting with tbis while subdural hematoma was found to be the least contributor. the use of cat scan in establishing appropriate diagnosis and planning management accordingly is of utmost importance.24 majority of the patients were treated conservatively in view of their gcs findings at the time of their presentation and diagnosis. this was in agreement with a study conducted in 2008 by gh yattoo who concluded that only 10% to 20% of tbi patients need surgical management while the rest benefit from nonsurgical management options.25 with majority of the patients falling in a category of younger age i.e. below 40 years 26, gcs score of more than 8 27 and most of the patients requiring conservative treatment, the outcome for a tremendous number of patients was good as expected. c o n c l u s i o n fall by far is the most common external cause of tbi followed by road traffic accidents. gcs correlates positively with the outcome and most of the patients fall between a gcs score of 8 and 12. most of the patients have no lesion at the time of their preliminary diagnosis on cat scan while depressed skull fracture is the most common abnormality of all on cat scans at the time of their presentation. majority of the patients are managed conservatively and the results are substantially positive for a great number of patients. with the exceptionally great number of patients being treated successfully at ayub teaching hospital, it can be safely concluded that the quality of care for traumatic brain injuries patients is up to the mark at the neurosurgery unit of ath. r e c o m m e n d a t i o n s specific trauma centers with staff specifically trained for traumatic brain injuries should be established in northern parts of the country including abbottabad. the healthcare units at kashmir and balakot should be looked into for flaws and thus should be corrected accordingly. data regarding traumatic brain injuries is lacking in pakistan. statistical analysis of traumatic brain injuries should be conducted at regular intervals of time and therefore standardized requirements should be met according to the needs of different localities. more studies should be conducted and thus an accurate and reliable prognostic scoring system should be introduced keeping in view the patterns of traumatic brain injuries identified r e f e r e n c e s 1. emedicine.medscape.com. traumatic brain injury (tbi) definition and pathophysiology: overview, epidemiology, primary injury [internet]. 2016 http://emedicine.medscape.com/article/326510overview 2. heegaard w, biros m. traumatic brain injury. emergency medicine clinics of north america. 2007;25(3):655-678 3. ninds.nih.gov. traumatic brain injury: hope through research [internet]. 2016 http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm 4. ribbers gm. brain injury: long term outcome after traumatic brain injury. https://brainhealthresources.wordpress.com/understa nding-tbi/brain-injury-long-term-outcome-aftertraumatic-brain-injury/ 5. afzal i, naz. r, afzal mk, mughal mi. head-injury and its consequences-a one-year study in karachi med forum monthly 2014; 25: 1029 385 284 j i m d c 2 0 1 7 284 6. umerani ms, abbas a, sharif s. traumatic brain injuries: experience from a tertiary care centre in pakistan. tukr neurosurg. 2014; 24(1): 19-24. 7. jamali ar. trauma care in pakistan. jour of pak med association. 2008; 58(3):102-103 8. hafeez m. poverty and poor health in pakistan: exploring the effects of privatizing healthcare harvard international review.2014 9. rathore fa, muzammil s. the decrepit state of trauma care in under-developed healthcare settings and the need to integrate trauma rehabilitation as a continuum of care. jou pak med assoc. 2015; 65(1):108-9 10. predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. bmj. 2008;336(7641):425-429 11. merriam-webster.com. definition of trauma. 2016 12. traumatic brain injury (tbi) definition and pathophysiology: overview, epidemiology, primary injuryhttps://emedicine.medscape.com/article/326510 -overview 13. burns j jr, hauser wa. the epidemiology of traumatic brain injury: a review. epilepsia. 2003; 44(s10):2-10 14. thompson hj, mccormick wc, kagan sh. traumatic brain injury in older adults: epidemiology, outcomes, and future implications. j am geriatr soc. 2006; 54(10):1590-1595 15. cassidy jd, carroll lj, peloso pm, borg j, von holst h, holm l, kraus j, coronado vg; who collaborating centre task force on mild traumatic brain injury. incidence, risk factors and prevention of mild traumatic brain injury: results of the who collaborating centre task force on mild traumatic brain injury. j rehabil med. 2004; 43:28-60 16. http://www.cdc.gov/traumaticbraininjury/pdf/bluebook _factsheet-a.pdf 17. kraus jf, black ma, hessol n, ley p, rokaw w, sullivan c, bowers s, knowlton s, marshall l. the incidence of acute brain injury and serious impairment in a defined population. am j epidemiol. 1984; 119(2):186-201 18. why men suffer more acquired brain injury. http://menshealth.about.com/library/bltrauma.htm 19. traumatic brain injury. the american association of neurological surgeons https://www.aans.org/en/patients/neurosurgicalconditions-and-treatments/traumatic-brain-injury 20. alwan a, ali m, aly e, badr a, doctor h, mandil a et al. strengthening national health information systems: challenges and response. emhj. 2016; 22(11):840850. 21. http://www.cdc.gov/traumaticbraininjury/pdf/bluebook _factsheet-a.pdf 22. https://tn.gov/assets/entities/health/attachments/ecod es_1996-2010.pdf 23. cifu dx, keyser-marcus l, lopez e, wehman p, kreutzer js, englander j, high w. acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis. archives of physical medicine and rehabilitation. 1997; 78(2):125-31. 24. stiell ig, wells ga, vandemheen k, clement c, lesiuk h, laupacis a, mcknight rd, verbeek r, brison r, cass d, eisenhauer ma. the canadian ct head rule for patients with minor head injury. the lancet. 2001; 357(9266):1391-6. 25. yattoo gh, tabish a. the profile of head injuries and traumatic brain injury deaths in kashmir. journal of trauma management & outcomes. 2008; 2(1):5. 26. stocchetti n, paterno r, citerio g, beretta l, colombo a. traumatic brain injury in an aging population. j neurotrauma.2012; 29(6):1119-25 27. bilgin s, gunduz ag, oruckaptan h, kose n, celik b. gait and glasgow coma scale scores can predict functional recovery in patients with traumatic brain injury. neural regen res. 2012; 7(25): 1978–1984. http://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet-a.pdf http://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet-a.pdf https://www.ncbi.nlm.nih.gov/pubmed/6695898 299 j i m d c 2 0 1 7 299 open access f u l l l e n g t h a r t i c l e efficacy of microneedling with dermaroller alternating with cross peeling with 30% tca in management of acne induced scarring nadia waqas 1, muhammad amer saleem 2 1 assistant professor, department of dermatology, benazir bhutto hospital, rawalpindi 2 postgraduate trainee, department of dermatology), benazir bhutto hospital, rawalpindi a b s t r a c t objective: to study the effect of combination of two therapies i.e. microneedling with dermaroller alternating with chemical reconstruction skin scar (cross) peeling with 30% tca in management of acne induced scarring. patients and methods: this experimental study was conducted in the department of dermatology, benazir bhutto hospital, rawalpindi from march 2017 to december 2017. a total of 20 patients underwent microneedling with dermaroller at week=0 (baseline) and were subjected to cross peeling with 30% tca on follow up after 2 weeks. four sessions of each procedure were repeated at 2 weeks’ interval. photographs were taken at baseline and 4 weeks after the end of therapy (week=18). the baseline and final photographs were assessed for acne scar grading as per goodman and baron qualitative scale by two dermatologists who were blinded to the whole study. results: out of 20 patients, 16 (80%) of the patients had grade iv acne scarring and 4 (20%) had grade iii scarring at baseline (week=0). on assessment at 4 weeks after the end of therapy (week=18), 16 patients who were having grade iv acne 6 (37.5%) improved to grade iii, and 10 (62.5%) improved to grade ii. out of 4 patients who were initially having grade iii at week=0, all 4 (100%) improved to grade ii by week=18. a wilcoxon signed rank test showed highly significant improvement in the grading of scarring (z=-3.92, p=0.00008). conclusion: the combination therapy of microneedling with dermaroller, alternating with cross peeling with 30% tca was highly effective in treating all types of atrophic acne scarring. key words: acne, microneedling, scarring, tca cross. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence nadia waqas email: nadia_doctor@hotmail.com article info. received: october 20, 2018 accepted: november 11, 2018 cite this article. waqas n, saleem ma. efficacy of microneedling with dermaroller alternating with cross peeling with 30% tca in management of acne induced scarring. jimdc.2018; 7(4):299-303 funding source: nil conflict of interest: nil i n t r o d u c t i o n acne vulgaris, commonly known as acne, pimples or zits is a chronic disorder of the pilosebaceous unit.1 it is the most common dermatological presentation in the usa.2 the disorder results from the blockage of the sebaceous duct by keratinocytes and over production of sebum resulting in overgrowth of propionibacterium acnes, which eventually initiates a cascade of inflammatory and immune responses that manifest as comedones, papules, pustules, nodules or cysts depending on the severity of the disease. the genetic and environmental factors, severity of acne and the delay in seeking medical consultation contribute towards formation of post acne scarring.3 the acne scarring is in turn, responsible for low self-esteem and psychological morbidity. the acne scarring can be classified into atrophic, hypertrophic and keloidal varieties. the atrophic scarring, the commonest variant, is further sub-classified into ice pick, rolling and boxcar types. within this commonest variant of acne o r i g i n a l a r t i c l e 300 j i m d c 2 0 1 7 300 scarring, the ice pick is most prevalent followed by boxcars.4 numerous options for treating these scars have been explored over time with variable success. the major modalities for treatment of acne scarring include the energy based devices, chemical peels and surgical methods. acne scarring is a major concern of many patients presenting to the dermatology outpatient departments of the public sector hospitals in pakistan. in our government hospitals, energy based devices (lasers, fractional radiofrequency, ipl) are less commonly used because of the high cost required to carry out these procedures. however, chemical peels and microneedling are frequently employed to manage such patients. a wide range of chemical peels are available for treating acne scarring and are classified on the basis of their penetration depth into very superficial, superficial, medium and deep penetrating peels. these peels cause chemical destruction of the defective cutaneous layer, which prompts remodeling and reduce scarring.5 the chemical peels are generally safe, however, deep peels may have serious side effects and also require preprocedural topical anaesthesia. microneedling denotes puncturing skin at multiple sites repeatedly using a dermaroller and is used to treat a number of dermatological conditions including acne scarring.6 the procedure is usually safe and well tolerated, however, topical anaesthesia is essential to control the pain associated with microneedling. as mentioned earlier, we see a large number of patients with complaint of acne induced scarring in our setup i.e. a tertiary care public sector hospital of pakistan. the aim of our study was to compare the efficacy of microneedling using dermaroller alternating with chemical reconstruction of skin scars (cross) using a medium depth penetrating chemical peel, 30% trichloroacetic acid (tca). the rationale for using this combination was to see the effects of two minimally invasive, relatively safe & cheap procedures brought together for supposedly better management of acne scars. p a t i e n t s a n d m e t h o d s this experimental study was carried out department of dermatology, benazir bhutto hospital, rawalpindi from march 2017 to december 2017. a total of 20 patients with severe acne scarring grade iv/ iii and aged 18 to 35 years of either gender with otherwise good health, were included in the study. patients with keloid tendency, active herpes virus; bacterial or fungal infections, any allergy to topical anaesthesia, local or systemic disease, altering wound healing, concurrent use of antiplatelet or anticoagulants and pregnant plus lactating mothers were excluded from the study. on successful selection of the subjects in study, after written informed consent and keeping in view the inclusion and exclusion criteria, his baseline digital photographs of the face were taken including frontal and lateral views. the demographic details of the subjects along with duration and type of acne scarring were noted. acne scar grading was done by two dermatologist blinded to the study otherwise, on the basis of the digital photographs at baseline using goodman and baron qualitative acne scarring scale.7 at week 0, patients were subjected to microneedling with dermaroller. before the procedure, a local anaesthetic agent (lignocaine 2%) was applied for 45 minutes. it was then removed and microneedling done with dermaroller containing 540 needles with needle length of 1.5 mm. for microneedling, movements were performed in eight directions vertical up and down, horizontal right and left, and both diagonal directions. multiple movements were performed until fine bleeding points were seen. blood was cleaned with gauze piece and sunblock was applied. post procedure strict photo-protection was advised and patient was requested to follow up after 2 weeks. at week 2, cross peeling with 30% tca was done in all the patients and patients were advised strict photo-protection after the procedure and requested to follow up again after 2 weeks. four sessions, each of microneedling with dermaroller (weeks= 0, 4, 8 and 12) and cross peeling with 30% tca (weeks= 2, 6, 10, 14) were performed two weeks apart in this manner. by the end of 14 weeks from baseline (week 0) the therapy was completed. the patients were advised to continue strict photo-protection for the next 4 weeks and follow up again afterwards. digital photographs of the face of patients including frontal and lateral views were taken again after 4 weeks of the end of therapy or 18 weeks from baseline (week 0) with the same device as used earlier. the two dermatologist (blinded to the whole procedure and study) who graded the patients’ scars at baseline (week=0) were 301 j i m d c 2 0 1 7 301 requested again to go through the photographs and grade the scarring again using goodman and baron qualitative acne scarring scale at week=18. throughout the study, a record of adverse events reported by the patients was maintained. statistical analysis was done using spss version 23. r e s u l t s out of a total of 20 subjects who took part in the study, 11 (55%) were males and 9 (45%) were females. the mean age of the participants was 24.5 ± 4.0 years. the mean duration of acne scarring was 2.4 ± 2.0 years. predominantly a combination of various types of atrophic acne scarring was observed in the subjects. among 20 patients, 6 (30%) patients had only one type of acne scarring and it was rolling type in all individuals. rolling type of atrophic acne scarring was present in 19 (95%), both ice pick and boxcar types were present in 12 (60%) of the patients. at baseline (week=0), 16 (80%) of the patients had grade iv acne scarring and 4 (20%) had grade iii scarring. at assessment on 4 weeks after the end of therapy (week=18), out of 16 patients who were having grade iv acne 6 (37.5%) improved to grade iii and 10 (62.5%) improved to grade ii. out of 4 patients who were initially having grade iii at week=0, all (100%) improved to grade ii by week=18, shown in graph i and figures 1-3. a wilcoxon signed rank test was used to evaluate the significance of improvement in the grade of scarring. the test revealed a significant improvement in the score of the participants at 4 weeks after the end of therapy (week=18) as compared to baseline (week=0), (z=-3.92, p=0.00008). graph i: grades of acne scarring at baseline (week =0) as compared to the grades 4 weeks after the end of treatment (week=18) no serious adverse reaction by the therapy was seen. a few patients reported mild transient erythema and oedema more so after microneedling but it settled after application of emollients. d i s c u s s i o n acne scarring is a major and common complication of acne vulgaris. the most common type is atrophic scarring.8 the cosmetic concern has dire consequences on the mental health of the individual. various modalities are available for the treatment of acne scarring. these can be broadly divided in to energy and non-energy based modalities.9 the energy based devises are costly but the results are relatively promising and include lasers, fractional radiofrequency & ipl. these modalities also have a high proportion of side-effects and relatively longer downtime.10 on the other hand, non-energy based devises are accessible to more people and have proved to be quite effective as well. the non-energy based modalities include chemical peels, dermabrasion, microneedling, etc. currently, the treatment of acne scarring is individualized depending on the demand and expectations of the patients plus the availably of expertise and equipment. combinations of various modalities are being explored extensively in order to reach a consensus for the best therapy of acne scarring. microneedling with either derma-pen or dermaroller combined with various chemical peels and other agents like platelet rich plasma (prp) and glycolic acid has been researched extensively to find out the right combination with best results.11-13 we also used such a combination that included microneedling with dermaroller, alternating with a medium depth chemical peel 30% tca and the results have turned out be highly significant for improvement in acne scar grading from baseline. the improvement was observed more in the acne scars having grade iv at baseline (week=0) as compared to the ones having grade iii. however, all of the patients showed some improvement with either grade iv or iii with no failure rate. there were no major side-effects associated with this combination therapy and was well-tolerated by all the patients. moreover, all sub-types of atrophic post acne scars responded to our treatment. the rating was done by two well trained and experienced dermatologists that were 302 j i m d c 2 0 1 7 302 figure 1: patient with grade iv acne scrring improved to grade ii after treatment figure 2: patient with grade iv acne scarring improved to grade iii after treatment figure 3: patient with grade iv acne scarring improved to grade iii after treatment completely blinded to the whole study including the sampling of the patients and the procedure done on the subjects which, in turn, improved the reliability of the results. as microneedling opens the pores of the epidermis and results in more penetration of the topical agents applied, the microneedling was done before each of the cross peeling with 30% tca for better results. moreover, the technique that we used is cheap, an outpatient procedure and does not require a lot complex technology. these advantages are imperative for our patients as most of them are under-privileged. c o n c l u s i o n our study proved that four sessions, each of microneedling with dermaroller alternating with cross peeling with 30% tca at an interval of two weeks inbetween is a cheap and effective procedure for treating all types of atrophic acne scarring particularly having grade iv initially as per goodman and baron qualitative scale for acne scarring. it does not require complex and expensive equipment; moreover, adverse events related to regimen are minimal. r e f e r e n c e s 1. bek-thomsen m, lomholt hb, scavenius c, enghild jj, brüggemann h. proteome analysis of human sebaceous follicle infundibula extracted from healthy and acne-affected skin. plos one. 2014; 9 (9): e107908. 2. gold mh, baldwin h, lin t. management of comedonal acne vulgaris with fixed‐combination topical therapy. journal of cosmetic dermatology. 2018; 17 (2): 227-31. 3. suh dh, kwon hh. what's new in the physiopathology of acne? british journal of dermatology. 2015; 172: 13-9. 4. lee sj, suh dh, chang ky, kim hj, kim ti, jeong kh, shin mk, song ky. the efficacy and safety of subcision using co2 gas combined with fractional laser for acne scars: clinical and microscopic evaluation. journal of cosmetic and laser therapy. 2016; 18 (7): 417-20. 5. sharma g, jha r. microneedling vs. scars remodelling with 30% salicylic acid-comparative study. journal of evolution of medical and dental sciences-jemds. 2018; 7 (37): 4072-6. 6. nair pa, arora th. microneedling using dermaroller: a means of collagen induction therapy. gmj. 2014; 69 (1): 24-7. 7. garg s, baveja s. combination therapy in the management of atrophic acne scars. journal of cutaneous and aesthetic surgery. 2014; 7 (1): 18. 8. lan t, xiao y, tang l, hamblin mr, yin r. treatment of atrophic acne scarring with fractional micro‐plasma 303 j i m d c 2 0 1 7 303 radio‐frequency in chinese patients: a prospective study. lasers in surgery and medicine. 2018. 9. sánchez viera m. management of acne scars: fulfilling our duty of care for patients. british journal of dermatology. 2015; 172: 47-51. 10. cohen be, brauer ja, geronemus rg. acne scarring: a review of available therapeutic lasers. lasers in surgery and medicine. 2016; 48 (2): 95-115. 11. asif m, kanodia s, singh k. combined autologous platelet‐rich plasma with microneedling verses microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split‐face study. journal of cosmetic dermatology. 2016;15 (4): 43443. 12. dhollan n, thirunavukkarasu v. microneedling vs. chemical reconstructon of skin scars with trichloroacetic acid: a comparative study. international journal of research in dermatology. 2017; 3 (2): 27781. 13. rana s, mendiratta v, chander r. efficacy of microneedling with 70% glycolic acid peel vs microneedling alone in treatment of atrophic acne scars—a randomized controlled trial. journal of cosmetic dermatology. 2017; 16 (4): 454-9 . j islamabad med dental coll 2022 204 open access functional outcome of ilizarov technique in managing proximal tibial fracture in combined military hospital, rawalpindi hassan u din hassan1, muhammad hassan2, adnan anwar3, usman arif4, muhammad rehan saleem5 1medical officer, krl hospital islamabad. 2senior registrar, orthopedic department, faisalabad medical university, faisalabad. 3consultant orthopedic, cmh abbottabad 4resident orthopedic department, cmh rawalpindi. 5orthopedic surgeon, cmh sialkot. a b s t r a c t background: tibial plateau fractures involve injuries affecting the major weight-bearing joint and result in functional impairment which can be prevented by implying competent treatment techniques including dual column plating, assisted reduction, internal fixation with plating and ilizarov circular fixator . the objective of this study was to evaluate the functional outcome of ilizarov technique in treating closed tibial plateau fractures. methodology: a quasi experimental study was conducted in the o rthopedic department of combined military hospital, rawalpindi from 30 th july 2019 to 29t h january 2020. a total of 100 patients with tibial plateau fractures of schatzker type iii to vi, 20 to 60 years of age of either gender were included. in all patients, ilizarov technique was performed . data were entered in spss 22. descriptive analysis was done for quantitative variables and percentages were calculated for qualitative variables. chi square test was applied to determine association of variables with functional outcome. results: mean age of patients was 37.42 ± 8.94 years. out of 100 patients, 70 % were males and 30% were females, 76% patients managed with ilizarov technique in treating closed tibial plateau fracture had excellent functional outcome, 15 % good outcome, 5% fair and 4% poor outcome. functional outcome with respect to age, gender, bmi and dm showed statistically significant difference with p value 0.017, 0.016, 0.004 and 0.001 respectively. conclusion: functional outcome of ilizarov technique in treating closed tibia l plateau fracture is significantly better. keywords: ilizarov technique, orthopedic fixation devices, tibial fractures authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; ,4,5data analysis; manuscript editing. correspondence: hassan u din hassan email: hassaanudin11@yahoo.com article info: received: august 7, 2021 accepted: september 9, 2022 cite this article. hassan h d, hassan m, anwar a, arif u, saleem m r.functional outcome of ilizarov technique in managing proximal tibial fracture in combined military hospital, rawalpindi. j islamabad med dental coll. 2022;11(4):204-210 doi: https://doi.org/10.35787/jimdc.v11i4.760 funding source: nil conflict of interest: nil i n t r o d u c t i o n tibial fracture is the most common long bone fracture due to its subcutaneous presence. tibia plateau fractures are about 1.2% of all the o r i g i n a l a r t i c l e j islamabad med dental coll 2022 205 fractures. the majority of tibial plateau fractures involve the lateral plateau. bicondylar fractures are not very frequent but they require freater competency and patience with treatment because of the complex configuration of the fracture and the related soft tissue injury. tibial plateau fractures involve a set of injuries affecting the major weight -bearing joint resulting in functional impairment .( 1) the classification for tibial fractures proposed by schatzker is most widely used. it divide them into two groups: the low energy and high-energy fracture patterns.( 2) reconstruction of highenergy fractures is a major challenge for the orthopedic surgeons. schatzker type-v and vi injuries are the result of high energy trauma resulting in proximal tibial fractures involving both the medial and lateral tibial condyles . the soft tissue injury usually gives the idea of th e underlying bony damage . a local study revealed percentage of open tibial fractures to be 42.6% and closed tibial fracture to be 57.4%. (3) presently different techniques are being implied for the treatment of tibial fracture including dual column plating, assisted reduction, internal fixation with plating and ilizarov circular fixator. (4) the advantages of dual plating are visual reduction and maintenance of proximal tibial alignment, but soft tissue complications and damage to the periosteal blood supply are major concerns. arthroscopy assisted reduction gives an advantage of the minimally invasive approach without violating the intra-articular structures but there is a high risk of iatrogenic compartment syndrome secondary to irrigation fluid extravasation. internal fixation permits shorter hospital stays, enables the patients to return to normal functioning earlier and reduces the incidence of nonunion and malunion of the fractured bones, however bone loss under the plates and refractures after plate removal have been reported. ( 5) pros and cons of each therapeutic method must be considered by the surgeon. external fixators may prove to show beneficial outcomes in case of lacerating soft tissue damage. ( 6) ilizarov circular fixation is an ideal method of treatment for high-energy fractures of the tibial plateau especially where vast dissection and internal fixation are contraindicated because of soft tissue injury, deficiency of bone stock and bony comminution. (7) rijal r et al and mardani-kivi m et al reported similar positive results regarding the efficacy of ilizarov. ( 8,9) although previously, many studies are available on treatment with ilizarov but these studies have shown large variation in results, so this study was conducted with the aim of reevaluation of the functional outcome of ilizarov technique in treating tibial plateau fracture in local pakistani population and its association with different variables. m e t h o d o l o g y a quasi experimental study was conducted in the orthopedic department of combined military hospital, rawalpindi from 30th july 2019 to 29th january 2020. approval of study was taken from the ethical review committee. total sample size was 100 by taking 95% confidence level, 7% margin of error and taking excellent functional outcome of ilizarov technique in treating tibial plateau fracture as 95%. ( 10) nonprobability, consecutive sampling technique was used. patients with tibial plateau fractures of schatzker type iii to vi and duration of fracture <7 days with age of 20-60 years of both the genders were included in the study. patients with concomitant injuries that may adversely affect the functional outcome of the patient s, were excluded from the study. these concomitant injuries included ipsilateral femoral shaft fracture, ipsilateral acetabulum fracture and bilateral fracture s as assessed on the x-ray, patients with chronic renal failure j islamabad med dental coll 2022 206 assessed by history and s/creatinine >1.5 mg/dl and chronic liver disease assessed by history of disease and serum bilirubin >2.0 mg/dl, open fractures, patients with previous surgery of fracture and patients who were lost to follow up. informed written consent was taken from every patient. in all patients, ilizarov technique was done under spinal anesthesia by the consultant orthopedic surgeon. in all the patients, minimal soft tissue manipulation, especially at the joint surface, was performed to reduce the fracture. this manipulation included fluoroscopy, arthroscopy, mini-open incision and adding two or three screws for anatomical maintenance of the joint surface. then, a suitable ilizarov ring with an appropriate diameter based on the diameters of the knee and leg was used and the distal rings were attache d to the proximal ring with three special rods. at least three olive pins in two levels were also inserted in the tibial plateau. in the distal part of the fracture site, at least two ilizarov rings, as hybrids connected to a 5-mm schanz, were used. all patients were followed on regular intervals post -operatively and functional outcome was assessed at the end of 3 months according to the jensen’s grading system. ( 8) it is the modified version of the knee scoring system of hohl and luck (1956). all the information regarding age, gender, duration of fracture, body mass index (bmi), place of living, diabetes mellitus (dm), type of fracture (iii/iv/v/vi) and functional outcome (excellent/good/fair/poor) was collected through pre-designed performa. collected data were entered in spss version 22. descriptive analysis was done for quantitative variables like age, bmi and duration of fracture . qualitative variables like gender, diabetes mellitus, place of living, type of fracture and functional outcome were presented as frequency and percentages. an association of functional outcome with age, gender, duration of fracture, bmi, type of fracture, diabetes mellitus and place of living was determined by chi square test. p-value ≤0.05 was considered as statistically significant. r e s u l t s mean age of the patients was 37.42 ± 8.94 years. majority of the patients 78 (78%) were between 20 to 40 years of age. out of 100 patients, 70 (70%) were males and 30 (30%) were females , with male to female ratio of 2.3: 1. mean duration of fracture was 3.88 ± 1.34 days. mean bmi was 27.96 ± 3.08 kg/m 2. according to schatzker type, 20 (20%) patients were type iii, 17 (17%) were type iv, 43 (43%) were type v and 20 (20%) were type vi. 25 (25%) patients had diabetes mellitus while 75 (75%) were disease free. 51 (51%) patients were from rural area while 49 (49%) belonged to urban areas. 76 (76%) treated with ilizarov technique in treating closed tibial plateau fracture had excellent functional outcome, 15 (15%) good outcome, 05 (5%) fair outcome and 04 (4%) poor outcome. association of functional outcome with age, gender, duration of fracture, bmi, schatzker type, diabetes mellitus and place of living was also evaluated using chi square test as shown in table i. functional outcome with respect to age, gender, bmi and dm showed statistically significant difference with p value 0.017, 0.016, 0.004 and 0.001 respectively , while other variables showed insignificant effect o n functional outcome. out of 78 patients who were between 20-40 years of age, 74% showed excellent outcome. while out of 22 patients who were between 41-60 years of age, 82% showed excellent outcome. younger patients tend to show more positive functional outcome. similarly, males particularly showed excellent functional outcome of 77% as compared to females with excellent functional outcome of j islamabad med dental coll 2022 207 73%. lean patients or decreased bmi (≤30 kg/m2) resulted in better functional outcome of 77% as compared to obese patients who showed excellent functional outcome in 72% of the patients. patients with no co morbid like diabetes mellitus displayed excellent functional outcomes as diabetes could hinder the healing process affecting the functional outcome. table i: association of functional outcome with all variables variables functional outcome pvalue excellent good fair poor age groups (years) 20-40 58 14 01 05 0.017 41-60 18 01 03 00 gender male 54 12 00 04 0.016 female 22 03 04 01 duration of fracture (days) ≤3 25 08 02 01 0.366 4-6 51 07 02 04 bmi (kg/m2) ≤30 58 13 00 04 0.004 >30 18 02 04 01 schatzker type iii 18 00 02 00 0.073 iv 13 02 00 02 v 30 10 00 03 vi 15 03 02 00 diabetes mellitus yes 19 00 04 02 0.001 no 57 15 00 03 place of living rural 40 04 03 04 0.101 urban 36 11 01 01 d i s c u s s i o n ilizarov external fixation meets all the treatment needs of a patient with tibial fractures which makes it attractive for the orthopedic surgeon. ilizarov is advantageous in terms of reduction of closed or mini-open fracture with low risk of wound infection, early mobility, functional loading and weight bearing, continuous improvement in reduction and alignment of the bones resulting in early recovery to proper functioning. ( 11) for cases which may require knee replacement in future, external fixation via j islamabad med dental coll 2022 208 ilizarov is a better option as compared to internal fixation as no extensive incisions are made for ilizarov, no soft tissue cover is needed and no introduction of hardware inside the body is required. a study compared internal fixation and ilizarov external fixation for comp lex tibial plateau fractures which concluded that the number and severity of complications are increased with open reduction and internal fixation while ilizarov external fixation leads to short hospital stay and functional mobility is achieved earlier. ( 11) in the present study 76 (76%) patients treated with ilizarov technique for managing closed tibial plateau fracture had excellent functional outcome, 15 (15%) good outcome, 05 (5%) fair and 04 (4%) poor outcome. in contrast, another study reported excellent results in only around 15%, good in about 60%, fair in about 20% and poor in only 3%. ( 12) in accordance with our results, a study by bari et al in 2014 has shown excellent results in 73.68% patients. they operated on 40 patients with ilizarov external fixator and had 28 patients with excellent, 9 patients with good, 2 with fair and 1 patient with poor result. ( 13) similarly, aziz ma et al has shown satisfactory outcome in 90% of patients. (14) the present study also showed that the functional outcome of the ilizarov technique is associated with age as younger patients give better results as compared to elderly, gender as males responded more positively to the treatment as compared to females, bmi with less than 30kg/m2 and patients with no dm correspond to better response to ilizarov treatment. farooq u et al evaluated closed ilizarov fixator for high grade fracture of tibial plateau in 40 patients. the patients were on follow up for 3 months. the results showed 90% patients acknowledging good to excellent range of motion and about 95% appreciated excellent stability. the study further concluded that ilizarov fixation is an ultimate treatment option for tibial plateau fracture when open osteosynthesis is contraindicated due to soft tissue trauma. ( 15) subramanyam et al evaluated 30 patients for external fixation with or without minimal internal fixation. the study concluded that the ilizarov external fixator with or without minimal internal fixation provides satisfactory outcome for complex tibial plateau fractures. ( 16) a local study showed that outcome of 22 patients treated with ilizarov were satisfactory out of 26 patients. the study concluded that hybrid external fixator allows early joint movement and reduces risk of serious complications. ( 17) aseri et al operated on 32 patients and had excellent results in 16, good in 13 and fair in 3 patients. (18) jahan et al in 2017 showed excellent results in 15 patients and fair in 4 patients. (19) kumar j el al conducted a retrospective study on 59 patients having high-energy intra-articular proximal and distal tibial fractures treated with ilizarov fixator. the study showed that ilizarov is a reliable minimal invasive procedure. ( 20) another study showed 27 patients with excellent results out of 30 operated cases. ( 21) in contrast to the present study, another study by berven h et al. compared the external fixation with ilizarov and internal fixation with locking plates while treating proximal tibia fractures with a complete metaphyseal component. the study revealed shorter healing time with internal plating for the management of proximal tibia fractures as compared to ilizarov. complications like heterotopic ossifications and superficial infections after internal plating were also less. ( 22) however, endorsing the results of present study, a study by bove f et al. determined the effectiveness of circular external fixation compared to fixed angle locking plates while treating complex tibial plateau fractures. according to the j islamabad med dental coll 2022 209 association for the study and application of the method of ilizarov criteria, the circular external fixation showed around 60% excellent functional outcome making it superior to plating (23) this study not only added to the data in the existing literature but also provided the local statistics as our population is differe nt from the western population socially, ethnically and lifestyle habits. however, some limitations were seen as the study was conducted on a small sample size within a single setting. further longitudinal studies with larger sample size and multicenter are recommended. c o n c l u s i o n excellent functional outcome of ilizarov technique in treating closed tibial plateau fracture is quite high. so, it is recommended that ilizarov technique should be used as a first line treatment for closed tibial plateau fracture in order to reduce the morbidity rate. r e f e r e n c e s 1. yoon rs, liporace fa, egol ka. definitive fixation of tibial plateau fractures. orthop clin north am. 2015;46(3):363-75, x. doi: 10.1016/j.ocl.2015.02.005. 2. elsoe r, larsen p. asymmetry in gait pattern following bicondylar tibial plateau fractures-a prospective one-year cohort study. injury. 2017;48(7):1657-61. doi: 10.1016/j.injury.2017.04.045. 3. malik a l, iqbal m, mehboob i. incidence of adult open tibial shaft fractures. 6-years study in lahore general hospital lahore, pakistan. pak post grad med j. 2016; 27(3):79-81 4 subash y di, jagadeesh b, preethi n, jayaram m, naidu gk. operative management of tibial plateau fractures: an assessment of functional and radiological outcomes with rasmusssens scoring system. int j res orthop. 2017;3:1092-8. doi: http://dx.doi.org/10.18203/issn.24554510.intjresorthop20174697 5 prat-fabregat s, camacho-carrasco p. treatment strategy for tibial plateau fractures: an update. efort open rev. 2016; 1(5):225-32. 6 messner j, johnson l, taylor dm, harwood p, britten s, foster p. treatment and functional outcomes of complex tibial fractures in children and adolescents using the ilizarov method. bone joint j. 2018;100-b(3):396-403. doi: 10.1302/0301-620x.100b3.bjj-2017-0863.r1 7 debnath uk, jha dk, pujari pk. results of ring (ilizarov) fixator in high energy schatzker type vi fractures of proximal tibia. j clin orthop trauma. 2018;9(2):186-91. doi: 10.1016/j.jcot.2017.08.005 8 rijal r sb, khanal gp, chaudhary p, paneru sr, kalawar rps . a study to evaluate the pattern and types of treatment of tibial plateau fracture at bpkihs dharan. . health renaiss. 2015;13(3):6572. doi: https://doi.org/10.3126/hren.v13i3.17929 9 mardani-kivi m mm, keyhani s, azari z. ilizarov fixator technique in type v and vi tibial plateau fractures: a case series.trauma mon. 2018;3:e67618. doi: 10.5812/traumamon.67618 10 jayabalan sv, ram gg, chandrasekaran a, kailash kk. functional outcome of displaced tibial plateau fracture treated by illizarov fixator. int j adv med. 2015;2(1):34. doi: 10.5455/23493933.ijam20150208 11 li z, wang p, li l, li c, lu h, ou c. comparison between open reduction with internal fixation to circular external fixation for tibial plateau fractures: a systematic review and meta-analysis. plos one. 2020 sep 17;15(9):e0232911. doi: 10.1371/journal.pone.0232911 12 el-gafary k, farouk o, marwa mk, abdelaziz m. . management of high-energy tibial plateau fractures by ilizarov external fixator. euro orthopaed traumatol. 2014;5(1):9-14. doi:10.1007/s12570-013-0187-1 13 bari mm, shahidul i sn, mahfuzer rm. . complex tibial plateau fractures treated with ilizarov ring fixator. moj orthop rheumatol 2014;1(2):9-11. doi: 10.15406/mojor.2014.01.00009 14 aziz ma fs. treatment of complex tibial plateau fractures using ilizarov external fixator with or without minimal internal fixation. egypt orthop j 2016;51:60-4. doi: 10.4103/1110-1148.194436 15 farooq u, javed s, ahmad i, aziz a. functional outcome of complex tibial plateau fractures managed with closed ilizarov. j pak med assoc. 2014;64(12 suppl 2):s104-7. j islamabad med dental coll 2022 210 16 subramanyam kn, tammanaiah m, mundargi av, bhoskar rn, reddy ps. outcome of complex tibial plateau fractures with ilizarov external fixation with or without minimal internal fixation. chinese j traumatol. 2019 jun 1;22(3):166-71. doi: 10.1016/j.cjtee.2018.11.003 17 raza a, kumar s, kumar d, qadir a, muzzammil m, lakho mt. complex tibial plateau fractures: primary fixation using the ilizarov external fixator. a two-year study at civil hospital karachi, pakistan. cureus. 2019 aug;11(8). doi: 10.7759/cureus.5375 18 aseri mk ga, khilji u. . role of hybrid external fixator in proximal tibial fractures: a prospective analysis. int j orthop sci. 2017;3(1):810-3. doi: http://dx.doi.org/10.22271/ortho.2017.v3.i1l.116 19 jahan a hm, wazir f. . treatment of high energy tibial plateau fractures with hybrid external fixator: intermediate term outcome. int j res med sci. 2017;5(10):4582-7. 20 kumar j, siddiqui aa, katto ms, jamil m, wasim ma, yaqoob u. treatment of high‐energy intra‐ articular fractures of tibia with ilizarov external fixator in adults: a tertiary center experience. int j clin prac. 2021; 11:e14488. doi: 10.1111/ijcp.14488 21 elsoe r, larsen p, petruskevicius j, kold s. complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported qol: a prospective observational study of 46 complex tibial fractures treated with a ring fixator. strategies trauma limb reconstr. 2018;13(1):25-33. doi: 10.1007/s11751017-0301-y 22. berven h, brix m, izadpanah k, kubosch ej, schmal h. comparing case-control study for treatment of proximal tibia fractures with a complete metaphyseal component in two centers with different distinct strategies: fixation with ilizarov frame or locking plates. j orthop surg res. 2018;13(1):121. 23 bove f, sala f, capitani p, thabet am, scita v, spagnolo r. treatment of fractures of the tibial plateau (schatzkervi) with external fixators versus plate osteosynthesis. injury. 2018;49 suppl 3:s12s8. j islamabad med dental coll 2022 120 open access covid 19 vaccination related misconceptions and myths tamkeen nishat jaffery1, hina shan2, rehma gillani3, uzma hassan4, bismillah sehar5, rubab zufiqar6. 1associate professor, department of public health, national university of medical sciences, islamabad, pakistan. 2,5assistant professor, department of public health, national university of medical sciences, islamabad, pakistan. 3senior lecturer, department of public health, national university of medical sciences, islamabad, pakistan. 4head of department, professor, department of public health, national university of medical sciences, islamabad, pakistan. 6trainee mph, afpgmi, national university of medical sciences, islamabad, pakistan. a b s t r a c t background: mass vaccination is the most effective way to fight against covid 19 but a significant number of people are unwilling to be vaccinated, mainly due to misinformation and false beliefs, associated with this drive. the objective of this study was to identify these misconceptions and myths and associate them with sociodemographic factors. methodology: this cross sectional survey was conducted on 562 residents of rawalpindi and islamabad from july 2021 to november 2021. data was collected through structured questionnaire both in english and urdu, analysed by spss version 23. χ2-test was used to check the association of categorical data with sociodemographic factors. results: out of all the participants, 328 (58.4%) had received covid19 vaccination. among these vaccinated individuals, 81.8% were graduates or above and 74.2% had family income more than rs.50,000. out of total, 40.7% respondents believed that, vaccine is harmful for diabetics, hypertensive and heart patients, 40.6% agreed that it is not safe for pregnant or lactating women and 40.4% assumed that they have acquired immunity through natural infection. a strong association of misconceptions and myths was found with residence (p value 0.0001), educational level (p value 0.0010) and monthly income (p value 0.0001). conclusion: several misconceptions and myths are related with covid 19 vaccination, strongly influenced by various socio demographic factors. hence, there is a need to launch various campaigns regarding the safety and effectiveness of vaccination. key words: covid-19, misinformation, vaccine authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; manuscript editing. correspondence: tamkeen nishat jaffery email: jaffery@numspak.edu.pk article info: received: november 3, 2021 accepted: june 21, 2022 cite this article. jaffery t n, shan h, gillani r, hassan u, sehar b, . covid 19 vaccination related misconceptions and myths. j islamabad med dental coll. 2022; 11(2): 120-126. doi: https://doi.org/10.35787/jimdc.v11i2.808 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e https://doi.org/10.35787/jimdc.v11i2.808 j islamabad med dental coll 2022 121 i n t r o d u c t i o n vaccination coverage is generally associated with low incidence of infectious diseases.1 from the very early days of covid 19 pandemic which has affected more than 185 countries2, scientists have been struggling to develop vaccines which can be effective in the control of this disastrous infection. although around the world, manufacturers have succeeded to introduce various brands of vaccines but unfortunately varied objections and doubts have also been linked with the vaccination, making this campaign a big challenge for the organizers. general public has a wide range of opinions regarding the production and safety of vaccine. although many are considering it safe and enthusiastic to get benefit from it, a huge portion of population is not willing to avail this opportunity. the resistance has aroused due to the poor concepts and false beliefs 3 which are basically influenced by the intellectual level and associated sociodemographic factors.4 people seem to get deceived by misinformation linked with vaccine due to lack of knowledge, and false religious beliefs.5 conspiracy theories related with the side effects of vaccine are also a basis of demotivation.6 in a country like pakistan where the polio drive has already been suffered due to untrue and fictitious news being circulated in the less educated segment of population7, covid vaccination campaign is in a big danger as people are concerned about the manufacturing, storage, side effects and reliability of vaccine. in this scenario, who and health professionals believe that responsibility lies with both the state and local organization to counter the misleading information.8,9as predicted that control of covid 19 pandemic won’t be possible without the mass vaccination coverage,10 comprehensive awareness programs are needed to modify the views, change perception and create willingness of the people regarding vaccination. the purpose of the current study was to identify the misconceptions and myths related with covid 19 vaccine and associate them with the sociodemographic factors. m e t h o d o l o g y it was a cross sectional survey conducted in urban and rural areas of rawalpindi and islamabad from july 2021 to november 2021. sample size was 562 calculated by open epi calculator with anticipated frequency 50% , confidence limit 2% and design effect 1. male and female participants were selected through nonprobability consecutive sampling technique. people under the age of 19 were excluded because of non-eligibility for vaccination for them at the time of data collection. ethical approval was taken from irb of national university of medical sciences. informed written consent was taken from the study participants. data was collected through a pretested selfadministered structured questionnaire written in both english and urdu. it comprised of two sections. first was related to socio demographic profile including the vaccination status. the second part included close ended questions associated with misconception and myths related to covid vaccination, the items were constructed through the available published literature of who, cdc and health care departments.11,12,13 data was analyzed by spss version 23. for categorical variables, frequency and percentages were calculated. inferential analysis was done, using the χ2-test to check the association of categorical data where required and p values less than 0.05 was considered statistically significant. j islamabad med dental coll 2022 122 r e s u l t s total respondents were 562 with mean age of 33 + 12.5 sd (19 to 71 years). out of total, 328 (58.4 %) were males and 384 (61.9 %) were married. the number of participants residing in urban areas was 329 (58.5 %). 298 (53%) respondents were graduate or above and 353 (62.8 %) had monthly family income of 50,000 pkr or below. (table 1) out of 562 respondents, 328 (58.4%) were either fully or partially vaccinated for covid 19. history of vaccination was strongly related with sociodemographic factors namely residence, educational level and per month family income. (table: 2) table: i sociodemographic characteristics characters frequency(percentage) gender male 328 (58.4%) female 234 (41.6%) residence urban 329 (58.5%) rural 233 (41.5%) marital status married 348 (61.9%) unmarried 214 (38.1%) occupation students 118(21.0%) labourer 98(17.4%) private officer 112(19.8%) public officers 137(24.4%) teachers 42(7.5%) businessmen 26(4.6%) others 29(5.3%) table: ii association of vaccination with sociodemographic factors variables history of vaccination yes n=328 (58.4) no n= 234(41.6) total p-value age 30 and below 145 (53.5%) 126 (46.5%) 271 0.021* above 30 184 (63.3%) 107 (36.7%) 291 gender male 196 (59.7%) 132 (40.3%) 328 0.428 female 132 (56.4%) 102 (43.6%) 234 residence urban 220 (66.8%) 109 (33.2%) 329 0.0001* rural 108 (46.3%) 125 (53.7%) 233 marital status married 202 (58.0%) 146 (42.0%) 348 0.038* un married 126 (58.8%) 88 (41.2%) 214 education under graduate 84 (31.8%) 180 (68.2%) 264 0.0001* graduate or above 244 (81.8%) 54 (18.2%) 298 income/ month in pkr 50,000 and below 173 (49.0%) 180 (51.0%) 353 0.0001* above 50,000 155 (74.2%) 54 (25.8%) 209 j islamabad med dental coll 2022 123 figure 1: misconceptions and myths regarding covid 19 vaccination. a strong association between socio demographic factors and misconception and myths related with covid-19 vaccination was found. fears that vaccination is harmful for diabetics, hypertensive or heart patients and for pregnant and lactating women were found to be associated with residence (p = 0.0001), educational level (p = 0.001) and monthly income of family (p=0.0001). there was a significant difference among people belonging to different residence (p = 0.001), having diverse educational level (p =0.0010) and monthly income of family (p = 0.0001) in believing that vaccine may cause infertility. misconception that virus in the vaccine may itself cause the disease was found to be strongly related with gender (p = 0.0001), residence (p = 0.0001), educational level (p = 0.0010) and monthly income of family (p = 0.0001). similarly, misunderstanding that vaccine has serious side effects was associated with gender (p =0.006), residence (p = 0.0001), educational level (p = 0.0001) and monthly income of family (p = 0.0001). a strong association of gender (p=0.002), residence (p = 0.0001), educational level (p = 0.0001) and monthly income of family (p =0.0001) was revealed with the misinformation that there won’t be any need of masks after vaccination and also with the concept that sufficient immunity is acquired through natural infection so no further need of vaccination with p=0.001, 0.0001, 0.0001 and 0.0001 for gender, residence, educational level and monthly income respectively. additionally the belief that covid-19 vaccination has no role in control of pandemic was also associated with residence (p = 0.0001), educational level (p =0.001) and monthly income of family (p = 0.0001). d i s c u s s i o n according to the present study conducted among the general population, 328 (58.4%) respondents were vaccinated. a strong association was observed with history of vaccination and sociodemographic factors specially age, marital status, residence, educational standard and monthly family income. the results are comparable with various international and national studies. a study conducted in saudi arabia indicated that 44.7% 229 228 66 62 179 227 200 173 137 103 0 50 100 150 200 250 300 350 400 harmful for diabetics, hypertensive or heart patients harmful for pregnant & lactating women causes infertility looses efficiency if not stored at low temp the virus in vaccine can itself cause disease already acquired natuaral immunity so no need of… causes serious side effects no need of masks after vaccination vaccination has no role in control of pandemic vaccination campaign is a publicity stunt agree not sure disagree j islamabad med dental coll 2022 124 population agreed to accept vaccination14 because of higher educational level while in bangladesh only 35.1% respondents were ready for immediate vaccination and regression analysis showed that gender, residence, education level and income were closely associated with readiness for vaccination.15 however, the study conducted in romania and vietnam showed no relationship of gender or education with the acceptance level of vaccination.16,17. the current study also concluded that various misconception and myths were related with covid 19 vaccination, as participants were of the view that they have acquired immunity through natural infection so there is no need of any further vaccination and also agreed that vaccine has serious side effects besides it may itself cause disease. similarly, respondents believed that vaccine is neither safe for diabetics, hypertensive or cardiac patients nor for pregnant or lactating women. these findings are comparable with an international study conducted in england and some national studies of sindh and punjab which state that people think of vaccine as being unsafe because it has serious side effects and may itself can cause disease.1,18 according to another national cross sectional study, health care workers were concerned about the side effects and had denied vaccination due to prior exposure with covid 19.19 our study shows that a small minority feared infertility as a result of vaccination which is comparable with a study conducted in a rural area of sindh, where people believed that it’s a western conspiracy.20similarly another study conducted in various districts of sindh revealed that conspiracies, beliefs and safety issues were related with vaccination comparable with the present study.21 according to our study, sociodemographic factors like gender, residence, education and family income were found associated with various misconception and myths related with vaccination. a united states based study established that blacks, people with low educational standards and unvaccinated individuals have similar misconception.22 the studies conducted at national level revealed the same association of misconceptions with sociodemographic factors.23, 24 our study has several limitations. firstly the study was restricted to the twin cities of rawalpindi and islamabad and the nation wide data was missing. secondly study was based on non-probability sampling technique thus compromising the validity and reliability. thirdly the time period was limited as it can be predicted that the data collected over a longer period of time might have revealed difference in the opinion of the respondents. as a way forward study may be conducted at the national level. furthermore, a qualitative research on the subject may help to get an in depth analysis. this cross sectional study addresses wide range of sociodemographic barriers creating hindrance in the vaccination drive. moreover as the study is based on the knowledge and attitude, we can anticipate to create awareness among the general public which may assist in changing their behaviour towards this valuable campaign. c o n c l u s i o n various misconceptions and myths are related with covid 19 vaccination. sociodemographic factors especially residence, education and income strongly influence these opinions and beliefs. r e c o m m e n d a t i o n various campaigns should be launched in the masses regarding the safety and effectiveness of vaccination. responsibility lies with the state to promote the facts over doubts and provide proper guidance to change the views and perception. j islamabad med dental coll 2022 125 r e f e r e n c e s 1 hall vj, foulkes s, saei a, andrews n, oguti b, charlett a,et al. covid-19 vaccine coverage in health-care workers in england and effectiveness of bnt162b2 mrna vaccine against infection (siren): a prospective, multicentre, cohort study. the lancet. 2021 may 8;397(10286):172535. doi: 10.1016/s0140-6736(21)00790-x 2 world health organization. coronavirus disease (covid19): situation report 106. world health organization; 2020. accessed on 9th may,2022 at www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200505covid19-sitrep-106.pdf on 9 may 2020. 3 islam ms, kamal ah, kabir a, southern dl, khan sh, hasan sm, et al. covid-19 vaccine rumors and conspiracy theories: the need for cognitive inoculation against misinformation to improve vaccine adherence. plos one. 2021 may 12;16(5) https://doi.org/10.1371/journal.pone.0251605 4 barman mp, nath k, hazarika j. factors affecting timeliness of immunization coverage among children of assam, india: a cross-sectional study. journal of health management. 2015 sep;17(3):274-84. https://doi.org/10.1177%2f0972063415589243 5 ullah i, khan ks, tahir mj, ahmed a, harapan h. myths and conspiracy theories on vaccines and covid-19: potential effect on global vaccine refusals. vacunas. 2021 may-aug;22(2):93-97. doi: 10.1016/j.vacun.2021.01.001. 6 pivetti m, melotti g, bonomo m, hakoköngäs e. conspiracy beliefs and acceptance of covid-vaccine: an exploratory study in italy. social sciences. 2021 mar;10(3):10824 https://doi.org/10.3390/socsci10030108 7 khan mu, ahmad a, aqeel t, salman s, ibrahim q, idrees j, et al.knowledge, attitudes and perceptions towards polio immunization among residents of two highly affected regions of pakistan. bmc public health. 2015 dec;15(1):1-8. doi: 10.1186/s12889-015-2471-1. 8 al-kassmy j, pedersen j, kobinger g. vaccine candidates against coronavirus infections. where does covid-19 stand?. viruses. 2020 aug;12(8):861. doi: 10.3390/v12080861 9 chou w-ys, budenz a. considering emotion in covid-19 vaccine communication: addressing vaccine hesitancy and fostering vaccine confidence. health commun. 2020;35(14):1718–22. doi: 10.1080/10410236.2020.1838096. 10 fisher ka, bloomstone sj, walder j, crawford s, fouayzi h, mazor km. attitudes toward a potential sars-cov-2 vaccine: a survey of us adults. annals of internal medicine. 2020 dec 15;173(12):964-73. doi: 10.7326/m20-3569. 11the 12 common myths & misconceptions about covid-19 vaccination.covid 19 response[online].published 19th may,2021.available at https://www.un.org/sites/un2.un.org/files/covid19_vacc ine_common_myths_and_misconceptions.pdf. 12myths and facts about covid-19 vaccines.centers for disease control and prevention[online].available at https://www.cdc.gov/coronavirus/2019ncov/vaccines/facts.html 13 abbas q, mangrio f, kumar s. myths, beliefs, and conspiracies about covid-19 vaccines in sindh, pakistan: an online cross-sectional survey. authorea preprints. 2021 mar 8. doi: 10.22541/au.161519250.03425961/v1 14 magadmi rm, kamel fo. beliefs and barriers associated with covid-19 vaccination among the general population in saudi arabia. bmc public health. 2021 dec;21(1):1-8. doi/doi.org/10.1186/s12889-021-11501-5 15 mahmud s, mohsin m, khan ia, mian au, zaman ma. knowledge, beliefs, attitudes and perceived risk about covid-19 vaccine and determinants of covid-19 vaccine acceptance in bangladesh. plos one. 2021 sep 9;16(9):e0257096. https://doi.org/10.1371/journal.pone.0257096 16 maftei a, holman ac. sars-cov-2 threat perception and willingness to vaccinate: the mediating role of conspiracy beliefs. frontiers in psychology. 2021;12. https://doi.org/10.3389/fpsyg.2021.672634 17 huynh g, van nguyen t, nguyen dd, lam qm, pham tn, nguyen ht. knowledge about covid-19, beliefs and vaccination acceptance against covid-19 among high-risk people in ho chi minh city, vietnam. infection and drug resistance. 2021;14:1773. https://doi.org/10.2147/idr.s308446 18 saleem s. covid-19 vaccine, myths, and facts. journal of rawalpindi medical college. 2021 mar 30;25(1):1-2. 19 malik a, malik j, ishaq u. acceptance of covid-19 vaccine in pakistan among health care workers. medrxiv. 2021 jan 1 doi: https://doi.org/10.1101/2021.02.23.21252271 20 ali i, sadique s, ali s. covid-19 and vaccination campaigns as “western plots” in pakistan: government policies,(geo-) politics, local perceptions, and beliefs. http://www.who.int/docs/default-source/coronaviruse/situation-reports/20200505covid-19-sitrep-106.pdf http://www.who.int/docs/default-source/coronaviruse/situation-reports/20200505covid-19-sitrep-106.pdf http://www.who.int/docs/default-source/coronaviruse/situation-reports/20200505covid-19-sitrep-106.pdf https://dx.doi.org/10.3390%2fv12080861 https://www.un.org/sites/un2.un.org/files/covid19_vaccine_common_myths_and_misconceptions.pdf https://www.un.org/sites/un2.un.org/files/covid19_vaccine_common_myths_and_misconceptions.pdf https://doi.org/10.22541/au.161519250.03425961/v1 https://doi.org/10.1186/s12889-021-11501-5 j islamabad med dental coll 2022 126 frontiers in sociology. 2021 apr 23;6:82. https://doi.org/10.3389/fsoc.2021.608979 21 abbas q, mangrio f, kumar s. myths, beliefs, and conspiracies about covid-19 vaccines in sindh, pakistan: an online cross-sectional survey. authorea preprints. 2021 mar 8. https://doi.org/10.22541/au.161519250.03425961/v1 22 kreps se, goldfarb jl, brownstein js, kriner dl. the relationship between us adults’ misconceptions about covid-19 vaccines and vaccination preferences. vaccines. 2021 aug;9(8):901. doi: 10.3390/vaccines9080901 23 khan mu, ahmad a, aqeel t, salman s, ibrahim q, idrees j, et al.knowledge, attitudes and perceptions towards polio immunization among residents of two highly affected regions of pakistan. bmc public health. 2015 dec;15(1):1-8. doi: 10.1186/s12889-015-2471-1. 24 arshad ms, hussain i, mahmood t, hayat k, majeed a, imran i,et al. a national survey to assess the covid-19 vaccine-related conspiracy beliefs, acceptability, preference, and willingness to pay among the general population of pakistan. vaccines. 2021 jul;9(7):720. https://doi.org/10.3390/vaccines9070720 https://dx.doi.org/10.3390%2fvaccines9080901 j islamabad med dental coll 2023 150 open access a case report on abdominal cocoon syndrome fahad akhtar1, kanza farrukh 2, sidra rauf 3, aiman noor 4, manzer mehmood 5 1,2,5 post graduate resident, department of general surgery, pakistan institute of medical sciences, islamabad 3post graduate resident, department of gynae and obstetrics ,pakistan institute of medical sciences, islamabad 4post graduate resident, department of anesthesia, pakistan institute of medical sciences, islamabad a b s t r a c t abdominal cocoon syndrome (acs) is encapsulation of the abdominal organs by thick fibro-collagenous material forming cocoons. on the basis of the part of abdominal organ encapsulated, acs is classified into three types. patients with this condition usually present with intestinal obstruction. we present a case who presented to us with features of intestinal obstruction and was diagnosed as a rare case of abdominal cocoon syndrome on ct scan. he was managed operatively where adhenolysis was performed and patient had uneventful recovery. ct scan is found to be the investigation of choice. laparotomy with excision of membrane overlying bowel loops is the treatment most commonly adopted by surgeons and it has satisfactory results. key words: cocoon syndrome, computed tomography, intestinal obstruction. cite this article. akhtar f, farrukh k, rauf s, noor a, mehmood m. a case report on abdominal cocoon syndrome. j islamabad med dental coll. 2023; 12(2): 150-152 doi: https://doi.org/10.35787/jimdc.v12i2.988 funding source: nil conflict of interest: nil i n t r o d u c t i o n abdominal cocoon syndrome (acs) is a encapsulation of the abdominal organs by thick fibro-collagenous membrane forming cocoons. there are two types of abdominal cocoon syndrome i.e., primary and secondary. primary also known as idiopathic, is the one in which no associated cause has been identified. it is found to be linked with retrograde menstruation and therefore is more common in young females. the secondary type is associated with various conditions like trauma, peritoneal dialysis, peritonitis, previous abdominal surgery, sarcoidosis, tuberculosis, autoimmune disorders, pelvic inflammatory disease, endometriosis, beta-blockers, chemotherapy, hepatitis c, liver transplantation or gastrointestinal malignancy.1 this rare syndrome mostly presents as intestinal obstruction. computed tomography (ct scan) being radiological investigation of choice for this condition.2 diagnosis of this condition is difficult to establish, pre operatively. therefore, mostly the condition is diagnosed intra operatively when its pathognomonic features of thick fibrous membrane encapsulating abdominal viscera are seen. 3 here we present a case who presented to us with intestinal obstruction diagnosed as cocoon syndrome. c a s e r e p o r t a 35 years old male man reported to us in emergency with complain of pain in abdomen for the past 10 days associated with vomiting, constipation and abdominal distension from 8 days along with multiple episodes of vomiting, bilious in nature and patient hadn’t pass stool and flatus from 8 days. following these complaints patient developed abdominal distension as well. on c a s e r e p o r t j islamabad med dental coll 2023 151 examination his gcs was 15/15, with pulse of 110/min, blood pressure of 95/60, and was maintaining spo2 at room air. chest auscultation showed b/l equal air entry. on abdominal inspection his whole abdomen was distended with symmetrical appearance and central umbilicus. palpation showed generalized tense abdomen and was resonant on percussion with sluggish bowel sounds. rest of the systemic examination was unremarkable. patient was initially managed conservatively. work up was done that showed all baseline investigations, genexpert mtb and afb direct smear were negative. erect abdominal xrevealed multiple air fluid levels. abdominal ultrasound showed matted fluid filled gut loops with sluggish peristalsis in central abdomen. ct scan abdomen with iv contrast was carried out that reported dilated encapsulated thick walled jejunal loops in left upper hemiabdomen. intervening gut loops showed streak of fluid and engorged mesenteric vessels. overall features suggested intraperitoneal adhesions with small gut encapsulated at multiple levels along with small bowel obstruction (abdominal cocoon) (figure1). figure 1: per-operative findings showing multiple bands with dilated small bowel. figure 2: ct scan abdomen showing intraperitoneal adhesions encapsulating small gut. as patient didn’t respond to conservative management, he had exploratory laparotomy. perop findings were; 500ml ascitic fluid, thick fibrous membrane enclosing whole small bowel with multiple bands and markedly dilated small bowel (figure-2) for which adhesiolysis was conducted. post-operatively patient recovered uneventfully. d i s c u s s i o n abdominal cocoon syndrome is a condition that involves peritoneum.4 it is considered a variation of retroperitoneal fibrosis or ormond disease. on the basis of the part of abdominal organ encapsulated, acs is further classified into 3 types. in type 1, only part of the small intestine is encased while in type 2, the entire small intestine is covered by membrane and in last type, abdominal organs like stomach, ovaries, liver or appendix can be encapsulated.2 patients of this condition have complaints of abdominal pain and constipation associated with vomiting. abdominal x-ray in erect view shows multiple airfluid levels, finding being non-specific. sonography usually reveals dilated bowel loops, and specific trilaminar appearance formed by the gut wall, overlying membrane, and posterior abdominal wall with which bowel loop is adherent.5 the j islamabad med dental coll 2023 152 findings on ct scan are consistent with features of intestinal obstruction along with of abdominal cocoon in which there are conglomerated, adherent gut loops enclosed in thick peritoneal membrane giving an appearance of cauliflower sign in the center of abdomen. if secondary acs is suspected then, further investigations like esr, gene xpert for tuberculosis and even biopsies with diagnostic laparoscopy are taken to rule out inflammatory, malignant, autoimmune and gynecological cause.6 exploratory laparotomy with complete excision of membrane and adhesiolysis is considered the surgical treatment of choice. abdominal cocoon syndrome must be considered by surgeons to be a cause of intestinal obstruction after other causes been ruled out. computed tomography of the abdomen is a useful radiological investigation for establishing preoperative diagnosis. adhesiolysis is the treatment of choice. in general, the outcome of this management showed satisfactory results. r e f e r e n c e s 1. krishna dhali g, akbulut s, minh duc n, alsadery ha. abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): an extremely rare cause of small bowel obstruction—two case reports and a review of literature. https://www.frontiersin.org/journals/medicine. 12 october 2022 doi 10.3389/fmed.2022.1003775 2. karona p, blevrakis e, kastanaki p, tzouganakis a, kastanakis m. abdominal cocoon syndrome: an extremely rare cause of small bowel obstruction. cureus. 2021 apr 7; 3. çolak ş, bektaş h. abdominal cocoon syndrome: a rare cause of acute abdomen syndrome. ulusal travma ve acil cerrahi dergisi. 2019;25(6):575–9. 4. singh au, subedi ss, yadav tn, gautam s, pandit n. abdominal cocoon syndrome with military tuberculosis. clin j gastroenterol. 2021 apr 1;14(2):577–80. 5. chorti a, panidis s, konstantinidis d, cheva a, papavramidis t, michalopoulos a, et al. abdominal cocoon syndrome: rare cause of intestinal obstruction case report and systematic review of literature. vol. 101, medicine (united states). lippincott williams and wilkins; 2022. p. e29837. chorti et al • medicine 101(27):p e29837, july 8, 2022. | doi: 10.1097/md.0000000000029837 6. aziz w, malik y, haseeb s, mirza rt, aamer s. abdominal cocoon syndrome: a laparoscopic approach. cureus 2021. 13(7): e16787. doi 10.7759/cureus.16787 https://www.frontiersin.org/journals/medicine https://journals.lww.com/md-journal/toc/2022/07080 https://journals.lww.com/md-journal/toc/2022/07080 j islamabad med dental coll 2022 222 open access c -reactive protein, leukocyte count and neutrophils: a diagnostic aid in acute appendicitis ashar ahmed khan1, abdul manan2, irfan ahmed3, tania mahar4, muhammad usman5, abdul qadir6. 1,2,3associate professor, department of surgery, nishtar hospital, multan, pakistan. 4,6assistant professor, department of surgery, nishtar hospital, multan, pakistan. 5senior registrar, department of surgery, nishtar hospital, multan, pakistan. a b s t r a c t background: many clinical methods, scoring systems, radiological and laboratory investigations are used to diagnose and differentiate simple from complicated appendicitis. proactive approach results in high rate of negative appendectomies and conservative approach results in increased rate of post-operative complications. the objective of this study was to evaluate the role of crp, tlc and neutrophil percentage in the diagnosis and differentiation of simple and complicated appendicitis. methodology: this cross sectional study was conducted at department of surgery, nishtar medical university/hospital, multan from 1st november, 2019 to 30th april, 2021. blood samples from patients were collected after admission, for crp, tlc and neutrophil percentage. data were collected and analyzed through spss version 23. results: a total of 320 patients more than 12 years of age, 168 (52.5%) male and 152 (47.5%) female with 1.10:1, were included in the study. sensitivity, specificity, positive predictive value (ppv) and negative predictive values (npv) of crp were 90.6%, 80%, 96% and 61.5% for acute appendicitis and 96.7%, 80%, 98.3%, and 66.7% for perforated appendicitis respectively with p-value of <0.000. sensitivity, specificity, ppv and npv of tlc were 87.5%, 80%, 95.9% and 54.5% for acute and 93.3%, 90%, 99.1% and 52.9% for perforated appendicitis with p= <0.000. sensitivity, specificity, ppv and npv of neutrophils, in acute and perforated appendicitis were 83.8%, 76.7%, 95%, and 46.9% versus 87.5%, 70%, 97.2%, 31.8% respectively with p-value < 0.000. conclusion: sensitivity, specificity and ppv of crp, tlc and neutrophils increased with the severity of appendicitis. combining the results of the above three markers increased the diagnostic accuracy. keywords: acute appendicitis, crp (c-reactive protein), tlc (leukocyte count) and neutrophils. cite this article. khan a a, manan a, ahmed i, mahar t, usman u, qadir a. c -reactive protein, leukocyte count and neutrophils: a diagnostic aid in acute appendicitis. j islamabad med dental coll. 2022; 11(4): 222-228. funding source: nil conflict of interest: nil doi: https://doi.org/10.35787/jimdc.v11i4.741 i n t r o d u c t i o n abdominal pain and vomiting are the commonest presentations in surgical emergency.1 appendicitis is commonest condition, which requires surgical intervention. there is 7-8 % life time risk to develop acute appendicitis. even in the presence of modern technology, proper diagnosis of acute appendicitis is still a challenge. proactive approach results in high rate of negative appendectomy and conservative approach results in increased rate of post-operative complications like pelvic abscess, fecal fistula, intestinal obstruction and wound infection. rate of negative appendectomy mentioned in the literature is about 20%. this rate increased to 30-50% in authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3,4critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: ashar ahmed khan email: asharahmed71@hotmail.com article info: received: july 10, 2021 accepted: december 20, 2022 o r i g i n a l a r t i c l e j islamabad med dental coll 2022 223 females of child bearing age. about 0.05% of geriatric population (>65 years) develops acute appendicitis each year, which is quite significant.2 diagnosis is difficult and complication rate is very high in this age group. rate of complicated appendicitis reported in literature is 30 to 35%.3 literature showed that mortality rate increases to 6% in cases of perforated appendicitis as compared to only 0.3% in simple appendicitis. hospital stay also increases in cases of perforated appendicitis as compared to acute appendicitis (5 versus 3 days).4 in the past many clinical methods and scoring systems were devised for early diagnosis and differentiation of simple from complicated appendicitis. alvarado/ modified alvarado scores were the most frequently used scores. these were useful in the west but their sensitivity and specificity were found to be very low in middle east and asia. there was a need of an objective test for proper diagnosis of acute appendicitis. ultrasound was helpful in the diagnosis of acute appendicitis with reported sensitivity and specificity of 82% and 97% respectively.5 ct scan has high sensitivity (99%) and specificity (95%)6 but its use is limited because of high cost, limited availability and risk of radiations, especially in children and females of child bearing age. efforts were made to use different inflammatory markers to make an early diagnosis. among these are tlc, neutrophil percentage, crp, serum bilirubin, serum amyloid a, procalcitonin and esr are important markers.7 crp is an acute phase protein produced in the liver. interleukin-6 plays an important role in its production and is increased to 10 to 1000 times in a few minutes. crp is nonspecific and increased in pregnancy, infection, autoimmune disorders, inflammatory arthritis, neoplasia and aging.8 literature search showed variable sensitivity and specificity of crp for the diagnosis of acute appendicitis. sensitivity varies with duration of symptoms and presence of other inflammatory conditions. the objective of our study was to evaluate the role of crp, tlc, and neutrophils in diagnosis and differentiation of simple from complicated appendicitis. m e t h o d o l o g y this cross-sectional study was conducted at general surgery department, nishtar medical university/hospital, multan from 1st november, 2019 to 30th april, 2021, after approval from institutional review board (irb). a total of 320 patients more than 12 years of age and who underwent appendectomy in the emergency were selected by consecutive and nonrandomized technique. patients with other inflammatory and autoimmune disease were excluded from the study. blood samples were taken for cbc, neutrophils and crp in the first hour of admission. predesigned proforma was used and was filled in by senior surgical resident on duty in emergency department. patient’s information regarding age, gender, duration of signs and symptoms, cbc, neutrophil percentage, crp, operative findings and histopathology reports were noted. decision for appendectomy was taken by resident consultant surgeons (senior registrar). the main outcome was to assess the role of crp, tlc and neutrophils in the diagnosis of acute appendicitis (which was later confirmed by histopathology). the efficacy of these tests was measured in terms of sensitivity, specificity, ppv and npv. data entry and analysis was done through spss version 23. validity (sensitivity and specificity) and yield (positive and negative predictive values) of crp, tlc and neutrophils were calculated. pearson chi-square test was applied and p-value less 0.05 was considered significant. r e s u l t s a total 320 patients >12 years of age who underwent emergency appendectomy in er department, were included in the study. crp value above 10 mg/l was taken as raised. sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of crp were 87.5%, 80%, 95.9%, and 54.5% j islamabad med dental coll 2022 224 respectively in acute appendicitis with p-value of < 0.000. sensitivity, specificity, ppv and npv in perforated appendicitis were 96.7%, 80%, 98.3%, and 66.7% respectively with pvalue of < 0.000. sensitivity, specificity, ppv and npv of tlc in histologically proven acute appendicitis was 90.6%, 80%, 96% and 61.5% respectively with significant p value, <0.000. sensitivity, specificity and ppv of tlc increased in cases of perforated appendicitis to 93.3%, 90%, 99.1% and npv decreased to 52.9% respectively. p-value = < 0.000. sensitivity, specificity, ppv and npv of neutrophil percentage in acute and perforated appendicitis were 83.8%, 76.7%, 95%, and 46.9% versus 87.5%, 70%, 97.2%, 31.8% respectively with p-value= < 0.000. tablei: demographic data (n=320) age in years gender male no (percentage) female no (percentage) 12-20 year 66 (20.62) 58 (18.12) 21-30 year 76 (23.75) 60 (18.75) >30 year 26 (8.1) 34 (10.62) total 168 (52.5) 152 (47.5) table ii: inflammatory markers in acute appendicitis (n= 320) histopathological findings raised leucocyte count raised neutrophils raised crp normal appendix n=40 (12.5%) 18/40 (45%) 21/40 (52.5%) 18/40 (45%) acute appendicitis n=160 (50%) 145/160 (76.25%) 134/160 (68.75%) 140/160 (74.3%) perforated appendicitis n=120 (37.5%) 112/120 (91.6%) 105/120 (81.6%) 116/120 (90%) (reference values: tlc= 4000-10,000 mm3, neutrophils=50-75%, crp= <10 mg/dl) table iii: inflammatory markers in acute appendicitis (n = 320) histopathological finding tlc mean ± sd neutrophils mean ±sd crp mean ± sd normal appendix n=40 (12.5%) 6.8 ± 5.1 64.6 ± 13.4 8.6 ± 11 acute appendicitis n=160 (50%) 11.4 ± 4.2 76 ± 14.2 18.6 ± 22.4 perforated appendicitis n=120 (37.5%) 12.3 ± 6.4 81.6 ± 7.3 61.4 ± 52 tableiv: predictive value of inflammatory markers (n=320) diagnostic test validity & yield acute appendicitis gangrenous/perforated appendicitis crp sensitivity 87.5% 96.7% specificity 80% 80% ppv 95.9% 98.3% npv 54.5% 66.7% p-value < 0.000 < 0.000 tlc sensitivity 90.6% 93.3% j islamabad med dental coll 2022 225 specificity 80% 90% ppv 96% 99.1% npv 61.5% 52.9% p-value < 0.000 < 0.000 neutrophils sensitivity 83.8% 87.5% specificity 76.7% 70% ppv 95% 97.2% npv 54.5% 31.8% p-value < 0.000 < 0.000 (crp= c-reactive protein, tlc= total leukocyte count, ppv= positive predictive value and npv= negative predictive value) d i s c u s s i o n appendicitis always poses a diagnostic challenge for general surgeons. clinical findings can confirm the diagnosis in only 50 % cases. delay in diagnosis leads to gangrene and perforation of the appendix (in upto 50% cases).9 in the past many scoring systems, inflammatory markers, ultrasonography and ct scan were used to reduce the rate of negative and complicated appendicitis. ultrasound is cost effective, noninvasive and repeatable investigation but it is operator dependent thus, has wide range of sensitivity (67-100%) and specificity (95-100%). visualization of the appendix can increase sensitivity and specificity of usg.5 external diameter of the appendix can be used to differentiate between acute and perforated appendicitis, 6.9mm versus 7.63 mm repectively.10 among total of 320 patients in current study, sixty (18.75%) were above the age of 30 years and 260 (81.25%) were below 30 years, among these, the most prevalent age group was 21-30 years (38.8%). rimsha et al mentioned age range of 13-60 years with the most prevalent group 21-30 years (38.8%) in their study.11 shefki et al reported age range of 559 years with median age of 19.7 years.8 faith mehmet et al mentioned mean age of 39.23±18.02 and 35.27±14.8 years in histologically positive and negative appendicitis respectively.12 the m:f ratio mentioned in different studies was 2.2: 111, 1:1.219 and 1: 1.18.13 results of two studies were comparable with our study but the study done by rimsha showed male patients double of the female patients.11 among 320 patients included in our study, 40 (12.5%) were found to have a normal appendix on histopathology, the findings somewhat comparable to 20% mentioned by satendra kumar.1 high rate was mentioned by david keohane14 (27.4%) and rimsha et al11 (19.78%) respectively and a low rate was mentioned by nauman ahmed (7.1%).13 in the present study, 160 (50%) patients had acute and 120 (37.5%) gangrenous/ perforated appendicitis. rate of gangrenous/ perforated appendicitis in our study was comparable to that reported by cristina et al and savas bayrak (31.7 % and 17.14% respectively).3,2 khurram et al and shefki et al reported high rate in 15.7%9and 52.6%8 respectively. in our study, sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of crp was 87.5%, 80%, 95.9%, 54.5% in acute appendicitis and 96.7%, 80%, 98.3%, and 66.7% in perforated appendicitis respectively. significant increase was noted in perforated appendicitis. the results were comparable with sensitivity and specificity of 57% and 87% respectively for crp reported by c.-w.yu et al in his meta-analysis.15 faith mehmet et al mentioned very low sensitivity (37.5%) and 86.7% specificity for crp.12 khurram siddique et al reported sensitivity, specificity, ppv, npv and diagnostic accuracy of crp in simple acute and perforated appendicitis were 75%, 72%, 90%, 46%, 75.5% versus 93%, 40%, 23%, 97% and 50% j islamabad med dental coll 2022 226 respectively.9 very low sensitivity (25.9%) but high specificity (100%) of crp was reported by nauman ahmed et al from quetta when they use crp > 24 mg/l. he also mentioned that crp> 48 mg/l as an indicator for perforated appendix.13 okus et al reported that patients having crp=80.8 mg/l or above did not respond to conservative therapy.16 nalin h et al mentioned that 8.54% patients with confirmed acute appendicitis present with normal crp.17 sevgi buyukbese et al highlighted the importance of cut off value of crp regarding its sensitivity and specificity. they reported change in sensitivity, specificity, ppv, npv and diagnostic accuracy of crp from 70.9%, 68.7%, 62.9%, 75.8% and 69.6% when crp= 6mg/l to 86.1%, 81.9%, 58.6%, 95.2% and 77.7% when crp=11.7 mg/l respectively.18 this explains the difference in results among studies. in our study, sensitivity, specificity, ppv and npv of tlc in histologically proven acute appendicitis were 90.6%, 80%, 96%, 61.5% and 93.3%, 90%, 99.1%, 52.9% in perforated appendicitis respectively. results showed that there is increase in sensitivity, specificity and ppv while decrease in npv in cases of perforated appendicitis. our results are comparable to the study done by c.-w.yu et al in which sensitivity and specificity of tlc were 62% and 75% respectively.15 faith mehmet et al reported sensitivity and specificity of tlc 65% and 60% respectively.12 sensitivity, specificity, ppv and diagnostic accuracy of tlc reported by shefki xharra were 82.6%, 85%, 68% and 94% respectively.8 sensitivity, specificity, ppv, npv and diagnostic accuracy of tlc in acute and perforated appendicitis reported by khurram siddique were 80.5%, 68%, 89%, 50% and 77% versus 93%, 40%, 21%, 96% and 44% respectively.9 sensitivity and specificity of neutrophils were low in our study as compared to crp and tlc. sensitivity, specificity, ppv and npv in acute and perforated appendicitis were 83.8%, 76.7%, 95%, and 46.9% versus 87.5%, 70%, 97.2%, 31.8% respectively with p-value= < 0.000. our results are close to the results reported by shefki xharra et al which showed sensitivity, specificity, ppv and diagnostic accuracy of neutrophils were 79.1%, 68%, 93.6% and 77.5% respectively.8 faith mehmet et al mentioned sensitivity and specificity of 74.7% and 80% for neutrophil count.12 joshua davis et al19 and david keohane et al14 reported sensitivity and specificity of neutrophil percentage were 86.5%, 70.8% and 82%, 62.5% respectively. kelly me et al used nlr (neutrophil to lymphocyte ratio) to differentiate simple (7.29) from perforated appendicitis (13.6%).20 muhammad h. abbas et al used different inflammatory markers and they reported high sensitivity of saa (serum amyloid a) and proct (procalcitonin) 91.8% and 85% than tlc (80.3%) and crp (75%).21 when crp, tlc and neutrophil percentage were combined, there was a marked increase in sensitivity (96.5%), specificity (80%), ppv(98%) and npv(56.6%). similar trend was seen in other studies also. in combination sensitivity, specificity, ppv and npv reported were 96%, 45.3%, 82.7% and 80.6% by david keohane et al14 and 95.3%, 72.2%, 95.3% by shefkin xharra8 respectively. limitations of this study are that it was done in only one center and crp, tlc and neutrophils were done only once after admission. in equivocal cases, if we had repeated the inflammatory markers after 12 or 24 hours, it would have been more beneficial. c o n c l u s i o n inflammatory markers crp, tlc and neutrophils are useful and their sensitivity, specificity and ppv increase with the severity of appendicitis. sensitivity and specificity of crp and tlc are greater than neutrophils. combining the results of above three markers increased the diagnostic accuracy. r e c o m m e n d a t i o n we recommend to perform crp in addition to tlc and neutrophils as a routine test for the diagnosis of acute appendicitis. j islamabad med dental coll 2022 227 r e f e r e n c e s 1kumar s, maurya j, kumar s, patne sk, dwivedi a. a study of c-reactive protein and d-dimer in patients of appendicitis. j family med prim care, 2020; 9(7):3492-95. doi: 10.4103/jfmpc.jfmpc_197_20. 2bayrak s, tatar c, cakar e, colak s, gunes me, tekesin k et al. evaluation of the predictive power of laboratory markers in the diagnosis of acute appendicitis in the elderly. north clin istanb 2019;6(3):293-301. doi: 10.14744/nci.2019.93457. 3amador cg, arteaga v, plaza rd, torralba m, veladco am, ramia jm. evaluation of preoperative clinical and serological determination in complicated acute appendicitis: a score for predicting complicated appendicitis. cir esp 2021; 99 (4): 282-288. doi: 10.1016/j.ciresp.2020.05.031. 4koymen s, ismail d. the role of c-reactive protein to lymphocyte ratio in the differentiation of acute and perforated appendicitis. ulus travma acil cerrahi derg 2020; 26: 760-64. doi: 10.147444/tjtes.2020.47973. 5lofvenberg f, salo m. ultrasound for appendicitis: performance and integration with clinical parameters. biomed reseach international 2016; 5697692. doi.org/10.1155/2016/5697692. 6kim th, sun cho b, jung jh, lee ms, jang jh, kim cn. predictive factors to distinguish between patients with non-complicated appendicitis and those with complicated appendicitis. ann coloproctol 2015; 31 (5):192-197. doi: 10.3393/ac.2015.31.5.192. 7tanrikulu cs, karamercan ma, tanrikulu y, ozturk m, yuzbasioglu y, coskun f et al. the predictive value of alvarado score, inflammatory parameters and ultrasound imaging in the diagnosis of acute appendicitis. ulus cerrahi derg 2016; 32: 115-121. doi: 10.5152/ucd.2015.3103. 8xharra s, gashi-luci l, xharra k, veselaj f, bicaj b, sada f et al. correlation of serum c-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis. world journal of emergency surgery 2012; 7:27. doi: 10.1186/1749-7922-7-27. 9siddique k, baruah p, bhandari s, mirza s, harinath g. diagnostic accuracy of white cell count and creactive protein for assessing the severity of paediatric appendicitis. j r soc med sh rep 2011; 2:59. doi: 10.1258/shorts.2011.011025. 10kartal k, yazici p, unlu tm, uludag m, mihmanli m. how to avoid negative appendicectomies: can us achieve this? ulus trauma acil cerrahi derg 2017; 23(2): 134-138. doi: 10.5505/tjtes.2016.79328. 11fatima sr, zaheer f, moosa fa, shah s, arqam m, mussab rm et al. combine diagnostic accuracy of total leukocyte count, neutrophil %age and ultrasonography for the diagnosis of acute appendicitis. cureus 2021; 13086. doi: 10.7759/ cureus. 13086. 12yazar fm, urfalioglu a, bakacak m, boran of, bulbuloglu e. efficacy of the evaluation of inflammatory markers for the reduction of negative appendectomy rates. indian j surg 2018; 80(1): 61-67. doi: 10.1007/s12262-016-1558-y. 13ahmed n. c-reactive protein: an aid for diagnosis of acute appendicitis. j ayub med coll abbottabad 2017; 29(2): 250-3. 14keohane d, leary po, nagle m, cichelli k, mccormack t. a correlation of blood panel results and histologically confirmed appendicitis. cureus 2020; 12 (9): e 10641. doi: 10.7759/ cureus. 10641. 15 yu cw, juan li, wu mh, shen cj, wu jy, lee cc. systemic review and meta-analysis of the diagnostic accuracy of procalcitonin, c-reactive protein and white blood cell count for suspected acute appendicitis. british journal of surgery 2013; 100: 322-29. doi: 10.1002/bjs.9008. 16okus a, ay s, karahan o, eryilmaz ma, sevinc b, aksoy n. monitoring c-reactive protein levels during medical management of acute appendicitis to predict the need for surgery. surg today 2015; 45(4): 451-6. doi:10.1007/s00595-014-10996 17nalin h, dayawansa, julian d, segan s, yao hhi, hon i et al. incidence of normal white cell count and c-reactive protein in adults with acute appendicitis. anz j surg 2016. doi: 10.1111/ans.13760. 18sarsu sb, sarc f. diagnostic value of white blood cell and c-reactive protein in pediatric appendicitis. bio med research international, 2016; 6508619. doi: org/10.1155/2016/6508619. 19davis j, kasmire k. utility of symptom duration and c-reactive protein, white blood cell count and absolute neutrophil %age in the evaluation of pedistric appendicitis. j emerg med 2021; 60 (4): 428-35. doi: 10.1016/j.jemermed.2020.10.040. 20kelly me, khan a, riaz m, bolger jc, bennani f, khan w et al. dig surg 2015; 32 (6): 459-63. doi: 10.1159/000440818. 21abbas mh, choudhry mn, hamza n, ali b, amin aa, ammori bj. admission levels of serum amyloid a and procalcitonin are more predictive of the diagnosis of acute appendicitis compared with creactive protein. surg laparosc endosc percutan j islamabad med dental coll 2022 228 tech 2014; 24 (6): 488-494. doi: 10.1097/sle.0000000000000067. j islamabad med dental coll 2019 107 open access accuracy, sensitivity and specificity of oral brush cytology in the diagnosis of oral epithelial lesions abdul majid1, bushra sajid2, kiran shaikh2, amin fahim3, farkhunda nadeem4, ghulam shah nizaman4 1 assistant professor, department of pathology, isra university hyderabad 2 lecturer, department of pathology, isra university hyderabad 3 associate professor, department of pathology, isra university hyderabad 4 professor, department of pathology, isra university hyderabad a b s t r a c t background: oral squamous cell carcinoma (scc) is highly prevalent in pakistan than the rest of the world. five-year survival rate is 80% if scc is diagnosed at an early stage. the survival rate declines to 20% if diagnosed at a later stage. the objective of the present study was to find out the usefulness of oral brush cytology in detecting oral lesions. material and methods: in the present prospective observational study, 88 samples were collected from maxillofacial surgery outpatient department (opd), liaquat university hospital and isra university hospital from july 2015 to december 2015. after taking written informed consent, oral brush cytology was performed and stained with standard papanicolaou (pap) staining protocol. the biopsy of the patients was performed by standard protocols of oral biopsy and specimen preserved in 10% buffered formalin. cross tabulation between diagnosis of brush cytology and biopsy of same patients was done and accuracy, sensitivity and specificity were calculated. results: according to the distribution of patients on brush cytology, 59.1% patients were diagnosed with malignant tumors, whereas 17.1% had benign tumors. on biopsy of the same patients, squamous cell carcinoma was confirmed in 72.7% and benign tumors were found in 17% of the patients. comparison of brush cytology with biopsy of same patients revealed no significant difference. accuracy, sensitivity and specificity of brush cytology of the oral cavity for detection of malignant tumor were calculated as 86.36%, 81.25% and 100% respectively. whereas accuracy, sensitivity and specificity of brush cytology of the oral cavity for detection of benign and inflammatory conditions were 100%. conclusion: oral brush cytology has good accuracy, sensitivity and specificity for detection of oral epithelial lesions and can be useful in early detection of oral cancer as well as other lesions. moreover, as an easy-to-do, painless and non-invasive procedure, it can be a good screening method for detection of oral lesions. key words: biopsy, cytology, squamous cell carcinoma authors’ contribution: 1-3 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 4-6 active participation in data collection data analysis. correspondence: amin fahim email: draminfahim@gmail.com article info: received: february 4, 2019 accepted: july 19, 2019 cite this article. majid a, sajid b, shaikh k, fahim a, nadeem f, nizamani gs. accuracy, sensitivity and specificity of oral brush cytology in the diagnosis of oral epithelial lesions. j islamabad med dental coll.2019; 8(3):107-111. doi:10.35787/jimdc. v8i3.289 funding source: nil conflict of interest: nil i n t r o d u c t i o n oral lesions are very commonly reported lesions in the world, including pakistan. these lesions are broadly classified into inflammatory, benign, potentially malignant and malignant.1 among malignant neoplasm, oral squamous cell carcinoma (oscc) is the most common and constitutes 90% of all head and neck cancers, while other cancers are adenocarcinomas and salivary gland tumors.2,3 in 2013, 1,35,000 people died from oral cancer, whereas in the year 1990, 84,000 people died from this disease, which means that the global burden of this disease is o r i g i n a l a r t i c l e j islamabad med dental coll 2019 108 increasing day by day.4,5 five-year survival rate is 80% with an early stage diagnosis of the malignancy, whereas the survival rate declines to 20% if diagnosed at a late stage.6 conventional method of diagnosing squamous cell carcinoma is biopsy of the lesion followed by a histopathological diagnosis.7 most of the patients in our setup are habituated to tobacco, cigarette smoking, betel quid, areca nut and gutka. they usually present very late, when little can be done for them.8 early diagnosis of cancer can be helpful in improving the five-year survival rate.8,9 oral brush cytology is a technique in which cells are obtained from a lesion by scrapping its surface and smears are made for cytopathological analysis. it has been introduced for diagnosis of oral lesions. it has certain advantages over biopsy. this technique is based on the principal that cancer cells are less cohesive and can easily be scraped off. research studies in some parts of the world show exfoliative cytology as a diagnostic tool while some use fine needle aspiration cytology.10,11 in the present study, brush cytology samples were collected from clinically detectable lesions followed by a standard biopsy of the lesion. rationale of this study is to see the usefulness of oral brush cytology for detection of oral lesions. oral brush cytology is not the routine practice of dental practitioners for detection of oral lesion. through this study, we want to know about the accuracy, sensitivity and specificity of oral brush cytology for early detection of oral lesions. m a t e r i a l a n d m e t h o d s in this comparative experimental study, samples were collected by non-probability purposive sampling from maxillofacial surgery opd of isra dental hospital, isra university hyderabad and oral and maxillofacial surgery opd, liaquat university hospital hyderabad from july 2015 to december 2015. study was approved by ethical review committee of isra university hospital. for calculation of sample size yamane formula was used at confidence interval of 95% and 0.05 degree of variability12.thus a total of 88 patients who presented with leukoplakia, erythroplakia or growth in oral cavity were included in the study. patients with oral lesions in whom biopsy could not be done and those who refused to give consent were excluded from the study. the whole procedure was explained to the patients and written informed consent was taken. oral brush cytology was performed by using tooth brush. the material was spread on a glass slide, then fixed in alcohol and stained with standard pap staining protocol. the stained slide was observed under light microscope. biopsy was performed using standard protocols of oral biopsy by the dental surgeon. specimen was preserved in 10% buffered formalin. gross examination was followed by staining the slides with haematoxylin and eosin stains for light microscopy. all the histopathological findings were recorded on a proforma. spss version 21.0 was used to analyze data. categorical variables were analyzed using chi-square test. means (±sd) were calculated for continuous variables and percentages and frequencies were recorded for categorical variables, respectively. data was exhibited as graphs, tables and charts. p-value ≤ 0.05 was described as significant. accuracy, sensitivity and specificity were calculated by using the following formula.13 accuracy=true positives +true negatives x100 total number of patients sensitivity=true positives x100 true positives +false negatives specificity=true negatives x100 true negatives +false positives whereas; true positive (tp) = diagnosed as positive on both oral brush cytology and oral biopsy true negative (tn) = diagnosed as negative on both oral brush cytology and oral biopsy false positive (fp) = diagnosed as positive on oral brush cytology and negative on oral biopsy false negative (fn) = diagnosed as negative on oral brush cytology but positive on oral biopsy. r e s u l t s according to the distribution of patients on brush cytology, 17.1% had benign tumors (figure 1) and 59.1% patients were found with malignant tumor (figures 2 and 3). on biopsy of the same patients, squamous cell carcinoma j islamabad med dental coll 2019 109 was confirmed in 72.7% and benign tumors were found in 17% of the patients. figure 4 reveals well differentiated squamous cell carcinoma on histology. comparison of brush cytology with biopsy of same patients revealed no significant difference (table i). true positive cases diagnosed as positive on both oral brush cytology and oral biopsy were 52, whereas true negative cases diagnosed as negative on both oral brush cytology and oral biopsy were 24 in number. there were no false positive cases diagnosed as positive on oral brush cytology and negative on oral biopsy. the false negative cases diagnosed as negative on oral brush cytology but positive on oral biopsy were 12 in number (table 2). figure 1: oral brush cytology in a patient with benign oral lesion (using a tooth brush). the accuracy, sensitivity and specificity of oral brush cytology for malignant tumors were calculated and found to be 86.36%, 81.25% and 100% respectively. whereas brush cytology for detection of benign and inflammatory conditions revealed that all the 15 cases of benign tumors and 06 cases as inflammatory were confirmed as benign and inflammatory on biopsy respectively without any variation. figure 2: gross appearance of an oral malignant lesion. figure 3: oral brush cytology smear showing malignant cell. figure 4: histological section showing well-differentiated squamous cell carcinoma (h&e; 40x) table i: comparison of oral brush cytology with oral biopsy in patients with oral lesions (n= 88) diagnosis oral brush cytology n (%) oral biopsy n (%) p-value malignant tumor 52(59.1) 64(72.7) 0.89 benign tumor 15(17.1) 15(17) suspicious for malignancy 06(6.8) 00(0) inflammatory 06(6.8) 06(6.8) material inadequate 09(10.2) 03(3.4) table ii: distribution of patients diagnosed by oral brush cytology and biopsy (n= 88) diagnosis by oral brush cytology diagnosis by biopsy total yes no yes 52(tp) 0(fp) 52 no 12(fn) 24(tn) 36 total 64 24 88 j islamabad med dental coll 2019 110 d i s c u s s i o n squamous cell carcinoma of the oral cavity constitutes 90% of all oral cancers.1 the incidence of oral cancer is 2% to 4% in the western countries while it is very high in south asian countries like pakistan and india. in india, oscc accounts for 40% of all cancers,14 while in pakistan the prevalence of oral cancer is highest than rest of the world.15 the diagnostic accuracy of the brush biopsies was calculated in a study by remmerbach et al16 reporting a sensitivity of 97.8% and specificity of 100%. another study by maraki and colleagues17 exhibited cytology along with dna cytometry to be highly specific, sensitive and non-invasive technique resulting in 100% sensitivity. an additional study also established a high sensitivity (92.5%) and specificity (100%) of the cytological diagnosis for oscc. driemel et al18 estimated the oral brush biopsies performance by means of standard morphological analysis to detect oscc and their respective precursor lesions, with a sensitivity of 79% and specificity of 93% respectively. in another study of remmerbach and coworkers19 a high diagnostic accuracy of oral brush cytology in doubtful oral lesions was reported with a specificity of 99.5% and sensitivity of 94.6%. babshet et al20 stated that the oral brush cytology had a sensitivity of 71.4%, using oral cdx technique. a uk audit with hindsight established the specificity, sensitivity and negative and positive predictive rates of brush cytology in the diagnosis of pre-malignant lesions in 112 cases exhibited a sensitivity of 71.4% in detection of oscc or dysplasia. present study is consistent with all these studies, as it shows an accuracy of 86.3%, sensitivity of 81.25% and specificity of 100%. thus, oral brush cytology followed by biopsy and histopathological examination have a significant role in diagnosis and can be recommended for all patients exposed to risk factors of developing oral cancer, for example tobacco chewers. oral brush cytology may as well be applied as a population screening test for early detection of squamous cell carcinoma of oral cavity. it can also help in follow up after operation. in this way oral brush cytology could help in improving the five-year survival rate. c o n c l u s i o n the present study concludes that oral brush cytology has good accuracy, sensitivity and specificity for detection of oral epithelial lesions and can be useful in early detection of oral cancer as well as other lesions. brush cytology is an easy and painless procedure, and due to its noninvasiveness can be a good screening method for detection of oral lesions. r e f e r e n c e s 1. haines, gk "pathology of head and neck cancers i: epithelial and related tumors". head & neck cancer: current perspectives, advances, and challenges. springer science & business media. 2013;257–87. doi: 10.1007/978-94-007-5827-8 2. chi ac, day ta, neville bw. oral cavity and oropharyngeal squamous cell carcinoma—an update.ca cancer j clin 2015; 65(5):401–21. doi: 10.3322/caac.21293 3. porcheri c, meisel ct, mitsiadis t. multifactorial contribution of notch signaling in head and neck squamous cell carcinoma. int. j. mol. sci. 2019, 20(6), 1520. doi: 10.3390/ijms20061520. 4. naghavi m, wang h, lozano r, davis a, liang x, zhou m, et al. global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study 2013. lancet 2015; 385(9963): 117–71. doi: 10.1016/s01406736(14)61682-2 5. martin-hernan f, sanchez-hernandez jg; cano j, campo j, del romero j. "oral cancer, hpv infection and evidence of sexual transmission". med oral, patol oral cir bucal 2013;18(3): 439–44. doi: 10.4317/medoral.18419 6. cancer institute. seer stat fact sheets: oral cavity and pharynx cancer. available at: http://seer.cancer.gov/statfacts/html/oralcav.html. 2015. 7. maher ng, collgros h, uribe p, ch’ng s, rajadhyaksha m, guitera p. in vivo confocal microscopy for the oral cavity: current state of the field and future potential. oral oncol, 2016, 54 28-35. doi: 10.1016/j.oraloncology.2016.01.003. j islamabad med dental coll 2019 111 8. fang qg, shi s, li zn, zhang x, liua fy, xu zf et al. squamous cell carcinoma of the buccal mucosa: analysis of clinical presentation, outcome and prognostic factors. mol clin oncol. 2013; 1(3): 53134. doi: 10.3892/mco.2013.86 9. keshavarzi m, darijani m, fatemeh m. molecular imaging and oral cancer diagnosis and therapy. j. cell bioche. 2017; 118(10): 3055-60. doi: 10.1002/jcb.26042 10. kumaresan gd, jagannathan n. exfoliative cytologya predictive diagnostic tool. int j pharma pharm sci. 2014;6(5):1-3. 11. chaturvedi p, datta s, arya s, rangarajan v, kane sv, naird et.al. prospective study of ultrasound‐guided fine‐needle aspiration cytology and sentinel node biopsy in the staging of clinically negative t1 and t2 oral cancer. head neckj sci spec. 2015; 37(10):1504-8. doi: 10.1002/hed.23787. 12. yamane, taro. statistics: an introductory analysis, 2nd edition, new york: harper and row. 1967. 13. baratloo a, hosseini m, negida a, el ashal g. part 1: simple definition and calculation of accuracy, sensitivity and specificity. emerg (tehran)., 2015; 3(2): 48-9. pmid: 26495380 14. mehrotra r, singh m, kumar d, pande an, gupta rk, sinha us. age specific incidence rate and pathological spectrum of oral cancer in allahabad. ind j med sci. 2003;57(9):400–4. pmid: 14515030 15. siddiqui pqr. oral cancer: a new epidemic can be foreseen in pakistan, pakistan journal of medicine and dentistry 2013, 2 (01): 1-2. 16. remmerbach tw, mathes sn, weidenbach h, hemprich a, bocking a. noninvasive brush biopsy as an innovative tool for early detection of oral carcinomas. mund kiefer gesichtschir. 2004; 8:22936. doi: 10.1007/s10006-004-0542-z 17. maraki d, becker j, boecking a. cytologic and dnacytometric very early diagnosis of oral cancer. j oral pathol med 2004; 33(7):398-404. doi: 10.1111/j.1600-0714.2004. 0235.x 18. driemel o, kunkel m, hullmann m, kleinsasser n, staudenmaier r, muller-richter u, et al. performance of conventional oral brush biopsies. hno. 2008; 56(2):205-10. doi: 10.1007/s00106-007-1662-1 19. remmerbach tw, weidenbach h, muller c, hemprich a, pomjanski n, buckstegge b et al. diagnostic value of nucleolar organizer regions (agnors) in brush biopsies of suspicious lesions of the oral cavity. anal cell pathol. 2003;25(3):139-46. pmid: 12775918 20. babshet m, nandimath k, pervatikar sk, naikmasur vg. efficacy of oral brush cytology in the evaluation of the oral premalignant and malignant lesions. j cytol. 2011; 28(4): 165–172. doi: 10.4103/09709371.86342. j islamabad med dental coll 2021 44 open access association of heavy school bags with musculoskeletal discomfort among primary school children of islamabad, pakistan humaira khan1, hadiqa adnan2, sara qayyaum3, hajar jamshaid3, rabiya tahir3, qurat-ul-ain2 1house officer, department of physical therapy, islamabad medical and dental college, pakistan 2lecturer, department of physical therapy, islamabad medical and dental college, pakistan 3ex student, doctor of physical therapy, shifa tameer-e-milat university islamabad, pakistan a b s t r a c t background: musculoskeletal disorders, an increasing concern among school going children, primarily affect muscles and tendons. they lead to secondary damage to nerves and joints in the neck, upper ba ck, shoulders, arms, and hands, etc. the objective of this study was to determine the association of carrying heavy school bags with musculoskeletal discomfort among primary school children in government schools of islamabad, pakistan . material and methods: this cross-sectional survey was conducted in different government schools of islamabad , pakistan from june 2018 to november 2018. after an informed consent from parents, 377 healthy school going children aged 6-14 years were included in this study. data was collected through backpack questionnaire. chi square test was used to compare the frequency of musculoskeletal discomfort with demographic characteristics and backpack -related features. p-value less than .05 was considered statistically significant. results: mean age of the school children was 9.49 ± 1.53 years with 179 (46.9%) male and 203 (53.1%) female students. majority of students (89.8%) were found with school bags more than 15% of their body weight. shoulder pain was the most commonly reported complaint (67.3%). there was a significant association between pain and perceived backpack weight (p=.001), and between pain and self-perceived posture (p=.001). leaning forward (66.2%) was the most commonly adopted posture followed by leaning sid eways (15.4%) and stooping (2.9%), respectively. the association between pain and duration of carrying backpack from home to school was insignificant ( p=.055) in contrast to pain and duration of carrying bag from school to home (p=.007), respectively. conclusions: musculoskeletal discomfort was found commonly among primary school children with shoulder pain being the most frequent, as maximum students were carrying heavy school bags . key words: back pain, musculoskeletal pain, posture, primary school ch ildren. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-6data analysis; manuscript editing. correspondence: hadiqa adnan email: hadiqa.adnan@imdcollege.edu.pk article info: received: january 21, 2020 accepted: november 10, 2020 cite this article. khan h, adnan h, qayyaum s, jamshaid h, tahir r, qurat-ul-ain. association of heavy school bags with musculoskeletal discomfort among primary school children of islamabad, pakistan. j islamabad med dental coll. 2021; 10(1): 44-50. doi: 10.35787/jimdc.v10i1.492 funding source: nil conflict of interest: nil or i gi n a l a r ti c le j islamabad med dental coll 2021 45 i n t r o d u c t i o n the way a society treats its children speaks a lot about its soul.1 children of today are adults of tomorrow. worldwide there is an increasing concern, about the musculoskeletal health of school going children.2 early morning, it is a common sight to see children going to their schools hunched over due to heavy weight of their school bags.3 musculoskeletal discomfort occurs due to repetitive injury to musculoskeletal system overtime. it primarily affects muscles and tendons and causes secondary damage to nerves and joints in the neck, upper back, shoulders, arms, and hands. 4 worldwide more than 90% of school going children use backpack. ideal posture is the one in which there is minimum amount of stress and strain and facilitate maximum efficiency of the body.5 according to the bone and joint decade, more than 2 million children between the ages of 5 to 14 years are treated yearly for musculoskeletal conditions estimating more than $7 billion.6 studies have shown that 10-30% of healthy teenage children experience low back pain.4,6 a study conducted by talbott et al. in university of cincinnati college, cincinnati usa reported pain in 33.5% of the students, while wearing backpack.7 there is evidence that the presence of musculoskeletal disorders (including neck, shoulder and low back pain) in childhood and adolescence is a significant risk factor for the development of such symptoms in adulthood.8 that is why it is important to identify these health problems at an early stage, so that its consequences in later life can be prevented.2 human growth is at a climax during puberty and growth of appendicular skeletal system comes to a halt around 18 years for males and 16 years of age for females.4 when wearing backpack, the centre of gravity shifts posteriorly. to compensate for the shift, body leans forward causing muscular distress. this postural shift is likely to cause tissue damage and has been linked with spinal pain. 4 when the backpack is carried on one shoulder, to achieve a stable position there is a lateral trunk shift. this temporary alteration in the spinal curvature is termed as functional scoliosis.5 grimmer et al. found notable relationship between the weight of the school bag and forward head posture measured as the cva ( craniovertebral angle). significant changes were observed in the cva (5.23°) with a 10% body weight backpack load among children with complaints of neck pain. 9 according to american physical therapy association guidelines, weight of the school bag should be 1015% of body weight, while the american academy of paediatrics approves 10–20% of bodyweight.10 literature shows that school bags with weight more than 20% of body weight causes back pain, increased deviation angle of upper body and cardiorespiratory changes.7 studies have proposed that wearing backpack on both shoulders is the safest method and recommend that straps of the school bag should be padded and adjustable according to child’s anthropometric measurements. a standard backpack should have chest and waist strap to reduce the force of centre of gravity acting on shoulders. backpacks with suitable padding decrease the risk of sharp objects poking into the back. backpack should be at the level of dorsum with adjustable straps fitted tightly. as loose straps can increase the risk of injuries and may lead to kyphosis and lordosis.6 this study was designed to explore different features of school bags, methods and duration of j islamabad med dental coll 2021 46 carriage, self-perceived pain and posture as well as self-perceived weight of the school bag. contrary to previous researches which were conducted on secondary school students, this study will target the primary school students in government schools of islamabad, pakistan.11 m a t e r i a l a n d m e t h o d s this cross-sectional survey was conducted in different government schools of islamabad, from june 2018 to november 2018. a sample size of 377 was calculated through rao software. nonprobability convenient sampling technique was used to select participants for the study. all healthy primary school children of both genders, aged 6-14 years were included, while children with impaired cognition or any musculoskeletal deformities were excluded from the study. a written informed consent explaining the purpose of the research study, its methodology and agreement for voluntary participation was signed by parents of all the participants. the confidentiality of the acquired data was affirmed on the consent form. approval from the federal directorate of education, islamabad was taken to gain access to the different government schools of islamabad f or carrying out this research. height and weight of each student, and the weight of full school bag including all additional items brought by the students were me asured. the guidelines of american physical therapy association stating that weight of the school bag should be 1015% of body weight were followed. height was measured using measuring tape and body weight was measured using camry analog weight scale machine. the questionnaire used in this study was taken from the study by talbot et al.7, a modified version of the survey by grimmer and william. the original tool collected information on the backpack's characteristics, wear time, after-school activity, medical conditions, and symptoms. the questions were related to backpack characteristics (straps, belts, wheels) and methods of carriage (one shoulder, two shoulders). self-perceived weight was indicated by students as being light, medium or heavy. the number of times back-pack was carried both to school and from school was used to record carriage times. posture was assessed by perception of position and the perception of time spent standing upright. there were questions on perception of pain as well. questionnaire was filled by the researcher on behalf of the children. data was analysed using spss version 21.0. chi square test was used to compare the frequency of musculoskeletal discomfort with demographic characteristics and backpack-related features. pvalue less than .05 was considered as statistically significant. r e s u l t s of the 377 primary school children included in this study, 46.9% (n=179) were males and 53.1% (n=203) females. mean age of students was 9.49+1.53 years with an age range of 6-14 years. anthropometric measurements of the participants, and school bagrelated parameters are shown in table i. kg-kilogram; m-meter; sd-standard deviation almost all of our study participants used backpacks (99.5%). various features of backpacks including waist belt, chest strap, wheels, adjustable shoulder table i: anthropometric and school bag related parameters parameters mean ± sd age (years) 9.49 ± 1.53 weight of the students (kg) 27.12 ± 7.49 height of the students (m) 1.62 ± .27 weight of the school bags (kg) 6.33 ± 2.08 weight of the school bags in percentage of body weight (kg) 24.25 ± 8.15 body mass index (kg/m2) 16.63± 2.96 j islamabad med dental coll 2021 47 straps and padded shoulder straps were inquired from children. among all the characteristics, most commonly used backpack features were adjustable (98.7%) and padded shoulder straps (91.4%). most of our students had school bags with no waist belt (99.5%) and chest strap (98.2%). majority of the students (83.2%) in this study carried their bags on both shoulders with only 8.1% children carrying bags over the right shoulder. when students were asked about the reason for carrying backpacks in a certain way, comfort (74.1%) and habit (25.9%) were the more common responses. almost half of the students (56.5%) were always bent-over when carrying their backpacks while 22% children carried their bags with a straight posture most of the time and only 1.3% always had a straight posture. regarding self-perceived posture, leaning forward was the most common response (66.2%) followed by leaning sideways (15.4%), while stooping was found in only 2.9% of the children. students were asked to self-rate the weight of the bag. approximately 59.7% of the students perceived their backpack weight as heavy, 21.5% as medium and only 18.8% as light. weight of the school bag calculated in percentage of students’ body weight is shown in figure 1. the commonly reported sites of pain are shown in figure 2. figure 1: weight of the school bag in percentage of body weight of the study participants. for more accurate examination, respondents were also given a checklist to identify any pain experienced due to wearing school bags in areas like upper back, legs, arms and lower back. both upper (39.8%) and lower back pain (37.4%) were reported. leg pain was also more frequent (33.8%) in comparison to arm (18.1%) and neck pain (17.3%). less common symptoms included muscle soreness, tingling in arms and legs and others. figure 2: commonly reported sites for pain difference in pain threshold among males and females were also observed. females (76.35%) experienced more pain than males (62%). there was significant association between pain and perceived backpack weight (p < .001) and pain and selfperceived posture (p < .001). the association between pain and duration of carrying backpack from home to school was insignificant ( p=.055) in contrast to pain and duration of carrying bag from school to home (p=.007). d i s c u s s i o n in the present study, most of the primary school students reported to have bags with no waist (99.5%) and chest belt (98.2%), respectively. these components of a standard backpack help to minimize the forces of gravity. the students were found with heavy backpack mainly because they were carrying too many text books. 6 only 2.9% students in our study had backpacks weighing less j islamabad med dental coll 2021 48 than 10% of their bodyweight, 7.3% had backpacks between 10-15%, while majority (89.8%) were found with backpacks exceeding 15% of bodyweight. similar results were reported in a study by shahid et al., in which only 7% students were observed in 10-15% limit of their body weight.8 wearing backpacks with weight more than 10% of body weight results in significant postural changes and subjective complaints. although there is evidence that the use of inclinometer or goniometer is a better tool for posture analysis, but there has been established validity among the children with scoliosis about the perception of the presence or absence of deformities.12 self-perceived posture was evaluated among children and 66.2% reported leaning forward while wearing backpacks. similarly, in a study by rubina et al., 58.5% of students exhibited forward lean posture while carrying backpacks. due to the changes in the center of gravity while carrying heavy objects, the body compensates by leaning forward. this postural shift is likely to cause tissue damage and is the reason behind spinal pain. 13 in this study, 69.6% of the students reported “yes” to “any pain present at the current time while wearing backpack”. pain is a subjective measure. perception of pain is a multi-factorial phenomenon and many psychosocial factors are associated with it; for example, time spent watching tv, family history, tight hamstrings and tight quadriceps.6 the perception of pain in this study could also be influenced by any one of these factors. regarding common sites of pain, 67.3% reported shoulder pain. this is in contrast to a study by shahid et al. in which 93.8% students reported shoulder pain while carrying backpacks.8 our study participants did not report any pain while carrying their bags from home to school, however a significant association was reported on the way back from school to home. this finding has been reported by other studies showing a positive association between duration of carrying school bags and pain.9 we also found a significant association between pain and self-rating of the bag and pain with selfperceived posture. similar results have been reported by talbott et al.7 gender differences in reporting of pain were also observed in our study with 76.35% of females and 62% of males experiencing current pain while carrying their bags. these findings are similar to those documented by grimmer et al., dianat et al. and young et al., suggesting that the recommended weight limit should not be the same for boys and girls. that limit needs to be lower for girls. 9,12,14 in contrast, watson et al. showed that mechanical factors (weight of the school bag) are not significantly associated with low back pain in school children, and suggested that psycho-social factors are more important.15 similar results have been reported by perrone et al., as students carried over 15% of bag weight which caused biomechanical and physiological adaptations that could increase musculoskeletal injury risk and discomfort.16 batista et al. also found that almost half (47.7%) of the students evaluated carried a weight of more than 10% of their body weight.17 the findings by akbar et el. also shows significant association between perceived bag pack weight and pain, and the pain is essentially higher in females.18 over 70% of the subjects had a schoolbag that exceeded the recommended 10% bag weight to body ratio. a total of 32% of the sample complained of back pain, with 74% of these defining it as low in intensity. gender, body mass index (bmi), school and bag weight to body weight ratio was statistically related to back pain. self-reported back pain in schoolchildren is independently linked to carrying heavy schoolbags.19 growing children are not sufficiently developed in terms of their skeletal and bone structure to tolerate the stress and physical j islamabad med dental coll 2021 49 demand of carrying a school bag that led to musculoskeletal disorders.20 the mean pressure on the body is increased with heavier loads. it is also proposed that with increasing load, there is an increase in the mechanical load and a change in the spatiotemporal parameters of the gait due to carrying the heavy backpack.21 c o n c l u s i o n musculoskeletal discomfort, especially shoulder pain was common among primary school children due to carrying heavy school bags, more than 15% of their body weight. gender was an independent factor, but females perceived more pain as compared to males. there was a significant association between pain and perceived backpack weight, self-perceived posture and time duration of carrying bag. r e c o m m e n d a t i o n weight of the school bag should be strictly limited to 10% of body weight and backpacks with proper chest and waist straps should be used to reduce compression forces. the students should be guided to wear backpack at the level of dorsum. seminars should be arranged on the national school backpack awareness day celebrated annually in the third week of september. students should be allotted lockers by the school and strictly restricted to bring books according to time table. r e f e r e n c e s 1. kesavan a, jose r, nithya tc. overloaded bags of school childrena precursor to “school bag syndrome”? njmdr. 2016; 5(1): 6 –11. 2. rajan p, koti a. ergonomic assessment and musculoskeletal health of the underprivileged school children in pune, india. health promot perspect. 2013; 3(1): 36-44. doi: 10.5681/hpp.2013.005 . 3. khalid f, amjad f, ahmad a, gilani sa, hanif mk. frequency of neck pain due to school bag usage among students of public high schools in lahore, pakistan. pak paed j. 2018; 42(3): 207 -11. 4. brzęk a, dworrak t, strauss m, sanchis-gomar f, sabbah i, dworrak b, et al. the weight of pupils’ schoolbags in early school age and its influence on body posture. bmc musculoskelet disord. 2017; 18(1): 1–11. doi: 10.1186/s12891-017-1462-z. 5. kistner f, fiebert i, roach k, moore j. postural compensations and subjective complaints due to backpack loads and wear time in schoolchildren. pediatr phys ther. 2013; 25(1): 15 -24. doi: 10.1097/pep.0b013e31827ab2f7 . 6. mohammadi s, mokhtarinia h, nejatbakhsh r, scuffham a. ergonomics evaluation of school bags in tehran female primary school children. work. 2017; 56(1): 175-81. doi: 10.3233/wor-162469. 7. talbott nr, bhattacharya a, davis kg, shukla r, levin l. school backpacks: it’s more than just a weight problem. work. 2009; 34(4): 481 –94. doi: 10.3233/wor-2009-0949. 8. shahid g, aziz k, arif a, fahim mf. prevalence of musculoskeletal pain due to heavy backpacks in school going children of karachi. int j phys med rehabil. 2018; 6(3): 1000471. doi: 10.4172/23299096.1000471. 9. grimmer k, dansie b, milanese s, pirunsan u, trott p. adolescent standing postural response to backpack loads: a randomised controlled experimental study. bmc musculoskeletal disord. 2002; 3(1): 10. doi: 10.1186/1471-2474-3-10. 10. dockrell s, blake c, simms c. guidelines for schoolbag carriage: an appraisal of safe load limits for schoolbag weight and duration of carriage. work. 2016; 53(3): 679-88. doi: 10.3233/wor-162260. 11. walicka-cuprys̈ k, skalska-izdebska r, rachwał m, truszczyńska a. influence of the weight of a school backpack on spinal curvature in the sagittal plane of seven-year-old children. biomed res int. 201 5: 817913. doi:10.1155/2015/817913 . 12. dianat i, javadivala z, allahverdipour h. school bag weight and the occurrence of shoulder, hand/wris t and low back symptoms among iranian elementary schoolchildren. health promot perspect. 2011; 1(1): 76-85. doi: 10.5681/hpp.2011.008. 13. khan r, jabeen h, arshad hs. neck, shoulder, and back pain with carrying heavy back packs among the spirit school children in lahore. ijsr. 2016; 5(6): 397 400. 14. young ia, haig aj, yamakawa ks. the associatio n between backpack weight and low back pain in children 1. j back musculoskelet rehabil. 2006; 19(1): 25-33. doi: 10.3233/bmr-2006-19104. 15. watson kd, papageorgiou ac, jones gt, taylor s, symmons dp, silman aj, et al. low back pain in schoolchildren: the role of mechanical and j islamabad med dental coll 2021 50 psychosocial factors. arch dis child. 2003; 88(1): 12 -7. doi: 10.1136/adc.88.1.12. 16. perrone m, orr r, hing w, milne n, pope r. the impact of backpack loads on school children: a critical narrative review. int j environ res public health. 2018; 15: 2529. doi: 10.3390/ije rph15112529. 17. batista its, de melo-marins d, da silva carvalho rg, lara elena gomes le. weight and mode of carrying schoolbags at elementary school: effect of the school grades and sex. fisioter pesqui. 2016; 23(2): 210 -5. doi: 10.1590/1809-2950/15376823022016. 18. akbar f, albesharah m, al-baghli j, bulbul f, mohammad d, qadoura b, et al. prevalence of low back pain among adolescents in relation to the weight of school bags. bmc musculoskelet disord. 2019; 20: 37. doi: 10.1186/s12891-019-2398-2. 19. spiteri k, busuttil m-l, aquilina s, gauci d, camilleri e, grech v. schoolbags and back pain in children between 8 and 13 years: a national study. br j pain. 2017; 11(2): 81-6. doi:10.1177/2049463717695144. 20. nazari m, beigi r, salesi m, cousins r, mokarami h. development and validation of the tool for the evaluation of the behavioral factors affecting the prevalence of musculoskeletal disorders in iranian students. bmc pediatr. 2020; 20: 551. doi: 10.1186/s12887-020-02452-8. 21. ahmad hn, barbosa tm. the effects of backpack carriage on gait kinematics and kinetics of schoolchildren. sci rep. 2019; 9: 3364. doi: 10.1038/s41598-019-40076-w. j islamabad med dental coll 2023 110 open access comparison of wound infection after reversal of loop ileostomy in linear versus purse-string skin closure of stoma site sohaib haider1, muhammad waqas raza2, aurangzeb khan3, munema khan4, khurram waqas5, malik irfan ahmed6, hamza waqar bhatti7, muhammad hanif 8 1 registrar, department of surgery, dhq hospital, rawalpindi. 2 professor of surgery, rawalpindi medical university, rawalpindi 3 assistant professor of surgery, surgical unit ii, benazir bhutto hospital, rawalpindi 4 resident surgeon, department of surgery, dhq hospital, rawalpindi 5,6 senior registrar, department of surgery, dhq hospital rawalpindi 7 resident surgeon, surgical unit ii benazir bhutto hospital rawalpindi 8 professor of surgery, rawalpindi medical university rawalpindi a b s t r a c t authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3,4,5 critical analysis and manuscript review; 6,7,8 data analysis; manuscript editing. correspondence: aurangzeb khan email: aurangzebkhandr@gmail.com article info: received: february 2, 2023 accepted: june 5, 2023 cite this article. haider s, raza m w, khan a, khan m, waqas k, ahmed m i. comparison of wound infection after reversal of loop ileostomy in linear versus purse-string skin closure of stoma site .j islamabad med dental coll. 2023; 12(2): 110-115 doi: https://doi.org/10.35787/jimdc.v12i2.948 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e introduction: loop ileostomy is a surgical procedure which is done to divert intestinal contents away from distal bowel to allow healing of the distal anastomosis and also for the relieve of obstruction in emergency situations. reversal is done through local stoma site via linear closure technique as the standard procedure. surgical site infection is the most commonly occurring & morbid complications of this technique and it can be reduced if closure is done by purse string method. the aim of this study was to determine the more effective method of the two in terms of post-op surgical site infection. material & methods: this randomized controlled trial was conducted for six-month duration in benazir bhutto hospital, rawalpindi. reversal patients presenting in outdoor-department were included and allocated randomly into either purse-string closure group or linear skin closure group. follow-up was done for thirty days and wound infection was identified by presence of purulent discharge from incision site. organisms were isolated from fluid culture or tissue culture from the wound or abscess. results: we included a total of 90 patients in this study. 45 patients were randomly alloted to each group. the two groups were matched for various entry parameters. wound infection was observed among 27(60%) in the linear closure group whereas 12(26.7%) in the purse-string group developed wound infection. this difference was statistically significant. conclusion: given the low rate of associated wound infection, purse string closure of stoma reversal is recommended to be the preferred procedure for ileostomy reversal. key words: loop ileostomy, linear closure, purse string closure, wound infection. j islamabad med dental coll 2023 111 i n t r o d u c t i o n intestinal stoma construction is a common procedure which is a surgically formed opening of the intestines onto the surface of the body. stoma formation can be temporary or permanent. a temporarily formed stoma is used for the management of a spectrum of colorectal diseases such as malignancy , inflammatory bowel disease, bowel perforation and fistulae and also considered the standard mode of treatment in patients undergoing resection of part of bowel where primary anastomosis is unable to be done. the main purpose of stoma creation is to lead the intestinal contents away from distal bowel so that a distally formed meticulous anastomosis can heal and to prevent leakage or fistula formation as well as to relieve any obstruction in emergency. reversal of a loop ileostomy reversal is typically done from 8 to 12 weeks after it is made, allowing sufficient time for recovery from the preceded changes.1 the reversal is done usually through local stoma site. morbidity of stoma revers is reported to be quite low. the associated complications are reported in 241% of the pateints.2 these include anastomotic breakdown and subsequent leakage, obstruction, post operative hernia, wound infection and nonsurgical complications. surgical site infection (ssi) is the most common complication associated with sr and the reported incidence varies widely, from 2-40%.3 exposure to skin flora is considered to be involved in the pathophysiology of infection. this wound infection has a great impact on the patients’ life such as prolonged the hospital stay, increasing cost of treatment but can progress to septicemia and long-term complications leading to delay in return to normal life.4 it is the second most common hospital acquired infection accounting for 21.5% of all such infections.5 the treatment of surgical site infection requires wound care and, in some cases, antibiotics. however, the cosmetic results are not satisfactory and the healing time is prolonged. different techniques of wound closure post reversal are described with variation in ssi rate. however, no common consensus is found for the best method of wound closure. the commonly employed methods fall in two categories i.e. primary closure and secondary closure. among secondary closure, are various subtype e.g. wounds left open, delayed secondary suturing, partial wound closure and purse string closure.6 in primary linear closure (lc) wound edges are approximated and closed in linear fashion. healing by this option is rapid, avoids long healing time and requires less dressings. however, there is an increased chance of wound infection rate in primary group; this might be because of retention of bacterial contamination in closed superficial wound space. purse-string closure (psc) of wound is a form of secondary closure. wound is left open and becomes natural drainage pathway avoiding wound infection. this wound closes with granulation tissues until skin is epithelialized and defect closed. sureshkumar reported significantly less surgical site infection & better cosmesis after secondary closure.7 however frequent dressings are needed which increase the cost & burden of work. in previous studies wound infection was found in 3.15.4% of patients, whose wound was closed by purse-string as compared to 20.2-22.8 of patients by conventional linear method, similar findings noted in a meta-analysis. 8-9 the purpose of this study is to determine the effective method which carries less infection rate and better overall post-operative outcome. m e t h o d o l o g y this study was a randomized controlled trial conducted at surgical department, benazir bhutto hospital rawalpindi over a duration of 6 months. blinding of the surgeons was not possible, however the data collecting doctors were blinded from the procedure performed. the two groups were matched for various entry parameters. 90 patients j islamabad med dental coll 2023 112 were included and the power of the study was set at 95%. patients were randomly allocated into group a – purse string closure or group b – conventional linear closure by lottery method. all patients between 20-60 years of age presenting in surgical opd were included. exclusion criteria was set as patients with immunosuppression, malignancy, debilitating medical illness, distal loop obstruction, tuberculosis, diabetes and cirrhosis. standard guidelines were followed in the pre-operative preparation of each case & prophylactic preand post-op antibiotics were administered. the surgery was performed by senior registrars & discharge was scheduled for 7th post-op day with stitch removal at 10-14 post-op day. patients were followed at 10, 20th and 20th post-op day for wound infection. wound infection was identified as presence of any one of the following: 1) purulent discharge from incision site, 2) organisms isolated by obtaining culture of fluid or tissue from wound, 3) abscess formation confirmed by ultrasound. approval was obtained from the hospital ethical committee & informed consent was obtained from the patients. a specialized proforma was used for data collection and statistical analysis was done via ibm spss version 23. chi square test was applied and the p value calculated was calculated. p value of less than 0.05 was considered statistically significant. r e s u l t s we included a total of 90 patients in the study. 45 patients were randomly assigned to each group by lottery method. wound infection was observed among 27(60%) in the linear closure group whereas 12(26.7%) in the purse-string group developed wound infection. this difference was statistically significant. 90 patients were included in this study. 48.9% patients were males (n=44) and 51.1% (n=46) were females, with slight female predominance. age range was 20 to 60 years with mean age of 40.30 years. maximum number of patients was in 31-50 age group. table i : gender distribution in study groups gender total male female group group a 22 23 45 group b 22 23 45 total 44 46 90 each study group was allocated 45 patients. both had comparable gender ratio and age proportion. (table 1) (figure 1) in purse string group (group a) 26.7% patients (n=12) developed infection at ileostomy wound site whereas 73.3% (n=33) had no infection at wound site. while in linear closure group (group b) 60% of patients (n=27) developed infection at ileostomy wound site whereas 40% patients (n=18) had no infection with p value of 0.003. d i s c u s s i o n loop ileostomy is a frequently performed surgical procedure in gastrointestinal surgery in which an opening is created in ileum and is extracted out as a stoma from the abdomen. the distal ileum is usually j islamabad med dental coll 2023 113 used and objective is to cause diversion of intestinal contents. multiple indications for the surgery exist including but not limited to congenital disorders, inflammatory bowel disease, distal anastomosis, large bowel obstruction and trauma. it is a temporary procedure and usually reversed after 4 months through local stoma site by primary anastomosis. reversal of loop ileostomy comprises many complications including small bowel obstruction, anastomotic leakage and wound infection at ileostomy site which is the most common complication with an incidence of up to 40%.10 surgical site infection is a preventable but exhaustive complication effecting patient’s general well-being and associated cost of treatment. if neglected, it can progress to sepsis and overshadow the very primary pathology itself that indicated the stoma formation. centers for disease control and prevention (cdc) defines ssi as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery.11 it has been reported that over one-third of the postoperative deaths are related to ssi. it is imperative that every effort is made to avert this morbid & potentially fatal complication. there are several methods described in literature for closure of the skin wound at stoma site like linear (primary) closure, delayed primary closure, secondary closure and purse string closure (psc) to achieve minimal wound infection rate but no method has found to attain superiority over the other.12 thus, there is no common consensus regarding wound closure technique in terms of infection rate. while common practice dictates closure of the wound with primary or linear closure technique, this is associated with an infection rate of up to 20%.13 ileostomy closure is a type of contaminated surgery due to spillage of intestinal contents containing microorganisms at stoma site, thus carrying an increased risk of ssi. therefore, certain studies have shown that if wound is left open to heal by secondary intention, the rate of wound infection is comparatively less. purse-string technique for closure of ileostomy wound was described first time by banerjee in 1997, it recommends the placement of circumferential suture into the dermis of skin along the wound margins which allows uniform tension throughout the wound edges and the wound had complete healing in >90% of the patients within 8 weeks.14 psc (purse-string closure) has also been used to close small skin defects or as partial closure of larger circular wounds after skin cancer excision.15 pursestring closure of the wound is a form of secondary closure in which wound remains partially open with a small defect allowing formation of granulation tissue over which epithelialized skin regenerates. the defect serves as a natural drainage pathway, thus avoiding wound infection. it was evident from our study that pcs is a better technique to close ileostomy wound in terms of infective complications. various publications are available regarding purse-string wound closure which mirror our results. a recent study resembling ours was conducted by reid et al.8 they enrolled total 61 patients. two out of thirty patients (6.66%) developed infection in psc group while twelve out of thirty-one patients (38.7%) developed infection in lc group, the difference was statistically significant. similarly, in another study conducted by milanchi et al,16 it was established that psc was safe and more effective having significantly lower incidence of wound infection post reversal and additionally had better cosmetic results. milanchi included 49 patients out of which 24 patients underwent psc and 25 patients underwent the latter. no wound infections occurred in the psc group compared to 40% wound infection rate observed in the primary lc group with p value of 0.002. however certain contradictory studies propose that there is no significant difference between these two techniques regarding wound infection. lahat et al13 compared primary closure with delayed primary closure and showed, decreased incidence of wound j islamabad med dental coll 2023 114 infection in primary closure group. 40 patients were included and reported wound infection in 10% patients whose wound was closed primarily compared to 20% with delayed closure. similarly hospital stay is same in patients of both groups. a study was conducted in pakistan by munir ahmad et al9 which found that incidence of wound infection in linear closure was in 11.7% of patients and 10% of patients in purse string wound closure with a difference not statistically significant. conjunctionally murtaza et al 17 reported the same results. he reported infective rate of 16.9% in primary closure group than 4.2% in open group. thus risk of wound infection was 5.8 times greater in wounds that were closed primarily. suh et al 18 compared the two techniques in terms of postoperative wound infection as well as pain pattern and found significantly less incidence of infection rate of 0% in patients of psc vs. 11.39% in conventional lc group with p value of 0.003. while there was no difference in postoperative pain between these two groups. lee et al19 suggested that purse-string skin closure after a loop ileostomy reversal had comparable outcomes, in terms of wound infection rates, to those of linear skin closure. also, psc showed cosmetically better results than lc of wound. 48 patients were included in this study & wound infection was found to be 16.7% in patients in linear closure group vs 5.6% patients in purse-string group. while the median hospital stays were 11 days in lc group and 7 days in psc group with p value < 0.001. camacho et al 20 in his comparison reflected our findings substantially by noting an infective rate of 36.6% in patients in lc group and no wound infection in psc group. his p-value being p < 0.0001. healing time was also significantly reduced in the psc group being 3.8 weeks in contrast to 5.9 weeks in the linear closure group. lastly, but most significantly he noted that 70% of the patients with purse-string closure were satisfied with their outcome in comparison with 20% in the linear closure group (p = 0.0001). overall, it can be inferred that psc is not only reliable in terms of ssi but additionally has a better profile concerning duration of hospitalization, cosmesis & pain-pattern. these findings are pertinent not only regarding patient satisfaction but the total costeffectiveness imparted by the aversion of utilization of hospital resources for wound care & secondary surgical interventions. c o n c l u s i o n purse string closure of stoma site after reversal of loop ileostomy is a safe & efficacious modality and showed better results in terms of wound infection rate to those of linear wound closure. a significantly greater number of patients achieved satisfactory healing without infection and better cosmetic results. given the low rate of associated wound infection, purse string closure of stoma reversal is recommended to be the preferred procedure for ileostomy reversal. thus, r e f e r e n c e s 1. uptodate. 2023 [cited 2023mar15]. available from: https://www.uptodate.com/contents/overview-ofsurgical-ostomy-for-fecal-diversion 2. sherman kl, wexner sd. considerations in stoma reversal. clin colon rectal surg. 2017 jul;30(3):172177. doi: 10.1055/s-0037-1598157. epub 2017 may 22. pmid: 28684934; pmcid: pmc5498167. 3. li lt, brahmbhatt r, hicks sc, davila ja, berger dh, liang mk. prevalence of surgical site infection at the stoma site following four skin closure techniques: a retrospective cohort study. dig surg. 2014;31(2):73-8. doi: 10.1159/000354426. epub 2014 apr 23. pmid: 24776653. 4. chu di, schlieve cr, colibaseanu dt, simpson pj, wagie ae, cima rr, habermann eb. surgical site infections (ssis) after stoma reversal (sr): risk factors, implications, and protective strategies. j gastrointest surg. 2015 feb;19(2):327-34. doi: 10.1007/s11605014-2649-3. epub 2014 sep 13. pmid: 25217092. 5. monegro af, muppidi v, regunath h. hospital acquired infections. [updated 2022 aug 22]. in: statpearls [internet]. treasure island (fl): statpearls j islamabad med dental coll 2023 115 publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk441857/ 6. ghildiyal j, agrawal a, sood r, amritesh k. prospective randomized clinical trial of wound closure technique after ileostomy closure. 2013. 7. sureshkumar s, jubel k, ali m s, et al. comparing surgical site infection and scar cosmesis between conventional linear skin closure versus purse-string skin closure in stoma reversal a randomized controlled trial . cureus 2018; 10(2): e2181. doi:10.7759/cureus. 2181 8. ali d, zubair m, kaiser ma, khokhar i, afzal mf. outcome of purse-string versus linear skin closure after ileostomy stoma reversal in terms of stoma sites infection and cosmesis. j pak med assoc. 2021 feb;71(2(a)):414-416. doi: 10.47391/jpma.05-673. pmid: 33819218.. 9. gachabayov m, lee h, chudner a, dyatlov a, zhang n, bergamaschi r. purse-string vs. linear skin closure at loop ileostomy reversal: a systematic review and meta-analysis. tech coloproctol. 2019 mar;23(3):207-220. doi: 10.1007/s10151-019-019529. epub 2019 feb 26. pmid: 30809775. 10. mccartan dp, burke jp, walsh sr, coffey jc. pursestring approximation is superior to primary skin closure following stoma reversal: a systematic review and meta-analysis. tech coloproctol. 2013;17(4):34551 11. horan tc, gaynes rp, martone wj, jarvis wr, emori tg. cdc definitions of nosocomial surgical site infections, 1992: a modification of cdc definitions of surgical wound infections. infect control hosp epidemiol. 1992;13(10):606-8. 12. li lt, hicks sc, davila ja, kao ls, berger rl, arita na, et al. circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment metaanalysis. colorectal dis. 2014;16(6):406-16. 13. lahat g, tulchinsky h, goldman g, klauzner jm, rabau m. wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques. tech coloproctol.2005;9(3):206-8. 14. banerjee a. pursestring skin closure after stoma reversal. dis colon rectum. 1997;40(8):993-4. 15. mirbagheri n, dark j, skinner s. factors predicting stomal wound closure infection rates. tech coloproctol. 2013;17(2):215-20. 16. milanchi s, nasseri y, kidner t, fleshner p. wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation. dis colon rectum. 2009;52(3):469-74 17. murtaza g, nuruddin r, memon aa, chawla t, azam i, mukhtar y. does primary closure increase surgical site infection after intestinal stoma reversal? a retrospective cohort study. surg infect (larchmt). 2014;15(1):58-63. 18. suh yj, park jw, kim ys, park sc, oh jh. a beneficial effect of purse-string skin closure after ileostomy takedown: a retrospective cohort study. int j surg. 2014;12(6):615-20. 19. lee jr, kim yw, sung jj, song o-p, kim hc, lim c-w, et al. conventional linear versus purse-string skin closure after loop ileostomy reversal: comparison of wound infection rates and operative outcomes. j korean soc coloproctol. 2011;27(2):58-63. 20. camacho-mauries d, rodriguez-díaz jl, salgadonesme n, gonzález qh, vergara-fernández o. randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection. dis colon rectum. 2013;56(2):205-11 journal of islamabad medical & dental college (jimdc); 2012(2):102-106 102 review article diabetes mellitus and its laboratory diagnosis wajiha mahjabeen assistant professor pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) diabetes mellitus is a group of metabolic disorder characterized by hyperglycemia either due to deficiency of insulin production or resistance of organs to the effect of normal amount of insulin or both.1 in healthy individuals after taking meals, according to the blood glucose concentration appropriate amount of insulin is produced by the pancreas and this insulin transports glucose from blood into the cells. in diabetic individual, either little or no insulin is produced by the pancreas, or the cells do not give appropriate response to the produced insulin. this insulin dysfunction leads to decreased synthesis and increased degradation of glycogen, protein and fat in the body, ultimately causing hyperglycemia and overflow of glucose into urine.2 characteristic symptoms of diabetes are thirst, polyuria, weight loss and blurring of vision. most severe form is characterized by ketoacidosis or non ketotic hyperosmolar coma, ultimately leading to stupor, coma and death. chronic hyperglycemia develops pathological and functional changes characterized by retinopathy, nephropathy and neuropathy. risk of cardiovascular, peripheral vascular and cerebrovascular diseases is also common in chronic state.3 diabetes is a universal health issue. its prevalence is continuously increasing worldwide. estimated rise in world prevalence of diabetes is 6.4% to 7.7% from 2010 to 2030. different factors like population growth, ageing and sedentary life styles are responsible for continuously increasing burden of diabetes in developing countries. in pakistan in 2010 about 7.1 million people were suffering with diabetes. this number is expected to rise up to 13.8 million by 2030.4 on the basis of etiology diabetes can be classified into various types (table 1). among all of them most important are type i, type ii and gestational diabetes mellitus. type 1 diabetes type 1 diabetes was previously known as insulin dependent diabetes or juvenile onset diabetes. being an autoimmune disease, it is characterized by destruction of insulin producing beta cells in the pancreas by the body’s own immune system. in turn insulin production is either decreased or completely lost depending upon the extent of pancreatic injury.5 type 1 diabetes, although most commonly encountered during childhood and adolescence, can also be diagnosed as late as the 8th or 9th decade of life.6 rate of destruction of pancreatic beta cells varies from very high to low among different age groups. most frequently in children, but also in some adults, rapid progressive beta cells destruction is commonly manifested by absolute insulin deficiency. on the other hand, a slowly progressive form is usually observed in adults and is sometimes known as “latent autoimmune diabetes in adults (lada)”.7,8 genetic inclination and environmental factors play an important role in its pathogenesis.5 some individuals who present with permanent hypoinsulinemia, have tendency to develop ketoacidosis, but have no evidence of autoimmunity, are labeled as type 1 idiopathic diabetes.9 in individuals with type 1 diabetes process of beta cells destruction usually starts very early, but symptoms may appear late. that is why in 85-90% of such individuals when first diagnosed with fasting hyperglycemia, markers of immune destruction including islet cell autoantibodies and/or autoantibodies to insulin, and autoantibodies to glutamic acid decarboxylase (gad) will also be detected in their blood.10 role of hla, with linkage to dqa and dqb genes and influence by drb genes is also evident in type 1 diabetes.5 children usually present with severe symptoms, marked hyperglycemia or ketoacidosis as the first manifestation of the disease.11 while some individuals present with moderate hyperglycemia and in the presence of different contributory factors like infection or stress this moderate form may deteriorate into severe hyperglycemia or ketoacidosis. adults having type 1 diabetes usually present with less severe symptoms due to residual beta cell functions. these individuals develop ketoacidosis after many years of diagnosis when beta cells completely lose their function leading to little or no insulin production as manifested by low or undetectable levels of plasma cpeptide.7,12 patients with type 1 diabetes may also suffer from other autoimmune disorders like grave’s disease, hashimoto’s thyroiditis and addison’s disease.13 type 2 diabetes type 2 diabetes was previously recognized as non insulin dependent diabetes or adult onset diabetes. it is the most common form of diabetes characterized by relative insulin deficiency. in individuals presenting with type 2 diabetes, at the time of diagnosis the production of insulin from journal of islamabad medical & dental college (jimdc); 2012(2):102-106 103 pancreas is sufficient, but ability of the body to utilize this insulin decreases; the condition is called insulin resistance that leads to hyperglycemia. over the subsequent years, the function of beta cells also decreases gradually; concentration of glucose in blood further enhances and body is no more able to do efficient use of its main source of fuel.14,15 initially hyperglycemia is not so severe as to produce considerable symptoms; therefore, the patients are usually diagnosed after many years. long term risk of microand macrovascular complications is greater in such patients.16 ketoacidosis rarely occurs in this type of diabetes. if present it usually occurs in the presence of infection or some other illness.5 this form of diabetes is most often associated with older age, obesity and other risk factors (table 2). about 80 percent of people with type 2 diabetes are overweight or obese.17 obesity itself is responsible for insulin resistance in type 2 diabetes. due to the polygenic nature, type 2 diabetes may involve polymorphisms in multiple genes that encode the proteins involved in insulin signaling, insulin secretion and intermediary metabolism.2 gestational diabetes gestational diabetes is defined as carbohydrate intolerance with onset or first recognition during pregnancy (approximately after 24 weeks of gestation). in pregnancy, up to first half of second trimester glucose levels, both in fasting and postprandial states are usually lower than such levels in normal non pregnant women. women having increased glucose concentration during this time are usually labelled as having overt diabetes mellitus, but not the gestational diabetes. risk of gestational diabetes in women increases with increasing age, in those who have previous history of glucose intolerance, and those who have history of ‘large for gestational age babies’, in different ethnic groups. women having these risk factors should be screened during the first trimester in order to rule out the previously undiagnosed diabetes mellitus. gestational diabetes occurs due to placental hormone changes that affect the insulin functions. gestational diabetes mellitus usually disappears after the birth of baby, but there are greater chances of developing diabetes mellitus type 2 within next few years. maintenance of body weight and appropriate physical activity may help in reducing this risk.3,17 other specific types other specific types of diabetes, which are relatively less common aredepicted in table 1.5 pre diabetes pre diabetes is defined as a condition in which the blood glucose concentration is greater than normal but lesser than the levels essential for the diagnosis of diabetes mellitus. this encompasses the conditions of impaired fasting glucose (ifg) and impaired glucose tolerance (igt) representing glucose regulation abnormalities during fasting and postprandial state, respectively. due to insulin resistance, pancreatic beta cells initially undergo compensatory state and produce larger amount of insulin than normal. this higher concentration of insulin tries to overcome the increase demand and ultimately maintains the blood glucose concentration some way intermediate between normal glucose levels and diabetic glucose level.3,17 hemoglobin a1c hemoglobin a1c (hba1c) is stable glycosylated hemoglobin. it shows the average blood glucose level of last 2-3 months (120 days life span of erythrocytes). it gives a percentage that indicates the risk of development, diagnosis and previous 2-3 months control of diabetes. in certain conditions hba1c is not considered appropriate for diagnosis of diabetes. these conditions include18 1. all children and young people 2. patients of any age suspected of having type 1 diabetes or type 2 diabetes with a severe insulin deficiency (glycemic variability) 3. patients with symptoms of diabetes for less than 2 months 4. patients at high diabetes risk who are acutely ill (e.g. those requiring hospital admission) 5. patients taking medication (e.g. steroids, antipsychotics) that may cause rapid glucose rise 6. patients with acute pancreatic damage, including pancreatic surgery 7. pregnancy 8. presence of genetic, haematologic and illness-related factors that influence hba1c and its measurement screening for diabetes mellitus because of the acute onset of symptoms, most cases of type 1 diabetes are detected soon after symptoms develop; screening is therefore not so important in this type of diabetes. according to some studies analysis of islet autoantibodies in some high risk individuals like those with previous transient hyperglycemia, or having family history of type 1 diabetes may be appropriate. but screening for type 1 diabetes in asymptomatic low risk individuals is not currently recommended.20 on the other hand, in case of type 2 diabetes, situation is quite different. individuals usually present with clinical signs and symptoms several years after the commencement of the disease process. sometimes the complications may develop in individuals several years prior to the clinical diagnosis. therefore screening is considered necessary in type 2 diabetes mellitus to identify asymptomatic individuals who are prone to develop diabetes or pre diabetes. due to the increased chances of diabetes type 2 in children, screening is also considered important in them.19,20 screening criteria in children for type 2 diabetes screening for type 2 diabetes is recommended, if a child is overweight with bmi >85th percentile for age and sex, journal of islamabad medical & dental college (jimdc); 2012(2):102-106 104 table 1. classification of diabetes mellitus5 1. type 1 diabetes 2. type 2 diabetes 3. genetic defects of β-cell function a. chromosome 20, hnf-4 a (mody 1) b. chromosome 7, glucokinase (mody 2) c. chromosome 12, hnf-1 a (mody 3 ) d. chromosome 13, insulin promoter factor-1 ( ipf-1; mody 4 ) e. chromosome 17, hnf-1 b (mody 5 ) f. chromosome 2 , neurod1 (mody 6) g. mitochondrial dna and others 4. genetic defects in insulin processing or insulin action a. type a insulin resistance b. leprechaunism c. rabson-mendenhall syndrome d. lipoatrophic diabetes and others 5. exocrine pancreatic defects a. pancreatitis b. trauma/pancreatectomy c. neoplasia d. cystic fibrosis e. hemochromatosis and others 6. endocrinopathies a. acromegaly b. cushing’s syndrome c. glucagonoma d. pheochromocytoma e. hyperthyroidism and others 7. infections a. congenital rubella b. cytomegalo virus and others 8. drugs a. nicotinic acid b. glucocorticoid c. thyroid hormone d. diazoxide e. β -adrenergic agonists f. thiazides g. dilantin h. γinterferon and others 9. genetic syndromes associated with diabetes a. down syndrome b. klinefelter syndrome c. turner syndrome d. friedreich ataxia and others 10. gestational diabetes mellitus weight for height >85th percentile or weight >120% of ideal (50th percentile for height) and presents with any two of the following listed risk factors:  positive family history of type 2 diabetes in first or second degree relative(s)  certain races or ethnicities like asian/pacific islanders, american indian, african-americans, and hispanics. table 2: risk factors associated with type 2 diabetes mellitus  family history of diabetes (i.e. parents or siblings have diabetes)  overweight (bmi > 25 kg/m2)  habitual physical activity  race/ethnicity (e.g. african-american, hispanicamerican, native americans, asian-americans, and pacific islanders)  previously identified ifg or igt or hba1c 5.7-6.4%  hypertension (>140/90 mmhg in adults)  hdl cholesterol <35 md/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l)  history of gdm or delivery of a baby weighing >9lbs  polycystic ovarian syndrome or acanthosis nigricans  history of vascular disease table 3: glucose levels enlightening normal condition, increase risk and diabetes mellitus glucose level mg/dl (mmol/l) hba1c (%) fasting random ogtt euglycemia (normal glucose levels) <100 (5.6) <200 (11.1) <140 (7.8) <5.7 increased risk for diabetes 100-125 (5.6-6.9) ( ifg) 140-199 (7.8-11) ( igt) 5.7-6.4 (pre diabetic) diabetes mellitus ≥126 (7.0) ≥200 (11.1) ≥200 (11.1) ≥6.5%  history of hypertension, dyslipidemia, polycystic ovary syndrome or acanthosis nigricans (conditions associated with signs of insulin resistance)  maternal history of diabetes or gestational diabetes mellitus table 4: criteria for diagnosis of diabetes mellitus 1. hba1c ≥6.5%, done in laboratory using a national glycohemoglobin standardization program (ngsp) certified method and standardization to diabetes control and complications trial (dcct) reference assay 2. fasting plasma glucose (fpg) ≥126mg/dl (7.0 mmol/l). fasting is described as no calorie intake for at least 8 hours, only water is allowed 3. during an ogtt, 2 hours plasma glucose ≥200mg/dl (11.1mmol/l) as described by world health organization. 4. a random plasma glucose concentration of ≥ 200 mg/dl (11.1 mmol/l) with classical sign and symptoms of diabetes or with hyperglycemic crises journal of islamabad medical & dental college (jimdc); 2012(2):102-106 105 screening should start at age of 10 years or at the start of puberty if puberty occurs at early age and it should be repeated after every two years. fasting plasma glucose is most preferable method of screening.21 screening criteria in adults for type 2 diabetes 1. screening should be started in adults ≥ 45 years of age, especially if they have bmi ≥25 kg/m2. if results are normal, the screening should be repeated at an interval of 3 years. 2. adults should be screened early (< 45 years of age) and more frequently if they are overweight (bmi ≥25 kg/m2) and have additional risk factors (table 2) 3. for screening, either fasting plasma glucose (fpg) or 2 hour ogtt (75 gm glucose load) or hba1c or all are considered suitable. 5,21 (table 3) diagnosis of diabetes mellitus symptoms of diabetes mellitus include fatigue, nausea, frequent urination/polyuria, excessive thirst, obesity (mostly in type 2 diabetes), unusual weight loss, blurred vision, frequent infections, slow healing of wounds or sores. sometimes no specific symptoms are present.17 although glucose analysis can be done in whole blood or serum but the most preferable sample is plasma. in case of normal hematocrit, glucose concentration is about 11% more in plasma as compared to whole blood. in whole blood, glucose decreases due to glycolysis. such decreases in glucose concentration can miss the diagnosis of diabetes in a large proportion of population who have glucose concentrations near the cut points for diagnosis. in plasma and serum glucose variation is only about 1-2%.22-24 however, immediate centrifugation in case of plasma prevents glycolysis while in case of serum, sample has to clot first and thus causes loss of glucose due to glycolysis.5 diagnostic criteria of diabetes mellitus are mentioned in table 4. in the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing. for example, if only one test like hba1c or fpg or ogtt is performed, then in order to confirm the diagnosis, the same test should be repeated. sometimes, if the results of fpg are <7 mmol/l, but still there is strong suspicion of diabetes, then an ogtt should be performed. if the results of two different tests of same patient are provided, and both are above the diagnostic values of diabetes mellitus, then the diagnosis of diabetes is confirmed and there is no need to further repeat the test. in cases where the results of two tests in same patient are opposite to each other (one above the diagnostic value of diabetes while second one in normal range), then the test whose result is above the diagnostic cut point should be repeated. the diagnosis in such a situation should be confirmed on the basis of repeat test results. considering the pre-analytical and analytical variabilities, sometimes in contrast to the first test result, the repeat test may show a value within the reference range. this is most common in case of ogtt than fpg and least common in case of hba1c. in such a situation, patient should be followed closely, and it is recommended that the test should be repeated within 3-6 months.5 prognosis/control of diabetes hba1c is a widely used method to calculate the last 2-3 months diabetic control. in diabetics, it should be maintained at or below 7%. as the value of hba1c increases, there will be more risk of developing microvascular and to lesser extent macrovascular complications.5,20 it is generally recommended that hba1c should be repeated at an interval of six months in patients who respond well to their treatment and have good glucose control. if diabetics have a bad glycemic control or if the anti-diabetic medication is to be changed, the test should be repeated at an interval of three months.20 oral glucose tolerance test (ogtt) indications: equivocal blood glucose levels, pregnancy or epidemiological studies. preparation: patient should be advised to take unrestricted diet (greater than 150 g of carbohydrate daily) and maintain usual physical activity at least for three days before the test. reasonable (30-50g) carbohydrate containing meal should be consumed on the evening before the test. the test should be preceded by an overnight fast of 8-14 hours, during which water may be allowed. smoking is not permitted during the test. the presence of factors that influence interpretation of the results of the test must be recorded (e.g. medications, inactivity, infection, etc.). procedure: after collection of the fasting blood sample, the subject should drink 75 g of anhydrous glucose or 82.5 g of glucose monohydrate (or partial hydrolysates of starch of the equivalent carbohydrate content) in 250-300 ml of water over a course of 5 minutes. for children, the test load should be 1.75 g of glucose per kg body weight up to a total of 75 g of glucose. timing of the test is from the start of the drink. blood samples must be collected 2 hours after the test load. unless the glucose concentration can be determined immediately, the blood sample should be collected in a tube containing sodium fluoride (6 mg/ml whole blood) and immediately centrifuged to separate the plasma; the plasma should be frozen until the glucose concentration can be estimated.3 results are interpreted according to table 3. references 1. shoback, edited by david g. gardner, dolores shoback (2011).greenspan's basic & clinical endocrinology (9th ed.). new york: mcgraw-hill medical. pp. chapter 17 2. saltiel ar, kahn cr. insulin signaling and the regulation of glucose and lipid metabolism. nature. 2001; 414: 799-806 3. report of a who consultation. definition, diagnosis and classification of diabetes mellitus and its complications. world health organization department of noncommunicable disease surveillance geneva. 1999 journal of islamabad medical & dental college (jimdc); 2012(2):102-106 106 4. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes research and clinical practice. 2010; 87: 4-14 5. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care. 2012; 35(s1): s64-s71). 6. mølbak ag, christau b, marner b, borch–johnsen k, nerup j. incidence of insulin–dependent diabetes mellitus in age groups over 30 years in denmark. diabet med. 1994;11:650–55 7. zimmet pz, tuomi t, mackay r, rowley mj, knowles w, cohen m et al. latent autoimmune diabetes mellitus in adults (lada): the role of antibodies to glutamic acid decarboxylase in diagnosis and prediction of insulin dependency. diabetic med 1994; 11: 299–303 8. humphrey arg, mccarty dj, mackay ir, rowley mj, dwyer t, zimmet p. autoantibodies to glutamic acid decarboxylase and phenotypic features associated with early insulin treatment in individuals with adult–onset diabetes mellitus. diabetic med 1998;15: 113– 19 9. mclarty dg, athaide i, bottazzo gf, swai abm, alberti kgmm. islet cell antibodies are not specifically associated with insulin–dependent diabetes in rural tanzanian africans. diabetes res clin pract. 1990;9: 219–24 10. verge cf, gianani r, kawasaki e, yu l, pietropaolo m, jackson ra et al. predicting type i diabetes in first–degree relatives using a combination of insulin, gad, and ica512bsdc/ia–2 autoantibodies. diabetes 1996;45: 926– 33 11. japan and pittsburgh childhood diabetes research groups. coma at onset of young insulin–dependent diabetes in japan: the result of a nationwide survey. diabetes 1985;34: 1241– 46 12. hother–nielsen o, faber o, sørensen ns, beck– nielsen h. classification of newly diagnosed diabetic patients as insulin–requiring or non–insulin–requiring based on clinical and biochemical variables. diabetes care. 1988; 11: 531–37 13. betterle c, zanette f, pedini b, presotto f, rapp lb, monsciotti cm et al. clinical and subclinical organ– specific autoimmune manifestations in type 1 (insulin– dependent) diabetic patients and their first–degree relatives. diabetologia. 1983; 26: 431–36 14. lillioja s, mott dm, spraul m, ferraro r, foley je, ravussin e et al. insulin resistance and insulin secretory dysfunction as precursors of non–insulin– dependent diabetes. prospective study of pima indians. n engl j med. 1993; 329: 1988–92 15. withers, d. j. et al. disruption of irs-2 causes type 2 diabetes in mice. nature. 1998; 391: 900–904 16. mooy jm, grootenhuis pa, de vries h, valkenburg ha, bouter lm, kostense pj et al. prevalence and determinants of glucose intolerance in a dutch population. the hoorn study. diabetes care. 1995; 18: 1270–73 17. kumar bv, abbas ak, fausto n, mitchell r. diabetes mellitus. in: kumar bv, abbas ak, fausto n, mitchell r, editors. robbins basic pathology, 8th edition. philadelphia: saunders; 2007:775–787 18. who recommendations. use of haemoglobin a1c (hba1c) in the diagnosis of diabetes mellitus in the uk. 2011 19. sacks db, arnold m, bakris gl, bruns de, horvath ar, kirkman ms, lernmark a, metzger be, nathan dm. guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. diabetes care. 2011;34: e61-e99 20. american diabetes association. standards of medical care in diabetes-2011. diabetes care. 2011; 34(1): s11-s61 21. american diabetes association. standards of medical care in diabetes-2006. diabetes care. 2006;29(1):s4 s42 22. ladenson jh. nonanalytical sources of variation in clinical chemistry results. in: sonnenwirth a,jarett l,eds.clinical laboratory methods and diagnosis . st. louis : c.v. mosby co .; 1980 :149–92 23. gambino r, piscitelli j, ackattupathil ta , t heriault jl , andrin rd, sanfilippo ml , etienne m . acidification of blood is superior to sodium fluoride alone as an inhibior of glycolysis. clin chem 2009; 55:1019–21 24. carstensen b, lindstrom j, sundvall j, borch-johnsen k, tuomilehto j. measurement of blood glucose: comparison between different types of specimens. ann clin bio chem. 2008 ;45:140–8  i radiological images post covid fibrosis hepatocellular carcinoma with pulmonary metastases contributed by: department of radiology dr. akbar niazi teaching hospital, islamabad 104 j i m d c 2 0 1 7 104 op e n ac c e ss f u l l l e n g t h a r t i c l e aetiology of cytopenias in children admitted to a tertiary care hospital rehmana waris 1, gulbin shahid 2, sadaf tariq khalid 3, abdullah riaz 4, abdul rehman 5 1 senior registrar, children’s hospital, pakistan institute of medical science, islamabad 2 assistant professor, children’s hospital, pakistan institute of medical science, islamabad 3 senior lecturer, islamabad medical & dental college, islamabad 4. 5 postgraduate trainee, children’s hospital, pakistan institute of medical science, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) a b s t r a c t objective: to determine the aetiology of cytopenias (pancytopenia and bicytopenia) in children and to assess their relationship with demographic factors, clinical manifestations and disease outcome. patients and methods: this cross-sectional study was carried out at the children’s hospital, pakistan institute of medical sciences (pims), islamabad from january 2015 to june 2016. total of 154 children between the ages of 2 months to 12 years presenting with bicytopenia or pancytopenia, at the time of admission were enrolled in the study. patients with known causes of cytopenias and those with chronic illnesses and on long term medications like chemotherapy or immunosuppressant were excluded. results: the causes of cytopenia in order of frequency were acute leukemia (25%), aplastic anemia (20%), enteric fever (19%) and megaloblastic anemia (11%).out of 38 acute leukemia patients, 61 % presented with bicytopenia and 39% with pancytopenia, whereas out of the 31 patients of aplastic anemia, 29 (94%) presented with pancytopenia. among 19 patients of enteric fever, 13(68%) had bicytopenia and 6 (32%) patients presented with pancytopenia. total patients of megaloblastic anemia were 17 out of which 10 (59%) presented with bicytopenia and 7 (41%) with pancytopenia. all patients of idiopathic thrombocytopenic purpura itp (n=9), osteopetrosis (n=3), amegakaryocytic thrombocytopenia (n=2), and myelodysplastic syndrome (n=2) presented with bicytopenia. conclusion: the most common cause of cytopenia was found to be acute leukemia followed by aplastic anemia, enteric fever and megaloblastic anemia keywords: children, bicytopenia, pancytopenia author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4, 5 active participation in data collection address of correspondence sadaf tariq khalid drsadafkhalid243@gmail.com article info. received: april 19, 2017 accepted: may 23, 2017 cite this article: waris r, shahid g, khalid st, riaz a, rehman a. aetiology of cytopenias in children admitted to a tertiary care hospital jimdc. 2017; 6(2):104-109. funding source: nil conflict of interest: nil i n t r o d u c t i o n peripheral cytopenia is defined as reduction in any one of the cellular elements of blood i.e., red blood cells, white blood cells or platelets. cytopenia is taken as hemoglobin <10 gm/dl and/or tlc <4000 cmm and/or platelets < 100x106/l (i). bicytopenia (bc) is reduction in any of the two cell lines and pancytopenia (pc) is reduction in all the three cell lines.1,2 the etiology of cytopenias varies widely in children ranging from transient marrow suppression to marrow infiltrations by life threatening malignancies.1 the underlying pathogenic mechanisms of cytopenias are variable and include decrease in hematopoietic cell production, marrow replacement by abnormal cells, suppression of marrow growth and differentiation, ineffective hematopoiesis with cell death, defective cell o r i g i n a l a r t i c l e mailto:drsadafkhalid243@gmail.com 105 j i m d c 2 0 1 7 105 formation which are removed from the circulation, antibody mediated destruction of cells or trapping of cells in hyperplastic and overactive reticuloendothelial system.1-3 other causes of suppressed hematopoiesis are nutritional deficiencies as observed in vitamin b12, folate and iron deficiency.1,2 irrespective of aetiology, patients with cytopenias may present with fever, pallor, bleeding, hepatosplenomegaly etc. however, outcomes of cytopenias vary widely depending on the cause, from being a mild transient illness to a serious life-threatening disease. to start appropriate treatment timely, knowledge of various diseases underlying cytopenic process is essential.3 different frequencies of causes of pc have been reported in a number of studies.3,5 this study was conducted with the aim to assess the variable causes of bicytopenia/pancytopenia in the pediatric age group in our setup and to determine their association with various demographic factors, clinical manifestations and disease outcome. p a t i e n t s a n d m e t h o d s this cross-sectional study was carried out at children’s hospital, pims from 1st jan 2015 to 30th june 2016. a total of 154 children between 2 months-12 years, presenting and being admitted for the first time with bicytopenia/pancytopenia on complete blood counts were included in the study. cytopenia was defined as hemoglobin <10 gm/dl and/or tlc <4000 cmm and/or platelets < 100x106/l.2 patients on long term therapy with immunosuppressant, anticonvulsants, chemotherapeutic agents or any other drugs being taken for any chronic illness were excluded from the study as were children who had already been worked up for cytopenias previously. detailed history was taken and a thorough physical examination was done on all the study patients at the time of presentation. hematological profile included hemoglobin, red cell indices, total and differential leukocyte count, platelet count, and peripheral blood smear morphology. ict mp and typhidot were also performed on selected cases where there was a clinical suspicion of malaria or typhoid fever. blood counts were done on automated hematology analyzer and were confirmed by peripheral blood smear examination. bone marrow aspirate and trephine biopsy were carried out as per clinical indication. r e s u l t s our sample size of 154 represents 5.58% of the total admissions in general pediatric ward. out of these 154 patients, 85(55%) were presented with bc whereas 69(45%) with pc. the mean age of the study population was 5.7 years ±3.6 (range 2 months-12years) with a male to female ratio of 1.5:1. as regards the geographical distribution (gd) of our patients, most of the patients were from punjab province (n=50 [32.4%]) and twin cities of rawalpindi/ islamabad (n=43 [27.9%]). rest of the patients were from azad jammu kashmir (ajk) and khyber-pakhtunkhwa (kpk) province. the geographical distribution of the study population is represented in figure.1. figure 1: geographical distribution of patients with pancytopenia/ bicytopenia if we look at the aetiology of cytopenias according to the gd, out of 43 patients from rawalpindi/ islamabad; 12 (28 %) were diagnosed with enteric fever and 11 (23%) with all, followed by megaloblastic anemia and aplastic anemia 5 (12%) each. most common diagnosis in patients from other areas of punjab was all 13 (26%), followed by megaloblastic anemia and aplastic anemia 20% each, and enteric fever 8%. there were 11 cases of leishmaniasis, and all of them were from ajk, and these represent 41% of all cases from ajk. other common causes from ajk were aplastic anemia 19%, itp 15% and all 7%. patients from kpk were diagnosed as all (37%) followed by aplastic anemia (31%). 106 j i m d c 2 0 1 7 106 overall, the causes of cytopenia in order of frequency were all (25%), aplastic anemia (20%), enteric fever (19%) and megaloblastic anemia (11%). other less frequent causes included leishmaniasis, malaria, itp, unspecified infections, osteopetrosis, hlh, autoimmune hemolytic anemia, amegakaryocytic thrombocytopenia, chediak-higashi syndrome, and myelodysplastic syndromedetails shown in table 1. the age distribution of the various aetiologies (table 1) were as follows; allmean age of 5.2 ± 2.8 yrs (range 111 yrs), aplastic anemiamean age of 9.7 ±2.0 (range 412 yrs), enteric fever mean age of 6.2 ±3.7 (range 1-12 yrs) and megaloblastic anemia mean age 3.9±3.8,( range 1-12 yrs). the most common cause of bicytopenia was acute leukemia (27%) and of pancytopenia was aplastic table 2: etiological profile of children presented with bicytopenia and pancytopenia etiological profile cytopenia total pancytopenia bicytopenia acute leukemia (al) 15 (22%) 23(27%) 38 aplastic anemia 29(42%) 2(2%) 31 enteric 6(9%) 13(15%) 19 megaloblastic anemia 7(10%) 10(12%) 17 leishmaniasis 5(7%) 6(7%) 11 malaria 1(1%) 9(11%) 10 immune thrombocytopenic purpura (itp) 0(0%) 9(11%) 9 infection related changes 2(3%) 3(4%) 5 osteopetrosis 0(0%) 3(4%) 3 hemophagocytic lymphohistiocytosis (hlh) 2(3%) 1(1%) 3 autoimmune hemolytic anemia 1(1%) 2(2%) 3 amegakaryocytic thrombocytopenia 0(0%) 2(2%) 2 chédiak–higashi syndrome 1(1%) 0(0%) 1 myelodysplastic syndrome 0(0%) 2(2%) 2 total 69 85 154 table 1: etiological profile according to age group etiological profile age group total no. (%) mean age ±sd (range) 2 mon -5 yrs >5-10 yrs >10-12 yrs acute leukemia (al) 25 10 3 38 (25) 5.2±2.8 (1-11) aplastic anemia 1 14 16 31 (20) 9.7±2.0 (4-12) enteric 7 9 3 19 (12) 6.2±3.7 (1-12) megaloblastic anemia 12 3 2 17 (11) 3.9±3.8 (1-12) leishmaniasis 9 2 0 11 (7) 2.8±2.6 (1-9) malaria 5 4 1 10 (6) 5.1±3.4 (0.2-11) immune thrombocytopenic purpura (itp) 6 1 2 9 (6) 5.1±3.2 (1-11) infection related changes 4 1 0 5 (3) 2.9±1.9 (1-6) osteopetrosis 2 1 0 3 (2) 2.9±3.5 (0.6-7) hemophagocytic lymphohistiocytosis (hlh) 2 1 0 3 (2) 3.0±4.3 (0.3-8) autoimmune hemolytic anemia 2 1 0 3 (2) 3.5±2.8 (1-5) amegakaryocytic thrombocytopenia 2 0 0 2 (1) 3.0±2.8 (1-5) chédiak–higashi syndrome 0 1 0 1 (1) 7 myelodysplastic syndrome 1 1 0 2 (1) 5±2.8 (3-7) total 78(51) 49 (32) 27 (18) 154 (100) 107 j i m d c 2 0 1 7 107 anemia (42%).details of other cause of pc and bc are shown in (table 2). lymphadenopathy (14%). patients with bc presented comparison of different national and international studies on the etiology of cytopenias is represented in table 3. d i s c u s s i o n cytopenias are fairly common hematologic abnormalities encountered in clinical practice.5-9 etiology is highly variable with prognosis varying from a mild transient ailment to a severe life-threatening illness.8-10 frequencies of causes of pancytopenia have been reported in a number of studies.3-5 early and appropriate investigations and management has a significant effect on the disease course. in this study, there was a predominance of males with the ratio being 1.48:1. several studies have cited a similar male predominance.5-14 the reason could be due to social/cultural taboos in our society making health care facilities more readily available to male as compared to females leading to increased male presentation in the hospitals especially in rural areas. about 50.6% of our study patients were less than 5yrs of age. sharif m et al showed a somewhat greater number (61%) of under 5year-old children.13 looking at the age distribution in table 3: summary of studies on etiological profile of patients presenting with cytopenia author year place study population number of cases duration of study most common causes memon et al.12 2008 pakistan (jamshoro) children 230 17 months aplastic anemia 23.9%, megaloblastic anemia 13.04%,leukemia 13.05% shafi.et al.15 2012 pakistan (lahore) children 279 15 months acute leukemia 32.2%, aplastic anemia 30.8%, megaloblastic anemia 13.2% jan az et al.5 2013 pakistan (peshawar) children 205 72 months aplastic anemia 28.3%, leukemia 23.9%, megaloblastic anemia 19.5%, sharif et al.15 2014 pakistan (rawalpindi) children 105 12 months megaloblastic anemia 41.9%, infective etiology 19%, aplastic anemia 13.3%, acute leukemia 10.5% arshad et al.19 2016 pakistan (faisalabad) children and adults 330 12 months aplastic anemia 37.5%, infections/septicemia 25%, myelodysplastic syn 12.5%, vl 12.5% present study 2017 pakistan (islamabad) children 153 18 months acute leukemia 25%, aplastic anemia 20%, enteric fever 19%, megaloblastic anemia 11%. alawadi et al.4 2009 iraq (hilla) children and adults 74 15 months acute leukemia 32.4%, aplastic anemia 24.3%, kalaazar 10.8% pine m et al.18 2010 united states children 64 72 months infections 64%,hematologic causes 28%, miscellaneous 8% naseem s etal.3 2011 india (chandigarh) children 571 24 months aplastic anemia 33.8%, acute leukemia 26.6% , megaloblastic anemia 13.7 pathak r et al.20 2012 nepal (khatmandu) children and adults 503 12 months hypoplastic anemia 42.1%, megaloblastic anemia 11.7%, acute leukemia 8.8% bae mh et al.21 2015 korea children and adults 640 adults/ 261 children 60 months acute leukemia 45.8%,aplastic anemia 27.3%, hemophagocytic lympho histiocytosis 18.8% dobey srk et al.16 2016 india (khanpur up) children 170 20 months megaloblastic anemia 47%, aplastic anemia 25.8%, leukemia 17.6% singh g et al.22 2016 india (rajhastan) children 153 12 months severe acute malnutrition 27.3%, leukemia 18.2%, dengue and thalassemia with hypersplenism 9.1% 108 j i m d c 2 0 1 7 108 context of different aetiologies of pancytopenia, only aplastic anemia was almost exclusively diagnosed in children more than 4 years of age whereas almost all of the rest of the causes were more common in under 5year-old children.3 the most common cause of cytopenia in our study was acute leukemia (25%), followed by aplastic anemia (20%), enteric fever (12%) and megaloblastic anemia (11%).these results are somewhat similar to a study by khan fh et al, who reported all (32.2%) as the most common cause of pancytopenia closely followed by aplastic anemia (30.8%) and megaloblastic anemia (13.2%).15 however, majority studies have reported megaloblastic anemia and aplastic anemia as the most common causes of cytopenias.5, 11 likely explanation is that our hospital is the largest public-sector tertiary care hospital in the area with a well-established, specialized pediatric oncology unit and therefore receives a number of referrals of suspected malignancies from neighboring areas like kpk, ajk, and other parts of punjab. certain other studies have cited megaloblastic anemia as being the most common aetiology.16,17 a study conducted at the twin city of rawalpindi/islamabad showed a very high number of patients with megaloblastic anemia (42%) followed by infections 19%, aplastic anemia 18.3%, all 10.5% and itp 5.7 %.13 the reason for megaloblastic anemia being the most common cause of cytopenia in their study may be probably because of the fact that their study comprised of a very large number (71%) of patients having malnutrition and therefore frequency of vit.b12 and folic acid deficiency is understandably high. even then, the most common cause for pancytopenia is megaloblastic anemia but it is under-reported because most of the patients do not get their b12 and folate levels done. as regards infection is concerned infection rate was similar to other studies; we found enteric fever in 17%, malaria in 6% and visceral leishmaniasis in 7%, infection related changes 3%. there are hardly any studies on the subject from the developed countries. pine et al in their five-year review focused on children presenting with pancytopenia at children’s hospital in the united state.18 their selection criteria however, was different as they excluded children with malignancies and their age range was also different as they included children from 2 months and upto 18 years of age. they found infections as the most common cause (64%) followed by hematologic causes (28%). in our study 33% of patients with infections presented with cytopenia(s). not many studies have determined the aetiology of pc and bc separately. in our study, acute leukemia was the most common cause of bc whereas aplastic anemia was the most common diagnosis in those who presented with pc. similar results were shown by a study in india. the causes of pc/bc may vary in different patients and in diverse areas of the world. variations in the frequency of various diagnostic entities have been attributed to differences in patient selection criteria, genetic differences and geographical distribution of the study population. knowing the etiologies in our own setup helps in the better evaluation and prompt management of patients. c o n c l u s i o n the most common cause of cytopenia was found to be acute leukemia followed by aplastic anemia, enteric fever and megaloblastic anemia in a tertiary care hospital setting with a well-established pediatric oncology setup. r e f e r e n c e s 1. bates i, bain bj. approach to diagnosis and classification of blood diseases. dacie and lewis practical hematology. 10th ed. philadelphia: churchill livingstone; 2006.p. 60924. 2. raja s, suman fr, scott jx, latha ms, rajenderan a, ethican a. pancytopenia – (?) an obstacle in the diagnosis and outcome of pediatric acute lymphoblastic leukemia. south asian j cancer. 2015; 4(2):68–71. 3. naseem s, verma n, das r, ahluwalia j. pediatric patients with bycytopenia/pancytopenia: review of etiologies and clinic hematological profile at a tertiary center. indian j patholmicrobiol 2011; 54(1):75-80 4. al–awadi nb, al-awad as, al-yasiri hh. patterns of pancytopenia according to the cause in babylon. medicine (jiacm). 2014; 6(4):434-440. 5. jan az, zahid b, gul z. pancytopenia in children: a 6 year spectrum of patients admitted to pediatric department of rehman medical institute peshawar. pak j med sci. 2013; 29(5):1153-1157 6. makheja kd, maheshwari bk, arain s, kumar s. the common causes leading to pancytopenia in patients presenting to tertiary care hospitals. pak j med sci. 2013; 29(5):1108. 109 j i m d c 2 0 1 7 109 7. erlacher m, strahm b. missing cells: pathophysiology, diagnosis, and management of (pan) cytopenia in childhood. front pediatr. 2015; 3. 8. azaad ma, li y, zhang q, wang h. detection of pancytopenia associated with clinical manifestation and their final diagnosis. open j blood dis. 2015. 24; 5(3):1730. 9. jella r, jella v. clinico-hematological analysis of pancytopenia. international journal of advances in medicine. 2017.2; 3(2):176–9. 10. khan a, aqeel m, khan ta, munir a. pattern of hematological diseases in hospitalized paeditric patients based on bone marrow examination. journal of postgraduate medical institute (peshawar-pakistan). 2011; 22(3). 11. gul z, ahmed s, jan az. spectrum of hematological diseases in pediatric patients presenting with anemia based on bone marrow examination. gomal journal of medicine sciences. 2014; 12(2):60-3. 12. memon s, shaikh s, nizamani a a. eitiological spectrum of pancytopeniabased on bone marrow examination in children. jcoll physicians surg pak. 2008; 18(3):163-167 13. sharif m, masood n, ul haq mz, dodhy ma, muhammad r. etiological spectrum of pancytopenia/bicytopenia in children 2 months to 12 years of age. journal of rawalpindi medical college (jrmc). 2014; 18(1):61-4. 14. chhabra a, chander v, patel a. clinico-aetiological profile of pancytopenia in paediatric practice. j indian acad clin med. 2012; 13:282-5. 15. khan fs, hasan rf. bone marrow examination of pancytopenic children. jpma-journal of the pakistan medical association. 2012; 62(7):660. 16. dobey sr, patel sk, ary ak, singh rp. clinico-etiological spectrum of pancytopenia in hospitalized children.int j contemp pediatr.2016;3(1):169-172 17. reddy gp, rao kv. clinical features and risk factors of pancytopenia: a study in a tertiary care hospital. international journal of advances in medicine. 2016;3(1):68-72. 18. pine m, walter aw. pancytopenia in hospitalized children: a five-year review. journal of pediatric hematology/oncology. 2010; 32(5):192-4. 19. arshad u, latif rk, ahmad sq, imran mm, khan f, jamal s. clinical and aetiological spectrum of pancytopenia in a tertiary care hospital. pakistan armed forces medical journal. 2016; 66(3):323-7. 20. pathak r, jha a, sayami g. evaluation of bone marrow in patients with pancytopenia. journal of pathology of nepal. 2012 vol.2, 265-271 21. bae mh, cho yu, kim b et al. pancytopenia or bicytoppenia in a korean tertiary care center; etiological profile based on bone marrow examination and suggestion for diagnostic approach. blood journal 2015;126(23):5610 22. singh g, agrawal dk, agrawal r. etiological profile of childhood pancytopenia with special reference to nonmalignant presentation. int j med res prof. 2016;2(2):20408 j islamabad med dental coll 2021 194 o p e n a c c e s s effect of ajwa date seed powder on inflammatory response in high fat fed sprague dawley female rat farhana yasmin bhatti1, fariha ahmad khan2, abdul mudabbir rehan3, zoobia irum4, sadia chiragh5 1medical officer, department of gynaecology and obstetrics, university of lahore teaching hospital 2assistant professor, department of pharmacology, akhtar saeed medical and dental college, lahore 3assistant professor, department of pharmacology, d. g. khan medical college, punjab 4assistant professor, department of pharmacology, cmh institute of medical sciences, bahawalpur 5professor, department of pharmacology, al-aleem medical college, lahore a b s t r a c t background: central obesity a worldwide metabolic and cosmetic problem poses significant health risk. ajwa date seed has antioxidant property and its high fiber content may prevent fat absorption and reduce fat deposition. the objective of this research was to evaluate the effect of ajwa date seed powder on visceral fat depots and inflammatory response in high fat fed sprague dawley female rats. methodology: thirty-six healthy rats of four weeks age were divided into three groups and followed for 12 weeks. group a (normal control) received regular diet. group b (hfd control) received high fat diet, while group c (hfd+ajwa group) received high fat diet along with 2% ajwa date seed powder. body weight was measured weekly. blood samples were drawn for the estimation of serum il-6 and leptin levels by elisa method at 12th week, after which, rats were euthanized; perinephric fat was removed and weighed in grams. results: hfd+ajwa group gained less body weight as compared to hfd control group (p value = 0.012). there was a remarkable reduction in perinephric fat weight (p value ≤ 0.001) and level of il-6 in hfd+ajwa group (p value ≤ 0.001) as compared to hfd control. there was no significant difference in serum leptin level of the rats of all groups (p value = 0.567). conclusion: ajwa date seed can prevent visceral adiposity and gain in body weight. moreover, it has anti-inflammatory effect; but no significant effect on satiety hormone. keywords: ajwa date seed extract, leptin, obesity, visceral fat. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: abdul mudabbir rehan email: abdulmudabbir@yahoo.com article info: received: january 23, 2021 accepted: december 16, 2021 cite this article. bhatti fy, khan fk, rehan am, irum z, chiragh s. effect of ajwa date seed powder on inflammatory response in high fat fed sprague dawley female rat. j islamabad med dental coll. 2021; 10(4): funding source: pgmi, lahore conflict of interest: nil i n t r o d u c t i o n obesity is a medical condition in which excessive body fat accumulates in the body to an extent that it may have a negative impact on health, leading to reduced life expectancy or increased risk of major health problems (1). statistically, obesity has increased at an alarming rate over the past several decades. in the past, it was considered a problem of high-income countries especially usa, but now it is widely spreading all over the world (2). a national survey in usa showed that obesity epidemic began over 40 years ago and its prevalence has doubled from 1980-2010 (3). according to who, 1.9 billion adults who were greater than 18 years of age were overweight in 2016 and out of these, 650 million o r i g i n a l a r t i c l e j islamabad med dental coll 2021 195 adults suffered from obesity. in pakistan, 28% of men and 38% of women were obese according to a report of 2013 (4). another study reported that 25% of adults were either obese or overweight (5). in 2011, a health survey conducted in pakistan showed that obesity is more prevalent in urban dwellers. (6) obesity is a multifactorial condition and it is predominantly caused by increasing trend in consumption of low-cost westernized diet and adoption of sedentary lifestyle. there is a rich evidence-based literature that presents obesity as a complicated chronic medical condition caused by the interplay of genetic, environmental, metabolic, physical inactivity and behavioral factors (7). the primary step to reduce weight is dietary modification and adoption of active lifestyle. low caloric intake with the increase in physical exercise shifts the positive energy balance into negative energy balance eventually causing reduction in the body weight (8, 9). currently, the available therapeutic approaches for obesity management have numerous side effects except herbal medications. therefore, growing attention has been given to natural products as they are not only rich in nutrition, vitamins and minerals but also a source of numerous phytochemicals (10). phoenix dactylifera l plant has the highest rank among all the natural products used so far due to its nutritious value and historical background. moreover, its medicinal potential as an anti-inflammatory, antihyperlipidemic and anti-diabetic agent is suggestive of anti-obesity effect. its fruit (ajwa date) seed contains rich amount of fiber and polyphenols (11). the increase in dietary fiber intake can increase the amount of fat excreted in the stool as the soluble part of fiber binds to bile salts and affects the absorption of dietary fat from gut. the dietary fat is lost in stool instead of being absorbed from gut, that ultimately results in reduced accumulation in the body. polyphenols are the naturally occurring bioactive phytochemical. polyphenols modulate physiological and molecular pathways, that are involved in energy metabolism; adipocytes differentiation and ꞵoxidation thus have antiobesity effect (12). polyphenols produce antiinflammatory effect by inhibiting the production of proinflammatory cytokine il-6 which is one of the major mediators of obesity induced inflammation (13). there are limited clinical trials and little published information regarding the anti-obesity effect of herbs or natural products (14). there are also limited local studies regarding anti-obesity effects of herbs. one local study done on ethanolic extract of cosmos caudatus kaunth leaf showed anti-obesity effect in high fat diet rats (15). till now, no other local study is conducted regarding anti-obesity effect of herbs. in the current study, seed powder of phoenix dactylifera l (ajwa date) has been used along with high fat diet to prevent the adiposity and inflammation in view of its richest proportion of polyphenols and fiber content. m e t h o d o l o g y it was an experimental study conducted at post graduate medical institute lahore from june to september 2017. four weeks old female spraguedawley rats, weighing 40-50g were taken and shifted to the animal house. rats showing any signs of disease or altered behaviour were excluded from the study. thirty-six female rats were randomly divided into three groups containing 12 rats in each group; group a (normal control), group b (hfd control) and group c (hfd+ajwa group). calculated sample size using 90% power of study and 5% level of significance was 9 in each group but keeping in view the previous study design of similar published studies, we took a sample size of 12 in each group (16). they were kept in iron cages, 6 rats in each cage to avoid overcrowding. for one week, they were given normal chow for acclimatization. they had free access to food and water. the temperature was maintained in between 22-24 ºc with natural day and night cycle. it was approved from ethical committee for basic sciences of pgmi j islamabad med dental coll 2021 196 ajwa dates were purchased and its seeds were separated from flesh. separated seeds were washed, remaining fruit pulp was removed and the seeds were air dried. when they were full dry, they were ground in electric grinder to powder form. weight of seed powder was approximately 250 g obtained from 2 kg dates (17). high fat diet was prepared from fresh beef tallow. it was melted to oil in 5 hours and cooled down to room temperature. 210 g beef tallow oil was weighed in a glass container and mixed with 780 g of normal rat chow. 10g sodium deoxycholate was also added to help in absorption of fat. after proper mixing of all the contents, feed was shaped into pellet (18). these feed pellets were air dried and then stored into feed boxes. diet for group c (hfd+ajwa group) was prepared by adding 20 g of ajwa date seed powder to 980 g of high fat diet (17). before euthanizing the rats after 12th week, 2ml blood sample was collected for serum markers testing. it was done by doing cardiac puncture. then blood samples were put in yellow cap vacutainers (biovac), allowed to clot and centrifuged at 2500 rpm for 10 minutes at room temperature for obtaining sera. samples were stored in serum cups and kept at -20ºc. rats were euthanized after taking the blood sample. perinephric fat was removed, collected into airtight plastic bags and weighed in grams. study variables were body weight (gm), serum il-6 & leptin levels, perinephric fat weight and adiposomatic index. rat’s body weight was measured in grams in all study groups at day 0, then weekly for 12 weeks. concentration of serum il-6 and serum leptin was measured by enzyme linked immunosorbent assay (elisa) technique. a rat specific research grade kit made by glory science co.; usa was used. adiposomatic index was calculated by dividing perinephric fat pad weight by body weight and multiplying with hundred. after data collection, it was transcribed into computerized package i.e., statistical package for social sciences (spss 20). kolmogorov-smirnov test was applied to check the normal distribution of data. necessary graphic representation was done by using graph pad prism version 8. quantitative variables were presented in form of mean ± s.d. analysis of variance (anova) was applied between three groups. post hoc tukey’s test was applied for multiple comparisons in all groups. p value of ≤ 0.05 was considered significant. r e s u l t s body weights were almost similar at week zero in all the study groups. the body weight of animals belonging to all groups increased steadily from baseline till end of study. the body weight of hfd control was significantly higher than that of normal control as well as hfd+ajwa group. figure 1 illustrates the body weight of animals (mean ± sd) in all groups at the beginning and end of study. figure. 1: effect of phoenix dactylifera l seed powder on body weight level of serum il-6 was highest in hfd control followed by normal control whereas, hfd+ajwa group showed the lowest level. multiple comparison by post hoc tukey’s test revealed that the level of il6 in hfd+ajwa group was lower than that of hfd control group and the difference was statistically significant. serum leptin level was highest in normal control followed by hfd+ajwa group while hfd control showed the lowest level. no significant difference was observed between the mean values of all the groups by anova with p value of 0.567 (table i) j islamabad med dental coll 2021 197 table i: effect of phoenix dactylifera l (ajwa date) seed powder on serum il6 and leptin level of hfd induced obese rats (n=12). paramet er normal control hfd control hfd+ajw a group anov a p value mean ± sd mean ± sd mean ± sd il6 level (ng/l) 83±37.36 ** 108±44. 56 66±12.1* ** 0.02* leptin level (µg/l) 3.08±0.9 2 2.41±1.1 2 2.95±0.6 8 0.567 *p value<0.05 the perinephric fat weight and adiposomatic index of hfd control group were insignificantly higher than normal control group, while that of hfd+ajwa group were significantly lower than hfd control as well as normal control group (table ii) table. ii: effect of phoenix dactylifera l (ajwa date) seed powder on perinephric fat weight &adiposomatic index (mean±sd) of hfd induced obese rats (n=12). paramete r normal control hfd control hfd+ajw a group anov a p value mean ± sd mean ± sd mean ± sd fat weight (g) 4.3±1.32 ## 5.6±3.3 0 1.9±2.53 *** 0.001* ** adiposom atic index 2.54±0.7 1## 3.00±1. 57 1.1±0.32 *** 0.001* ** d i s c u s s i o n at the end of the study, highest weight was observed in hfd control followed by hfd+ajwa group and normal control. the difference in body weight was statistically significant (p=0.012). similar results were observed in a local study done to evaluate the hypolipidemic effect of ajwa date seed compared to simvastatin in butter fed dyslipidemic rats. hypolipidemic effect was observed in the group which was given ajwa date and there was also less weight gain in that group (p≤0.05). other inflammatory markers like il-6 and serum leptin was not assessed in that study (19). at the end of 12th week, perinephric fat was resected, weighed and adiposomatic index was calculated. the hfd control rats had the largest amount of perinephric fat that was grossly appreciable, whereas hfd+ajwa group rats had smaller amount of perinephric fat, even a few of them showed a negligible amount. perinephric fat in hfd+ajwa group was not only significantly less than hfd control but was less than normal control. these results propose that ajwa date seed powder prevents the visceral fat deposition. similar results were found in a chinese study on the similar animal model through administration of green tea extract (contains the same active principal polyphenols) along with high fat diet in rats. the study with total green tea extracts, at a dose of 400 or 800 mg/ kg were done on high-fat diet fed rats for 6 weeks to observe their anti-obesity effects. the results showed that polyphenols and polysaccharides were responsible for the suppressive effect of green tea extracts on body weight increase and fat accumulation (p-value <0.05). moreover, polyphenols, polysaccharides, or caffeine can improve blood lipid and antioxidant levels, effectively reducing rat serum leptin levels, and markedly reducing the expression levels of the il-6 and tnf-α gene (10). in our study, leptin level did decrease significantly. one local study also showed hypolipidemic effect of ajwa date and hallawi date and it was proposed that ajwa date may have anti-obesity effect (18). the mechanism could be that ajwa seed powder contains 78-80% fiber content (23) and the soluble fibers bind to bile salts secreted by the gallbladder into small intestine (20). another study also support our study, in which it was found that increased fiber intake in diet can increase the amount of fat secreted in the stool (21). a study done in gulf region was conducted to evaluate the antidiabetic, hypolipidemic and antioxidative activities of ajwa date seed extract on streptozotocin induced diabetic rats. administration of date seed extracts to diabetic rats caused a significant reduction in blood glucose j islamabad med dental coll 2021 198 level, oxidative stress and maintaining in the body weight. serum leptin level and il-6 was not analyzed in that study. (21) in the current study, serum il-6 level was measured as inflammatory marker at the end of 12th week. interleukin-6 is an immune mediator lymphokine protein that causes b cell growth, activation and differentiation into plasma cells and antibodies which proceeds to inflammation. usually this mediator is released from helper t-cell lymphocytes, but is also released from adipose tissue (22). in the current study, it was observed that hfd control group showed highest level of il-6 as well as highest visceral fat amount indicating a possible link between adipose tissue and level of il-6. hence it can be concluded that il-6 level raised due to the presence of higher amount of visceral fat. on the other hand, the hfd+ajwa group showed a marked reduction in the level of il-6 along with reduction in perinephric fat indicating that il-6 serum level is directly proportional to visceral fat amount. one study done in indonesia on anti-inflammatory effect of dates seeds on carrageenaninduced edema in rats, showed decrease in several inflammatory mediators like il-2, il-1b, pge-2, cox-1 and cox-2 (23). in our study, serum leptin was also analyzed at the end of 12 weeks to see the effect of ajwa date seed powder on food intake. leptin is a satiety hormone that is released from adipose tissue and regulates hunger by stimulating satiety center located on the lateral nucleus of hypothalamus (23). on the other hand, elevated serum leptin level is observed in obese individuals which is considered to be due to development of leptin resistance (24). in the current study, no difference was observed in serum leptin level of three study groups. one local study is done to evaluate the anti-obesity effect of cosmos caudatus kunth leaf in obesity induced high fat diet fed rats. rats who received ethanolic extract of the leaf together with hfd showed significant (p < 0.05) reduction in body weight gain compared to rats receiving hfd only. other related obesity biomarkers including plasma lipid profiles, insulin, leptin, ghrelin and adiponectin levels also showed significant improvement (p < 0.05). administration of ethanolic leaf extract caused significant (p < 0.05) increase in fecal fat excretion (15) . highlight of our study is remarkable reduction of visceral fat in hfd+ajwa group, not only from hfd group but also significantly less from normal control. although visceral fat is smaller in quantity, but all the major health risks are associated with visceral fat (25). it is a limitation of this study that phytochemical analysis was not performed, and proposal is based on results of other analytical studies. other limitations of study are that neither food and calories intake were measured nor mechanism of fat loss was determined. c o n c l u s i o n addition of ajwa date seed powder to diet can prevent weight gain and visceral adiposity but it has no significant effect on satiety hormone. acknowledgement: authors are thankful to staff of animal house and chemical pathology laboratory of postgraduate medical institute, lahore for their cooperation. disclaimer: data is part of m. phil thesis. r e f e r e n c e s 1. bayliak mm, abrat ob, storey jm, storey kb, lushchak vi. interplay between diet-induced obesity and oxidative stress: comparison between drosophila and mammals. comp biochem physiol part a mol integr physiol. 2019;228:18-28. doi: 10.1016/j.cbpa.2018.09.027 2. malik vs, willett wc, hu fb. global obesity: trends, risk factors and policy implications. nat rev endocrinol. 2013;9(1):13-27. doi: 10.1038/nrendo.2012.199 3. finucane m, stevens g, cowan m, danaei g, lin j, paciorek c, et al. global burden of metabolic risk factors of chronic diseases collaborating group (body mass index) national, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. lancet. 2011;377(9765):55767. doi: 10.1016/s0140-6736(10)62037-5 j islamabad med dental coll 2021 199 4. siddiqui m, hameed r, nadeem m, mohammad t, simbak n, latif a, et al. obesity in pakistan; current and future perceptions. j curr trends biomed eng biosci. 2018;17:1-4. doi: 10.19080/ctbeb.2018.17.555958 5. asif m, aslam m, altaf s, atif s, majid a. prevalence and sociodemographic factors of overweight and obesity among pakistani adults. j obes metab syndr. 2020;29(1):58. doi: 10.7570/jomes19039 6. mushtaq mu, gull s, abdullah hm, shahid u, shad ma, akram j. prevalence and socioeconomic correlates of overweight and obesity among pakistani primary school children. bmc public health. 2011;11(1):724. doi: 10.1186/1471-2458-11-724 7. upadhyay j, farr o, perakakis n, ghaly w, mantzoros c. obesity as a disease. med clin north am. 2018;102(1):13-33.doi: 10.1016/j.mcna.2017.08.004 8. westerterp kr. exercise, energy balance and body composition. eur j clin nutr. 2018;72(9):1246-50. doi:10.1038/s41430-018-0180-4 9. dhurandhar nv, schoeller d, brown aw, heymsfield sb, thomas d, sørensen ti, et al. energy balance measurement: when something is not better than nothing. int j obes. 2015;39(7):1109-13. doi:10.1038/ijo.2014.199 10. xu y, zhang m, wu t, dai s, xu j, zhou z. the antiobesity effect of green tea polysaccharides, polyphenols and caffeine in rats fed with a high-fat diet. food funct. 2015;6(1):296-303. doi: 10.1039/c4fo00970c 11. khalid s, khalid n, khan rs, ahmed h, ahmad a. a review on chemistry and pharmacology of ajwa date fruit and pit. trends food sci technol. 2017;63:60-69. doi: 10.1016/j.tifs.2017.02.009 12. boccellino m, d’angelo s. anti-obesity effects of polyphenol intake: current status and future possibilities. int j mol sci. 2020;21(16):5642. doi:10.3390/ijms21165642 13. tangvarasittichai s, pongthaisong s, tangvarasittichai o. tumor necrosis factor-α, interleukin-6, c-reactive protein levels and insulin resistance associated with type 2 diabetes in abdominal obesity women. indian ind j clin biochem. 2016;31(1):68-74. doi: 10.1007/s12291-015-0514-0 14. panigrahi t, vishwas s, dash d. a herbal approach to obesity management: a review. asian j pharmaceut educ res. 2017;6:1-5. issn : 2278 7496 15. rahman ha, sahib ng, saari n, abas f, ismail a, mumtaz mw, et al. anti-obesity effect of ethanolic extract from cosmos caudatus kunth leaf in lean rats fed a high fat diet. bmc complement altern med. 2017;17(1):1-17. doi: 10.1186/s12906-017-1640-4 16. an hm, park sy, lee dk, kim jr, cha mk, lee sw, et al. antiobesity and lipid-lowering effects of bifidobacterium spp. in high fat diet-induced obese rats. lipids health dis. 2011;10(1):116. doi: 10.1186/1476-511x-10-116 17. mushtaq z, kausar s, kousar n, chiragh s. effect of ajwa date seed on lipid profile of diet induced hyperlipidemic rabbits. kmuj. 2017;9(3):135-139 18. hariri n, thibault l. high-fat diet-induced obesity in animal models. nutri res revi. 2010;23(2):270-99. doi:10.1017/s095442241000016 8 19. farooq sultan sa, saadia shahzad alam, hassan farooq, ajmal afzal, moneeb ashraf. anti-obesity and hypolipidemic effects of ajwa date seed compared to simvastatin in butter fed dyslipidemic rats. proceedings 2019;33(2):7. 20. harvey r, ferrier d. illustrated reviews: biochemistry. lippincott williams & wilkins, philadelphia; 2011:112-113 21. slavin jl. dietary fiber and body weight. nutrition. 2005;21(3):411-8. doi: 10.1016/j.nut.2004.08.018 22. jones be, maerz md, buckner jh. il-6: a cytokine at the crossroads of autoimmunity. curr opin immunol. 2018;55:9-14. doi: 10.1016/j.coi.2018.09.002 23. kuryszko j, slawuta p, sapikowski g. secretory function of adipose tissue. pol j vet sci. 2016;19(2):441-446. doi: 10.1515 / pjvs-2016-0056 24. liu j, yang x, yu s, zheng r. the leptin resistance. neural regulation of metabolism: springer; 2018:145-63. doi: 10.1007/978-981-13-1286-1_8 25. elffers tw, de mutsert r, lamb hj, de roos a, willems van dijk k, rosendaal fr, et al. body fat distribution, in particular visceral fat, is associated with cardiometabolic risk factors in obese women. plos one. 2017;12(9):1-10. doi: 10.1371/journal.pone.0185403 j islamabad med dental coll 2022 60 o p e n a c c e s s the impending threat of monkey pox: responsiveness of pakistan’s health system muhammad ahmed abdullah1 1assistant professor, community medicine, islamabad medical and dental college monkeypox is a viral zoonotic disease, with symptoms much similar to smallpox.1 the term monkeypox was coined when the virus was first discovered in monkeys in a danish laboratory in 1958. the first known human case was identified in a child in the democratic republic of the congo in 1970.2 the causative agent is a virus belonging to orthopoxvirus genus of the poxviridae family.3 the virus is transmitted through direct contact and also through droplet transmission. in a recent surge of cases in non-endemic countries, most but no exclusively the disease has occurred in homosexual men.4 monkeypox disease starts with a prodrome of symptoms, which include fever, lymphadenopathy, headache, and muscle aches followed by development of a characteristic rash climaxing in firm, deep-seated, well-circumscribed and sometimes umbilicated lesions. the rash usually starts from the face or the oral cavity and progresses through several corresponding stages on each affected area and concentrates on the face and extremities, including lesions on the palms and soles.5 correspondence: muhammad ahmed abdullah email: drahmed.abdullah@imdcollege.edu.pk cite this editorial: abdullah m a. the impending threat of monkeypox: responsiveness of pakistan’s health syetem. j islamabad med dental coll. 2022; 11(2):60-61. doi: https://doi.org/10.35787/jimdc.v11i2.892 since the covid 19 pandemic, the world has become more cautious about infectious diseases.6 in a recent turn of events, since may 2022 monkeypox outbreaks have been reported in 12 non-endemic countries namely; austrailia, belgium, france, germany, italy, spain, sweden, usa, uk, netherlands, portugal and canada. the disease has been known to be endemic mostly in african countries, which include; benin, cameroon, the central african republic, the democratic republic of the congo, gabon, ghana (identified in animals only), ivory coast, liberia, nigeria, the republic of the congo, sierra leone, and south sudan.7 the covid 19 pandemic has taught us many things. the modern transportation systems created by humans, don’t only carry people and goods, they also carry diseases. countries with weaker health systems are at a greater threat of crumbling under pressure when faced with epidemiological emergencies.8 pakistan has a weak health system, especially in terms of infectious disease monitoring, surveillance and control. we have been unable to eliminate polio,9 important concepts like contact tracing and partner notification are almost non-existent even for easily traceable diseases such as hiv and syphilis,10 and the data we gather as evidence is often nontrustworthy. 11 pakistan is a low middle income country, with inequitable distribution of scarce resources.12 in the year 2021, the government spent 1.2 percent of the gdp on health, this amount is far less than the who recommendation of five percent.13 the e d i t o r i a l j islamabad med dental coll 2022 61 responsiveness of the health system is another major issue, added on by a reactive instead of a proactive approach, we usually identify problems when they have already been complicated. the same holds true when we are faced with disasters of varying intensity.14 in conclusion the health system of pakistan needs a major paradigm shift, in order to tackle disease outbreaks. the infectious disease burden of pakistan is immense, as we are persistently r e f e r e n c e s 1 oladoye mj. monkeypox: a neglected viral zoonotic disease. electronic journal of medical and educational technologies. 2021 may 15;14(2):em2108. 2 brown k, leggat pa. human monkeypox: current state of knowledge and implications for the future. tropical medicine and infectious disease. 2016 dec;1(1):8. doi: 10.3390/tropicalmed1010008. 3 lefkowitz ej, wang c, upton c. poxviruses: past, present and future. virus research. 2006 apr 1;117(1):105-18. doi: 10.1016/j.virusres.2006.01.016. 4 memariani m, memariani h. multinational monkeypox outbreak: what do we know and what should we do?. irish journal of medical science (1971-). 2022 jun 6:12. 5 duque mp, ribeiro s, martins jv, casaca p, leite pp, tavares m, et al. ongoing monkeypox virus outbreak, portugal, 29 april to 23 may 2022. eurosurveillance. 2022 jun 2;27(22):2200424. 6 balkhair aa. covid-19 pandemic: a new chapter in the history of infectious diseases. oman medical journal. 2020 mar;35(2):e123. doi: 10.5001/omj.2020.41 7 world health organization. multi-country monkeypox outbreak in non-endemic countries. [available from: https://www.who.int/emergencies/diseaseoutbreak-news/item/2022-don385 ] struggling to reduce the burden caused by chronic communicable diseases like viral hepatitis, tuberculosis and hiv. the constant impending threat of emerging infectious diseases has the potential to force the health system to redirect the already scarce resources from already existent health needs and problems, towards newer challenges. a health systems approach is imperative to simultaneously deal with our long list of public health problems. 8 abdullah ma, rashid f. covid-19 pandemic: impact on countries with weak health systems. journal of islamabad medical & dental college. 2020 mar 29;9(1):4-5. 9 andrade ge, hussain a. polio in pakistan: political, sociological, and epidemiological factors. cureus. 2018 oct 27;10(10). doi: 10.7759/cureus.3502 10 abdullah ma, shaikh bt, ghazanfar h. curing or causing? hiv/aids in health care system of punjab, pakistan. plos one. 2021 jul 9;16(7):e0254476. 11 qazi ms, ali m. pakistan's health management information system: health managers' perspectives. jpma. the journal of the pakistan medical association. 2009 jan 1;59(1):10. 12 abdullah ma, mukhtar f, wazir s, gilani i, gorar z, shaikh bt. the health workforce crisis in pakistan: a critical review and the way forward. world health popul. 2014 jan 1;15(3):4-12. 13 bollyky tj, templin t, cohen m, dieleman jl. lowerincome countries that face the most rapid shift in noncommunicable disease burden are also the least prepared. health affairs. 2017 nov 1;36(11):1866-75. doi: 10.1377/hlthaff.2017.0708 14 khan i, ali a, waqas t, ullah s, ullah s, shah aa, et al. investing in disaster relief and recovery: a reactive approach of disaster management in pakistan. international journal of disaster risk reduction. 2022 jun 1;75:102975. https://doi.org/10.5001%2fomj.2020.41 https://www.who.int/emergencies/disease-outbreak-news/item/2022-don385 https://www.who.int/emergencies/disease-outbreak-news/item/2022-don385 j islamabad med dental coll 2022 135 o p e n a c c e s s a breakthrough in alzheimer’s disease taimoor hassan lecturer, department of health professional technologies, university of lahore. dear editor, i am writing to you in order to highlight one of the causative factors of alzheimer's disease which is among the most prevalent types of dementia worldwide. australian researchers discovered one of the possible origins of alzheimer's disease which is a "breakthrough" according to some. scientists have gained a better grasp of why and how alzheimer's disease arises by researching the blood-brain barrier. their findings point to possible therapy and preventive strategies for the neurodegenerative disorder.1 alzheimer's disease is a neurodegenerative illness that affects areas of the brain involved in memory, thinking, and language. its symptoms range from moderate memory loss to inability to hold conversations to disorientation and mood swings in the environment. centers for disease control and prevention (cdc) opines that, up to 7 million american residents have alzheimer's disease. previous literature has demonstrated that a person's risk of getting alzheimer's disease is influenced by plethora of factors.2 nevertheless, scientists in australia have now uncovered a new component that may be to blame for the onset of this neurodegenerative disease. dr. john mamo, head of correspondence: taimoor hasaan email:taimoorhassan408.th@gmail.com cite this editorial: hassan t. a breakthrough in alzheimer’s disease j islamabad med dental coll. 2022; 11(3):135-137 doi: https://doi.org/10.35787/jimdc.v11i3.793 the curtin health innovation research institute at curtin university in perth, australia and lead study author described the new research's findings to medical news today. “to identify new chances to prevent and cure alzheimer's, we need to understand what truly causes the illness, which is currently unknown,” he added.1 “this work indicates that an excess of potentially hazardous fat-protein complexes in the blood can damage small brain blood vessels called capillaries and then seep into the brain, triggering inflammation and brain cell death,” changes in dietary habits and some medicines may possibly reduce blood concentrations of these hazardous fatprotein complexes, thus lowering the risk of alzheimer's or slowing disease progression,” he concluded.1,2,3 dr. mamo and his colleagues are attempting to identify previously unknown origins of alzheimer's disease. they believe that this may lead to new areas of research and unique possible therapies for the disease.4 the researchers utilized two mouse models in their latest study. they genetically changed the test animals' livers such that they produced human amyloid-beta. this is the protein component of the deadly protein-fat complex that scientists suspected was the cause of alzheimer's disease. the control group showed no genetic changes. the researchers treated both groups to a fear-motivated memory test for cognitive skills over time and recorded the findings. l e t t e r t o e d i t o r mailto:taimoorhassan408.th@gmail.com j islamabad med dental coll 2022 136 the researchers discovered that when amyloid-beta proteins produced in the test mice's liver merged with lipids and went to the brain, they disrupted the correct functioning of the brain's tiny blood vessels, or capillaries. because of the malfunction in the blood-brain barrier, protein-fat complexes leaked from the blood into the brain, causing inflammation. this inflammation occurred in both the test and control groups, although it began considerably earlier in the test group.6 the researchers also looked at a neurodegenerative marker and discovered that it was around two times higher in the test animals than in control mice of the same age. as a result, it was expected that during the cognitive function test, the test mice did around half as well as the control group in terms of learning retention. these findings provide answers to longstanding concerns concerning the function of amyloid-beta in the development of alzheimer's disease. the importance of the study results was conveyed to mnt by warren harding, board chairman of alzheimer's wa. he stated: “without significant medical advances like the one made by prof. mamo's team, the number of australians living with dementia is expected to exceed one million by 2058. these findings have the potential to have a large global impact on the millions of people living with alzheimer's disease.”1,6 previously, it was considered that genetic variables had a significant influence in the likelihood of getting alzheimer's disease (ad). early-onset familial alzheimer's disease is caused by rare mutations in at least three genes. a frequent variation in the apolipoprotein e gene is the main risk factor among families with late-onset ad, and in the local population. however, advanced age remains the most well-established risk factor for alzheimer's disease. environmental factors may also play a role in disease manifestation.7 oxidative damage and messenger rna alterations are two pathogenic causes that are directly linked to aging. other variables unrelated to aging may be susceptible to therapeutic intervention in the future, such as estrogen replacement treatment for postmenopausal women, anti-inflammatory medication therapy, and lowering vascular risk factors. older beliefs, such as aluminum's role in the pathogenesis of alzheimer's disease, have mainly been abandoned as our understanding of the pathogenic pathways of alzheimer's disease has evolved.8 with limited known risk factors associated with alzheimer’s disease, we have also very limited choice of allopathic treatment for ad patients such as cholinesterase inhibitors (tacrine, donepezil, metrifonate etc.). plant extracts such as alphatocopherol, selegiline, gingko biloba etc., are also being used widely to treat this neurodegenerative disorder.8 the fact that the researchers only used animal models is one of the study's limitations. this means that, despite promising results, more research, particularly in humans, is required. nevertheless, acknowledging how the amyloid-beta-fat complex affects brain capillaries could start opening potential medical possibilities to either cure alzheimer’s disease or slow down the condition’s development. although, it is a long road from mouse studies to human treatments, but such laboratory research is critical to making the advances needed to combat this severe, and increasingly common, condition.2,4 keywords: alzheimer disease, blood brain barrier, beta-amyloid protein, dementia. r e f e r e n c e s 1. yahaya h. likely cause of alzheimer’s identified in a new study. medical news today. [available online from september 18, 2021]. available online at: https://www.medicalnewstoday.com/articles/li kely-cause-of-alzheimers-identified-in-newstudy?utm_source=sailthru%20email&utm_me dium=email&utm_campaign=dedicated&utm_c ontent=2021-1003&apid=38880177&rvid=099b221a12ebaa5e8f j islamabad med dental coll 2022 137 c3f5857833d63a836dcadcdfaaffb83ce4c7db6a7 76d2f [cited on october 4, 2021] 2. centers for disease control and prevention. alzheimer’s disease and related dementias. cdc. [online]. available online at: https://www.cdc.gov/aging/aginginfo/alzheime rs.htm [cited on october 4, 2021] 3. nih. what causes alzheimer’s disease?. nih. [online]. available online at: https://www.nia.nih.gov/health/what-causesalzheimers-disease [cited on october 4, 2021] 4. curtin university. likely cause of alzheimer’s disease identified. sciencedaily. [available online from september 15, 2021]. available online at: https://www.sciencedaily.com/releases/2021/0 9/210915161348.htm [cited on october 4, 2021] 5. scitechdaily. groundbreaking research identifies likely cause of alzheimer’s disease – potential for new treatment. [available online from september 15, 2021]. available online at: https://scitechdaily.com/groundbreakingresearch-identifies-likely-cause-of-alzheimersdisease-potential-for-new-treatment/ [cited on october 4, 2021] 6. robtizski d. scientists may have been discovered the cause of alzheimer’s disease. futurism. [available online from september 2021]. available online at: https://futurism.com/neoscope/scientistscause-alzheimers-disease [cited october 4, 2021] 7. armstrong ra. what causes alzheimer's disease?. folia neuropathol. 2013 dec 31;51(3):169-88. 8. hassan t, saeed s, hassan m, naseem s, siddique s. ethnomedicinal plants in the treatment of neurodegenerative diseases: a narrative. gomal j med sci. 2021 jan;19(1):35-44. https://www.sciencedaily.com/releases/2021/09/210915161348.htm https://www.sciencedaily.com/releases/2021/09/210915161348.htm j islamabad med dental coll 2022 256 o p e n a c c e s s ectopic mediastinal parathyroid adenoma excision via video assisted thoracoscopic approach: a case report bilal umair1, sohail saqib chatha2, rashid husnain3, farhan ullah4, raheel khan5. 1professor and hod, thoracic surgery, cmh, rawalpindi, pakistan. 2,4,5 registrar thoracic surgery, cmh, rawalpindi, pakistan. 3consultant thoracic surgeon, cmh, rawalpindi, pakistan. a b s t r a c t ectopic parathyroid adenomas can be a cause of recurrent and refractory hyperparathyroidism. majority of parathyroid adenomas are located in the neck region, however in very few cases they are located within the mediastinum. in such cases excision via cervical approach is not possible and it becomes a diagnostic as well as surgical challenge. excision via thoracoscopic approach is a preferred approach in this regard. here we represent a case of ectopic parathyroid adenoma embedded within thymus gland which underwent surgical excision via thoracoscopic approach. key words: ectopic, parathyroid adenoma, thoracoscopy correspondence: sohail saqib chatha email: drsohailchatha@hotmail.com article info: received: august 15, 2022 accepted: december 27, 2022 cite this article. umair b, chatha s s, husnain r, ullah f, khan r.ectopic mediastinal parathyroid adenoma excision via video assisted thoracoscopic approach: a case report.j islamabad med dental coll. 2022; 11(4): 256-258 funding source: nil conflict of interest: nil https://doi.org/10.35787/jimdc.v11i4.901 i n t r o d u c t i o n primary hyperparathyroidism (phpt) occurs due to excessive secretion of parathyroid hormone by parathyroid glands. causes of primary hyperparathyroidism include parathyroid adenoma or parathyroid carcinoma. majority of cases of primary hyperparathyroidism are caused by solitary parathyroid adenoma.1,2 majority of the parathyroid adenomas are located in cervical region, however in 1-2% cases they are located at ectopic location in mediastnum.3 the presence of ectopic location for parathyroid adenoma is due to abnormal migration during embryogenesis. localisation of ectopic parathyroid gland can present as a diagnostic challenge and a combination of high-resolution computed tomography, mri and nuclear scintigraphy are needed for appropriate localisation. surgical resection is the most effective treatment for the management of phpt secondary to parathyroid adenoma. however surgical resection of ectopic parathyroid gland located in mediastinum is usually not possible via cervical approach so a thoracoscopic approach is considered a most appropriate approach. the video-assisted thoracoscopic surgery (vats) offers an excellent modality combining the merits of a minimally invasive approach and magnification of the surgical field.4 here we represent a case of ectopic parathyroid adenoma c a s e r e p o r t j islamabad med dental coll 2022 257 located within the mediastinum for which video assisted thoracoscopic resection was performed. c a s e r e p o r t a 45-year-old lady presented to medical opd with complaints of bone pains for the past 8 months. she has been regularly using pain killers but without any relief. she was hypertensive well controlled on medication. on being investigated she was found to have raised serum calcium levels. her pth levels were also found to be raised and a provisional diagnosis of primary hyperparathyroidism was made. ultrasound neck gave suspicion of parathyroid adenoma on left lower pole of thyroid gland. her cect neck and chest was done which gave suspicion of parathyroid adenoma at ectopic place on left mediastinum. her sesta-mibi scan showed small sesta-mibi avid lesion anterior mediastinum and confirmed the diagnosis of ectopic mediastinal parathyroid adenoma. she was counselled and planned for surgical resection of the parathyroid adenoma. due to ectopic location of the parathyroid adenoma video assisted thoracoscopic resection of the adenoma was performed. per-op no discrete adenoma was identified, however based on the area identified by ct scan and sesta-mibi scan, the whole area suspicious of containing parathyroid adenoma was cleared and removal of gland was confirmed by postop pth levels which dropped drastically from 16.5 mmol/l pre-op to 1.62 post-op. her post-op recovery was uneventful and she was discharged on second post-op day. histopathology report confirmed the presence of ectopic parathyroid gland embedded within the thymus gland. d i s c u s s i o n primary hyperparathyroidism is caused by excessive secretion of parathyroid hormone causing hypercalcemia.5 primary hyperparathyroidism affects approximately 1% of the adult population.6 majority of the patients affected are woman. in about 80% of cases, phpt is caused by solitary parathyroid adenoma.7 other less common causes are parathyroid hyperplasia, multi-gland disease (mgd), and parathyroid carcinoma.8 most of the parathyroid adenomas are usually located in the neck especially on posterior capsule of thyroid gland or in ectopic locations such as mediastinum due to migratory pathway of embryological origin. in primary hyperparathyroidism the incidence of ectopic mediastinal parathyroid adenoma is about 12%.9 mediastinal parathyroid adenomas are usually small and accurate preoperative localisation is often challenging and difficult. ultrasound, scintigraphy, and ct scan are commonly used to diagnose and localise parathyroid adenomas. the diagnostic rate of lesion responsible for causing primary hyperparathyroidism is increased using sesta-mibi scan and similar was done in this case as well where sesta-mibi scan was more helpful in localising the adenoma. sagan et al in his study showed that use of intraoperative intact pth measurement, decreases the failure rate of surgery from 21% to 3%10 and this technique was used in this case as well where intraoperative decrease in pth levels confirmed the removal of adenoma. biochemical evaluation demonstrating raised serum calcium levels along with an elevated intact pth level, are required for diagnosis of phpt, whereas parathyroid imaging has no role in diagnosis but is used for anatomic localization of ectopic parathyroid gland and hence for planning a suitable surgical approach. in about 1–2% of cases, parathyroid adenoma may be located so deep within j islamabad med dental coll 2022 258 the mediastinum that cervical approach is not possible and thoracotomy is required. surgical resection is the treatment of choice for ectopic parathyroid adenomas causing primary hyperparathyroidism. depending upon preoperative localisation, various surgical approaches can be used for removal of ectopic mediastinal parathyroid adenoma starting from cervical approach to sternotomy, thoracotomy or minimal invasive thoracoscopic approach, in experienced hands. vats was used in this case as well for removal of parathyroid gland. r e f e r e n c e s 1. hoang jk, sung wk, bahl m, phillips cd. how to perform parathyroid 4d ct: tips and traps for technique and interpretation. radiology 2014; 270:15e24. 2. ruda jm, hollenbeak cs, stack jr bc. a systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. otolaryngol head neck surg 2005;132:359e72. 3. noussios g, anagnostis p, natsis k. ectopic parathyroid glands and their anatomical, clinical, and surgical implications. exp clin endoclinol diabetes.2012;120:604–10. 4. k.e. isaacs, s. belete, b.j. miller, a.n. di marco, s. kirby, t. barwick, et al., video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid adenoma, bjs open 3 (6) (2019) 743– 749. 5. walker md, silverberg sj. primary hyperparathyroidism. nat rev endocrinol 2018; 14:115–25. 6. aace/aaes task force on primary hyperparathyroidism. the american association of clinical endocrinologists and the american association of endocrine surgeons position statement on the diagnosis and management of primary hyperparathyroidism. endocr pract 2005;11:4954. 7. taghavi kojidi h, vagharimehr n, mohseni s, pajouhi m, mohajeri-tehrani mr. unusual ectopic parathyroid adenoma: a case report. acta med iran 2016; 54:547–50. 8. ruda jm, hollenbeak cs, stack jr bc. a systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. otolaryngol head neck surg 2005;132:359e72. 9. noussios g, anagnostis p, natsis k. ectopic parathyroid glands and their anatomical, clinical, and surgical implications. exp clin endoclinol diabetes. 2012;120:604–10. 10. sagan d, gozadziuk k. surgical treatment of mediastinal parathyroid adenoma: rationale for intraoperative parathyroid hormone monitoring. ann thorac surg. 2010;89:1750–5. j islamabad med dental coll 2022 1 o p e n a c c e s s challenges for the academia for producing future doctors syed nauman bazmi inam1 1professor & head of the department of community medicine and professor, department of medical education, nums-cmh institute of medical sciences, bahawalpur medical education is a process in continuum. it takes five years of undergraduate study, plus one year of internship to produce undifferentiated physicians with certain knowledge attitudes, and skills to make them able to go further in their education in specific residency programs, which consist of four to five years. globally, it is recognized that medical graduates should have 1) a scientific approach to practice1, 2, 2) an evidence-based patient care2, 3) research skills1, 2, 4) professionalism1, 2, ethical and compassionate attitude towards patients1, 5) communication and collaborative interpersonal skills1, 2 and 6) community-oriented practice2. embedded in evidence-based practice is a selfregulated and self-directed lifelong learning approach. the reason being that the exponential growth in knowledge doubling time which was estimated that in 1950 was 50 years, in 1990 it was 7 years, in 2010 was 3.5 years and in 2020 it was 73 days3. thus, graduates should also be curious seekers of recent knowledge, self-appraisers of competence deficit, optimal users of health care resources, and team players. graduates are also expected to demonstrate leadership qualities in the decision-making process. correspondence: syed nauman bazmi inam email: drbazmiinam@gmail.com cite this editorial: bazmi inam sn. challenges for the academia for producing future doctors. j islamabad med dental coll. 2022; 11(1): 1-2 doi: 10.35787/jimdc.v11i1.867 challenges for the academia there are several challenges for the academia in developing dynamic, regularly updated curricular content, which is integrated and applied to achieve the expected outcome in the graduates mentioned above1. there are certain internal and external challenges faced by academia to incorporate changes in learning and teaching strategies for current and future medical practitioners. medical knowledge is increasing exponentially every day. newer diagnostic technologies and use of artificial intelligence are rapidly being incorporated in healthcare delivery system. the challenge that how to extract relevant and applied knowledge and skills at the learners’ level and to combine diverse range of subjects, new areas of knowledge, and emergent specialties in undergraduate medical curriculum to produce a medical graduate who comes up to meet the rising community expectations and ever-changing health system need is among the most important to address4. it is immensely challenging to integrate preventive and palliative care, molecular genetics and radiodiagnostics, medical ethics and information technology into present curriculum keeping patient safety at all levels of care4. addressing resource constraints both at academia and health systems level to be cultivated in training to produce optimal efficient and effective medical practitioner at all levels of health care without compromising patient safety. academic institution’s curriculum committees, as they contemplate change, the most common problem they face is the “mini-me” syndrome, in e d i t o r i a l j islamabad med dental coll 2022 2 which faculty strongly advocate for content that mimics their professional leanings5. on the other hand, if the institutions exercise “greater central oversight” for the curriculum has results in decreased personal satisfaction in teaching and emerging alternate methods of teaching may result in unguided self-directed learning and decreased teacher – student interaction time.3,6 another major challenge in medical education is growing disconnections between the curricular content delivery and the changing dynamics of health care3. collaborative approach with stakeholders makes change always uncomfortable, therefore, when evaluation of learners is done on individual performance and on the scope to which learners are skilled of performing independent and the health professionals are trained for independent practice and in research practices in health care system introducing other members of the team and recipient of the health care for assessing the care giver practitioner and students is strongly resisted. 7. likewise, potentially more proficiency of learners/patients than of teachers) and resistance to change among faculty members remains a recurring issue in the medical education7 this also can only be addressed through faculty development which without any doubt is need of the day3. the teaching skills of faculty are outdated compared with the learning patterns of their students5. on-going faculty and health care teams continuing educational training is the requirement of the day to improve imparting training, improving teaching and skills as well as using appropriately well-designed learners’ assessment tools. one more challenge faced today is ‘simulation science’ and quality improvement 3. in the developed world medical schools training on simulation models helps in learners’ confidence and decreasing errors when interacting and caring for patients. simulation facilitates development and grooming of technical skills within the learner’s own environment and enhance patient safety. adaptation to artificial intelligence8 – “a machine with intelligent behavior such as perception, reasoning, learning, or communication and the ability to perform human tasks” is another big issue. institutional review of the curriculum is a demanding process, the current medical school curriculum is unable to accommodate artificial intelligence due to two main reasons—insufficient time and lack of expertise8. nonetheless institutions should be flexible and visionary to anticipate changes and training for skills required in future practice of doctors. r e f e r e n c e s 1. rania g. zaini, khalid a. bin abdulrahman, abdulaziz a. al-khotani, abdol monem a. al-hayani, ibrahim a. al-alwan & saddig d. jastaniah (2011) saudi meds: a competence specification for saudi medical graduates, medical teacher, 33:7, 582584, doi: 10.3109/0142159x.2011.578180 2. frank jr, snell l, sherbino j, boucher a. canmeds 2015. physician competency framework series i. 2015. 3. densen p. challenges and opportunities facing medical education. trans am clin climatol assoc. 2011; 122: 48–58. pmid: 21686208 4. ozuah, p.o. undergraduate medical education: thoughts on future challenges. bmc med educ 2002;2(8). doi: 10.1186/1472-6920-2-8 5. wartman s a. the empirical challenge of 21stcentury medical education. academic medicine. 2019; 94 (10):1412-1415. doi: 10.1097/acm.0000000000002866 6. venance sl, ladonna ka, watling cj. exploring frontline faculty perspectives after a curriculum change. medical education. 2014;48(10): 998-1007. doi: 10.1111/medu.12529 7. mennin s. ten global challenges in medical education: wicked issues and options for action. med sci educ. 2021;31, 17–20. doi:10.1007/s40670-021-01404-w 8. chan ks. zary n. applications and challenges of implementing artificial intelligence in medical education: integrative review. jmir med educ. 2019; 5(1). doi: 10.2196/13930 https://doi.org/10.3109/0142159x.2011.578180 https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-2-8 j islamabad med dental coll 2020 123 open access altered coagulation pattern in different histological grades of squamous cell carcinoma kiran shaikh 1 , ghulam shah nizamani 2 , yar muhammad nizamani 3 , naila nizamani 4 , amin fahim 5 , farkhunda nadeem 2 1 lecturer, department of pathology, isra university hyderabad, pakistan 2 professor, department of pathology, isra university hyderabad, pakistan 3 assistant professor, department of physiology, isra university hyderabad, pakistan 4 phd scholar, isra university hyderabad, pakistan 5 associate professor, department of pathology, isra university hyderabad, pakistan a b s t r a c t background: the incidence of squamous cell carcinoma has doubled in the last three decades associated with a high rate of morbidity and mortality. the incidence of bleeding and/or thrombosis in advanced stage cancer necessitates a need for research in blood coagulation abnormalities in malignancy. the objective of the present study was to determine the alteration in coagulation pattern among patients diagnosed with squamous cell carcinoma (scc). material and methods: this cross-sectional study was conducted in pathology department of isra university hospital, hyderabad over a period of 06 months. a total of 126 samples were selected through non-probability convenient sampling. both male and female patients of all age groups having scc of skin, gastrointestinal and genital tract were included. the coagulation profile was analyzed by sysmax ca 50 and nycocard reader ii. data was entered into spss version 22.0 and results were analyzed. results: the mean age of the patients with scc in the present study was 55.5 ± 12 years with more male patients (n=81; 64.3%) as compared to females (n=45; 35.7%). oral scc was found to be the most common site of squamous cell carcinoma (43.7%). majority of the patients had well differentiated scc (42.1%) followed by moderately differentiated (40.5%) and poorly differentiated scc (17.4%). the comparison of severity of scc with coagulation profile revealed that pt (p=0.01), aptt (p=0.001), d-dimers (p=0.01 and tt (p=0.01) were significantly increased, whereas fibrinogen was significantly decreased (p=0.001). conclusions: the histological differentiation of scc (from well differentiated to poorly differentiated tumors) showed a highly significant association with different coagulation profile parameters like pt, aptt, bt, ct, d-dimer, tt, and fibrinogen levels. key words: coagulation, d-dimers, fibrinogen, prothrombin time, squamous cell carcinoma, thrombin authors’ contribution: 1-3 conception; literature research; manuscript design and drafting; 4-6 critical analysis and manuscript review; data analysis; manuscript editing. correspondence: amin fahim email: draminfahim@gmail.com article info: received: february 6, 2019 accepted: june 22, 2020 cite this article. shaikh k, nizamani gs, nizamani ym, nizamani n, fahim a, nadeem f. altered coagulation pattern in different histological grades of squamous cell carcinoma. j islamabad med dental coll.2020; 9(2): 123-128. doi: 10.35787/jimdc.v9i2.281 funding source: nil conflict of interest: nil i n t r o d u c t i o n squamous cell carcinoma is the second most common malignancy of skin. it also arises from head and neck, vagina, cervix and anus. 1 the prostate, urinary bladder, esophagus and lung are o r i g i n a l a r t i c l e j islamabad med dental coll 2020 124 further possible locations. 2 the incidence of squamous cell carcinoma has doubled in the last three decades in united states and approximately 2% of those affected die from this disease. 2 most of the cases of oral and throat scc are diagnosed at a late stage. the prevalence of scc is higher in pakistan and other south east asian nations. 3 risk of this cancer is intensified by direct and prolonged exposure to sunlight. 4 patients presenting with squamous cell carcinoma unveil discrepancies in their signs and symptoms and response to treatment. the common age at diagnosis of scc of skin is 8th decade of life. 5 males are more affected by this disease as compared to females. like any malignancy, it affects bone marrow and decreases hemopoiesis as well. fibrinolytic system is activated in scc cases at subclinical and clinical stages. the biological consequences of the haemostatic deviations in squamous cell carcinoma are imprecise. there is evidence that malignant cells activate the coagulation system with an increase in fibrinolytic activity. this may result in increased metastatic activities leading to dic. 6 so it is multifaceted interaction between pathologic mechanism of thrombosis, tumor cells and haemostatic system. 7 plasma concentration of ddimer is increased in malignancy due to activation of fibrinolytic system. 8 raised levels of prothrombin time (pt), activated partial thromboplastin time (aptt), thrombin time (tt), low anti thrombin-iii activity and increased fibrin degradation products (fdp) indicates disseminated intravascular coagulation. 9-11 tumor cells lead to activation of coagulation system either directly, by release of procoagulants from tumor cells, or indirectly, through production of tumor cells cytokines that trigger procoagulant substances in the systemic circulation by monocytes, macrophages and endothelial cells. 12 the bleeding and/or thrombosis in advanced stage cancer provides need for a research in blood coagulation abnormalities in malignancy. this study is intended to detect coagulation abnormalities that lead to disseminated intravascular coagulation and might predict hemorrhagic or thrombotic complications. 13 thromboembolic disease is a common complication of malignancy which occurs due to disturbance in haemostatic balance comprising interactions between endothelial cells, thrombocytes, coagulation, and fibrinolysis. lack of early and prompt diagnosis of dic leads to development of lethal complications and bleeding diathesis. therefore, dic screening is associated with a reduction in mortality in patients presenting with sepsis. the aim of this study was to determine the relationship between the hematological and coagulation parameters with various morphological grades of squamous cell carcinoma. m a t e r i a l a n d m e t h o d s this cross-sectional study was conducted in the pathology department of isra university hospital. both male and female patients of all age groups having scc of skin, gastrointestinal and genital tract were selected through non probability convenient sampling. study duration was 6 months from may 2017 to october 2017. patients with chronic comorbidities like skin infections, congenital haematological abnormalities and those on chemotherapy were excluded. using aseptic techniques, approximately 3ml whole blood was collected by venipuncture in citrated bottles. plasma was separated by centrifuging at 2000 rpm for 10 minutes, and stored at -24˚c until analysis. the coagulation profile was analyzed by sysmax ca 50 coagulation analyzer and nycocard reader ii. data was analyzed using spss version 22.0. frequency and percentages were calculated for qualitative variables. anova test was applied for comparison of more than 2 variables like prothrombin time (pt), activated partial thromboplastin time (aptt), thrombin time (tt), j islamabad med dental coll 2020 125 anti thrombin-iii activity and d-dimers. p-value <0.05 was taken as statistically significant. r e s u l t s in this study mean age of the patients was 55.5 ± 12 years, with an age range of 23 80 years. most of the patients were males (n=81; 64.3%) as compared to females (n=45; 35.8%). majority of the patients were found with well differentiated (42.1%) and moderately differentiated scc (40.5%), while poorly differentiated scc was found only in 17.4%. oral scc (43.7%) was the most common site of squamous cell carcinoma followed by esophageal scc (28.6%) (table i). table i: distribution of squamous cell carcinoma cases according to site (n=126) site n (%) oral cavity 55 (43.7) esophagus 36 (28.6) skin 14 (11.1) cervix 13 (10.3) anus 5 (3.9) vagina 3 (2.3) the coagulation profile comprising the pt, aptt, clotting time, bleeding time, d-dimer, fibrinogen and thrombin time was compared with histological grades of scc (table ii). the mean prothrombin time increased significantly from 15.22 ± 3.71 seconds in well differentiated scc to 24.01 ± 2.9 seconds in poorly differentiated squamous cell carcinoma (p=0.01). similarly, the mean aptt (p=0.001), bleeding time (p=0.05), clotting time (p=0.05), thrombin time (p=0.01) and d-dimers (p=0.01) showed a significant increase from well differentiated scc to poorly differentiated scc (table ii). however, fibrinogen levels decreased as tumor progressed from well differentiated to poorly differentiated grade (p=0.001) (table ii). d i s c u s s i o n in this study, the coagulation profile (pt, aptt, bt, ct, tt, fibrinogen, d-dimer) is found deranged in accordance with the different histological grades of scc. the deranged values were more pronounced in poorly differentiated squamous cell carcinoma. these results are in accordance with the study conducted by tas et al 15 who reported elevated plasma levels of d-dimer, fibrinogen, pt, aptt and inr in lung cancer patients. in the present study, significant alteration was seen in bt and ct, which is parallel with the study conducted by engheta et al. 16 who also conveyed similar findings. zhang et al. and li et al. reported that the triggered hemostatic system for instance, hyperfibrinogenemia and higher d-dimer levels are found in scc which is parallel with the present revision. 17,18 studies by liu et al. and feng et al. also found increased plasma levels of d-dimer in scc patients, which is consistent with the current study. 19,20 however, the current study also assessed the d-dimer levels in squamous cell carcinoma patients on the basis of grading. study conducted by nakano et al. altered levels of blood coagulation factors in different pathologic types of lung cancer. 21 in addition fibrin/fibrinogen degradation products, fibrinogen, and d-dimer levels differed significantly between cancer patients and the control group. these findings are consistent with our study which also showed raised level of d-dimer and pt in different histopathologic types of squamous cell carcinoma. the result of the present study shows significantly increased levels of d-dimer in different histologic types of squamous cell carcinoma. these findings are similar to a study by luo et al who also reported increased level of d-dimer for different histologic grades of squamous cell carcinoma. 22 mariani et al. also showed raised levels of pt, aptt, and tt indicating hypercoagulability with significantly j islamabad med dental coll 2020 126 table ii: comparison of coagulation profile with histological grades of squamous cell carcinoma (n=126) groups prothrombin time f-value p-value* wd vs md 15.22±3.71 16.33±2.55 4.49 0.82 wd vs pd 15.22±3.71 24.01±2.90 0.01 pd vs md 24.01±2.90 16.33±2.55 0.03 wd vs md aptt 7.49 0.08 35.10±9.10 37.36±13.89 wd vs pd 35.10±9.10 43.39±13.68 0.001 pd vs md 43.39±13.68 37.36±13.89 0.01 wd vs md bleeding time 2.60 0.01 3.40±0.73 5.44±0.63 wd vs pd 3.40±0.73 6.17±0.42 0.05 pd vs md 6.17±0.42 5.44±0.63 0.82 wd vs md clotting time 2.58 0.99 4.88±0.89 5.22±1.25 wd vs pd 4.88±0.89 6.93±1.32 0.05 pd vs md 6.93±1.32 5.22±1.25 0.72 wd vs md d-dimers 2.49 0.82 0.74±0.16 0.83±0.23 wd vs pd 0.74±0.16 1.01±0.31 0.01 pd vs md 1.01±0.31 0.83±0.23 0.03 wd vs md fibrinogen 5.46 0.05 174.75±20.8 186.58±18.1 wd vs pd 174.75±20.8 227.9±22.1 0.001 pd vs md 227.9±22.1 186.58±18.1 0.001 wd vs md thrombin time 2.09 0.08 50.11±7.92 45.18±6.68 wd vs pd 50.11±7.92 82.51±5.74 0.01 pd vs md 82.51±5.74 45.18±6.68 0.01 *p-value <0.05 was considered statistically significant. wd=well-differentiated, md=moderately-differentiated, pd=poorly-differentiated, vs=versus, aptt=activated partial thromboplastin time f-value = used in analysis of variance (anova) to determine whether the test is statistically significant decreased levels of platelets in lung cancer patients. 23 the d-dimer levels remained unchanged. these findings are consistent with our study, except d-dimer, as all the coagulation markers significantly increased as the severity of histological grade of squamous cell carcinoma increased from well differentiated to poorly differentiated cancer. the main limitation of this study was that immunomarkers for confirmation of doubtful cases were not applied due to financial constraints. another limitation was that the results cannot be generalized as comparatively lower number of scc cases were studied with an unequal distribution of cancers arising from different sites. c o n c l u s i o n the different coagulation profile parameters like pt, aptt, bt, ct, d-dimer and tt are elevated in scc, with a decrease in fibrinogen levels, proportional to the severity of the histological grade. j islamabad med dental coll 2020 127 recommendations: changes in hemostasis play an important role in anticipation of future hemorrhagic manifestation and thrombotic event during cancer progression. early workup for presence of coagulation abnormalities will prevent mortality and other bleeding diathesis in cancer, as alterations in coagulation pathway leads to lethal complication of hemostasis. r e f e r e n c e s 1. brianti p, de flammineis e, mercuri sr. review of hpv-related diseases and cancers. new microbiol. 2017; 40(2): 80-5. pmid: 28368072 2. sánchez-danés a, blanpain c. deciphering the cells of origin of squamous cell carcinomas. nat rev cancer. 2018; 18(9): 549-61. doi: 10.1038/s41568018-0024-5 3. qamar s, fatima s, rehman a, khokhar ma, mustafa z, awan n. glucose transporter 1 overexpression in oral squamous cell carcinoma. j coll physicians surg pak. 2019; 29(8): 724-27. doi: 10.29271/ jcpsp.2019.08.724 4. diepgen t, fartasch m, drexler h, schmitt j. occupational skin cancer induced by ultraviolet radiation and its prevention. brit j dermatol. 2012; 167: 76-84. 5. shaikh ah, mohammad t, qureshi nr. histopathological patterns of oral squamous cell carcinoma. podj. 2014; 34(3): 449-51. 6. falanga a, schieppati f, russo l. pathophysiology 1. mechanisms of thrombosis in cancer patients. in: thrombosis and hemostasis in cancer. 2019 (pp. 1136). springer, cham. 7. nadir y, brenner b. cancer and thrombosis—new insights. rambam maimonides med j. 2018 oct;9(4); e0033. doi: 10.5041/rmmj.10349 8. masago k, fujita s, mio t, togashi y, kim yh, hatachi y, et al. clinical significance of the ratio between the alpha 2 plasmin inhibitor–plasmin complex and the thrombin–antithrombin complex in advanced nonsmall cell lung cancer. med oncol. 2011; 28(1): 3516. doi: 10.1007/s12032-010-9454-y 9. vincent jl, castro p, hunt bj, jörres a, praga m, rojas-suarez j, et al. thrombocytopenia in the icu: disseminated intravascular coagulation and thrombotic microangiopathies—what intensivists need to know. crit care. 2018; 22(1):158. doi: 10.1186/s13054-018-2073-2 10. khorana aa. malignancy, thrombosis and trousseau: the case for an eponym. j thromb haemost. 2003; 1(12): 2463-5. doi: 10.1111/j.1538-7836.2003. 00501.x 11. falanga a, marchetti m, vignoli a. coagulation and cancer: biological and clinical aspects. j thromb haemost. 2013; 11(2): 223-33. doi: 10.1111/ jth.12075 12. ujjan id, khokhar na, shaikh ma, shaikh ia, memon ra, maheshwari n. evaluation of coagulation abnormalities in lung cancer patients. jlumhs. 2009; 8(02): 118-20. 13. zhang x, chen g, li j. relationships between coagulation indicators and clinicopathological characteristics of patients with esophageal squamous-cell carcinoma. shandong medical journal. 2017; 2017(22): 5. 14. wu y. contact pathway of coagulation and inflammation. thrombosis j. 2015; 13(1): 17. doi: 10.1186/s12959-015-0048-y 15. tas f, kilic l, serilmez m, keskin s, sen f, duranyildiz d. clinical and prognostic significance of coagulation assays in lung cancer. resp med. 2013; 107(3): 4517. doi: 10.1016/j.rmed.2012.11.007 16. engheta a, abianeh sh, atri a, sanatkarfar m. aspirin use and bleeding volume in skin cancer patients undergoing surgery: a randomized controlled trial. daru. 2016; 24(1): 20. doi: 10.1186/s40199-016-0159-4 17. zhang f, wang y, sun p, wang zq, wang ds, zhang ds, et al. fibrinogen promotes malignant biological tumor behavior involving epithelial–mesenchymal transition via the p-akt/p-mtor pathway in esophageal squamous cell carcinoma. j cancer res clin oncol. 2017; 143(12): 2413-24. doi: 10.1007/s00432-017-2493-4 18. li j, zheng z, fang m. impact of pretreatment plasma d-dimer levels and its perioperative change on prognosis in operable esophageal squamous cell carcinoma. oncotarget. 2017; 8(45): 79537-545. doi: 10.18632/oncotarget.18552 19. liu dq, li ff, jia wh. cumulative scores based on plasma d-dimer and serum albumin levels predict survival in esophageal squamous cell carcinoma j islamabad med dental coll 2020 128 patients treated with transthoracic esophagectomy. chin j cancer. 2016; 35(1): 11. doi: 10.1186/s40880015-0062-2 20. feng jf, yang x, chen s, zhao q, chen qx. prognostic value of plasma d-dimer in patients with resectable esophageal squamous cell carcinoma in chin j cancer. 2016; 7(12):1663-67. doi: 10.7150/jca.15216 21. nakano k, sugiyama k, satoh h, shiromori s, sugitate k, arifuku h, et al. risk factors for disseminated intravascular coagulation in patients with lung cancer. thorac cancer. 2018; 9(8): 931-8. doi: 10.1111/1759-7714.12766 22. luo yl, chi pd, zheng x, zhang l, wang xp, chen h. preoperative d-dimers as an independent prognostic marker in cervical carcinoma. tumour biol. 2015; 36(11): 8903-11. doi: 10.1007/s13277015-3650-5 23. mariani m, hariman h, soeroso ns. hypercoagulability in patients with lung cancer undergoing chemotherapy. indones j clinical pathol med laboratory. 2018; 24(3): 210-4 j islamabad med dental coll 2023 127 open access the assessment of self care practices amongst diabetic patients of rawalpindi, pakistan rubab zulfiqar,1 sumaira masood,2 humaira mahmood,3 uzma hassan,4 bibi razia bano5, rimsha tahreem6 1 lecturer, department of public health, national university of medical sciences rawalpindi. 2 assistant professor, department of community medicine, foundation university medical college, islamabad 3 associate professor, department of public health , armed forces postgraduate medical institute, national university of medical sciences rawalpindi 4 professor, department of public health, national university of medical sciences rawalpindi 5,6 mph trainee, armed forces postgraduate medical institute, national university of medical sciences rawalpindi. a b s t r a c t background: diabetes mellitus is a chronic disease and with rapidly increasing prevalence, it requires continuous diabetic care beyond just glycemic control. it needs continuous self-management and multi factorial risk reduction strategies. this study aims to assess the self-care practices of diabetic patients living in rawalpindi and to determine the relationship of sociodemographic characteristics with their self-care practices. methodology: this cross-sectional study was conducted in two private diabetic clinics of rawalpindi from february to july 2022. a validated structured questionnaire using summary of diabetes self-care activities (sdsca) scale was administered to assess self-care practices of the study participants. a total of 230 participants through convenience sampling aged 25 to 86 years were recruited in the survey. spss version 22 was used to carry out the statistical analysis. results: the current study comprised of 107(46.5%) males and 123 (53.5%) females with mean age of 54.85 ±12.41 years. among them, 65.2% had adequate self-care practices. it was found that marital status (p=0.004), educational status (p=0.002), monthly income (p=0.001) and duration of diabetes (p=0.006) were significantly associated with selfcare practices of the participants. conclusion: more than half of the participants had adequate self-care practices. sociodemographic variables like marital status, education, monthly household income and duration of diabetes were significantly associated with the self-care practices of diabetic patients. key words: diabetes mellitus, pakistan, self-care, selfmanagement, survey authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: rubab zulfiqar email: rubab.zulfiqar00@gmail.com article info: received: november22, 2022 accepted: june 15 2023 cite this article. zulfiqar r, masood s, mahmood h, hassan u, bano b r, tahreem r.the assessment of self care practices among diabetic patients of rawalpindi. j islamabad med dental coll. 2023; 12(2): 127-132 doi: https://doi.org/10.35787/jimdc.v12i2.929 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus with its increasing prevalence is a significant public health concern.1 globally in the past few decades, the burden of diabetes is increasing continuously and in the coming years this trend is expected to continue.2 around 425 million people are diabetic, among them four-fifths are in lowand middle-income countries.3 as it is a chronic condition, so it requires continuous medical care and o r i g i n a l a r t i c l e j islamabad med dental coll 2023 128 self-management.4 diabetes results in a heavy economic burden as it leads to increased disability rates and several other complications. in view of the rising disabilities and comorbidities due to diabetes, it is need of the time to develop appropriate and reasonable prevention strategies.5 self-management support is an important element of the “chronic care model” for the management of chronic conditions.6 the process of selfmanagement comprises of various self-care activities such as planning healthy meals, physical activity, monitoring levels of blood glucose regularly, and to deal with diabetes related complications.7 self-care activities are associated with various sociodemographic variables so there is a need for self-management interventions as it is the only way possible to make individuals self-sufficient to combat this chronic disease. self-care is crucial for diabetic people as it involves gaining knowledge of the complex nature of diabetes and learning to live with it in a social context.8 this study aims to assess the self-care practices of diabetic patients in rawalpindi and the association of these self-care practices with sociodemographic characteristics of the diabetic patients. m e t h o d o l o g y this cross-sectional study was conducted in two private clinics of rawalpindi from february to july 2022 after taking ethical approval from armed forces postgraduate medical institute (afpgmi), nums rawalpindi. the study population comprised of type 2 diabetic patients and sample size came out to be 230 by applying the following formula: s= z2 x p x q e2 (where z= 1.96 (95% ci), p= 0.17 (as prevalence of diabetes is 17.1% in pakistan (9), q (1-p)= 0.83, e= 0.05) type 2 diabetic patients were recruited as study participants by using non-probability convenience sampling technique. the known patients of type 2 diabetes of both genders, aged ≥ 13 years, diagnosed for at least 6 months, willing to participate and able to take part in interview were included in the study. women suffering from gestational diabetes were excluded. the toobert and glasgow self care questionnaire was used in this study.10 it is a validated questionnaire as it has been utilized in several studies. it consists of several self-care behaviors and questions related to physical activity self-care (2 questions), blood glucose monitoring (2 questions), feet selfcare (2 questions) and diet self-care (4 questions). the data was self-administered to minimize methodological bias. the participants reported their self-care behaviors in 7 days. informed verbal and written consent were given by the participants. mean scores for all the domains of self-care (diet, physical activity, foot care and blood glucose monitoring) were calculated individually. the overall mean score of the self-care practices was calculated by adding scores for diet, physical activity, foot care and blood glucose monitoring then dividing by the sum of number of questions under each sub-scale. after calculating an overall mean score, self-care practices would be categorized as adequate if the patient scored more than or equal to mean score or self-care practices would be categorized inadequate if the patient scored less than mean score. statistical analysis was carried out using spss version 22. for descriptive statistics, percentages and frequencies were calculated while associations among independent variables and self-care practices of the study population were checked by applying chi square test of significance. r e s u l t s the sociodemographic characteristics of participants are shown in table 1. j islamabad med dental coll 2023 129 among 230 study participants, 107(46.5%) were males and 123 (53.5%) were females with a mean age of 54.85 years (sd = ±12.41). the average duration of diabetes was 7.6 years (sd = ±5.6 years). most of the participants were married (88.3%), with 44.3% of participants having graduation or above level of education. majority of the participants were working in private and government sector (38.7%) with 40.9% of the participants earning a monthly income between rs.50,000 to rs.100,000. distribution of various domains of self-care practices is presented in table 2. among different domains of self-care practices, the most practiced domain was physical activity with 65.7% participants having an adequate physical activity and least practiced (55.2%) domain was blood glucose monitoring. the participants who reported following adequate diet were 62.6% while 55.7% of the participants followed adequate foot care practices. the association of socio-demographic variables with self-care practices are shown in table 3 after applying chi square test of significance. it was found that marital status, educational status, monthly income and duration of diabetes were significantly associated with self-care practices of the diabetic patients while age and gender had no significant association with self-care practices. d i s c u s s i o n the findings of the current study revealed that 65.2% (n=230) have adequate self-care practices. among different domains of self-care practices, the most practiced are the physical activity and diet. sociodemographic variables like marital status, education, duration of diabetes and monthly household income are significantly associated with the self-care practices. the percentage of adequate self-care practices reported by the current study is higher than studies conducted in ethiopia11 and india12 which reported 60.7% and 46.4% respectively but it is less than a table i: frequencies and percentages of demographic variables (n=230) variable category frequency (%) gender male 107 (46.5) female 123 (53.5) age (years) < 35 10 (4.3) ≥35-≤60 153 (66.5) >60 67 (29.1) marital status single/widow/ divorced 27 (11.7) married 203 (88.3) educational status no formal education 46 (20) primary 45 (19.6) secondary 37 (16.1) graduation or above 102 (44.3) occupation housewife 81 (35.2) private/govt job 89 (38.7) self employed 37 (16.1) unemployed/ retired 23 (10) monthly income (pkr) < 25000 31 (13.5) ≥25000< 50000 67 (29.1) ≥50000< 100000 94 (40.9) ≥100000< 150000 14 (6.1) ≥ 150000 24 (10.4) duration of diabetes ≤ 10 years 171 (74.3) >10 years 59 (25.7) table ii: distribution of selfcare practices domains self-care practice domains adequate n (%) inadequate n (%) physical activity 151 (65.7) 79 (34.3) diet 144 (62.6) 86 (37.4) foot care 128 (55.7) 102 (44.3) blood glucose monitoring 127 (55.2) 103 (44.8) j islamabad med dental coll 2023 130 study conducted in nigeria`13 according to which 79.5% had adequate self-care practices. these differences could be due to culture or socioeconomic aspects of the participants under study. the most practiced domain of self-care activities among diabetic patients is physical activity and diet with 65.7% and 62.6% of the participants following it. it is consistent with the results of another study performed in ethiopia which reported physical activity and diet as the most practiced domain.(11) the least followed self-care practice was blood glucose monitoring and foot care. same has been observed in a study conducted in china.14 as already discussed, the current study reported that sociodemographic variables like marital status, level of education, monthly household income and duration of diabetes are significantly associated with the self-care practices. in another study conducted in lahore to assess the impact of sociodemographic variables on self-care practices of patients suffering from type 2 diabetes, same has been observed except that there is an association of age and gender as well in their study but in the current study no such association has been observed.15 this could be due to influence of other factors like education status and monthly income. according to another study done by allah bakhsh and his colleagues, there is no association of age and gender with selfmanagement practices of diabetic patients.16 in the present study participants with higher education are more likely to adhere to good self-care practices. it is consistent with the finding of study conducted in india.17 duration of diabetes has a significant association with self-care practices. the patients diagnosed with diabetes for more than 10 years have better self-care practices. similar findings were reported from ayder comprehensive specialized hospital.18 the current study highlighted the compliance of diabetic patients with self-care practices in rawalpindi. the use of a validated instrument in native urdu language for measuring self-care practices is one of the strengths of this study. limitations of this study include inclusion of only those diabetics who attended private health care facilities. like elsewhere in low and middle-income countries, private sector provides better healthcare facilities. therefore, the findings cannot be easily generalized to people with diabetes who receive public sector care. secondly, this study provides an insight into the practices of people living in urban table iii: association of socio-demographic variables with self-care practices variable category self-care practices adequate inadequate pvalue gender male 73 (68.2%) 34 (31.8%) 0.407 female 77 (62.6%) 46 (37.4%) age < 35 4 (40%) 6 (60%) 0.203 35-60 100 (65.4%) 53 (34.6%) >60 46 (68.7%) 21 (31.3%) marital status single/wido w/divorced 8 (29.6%) 19 (70.4%) 0.004* married 142 (70%) 61 (30%) educatio nal status no formal education 18 (39.1%) 28 (60.9%) 0.002* primary 29 (64.4%) 16 (35.6%) secondary 21 (56.8% 16 (43.2%) graduation or above 82 (80.4%) 20 (19.6%) monthly income < 25000 7 (22.6%) 24 (77.4%) 0.001* ≥25000< 50000 31 (46.3%) 36 (53.7%) ≥50000< 100000 81 (86.2%) 13(13.8%) ≥100000< 150000 13 (92.9%) 1 (7.1%) ≥ 150000 18 (75%) 6 (25%) duration of diabetes ≤ 10 years 97(56.7%) 74 (43.3%) 0.006* >10 years 53 (89.8%) 6 (10.2%) j islamabad med dental coll 2023 131 areas only and thirdly, it was self-reported practices, so reporting bias could have occurred. c o n c l u s i o n more than half of the participants had adequate selfcare practices. sociodemographic variables like marital status, education, monthly household income and duration of diabetes were significantly associated with the self-care practices of diabetic patients. r e c o m m e n d a t i o n s it is the need of the time to provide more vigorous support of diabetes education and self-management by the identification of priority areas for action. the shortcomings identified in the diabetes related selfcare practices recommend an urgent action to develop and incorporate diabetes self-care education programs in standard clinical practice. the engagement of health care providers should be made mandatory in the planning, implementation and evaluation of such programs. d i s c l a i m e r this manuscript is a part of thesis of master in public health at afpgmi. r e f e r e n c e s 1. adu md, malabu uh, malau-aduli aeo, malau-aduli bs. enablers and barriers to effective diabetes selfmanagement: a multi-national investigation. rodda s, editor. plos one. 2019 jun 5;14(6):e0217771. doi: 10.1371/journal.pone.0217771 2. bennett je, stevens ga, mathers cd, bonita r, rehm j, kruk me, et al. ncd countdown 2030: worldwide trends in non-communicable disease mortality and progress towards sustainable development goal target 3.4. the lancet. 2018 sep;392(10152):1072– 88. doi: 10.1016/s0140-6736(18)31992-5 3. ramachandran a. trends in prevalence of diabetes in asian countries. world j diabetes. 2012;3(6):110. doi: 10.4239/wjd.v3.i6.110 4. tiruneh sa, ayele aa, emiru yk, tegegn hg, ayele ba, engidaw mt, et al. factors influencing diabetes selfcare practice among type 2 diabetes patients attending diabetic care follow up at an ethiopian general hospital, 2018. j diabetes metab disord. 2019 jun 1;18(1):199–206. doi: 10.1007/s40200-01900408-z 5. liu j, ren zh, qiang h, wu j, shen m, zhang l, et al. trends in the incidence of diabetes mellitus: results from the global burden of disease study 2017 and implications for diabetes mellitus prevention. bmc public health. 2020 dec;20(1):1415. doi: 10.1186/s12889-020-09502-x 6. van smoorenburg an, hertroijs dfl, dekkers t, elissen amj, melles m. patients’ perspective on selfmanagement: type 2 diabetes in daily life. bmc health serv res. 2019 dec;19(1):605. doi: 10.1186/s12913-019-4384-7 7. lambrinou e, hansen tb, beulens jw. lifestyle factors, self-management and patient empowerment in diabetes care. eur j prev cardiol. 2019 dec;26(2_suppl):55–63. doi: 10.1177/2047487319885455 8. shrivastava sr, shrivastava ps, ramasamy j. role of self-care in management of diabetes mellitus. j diabetes metab disord. 2013 dec;12(1):14. doi: 10.1186/2251-6581-12-14 9. tariq m, nisar s, anwer a, ellahi a, khan ms, hussain mz. effectiveness of short message service (sms) based glycaemic control. pak armed forces med j. 2022 dec 29;72(6):1957–60. doi: https://doi.org/10.51253/pafmj.v72i6.6270 10. toobert dj, hampson se, glasgow re. the summary of diabetes self-care activities measure: results from 7 studies and a revised scale. diabetes care. 2000 jul 1;23(7):943–50. doi: 10.2337/diacare.23.7.943 11. dedefo mg, ejeta bm, wakjira gb, mekonen gf, labata bg. self-care practices regarding diabetes among diabetic patients in west ethiopia. bmc res notes. 2019 dec;12(1):212. doi: 10.1186/s13104019-4258-4 12. selvaraj k, ramaswamy g, radhakrishnan s, thekkur p, chinnakali p, roy g. self-care practices among diabetes patients registered in a chronic disease clinic in puducherry, south india. j soc health diabetes. 2016 jun;04(01):025–9. doi:10.4103/23210656.176572 13. jackson il, adibe mo, okonta mj, ukwe cv. knowledge of self-care among type 2 diabetes patients in two states of nigeria. pharmacy practice. j islamabad med dental coll 2023 132 2014 jul;12(3). doi: 10.4321/s188636552014000300001. 14. tang j, wu t, hu x, gao l. self‐care activities among patients with type 2 diabetes mellitus: a cross‐ sectional study. international journal of nursing practice. 2021 dec;27(6):e12987. doi: 10.1111/ijn.12987 15. bhatti zi, manzoor n, korai na, khaliq ih. impact of sociodemographic factors on self-care practices among patients with type 2 diabetes in lahore, pakistan: an exploratory study. journal of fatima jinnah medical university. 2018;12(4). 16. bukhsh a, khan tm, sarfraz nawaz m, sajjad h, chan kg, lee lh, et al. association of diabetes related selfcare activities with glycemic control of patients with type 2 diabetes in pakistan. patient prefer adherence. 2018 nov;volume 12:2377–85. doi: 10.2147/ppa.s177314 17. chinnappan j, kp a, iqbal f, v j, ashok p, varghese rs. assessment of self-care practices among type 2 diabetic patients in a secondary care teaching hospital. j drug deliv ther. 2020 may 15;10(3):119– 24. doi https://doi.org/10.22270/jddt.v10i3.4098 18. niguse h, belay g, fisseha g, desale t, gebremedhn g. self-care related knowledge, attitude, practice and associated factors among patients with diabetes in ayder comprehensive specialized hospital, north ethiopia. bmc res notes. 2019 dec;12(1):34. doi: 10.1186/s13104-019-4072-z j islamabad med dental coll 2023 11 open access immunohistochemical approach to the study of pulmonary neuroendocrine tumors sohail anwar1 , sheeba ishtiaq2 , rajia liaqat3, amna rehman4 , nadeem riaz5 , sana haseeb khan6 1associate professor, department of pulmonology, university of lahore teaching hospital, lahore, pakistan 2assistant professor, department of histopathology, gulab devi hospital, lahore, pakistan 3professor, department of histopathology, gulab devi hospital, lahore, pakistan 4post graduate trainee, department of histopathology, gulab devi hospital, lahore, pakistan 5associate professor, department of histopathology, gulab devi hospital, lahore, pakistan 6assistant professor, department of pathology, al aleem medical college, lahore , pakistan a b s t r a c t background: tumors that arise from neuroendocrine cells can present throughout the body, most commonly in the gastrointestinal tract and pulmonary systems. neuroendocrine tumors (nets) of the lungs account for about 25% of primary lung cancers, as well as 20–25% of primary nets objective: to analyze the immune-histochemical aspects of neuro-endocrine tumors and apprise the reactivity of various immune-histochemical markers. methodology: this cross-sectional study was conducted in pathology department of gulab devi hospital lahore from january 2021 to december 2021. total 112 patients with pulmonary nets cases diagnosed with medical records patients data, clinical features and radiologic images were obtained and both genders with ct scan findings of lung mass were included in the study. data was entered and analyzed in spss. gender, diagnosis, techniques etc. were presented as frequency and percentage. age was presented as mean and sd. results: the mean age was 45.2+12.1 years. the age range between 20 to 60 years. there were 96(86%) male and 16(14%) female. typical carcinoid was prevailing in young age group while small cell neuro-endocrine tumor was dominant in older patients. most of the samples were collected using bronchial biopsy 86(77%), 18(16%) of the samples were collected by ct guided biopsy while 7(6%) were collected by ultrasound guided biopsy and 1(1%) by surgical resection. patients were diagnosed as small cell lung carcinoma 96(86%), typical carcinoid was the second most common diagnosis 10(9%), large cell lung carcinoma was 4(3.0%) and atypical carcinoid tumor was seen in 2(2%) in cases. conclusion: sclc was found to be the predominant pulmonary net. chromogranin is less sensitive than synaptophysin, raised ki67 and ttf1 demarcates sclc from carcinoid particularly in minute biopsy with obscure morphology. key words: immunohistochemistry, neuroendocrine carcinoma, small cell lung carcinoma. authors’ contribution: 1,2conception; literature research; 3manuscript design and drafting; 4,5critical analysis and manuscript review; 6data analysis; manuscript editing. correspondence: sheeba ishtiaq email: sheeba_i@yahoo.com article info: received: september 15, 2022 accepted: march 30, 2023 cite this article. anwar s, ishtiaq s, liaqat r, rehman a, riaz n, khan s h. immunohistochemical approach to the study of pulmonary neuroendocrine tumors. j islamabad med dental coll. 2023; 12(1):11-16 doi: https://doi.org/10.35787/jimdc.v12i1.907 funding source: nil conflict of interest: nil i n t r o d u c t i o n tumors that arise from neuroendocrine cells can present throughout the body, most commonly in the o r i g i n a l a r t i c l e mailto:sheeba_i@yahoo.com j islamabad med dental coll 2023 12 gastrointestinal tract and pulmonary systems. neuroendocrine tumors (nets) of the lung account for about 25% of primary lung cancers, as well as 20– 25% of primary nets.1,2 approximate 20% of lung cancers are complimented by pulmonary (nets).3 the frequency of pulmonary nets in modern times has expanded significantly (6% per year)partially due to early diagnostic imaging most however are still discovered accidently.4 currently, nets comprise between 0.5 and 2% of all malignancies.5 both the incidence and prevalence of neuroendocrine tumors have increased linearly. nets are considered rare tumours. data collected over the past 20 years in several european countries and the usa estimated an incidence of 1–5 per 100,000 inhabitants, with an increasing tendency over the past years.6 the diagnosis of lung nets remains challenging due to the variable presentation of patients. depending on the location of the tumor, patients may be asymptomatic or have symptoms that are very non-specific, making a definitive diagnosis difficult.7 currently, curative treatment depends on the tumour location and generally consists of the resection of the tumour and adjacent tissue that can be accompanied with adjuvant chemotherapy in intermediate and high grade nets8,9 other treatment options for the control of symptoms are somatostatin analogues or the use of targeted therapies pulmonary neuroendocrine tumors encompass a wide array of cancers ranging from the welldemarcated typical carcinoid tumor, to the intermediate-grade atypical carcinoid tumor, to the high-grade neuroendocrine carcinomas comprised of large and small cell tumors.10 diagnosis is fundamentally established on a cluster of distinct physical aspects such as cytological appearance , mitotic activity , necrosis and architecture.11 categorical diagnosis of large cell tumor and atypical carcinoid is exacting on minute biopsies. the growth in immunohistochemistry in the diagnosis is convenient and now regularly vital in the diagnosis of pulmonary nets. the discernment of large and small cell tumor is critical, as they are in high-grade variety, as the treatment options of both these tumors bifurcate.5 the aim of the study was to find the immunohistochemical assessment of neuroendocrine tumors and to apprise the reactivity of various immunohistochemical markers used in our institute for diagnosis pulmonary nets. m e t h o d o l o g y this cross-sectional study was conducted in pathology and pulmonary department of gulab devi hospital, lahore from january 2021 to december after approval from institutional review board. sample size was 112, which was calculated with 5% level of significance and 5% margin of error by taking expecting percentage of endocrine tumors inclusion criteria: pulmonary nets cases diagnosed with medical records patients data, clinical features and radiologic images were obtained and both genders with ct scan findings of lung mass were included in the study. exclusion criteria: diffuse idiopathic pulmonary neuro-endocrine cell hyperplasia and tumor let were excluded in the study. world health organization (who) classification of pulmonary nets was the ground for classification of lung tumors. fully automated immunostainer (xmatrx elite; biogenex) was used for ihcs. cd 56, chromogranin, synaptophysin, thyroid transcription factor-1 (ttf-1), ki67, napsin-a and p-40 were the array of tumor markers used for ihc. patterns of immune-histochemical stains were membranous for cd56, cytoplasmic for synaptophysin and chromogranin, nuclear staining for ttf-1 plus p40 and granular staining for napsin-a. ki67 labeling index of 2% and 10 % was considered demarcation for typical and atypical carcinoids, respectively. data were entered and analyzed in spss. gender, diagnosis, techniques etc. were presented as j islamabad med dental coll 2023 13 frequency and percentage. age was presented as mean and sd. r e s u l t s total 112 patients were included in the study. the mean age was 45.2+12.1 years. with age range between 20 to 60 years of age. there were 96(86%) male and 16(14%) female. typical carcinoid was prevailing in young age group while small cell neuroendocrine tumor was dominant in older patients. most of the samples were collected using bronchial biopsy 86(77%), 18(16%) of the samples were collected by ct guided biopsy while 7(6%) were collected by ultrasound guided biopsy and 1(1%) by surgical resection(figure: 1) patients were diagnosed as small cell lung carcinoma 96(86%), typical carcinoid was the second most common diagnosis 10(9%), large cell lung carcinoma was 4(3.0%) and atypical carcinoid tumor was 2(2%). (table: 1) morphologically small cell neuroendocrine tumor displayed sheets and nests of little oval-to-round cells with sparsecytoplasm, apoptoticremains, necrosis, recurring mitosis, nuclear molding, increased n:c ratio and exquisitely granular chromatin the typical carcinoid largely had pseudoglandular, organoid and trabecular pattern. there were homogenous cells with subtle granular nuclear chromatin and inconspicuous nucleoli. necrosis was not observed and mitosis was than 2 per hpf. there was similar growth pattern in typical and atypical carcinoids. they were demarcated by the existence of necrosis and/mitosis (2–10 per 10 hpf). necrosis observed in 50% atypical carcinoid cases. the typical carcinoid predominantly had organoid, trabecular, and pseudoglandular pattern. spindling of the cells was noted in one case. the cells were uniform with finely granular nuclear chromatin and inconspicuous nucleoli. mitosis was <2 per 10 hpf and necrosis were not seen. (figure : 2) the sensitivity of the various markers is shown in table 2. cd 56 was 91(94.8%) sensitive in small cell cancer followed by synaptophysin which was 87(90.6%) sensitive while 73(76.0%) sensitive was chromogranin and ttf1 was 58(60.4%) sensitive. for typical carcinoids cd56, chromogranin, synaptophysin were all 10(100%) sensitive while for atypical carcinoids cd56, chromogranin, synaptophysin and ttf 1 were all 4(100%) sensitive. (table: 2) table i: distribution of age & diagnosis of biopsy (n=112) frequency (%) age mean+ sd 45.2+12.1 gender male 96(86) female 16(14) diagnosis of biopsy small cell neuroendocrine 96(86) typical carcinoid tumor 10(9.0) atypical tumor 4(3.0) large cell neuroendocrine 2(2.0) table ii: immunohistochemistry of neuroendocrine tumor (n=112) histopathology ihc marker frequency (%) small cell lung carcinoma cd56 91(94.8) chromogranin 73(76.0) synaptophysin 87(90.6) ttf 1 58(60.4) typical carcinoid cd56 10(100) chromogranin 10(100) synaptophysin 10(100) atypical carcinoid cd56 4(100) chromogranin 4(100) synaptophysin 4(100) ttf 1 4(100) large cell lung carcinoma cd56 2(100) chromogranin 2(100%) j islamabad med dental coll 2023 14 synaptophysin 2(100%) ttf 1 1(50%) figure:1 techniques of biopsies figure 2: typical carcinoid a. sheets of monomorphic cells with uniform nuclei and hyperchromatism showing positivity for b. chromogranin c. synaptophysin d. cd56 d i s c u s s i o n pulmonary neuro-endocrine tumors represent a morphologic spectrum of tumors from the welldifferentiated typical carcinoid tumor, to the intermediate-grade atypical carcinoid tumor, to the high-grade neuro-endocrine carcinomas comprising of small-cell carcinoma and large-cell neuroendocrine carcinoma. the addition of immunohistochemistry in diagnostics is helpful and often essential, especially in the classification of large-cell neuroendocrine carcinomas.12 cd56 chromogranin and synaptophysin were 100% https://www.sciencedirect.com/topics/medicine-and-dentistry/carcinoid https://www.sciencedirect.com/topics/medicine-and-dentistry/neuroendocrine-carcinoma j islamabad med dental coll 2023 15 affirmative in typical carcinoid and atypical carcinoid. in small cell cancer cd56, chromogranin and synaptophysin expression was 94.8%, 76.0% and 90.6% respectively. cd56 was more sensitive for small cell tumors in typical carcinoid, ttf-1 was negative in all cases. in atypical carcinoid 100 % cases were positive. ttf-1 positivity was 60% in sclc. p-63 staining was done for all in all the 96.0 cases of sclc , 14 were positive showing squamoid component. napsin-a negativity ruled out adenocarcinoma in all cases. pulmonary neuro endocrine tumors constitute 25% of all neuro-endocrine cancers.13 there are 20% small cell neuro-endocrine tumors, 3.0% are large cell tumor, 2.0% and 0.2% are the carcinoids (typical and atypical) respectively.14,15 the first two delegated as poorly differentiated, and the last two grouped as well and intermediate differentiated cancers, respectively. combined, these four deviations have been classified as a separate division under nets in lung tumors classification of who 2015.16 furthermore, both types of lung carcinoids are still cited as pulmonary carcinoid tumors, while elsewhere like gut, the term well-differentiated nets is now being used for them. studies have demonstrated an increasing frequency of carcinoid in this century while there is a fall in small cell lung cancers diagnosis.17 the carcinomas emerge from kulchitzky cells occurring in the bronchial mucosa. there is a substantial predisposition in elderly and an increased risk in smokers in small cell and large cell tumors as compared to carcinoid tumors.15 the mean age in small cell neuro-endocrine tumors patients was a decade older with increased male prevalence in comparison to carcinoid in the present study. cd56, chromogranin and synaptophysin are used to certify the net character. ttf-1 is compulsory to subtype variants of net, it is fairely positive in 70%–90% of sclc cases.3,12 unlike pulmonary adenocarcinoma, it is not a site-specific marker as ttf-1 expression is 20%–80% in of extra pulmonary small cell tumor such as gastrointestinal tract, cervix, prostate and bladder.18 pasala et al identified a ki67 index mean of 53.9% for sclc, 6.6% for atypical and 1.4% for typical carcinoid which is in accordance with this study.19 ki67 demarcates large and small cell tumors from carcinoid as small cell tumor shows an immense proliferative index. it is notably of considerable aid in minute biopsies with crushed appearance. it is not dependable in discriminating atypical from typical carcinoid in minute biopsies. in 2015, pulmonary nets classification by who submitted advisement on ki67 labeling index which includes 5% for typical, up to 20% for atypical carcinoid and 50 to 100% for sclc.20 ki67 is not considered as a diagnostic benchmark in classification of lung nets as there isn’t sufficient evidence.21 however addition of ki67 in ihc panel assists in individualizing treatment by oncologist.22 c o n c l u s i o n sclc was the predominant pulmonary net. chromogranin is less sensitive than synaptophysin, raised ki67 and ttf1 demarcates sclc from carcinoid particularly in minute biopsy with obscured morphology. r e f e r e n c e s 1. xu z, wang l, dai s, chen m, li f, sun j, et al. epidemiologic trends of and factors associated with overall survival for patients with gastroenteropancreatic neuroendocrine tumors in the united states. 2021;4(9):e2124750-e. doi: 10.1001/jamanetworkopen.2021.24750 2. petursdottir a, sigurdardottir j, fridriksson bm, johnsen a, isaksson hj, hardardottir h, et al. pulmonary carcinoid tumours: incidence, histology, and surgical outcome. a population-based study. 2020;68:523-9. doi: 10.3892/ol.2020.11347 3. uprety d, halfdanarson tr, molina jr, leventakos kjctoio. pulmonary neuroendocrine tumors: adjuvant and systemic treatments. 2020;21:1-19. pmc8394158 https://doi.org/10.1001%2fjamanetworkopen.2021.24750 https://doi.org/10.3892%2fol.2020.11347 j islamabad med dental coll 2023 16 4. cives m, strosberg jrjcacjfc. gastroenteropancreatic neuroendocrine tumors. 2018;68(6):471-87. . doi: 10.3322/caac.21493. 5. darbà j, marsà ajbc. exploring the current status of neuroendocrine tumours: a population-based analysis of epidemiology, management and use of resources. 2019;19(1):1-7. doi: 10.1186/s12885019-6412-8. 6. hallet j, law chl, cukier m, saskin r, liu n, singh sjc. exploring the rising incidence of neuroendocrine tumors: a population‐based analysis of epidemiology, metastatic presentation, and outcomes. 2015;121(4):589-97. doi: 10.1002/cncr.29099. 7. tanaka h, del giglio aje. international trends in pulmonary neuroendocrine cancer studies: a scientometric study. 2022;20. doi: 10.31744/einstein_journal/2022rw0113. ecollectio n 2022. 8. falconi m, eriksson b, kaltsas g, bartsch d, capdevila j, caplin m, et al. enets consensus guidelines update for the management of patients with functional pancreatic neuroendocrine tumors and nonfunctional pancreatic neuroendocrine tumors. 2016;103(2):153-71. doi: 10.1159/000443171 9. o'toole d, kianmanesh r, caplin mjn. enets 2016 consensus guidelines for the management of patients with digestive neuroendocrine tumors: an update. 2016;103(2):117-8. doi: 10.1159/000443169. 10. derks jl, rijnsburger n, hermans bc, moonen l, hillen lm, von der thüsen jh, et al. clinicalpathologic challenges in the classification of pulmonary neuroendocrine neoplasms and targets on the horizon for future clinical practice. 2021;16(10):1632-46. doi: 10.1016/j.jtho.2021.05.020. 11. derks jl, leblay n, lantuejoul s, dingemans a-mc, speel e-jm, fernandez-cuesta ljjoto. new insights into the molecular characteristics of pulmonary carcinoids and large cell neuroendocrine carcinomas, and the impact on their clinical management. 2018;13(6):752-66. doi: 10.1016/j.jtho.2018.02.002. 12. borczuk acjspc. pulmonary neuroendocrine tumors. 2020;13(1):35-55. doi: 10.1016/j.path.2019.10.002. 13. volante m, mete o, pelosi g, roden ac, speel ejm, uccella sjep. molecular pathology of welldifferentiated pulmonary and thymic neuroendocrine tumors: what do pathologists need to know? 2021;32:154-68. 14. wang j, ye l, cai h, jin mjjoc. comparative study of large cell neuroendocrine carcinoma and small cell lung carcinoma in high-grade neuroendocrine tumors of the lung: a large population-based study. 2019;10(18):4226. doi: 10.7150/jca.33367 15. rekhtman njmp. lung neuroendocrine neoplasms: recent progress and persistent challenges. 2022;35(suppl 1):36-50. doi: 10.1038/s41379-02100943-2. 16. metovic j, barella m, pelosi gjm-moemo. neuroendocrine neoplasms of the lung: a pathology update. 2021;14(4):381-5. doi:10.1007/s12254-02100681-w 17. yoon jy, sigel k, martin j, jordan r, beasley mb, smith c, et al. evaluation of the prognostic significance of tnm staging guidelines in lung carcinoid tumors. 2019;14(2):184-92. doi: 10.1016/j.jtho.2018.10.166 18. wu h, du j, li h, li y, zhang w, zhou w, et al. aberrant expression of thyroid transcription factor-1 in meningeal solitary fibrous tumor/hemangiopericytoma. 2021;38:122-31. doi: 10.1007/s10014-021-00395-1 19. pasala ujs, hui m, uppin sg, kumar nn, bhaskar k, paramjyothi gjlioooics. clinicopathological and immunohistochemical study of pulmonary neuroendocrine tumors–a single-institute experience. 2021;38(2):134. doi: 10.4103/lungindia.lungindia_482_19. 20. travis wd, brambilla e, burke ap, marx a, nicholson agjjoto. introduction to the 2015 world health organization classification of tumors of the lung, pleura, thymus, and heart. 2015;10(9):1240-2. 21. pelosi g, pattini l, morana g, fabbri a, faccinetto a, fazio n, et al. grading lung neuroendocrine tumors: controversies in search of a solution. 2017;32(3):223-41. doi:10.14670/hh-11-822 22. naheed s, holden c, tanno l, jaynes e, cave j, ottensmeier ch, et al. the utility of ki-67 as a prognostic biomarker in pulmonary neuroendocrine tumours: protocol for a systematic review and metaanalysis. 2019;9(8):e031531. doi:10.1136/bmjopen-2019-031531 http://dx.doi.org/10.1007/s12254-021-00681-w http://dx.doi.org/10.1007/s12254-021-00681-w http://dx.doi.org/10.14670/hh-11-822 http://dx.doi.org/10.1136/bmjopen-2019-031531 j islamabad med dental coll 2021 200 o p e n a c c e s s antimicrobial activity by solvents extracted from ocimum basilicum herb against multidrug resistant gram-negative rods amna ikram1, sidrah saleem2, muhammad imran3, ayesha ghazal4 1scholar, microbiology, university of health sciences, lahore 2head of department, department of microbiology, university of health sciences, lahore 3assistant professor, department of microbiology, university of health sciences, lahore 4lecturer, department of microbiology, university of health sciences, lahore a b s t r a c t background: failure of treatment with antibiotics occurs due to increase in number of multidrug resistant gramnegative bacteria, worldwide. the objective of this study was to find out the antimicrobial activity of crude ethanolic extract and its further three fractions by ocimum basilicum leaves against multi drug resistant gram-negative rods. material and methods: this descriptive study was conducted in the department of microbiology, university of health sciences, lahore from 1stjuly 2016 to 30thjune 2017. a total of 80 multidrug resistant gram-negative rods were included in this study. agar dilution method was performed to determine minimum inhibitory concentration of crude ethanolic extract and different fractions i.e., n-hexane, chloroform and ethyl acetate of ocimum basilicum leaves against multidrug resistant gram-negative rods i.e., extended spectrum beta lactamases and carbapenemase producers. multi-inoculater was used for inoculation. result: the mean mics of crude ethanolic extract, n-hexane fraction, chloroform fraction, and ethyl acetate fraction of ocimum basilicum against esbls were 100.0±8.00, 168.13±8.00, 176.88±8.00 and 41.75±8.00 respectively. similarly, the mean mics of crude ethanolic extract, n-hexane fraction, chloroform fraction, and ethyl acetate fraction of ocimum basilicum against carbapenemase producers were 77.50±8.00, 113.75±8.00, 132.50±8.00 and 29.50±8.00 respectively. conclusion: ethyl acetate fraction and crude ethanolic extract from leaves of ocimum basilicum showed good antibacterial effectiveness against esbls and carbapenem resistant organisms than other fractions. this finding may also promote the effective use of o. basilicum herb and its components in modern medicine. key words: multi-drug resistance, minimum inhibitory concentration (mic), ocimum bassilicum authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing. correspondence: amna ikram email: amnaikramm@gmail.com article info: received: february 1, 2021 accepted: december 13, 2021 cite this article. ikram a, saleem s, imran m, ghazal a. antimicrobial activity by solvents extracted from ocimum basilicum herb against multidrug resistant gram-negative rods. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: n i n t r o d u c t i o n failure of treatment with antibiotics occurs due to increase in number of mdr bacteria worldwide.1one of the most significant problems in hospital settings is multidrug resistant gramnegative rods (mdr-gnr), which includes mdr pseudomonas aeruginosa, acinetobacter baumannii, carbapenemase-producing klebsiella pneumonia and extended-spectrum-betalactamase (esbl) producing escherichia coli.2 medicinal plants are a wealthy source of antimicrobial components. a wide range of medicinal plant extracts were used to treat several o r i g i n a l a r t i c l e j islamabad med dental coll 2021 201 infections before the progression of western medicine, due to their possible antimicrobial activity.3 in pakistan, 80% of the people (mostly rural) depend upon the traditional medicines.4 ocimum basilicum is a common pharmaceutical plant that is traditionally used for the treatment of various diseases worldwide.4 it is a cultured plant widespread in the tropics of africa and asia.5 it belongs to the family lamiaceace and it is the most abundant of the genus ocimum.6o.basilicum is a culinary herb, commonly called basil, also called sweet basil. arial parts which include leaves and flower of o. basilicum are conventionally used as galactagogue, carminative, digestive, stomachic, aromatic, antispasmodic and tonic agent.7 ethanolic, methanolic, hexane and watery extracts of o.basilicum were assessed in a previous study and out of all these extracts of o.basilicum, hexane extract showed the strongest spectrum of antimicrobial activity.8extract of leaves of basil show antimicrobial activity against human dental plaque pathogens and reduced streptcoccus mutans and lactobacillus acidophilus colony count.9 the present study was conducted to find out the antimicrobial activity of o. basilicum herb against mdr-gnr. this study will provide an adequate knowledge about possible advantage of this natural therapeutic product. this study may also promote the effective use of o. basilicum herb and its components in modern medicine. m e t h o d o l o g y this descriptive study was conducted in the department of microbiology, university of health sciences, lahore over a period of 1 year, from 1stjuly 2016 to 30thjune 2017. who calculator was used for the calculation of sample size with anticipated population proportion to be 70%, significance level 95%, and margin of error 10%. 10 eighty (80) multidrug resistant gram-negative rods including 40 esbls and 40 carbapenem resistant gram-negative rods were collected conveniently from microbiology section of cmh lahore, jinnah hospital lahore and post graduate medical institute (pgmi) lahore. they were re-confirmed at the department of microbiology, university of health sciences lahore on the basis of morphology, cultural characteristics and biochemical identifications. all carbapenemase producing gram negative rods were reconfirmed for meropenem resistance. modified hodge test (mht) was performed to confirm the organisms for carbapenemase production. to reconfirm esbls producing organisms, double disk diffusion test was performed. the results were interpreted according to clinical laboratory standard institute guidelines (2017).11organisms sensitive to cephalosporins were excluded (because we used esbls which are resistant to cephalosporin), confirmed mdr strains were preserved in 16% (v/v) glycerol in brain heart infusion and stored in refrigerator at -70°c till use. ethical approval was taken from ethical review committee of institute. ocimum basilicum (basil) leaves were collected from local nursery of lahore. plant was confirmed by taxonomist who worked at botany department, university of the punjab (lahore). after collection, the leaves were washed first with tap water and then with sterilized distilled water and air dried at room temperature.12dried leaves of the plant were ground by using electric grinder. two kilogram of powdered material was soaked in ten liter of ethanol for two weeks. after two weeks, whatmann (1) filter paper was used for filtration. as a result, ethanolic extract of o. basilicum was obtained which was dried under vacuum in a rotary evaporator. the ethanolic extract was concentrated by using a rotary evaporator at temperature 40°c.13 crude ethanolic extract of o. basilicum was further partitioned according to increasing polarity into nhexane, chloroform and ethyl acetate fraction. separating funnel was used for further successive partitioning by three solvents in order of increasing polarity, first by n-hexane, second by chloroform j islamabad med dental coll 2021 202 and third by ethyl acetate. the layers that were formed in a flask were separated. rotary evaporator was used to evaporate respective solvent and fractions of o. basilicum dried. air tight containers were used to store all solvent extracts at 4°c till further investigation.14 agar dilution method was used for the determination of mic. the stock solution was prepared using the extract and fractions to be tested. dmso (dimethyl sulfoxide) (universal solvent having no antibacterial activity) was used for the preparation of stock.15 the organisms were streaked on nutrient agar medium. after incubation at 37°c for 24h, 4 or 5 pure colonies were selected. they were shifted in a sterile normal saline tube and carefully rotated. prepared suspension was equal to the 0.5 mcfarland’s standards. further, diluted this suspension in 1:10 sterile normal saline. inoculums in this dilution had 106cfu/ml concentration. within 15min of preparation, this suspension was used.16 multi inoculator was used for inoculation of the prepared extract plates. after inoculation, plates were incubated at 35°c for 24 hours. after 24 hours of incubation, the plates were seen for any kind of growth. already identified by pcr, esbl producing strain and modified hodge test, positive strains were used as positive control for esbls and carbapenemase producing organisms respectively from microbiology department of university of health science lahore. dmso incorporated in plate containing mueller-hinton agar was used as negative control.2 all statistical analysis was done by using spss software (version 17.0, spss inc). all mics results of crude extract and different solvent fractions of ocimum basilicum leaves were expressed as mean ± s.d. for comparison of mean among mics of crude extract and different solvent fractions of ocimum basilicum leaves, anova test was applied followed by post hoc tukey test. r e s u l t out of 40 carbapenemase producing gram negative rods, there were 22(55%) acinetobacter baumanii, and 18(45%) pseudomonas aeroginos. similarly out of 40 esbl producing organisms, there were 16(35%) klebsiella pneumoniae and 24(65%) escherichia coli. minimum inhibitory concentration (mic) of crude extract and three different fractions of ocimum basilicum leaves against mdr gram negative rods is shown in (table i). mean mics of crude extract and different fractions of o.basilicum leaves against multidrug resistant gram negative rods is shown in (table ii). the minimum inhibitory concentration of extract and all fractions of ocimum basilicum leaves against cabapenemase producing organisms and esbls are shown in (figure i, ii). anova test was applied to compare mean mics of crude extract and different solvent fractions of ocimum basilicum leaves, for multiple comparison post hoc tukey test was applied. all the results were statistically significant (table ii). table i: minimum inhibitory concentration (mic) of crude extract and three different fractions of ocimum basilicum leaves against mdr gram negative rods. organisms crude ethanolic extract n-hexane fraction chloroform fraction ethyl acetate fraction esbls (n=40) 75mg/ ml 100m g/ml 125m g/ml 125m g/ml 150m g/ml 175m g/ml 175m g/ml 200mg/ml 40mg/ ml 50mg/ml 2 36 2 2 7 31 37 3 31 9 carbapen em (n=40) crude ethanolic extract n-hexane fraction chloroform fraction ethylcetate fraction 75mg/ ml 100mg/ml 75mg /ml 100m g/ml 125m g/ml 150m g/ml 100m g/ml 125m g/ml 150mg /ml 30mg/ml 36 4 7 11 15 7 7 13 19 40 j islamabad med dental coll 2021 203 analysis of the mean mics of crude extract and different fractions of o.basilicum leaves against multidrug resistant gram negative rods show significant difference. figure 1: comparative analysis of mean mics against carbapenemase procedures figure 2: comparative analysis of mean mics against esbl procedures ethyl acetate fraction has least value of mic and shows greatest antibacterial activity against carbapenemase producing organisms and esbls followed by crude ethanolic extract, n-hexane fraction and then chloroform fraction. d i s c u s s i o n phytochemical active compounds like flavonoids, tannins, alkaloids and phenolic compounds in o.basilicum plant extract are potent inhibitors of microbial growth.17-18in the present study, crude ethanolic extract and its further three fractions i-e n-hexane, chloroform and ethyl acetate were used for evaluating its antimicrobial activity. out of these fractions, ethyl acetate fraction exhibited best antimicrobial activity against mdr-gnr. ethyl acetate fraction of basil leaves contain polyphenolics, flavonoids and alkaloids.19the highest antimicrobial action of ethyl acetate fraction could be due to these bioactive compounds.17these findings support the idea that ethyl acetate fraction of o.basilicum leaves could be used as antimicrobial with broad-spectrum antimicrobial properties. crude ethanolic extract showed second best antimicrobial activity. n-hexane and chloroform fractions showed less activity as compared to the fraction of ethyl acetate. ad khalil 201320 in his study discussed that o.basilicum ethanolic extract contain compounds which have strong antibacterial activity against gram positive (staph aureus) and gram negative organisms (e.coli). it is known that ethanol is a highly polar solvent which is able to extract phytochemicals efficiently; greater number of active constituents could have been produced by extraction of ethanol which are responsible for good antibacterial activity. abubutain i 201921 used gas chromatography coupled with mass spectrometry (gc/ms) to table ii: mean mics of crude extract and different fractions of o.basilicumleaves against multidrug resistant gram negative rods organism crude ethanolic extract n-hexane fraction chloroform fraction ethyl acetate fraction pvalue mic against carbapenemase producers 77.50±8.00 113.75±8.00 132.50±8.00 29.50±8.00 <0.05 * mic agaisnt esbl producers 100±8.00 168.13±8.00 176.88±8.00 41.75±8.00 j islamabad med dental coll 2021 204 analyze ethanolic extract of o.basilicum, results of his study showed that extract contains phenols, terpene, esters, steroids and fatty acids. these compounds showed antimicrobial activity against some gram positive, gram negative and fungal stains that were used in his study. issazadeh k 201217also reported that crude ethanolic extract exhibited antibacterial activities more than the aqueous extract. this is consistent with findings of this study. n-hexane fraction obtained from crude ethanolic extract of o.basilicum herb exhibited a high range of mic against multidrug resistant gram negative rods. in a previous research, patil d 7 reported that n-hexane extract of o.basilicum showed antimicrobial activity against bacterial (gram positive and gram negative) and fungal strains that were used in their study. the results revealed that hexane extract had broad-spectrum activity followed by ethanolic extract against all tested bacteria. bilal a. 201222also reported that hexane extract of o.basilicum has strong, broad spectrum antimicrobial and anticandidal activity than ethanolic extract. in contrast, the results obtained from current study showed that crude ethanolic extract had strong antibacterial activity than nhexane fraction. variations between these results could be due to mdr strains used in current study. tabassum s 201612 reported the effect of hexane extract of o.basilicum on selected bacterial strains. staphylococcus aureus, pseudomonas aeruginosa, e coli, proteus mirabilis and klebsiella pneumoniae were included in their study. the results of their study revealed that antimicrobial activity of crude ethanolic and hexane extracts for gram negative bacteria was much higher than gram positive bacteria. in current study, no gram-positive bacteria were used so, in future a study could be designed against mdr-gram positive bacteria. useful phytochemicals of o. basilicum can be a great scope for future researches. moreover, isolation and purification of pure compounds should be carried out. hplc analysis should be done to identify active compounds, because a variety of multifunctional compounds is present in the extract and fractions of ocimum basilicum, which can be used for the production of novel antibiotics. chloroform fraction obtained from crude ethanolic extract of o.basilicum herb exhibited high range of mic against multidrug resistant gram negative rods than all other fractions. aruna k 201523 showed the effect of o.basilicum leaf extracts against esbl and mbl producing uropathogens. methanol, ethanol, chloroform, acetone and butanol extracts of o.basilicum were analyzed against these organisms. chloroform extract showed best strong and broadspectrum antibacterial activity against tested strains than others. the difference in results might be due to difference in extraction technique e.g, the plant extract used in the current study being fractionated from crude, whereas others used pure active chloroform extract. further gc-ms analysis of the chloroform extract of o.basilicum also done by arunak 201523 showed that eugenol and estragole are major contributors. these compounds express good antibacterial activity in the chloroform extract of o.basilicum. gebrehiwot h 201613 also reported that major constituent of chloroform extract of leaves of o. basilicum was estragole (38.22%). estragole is a potent phytochemical compound which has the ability to inhibit all tested bacteria and fungi. 13 it can be assumed that the extracts or its components affect some key processes in the organism’s growth. antimicrobial activity of the different extracts of o.basilicum could be due to some active components (flavonoids, alkaloids, estragole, phenolics, tannins, linalools) which have the ability to combine with extra cellular and soluble protein and to make a complex with bacterial cell wall disrupting membrane of microbes.24 j islamabad med dental coll 2021 205 c o n c l u s i o n ocimum basilicum crude ethanolic extract and different solvent fractions had potent antibacterial activity against all tested strains of esbls and carbapenemase producing gram negative rods. o.basilicum can be used as alternative antimicrobial drug. the medicinal value of o.basilicum extract might be due to natural bioactive phytochemicals. acknowledgement we are thankful to university of health sciences, lahore for full technical and financial support to perform this research activity. r e f e r e n c e s 1. azimi t, maham s, fallah f, azimi l, gholinejad z. evaluating the antimicrobial resistance patterns among major bacterial pathogens isolated from clinical specimens taken from patients in mofid children’s hospital, tehran, iran: 2013–2018. infect drug resist: 2019, 12:2089. doi: 10.2147/idr.s215329 2. jean ss, gould im, lee ws, hsueh pr. new drugs for multidrug-resistant gram-negative organisms: time for stewardship. drugs. 2019;79(7):705-14. doi.10.1007/s40265-019-01112-1 3. helal im, el-bessoumy a, al-bataineh e, joseph mr, rajagopalan p, chandramoorthy hc, ben hadj ahmed s. antimicrobial efficiency of essential oils from traditional medicinal plants of asir region, saudi arabia, over drug resistant isolates. biomed research international. 2019. doi.10.1155/2019/8928306 4. jamal qa, munir sh, sherwani sk, sualeh mo, jabeen uz, malik m, hussain mu. antibacterial activity of two medicinal plants: withania somnifera and curcuma longa. european academic research. 2013;1:1335-45. 5. snoussi m, dehmani a, noumi e, flamini g, papetti a. chemical composition and antibiofilm activity of petroselinum crispum and ocimum basilicum essential oils against vibrio spp. strains. microbial pathogenesis. 2016; 90:13-21. doi.10.1016/j.micpath.2015.11.004 6. balakrishnan p, ramalingam p, nagarasan s. a comprehensive review on ocimum basilicum. journal of natural remedies. 2018;8(3):71-85. doi.10.18311/jnr/2018/21324 7. shahrajabian mh, sun w, cheng q. chemical components and pharmacological benefits of basil (ocimum basilicum): a review. international journal of food properties. 2020;23(1):1961-70. doi.10.1080/10942912.2020.1828456 8. patil dd, mhaske dk, wadhawa gc. antibacterial and antioxidant study of ocimum basilicum labiatae (sweet basil). j. adv. pharm. educ. res. 2011;2:10412. issn 2249-3379 9. eswar p, devaraj cg. the effect of chewing fresh ocimum basilicum leaves on caries microorganisms in human dental plaque. advances in human biology. 2015;5(3):56. 10. sun y, li m, chen l, chen h, yu x, ye j, zhang y, ma c, zhou t. prevalence and molecular characterization of carbapenemase-producing gramnegative bacteria from a university hospital in china. infectious diseases. 2016 ;48(2):138-46. doi.10.3109/23744235.2015.1094822 11. clinical & laboratory standard institute. performance standard for antimicrobial disk suseptability tests: twenty seventh information supplement m100s, 27th ed. clsi, wayne, pa,usa,2017. issn 2162-2914 12. tabassum s, amin f, erum s, javed h, kazmi f, nisar mf, ullah i, murtaza i, ashraf m. effect of hexane and ethanol extracts of ten basil genotypes on the growth of selected bacterial strains. international journal of agriculture & biology. 2016;18(4). 735-40. doi:10.17957/ijab/15.0157 13. gebrehiwot h, bachetti rk, dekebo a. chemical composition and antimicrobial activities of leaves of sweet basil (ocimum basilicum l.) herb. int. j. basic clin. pharmacol. 2015;4(5):869-75. doi.10.18203/2319-2003.ijbcp20150858 14. emran tb, rahman ma, uddin mm, rahman mm, uddin mz, dash r,et al. effects of organic extracts and their different fractions of five bangladeshi plants on in vitro thrombolysis. bmc complementary and alternative medicine. 2015;15(1):1-8. doi. 10.1186/s12906-015-0643-2 15. hakim ml, kusdarwati r. the effectiveness of extracts basil leaves (ocimum sanctum linn) against saprolegnia sp. by in vitro. iop conf. ser.: earth environ. sci.2017;5(1): 012010. iop publishing. doi:10.1088/1755-1315/55/1/012010 16. silva va, sousa jp, guerra fq, pessôa hl, freitas af, alves lb, et al. antibacterial activity of ocimum basilicum essential oil and linalool on bacterial isolates of clinical importance. international journal of pharmacognosy and phytochemical research. 2015;7(6):1066-71. issn: 0975-4873 17. issazadeh k, majid kp, massiha a, bidarigh s, giahi m, zulfagar mp. analysis of the phytochemical j islamabad med dental coll 2021 206 18. contents and anti-microbial activity of ocimum basilicum l. ijmcm.ir. 2012;2(1). 141-47. 19. nsele nw. assessment of the antibacterial activity of artemisia afra, erythrina lysistemon and psidium guajava (doctoral dissertation). 2013 20. sholichah ar. phytochemical screening and antioxidant activity of ethanolic extract and ethyl acetate fraction from basil leaf (ocimum basilicum l.) by dpph radical scavenging method. iniop conference series: materials science and engineering 2017 nov 1 (vol. 259, no. 1, p. 012008). iop publishing. doi:10.1088/1757899x/259/1/012008 21. khalil a. antimicrobial activity of ethanolic extracts of ocimum basilicum leaf from saudi arabia. biotechnology. 2013;12(1):61-4. doi: 10.3923/biotech.2013.61.64 22. ababutain im. antimicrobial activity and gas chromatography-mass spectrometry (gc-ms) analysis of saudi arabian ocimum basilicum leaves extracts. j pure appl microbiol. 2019;13(2):823-33. doi.org/10.22207/jpam.13.2.17 23. bilal a, jahan n, ahmed a, bilal sn, habib s, hajra s. phytochemical and pharmacological studies on ocimum basilicum linn-a review. ijcrr. 2012;4(23):73-83. issn: 0975-5241 24. aruna k, gore m, tariq m. synergistic interaction of ocimum basilicum extracts with antibiotic against βlactamase producing uropathogens. intr. j. adv. pharm. res: 2015; 6:177-184. 25. adam za, omer aa. antibacterial activity of ocimum basilicum (rehan) leaf extract against bacterial pathogens in sudan. american journal of research communication. 2015;3(8):94-9. issn: 2325-4076 j islamabad med dental coll 2021 192 o p e n a c c e s s quantum physics: a doorway for the potential treatment of cancer maria shahzadi1, muhammad bilal2 1,2 lecturer, department of health professional technologies, the university of lahore dear editor, questions exist regarding the scope of quantum physics and its potential applications. this field is so vast that someday, with little strife, it might come true that almost all the walks of life are entwined with quantum studies. quantum physics has the potential to revolutionize medicine especially after the observation of some non-trivial phenomena of quantum mechanics like quantum tunnelling and superposition, being followed in living organisms at the cellular and molecular levels.1 quantum physics has proven a foundational cornerstone in technological advancements. it’s a novel field with the potential to morph our lives.2 researchers are working on the development of quantum biological models to have a better understanding of biological activities, which include genetic defects, poor protein biosynthesis and inefficiencies in transmitted procedures like translation and transcription. models in cancer research have benefited from concepts like quantum metabolism and entropy. over generations, cancer has developed by quantum-selective adjustments in the environment. telomere length loss triggers a response to dna mutation, resulting in senescence and the breakdown of cell checkpoints, which would otherwise kill cancer cells.3 oncological applications of quantum physics are reflected as game-changers in a variety of domains. quantum dots technology and quantum cascade laser technologies employ a variety of quantum physics principles that aid in the detection, imaging and treatment of cancerous cells which is otherwise challenging to do by using other fluorescent dyes such as green indocyanine, 5-aminolevulinic acid, and methylene blue. the principles of quantum physics have the potential to be deployed in the future to diagnose and treat cancer.4 the relevance of telomere shortening in cancer cells is uncertain, although it is conceivable that it triggers conditions that encourage or hinder cancer cell development. however, quantum mechanics can be considered to demonstrate cancer cell proliferation.4 medical community must pay attention to quantum physics which might play a strong role as a stakeholder to treat cancer at quantum levels. 5 keywords: cancer treatment, quantum physics, quantum physics principles acknowledgement: authors would like to acknowledge our colleague mr. taimoor hassan for guiding us in writing and manuscript submission. l e t t e r t o e d i t o r correspondence: maria shahazadi email: mariashahzadi58993@gmail.com cite this editorial: shahzadi m, bilal m. quantum physics: a doorway for the potential treatment of cancer. j islamabad med dental coll. 2021; 10(4): doi: mailto:mariashahzadi58993@gmail.com j islamabad med dental coll 2021 193 r e f e r e n c e s 1. faramarzpour m, ghaderinia m, abadijoo h, aghababa h. the possibility of quantum medicine in cancer research: a review. biophysical reviews and letters. 2021:1-20. doi: 10.1142/s1793048021300012 2. raghunandan r, voll m, osei e, darko j, laflamme r. a review of applications of principles of quantum physics in oncology: do quantum physics principles have any role in oncology research and applications? journal of radiotherapy in practice. 2019;18(4):383-94.doi: 10.1017/s1460396919000153 3. uthamacumaran a. a biophysical approach to cancer dynamics: quantum chaos and energy turbulence. biosystems.2017; 156–157: 1–22. doi: 10. 1016/j.biosystems.2017.03.004. 4. jacobson ji. a quantum theory of disease, including cancer and aging. integr mol med. 2016 ;3(1):52441. doi: 10.15761/imm.1000200 5. goh bh, tong es, pusparajah p. quantum biology: does quantum physics hold the key to revolutionizing medicine? progress in drug discovery & biomedical science. 2020;3(1). doi:10.36877/pddbs.a0000130 j islamabad med dental coll 2022 196 open access vascular complications and their risk factors in patients of diabetes mellitus, type 2 tariq farhad1, muhammad rahim burghri2, muhammad uzair memon3, soha fatima4, yasir latif5, abdullah memon6. 1general practitioner, department of family medicine, ambulatory health services, seha, abu dhabi. 2assistant professor, department of anatomy, muhammad medical college, mirpurkhas. 3medical officer, department of medicine, isra university, hyderabad. 4house officer, medicine, jinnah postgraduate medical centre, karachi. 5medical officer, indus hospital, badin indus hospital, badin. 6medical student, third year mbbs isra university, hyderabad. a b s t r a c t introduction: to evaluate the vascular complications and their correlation with different risk factors among type-2 diabetic patients in hyderabad, sindh, pakistan. methodology: cross-sectional study was conducted at the department of medicine isra university hospital, hyderabad from march to september 2021. type 2 diabetics of either sex, between ages 20 and 70 years, on diabetic medication, were included in the study. while patients with type i diabetes, unconscious or with any mental health issues were excluded. a non-random consecutive sampling technique was applied for the selection of participants. socio-demographic, disease and medication information was collected using a written questionnaire while serum glucose level, albumin and lipid profile was analyzed. results: over half of the participants (51.72%) were females, while most (70.87%) of the participants were aged < 40 years. a total of 124(28.5%) patients showed symptoms of macro-vascular complications with most (16.78%) of them having coronary artery disease. a significant relation (p<0.05) was found between coronary artery disease and age, duration of diabetes, blood pressure, body mass index and serum triglycerides. peripheral vascular disease was significantly related (p<0.05) to the duration of diabetes, systolic blood pressure and serum triglyceride. while significant relation (p<0.05) between cerebrovascular disease with age, systolic and diastolic bp was there. conclusion: coronary artery disease seems to be the most common macro-vascular complication among type 2 diabetic patients, with a high prevalence of risk factors such as advanced age, duration of dm, male sex, hypertension, body mass index, and serum triglycerides. keywords: coronary artery disease, diabetes mellitus type 2, macro-vascular complications, peripheral vascular disease. authors’ contribution: 1conception; literature research; 1,2manuscript design and drafting; 3,4critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: palvisha qadri email: tariq_farhad@yahoo.com article info: received: april 20, 2022 accepted: december 27, 2022 cite this article.farhad t, burghri m r, memon m u, fatima s, latif y, memon a.vascular complications and their risk factors in patients of diabetes mellitus, type 2 .j islamabad med dental coll. 2022; 11(4):196-203 doi: https://doi.org/10.35787/jimdc.v11i4.875 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2022 197 i n t r o d u c t i o n diabetes mellitus (dm), is a universally occurring non-communicable disease as well as an exemplary health problem affecting people worldwide1.the overall incidence of dm is increasing at a staggering rate and this rise in number poses an enormous social and economic burden to the population. international diabetes federation reported that roughly 463 million people between ages 20 and 79 years are living with dm this toll is expected to rise up to 700 million by 2045. over two third of dm cases are residing in low and middle-income countries.2 diabetes mellitus type 2 (dmt2) is the most common type of dm that accounts for around 90% of dm cases throughout the globe.3approximately, 374 million people are already at risk of developing type 2 diabetes worldwide.1numerous micro and macro-vascular complications are associated with dmt2 that may have severe individual and social consequences.4peripheral neuropathy (pn) and peripheral vascular disease (pvd) are long-term complications of diabetes and are difficult to diagnose because they are asymptomatic, resulting in foot ulceration, infection, and ultimately amputation. early detection and treatment, on the other hand, reduce the incidence of ulceration.5other macro-vascular complications like coronary artery diseases (cad) and cerebrovascular diseases like stroke are rapidly growing and strongly associated with dmt2 and 2-4 folds more common in dmt2 patients compared with those without diabetes.6according to the world health organization (who), the prevalence of cad only in the eastern mediterranean region (emro) is 54% while these deaths may vary from 13% to 49% depending on the country also accounts for a considerable number of deaths in the region.7 pakistan is amongst the low-middle income country where overall 70% of the global burden of diabetics is present.8the idf reported the prevalence of dm is 6.8% during the year 2019 among 20–79 years’ age adults in pakistan. while the prevalence of dmt2 has risen significantly, 33 million adults in pakistan are affected by this type of diabetes which is a 70% increase in toll since 2019. with the rise in the prevalence of dmt2 in pakistan, the complications associated with the disease are also on the rise among the pakistani population. studies have reported that among the complications, cad is a more frequently reported complication of t2dm.9 while a significant relationship between t2sdm and stroke in asian countries like pakistan also reported by different studies. despite this rise in prevalence, very limited studies have reported the burden of dm complications and the risk factors linked with the complications of the disease in the country.10 prevalence studies on the complications of dm give noticeable and significant information that have a significant impact on policy and practice. but still the scantiness of information related to the risk factors for the co-morbidities in dm patients in pakistan specially in sindh and its cities demand a need for attention, screening and interventional program to estimate the prevalence and correlation of risk factors of different co-morbidities of dm in sindh. for this reason, the present study was designed with an objective to evaluate the macro-vascular complications and its relationship with different risk factors among type-2 diabetic patients in at tertiary care hospital of hyderabad, sindh, pakistan. m e t h o d o l o g y after getting ethical approval from ethical and research review committee of isra university # iu/rr-10-irc-21/n/2021/037, cross-sectional study was conducted at the department of medicine isra university hospital (iuh), hyderabad from march to september 2021. all patients admitted or visited the medicine department hyderabad with positive history of dmt2, taking any diabetic medication (insulin or oral hypoglycemic drugs or both), between age of 20 and 70, either sex, regardless of socioeconomic status or religion, given consent of j islamabad med dental coll 2022 198 participation were included in the study. patients with type i dm, not willing to participate, mentally compromised or unconscious were excluded from the study. informed consent was obtained from all the participants individually prior to the commencement of the interviews. sample size of was calculated using online sampling calculator open-epi.11 keeping 95% confidence interval, 5% margin of error and prevalence of macro-vascular complications among type ii diabetics of 27.2% 15, after adding ±10% the sample size of 335 was drawn. non-random consecutive sampling technique was applied for the selection of participants. a predesigned and pre-tested written questionnaire was used to collect information of all the study participants. the questionnaire comprises of three parts, first part of the questionnaire having questions regarding socio-demographic variables like; age, sex, economic status, education status. second part of the questionnaire with information of body mass index (bmi), duration of disease, medication history, family history of diabetes and smoking history. the third section contains the details of the laboratory diagnostic as well as any comorbidities discovered during the test. the height was measured without shoes and the body weight was estimated while wearing the least amount of clothing possible using stadiometer with weighing scale. the usual formula (weight (kg) per height) was used to calculate bmi (m2) that is if a person having bmi between 18.5 and 24.9 was labelled as healthy while bmi <18.5 (underweight), 25.0-29.9 (overweight) and ≥30.0 was considered as obese. using aseptic measures, 5cc of blood was drawn and sent for serum glucose (random and fasting) levels, glycated hemoglobin (hba1c), and total lipid profile were measured on a fully automated chemistry analyzer.blood pressure was measured using a mercury sphygmomanometer by trained nursing staff to assess the patient’s hypertension (htn) status using the who standard definition for htn. peripheral neuropathy was assessed by testing the strength of muscles, monofilament as well as tendon reflex. patients with painful pn were confirmed if they had a history of body pain that worsened at night. diabetic nephropathy was evaluated by urinalysis for macro and microalbuminuria. spss version 22 was used for statistical analysis. descriptive statistics were used to show demographic variables and co-morbidities. for quantitative data, mean and standard deviation (sd) were calculated. the relationship between macrovascular disease and clinical variables was determined using the student t-test. p < 0.05 was considered significant. r e s u l t s a total of 335 patients fulfilled the selection criteria; of them 173 (51.6%) were females and 162 (48.4%) were males. most (70.8 %) participants belong to 40 and above year while 29.13% were younger than 40 years of age. the mean age of participants was 48.7 ± 10.9 years (age range 27-71 years). the duration of dm was between 3–31 years with the mean duration of dm being 8.7±4.6 years. hba1c levels revealed that 86.58% of all participants had levels ≥ 7%. table i: complications prevalent among diabetic patients (n=335) complications n (%) coronary artery disease 56 (16.7) diabetic nephropathy 53 (16.0) diabetic neuropathy 104(31.0) diabetic retinopathy 82 (24.5) cerebrovascular disease 22 (6.5) peripheral vascular disease 18 (5.3) j islamabad med dental coll 2022 199 table ii: socio-demographic and clinical details of study participants (n=335) socio-demographic & clinical features total 335 n % family history of dm positive negative 159 176 47.5 52.5 duration of dm upto 5 years over 5 years 108 227 32.3 67.7 hypertension (mmhg) (n=254) systolic htn diastolic htn 157 97 62.0 38.0 bmi (kg/m2) normal overweight obese 191 114 30 57.0 34.0 9.0 smoker yes no 128 207 38.2 61.8 laboratory findings mean s.d glycemic status fbs (mg/dl) 2 hours ppbg* (mg/dl) hba1c (%) 210.1 309.4 9.6 87.5 112.9 2.5 lipid profile (mg/dl) total cholesterol hdl cholesterol ldl cholesterol tgs 188.2 42.1 141.2 221.5 48.1 28.7 43.7 115.4 * ppbg: post prandial blood glucose table iii: gender wise distribution of demographic, clinical and laboratory findings (n=335) socio-demographic & clinical features male female 173 162 n % n % family history of dm positive negative 91 82 52.6 47.4 68 94 42.3 57.4 duration of dm upto 5 years over 5 years 45 128 26.0 74.0 63 99 39.0 61.0 bmi (kg/m2) normal overweight obese 114 44 15 66.0 25.4 8.6 77 70 15 47.6 43.2 9.2 smoker yes no 110 63 63.6 36.4 18 144 11.0 89.0 laboratory findings mean s.d mean s.d j islamabad med dental coll 2022 200 glycemic status fbs (mg/dl) 2 hours ppbg* (mg/dl) hba1c (%) 203.5 301.7 8.81 81.3 100.3 2.4 206.4 309.6 9.4 92.1 115.2 2.7 lipid profile (mg/dl) total cholesterol hdl cholesterol ldl cholesterol tgs 186.2 43.5 140.3 231.1 47.7 26.7 42.6 126.9 188.8 42.6 143.5 213.1 47.9 25.4 45.3 103.4 * ppbg: post prandial blood glucose * htn: hypertension table iv: macro-vascular complications and their relation with different risk factors peripheral vascular disease yes 18 no 317 p-value mean ±s.d mean ±s.d age (years) 54.6 8.4 53.9 9.6 0.73 duration of dm (years) 11.4 8.4 5.9 6.2 0.00* systolic bp (mmhg) 144.5 22.7 134.4 21.1 0.02* diastolic bp (mmhg) 88.5 13.7 84.9 11.5 0.14 hba1c (%) 8.6 2.1 9.3 2.7 0.22 bmi (kg/m2) 22.7 3.4 23.8 3.9 0.18 serum cholesterol (mg/dl) 182.6 56.3 188.4 43.3 0.53 hdl cholesterol (mg/dl) 41.5 27.8 43.3 26.5 0.75 serum triglyceride (mg/dl) 285.5 113.7 237.3 112.6 0.04* ldl cholesterol (mg/dl) 136.1 47.3 144.5 42.7 0.36 coronary artery disease yes 56 no 279 p-value mean ±s.d mean ±s.d age (years) 58.4 10.4 51.7 10.7 0.00* duration of dm (years) 10.7 6.8 5.8 6.2 0.00* systolic bp (mmhg) 148.3 27.8 135.3 26.5 0.00* diastolic bp (mmhg) 89.3 15.8 83.5 13.8 0.00* hba1c (%) 9.4 2.3 9.2 2.1 0.46 bmi (kg/m2) 24.4 3.6 22.3 4.1 <0.001* serum cholesterol (mg/dl) 185.4 51.3 189.3 47.4 0.52 hdl cholesterol (mg/dl) 45.7 42.4 40.1 19.3 0.07 serum triglyceride (mg/dl) 240.2 151.5 211.3 100.8 0.04* ldl cholesterol (mg/dl) 140.9 44.8 141.2 43.6 0.95 cerebrovascular disease yes 22 no 313 p-value mean ±s.d mean ±s.d age (years) 59.6 11.2 50.6 11.3 <0.001* duration of dm (years) 9.4 5.2 7.4 5.4 0.058 systolic bp (mmhg) 150.3 26.8 135.7 25.4 0.003* diastolic bp (mmhg) 90.5 13.3 82.6 12.3 0.001* hba1c (%) 9.2 2.4 9.6 2.7 0.44 bmi (kg/m2) 24.3 4.7 23.3 4.1 0.21 j islamabad med dental coll 2022 201 serum cholesterol (mg/dl) 191.6 49.0 186.9 49.7 0.62 hdl cholesterol (mg/dl) 43.2 18.5 41.7 23.2 0.73 serum triglyceride (mg/dl) 253.5 167.0 219.6 112.8 0.13 ldl cholesterol (mg/dl) 138.6 44.1 140.2 42.4 0.84 d i s c u s s i o n dm is a complex metabolic disorder, which has emerged not only as a major public health issue around the world but also as a major cause of economic burden worldwide.12 the global incidence of dm is rising at an astonishing rate and this mounting toll of dm related morbidities and mortalities is posing a serious threat to the developing as well as developed world.13 the complications related to the disease are affecting masses not only socially but also economically. while the complications related to dm are further imposing economic burden on the country and specifically the common man. proper knowledge about the incidence rate of these dm related complications as well as early diagnosis and possible strategies to treat these complications is the need of the hour for developing and developed countries alike.14,15 the findings of this study provided a potential insight of the prevalence of complications and their risk factors in the type 2 dm patients of sindh. our study findings strongly suggest that there is an association between dm and chronic macro vascular complications. the overall prevalence of macro vascular complications among our study population with type 2 dm was 28.5%. in comparison to previous studies, rising trends in the prevalence of complications were observed. a study conducted in punjab, pakistan by gillani et al.16 reported the prevalence of macro vascular complication in their study was 21.7%. while a study by li j. et al. reported that comparable proportion of their participants with dmt2 were having macro vascular complication.17 a study from saudi arabia reported 12.1% of total macro vascular diseases among their diabetic participants that is quite lower than our study.18 in the present study, among the patients of macro vascular complication, 16.7% had cads, 6.5% had cvd and 5.3% had pvd. several studies also reported similar trend of macro vascular complications as demonstrated in this study. alaboud et al. reported the consistent findings of macro vascular complications in their study participants. another study by gedebjerg et al. also reported higher prevalence (15%) of cads in their patients followed by 5% cvds and 2% pvds in their study. moreover, uddin et al. reported prevalence of 8.5% cads, 2.0% cvd and 2.2% pvd in their newly diagnosed diabetics patients. 19 the risk factors analysis in the present study demonstrated that duration of dm was the main risk factor (p<0.05) for cad and pvd but not for cvd while systolic hypertension was the risk factor common (p<0.05) in cad, pvd and cvd. ahmed m.s et al also reported the findings consistent with our study.20 moreover, age and diastolic blood pressure were significantly associated with cad and cvd, but not pvd. a pakistani study by gillani et al. reported the strong association between age and cad, which is consistent with the findings of present study.16 serum triglycerides was a common significantly associated (p<0.05) factor of cad and pvd in this study. this may be due to fact that high serum triglycerides may lead to increase chances of thrombus formation within the vessels and lead to blockage of blood circulation in the vessels. with strengths, there are many limitations in the study. foremost, limited duration and resources only one center was included in the study. furthermore, only macro vascular complications were studied in the present study while many risk factors like economic status, treatment etc. are not included for the study. j islamabad med dental coll 2022 202 c o n c l u s i o n the cad seem to be the most common macro vascular complication among type 2 diabetic patients, with a high prevalence of risk factors such as advanced age, duration of dm, male sex, hypertension, bmi, and serum triglycerides. r e f e r e n c e s 1. world health organization who. diabetes: who; 2020 [cited 2021 21 march]. available from: https://www.who.int/healthtopics/diabetes#tab=tab_1. 2. saeedi p, salpea p, karuranga s, petersohn i, malanda b, gregg ew, et al. mortality attributable to diabetes in 20–79 years old adults, 2019 estimates: results from the international diabetes federation diabetes atlas. diabetes research and clinical practice. 2020;162:108086. 3. meo sa, zia i, bukhari ia, arain sa. type 2 diabetes mellitus in pakistan: current prevalence and future forecast. jpma the journal of the pakistan medical association. 2016;66(12):1637-42. 4. bekele bb. the prevalence of macro and microvascular complications of dm among patients in ethiopia 1990–2017: systematic review. diabetes & metabolic syndrome: clinical research & reviews. 2019;13(1):672-7. 5. handoko h, rahardjo ss, murti b. predictors of macro and microvascular complication in type 2 diabetes mellitus patients at dr. moewardi hospital, surakarta. indonesian journal of medicine. 2018;3(1):1-13. 6. dobrica e, gaman m, cozma m, gaman a, diaconu c. macrovascular and microvascular complications in type 2 diabetes mellitus: did hypertension change the setting? journal of hypertension. 2019;37:e140-e1. 7. world health organization who. cardiovascular diseases 2018 [cited 2021 13 april]. available from: http://www.emro.who.int/healthtopics/cardiovascular-diseases/index.html 8. basit a, fawwad a, baqa k. pakistan and diabetes—a country on the edge. diabetes research and clinical practice. 2019;147:166-8. 9. zia a, bhatti a, jalil f, wang x, john p, kiani ak, et al. prevalence of type 2 diabetes–associated complications in pakistan. international journal of diabetes in developing countries. 2016;36(2):17988. 10. adnan m, aasim m. prevalence of type 2 diabetes mellitus in adult population of pakistan: a metaanalysis of prospective cross-sectional surveys. annals of global health. 2020;86(1). 11. kevin t, sullivan a. open epi: sample size for xsectional, cohort and clinical trials 2018. available from: http://www.openepi.com/samplesize/sspropor.h tm. 12. gedebjerg a, almdal tp, berencsi k, rungby j, nielsen js, witte dr, et al. prevalence of micro-and macrovascular diabetes complications at time of type 2 diabetes diagnosis and associated clinical characteristics: a cross-sectional baseline study of 6958 patients in the danish dd2 cohort. journal of diabetes and its complications. 2018;32(1):34-40. 13. yuen l, saeedi p, riaz m, karuranga s, divakar h, levitt n, et al. projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: results from the international diabetes federation diabetes atlas. diabetes research and clinical practice. 2019;157:107841. 14. belsti y, akalu y, fekadu h, animut y. awareness of complications of diabetes mellitus and its associated factors among type 2 diabetic patients at addis zemen district hospital, northwest ethiopia. bmc research notes. 2019;12(1):1-7. 15. bommer c, sagalova v, heesemann e, mannegoehler j, atun r, bärnighausen t, et al. global economic burden of diabetes in adults: projections from 2015 to 2030. diabetes care. 2018;41(5):96370. 16. gillani ah, bashir s, ahmed ab, usman m, mustafa a, iqbal t, et al. macro and micro-vascular complications and their risk factors in diabetes mellitus patients of southern punjab, pakistan. journal of pharmacy practice and community medicine. 2018;4(2). 17. li j, chattopadhyay k, xu m, chen y, hu f, chu j, et al. prevalence and associated factors of vascular complications among inpatients with type 2 diabetes: a retrospective database study at a tertiary care department, ningbo, china. plos one. 2020;15(6):e0235161. 18. alaboud af, tourkmani am, alharbi tj, alobikan ah, abdelhay o, al batal sm, et al. microvascular and macrovascular complications of type 2 diabetic mellitus in central, kingdom of saudi arabia. saudi medical journal. 2016;37(12):1408. 19. uddin f, ali b, junaid n. prevalence of diabetic complications in newly diagnosed type 2 diabetes patients in pakistan: findings from national registry. j ayub med coll abbottabad. 2018;30(suppl 1):s652-s8. 20. ahmad m, alslamah t, alannaz s, shaik r, ahmad r, yusuf m, et al. prevalence of micro and macro http://www.who.int/health-topics/diabetes#tab=tab_1 http://www.who.int/health-topics/diabetes#tab=tab_1 http://www.emro.who.int/health-topics/cardiovascular-diseases/index.html http://www.emro.who.int/health-topics/cardiovascular-diseases/index.html http://www.openepi.com/samplesize/sspropor.htm http://www.openepi.com/samplesize/sspropor.htm j islamabad med dental coll 2022 203 vascular complications and their risk factors in type 2 diabetes in saudi arabian population: an analysis from shis. eur rev med pharmacol sci. 2021;25:4308-16. j islamabad med dental coll 2022 103 open access evaluation of dental caries and periodontal health status in children with autism: a case control study ahmed bin khalid khan1, seeme nigar2, naseer ahmed3, anum tanwir4, chander kumar5, sara altamash6 1senior registrar, department of periodontology, altamash institute of dental medicine, karachi, pakistan. 2senior registrar, department of oral pathology, altamash institute of dental medicine, karachi, pakistan. 3professor, department of prosthodontics, altamash institute of dental medicine, karachi, pakistan. 4assistant professor, department of pediatric dentistry, baqai medical university, karachi, pakistan. 5associate professor, department of periodontology, dow dental college, dow university of health sciences, karachi pakistan. 6assistant professor, department of orthodontics, altamash institute of dental medicine, karachi, pakistan. a b s t r a c t background: dental problems are common in autistic children due to poor oral hygiene. during the dental treatment, main challenge is reduced ability of autistic kids to communicate. the objective of this study was to investigate about the oral health status of autistic children and to compare the risk of dental caries and periodontal disease between children with autism and healthy controls. methodology: this case-control study was conducted at the milestone charitable trust and defense housing authority (dha), sheikh khalifa bin zayed school, for the duration of 04 months (1st dec 2019 – 30th march 2020). among cases, 67 autistic children and among controls,67 healthy children, of age 7 to 17 years, of either gender, were included. all the participants were examined and assessed for presence or absence of any carious lesions, and periodontal health. data analysis was done using spss version 23. results: the overall mean age of included children was 12.51±2.99 years. of 134 children, 53.7% were males and 46.3% females. the odds of periodontal disease were 5.52 times higher in autistic children as compared to healthy children (p < .001). the odds of dental caries were 3.43 times higher in autistic children as compared to healthy children (p < .001). in both age groups (<=10 years and >10 years), the risk of periodontal disease and dental caries was higher among autistic children as compared to normal children. while, according to gender, the risk of dental caries was higher among male autistic children as compared to normal children. conclusion: the odds of dental caries and periodontal disease were higher among autistic children as compared to healthy controls. keywords: autism spectrum disorder, dental caries, periodontitis authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; 6manuscript editing. correspondence: naseer ahmed email: naprosthodontist@gmail.com article info: received: july 1, 2021 accepted: may 23, 2022 cite this article. khan a b h, nigar s, ahmed n, tanveer a, kumar c, altamash s. evaluation of dental caries and periodontal health status in children with autism: a case control study. j islamabad med dental coll. 2022; 11(2):103-109. doi: https://doi.org/10.35787/jimdc.v11i2.734 funding source: nil conflict of interest: nil i n t r o d u c t i o n o r i g i n a l a r t i c l e j islamabad med dental coll 2022 104 autism spectrum disorder (asd) is a complex developmental illness characterized by long-term neuro-developmental symptoms that appear in childhood. they are characterized by difficulties in social communication or interaction, as well as confined, repetitive patterns of interests, behavior, or activities, and odd sensory sensitivities or preferences. an "epidemic of autism" has been witnessed, all across the world, in the last decade or two. according to recent estimates, from the world health organization, one out of every 160 children have an asd.1 cdc 2020 data have reported that the prevalence rate of asd ranges from 0.1 to 43.6 with an average male: female ratio of 4:1. due to their complex clinical manifestations, children with asd pose unique behavioral challenges for dentists in provision of effective oral health care mainly due to anxiety and aggressive behavior of autistic children. poor manual dexterity and lack of eye contact further complicate the problem. parents and caregivers also face difficulties in provision of regular oral hygiene measures, due to the uncooperative behavior of children with asd.2 the american academy of pediatrics has reported a prevalence rate of 1 out of 91 children in the age group of 3–17 years. autistic patients display a higher propensity to specific malocclusions, open bite and swarming, and crowding. oral habits like tongue thrusting, bruxism, lip biting and gingival pricking are most common complaints among kids with autism. it has been reported that children with asd generally prefer sweet, soft and sticky food and therefore are more susceptible to dental caries. in addition, failure to maintain oral hygiene without assistance, predisposes children to periodontal diseases. 3 oral health of autistic children has been studied by many researchers, as a whole or in contrast to healthy controls. literature shows that the occurrence of dental caries in children with asd is debatable.4-11 according to few studies, children with autism have an increased risk of dental caries due to food selectivity, poor oral hygiene maintenance and infrequent use of oral health care services. furthermore, an increased risk of periodontal diseases has also been reported in the literature because of the same reasons.4,7,11 contrarily, some studies show that children with asd have a decreased incidence of dental caries and periodontal problems.6,9,10. moreover, very few studies have assessed the oral health status of autistic children in pakistan. with such conflicting results and lack of available information, the study was planned to investigate the oral health status of autistic children in pakistan to update the existing knowledge and to help in planning dental care for the children with special needs. m e t h o d o l o g y this case-control study was conducted at the milestone charitable trust and defense housing authority (dha), sheikh khalifa bin zayed school, karachi for the duration of 04 months from 1st dec2019 – 30th march,2020. the sample size was estimated using online open epi calculator by taking statistics of dental caries in autistic kids as 76% 7 and in normal kids as 34.9% 8, level of significance as 95% and 90% power of study. the total sample size was 134. the data were obtained from the schools, by means of non-probability convenience sampling technique. in case group, children with confirmed diagnosis of autism, of age 7 to 17 years, of either gender were included whereas in control group, healthy children of age 7 to 17 years, of either gender were included. agitated and aggressive children, children scared of dental evaluation, children having any dental treatment or thorough cleaning procedure during the last 6 months, children with presence of certain diseases that might increase or influence tooth decay, caries and the severity of periodontal disease, for example, diabetes mellitus were excluded from the study. j islamabad med dental coll 2022 105 the study was approved from ethical review committee altamash institute of dental medicine . permission letter or consent to examine the children was taken from the faculty members and class teachers as well as from the parents. all of the children were checked and assessed for dental health status, presence or absence of any carious lesions and periodontal health. the children were asked to sit on a normal chair. illumination was provided using artificial light (torch). oral health status was checked by using examination instruments including dental mirror, probe and explorer. overall periodontal status was evaluated by basic periodontal examination (bpe). dental caries was recorded using the decayed missing filled teeth index according to the established who criteria.12 the condition, health and inflammatory status of the gingiva was assessed by the gingival index. oral hygiene status was noted as good, fair or poor depending on the oral hygiene index. plaque and calculus accumulation were assessed by plaque index and calculus index. cpitn or who probe was used for the periodontal examination. the oral cavity was divided into six sextants. each sextant contained at least two teeth. periodontal probe was inserted parallel to the vertical axis of the tooth and walked circumferentially around the sulcus or pockets in all sextants and the scores were recorded. lastly, questions were asked from the parents about overall oral health status of the children, either they followed regular tooth brushing or not, and the frequency of tooth brushing from both groups. they were asked if their child has any dental issues like bleeding either spontaneous or easily provoked, any irritation or inflammation, pain or toothache. a single dentist (principal author) carried out all examinations. the parents/guardians were informed about the clinical findings through written information sheets made for the school record. following the examination, oral health education was given, in addition to referrals to dental clinics, whenever these were deemed necessary. data analysis was done using spss version 23. mean and sd were computed for age and dmft score. frequency and percentage were computed for gender, periodontal disease and dental caries. chisquare test/fischer exact test was applied for the comparison of periodontal disease and dental caries between autistic and healthy children. crude odds ratio with 95% ci was estimated. stratification with respect to age and gender were performed for comparison of periodontal disease and dental caries between autistic and healthy children. adjusted odds ratio with 95% ci was estimated. r e s u l t s the mean age of children from both groups was 12.51±2.99 years (range: 7-17 years). the mean age of autistic children (n=67) was 13.06±2.917 years with 50.7% females and 49.3% males. the mean age of healthy children (n=67) was 11.97±2.99 years and majority of them were males (58.2%). only 19.4% autistic children brushed their teeth twice or thrice a day and 16.4% once a day while 26.9% normal children brushed their teeth twice/thrice daily and 38.8% brushed at least once a day. the remaining 64.2% autistic and 34.3% healthy children brushed their teeth occasionally. there was a significant association between oral hygiene and brushing among both groups with p value 0.005. out of 134 children, 67 children had periodontal disease. the odds of periodontal disease were 5.52 times higher in autistic children as compared to healthy children (or=5.52, 95% ci=2.64-11.57). hence, there was statistically significant association between autism and periodontal disease (p < .001). out of the total (67) autistic children, 47 developed periodontal diseases. whereas in the control group, 20 developed periodontal diseases. furthermore, in age group ≤10 years, the odds of periodontal disease were 6.37 times higher among autistic children as compared to normal children (aor=6.37, 95% ci=1.42-28.60). similarly in age group>10 years, the j islamabad med dental coll 2022 106 odds of periodontal disease were 2.70 times higher among autistic children as compared to normal children (aor=2.70, 95% ci=1.18-6.13). among males, the odds of periodontal diseases were 7.95 times higher in autistic children as compared to normal children (aor=7.95, 95% ci=2.76-22.92). whereas in females, the odds of periodontal disease were 3.87 times higher in autistic children as compared to normal children (aor=3.87, 95% ci=1.34-11.17). therefore, autistic male children had high proportion of periodontal disease as compared to female autistic children (75.7% vs 64.7%). a statistically significant association between autism and periodontal disease (p < .001) was found. (table 1) in addition, 49.3% of the total children had dental caries. the minimum dmft recorded was 1 while the maximum was 3 with mean ± sd of 1.74± 0.83. the odds of dental caries were 3.43 times higher in autistic children as compared to healthy children (or=3.43, 95% ci: 1.68-6.97). there was statistically significant association between autism and dental caries (p=0.001). out of the total (67) autistic children, 43 developed dental caries. whereas in the control group, 23 developed dental caries. moreover, in age group, ≤10 years, the odds of dental caries were 6.37 times higher among autistic children as compared to normal children (aor=6.37, 95% ci=1.42-28.60). similarly in age group>10 years, the odds of dental caries was 2.70 times higher among autistic children as compared to normal children (aor=2.70, 95% ci=1.18-6.13). among males, the odds of dental caries were 4.50 times higher in autistic children as compared to normal children (aor=4.50, 95% ci=1.66-12.14). whereas among females, statistically insignificant association was observed between dental caries and autism (p=0.078). however, autistic male children had high proportion of dental caries as compared to female autistic children (66.7% vs 61.8%). (table 2) table i: stratification analysis with respect to age and gender of periodontal disease between both groups autistic children (n=67) healthy children (n=67) pvalue adjusted or (95% ci) age group≤10 years period ontal disease yes 10 (76.9%) 7 (30.4%) 0.014 * 6.37 (1.4228.60) no 3 (23.1%) 16 (69.6%) age group>10 years period ontal disease yes 37 (68.5%) 13 (29.5%) 0.000 1* 2.70 (1.186.13) no 17 (31.5%) 31 (70.5%) male period ontal disease yes 25 (75.8%) 11 (28.2%) 0.000 1* 7.95 (2.7622.92) no 8 (24.2%) 28 (71.8%) female period ontal disease yes 22 (64.7%) 9 (32.1%) 0.011 * 3.87 (1.3411.17) no 12 (35.3%) 19 (67.9%) j islamabad med dental coll 2022 107 table ii: stratification analysis with respect to age and gender of dental caries between both groups autistic childre n (n=67) healthy children (n=67) pvalue adjusted or (95% ci) age group≤10 years dental caries yes 9 (69.2%) 6 (26.1%) 0.017 * 6.37 (1.4228.60) no 4 (30.8%) 17 (73.9%) age group>10 years dental caries 2.70 (1.186.13) yes 34 (63%) 17 (38.6%) 0.025 * no 20 (37%) 27 (61.4%) male dental caries yes 22 (66.7%) 12 (30.8%) 0.002 * 4.50 (1.6612.14) no 11 (33.3%) 27 (69.2%) female dental caries yes 21 (61.8%) 11 (39.3%) 0.078 2.49 (0.896.96) no 13 (38.2%) 17 (60.7%) d i s c u s s i o n gingival and periodontal diseases, as well as compromised oral health, are crucial and major difficulties in children with autism and other learning impairments.7 when compared to normal persons with no special requirements or impairments, the frequency and occurrence of numerous oral illnesses are much greater in exceptional children with autism disorder.1,6 people with autistic condition may find it difficult to execute simple and basic chores, such as keeping proper dental hygiene.1 caries in autistic children should be closely monitored, and interventions should be devised to alter the children's everyday activities in order to encourage them to acquire more favorable dental health practices.13,14 in the current study, we have evaluated the proportion of dental caries and periodontal disease among children with autistic disorders as compared to healthy controls. it shows that 64.2% of the autistic children had dental caries whereas only 34% of the normal children had decayed teeth. suhaib et al. observed similar results in a pakistani study, with autistic children having a greater prevalence of dental caries than healthy controls (50% vs 22.2%).15the reason that dental caries is more common in children with asd might be related to the children's inability to brush properly, independently and brushing less frequently , resulting in poor oral hygiene.15,16 another fact is that the children with autism occasionally favor sweetened and soft meals, and they prefer to stuff them into their pockets and mouths to the brim rather than swallowing them which may lead to dental caries.16,17 moreover, dental caries was observed in 69.2% of the autistic children belonging to age group age≤10 where as in age group >10 years, 63% of autistic children showed carious lesions. this is in contrast to the other studies, where it was observed that as the age of asd children increases, the frequency of dental caries also increases. this finding was observed among autistic children with a growing number of permanent teeth. caretakers are finding it more difficult to brush their children's teeth as they become older.17-19 we also found male gender as a significant risk factor for dental caries among autistic children. hassan et al. also found that male gender in autistic children was significantly associated with dental caries.17 another study also showed that male autistic children had high frequency of caries than females.20 according to our study, 70.1% of the autistic children had periodontal disease. we also found that frequency of periodontal disease was higher in j islamabad med dental coll 2022 108 autistic children of age≤10 years and male gender. in another study hussein et al. also observed high incidence of periodontal disease among children with autism as compared to normal children (p<0.05).21 vajawat et al. also revealed the frequency of periodontal disease was higher among autistic children as compared to healthy controls (p=0.001).22 due to difficulties with plaque management and oral defensiveness to oral hygiene equipment in the mouth, such as tooth brushing, people with asd are more prone to develop periodontal disease.23 however, there are certain limitations of the study, the mean age did not match between the two groups and there was a 1-year difference; this cofounder should be controlled in future study as this might have an effect on the results. moreover, blinding was not performed. within limitations of the study, it is concluded that the outcome of the study should be considered as the baseline and to be used with caution. further studies are warranted to work on the identified loopholes. furthermore, the children with autistic disorder have bad oral hygiene, various dental, gingival and periodontal problems which are most likely due to improper coordination, lack of proper understanding, physical and mental disability and various other associated abnormalities, or muscular restrictions and constraints.16,17,20,24 this study provides necessary data and information regarding dental conditions and dental needs of the group of children suffering from autism which might enable and help policy makers to design and create successful oral health educational programs for children with learning disabilities particularly autistic children. this research highlights the need for more efforts and work in this field. further awareness is needed for the accomplishment of long term oral and periodontal needs of children with autism. c o n c l u s i o n the odds of dental caries and periodontal disease were higher among autistic children as compared to healthy children. r e f e r e n c e s 1. who. autism spectrum disorders 2021 [cited 2021 11 jun]. available from: https://www.who.int/newsroom/fact-sheets/detail/autism-spectrum-disorders. 2. alhumaid j. dental experiences related to oral care of children with autism spectrum disorders in saudi arabia: a literature review. saudi dent j. 2021;27;34(1):1-10. https://doi.org/10.1016/j.sdentj.2021.09.023 3. suhaib f, saeed a, gul h, kaleem m. oral assessment of children with autism spectrum disorder in rawalpindi, pakistan. autism. 2019;23(1):81-6. 4. ferrazzano gf, salerno c, bravaccio c, ingenito a, sangianantoni g, cantile t. autism spectrum disorders and oral health status: review of the literature. eur j paediatr dent. 2020 mar;21(1):9-12. doi: 10.23804/ejpd.2020.21.01.02. 5. pi x, liu c, li z, guo h, jiang h, du m. a meta-analysis of oral health status of children with autism. j clin pediatr dent. 2020;44(1):1-7. doi: 10.17796/10534625-44.1.1. 6. kalyoncu i, tanboga i. oral health status of children with autistic spectrum disorder compared with nonauthentic peers. iran j public health. 2017;46(11):1591-3. 7. alhumaid j, gaffar b, alyousef y, alshuraim f, alhareky m, el tantawi m. oral health of children with autism: the influence of parental attitudes and willingness in providing care. scientific world journal. 2020;2020:8329426. 8. morales-chávez mc. oral health assessment of a group of children with autism disorder. j clin pediatr dent. 2017;41(2):147-149. doi: 10.17796/1053-462841.2.147. 9. zhang y, lin l, liu j, shi l, lu j. dental caries status in autistic children: a meta-analysis. j autism dev disord. 2020apr;50(4):1249-1257. doi: 10.1007/s10803-019-04256-x. 10. fakroon s, arheiam a, omar s. dental caries experience and periodontal treatment needs of children with autistic spectrum disorder. eur arch paediatr dent. 2015 apr;16(2):205-9. doi: 10.1007/s40368-014-0156-6. https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders https://doi.org/10.1016/j.sdentj.2021.09.023 j islamabad med dental coll 2022 109 11. du ry, yiu ck, king nm, wong vc, mcgrath cp. oral health among preschool children with autism spectrum disorders: a case-control study. autism. 2015;19(6):746-51. doi: 10.1177/1362361314553439. 12. who. mean number of decayed, missing, and filled permanent teeth (mean dmft) among the 12-yearold age group (internet). available from: https://www.who.int/data/gho/ indicatormetadata-registry/imr-details/3812 13. goenka p, dutta s, marwah n, sarawgi a, nirwan m, mishra p. prevalence of dental caries in children of age 5 to 13 years in district of vaishali, bihar, india. int j clin pediatr dent. 2018;11(5):359-64. 14. delli k, reichart pa, bornstein mm, livas c. management of children with autism spectrum disorder in the dental setting: concerns, behavioural approaches and recommendations. med oral patol oral cir bucal. 2013;18(6):e862-8. 15. suhaib f, saeed a, gul h, kaleem m. oral assessment of children with autism spectrum disorder in rawalpindi, pakistan. autism. 2019;23(1):81-6. 16. hariyani n, soebekti rh, setyowati d, bramantoro t, palupi ls, oktarina, et al. factors influencing the severity of dental caries among indonesian children with autism spectrum disorder a pilot study. clin cosmetinvestig dent. 2019;11:227-33. 17. hassan gs, rafique t, ghosh r, biswas ak, rahman ha. oral hygiene practice and dental status of autistic children. bangladesh medical research council bulletin. 2020;46(2):90-8. 18. sharp wg, berry rc, mccracken c, nuhu nn, marvel e, saulnier ca, et al.feeding problems and nutrient intake in children with autism spectrum disorders: a meta-analysis and comprehensive review of the literature. j autism dev disord. 2013;43(9):2159-73. 19. heaton lj, swigart k, mcnelis g, milgrom p, downing df. oral health in patients taking psychotropic medications: results from a pharmacy-based pilot study. j am pharm assoc. 2016;56(4):412-7. 20. naidoo m, singh s. the oral health status of children with autism spectrum disorder in kwazulu-nata, south africa. bmc oral health. 2018;18(1):165. 21. hussein f, mustafa a, sabir s. dental caries experience and periodontal health status in a sample of autism children. zanco j med sci.2018; 22(1), 73 81. https://doi.org/10.15218/zjms.2018.010 22. vajawat m, deepika pc. comparative evaluation of oral hygiene practices and oral health status in autistic and normal individuals. j int soc prev community dent. 2012;2(2):58-63. 23. du ry, yiu cky, king nm. oral health behaviors of preschool children with autism spectrum disorders and their barriers to dental care. j autism dev disord. 2019;49(2):453-9. 24. poustka l, brandeis d, hohmann s, holtmann m, bölte s, banaschewski t. neurobiologically based interventions for autism spectrum disorders-rationale and new directions. restor neurol neurosci. 2014;32(1):197-212. https://www.who.int/data/gho/%20indicator-metadata-registry/imr-details/3812 https://www.who.int/data/gho/%20indicator-metadata-registry/imr-details/3812 j islamabad med dental coll 2023 122 open access the spectrum of biochemical changes in thyroid function tests, performed at sahiwal medical college, sahiwal maryam rafiq1, amna arooj2, ayesha siddiqa3, nudrat fayyaz4, sara khan5, rabia saeed6 assistant professor, department of chemical pathology, sahiwal medical college, sahiwal, pakistan assistant professor, department of pathology, sahiwal medical college, sahiwal, pakistan assistant professor, department of pathology, pakistan institute of medical sciences, islamabad, pakistan associate professor, department of pathology, multan medical & dental college, multan assistant professor, department of chemical pathology, cmh institute of medical sciences, bahawalpur assistant professor, department of pathology, cmh institute of medical sciences, bahawalpur a b s t r a c t background: thyroid disorders are among one the leading causes of endocrine problems worldwide. hypothyroidism is very common and usually is more prevalent in females. thyroid function tests (tfts) play a vital role in the diagnosis and monitoring of thyroid diseases. methodology: this cross-sectional study was conducted at sahiwal medical college, sahiwal after approval from the institutional review board. the results of 2281 specimens tested for tfts in the pathology laboratory between august 2018 to december 2020 were included. samples were analyzed by immunochemiluminescent assay method on an access 2 analyzer by beckman coulter. data were analyzed using statistical package for the social sciences (spss) version 25. a chi-square test was applied. p-value <0.05 was considered significant. results: a total of 2281 patient data was included in the study. the mean age of participants was 38.86±15.30 years and the majority were females. 64.1% of results were within the normal limit (euthyroid) while the remaining 35.9% had abnormal thyroid profiles. hyperthyroidism was the most common abnormality (9.5%) followed by subclinical hypothyroidism (8.9%). chi-square test revealed a statistically significant difference in age groups, with p-value of 0.004. conclusion: thyroid diseases are quite common. hyperthyroidism is slightly more prevalent than hypothyroidism in our community. key words: hypothyroidism, hyperthyroidism, thyroid disorders, subclinical thyroid disease. authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: maryam rafiq email: : mariamsheikh15@yahoo.com article info: received: january 22, 2022 accepted: may 17, 2023 cite this article. rafiq m, arooj a, siddiqa a, fayyaz n, khan s, saeed r. the spectrum of biochemical changes in thyroid function tests, performed at sahiwal medical college, sahiwal .j islamabad med dental coll. 2023; 12(2): 122-126 doi: https://doi.org/10.35787/jimdc.v12i2.842 funding source: nil conflict of interest: nil i n t r o d u c t i o n endocrine disorders, particularly thyroid gland abnormalities, are quite common.1,2 thyroid disorders account for 30 to 40 % of patients in the endocrine practice, thereby significantly adding to the global burden of endocrine diseases.3 the thyroid gland, one of the vital glands, produces hormones; triiodothyronine (t3) and thyroxine (t4), which regulate the metabolism, growth, and various vital functions of the body. any imbalance in thyroid o r i g i n a l a r t i c l e mailto:mariamsheikh15@yahoo.com j islamabad med dental coll 2023 123 hormones has an impact on the entire body and also affects the growth and well-being of an individual.4,5 along with clinical examination, thyroid function tests (tfts) play a vital role in diagnosing and monitoring thyroid disease.6,7. thyroid dysfunctions can broadly be classified as hyperthyroidism or hypothyroidism. patients can present either with subclinical or overt disease.4 hyperthyroidism is a catabolic state in which there is elevated t3 and t4, while in hypothyroidism there is an insufficient level of thyroid hormones. both of these conditions are associated with many sclinical effects on the body like coronary artery disease, dyslipidemia, arrhythmias, and many more.1,4. american association of clinical endocrinologists reported that around 13 million or 4.78% of people have an overt or subclinical thyroid disorder. in a global scenario, hypothyroidism is more common than hyperthyroidism.3 iodine deficiency is the commonest cause of thyroid dysfunction while in areas with sufficient iodine supplementation, autoimmune thyroiditis, and hashimoto thyroiditis are common causes of hypothyroidism1. according to one estimate, iodine deficiency affects over 2.5 billion individuals globally, with 313 million residing in southeast asia, including pakistan.5 common causes of hyperthyroidism are graves’s disease, multinodular goiter, and toxic adenoma. rarely, it may be due to subacute thyroiditis. it is also evident from studies that thyroid issues are more common in females than in males in pakistan and around the world.1,3 current evidence highlights the need to understand the prevalence and the factors governing it. there is a paucity of national data about biochemical changes in thyroid function tests (tfts). the purpose of this study was to examine the frequency of abnormalities in thyroid function tests, in the people of sahiwal district presented to sahiwal medical college laboratory for evaluation of thyroid hormones and to also determine the gender distribution of these disorders. this will help to know the frequency of these disorders in the local population and will raise awareness among clinicians dealing with these issues. m e t h o d o l o g y the cross-sectional study was conducted at slmc, sahiwal after approval from the institutional review board of sahiwal medical college. in total 2281 specimens tested for tfts in the laboratory between august 2018 to december 2020 were included in the study. serum concentrations of thyrotropin, total triiodothyronine, and total thyroxine were measured using the immunochemiluminescent assay method on the access 2 analyzer. for interpretation, the results of the thyroid function tests were classified into six categories: euthyroid, subclinical hypothyroidism, overt hypothyroidism, sub-clinical hyperthyroidism, overt hyperthyroidism, and equivocal. data were analyzed using statistical package for the social sciences (spss) version 25. descriptive statistics were applied to determine the frequency and percentages of qualitative variables like age groups, gender, and biochemical diagnosis. mean and sd was calculated for numerical variables. a chisquare test was applied. p-value <0.05 was considered significant. r e s u l t s a total of 2281 patients’ data was included in the study, among which majority were females (84.7%). most of the patients were adults with a mean age of 38.86±15.30 years. the age distribution is shown in figure 1 below. data from 64.1% of patients revealed a normal thyroid profile(euthyroid) while the remaining 35.9% had an abnormal thyroid profile. the cumulative frequency of hypothyroid disease was slightly higher than that of hyperthyroid disease, as shown in table no 1. the results of the j islamabad med dental coll 2023 124 cross-tabulation of age with the biochemical diagnosis is illustrated in table 2 which indicated that thyroid disorders were more prevalent in the age group 18-50 years. hyperthyroidism was the most common abnormality (9.5%) followed by subclinical hypothyroidism (8.9%). the chi-square test revealed a statistically significant difference in age groups, with a p-value of 0.004. thyroid disorders were also evaluated concerning gender. difference between males and females was found to be statistically non-significant (table 3). figure 1: age distribution of the study population. table i: distribution of thyroid disorders biochemical diagnosis frequency percentage euthyroid 1462 64.1 subclinical hypothyroidism 202 8.9 hypothyroidism 147 6.4 subclinical hyperthyroidism 180 7.9 hyperthyroidism 217 9.5 equivocal 73 3.2 total 2281 100 table ii: cross-tabulation of age in years and diagnosis diagnosis age in years total p value <18 n (%) 18-50 n (%) >50 n (%) euthyroid 143 (6.3) 1207 (52.9) 112 (4.9) 1462 (64.1) 0.004 subclinical hypothyroidism 26 (1.1) 157 (6.9) 19 (0.8) 202 (8.9) hypothyroidism 7 (0.3) 123 (5.4) 17 (0.7) 147 (6.4) subclinical hyperthyroidism 5 (0.2) 158 (6.9) 17 (0.7) 180 (7.9) hyperthyroidism 15 (0.7) 178 (7.8) 24 (1.1) 217 (9.5) equivocal 4 (0.2) 59 (2.6) 10 (0.4) 73 (3.2) total 200 (8.8) 1882 (82.5) 199 (8.7) 2281 (100) table iii: crosstabulation of diagnosis and gender diagnosis gender n (%) total p value male female euthyroid 235 (10.30) 1227 (53.8) 1462 (64.1 ) 0.638 subclinical hypothyroidism 28 (1.2) 174 (7.6) 202 (8.9) hypothyroidism 18 (0.8) 129 (5.7) 147 (6.4) subclinical hyperthyroidism 22 (1) 158 (6.9) 180 (7.9) hyperthyroidism 34 (1.5) 183 (8) 217 (9.5) equivocal 11 (0.5) 62 (2.7) 73 (3.2) total 384 1933 2281 200(8.8% ) 1882(82. 5%) 199(8.7% ) age in years <18 19-49 >50 j islamabad med dental coll 2023 125 d i s c u s s i o n thyroid disturbances are fairly common but the data about their prevalence in the sahiwal district is quite limited.8 they frequently remain undiagnosed because of variable clinical manifestations and lack of uniform recommendations on the screening and diagnosis of thyroid problems.9 thyroid function tests play a vital role in diagnosing and monitoring thyroid disorders.6 the current study included the data of 2281 patients. the majority of the participants were females, and the occurrence of abnormal thyroid function tests was also higher in females as compared to males. these findings agree with a few studies conducted locally and in neighboring countries like india.1,10 various studies conducted in saudi arabia and india also revealed concordant results. 11,12,13 most of the participants belonged to the adult age group (18 to 50 years). it was reported that both hypothyroidism and hyperthyroidism are more common in adults than in extreme ages.14 similar findings were observed in a study conducted in europe.15 when the results of tfts were studied, the most common biochemical abnormality was hyperthyroidism. 9.5% of subjects had hyperthyroidism followed by subclinical hypothyroidism (8.9%), subclinical hyperthyroidism (7.9%), and hypothyroidism (6.4%), respectively. in indian research, 2.5% of the participants were overtly hyperthyroid, whereas 5.97% were subclinically hyperthyroid.8 similarly, according to a study in pakistan, hyperthyroidism and subclinical hyperthyroidism were found to be present in 5.1% and 5.8% of the population, respectively.16 these results are slightly lower than what we found in our research. in our study prevalence of subclinical hypothyroidism is 7.9%, while overt hypothyroidism is 6.4%. a study from india reported subclinical hypothyroidism in 9.44% of patients. these are quite like the present study.8 when the sum of overt and subclinical disease was calculated, 17.4% had hyperthyroidism while 15.3% cases had hypothyroidism, though the difference was not statistically significant. in contrast to current results, hypothyroidism is a more frequent thyroid disorder. a study conducted in india by maurya h reported that hypothyroidism was observed in the maximum number of patients.17 two more studies from india by jaikhai et al and deokar et al also reported similar findings.8,10 studies from pakistan also indicated that hypothyroidism is more prevalent in pakistan. a study reported that around 60% of the cases of thyroid disorder are of hypothyroidism.14 whereas results of some studies are not comparable e.g. abdullah et al showed a slight predominance of hyperthyroidism.1 another study from gujranwala also had similar findings, with hyperthyroidism being more common.5 an indian study also has similar findings.10 a study from peshawar reported 13.17% of cases had hyperthyroidism followed by 11.3% cases of hypothyroidism.1 findings reported in a study conducted in peshawar’s study is in agreement with the current study. variability in results may be due to regional variation, diet differences, and iodine supplementation. as observed from the literature, thyroid disorders have regional variation and their prevalence is also affected by diet, iodine supplementation, medication, and exposure to radiation, etc.18 an association of thyroid problems with different illnesses has been established by many studies like coronary artery disease, lipid disorder, arrhythmia, heart disease, and skin disorder.3 one important finding in the current study was that out of 2281, the results of 1462 (64.1%) patients tested for tfts were within normal limits. similar findings were seen in an indian study that showed 59.64% of total patients had a normal thyroid profile.10 however another prevalence study in india reported 84.65% of the result as euthyroid.19 this j islamabad med dental coll 2023 126 high percentage of normal tfts, though is in concordance with previously reported results but is not in agreement with the current study.9 it is suggested that when referring a patient for thyroid evaluation, symptom complexity should be kept in mind, considering one or two symptoms may result in undue testing and normal results. it will not only add financial burden but will also create disease anxiety in patients. c o n c l u s i o n thyroid disorders are not infrequent in our community. females are more affected than males. hyperthyroidism is a slightly more common disorder in sahiwal. there is a dire need to redefine the case description of thyroid disorders and a rational and cost-effective approach should be employed in ordering tfts. r e f e r e n c e s 1. attaullah s, haq bs, muska m. thyroid dysfunction in khyber pakhtunkhwa, pakistan. pak j med sci. 2016;32(1):111-115. doi: 10.12669/pjms.321.8476. 2. crafa a, calogero ae, cannarella r, mongioi lm, condorelli ra, greco ea, et al. the burden of hormonal disorders: a worldwide overview with a particular look in italy. front endocrinol. 2021;16(12):745. doi:10.3389/fendo.2021.694325. 3. sulejmanovic m, cickusic aj, salkic s, bousbija fm. annual incidence of thyroid disease in patients who first time visit department for thyroid diseases in tuzla canton. mater sociomed. 2019;31(2):130134. doi: 10.5455/msm.2019.31.130-134. 4. shah n, ursani tj, shah na, raza hm. prevalence and manifestations of hypothyroidism among population of hyderabad, sindh, pakistan. pure appl. biol. 2021; 10(3):668-675. 5. naz n, rizvi s, sadiq z. assessment of thyroid hormone levels and thyroid disorders: a case study from gujranwala, pakistan. pak j pharm sci. 2017;30(4):1245-1249. 6. anandkumar s, chacko j, usha m. thyroid disorder: an overview. research journal of pharmacology and pharmacodynamics. 2020;12(1):1-4. 7. soh sb, aw tc. laboratory testing in thyroid conditions-pitfalls and clinical utility. annals of laboratory medicine. 2019; 39(1): 3-14. 8. deokar pg, nagdeote an, lanje mj, basutkar dg. prevalence of thyroid disorders in a tertiary care center. int j cur res rev. 2016;8(9):26-30. 9. alzahrani as, al mourad m, hafez k, almaghamsy am, alamri fa, al juhani nr et al. diagnosis and management of hypothyroidism in gulf cooperation council (gcc) countries. adv ther. 2020; 37:3097-3111. doi: 10.1007/s12325-02001382-2 10. jailkhani r, ramachandrayya sa, patil vs. a hospitalbased study of prevalence of thyroid dysfunction in srinagar, jammu and kashmir state of india. int j med sci public health. 2015;4(2):151-4. doi 10.5455/ijmsph.2015.0310201433 11. aljabri ks, alnasser im, facharatz bs, alshareef ma, khan pm, mallosho am et al. the frequency of hypothyroidism in saudi community-based hospital: a retrospective single center study. trends diabetes metab. 2019; 2(1):1-4. doi:10.15761/tdm.1000107 12. rabeya r, zaman s, chowdhury ab, nabi mh, hawlader md. magnitude and determinants of hypothyroidism among dyslipidemic patients in bangladesh: a hospital-based cross-sectional study. int j diabetes metabol. 2019; 25(1-2): 19-25. 13. umman p, mathews mz, johnson ak, varghese n. clinicopathological spectrum of operated thyroid lesions in a tertiary care center: a cross-sectional study. international journal health and clinical research.2020;3(6): 108-115. 14. taylor pn, albrecht d, scholz a, gutierrez-buey g, lazarus jh, dayan cm et.al. global epidemiology of hyperthyroidism and hypothyroidism. nat rev endocrinol. 2018 may;14(5):301-16. https://doi.org/10.1038/nrendo.2018.18. 15. diab n, daya nr, juraschek sp, martin ss, mcevoy jw, schultheiß ut et al. prevalence and risk factors of thyroid dysfunction in older adults in the community. sci rep. 2019;9(1):13156. doi: 10.1038/s41598-019-49540-z. 16. malik j, malik a, javaid m, zahid t, ishaq u, shoaib m. thyroid function analysis in covid-19: a retrospective study from a single center. plos one. 2021;16(3): e0249421. doi.org/10.1371/journal.pone.0249421. 17. maurya h. thyroid function disorders among the indian population. ann thyroid res. 2018; 4:172-3. doi:10.26420/annalsthyroidres.2018.1044. 18. prevalence and risk factors of thyroid dysfunction in older adults in the community. scientific reports. 2019;9(1):1-8. doi: 10.1038/s41598-019-49540-z. 19. bose a, sharma n, hemvani n, chitnis ds. a hospital-based prevalence study on thyroid disorders in malwa region of central india. int j curr microbiol app sci. 2015;4(6):604-11. https://dx.doi.org/10.12669%2fpjms.321.8476 http://dx.doi.org/10.3389/fendo.2021.694325 https://dx.doi.org/10.5455/ijmsph.2015.0310201433 https://doi.org/10.1038/nrendo.2018.18 https://dx.doi.org/10.1038%2fs41598-019-49540-z https://doi.org/10.1371/journal.pone.0249421 http://dx.doi.org/10.26420/annalsthyroidres.2018.1044 https://dx.doi.org/10.1038%2fs41598-019-49540-z j islamabad med dental coll 2023 147 open access actinomycosis, a rare cause of perianal fistula nosheen nabi1, umer mehmood2, naseer ahmed3. 1pathologist, department of histopathology, excel laboratory, islamabad 2 medical officer, university of lahore medical and dental college, laj=hore 3ceo and chief pathologist, excel laboratory, islamabad a b s t r a c t perianal fistula (fistula-in-ano) is one of the most common anorectal diseases. it is an abnormal connection between the anal canal and the perianal skin and is lined with granulation tissue. although benign, the condition can cause significant distress and embarrassment to the patient. major causes of an anal fistula are clogged anal glands forming anal abscesses. other, much less common, conditions are infections, trauma and tumors. the treatment of an anal fistula depends on the etiology and location of the fistula. most fistulas are treated surgically, through a variety of different procedures. actinomycosis which is a gram positive bacteria can rarely cause perianal fistulas which is difficult to diagnose clinically so can result in mismanagement and recurrences leading to repeated surgeries. key words: actinomycosis, fistula in ano, gram positive bacteria. cite this article. nabi n, mehmood u, ahmed n. actinomycosis, a rare cause of perianal fistula. j islamabad med dental coll. 2023; 12(2): 147-149 doi: https://doi.org/10.35787/jimdc.v12i2.922 funding source: nil conflict of interest: nil i n t r o d u c t i o n a fistula is generally defined as a pathological communication between the two epithelialized surfaces.1 perianal fistula is one of the common colorectal diseases with an incidence rate between 1.1 and 2.2 per 10,000 persons per year.2 the main cause of perianal fistula development is sepsis originating from the crypt glands. other etiologies include crohn’s disease (cd), chronic fissures, malignancies, radiation, trauma or foreign bodies.3 fistulectomy is a gold standard treatment of perianal fistulas.4. perianal fistulas are rarely caused by a gram positive actinomyces. because of low index of suspicion its diagnosis is usually missed by the clinicians and proper treatment is delayed.5 we report a case of 38 years old male who presented in a clinic with history of recurrent fistula in ano. previous fistulectomies were not followed by histopathological examination so tissue was sent to exclude any granulomatous disease or malignancy. c a s e r e p o r t a 38 years old male patient presented in a clinic with recurrent fistula in ano. his fistulectomy was done and we received the specimen in formalin filled container. it consisted of single irregular soft tissue fragment, brown in colour and measuring 1x1cm. the specimen was entirely submitted in one cassette. on microscopic examination it showed colonies of actinomyces surrounded by inflammatory cells. no evidence of malignancy was seen. gram stain highlighted gram positive filaments of actinomyces. d i s c u s s i o n fistula in ano is a debilitating disease which is defined as a tract formed between two epithelial lined surfaces and itself lined by granulation tissue. mostly it occurs as a consequence of infectious process in the perianal glands with budding off into c a s e r e p o r t j islamabad med dental coll 2023 148 the surrounding tissue. mostly males above 40 years are affected with an incidence range of 0.7 to 35%.6 recurrence rate is high after treatment and is defined as formation of the fistula within one year after the surgical treatment when the wound is completely healed. if the fistula appears after one year, then it is considered as de novo fistula formation. the causes are usually divided into preoperative, operative and post operative. thorough assessment is required to avoid reurrncees.7 actinomycoses infection is one of the important but rare cause of perianal fistulas which is usuallry underdiagnosed. actinomyces is a nonmotile,obligate, filamentous, anaerobic bacteria which is gram-positive. they are part of normal flora of genitourinary tract, and skin and are facultatively pathogenic. they invade breached or necrotic tissue and proliferate and start pathogenesis.8 diagnosis depends upon patient's clinical history, radiological studies, microbiological cultures and histopathological examination.9 treatment of actinomycetes is both medical and surgical, depending on the lesion. penicillin in high doses is the drug of choice with ceftriaxone or figure 1: fibromuscular tissue showing colonies of actinomyces h&e x10; b: single colony of actinomyces showing filaments of actinomyces; c: fistulectomy tract lined by granulation tissue and colonies of actinomyces; d: gram stain highlighting the filaments of gram positive actinomyces. amoxicillin as alternatives. the duration of medical therapy is usually extended from weeks to months depending on the severity of the disease.10 sulfa drugs such as sulfamethoxazole are added to penicillin in non-responsive cases to penicillin. surgical intervention depends upon the site, severity and extent, and location of the lesion. it is done mainly to reduce the bulk of the disease and necessary in case of bone involvement, abscess and fistula formation.11 although actinomyces infection is rare but its important to keep this entity in mind because it is clinically confused with either carcinogenic process or some other etiologies thus leading to unnecessary surgical procedures and thus recurrences as its main treatment is extended systemic antibiotic therapy.12 c o n c l u s i o n actinomycosis can rarely cause perianal fistulas. it is difficult to diagnose clinically, resulting in mismanagement and recurrence, and thus repeated surgeries. . r e f e r e n c e s 1. tuma f, crespi z, wolff cj, daniel dt, nassar ak. enterocutaneous fistula: a simplified clinical approach. cureus. 2020. 22;12(4). doi: 10.7759/cureus.7789. 2. zhang y, ni m, zhou c, wang y, wang y, shi y, jin j, zhang r, jiang b. autologous adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistula: a prospective case-control study. stem cell res ther. 2020 ;11(1):1-0. https://doi.org/10.1186/s13287-020-01995-y. 3. stellingwerf me, bak mt, de groof ej, buskens cj, molenaar cb, gecse kb, et al. knotless seton for perianal fistulas: feasibility and effect on perianal disease activity. scientific reports. 2020 oct 7;10(1):1-8. doihttps://doi.org/10.1038/s41598020-73737-2. 4. włodarczyk m, włodarczyk j, sobolewska-włodarczyk a, trzciński r, dziki ł, et al. current concepts in the pathogenesis of cryptoglandular perianal fistula. j int med res. 2021;49(2). https://doi.org/10.1177/0300060520986669 5. dosis a, khan a, leslie h, musaad s, smith a. perianal actinomycosis: a surgeon’s perspective and review of literature. anns coloproctol. 2021;37(5):269. doi: 10.3393/ac.2021.00332.0047 a b c d https://doi.org/10.1186/s13287-020-01995-y https://doi.org/10.1177/0300060520986669 j islamabad med dental coll 2023 149 6. bakhtawar n, usman m. factors increasing the risk of recurrence in fistula-in-ano. cureus. 2019 mar 7;11(3). doi:10.7759/cureus.4200 7. emile sh. recurrent anal fistulas: when, why, and how to manage?. w j clin cases. 2020 6;8(9):1586.doi: 10.12998/wjcc.v8.i9.1586. 8. li j, li y, zhou y, wang c, wu b, wan j. actinomyces and alimentary tract diseases: a review of its biological functions and pathology. biomed res int. 2018. 26;2018.https://doi.org/10.1155/2018/3820215. 9. stájer a, ibrahim b, gajdács m, urbán e, baráth z. diagnosis and management of cervicofacial actinomycosis: lessons from two distinct clinical cases. antibiotics. 2020 apr;9(4):139.https://doi.org/10.3390/antibiotics904 0139 10. hashem q. a conservative management approach for unusual presentation of oral actinomycosis. case reports in dentistry. 2021,18;2021. https://doi.org/10.1155/2021/5570758 11. moturi k, kaila v. cervicofacial actinomycosis and its management. anns maxillofacial surg. 2018;8(2):361. doi: 10.4103/ams.ams_176_18 12. baba h, fassi fihri j, ramraoui me, elguazzar a, zeroual a, lahkim m, et al. when a rare simultaneous infection simulates a local extension of a rectal cancer: a case report. j med case reports. 2021;15(1):1-4. https://doi.org/10.1186/s13256021-02989 https://doi.org/10.1155/2021/5570758 https://doi.org/10.1186/s13256-021-02989 https://doi.org/10.1186/s13256-021-02989 275 j i m d c 2 0 1 7 275 op e n ac c e ss c a s e r e p o r t marchiafava-bignami disease: a rare disease with mri findings and literature review ateeque ahmed khan 1, sasui memon 2, rehana shaikh 3, unaiza raheem 4 1 chairperson and head of radiology department, dow university of health sciences/civil hospital karachi, 2 resident radiology department, dow university of health sciences/civil hospital karachi, 3 consultant radiology, ct & mri centre, dow university of health sciences/civil hospital karachi, 4 resident radiology department, dow university of health sciences/civil hospital karachi a b s t r a c t marchiafava bignami disease (mbd) is an unusual complication of chronic alcoholism that typically results in demylination of corpus callosum, but sometimes it can involve the adjacent white matter and even the subcortical and cortical regions. the pathophysiology of mbd is still unknown but thought to be due to vitamin b complex deficiency. magnetic resonance imaging (mri) is crucial for its diagnosis that shows the characteristic lesions in corpus callosum which may also extend into deep white matter, subcortical and cortical regions. we present a case of marchiafava bignami disease in 55-year chronic alcoholic referred to us for mri brain by medical unit. this case is presented here for its rarity along with its clinical and radiological findings as well as literature review to generate awareness regarding this uncommon toxic complication of chronic alcoholism. key words: alcoholism, corpus callosum, marchiafava bignami disease, mri address of correspondence sasui memon email: sassuimemon290@gmail.com article info. received: november 24, 2017 accepted: december 12, 2017 cite this case report: khan a.a, memon s, shaikh r, raheem u. marchiafava-bignami disease with mri findings and literature review. 2017; 6(4) funding source: nil conflict of interest: nil i n t r o d u c t i o n marchiafava-bignami disease (mbd) is a rare neurological disease related to chronic alcohol consumption. it is characterized by primary degeneration of the corpus callosum seen in their middle or late ages.1 this disease may occasionally occur in patients who are not alcoholic, hence, it is thought that alcohol is not a single reason for mbd.2 the exact pathophysiology of mbd is still not elucidated but thought to be due to vitamin b complex deficiency.1,3 patients usually present with variety of neurological features such as seizures, deterioration of consciousness, irritability, dysarthria, dementia, behavior disorder and limb weakness which are difficult to differentiate from other alcohol related disorder and even sometimes from motor neuron disease. so diagnosis is generally the result of neuroimaging, particularly by mri, that shows hyperintense lesions without significant mass effect within the corpus callosum, that may extend to adjacent white matter on t2wi, flair and dwi.2 we are reporting this case of mbd in a chronic alcoholic who presented with altered level of consciousness, irritability, parasthesia of right upper and lower limb, dysarthria, gait disturbances and dementia, and evaluated with mri brain. it highlights the importance of mri as good imaging tool to diagnose mbd in the relevant clinical scenario. c a s e r e p o r t a 55-year old chronic alcoholic with daily consumption of alcohol about one pint for last 35 years referred to c a s e r e p o r t 276 j i m d c 2 0 1 7 276 radiology department, civil hospital karachi for mri brain. he had complaints of progressive dysarthria, gait disturbances and dementia over a year but now presented with altered level of consciousness, irritability, and paresthesia of right upper and lower limb. there was no history of fever. on neurological examination, he responded to eye opening on pain with incomprehensible sounds and flexion withdrawal of limbs to painful stimulus, with total glasgow coma scale of 8/15. reflexes were diminished. there were no signs of meningeal irritation and cranial nerve palsies. there was nothing special in the patient’s medical and personal history except the alcoholism. family history was also unremarkable. his routine laboratory investigations did not show any pathology. afb (acid fast bacilli) smear and culture was negative. his liver and renal functions were almost normal. initial diagnosis of motor neuron disease was made on the basis of clinical picture but his electrophysiological analysis was normal. cerebrospinal fluid examination wasn’t performed. so he was evaluated with mri which shows hypointense signals on t1wi and hyperintense signals on t2wi and flair in genu and splenium of corpus callosum without significant mass effect, extending into adjacent deep and subcortical white matter (figure 1). figure 1: mri axial t2wi, coronal flair and axial dwi demonstrate hyperintense signals in genu and splenium of corpus callosum extending into subcortical regions (best seen on flair image) showing diffusion restriction. these lesions showed diffusion restriction on dwi. on the basis of clinical picture, neurological examination findings and typical corpus collasum involvement on mri, workup for vitamin b level was done that showed low serum level so the diagnosis of marchiafava bignami disease was made. then patient was treated with vitamin b complex and showed clinical improvement on 1-month follow up that led to definite diagnosis of mbd. d i s c u s s i o n marchiafava-bignami disease is a rare toxic neurological disease seen mostly in chronic alcoholics but may rarely occur in non-alcoholics. it is characterized by progressive demyelination and necrosis of the corpus callosum which may extend into the adjacent white matter and occasionally as far as the subcortical and cortical regions.1,2 the pathological mechanism of mbd is still not completely understand but thought to be due to vitamin b complex deficiency.1,3 majority of patients are male between 40 and 60 years of age, and have a history of chronic alcoholism and malnutrition.1,4 this disease was described by italian pathologists, amico bignami and ettore marchiafava, in the postmortem study of a chronic italian alcoholic in 1903 and approximately 250 cases are reported in the literature.3,4 the clinical spectrum of this disease is very diverse, including impaired consciousness, seizure, dysarthria, behavior disturbance, limb weakness, dementia, interhemispheric disconnection syndromes and even coma and death.4,5 the clinical diagnosis of marchiafava-bignami disease (mbd) has considerably changed during recent decades with improvement in modern neuroimaging especially brain mri providing the opportunity of a reliable in-vivo diagnosis.6 the lesions typically involved the corpus callosum with affection most commonly towards the body of the corpus callosum followed by the genu and finally the splenium.1 the other sites can also be involved and include the cerebral peduncles, middle cerebellar peduncles, hemispheric white matter as well as internal capsules.3,7 cortical involvement in very rare but is a poor prognostic indicator.8 the pathognomonic mri findings for the diagnosis of mbd are hyperintense signal lesions without significant mass effect within the corpus callosum, which may extend to adjacent white matter on t2wi, flair and dwi sequences2, as seen in our patient’s mri. diffusion restricted lesions on dwi are associated with poor outcome, however these do not predict irreversibility of the lesion.9 there is no specific therapy for mbd but after prompt diagnosis, early initiation of treatment by alcohol abstinence along with vitamin b complex and folic acid can improve the outcome.7 277 j i m d c 2 0 1 7 277 c o n c l u s i o n marchiafava bignami disease is a rare condition and mri is very helpful to make early diagnosis especially if the clinical signs are not specific and severe, as prompt therapy may result in survival of these patients. mri has also role in follow up of patients with mbd. this case was reported not only due to its rarity but also to emphasize the role of mri in diagnosing mbd and differentiating it from other alcohol related disorders, and to assist the clinicians by reviewing literature and summarizing important features of the mbd. r e f e r e n c e s 1. arbelaez a, pajon a, castillo m. acute marchiafavabignami disease: mr findings in two patients. am j neuroradiology. 2003, 24 (10) 1955-57. 2. hoshino y, ueno y, shimura h, miyamoto n, watanabe m, hattori n, et al. marchiafava-bignami disease mimics motor neuron disease: case report. bmc neurology. 2013;13(1):208. 3. leblebi̇ci̇ f, yağmurdur h, soyal öb, ciliz ds, sakman b. magnetic resonance imaging findings in a patient with acute marchiafava-bignami disease: case report. turkiye klinikleri journal of case reports. 2015; 23(2):162-5. 4. carrilho pe, santos mb, piasecki l, jorge ac. marchiafava-bignami disease: a rare entity with a poor outcome. rev bras ter intensiva. 2013; 25(1):68-72. 5. kuroda t, kawamura m. diagnostic imaging of marchiafava-bignami disease. brain and nerve. 2014; 66(9):1079-88. 6. heinrich a, runge u, khaw av. clinicoradiologic subtypes of marchiafava-bignami disease. j neurol. 2004; 251(9):1050-9. 7. pansari n, goyal r, aswani m, agrawal s, verma h, mahur h, et al. marchiafava-bignami disease: a rare clinical dilemma. j assoc physicians india. 2017; 65 (3):106-7. 8. namekawa m, nakamura y, nakano i. cortical involvement in marchiafava-bignami disease can be a predictor of a poor prognosis: a case report and review of the literature. intern med. 2013;52(7): 811-3. 9. kakkar c, prakashini k, polnaya a. acute marchiafavabignami disease: clinical and serial mri correlation. bmj case reports. 2014; bcr2013203442. 196 j i m d c 2 0 1 7 196 open access f u l l l e n g t h a r t i c l e spectrum of mutations of beta thalassemia khalid hassan 1, memoona rasheed 2, naghmi asif 3, tazeen anwar 4 and mohammad tahir 5 1 prof and head, department of pathology, islamabad medical & dental college 2, 5 research officer, islamabad medical & dental college 3 prof of pathology, islamabad medical & dental college 4 medical officer, thalassemia centre, pakistan institute of medical sciences, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) a b s t r a c t objective: to identify gene mutations known to cause thalassemia major and intermedia amongst patients coming to thalassemia centre of pakistan institute of medical sciences(pims). patients and methods: hundred transfusion dependent thalassemia patients were recruited from pims. genome dna was isolated by using phenol-chloroform method. allele specific pcr was performed by using primers specific for twelve known disease causing mutations, prevalent in pakistan. the pcr product was run on 6% polyacrylamide gel electrophoresis and visualized by silver staining technique. results were recorded and data were entered and analyzed using spss version 16. results: total number of patients included in the study was 100, among them 46% were males and 54% were females. parenteral consanguinity was seen in 95% cases. most common homozygous mutations were fr 8-9 [23(28.7%)], followed by ivsi-5 [17(21.3%)] cases. compound heterozygous mutations were seen in 20% cases, among them the most common was fr 8-9/ivs1-5 (5/20 cases), and fr 8-9/del 619 (3/20 cases). analysis of type of mutation in different ethnic groups showed that fr 8-9 was the most common mutation in punjabis and pathans seen in 14/63 and 6/28 cases respectively, followed by ivs1-5 seen in 11/63 and 5/28 cases respectively. the most common mutation in thalassemia major was fr 8-9 seen in 22 (25%) cases followed by ivs1-5 seen in 15 (17%) cases and fr 41-42 seen in 10 (11.4%) cases. the number of patients of thalassemia intermedia was low in this study (n=12), however among these the commonest mutations were cap +1, fr 8-9, ivs1-5 and del 619, presenting as homozygous or compound heterozygous mutations. conclusion: molecular characterization of thalassemia major and intermedia patients is very essential so that we can set trigger of hemoglobin level accordingly before putting them on regular transfusion. less frequent transfusion, iron chelation and hu therapy will significantly reduce serum ferritin, liver and spleen size of this group of patients and thus significantly improve their quality of life. key words: beta thalassemia, spectrum, mutation, thalassemia major. author`s contribution 1 conception, synthesis, planning of research and review 2 data analysis, interpretation 3 manuscript writing and review 4,5 data collection address of correspondence khalid hassan email: kh.pims@gmail.com article info. received: october 21, 2017 accepted: december 5, 2017 cite this article. hassan k, rasheed m, asif n, anwar t, tahir m. spectrum of mutations of beta thalassemia. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n beta thalassaemia is one of the most common monogenic disorders in pakistan with career rate of 58%.1 every year, almost 5000 new children are born with thalassemia major.2 among haemoglobin disorders, β o r i g i n a l a r t i c l e 197 j i m d c 2 0 1 7 197 thalassemia is one of the most common causes of morbidity and mortality worldwide.3 beta thalassemia is inherited in autosomal recessive pattern and almost 300 mutations have been identified in α or β globin gene which impairs transcription, mrna processing or its translation.4 with exception of a few deletions, vast majority of β thalassaemias are caused by point mutations within the gene or its immediate flanking sequences.5 depending on whether thalassemia is heterozygous or homozygous, the phenotypic form varies from asymptomatic state known as thalassemia minor to a transfusion dependent form known as thalassemia major. this clinical variability mainly depends on β-globin genotype. about 20 mutations account for 90 percent of β-globin genes effects in the world and it is noted that each ethnic population has its own unique set of most frequent mutations.6 βl0/β0 is the severest-manifesting genotype, in which no β-chain production occurs; in β+/β + or βl0/β+ genotype, β-chains are produced in small quantities, allowing a small amount of hba production. a small percentage of patients have silent β thalassemia; these patients have β+ thalassaemia in which the deficit in β globin chains production is minimal. such individuals present with normal hba2 levels on haemoglobin electrophoresis, making their identification difficult with conventional methods, thus making genetic analysis mandatory for detection of thalassemia.2,7 further, a coinheritance of α-thalassemia or various hemoglobinopathies with β-thalassemia may manifest as thalassemia intermedia, in which anemia is moderate, and the patient is usually not transfusion dependent, except in stress like various types of infections.8 epidemiological data about prevalence and distribution of mutations plays a very crucial role in development of effective disease management strategies. previous studies conducted in different ethnic groups of pakistan showed prevalence of six mutations, fr 8-9 (+g), ivsi-5 (g-c), fr 41-42 (–ttct), del 619 bp, cd 15 (g-a) and ivsi-1 (g-t). similarly, thalassemia intermedia (ti)encompasses a wide clinical spectrum of beta thalassemia phenotype and various genetic factors affect the severity of disease and response to treatment, particularly in ti. this study was aimed to identify disease causing mutations in selected pakistani patients. p a t i e n t s a n d m e t h o d s the study was designed to identify underlying beta globin gene mutation in patients with beta thalassemia major. the study protocol was approved by the institutional review board and informed written consent was obtained before sample collection from patients. a total of 100 transfusion dependent beta thalassemia cases were recruited from pakistan institute of medical sciences, islamabad. clinical details of the patients were obtained and blood samples of the selected patients were collected in edta vacutainer tubes. genomic dna was isolated by using phenol-chloroform method.9 the isolated dna was then amplified to detect 12 previously known mutations in pakistani subjects [ivsi-5 (g-c), fr 8-9 (+g), ivsi-1 (gt), fr 41-42 (–ttct), del 619 bp, cd 15 (g-a), cd 5 (– ct), cd30 (g-c), cd 30 (g-a), fr 16 (–c), ivsii-1 (g-a), cap +1 (a-c)] by using mutation specific primers.1 multiplex amplification refractory mutation system (arms) pcr was performed in three separate reaction mixtures. the first reaction mixture contained primers specific for amplification of fr 8-9 (+g), fr 41-42 (-ttct), ivsi-5 (gc), ivsi-1 (g-t) and del 619. the second reaction mixture contained primers specific for cd 5 (-ct), fr 16(c), ivsi-1 (g-t), cd30 (g-c), cd 30 (g-a), and ivsii-1 (g-a) while the third reaction mixture contained primers specific for cd 15 (g-a) and cap +1 (a-c). pcr reaction mixture was prepared by using 5 pmol of each primers, 0.2 units of taq polymerase (company name), 10 mm of each dntp (company name), 25 mmol mgcl2, 100 mm tris-hcl and 500 mm kcl (ph 8.3) and 30-50 ng of dna. the pcr amplification process consisted initial denaturation at 94oc for 10 minutes followed by of 25 cycles of denaturation at 94oc for one minute, primer annealing at 65oc for one minute, and dna extension reaction at 72oc for 1.5 minute. final extension was done at 72oc for 3 minutes. the amplified product was resolved by using 6% mini polyacrylamide gel at 180 v for 20 minutes. after electrophoresis, gels were stained by dipping it in 0.1% silver nitrate solution for 15 mins and later treating with a freshly prepared solution of 1.5% naoh and 0.15% formaldehyde until the bands appear. gels were interpreted and images were recorded. if a single mutation was obtained, a second pcr was performed with a set of primers specific for the normal 198 j i m d c 2 0 1 7 198 allele of the respective mutation to detect the presence of wild type sequence. if the normal allele was amplified, the patient was considered heterozygous carrier. however, if the normal counterpart was not detected, the patient was considered homozygous recessive the respective mutation. r e s u l t s total number of patients included in the study was 100, among them 46% were males and 54% were females. mean age (in months) at diagnosis was 13.48±11.65 (366 months) and median age (in months) at diagnosis was 8 (2-156 months). mean age at diagnosis of thalassemia major was 8.09±3.30 months and mean age at diagnosis of thalassemia intermedia was 44.50±39.5. as shown in table 1, the most common ethnic groups were punjabis (63%) and pathans (29%). parenteral consanguinity was seen in 95% cases; out of these 92% being 1st cousins. table 1: demographic characteristics of patients n (%) gender male 46 (46 ) female 54 (54) ethnicity hinko 1 (1) punjabi 63(63) potohari 1 (1) pathan 29 (29) kashmiri 4 (4) other 3 (3) parental consanguinity yes 95 (95) no 5 (5) relationship between parents 1st cousins 97 (97) more distant relationship 3 (3) homozygous mutations were seen in 76% cases; the most common homozygous mutations were fr 8-9 [23(28.7%)], followed by ivsi-5 [17(21.3%)] cases, table 2. in 4% cases no mutation was found. compound heterozygous mutations were seen in 20% cases, among them the most common was fr 8-9/ivs1-5 (5/20 cases), and fr 8-9/del 619 (3/20 cases) table 3. table 2: frequency of homozygous mutations (n=80) s.no mutation frequency (%) 1 fr 8-9 23 (28.7) 2 fr 41-42 10 (12.5) 3 fr 16 6 (7.5%) 4 del 619 10 (12.5) 5 cd 30 4 (5%) 6 cap +1 2 (2.5) 7 ivsi-1 3 (3.8) 8 ivsii-1 1 (1.2) 9 ivsi-5 17 (21.3) 10 no mutation 4 (5) table 3: compound heterozygous mutations in beta-globin gene (n=20) s. no mutation frequency 1 cap+1/ivsii-1 1 (5) 2 cd 30/fr 16 1 (5) 4 fr 8-9/ fr 16 1 (5) 5 fr 8-9/ fr 41-42 1 (5) 6 fr 8-9/cd 5 1 (5) 7 fr 8-9/del 619 3 (15) 8 fr 8-9/ivsi-5 5 (25) 10 fr 8-9/cap+1 2 (10) 11 fr 41-42/ ivsi-5 2 (10) 12 fr 41-42/ ivsi-1 1 (5) 13 ivsi-5/ ivsii-1 1 (5) 14 ivsii-1/ cd 5 1 (5) analysis of type of mutation in different ethnic groups showed that fr 8-9 was the most common mutation in punjabis and pathans seen in 14/63 and 6/28 cases respectively, followed by ivs1-5 seen 11/63 and 5/28 cases respectively (table 4). as shown in the table 5, the most common mutation in thalassemia major was fr 8-9 seen in 22 (25%) cases followed by ivs1-5 seen in 15 (17%) cases and fr 41-42 seen in 10 (11.4%) cases. the number of patients of thalassemia intermedia was low in this study (n=12), however among these the commonest mutations were cap +1, fr 8-9, ivs1-5 and del 619, presenting as homozygous or compound heterozygous mutations. 199 j i m d c 2 0 1 7 199 d i s c u s s i o n beta thalassaemia is a major health burden in pakistan. despite preventive measures, around 5000 children with transfusion dependent ti or tm are annually added to the registry. no permanent cure is available, except stem cell transplantation, which is unaffordable due to high cost. the majority of patients with transfusion-dependent thalassaemia have no choice but to have regular blood transfusions and iron chelation therapy. haemoglobin f augmentation through hu therapy is another ray of hope to avoid blood transfusions and associated complications. it is thus important to predict phenotype from genotype as; different patients have different clinical severity and response to treatment to hu depending upon their genetic makeup. the present study showed that mean age at diagnosis in thalassemia major patients was 8 months and those of thalassemia intermedia was more than 3 years. consanguinity was seen in 95% cases majority being 1st cousins. in a study conducted by khan et al in district bannu to find consanguinity ratio in beta thalassemia major patients, consanguinity was reported in 74% parents while 26% were unrelated.10 regarding genetic mutations, fr 8-9 and ivs1-5 were the most common mutations seen in different studies (table 6). similar finding are reported by ali et al.11 another study conducted by usman et al in 2009 reported that ivs-1-5 (g→c), fr 8/9 (+g), fr 41/42 (-ttct), ivs-1-1(g→t) and del 619 comprised 90 % of beta thalassemia mutations in pakistani population.12 in a study conducted by tariq et al, it was reported that out of the 13 mutations tested, three mutations accounted for 71% of the total, and these included, ivs1-5, fr 8-9 and del 619 bp.13 our study shows similar result. the population of pakistan is mainly divided into punjabis and pathans in the north and balochis and sindhis in south. apart from these, there are other groups such as urdu speaking, memons, gujrati, saraiki, kashmisri, pothohari etc. frequency of mutations may be different in different ethnic groups. khan et al reported that four most common mutations, ivsi-5 (g+c) (37.7%), codons 8/9 table 4: types of mutations in different ethnic groups (n=100) hinko (n=1) kashmiri (n=4) pathan (n=28) pothohari (n=1) punjabi (63) others (n=3) fr 8-9 (n=23) 2 6 1 14 ivsi-5 (n=17) 1 5 11 del 619 (n=10) 1 2 6 1 fr 41-42 (n=10) 1 4 5 fr-16 (n=6) 2 4 cd-30 (n=4) 2 2 ivsi –1 (n=3) 2 1 cap +1 (n=2) 1 1 ivsii-1 (n=1) 1 cap +1 /ivs11-1 (n=1) 1 cd-30/fr 16 (n=1) 1 fr 16 / fr 8-9 (n=1) 1 fr 41-42 / fr 8-9 (n=1) 1 fr 41-42 / ivsi-1 (n=1) 1 fr 41-42/ivsi-5 (n=2) 1 1 fr 8-9 / ivsi-5 (n=5) 1 4 fr 8-9 / del619 (n=3) 3 fr 8-9 /cd-5 (n=1) 1 fr 8-9/ cap+1 (n=2) 1 1 ivsi-5 /ivsii-1 (n=1) 1 ivsii 1 /cd-5 (n=1) 1 no mutation (n=4) 1 3 200 j i m d c 2 0 1 7 200 (+g) (21.1%), the 619 bp deletion (12.4%), and ivsi-1 (g+t) (9.5%), collectively comprise 80.7 % of mutations. they also reported that in the four provinces of pakistan, ivsi-5 (g-c) mutation was more prevalent in sindh and balochistan, which share borders with india in the south and iran in the southwest, while fr 8-9 mutation was more common in the punjab and the khyber pakhtoon khawa province, sharing borders with india in the northeast and afghanistan, respectively. they further highlighted that 619 bp deletion was high (46%) in gujratis and memons residing in the province of sindh, neighboring the indian gujrat.14 table 5: different types of mutations in thalassemia major and intermedia patients(n 100) mutations thalassemia major (n=88) thalassemia intermedia (n=12) fr 8-9 (n=23) 22 1 ivsi-5 (n=17) 15 2 fr 41-42 (n=10) 10 0 del 619 (n=10) 8 2 fr-16 (n=6) 5 1 cd-30 (n=4) 4 0 fr 8-9 / del619 (n=3) 3 0 fr 8-9/ivsi-5 (n=5) 4 1 ivsi – 1 (n=3) 2 1 fr 41-42/ivsi-5 (n=2) 2 0 cap + 1 (n=2) 2 0 cap + 1 / ivs11-1 (n=1) 0 1 cd-30/fr 1 (n=1) 1 0 fr 16 / fr 8-9 (n=1) 0 1 fr 41-42 / fr 8-9 (n=1) 1 0 fr 41-42 / ivsi-1 (n=1) 1 0 fr 8-9 /cd-5 (n=1) 1 0 fr 8-9/ cap+1 (n=2) 1 1 ivsi-5 /ivsii-1 (n=1) 1 0 ivsii 1 /cd-5 (n=1) 0 1 ivsii-1 (n=1) 1 0 uncharacterized (n=4) 4 0 we found that fr 8-9 was the most common mutation in punjabis and pathans followed by ivs 1-5. ansari et al found that ivs1-5 was the most common mutation in sindis, blochis and punjabis followed by fr 8-9, whereas in pathans fr 8-9 was the commonest mutation followed by ivs1-5. 6 similarly a study done by akhtar et al to look for spectrum of beta thalassaemia mutations, reported predominance of fr 8-9 and ivsi-5 mutation in punjabis and pathans and cap+1 as the commonest silent mutation.15 same results have been observed for the indian population as shown by the studies of garewal g et al 16 and varawalla ny et al 17. a study done by baig et al to look for spectrum of betathalassemia mutations in various regions of punjab and islamabad, reported that distribution of mutations in punjab and the capital territory was different from the overall pattern in pakistan. they reported that three most common mutations; ivs-i-5 (g-c), codons 8/9, (+g) and codons 41/42 (-ttct) constitute 86.8% of mutations. they further highlighted that ivs-i-5 was the most common mutation seen in 39.0% cases in all regions being highest in south punjab (45.0%) i.e. d.g. khan, bahawalpur and multan region, whereas codons 8/9 (+g) was the second most frequent mutation seen in 37.3% cases but was number one in the patients from rawalpindi-islamabad (34.9%). the deletion of ttct between codons 41 and 42 of the beta-globin gene was the third most common mutation (10.6%) in their study. the rest of 14 beta thalassemia mutations were less common or rare and comprised only13.9 %.18 taking into consideration all the studies, the primary and secondary panels of primers of ethnic specific mutations can be devised. with reference to uncharacterized mutation, samples should be sent for genetic sequencing. a study conducted to analyze spectrum of β-thalassaemia mutations in india, pakistan and sri lanka showed that ivsi-5 (g>c) was the most common β-thalassaemia mutation in all three countries, with different frequencies, i.e. 64.6% in sri lanka to 56.3% in india and 36.5% in pakistan. the second most common mutation in india was a 619-bp deletion (9.2%), in pakistan fr 8-9 (31.2%), and in sri lanka ivs i-1 (g>a) (17.5%). in pakistan, the frequency of fr 8-9 (31.2%) was close to that of ivsi-5 (g>c) (36.5%). this study also highlighted the frequency of mutations in different ethnic groups. 201 j i m d c 2 0 1 7 201 they reported that data from pakistan showed a significant variability in the distribution of β-thalassaemia mutations in four provinces. it was reported that, unlike any region of india, ivsi-5 (g>c) was the most common mutation in sindh and baluchistan, whereas, fr 8/9 (+g) was the most common β-thalassaemia allele in both punjab (38.6%) and khyber pakhtunkwha (47.7%), though it was only the fourth most common allele across india, suggesting that its origin may have been effected by mutations of adjoining regions of neighboring countries, such as afghanistan.19 these findings are comparable to our study, where fr 8-9 was most common mutation observed in punjabis and pathans. in our study, cap + 1 mutation was seen in 5 cases (2 homozygous and 3 heterozygous cases). karim et al reported cap+1 mutation in 5% in targeted thalassemic families (having patients with beta-thalassemia intermedia) while its frequency was observed 2% in total thalassemic genes in pakistani population.20 in our study, number of patients of thalassemia intermedia was low, i.e. 12 patients and among them ivsi-5 and del 619 were most common mutations. in a study conducted by j khan et al, ivs-i-5 (50.0%) was the most frequent mutation in beta-ti followed by fr 8-9 (9.5%), codons 41/42 (3.4%), and cap + 1 (3.1%). homozygous beta + allele, co-inheritance of alpha gene deletion and co-inheritance of xmnl1 polymorphism all contribute to reduced severity of disease in thalassemia intermedia.21 response to hu therapy has also been reported as more favorable in the presence of xmni1 polymorphism.11 however, limitation of our study was that we did not evaluate for xmnl1 polymorphism and alpha gene deletion. we also observed, though some patients presented after two years but they were started regular transfusions without knowing their genotype (thalassemia major or intermedia) and were treated as thalassemia major cases. it is thus suggested to evaluate the genetic mutation of all cases of beta thalassemia major and intermedia first, and put them on transfusion therapy accordingly. as ti patients, not only require less frequent transfusions, they can withstand low hemoglobin level as compared to tm patients. and respond better to hu than thalassemia major patients. if we know the genotype of these patients of thalassemia intermedia, and they are managed with less transfusions, hu therapy and good iron chelation we can significantly improve their quality of life. c o n c l u s i o n this study adds to the pre-existing data in pakistan. we can device primary and secondary panels of primers of genetic mutations for a specific population. molecular characterization of thalassemia major and intermedia patients is very essential so that we can set a trigger hemoglobin accordingly before putting them on regular transfusion. less frequent transfusion, iron chelation and table 6: frequency of mutations seen in different studies from pakistan type of mutation khan et al 1998 (14) usman et al 2009 (120 akhtar et al 2012 (15) ali et al 2015 (11) baig et al 2006 (18) ansari et al 2011 (6) present study 2017 ivs 1-5 37.7 44.4 24.5 36 38.9 40.89 21% fr 8-9 21.1 14.6 35.5 40 37.3 15.7 29.5% fr 41-42 17.5 14.8 4 10.6 12% fr 16 1.6 2 7% cd5 3.1 6.6 8 1.3 2.16 1% cd15 3.1 07 8 1.8 cd30 3.9 1 0.7 8.02 4.5% ivs ii-1 0.7 1 0.8 2.5% 619 bp del 12.4 0.6 1.6 1.9 11.11 6.5% ivs 1-1 g-t 9.5 7.5 1.9 1.9 8.17 3.5% cap+ 1 1.2 1.7 3.5% uncharacterized 0.8 2% 202 j i m d c 2 0 1 7 202 hu therapy will significantly reduce serum ferritin, liver and spleen size of this group of patients and thus significantly improve their quality of life. r e f e r e n c e s 1. ahmed s, petrou m, saleem m. molecular genetics of beta thalassemia in pakistan: a basis for prenatal diagnosis. br j haematol, 1996; 94(3):476–482. 2. khattak sak, ahmed s, jaleel anwar j, ali n, shaikh kh. prevalence of various mutations in beta thalassaemia and its association with haematological parameters. jpma, 2012; 62(1): 40-43. 3. weatherall dj. the inherited diseases of hemoglobin are an emerging global health burden. blood, 2010; 115(22):4331-4336. 4. giardine b, borg j, viennas e, pavlidis c, morakhani k, joly p, bartsakoulia m, riemer c, miller w, tzimas g, wajcman h, hardison rc, patrinos gp. updates of the hbvar database of human hemoglobin variants and thalassemia mutations. nucleic acids res, 2013;42(d1): d1063-d1069. 5. thein sl. genetic modifiers of the betahaemoglobinopathies. br j hematol, 2008; 141(3): 357-66. 6. ansari sh, shamsi ts, ashraf m, bohray m, farzana t, khan mt, perveen k, erum s, ansari i, nadeem m, ahmed m, raza f. molecular epidemiology of βthalassemia in pakistan: far reaching implications. int j mol epidemiol genet 2011;2(4):403-408. 7. bianco i, cappabianca mp, foglietta e, lerone m, deidda g, morlupi l, grisanti p, ponzini d, rinaldi s, graziani b. silent thalassemias: genotypes and phenotypes. haematologica 1997; 82(3): 269-280. 8. sharma n, das r, kaur j, ahluwalia j, trehan a, bansal d, panigrahi i, marwaha rk. evaluation of the genetic basis of phenotypic heterogeneity in north indian patients with thalassemia major. eur j haematol, 2010; 84(6):531537. 9. sambrook j, fritsch ef, maniatis t. molecular cloning: a laboratory manual, 2nd ed. cold spring laboratory, cold spring harbor ny.1989. 10. khan ms, ahmed m, khan ra, mushtaq n, wasim m, shah u. consanguinity ratio in β-thalassemia major patients in district bannu. j. pak. med. assoc. 2015; 65(11):1161-3. 11. ali n, ayyub m, khan sa, ahmed s, abbas k, malik hs, tashfeen s. of gc-globin promoter à158.2015; 8(1): 1015. 12. usman m, moinuddin m, ghani r, usman s. screening of five common beta thalassemia mutations in the pakistani population: a basis for prenatal diagnosis. sultan qaboos university medical journal. 2009; 9(3):305-310 13. moatter t, kausar t, aban m, ghani s, pal ja. prenatal screening for β-thalassemia major reveals new and rare mutations in the pakistani population. int jour of hematology. 2012; 95(4):394-8. 14. s.n. khan and s. riazuddin. molecular characterization of p-thalassemia in pakistan. hemoglobin 1998;22(4): 333-345. 15. khattak sa, ahmed s, anwar j, ali n, shaikh kh. prevalence of various mutations in beta thalassaemia and its association with haematological parameters. jpmajournal of the pakistan medical association. 2012; 62(1):40-43. 16. garewal g, das r, awasthi a, ahluwalia j, marwaha rk. the clinical significance of the spectrum of interactions of cap+1 (a-->c), a silent betaglobin gene mutation, with other beta-thalassemia mutations and globin gene modifiers in north indians. eur j haematol 2007; 79(5): 417-21 17. varawalla ny, old jm, sarkar r, venkatesan r, weatherall dj. the spectrum of beta-thalassaemia mutations on the indian subcontinent: the basis for prenatal diagnosis. br j haematol 1991; 78(2): 242-7. 18. baig sm, azhar a, hassan h, baig jm, kiyani a, hameed u, rabbi f, bokhari h, aslam m, din mu, baig sa. spectrum of beta-thalassemia mutations in various regions of punjab and islamabad, pakistan: establishment of prenatal diagnosis. haematologica. 2006; 91(3): elt02-. 19. black ml, sinha s, agarwal s, colah r, das r, bellgard m, bittles ah. a descriptive profile of β-thalassaemia mutations in india, pakistan and sri lanka. jour of community genetics. 2010; 1(3):149-57. 20. karim a, usman m, moinuddin m, babar su. cap+ 1 mutation; an unsuspected cause of beta thalassaemia transmission in pakistan. turk jour of hematology. 2009; 26(4):167-70. 21. khan j, ahmad n, siraj s, hoti n. genetic determinants of β-thalassemia intermedia in pakistan. hemoglobin. 2015; 39(2):95-101. journal of islamabad medical & dental college (jimdc); 2012(2):89-92 89 original article anemia of chronic diseases nadeem ikram*, haider zaigham baqai**and khalid hassan*** *assistant professor, department of pathology, rawalpindi medical college, rawalpindi **associate professor of medicine, rawalpindi medical college, rawalpindi ***professor and head, department of pathology, islamabad medical and dental college, islamabad (***bahria university, islamabad) abstract objective: to evaluate the etiology and clinicohematological profile of patients with anemia of chronic disease. patients and method: patients with anemia of chronic disease were included. all underwent bone marrow examination, and bone marrow trephine biopsy, where required. etiology was elucidated on the basis of clinical history and relevant investigations. diagnosis of anemia of chronic disease was based on increased iron in fragments with decreased or absent siderocytes and sideroblasts results: definitive cause of anemia was not ascertained in 57.1%. in the rest of the cases tuberculosis (17.1%) was the commonest. majority of the patients (54.3%) were more than 60 years of age. fever (51.4%) was the commonest complaint. severe anemia was found in 25.8%. bone marrow iron stain revealed increased iron in stores with absent siderocytes and sideroblasts conclusion: a high number of unexplained cases (57.1%) highlights the need to characterize the causes of anemia of chronic disease as treatment of underlying disease will actually improve the hemoglobin concentration in these patients. key words: anemia, chronic infection, microcytic hypochromic blood picture, sle, tuberculosis, rheumatoid arthritis introduction anemia of chronic disease (acd) is a hypoproliferative anemia that develops in response to systemic illness or inflammation. it was first described in the 1930s and was more fully characterized by cartwright and wintrobe in the 1950s.1 amongst microcytic hypochromic anemias, acd is the second most prevalent anemia only after iron deficiency. unfortunately, it is commonly under diagnosed in clinical practice, and is frequently misunderstood and managed inappropriately. significant gaps remain in comprehension of the true prevalence or consequences of acd. different diseases are found to be associated with acd. infections (tuberculosis, bacterial, parasitic, fungal and viral infections, including human immunodeficiency virus infection), cancers, autoimmune diseases, chronic renal diseases and inflammations are most commonly incriminated.2 acd is characterized by inadequate erythrocyte production in the setting of low serum iron, low iron binding capacity, low transferrin, but normal or high serum ferritin with a preserved or even increased macrophage iron stores in the bone marrow, with absence of siderocytes and sideroblasts. iron is very much available in stores but paradoxically is unavailable for hemoglobin synthesis (reticuloendothelial block).the erythrocytes are usually normocytic and normochromic, but long standing anemia can give rise to microcytic and hypochromic blood picture.3-5 in the pathogenesis of acd different cytokines play important role. cytokines along with the cells of reticuloendothelial system induce changes in iron homeostasis, affect the proliferation of erythroid progenitor cells, down-regulate erythropoietin production and decreases the life span of red cells. all of these then contribute to the pathogenesis of anemia. the invasion of microorganisms, the emergence of malignant cells or autoimmune dyrsregulation leads to activation of t cells (cd3+) and monocytes. these cells induce immune effector mechanisms, thereby producing cytokines such as interferon-γ, tumor necrosis factor-α (tnf-α) and interleukin-1. interkeukin-6 and lipopolysaccharide stimulate the hepatic expression of the acute phase protein hepcidin, which inhibits duodenal absorption of iron. interferon-γ, lipopolysaccharide, or both increase the expression of divalent metal transporter-1 on macrophages and stimulate the uptake of ferrous iron (fe2+). the antiinflammatory cytokine interleukin-10 upregulates transferrin receptor expression and increases transferrin receptormediated uptake of transferrin-bound iron into monocytes. this increased uptake and retention of iron within cells of the reticuloendothelial system leads to diversion of iron from the circulation into storage sites of the reticuloendothelial system, subsequently leading to the limitation of availability of iron for erythropoiesis. interferon-γ and lipopolysaccharide down-regulate the expression of the macrophage iron transporter ferroproteinjournal of islamabad medical & dental college (jimdc); 2012(2):89-92 90 1. ferroportin is a transmembrane exporter of iron, i.e., it is responsible for the transfer of absorbed ferrous iron from duodenal enterocytes to the circulation. at the same time, tnf-α, interleukin-1, interleukin-6 and interleukin-10 induce ferritin expression and stimulate the storage and retention of iron within macrophages. finally, all these mechanisms lead to a decreased iron concentration in the circulation and thus to a limited availability of iron for erythroid cells. tnf-α, and interferon-γ inhibit the production of erythropoietin in the kidney. tnf-α, interferon-γ and interleukin-1 directly inhibit the differentiation and proliferation of erythroid progenitor cells.6,7 identification of hepcidin is an important finding in acd. il-6, released during inflammatory process, induces hepcidin expression. hepcidin excess causes the endocytosis and degradation of the sole known cellular iron exporter, ferroportin, a 12-transmembrane segment protein. ferroportin is found in all tissues that export iron to blood plasma. this inhibition and depletion of ferroportin from the cellular membranes progressively inhibits iron efflux from duodenal eneterocytes, macrophages and other cells involved in iron export to erythroid cells.8,9 another protein involved in acd is lactoferrin. lactoferrin is similar to transferrin, in respect to its size, shape and affinity for binding iron. lactoferrin competes transferrin, get hold of the iron and traps it back to macrophages, making it unavailable for hemoglobin synthesis.10 several mechanisms independently contribute to acd. the relative contribution of these mechanisms is uncertain. the occurrence of several independent processes, each contributing in concert to the reduction of hemoglobin, suggests a process of evolutionary adaptation.11patients have microcytic hypochromic or normocytic normochromic anemia. determination of cause of anemia holds a significant importance as treatment strategies vary with diagnosis. the present study was aimed to look into various causes of acd in patients with anemia referred for bone marrow biopsy. patients and methods this retrospective study was conducted in the department of pathology, district head quarters hospital, rawalpindi, from january 2010 to december 2011. all the cases diagnosed as anemia of chronic disease (n 35) on the basis of bone marrow findings and iron staining pattern (increased iron in histiocytes with absence of sideroblasts and siderocytes) during the study period were included. demographic data (age, sex), the available clinical data (duration of illness, presenting complaints, symptoms, history of blood transfusion and provisional diagnosis) and blood as well as bone marrow findings were recorded. the patients were categorized as having severe anemia (hb <8.0 g/dl), moderate anemia (hb 8.19.5 g/dl) and mild anaemia (hb >9.6/dl and less than 11.0 g/dl in females and <13.0 g/dl in males). the giemsa and iron-stained bone marrow smears and h & e stained trephine sections, if available, were studied, and data were recorded. the data were analyzed for frequencies, where ever applicable. results table 1 details the demographic and available clinical & laboratory data of our patients. males comprised 60% of cases; male: female ratio was 3: 2. majority of patients was >60years of age. about three fourth of the patients had been symptomatic for > 6 months. fever was a prominent symptom in about half of the patients. anemia was the most consistent feature; it was severe (hb< 8.0 g/dl) in 25.7%, and moderate (hb between 8.1 and 9.5 g/dl) in 45.7% patients. nearly half of the patients had been transfused red cell concentrates before they were referred to us. table 1: demographic, clinical and laboratory features (n=35)* parameter no (%) sex male female age (yrs) 18-45 46-60 >60 duration of illness (months) <6 >6 to 12 > 12 history of fever history of blood transfusion degree of anaemia (hb g/dl) severe (< 8) moderate (8 to 9.5) mild (> 9.5) red blood cells morphology normocytic & normochromic microcytic & hypochromic bone marrow haemophagocytosis 21(60) 14 (40) 06 (17.1) 10 (28.6) 19 (54.3) 09 (25.7) 18 (51.4) 08 (22.9) 18 (51.4) 17 (48.6) 09 (25.7) 16 (45.7 ) 10 (28.6) 23 (65.7) 12 (34.3) 10 (28.6) *all cases showed increased iron in bone marrow macrophages with absent or decreased siderocytes and sideroblasts as shown in table 2, a diagnosis of chronic disease was manifest, before bone marrow biopsy was performed, in only 15 (42.9%) cases. tuberculosis was the commonest already diagnosed underlying chronic disorder, followed by other infections (typhoid, respiratory infections, etc), chronic liver disease, systemic lupus erythematosus, and chronic renal disease, respectively. in the remaining patients (57.1%), who were referred to us journal of islamabad medical & dental college (jimdc); 2012(2):89-92 91 for bone marrow biopsy with an attempt to investigate for anemia, other cytopenias(s), or fever, the findings indicated chronic underlying disorder. in these patients, there was no previous clinical suspicion of any chronic disease. red cell morphology was normocytic normochromic in two thirds and microcytic hypochromic in the remaining one third of the cases. on bone marrow smears, iron overload with absence of siderocytes and sideroblasts & siderocytes was a consistent feature; haemophagocytosis was a prominent feature in 28.6% of cases. table 2: anaemia of chronic diseases-causes (n 35) cause no (%) tuberculosis chronic liver disease systemic lupus erythrmatosus typhoid chronic renal failure chronic infections no chronic disease suspected before bone marrow biopsy 6 (17.1) 3 ( 8.6) 2 (5.7) 1 (2.9) 1 (2.9) 2 (5.7) 20 (57.1) discussion acd is a hypoproliferative anemia that accompanies chronic inflammatory, infectious, or neoplastic disorders. the anemia of chronic disease is primarily an anemia due to underproduction of red cells, with low reticulocyte production, and is most often a normochromic, normocytic anemia. however, in 30% to 50% of patients, the red cells are hypochromic and microcytic and, most often, the serum iron, total iron-binding capacity, and transferrin saturation are reduced in the presence of adequate iron stores.12 in comprehensive population-based studies, precise estimates of prevalence are difficult to ascertain because many patients with anemia are not investigated sufficiently to establish the cause. moreover, no consensus research criteria exist for the diagnosis of anemia of chronic disease, and patients may have multifactorial causes for anemia, wherein acd is only a part.10 according to the world health organization (who) mild anemia corresponds to a hb 9.5 g/dl, moderate anemia to a hb 8 g/dl but <9.5 g/dl, and severe anemia to a hb <8.0 g/dl. anemia of chronic disease is usually patients have mild to moderate.13 our results also showed that most of patients diagnosed as acd (74.5%) had mild to moderate degree of anemia. majority of our patients (54%) were more than 60 years age. this is also important because such patients do not respond to treatment unless underlying disease is diagnosed and treated. bone marrow examination also differentiates these cases of acd from refractory anemia (mds) which is suspected in elderly patients not responding to treatment. in 57% of our cases there was no definitive diagnosis of an underlying disease was evident. they were referred for bone marrow biopsy to evaluate the cause of anemia and showed iron staining pattern of underlying disorder. it is important to investigate these patients for an underlying pathology. there were 6 cases of tuberculosis in our cases showing iron staining pattern of anemia of chronic disease. multiple causes of anemia in tuberculosis have been identified. these include iron deficiency, folate deficiency (most probably because of drug therapy) decreased red cell life span, depressed erythropoiesis and defective ferrokinetics.14 in this regard it is particularly important to differentiate anemia due to iron deficiency from that of acd. various tests differentiate iron deficiency anemia from acd. these include serum iron, tibc, transferrin saturation, serum ferritin, serum transferrin receptors and red cell zinc protoporphyrin. however determination of iron stores by bone marrow examination remains the best method for assessment of iron stores.15 other tests include crp and esr (both braised in acd). tb-associated anemia is usually mild and resolves with anti-tb treatment.16 there were 2 diagnosed cases of sle showing iron staining pattern of underlying disorder. hematological abnormalities are very common in systemic lupus erythematosus. αnemia is found in approximately 50% of patients, with anemia of chronic disease being the most common form. other mechanisms contributing to development of anemia in sle include renal insufficiency, blood loss, dietary insufficiency, medications, hemolysis, infection, hypersplenism, myelofibrosis, myelodysplasia, and aplastic anemia (probably having an autoimmune pathogenesis).17 in the absence of either symptom attributable to anemia, anemia of chronic inflammation does not require specific treatment (provided other causes mentioned above are ruled out). some of the patients of sle show improvement in hemoglobin concentration when treated with repo (recombinant erythropoietin) acd is considered the most frequent cause of anemia in ra; however, iron deficiency due to gastrointestinal blood loss or a combination of both. it is important to determine the cause of anemia in order to treat these patients. the most reliable characteristic for the detection of iron deficiency is stainable iron content in bone marrow aspirate. significant increase in hemoglobin concentration in these patients has been observed in patients of rheumatoid arthritis treated with erythropoietin.18 similarly in celiac disease though major cause for anemia in deficiency of b12, folic acid and iron, but it has been observed that in different studies acd affects a significant portion of celiac disease patients at presentation, contributing to significant number of cases and the response of anemic patients to a gluten-free diet was not influenced by the presence of acd.19 this has also been observed that mean serum levels of inflammatory cytokines that contribute to acd, including interleukin1b, interleukin-6, tumor necrosis factor-a, and interferon-g, are increased in active celiac disease.20,21 journal of islamabad medical & dental college (jimdc); 2012(2):89-92 92 anemia is a common association of malignant disease and may affect treatment decisions. it is important to recognize the factors leading to development of anemia and to exclude those that are treatable. the recognition that tumorassociated cytokine production is a major factor in the anemia of malignancy, and repo can overcome this suppression.22 acd, if marked, can be a reflection of more progressive underlying disease. treatment of underlying disease is the therapeutic approach of choice for acd. treatment with iron therapy is contraindicated in acd. in general iron therapy should only be considered if there is concomitant iron deficiency and this should be with oral iron therapy. treatment with parenteral iron therapy should be avoided due to possible aggravation of infection by large bolus of infection. blood transfusions are helpful in the context of severe life threatening anemia. although the positive short term effects of therapy with erythropoietic agents on the correction of anemia and avoidance of blood transfusion are well documented, few data are available on possible effects on the course of disease. the therapeutic effects of these agents primarily include the stimulation of iron uptake and heme biosynthesis in erythroid cells. additionally they can counter act the antiproliferative effects of cytokines. the pivotal role of hepcidin in iron metabolism and in the pathogenesis of acd could lead to development of inhibitors of hepcidin for clinical use. future strategies, to treat acd, may thus include the use of these inhibitors and iron-chelation therapy to induce the endogenous antagonists that overcome the retention of iron within the reticuloendothelial system, and hormones or cytokines that might effectively stimulate erythropoiesis under inflammatory conditions.23-25 it is thus very important to determine the cause of anemia in various chronic inflammatory conditions as this would affect the treatment outcome and quality of life in these patients. conclusions a high number of unexplained cases (57.1%) highlights the need to characterize the causes of anemia of chronic disease as treatment of underlying disease will actually improve the hemoglobin concentration in these patients. references 1. zarychanski r, houston d. anemia of chronic disease: a harmful disorder or an adaptive, beneficial response? cmaj 2008;179(4): 333-37 2. ikram n, hassan k. anaemia of chronic disease. hematology updates, 2011; 17-22 3. anwar m. pathogenesis of anaemia of chronic disorders recent advances. proceedings 13th national conference pakistan society of haematology, 2011;12 4. ganz t. molecular pathogenesis of anaemia of chronic disease. pediatr blood cancer,2006; 46:554-57 5. wilson a, yu ht, goodnough lt. prevalence of anaemia and outcomes of anaemia in rheumatoid arthritis : a systemic review of the literature .am j med, 2004; 116( 7a0: 50-55 6. weiss g and goodnough lt. anaemia of chronic disease. n eng j med, 2005; 10: 1011-23 7. dominic sc. role of interleukin -6 in the anaemia of chronic disease. semin arthritis rheum; 2009; 46: 387-93 8. ganz t and nemeth e. iron sequestration and anaemia of inflammation. semin hematol, 2009; 46: 387-93 9. banitt jl, lin hy. molecular mechanisms of hepcidin regulation: implications for anaemia of chronic of chronic kidney disease. am j kidney dis, 2010: 726-41 10. mazza jj. anemia of chronic disease. in manual of clinical hematology, 2002. 3rd ed;54-61 11. zarychanski r, houston ds. anaemia of chronic disease: a harmful disorder or an adaptive, beneficial response? cmaj 2008; 179(4): 150308 12. krantz sb. pathogenesis and treatment of the anemia of chronic disease. am j med sci. 1994 may; 307(5):353-9 13. theurl i, mattle v, seifert m, mariani m, marth c, weiss g. dysregulated monocyte iron homeostasis and erythropoietin formation in patients with anemia of chronic disease. blood 2006; 107: 4142-8 14. chakrabarti k, dutta a.k, dasgupta b and dand g et al. haematological changes in disseminated tuberculosis ind. j. tub., 1995, 42, 165-68 15. metz j. the anemia of infection. samj 2007; 97(11):116568 16. lee sw, kang ya, yoon ys and um sw et al. the prevalence and evolution of anemia associated with tuberculosis. j korean med sci. 2006; 21(6):1028-32 17. anaemia in systemic lupus erythematosus: from pathophysiology to clinical assessment. au giannouli s, voulgarelis m, ziakas pd, tzioufas ag ann rheum dis. 2006;65(2):144 18. swaak a. anemia of chronic disease in patients with rheumatoid arthritis: aspects of prevalence, outcome, diagnosis and the effect of treatment on disease activity. j rheumatol 2006; 33(8):1467-68 19. bergamaschi g, markopoulos k, albertini r and sabatino a et al anemia of chronic disease and defective erythropoietin production in patients with celiac disease haematologica 2008; 93(12):1785-91 20. cataldo f, lio d, marino v, scola l, crivello a, corazza gr. working group of the sigep; working group of ‘club del tenue’. plasma cytokine profiles in patients with celiac disease and selective iga deficiency. pediatr allergy immunol 2003;14: 320-4 21. romaldini cc, barbieri d, okay ts, raiz r jr, cançado el. serum soluble interleukin-2 receptor, interleukin6, and tumor necrosis factor��levels in children with celiac disease: response to treatment. j pediatr gastroenterol nutr 2002;35:513-7 22. frenkel ep, bick rl, rutherford cj anemia of malignancy. hematol oncol clin north am. 1996 aug; 10(4):861-73. 23. means rt, recent developments in the anaemia of chronic disease. blood rev, 2002; 16: 87-96 24. mayhew m. anaemia of chronic disease in the elderly. journal for nurse and practitioners,2006; 3(2): 26167 25. weiss g. pathogenesis and treatment of anaemia of anaemia of chronic disease. blood 2002; 16:87. 26.   208 j i m d c 2 0 1 8 208 open access f u l l l e n g t h a r t i c l e port-site related complications and their management in patients undergoing laparoscopic cholecystectomy riffat jabeen memon 1, zeeshan zia qureshi 2, fida hussain shah 3, mujeeb-ur-rehman laghari 4 1,4senior registrar, department of general surgery 2 assistant professor, department of general surgery indus medical college tando muhammad khan 3 assistant professor, department of general surgery 1,3,4 liaquat university of medical & health sciences, jamshoro a b s t r a c t objective: to determine the port site complications associated with laparoscopic cholecystectomy. patients and methods: this cross sectional study was carried in the department of surgery of liaquat university hospital (luh) jamshoro for 1-year duration. about 100 symptomatic cholelithiasis patients those underwent laparoscopic cholecystectomy were inducted in the study. details of patients (history, investigations, and clinical examination) were recorded in proforma at the time of admission. postoperative and operative port site associated complications were noted. results: the patients presented with mean age of 37.33±12.12 years. out of total 100 cases, there were 82 females and 18 males with male to female ratio of 1:4.5. the inclusive port site problems were noticed within 12 (12%) cases. the infection was the most common complication (6%) followed by bleeding (4%), hernia (1%) and hematoma (1%). no significant difference was found in port site complications according to age and gender; p-values are quite insignificant. conclusion: laparoscopic cholecystectomy is the standard procedure with very lower rate of port-site complications key words: complications, laparoscopic cholecystectomy, port sites, author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence riffat jabeen memon email: memon.riffat12@gmail.com article info. received: july 13, 2018 accepted: august 12, 2018 cite this article. memon rj, qureshi zz, shah fh, laghari m. port site related complication and their management in patients undergoing laparoscopic cholecystectomy. jimdc.2018; 7(3):208-212 funding source: nil conflict of interest: nil i n t r o d u c t i o n minimally invasive procedures have become common in recent surgery and now laparoscopic surgery is a tool which is practiced in nearly all surgical fields.1 open cholecystectomy, traditionally, has long been established as benchmark treatment for gallstones.2 in 1987, revolution in gallstones treatment instigated with the practice of an earliest laparoscopic cholecystectomy.3 today laparoscopic c cholecystectomy is believed to be a well-known technique due to minimal pain, shorter hospital stay, lower rate of morbidities and accelerated postoperative recoveries 3-5. although, laparoscopic cholecystectomy is better, contrast to open cholecystectomy, however it does not exclude problems and is also accountable for several insignificant to significant complications. port-site associated complications related to laparoscopic cholecystectomy could be postoperative or intra operative bleeding, metastatic malignancy, painful scar, wound infection, hernia and haematoma. port-site bleed can possibly present as much slow discharge or frank bleed in case of damage to a major vessel. it could be observed on overlapping dressing or can present as internal bleed o r i g i n a l a r t i c l e 209 j i m d c 2 0 1 8 209 postoperatively.7 probably it is the commonest complication related to port site which affects 5-6.3% of patients as reported in literature.8 port site hernia (psh) is an incisional hernia which takes place at trocar/port site following laparoscopic surgical procedure. it is generally noted at the port site of 10 mm within umbilical or epigastric and infra umbilical region. it is infrequently observed on cannula site of 5 mm. prevalence of port-site hernia ranges between 1% and 6%9. the current study evaluates several complications related to port accompanied by their administration which will encounter throughout laparoscopic cholecystectomy. p a t i e n t s a n d m e t h o d s this cross sectional study was held at surgical department liaquat university hospital jamshoro. duration of study was 1 year. after ethical approval, all the symptomatic gallstone patients who were offered laparoscopic cholecystectomy as well as subjects with age more than 16 years, who were easy to deal with laparoscopy were included in the study. all the subjects with blood coagulation abnormalities, chronic hepatitis b and c, acute pancreatitis and severe co-morbidities were excluded. after getting written consent, complete medical history and clinical examination along with ultrasound and routine laboratory investigations were carried out. postoperative and operative port site associated complications were noted in the subjects those underwent laparoscopic cholecystectomy. all the data regarding demographic characteristics and complications was recorded in proforma at the time of admission and after surgery. analysis was performed by spss-16. figure:1. post-operative complications after laparoscopic cholecystectomy n=100 mean and standard deviation were computed for quantitative variables such as age. percentage and frequencies were calculated for qualitative variables such as gender, socioeconomic status, clinical presentation and port site complications. after stratification of effect modifier like age and gender, the chi-square test/fischer exact test was applied. p-value <0.05 was considered as statistically significant. r e s u l t s the mean age of total 100 patients was 37.33±12.12 years. mean diastolic and systolic bp, respiratory rate and pulse rate are shown in table 1. out of 100 patients, male to female ratio was 1:4.5. right hypochondrium pain was considered as most common clinical presentation (95.0%) followed by abdominal pain (85.0%) (table 2). history of earlier hospitalization was noted within 24.0% patients and family history of gallstone was present in just 5% cases. majority of patients (63%) belonged to middle socioeconomic class (table 2). most of the patients (70.0%) presented between 21 to 40 years and 30% were with age group of >40 years. generally port site complications rate was 12.0%. the commonest complication was infection (6.0 %) followed by the bleeding (4%) (figure 1). no significant difference was found in port site complications according to gender and age, p-values are quite insignificant (table 3). d i s c u s s i o n all surgeries performed carry certain risks and complications. infection of abdominal surgical site is a most frequent complication in admitted patient’s and carries serious concerns for costs and outcomes. advances in technology-related surgeries include a tendency towards a less invasive procedure, directed by potential advantages to patients. laparoscopic cholecystectomy since its institution in 1987, rapidly achieved reputation so much that it is now being considered as a benchmark for the treatment of symptomatic gallstones disorders.1,10 it is nowadays considered as a safe procedure for out-patients.11 large series report a downgraded prevalence of infection of port site and further wound-associated complications after laparoscopic surgical procedure.12 in current study, mean age of the 100 patients was 37.33±12.12 and 210 j i m d c 2 0 1 8 210 table 1: demographic characteristics of patients (n=100) variables mean± sd 95% confidence interval lower bound upper bound age (years) 37.33±12.124 34.86 39.80 diabetic bp (mmhg) 76.32±13.919 73.48 79.15 systolic bp (mmhg) 127.68±4.241 126.82 128.55 pulse (beat/min) 78.63±2.241 78.18 79.09 respiratory rate 20.57±1.814 20.20 20.94 in majority 82% were females and 18% were males along with male to female ratio of 1:4.5. comparable results were as well reported in study of memon mr et al,12 in which he mentioned that the 183 were females and 33 were males along with male to female ratio of 1:5.5 years, average age around 35 years ranging from 20 to 70 years. in the study of brohi et al 5 reported that females were 79 (79%) and males 21(21%) with male to female ratio was 1:3.76 and average age was 46.28±7.20 years. table 2: gender, socioeconomic status and presenting complaints of patients (n=100) variables frequency percentage gender female 82 82.0 male 18 18.0 socioeconomic status upper 11 11.0 middle 63 63.0 poor 26 26.0 presenting complaints pain in right hypochondrium 95 95 abdominal pain 85 85 dyspepsia 79 79 vomiting 31 31 fever 23 23 in this series, pain right hypochondrium (95.0%) was the most common clinical presentation following by abdominal pain (85.0%), dyspepsia (79.0%), vomiting (31.0%) and fever (23.0%). brohi et al 5 demonstrated symptoms of cases as right hypochondrium pain 87.0%, epigastrium pain 78.0%, vomiting and nausea 15.0%, elevated temprature10.0% and dyspepsia in 50.0% cases. in this study, the total complication rate for port site was 12%, particularly as infection was the commonest problem noted within 6% of the cases afterward 4% bleeding, 1% hernia and 1% haematoma. in the study conducted by shindholimath vv et al., it was observed the prevalence of infection of port site infection 6.3%.13 in 2006, a national study exhibited the rate of surgical site infection to be 2%, in association to 6% within open cholecystectomy.15 according to colizza et al14 during 2004 the prevalence of port site infection was < 2%. in a fresh national review, a prevalence of 2.23% was documented of port site infection. a reason that could explain the prevalence to be greater in comparison to further studies possibly is the reuse of disposable ports following sterilization because of the cost of fresh ports, which are nonaffordable for both the hospital and the patient. jan wa et al9 conducted study to see the port site infection and reported that out of 17 infected cases 12 had superficial infection and 5 had deep infection. similarly, in the study of usman j et al16 reported that total 6% patients had superficial surgical site infection those underwent laparoscopic cholecystectomy. it involved the muscle layers and deeper fascia. the outcome of study revealing that infection of superficial skin is far more frequent in contrast to deeper ones has as well been supported by a review from the disease control and preventive centers, atlanta and georgia in 2003.17 several factors could be concerned in direct contamination of port site and hence resulting in infection. bleeding is a dangerous and commonly encountered problem of laparoscopic cholecystectomy. bleeding can possibly take place in the course of insertion of veress needle, gall bladder dissection, and damage to cystic duct or slippage of clips from cystic artery. according to our study, 4 cases had bleeding. just 2 cases required conversion to open procedure due to laparoscopically uncontrolled bleeding. minor bleeding can be regulated by diathermy or suture and by inserting 211 j i m d c 2 0 1 8 211 table 3: port site complications according to age and gender (n=100) variables bleeding infection haematoma hernia without complications p-value gender female 4 6 1 0 71 male 0 0 0 1 17 0.072 total 4 6 1 1 88 age groups (years) >60 1 0 0 0 5 51 to 60 0 2 0 1 07 41 to 50 1 1 2 0 10 0.091 31 to 40 2 0 0 0 30 21 to 30 0 2 0 0 36 total 3 6 2 1 88 pressure. factors playing role in bleeding of operative site can possibly include portal hypertension, acute inflammation, inadequate exposure, adhesion, rough technique and coagulopathy.18 local study of arain gm et al19 has documented bleeding within around 3.18% of cases while one more study by usal et al20 documented damage to major vessel (inferior vena cava, portal vein and aorta) in around 0.11% of cases. tocchi et al21 also documented higher prevalence of port-site infection within acute cholecystitis cases. in present study we found insignificant association of port site complication according to gender and age. similair results were found in the study of maitra tk et al.23 many conditions contribute to make it technically problematic laparoscopic cholecystectomy procedures. these comprise empyema of gall bladder, acute cholecystitis, gallbladder gangrene, intrahepatic and porcelain gallbladder.22 additionally, there are several others factors which can be much problematic to laparoscopic cholecystectomy including earlier laparotomy and surgical adhesions, liver cirrhosis and portal hypertension. c o n c l u s i o n laparoscopic cholecystectomy is an acceptable and safe choice in empyema of gallbladder. port site infections and bleeding were the most common complications. lc has a low risk of infection of port-site which is just superficial responding to local measures. r e f e r e n c e s 1. chowbey pk. laparoscopic cholecystectomy: emerging horizons. 2003;2 :36-40. 2. chok ks, fan st, yuen wk, lau h, lee f. outpatient laparoscopic cholecystectomy in hong kong chinese–an outcome analysis. asian journal of surgery. 2004; 27(4):313-6. 3. targarona em, balague c, knook mm, trias m. laparoscopic surgery and surgical infection. british journal of surgery. 2000; 87(5):536-44. 4. memon w, khanzada tw, samad a, laghari mh. complications of laparoscopic cholecystectomy at isra university hospital, hyderabad. pak j med sci. 2009; 25(1):69-73. 5. brohi s, laiq-uz-zaman khan m, shaikh u, shaikh su. laparoscopic cholecystectomy; to assess various intra operative predictive factors which are responsible for difficulty in performing laparoscopic cholecystectomy. professional medical journal. 2014;21(4). 6. al-mulhim as, amin tt. outcome of laparoscopic cholecystectomy at a secondary level of care in saudi arabia. saudi journal of gastroenterology: official journal of the saudi gastroenterology association. 2011; 17(1):47. 7. osborne da, alexander g, boe b, zervos ee. laparoscopic cholecystectomy: past, present, and future. surgical technology international. 2006; 15:81-5. 8. al-mulhim aa. male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience. saudi journal of gastroenterology: official journal of the saudi gastroenterology association. 2008; 14(2):73. 9. jan wa, ali is, shah na, ghani a, khan m, khan as. the frequency of port-site infection in laparoscopic cholecystectomies. journal of postgraduate medical institute (peshawar-pakistan). 2011 aug 15;22(1) 10. chok ks, yuen wk, lau h, lee f, fan st. outpatient laparoscopic cholecystectomy in hong kong chinese -an outcome analysis. asian j surg 2004:27: 313. 11. targarona em, balague c, knook mm, trias m. lapa ros copi c surge ry and surgi c a l infections. br j surg 2000;87:536. 12. memon mr, muhammad g, arshad s, jat ma, bozdar ag, shah sqa. study of open conversion in laparoscopic cholecystectomy. gomal j med scie 2011;9(1):51-54. 212 j i m d c 2 0 1 8 212 13. shindholimath vv, seenu v, parshad r, chaudhry r, kumar a. factors influencing wound infection following laparoscopic cholecystectomy. trop gastroenterol. 2003;24:90-2.. 14. colizza s, rossi s, picardi b, carnuccio p, pollicita s, rodio f, et al. surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis. a prospective study. chir ital 2004;56:397402 15. siddiqui k, khan af. comparison of frequency of wound infection: open vs laparoscopic cholecystectomy. j ayub med coll abbottabad. 2006;18(3):21-4. 16. usman j, janjua a, ahmed k. the frequency of port-site infection in laparoscopic cholecystectomies. pak j med health sci. 2016 oct 1;10(4):1324-6 17. richards c, edwards j, culver d, emori tg, tolson j, gaynes r, national nosocomial infections surveillance (nnis) system. does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection?. annals of surgery. 2003 mar;237(3): 358. 18. vagenas k, karamanakos sn, spyropoulos c, panagiotopoulos s, karanikolas m, stavropoulos m. laparoscopic cholecystectomy: a report from a single center. wjg. 2006 jun 28;12(24):3887. 19. arain gm, hasan a, randhawa mh, malik sa. laparoscopic cholecystectomy and its comlications. a study of 1100 cases. pak j gastroenterol 1998;12:1-2 20. usal h, sayad p, hayek n, hallak a, huie f, ferzli g. major vasclar injuries during laproscopic cholecystectomy. an institutional review of experience with 2589 procedures and literature review. surg endosc 1998;12(7):960-2 21. tocchi a, lepre l, costa g, liotta g, mazzoni g, maggiolini f. the need for antibiotic prohylaxis in elective laparoscopic cholecystectomy: a prospective randomized study. archives of surgery. 2000 jan 1;135(1):67-70. 22. malik a, laghari aa, talpur ka, memon a, mallah q, memon jm. laparoscopic cholecystctomy in empyema of gall bladder: an experience at liaquat university hospital, jamshoro, pakistan. journal of minimal access surgery. 2007 apr;3(2):52. 23. maitra tk, ullah me, mondol sk. operative and postoperative complications of laparoscopic cholecystectomy: experience from a tertiary care hospital of bangladesh. bangladesh critical care journal.;5(1):11-6. j islamabad med dental coll 2022 14 o p e n a c c e s s histo-pathological effects of raphanus sativus leaf extract on carbon tetrachloride induced hepatotoxicity ahsan aslam1, muhammad saleh2, farzana raheem mahmood3, sadia khan4, saboor pathan5, kazbano ramsha6 1senior lecturer, department of pharmacology, isra university, hyderabad 2cmo, cod, liaquat university hospital 3assistant professor, department of physiology, isra university, hyderabad 4,5lecturer, department of biochemistry, isra university, hyderabad 6fmo, pphi a b s t r a c t background: raphanus sativus is a cruciferous plant which possesses free radical scavenging properties that defend the body against the deleterious effects of reactive oxygen species. the study objective was to assess the protective effect of raphanus sativus in carbon tetrachloride induced hepatotoxicity in albino wistar rats. methodology: this animal based experimental research was conducted from september 2019 to march 2020 at the postgraduate research laboratory, isra university, hyderabad. non-random purposive sampling technique was used for selection of study animals. rats were distributed evenly in three different groups: group 1 (control group), group 2 (ccl4 induced experimental group), and group 3 (ccl4 plus raphanus sativus treatment group). data was analyzed using spss version 24. results: liver weight and serum markers of hepatic function were high in group 2 as compared to group 1 and c rats (p<0.05). treatment with raphanus sativus significantly reduced serum levels of lfts (p<0.05). there was a significant decline in the plasma levels of oxidative markers in group 2 while marked histo-pathological changes like necrosis, sinusoidal dilatation and congestion observed among animals of group 2. conclusion: raphanus sativus wields anti-oxidative as well as hepato-protective effect against carbon tetrachloride induced hepatotoxicity and tissue damage. keywords: carbon tetrachloride, raphanus, oxidative stress authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; 4manuscript editing5. correspondence: ahsan aslam email: aaslam206@caledonian.ac.uk article info: received: february 22, 2021 accepted: march 31, 2022 cite this article. aslam a, saleh m, mahmooed fr, khan s, pathan s, ramsha k. histopathological effects of raphanus sativus leaf extract on carbon tetrachloride induced hepatotoxicity. j islamabad med dental coll. 2022; 11(1):14-19. doi:10.35787/jimdc.v11i1.684 funding source: nil conflict of interest: nil i n t r o d u c t i o n liver, with its crucial role in the conservation of homeostasis and detoxifying baneful drugs, is one of the most vital organs required for survival.(1) globally, liver diseases account for more than 1.5 million deaths every year, half of which are owed to complications of liver disease such as cirrhosis and liver cancer. altogether, liver diseases are responsible for more than 3% of overall mortality around the world.(2) various elements recognized to adversely affect the structural/ and or functional properties of the hepatic tissue, leading to grave implications, have been regarded as hepato-toxic. carbon tetrachloride (ccl4) being one of those elements, results in hepato-toxicity owing to its innate potential to undergo dehalogenation yielding trichloromethyl (ccl3¯), which in turn stimulates o r i g i n a l a r t i c l e j islamabad med dental coll 2022 19 oxidative stress eventually leading to cell-injury and cell death.(3) in addition, actuation of kupffer cells induces the onset of an inflammatory cascade, thereby increasing the serum levels of inflammatory markers.(4, 5) due to reported side effects of certain drugs currently being used for the mitigation of hepatotoxicity, alternative plant based compounds have gained tremendous interest in recent years .(6) among such plants is raphanus sativus (r. sativus), a cruciferous plant also commonly called radish, which has since long been used in traditional medicine.(7) the chemicals found within the roots and leaves of r. sativus include various nitrogenous compounds, alkaloids, and phenols, etc. which have shown to possess free radical scavenging properties that defend the body against the deleterious effects of reactive oxygen species.(8) r. sativus extract has also shown to augment the activity of various antioxidants within the body, such as catalase and glutathione peroxidase which consequently prevent lipid peroxidation.(9) pakistan, holding a liver disease related mortality rate of 23.24 per 100,000 deaths, bears a huge burden of liver disease.(10, 11) to the best of our knowledge, no studies have been conducted in pakistan, in recent years, on the possible hepatoprotective effect of the indigenous species of r. sativus growing in the country, which itself poses a significant knowledge gap. the aim of the current study was to explore the protective effects of raphanus sativus on ccl4 induced hepatotoxicity by examining different makers of hepatic function as well as analysis of hepatic histological parameters. m e t h o d o l o g y this animal based, quasi-experimental study was conducted from september 2019 to march 2020.total thirty male, healthy wistar albino rats of age from 8-10 weeks and having body weight 250-300 grams, were included in the study. the study animals were acquired from the sindh agriculture university, tando jam, sindh. while the experiment was conducted at the postgraduate research laboratory, isra university, hyderabad. selection of rats was done by non-random purposive sampling technique while the standard method of power analysis for animal studies was used for the sample size calculation.(12, 13) the procured wistar rats were placed in plastic cages at postgraduate laboratory in isra university, hyderabad. the animals were kept in a for ten days acclimatization period at the optimal temperature of 24-26℃ in a day-night (12/12) hours cycle. each cage was having nozzles of stainless steel bedded with sawdust along with feed containers to avoid any harm to the study animals. while rats were provided with chow diet and clean water ad libitum during this period. fresh leaves of raphanus sativus were procured, taxonomically identified and authenticated from the department of horticulture, sindh agriculture university, tando jam. fresh leaves were splashed thoroughly to remove dirt or any potential contaminants. the leaves were dried at room temperature for 10 days. after that all the leaves were further dried at the temperature of 60ᵒc for six hours in a hot air oven. the dried leaves then grinded using an electric grinder and the powder obtained was then filtered through mesh sieve. later the 80% ethanol was mixed with the filtered powder and then extracted with as well as filtered with filter paper (whatman no. 2). the extracts were concentrated in a hot air oven at 37ºc, lyophilized by freeze drying apparatus (christ germany model # alpha 1 4lsc) and subsequently air tightly stored at 20ºc.(14) after the period of acclimatization, the rats were weighed individually before the experiment began. rats were divided into three groups, each group have same number (n=10) of rats. group 1 was the control group, in which rats were given a normal chow diet and clean water ad libitum only, j islamabad med dental coll 2022 19 group 2 was the experimental group, in which rats were given (single dose of ccl4, 1.2 mg/kg in 50 mm phosphate buffer solution, subcutaneously), and group 3 (single dose of ccl4, 1.2 mg/kg in 50 mm phosphate buffer solution, subcutaneously + 100 mg/kg r. sativus extract). treatment of r. sativus extract orally was done by force feeding the animals for a span of 28 days through a stainless-steel feeding syringe. the level of the orally administered dosage of r.sativus extract (100 mg/kg) and the subcutaneous dose of ccl4 (ccl4 1.2 mg/kg) was based on previous studies.(15, 16) on completion of experiment period of four weeks, the body weight of rats in all three groups were measured once again using an electronic precision balance. later, all rats were sacrificed by cervical dislocation under anesthesia. later, blood samples were collect from all rats by cardiac puncture for analysis of oxidative and liver function markers. the viscera of animals were dissected out and preserved after weighing them on an electronic scale. the liver of all animals were used for further evaluation, 10% buffered formalin was used for fixing and then the tissues were lodged in paraffin wax after passing in xylene for clearing purpose. 4-μm thich slices of the liver tissues were then obtained via a rotary microtome 290. hematoxylin and eosin (h&e) was used for staining. histo-pathological analysis of hepatic tissue was performed by; appraising the degree of infiltrated inflammatory cells, fibrosis, necrosis, sinusoidal dilatations, and congestion of portal vein. a grading scale was adopted for observing the alterations and extent of tissue damage. scale was comprised of four categories (none, mild, moderate and severe) depends on the level of alterations and severity.(12) the collected data was entered and analyzed in spss version 24.0. one-way anova with post hoc tukey’s analysis was applied. significance level of p-value ≤ .05 was considered as significant. r e s u l t s the mean pre-experiment body weight of group 1 was 213.2±3.82 grams, group 2 was 215.4±3.78 grams and group 3 was 218.6±3.84 grams. there was a significant difference in mean post experimental body weight in all three groups i.e., in group 1 there was a rise in body weight (226.3±3.76 grams), while in experimental groups 2 and 3 ,significant decline in mean body weight (189.4±2.77 grams and 213.2±3.54 grams) respectively. however, in group 3 the weight loss was not as much as seen in group 2. there was a statistically significant difference (p<0.05) between the experimental groups. the relative liver weight was significantly raised in group 2 as compared with other experimental groups (p<0.05). a statistically significant rise in serum markers of hepatic function (lft) was observed after ccl4 administration in group 2. treatment with raphanus sativus administration significantly reduced serum levels of lfts (p<0.05). (table i) table i. comparative analysis of liver function markers among animal groups. group 1 group 2 group 3 pvalue alt (iu/l) 43.21±8.63 210.4±17.73a 72.11±9.63a,b <0.05 ast (iu/l) 45.81±7.4 165.7±12.03a 71.56±9.02a,b <0.05 alp (iu/l) 81.6±15.12 261.9±6.73a 120.3±6.04a,b <0.05 total bilirubin (mg/dl) 0.26±0.07 1.39.3±0.08a 0.51±0.08a,b <0.05 direct bilirubin (mg/dl) 0.19±0.03 1.12.2±0.06a 0.28±0.03a,b <0.05 a p value < 0.05 as compared with group 1 b p value < 0.05 as compared with group 2 c p value <0.05 as compared group 3 statistically significant difference (p<0.05) in markers of oxidative stress was observed in all three groups i.e., in experimental group 2, there was a decline in the plasma levels of oxidative markers j islamabad med dental coll 2022 19 while in group 3 the decline on oxidative markers was not as much as seen in group 2. (table. ii) table ii. distribution of markers of oxidative stress among animal groups. group 1 group 2 group 3 pvalue mda (nmol/m g) 2.19 ± 1.57b 4.6 ± 0.73c,a 2.9 ± 0.08b <0.05 cat (u/mg) 24.31 ± 0.68b,c 18.11 ± 0.62a,c 21.14 ± 0.61a,b <0.05 gpx (ng/dl) 1.39 ± 0.17b 0.94 ± 0.09a,c 1.28 ± 0.11b <0.05 a p value < 0.05 as compared with group 1 b p value < 0.05 as compared with group 2 c p value <0.05 as compared group 3 on histological examination, fibrotic changes were significantly higher among experimental groups as compared to control group. necrotic changes, hepatic inflammatory changes, sinusoidal dilatation and congestion due to inflammatory changes present in intra-lobular area, were found markedly higher among animals of group 2. histomorphological changes in different groups of rats is presented in table iii. grading score: none (-), mild (+), moderate (++) and severe (+++) figure 1. photomicrograph showing histological section of liver of control and experimental rats. (h&e) x 400. (a) – control group rat with normal hepatic histological architecture without any infiltration. (b) – experimental group 2 rat with areas of lymphocytic infiltration, marked congestion and fibrosis. (c) – experimental group 3 rat with marked reduction in inflammation, necrosis and fibrosis. d i s c u s s i o n the aim of the current study was to explore the protective effects of raphanus sativus on table iii: histo-pathological grading comparison of hepatic tissues in study groups rats fibrosi s necrosi s inflamm atory cell infiltrati on sinusoi dal dilatati ons cong ested portal vein group 1 group 2 +++ +++ +++ +++ +++ group 3 + ++ ++ + ++ j islamabad med dental coll 2022 19 hepatotoxicity produced by ccl4 administration. this was achieved by examining different makers of hepatic function as well as analysis of hepatic histological parameters. ccl4 administration was associated with marked alteration of hepatic histological architecture as well as disruption of the normal liver function and lowered body weight. however, these toxic changes were significantly lower in the experimental animals receiving concomitant raphanus sativus therapy. this shows that raphanus sativus exerts an ameliorative effect on the toxicity induced by ccl4. a commonly used solvent for various dry-cleaning agents as well as certain refrigerants, ccl4 exerts both nephrotoxic and hepatotoxic effects.(17) in the current study, ccl4 administration led to a decline in the body weight of experimental animals. on the other hand, the experimental animals receiving concomitant raphanus sativus therapy showed a far less decline in their body weight. this is consistent with the results reported by anwar et al. who also reported that raphanus sativus therapy prevents the weight loss in experimental animals which occurs secondary to liver toxicity.(16) in the present study, a marked increase in the serum lfts levels was noted in the animals receiving ccl4 therapy as compared with the animals of the control group. these findings are in accordance with the results reported by jeongtae et al.(18) however, the serum lft levels in the experimental animals receiving concomitant raphanus therapy were less than those receiving sole ccl4 therapy. these findings are also in accordance with the results reported by jeongtae et al. and rahman et al. (18) (15) ccl4 administration also led to oxidative stress, which was evident from the elevated levels of malondialdehyde (mda) and decreased serum levels of glutathione peroxidase (gpx) and catalase (cat). however, these changes were not as exaggerated in the experimental animals receiving adjunct raphanus sativus therapy. these findings are consistent with those reported by rahman et al., meejung et al., and shariq et al. who reported that raphanus sativus therapy ameliorates oxidative stress.(7, 15, 19) in the current study, ccl4 administration also caused marked alteration of hepatic histological architecture with significant inflammatory cells infiltration, necrosis, fibrosis and congestion, which is in accordance with previous literature.(20) however, these changes were not as markedly evident in the experimental animals receiving adjunct therapy of raphanus sativus. these results are in accordance with those reported in previous studies by shariq et al. and rahman et al., who also observed that the histological anomalies were less pronounced in the experimental animals that were receiving adjunct raphanus sativus therapy.(15, 19) owing to limited availability of time and monetary resources, other parameters such as inflammatory markers could not be explored. therefore, further studies are recommended to investigate the effects of raphanus sativus, both individually as well as in combination with other antioxidants. c o n c l u s i o n raphanus sativus exerts an protective effect on hepatic tissue against ccl4 induced hepatotoxicity and oxidative stress. r e f e r e n c e s 1. singh h, sidhu s, chopra k, khan m. hepatoprotective effect of trans-chalcone on experimentally induced hepatic injury in rats: inhibition of hepatic inflammation and fibrosis. can. j. physiol. pharmacol. 2016;94(08):879-87. doi:10.1139/cjpp-2016-0071 2. asrani sk, devarbhavi h, eaton j, kamath ps. burden of liver diseases in the world. j hepatology. 2019;70(1):151-71.doi:10.1016/j.jhep.2018.09.014 3. choi h-s, kang j-w, lee s-m. melatonin attenuates carbon tetrachloride–induced liver fibrosis via inhibition of necroptosis. translational research. 2015;166(3):292-303. doi:10.1016/j.trsl.2015.04.002 4. ma j-q, ding j, zhang l, liu c-m. hepatoprotective properties of sesamin against ccl4 induced oxidative stress-mediated apoptosis in mice via jnk pathway. fct. 2014;64:41-8. doi: 10.1016/j.fct.2013.11.017 5. huang w, li l, tian x, yan j, yang x, wang x, et al. astragalus and paeoniae radix rubra extract inhibits j islamabad med dental coll 2022 19 liver fibrosis by modulating the transforming growth factor‑β/smad pathway in rats. mol. med. rep.2015;11(2):805-14.doi:10.3892/mmr.2014.2868 6. rajaratnam m, prystupa a, lachowska-kotowska p, załuska w, filip r. herbal medicine for treatment and prevention of liver diseases. journal of pre-clinical and clinical research. 2014;8(2):55-60. doi:10.5604/18982395.1135650 7. ahn m, kim j, hong s, kim j, ko h, lee n-h, et al. black radish (raphanus sativus l. var. niger) extract mediates its hepatoprotective effect on carbon tetrachloride-induced hepatic injury by attenuating oxidative stress. journal of medicinal food. 2018;21(9):866-75. doi.org/10.1089/jmf.2017.4102 8. jaafar na, ahmed as, al-sandooq dl. detection of active compounds in radish raphanus sativus l. and their various biological effects. plant archives. 2020;20(2):1647-50. issn:2581-6063 9. kamble s, ahmed mz, ramabhimaiaha s, patil p. antiinflammatory activity of raphanus sativus l in acute and chronic experimental models in albino rats. biomedical pharm j 2015;6(2):173-7.doi: 10.13005/bpj/420 10. who. pakistan tackles high rates of hepatitis from many angles 2017. 11. who. world health rankings: liver disease. 2018. 12. meghji ka, memon tf, ahmed i, memon sg, noor n, abbas a. nephroprotective effects of l-arginine against chemotherapy induced acute kidney injury in wistar rats. jimdc. 2020;9(4):249-55. doi: 10.35787/jimdc.v9i4.535 13. hanif ms, baloch ms, meghji ka, abbas a, kashif s, qureshi r. histopathological changes in the gastric mucosa induced by carbaryl toxicity: an experimental rat model. khyber medical university journal. 2020;12(2). doi:10.35845/kmuj.2020.19896 14. obaid a, mazhar i, sadia c, owais bin qadeer g, muhammad i. effect of raphanus sativus (radish) leaf extract on atorvastatin induced hepatotoxicity in rabbits. journal of bahria university medical and dental college. 2021;8(4):204-9. 15. rahman hs, bayz ka, hussein rh, abdalla ai, othman hh, amin km, et al. phytochemical analysis and hepatoprotective activity of raphanus sativus var. sativus in sprague-dawley rats. trop. j. pharm. res. 2020;19(8):1745-52. doi: 10.4314/tjpr.v19i8.25 16. anwar o, iqbal m, khan am, tariq s, ambreen a. effect of raphanus sativus (radish) leaf extract and high doses of atorvastatin on body weight, liver weight and liver/body weight ratio. annals of punjab medical college (apmc). 2020;14(4):313-7. doi: 10.29054/apmc/2020.721 17. mughal ta, saleem mz, ali s, anwar kk, bashir mm, babar m, et al. evaluation of hepatotoxicity of carbon tetrachloride and pharmacological intervention by vitamin e in balb c mice. pakistan j zool. 2019;51(2). doi: 10.17582/journal.pjz/2019.51.2.755.761 18. kim j, ahn m, kim s-e, lee hs, kim hk, kim go, et al. hepatoprotective effect of fermented black radish (raphanus sativus l. var niger) in ccl4 induced liver injury in rats. 예방수의학회지. 2017;41(4):143-9. doi :10.13041/jpvm.2017.41.4.143 19. syed sn, rizvi w, kumar a, khan aa, moin s, ahsan a. in vitro antioxidant and in vivo hepatoprotective activity of leave extract of raphanus sativus in rats using ccl 4 model. afr j tradit complement altern med. 2014;11(3):102-6. doi: 10.4314/ajtcam.v11i3.15 20. rahmouni f, badraoui r, amri n, elleuch a, el-feki a, rebai t, et al. hepatotoxicity and nephrotoxicity in rats induced by carbon tetrachloride and the protective effects of teucrium polium and vitamin c. toxico mecha metho. 2019;29(5):313-21.doi: 10.1080/15376516.2018.1519864 203 j i m d c 2 0 1 7 203 open access f u l l l e n g t h a r t i c l e hepatocellular carcinoma in patients suffering from chronic hepatitis b versus co-infection of hepatitis b and d virus riaz hussain khokhar 1, anwar ali jamali 2, shohabudin rind 3 1 postgraduate department, gastrointestinal & liver diseases, isra university hospital at hyderabad 2 assistant professor, department of medicine, peoples university of medical and health sciences nawabshah, sind 3 postgraduate department, gastrointestinal & liver diseases of isra university hospital at hyderabad a b s t r a c t objective: to determine the frequency of hepatic cancer in subjects suffering from chronic liver disease due to hepatitis b versus hepatitis b with co-infection of viral hepatitis d. patients and methods: this cross-sectional study was carried out in the department of medicine (hepatology & gastroenterology) at isra university hospital, hyderabad sindh, from march 2015 to february 2016. both male and female patients, from 20-70 years of age either suffering from viral hepatitis b alone or co-infected with viral hepatitis d were included in our research. individuals having co-infection of human immunodeficiency virus, viral hepatitis c, wilson's disease, hepatitis due to auto-immune diseases, alcoholic fatty liver disease, haemochromatosis, pregnant women and those patients who refused to give consent were excluded from study. results: out of total 200 patients, 142(71%) were males while 58(29) were females. mean age was 52.83+15.6 years. total 173(86.5%) patients were suffering from viral hepatitis b alone, while 27(13.5%) were infected by co-infection of viral hepatitis b and d. total frequency of hepatocellular carcinoma was 45(22.5%) in all cases. hcc was more frequent (33.34%) in patients with co-infection of chronic hepatitis b and d, as compared to only chronic hepatitis b patients (20.80%) but the difference was non-significant (p-value 0.14). conclusion: hepatocellular carcinoma was more frequent amongst patients co-infected with viral hepatitis d as compared to alone infection of hepatitis b virus. key words: hepatocellular carcinoma, viral hepatitis b, viral hepatitis d. author`s contribution 1, conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion data analysis, 3 interpretation, manuscript writing and active participation in data collection address of correspondence anwar ali jamali email: dr.saeedarain786@gmail.com. article info. received: 2017 accepted: 2017 cite this article. khokhar rh, jamali aa, rind s. hepatocellular carcinoma in patients suffering from chronic hepatitis b versus co-infection of hepatitis b and d virus. jimdc.2017;6(4): funding source: nil. conflict of interest: nil i n t r o d u c t i o n hepatocellular carcinoma (hcc) is the commonest primary hepatic malignancy. it is also the leading cause of malignancy related mortality throughout the world. in the united states it is the ninth leading cause of mortality.1 according to recent data, the rate of hcc is still rising globally, although it is variable throughout the world. chronic viral hepatitis can lead to cirrhosis and hcc. hepatitis b, c and d infections are the commonest reasons of chronic hepatitis worldwide. hepatitis b virus is the double-stranded circular dna and having 8 genotypes “a to h”. many epidemiological studies showed that hepatitis b infection is responsible for significant o r i g i n a l a r t i c l e 204 j i m d c 2 0 1 7 204 hepatocarcinogenicity.1,2 hepatitis b virus carriers have 10%–25% lifetime risk of hcc development. unlike other reasons of hepatitis severity, hepatitis b virus is the unique and may develop hcc without cirrhotic evidence.3 persistent replication of hepatitis d virus and inflammation of liver may cause cirrhosis and development of hepatocellular carcinoma, while active replications of the both hepatitis b virus and hepatitis d virus may be responsible for high progression in disease, which leads to early liver cirrhosis and hepatic malignancy.4 several epidemiological studies controversially showed different role of hepatitis d virus infection in the rising hcc risk. many previously published studies did not found elevated rates of hcc in cases having hepatitis d co-infection, but in recent literature, it is mentioned that co-infection may increase the tumor incidence.4 risk of the hepatocellular carcinoma should be reassessed according to the alteration of the natural history of hepatitis d chronic disease. however, burden of hepatitis d virus has decreased in several countries of the western world, on other hand it is still prevalent still other countries, particularly in asia pacific region.5 association of hcc with co-infection of hepatitis d virus and hepatitis b virus or with hepatitis b viral infection alone, is still unclear. as in many studies it is reported that the development hepatocellular carcinoma itself is the complex process concerning cumulative gain and the loss of functions and mutations affecting tumor suppressor and oncogenic products.6,7 it has been reported that hepatitis b virus is more responsible for development of hepatocellular carcinoma, and hepatitis d virus seems to exert epigenetic control over hbv transcription and replication. a possible explanation may be that p24 and p27 both repress hbv enhancers, piie1 and piie2 inhibit replication, thus accounting for the low serum levels of hbv dna in co-infected patients.8 on other hand, pakistan have recognized a huge difference in the occurrence and sharing of hcc between population, who are suffering from viral hepatitis b virus alone and viral hepatitis b co-infected with viral hepatitis d in different areas.9 the purpose of our study was to determine the frequency of hcc in subjects suffering from viral hepatitis b alone versus viral hepatitis b co-infected with viral hepatitis d virus. p a t i e n t s a n d m e t h o d s this cross-sectional research study was carried out in the department of medicine (hepatology & gastroenterology) isra university hospital, hyderabad sindh from march 2015 to february 2016. informed written consent was taken from patients or their relatives. both male and female patients of chronic liver disease, either suffering from viral hepatitis b alone or co-infected with viral hepatitis d, from 20-70 years of age were included in our research. individuals having age less than 20 years or more than 70 years, co-infection with human immunodeficiency virus, viral hepatitis c, wilson's disease, hepatitis due to auto-immune diseases, alcoholic fatty liver disease, haemochromatosis, pregnant women and those patients who refused to give consent were excluded from study. complete clinical examination of all patients was carried out. all the patients were divided in two groups. group 1 included chronic hbv mono-infection patients and group 2 comprised of patients having coinfection of chronic hbv and hdv. viral hepatitis b was diagnosed on the basis of hbsag positive on enzymatic assays analysis through elisa. viral hepatitis d was diagnosed in hbsag positive cases on the basis of hepatitis d virus antibodies on elisa. the diagnosis of hepatocellular carcinoma was suggested in those patients who had the clinical features suggestive of hepatocellular carcinoma which was further confirmed by tri-phasic contrast enhanced ct scan / magnetic resonance imaging abdomen, typically showing hyper vascular solid hepatic mass with support of high levels (>100 ng/ml) of alpha-fetoprotein. socioeconomic status according to monthly income was defined as upper >50,000 rupees/month, middle 15,00049,000 rupees/month and lower <15,000 rupees/month. all data was recorded in the pre design performa. data were entered and analyzed in spss 16. mean and standard deviation (sd) were calculated for quantitative variables. frequency and percentage were calculated for qualitative variables. chisquare test was applied to compare the frequency of hcc in hbv mono infection versus hbv+hdv co-infection. pvalue less the 0.05 was considered as statistically significant. 205 j i m d c 2 0 1 7 205 r e s u l t s out of total 200 patients, 142(71%) were male while 58 (29%) were females. mean age of subjects was 52.83+15.6 years (range was 20-70 years). most of our patients (67%) belonged to middle age group. regarding the education level, out of 200 subjects 115(57.5%) were un-educated. majority of subjects (56.5%) in our study belonged to lower economic class (table1). among these subjects, 173 were suffering from viral hepatitis b alone while 27 subjects were diagnosed to have viral hepatitis b and d co-infection (figure 1). figure 1: patient’s distribution according to hbv and hbv+hdv co-infection (n=200). out of all study participants, 45 were diagnosed with hcc and 155 were without hepatocellular carcinoma. thus, total hcc frequency was 22.5% (figure 2). figure 2: patient’s distribution according to frequency of hcc (n=200). ultrasound abdomen revealed that 127(63.5%) subjects had evidence of chronic liver disease without decompensation and remaining 73(36.5%) subjects were present with decompensation indicated by ascites, dilated portal vein, splenomegaly and malignant change / growth /mass. these suspected cases of hcc were stepped up for alpha-feto protein level, ct-scan abdomen. after performing these investigations, 45(22.5%) individuals were diagnosed as having hepatic cancer. all the suspected cases of hcc were also confirmed on biopsy. mean alpha fetoprotein level in our study was 5322.44 +2779.82 ng/ml. hcc was more frequent (33.34%) in patients with co-infection of chronic hepatitis b and d, as compared to patients having only chronic hepatitis b (20.80%) but difference was not significant p-value 0.14 (table.2). d i s c u s s i o n hepatic carcinoma is the fifth most frequent cancer and 3rd common reason of mortality. it is documented that the table 1: demographic characteristics of participants (n=200) characteristics n(%) age groups (years) 20-40 44(22) 41-60 134(67) >60 22(11) gender male 142(71) female 58(29) educational status un-educated 114(57) primary 57(28.5) middle-matric 13(6.5) intermediate 10(05) graduate socioeconomic status 06(03) lower 113(56.5) middle 70(35) upper 17(08.5) table 2: association of hcc with hbv & hbv+hdv co-infection (n=200) parameter hcc total p-value with hcc n (%) without hcc n (%) hbv 36(20.80) 137(88.20) 173 0.14 hbv+hdv 09(33.34) 18(66.66) 27 206 j i m d c 2 0 1 7 206 hepatitis b virus is one of the commonest oncogenic virus in human.10 prevalence of hcc is high in population infected by hepatitis b virus. additionally, increased risk of hcc is reported in hdv infected cases.10 present study has been carried out to determine the proportional frequency of hcc in patients affected by chronic hepatitis b or chronic co-infection of hepatitis b and hepatitis d. the mean age of subjects was 52.83+15.6 years with minimum of 20 years and maximum 70 years. similarly, study of abbas z et al10 reported that patient’s mean age was 54.6 ± 11.1 years. another study of kim hs et al11 also indicated that mean age was 48 years, with range of 18 years-94 years and male predominance (64.5%). these gender findings are also comparable to our study, as out of 200 patients, 142(71%) were male, while 58(29%) were females. in this study, 27(12.5%) subjects were suffering from viral hepatitis b and d co-infection. similarly, a national study of shaikh ma et al12 reported that anti-hdv was positive in (23.6%) patients with hbv positive. in some other international studies, the sero-prevalence of anti-hdv in hbv was reported as 11.5% in iran and 10.6% in india.13,14 in turkey, the prevalence of anti-hdv serological markers were observed as 27.5% in hbv related chronic hepatitis.15 in this current analysis, hcc was more frequent in patients with co-infection of chronic hepatitis b and d as 09(33.34%) out of 27 cases, as compared to only chronic hepatitis b patients as 20.80% out of 173 cases. amougou ma et al16 reported that in hcc-cases found, hepatitis delta antibody (anti-hdv) co-infection was present in 41.4 %. studies had also shown that extravagant reproduction of virus particles by hbv in combination with hdv leading to massive necroinflammation results in hcc.17 cases infected by combination of hbv and hdv also develop hcc earlier as compared to those having hbv infection only.18,19 saravanan s et al20 researches showed the subjects of chronic hepatitis group, suffering from viral hepatitis b and are chronically ill, antibodies against hepatitis d virus were present in approximately 5.7% of diseased persons. this generally leads to chronic liver disease (cirrhosis) in about 5.9% patients. co-infection including hepatitis d virus is linked to diverse patterns of the reciprocal inhibitions of the replication of virus.21 in literature it has been reported that hdv suppresses hbv replication with most cases being hbeag -ve and with decreased hbv dna level as compared to cases having hbv monoinfection.22-24 potential mechanisms of virology of hbv suppression by hdv as inhibitions of hbv enhancers may include proteins of hdv (p24 and p27).25 consistently previous studies reported that hbv/hdv coinfection has higher level of alt and ast and decreased plt and pta levels.23,26 as well as patients infected by hbv/hdv co-infection are estimated, 1.43 times more likely to progress to esld (end stage liver disease) as compared to those cases having hbv infection only. it is suggested that hbv/hdv co-infection leads to more rapid progression in hepatic disease as compared to those only infected by mono-infection of hbv.16 it is suggested that studies should also be conducted in other centers, to find out association of hcc with chronic hbv mono-infection and chronic co-infection of hepatitis b virus and hepatitis d virus and to find out the mechanisms of their oncognesis. c o n c l u s i o n this study accomplished that hcc was more frequent amongst patients having co-infection with viral hepatitis d as compared to infection of hepatitis b virus alone. mono infected viral hepatitis b or all hbv infected patients should be screened for hdv, because early recognition and treatment of co-infected hbv and hdv, may reduce the burden of associated morbidity and mortality. r e f e r e n c e 1. balogh j, david victor iii eh, burroughs sg, boktour m, saharia a, li x, ghobrial rm, monsour jr hp. hepatocellular carcinoma: a review. journal of hepatocellular carcinoma. 2016; 3:41-53. 2. international agency for research on cancer (iarc) monographs on the evaluation of carcinogenic risks to humans. hepatitis viruses. 1994; 59:182–221 3. crissien am, frenette c. current management of hepatocellular carcinoma. gastroenterol hepatol. 2014;10(3):153–161 4. abbas z, abbas m, abbas s, shazi l. hepatitis d and hepatocellular carcinoma. world journal of hepatology. 2015 apr 18;7(5):777-86 5. abbas z, jafri w, raza s. hepatitis d: scenario in the asia-pacific region. world j gastroenterol. 2010;16(5):554–562 207 j i m d c 2 0 1 7 207 6. gao c, fang l, zhao hc, li jt, yao sk. potential role of diabetes mellitus in the progression of cirrhosis to hepatocellular carcinoma: a cross-sectional case-control study from chinese patients with hbv infection. hepatobiliary pancreat dis int. 2013;12(4):385– 393. 7. levrero m. viral hepatitis and liver cancer: the case of hepatitis c. oncogene. 2006; 25(27):3834–3847. 8. wedemeyer h, manns mp. epidemiology, pathogenesis and management of hepatitis d: update and challenges ahead. nat rev gastroenterol hepatol. 2010;7(1):31–40 9. zaidi g, idrees m, malik fa, amin i, shahid m, younas s, hussain r, awan z, tariq a, parveen k. prevalence of hepatitis delta virus infection among hepatitis b virus surface antigen positive patients circulating in the largest province of pakistan. virol j. 2010; 7(1):283. 10. abbas z, qureshi m, hamid s, jafri w. hepatocellular carcinoma in hepatitis d: does it differ from hepatitis b monoinfection? saudi j gastroenterol. 2012; 18(1):18-22. 11. kim hs, kim sj, park hw, shin wg, kim kh, lee jh, kim hy, jang mk. prevalence and clinical significance of hepatitis d virus co‐infection in patients with chronic hepatitis b in korea. journal of medical virology. 2011 ;83(7):1172-7. 12. shaikh ma, shaikh wm, solangi ga, shaikh ba, soomro ma. frequency of hepatitis d virus infection in hepatitis b surface antigen-positive liver diseases. j coll physicians surg pak. 2011; 21(1):23-5. 13. roshandel g, semnani s, abdolahi n, besharat s, keshtkar aa, joshaqani h, et al. prevalence of hepatitis d virus infection in hepatitis b surface antigen-positive subjects in golestan province, northeast iran. j microbiol immunol infect 2008; 41(3): 227-30. 14. chakraborty p, kailash u, jain a, goyal r, gupta rk, das bc, et al. seroprevalence of hepatitis d virus in patients with hepatitis b virus-related liver diseases. indian j med res 2005; 122(3):254-7. 15. celen mk, ayaz c, hosoglu s, geyik mf, ulug m. antihepatitis delta virus seroprevalence and risk factors in patients with hepatitis b in southeast turkey. saudi med j 2006; 27(5):617-20. 16. amougou ma, noah dn, moundipa pf, pineau p, njouom r. a prominent role of hepatitis d virus in liver cancers documented in central africa. bmc infectious diseases. 2016; 16(1):647. 17. ott jj, stevens ga, groeger j, wiersma st. global epidemiology of hepatitis b virus infection: new estimates of age-specific hbsag seroprevalence and endemicity. vaccine 2012; 30(12):2212-9. 18. verme g, brunetto mr, oliveri f, baldi m, forzani b, piantino p, et al. role of hepatitis delta virus infection in hepatocellular carcinoma. dig dis sci. 1991; 36(8):1134– 6. 19. brunetto mr, oliveri f, colombatto p, bonino f. hepatocellular carcinoma and infections with multiple hepatitis viruses. princess takamatsu symp. 1995; 25:61– 6. 20. saravanan s1, velu v, kumarasamy n, shankar em, nandakumar s, murugavel kg et al. seroprevalence of hepatitis delta virus infection among subjects with underlying hepatic diseases in chennai, southern india. trans r soc trop med hyg. 2008; 102(8):793-6. 21. schaper m, rodriguez-frias f, jardi r, tabernero d, homs m, et al. quantitative longitudinal evaluations of hepatitis delta virus rna and hepatitis b virus dna shows a dynamic, complex replicative profile in chronic hepatitis b and d. j hepatol 2010;52(5): 658–664. 22. cross tj, rizzi p, horner m, jolly a, hussain mj, et al. the increasing prevalence of hepatitis delta virus (hdv) infection in south london. j med virol 2008; 80(2):277– 282. 23. zachou k, yurdaydin c, drebber u, dalekos gn, erhardt a, et al. quantitative hbsag and hdv-rna levels in chronic delta hepatitis. liver int 2010;30(3): 430–437. 24. heidrich b, deterding k, tillmann hl, raupach r, manns mp, et al. virological and clinical characteristics of delta hepatitis in central europe. j viral hepat 2009;16(12):883–894. 25. williams v, brichler s, radjef n, lebon p, goffard a, et al. hepatitis delta virus proteins repress hepatitis b virus enhancers and activate the alpha/beta interferon-inducible mxa gene. j gen virol 2009; 90(11): 2759–276 26. mumtaz k, ahmed us, memon s, khawaja a, usmani mt, et al. virological and clinical characteristics of hepatitis delta virus in south asia. virol 2011; 8(1): 312. 3 j i m d c 2 0 1 7 3 op e n ac c e ss f u l l l e n g t h a r t i c l e full dose steroid responsiveness within 8 weeks in initial treatment of childhood nephrotic syndrome jai krishin1, maqbool hussain2, aqeela ayub3, saleem abbasi4 1 professor of paediatric, children`s hospital, pakistan institute of medical sciences pims, islamabad 2 associate professor of paediatrics, children`s hospital, pakistan institute of medical sciences, islamabad 3 assistant professor, children`s hospital, pakistan institute of medical sciences, islamabad 4 data manager, ari research cell, children hospital, pakistan institute of medical sciences, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) a b s t r a c t objective: to determine the steroid responsiveness within 8 weeks of the initial treatment of childhood nephrotic syndrome. patients and methods: this prospective study was conducted in children hospital, pakistan institute of medical sciences, islamabad from january 2012 to june 2012. a total of 139 children aged 1 to 10 years of both genders diagnosed as nephrotic syndrome were included in the study. those children who were already taking any form of therapy for nephrotic syndrome were excluded from the study. these children were given prednisolone 60 mg/m2 of body surface area, divided into 3 doses for a period of 8 weeks and then switched over to 40 mg/m2 as a single morning dose on alternate days, in those children who showed a response. the primary outcome of the study was to see the response of steroid therapy at different occasions for up to 8 weeks. spss version 11.0 was used for data analysis. mean and standard deviation were calculated for numerical variables and frequency and percentages were calculated for categorical variables. results: in this study 16.5% of cases responded to steroids within 2 weeks, major bulk of patients (43.5%) showed response between 3-4 weeks, (20.1%) and (2.1%) patients responded between 5-6 weeks and 7-8 weeks respectively. steroid resistant nephrotic syndrome was seen in 16% of the study cases. conclusion: steroids are first line treatment for the idiopathic nephrotic syndrome. the majority of the patients show a response within 8 weeks of their first presentation. maximum number responds between 3-4 weeks. keywords: children, nephrotic syndrome, steroid therapy. author`s contribution 1conception, synthesis and planning of the research, 2,3active participation in active methodology, interpretation and discussion, 4 data analysis address of correspondence dr. maqbool hussain drmaqboolhusssain@gmail.com article info. received: aug 6, 2016 accepted: march 6, 2017 cite this article: krishin j, hussain m, ayub a, abbasi s. full dose steroid responsiveness within 8 weeks in initial treatment of childhood nephrotic syndrome jimdc. 2017; 6(1):3-7. funding source: nil conflict of interest: nil i n t r o d u c t i o n nephrotic syndrome (ns) is characterized by heavy proteinuria (>40 mg/m2/hr), hypoalbuminemia (<2.5 gm/dl), oedema and hypercholesterolemia (>200 mg/dl). it is a very common glomerular disorder in developing countries including pakistan and has significant morbidity and mortality due to various complications. the majority of children with ns show a good response to steroids within 8 weeks of their first presentation. ns is a common glomerular disorder and 15 times more common in children than adults.1 estimates of annual incidence ranges from 2 to 7 new cases in children under 16 years per 100,000 population.2 the general consensus for the o r i g i n a l a r t i c l e 4 j i m d c 2 0 1 7 4 treatment at first presentation is daily induction therapy of prednisolone at 60 mg/m2 given in 3 divided doses for 6 weeks, followed by alternate day maintenance therapy of 40 mg/m2 given as single morning dose for 6 weeks.3 studies found that the longer duration of corticosteroids lasting 12-16 weeks for the initial episode results in higher remission rates, longer duration of remissions and lower rate of subsequent relapses.4-6 thus more aggressive treatment of idiopathic nephrotic syndrome with a longer initial course of corticosteroids (12-16 weeks) may improve the steroid responsiveness and consequently decrease the population of patients labeled as having a steroid-resistant nephrotic syndrome (srns) which is defined as failure to achieve remission on completion of 8 weeks of full dose daily steroids. steroid responsiveness in childhood idiopathic nephrotic syndrome (ins) have been found consistent,1,7 however, in some studies variability has also been reported. numerous reports have shown wide racial and geographical variation in the presentation of ins and response to therapy.8-10 minimal change disease (mcn) is the most common histopathological lesion (85%) and generally has a favorable response to steroids therapy in 85-90% of the patients1,7,11-13 this is followed by focal segmental glomerulosclerosis (fsgs) 10% and mesengial proliferation (5%), which shows less (approx. <20%) response to steroids. approximately 50% of patients with diffuse early membranoproliferative glomerulonephritis (mpgn) show an early response to steroid and undergo complete remission. an additional 20% have continued proteinuria and 6% progress to renal insufficiency and chronic renal failure.14 the present study was planned to estimate the efficacy of steroid responsiveness in childhood nephrotic syndrome within 8 weeks of the first presentation in order to develop strategies to reduce the complications of ins which prove to be fatal in children. p a t i e n t s a n d m e t h o d s this prospective study was conducted at the department of pediatrics medicine at children’s hospital, pakistan institute of medical sciences, islamabad from january 2012 to june 2012. a total of 139 patients, aged 1 to 10 years of both genders, with newly diagnosed nephrotic syndrome, including those patients who were referred from health facilities to the nephrology clinic of the children hospital were included in the study. children who were already taking any form of medication for ns were excluded from the study. similarly, those patients with impaired renal function and secondary etiologies of ns like systemic lupus erythematosus, hersch scholien purpura, sickle cell anemia, malignancies, metabolic disorders, hepatitis and any form of renal malformations were excluded from the study. ethical approval was taken from the ethical committee of pims hospital. a detailed history including history of gross haematuria, hypertension, jaundice, joint pain, rash and drug intake was recorded. patients were evaluated for hypertension, anthropometric parameters (height, weight, body surface area) and systemic involvement. they were investigated for confirmation of nephrotic syndrome and exclusion of secondary causes. after diagnosing ns they were started on prednisolone 60 mg/m2 of body surface area divided into 3 doses for a period of 8 weeks and then switched over to 40 mg/m2 as a single morning dose on alternate days in those patients who showed a response, irrespective of underlying histopathology. the primary outcome of the study was to see the response of steroid therapy at different occasions up to 8 weeks. steroid response was seen and recorded into groups i.e. within 2 weeks, 3-4 weeks, 5-6 weeks and 7-8 weeks. spss versions 11.0 was used for data analysis. the frequency and percentage were calculated for categorical data (gender, steroid response). mean and standard deviations were calculated for numerical data (age, height, weight, body surface area). r e s u l t s in this study, a total of 139 patients with nephrotic syndrome were enrolled. the mean±sd age of study patients was 48.1 months +25.3sd, ranging from 10 to 120 months. the majority of the children 82 (58.9%) were between 24 to 59 months of age. twenty-one (15.1%) children were up to 24 months of age while 36 (25.9%) were off 60 months or above. male gender was found in dominance in this study, comprising of almost 75% patients. the male to female ratio was 2.9 : 1 (table 1). 5 j i m d c 2 0 1 7 5 23 (16.5%) 63 (45.3%) 28 (20.1%) 3 (2.1%) 0 10 20 30 40 50 60 70 n o o f c a s e s up to 2 weeks 3 to 4 weeks 5 to 6 weeks 7 to 8 weeks table 1: demographic characteristic of study patients (n = 139) number percentage age (months) up to 24 24 to 59 60 and above 21 82 36 15.1 58.9 25.9 age (months) age; mean±sd range (min – max) 48.1 (25.3) 10 – 120 gender male female 104 35 74.8 25.2 male:female ratio 2.9: 1 the response of steroid was calculated on different occasions. in this study, 23 (16.5%) of newly diagnosed nephrotic syndrome patients responded to steroids within 2 weeks of therapy. the response rate between 3 to 4 weeks was even high as 63 (45.3%) of study patients responded in this period. out of the total 139 patients, 28 (20.1%) patients responded between 5 to 6 weeks of therapy. similarly, 3 (2.1%) cases responded between 7 to 8 weeks of initiation of steroid therapy. however, 22 (16.0%) of patients showed no response to steroid even in 8 weeks and were labeled as steroid resistant. (figure i) time of steroid response figure i: the trend of steroid response in the study (n = 139) we also analyzed the steroid response according to the gender of patients. out of total 104 male patients, 20 (19.2%) responded within 2 weeks, 50 (48.1%) responded between 3 to 4 weeks, 19 (18.2%) responded between 5 to 6 weeks while 1 (0.9%) patient responded between 7 to 8 weeks. fourteen (13.4%) of the male patients showed resistance. similarly, out of total 35 female patients, 4 (11.4%) responded within 2 weeks, 13 (37.1%) responded between 3 to 4 weeks, 9 (25.7%) responded between 5 to 6 weeks and 1 (2.8%) patient responded between 7 to 8 weeks. eight (22.8%) of the females were found resistant to steroid therapy (table 2). table 2. steroid response according to gender. male (n = 104) n(%) female (n = 35) n(%) up to 2 weeks 20 (19.2) 4 (11.4) 3 to 4 weeks 50 (48.1) 13 (37.1) 5 to 6 weeks 19 (18.2) 9 (25.7) 7 to 8 weeks 1 (0.9) 1 (2.8) resistance to steroids 14 (13.4) 8 (22.8) while analyzing steroid response according to age of the patients it was found out that of the total 22 patients of up to 24 months, 4 (18.1%) responded within 2 weeks, 11 (50.0%) responded between 3 to 4 weeks, 3 (13.6%) responded between 5 to 6 weeks while 1 (4.5%) patient responded between 7 to 8 weeks. three (13.6%) of the under 24 months’ patients showed resistance to steroid therapy. similarly, out of total 82 patients between 24 and 59 months of age, 16 (19.5%) responded within 2 weeks, 36 (43.9%) responded between 3 to 4 weeks, 18 (21.9%) responded between 5 to 6 weeks and 0 (0.0%) patient responded between 7 to 8 weeks. twelve (14.6%) of the patients were found to have resistance to steroid therapy. out of 35 patients of 60 or above months of age, 4 (11.4%) responded within 2 weeks, 16 (45.7%) responded between 3 to 4 weeks, 7 (20.0%) responded between 5 to 6 weeks and 1 (2.8%) patient responded between 7 to 8 weeks. while 7 (20.0%) of the patients were found to have resistance against steroid therapy in this age group. (table 3) overall out of 139 patients, 22 (16.0%) had steroid-resistant nephrotic syndrome (srns). 6 j i m d c 2 0 1 7 6 table 3: steroid response according to age. up to 24 mon (n = 22) n(%) 24-59 mon (n = 82) n(%) 60 and above (n = 35) n(%) up to 2 weeks 4 (18.2) 16 (19.5%) 4 (11.4) 3 to 4 weeks 11 (50.1) 36 (43.9) 16 (45.7) 5 to 6 weeks 3 (13.6) 18 (21.9) 7 (20.0) 7 to 8 weeks 1 (4.5) 0 (0.0) 1 (2.8) resistance to steroids 3 (13.6) 12 (14.6) 7 (20.0) d i s c u s s i o n nephrotic syndrome is the most common chronic glomerular disease in children. in 85% of children, there is minimal change disease and it generally has a favorable response to glucocorticoid therapy in 90% of patients.1 in about 40% of the steroid-sensitive nephrotic syndrome (ssns), relapse may occur and some of these patients may become steroid dependent. response to steroids also vary geographically.15-17 in few studies from the african region, the steroid response rate was as low as 20% in children with nephrotic syndrome while some reports showed paucity of minimal change disease and also poor response to steroids.15-17 in our study patients, demographic features are comparable to these reports where we found out the mean age of 4.1 years with male population in majority 75%. the dominance of male gender in our study could be due to the social norms in the developing world as parents and caretakers give priority care to boys compared to girls even for medical consultation. in a study by safaei a and maleknejad s on the spectrum of childhood nephrotic syndrome, the mean age of patients was 4.8 years and the male population was dominant with 66% proportion.18 in another study the mean age of patients was 5.8 years and gender distribution was equal with 50% in each strata.12 in this study conducted for evaluation of steroid response in children with ns, 17% of cases responded to steroids within 2 weeks, 46% responded between 3 to 4 weeks while 22% and 9% patients responded to steroid between 5 to 6 weeks and 7 to 8 weeks respectively. it was proven again that ns responds well to steroids in the pediatric population as more than 60% of our patients responded within 4 weeks of start of therapy. steroid resistance was found in 16.0% of our cases. in a local study by azam m and colleagues on nephrotic syndrome, the steroid response was reported to be 76% within 4 weeks of therapy, 16% responded within 8 weeks of steroid therapy while 6% did not responded even after 8 weeks.8 in another study by anochie i and colleagues on the pattern of steroid response in children with ns after 1 month of therapy, more than 70% had responded well and 57% got complete remission while 14.3% had resistance against steroids. another 14.3% had frequent relapsing nephrotic syndrome and became steroid dependent.12 in a study from iran it was reported that 66% children with nephrotic syndrome were steroid sensitive, 20% were steroid resistant while 14% were steroid dependent.18 the above-mentioned steroid response rate is comparable to our study findings, we found out that more than 60% of the children responded to steroid within 4 weeks of therapy, 22% responded between 5 to 6 weeks while 10% responded between 7 to 8 weeks after start of steroid therapy. in our study, more than 53% of the responders were between 2 to 6 years of age. these findings are almost similar to anochie i’s study, where they noted that about 50% of cases who responded to steroid therapy were between 1 to 4 years.12 the steroid response according to the gender of patients was quite similar. out of total 104 males, 18.2% responded within 2 weeks, 48.1% responded between 3 to 4 weeks, 18.2% responded between 5 to 6 weeks while 0.9% responded between 7 to 8 weeks. similarly, of total 35 female patients, 11.4% responded within 2 weeks, 37.1% responded between 3 to 4 weeks, 25.7% responded between 5 to 6 weeks and 2.8% responded between 7 to 8 weeks. overall out of 139 study patients, 22 (16.0%) had steroidresistant nephrotic syndrome (srns). in a study by iyengar a and colleagues, steroid resistance was found in 36% of under 24 months’ patients while in 46.2% patients above 24 months of age.19 overall 58.3% of their study patients had steroid resistance, which was quite high compared to our study as we found steroid resistance in 16% cases. another study from iran reported a similar (20.0%) resistance to steroids which is close to our study findings.18 the current study was one of the very few 7 j i m d c 2 0 1 7 7 prospective trials done in the local settings on children with nephrotic syndrome. the sample size was adequate for a reasonable study population comprising of 139 children. one of the benefits of the study is that steroid response has been evaluated in almost all pediatric age groups from 1 year to 10 years. there were few limitations of the current study, as there was no collection of information regarding patients presenting complaints and etiology of the disease. a more dynamic approach of collection study information would have provided some details regarding etiology of study patients and understanding the pattern of steroid response better. c o n c l u s i o n our study approves the scientific evidence in favor of steroids for children with nephrotic syndrome. idiopathic nephrotic syndrome is a constant presentation in our setting and steroids can be a sensitive drug for its treatment. the majority of the patients showed a response within 8 weeks of their first presentation. most of these patients respond to steroid therapy during 4 weeks of initiation of treatment. there is also a need to study different doses of steroids for the different duration in these patients to check efficacy. r e f e r e n c e s 1. kliegman rm, behrman re, jenson hb, stanton bf. nephrotic syndrome. in: nelson textbook of paediatrics. 20th edition. saunders 2015; 2521-2. 2. nadir sj, saleem n, amin f, mehmood kt. steroid sensitive nephrotic syndrome in paediatrics. pak j pharm sci 2011; 24: 207-10. 3. gipson ds, massengill sf, yao l. management of childhood onset nephrotic syndrome. pediatrics. 2009; 124:747-57. 4. hodgson em, willis ns, craig jc. corticosteroid therapy for nephrotic syndrome in children. cochrane database syst rev 2007;4:cd001533 5. harambat j, stralen kj, kim jj, tizard ej. epidemiology of chronic kidney disease in children. pediatr nephrol. 2012; 27: 363–73. 6. kim yc, lee tw, lee h, koo hs, oh kh. complete remission induced by tacrolimus and low-dose prednisolone in adult minimal change nephrotic syndrome: a pilot study. kidney research and clinical practice 2012; 31: 112–7. 7. bhimma r. steroid sensitive nephrotic syndrome in children. j nephrol therapeutic 2014; s11:003. doi:10.4172/2161-0959.s11-003 8. azam m, suleman h, khan pa. nephrotic syndrome. professional med j 2005;12:23-31 9. arif mk, arif m, amjad n. a histopathological outlook on nephrotic syndrome: a pediatric perspective. indian j nephrol. 2016 ; 26(3): 188–91. 10. landau d, oved, geiger d, abizov l, shalev h, parvari r. familiar steroid sensitive nephrotic syndrome in southern israel; clinical and genetic observations. pediatric nephrol 2007;22:661-9. 11. kayange nm, smart lr, tallman je, chu ey, fitzgerald dw, et al. kidney disease among children in sub-saharan africa: systematic review. pediatric research 2015; 77: 272– 281. 12. anochie i, eke f, okpere a, harcourt p. childhood nephrotic syndrome: change in pattern and response to steroids. j national med assoc 2006; 98: 1977-81 13. kari ja, halawani m, mokhtar g, jalalah sm, anshasi w. pattern of steroid resistant nephrotic syndrome in children living in the kingdom of saudi arabia: a single center study. saudi j kidney dis transpl 2009;20:854-7 14. agraharka m. nephrotic syndrome, [online] 2007. available from url: http://www.emedicine.com/med/topic 1612.htm 15. abdelraheem mb, ali etm, mohamed rm, hassan eg, abdalla oa, et al. pattern of glomerular diseases in sudanese children: a clinico-pathological study. saudi j kidney dis transpl 2010;21:778-83. 16. bhimma r. steroid sensitive nephrotic syndrome in children. j nephrol therapeutic 2014; s11: 003. doi:10.4172/2161-0959.s11-003. 17. amin j. barakat. presentation of the child with renal disease and guidelines for referral to the pediatric nephrologist. international journal of pediatrics 2012; vol. 2012, article id 978673, 5 pages, 2012. doi:10.1155/2012/978673 18. safaei a, maleknejad s. spectrum of childhood nephrotic syndrome in iran: a single center study. indian j nephrol 2009; 19: 87-90. 19. iyengar a, karthik s, kumar a, biswas s, phadke k. cyclosporine in steroid dependent and resistant childhood nephrotic syndrome. indian pediatr 2006;43:14-19. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3264851/ http://www.sciencedirect.com/science/article/pii/s2211913212003531 http://www.sciencedirect.com/science/article/pii/s2211913212003531 http://www.sciencedirect.com/science/article/pii/s2211913212003531 http://www.sciencedirect.com/science/article/pii/s2211913212003531 http://www.sciencedirect.com/science/article/pii/s2211913212003531 http://www.sciencedirect.com/science/journal/22119132 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4862264/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4862264/ https://www.ncbi.nlm.nih.gov/pubmed/?term=kari%20ja%5bauthor%5d&cauthor=true&cauthor_uid=19736491 https://www.ncbi.nlm.nih.gov/pubmed/?term=halawani%20m%5bauthor%5d&cauthor=true&cauthor_uid=19736491 https://www.ncbi.nlm.nih.gov/pubmed/?term=mokhtar%20g%5bauthor%5d&cauthor=true&cauthor_uid=19736491 https://www.ncbi.nlm.nih.gov/pubmed/?term=jalalah%20sm%5bauthor%5d&cauthor=true&cauthor_uid=19736491 https://www.ncbi.nlm.nih.gov/pubmed/?term=anshasi%20w%5bauthor%5d&cauthor=true&cauthor_uid=19736491 https://www.ncbi.nlm.nih.gov/pubmed/19736491 http://www.emedicine.com/med/topic%201612.htm http://www.emedicine.com/med/topic%201612.htm j islamabad med dental coll 2022 229 open access role of steroids in reducing recurrence of urethral stricture after direct vision internal urethrotomy umer farooq1, faraz basharat khan2, irfan ahmed3, muhammad nawaz4, shabbar hussain changazi5, muhammad imran6 1consultant, department of urology, regional head quarter hospital, gilgit, pakistan. 2consultant, department of urology, basharat hospital, rawalpindi, pakistan. 3assistant professor, department of urology, pims, pakistan. 4consultant, department of urology, armed forces institute of urology, rawalpindi, pakistan. 5assistant professor, department of surgery, services institute of medical sciences, lahore, pakistan. 6consultant, department of surgery, regional head quarter hospital, gilgit, pakistan. a b s t r a c t background: recurrence of urethral strictures is the most frequent and bothersome complication, with majority of stricturesrecurring after optical internal urethrotomy. the objective of this study was to establish the role of oral steroid therapy after direct vision internal urethrotomy (dviu) in minimizing recurrence of urethral stricture. methodology: it was a randomized controlled trial carried out at armed forces institute of urology, rawalpindi from january 2018 to march 2021. a total of 180 male patients with urethral stricture of ≤2 cm were included. patients with traumatic stricture, post-anastomotic urethroplasty strictures, neurogenic bladder and history of steroid intake were excluded. patients were randomly categorized into two groups i.e. group a patients were given oral prednisolone (6 mg tablet twice daily for 4 weeks) while group b was control group. patients were followed up to 12 months for recurrence of stricture. results: the mean age of patients in group a was 44.38 ± 8.03 years while in group b was 46.64 ± 6.66 years. the mean length of stricture in group a was 0.93 ± 0.26 cm and in group b was 0.95 ± 0.27 cm. recurrence of stricture was seen in 18 (20.0%) patients in group a (oral steroids group) and 42 (46.67%) patients in group b (no oral steroids) with pvalue of 0.0001. conclusion: oral prednisolone therapy after internal urethrotomy waseffective in decreasing the rate of recurrence of urethral stricture. keywords: oral, recurrence, steroid, urethral stricture. authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3, 4 critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: shabbar hussain changazi email: shabbar changazi246@gmail.com article info: received: october 19, 2021 accepted: december 27, 2022 cite this article. farooq u, khan f b, ahmed i, nawaz m, role of steroids in reducing recurrence of urethral stricture after direct vision internal urethrotomy. j islamabad med dental coll. 2022; 11(4): doi: https://doi.org/10.35787/jimdc.v11i4.799 conflict of interest: nil funding source: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2022 230 i n t r o d u c t i o n urethral stricture is narrowing of the anterior urethral caliber. any insult to the urethra disrupts the pseudostratified columnar epithelium, causing the extracellular tissue in the corpus spongiosum to scar during healing and ultimately fibrosis.1, 2urethral stricture is the most frequent cause of admissions in urological department. not only it adversely effects the quality of life of the patients but in addition increases the cost of treatment and financial burden to the patient due to sequelae of urinary stasissuch as urinary tract infections, bladder stones, fistulas and extreme cases renal failure.3, 4 male population is highly susceptible to urethral stricture due to long length of urethra. majority of strictures (80%) are iatrogenic and usually occurs at the level of membranous urethra. urinary procedures such as catheterization, cystoscopy, transurethral prostate surgeries result in injury to urethra, which heals with fibrosis resulting in stricture.5, 6, 7 other causes of urethral strictures include infection of urethra (commonly due to gonococcus or chlamydia) and malignancy of urethra.8 urethral stricture disease may be asymptomatic or may present with certain symptoms like weak urinary stream, urinary hesitancy, dribbling, urinary retention or recurrent urinary tract infections.9, 10 current management options for urethral stricture include urethral dilatation, direct vision internal urethrotomy (dviu), urethroplasty, and regenerative therapies. direct vision internal urethrotomy is the most widely used procedure for urethral stricture.10 despite of expert surgical hand, recurrence is the most common and unwanted complication of dviu. recurrence risk is also associated to the length of the stricture, the location of the stricture and follow-up length since the procedure. in addition, the risk of recurrence increases exponentially after subsequent urethrotomy.11, 12 different methods have been used to decrease the risk of recurrence following dviu. some studies have shown promising results when local steroid or mitomycin injections are used following dviu to reduce the risk of recurrence. some centers have also proposed selfcatheterization to reduce recurrence.6, 11while many trials have shown reduced recurrence with intralesional steroids use, there is limited data on oral steroids for this purpose.13therefore, this study was conducted to establish the role of oral steroids after dviu to prevent the recurrence of strictures in the local population. m e t h o d o l o g y this randomized controlled trial was conducted at armed forces institute of urology (afiu), rawalpindi from january 2018 to march 2021.the study was registered at clinicaltrials.gov identifier: nct05069883.a sample size of 180 patients was computed (n=90 in the oral steroid group, n=90 in the control group) at 80% power and 95% confidence interval, considering estimated percentage of 19.44% and 36.11% of recurrence in the steroid group and control group, respectively.5this study was approved by ethical review committee of afiu. all male patients between the age group of 20-60 years presenting with urethral stricture of length ≤2 cmresulting from iatrogenic or inflammatory causes with urine flow of less than 15 ml/min on uroflowmetry and dilation of proximal urethra and prostatic ducts on retrograde urethrogram were enrolled in the study after taking informed consent. patients with urethral stricture after anastomotic urethroplasty, patients with stricture after transurethral resection of prostate, patients with neurogenic bladder, patients with history of steroid intake and patients with extravasation during optical internal urethrotomy (oiu) were excluded from the study. patients were randomly distributed into two equal groups a and b. randomization was carried out through lottery method. in both groups direct internal visual urethrotomy (dviu) was performed j islamabad med dental coll 2022 231 under spinal anesthesia by consultant urologist (at least three years of post-fellowship experience). in dviu, a urethrotome (21 fr) was inserted into the urethral orifice and advanced up to stricture. the stricture was then incised at 5, 7 and 12 o’ clock position with a cold knife under the guidance of guide wire. the urethrotome was then advanced till it reaches the urinary bladder. once the uretherotome reached the urinary bladder,it was removed and a 16 french foley’s catheter was inserted over the guide wire which was kept for 7 days. group a patients were given predisolone 5 mg tablet twice daily for 4 weekswhile group b patients were given placebo(specially designed pill) and double blinding ensured. patients were then followed weekly for first month then monthly for next 6 months. recurrence was measured in terms of restricted urine flow (<15 ml/min) on uroflowmetry and/or dilation of the proximal urethra and prostatic ducts (on retrograde urethrogram) after six months of treatment. all the data (age, length of stricture, site of stricture and efficacy) was recorded on a specially designed performa. statistical analysis was performed using spss version 25. quantitative variables such as age, duration of stricture and length of stricture were expressed as mean and standard deviation (sd). qualitative variables like site of stricture (penile/bulbar/membranous/prostatic) and recurrence of stricture were presented as frequency and percentage. the recurrence of stricture was compared using a chi-square test. stratification was done for age, duration of stricture, site of stricture and length of stricture. poststratification chisquare test was applied to see their effect on recurrence of stricture. a p-value <0.05 was considered as statistically significant. r e s u l t mean age of patients in the study population was 44.95 + 7.98 years with an age range of 20-60 years. majority of the patients 55 (70.51%) were lying between the age group of 41 to 60 years. baseline characteristics of the patients in both groups are elaborated in table 1. patients were further divided in both groups according to site of stricture. in group a, 11(12.2%) patients presented with a stricture in penile urethra, 44 (48.9%) patients bulbar urethra, 15 (16.7%) patients membranous urethra and 20 (22.2%) patientswith prostatic urethra. in group b, 13 (14.4%) patients developed stricture in penile urethra, 45 (50%) patients in bulbar urethra, 14 (15.6%) patients in membranous urethra and 18 (20%) patients in prostatic urethra. both groups showed maximum number of patients presenting with a stricture in bulbar area. recurrence of stricture was observed in 18 (20.0%) patients in group a (oral steroids group) while 42 (46.67%) patients in group b (no oral steroids) with p-value of 0.0001. stratification for recurrence among the groups with respect to age, site of stricture, length of stricture and duration of stricture is shown in table 2. majority of the stratified groups showed significant difference in recurrence between table i: baseline characteristics of the patients (n=180) baseline characteristics group a (n=90) (mean + sd) group b (n=90) (mean + sd) age (years) 44.38 ± 8.03 46.64 ± 6.66 duration of strictures (months) 4.33 ± 1.57 4.38 ± 1.53 length of stricture (cm) 0.93 ± 0.26 0.95 ± 0.27 j islamabad med dental coll 2022 232 group a and b. however, no statistically significant difference was noted between the groups in patients presenting with a stricture in membranous or prostatic area and with a stricture of less than four months duration. d i s c u s s i o n there are multitude of surgical options for the management of urethral strictures depending upon the site, etiology and length of stricture. different surgical procedures include urethral dilation, internal urethrotomy and reconstructive procedures such as urethroplasty. urinary diversion is usually required for long stricture in those patients which are not fit for complex surgical procedures. these surgical procedures can be done easily in any ambulatory settings; however, the main concern is risk of high recurrence of stricture. there is still lack of consensus on the best available solution to lessenthe recurrence of strictures. our study aimed to demonstrate the role of oral steroid therapy after dviu in reducing the rate of stricture recurrence.14 in this study, there is a low recurrence rate of stricture after internal urethrotomy with patients taking oral steroid therapy as compared to the patients without taking oral steroid therapy. similarly in a study conducted by gupta et al15, the recurrence rate of urethral stricture after internal urethrotomy with oral steroid therapy was reported as 19.4% while it was 36.1% in control group, a finding concurrent with our study. mazdak et al16 carried out a clinical trial in 50 patients with urethral stricture. according to this study, patients taking oral steroids after internal urethrotomy had recurrence rate of 21.7% while patients with only internal urethrotomy had recurrence rate of 50% after a mean follow-up time of 13.7 + 5.5 months. these results are also in concordance with our study. this study demonstrated that there was an increased efficacy of oral steroids in patients with stricture less than 1 cm as compared to those with stricture more than 1 cm. kumar et al17 conducted a study with total of fifty patients with less than 3 cm urethral stricture managed with holmium laser with intralesional steroid (triamcinolone). the recurrence in patients presenting with strictures less than 1 cm in length was 4.2%, while patients who developed urethral strictures of 1 to 3 cm in length, the recurrence was 42.3%. these results are similar to our study. furthermore, there is also role of intralesional steroid therapy in reduction of stricture recurrence. a study conducted by modh et al18 evaluated the role of intralesional steroid after optical internal urethrotomy. the study concluded that high doses of steroid injections played a definite role in table ii:stratification of efficacy in both groups according to age, length of stricture, site of stricture and duration of stricture in both groups(n=180) variables group a (n=90) group b (n=90) p-value recurrence recurrence yes no yes no age(years) 20-40 years 10 28 10 08 0.033 41-60 years 08 54 22 40 0.0001 length(cm) <1 cm 16 46 30 29 0.005 1-2 cm 02 26 12 19 0.004 site of stricture penile 06 05 02 11 0.043 bulbar 04 40 26 19 0.0001 membranous 01 14 05 09 0.054 prostatic 07 13 09 09 0.350 duration (months) <4 months 12 24 06 30 0.102 >4 months 06 48 36 18 0.0001 j islamabad med dental coll 2022 233 reduction of recurrence rate of strictures. in another placebo-controlled trial conducted by tabassi et al19, 70 patients treated with internal urethrotomy were enrolled, 34 were given intraurethral submucosal triamcinolone injection and rest 36 were taken as the control group. the study demonstrated that the steroid group had significantly decreased time to recurrence (8.08 ± 5.55 months) as compared to the control group (3.6 ± 1.59 months). there was no associated complication from steroid injection in the study. finally, there is also role of local steroid in lessening stricture recurrence after internal urethrotomy. a systematic review of eight studies with patient population 0f 203 patients done by zhang et al20 in 2014 reported that dviu with steroid therapy were shown to have significant reduction in recurrence time as compared to dviu alone (10.14 months in steroid group versus 5.07 months in control group, p < 0.00001). our study has certain limitations. firstly, it was a single center study. secondly,we assessed the efficacy of steroids at a fixed dose. lastly, we had a follow up of 6 months. there is a need for more vast research studies assessing the efficacy of steroids at different doses with longer follow ups. c o n c l u s i o n oral prednisolone therapy after internal urethrotomy was effective in decreasing the rate of recurrence of urethral stricture. r e c o m m e n d a t i o n oral prednisolone therapy for 4 weeks after optical internal urethrotomy should be considered in selective patients of urethral stricture to reduce the risk of recurrence. r e f e r e n c e s 1. bayne db, gaither tw, awad ma, murphy gp, osterberg ec, breyer bn. guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up. translational andrology and urology. 2017 apr;6(2):288. doi: 10.21037/tau.2017.03.55 2. yenice mg, seker kg, sam e, colakoglu y, atar fa, sahin s, et al. comparison of cold-knife optical internal urethrotomy and holmium: yag laser internal urethrotomy in bulbar urethral strictures. central european journal of urology. 2018;71(1):114.doi: 10.5173/ceju.2017.1391 3. verla w, waterloos m, lumen n. urethroplasty and quality of life: psychometric validation of a dutch version of the urethral stricture surgery patient reported outcome measures. urologiainternationalis. 2017;99(4):460-6.doi: 10.1159/000479189 4. verla w, oosterlinck w, spinoit af, waterloos m. a comprehensive review emphasizing anatomy, etiology, diagnosis, and treatment of male urethral stricture disease. biomed research international. 2019 apr 18;2019.article id 9046430.doi: 10.1155/2019/9046430 5. davis nf, quinlan mr, bhatt nr, browne c, maccraith e, manecksha r, et al.incidence, cost, complications and clinical outcomes of iatrogenic urethral catheterization injuries: a prospective multi-institutional study. the journal of urology. 2016 nov 1;196(5):1473-7. doi: 10.1016/j.juro.2016.05.114. 6. chen c, zeng m, xue r, wang g, gao z, yuan w, et al. causes and management for male urethral stricture. zhong nan da xuexue bao. yi xue ban= journal of central south university. medical sciences. 2018 may 1;43(5):5207.doi: 10.11817/j.issn.1672-7347.2018.05.010 7. kizilay f, simşir a, ozyurt s. analysis of recurrent urethral strictures due to iatrogenic urethral trauma. turk j med sci. 2017;47:1543-48. doi: 10.3906/sag-1701-36. 8. king c, rourke kf. urethral stricture is frequently a morbid condition: incidence and factors associated with complications related to urethral stricture. urology. 2019 oct 1;132:189-94.doi: 10.1016/j.urology.2019.07.013. 9. wessells h, angermeier kw, elliott s, gonzalez cm, kodama r, peterson ac, et al. male urethral stricture: american urological association guideline. the journal of urology. 2017 jan;197(1):182-90. doi: 10.1016/j.juro.2016.07.087 10. ekeke on, amusan oe. clinical presentation and treatment of urethral stricture: experience from a tertiary hospital in port harcourt, nigeria. african journal of urology. 2017 mar 29;23(1):72-7.doi: org/10.1016/j.afju.2016.06.003 https://dx.doi.org/10.21037%2ftau.2017.03.55 https://dx.doi.org/10.5173%2fceju.2017.1391 https://doi.org/10.1159/000479189 https://doi.org/10.1159/000479189 https://doi.org/10.1155/2019/9046430 https://doi.org/10.1155/2019/9046430 https://doi.org/10.11817/j.issn.1672-7347.2018.05.010 https://doi.org/10.1016/j.afju.2016.06.003 https://doi.org/10.1016/j.afju.2016.06.003 j islamabad med dental coll 2022 234 11. kluth la, ernst l, vetterlein mw, meyer cp, reiss cp, fisch m, et al.direct vision internal urethrotomy for short anterior urethral strictures and beyond: success rates, predictors of treatment failure, and recurrence management. urology. 2017 aug 1;106:2105.doi:10.1016/j.urology.2017.04.037 12. pickard r, goulao b, carnell s, shen j, maclennan g, norrie j, et al.open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the open rct. health technology assessment (winchester, england). 2020 nov;24(61):1. doi: 10.3310/hta24610 13. yıldırım me, kaynar m, ozyuvali e, badem h, cakmak m, kosem b, et al.the effectiveness of local steroid injection after internal urethrotomy to avoid recurrence. archivioitaliano di urologia e andrologia. 2015;87(4):295-8.doi: 10.4081/aiua.2015.4.295 14. mundy ar, andrich de. urethral strictures. bju international. 2011;107(1):6– 26. doi: 10.1111/j.1464-410x.2010.09800.x. 15. gupta s, roy s, pal dk. efficacy of oral steroids after optical internal urethrotomy in reducing recurrence of urethral strictures. turk j urol. 78 2018;44(1):42–4. doi: 10.5152/tud.2017.66564. 16. mazdak h, izadpanahi mh, ghalamkari a. internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. international urology and nephrology. 2010;42(3):565–568. doi: 10.1007/s11255-0099663-5. 17. kumar s, kapoor a, ganesamoni r, nanjappa b, sharma v, mete uk. efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture. korean j urol. 2012;53:614–8. doi:10.4111/kju.2012.53.9.614. 18. modh r, cai py, sheffield a, yeung ll. outcomes of direct vision internal urethrotomy for bulbar urethral strictures: technique modification with high dose triamcinolone injection. adv urol. 2015;28:1969. doi: 10.1155/2015/281969. 19. tabassi kt, yarmohamadi a, mohammadi s. triamcinolone injection following internal urethrotomy for treatment of urethral stricture. urology journal. 2011;8(2):132– 136.https://journals.sbmu.ac.ir/urolj/index.php/u j/article/view/1024/549 20. zhang k, qi e, zhang y, sa y, fu q. efficacy and safety of local steroids for urethra strictures: a systematic review and meta-analysis. j endourol. 2014;28(8):962–968. doi: 10.1089/end.2014.0090. https://doi.org/10.1016/j.urology.2017.04.037 https://dx.doi.org/10.3310%2fhta24610 https://doi.org/10.4081/aiua.2015.4.295 https://doi.org/10.4081/aiua.2015.4.295 https://journals.sbmu.ac.ir/urolj/index.php/uj/article/view/1024/549 https://journals.sbmu.ac.ir/urolj/index.php/uj/article/view/1024/549 j islamabad med dental coll 2022 158 open access outcome of ultrasound guided trucut biopsy of adnexal masses with suspected malignancy syeda zakia shah1, sara shahid2, syed murtaza hussain3, hadia hina4, hyder wajid abbasi5, haseeb noor6. 1assistant professor, radiology department, pims, islamabad. 2medical officer, radiology department, pims, islamabad. 3medical officer, cda hospital, islamabad. 4assistant professor, gynaecology department, pims, islamabad. 5medical officer, department of gastroenterology, pims, islamabad. 6medical officer, polyclinic hospital, islamabad. a b s t r a c t background: ultrasound guided sampling techniques are frequently used in the tissue diagnosis of various tumours. female patients commonly present with adnexal masses and require tissue diagnosis by trucut biopsy for initiation of the treatment. this study was done to determine the outcome of ultrasound guided trucut biopsy in patients presenting with suspected adnexal malignancy. methodology: this cross sectional study was done at the department of radiology, mch centre, pims hospital, islamabad from october 2018 to september 2020. in this study, all female patients aged 18 years and above with suspected adnexal malignancy were included. trucut biopsy was performed under ultrasound guidance, sample sent for histopathology and various histopathological outcomes were assessed. patients were kept under observation for 2 hours following biopsy. the data was entered and assessed by using spss version 24.0. frequencies and percentages were calculated for nominal data and mean and standard deviation for numerical data. results: mean age of the subjects was 50.24±10.52 years and mean duration of symptoms was 2.97±1.23 months. definitive diagnosis made in 59 (95.1%) out of 62 cases and only 3 (0.04%) cases were inconclusive; among which two showed inadequate sample and one showed normal tubo-ovarian tissue. 90% histopathological findings were conclusive and no complication was reported. conclusion: trucut biopsy has high diagnostic yield with no complications and most common malignancy detected was serous cystadenocarcinoma followed by mucinous carcinoma. key words: biopsy, malignancy, ultrasound authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: syeda zakia shah email: sphoolsh@gmail.com article info: received: july 10, 2021 accepted: september 20, 2022 cite this article. shah z s, shahid s, hussain m s, hina h, abbasi w h, noor h. outcome of ultrasound guided trucut biopsy of adnexal masses with suspected malignancy.j islamabad med dental coll. 2022; 11(3): 158-163 doi: https://doi.org/10.35787/jimdc.v11i3.742 funding source: nil conflict of interest: nil i n t r o d u c t i o n adnexal mass etiology accounts for a substantial number of gynaecologic diseases and approximately 10% of females undergo surgery for adnexal masses during their life. 1-2 despite great evolution in cancer control and healthcare, mortality from ovarian cancer is still rising high due to late stage diagnosis of the disease thus significantly affecting the 5-year survival rate of only 47.4%, whilst only 14.9% of ovarian cancers are diagnosed when localized with a remarkable survival rate of 92.3%.3 o r i g i n a l a r t i c l e j islamabad med dental coll 2022 159 the most common associated risk factors are higher age, postmenopausal status, radiation exposure, smoking and family history of malignancies. abdominal pain, distension, weight loss and bleeding are the cardinal manifestations of these lesions and early and prompt diagnosis is the key to success.4-5 apart from the detailed history and clinical examination, ultrasonography (usg) and contrast enhanced computed tomography (ct) are the investigations of choice. the cardinal features leading towards malignant etiology include complex solid cum cystic mass, multiloculated mass with irregular walls, vascularity on colour doppler, presence of ascites and the increasing biomarker production like ca125.6 with advent of neoadjuvant chemotherapy, biopsy is desired investigation for pathologic diagnosis to initiate therapy. in addition, metastatic gastrointestinal tumours such as colon, gastric, and pancreatic adenocarcinomas and even breast cancer can mimic ovarian cancer therefore tissue diagnosis is ultimately needed to reach a definitive diagnosis and to target management therapy.7 it can be done either through needle biopsy under image guidance or open or laparoscopic surgical biopsies where latter are invasive and require general anaesthesia. belinga et al reported 6.77% complication rate in gynaecological laparoscopic procedures. 8 trucut biopsy is an easy and cheap method with relatively lesser risk associated to reach a definitive diagnosis. addition of immunohistochemistry staining can also increase the probability of diagnosis. biopsy sample can be obtained through various imaging modalities like ultrasound, fluoroscopy, ct and mri. ct and fluoroscopy cause exposure to considerable amount of ionizing radiation. leng et al. found that the mean dlpbody (dose length product) of ct-guided interventional procedure was 909 mgy cm thus resulting in significant exposure to patient as well as to the staff.9 mr guided biopsy also becomes tough with hefty price and requiring all instruments to be mr compatible. therefore, ultrasound is the most convenient option with no radiation exposure, ease of portability, real time imaging and being cost effective. 10 perfection in imaging of adnexal mass characterization can lead to appropriate triage, resulting in better treatment outcomes. 11so far very few studies have been reported on the outcome of ultrasound guided biopsy. image guided biopsy plays an important role in providing quick and fast definitive histological diagnosis, making invasive debulking surgeries ineffectual and unnecessary for initiation of neoadjuvant chemotherapy. the current study was conducted to acknowledge the efficacy of the procedure by confirming it with the histopathological report as well as recognizing various tumour subtypes in adnexal lesions histologically. m e t h o d o l o g y this descriptive cross-sectional study was performed in pims hospital, islamabad from october 2018 to september 2020. the study included patients with suspected malignancy who were being referred on opd basis to the radiology department for establishing definite diagnosis through ultrasound guided trucut biopsy. in this study, all female patients with age ranging from 18 years and above, presenting with abdominal pain with or without distension and with history of weight loss were recruited. they were assessed with ultrasound for adnexal mass with or without ascites. the inclusion criteria had specification for the mass that was solid/ complex cystic lesion containing thick septa or solid component with in it. the size of the mass not more than 2cm was considered for the study. large cystic lesions without thick internal septation or solid component, patients having gut loops anterior to the adnexal lesion and patients j islamabad med dental coll 2022 160 having bleeding diathesis were excluded from this study. the sample size calculated was 62 using epitools sample size calculator, by keeping the confidence interval as 95%, estimated proportion of 95.8% and desired precision of 0.05.12 the data was entered and assessed by using spss version 24.0. frequencies and percentages were calculated for nominal data and mean and standard deviation for numerical data. ethical certificate was obtained prior to commencing the study from hospital’s ethical committee. (reference number f.1-1/2015/erb/szambu/759). for ultrasound-guided trucut biopsy, coagulation profile of the patient was done initially. if normal, then written consent from the patients/ patients’ attendants was taken. site of biopsy needle insertion was marked with ultrasound guidance. under strict aseptic measures, local anaesthetic was administered (10 ml of 1% xylocaine) for trans abdominal biopsy. a trucut monopty needle of 18 gauge was used for the procedure. the tip of the biopsy needle was carefully visualized on monitor of ultrasound machine (aplio500) avoiding injury to gut loops, major vessels and areas with high vascularity with in the lesion. biopsy sample was taken from solid component or thick internal septation avoiding cystic/ necrotic areas, preserved in formalin, and sent for histopathology and immunohistochemistry. figure 1. needle tracking under ultrasound guidance with aided colour doppler to avoid areas with high vascularity with in the lesion. if either a benign or malignant tumor was acknowledged on biopsy report, the procedure was labelled as accurately performed. in patients with inconclusive results on gross and microscopic histopathology report, immunohistochemistry staining was done to reach a definitive diagnosis and when that also failed to give result, report was considered inconclusive. the final outcome was recorded. r e s u l t s in this study, 62 cases with suspected adnexal malignancy were included. mean age of the subjects was 50.24±10.52 years and mean duration of symptoms was 2.97±1.23 months as shown in table i. table i: demographics of study subjects (n= 62) mean range age (years) 50.24±10.52 18-62 bmi (kg/m2) 23.25±2.36 20-27 duration of symptoms (months) 2.97±1.23 1-6 j islamabad med dental coll 2022 161 on trucut biopsy, definitive diagnosis was made in 59 (95.1%) out of 62 cases and only 3 (0.04%) cases were inconclusive; among which two showed inadequate sample and one showed normal tuboovarian tissue. on further analysis, ovarian serous cystadenocarcinoma was the most commonly detected lesion seen in 29 (46.77%) of the cases followed by mucinous ca seen in 13 (20.96%) of the cases. one of the samples also showed extensive necrotic material which on repeated biopsy yielded small fragments of adenocarcinoma with extensive necrosis that raised the possibility of metastatic disease with colorectal primary. d i s c u s s i o n adnexal pathology has various etiological factors depending on congenital, inflammatory and neoplastic processes and are prevalent in women of all age groups.13 ultrasound is primary imaging modality for evaluation and management of adnexal pathology having significant correlation with histological features but some of the benign lesions also have similar appearance as malignancy requiring additional work-up. 14-15. in approximately 70% cases, ovarian malignancy does not become clinically overt until it has metastasized therefore effective detection approaches are the need of the hour.16-17 our results show that usg-guided trucut biopsy of adnexal masses is high yielding with definitive diagnosis in 59 (95.1%) out of 62 cases and only 3 (0.04%) cases were inconclusive. these results are fairly comparable to the findings of the studies done in the past confirming high reliability and safety of this minimally invasive procedure. according to a study done by vlasak et al, ultrasound guided biopsy confirmed malignancy in 96.2% patients and the sample obtained was insufficient in three patients for complete identification of the tumor. 12 another study done by oge t et al to assess the utility of usg guided trucut biopsy revealed a definitive diagnosis in 96.4% of the cases while in 3.6% of the cases, the tissue material was inadequate to reach a definitive diagnosis, and among various lesions detected primary ovarian ca was seen in 65.4% of the cases with its serous type most common 58.2%.18 this is also similar to the present study where serous cystadenocarcinoma was the most commonly detected lesion seen in 29 (46.77%) of the cases followed by mucinous ca seen in 13 (20.96%) of the cases. accurate diagnosis depends on the adequacy of the technique and an table: ii type of lesion detected on trucut biopsy biopsy outcome n (%) ovarian serous cystadenocarcinoma 29 (46.77%) ovarian mucinous cystadenocarcinoma 13 (20.96%) spindle cell ca 3(4.83%) adenocarcinoma 3(4.83%) inconclusive (scanty tissue/normal tissue) 3(4.83%) smooth muscle neoplasm 2(3.22%) poorly differentiated neoplasm 2(3.22%) granulomatous inflammatory disease 1(1.61%) benign serous cystadenoma 1(1.61%) cystic teratoma 1(1.61%) dysgerminoma 1(1.61%) struma ovarii 1(1.61%) other benign lesions (fibroid/benign stromal tumors) 2(3.22%) total 62(100%) j islamabad med dental coll 2022 162 experienced operator can definitely do best. verschuere et al. reported increasing adequacy of the biopsy over the years likely due to the operators’ improving skills with the procedure19. it has also been noticed that elevated ca-125 and ascites are good predictors and increase the yield of trucut biopsy while obesity is considered a factor hindering the accuracy of ultrasound thereby indirectly limiting yield of trucut biopsy as well. previous literatures do not signify any specific relationship between biopsy needle gauge and better diagnostic accuracy but hoffmann p et al reported 16 g or wider needle more suitable for pelvic lesion biopsies, likely attributable to a fact that wider bore needles allow for extraction of more diseased tissue.20 however the use of a 18 g needle is the most mentioned biopsy tool in literature therefore was needle of choice in our patients as well. like any other invasive procedure, ultrasound guided biopsies can also result in various complications like bleeding at the site of biopsy, visceral injury, hemoperitoneum and infectious complications reported previously in the scientific articles.13 post procedure, patients were again assessed with doppler usg in our study which was beneficial in evaluating the target organ for any haemorrhage. the identification of a “track” or a haemorrhagic jet is a good indicator of post-biopsy bleeding.21 in our study no complication was noted. on completion of the procedure, bleeding from the biopsy site was checked for. patients were kept under observation for 2 hours following the biopsy and then discharged. mild subjective discomfort or momentary mild pain at the site of the biopsy was reported, however no major complication was reported. thus with increasing incidence of malignancy worldwide, this minimally invasive procedure is an important step in patients’ management. fine needle aspiration cytology of ascites has been done routinely which is easier and even less invasive but it has a poor predictive value for organ-specific tumor diagnosis. furthermore, core needle biopsy yields tissue for immunohistochemistry and molecular profiling thus modifying the treatment according to the tumor genotype.7 the study has limitations, which include the fact that some patients with adnexal masses didn’t show up on the given time for procedure even when advised for it by the clinician. it was a small sample size and further studies with larger sample size may better characterize the outcomes of biopsy. c o n c l u s i o n ultrasound guided trucut biopsy in adnexal masses is a befitting modality to reach the definitive diagnosis in adnexal masses with no major complication. it can help the patients’ selection for surgery, chemotherapy as well as by providing fast definitive histological diagnosis in advanced disease patients, makes invasive debulking surgeries unnecessary for the initiation of neoadjuvant chemotherapy. r e f e r e n c e s 1. rai r, bhutia pc, tshomo u. clinicopathological profile of adnexal masses presenting to a tertiary-care hospital in bhutan. south asian journal of cancer. 2019 jul; 8(3):168. (10.4103/sajc.sajc_303_18) 2. casarin j, lagana as, uccella s, cromi a, pinelli c, gisone 2b, et al. surgical treatment of large adnexal masses: a retrospective analysis of 330 consecutive cases. minimally invasive therapy & allied technologies; 2019. 2:19. doi: 10.1080/13645706.2019.1649700 3. shetty m. imaging and differential diagnosis of ovarian cancer. inseminars in ultrasound, ct and mri. 2019; 40(4): 302-318. doi: 10.1053/j.sult.2019.04.002 4. gharwan h, bunch kp, annunziata cm. the role of reproductive hormones in epithelial ovarian carcinogenesis. endocrine-related cancer. 2015; 22(6):339-63. doi: 10.1530/erc-14-0550aarestrup j, 5. trabert b, ulrich lg, wentzensen n, sørensen ti, baker jl. childhood overweight, tallness, and growth increase risks of ovarian cancer. cancer epidemiology and prevention biomarkers. 2019; 28(1):183-8. doi: 10.1158/1055-9965.epi-18-0024 https://doi.org/10.4103%2fsajc.sajc_303_18 https://doi.org/10.1080/13645706.2019.1649700 https://doi.org/10.1053/j.sult.2019.04.002 https://doi.org/10.1530/erc-14-0550 https://doi.org/10.1158%2f1055-9965.epi-18-0024 j islamabad med dental coll 2022 163 6. van nagell jr, miller rw. evaluation and management of ultrasonographically detected ovarian tumors in asymptomatic women. obstet gynecol. 2016; 127:848. doi: 10.1097/aog.0000000000001384 7. thabet a, somarouthu b, oliva e, gervais da, hahn pf, lee si. image-guided ovarian mass biopsy: efficacy and safety. journal of vascular and interventional radiology.2014;25(12):1922-7. https://doi.org/10.1016/j.jvir.2014.08.009 8. belinga e, ndoua cc, um ej, ayissi g, ntsama jm, chatour h. complications of gynaecological laparoscopy and associated factors at the maternity ward of the gonesse general hospital. gynecol obstet. 2019; 9:512. 9. guberina n, forsting m, ringelstein a, suntharalingam s, nassenstein k, theysohn j, et al. radiation exposure during ct-guided biopsies: recent ct machines provide markedly lower doses. european radiology. 2018; 28(9):3929-35. doi: 10.1007/s00330-018-5350-1 10. akhtar s, riaz r, waris r, manzoor r. role of ultrasound guided percutaneous liver biopsy using semi-automatic needle in pediatric liver diseases. pak pediatr j. 2018; 42(3):177-80. 11. atri m, alabousi a, reinhold c, akin ea, benson cb, bhosale pr, et al. acr appropriateness criteria clinically suspected adnexal mass, no acute symptoms. journal of the american college of radiology. 2019; 16(5):s77-93. doi: 10.1016/j.jacr.2019.02.011 12. vlasak p, bouda j, kostun j, berezovskiy d, zikan m, weinberger v, et al. diagnostic reliability, accuracy and safety of ultrasound-guided biopsy and ascites puncture in primarily inoperable ovarian tumours. anticancer research. 2020 jun 1;40(6):3527-34. doi: 10.21873/anticanres.14341 13. karlı p, kilitci a. evaluation of the histopathology results of patients operated due to ovarian mass. journal of gynecological research and obstetrics. 2019 jan 5;5(1):001-4. doi: 10.17352/jgro.000060 14. roshed mm, akhter md, hossain sm. a comparative study of nature of adnexal masses by ultrasonography and histopathology. bangladesh medical journal khulna. 2018;51(1-2):7-11. doi: https://doi.org/10.3329/bmjk.v51i1-2.40459 15. baig f, khadija s, afzal n, raheem i. sonographic advancements in characterization of benign and malignant ovarian masses: a systematic review. annals of medical and health sciences research. 2021 oct 1;11(8). 16. hebbar s, moideen n. imaging in ovarian cancer. int. j. reprod. contraception, obstet. gynecol. 2015; 4(1):23201770. 17. arora t, mullangi s, lekkala mr. ovarian cancer. statpearls [internet]. 2022 jan 4. 18. oge t, yalcin ot, ozalp ss, kebapci m, aydin y, telli e. sonographically guided core biopsy: a minimally invasive procedure for managing adnexal masses. journal of ultrasound in medicine. 2013; 32(11):2023-7. doi: 10.7863/ultra.32.11.2023 19. arezzo f, loizzi v, la fd, abdulwakil k a, silvestris e, cataldo v, et al.the role of ultrasound guided sampling procedures in the diagnosis of pelvic masses: a narrative review of the literature. diagnostics. 2021 nov 26;11(12):2204.doi.org/10.3390/diagnostics1112 2204) 20. hoffmann p, balik m, hoffmannova m, spacek j, vanasek j, rezac a,et al.long-term experience with percutaneous biopsies of pelvic lesions using ct guidance. science progress. 2021 oct;104(4):00368504211058555. (https://doi.org/10.1177/0036850421105855) 21. carberry ga, lubner mg, wells sa, hinshaw jl. percutaneous biopsy in the abdomen and pelvis: a step-by-step approach. abdominal radiology. 2016; 41(4):720-42. doi: 10.1007/s00261-0160667-1 https://doi.org/10.1097/aog.0000000000001384 https://doi.org/10.1016/j.jvir.2014.08.009 https://doi.org/10.1007/s00330-018-5350-1 https://doi.org/10.1016/j.jacr.2019.02.011 https://doi.org/10.21873/anticanres.14341 https://doi.org/10.17352/jgro.000060 https://doi.org/10.3329/bmjk.v51i1-2.40459 https://doi.org/10.7863/ultra.32.11.2023 https://doi.org/10.1177/00368504211058555 https://doi.org/10.1007/s00261-016-0667-1 https://doi.org/10.1007/s00261-016-0667-1 128 j i m d c 2 0 1 8 7 128 open access f u l l l e n g t h a r t i c l e prevalence of hepatitis b amongst pregnant women aneela jamil1, sidra hamid2, qaiser aziz3 1 assistant professor, department of biochemistry, foundation university medical college rawalpindi 2 assistant professor, department of physiology, rawalpindi medical college, rawalpindi 3 senior registrar, department of medicine, holy family hospital, rawalpindi a b s t r a c t objective: to study the prevalence of hepatitis b virus infection amongst pregnant women. subjects and methods: a hospital based cross-sectional study was conducted among pregnant women who attended antenatal care clinic for routine pregnancy check-up from july 2016 to february 2017. sample size was calculated by using who sample size calculator and 900 pregnant women were enrolled in the study. data were collected by face to face interview using a questionnaire. serum was withdrawn from each study subject and tested for hepatitis b surface antigen (hbsag) by an enzyme linked immunosorbent assay (elisa) test kit. data were analyzed using spss version 20. results: the prevalence of hbv infection among pregnant women attending benazir bhutto hospital, rawalpindi, was found to be 2.78%. conclusion: this study determined that the prevalence of hbv infection among pregnant women in rawalpindi was 2.78%, implying that it is intermediate endemic area. key words: hepatitis b, pregnancy, prevalence. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence aneela jamil email: aneela_55@yahoo.com article info. received: july 25, 2017 accepted: november 20, 2017 cite this article. jamil a, hamid s, aziz q, asim m. prevalence of hepatitis b among pregnant women. jimdc.2018; 7(2):128-131 funding source: nil conflict of interest: nil i n t r o d u c t i o n hepatitis b infection is caused by hepatitis b virus. it is an enveloped dna virus that infects liver and causes hepatocellular necrosis and inflammation. hbv infection is one of the serious public health problem worldwide.1 many of the carriers do not realize that they are infected with virus rendering the hbv to be known as a “silent killer”. worldwide, it is estimated that 350 million people are chronically infected with hepatitis b.2 recent reports demonstrated that 68,600 people die of hbv infection and globally every year, more than 300,000 deaths are due to liver cancer secondary to hepatitis b.3 in pakistan, the situation is worse than in the developed countries of the world. hbv infection is a contagious disease that can be transmitted vertically from mothers to their neonates or horizontally through blood products and body secretions.4 chronic hepatitis b infection in the female population has implications not just for the individual but for her children as well.5 hbv positive mothers with an hbsag positive status can vertically transmit the infection to their infants.6 this risk of transmission may increase, if the mother develops the hbv infection during the third trimester of pregnancy.7 the prevalence of hbv infection among women of childbearing age may be as high as 2–8 % in china8 whereas in the usa it is only 0.4 %.9 acute hbv infection during pregnancy is less severe and is not directly associated with increased mortality or teratogenicity.10 however, increased incidences of low birth weight and prematurity in infants born to mothers with acute hbv infection have been recorded. furthermore, acute hbv infection in early pregnancy has o r i g i n a l a r t i c l e 129 j i m d c 2 0 1 8 7 129 been associated with a 10% perinatal transmission rate.10 transmission rates as high as 60% have been reported to increase significantly if acute infection occurs at or near the time of delivery.11 although there is a safe and effective vaccine, 50 million new cases are diagnosed annually worldwide.12 majority of new diagnoses, however, are classified as mother-to-child transmission, especially in regions with high prevalence of the disease.13 the risk for development of chronic hbv infection is inversely related to the age of exposure. infants exposed to hbv progress to a chronic infection in 90% of cases, whereas toddlers and young children clear the virus in only 50% of cases.14 infection in the adult population, however, is associated with only a 5% rate of progression to chronic disease. in adults, exposure to hepatitis b typically presents with an acute syndrome and viral clearance is more prevalent.15 viral hepatitis during pregnancy is associated with a high risk of maternal complications.16 administration of hepatitis b immunoglobulin and hepatitis b vaccine to infants at birth, followed by completion of the vaccine series, prevented approximately 95% of hbv transmission from hbsag-positive mothers to their infants.16 hbv carrier status is relatively common among pregnant women, especially in endemic countries such as pakistan. however, data on the epidemiology of hbv infection in pakistan are limited. the magnitude of the problem is not yet addressed in many parts of pakistan. the present study was planned to determine the prevalence of hbv infection among pregnant women in rawalpindi district of pakistan. s u b j e c t s a n d m e t h o d s this cross sectional study was conducted at benazir bhutto hospital, rawalpindi, pakistan from july 2016 to february 2017. it is a tertiary care hospital that shares a major load of gynecology & obstetrics patients and provides antenatal and other specialized obstetric services for the inhabitants of the rawalpindi district and beyond. the study population was all consecutive pregnant females, who attended antenatal care clinic for check-up services at benazir bhutto hospital, rawalpindi. sample size was calculated by using who sample size calculator, total of 900 pregnant women were included in the study. all study participants were informed about the study and assured about the confidentiality of data. a written informed consent was obtained from all participants. approximately 5 ml of venous blood was collected from each individual in a gel vacutainer by an experienced laboratory technologist. the samples were centrifuged at 2000 revolutions per minutes (rpm) for 5 minutes in order to obtain a clear supernatant serum. the sera were then stored at -20°c prior to the serologic assay of hbv. screening for hbsag was performed using hbsag elisa kit. it is a solid-phase sandwichimmunoassay, which employs specific monoclonal antibodies and polyclonal antibodies. protocol for the measurement was done according to the manufacturer's instruction and reading was done at o.d. of 450 nm with an eia plate reader. the tests ran were validated and results were interpreted according to the manufacturer's instruction. positive and negative controls were run along with each batch of elisa test kit. data were entered into spss version 20 for analysis. r e s u l t s a total of 900 blood samples were collected from pregnant women and then screened for hbv infection using the elisa kit. among total of 900 pregnant females, 2.78% (n=25) were positive and 97.2% (n=875) were negative for hbs antigen. d i s c u s s i o n hepatitis is considered to be an important public health problem for which reliable screening tests do exist. the hepatitis b virus infection is a common cause of morbidity and mortality globally.17 it is estimated that about 2 billion people worldwide have serologic evidence of hepatitis b, of which 350 million are chronic carrier.17 about 1.2 million die annually from chronic hepatitis, cirrhosis, and hepatocellular carcinoma.18 of the estimated 350 million chronically infected individuals, about 50% acquired their infections either perinatally or in early childhood.9 most pregnant women with hbv infection are chronic carriers.19 chronic hepatitis b virus infection due to mother-to-child transmission during perinatal period remains an important public health problem.20 high rate of mother-to-child transmission of hbv in an endemic country is of concern.21 hepatitis b virus infection characterized by hbsag positivity during pregnancy is a well-recognized issue in developing countries.22 the prevalence of chronic hbv infection worldwide is categorized as high (≥8%), intermediate (2–7%), and low (<2%) endimicity.23 the prevalence of hbv infection varies markedly throughout regions of the world, being 130 j i m d c 2 0 1 8 7 130 highly endemic in developing regions with large population such as south east asia, china and subsaharan africa, where at least 8% of the population are hbv chronic carrier.23 transmission of hbv from carrier mothers to their babies appears to be the most important factor in determining the prevalence of the infection in high endemic areas.24 there are three possible routes of transmission of hbv from infected mothers to infants: transplacental transmission of hbv in utero; natal transmission during delivery; or postnatal transmission during care or through breast milk.24 in developed countries, the incidence of hepatitis is around 0.1% whereas in developing countries it ranges from 3 to 20% and even higher in some areas.25 in africa and asia, the prevalence of hbv is > 8% and 2 billion people have markers of current or past infection with hbv.26 about half of new infections result from vertical transmission during pregnancy, a statistic that is linked to the fact that hbv screening is not part of routine antenatal care in the area.25 in this study, we found that the prevalence of hbsag among study participants was 2.78%. overall prevalence of hbv infection among pregnant women in rawalpindi is intermediate (2.78%) endemic area according to the who classification criteria. the frequency of hbsag among pregnant women in our study was comparable with studies conducted in other parts of world. in a study conducted in kpk (khaber pukhtunkhawa), prevalence of hbv in pregnant women was reported to be 1.16%.27 in a study by abdi umare et al, the frequency of hbsag among study participants was 6.9%.28 the hbsag prevalence rate of 3.8% was found among enrolled pregnant participants in kenya indicating intermediate endemicity.29 the seroprevalence of hbsag was 8.3% among pregnant women in nigeria.30 prevalence of hbsag among pregnant women in china was noted to be 2.5% as reported by ai-ming cui et al.19 the american congress of obstetrics and gynecology recommend that every pregnant patient should undergo screening for hbv.31 all infants require the hbv vaccination series and hepatitis b immunoglobulin within 12 hours of birth. 31 c o n c l u s i o n this study shows that hepatitis b virus infection is of intermediate endemicity in rawalpindi, with prevalence rate 2.78%. early screening and detection of infected pregnant females, immunoprophylaxis and surveillance for exposed newborns are essential components of health care system. r e f e r e n c e s 1. adibi p, akbari l, kahangi ls, abdi f. health-state utilities in liver cirrhosis: a cross-sectional study. int j prev med. 2012;3(suppl 1):s94-s101. 2. aghemo a, lampertico p, colombo m. assessing long-term treatment efficacy in chronic hepatitis b and c: between evidence and common sense. j hepatol. 2012;57(6):1326-35. 3. global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the global burden of disease study 2013. lancet. 2015;385(9963):117-71. 4. mohebbi sr, sanati a, cheraghipour k, rostami nejad m, shalmani hm, zali mr. hepatitis c and hepatitis b virus infection: epidemiology and risk factors in a large cohort of pregnant women in lorestan, west of iran. hepat mon. 2011;11(9):736-9. 5. cohen e, tran tt. hepatitis b in the female population. gastroenterol clin north am. 2016;45(2):359-70. 6. patton h, tran tt. management of hepatitis b during pregnancy. nat rev gastroenterol hepatol. 2014;11(7):402-9. 7. lamberth jr, reddy sc, pan jj, dasher kj. chronic hepatitis b infection in pregnancy. world j hepatol. 2015;7(9):1233-7. 8. lao tt, sahota ds, law lw, cheng yk, leung ty. age-specific prevalence of hepatitis b virus infection in young pregnant women, hong kong special administrative region of china. bull world health organ. 2014;92(11):782-9. 9. sorrell mf, belongia ea, costa j, gareen if, grem jl, inadomi jm, et al. national institutes of health consensus development conference statement: management of hepatitis b. hepatology. 2009;49(5 suppl):s4-s12. 10. ephraim r, donko i, sakyi sa, ampong j, agbodjakey h. seroprevalence and risk factors of hepatitis b and hepatitis c infections among pregnant women in the asante akim north municipality of the ashanti region, ghana; a cross sectional study. afr health sci. 2015;15(3):709-13. 11. sookoian s. liver disease during pregnancy: acute viral hepatitis. ann hepatol. 2006;5(3):231-6. 12. terrault na, bzowej nh, chang km, hwang jp, jonas mm, murad mh. aasld guidelines for treatment of chronic hepatitis b. hepatology. 2016;63(1):261-83. 13. tran tt. hepatitis b in pregnancy. clin infect dis. 2016;62 (suppl 4):s314-7. 14. alter mj. epidemiology of hepatitis b in europe and worldwide. j hepatol. 2003;39 (suppl 1):s64-9. 15. ayoub ws, cohen e. hepatitis b management in the pregnant patient: an update. j clin transl hepatol. 2016;4(3):241-7. 16. zhuang h. [prevention of mother-to-child transmission of hepatitis b virus]. zhonghua gan zang bing za zhi. 2016;24(12):881-4. 17. alavian sm, ebrahimi e, abedini m. necessity for hepatitis b surface antigen screening in pregnant females in iran. iran red crescent med j. 2016;18(9):e40844. 18. merrill rm, hunter bd. seroprevalence of markers for hepatitis b viral infection. int j infect dis. 2011;15(2):e78-121. 19. cui am, cheng xy, shao jg, li hb, wang xl, shen y, et al. maternal hepatitis b virus carrier status and pregnancy outcomes: a prospective cohort study. bmc pregnancy childbirth. 2016;16:87. 20. yi p, chen r, huang y, zhou rr, fan xg. management of mother-to-child transmission of hepatitis b virus: propositions and challenges. j clin virol. 2016;77:32-9. 21. jutavijittum p, yousukh a, saysanasongkham b, samountry b, samountry k, toriyama k, et al. high rate of hepatitis b virus 131 j i m d c 2 0 1 8 7 131 mother-to-child transmission in lao people's democratic republic. southeast asian j trop med public health. 2016;47(2):214-8. 22. tan j, liu x, mao x, yu j, chen m, li y, et al. hbsag positivity during pregnancy and adverse maternal outcomes: a retrospective cohort analysis. j viral hepat. 2016;23(10):812-9. 23. hou j, liu z, gu f. epidemiology and prevention of hepatitis b virus infection. int j med sci. 2005;2(1):50-7. 24. xu zy, liu cb, francis dp, purcell rh, gun zl, duan sc, et al. prevention of perinatal acquisition of hepatitis b virus carriage using vaccine: preliminary report of a randomized, double-blind placebo-controlled and comparative trial. pediatrics. 1985;76(5):713-8. 25. yohanes t, zerdo z, chufamo n. seroprevalence and predictors of hepatitis b virus infection among pregnant women attending routine antenatal care in arba minch hospital, south ethiopia. hepat res treat. 2016;2016:9290163. 26. leung n. chronic hepatitis b in asian women of childbearing age. hepatol int. 2009;3 suppl 1:24-31. 27. ahmad i. prevalence of hepatitis b and c viral infection among pregnant women in peshawar, pakistan. hepat mon. 2016;16(6):e36383. 28. umare a, seyoum b, gobena t, haile mariyam t. hepatitis b virus infections and associated factors among pregnant women attending antenatal care clinic at deder hospital, eastern ethiopia. plos one. 2016;11(11):e0166936. 29. ngaira ja, kimotho j, mirigi i, osman s, ng'ang'a z, lwembe r, et al. prevalence, awareness and risk factors associated with hepatitis b infection among pregnant women attending the antenatal clinic at mbagathi district hospital in nairobi, kenya. pan afr med j. 2016;24:315. 30. anaedobe cg, fowotade a, omoruyi ce, bakare ra. prevalence, sociodemographic features and risk factors of hepatitis b virus infection among pregnant women in southwestern nigeria. pan afr med j. 2015;20:406. 31. acog practice bulletin no. 86: viral hepatitis in pregnancy. obstet gynecol. 2007;110(4):941-56. j islamabad med dental coll 2020 59 open access swallowing difficulties with tracheostomy: a neurorehabilitation perspective ghulam saqulain1, nazia mumtaz2 1head, department of otorhinolaryngology, capital hospital, islamabad 2in-charge post graduate programs, allied health sciences, shifa tameer-emillat university, islamabad a b s t r a c t swallowing and breathing are complex and highly coordinated functions. these functions depend on well -coordinated work of many organs with larynx and nervous system playing a critical role. disturbance in one of these functions negatively affects the other. surgical airways like tracheostomies are required in a number of situations , including but not limited to major head and neck procedures, cases with decreased lung function, excessive bronchial secret ions and cases requiring neuro-rehabilitation when prolonged airway is required for mechanical ventilation. extensive neuro-rehabilitation is required since patients with surgical airway may develop swallowing difficulties including dysphagia and/or aspiration with a very high prevalence, which can pose a threat to life. th is article reviews the current status of the diagnostic and therapeutic modalities for swallowing difficulties with special emphasis on current neuro-rehabilitative strategies. electronic databases including medline, web-of-science, cochrane library, and google scholar were used for literature search. downloaded articles were subsequently assessed independently by two researchers to determine suitability for inclusion in the study . key words: neurorehabilitation, tracheostomy, transcranial direct current stimulation, transcranial magnetic stimulation, swallowing difficulty authors’ contribution: 1,2conception; literature research; manuscript design and drafting; critical analysis and manuscript review; manuscript editing correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: february 20, 2019 accepted: february 10, 2020 cite this article. saqulain g, mumtaz n. swallowing difficulties with tracheostomy: a neuro-rehabilitation perspective. j islamabad med dental coll.2020; 9(1):59-64. doi: 10.35787/jimdc.v9i1.290 funding source: nil conflict of interest: nil i n t r o d u c t i o n breathing and swallowing are essential and highly coordinated functions. these functions depend on well-coordinated work of many organs with larynx and nervous system playing a critical role. disturbance in one of these functions negatively affects the other. swallowing being a complex neurological process plays an essential part in food digestion. its main role is lower respiratory tract (lrt) protection, demanding precise coordination between the essential functions of breathing and swallowing. this is mediated through a swallowing reflex. any pathological or physiological deficiency or impairment of central nervous, neuromuscular, musculoskeletal or cardiopulmonary system may modulate the swallow reflex arc and lead to a potential delay, deficiency or disorder in swallowing function.1 r e v i e w a r ti c le j islamabad med dental coll 2020 60 surgical airways like tracheostomies are required in a number of situations including but not limited to major head and neck procedures, in cases with decreased lung function, excessive bronchial secretions and cases requiring neuro-rehabilitation when prolonged airway is required for mechanical ventilation. according to loss et al. a large percentage (41.5%) of patients requiring intensive unit care, require mechanical ventilation (mv) with 9.9% requiring mv for prolonged period. 2 of these critically ill survivors, many face dysphagia and in these cases tracheostomy is an important risk factor.3 thus, in the intensive care units (icu) mechanical ventilation after tracheostomy may lead to loss of pulmonary protection or swallowing abnormality.4 the prevalence of swallowing disorders in critical tracheostomized patients who are on mv ranges from 50 to 83%.5 regardless of the presence or absence of neuromuscular issues it has been reported to be 3 to 62% in another study,3 nevertheless its real incidence is not yet established. the swallowing reflex can be modulated by pathological as well as some physiological conditions.1 the placement of tracheostomy disturbs the normal vertical hyoid and laryngeal movements essential for normal swallowing.6 tracheostomy also reduces the sensitivity of the larynx,7 and the cuff of tracheostomy tube may alter the stimulation of th e pressure receptors in the subglottic area, 8 which can result in aspiration. hernandez et al. have claimed that deflation of tracheostomy tube cuf f in these patients shorten the weaning thus reducing the respiratory infections and improving swallowing.9 hence tracheostomy tube results in difficulty in verbal communication and reduction in laryngeal movement results in further comprom is e in swallowing.10 also tracheostomy has been note d as an independent risk factor for development of aspiration and dysphagia.4 extensive neurorehabilitation is required since patients with surgical airway may develop swallowing difficulties including dysphagia and / or aspiration with a very high prevalence, which can pose a threat to life. this paper attempts to review the current status o f therapeutic modalities for swallowing difficulties with special emphasis on current neurorehabilitative strategies. this has significance since such cases are neglected and result in morbidity and mortality. literature search was conducted using electronic databases including medline, webof-science, cochrane library, and google scholar for articles published between 2000 to 2018 using keywords like “neurorehabilitation”, “tracheostomy”, “transcranial direct current stimulation”, “transcranial magnetic stimulation”, “swallowing difficulty” and a combination of these words. downloaded articles were subsequently assessed independently by two researchers to determine suitability for inclusion in the study. d i s c u s s i o n tracheostomy is a common airway procedure associated with complications of swallowing difficulties as well as airway protection abnormalities. these complications demands a multidisciplinary team approach, with good coordination between its team members, for evaluation and rehabilitation to ensure the safety and quality care of these patients. 10,11 in a study, mah et al. concluded that, “the introduction of care bundle for post tracheostomy care to the multidisciplinary tracheostomy service significantly improve oral diet intake as well as decannulation”.12 thus restoration of function of respiration, phonation, feeding and swallowing demands a strict integration and participation among different members of the multidisciplinary rehabilitation team. a number of strategies are used conventionally to facilitate swallowing and prevent aspiration easing de -cannulation including digital occlusion of tracheostomy during swallowing, use of one-way valves, adjustment of tidal volume and timing of swallow with expiratory j islamabad med dental coll 2020 61 cycle for patients on mv. these strategies, increas e subglottic pressure and prevents aspiration, with partial or complete cuff deflation as the case may be, allowing deglutition and phonation system rehabilitation. also, the tracheostomy cannula should preferably not fill more than two-third to three-fourths of the tracheal lumen, since it will make rehabilitation difficult.9 evaluation is usually carried out using existing simple screening tools like 3-oz water tests as well as specific assessment tools. these include video fluoroscopy, modified barium swallows, fiber-optic endoscopic evaluation of swallowing (fees) with the validated grading measures. the grading measures include modified barium swallow impairment profile (mbsimp) and penetrationaspiration scale. mbsimp provides a standardized protocol to interpret and communicate swallowing impairment in an accurate and objective manner with 17 components grouped in three functional domains each to access oral impairment, pharyngeal impairment, and esophageal impairment.13 knowledge is incomplete for using these tools to assess post extubation dysphagia. fees being the method of first choice is easy to use, with bedside evaluation, and can help remove misjudgment in dysphagia diagnosis and help revise diet in around 70% cases.14 to assess swallowing reflex, the integrity of the oropharyngeal-cortical afferent pathways can be assessed by electroencephalography (eeg) while generating sensory-evoked potentials by pharyngeal electrical stimulation and the corticalpharyngeal efferent pathways can be considered by electromyography through motor-evoked potentials by transcranial magnetic stimulation. 15 when tracheostomy tube is in place, swallowing can be assessed by oral motor and vocal cord assessment with adduction of vocal cord by phonation and strength of cough reflex and pharyngeal assessment with per oral trials. air le ak around tracheostomy tube can be assessed by occluding tracheostomy tube by a finger during exhalation with instruction to phonate while feeling for pressure on finger and listening for air movement and phonation. good air leak is indicated by clear phonation, no pressure on fin ge r and no pressure release whe n finger is removed. poor air leak is indicated by none or strangled phonation, pressure on finger and air pressure release when finger is removed. however, if the cuff cannot be fully deflated a minimal leak technique can be considered. due to risk of silent aspiration, cuff manometry is a better option.16 chronic mv patients who require full cuff inflation can be assessed by fees. if the air leak is good th e n the tracheostomy tube is capped to observe oxygen saturation, respiratory rate, difficulty in cle aring secretions and signs of breathing difficulty. if all remains fine orders can be obtained to leave cap as tolerated. de-cannulation can be done if the patient tolerates 48 hours of capping without need of deep suction; however different centers follow different criteria. most guidelines regarding the management of swallowing disorders in these patients basically aim to prevent complications,17 with conventional compensatory strategies like modification in diet including changes in consistency; bolus presentation i.e. amount, frequency and placement; other strategies like non oral options (no straw), liquid by spoon, moisten mouth before swallow; and other safe swallowing techniques lik e digital occlusion during swallow etc. 18 changes in posture involve chin tuck, head turn, head tilt and head back. other facilitation technique includes effortful swallow, mendelshon maneuver, supraglottic swallow and super-supra-glottic swallow maneuver along with laryngeal closure exercises. j islamabad med dental coll 2020 60 table i: summary of conventional and neurorehabilitation interventions for dysphagia class type technique conventional compensatory strategies 18,19 modification in diet • consistency • bolus presentation • amount • frequency • placement non-oral options • liquid by spoon • moisten mouth before swallow other safe swallowing techniques • digital occlusion during swallow changes in posture • chin tuck • head turn • head tilt • head back other facilitation techniques • effortful swallow • mendelsohn maneuver • supra-glottic swallow • super-supra-glottic swallow maneuver • laryngeal closure exercises conventional therapeutic techniques 20 oral exercises • oral motor exercises pharyngeal exercises • tongue base exercises • pharyngeal exercises (masako) laryngeal exercises • laryngeal elevation and closure exercises thermal tactile stimulation swallow exercises • sour bolus exercises neurorehabilitation treatment 19,20,21 peripheral non-invasive stimulation • neuromuscular electrical stimulation • oro/facial electrical stimulation • deep pharyngeal neuromuscular stimulation • pharyngeal electrical stimulation–for neuroplasticity 23 • palatal electrical stimulation 24 • functional magnetic stimulation 25 central non-invasive brain stimulation 15, 26,27,28 • repetitive transcranial direct current stimulation • paired associative stimulation • transcranial magnetic stimulation focus of these strategies being compensation rather than physiological restoration of function. 19 the therapeutic techniques commonly used include oral motor exercises, tongue base exercises, pharyngeal exercises (masako), laryngeal elevatio n and laryngeal closure exercises, thermal tactile stimulation and sour bolus swallow. 20 oropharyngeal dysphagia still lacks specific neurorehabilitation treatment with current advances including peripheral and central noninvasive stimulation.21 according to cabib et al., rehabilitation strategies are shifting from compensatory techniques to promotion of brain plasticity with the aims of recovering swallow function as well as swallow dysfunction caused by neurological damage.21 electrical and magnetic stimulation has gained momentum in the treatment of dysphagia to improve physiological restoration of swallowing with a number of therapeutic interventions gaining interest. vitalstim therapy (vst) also known as neuromuscular electrical stimulation (nmes) has been used for neuromuscular re-education in cases with oropharyngeal dysphagia.19,20 the oral/facial electrical stimulation is applied to restore muscle function and deep pharyngeal neuromuscular j islamabad med dental coll 2020 63 stimulation (dpns) for restoring reflexes within th e pharynx. fda (usa) protocol for dysphagia recommends use of electrode positioning on submental musculature. humbert et al. 22 noted significant results especially for muscle strengthening in cases with oropharyngeal dysphagia. pharyngeal electrical stimulation (pes), using a catheter-electrode placed intra-luminal in the pharynx and attached to stimulator unit to generate the required stimulus has been explored for exploitation of neuroplasticity in motor cortex and has been found to be of benefit as it results in less aspiration and dysphagia.23 palatal electrical stimulation has also been used by some researchers to initiate sensory feedback, so as to get swallow reflex involuntarily, with controversial results.24 momosaki et al.25 used functional magnetic stimulation (fms) and noted a statistically significant improvement in swallowing function, both in terms of capacity and speed of swallowing. in this noninvasive method instead of electrodes, parabolic coil is used to deliver fms at 30 hz to suprahyoid muscles in a 20 second train for 10 minutes and total 1200 pulses were given. it is said to reach a greater depth compared to electrical stimulation without causing discomfort.26 recent neurorehabilitation development includes non-invasive brain stimulation (nibs) comprising of transcranial magnetic stimulation (tms) as well as transcranial direct current stimulation (tdcs) and paired associative stimulation (pas), with a number of studies suggesting promising results. 15,26,27 simons et al found mixed results when used for management of neurogenic dysphagia and poin te d out controversies that exist regarding treatment with this modality. these controversies include the appropriate site of stimulation, strength and the time duration of the stimulus for producing the most beneficial effect.26 kim et al found repetitive (r) tms to be useful for recovery of swallow function in cases with brain injury and dysphagia, with superior results compared to conventional interventions,26 while dionisiio et al.28 in a systematic review found rtms to be a useful tool in rehabilitation of stroke cases. lee et al., studied the effect of rtms according to site of stimulation and reported that stimulation of the area of brain cortex which generated motor evoked potentials (mep) from suprahyoid muscles caused maximum improvement in swallowing function when compared to that over the interconnected site. 29 different researchers have also studied reorganization of intact hemisphere for the purpose of recovery from post-stroke dysphagia (psd). significant results have been reported in connection with the use of nibs on the contralateral side of the brain as a therapeutic potential for psd rehabilitation in different studies. 27 c o n c l u s i o n the complications of tracheostomy and swallowing impairment decree an accurate assessment using modern methodologies like fees with mbsimp an d penetration aspiration scale. individualized treatments including most recent neurorehabilitation with dcs and tcs is of utmost significance. r e f e r e n c e s 1. nishino t. the swallowing reflex and its significance as an airway defensive reflex. front physiol. 2013; 3: 489. 2. loss sh, de oliveira rp, maccari jg, savi a, boniatti mm, hetzel mp, et al. the reality of patients requiring prolonged mechanical ventilation: a multicenter study. rev bras ter intensiva. 2015; 27(1): 26-35. 3. macht m, king cj, wimbish t, clark bj, benson ab, burnham el, et al. post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment. crit care. 2013; 17(3): 119. 4. zielske j, bohne s, brunkhorst fm, axer h, guntinaslichius o. acute and long-term dysphagia in critically ill patients with severe sepsis: results of a j islamabad med dental coll 2020 64 prospective controlled observational study. eur arch otorhinolaryngol. 2014; 271(11): 3085–93. 5. fernández a, macías i, gutiérrez r, martínez p, díaz ma, dysphagia following prolonged mechanical ventilation and tracheostomy in critical ill patients. results of edisval study pilot phase. intensive care med exp. 2015; 3(suppl 1): 677. 6. jung s j, kim dy, kim yw, koh yw, joo sy, kim es. effect of decannulation on pharyngeal and laryngeal movement in post-stroke tracheostomized patients. ann rehabil med. 2012; 36(3): 356–364. 7. feldman sa, deal cw, urguhart w. distarbance of swallowing after tracheostomy, lancet 1966; 1(7444): 954-5. 8. gross rd, mahlmann j, grayhack, jp. physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. ann otol rhinol laryngol. 2003; 112(2): 143-52. 9. hernandez g, pedrosa a, ortiz r, cruz accuar oni mdel m, cuena r, vaquero collado c et al. the effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. intensive care med. 2013; 39(6): 1063-70. 10. garuti g, reverberi c, briganti a, massobrio m, lombardi f, lusuardi m, et al. swallowing disorders in tracheostomised patients: a multidisciplinary /multiprofessional approach in decannulation protocols. multidiscip respir med. 2014; 9(1): 36. 11. bonvento b, wallace s, lynch j, coe b, mcgrath ba. role of the multidisciplinary team in the care of the tracheostomy patient. j multidiscip healthc. 2017; 10: 391-398. 12. mah jw, staff ii, fisher sr, butler kl. improving decannulation and swallowing function: a comprehensive, multidisciplinary approach to posttracheostomy care. respir care. 2017; 62(2): 137143. 13. martin-harris b, brodsky mb, michel y, castell do, schleicher m, sandidge j, et al. mbs measurement tool for swallow impairment--mbsimp: establishing a standard. dysphagia 2008; 23(4): 392-405. 14. braun t, juenemann m, viard m, meyer m, fuest s, reuter i, et al. what is the value of fibre -endoscopic evaluation of swallowing (fees) in neurological patients? a cross-sectional hospital-based registry study. bmj open 2018; 8: e019016. doi: 10.1136/bmjopen-2017-019016 15. gallas s, moirot, p, debono g, navarre i, denis p, marie et al. mylohyoid motor-evoked potentials relate to swallowing function after chronic stroke dysphagia. neurogastroenterol. motil. 2007; 19 (6): 453-8. 16. hess dr, altobelli np. tracheostomy tubes. respir. care.2014; 59 (6): 956-3. 17. simons a, hamdy s. the use of brain stimulation in dysphagia management. dysphagia. 2017; 32(2): 209-15. 18. rosenvinge sk, starke id. improving car e for patients with dysphagia. age ageing. 2005; 34(6): 587-93. 19. vose a, nonnenmacher j, singer ml, gonzálezfernández m. dysphagia management in acute and sub-acute stroke. curr phys med rehabil rep. 2014; 2(4): 197–206. doi:10.1007/s40141-014-0061-2 20. johnson dn, herring hj, daniels sk. dysphagia management in stroke rehabilitation. curr phys med rehabil rep. 2014; 2: 207–218. doi:10.1007/s40141-014-0059-9 21. cabib c, ortega o, kumru h, palomeras e, vilardell n, alvarez-berdugo d et al. neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function. ann n y acad sci. 2016; 1380(1): 121-38. 22. humbert ia, robbins j. dysphagia in the elderly. phys med rehabil clin n am. 2008; 19(4): 853–x. doi:10.1016/j.pmr.2008.06.002 23. scutt p, lee hs, hamdy s, bath pm. pharyngeal electrical stimulation for treatment of poststroke dysphagia: individual patient data meta-analysis of randomised controlled trials. stroke res treat. 2015; 2015: 429053. 24. park cl, o’neill pa, martin df. a pilot exploratory study of oral electrical stimulation on swallow function after stroke: an innovative technique. dysphagia. 1997; 12(3): 161–6. 25. momosaki r, abo m, watanabe s, kakuda w, yamada n, mochio k. functional magnetic stimulation using a parabolic coil for dysphagia after stroke. neuromodulation. 2014; 17(7): 637–41. 26. kim l, chun mh, kim br, lee sj. effect of repetitive transcranial magnetic stimulation on patients with brain injury and dysphagia. ann rehabil med. 2011; 35(6): 765-71. 27. wang z, song wq, wang l. application of noninvasive brain stimulation for post-stroke dysphagia rehabilitation. kaohsiung j med sci. 2017; 33(2): 55-61. 28. dionisio a, duarte ic, patricio m, branco mc. the use of repetitive transcranial magnetic stimulation for stroke rehabilitation: a systematic review. j stroke cerebrovasc dis. 2018; 27(1): 1-31. 29. lee jh, kim sb, lee kw, lee sj, lee ju. effect of repetitive transcranial magnetic stimulation according to the stimulation site in stroke patie nts with dysphagia. ann rehabil med. 2015; 39(3): 4329. j islamabad med dental coll 2023 103 open access pattern of biopsy-proven renal disease in pakistan: a single center experience muhammad sajid rafiq abbasi1, khawar sultan2, kanza kanwal3, ahmareen khalid sheikh4, fareeha tayyab5, zainab maqsood6 1 associate professor, department of nephrology, paf hospital islamabad 2 registrar, department of nephrology pims, islamabad 3consultant, department of nephrology, dhq hospital jehlum, pakistan 4 associate prof, histopathology pims, islamabad 5 resident, department of nephrology, paf hospital islamabad 6 medical officer, thq, gujar khan a b s t r a c t background: this study was conducted to determine pattern (spectrum) of renal diseases on basis of renal biopsy in a tertiary care hospital in islamabad. methodology: this retrospective observational study was conducted at nephrology department of pakistan institute of medical sciences islamabad from february 2012 to april 2020. results of all biopsies done during this period were analyzed to determine the prevalence of different renal diseases on basis of histopathology and immunofluorescence. results: there were 254 kidney biopsy samples studied during the course of study. out of total 254 patients 133 (52.4%) were male and 121 (47.6%) were female. mean age of participants was 34.47±7.67 years (range:15-60 years). primary glomerulonephritis and secondary glomerulonephritis was found in 169 (66.5%) and 48 (18.9%) respectively, while tubulo-interstitial disease was reported in 37 (14.6%) of the total biopsies. among 169 biopsies that showed primary gn, iga nephropathy (igan) was the most common in 16% of the biopsies, followed by membranous gn in 15.4% while membranoproliferative gn (mpgn) was seen in 13.6%, and focal and segmental glomerulosclerosis (fsgs) was seen in 13% of primary gn. among 48 biopsies with secondary gn, lupus nephritis (ln) was found to be most common in 83.3% followed by amyloidosis in 6.3%. among 37 biopsies having tubulo-interstitial disease, acute tubular nephritis (atn) and renal cortical necrosis was seen in 29.7% each followed by tubulo-interstitial nephritis in 18.9% and acute interstitial nephritis (ain) was seen in 16.2%. conclusion: this study shows that primary gn is the most common finding on renal biopsy. among them iga nephropathy is the commonest lesion followed by membranous nephropathy, mpgn and fsgs. among secondary gn, lupus nephritis is the commonest lesion. key words: glomerulonephritis, renal biopsy, renal disease, renal histopathology authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: khawar sultan email: khawar thakur@gmail.com article info: received: september 2, 2021 accepted: may 20, 2023 cite this article. abbasi m s r, sultan k, kanwal k, sheikh a k, tayyab f, maqsood z. pattern of biopsy-proven renal dysfunction in pakistan: a single center experience. j islamabad med dental coll. 2023; 12(2): 103-109 doi: https://doi.org/10.35787/jimdc.v12i2.782 funding source: nil conflict of interest: nil i n t r o d u c t i o n renal biopsy is considered to be the investigation of choice to diagnose renal diseases especially o r i g i n a l a r t i c l e j islamabad med dental coll 2023 104 glomerulopathies. its safety has been repeatedly assessed and it was proven to be a safe and effective tool.1 it plays a vital role in the diagnosis of vascular, glomerular, tubulointerstitial, and genetic diseases. it provides important information regarding stage of the disease and also helps in management as well. the indications for renal biopsy are divergent and vary from center to center.2 various familial renal diseases are among the common clinical conditions where a biopsy is required.3 in a developing country, the exact prevalence of renal diseases is difficult to determine since medical facilities are limited and unevenly distributed between urban and rural areas. in the absence of a central registry, the only data available is center based.4 in order to understand the regional epidemiology of glomerular disease in a specific geographic area, it is crucial to study the prevalence of biopsy-proven renal disease (bprd) and its variation and distribution as per geographic areas, socioeconomic conditions, race, age, and indication for renal biopsy.5 data from numerous international journal publications suggests that the course of glomerular disease has changed during the past few decades.6-9 the study of epidemiology of renal pathologies on biopsy not only helps us to understand the incidence and prevalence of different kidney diseases but also aids to understand the specific pattern of disease in a specific region and change of disease pattern as well. this change and variation of disease pattern has been observed within a country10,11 and internationally.12-14 the most frequent diagnosis found on renal biopsy is glomerulonephritis (gn). glomerulonephritis is characterized by inflammation of the glomerular compartment of the kidney and is caused by the different immune mediated mechanisms.15 glomerulonephritis (gn) can be divided into primary and secondary gn. if no associated cause is found it is said to be primary gn. if it is associated with any other disease like systemic lupus erythematosus (sle) or polyarteritis nodosa, rheumatoid arthritis, hepatitis or malignancy it is called as secondary gn. glomerulonephritis is also classified on the basis of their clinical presentation and histopathological findings.16 it became clear that patients with immunological complex gn displayed a diversity of histologic characteristics once renal biopsy was implemented into clinical practice. the first pathologic classification of lupus nephritis was developed in 1974 under by world health organization in an effort to standardize definitions and improve communication. this classification has been revised multiple times, most recently in 2003 and 2018 by the international society of nephrology/renal pathology society (isn/rps). these amendments' specifics, which are covered elsewhere, are outside the purview of this review.17 if we look at the international data18, it is difficult to predict that which diseases are more prevalent in local population. second, has variation of disease pattern been also observed with the passage of time or not. however, the literature on the entire spectrum of glomerular diseases of renal biopsy, especially from pakistan, is scanty; hence, the present study was undertaken. to explore an updated and local data showing different histopathological lesions on renal biopsy in a single center tertiary kidney hospital, pakistan institute of medical sciences, islamabad, pakistan. m e t h o d o l o g y this observational study was conducted at nephrology department of pakistan institute of medical sciences islamabad pakistan from february 2012 to april 2020 after approval from institutional ethical review board. every procedure was carried out in accordance with the helsinki declaration. nephrotic syndrome, nephritic syndrome, asymptomatic hematuria with proteinuria, acute renal failure, and chronic renal failure with a kidney of relatively normal size were the reasons for renal j islamabad med dental coll 2023 105 biopsy. all patients who were above the age of 18 years and underwent renal biopsy during the study period were included in the study. cases with graft biopsies or inadequate biopsies were excluded from the study. all biopsies were done with patient’s consent according to hospital protocol. two samples were taken through percutaneous approach under ultrasound visualization and sent to the laboratory. the samples of biopsies were processed in the laboratory according to the standard protocols. light microscopy and immunofluorescence were done on each biopsy specimen; however, electron microscopy could not be performed due to its nonavailability in our setup. results of biopsies were analyzed. experienced nephropathologists made all of the diagnoses based on histology and clinical research. the date of the kidney biopsy, the patient's age, gender, and pathological diagnosis were all recorded. the baseline demographics and clinical data/ biochemical parameters like serum creatinine, serum urea and 24-hour urinary protein were also analyzed. spss version 21.0 was used to analyze the data. all categorical variables were characterised using frequency and percentage, and all continuous variables were reported using mean and standard deviation. r e s u l t s in total 254 kidney biopsy samples studied during the course of study from february 2012 to april 2020. out of 254 patients, 133 (52.4%) were male while 121 (47.6%) were female. mean age of participants was 34.47±7.67 years with a range of 15-60 years. (table i). regarding glomerulonephritis (gn) type, primary gn was found in 169 (66.5%), secondary gn was found in 48 (18.9%) and tubuleinterstitial disease was reported in 37 (14.6%) of the total 254 biopsies (table i). among 169 biopsies that showed primary gn, immunoglobulin a nephropathy (igan) was the most common in 27 (16%) biopsies, 19 males and 8 females, followed by membranous gn in 26 (15.4%), 16 males and 10 females followed by membranoproliferative gn (mpgn) lesion in 23 (13.6%), 12 males and 11 females and focal and segmental glomerulosclerosis (fsgs) was seen in 22 (13%), 13 males and 9 females while mcd and crescentic gn has equal number i.e. (15) 8.9% each. however 14 out of 15 patients were males in minimal change disease (table ii). with regards to different histopathological lesions of iga nephropathy, among total 27 biopsies with igan subclass iii (mesangial expansion with hypercellularity) was found to be most prevalent in 10 (37%) biopsies followed by subclass v (sclerosis of glomeruli) in 7 biopsies (26%). 5 biopsies (18.5%) fall in subclass iv (diffuse proliferation) while 3 (11%) in subclass ii (focal and segmental sclerosis). only 2 biopsies (7.4%) were classified as subclass i (minimal changes without hypercellularity). among biopsies with secondary gn, lupus nephritis (ln) was seen in 83.3% of the biopsies followed by amyloidosis among 6.3% of the 48 biopsies (table iii). distribution of lupus nephritis types with ln v was most abundant with 25%, followed by ln iv was 18%, ln ii was present among 17%, ln iv was present among 15% of the lupus nephritis types. among 37 biopsies having tubulo-interstitial disease, acute tubular nephritis (atn) and renal cortical necrosis was seen in 11 (29.7%) each followed by tubulo-interstitial nephritis among 7 (18.9%) and acute interstitial nephritis (ain) was seen in 6% (16.2%) biopsies (table iv). the frequencies of kidney diseases, gender ratio, mean age (years), mean 24 hours urinary protein, mean creatinine and mean urea among primary gn, secondary gn and tubulo-interstitial disease (table i to iv). j islamabad med dental coll 2023 106 table i: frequency of renal diseases (n=254) variables frequency male/female age (years) serum creatinine (µmol/l) blood urea (mmol/l) proteinuria (g/24-h) primary glomerulonephritis 169 (66.5%) 112/57 33.34±7.71 (15-50) 1.98±1.64 (0.6-7.8) 50.16±26.36 (20-149) 3.21±2.94 (0.2-22.8) secondary glomerulonephritis 48 (18.9%) 10/38 37.91±7.53 (23-60) 1.24±0.81 (0.6-5.5) 39.39±16.92 (23-134) 2.62±1.41 (0.3-5.8) tubulo-interstitial nephritis 37 (14.6%) 11/26 35.16±6.34 (25-55) 5.29±1.68 (0.7-8.7) 99.16±37.84 (28-222) 0.94±0.74 (0.3-4.4) total 254 (100%) 133/121 34.47±7.67 (15-60) 2.33±1.98 (0.6-8.7) 55.27±32.64 (20-222) 2.77±2.61 (0.2-22.8) table ii: frequency of types of primary glomerulonephritis in the kidney biopsies studied (n=169/254) variables frequency male/female age (years) serum creatinine (µmol/l) blood urea (mmol/l) proteinuria (g/24-h) immunoglobulin a nephropathy (igan) 27 (16%) 19/8 28.63±5.86 (18-37) 1.07±0.21 (0.7-1.5) 38.85±9.41 (25-65) 3.14±3.95 (1.3-22.8) membranous glomerulonephrit is (mgn) 26 (15.4%) 16/10 34.69±6.47 (22-47) 0.81±0.15 (0.6-1.1) 31.77±4.61 (23-38) 7.60±2.44 (2.5-14.1) membranous proliferative glomerulonephrit is (mpgn) 23 (13.6%) 12/11 33.22±4.78 (23-40) 1.30±1.15 (0.8-6.5) 43.56±12.14 (29-76) 2.86±0.55 (1.73.8) focal & segmental glumerosclerosis (fsgs) 22 (13%) 13/9 35.54±6.60 (22-44) 1.10±0.26 (0.6-1.7) 41.27±11.57 (23-60) 3.6±0.44 (2.84.6) minimal change diseases 15 (8.9%) 14/1 38.67±3.31 (33-45) 2.62±0.59 (1.8-3.6) 51.53±11.51 (35-70) 0.84±0.24 (0.51.2) crescentic gn 15 (8.9%) 9/6 27.2±3.69 (23-36) 5.95±0.98 (4.6-7.8) 115.93±24.5 9 (70-149) 1.78±0.42 (1.32.9) table iii: frequency of secondary glomerulonephritis in the kidney biopsies studied (n=48/254) variables frequency male/female age (years) serum creatinine (µmol/l) blood urea (mmol/l) proteinuria (g/24-h) lupus nephritis (ln) 40 (83.3%) 5/35 36.85±4.41 (27-45) 1.09±0.5 (0.6-3.6) 36.45±9.49 (23-60) 2.74±1.38 (0.75.8) amyloidosis 06 (6.3%) 3/3 32.5±4.64 (26-38) 4.55±1.79 (1.1-6.1) 82.67±27.74 (34-112) 1.2±0.65 (0.62.3) secondary membranous glomerulonephritis (secondary mgn) 02 (4.2%) 2/0 57.67±2.52 (55-60) 1.07±0.06 (1.0-1.1) 35.67±1.53 (34-37) 3.6±0.36 (3.34.0) j islamabad med dental coll 2023 107 table iv: frequency of tubulo-interstitial in the kidney biopsies studied (n=37/254) variables frequency male/ female age (years) serum creatinine (µmol/l) blood urea (mmol/l) proteinuria (g/24-h) acute tubular nephritis 11 (29.7%) 4/7 38.0±8.61 (25-55) 5.4±1.06 (2.86.8) 107.18±28.26 (51-145) 0.59±0.13 (0.30.7) renal cortical necrosis 11 (29.7%) 00/11 31.81±3.19 (27-36) 6.58±1.21 (4.48.7) 121.91±42.59 (76-222) 0.62±0.07 (0.50.7) tubular interstitial nephritis 07 (18.9%) 02/05 38.43±5.19 (28-43) 4.54±1.43 (2.97.2) 78.57±28.67 (55-134) 1.3±0.53 (0.62.2) acute interstitial nephritis 06 (16.2%) 03/03 32.5±4.64 (26-38) 4.55±1.79 (1.16.1) 82.67±27.74 (34-112) 1.20±0.65 (0.62.30) d i s c u s s i o n this study showed that mean age of kidney disease is 34 years. it was almost the same as found in the study reported from india.19 gender distribution showed male predominance. these findings are comparable to other studies except one reported from oman where females patients were higher than the males.20,21 regarding glomerular diseases, a great variation in prevalence of different lesions has been reported worldwide. for example, north america fsgs has been found to be the most common lesion in all ethnic groups.22 on the other hand, if we look at the data available from the studies conducted in europe population, iga nephropathy is a common lesion while fsgs is a very uncommon.23 a study conducted in japan reported that the most common cause of proteinuria is mcd7, while data from northern india showed mn is most common lesion.11 a study conducted in brazil reported fsgs as the most prevalent lesion.24 in our study gn (85.4%) was the most common diagnosis. primary gn was seen in 66.5% and secondary gn was found in 18.9% followed by tubulointerstitial disease 14.6%. among primary gn iga nephropathy (igan) was the most commonly seen in 16% of the biopsies, followed by membranous gn in 15.4%, followed by membranoproliferative gn (mpgn) in 13.6%, and focal and segmental glomerulosclerosis (fsgs) were seen in 13% among 169 biopsies. among biopsies with secondary gn, lupus nephritis (ln) was seen in 83.3% of the biopsies followed by amyloidosis among 6.3% of the 48 biopsies. khalid et al. and others reported that fsgs was the commonest lesion followed by membranous nephropathy and iga nephropathy in proteinuria patients.15,25,26 all these studies reported that fsgs was the commonest lesion, and third commonest lesion was iga nephropathy. in contrast to these studies, in our study iga nephropathy is the most common lesion followed by membranous nephropathy, mpgn and then fsgs. why is there difference? it is difficult to answer! it may be due to different sociodemographic characteristics change of pattern. it is thus required to conduct further studies locally. a recent article by al yousef et al published from kuwait showed that iga nephropathy was the most common cause of glomerular disease on renal biopsy.27 secondary gn is another common finding seen on renal biopsy. lupus nephritis was the most common diagnosis on biopsy followed by amyloidosis. .lupus is high in middle east, oman.18 j islamabad med dental coll 2023 108 c o n c l u s i o n primary gn is the most common finding on renal biopsy. among them iga nephropathy is the commonest lesion followed by membranous nephropathy, mpgn and fsgs. however, almost across the world, the most common secondary glomerular disease is lupus nephritis, the commonest lesion. acknowledgement: we thank dr. sidra, department of histopathology for providing us picture of histopathology slide of iga nephropathy. r e f e r e n c e s 1. burke jp, pham t, may s, okano s, ratanjee sk, thet z, wong jk, venuthurupalli s, ranganathan d. kidney biopsy practice amongst australasian nephrologists. bmc nephrology. 2021 aug 26;22(1):291. doi: 10.1186/s12882-021-02505-9. 2. farah ri. glomerulonephritis pattern at a jordanian tertiary care center. international journal of nephrology. 2018 oct 11;2018. doi:10.1155/2018/2751372. 3. zajjari y, aatif t, bahadi a, hassani k, el kabbaj d, benyahia m. kidney biopsy in the military hospital of morocco: complications and histopathological findings. saudi journal of kidney diseases and transplantation. 2015 sep 1;26(5):1044-9. 4. rizvi sa, manzoor k. causes of chronic renal failure in pakistan: a single large center experience. saudi journal of kidney diseases and transplantation. 2002 jul 1;13(3):376-9. 5. mubarak m, kazi ji, naqvi r, ahmed e, akhter f, naqvi sa, rizvi sa. pattern of renal diseases observed in native renal biopsies in adults in a single centre in pakistan. nephrology. 2011 jan;16(1):87-92. 6. rychlík i, jančová e, tesař v, kolský a, lácha j, stejskal j, stejskalová a, dušek j, herout v. the czech registry of renal biopsies. occurrence of renal diseases in the years 1994–2000. nephrology dialysis transplantation. 2004 dec 1;19(12):3040-9. 7. choi ij, jeong hj, han ds, lee js, choi kh, kang sw, ha sk, lee hy, kim pk. an analysis of 4,514 cases of renal biopsy in korea. yonsei medical journal. 2001 apr 1;42(2):247-54. 8. chang jh, kim dk, kim hw, park sy, yoo th, kim bs, kang sw, choi kh, han ds, jeong hj, lee hy. changing prevalence of glomerular diseases in korean adults: a review of 20 years of experience. nephrology dialysis transplantation. 2009 aug 1;24(8):2406-10. 9. asif n, ahsan mn, khanzada sw. spectrum of renal parenchymal diseases: an eleven year retrospective review of renal biopsy data from a tertiary care hospital in pakistan. annals of king edward medical university. 2017 mar 11;23(1). 10. hull kl, adenwalla sf, topham p, graham-brown mp. indications and considerations for kidney biopsy: an overview of clinical considerations for the nonspecialist. clinical medicine. 2022 jan;22(1):34-40. doi:10.7861/clinmed.2021-0472. 11. molnár a, thomas mj, fintha a, kardos m, dobi d, tislér a, ledó n. kidney biopsy-based epidemiologic analysis shows growing biopsy rate among the elderly. scientific reports. 2021 dec 29;11(1):24479. doi.org/10.1038/s41598-021-04274-9 12. nadium wk, abdelwahab hh, ibrahim ma, shigidi mm. histological pattern of primary glomerular diseases among adult sudanese patients: a single center experience. indian journal of nephrology. 2013 may;23(3):176. doi: 10.4103/09714065..111838. 13. wang yt, zhou cy, zhu tc, yang j, zhang y, xu qy, guo mh. analysis of kidney biopsy data from a single center in the midland rural area of china, 1996– 2010. current therapeutic research. 2013 jun 1;74:22-5. doi: 10.1016/j.curtheres.2012.12.005. 14. sugiyama h, yokoyama h, sato h, saito t, kohda y, nishi s, tsuruya k, kiyomoto h, iida h, sasaki t, higuchi m. japan renal biopsy registry and japan kidney disease registry: committee report for 2009 and 2010. clinical and experimental nephrology. 2013 apr;17:155-73. doi: 10.1007/s10157-0120746-8. 15. pesce f, stea ed, rossini m, fiorentino m, piancone f, infante b, stallone g, castellano g, gesualdo l. glomerulonephritis in aki: from pathogenesis to therapeutic intervention. frontiers in medicine. 2021 mar 2;7:582272. doi:10.3389/fmed.2020.582272. 16. mastrangelo a, serafinelli j, giani m, montini g. clinical and pathophysiological insights into immunological mediated glomerular diseases in childhood. frontiers in pediatrics. 2020 may 12;8:205. doi:10.3389/fped.2020.00205. 17. yahya tm, pingle a, boobes y, pingle s. analysis of 490 kidney biopsies: data from the united arab emirates renal diseases registry. journal of nephrology. 1998 may 1;11(3):148-50. 18. al riyami d, al shaaili k, al bulushi y, al dhahli a. the spectrum of glomerular diseases on renal biopsy: data from a single tertiary center in oman. oman j islamabad med dental coll 2023 109 medical journal. 2013 may;28(3):213. doi: 10.5001/omj.2013.58. 19. kumar s, kumari a, agrawal sc. pattern of kidney diseases in northern india: an overview through histopathological findings in biopsy-proven cases. the egyptian journal of internal medicine. 2020 dec;32(1):1-5. doi: 10.1186/s43162-020-00021-0 20. thomé gg, bianchini t, bringhenti rn, schaefer pg, barros ej, veronese fv. the spectrum of biopsyproven glomerular diseases in a tertiary hospital in southern brazil. bmc nephrology. 2021 dec;22(1):16. doi:10.1186/s12882-021-02603-8. 21. jesudason s, grace bs, mcdonald sp. pregnancy outcomes according to dialysis commencing before or after conception in women with esrd. clinical journal of the american society of nephrology. 2014 jan 7;9(1):143-9. 22. rosenberg az, kopp jb. focal segmental glomerulosclerosis. clinical journal of the american society of nephrology. 2017 mar 7;12(3):502-17. doi: 10.2215/cjn.05960616. 23. coppo r. iga nephropathy: a european perspective in the corticosteroid treatment. kidney diseases. 2018;4(2):58-64. doi:10.1159/000487265. 24. khalid m, ahmad j, khan ma. histopathological pattern of glomerular lesions on percutaneous renal biopsy in proteinuric patients. pakistan armed forces medical journal. 2017 apr 30;67(2):211-15. 25. mcgrogan a, franssen cf, de vries cs. the incidence of primary glomerulonephritis worldwide: a systematic review of the literature. nephrology dialysis transplantation. 2011 feb 1;26(2):414-30. 26. wetmore jb, guo h, liu j, collins aj, gilbertson dt. the incidence, prevalence, and outcomes of glomerulonephritis derived from a large retrospective analysis. kidney international. 2016 oct 1;90(4):853-60. 27. alyousef a, alsahow a, alhelal b, alqallaf a, abdallah e, abdellatif m, nawar h, elmahalawy r. glomerulonephritis histopathological pattern change. bmc nephrology. 2020 dec;21(1):1-7. j islamabad med dental coll 2023 95 open access challenge of multidrug-resistant strains of enterobacteriaceae isolated from clinical samples farhat khurshid1,aftab ahmad khan2, rizwan uppal3, khurshid ahmad4, salman riaz5, gul-e-rehan6, afrah malik7 1associate microbiologist, islamabad diagnostic centre (idc), islamabad, pakistan 2director lab and consultant haematologist, islamabad diagnostic centre (idc), islamabad, pakistan 3 ceo and consultant medical specialist, islamabad diagnostic centre (idc), islamabad, pakistan 4consultant microbiologist, islamabad diagnostic centre (idc), islamabad, pakistan 5 microbiologist, islamabad diagnostic centre (idc), islamabad, pakistan 6consultant haematologist, islamabad diagnostic centre (idc), islamabad, pakistan 7resident medical officer, paf hospital, islamabad a b s t r a c t background: the rising level of antimicrobial resistance among bacterial pathogens is one of the most significant public health problems worldwide. antibiotic resistance of clinically important bacteria, the types and levels of resistance and multidrug resistance (mdr) among pathogens is extremely important. with the rise of infections caused by esbl-producing enterobacteriaceae (esbl-e) and with their co-resistance to many other antibiotic classes, carbapenems have been considered to be the last line of defence against these life-threatening infections. the current study was carried out to determine the frequency, disease burden and therapeutic challenge of infections caused by multidrug resistant strains of enterobacteriaceae with particular reference to extended-spectrum beta-lactamaseproducing enterobacteriaceae (esbl-e), carbapenem-resistant enterobacteriaceae (cre) and the emerging infections caused by extended-spectrum beta-lactamase-producing carbapenem-resistant enterobacteriaceae (esbl-cre) methodology: this cross-sectional study was carried out in the microbiology department of islamabad diagnostic centre over a period of two years, from january 2018 to december 2020. enterobacteriaceae isolated on culture from clinical samples were identified using appropriate characterization tests including the selective use of api 20e. antimicrobial susceptibility testing (ast) and esbl detection was performed on vitek 2 compact system by minimum inhibitory concentration (mic) methodology. isolates that were resistant to more than one carbapenem were identified as carbapenem-resistant enterobacteriaceae (cre). results: out of 7270 specimens that yielded the growth of enterobacteriaceae, 2943 (40.5%) were esbl positive (esbl-e) and 487 (6.7%) were carbapenem resistant (cre). further analysis of cre revealed 247/487 as non-esbl-cre and 240/487 as esbl-producing cre (esbl-cre). maximum number of cre isolates both non-esbl and esbl cre were from urine specimens. klebsiella species followed by escherichia coli and enterobacter were the dominant esblcre isolates. admission to a health care facility was the major risk factor followed by advancing age. conclusion: besides esbl-e, carbapenum-resistant enterobacteriaceae (cre), particularly those co-producing extended-spectrum beta-lactamase (esbl-cre), (wherein resistance mechanisms to both carbapenems as well as to beta-lactam antibiotics are concomitantly expressed in the same organism), have emerged as the major pathogens of concern.the later appears to have introduced a new dimension in the resistance profile of infections caused by multidrug-resistant enterobacteriaceae. keywords: esbl-producing enterobacteriaceae, carbapenem-resistant enterobacteriaceae (cre), esbl-producing carbapenem-resistant enterobacteriaceae (esbl-cre), escherichia coli, klebsiella, multi-drug resistant enterobacteriaceae. authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: khurshid ahmad email: irfankhurshid70@gmail.com article info: received: april 23,2023 accepted: june 10, 2023 cite this article. khurshid f, khan a a, uppal r, ahmad k, riaz s, rehan g, malik a. challenge of multidrug resistant strains of enterobacteriaceae isolated from clinical samples. j islamabad med dental coll. 2023; 12(2):95-102https://doi.org/10.35787/jimdc.v12i2.978 funding source: nil conflict of interest:nil o r i g i n a l a r t i c l e j islamabad med dental coll 2023 96 i n t r o d u c t i o n ever since the emergence of infections caused by esbl-producing enterobacteriaceae (esbl-e), along with their genetically determined co-resistance to many other antibiotic classes, carbapenems have traditionally been considered to be the last line of defence and virtual life-saving agents against these life-threatening infections.1emergence of strains that had developed resistance to carbapenems was, therefore, a serious development. first reported from japan in 1994,2carbapenem-resistant enterobacteriaceae (cre), with their marked propensity for nosocomial spread, have emerged as one of the most serious threats to the management of infections in health care facilities all over the world.3,4ominously, we are now faced with the more formidable challenge of emerging infections caused by esbl-producing carbapenem-resistant enterobacteriaceae (esbl-cre). these strains, reported sporadically worldwide in recent years, harbour both esbl and carbapenemase genes in the same organism that confer a high level of resistance to both the carbapenems as well as to higher generation cephalosporins, thus leaving extremely limited therapeutic options. 5-7 the present study, conducted at the microbiology department of islamabad diagnostic centre (idc) over a period of two years, was essentially a comparative analysis of the etiological roles played by these three strains of multidrug resistant (mdr) enterobacteriaceae in the causation of clinical infections namely extended-spectrum betalactamase-producing enterobacteriaceae (esbl-e), carbapenem-resistant enterobacteriaceae (cre), and, importantly, the newly emerging esblproducing carbapenem-resistant enterobacteriaceae (esbl-cre), and to determine their frequency, clinical significance, risk factors and therapeutic options available within our healthcare set-up. m e t h o d o l o g y clinical specimens were collected with full aseptic precautions using transport media where necessary and were processed according to standard protocols. clean-catch midstream urine collected in sterile containers was cultured within one hour of collection or stored at 4oc until inoculated. blood cultures were performed on versa trek automatic microbial detection system (thermo-fisher scientific usa). cled agar (oxoid ltd, basingstoke, uk) was used for quantitative urine culture; a colony count of ≥ 105 colony-forming units (cfu) per ml having been taken assignificant. all other routine specimens were inoculated on blood agar, macconkey agar and chocolate agar (oxoid ltd, uk) and incubated at 37oc for 24-48 hours. appropriate characterization tests were used to identify the isolates, including the selective use of api-20e and/or vitek 2 id card. all gram-negative rods (gnrs) characterized as enterobacteriaceae were included in the study. all oxidase positive and nonfermenting gnrs were excluded. antimicrobial susceptibility testing (ast) and esbl detection was performed on vitek 2 compact system (biomérieux, marcy-l’e’toile, france) by minimum inhibitory concentration (mic) methodology. appropriate vitek 2 standard susceptibility cards were used throughout the study to test susceptibility against amikacin, amoxiclav, ceftriaxone, ciprofloxacin, imipenem, meropenem, ertapenem, cotrimoxazol, piperacillin/tazobactam, minocycline and tigecycline. esbl positive strains were detected by vitek 2 advanced expert system (aes).isolates identified as esbl-positive by vitek 2 aes were further confirmed by double disc diffusion (disc approximation) method performed on muellerhinton agar (oxoid ltd, uk) ; results were interpreted as previously described.8 clinical laboratory standards institute’s (clsi) performance standards for ast were followed j islamabad med dental coll 2023 97 throughout, including the reduced mic breakpoints for carbapenems susceptibility that were used to interpret the susceptibility or resistance to imipenem, meropenem and ertapenem. this approach effectively obviated the need for carbapenemase testing9. eucast breakpoints were used for interpreting susceptibility to colistin / polymyxin b and tigecycline.10 cdc’s 2015 definition of cre, primarily meant for use in usa health care facilities, was slightly modified and all the gnr isolates that were resistant to more than one carbapenem in our series were identified as carbapenem-resistant enterobacteriaceae (cre).11relevant demographic and clinical data including age, gender, hospital or community infection, icu admission (wherever available) were recorded. site of infection was determined from the nature of clinical samples received. findings were analysed by calculating frequencies and percentages. pearson’s chi square test was applied as test of significance for categories of variables; p-value of ≤ 0.05 (95% ci) was taken as statistically significant study was duly approved by the idc ethical committee. since all patient data was analysed anonymously from the lab records, requirement for informed consent of participants was waved by the approval committee. r e s u l t s during the study period, a total of 7270 specimens yielded growth of enterobacteriaceae. initially the isolates were divided into two main study groups; 2943 (40.5%) were esbl positive enterobacteriaceae (esbl-e) and 487(6.7%) were carbapenem-resistant enterobacteriaceae (cre). on the basis of co-production of esbl, cre were further divided into two sub-groups, with more or less equal distribution; 247/487 were non-esbl-cre as opposed to 240/487 that were esbl-cre (being esbl producers as well as carbapenem-resistant). the frequencies of the three major groups of "pathogens of concern" that have emerged from this analysis, namely esbl-e, non-esbl-cre and esbl-cre, are shown in tables i, ii and iii according to clinical specimens/site of infection, species of organisms isolated and the demographic characteristics, respectively. *gnr – gram negative rods (for the sake of brevity this term is used synonymously with enterobacteriaceae) table i: cre (non-esbl and esbl-cre both), from different clinical samples as compared to total esbl (n : 7270) specimens / site of infection gnrs* no. of isolates (%) esbl (n:2943) cre (n : 487) no (% of gnr in the samples) total (%) non-esbl cre esbl cre urine (uti) 4652(64) 2094 (45) 185 (3.4) 87 98 pus/wound swab (sssi, ssi) 852(11.6) 239 (28) 123 (14.4) 64 59 catheter tips (inv med dev) 426(6) 207 (49) 59 (13.8) 28 31 sputum/bal (lower resp tract inf) 392(5.4) 165 (42) 49 (12.5) 24 25 blood (bsi) 630(8.7) 93 (15) 17 (2.7) 13 04 others (misc) 318(4.3) 145 (45.6) 54 (16.9) 31 23 total 7270 2943 (40.5) 487 (6.7) 247(3.4%) 240(3.3%) j islamabad med dental coll 2023 98 table ii: frequency according to species of isolates – both non-esbl cre as well as esbl-cre, as compared to total esbl frequency (n: 7270) organisms no. of isolates esbl ( % of total isolates) cre (n:487) total ( % of total isolates) non-esbl cre (%) esbl – cre (%) klebsiellaspp 1351 405 (30 ) 235 (17.4) 133 (9.8) 102 (7.5) e. coli 4778 2384 (49.9 ) 179 (3.7 ) 76 (1.6) 103 (2.1) enterobacterspp 239 52 (22 ) 60 (25 ) 28 (11.7) 32 (13.4) others (misc.) 902 102 (11.8 ) 13 (1.4 ) 10 (1.1) 03 (0.33) total 7270 2943(40.5 ) 487 (6.7 ) 247 (3.4) 240(3.3) table iii: demographic distribution of cre (n : 487) variables c r e total % non-esbl cre p value* esbl-cre p value* healthcare versus community associated healthcare associated 322 (66.1) 149 0.0009 173 < 0.0001 community associated 165 (33.8) 98 67 gender-based frequency male 295 (60.6) 150 < 0.0001 145 0.0625 female 192 (39.4) 77 115 age related frequency age < 1 40 yrs 152 (31.2) 80 < 0.0001 72 < 0.0001 age 40 100 yrs 335 (68.8) 167 168 mean age 52.35 yrs 56.31 yrs 0.7003 age distribution 1d – 100 yrs 2d – 100 yrs ( p values that have been highlighted are statistically significant )* * pearson’s chi square test has been applied as test of significance for categories of variables; * p-value of ≤ 0.05 (95% ci ) has been taken as significant. table iv: antibiograms showing antimicrobial susceptibility profiles of the two most frequent cre isolates (both esbl and non-esbl) e. coli (n : 179) cre no. of isolates antibiotics (percentage susceptible) ak cip sxt tzp mh tgc cephs ct/pb non-esblcre 76 61 3.8 5.2 2.6 40 40 0 100 esbl-cre 103 62 03 7.7 7.7 36 37 0 100 klebsiella (n : 235) cre no. of isolates antibiotics (percentage susceptible) ak cip sxt tzp mh tgc cephs ct/pb non-esbl -cre 133 16.5 5.2 6.7 1.3 10.8 47.4 0 100 esbl-cre 102 24.5 3.9 6.8 2.9 33 47 0 100 ak: amikacin; cip:ciprofloxacin; sxt: cotrimoxazol; tzp: pipracillin-tazobzctum; mh: minocycline; tgc: tigecycline ; cephs : 3rd gen cephalosporins (ceftriaxone used as class representative) ; ct: colistin; pb: polymyxin b. figures in the columns indicate percentage strains susceptible j islamabad med dental coll 2023 99 d i s c u s s i o n global spread of esbl-e and cre infections, with their substantial morbidity and mortality, is presently one of the greatest challenges facing the healthcare authorities all over the world. recent reports of infections caused by extended-spectrum beta-lactamase–producing carbapenem-resistant enterobacteriaceae (esbl-cre), wherein both esbl and cre resistance mechanisms are expressed in the same species, appear to have introduced a new and more serious dimension in the natural history of infectious diseases.5,7 who has included esblcre in its list of three top priority multi-drug resistant (mdr) pathogens (priority 1“critical”), requiring intensive research and development (r&d) efforts.12 despite the fact that piperacillin-tazobactam has been famously termed as carbapenem-sparing antibiotic against esbl-e infections,13 in actual clinical practice, carbapenems have been found to be the most effective and, by consensus, a preferred first line choice for severe esbl-e infections, necessarily resulting in their substantial overuse.14,15following the well-established historical pattern of genesis of antimicrobial resistance, carbapenem-resistant enterobacteriaceae (cre), therefore, did not take very long to appear and was soon followed by the emergence of esbl-producing carbapenemresistant strains (esbl-cre). overall esbl-e prevalence of 40.5% in our study is more or less similar to those reported in other recent studies. in a systemic meta-analysis report, ibrar et al have quoted a figure of 40% from pakistan as against 46% and 42% from china and east africa respectively.16 on the other hand, our findings of 40.5% esbl-e and 6.8% cre differ from those reported by (i) taqi m et al who reported 24.9% esbl-e and 5.7% cre in a sample size of 543 enterobacteriaceae isolated from blood cultures 17 and (ii) from those reported by legese et al 78.6% esbl-e and 12.12% cre in a small sample size of 28 only from ethiopia.18 our findings of 6.7% overall cre, with almost equal distribution between esbl-cre and non-esbl-cre, also appear to be at variance with another study from china wherein out of a total number of 149 cre strains detected over a four-year period, 32 (21.5%) were non-esbl cre and 117 (78.5%) were esbl-cre.5 in a study from turkey, among 210 esbl-producing enterobacteriaceae isolated from blood, 23 (11%) were identified as esbl-cre, being resistant, as in our series, to all the three carbapenems tested.7 maximum yield of esbl-cre from urine samples in our series, however, compares favourably with the findings in the chinese study making "urinary system disease as an independent predictor associated with the isolation of esbl-cre"5. significant association with invasive medical devices in our study also concurs with that reported in the same chinese study. however, there is a notable difference between the two studies in the most frequent esbl-cre and nonesbl cre species: our study shows klebsiella spp., e. coli and enterobacter frequencies in that order while the chinese report mentions enterobacter, e. coli and klebsiella in the same order. in their molecular based study of 46 cre isolates (9 e. coli and 37 klebsiella), duangkaw w et al found that esbl genes were co-harboured with carbapenemase genes in all but three cre isolates,19 an exceptionally high percentage of esblcre indeed. as for any reports of esbl-cre infections from pakistan, a literature review, including google search, unfortunately returned no results. in that case, to the best of our knowledge and belief, this report would be the first published account of the prevalence of multidrug-resistant infections from pakistan caused by esbl-producing carbapenum-resistant enterobacteriaceae (esblcre). coexistence of esbl and cre genetic elements in the same organism potentially makes a deadly combination as both strains often harbor plasmid mediated genes conferring resistance to http://www.healio.com/infectious-disease/news/print/infectious-disease-news/%7b24735a61-84f9-49c3-8083-cc981828e391%7d/cre-deemed-nightmare-bacteria-by-cdc http://www.healio.com/infectious-disease/news/print/infectious-disease-news/%7b24735a61-84f9-49c3-8083-cc981828e391%7d/cre-deemed-nightmare-bacteria-by-cdc http://www.healio.com/infectious-disease/news/print/infectious-disease-news/%7b24735a61-84f9-49c3-8083-cc981828e391%7d/cre-deemed-nightmare-bacteria-by-cdc j islamabad med dental coll 2023 100 other antimicrobial classes.15longer hospital stays, increased morbidity and mortality, propensity to spread widely within the health care settings, cre both esbl and non-esbl, require extensive infection control measures and preventive interventions to limit their spread.20 according to cdc, hospitalized patients with cre including esblcre infections have one of the highest mortality rates, ranging from a low of 24 % to as high as 70 %. 3,10,11 according to a standardized terminology, proposed by an international group of experts, to describe acquired resistance profiles of common pathogens,21 majority of esbl-e and cre isolates (non-esbl) in our series would be categorized as mdr (non-susceptible to at least one agent in three or more antimicrobial categories) and a significant number of esbl-cre as extensively drug resistant (xdr non-susceptibility to at least one agent in all but two or fewer antimicrobial categories). admission to a health care facility (table iii) appears to be the single, most important independent risk factor for developing cre infection, both non-esbl (p = 0.0009) as well as esbl-cre (p = < 0.0001) followed by advancing age, maximum cases having been found in 40 plus individuals (p = < 0.0001). these findings are consistent with those of another study reported from middle east.22 significantly no age was found to be exempt from cre both nonesbl as well as esbl-cre having been isolated even from day-old newborns. as mentioned earlier, invasive medical devices, because of their enhanced infective potential due to bacterial adherence and biofilm formation, appear to be a significant risk factor.5other risk factors include treatment and length of treatment with piperacillin-tazobactam, combination of carbapenems with fluoroquinolones23, previous exposure to β-lactam antibiotics, transfer from another hospital, and some underlying diseases.5based on susceptibility profiles of cre isolates, our lab findings, as regards therapeutic options, are largely consistent with those reported in the literature. combination therapy consisting of colistin and tigecycline would appear to be the best option in these infections, with fosfomycin replacing tigecycline in uti.24 this regimen however may have its own limitations; tigecycline has not yet been approved for use in children and colistin has its own nephrotoxicity and neurotoxicity profiles. despite the co-existence of esbl and cre genetic elements in the same species portraying a higher level of antimicrobial resistance, absence of any significant difference between the antibiograms of esbl-cre and non-esbl-cre in our study, appears to be somewhat paradoxical that defies a plausible explanation and arguably makes it a valid subject for further studies. l i m i t a t i o n s one of the major limitations of the study is that it has been more or less entirely lab-based, with little clinical information available. such information would be crucial to determine as to whether or not, or how far, the lab-reported susceptibility profiles are translated into matching clinical reality. there is a remote possibility of discordance between invitro susceptibility results and in-vivo clinical outcomes; as an example, esbl-e infections based on invitro susceptibility to piperacillin-tazobactam and cefepime have been reported to have doubtful outcomes in clinical settings.1 c o n c l u s i o n data presented in this study, spanning over a period of 2-years, shows that, besides the commonly encountered esbl-producing enterobacteriaceae (esbl-e) in clinical samples, strains of carbapenem-resistant enterobacteriaceae (cre), particularly those coproducing extended-spectrum beta-lactamase (esbl-cre), wherein resistance mechanisms to both the carbapenems as well as to beta-lactam antibiotics are concomitantly expressed in the j islamabad med dental coll 2023 101 same organism, have emerged as the major “pathogens of concern”. the later appears to have introduced a new dimension in the resistance profile of infections caused by multidrug-resistant enterobacteriaceae. suggested therapeutic options for cre, both esbl and non-esbl, would appear to be a combination of colistin and tigecycline, with fosfomycin replacing tigecycline as a priority in uti. relentless emergence of successive generations of resistant gnrs as highlighted herein calls for judicious restraints on the use of antibiotics under the who’s stewardship programme. r e f e r e n c e s 1. sheu cc, chang yt, lin sy, chen yh, hsueh pr. infections caused by carbapenem-resistant enterobacteriaceae: an update on therapeutic options. front microbiol 2019; 10: 80. doi: 10.3389/fmicb.2019.00080 2. osano e, arakawa y, wacharotayankun r, ohta m, horii t, ito h, et al. molecular characterization of an enterobacterial metallo-β-lactamase found in a clinical isolate of serratia marcescens that shows imipenem resistance. antimicrob agents chemother. 1994;38:71–78 . doi: 10.1128/aac.38.1.71 3. european centre for disease prevention and control. carbapenem-resistant enterobacteriaceae, second update – 26 september 2019. ecdc: stockholm; 2019. 4. van duin d and doi y. the global epidemiology of carbapenemase-producing enterobacteriaceae. virulence 2017; 8(4): 460–469. 5. tian x, sun s, jia x, zou h, li s and zhang l. epidemiology of and risk factors for infection with extendedspectrum β-lactamase-producing carbapenem-resistant enterobacteriaceae: results of a double case–control study. infec drug resist. 2018;11:1339-1346. doi:10.2147/idr.s173456. 6. yan j, pu s, jia x, xu x, yang s, shi j, et al. multidrug resistance mechanisms of carbapenem resistant klebsiella pneumoniae strains isolated in chongqing, china. ann lab med. 2017;37(5):398– 407. 7. eser ok, altunuludağ h, ergin a, boral b, sener b, hasçelik g. carbapenem resistance in esbl positive enterobacteriaceae isolates causing invasive infections. mikrobiyol bul. 2014;48(1):59–69. 8. rupp me, fey pd. extended spectrum betalactamase (esbl)-producing enterobacteriaceae: considerations for diagnosis, prevention and drug treatment. drugs. 2003;63 (4): 353-365. 9. clsi. performance standards for antimicrobial susceptibility testing. 30th ed. clsi document m 100, s30. wayne, pa: clinical and laboratory standards institute 2020. 10. eucast. 2017. european committee on antimicrobial susceptibility testing breakpoint tables for interpretation of mics and zone diameters, version 7.1 http://www.eucast.org/fileadmin/src/media/pdfs/e ucast_files/breakpoint_tables/v_7.1breakpoint_ta bles.pdf (accessed january 2022) 11. cdc: facility guidance for control of carbapenem-resistant enterobacteriaceae (cre); november 2015 update. cre toolkit. (accessed november 2021) 12. who: list of priority pathogens 2017. http://www.who.int/mediacentre/news/releases/20 17/bacteria-antibiotics-needed/en/ (accessed january 2022) 13. yoon yk, kim jh, sohn jw, yang ks, kim mj. role of piperacillin/tazobactam as a carbapenem-sparing antibiotic for treatment of acute pyelonephritis due to extended-spectrum β-lactamase-producing escherichia coli.int j antimicrob agents. 2017 apr;49(4):410-415. 14. tamma pd, han jh, rock c, harris ad, lautenbach e, hsu aj, et al. carbapenem therapy is associated with improved survival compared with piperacillintazobactam for patients with extended-spectrum β lactamase bacteremia. clin infect dis. 2015;60(9):1319–25. 15. rodríguez-baño j, gutiérrez-gutiérrez b, machuca i, pascual a. treatment of infections caused by extended spectrum-beta-lactamase-, ampc-, and carbapenemase-producing enterobacteriaceae. clin microbiol rev 2018;31(2): e00079-17. doi: 10.1128/cmr.00079-17. 16. abrar s, hussain s, khan ra, ain nu, haider h and riaz s. prevalence of esbl-producing enterobacteriaceae: first systemic meta-analysis report from pakistan. anti-microbial res infect cont 2018;7:26. doi: 10.1186/s13756-018-0309-1 17. taqi m, jamal w, rotini v. prevalence of esbl and cre isolates in positive blood cultures of patients in a teaching hospital in kuwait over two years period. open forum infect dis 2017; 4(supp 1):55-64. 18. legese mh, welearegay gm, asrat d. esbl-e and cre among ethiopian children. infect drug resist 2017;10:27-34. 19. duangkaw w, khamprom n, tuntrakul p, deeudom m, amornthipayawong d, phannachet k. identification of extended-spectrum beta-lactamase (esbl) and carbapenemase genes in carbapenem resistant enterobacteriaceae(cre) clinical isolates from hospitals in nan province: esbl and https://doi.org/10.3389/fmicb.2019.00080 https://doi.org/10.1128/aac.38.1.71 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20duin%20d%5bauthor%5d&cauthor=true&cauthor_uid=27593176 https://www.ncbi.nlm.nih.gov/pubmed/?term=doi%20y%5bauthor%5d&cauthor=true&cauthor_uid=27593176 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5477705/ https://www.ncbi.nlm.nih.gov/pubmed/?term=tian%20x%5bauthor%5d&cauthor=true&cauthor_uid=30214254 https://www.ncbi.nlm.nih.gov/pubmed/?term=sun%20s%5bauthor%5d&cauthor=true&cauthor_uid=30214254 https://www.ncbi.nlm.nih.gov/pubmed/?term=jia%20x%5bauthor%5d&cauthor=true&cauthor_uid=30214254 https://www.ncbi.nlm.nih.gov/pubmed/?term=zou%20h%5bauthor%5d&cauthor=true&cauthor_uid=30214254 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20s%5bauthor%5d&cauthor=true&cauthor_uid=30214254 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20l%5bauthor%5d&cauthor=true&cauthor_uid=30214254 http://www.eucast.org/fileadmin/src/media/pdfs/eucast_files/breakpoint_tables/v_7.1breakpoint_tables.pdf http://www.eucast.org/fileadmin/src/media/pdfs/eucast_files/breakpoint_tables/v_7.1breakpoint_tables.pdf http://www.eucast.org/fileadmin/src/media/pdfs/eucast_files/breakpoint_tables/v_7.1breakpoint_tables.pdf http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/ http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/ https://doi.org/10.1186/s13756-018-0309-1 j islamabad med dental coll 2023 102 carbapenemase genes in cre clinical isolates. chiang mai med j. 2020 dec. 29 ;57(4):183-94. 20. van duin d, paterson dl. multidrug-resistant bacteria in the community: trends and lessons learned. infect dis clin north am 2016; 30:377-90; 21. magiorakos ap1, srinivasan a, carey rb, carmeli y, falagas me, giske cg et al.multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. clin microbiol infect. 2012 mar;18(3):268-81. 22. saeed nk, alkhawaja s, azam nfaem, alaradi k, albiltagi m. epidemiology of carbapenem-resistant enterobacteriaceae in a tertiary care centre in the kingdom of bahrain. j lab physicians 2019; 11(2):111-117. 23. kritsotakis e i, tsioutis c, roumbelaki m, christidou a, gikas a. antibiotic use and the risk of carbapenem-resistant extended-spectrum-{beta}lactamase-producing klebsiella pneumoniae infection in hospitalized patients: results of a double case-control study. j antimicrob chemother. 2011;66(6):1383-91. 24. martin a., fahrbach k., zhao q., lodise t. association between carbapenem resistance and mortality among adult, hospitalized patients with serious infections due to enterobacteriaceae: results of a systematic literature review and meta-analysis.open forum infect. dis. 2018; 5(7): ofy150. 10.1093/ofid/ofy150. doi: 10.1093/ofid/ofy150. https://www.ncbi.nlm.nih.gov/pubmed/?term=magiorakos%20ap%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/?term=srinivasan%20a%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/?term=carey%20rb%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/?term=carmeli%20y%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/?term=falagas%20me%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/?term=giske%20cg%5bauthor%5d&cauthor=true&cauthor_uid=21793988 https://www.ncbi.nlm.nih.gov/pubmed/21793988 https://pubmed.ncbi.nlm.nih.gov/?term=kritsotakis+ei&cauthor_id=21454344 https://pubmed.ncbi.nlm.nih.gov/?term=tsioutis+c&cauthor_id=21454344 https://pubmed.ncbi.nlm.nih.gov/?term=roumbelaki+m&cauthor_id=21454344 https://pubmed.ncbi.nlm.nih.gov/?term=christidou+a&cauthor_id=21454344 https://pubmed.ncbi.nlm.nih.gov/?term=gikas+a&cauthor_id=21454344 j islamabad med dental coll 2022 77 open access effect of replacement of vit-d in diabetic painful neuropathy among chronic type 2 diabetic patients amna ahmed1, sehrish jahan asif2, sumera mushtaq3, ghulam murtaza gondal4, beenish azhar5, tassawar hussain6 1registrar, medicine, foundation university medical college, rawalpindi pakistan. 2senior registrar, medicine, foundation university medical college, , rawalpindi pakistan. 3assistant professor, radiology, fauji foundation hospital, rawalpindi, pakistan. 4professor of medicine,, foundation university medical college, rawalpindi, pakistan. 5assistant professor, biochemistry, quaid –eazam university. islamabad, pakistan. 6professor and hod medicine, foundation university medical college, rawalpindi, pakistan. a b s t r a c t background: painful symptoms of diabetic neuropathy are more common in patients having type 2 diabetes. the objective in this trial was assessment of mean change in pain score upon giving vit-d supplementation in patients with diabetic painful neuropathy. methodology: this study was conducted from december 2019 to june 2020 in opd of fauji foundation hospital, rawalpindi after the ethical approval. a total of 251 diagnosed cases of diabetes (both male and female patients), with high hba1c and low vit-d levels were included in the study. patients having vit-d deficiency and chronic diabetic neuropathy were given vitamin supplementation and results were assessed after 1 month through change in pain score according to douleur neuropathique 4. a document of consent form was filled by patients who were recruited for this study. data analysis was done on spss version 16.paired sample ttest, was used to compare pain score where p value less than 0.05 was considered statistically significant. results: among the participants mean age was 48.22+17.06. there were 106 (42.2%) males and 145 (57.8%) female patients. a statistically significant (p<0.05)mean reduction in pain score of 2.20±1.19 was observed, upon giving vit-d supplementation in vit-d deficient patients having painful diabetic neuropathy. conclusion: vit-d supplementation significantly reduced pain in patients having diabetic painful neuropathy. keywords: diabetes mellitus, diabetic neuropathy, vitamin d3 authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; manuscript editing. correspondence: ghulam murtaza gondal email: drgmgondal@gmail.com article info: received: january 1, 2022 accepted: may 9, 2022 cite this article.ahmed a, asif t, mushtaq s, gondal g m, azhar b, hussain t.effect of replacement of vit-d in diabetic painful neuropathy in chronic type 2 diabetic patients. j islamabad med dental coll. 2022; 11(2):77-81. doi: https://doi.org/10.35787/jimdc.v11i2.834 funding source: nil conflict of interest:nil i n t r o d u c t i o n patients with type 2 diabetes are having lot of complications including microvascular triopathy i.e retinopathy, neuropathy and nephropathy. the recent studies according to international diabetes federation, estimated that diabetes is 8.3% prevalent worldwide and estimated increase by 2030 will be around 69% in adults.1 diabetic painful neuropathy (dpn) is considered as most devastating o r i g i n a l a r t i c l e j islamabad med dental coll 2022 78 complication in diabetes, affecting around 50% of patients with diabetes during their lifetime.2 it becomes a distress for the patients by affecting their everyday physical activities, leading to psychiatric manifestations and disability.3 generally, they are categorized into focal or multi-focal neuropathies like amyotrophy or polyneuropathies including diabetic sensori-motor polyneuropathy (dspn). one of most common microvascular complications of diabetes is painful diabetic neuropathy, with having symptoms of burning feet especially at night and often under diagnosed and mismanaged.4 vit-d is a hormone that is produced in skin and is dependent on exposure to sunlight. several observational studies on diabetes have shown association of vit-d deficiency with paresthesia and numbness.5 a pro-form of vit-d i.e., 25-hydroxy vitd has half life of almost three weeks and is much more active and stable than 1-25 hydroxy vit-d which has half life of only 4 hours. hence, vit-d status is evaluated by using 25-hydroxy vit-d as per institute of medicine in united states.6 worldwide in international literature, levels of 25-ohd in body below 50 nmol/l are taken as insufficient.7 several studies are available internationally considering the role and replacement of vit d in painful diabetic neuropathy but in our pakistani population, very less data is availableand this aspect needs further research.thereforethisresearchwas planned to evaluate the role of vit-d in diabetic polyneuropathy in our local population and make guidelines that can be implemented in favor of patients in future. m e t h o d o l o g y the quasi experimental study was conducted in diabetes clinic of fauji foundation hospital from december 2019 to june 2020.minimum sample size of 242was calculated by using who calculator using formula 2.1 and absolute precision value of 0.07. n=z21-α/2[p1(1-p1)+p2(1-p2)] d2 consecutive non-probability sampling strategy was used to include 251 patients and approval from the ethical review committee was taken before collecting the data. diabetic patients from both genders of age 25-70 years, with duration of diabetes more than five years, patients having hba1c levels more than 9 and vitamin d levels less than 27 ng/ml were included. patients who were already taking treatment for vitamin d, tuberculosis or epilepsy, patients with advanced renal disease, severe co-morbid diseases like chronic liver disease, advanced cardiac failure, cancer or renal implant were excluded. patients having either of thyroid disease, active hepatitis b and c or any peripheral neuropathies due to some other non-diabetic pathology were also not included. after taking written consent, both male and female patients presenting to opd were evaluated. subjects diagnosed with diabetes were tested for hba1c and vit-d levels at initial visit and those diagnosed with vitamin d deficiency and having chronic diabetic neuropathy were given vitamin d supplementation. results were assessed after 1 month through change in pain score according to douleur neuropathique 4. data was analyzed on spss 16 version. standard deviation as well as mean calculation was done for the quantitative variables i.e., pain score. percentage along with frequency calculation was done for qualitative variables like gender and age. paired sample ttest, was used to compare mean of pain score considering p-value of less than 0.05 taken as significant statistically. control of effect modifiers like age and gender was done by stratification and post stratification paired sample ttest. r e s u l t s out of 251 patients, mean age (years) in the study was 48.22+17.06. there were 106 (42.2%) males and 145 (57.8%) female patients. the mean pain score at baseline visit, according to douleur neuropathique 4 questions (dn4) was 5.06+1.14 and at 1 month after j islamabad med dental coll 2022 79 treatment was 2.87+0.33. there was a mean reduction in pain score of 2.20+1.19 upon giving vitamin d supplementation in vitamin d deficient patients having painful diabetic neuropathy. pre-treatment and post-treatment mean of pain score was compared according to age, gender, level of glycosylated hb, vitamin d levels and duration of diabetes as it is seen in table 1. a significant improvement in intensity of pain was seen (p<0.05) with respect to all parameters, upon giving vitamin d supplementation in v-it-d deficient patients. table. comparison of pre and post treatment diabetic neuropathic pain score according to different parameters parameters sub-parameter pre-treatment diabetic neuropathic pain score post-treatment diabetic neuropathic pain score p-value age group 25-50 years 5.00±1.06 2.87±0.33 <0.05 51-70 years 5.13±1.22 2.87±0.33 <0.05 gender male 5.07±1.11 2.88±0.31 <0.05 female 5.06±1.17 2.86±0.34 <0.05 hba1c < 9 5.05±1.14 2.87±0.32 <0.05 > 9 5.09±1.14 2.86±0.34 <0.05 vit d levels < 27 5.05±1.16 2.87±0.33 <0.05 > 27 5.18±1.04 2.84±0.36 <0.05 duration of diabetes < 8 years 5.07±1.12 2.87±0.33 <0.05 > 8 years 5.05±1.12 2.86±0.34 <0.05 d i s c u s s i o n painful diabetic polyneuropathy is an extremely disabling presentation of diabetes and affects every 5th patient having type 2 diabetes mellitus.8 the pathophysiology of diabetic painful neuropathy is very complicated with peripheral sensiomoter, autonomic and central thalamic perfusion abnormalities seen in chronic diabetic patients. typical presentation of these symptoms is dysesthesia, symmetrical paraesthesias and electric shocks-like pain especially in the feet with night time exacerbations.9 prevalence of vit-d deficiency is very high in these patients with diabetes and replacement of adequate dose of 25-hydroxy vit d (40,000 iu/week) for 24 weeks was found to be very effective in improving the clinical manifestations.10 recently there are studies which have found an strong link between vit-d deficiency and painful diabetic neuropathy. however, all of these trials have proven the differences between positive symptoms like hyperalgesia and allodynia and negative symptoms like paresthesia and numbness. in literature various epidemiological trials have concluded a much higher prevalence of diabetic painful neuropathy in south asian population despite of having a low overall prevalence of neuropathy in comparison with other ethnic groups.1 in our previous study, almost half of overall subjects were having deficiency of vit-d, with levels <27ng/ml, and there was a significant overlap with the patients suffering from diabetic painful neuropathy. the current study provides useful data on vitamin d therapy as a potential treatment for painful diabetic neuropathy (pdn). a few recent trials have shown a significant association between diabetes and vit-d deficiency.11 to establish the role of vit-d supplementation for decreasing pain due to diabetic neuropathy, we administered vit-d in diabetic patients having painful diabetic polyneuropathy (pdn). there are several therapies given for symptom relief and enhancing quality of j islamabad med dental coll 2022 80 life 12 but so far in literature, its estimated that all the medications have proven to relieve only50% of the pain and their dose can’t be increased due to undesirable side effects.13 a study done at baqai institute of diabetology and endocrinology (bide) assessed the effect of vitamin d replacement in chronic diabetic painful neuropathy14 the mean pain score at baseline according to dn4 was 3.0 + 1.8 and 2.6 + 1.9 at 8-12 weeks . single dose of vitamin d (600,000 iu) showed decrease in positive symptoms regarding dn4 (p<0.0001), a total pain score of (p<0.0001), and sfmpq of (p<0.0001) in patients with diabetic painful neuropathy. in our trial, mean age in years was 48.22+17.06 and in a study done locally by basit et al, 12 mean age in years was 52.31±11.48 with similar results. another study published in 2019established that oral replacement of vit-d3 in dose of 50,000 units weekly for about 12 week time, resulted in a marked increase in vit d levels and a reduction in diabetic painful neuropathy. they recommend regular check on vit d levels in chronicdiabetic patients, with replacement if found low, to improve the quality of life.15 asystemic review and meta-analysis published in 2021, evaluated the benefits of add-on therapy of vit d replacement and pdn in type 2 diabetic patients.16 it provided the evidence that vit-d deficiency was related to augmented risk of diabetic painful neuropathy in chronic type 2 diabetic patients (or of 2.68, 95 % ci of 1.67–4.30, p value < 0.0001). in the current study, we observed mean pain score at baseline according to douleur neuroopahtique 4 (dn4) at 5.06+1.14 and 2.87+0.33 after 1 month post treatment. a study conducted in 2016 observed mean pain score at baseline according to dn4 at 3.0 ± 1.8 and 2.6 ± 1.9 at 8-12 weeks. hence vitamin d supplementation has shown too beneficial for treating dpn as depicted from our data and several previous studies. traditionally vit-d is being used very effectively for treatment of pain in other conditions, specially certain rheumatologic diseases.17 however, a study done by abdelsadek et al. demonstrated that there was no significant relationship between vit-d replacement in chronic pain, as these trials studies were having variable quality along with variable outcomes due to difference in methodology used.18 based on these findings there is a strong need in use of novel medications in treatment of diabetic painful neuropathy. furthermore, there is emerging evidence that vit-d deficiency is related to diabetic painful neuropathy. there is a strong need of well constructed controlled clinical trials of replacement of vit-d in diabetic painful neuropathy in order to assess the exact effectiveness of this kind of treatment. while the results of these trials are awaited, we recommend the of an initial bolus of 40,000 iu of vit-d3 taken daily with evening meal for about 21 days, followed by a long term maintenance dose of between 20,000 to 40,000 iu once weekly. c o n c l u s i o n vit-d supplementation significantly reduced pain in patients with diabetic neuropathy. r e c o m m e n d a t i o n we strongly recommend the measurement of serum 25-oh vitamin d levels of in all diabetic patients and vit d replacement should be done in patients having deficiency. r e f e r e n c e s 1. saeedi p, petersohn i, salpea p, malanda b, karuranga s, unwin n, et al. idf diabetes atlas committee. global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the international diabetes federation diabetes atlas, 9th edition. diabetes res clin pract. 2019 nov;157:107843. doi: j islamabad med dental coll 2022 81 10.1016/j.diabres.2019.107843. epub 2019 sep 10. pmid: 31518657. 2. shillo p, selvarajah d, greig m, gandhi r, rao g, wilkinson id, et al. reduced vitamin d levels in painful diabetic peripheral neuropathy. diabet med. 2019, 36:44-51. doi:10.1111/dme.13798 3. alam u, arul-devah v, javed s, malik ra. vitamin d and diabetic complications: true or false prophet?. diabetes therapy. 2016 mar;7(1):11-26.doi: 10.1007/s13300-016-0159-x 4.almuhannadi h, ponirakis g, khan a, malik ra. diabetic neuropathy and painful diabetic neuropathy: cinderella complications in south east asia. j pak med assoc. 2018; 68(1): 8589. pmid: 29371725. 5.shillo p, selvarajah d, greig m, et al. decreased vit-d levels in diabetic painful peripheral neuropathy. diabet med 2019 ;36:44–51. doi:10.1111/dme.13798 6. yammine k, wehbe r, assi c. a systematic review of vitamin d supplementation on diabetic peripheral neuropathy. clin nutr 2020; 39(10):2970-4. doi: 10.1016/j.clnu.2020.01.022 7.maddaloni e, cavallari i, napoli n, conte c. vitamin d and diabetes mellitus. vitamin d in clinical medicine. front horm res. 2018;50:161–176. doi:10.1159/000486083 8. basit a, basit ka, fawwad a, shaheen f, fatima n, petropoulos in, et al. vitamin d for the treatment of painful diabetic neuropathy. bmj open diabetes research & care. 2016;4(1): 291-7 doi 000148. 9. liu x, xu y, an m, zeng q. the risk factors for diabetic peripheral neuropathy: a meta-analysis. plos one 2019; 14: (2) e0212574. doi:10.1371/journal.pone.0212574 10.karonova t, stepanova a, bystrova a, jude eb: highdose vitamin d supplementation improves microcirculation and reduces inflammation in diabetic neuropathy patients. nutrients. 2020, 12:2518. doi:10.3390/nu12092518 11. helde-frankling m, bjorkhem-bergman l. vitamin d in pain management. intl j mol sci. 2017;18(10). 2170 doi: 10.3390/ijms18102170. 12.hu z, chen j, sun x, wang l, wang a: efficacy of vitamin d supplementation on glycemic control in type 2 diabetes patients: a meta-analysis of interventional studies. medicine (baltimore). 2019, 98(14) e14970. doi:10.1097/md.0000000000014970 13.jane sw, lin ms, chiu wn, beaton rd, chen my, et al. prevalence, discomfort and self-relief behaviors of painful diabetic neuropathy in taiwan: a crosssectional study. bmj open 2016;6:e011897. doi: 10.1136/bmjopen-2016-011897 14. khan dm, jamil a, randhawa fa, butt nf, malik u: efficacy of oral vitamin d on glycated haemoglobin (hba1c) in type 2 diabetics having vitamin d deficiency a randomized controlled trial. j pak med assoc. 2018, 68:694-7. pmid: 29885163 15.ghadiri-anari a, mozafari z, gholami s, khodaei sa, aboutorabi-zarchi m, sepehri f, et al. does vitamin d supplementations improve peripheral diabetic neuropathy?a before-after clinical trial. diabetes metab syndr. 2019;13(1):890–893. doi:10.1016/j.dsx.2018.12.014 16. pinzon rt, wijaya vo, veronica v. the benefits of addon therapy of vitamin d 5000 iu to the vitamin d levels and symptoms in diabetic neuropathy patients: a randomized clinical trial. j pain res. 2021;14:3865-3875. https://doi.org/10.2147/jpr.s341862. 17. razzaghi r, pourbagheri h, momen-heravi m, bahmani f, shadi j, soleimani z, et al. the effects of vitamin d supplementation on wound healing and metabolic status in patients with diabetic foot ulcer: a randomized, double-blind, placebo-controlled trial. journal of diabetes and its complications. 2017 apr 1;31(4):766-72.doi: 10.1016/j.jdiacomp.2016.06.017 18.abdelsadek se, el saghier eo, abdel raheem si. serum 25(oh) vitamin d level and its relation to diabetic peripheral neuropathy in egyptian patients with type 2 diabetes mellitus. egypt j neurol psychiatr neurosurg. 2018;54(1):36. doi:10.1186/s41983-0180036-9 j islamabad med dental coll 2021 210 o p e n a c c e s s role of c-reactive protein in diagnosis of acute appendicitis mirza tassawar hussain1, muhammad kashif khan2, syed shamsuddin3, aabid ali4, erum khan5, ismat batool6 1assistant professor, department of general surgery, federal government polyclinic hospital 2associate surgeon, department of oncology, federal government polyclinic hospital 3associate surgeon, department of general surgery, federal government polyclinic hospital 4medical officer, department of general surgery, federal government polyclinic hospital 5senor registrar, department of general surgery, federal government polyclinic hospital 6surgical resident, department of general surgery, federal government polyclinic hospital a b s t r a c t background: appendicitis is a common surgical emergency and diagnostic dilemma. making the correct diagnosis is often difficult as the clinical presentation varies according to the age of the patient and the position of appendix. the objective of this study was to identify clinical applicability of creactive protein, as a diagnostic test for appendicitis. methods: this prospective study was carried out in federal government polyclinic hospital, islamabad from january to july 2019, 114 patients underwent appendectomy for clinically diagnosed acute appendicitis. the decision to operate the patient was given by senior registrar. the blood samples for c-reactive protein were drawn before taking the patient to the operating theatre. removed appendices were sent for histopathological confirmation of diagnosis. the c-reactive protein was then compared with the results of histopathology to determine its validity. the data was entered and analysed in spss 23. results: the sensitivity, specificity, positive and negative predictive values of c-reactive protein in patients with clinical diagnosis of acute appendicitis were found to be 94%, 78%, 93% and 74 % respectively. conclusion: crp is helpful in making diagnosis of acute appendicitis. it is highly sensitive but has a relatively low specificity. keywords: appendectomy, appendicitis, c-reactive protein, emergency authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 3,4critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: aabid ali email: aabidalidr@gmail.com article info: received: january 10, 2021 accepted: december 26, 2021 cite this article. hussain mt, khan mk, shamsuddin s, ali a, batool i. role of c-reactive protein in diagnosis of acute appendicitis. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: ni i n t r o d u c t i o n on an emergency floor, acute appendicitis is one of the commonest operative emergencies encountered. diagnosis is made usually on clinical grounds, with sometimes taking aid from radiological and laboratory testing.1,2 making the correct diagnosis all the time is often difficult with only clinical tools, as its clinical presentation varies depending upon the gender and age of patients, location of appendix and the amount of inflammation. moreover, many other diseases also mimic acute appendicitis making the diagnosis even more difficult, particularly in young females and children. different scoring systems designed to diagnose acute appendicitis incorporate different combinations of signs, symptoms and tests, but due to overlapping of these factors in other differentials, pinpoint accuracy cannot be achieved. dilemma remains, as appendectomy is usually carried out in patients using these same clinical scores, by clinical diagnostic expertise on individual level, that varies o r i g i n a l a r t i c l e j islamabad med dental coll 2021 211 considerably, which may result in negative appendectomy of 15 to 30 %.3,4 the developments in radiological system like ultrasound and ct scan have aided the surgeons to use them in diagnosis, but they are not widely available. if machines are available, the quality of training to interpret the images on individual level is not same, so the rate of negative explorations still remains high.4 on the other hand as a surgeon, one is always fearful of the consequences of a missed diagnosis of appendicitis that may lead to perforation, sepsis, portal pyaemia and even death in some late cases specially in old individuals.3,5 to prevent this horrible sequel of high morbidity and mortality , surgeon has to rely on his clinical skills and the option of appendectomy is usually adopted over conservation as benefit far outweighs the risk in suspected cases. the proportion of these negative explorations for acute appendicitis needs to be reduced because negative explorations are associated with significant but preventable morbidity4. therefore, some easy, quick, interpretable tests must be used with clinical skills dominated approach of diagnosing appendicitis, to improve the diagnostic accuracy and reduce the number of negative explorations.5 in response to inflammation and infection, hepatocytes are signalled to produce c-reactive protein (crp). its concentration increases within hours of the stimulus and peaks in 24-48 hours and stays high as long as there is ongoing tissue injury.6 in many of the studies in which the diagnostic value of crp was investigated, the results varied but nevertheless most of the studies supported its clinical applicability.7 crp was found to be more accurate in diagnosing acute appendicitis, than elevated leukocyte count and neutrophil count.8 the objective of this study was to evaluate the clinical applicability of qualitative crp analysis in patients with clinical diagnosis of acute appendicitis and its significance in reducing the number of negative explorations among them. m e t h o d o l o g y this prospective study was conducted over a period of 6 months from january to july 2019 at department of general surgery, federal govt polyclinic (pgmi), islamabad after taking ethical approval of the study. sample size of 114 patients was calculated using who sample size calculator. a non-probability consecutive sampling technique was used to include patients after taking informed consent. all the patients above 12 years of age, going through appendectomy for acute appendicitis, were included in the study regardless of their gender. pregnant patients, those with history of autoimmune diseases and the patients undergoing interval appendectomy were excluded from the study. all the patients were given pre-operative antibiotics. after taking an informed written consent, blood samples for qualitative c-reactive protein analysis were collected before taking the patient to the operation theatre. the decision to operate the patient was made by a senior registrar on the basis of clinical findings, independent of creactive protein level, whose results were available after the surgery. the laboratory staff were not aware of clinical findings, decisions or outcome. qualitative serum c-reactive protein was measured by the array protein chemistry system, usa. c-reactive protein level equal to or more than 10 mg/l was considered as high, thus dividing the patients into two groups i.e. creactive protein positive and c-reactive protein negative. removed appendix was sent to laboratory in formalin preparation where histopathological examination was done by the consultant histopathologist. histopathology was used as gold standard, to remove observation bias of different operating surgeons. specimen of appendix, particularly its tip was examined to exclude carcinoid tumour and granuloma. the patients were divided into two groups on the basis of histopathology i.e inflammation positive and inflammation negative. j islamabad med dental coll 2021 212 the data was entered and analysed in spss 23. sensitivity, specificity, positive and negative predictive values were calculated. crp analysis was carried out free of cost at the hospital laboratory and all the patients in this study underwent standard treatment. r e s u l t s out of 114 patients, who underwent appendectomy for suspected acute appendicitis, 76 were males and 38 were females, with male to female ratio of 2:1. table 1 shows general characteristics of patients in our study. total 75% patients had inflamed appendix while in 25% of the patients, appendix was not inflamed. among patients having inflamed appendix, 61(71%) were males while 25 (29%) were females. the negative appendicectomy was present in 15 (53%) males and 13 (46%) females. patients who had inflamed appendix, majority (94%) had their crp test positive. on the other hand, patients in whom the appendix was not inflamed, large number (79%) were crp negative. the sensitivity, specificity, positive and negative predictive values of serum c-reactive protein in patients with clinical diagnosis of acute appendicitis were found to be 94%, 78%, 93% and 74 % respectively. (table 2) out of the 28 patients whose appendices did not show inflammation, majority had non-specific abdominal pain (61%) followed by ruptured ovarian cyst (14%) (table 3). table 1: baseline characteristics of patients (n=114) characteristics value age ̶-years. mean±sd range 24.91±9.45 (12-55) gender male ̶ ̶̶̶ n (%) females ̶ ̶̶̶ n (%) 76(67) 38(33) crp positive ̶̶̶ n (%) negative ̶̶̶ n (%) 87(76) 27(24) appendicular inflammation positive ̶̶̶ n (%) negative ̶̶̶ n (%) 86(75) 28(25) table 2: association of c-reactive protein with appendicular inflammation (n=114) creactive protein appendicular inflammation statistical relation sensitivity=94% positive (n=86) negative (n=28) specificity=78% positive 81 6 ppv=93% negative 5 22 npv=74% table 3: alternative diagnosis in negative appendectomies alternative diagnosis value; n (%) ruptured ovarian cysts 4(14) pelvic inflammatory disease 3(11) mesenteric lymphadenitis 3(11) ovarian cyst torsion 1(3) non-specific abdominal pain 17(61) d i s c u s s i o n commonest surgical emergency, having no set criteria yet, to reach the correct diagnosis each time, is the main dilemma in acute appendicitis. reaching the correct diagnosis in this case is an art, but the skill varies. subjective criteria and scoring systems make it tough to reach the correct diagnosis all the time. consequently, the rate of negative explorations for acute appendicitis continues to remain high.9,10 making diagnosis of acute appendicitis among the elderly and females is rather more challenging, as in elderly, usual textbook signs are often diminished or absent, similarly in females, signs and symptoms are vague most of the time due to the wide range of causes, therefore the chances of wrong diagnosis are highest.6 the negative appendectomy rate of 24.56% in our study is inacceptable range; however it is relatively on higher end of 15% to 25% range mentioned in different studies6,9-11. so, it means that, there is a need to use more diagnostic tests, particularly in those patients in which the clinical diagnosis is dubious. using more widely available and interpretable tests for this purpose is a key issue. good history taking and sound clinical examination organized in different scoring systems helps us to reach the diagnosis in most of j islamabad med dental coll 2021 213 the cases.4 it is most cost effective, repeatable, fast and widely used method specially in periphery but the clinical presentation shows a wide range of variations, many other acute abdominal conditions also mimic acute appendicitis and missing a case of acute appendicitis can result in gangrenous perforation, abscess formation, peritonitis and sepsis. this subjective approach must be augmented with chemical markers or radiological assistance wherever they are available. although ultrasound and ct scan have improved the diagnosis, but they are still not available widely in periphery. crp, an acute phase protein, was first recognized in 1930 by tillet and francis, is produced by hepatocytes in response to tissue injury.12 crp is relatively a cheap and widely available test compared to more expensive and operator dependent radiological techniques specially in periphery. so, crp is long being used in diagnosis of different clinical conditions. varying results are present in different studies showing its relation to acute appendicitis to be uncertain but meta-analysis and systematic reviews concluded that crp not alone but in combination with other markers like raised wbcs, procalcitonin, hyperbilirubinemia, shows strong relationship with diagnosing acute appendicitis. 4,6,13 there are many studies of different serological markers related to diagnosis of acute appendicitis, some are termed as more efficient but we have to keep in mind ground realities of our healthcare system, where availability and cost are main concerns and this is what we addressed in our study framework. serum crp is widely available, in patients with suspected appendicitis, it is a very sensitive investigation.2 in our study, sensitivity of c-reactive protein is consistent with previous studies1-3,16. however serum crp has a relatively low specificity as crp is also increased in many other infective and non-infective conditions. our study acknowledges crp a very supportive diagnostic modality in acute appendicitis, but it still does not substitute the clinical diagnostic skills of general surgeons, it only supports the surgeons in diagnosis as mentioned in previous studies. 14,15 if in a patient presenting with pain right iliac fossa, both crp and white cell counts are normal, then acute appendicitis is rendered very improbable.4 a normal preoperative serum crp in patients with pain right iliac fossa is most likely associated with a normal appendix so deferring surgery can reduce the rate of negative explorations, thus reducing unwanted morbidity associated with operative therapy.7-9,16 studies also reveal that crp is not related to diagnosis of acute appendicitis, but it can suggest, degree of inflammation of appendix and need of early intervention.18 crp as a supplementary test can reduce the rate of negative appendectomies and their sequel specially where the new and improved diagnostic facilities are not available. c o n c l u s i o n crp analysis augments the clinical diagnosis of acute appendicitis. it is highly sensitive but has a relatively low specificity. it was a single centred study, sample size was small, sampling technique used was nonprobability consecutive and qualitative crp detection technique was used. acknowledgements: we would like to acknowledge the supervision and guidance of our mentor dr. innayat ullah baig r e f e r e n c e s 1. al-abed ya, alobaid n, myint f. diagnostic markers in acute appendicitis. am j surg. 2015;209(6):1043 7. doi:10.1016/j.amjsurg.2014.05.024 2. abedi s, ebrahimi m, zolfaghari p, nourian j, yarmohammadi m, yahyaei e, et al. comparison of diagnostic value of esr, crp and leukocytosis with pathologic findings among patients with acute appendicitis. int j health studies. 2018;3(4). doi:10.22100/ijhs.v3i4.287. 3. xharra s, gashi-luci l, xharra k, veselaj f, bicaj b, sada f, et al. correlation of serum c-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis. world j emerg surg. 2012;7(1):1-6. doi:10.1186/1749-7922-7-27 4. yu cw, juan li, wu mh, shen cj, wu jy, lee cc. systematic review and meta‐analysis of the diagnostic accuracy of procalcitonin, c‐reactive protein and white blood cell count for suspected acute appendicitis. br j surg. 2013;100(3):322-9. doi:10.1002/bjs.900 j islamabad med dental coll 2021 214 5. craig s, dalton s. diagnosing appendicitis: what works, what does not and where to go from here? j paediatr child health. 2016;52(2):168-73. doi:10.1111/jpc.12998 6. shogilev dj, duus n, odom sr, shapiro ni. diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. west j emerg med. 2014;15(7):859. doi:10.5811/westjem.2014.9.21568 7. peyvasteh m, askarpour s, javaherizadeh h, besharati s. modified alvarado score in children with diagnosis of appendicitis. arq bras cir dig (são paulo). 2017;30(1):51-2. doi:10.1590/01026720201700010014 8. ramula m, lakshmipathy n, karthik a, krishnamurthy a. a comprehensive study on diagnostic value of quantitative c-reactive protein measurement in acute appendicitis. j evol med dent sci. 2016;5(69):4995-9. 9. ohle r, o'reilly f, o'brien kk, fahey t, dimitrov bd. the alvarado score for predicting acute appendicitis: a systematic review. bmc med. 2011;9(1):139. doi:10.1186/1741-7015-9-139 10. msolli ma, beltaief k, bouida w, jerbi n, grissa mh, boubaker h, et al. value of early change of serum c reactive protein combined to modified alvarado score in the diagnosis of acute appendicitis. bmc emerg med. 2018;18(1):15. doi:10.1186/s12873018-0166-5 11. jamaluddin m, hussain sm, ahmad h. acute appendicitis with normal total leukocyte count. j surg academia. 2013;3(1):2-6. 12. buyukbese sarsu s, sarac f. diagnostic value of white blood cell and c-reactive protein in pediatric appendicitis. biomed res int.;2016. doi:10.1155/2016/6508619 13. salih ik, al-dabbagh aj, hassan qa. the value of inflammatory markers in acute appendicitis: a diagnostic accuracy study. pak j med health sci. 2017;11(4):1607-11. 14. dayawansa nh, segan jd, yao hh, chong hi, sitzler pj. incidence of normal white cell count and c‐ reactive protein in adults with acute appendicitis. anz j surg. 2018;88(6):539-43. doi:10.1111/ans.13760 15. mcgowan dr, sims hm, zia k, uheba m, shaikh ia. the value of biochemical markers in predicting a perforation in acute appendicitis. anz j surgery. 2013;83(1-2):79-83. doi:10.1111/ans.12032 16. aydin s, fatihoglu e, ramadan h, akhan bs, koseoglu en. alvarado score, ultrasound, and crp: how to combine them for the most accurate acute appendicitis diagnosis. iran j radiol. 2017;14(2). doi: 10.5812/iranjradiol.38160 17. ghimire r, sharma a, bohara s. role of c-reactive protein in acute appendicitis. kathmandu univ med j. 2016;14(54):130-3. pmid: 28166068 18. kaya b, sana b, eris c, karabulut k, bat o, kutanis r. the diagnostic value of d-dimer, procalcitonin and crp in acute appendicitis. int j med sci. 2012;9(10):909. doi: 10.7150/ijms.4733 j islamabad med dental coll 2023 17 open access evaluation of the occlusal contact between the opposing teeth and the cusp of carabelli in maxillary permanent first molars in patients visiting peshawar dental college sana arbab 1, munawar aziz khattak 2, imran khattak 3, yusra jamil 4, faiza ijaz 5, ambereen hamayun 6 1assistant professor, department of oral biology, peshawar dental college, peshawarpakistan 2associate professor, department of oral biology, peshawar dental college, peshawarpakistan 3assistant professor, department of oral biology, peshawar dental college, peshawarpakistan 4assistant professor, department of oral biology, rashid latif medical and dental college, lahorepakistan 5assistant professor, department of oral biology, ayub college of dentistry, abbottabad,pakistan 6assistant professor, department of anatomy, peshawar medical college, peshawarpakistan a b s t r a c t background: the cusp of carabelli is a small additional cusp which is situated on the mesiopalatal surface of first maxillary molars. this nonfunctional cusp comes in many forms including furrows, ridges or pits and is collectively known as the carabelli trait objective: to evaluate the frequency of the occlusal contacts between the accessory cusp of carabelli and the opposing arch tooth among both genders in patients attending the out-patients department of peshawar dental hospital, peshawar methodology: this descriptive cross-sectional study was conducted on 300 subjects visiting the opd of peshawar dental hospital from october 2022 to december 2022. the sample size was calculated using who formula n=p(100-p)z2/d2 (http://www.fao.orgthe age group selected for the participants was from 13-30 years. consecutive sampling technique was used.). articulating paper was used to assess the occlusal contacts caused by the cusp of carabelli. the data were analyzed using spss version 20. pearson’s chi square test was applied to analyze the data. p value of ≤ 0.05 was considered statistically significant. results: the results of the current study showed that 10.7% of the participants experienced occlusal contacts caused by the presence of their accessory cusp with the opposing arch tooth with no statistically significant difference between genders. conclusion: the cusp of carabelli is the most prevailing variation found on the palatal aspect of mesiopalatal cusp of permanent maxillary first molars in a hospital-based inhabitants of peshawar with rare occlusal contacts experienced by the patients. key words: cusp of carabelli, maxillary permanent first molars, occlusal contact. authors’ contribution: 1,2conception; literature research: 3manuscript design and drafting; 4,5critical analysis and manuscript review; 6data analysis; manuscript editing. correspondence: sana arbab email: sarbab33@yahoo.com article info: received: march 11, 2022 accepted: march 30, 2023 cite this article. arbab s, khattak m a, khattak i, jamil y, ijaz f, hamayun a . evaluation of the occlusal contact between the opposing teeth and the cusp of carabelli in maxillary permanent first molars in patients visiting peshawar dental college. j islamabad med dental coll. 2023; 12(1):17-22 doi: https://doi.org/10.35787/jimdc.v12i1.855 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e http://www.fao.org/ mailto:sarbab33@yahoo.com j islamabad med dental coll 2023 18 i n t r o d u c t i o n morphological variations exist in both primary and permanent teeth which can be expressed in crown and roots.1,2 accessary cusps including cusp of carabelli, talon cusp, central cusp, leong’s tubercle are the frequent occurrences.2,3 cusp of carabelli account for 52-68% in molars more frequently maxillary first molars and is located lingual to the mesiopalatal cusp of maxillary first permanent molars.4 it may also be found in second and third molars but less frequently.4 the development of this cusp is usually attributed to certain genetic or environmental factors however the exact etiology is unknown and these accessory cusps are attributed to different growth patterns.5 moreover the occurrence of the cusp of carabelli may be due to the overactivity of dental lamina due to a genetic influence.6 its size ranges from a large prominent cusp to a rudimentary eminence.7 certain vitamins, nutrients or size of the jaws may also contribute to the development of this cusp.8 a study conducted in mardan showed that 32% of the study population had cusp of carabelli on permanent maxillary first molars.9 another study conducted on a local population of peshawar showed an overall frequency of the cusp of carabelli to be 39.3% in permanent maxillary first molars.10 the clinical significance of cusp of carabelli and other accessory cusps is that they may cause some clinical disturbances such as occlusal interferences, esthetic problems, accidental cusp fracture, carious lesion in cusp of carabelli groove and irritation of tongue during speech and mastication etc.11,12 the occlusal contacts between the accessory cusps and opposing teeth cause attritional wear which are characterized by smooth and polished delineated areas known as wear facets.13 moreover, these occlusal contacts occur when the maxillary molars occlude with the lingual slopes of mandibular molars.14 these premature contacts caused by the accessory cusps occur because of their abnormal morphology and location.15 adequate assessment of occlusion is necessary for achieving proper mastication and functioning of masticatory apparatus. however, any irregular occlusal contacts can lead to various clinical symptoms such as migration of teeth, cracked enamel, gingival recession, fracture of restorations or prosthesis, diseases of tmj and orofacial pain. 16 the occlusal contacts can be clinically detected by two methods such as by using articulating papers or waxes and impression materials. 17 the main objective of the study was to determine the frequency of the occlusal contacts between the accessory cusp of carabelli and the opposing arch tooth among both genders in patients coming to the opd of peshawar dental hospital, peshawar. m e t h o d o l o g y this cross-sectional was conducted in peshawar medical & dental college from october 2022 to december 2022. a total of 300 patients were included in the study through convenient sampling technique. the sample size was calculated using who formula n=p(100-p)z2/d2 (http://www.fao.org). approval of the study was done by ethical review committee of peshawar medical & dental college. all the included participants were informed (written consent: annexure b) about the purpose of the study. two teeth per patient (600 in total) were examined. inclusion criteria set for the study was: both genders having complete eruption of permanent maxillary first molars bilaterally, age group 13-30 years, sound non-carious, no attrition or erosion or any dental disease deteriorating the morphology of permanent maxillary first molars were included in the study. patients having any congenital dental disease, carious or restored permanent maxillary first molars detected clinically delineating their morphology or any prosthesis/orthodontic appliance on maxillary permanent first molars were excluded. http://www.fao.org/ j islamabad med dental coll 2023 19 a proforma (annexure a) was made to document the data of patients. an intraoral examination of the participants’ permanent maxillary first molars was carried out by seating them in dental chair under proper illumination and assessing the teeth with the help of mouth mirror. dental explorer was used to detect any carious lesion on maxillary permanent first molars. all the observations were made by the author herself and no other observer was involved thus excluding interobserver variability. articulating paper was placed between the mesiopalatal surface of maxillary permanent first molars and the occlusal surface of mandibular first molars to detect occlusal contact caused by the cusp of carabelli and the patients were instructed to bite on the paper while opening and closing the jaws (centric relation). articulating paper was then removed and the teeth were evaluated. a mark on the cusp of carabelli or opposing arch tooth left by the paper indicated that the cusp does have contact with the opposing tooth of the patient. in case the paper left no mark showed that the cusp of carabelli did not interfere with occlusion. the data were analyzed using spss version 22. pearson’s chisquare test was used for data analysis. a p-value ≤ 0.05 to be considered statistically significant. r e s u l t s out of 300 participants, males accounted for 125 (41.7%) while females were 175 (58.3%) in number. the total number of teeth examined were 600 (two maxillary permanent first molars per patient). the candidates fell in age group 13-30 years having a mean age of 22.46± 5.1 years. the current research depicts an overall frequency of cusp of carabelli to be 39.3% (fig 1). a p value of 0.140 showed no significant relationship between genders for the distribution of the cusp (table 1). the total number of patients who had occlusal interference with cusp of carabelli and the opposing arch teeth were 10.7% (table 2). occlusal contacts caused due to cusp of carabelli found on the permanent maxillary first molars with their opposing arch teeth was present in 4% of the patients on right side, 2.7% patients on the left side and 4% on both right and left molars. statistical analysis showed no significant difference between males and females (p value 0.615) (table 3). table i: gender-wise distribution of cusp of carabelli in sample population (n=300) gender cc absent in patients n (%) cc present in patient s total n (%) right n (%) left n (%) both n (%) male 83(45.6) 12 (38.7) 7 (53.8) 23 (31) 125 (41.6) female 99 (54.3) 19 (61.2) 6 (46.1) 51 (68.9) 175 (58.3) total 182 (100) 31(100) 13 (100) 74(100) 300 (100) p value = 0.140 as calculated by pearson’s chi square test. df = 3. total number of patients having cc: males = 42 (35.5%), females = 76 (64.4%) 60.67% 4.33% 10.33% 24.67% figure 1: frequency of cusp of carabelli on maxillary first permanent molars absent left right both total j islamabad med dental coll 2023 20 p= 0.615 as calculated by pearson’s chi square test. df = 3. total number of patients having oc caused by cc in mpfm; males = 12 (37.5%), females = 20 (62.5%). d i s c u s s i o n cusp of carabelli is the most frequently occurring accessory cusp found on the permanent maxillary first molars.1-3 a number of researches have been put forth on the frequency, types or clinical significance of the cusp of carabelli, however, the current study emphasizes upon the occlusal contacts caused by the cusp of carabelli with their opposing arch teeth. these accessary cusps sometimes manifest themselves as larger tubercles which may interfere with occlusion with the opposing arch tooth. the results of the present survey revealed a frequency of cusp of carabelli occurring on permanent maxillary first molars to be 39.3% (fig 1) which is in concurrence with the findings of arbab et al 10, 11 and 32% prevalence was reported in a local population of mardan with unilateral presentation more common.9 a prevalence of 25% was reported in kashmiri population.2 other studies revealed no accordance with the findings of the present study. the frequency of the cusp of carabelli was found to be 87% in a racially mixed population from begaluru19, 72% in madurai population 20 , 68.3% in nepalese population,21 and 53.5% in a population of multan.25 however, a study conducted by bhavyaa et al reported a frequency of cusp of carabelli to be 90.6% in deciduous maxillary second molars among 3-4 years old children22 while the same authors conducted a meta-analysis which showed that the cusp of carabelli was found in 59% of the overall participants.18 the participants of the current study did not show a significant difference in gender distribution of the cusp as shown by p value 0.140 (table 1) which is similar to the findings of arbab et al10,11 and zafar et al 25 whereas other studies recruited on our local population 9 showed male predominance. cusp of carabelli rarely causes occlusal contacts with the opposing arch tooth as shown by frequency in the contemporary group of 10.6% (table 2). these findings go against the experimentations done by cakan et al23 and elhag et al24 who reported no occlusal interference caused by the accessory cusp. according to the findings of current study gender differentiation of the cuspal contacts showed no statistically significant difference (p value 0.615) (table 3). there were certain limitations of the study such as single centered study, dental casts were not obtained from the participants due to ethical issues. conclusion table ii: occlusal contact (oc) of cusp of carabelli with opposing arch tooth occlusal contact associated with cusp of carabelli number of patients having oc n (%) total number of patients having occlusal contacts n(%) absent 268 (89.3) right 12 (4.0) 32(10.7%) present left 8 (2.7) both 12 (4.0) total 300 (100) table iii: gender-wise distribution of occlusal contact of cusp of carabelli with opposing tooth gender oc absent in patients n (%) oc present in patients total n (%) right n (%) left n (%) both n (%) male 113 (42.1) 3 (25.0) 3 (25.0) 6 (50.0) 125 (41.6) female 155 (57.8) 9 (75.0) 5(62.5) 6(50.0) 175 (58.3) total 268 (100) 12 (100) 8 (100) 12 (100) 300 (100) j islamabad med dental coll 2023 21 1.the cusp of carabelli is a frequent finding on the palatal surface of mesiopalatal cusp of permanent maxillary first molars in a local population of a hospital-based society in peshawar having an overall prevalence of 39.3%. 2. rare occlusal contacts were experienced by the patients having cusp of carabelli. r e f e r e n c e s 1. sarpangala m, devasya a. occurrence of cusp of carabelli in primary second molar series of three cases. j clin diagn 2017; 11(3): 01-02. doi: 10.7860/jcdr/2017/24040.9340 2. hassan s, nadaf a, raina r. the prevalence of cusp of carabelli among kashmiri population. j adv med dent scie res, 2020; 8(1):42-44. 3. chowdhary z, gupta d, mohan r, bajaj a. parastyle cusp: a rare morphologic variation of maxillary second molars. j forensic dent sci, 2018;10:111-5 4. scheid rc. woelfl’s dental anatomy: its relevance to dentistry. 7th edition 2017. maryland: lippincott williams and wilkins. 5. algemy ao, barak aa, saed gm, fheelbhoom ha, aljotri aa. variations in occlusal morphology of permanent maxillary first molars in zawia population: a comparative study. university bulletin, 2022;24(2):222-234. 6. owens bm, blen bj, redmond dc. cusp of carabelli: observations of an odontogenic trait. gavin j dent sci 2016; 2016: 1-7. 7. niazi m, najmi y, qadri m. frequency of cusp of carabelli in orthodontic patients reporting to islamabad. pak orthod j, 2016; 8(2): 85-88. 8. cruz cv, soares la, braga dn, costa cm. diagnosis and surgical management of nonsyndromic nine supernumerary teeth and leong’s tubercle. case reports in dentistry. 2016. https://doi.org/10.1155/2016/8641867 9. qamar w, qayum m, ali a, idrees s. frequency and trends of cusp of carabelli in maxillary first molars of patients visiting dental teaching hospital in mardan, pakistan. pak orthod j, 2018; 10(1): 27-29. 10. arbab s, khattak ma, khattak i, rashid m. the frequency of unilateral and bilateral distribution of cusp of carabelli in maxillary permanent first molars in patients visiting peshawar dental hospital, peshawar. med forum mon 2022; 33(2):165-168 11. arbab s, khattak ma, shah sa. frequency of cusp of carabelli in maxillary permanent first molars and its association with dental caries in patients visiting peshawar dental hospital, peshawar. professional med j, 2021; 28(8): 1101-1106. 12. smitha t, venkatesh d, veeresh m, hema kn, sheethal hs, vidya ma. the cusp of carabelli: frequency, distribution and type in the bengaluru population. j oral maxillofac pathol, 2018, 22(3):418422 13. js rees, s somi. a guide to the clinical management of attrition. br dent j, 2018; 224: 319-323. 14. florenza l, kullmer o. the functional role of the carabelli trait in early and late hominins. j hum evol, 2020. 145. 15. jain s. variation in cuspal morphology in maxillary first permanent molar with report of 3 cusp molar. j clin diagn res, 2016;10(9):zc34-zc36. 16. bozhkova t, musulieva n, slavchev d, dimitrova m, rimalovska s. occlusal indicators used in dental practice: a survey study. biomed res int, 2021;2021. 17. warreth a, doody k, mo o, mohsen ma. fundamentals of occlusion and restorative dentistry. part ii: occlusal contacts, interferences and occlusal considerations in implant patients. j ir dent assoc, 2015; 61(5): 252-259. 18. ranka b, muthu ms, nirmal l, ponraj s. prevalence of cusp of carabelli: a systematic review and meta analysis. ann hum biol, 2022; 48(7-8):1-29. 19. venkatesh d, sanchitha v, smitha t, sharma g, gaonkar s, hema kn. frequency and variability of five non metric dental crown traits in the permanent maxillary dentitions of a racially mixed population from bengaluru, karnataka. j oral maxillofac pathol, 2019; 23(3): 458-465. 20. saravanan r. prevalence of cusp of carabelli in madurai population. int j rec ent sci res, 2020; 11(6): 38805-38807. 21. subedi n, sah s, chataut tp, paudel s, pradhan a. prevalence of carabelli trait in selected nepalese population. br j med med res 2014; 7(4): 285-91. 22. bhavyaa r, sujitha p, muthu ms, kithiga m. prevalence of cusp of carabelli and its caries susceptibility an ambidirectional cohort study. aust dent j 2020; 65(4): 294-301. 23. cakan dg, ulkur f, taner t. the genetic basis of dental anomalies and its relation to orthodontics. eur j dent, 2013 7(1); 143-47. 24. elhag sbi, abdulghani asi, elhag bi. concomitant mesiodens with cusp of carabelli on upper first molars; a rare case report. dent oral craniofacial res, 2015 1: doi: 10.15761/docr.1000142. 25. zafar r, shakoor a, haider mu, muhammad u, baloch n. the presence/absence of cusp of carabelli in patients presenting to the dental outdoor department in a teaching hospital in multan, pakistan. professional med j, 2023; 30(3): 281-284. https://doi.org/10.1155/2016/8641867 https://pubmed.ncbi.nlm.nih.gov/?term=venkatesh%20d%5bauthor%5d https://pubmed.ncbi.nlm.nih.gov/?term=sanchitha%20v%5bauthor%5d https://pubmed.ncbi.nlm.nih.gov/?term=smitha%20t%5bauthor%5d https://pubmed.ncbi.nlm.nih.gov/?term=sharma%20g%5bauthor%5d https://pubmed.ncbi.nlm.nih.gov/?term=gaonkar%20s%5bauthor%5d j islamabad med dental coll 2023 22 189 j i m d c 2 0 1 8 189 open access f u l l l e n g t h a r t i c l e role of modified ct severity index in assessment of acute pancreatitis at tertiary care hospital rehana shaikh 1, nasreen naz 2, sabiha zaheer 3, zahida qadri 4, aliya khan 5, hina rana 6 1 assistant professor, 2 associate professor, 3,5,6 resident radiology, 4 consultant radiologist, ct & mri centre (radiology department, dow medical college/civil hospital karachi, duhs) a b s t r a c t objective: to evaluate the diagnostic role of modified ct severity index (mctsi) in terms of severity of disease process and its complication in correlation to apache ii score. patients and methods: this cross-sectional study was conducted in ct & mri centre, dow university of health sciences/ dr. ruth k. m. pfau civil hospital karachi, from 1st july to 31st december 2017. this study includes 93 patients with clinical features of acute pancreatitis referred to our department for contrast enhanced ct of abdomen within 24 hours of presentation. patients were selected according to the study criterion. the pancreatitis was classified into mild, moderate and severe disease in term of severity by modified ct severity index. apache ii score was calculated within 24 hours of admission. clinical outcome parameters in terms of any intervention, systemic infection, organ failure and mortality were also collected. results: mean age of the patients was 39.82 + 12.04 years in the range of 20-70 years. majority of patients were categorized as moderate pancreatitis (45.16%) according to modified ct severity index followed by severe pancreatitis in 36 (38.71%) patients and mild pancreatitis in 15 (16.13%). raised apache ii score was observed in patients of severe pancreatitis. the clinical outcome parameters in terms of need of intervention, development of infection, organ failure and death rates, were also increased in patients with higher mctsi. conclusion: contrast enhanced ct had an excellent diagnostic value to assess the disease extent and to grade its severity. modified ctsi is a simplified and powerful tool with good sensitivity and specificity to assess the severe acute pancreatitis in correlation to apache ii. key words: acute pancreatitis, apache ii, complications, modified ct severity index author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-6 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence rehana shaikh email: rehanawazir@hotmail.com article info. received: april 17, 2018 accepted: july 10, 2018 cite this article. shaikh r, naz n, zaheer s, qadri z, khan a, rana h. role of modified ct severity index in assessment of acute pancreatitis in tertiary care hospital. jimdc.2018; 7(3):189-194 funding source: nil conflict of interest: nil i n t r o d u c t i o n acute pancreatitis is one of the most complex and clinically challenging diseases with variable outcome. majority of patients suffered from a mild disease process that resolves without any complication, but up to 20% of patients develop severe necrotizing pancreatitis with significant mortality reaching up to 30%,1 due to development of life threatening complications like secondary bacterial contamination, multi-organ failure, disseminated intravascular coagulation and gastrointestinal hemorrhage.2,3 imaging particularly contrast enhanced ct (cect) has main role in the diagnosis and assessment of disease severity by o r i g i n a l a r t i c l e 190 j i m d c 2 0 1 8 190 detecting pancreatic necrosis and then subsequent management of pancreatic disease.1 prompt evaluation of the disease severity and recognition of high risk patients is crucial for intensive therapy and intervention to improve their prognosis and survival. because these patients may take advantage from fluid resuscitation, proper antibiotic cover, close observation for organ failure and timely therapeutic radiological intervention.1,4 since 1970, multi-factorial scoring systems have been used to assess the severity of pancreatitis, initially including ranson’s criteria and acute physiology and chronic health evaluation (apache)-ii score. apacheii has high priority than other systems in indicating the disease severity because it includes all main clinical parameters that affect patient’s outcome.5-7 various studies reported the sensitivity and specificity of apache-ii up to 93.8% and 100% respectively.8,9 then balthazar developed the ct severity index (ctsi) in 1990 by uniting the original grading system of pancreatitis and pancreatic necrosis that show better prognostic value but it too had some drawbacks because it does not include the extrapancreatic complications like organ failure or vascular complications.10,11 due to these drawbacks, a modified and easier ct scoring system was created by mortele in 2004 to determine precisely the clinical outcome. the modified ctsi was simpler and closely corresponded with patient’s outcome parameters like duration of hospital stay, any surgery or intervention, infection occurrence, organ failure and death as compared to the balthazar ctsi.5,12 there is limited information regarding the data of mctsi in pakistan because it is not used in routine clinical practice. this study was undertaken to evaluate the diagnostic value of mctsi in terms of the severity of disease process and its complications, that would help in the proper management of the patient and in preventing development of severe life threatening complications. p a t i e n t s a n d m e t h o d s this cross-sectional hospital based study was conducted at ct & mri centre of radiology department, dow university of health sciences/ dr. ruth k.m pfau civil hospital karachi from july to december 2017. patients of either gender between 20-70 years of age referred for contrast enhanced ct (cect) of abdomen within 24 hours of presentation, having two and more features of epigastric pain radiating to back, elevated serum amylase/ lipase level or ultrasound findings of acute pancreatitis like enlarged pancreas, heterogeneous echogenicity, peripancreatic collections were included in the study. patients with diagnosed pancreatitis on follow up or pancreatic carcinomas were excluded. pregnant females’ and patients allergic to urograffin and with deranged renal function tests were also excluded from study. sample size was calculated by openepi version 3 taking 60% of patients of acute pancreatitis of moderate grading according to mctsi,13 10% confidence interval and 95% confidence level. the total calculated sample size was 93. written informed consent was obtained from each subject and permission was sought from institutional ethical committee. ct scan of abdomen was performed with iv contrast using 16 slice toshiba activion scanner with pancreatic protocol i.e. in the arterial (at 40 seconds) and the portal venous (at 70 seconds) phase acquisition. the scanning parameter were 120 kv, 150 ma, 1mm collimation, 1mm slice thickness for arterial phase and 3mm slice thickness for portal venous phase. images were obtained in contagious axial sections from xiphisternum to pubic symphysis and reformatted in sagittal and coronal planes for analysis. severity of pancreatitis was categorized by modified ctsi into mild (0-2), moderate (4-6) and severe (8-10) by assessing various parameters of pancreatic and peripancreatic inflammation, percentage of pancreatic necrosis and extra-pancreatic complications and each of these parameters was assigned different points (table 1). then apache-ii score was calculated within 24 hours of presentation that includes 12 variables such as temperature, mean arterial pressure, heart rate, respiratory rate, pao2, arterial ph, serum na, serum k, serum creatinine, hematocrit, white blood cells and glasgow coma score. apache-ii score of > was taken as cut off for severe pancreatitis. clinical outcome parameters were also collected from respective referral departments for correlation including any need of intervention, evidence of developing infection or organ failure and death. collected data was entered and statistical analyses were carried out on spss version 20. descriptive statistics of age, gender, modified ctsi, apache-ii score and clinical outcome parameters (any intervention, systemic infection, organ failure or death) were calculated. 191 j i m d c 2 0 1 8 191 table 1: modified ct severity index 5 prognostic indicators/parameters points pancreatic inflammation normal pancreas 0 intrinsic pancreatic abnormalities with or without inflammatory changes in peripancreatic fat 2 pancreatic or peripancreatic fluid collection or peripancreatic fat necrosis 4 pancreatic necrosis none 0 < 30% 2 >30% 4 extrapancreatic complications one or more of pleural effusion, ascities, vascular complications, parenchymal complications, or gastrointestinal tract involvement 2 table 2: mctsi and apache ii score mctsi patients (n) apache ii score pvalue <8 > 8 0-2 15 15(100%) 0 <0.001 4-6 42 17 (40.48%) 25 (59.52%) 8-10 36 0 36 (100%) total 93 32 (34.4%) 61(65.6%) table 3: mctsi and patient’s outcome parameters patient outcome parameter modified ct severity index (mctsi) pvalue mild moderate severe patients (n) 15 42 36 <0.001 intervention 0 5 (5.4%) 16 (17.2%) infection 0 2 (2.1%) 17 (18.3%) organ failure 0 3 (3.2%) 14 (15.1%) death 0 0 3 (3.2%) r e s u l t s ninety-three patients were enrolled to assess the diagnostic value of modified ct severity index in terms of severity of pancreatitis and its complications. the patients were in the range of 20-70 years with mean age of 39.82 + 12.04 years and maximum patients were between 3140 years (38.7%). out of 93 patients, 66 (71%) patients were males and 27 (29%) patients were females (figure 1). cholelithiasis was the most common etiological factor for pancreatitis, seen in 47.3% cases. majority of patients were categorized as having moderate pancreatitis (45.16%) according to mctsi, while 36 patients (38.71%) were categorized into severe pancreatitis and 15 patients (16.13%) as mild pancreatitis. all patients of mild pancreatitis (100%) had apache ii score of less than 8. out of 42 patients of moderate pancreatitis, 17 patients (40.48%) had apache ii score less than 8 while 25 patients (59.52%) had apache ii score equal/more than 8. all patients with severe pancreatitis (100%) had apache ii score equal/more than 8; none had apache ii score less than 8 (table 2). pancreatic and peripancreatic inflammatory changes (78.5%) were the commonest findings on ct followed by pancreatic abnormality only (19.3%). forty-five patients (48.4%) had pancreatic necrosis with 16 of them having >30% necrosis. no necrosis was noted in patients with mctsi 0-2. the commonest extra-pancreatic complication was pleural effusion in this study, seen in 48 (51.6%) patients. pleural effusion was common on left side and found in 28 patients (30.1%) and bilateral in 20 (21.5%) patients. figure 1: gender distribution of study population (n=93) 192 j i m d c 2 0 1 8 192 figure 2: axial images of cect abdomen show (a) enlarged pancreas with peripancreatic fat stranding (mctsi 2/10). (b) enlarged pancreas with heterogeneous enhancement, peripancreatic fat stranding and collections (mctsi 4/10). (c) left sided pleural effusion, enlarged pancreas, peripancreatic fat stranding and collections (mctsi 6/10) none of patients showed isolated right side pleural effusion. the next common extra-pancreatic complication was ascites found in 30 patients (32.2%). venous thrombosis was the common vascular complication found in 4 patients (3 in portal vein as well as superior mesenteric artery and 1 in splenic vein) followed by pseudoaneurysm in 2 patients (one in splenic artery and other in superior pancreticoduodenal artery). more than one complication was present in patients having severe pancreatitis.majority of patients who required interventional procedure or who developed infection or organ failure were in the group of severe pancreatitis. sixteen out of 21 patients required intervention, 17 out of 19 developed infections and 14 out of 17 patients developed organ failure were in this group (table 3). death was seen in 3 patients (3.2%), who also belonged to this group. figure 2 shows axial images of cect abdomen. d i s c u s s i o n acute pancreatitis is a common condition resulting in emergency visits all over the world due to unpredictable clinical course and outcome.1,14 early evaluation and diagnosis of severe pancreatitis is essential for its proper management and identifying those patients who may benefit from early intensive therapy, but it’s very difficult to assess clinically alone the severity of pancreatitis in most of the cases.4,5,15,16 computed tomography (ct) has an important role not only in the disease diagnosis, but also for evaluation of disease severity as well as its complications and in subsequent disease management.2,14 the modified ct severity index is a simple and easy way to assess the inflammation and necrosis of pancreas along with extra-pancreatic complications.14 when severe pancreatitis occurs it is usually observed at beginning and it’s very uncommon to observe the slow progression of disease from mild to severe grade. therefore, early evaluation is a crucial concern for its management and prognosis.4 apache ii scoring has a clinically significant value as falling score usually is associated with mild attack while rising score with clinical deterioration. this score is also helpful in monitoring the disease course and response to treatment.17 this study was done to evaluate the acute pancreatitis on cect and to determine the diagnostic value of modified ct severity index (mctsi) in terms of severity of disease process and its complications that helps in assessing the prognosis of patient. this study consisted of 93 patients with mean age of 39.82 + 12.04 years. this was in concurrent with study done by parhi et al.16 out of 93, 66 (71%) were male and 27 (29%) female with male to female ratio of 2:1, this was comparable with studies by chnad et al13 and kim et al18 in which 73.3% and 70% were males respectively. in our study, cholelithiasis was the most common etiological factor (47.3%). raghuwanshi et al11 noted gall stones in 42% as a causative factor of acute pancreatitis in his study done over 50 patients. in our study, 42 (45.16%) patients were graded as having moderate pancreatitis, 36 (38.71%) having severe pancreatitis and 15 (16.13%) as mild pancreatitis according to mctsi. this result was somewhat similar to studies by banday et al who graded pancreatitis as 38%, 44% and 18% and by chnad et al as 60%, 30% and 10% respectively.13,14 otherwise most studies showed more frequency of mild pancreatitis.16,18 this study showed higher number of patients with moderate and severe pancreatitis because our hospital is a tertiary care centre so very sick patients of pancreatitis were referred to us. in 193 j i m d c 2 0 1 8 193 the present study, all patients (100%) of mild pancreatitis (mctsi 0-2) had apache ii score of less than 8. out of 42 patients of moderate pancreatitis (mctsi 4-6), 17 patients (40.48%) had apache ii score less than 8 while 25 patients (59.52%) had apache ii score equal/more than 8. all patients (100%) with severe pancreatitis (mctsi 8-10) had apache ii score equal/more than 8; none had apache ii score less than 8. so we have found that the patients having higher mctsi score also have raised apache ii score. this is also observed by cho et al1 and kumar et al4 in their studies in predicting the acute severe pancreatitis. this study showed pancreatic and peri-pancreatic inflammatory changes (78.5%) as most common ct findings followed by pancreatic abnormality only (19.3%). forty-five patients (48.4%) had necrosis of the pancreas. twenty-nine (64.4%) out of 45 patients had less than 30% and 16 (35.6%) had more than 30% pancreatic necrosis. these ct findings were comparable to a study conducted by raghuwanshi et al.11 pleural effusion was the commonest extra-pancreatic complication in this study, seen in 48 (51.6%) patients, more common on left side. raghuwanshi et al11 and balthazar et al20 reported in their studies, the left sided pleural effusion as the commonest finding. ascites was found to be second most common extra-pancreatic complication in our study present in 30 patients (32.2%) which is similar to the studies conducted by raghuwanshi et al11 (34%) and by banday et al14 (36%). vascular complications were found in 6 patients (6.45%). among these, venous thrombosis was most common seen in 4 (4.4%) patients (3 in portal as well as superior mesenteric veins and 1 in splenic vein), similar to raghuwanshi et al.11 the patients who required interventional procedure or who developed infection or organ failure mostly fell in the severe pancreatitis group, as observed by various studies.11,14,19 during the study duration, death was recorded in 3 (3.2%) patients due to multiple organ failure who were categorized as having severe pancreatitis according to mctsi. jeevangi et al and singh et al found almost similar mortality (3.7% and 3.5% respectively) in their studies.5,21 this study showed that modified ctsi had highest accuracy for assessing severity of pancreatitis in terms of pancreatic and peripancreatic inflammation, pancreatic necrosis, extra-pancreatic complications, need for intervention and organ failure which was comparable to apache ii scoring. kumar et al showed comparable accuracy between the modified ctsi and apache ii score in his study.4. c o n c l u s i o n contrast enhanced ct is an excellent diagnostic modality for the staging of the severity of pancreatitis. it shows the severity of inflammatory processes, extent of pancreatic necrosis and the local complications. the modified ct severity index is a simpler scoring system that showed quite good correlation with severity of pancreatitis and patients outcome parameters especially for assessing the loco-regional complications, organ failure and mortality. r e f e r e n c e s 1. cho jh, kim tn, chung hh, kim kh. comparison of scoring systems in predicting the severity of acute pancreatitis. world j gastroenterol 2015; 21(8):2387-94. 2. chishty ia, bari v, pasha s, burhan d, haider z, rafique z. role of computed tomography in acute pancreatitis and its complications among age groups. j pak med assoc. 2005; 55(10):431-5. 3. o'connor oj, mcwilliams s, maher mm. imaging of acute pancreatitis. american journal of roentgenology. 2011; 197(2): w221-5. 4. kumar ah, griwan ms. a comparison of apache ii, bisap, ranson’s score and modified ctsi in predicting the severity of acute pancreatitis based on the 2012 revised atlanta classification. gastroenterology report. 2017, 1–5 doi: 10.1093/gastro/gox029 5. jeevangi ba, yeli rk, borugadda r, pyadala n. management of acute pancreatitis by using modified computed tomography severity index. international journal of contemporary medicine surgery and radiology. 2018;3(1):91-5. 6. mofidi r, patil pv, suttie sa, parks rw. risk assessment in acute pancreatitis. br j surg 2009; 96(2):137-50. 7. rehan a, shabbir z, riaz o, shaukat a. diagnostic accuracy of modified ct severity index in assessing severity of acute pancreatitis. j coll physicians surg pak. 2016; 26 (12): 967-70. 8. kulkarni sv, naik as, subramanian n jr. apache ii scoring system in perforative peritonitis. am j surg 2007; 194(4):549-52. 9. freire p, romaozinho jm, amaro p, ferreira m, sofia c. prognostic score in a gastroenterology intensive care unit. rev esp enferm dig 2010; 102(10):596-600. 10. balthazar ej, freeny pc, van sonnenberg e. imaging and intervention in acute pancreatitis. radiology. 1994;193(2):297–306. 194 j i m d c 2 0 1 8 194 11. raghuwanshi s, gupta r, vyas mm, sharma r.ct evaluation of acute pancreatitis and its prognostic correlation with ct severity index. j clin diagn res. 2016; 10(6): tc06–11. 12. mortele kj, mergo pj, taylor hm, et al. peripancreatic vascular abnormalities complicating acute pancreatitis: contrast-enhanced helical ct findings. eur j radiol. 2004;52(1):67–72. 13. chnad p, pahuja v, singh g, singh p, kumar v. assessment of the severity of acute pancreatitis by ranson’s criteria and modified ct severity index. international journal of contemporary medical research 2017;4(6):1280-2. 14. banday ia, gattoo i, khan am, javeed j, gupta g, latief m. modified computed tomography severity index for evaluation of acute pancreatitis and its correlation with clinical outcome: a tertiary care hospital based observational study. j clin diagn res. 2015;9(8):tc01-5 15. suvarna r, pallipady a, bhandary n, hanumanthappa. the clinical prognostic indicators of acute pancreatitis by apache ii scoring. journal of clinical and diagnostic research. 2011. 5(3): 459-63. 16. parhi ap, nisa s, panda bb , dash b, bhagat s. correlation of modified computed tomography severity index with complications of acute pancreatitis. jmscr. 2016; 4 (11): 13868-72. 17. yeung yp, lam by, yip aw. apache system is better than ranson system in the prediction of severity of acute pancreatitis. hepatobiliary pancreat dis int. 2006; 5(2):294–9. 18. kim ys, lee bs, kim sh, seong jk, jeong hy, lee hy. is there correlation between pancreatic enzyme and radiological severity in acute pancreatitis? world j gastroenterol. 2008; 14(15):2401-05. 19. bollen tl, singh vk, maurer r, repas k, van es hw, banks pa, et al. comparative evaluation of the modified ct severity index and ct severity index in assessing severity of acute pancreatitis. ajr am j roentgenol. 2011; 197(2):386-92. 20. balthazar ej. acute pancreatitis: assessment of severity with clinical and ct evaluation. radiology. 2002; 223(3):603–13. 21. singh vk, wu b, bollen tl, repas k , maurer r, johannes rs et al. a prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate marker of severity in acute pancreatitis. am j gastroenterol 2009;104(4):966– 71. j islamabad med dental coll 2019 176 ope n ac cess psychological stress among parents of hearing impaired versus intellectually disabled pakistani children nazia firdous1, nazia mumtaz2, ghulam saqulain3 1 speech & language pathologist, government special education centre, phalia, m.b din, pakistan 2 head of department of slp & hearing sciences, isra institute of rehab sciences, isra university, islamabad, pakistan 3 head, department of otorhinolaryngology, capital hospital, islamabad, pakistan a b s t r a c t background: parents of special children face physical, psychological and social impact of their child’s disability, including hopelessness and depression. this study is important as it will help professionals plan and provide effective coping strategies so parents could have a positive perception and behavior for disabilities (like hearing impaired and intellectual disability) in their children. the objective of this study was to analyze level of psychological stress among parents of children with hearing impaired (hi) versus intellectual disability (id) and relationship between disability and psychological stress. material and methods: this cross-sectional study comprised of parents (n = 200) of 100 hi and 100 id children, of both genders, aged 1 to 16 years. these were recruited by non-probability convenience sampling after taking consent from special education centers of punjab (pakistan), over a period of six months from may 2017 to october 2017. after collecting demographic details, quantitative assessment of parental stress was done using parental stress scale (pss). statistical analysis was carried out using spss v21. results: the sample population (n=200) consisted of 32.5% male and 67.5% female respondents, with a mean age of 41.23 ± 6.7 years. the mean of total parental psychological stress score was 61.85 ± 17.1 with significant association between disabilities (hi and id) and psychological stress (p<0.01). in hi group, moderate psychological stress was seen (n=53, 26.5%), while in id group, profound level of psychological stress was noted in majority (n=70, 35%) of participants. conclusions: parents of both hi and id children showed psychological stress, however, parents of id children suffered higher level of stress. key words: hearing impairment, intellectual disability, psychological stress, quality of life authors’ contribution: 1,2 conception, synthesis, planning of research and manuscript writing interpretation, discussion, 3, active participations in data collection data analysis. correspondence: ghulam saqulain email: ghulam_saqulain@yahoo.com article info: received: august 8, 2019 accepted: november 23, 2019 cite this article. firdous n, mumtaz n, saqulain g. psychological stress among pare nt s o f h e arin g impaired versus intellectually disabled pakistani children. j islamabad med dental coll.2019; 8(4): 176180. doi: 10.35787/jimdc.v8i4.282 funding source: nil conflict of interest: nil i n t r o d u c t i o n disability is associated with lot of stress, especially for th e parents and caregivers, resulting in physical, psychological and social impact thus affecting normal functioning1 and quality of life (qol).2 parents with hearing impaired (hi) and intellectually disabled (id) children , a re also affected. according to pipp-siegel et al mothers of h i children, with low family income and lacking social support face higher stress level.3 they also suffered from hopelessness and depression, as a result their qol is affected.4 hi, being one of the most common invisible disabilities prevailing in developing countries, marring social and communication development, is a critical eve n t and a source of stress for parents and caregivers, which is also related to the duration of disability.5 hi can occur with other comorbidities like id. the diagnostic and statistical manual of mental disorders-5 (dsm-5), describes intellectual disabilities as disorder of neurodevelopmental onset originating in childhood, with difficulties in conceptual, social and practical areas of life.6 id commonly occurs in the first two decades of life6, or i gi n a l a r ti c le j islamabad med dental coll 2019 177 resulting in adaptation problems for the disabled child and mental stress for the caregivers.7 the birth, care and upbringing of an id child in the family, can turn into a threat to the emotional health of parents/ caregiver. a high proportion of parents of such children face anxiety, depression8, distress, frustration, powerlessness, and hostility.9 a local study, mumtaz et al. reported that parents of children with hearing loss identified at an earlier stage were more satisfied.10 with joint family system still prevalent in the country, compared to nuclear families in the western society and with late identification of hi with a prevalence of 48% at 19-24 months of age 11, there is possibility of parental stress level being quite different from western societies. therefore, the current study was planned with the aim to analyze the level of parental stress among parents of hi versus id children and relationship between disability and psychological stress. this could help our speech language pathologists and psychologists in enhancing diagnostic, interventional and management approaches and in turn help provide effective coping strategies so parents could have a positive perception and behavior fo r disabilities like hi and id in their children. the current study is imperative since there is dearth of literature on this important issue and very few studies from this part of the world. m a t e r i a l a n d m e t h o d s this cross-sectional study was carried out over a period of six months from may 2017 to october 2017. a formal approval was taken from school heads to conduct the research at the respective special education centers in punjab, pakistan. ethical committee approval for study was obtained from isra university and consent was obtained from all the participants prior to enrollment. it includes a study population of 200 participant (parents) calculated using raosoft application with response distribution at 50% and population size on 20,000 at 9 0 % confidence level and 5.76% margin of error. a total of 10 0 parents of hi and 100 parents of id children visiting the special school in punjab pakistan satisfying the selection criteria were recruited in the study. these children belonged to both genders aged 1-16 years. sampling technique was non-probability convenience sampling. the sample parents belonged to both genders belonging to age group 25 to 60 years. following informed written consent and filling of basic demographic sheet, parents were asked to fill pss questionnaire to examine their functional, emotional and phycological problems. data was collected and tabulated using microsoft excel worksheet and analyzed using spss v 21. continuous data was presented as mean and standard deviation (sd ) while categorical results were calculated as frequency and percentage. to determine relationship between disability and psychological stress, independent t test a n d chi square tests were applied. p value of ≤ 0.05 was interpreted as statistically significant. r e s u l t s our study population comprised of a total of 200 parents, 100 parents of hi and 100 parents of id children, who consented for the inclusion in the study and met the selection criteria. the age range of the study population was 25 to 60 years with mean age of 41.04 ± 6.59 years in the hi group and 41.42 ± 6.86 years in the id group, of which 32.5% (n=65) were males (33 in hi and 32 in id group) and 67.5% (n=135) were females (67 in hi an d 6 8 in id group) with male: female ratio of 1: 2.07. the sample of the two groups (hi vs id) was kept balanced to avoid any gender and age bias in the study. the mean of total parental psychological stress score was 61.85 ± 17.1. a statistically significant association was found between type of disability (hi and id) and psychological stress with much higher pss score in parents of id as compared to hi. it indicates that parents of id children were facing much more stress than hi (table i). regarding levels of psychological stress, majority of parents of hearing-impaired children had moderate level of psychological stress, while most of parents of id children had profound level of psychologica l stress (table i). j islamabad med dental coll 2019 178 *p ≤ 0.05 was considered statistically significant d i s c u s s i o n the birth of a hearing impaired or intellectually disabled child affects the dynamics and interaction of the whole family. in this study, parents of both categories showed a significantly high level of psychological stress and there was significant correlation between both types of disability (hi and id) and psychological stress (p<0.01). studies show that parental stress is significantly higher in parents of children with disabilities 12, and other factors. 13 according to person and chan, mothers of children with learning disabilities are highly stressed compared to normal children.14 in this study, parents of children had significantly different levels of stress among two different etiologic groups of hi and id. most of the parents of children with hi (n=53, 26.5% ) exhibited significant, but moderate level of stress. these results are consistent with the work of different researchers. dehkordi et al. found significantly higher level of stress in mothers of hi compared to other disabilities.15 according to vinayak et al., mothers of the hi children had high level of hopelessness and depression, which was adversely affecting their quality of life.4 van driessche et al. also found higher level of psychological morbidities and strain in parents/caregive rs of hi.16 other authors have also reported higher stress levels in parents of hi children.5,17,18 spahn et al. found that 21% parents of cochlear implant (ci) using children suffered from higher level of stress.19 sarant and garrard, found negative correlation between parents’ stress level and language outcome in ci cases with parents of children with bilateral ci being less stressed than unilateral ci.20 in our study, 35% (n=70), parents of intellectually challenged children were suffering from profound level of psychological stress with mean score of 75.98 + sd 9.126. similarly, sheikh et al. found significant levels of parental depression and anxiety in 70% cases.21 chouhan et al. found statistically significant relationship between parenting stress and anxiety among parents of children with id. they further noted that parents of children with profound level of id had more stress compared to parents of children with borderline disability and normal children.22 also, tsai and wang found extreme levels of strain in mothers of id children.23 mcconnell and savage also found higher level of psychological distress as well as family dysfunction in parents of id children.24 one of the findings from current study was parents of children with id had significantly severe to profound levels of psychological stress as compared to parents of children with hi. this finding is consistent with a jordanian study reporting highest level of stress in parents of physical disabilities, followed by mental disabilities and lowest in parents of children with hi.25 the coping strategies may help reduce the stress associated with disabilities. the findings in a study by movallai et al. suggest a positive role of behavioral training, especially in reducing maternal psychological problems of hi children.26 this can thus result in good mental health in parents and indirectly improve the q o l o f id and hi children. however further research is required to explore the stressors and coping mechanisms for families as a whole and parents in particular, to deal more effectively with children disabilities c o n c l u s i o n majority of the parents, of children with both disabilities i.e., hi and id, suffer high level of psychological stress with parents of id having more stress than parents of hi children. table i: psychological stress among study participants suffering from hearing impairment and intellectual disability (n=200) variables hearing impaired group (n=100) mean ± sd intellectual disability group (n=100) mean ± sd *pvalue mean of psychological stress 47.73±10.09 75.98±9.13 0.001 levels of psychological stress (0-100) n (%) n (%) mild (0-25) 03 (1.5) 0 0.001 moderate (2650) 53 (26.5) 26 (13) severe (51-75) 44 (22) 70 (35) profound (76100) 0 4 (2) j islamabad med dental coll 2019 179 r e f e r e n c e s 1. gupta vb, mehrotra p, mehrotra n. parental stress in raising a child with disabilities in india. disability, cbr & inclusive development. 2012; 23(2): 41-52. doi 10.5463/dcid.v23i2.119 2. sreekeerthi d, kumar m. a comparative study of quality of life in caregivers of mental retardation and normal children. sch j app med sci. 2017; 5(9d): 3793-98. doi: 10.21276/sjams.2017.5.9.56 3. pipp-siegel s, sedey al, yoshinaga-itano c. predictors of parental stress in mothers of young children with hearing loss. j deaf stud deaf educ. 2002; 7(1): 1-17. doi: 10.1093/deafed/7.1.1 4. vinayak s, dhanoa sk, vinayak r. relationship of hopelessness, depression and quality of life in mothers of persons with disabilities. ijias. 2016; 17(1): 306-11. 5. meinzen-derr j, lim lh, choo di, buyniski s, wiley s. pediatric hearing impairment caregiver experience: impact of duration of hearing loss on parental stress. int j pediatr otorhinolaryngol. 2008; 72(11): 1693703. doi: 10.1016/j.ijporl.2008.08.005 6. boat tf, wu jt, editors. mental disorders and disabilities among low-income children clinical characteristics of intellectual disabilities. washington (dc); national academies press (us); 2015. 7. chaudhury s. anxiety and depression in mothers of deaf children: awareness needed. med. j. dy patil univ. 2014; 7(6): 720-21. 8. azeem mw, dogar ia, shah s, cheema ma, asmat a, akbar m et al. anxiety and depression among parents of children with intellectual disability in pakistan. j can acad child adolesc psychiatry. 2013; 22(4): 290 95. pmid: 24223048 9. burger t, spahn c, richter b, eissele s, löhle e, bengel j. parental distress: the initial phase of hearing aid and cochlear implant fitting. am ann deaf. 2005; 150(1): 5-10. doi: 10.1353/aad.2005.0017 10. mumtaz n, habibullah s, shafqat f, aftab a. benefits of early detection among hearing impaired children: contemporary parental response. int j rehabil sci. 2016; 5(2): 58-61. 11. mumtaz n, habibullah s. better late than never: identification of children with hearing loss in pakistan. pak armed forces med j 2017; 67 (2): 29295. 12. nadeem m, choudhary fr, parveen a, javaid f. parental stress among parents of children with and without disabilities. pjss. 2016; 36(2):1281-89. 13. katkić lo, morović ml, kovačić e. parenting stress and a sense of competence in mothers of children with and without developmental disabilities. croatian review of rehabilitation research. 2017; 53(supplement): 63-76. 14. pearson v, chan tw. the relationship between parenting stress and social support in mothers of children with learning disabilities: a chinese experience. soc sci med. 1993; 37(2):267-74. doi: 10.1016/0277-9536(93)90461-c 15. dehkordi ma, kakojoibari aa, mohtashami t, yektakhah s. stress in mothers of hearing-impaired children compared to mothers of normal and other disabled children. audiol. 2011; 20(1): 128-36. 16. van driessche a, jotheeswaran at, murthy gv, pilot e, sagar j, pant h, et al. psychological well-being of parents and family caregivers of children with hearing impairment in south india: influence of behavioural problems in children and social support. int rev psychiatry. 2014; 26(4): 500-7. doi: 10.3109/09540261.2014.926865. 17. abbas f, rafque u, majid s. stress level of parents of hearing-impaired children. j educ pract. 2013; 4(26): 69-77. 18. lederberg ar, golbach t. parenting stress and social support in hearing mothers of deaf and hearing children: a longitudinal study. j deaf stud deaf educ. 2002; 7(4): 330-45. doi: 10.1093/deafed/7.4.330 19. spahn, c, burger t, löschmann c, richter b. quality of life and psychological distress in parents of children with a cochlear implant. cochlear implants int.2004; 5(1): 13-27. doi: 10.1080/14670100.2004.11873747 20. sarant j, garrard p. parenting stress in parents of children with cochlear implants: relationships among parent stress, child language, and unilateral versus bilateral implants. j deaf stud deaf educ. 2014; 19(1): 85-106. doi:10.1093/deafed/ent032 21. sheikh mh, ashraf s, imran n, hussain s, azeem mw. psychiatric morbidity, perceived stress and ways of coping among parents of children with intellectual disability in lahore, pakistan. cureus. 2018; 10(2): e2200. doi:10.7759/cureus.2200. 22. chouhan sc, singh p, kumar s. assessment of stress and anxiety in parents of children with intellectual disability. ijhw. 2016; 7(5): 500-04. 23. tsai sm, wang hh. the relationship between caregiver’s strain and social support among mothers j islamabad med dental coll 2019 180 with intellectually disabled children. j clin nurs. 2009; 18(4): 539-48. 24. mcconnell d, savage a. stress and resilience among families caring for children with intellectual disability: expanding the research agenda. curr dev disord rep. 2015; 2(2): 100-09. doi 10.1007/s40474-0150040-z: 25. bawalsah ja. stress and coping strategies in parents of children with physical, mental, and hearing disabilities in jordan. j. educ.2016; 8(1): 122. doi: 10.5296/ije.v8i1.8811 26. movallali g, amiri m, afrashteh my, morovati z . parental stress and mental health in mothers of children with hearing impairment: the effectiveness of a behavioral training program. iosr-jhss. 2015; 20(7):89-95 j islamabad med dental coll 2022 241 open access sexually transmitted diseases and associated risk factors among transgenders in peshawar muhammad asif zeb1, arsalan waqas2, fawad inayat3, aman ullah4, amir afzal khan5, awal mir6 1,4,6lecturer, institute of paramedical sciences, khyber medical university, peshawar. 2mphil biochemistry student, abdul wali khan university, mardan. 3lecturer, allied health sciences, iqra national university, peshawar. 5lecturer, department of allied health sciences, iqra national university, peshawar. a b s t r a c t background: transgenders, male to female, are exceptionally predominant in india-pakistan, dreaded to be alarming for sexually transmitted diseases. the objective of this study was to determine the frequency of sexually transmitted diseases and their associated risk factors among transgenders. methodology: this cross-sectional study was conducted amongst transgenders at institute of paramedical sciences (ipms), khyber medical university peshawar from january to july,2021. about two ml of venous blood was collected in a gel tube under aseptic conditions among 100 individuals to check for hbsag, anti-hcv, hiv and syphilis by ict rapid strip method. positive samples of hbsag and anti-hcv were confirmed by polymerase chain reaction (pcr), while positive cases of syphilis were confirmed by treponema pallidum hemagglutination (tpha). chi-square test was applied to determine the association between sexually transmitted disease and associated risk factors. results: out of 100, seven (7%) samples were positive for hbsag, five (5%) for anti-hcv and nine (9%) were positive for syphilis while there were no positive cases of hiv. hbv infection was significantly associated with blood transfusion, a drug injection history and some surgical procedure (p<0.05). for syphilis, the data were significantly associated with a history of blood transfusion and drug injection (p<0.05). conclusion: frequency of hbv, hcv and syphilis infections are high in transgenders with common associated risk factors to be sexual activities, drug injection, unsafe blood transfusion and surgical procedures. keywords: chromatography, hepatitis b surface antigen, hepatitis c antibodies, hiv, syphilis, transgenders authors’ contribution: 1,2conception; literature research; manuscript design and drafting;3,4critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: muhammad asif zeb email: muhammadasif.ipms@kmu.edu.pk article info: received: october 1, 2021 accepted: november 9, 2022 cite this article.zeb a m, waqas a, inayat f, ullah a, khan a a, mir a. sexually transmitted diseases and associated risk factors among transgenders in peshawar.j islamabad med dental coll. 2022;11(4): 241-246. funding source: nil conflict of interest: ni doi: https://doi.org/10.35787/jimdc.v11i4.794 i n t r o d u c t i o n individuals whose gender presentation differs from their assigned sex at birth are referred to as transgender. various identities that fall under the umbrella of transgender are trans men, trans women, gender queer, non-binary, sister girl, brother boy, gender nonconforming, gender fluid or two-spirited. (1) viral hepatitis is a global health issue in which viral types a, b, c, d, and e are the main pathogenic agents. in 2013, 1.45 million people died as a result of hepatotropic viruses, with chronic hepatitis b o r i g i n a l a r t i c l e j islamabad med dental coll 2022 242 and c virus infections accounting for 91 percent of the deaths. (2) almost two billion individuals are infected by hbv worldwide and the number of chronic carriers is 350 million. every year, the hbv virus kills one million people. in latin america, 400,000 new cases are recorded each year, with 10 to 70% of them progressing to hepatocellular carcinoma. (3) on the basis of hbv infection epidemiology, the environment was categorised into high, middle, and low endemicity zones. infection rates of more than 8% are considered high, 2–8% are considered intermediate, and less than 2% are considered low endemicity zones. pakistan is one of the countries with the highest rates of chronic viral hepatitis infection in the world. (4) hepatitis c virus (hcv)-related liver disease is a serious public health concern that affects millions of individuals around the world. (5) hcv infection is spread mostly by contact with contaminated devices and tools, haemodialysis, infected blood or blood products, iv medication misuse and organ donation. (6) the prevalence of hcv infection in transgender men was 8.0% and 3.7% in transgender women. (7) the world health organization (who) predicted in 2015 that by 2030, viral hepatitis incidence and mortality would be reduced by 90% and 65%, respectively. however, in order to offer current prevalence/incidence figures, this global goal will necessitate regional studies (8) despite on-going attempts to manage hiv outbreaks, in 2019 a total of 1.7 million new hiv infections occurred, with sub-saharan africa having the highest disease burden. with almost 35 million deaths and counting, hiv continues to be a serious hazard to public health, and in 2016, there were still over 2 million infected individuals. (9) the frequency of hiv for transgender women was 17.7% according to a meta-analysis of ten middle and low-income countries. (10) in indonesia, among 1,150 transgender women who were frequently involved in sexual activities, 26.8% had syphilis, 24.4% hiv and 47% rectal sexually transmitted infections. (11) in indo-pak regions, transgender individuals are intensely demoralized as they are considered a major social taboo in society, therefore, they live in isolated communities. transgenders usually undergo unsafe sexual activities due to lack of education. this study was conducted to determine the frequency of sexually transmitted diseases and their associated risk factors among transgenders in peshawar that may help in devising strategies to create health awareness among this group. m e t h o d o l o g y this cross-sectional study was conducted in peshawar among transgenders from jan 2021 to july 2021 at institute of paramedical sciences (ipms), khyber medical university. the study was approved by the undergraduate ethical committee of ipms. a self-designed questionnaire was used for the risk assessment, based on previous literature. one hundred participants were included in this study, selected through convenience sampling technique. according to the census 2017, the total transgender population in k.p.k is 913 and the total population of transgenders in peshawar is 292. using the raosoft sample size calculator, the estimated sample size was 167 with confidence interval of 95% and margin error 5% but many refused to participate in the study with only 100 willing participants. transgenders between 18 to 50 years of age were included while those who had chronic liver disease were excluded from the study. informed consent was taken from all individuals. about two ml of venous blood was collected in a gel tube under aseptic conditions and centrifuged at 2500 rpm for 10 minutes to procure the serum. for screening of hbv, hcv, hiv and syphilis, immune chromatography technique (ict) was used. all positive samples were confirmed by polymerase chain reaction (pcr) and treponema pallidum hemagglutination (tpha) techniques. the data j islamabad med dental coll 2022 243 were analysed using spss v22.0. for descriptive statistics, the frequencies were calculated and presented in tabulated form. for categorical variables, fisher’s exact test was applied to determine the association with risk factors. r e s u l t s out of 100, seven (7%) were positive for hbv, five (5%) for hcv infection, and no positive case for hiv was reported. nine (9%) individuals had syphilis infection. the frequency of hbv, hcv, hiv and syphilis within their associated risk factors was also determined such as the previous history of blood transfusion, drug injection history, sexual behavior, surgical procedures, family history and organ piercing for jewelry. hbv and syphilis infections were frequent among transgenders having a blood transfusion, drug injecting history, sexual behaviors, having surgical procedures and organ piercing for jewelry purposes, while hcv infection was common in transgenders involved in sexual activities and organ piercing for jewelry purposes (table 1) table i: frequency of hbv, hcv, hiv and syphilis with associated risk factors among transgenders r isk f a cto rs p a ra m e te r f re q u e n cy (% ) hepatitis b status hepatitis c status syphilis status h iv s ta tu s p o sitiv e (% ) n e g a tiv e (% ) p v a lu e p o sitiv e (% ) n e g a tiv e (% ) p v a lu e p o sitiv e (% ) n e g a tiv e (% ) p value blood transfusion yes 33 (33) 5(5) 28(28) 0.0377 2(2) 31(31) 0.99 6(6) 27(27) 0 .0 5 5 n o n e o f th e p a rt ic ip a n ts w a s d ia g n o se d w it h t h e h iv i n fe ct io n no 67(67) 2(2) 65(65) 3(3) 64(64) 3(3) 64(64) drug injection yes 41(41) 6(6) 35(35) 0.018 2(2) 39(39) 0.99 7(7) 34(34 %) 0.055 no 59(59) 1(1) 58(58) 3(3) 56(56) 2(2) 57(57) sex behaviour yes 79(79) 4(4) 75(75) 0.15 4(4 ) 75(75) 0.99 7(7) 72(72) 0.17 no 21(21) 3(3) 18(18) 1(1 ) 20(20) 2(2) 19(19) surgical procedure yes 17(17) 5(5) 12(12) 0.0014 1(1 ) 16(16) 0.99 3(3) 14(14) 0.99 no 83(83) 2(2) 81(81) 4(4 ) 79(79) 6(6) 77(77) family history yes 12(12) 2(2) 10(10) 0.197 2(2 ) 10(10) 0.108 0 2(2) 10(10) 0.151 no 88(88) 5(5) 83(8) 3(3 ) 85(85) 4(4) 84(84) organ piercing (for jewellery purpose) yes 48(48) 4(4) 44(44) 0.7075 3(3 ) 45(45) 0.66 6(6) 4(42) 0.30 no 52(52) 3(3) 49(49) 2(2 ) 50(50) 3(3) 49(49) an association was established between hbv infection and risk factors. there was statistically significant association between hbv and associated risk factors such as blood transfusion (p=0.03), drug injected history (p=0.01) and surgical procedure (p=0.00), while insignificant association with family history, sexual behaviors and organ piercing with pvalue > 0.05. in case of hcv, there was no significant association with any parameter (p>0.05). (table 1) j islamabad med dental coll 2022 244 two individuals had both hbv and hcv infection, while three individuals had both hbv and syphilis infection. three individuals had hcv and syphilis, while one individual had hbv, hcv and syphilis. d i s c u s s i o n in this study, we determined the frequency of hbv, hcv, hiv and syphilis and their associated risk factors among transgenders. according to this study, 7% of transgenders were found to have hepatitis b infection, 5% hcv, while positive cases of hiv were not reported. the frequency of syphilis was 9%, which was highest among others. the current study revealed that 33% of transgenders were having previous history of blood transfusion, out of which 5% were positive for hbv, 2% for hcv and 6% had syphilis, while 67% had no history of blood transfusion. blood transfusion is a common transmission route for hbv, hcv, syphilis and blood parasites because of inappropriate blood screening facilities in pakistan. (12) in pakistan, 3.27% of donors were found to be infected with transmissible transfusion infection leading to infection in patients during transfusion. (13) in the present study, 79% of the transgenders had a sexual history with one or multiple sex partners. among them, 4% were diagnosed with hepatitis b and c, while 75% were negative for both hepatitis b and c. transgenders involved in sexual activities have the highest frequency of syphilis that is 7%. because of social discrimination and stigma, transgender individuals are deprived of higher education or initial compulsory education, leading to poor literacy and hence live in isolated societies. it is hard for them to get jobs in societies that indulge them to be involved in sexual activities for accomplishing their daily necessities. (14) in addition unprotected sexual relationship with partners may increase the risk of transmission of hepatitis b and c. (15) in a study conducted in rawalpindi, it was reported that the prevalence of hbv and hcv among transgender people was 2.94% and 25.5% respectively. in this study, majority of the transgenders were involved in sexual activities with one or multiple partners. (16) our results differed from this study because of the small sample size and geographical difference. in another study, it was reported that most transgender people were aware that using a condom during sex with their partners (17) could be another reason of reducing the prevalence of hbv, hcv and syphilis in peshawar. the current study reported that needle exchange for drug injection is another risk factor among transgenders. among drug addicts, the frequency of hbv, hcv, and syphilis were 6%, 2%, and 7%, respectively. according to awan et al, it was reported that exchanging needles for drug injection is a risk factor for transmitting viral hepatitis, syphilis and hiv infections. (13) a study conducted in sindh reported that using unsterilized syringe is a risk factor for transmitting hbv and hcv infections. (18) another study from pakistan reported that majority of the transgenders were involved in sharing drug injection needle with one another. (19) needle sharing is most common cause of transmitting infection among transgenders. (20) hence needle sharing for drug use is a risk factor among transgenders for transmitting hbv, hcv, syphilis and hiv infections. in this study, another significant risk factor among transgender was organ piercing (ear, nose, and j islamabad med dental coll 2022 245 tattoos) for jewelry purposes. transgender people with a history of organ piercing were 48%, while 52% had no history. among 48% individuals, 4% were hbv positive, 2% hcv positive and 6% syphilis. transgenders live in a community where they love to dress in female clothing and wear pieces of jewelry. for this purpose, they are piercing the ear, nose and make tattoos on various parts of the body using shared instruments/needles leading to a rise in hbv, hcv and other transmissible diseases. (21) the strength of this study is that it is the first study conducted in peshawar to determine the frequency of sexually transmitted diseases (hbv, hcv, hiv, syphilis) and their associated risk factors among transgender individuals. positive cases were confirmed using a gold standard method. however, this study has a few limitations. first, this study has a small sample size as most of the transgenders were reluctant to participate in this study. second, the ict method was used for screening the transgender population due to limited resources. c o n c l u s i o n frequency of syphilis is highest, followed by hepatitis b and c in the transgender community in peshawar. the common associated risk factors are unsafe blood transfusion, exchange of needles for drugs, sexual behavior and organ piercing. an appropriate screening program is essential for transgender individuals to prevent sexually transmitted infections. r e f e r e n c e s 1. nolan it, kuhner cj, dy gwjta, demographic and temporal trends in transgender identities and gender confirming surgery. urology. 2019;8(3):184. doi:10.21037/tau.2019.04.09. 2. laguna-meraz s, roman s, jose-abrego a, sigalaarellano r, panduro ajaoh. a hospital-based study of the prevalence of hbv, hcv, hiv, and liver disease among a low-income population in west mexico. 2022;27:100579. doi:https://doi.org/10.1016/j.aohep.2021.100579 . 3. raza a, mazhar mw, saif s, noor s, sikandar m, shahzadi i, et al. prevalence of hepatitis b virus infection among persons with hepatitis d virus and diabetes mellitus in pakistan, 2019-2021. 2022;8(1):001-4. doi:https://doi.org/10.17352/ahr.000031. 4. schweitzer a, horn j, mikolajczyk rt, krause g, ott jjjtl. estimations of worldwide prevalence of chronic hepatitis b virus infection: a systematic review of data published between 1965 and 2013. 2015;386(10003):1546-55. doi:https://doi.org/10.1016/s01406736(15)61412-x. 5. phanie popping s, el-sayed m, feld j, hatzakis a, hellard m, lesi o, et al. report from the international viral hepatitis elimination meeting (ivhem), 17–18 november 2017, amsterdam, the netherlands: gaps and challenges in the who 2030 hepatitis c elimination framework. elsevier; 2018. p. 193-5. doi: https://doi.org/10.1016/s2055-6640(20)30264-8 6. ul haq i, khan m, rehman z, anwar f, ullah h, ullah njijb. hbv prevalence in the volunteer blood donors in peshawar, khyber pakhtunkhwa pakistan. 2018;13(5):50-4. doi:10.12692/ijb/13.5.50-54. 7. luzzati r, zatta m, pavan n, serafin m, maurel c, trombetta c, et al. prevalence of human immunodeficiency virus, hepatitis b virus, and hepatitis c virus infections among transgender persons referred to an italian center for total sex reassignment surgery. 2016;43(7):407-11. doi:10.1097/olq.0000000000000452. 8. world health o. global health sector strategy on viral hepatitis 2016-2021. towards ending viral hepatitis. geneva: world health organization; 2016. contract no.: who/hiv/2016.06 9. heath k, levi j, hill aja. the joint united nations programme on hiv/aids 95–95–95 targets: worldwide clinical and cost benefits of generic manufacture. 2021;35(1):s197-s203. doi:https://doi.org/10.1097/qad.0000000000002 983. 10. baral sd, poteat t, strömdahl s, wirtz al, guadamuz te, beyrer cjtlid. worldwide burden of hiv in transgender women: a systematic review and meta-analysis. 2013;13(3):214-22. doi:https://doi.org/10.1016/s14733099(12)70315-8. 11. prabawanti c, bollen l, palupy r, morineau g, girault p, mustikawati de, et al. hiv, sexually transmitted infections, and sexual risk behavior https://doi.org/10.1016/j.aohep.2021.100579 https://doi.org/10.1016/j.aohep.2021.100579 https://doi.org/10.17352/ahr.000031 https://doi.org/10.1016/s0140-6736(15)61412-x https://doi.org/10.1016/s0140-6736(15)61412-x https://doi.org/10.1016/s2055-6640(20)30264-8 https://doi.org/10.1097/qad.0000000000002983 https://doi.org/10.1097/qad.0000000000002983 https://doi.org/10.1016/s1473-3099(12)70315-8 https://doi.org/10.1016/s1473-3099(12)70315-8 j islamabad med dental coll 2022 246 among transgenders in indonesia. 2011;15(3):663-73. doi: 10.1007/s10461-0109790-0. 12. saeed m, hussain s, rasheed f, ahmad m, arif m, rahmani mthjjpma. silent killers: transfusion transmissible infections-tti, among asymptomatic population of pakistan. 2017;67(3):369-74. 13. awan sa, junaid a, sheikh sjc. transfusion transmissible infections: maximizing donor surveillance. 2018;10(12): e3787. doi 10.7759/cureus.3787 14. ming lc, hadi ma, khan tmjtl. transgender health in india and pakistan. 2016;388(10060):2601-2. doi:https://doi.org/10.1016/s01406736(16)32222-x. 15. cocchetti c, romani a, mazzoli f, ristori j, lagi f, meriggiola mc, et al. prevalence and correlates of sexually transmitted infections in transgender people: an italian multicentric cross-sectional study. 2022;11(10):2774. doi:https://doi.org/10.3390/jcm11102774. 16. akhtar h, badshah y, akhtar s, hassan f, faisal m, qadri ijails. prevalence of hepatitis b and hepatitis c virus infections among male to female (mft) transgenders in rawalpindi (pakistan). 2018;5(2):46-55.doi: 10.1186/1743-422x-9-229 17. nijmeijer bm, koopsen j, schinkel j, prins m, geijtenbeek tbjjotias. sexually transmitted hepatitis c virus infections: current trends, and recent advances in understanding the spread in men who have sex with men. 2019;22:e25348. doi: https://doi.org/10.1002/jia2.25348. 18. samo aa, laghari za, baig nm, khoso gmjtajotm, hygiene. prevalence and risk factors associated with hepatitis b and c in nawabshah, sindh, pakistan. 2021;104(3):1101. doi:10.4269/ajtmh.20-1228. 19. manzoor i, khan zh, tariq r, shahzad rjpjoms. health problems & barriers to healthcare services for the transgender community in lahore, pakistan. 2022;38(1):138. doi:10.12669/pjms.38.1.4375. 20. nadoushan ahj, bahramian a, taban m, alavi k, sharifi h, shokoohi m, et al. high-risk sexual behaviors among transgender individuals in tehran, iran. 2021;59(2):113. doi:10.18502/acta.v59i2.5578. 21. rana na, munir b, hussain n, imtiaz njjobm. seroprevalence, biochemical investigation and risk factor assessment for hbv & hcv infection in hospital based patients of islamabad, pakistan. 2020;7(2):2. doi:https://doi.org/10.35691/jbm.0202.0127. https://doi.org/10.1016/s0140-6736(16)32222-x https://doi.org/10.1016/s0140-6736(16)32222-x https://doi.org/10.3390/jcm11102774 https://doi.org/10.1186%2f1743-422x-9-229 https://doi.org/10.1002/jia2.25348 https://doi.org/10.35691/jbm.0202.0127 j islamabad med dental coll 2021 220 o p e n a c c e s s non-motor symptoms and their associated factors in parkinson’s disease wajeeha qayyum1, sohail khan2, muhammad shahid iqbal3, muhammad fozan khan4, zaland ahmed yousafzai5, fawad jan6 1senor registrar, department of medicine and allied, rehman medical institute, khyber pakhtunkhwa 2,3assistant professor, department of neurology, rehman medical institute, khyber pakhtunkhwa 4consultant, physician and store medicine, rehman medical institute, khyber pakhtunkhwa 5medical officer, department of medicine and allied, rehman medical institute, khyber pakhtunkhwa 6assistant professor, department of neurology, gajju khan medical college, swabi, khyber pakhtunkhwa a b s t r a c t background: parkinson's disease is a common neurologic ailment that causes tremor and bradykinesia. the prevalence of parkinson's disease is estimated to be 1–2 in 1000, affecting about 1% of the population over the age of 60 years. the objective of this study was to find the frequency of non-motor symptoms in patients with parkinson’s disease (pd) and its association with various factors. methodology: a cross-sectional study was carried out in rehman medical institute, peshawar for 1 year from 1st oct 201930th sep 2020. a total of 68 patients with idiopathic parkinson’s disease (pd) were included by consecutive nonprobability sampling. non-motor symptoms (nms) were evaluated and noted in a predesigned proforma. data was entered and analyzed by spss 21. results: the age of the participants was 62.10±10.01 years. 58.82%(n=40) were males, 47.05%(n=32) belonged to urban residence. mean duration of illness was 4.52±3.82 years. nms were found in 100% (n=68) patients. among nms, sleep disturbance was the most common symptom found in 77.9% (n=53) followed by constipation that was present in 75% (n=51) of patients. among associated factors with nms, hallucinations were significantly associated with advanced age (p = 0.004). orthostatic hypotension was associated with longer duration of disease (p = 0.03). depression was significantly associated with other comorbid states. conclusion: non-motor symptoms were seen in all the patients presenting to neurology opd of rehman medical institute. the most common nms was sleep disturbance followed by constipation and depression. hallucinations were observed significantly more in elderly patients. key words: depression, orthostatic hypotension, parkinson disease authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: wajeeha qayyum email: drwajeeha13@yahoo.com article info: received: february 18, 2021 accepted: december 23, 2021 cite this article. qayyum w, khan s, iqbal ms, khan mf, yousafzai za, jan f. non-motor symptoms and their associated factors in parkinson’s disease. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n parkinson’s disease (pd) is a progressive neurodegenerative disorder characterized by the presence of a resting tremor, rigidity, bradykinesia and postural instability1. the prevalence and incidence for pd varies according to different studies and regions, but reported prevalence is 1 – 2 per 1000, affecting nearly 1% of all the population aged above 60 years.2 the overall incidence of pd in men o r i g i n a l a r t i c l e j islamabad med dental coll 2021 221 and women aged 40 years and above was found to be 61.21/100,000 and 37.55/100,000 respectively.3 the overall prevalence of pd in khyber pakhtunkhwa, pakistan was estimated to be 1.7/100.4 although parkinson’s disease is recognized as a motor disorder, over the past two decades, the nonmotor symptoms associated with parkinson’s disease have been given extensive consideration as they are usually under treated and overlooked. nonmotor symptoms (nms) are known to affect the quality of life of parkinson’s disease patients significantly.5,6 some of the most frequent and wellstudied non motor symptoms associated with parkinson’s disease include disturbances of the autonomic nervous system (ans) including orthostatic hypotension, decreased gastrointestinal motility, urinary urgency, hesitancy, nocturia and neuropsychiatric symptoms like depression, impaired cognition, and rem rapid eye movement sleep behavior disorders.7 a case series by gulunay et al, concluded that 100% of the patients had non-motor symptoms with fatigue (58%) and anxiety (56%) being the commonest symptoms.8 another study revealed that each of the subjects had almost 13 different non motor symptoms related to pd, with autonomic disturbances like nocturia, urgency and constipation being present in 60 to 77% of the subjects, followed by dementia in 58% of the subjects.9 a study from islamabad, pakistan determining the frequency of non motor symptoms in parkinson’s disease patients found out that urinary urgency and dizziness were the most common nms of parkinson's disease.10 another study from lahore revealed that 56% patients of parkinson’s disease had constipation and 49% had nocturia.11 pd is a disabling disease and nms may worsen the course of disease. non-motor symptoms greatly impair the functional status of patients, their timely identification and management cannot be underestimated. treatment of pd patients is mostly focused on their motor symptoms hence nms remains unaddressed. the purpose of our study is to emphasize the importance of elaborating history regarding nms hence treating this aspect also to bring improvement in patient’s quality of life. our study will identify, the magnitude of non-motor symptoms in pd and the factors associated with its high incidence. m e t h o d o l o g y : it was a cross-sectional study carried out over a period of one year from 1st oct 201930th sep 2020. ethical approval was obtained from research ethics committee, rehman medical institute. all patients of idiopathic parkinson’s disease (pd) presenting to opd were included. patients were diagnosed according to the united kingdom parkinson’s disease society brain bank (uk pds brain bank diagnostic criteria). sample size was calculated by taking the prevalence of nonmotor symptoms in pd as 50%. with confidence interval and absolute precision of 10% each, sample size was 68. patients were recruited by consecutive nonprobability sampling techniques. written informed consent was taken from the participants. a detailed history regarding nms was taken and entered in a predesigned proforma by neurologist. the following symptoms were assessed: neuropsychiatric symptoms (depression, anxiety, hallucinations, cognitive impairment, dementia), autonomic dysfunction symptoms (constipation, urinary symptoms (incontinence, retention, nocturia), perspiration, orthostatic hypotension), sleep disturbance, hyposmia, fatigue and pain. different tools were used to evaluate the symptoms. depression and anxiety were evaluated on the basis of patients health questionnaire (phq) and hamilton anxiety rating scale (ham-a) respectively.12,13 memory and concentration were evaluated using the montreal cognitive assessment (moca). gastrointestinal, urinary symptoms and perspiration were evaluated using the scopa-aut questionnaire.13 j islamabad med dental coll 2021 222 orthostatic hypotension was evaluated by the scopa-aut and assessed by taking blood pressure in lying and then in a standing position (a cutoff of > 10 mmhg in systolic blood pressure was considered as indicating orthostatic hypotension).14 sleep disturbance was evaluated by the pittsburgh sleep quality index (psqi).15 the fatigue was assessed using the parkinson’s fatigue scale, and pain was evaluated by the douleur neuropathique-4 (dn4) questionnaire.15 argentina hyposmia rating scale (ahrs) was used to assess hyposmia. data was entered and analyzed by spss 21 software. quantitative variables were expressed as mean ± sd and qualitative variables were expressed in frequency and percentages. frequency of nms was noted in pd. statistical significance in association of nms with gender, age and duration of illness was noted by chi square and t test and p value <0.05 was taken as significant. r e s u l t s mean age of the participants was 62.10±10.01 years. 58.82%(n=40) were males and 47.05%(n=32) belonged to urban residence. mean duration of illness was 4.52±3.82 years. 94.1%(n=64) were taking treatment for pd for their motor symptoms while rest were not on any treatment. 67.64%(n=46) had co morbidities; hypertension being most common 35.29%(n=24) followed by ischemic heart disease 22.05% (n=15) and diabetes mellitus 10.29% (n=7). nms were found in 100% (n=68) patients. among nms, sleep disturbance was the most common symptom found in 77.9% (n=53) followed by constipation that was present in 75%(n=51) of patients. table 1 represents the frequency of different nms. table 1: frequency of non-motor symptoms in parkinson’s disease. nms % (n=68) autonomic dysfunction urinary symptoms 47(32) gastrointestinal symptoms 75(51) orthostatic hypotension 40(27) thermo regulatory dysfunction 29(20) sleep disturbance 78(53) neuropsychiatric dysfunction cognitive impairment 32(22) depression 70(48) anxiety 28(19) hallucination 22(15) dementia 29(20) misc hyposmia 22(15) pain 37(25) fatigue 57(39) to find out the association of nms with age, we stratified the age into 3 groups. among associated factors with nms, hallucinations were significantly associated with advanced age (p = 0.004). duration of illness was also divided into less than 5years, 6-10years and above 10years. orthostatic hypotension was associated with longer duration of disease i.e., >10 years (p = 0.03). depression was significantly associated with other comorbid states. table 2 elaborates the association of each nms with age groups, duration of illness. table 3 describes the relation of nms with gender and comorbidities. j islamabad med dental coll 2021 223 table 2: association of each nms with age groups and duration of illness. nms age duration of illness ≤50 %(n) n=10 51-60 %(n) n=21 >60 %(n) n=37 p value <5 n(%) 6-10 n(%) >10 n(%) p value autonomic dysfunction urinary symptoms 40(4) 60(12) 46(17) 0.58 41(19) 67(10) 43(3) 0.4 gastrointestinal symptoms 70(7) 65(13) 81(30) 0.98 78(36) 80(12) 43(3) 0.47 orthostatic hypotension 50(5) 40(8) 35(13) 0.82 17(8) 67(10) 71(5) 0.03 thermo regulatory dysfunction 50(5) 40(8) 19(7) 0.18 22(10) 47(7) 43(3) 0.29 sleep disturbance 0(0) 15(3) 5(2) 0.33 80(37) 67(10) 100(7) 0.36 neuropsychiatric dysfunction cognitive impairment 0(0) 15(3) 32(12) 0.21 37(17) 33(5) 0(0) 0.33 depression 70(7) 80(16) 81(30) 0.67 74(34) 67(10) 43(3) 0.60 anxiety 20(2) 25(5) 40(15) 0.42 17(8) 20(3) 43(3) 0.55 hallucination 20(2) 65(13) 86(32) 0.004 22(10) 33(5) 0(0) 0.41 dementia 20(2) 25(5) 35(13) 0.58 33(15) 33(5) 0(0) 0.38 misc hyposmia 0(0) 25(5) 27(10) 0.35 17(8) 13(2) 28(2) 0.64 pain 20(2) 50(10) 35(13) 0.38 37(17) 33(5) 43(2) 0.84 fatigue 40(4) 25(5) 27(10) 0.93 52(24) 67(10) 71(5) 0.55 table 3: association of nms with gender and comorbidities. nms gender comorbidities male (n=40) females (n=28) p value yes(n=46) no(n=22) p value autonomic dysfunction urinary symptoms 46(18) 50(14) 0.79 52(24) 36(8) 0.42 gastrointestinal symptoms 79(32) 69(19) 0.45 80(37) 59(13) 0.17 orthostatic hypotension 37(15) 44(12) 0.69 37(17) 45(10) 0.58 thermo regulatory dysfunction 21(8) 44(12) 0.12 30(14) 32(7) 0.94 sleep disturbance 71(28) 94(26) 0.07 85(39) 68(15) 0.23 neuropsychiatric dysfunction cognitive impairment 33(13) 25(7) 0.58 30(14) 36(8) 0.57 depression 71(28) 69(19) 0.88 80(37) 45(10) 0.02 anxiety 29(12) 25(7) 0.77 30(14) 23(5) 0.66 hallucination 25(10) 19(5) 0.64 26(12) 14(3) 0.45 dementia 33(13) 25(7) 0.57 22(10) 45(10) 0.12 misc hyposmia 21(8) 25(7) 0.75 30(14) 9(2) 0.12 pain 29(12) 50(14) 0.18 43(20) 23(5) 0.19 fatigue 50(20) 69(19) 0.24 52(24) 68(15) 0.29 j islamabad med dental coll 2021 224 d i s c u s s i o n the mean age of our population was 62.10±10.01 years. the age range between 55 -65 years has been described in multiple studies conducted on parkinson’s disease.11,13-18 it is in accordance with disease natural history that, it affects elderly. male gender slightly predominated in our study making 58.8% of study population. the finding is similar to the study conducted by shalash et al, which has described 59.8 % males in their study on nms in pd.19 other studies described equal number of males and females in their studies.4,16,17 it stands true for pd as it affects males more than females. mean duration of disease was 4.52±3.82 years in our study. different research work on nms in pd has described variable duration of disease i.e 2.7 ± 2.08 years, 7 ± 6 years and 5.3± 4.1 years (17-19). the wide range of disease duration at presentation can be due to the unpredictable and slow coarse of disease, difference in availability of health facilities and population’s behavior towards seeking medical attention. nms are common in pd, ranging from 14% to 80%.19,20 it can occur at any stage of disease, may aggravate as the disease progresses and may present before onset of motor symptoms.19-21 all our patients (100%) had at least one nms. two other studies in literature also described 100% prevalence of nms in pd.18,19 the reason for the high frequency of nms in our population can be multifactorial. it can be related to progressive disease, late presentation and can be due to racial or ethnic difference which needs further clarification. on further description of nms, we found that sleep disturbance followed by constipation and depression was found as common nms. sleep and mood disorders were found in 88.3% and 80.6% of the patients studied by berganzo k et al. 22 regarding nms, the most common were urinary dysfunctions (82.6%), sleep (80.6%), and gastrointestinal (80%) disorders in a study carried out in morocco.18 a study conducted in pakistan from islamabad region described urinary symptoms as the most frequent nms followed by constipation. this study recorded significant number of patients suffering from neuropsychiatric symptoms.9 osama et al, in tanta university hospital, while studying 41 patients of pd observed that gastrointestinal symptoms especially constipation, depressive symptoms, and sleep disturbance were common in newly diagnosed pd.20 a study by mukhtar et al, stated constipation in 54% patients, nocturia in 50% and dementia in 48% of patients with pd. depression, pain and paresthesia were more common in female gender.11 the variation in different studies may be attributed to multiple tools used in studies, social and cultural factors or under reporting of symptoms by patients. we didn’t find association of any nms with gender. however, depression was significantly more in patients having other comorbidities whereas orthostatic hypotension was related to advanced disease. hallucinations were observed significantly in elderly. these relationships have not been described earlier in literature. it is one of the few studies published from pakistan throwing light on nms in pd. however, we have tried to cover almost all important nms in it and described their association with age, gender, comorbidities and disease duration. moreover, we didn’t rely on simple questionnaire filled by patients, rather we tried to evaluate every nms by wellestablished tool. there are some limitations to the study. it is single centered study, we kept absolute precision 10% and ci 90% in order to get less sample size because as the disease is rare, limited number of patients were expected in a single institution; studies in multiple centers can be carried out with optimal precision and ci to elaborate the findings. we didn’t describe the disease stage neither we elaborated nms according to it. j islamabad med dental coll 2021 225 c o n c l u s i o n nms were seen in all the patients presenting to neurology opd in our study. the most common nms was sleep disturbance followed by constipation and depression. orthostatic hypotension was associated with longer disease duration while depression was associated with comorbid states. hallucinations were observed significantly more in elderly patients. r e f e r e n c e s 1. hayes mt. parkinson’s disease and parkinsonism. am j med 2019;132(7):802–7. doi: 10.1016/j.amjmed.2019.03.001 2. tysnes ob, storstein a. epidemiology of parkinson’s disease. j neural transm.2017;124(8):901–5. doi:10.1007/s00702-017-1686-y 3. hirsch l, jette n, frolkis a, steeves t, pringsheim t. the incidence of parkinson’s disease: a systematic review and meta-analysis. neuroepidemiology. 2016;46(4):292-300. doi:10.1159/000445751 4. khan s, nabi g, naeem m, ali l, silburn pa, mellick gd. a door-to-door survey to estimate the prevalence of parkinsonism in pakistan. neuropsych dis treat. 2016;12:1499–506. doi: 10.2147/ndt.s86329 5. garcia-ruiz pj, chaudhuri kr, martinez-martin p. non-motor symptoms of parkinson’s disease a review from the past. j neurol sci. 2014;338(1–2):30– 3. doi:10.1016/j.jns.2014.01.002 6. raeder v, boura i, leta v, jenner p, reichmann h, et al. rotigotine transdermal patch for motor and nonmotor parkinson’s disease: a review of 12 years’ clinical experience. cns drugs.2021;35(2):215– 31. doi:10.1007/s40263-020-00788-4 7. chen h, zhao ej, zhang w, lu y, liu r, huang x, et al. meta-analyses on prevalence of selected parkinson’s nonmotor symptoms before and after diagnosis. transl neurodegener. 2015;4(1):4–11. doi:10.1186/2047-9158-4-1 8. gulunay a, cakmakli gy, yon mi, ulusoy ek, karakoc m. frequency of non-motor symptoms and their impact on the quality of life in patients with parkinson’s disease: a prospective descriptive case series. psychogeriatrics. 2020;20(2):206–11. doi:10.1111/psyg.12489 9. tanveer k, attique i, sadiq w, ahmad a. non-motor symptoms in patients with parkinson’s disease: a cross-sectional survey. cureus.2018;10(10):e3412. doi: 10.7759/cureus.3412 10. saad s, nomani az, badshah m, afzal a. frequency of non-motor symptoms in parkinson disease: experience from pakistan. pjns.2017; 12(1):8-15. 11. mukhtar s, imran r, zaheer m, tariq h. frequency of non-motor symptoms in parkinson’s disease presenting to tertiary care centre in pakistan: an observational, cross-sectional study. bmj open 2018;8(5). doi:10.1136/bmjopen-2017-019172 12. molebatsi k, motlhatlhedi k, wambua gn. the validity and reliability of the patient health questionnaire-9 for screening depression in primary health care patients in botswana. bmc psychiatry.2020; 20(1): 1-0. doi:10.1186/s12888020-02719-5 13. bostantjopoulou s, katsarou z, danglis i, karakasis h, milioni d, falup-pecurariu c. self-reported autonomic symptoms in parkinson's disease: properties of the scopa-aut scale. hippokratia.2016; 20(2):115-120. pmid: 28416907 14. centi j, freeman r, gibbons ch, neargarder s, canova ao, cronin-golomb a. effects of orthostatic hypotension on cognition in parkinson disease. neurology 2017 ;88(1):17–24. doi:10.1212/wnl.0000000000003452 15. mollayeva t, thurairajah p, burton k, mollayeva s, shapiro cm, colantonio a. the pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: a systematic review and meta-analysis. sleep med rev.2016;25:52–73. doi:10.1016/j.smrv.2015.01.009 16. gupta s, shukla s. non-motor symptoms in parkinson's disease: opening new avenues in treatment. crbs. 2021;2:100049. doi:10.1016/j.crbeha.2021.100049 17. simuni t, caspell-garcia c, coffey cs, weintraub d, mollenhauer b, lasch s, et al. baseline prevalence and longitudinal evolution of non-motor symptoms in early parkinson's disease: the ppmi cohort. j neurol neurosurg psychiatry. 2018;89(1):78-88. doi:10.1136/jnnp-2017-316213 18. tibar h, el bayad k, bouhouche a, ait ben haddou eh, benomar a, yahyaoui m, et al. non-motor symptoms of parkinson’s disease and their impact on quality of life in a cohort of moroccan patients. front neurol. 2018; 9:170. doi:10.3389/fneur.2018.00170 19. shalash as, hamid e, elrassas hh, bedair as, abushouk ai, khamis m, et al. non-motor symptoms as predictors of quality of life in egyptian patients with parkinson’s disease: a cross-sectional study using a culturally adapted 39-item parkinson’s disease questionnaire. front neurol 2018; 9:357. doi:10.3389/fneur.2018.00357 j islamabad med dental coll 2021 226 20. ragab oa, elheneedy ya, bahnasy ws. non-motor symptoms in newly diagnosed parkinson’s disease patients. egypt j neurol psychiatry neurosurg. 2019 ; 55:24. doi:10.1186/s41983-019-0070-2 21. liepelt-scarfone i, pilotto a, muller k. autonomic dysfunction in subjects at high risk for parkinson's disease. j neurol. 2015; 262: 2643–2652. doi:10.1007/s00415-015-7888-z 22. berganzo k, tijero b, gonzález-eizaguirre a, somme j, lezcano e, gabilondo i, et al. motor and non-motor symptoms of parkinson's disease and their impact on quality of life and on different clinical subgroups. neurologia. 2016;31(9): 585-59. doi:10.1016/j.nrleng.2014.10.016 disease severity the impact of disease severity and treatment in patients of psoriasis on quality of life palvisha qadri 1 , saadia tabassum 2 , umm-e-aiman chhipa 3 1senior registrar, dermatology, altibri medical college and hospital, karachi. 2assistant professor, director residency program, agha khan hospital karachi. 3masters candidate, biostatistics and epidemiology, community health sciences, agha khan university, karachi. introduction psoriasis is a spectrum of chronic debilitating inflammatory dermatoses which is multi factorial in etiology and complex in pathogenesis. it can occur at any age but most commonly present before 35 years of age. 1 it is a cause of significant health burden in asia especially china due to its large population size. 2 psoriasis affects many parts of the skin including scalp, nail, mucosal surfaces and joints. it can be seen in many clinical types, namely chronic plaque psoriasis, guttate psoriasis, pustular psoriasis, nail psoriasis, scalp psoriasis, inverse psoriasis and psoriatic arthritis. treatment options available for different types of psoriasis fall into two main categories that are topical and systemic agents. phototherapy is yet another treatment modality that is best suited for patients with moderate psoriasis and with contraindications to systemic agents. biologicals have taken over the lead during the last few years for their targeted action and long-term effects. 3 combination therapy (topical + systemic) is shown to be more efficacious and associated with significant improvement of qol as compared to topical therapy alone. 4 evidence based literature suggests that steroids, vitamin d analogues and tazarotene either alone or in combination are the cornerstone treatment for mild psoriasis. 5 generally, moderate to severe disease warrants the commencement of systemic agents for disease control. methotrexate (mtx), cyclosporin a, and retinoids are traditional systemic treatment options for psoriasis. among these agents, methotrexate is the most commonly prescribed medicine and is used with great success for patients having moderate to severe disease.6 biological agents are a preferred treatment option worldwide when treating moderate to severe disease, refractory disease, and skin disease associated with significant joint involvement. in biologics, tumor necrosis factor alpha and interleukin (il) inhibitors are the most widely used agents. ustekinumab (il 12-23 inhibitor) causes significant improvement in dlqi scores and other parameters of physical functioning specially in patients with coexisting psoriatic arthritis. 7 besides the aforementioned therapies, secukinumab (il 17 inhibitior) is a newer biological agent and is considered better in terms of improvement of qol, alleviation of symptoms and sustained clearance of the lesions at week 52. 8 although the impairment of qol related to psoriasis has been vastly studied in the available literature, treatment modalities for this disease with respect to their impact on qol have not been taken into consideration. therefore, the current study aims to evaluate effects of the disease severity along with available treatment options on health-related life quality. it will be helpful in limiting the use of certain drugs having major adverse effects on qol. additionally, compliance and adherence of patients to the treatment will be maximized. methodology this cross-sectional study was conducted in the department of dermatology, aga khan hospital, karachi. a total of 93 patients attending opd from november 2018 to april 2019 were enrolled. the sample size was calculated by using the efficacy of treatment on psoriasis as 41%, 9 95% confidence interval, and 10% error of estimation. participants were recruited through a consecutive sampling strategy. inclusion criteria comprised of all cases of psoriasis aged 18–70 years, on treatment for at least 3 months, and patients willing to take part in the study. patients with suspicious diagnoses and not receiving any treatment were excluded. the approval from the ethical review committee of the hospital was obtained (erc number: 5442-med-erc-18). written and informed consent was taken from the willing study participants. quality of life and disease severity were assessed through dlqi scoring system and pasi respectively. treatment modalities categorized into past and current treatments were evaluated by filling out a brief questionnaire. data confidentiality was maintained throughout the study and patient identification was not disclosed. statistical package for social science spss (release 20.0, standard version, copyright © spss; 1989-02) was used for data analyses.  descriptive statistics were presented as frequency and percentages for qualitative variables i.e., gender, pasi scores, treatment modalities and type of psoriasis. chi-square test was used to find out the association between categorical variables. the analysis using multinomial logistic regression was carried out by taking dermatology life quality index (dlqi) to be mild (0-5), moderate (6-10) and severe (>10) as the outcome variable. stratification with respect to previous treatment, current treatment modalities, disease severity and psoriasis type was done to observe effect of these modifiers on the outcome. p-value of ≤0.05 was considered as significant statistically. results the overall mean age of patients was 39 + (sd) years. there were 44 (47.3%) male and 49 (52.7%) female patients. treatment modalities were categorized into past and current treatments. furthermore, current treatments were divided into topical, topical and systemic combined and others (phototherapy and biologics). the majority of patients reported the use of topical treatment in the past as well as the current treatment modality (53% and 60% respectively). most common type of psoriasis was chronic plaque psoriasis 68 (73%). the frequency of mild and severe disease was equal . these findings are depicted in table 1. table i: descriptive analysis showing frequency of variables (n=93) variable no of patients (percentage) gender   male 44 (47.3) female 49 (52.7) previous treatment   both topical and systemic 40 (43.0) topical 49 (52.7) others 2 (2.2) systemic 1 (1.1) none 1 (1.1) current treatment   both topical and systemic 23 (24.7) topical 56 (60.2) others 14 (15.1) psoriasis types   palmoplantar keratoderma 15 (16.1) chronic plaque psoriasis 68 (73.1) erythroderma psoriasis 2 (2.2) pustular psoriasis 2 (2.2) guttate psoriasis 2 (2.2) chronic plaque psoriatic+ arthritis 2 (2.2) scalp psoriasis 2 (2.2) pasi severity   mild 38 (41) moderate 17 (18) severe 38(41) in our study, 39 (41.9%) cases were mildly compromised with qol, 44(47.3%) cases were moderately affected and in 10 (10.8%) cases, qol was severely impaired. the results showed significant association of dlqi scores with current treatment modalities (p=0.003) with maximum deterioration caused by combined topical, systemic and physical modalities while topicals alone were responsible for mild to moderate impairment of qol. statistically significant association was also found between disease severity and impact on qol (p=0.014). however, no positive association was observed with psoriasis type (p=0.32) or previous treatment (p=0.635) respectively. the detailed results of these associations are represented in table 2. table:ii frequency of dlql score severity according to treatment modalities and type of psoriasis (n=93) variable severe  n (%) moderate  n (%) mild  n (%) p value current treatment         topical 2 (20) 24 (54) 30 (76)     0.003* others 6 (60) 5 (11) 3 (7.69) both topical and systemic 2 (20) 15 (34.09) 6 (15.38) previous treatment         both topical and systemic 2 (20) 17 (38.6) 21 (53.8)     0.635 topical 7 (70) 25 (56.8) 17 (43.59) others   2 (4.4) systemic 1 (10) none 1 (2.5) type of psoriasis         palmoplantar keratoderma 8 (17.3) 9 (23)       0.32 chronic plaque psoriasis 8 (80) 29 (63) 28 (80) erythrodermic psoriasis 1 (10) 1 (2.1) pustular psoriasis 2 (4.3) guttate psoriasis 2 (4.3) chronic plaque+psoriatic arthritis 1 (10) 1(2.1) 1 (2.5) scalp psoriasis 1(2.1) 1 (2.5) gender         male 7(15) 17(38) 20 (45)   0.29 female 3 (6) 27 (55) 19 (38) pasi severity         mild 3 (30) 13(30) 22(56) 0.014* moderate 2(20) 24(54) 12(31) severe 5(50) 7(16) 5(13) significance level <0.05, * significant variable. on assessment of dlqi tool, it was found that 35% of subjects denied any symptom including itch, soreness or stinging. although psoriasis was not an obstacle in carrying out leisure activities and sports in majority, however, more than 40% of the patients were embarrassed about their disease, found it difficult to clothe themselves and had problems with their treatment applications and attending work/study (figure 1). discussion psoriasis has substantial and detrimental effects on the quality of life. most important factors are severity, site of involvement, presence of psoriatic arthritis and others resulting in stigmatization, lack of self-esteem, social rejection and absenteeism from work and schools. 10. more than half of respondents in a study from american population reported that psoriasis had a moderate to severe impact on their daily life. 11 the majority of patients in the study were on topical treatment as in our study. the reason for worsening of qol was non adherence to topical treatment which was related to forgetfulness and lack of ease of application. this observation is pertinent as our patients also reported similar reasons. also, around 70% of our patients with severe impairment of life quality had moderate to severe disease. generally,topical medications are indicated for mild disease. with moderate to severe disease, scalp and nails involvement or dlqi ≥10,commencement of systemic therapy is necessary. 12 this is contrary to our findings. of those who were exclusively on topical therapy currently, only 2(4%) were severely affected on their life quality and 30(76%) demonstrated only mild impairment of qol. this observation pinpoints the idea that systemic therapy might be the cause of impaired life quality due to the diverse adverse effects on overall body functions. the financial burden of extensive therapeutic agents also plays a role in altering life quality of patients with psoriasis. cost-conscious patients may alter their medication administration in an attempt to lower the expense either by reducing dosing frequency or stopping treatment altogether. in a recent study, topical treatment combined with systemic non biological agents was more cost effective than that combined with biological agents. 13 this is quite similar to our study as majority of our patients having dlqi≥10 (60%) were on other treatments than topical or conventional systemic combined with topicals. those treatments were phototherapy and biological agents. being a low-income country, our study participants had serious financial constraints in getting optimal treatment for this disease. this observation is also evidenced by an indian study, in which phototherapy led to reduction in severity of disease but failed to improve qol in psoriatic patients. 14 they used narrowband uvb therapy similar to what we have given to our patients, so the results are comparable. biological agents were among the current treatment modality in patients with severe impairment of qol. however, biological agents have been recognized as the preferred therapy in improving qol. 15 this may be grounded in the fact that biological agents are given for a long period and the results are assessed at least at weeks 12 and 24 respectively in order to know their exact efficacy and our patients were still under treatment during the study period. hence, we can say that phototherapy and biological therapy can only provide delayed improvement of severe disease but are unable to upgrade health related life quality rapidly due to delayed onset of action. the current study shows a significant influence of the affected body surface area (bsa) on qol, identified by pasi scores. we observed that the greater the disease severity, the more was the impairment of qol. half of the patients with severely impaired life quality were found to have severe disease (pasi scores >10). similarly, majority of patients having mild impairment of qol had mild disease severity. these results are consistent with those reported by several other authors. 16, 17, 18 this study has significantly elaborated on the quality of life being affected more by systemic treatment modalities than by the disease itself. the limitation was a single center study with relatively small sample size, conducted in an urban setting hence cannot be utilized for generalization of the results to larger populations. treatment of psoriasis must be tailored according to individual patient’s risks and vulnerabilities. optimal therapy can only be achieved by taking the patient perception of illness into account. long-term psychological support is warranted alongside the conventional therapy. conclusion disease severity, complex and multiple treatment modalities impair quality of life significantly in psoriasis patients. references parisi r, iskandar iyk, kontopantelis e, augustin m, griffiths cem, ashcroft dm. national, regional, and worldwide epidemiology of psoriasis: systematic analysis and modelling study. bmj. published online may 28, 2020:m1590. doi:10.1136/bmj.m1590 li j, yu m, wang y, zhang j, ju m, chen k, et al. prevalence of psoriasis and associated risk factors in china: protocol of a nationwide, population based, cross-sectional study. bmj open. 2019;9(7):e027685. doi: 10.1136/bmjopen-2018 027685 rendon a, schäkel k. psoriasis pathogenesis and treatment. international journal of molecular sciences. 2019;20(6):1475. doi:10.3390/ijms20061475 karamata vv, gandhi am, patel pp, sutaria a, desai mk. a study of the use of drugs in patients suffering from psoriasis and their impact on quality of life. indian j pharmacol. 2017;49(1):84-88. doi:10.4103/ijp.ijp_166_16 thappa dm, malathi m. topical therapy of psoriasis: where do we stand? j postgrad med. 2017;63(4):210-212. doi:10.4103/jpgm.jpgm_155_17 fougerousse ac, mery-bossard l, parier  ,taieb c, bertolotti a, maccari f, et al. use of methotrexate in the treatment of moderate to severe plaque psoriasis in france: a practice survey. clin cosmet investig dermatol. 2021;14:389-393. published 2021 apr 23. doi:10.2147/ccid.s311269 rahman p, puig l, gottlieb a, kavanaugh a, mcinnes i, ritchlin c, et al. ustekinumab treatment and improvement of physical function and health related quality of life in patients with psoriatic arthritis. arthritis care & research. 2016;68(12):1812-1822. doi:10.1002/acr.23000 puig l, augustin m, blauvelt a, gottlieb a, vender r, korman n, et al. effect of secukinumab on quality of life and psoriasis-related symptoms: a comparative analysis versus ustekinumab from the clear 52-week study. journal of the american academy of dermatology. 2018;78(4):741-748. doi:10.1016/j.jaad.2017.10.025 moradi t s, taheri a, alinia h, mansoori p, feldman s, sandoval l. emerging treatment options for psoriasis. psoriasis: targets and therapy. published online august 2014:27. doi:10.2147/ptt.s54068 sarkar r, chugh s, bansal s. general measures and quality of life issues in psoriasis. indian dermatol online j. 2016;7(6):481-488. doi:10.4103/2229 5178.193908 feldman sr. disease burden and treatment adherence in psoriasis patients. cutis. 2013;92(5):258-263. gisondi p, del giglio m, girolomoni g. treatment approaches to moderate to severe psoriasis. int j mol sci. 2017;18(11):2427. published 2017 nov 16. doi:10.3390/ijms18112427 azizam na, ismail a, sulong s, nor nm. cost effectiveness analysis of psoriasis treatment modalities in malaysia. international journal of health policy and management. 2019;8(7):394 402. doi:10.15171/ijhpm.2019.17 arora s, kar br. narrow-band uvb phototherapy does not consistently improve quality of life in psoriasis patients: a prospective observational study from eastern india. indian dermatol online j. 2018;9(6):394-404. doi:10.4103/idoj.idoj_63_18 norris d, photiou l, tacey m, dolianitis c, varigos g, foley p, et al. biologics and dermatology life quality index (dlqi) in the australian psoriasis population. journal of dermatological treatment. 2017;28(8):731-736. doi:10.1080/09546634.2017.1329501 geale k, henriksson m, schmitt-egenolf m. how is disease severity associated with quality of life in psoriasis patients? evidence from a longitudinal population-based study in sweden. health and quality of life outcomes. 2017;15(1):151. doi:10.1186/s12955-017-0721-x abrouk m, nakamura m, zhu th, farahnik b, koo j, bhutani t. the impact of pasi 75 and pasi 90 on quality of life in moderate to severe psoriasis patients. journal of dermatological treatment. 2017;28(6):488-491. doi:10.1080/09546634.2016.1278198 nayak pb, girisha bs, noronha tm. correlation between disease severity, family income, and quality of life in psoriasis: a study from south india. indian dermatol online j. 2018;9(3):165-169. doi:10.4103/idoj.idoj_250_17 an official publication of islamabad medical & dental college volume 11 issue 3 editorial address of correspondence palvisha qadri email: drpalvisha@gmail.com cite this article.article. qadri p, tabassum s, chhipa u. the impact of disease severity and treatment modalities of psoriasis on quality of life. j islamabad med dental coll. 2022; 11(3):138-144 j islamabad med dental coll 2021 68 open access comparing the outcomes of thyroid surgical procedures for benign diseases with expertise of the surgeon in a tertiary care hospital in rawalpindi, pakistan nadir mehmood1, liaquat ali bhatti2, m. idrees anwar3, m. aslam chaudhry4, malik irfan ahmed5, maha nadir6, hamza nadir7, mishal fatima7 1associate professor, department of surgery, holy family hospital, rawalpindi, punjab pakistan 2associate professor, department of surgery, sir ganga ram hospital, lahore, punjab pakistan 3professor, department of surgery, holy family hospital, rawalpindi, punjab pakistan 4professor, department of ent, benazir bhutto hospital, rawalpindi, punjab pakistan 5senior registrar, department of surgery, district headquarter hospital, rawalpindi, punjab pakistan 6house officer, department of surgery, rawalpindi medical university, rawalpindi, punjab pakistan 7medical student, rawalpindi medical university, rawalpindi, punjab pakistan a b s t r a c t background: there is a lack of standardized guidelines regarding selection of appropriate thyroid surgery for patients with benign diseases. as a result, an inexperienced surgeon may select a more aggressive surgical option, which may increase the complication rate. the objective of this study was to compare the outcomes of thyroid surgical procedures for benign diseases with the expertise of the surgeon. material and methods: a retrospective cross-sectional study from 1999 to 2018. the study setting is of a public sector tertiary care teaching hospital. patients undergoing thyroid surgery (lobectomy with isthmusectomy, subtotal thyroidectomy (stt), near total thyroidectomy (ntt), or total thyroidectomy (tt)) were included. expertise level 1, 2 and 3 (l1, l2, l3) of the surgeon was based on years of experience or number of thyroid surgeries to their credit. postoperative complications (hypocalcemia, recurrent laryngeal nerve (rln) damage, airway obstruction, hemorrhage and mortality) were measured against type of thyroid surgery and expertise of the surgeon. results: a total of 833 thyroid surgeries were performed on 695 (83.43%) females and 138 (16.57%) males. about 502 (60.26%) stt, 228 (27.37%) tt, 61 (7.32%) ntt, 42 (5.04%) lobectomies with isthmusectomies were performed, with li, 2, and 3 surgeons performing 21.25%, 45.74% and 33% of these procedures, respectively. surgeons with l1, 2 and 3 levels of expertise caused 49.47%, 33.45% and 17.08% of adverse events, respectively. permanent hypocalcemia, rln damage and mortality were significantly more common in surgeries performed by l1 compared with l2 and l3 surgeons (p<.05). transient and permanent hypocalcemia, transient and permanent rln damage and mortality were significantly more common for total thyroidectomy compared to subtotal thyroidectomy (p<.01). conclusions: minimizing the occurrence of complications like permanent hypocalcemia, rln damage and mortality, expertise of the surgeon and anticipated difficulty of the procedure needs to be taken into account while selecting a thyroid procedure. key words: hypocalcemia, postoperative complications, recurrent laryngeal nerve damage, thyroidectomy. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4-7 data analysis; manuscript editing. correspondence: nadir mehmood email: nadirmug@hotmail.com article info: received: march 18, 2021 accepted: june 7, 2021 cite this article. mehmood n, bhatti la, anwar mi, chaudhry ma, ahmed mi, nadir m, fatima m. comparing the outcomes of thyroid surgical procedures for benign diseases with expertise of the surgeon in a public hospital. j islamabad med dental coll. 2021; 10(2): 68-75. doi: 10.35787/jimdc.v10i2.697 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e j islamabad med dental coll 2021 69 i n t r o d u c t i o n thyroid diseases are the one of the most common endocrine disorders throughout the world with varying prevalence rate of thyroid dysfunction.1 thyroidectomy is a commonly performed procedure worldwide for the treatment of benign thyroid diseases2 and has low mortality and morbidity rates.3 it is performed by surgeons from various specialties and with varied experience.4 the outcome and complication rates are largely dependent on surgeon’s skill and experience, the extent of surgery, indication of surgery, the nature of underlying disease and number of thyroid surgeries performed at that particular center as well as by the particular surgeon.5 due to the advancements in surgical techniques, complication rate after thyroidectomy has decreased. in specialized centers, thyroidectomy has a very low complication rate and almost no mortality.6 hypocalcemia of hypoparathyroidism is among the well-recognized complications of thyroid surgery and its incidence in literature varies widely depending on the type of procedure (9% for total thyroidectomy), neck dissection, female gender and malignancy.7 incidence of transient hypocalcemia has ranged from 1% to 68% and that of permanent hypocalcemia from 0% to 13%.8-11 hypocalcemia is a sensitive measure of the quality of thyroid surgery. direct injury, devascularization, or unintentional removal of parathyroid glands can result in hypocalcemia.12 as all the blood supply to the four parathyroid glands comes from inferior thyroid artery, it is logical inference that this procedure would increase postoperative hypocalcemia. recurrent laryngeal nerve (rln) palsy is a wellknown complication of thyroid surgery and its incidence is around 1–2%.13 however, substantial recovery of vocal cord function can occur after thyroidectomy.14 female sex, type of surgical procedure and changes in serum calcium perioperatively may be associated with hypocalcemia development.12 iodine deficient areas have a higher incidence of recurrent goiter which may require re-operation in a distorted anatomy due to fibrosis.15 so, there is an increased relative risk of recurrent laryngeal nerve, parathyroid and vascular injury in such patients.16 postoperative neck hematoma formation may cause life threatening upper airway compromise, wound infection and scarring of the neck. new hemostatic devices have been developed that allow sutureless vessel ligation.17 a study performed to assess the safety of same day discharge of patients undergoing sutureless thyroidectomy using electrothermal bipolar vessel sealing system showed few major complications, reduced operative times and decreased incidence of hypocalcemia associated with this device.18 in the past, total thyroidectomy was usually performed for most thyroid cancers. today, active surveillance or thyroid lobectomy/isthmusectomy can be employed for many patients with low-risk papillary thyroid cancers.19 although total thyroidectomy as primary surgical management for thyroid disease has been in vogue in specialized units with low morbidity and mortality,6,20 there is fear of recurrence in the benign disease with initial conservative surgery (stt, ntt, lobectomy with isthmusectomy). this fear can be allayed by the fact that mean interval to re-operation for benign cases was 17.4 years and re-operative procedures comprised around 10% of thyroid surgery in a center over 20 years.21 hence, re-operative procedures can be safely considered if performed by experienced surgeons. because of widespread ambiguity on this matter and a gap in the literature that reviewed complications in general unspecialized units in j islamabad med dental coll 2021 70 resource starved countries, definitive recommendations are not available. the lack of prospective randomized clinical trials for most management topics in thyroid surgery tends to make management recommendations, which are based on retrospective observations and often incomplete data, subject to selection biases that may be conflicting. thus, the controversy continues as thyroid surgeons/experts review the same body of literature and reach differing conclusions based on their training, clinical perspective, experience, and personal bias. moreover, there was a mismatch between the international and local rates of post-operative complications in patients with benign thyroid disease. this prompted the managers and senior surgeons at our hospital to commence a study that assessed the rate of complication for thyroid surgery. the objective of this study was to compare the outcomes of thyroid surgical procedures for benign diseases with the expertise of the surgeon, and perform a review of national and international literature. m a t e r i a l a n d m e t h o d s this retrospective study spanning a period of 20 years (1999 to 2018) was carried out at benazir bhutto hospital, a public sector tertiary-care teaching hospital affiliated with rawalpindi medical university, rawalpindi, punjab pakistan. approval for the study was obtained from the rawalpindi medical university surgical ethics review board, headed by the dean of general surgery. since this study utilized patient data from hospital and postoperative records, informed consent was not required. the strobe (strengthening the reporting of observational studies in epidemiology) cross sectional reporting guidelines was used while writing this report.22 patient data was retrieved from the records of monthly surgical audits. inclusion criteria comprised of all patients with goiter irrespective of age and sex who underwent any thyroid surgery (lobectomy with isthmusectomy, subtotal thyroidectomy (stt), near total thyroidectomy (ntt), or total thyroidectomy (tt)). patients with malignant goiters, patients whose follow-up record for more than six months was not retrievable postoperatively or those with anesthetic or cardiovascular complications were excluded. patients with history of prior or concomitant parathyroidectomy, known hyperparathyroidism, concomitant central neck lymph node dissection, preoperative hypocalcemia, or a history of previous head and neck related chemotherapy and/or radiotherapy were also excluded from this study. as this was a retrospective study utilizing data from patient notes, no patient was directly involved in this study. patients’ records with detailed history, examination, thyroid function tests (t3, t4 & tsh), radioactive thyroid scan, ultrasound examination and fine needle aspiration cytology (fnac), ct/mri scan were retrieved from the archives. information regarding any preoperative vocal cord abnormality by indirect laryngoscopy was also obtained. the detail of surgical option for each patient was retrieved from the operative notes. all thyroid surgeries were performed using standard surgical techniques.23 surgical procedure carried out were thyroid lobectomy with isthmusectomy, subtotal, near total and total thyroidectomy, as according to empirical conviction of various heads of one surgical unit over 20 years. the level of expertise of the operating surgeon was divided in to three categories on either the number of total thyroid surgeries performed or years of surgical experience in a tertiary care teaching hospital. this data was acquired from their official service records and past five-year departmental records, respectively. level 1 was a surgeon with more than five years of experience or 50 thyroid surgeries to his credit (junior assistant professor or a senior registrar); level j islamabad med dental coll 2021 71 2, a surgeon with ten years of experience and 100 thyroid surgeries (associate or a senior assistant professor), and level 3 a senior surgeon with fifteen plus years of experience and 150 thyroid surgeries (professor or head of the department), respectively. the data for 23 operating surgeons during that period (1999-2018) is shown in table i. all the patient data were collected with a dedicated electronic microsoft office excel database (microsoft corp, redmond, wa, usa). differences between groups were analyzed with the chi-square test. p-value less than .05 was considered significant. table 1: levels of expertise of operating surgeons from 1999 to 2018 years level 1 (n) level 2 (n) level 3 (n) total (n) 1999-2003 sr (1) ap (0) sr (1) ap (2) assoc/ds (1) prof (1) 6 1999-2003 sr (1) ap (0) sr 1 ap (2) assoc/ds (1) prof (1) 6 2004-2010 sr (1) ap (1) sr 1 ap (2) ap/ds (1) prof (1) 7 2011-2018 sr (6) ap (1) sr 0 ap (1) ap (1) assoc (1) 10 total (n) 8 2 2 5 3 3 23 n-number; sr-senior registrar; ap-assistant professor; assoc-associate professor; ds-district surgeon; prof-professor all the patients were observed post operatively for a variable period of time in the ward. the patients were followed in the outpatient at weekly interval for 2 weeks, monthly for 6 months and then yearly or as necessary according to the nature of the disease. medical records were retrieved from the monthly audit data. they were reviewed for variables like age, sex, preoperative diagnosis, extent of surgery, postoperative calcium levels, transient and permanent hypocalcemia, hoarseness, reason and need for tracheostomy, hemorrhage/ hematoma, any need to re-explore, wound infection, histopathological records and mortality. the postthyroidectomy hypocalcemia on first, second and fifth postoperative day and at six months following surgery was measured. transient hypocalcemia was defined as serum calcium less than 8.0 mg/dl (2 mmol/l) on at least two consecutive measurements or signs and symptoms of hypocalcemia (perioral numbness, digital paresthesia, or positive chvostek or trousseau’s sign). permanent hypocalcemia was defined as the need for calcium and or vitamin d supplements to maintain normal calcium levels at six months or more after the date of surgery. the statistical analysis was performed using the ibm spss 23 software (statistical software, chicago, il, usa). r e s u l t s over a period of twenty years (199-2013), 833 thyroid patients were operated upon, of which 695 (83.43%) were females and 138 (16.57%) were males. the female-to-male ratio (f:m) was 5.04:1. the female-to-male patient distribution of surgical workload in opd (43.3% vs 56.7%), admitted cases (3.8% vs 4.95%) and elective surgical procedures (47.5% vs 52.5%) was almost equal (table ii). on an average, annually 41.65 thyroid procedures were performed, with a f:m of 5:1. about 90.5% of the females and 82.6% of males were euthyroid, while 87.6% females had multinodular goiter compared to 83.3% males (table iii). stt (n=502; 60.26%) were the most frequent thyroid surgeries performed, followed by tt (n=228; 27.37%), ntt (n=61; 7.32%) and lobectomy with isthmusectomy (n=42; 5.04%) with complications reported in 281 (33.73%) cases (table iv). j islamabad med dental coll 2021 72 table ii: frequency distribution of total opd and admitted patients, elective procedures and thyroid surgeries in both male and female patients included in this retrospective study years total opd patients (n) total admissions (n) elective procedures (n) thyroid surgeries (n) f m total f m total f m total f m total 20 years 114687 (43.3%) 150057 (56.7%) 264744 10129 (43.6%) 13095 (56.4%) 23224 8014 (47.67%) 8851 (52.4%) 16865 695 (83.4%) 138 (16.5%) 833 annual ave 5734.35 7502.85 13237.2 506.45 654.75 1161.2 400.7 442.6 843.3 34.8 6.9 41.7 opd-outpatient department; f-female; m-male; ave-average; %-percentage mng-multinodular goiter li, 2, and 3 surgeons performed 21.25%, 45.74% and 33% of thyroid surgeries, respectively (table iv & v). regarding complications occurring in thyroid procedures, l1 surgeons were responsible for 49.47% of adverse events, l2 for 33.45% and l3 for 17.08%, respectively (table v). complications like permanent hypocalcemia, recurrent laryngeal nerve damage and mortality were significantly more common in surgeries performed by l1 surgeons as compared to surgeons with l2 and l3 level of expertise (p<.05) (table v). transient and permanent hypocalcemia, transient and permanent rln damage and mortality were significantly more common for total thyroidectomy compared to subtotal thyroidectomy (p<.01). the complication rate of total thyroidectomy for permanent hypocalcemia, permanent rln paralysis and mortality was 7.9%, 6.1% and 7.9% respectively for all levels of expertise (table v). the definitive complication rate (combined rates for permanent hypocalcemia, permanent rln paralysis and mortality) was 36.36% for l1, 14.7% for l2 and 7.3% for l3, respectively (table v). table iv: distribution of type of thyroid surgeries, complications and level of surgical expertise in the study population type of surgery (n=833) complications n (%) level of expertise n (%) l1 l2 l3 stt (n 502) 54 (10.76) 270 (53.78) 178 (35.46) lobectomy (n=42) 92 (18.33) 12 (28.57) 20 (47.6) 10 (23.8) ntt (n=61) 13 (30.95) 12 (19.7) 30 (49.2) 19 (31.2) tt (n=228) 29 (47.5) 99 (43) 61 (28) 68 (29.8) total 147 (64.4) 177 381 275 stt-sub-total thyroidectomy; ntt-near-total thyroidectomy; tt-total thyroidectomy table iii: gender wise distribution of clinical presentation of patients with thyroid lesions clinical presentation male n (%) female n (%) euthyroid 114 (82.6) 629 (90.5) hyperthyroid 19 (13.8) 43 (6.2) hypothyroid 5 (3.6) 23 (3.3) mng 115 (83.3) 609 (87.6) solitary nodule 14 (10.1) 49 (7) diffuse 9 (6.5) 37 (5.3) total 138 695 j islamabad med dental coll 2021 73 tttotal thyroidectomies; rln-recurrent laryngeal nerve d i s c u s s i o n the results of our study suggest that rates of complication are significantly higher for total thyroidectomies performed for any benign condition and also for surgeons with lower level of expertise. literature suggests that it is possible to achieve a definitive complication rate approaching 0% for total thyroidectomy performed for mng24 whereas definitive complication rate of total thyroidectomy in our study, even for a level 3 surgeon, was around 7%. this can be due to the unspecialized and general training of our surgeons. another study comparing expertise of surgeons with complication rates for thyroidectomies found an overall complication rate of 5.1% for surgeons who had performed more than 100 thyroidectomies (all types) in a 6-year period which was much lower compared to other surgeons with lesser expertise.25 one study concluded that the complication rate after thyroidectomy can be significantly reduced if the procedure is performed by an experienced surgeon.6 our study also shows a significant association between level of expertise and complication rate but the complication rates are higher for all types of thyroidectomies when compared to similar studies performed in specialized units in other parts of the world.24,25 literature review indicates higher complication rates for total thyroidectomy like postoperative hypoparathyroidism (about 6%), recurrent laryngeal nerve paralysis and wound complications (≈ 1%).26,27 complications in total thyroidectomies were also higher in our study as compared to other surgeries but a worrying sign was the presence of higher complication rates for other surgeries as well. lack of experience on behalf of the surgeon performing total thyroidectomy can explain the higher morbidity and increased complication rates, but higher complications in other thyroid surgeries point towards a systemic workload and staff mismatch problem. there was a progressive increase in number of thyroid surgeries over 20 years along with an increase in outpatient workload, admissions and other elective procedures (table ii). in contrast, the number of operating surgeons increased from 6 in 1998-2003 to only 10 in 2011-2018 while the number of level 3 surgeons remained constant (table i). this indicates an exponential increase in workload for the surgeons at all levels. it is, therefore, not table v: comparison between levels of expertise of the surgeon and complications of thyroid surgeries type of surgery levels of expertise complications transient hypocalcemia permanent hypocalcemia transient rln paralysis permanent rln paralysis tracheostomy hemorrhage mortality tt (n=228) l1 (n=99) 13 (13%) 14 (14%) 12 (12%) 10 (10%) 9 (9%) 1 (1%) 12 (12%) l2 (n=61) 17 (28%) 3 (5%) 10 (16%) 3 (5%) 2 (3.2%) 0 3 (5%) l3 (n=68) 11 (16%) 1 (1.47%) 4 (5.8%) 1 (1.47%) 2 (3.2%) 1 (1%) 3 (4.4%) percentage 18 7.9 11.4 6.1 5.7 0.87 7.9 p-value >.05 <.01 >.05 <.05 >.05 >.05 <.05 other surgeries (n=605) l1 (n=78) 13 2 12 1 2 4 3 l2 (n=320) 8 0 8 0 2 4 1 l3 (n=207) 5 0 2 0 0 0 0 percentage 4.3 0.3 3.6 0.1 0.6 1.3 0.6 p-value <.05 <.05 <.05 >.05 >.05 <.05 <.05 j islamabad med dental coll 2021 74 surprising that complications increase when l1 surgeons are obligated to take on operating duties, perhaps, with inadequate experience. another issue is the trend of changing practices with the changing leadership. a new department head, oftentimes, promotes a certain experience-based practice. so, where his/her predecessor was in favor of stt, the new head might promote tt or ntt to prevent recurrence. these changing practices do not take into account the level of expertise of the junior surgeons which leads to more complications. the surgeons either do not select the correct procedure for the patient according to the pathology or their perceived level of expertise is inadequate in avoiding complications. certain strategies can be implemented to minimize these risk factors. preoperatively, a thyroidectomy difficulty scale can be employed28 and a detailed management plan and type of surgery needed to be performed should be selected based on this. it is prudent for a more experienced member of the team to perform the surgery if complications are anticipated and the procedure selected must take into account all the available evidence. in order to achieve this, surgeons should receive appropriate training and follow best practice guidelines. this study included data from over a period of 20 years and thus its findings and interpretations are reflective of the culture of surgical practice in a tertiary care teaching hospital with resource constraints. the surgical procedures performed for a given indication often reflect the surgeon’s or the department head’s convictions based on his/her past experience and are not always completely evidence-based. this is a limitation for many surgical studies that are performed. since, the study is set in a public sector hospital catering to patients from underprivileged backgrounds from far flung areas, follow-up could not be ensured in all cases and the findings in this study may be underreporting the actual occurrence of complications. c o n c l u s i o n our study concluded that to minimize the rate of definitive complications, expertise of the surgeon and anticipated difficulty of the procedure needs to be taken into account. however, these outcomes can only be achieved if the surgeon is well-versed in the anatomy of the gland, is mindful of its pathology, and has received proper training. r e f e r e n c e s 1. maniakas a, davies l, zafereo me. thyroid disease around the world. otolaryngol clin north am. 2018; 51: 631-642. doi: 10.1016/j.otc.2018.01.014. 2. makay ö. less than total thyroidectomy for goiter: when and how? gland surg. 2017; 6(suppl 1): s49s58. doi: 10.21037/gs.2017.10.02. 3. padur aa, kumar n, guru a, badagabettu sn, shanthakumar sr, virupakshamurthy mb, et al. safety and effectiveness of total thyroidectomy and its comparison with subtotal thyroidectomy and other thyroid surgeries: a systematic review. j thyroid res. 2016; 2016: 1-6. doi: 10.1155/2016/7594615. 4. khanzada tw, samad a, memon w, kumar b. post thyroidectomy complications: the hyderabad experience. j ayub med coll. 2010; 22(1): 65-8. pmid: 21409907. 5. meltzer c, hull m, sundang a, adams jl. association between annual surgeon total thyroidectomy volume and transient and permanent complications. jama otolaryngol head neck surg. 2019; 145(9): 830–7. doi: 10.1001/jamaoto.2019.1752. 6. ahmad z, kutaiman a, hassan y, amin p, khan m. complication rates of thyroidectomy by an experienced, high-volume thyroid surgeon in a private hospital in abu dhabi, united arab emirates. hamdan med j. 2018; 11(1): 17-21. doi: 10.7707/hmj.735. 7. baldassarre rl, chang dc, brumund kt, bouvet m. predictors of hypocalcemia after thyroidectomy: results from the nationwide inpatient sample. isrn surg. 2012; 838614. doi: 10.5402/2012/838614. 8. eismontas v, slepavicius a, janusonis v, zeromskas p, beisa v, strupas k, et al. predictors of postoperative hypocalcemia occurring after a total thyroidectomy: j islamabad med dental coll 2021 75 results of prospective multicenter study. bmc surg. 2018; 18(1): 55. doi: 10.1186/s12893-018-0387-2. 9. merchavy s, marom t, forest vi, hier m, mlynarek a, mchugh t, et al. comparison of the incidence of postoperative hypocalcemia following total thyroidectomy vs completion thyroidectomy. otolaryngol head neck surg. 2015; 152(1): 53-6. 10. doi: 10.1177/0194599814556250. 11. edafe o, balasubramanian sp. incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism. gland surg. 2017; 6(suppl 1): s59-s68. doi: 10.21037/gs.2017.09.03. 12. baloch n, taj s, anwer m, naseem m. frequency of hypocalcaemia following total thyroidectomy. pak j med sci. 2019; 35(1): 262-5. doi: 10.12669/pjms.35.1.93. 13. del rio p, rossini m, montana cm, viani l, pedrazzi g, loderer t, et al. postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery. bmc surg. 2019; 18(s1): 25. doi: 10.1186/s12893-019-0483-y. 14. gambardella c, polistena a, sanguinetti a, patrone r, napolitano s, esposito d, et al. unintentional recurrent laryngeal nerve injuries following thyroidectomy: is it the surgeon who pays the bill? int j surg. 2017; 41(1): s55-9. doi: 10.1016/j.ijsu.2017.01.112. 15. pantvaidya g, mishra a, deshmukh a, pai ps, d’cruz a. does the recurrent laryngeal nerve recover function after initial dysfunction in patients undergoing thyroidectomy? rln recovery after thyroidectomy. laryngoscope investig otolaryngol. 2018; 3(3): 249-52. doi: 10.1002/lio2.167. 16. gurleyik e, cetin f, dogan s, yekenkurul e, onsal u, gursoy f, ipor a. displacement of the recurrent laryngeal nerve in patients with recurrent goiter undergoing redo thyroid surgery. j thyroid res. 2018; 4763712. doi: 10.1155/2018/4763712. 17. levin ke, clark ah, duh qy, demeure m, siperstein ae, clark oh. reoperative thyroid surgery. surgery. 1992; 111(6): 604-9. pmid: 1595056. 18. kiriakopoulos a, dimitrios t, dimitrios l. use of a diathermy system in thyroid surgery. arch surg. 2004; 139(9): 997-1000. doi: 10.1001/archsurg.139.9.997. 19. inabnet wb, shifrin a, ahmed l, sinha p. safety of same day discharge in patients undergoing sutureless thyroidectomy: a comparison of local and general anesthesia. thyroid. 2007; 18(1): 57-61. doi: 10.1089/thy.2007.0148. 20. tuttle rm, zhang l, shaha a. a clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management. expert rev endocrinol metab. 2018; 13(2): 77-85. doi: 10.1080/17446651.2018.1449641. 21. hu j, zhao n, kong r, wang d, sun b, wu l. total thyroidectomy as primary surgical management for thyroid disease: surgical therapy experience from 5559 thyroidectomies in a less-developed region. world j surg oncol. 2016; 14(1): 20. doi: 10.1186/s12957-016-0772-1. 22. hardman jc, smith ja, nankivell p, sharma n, watkinson jc. re-operative thyroid surgery: a 20year prospective cohort study at a tertiary referral centre. eur arch otorhinolaryngol. 2015; 272(6): 1503-8. doi: 10.1007/s00405-014-3068-5. 23. von elm e, altman dg, egger m, pocock sj, gøtzsche pc, vandenbroucke jp. strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies. bmj. 2007; 335(7624): 806-8. doi: 10.1136/bmj.39335.541782.ad. 24. farquharson mm, brendan. surgery of the neck. farquharson's textbook of operative general surgery. 10th ed: crc press; 2014. p. 155-78. 25. ciftci f, sakalli e, abdurrahman i. total versus bilateral subtotal thyroidectomy for benign multinodular goiter. int j clin exp med. 2015; 8(3): 4596600. pmid: 26064391. 26. sosa ja, bowman hm, tielsch jm, powe nr, gordon ta, udelsman r. the importance of surgeon experience for clinical and economic outcomes from thyroidectomy. ann surg. 1998; 228(3): 320-30. doi: 10.1097/00000658-199809000-00005. 27. bhattacharyya n, fried mp. assessment of the morbidity and complications of total thyroidectomy. arch otolaryngol head neck surg. 2002; 128(4): 389-92. doi: 10.1001/archotol.128.4.389. 28. alqahtani s m, almussallam b, alatawi a, alsuhaimi na, albalawi a, albalawi ns, et al. postthyroidectomy complications and risk factors in tabuk, saudi arabia: a retrospective cohort study. cureus. 2020; 12(10): e10852. doi:10.7759/cureus.10852. 29. bothra s, sabaretnam m, kannujia a, chand g, agarwal g, mishra sk, et al. patient, thyroid, and surgeon related factors that make thyroidectomy difficult-cohort study. ann med surg. 2020; 49: 14-8. doi: 10.1016/j.amsu.2019.11.010. 56 j i m d c 2 0 1 7 56 address of correspondence: dr.rafiq ahmad email: rafiqahmad2012@gmail.com r e f e r e n c e s 1. suleiman de. pathologist clinician collaboration: a marriage of necessity toward improving the quality of patient care. ann nigerian med. 2015; 9(1):1-3. 2. osega id, afolabi o, onyenekwu cp. the effectiveness of clinical education on the adequate completion of laboratory test request forms at a tertiary hospital. ann med health sci res. 2016; 6(2):90-4. 3. association of clinical pathologists of nepal. right test cycle. j pathol. 2013; 3(2):1. 4. powsner sm, costa j, homer rj. clinicians are from mars and pathologists are from venus: clinical interpretation of pathology reports. arch pathol lab med. 2000; 124:10406. microalbuminuria: a urinary biomarker of diabetic kidney disease rafiq ahmad assistant professor, department of pathology, islamabad medical & dental college islamabad diabetes mellitus is a chronic metabolic disorder characterized by persistent hyperglycemia and disorders of carbohydrate, protein and lipid metabolism.1 it is expected that by the year 2030, about 552 million people globally will be affected from diabetes mellitus.2 if not well controlled, diabetes mellitus leads to both microvascular and macrovascular complications.2 diabetic mellitus is the most common cause of diabetes nephropathy that has a momentous impact on quality of life and survival of the patient.1 it is estimated that about 40 % of type i and type ii diabetes mellitus develop diabetic kidney disease.2 if not timely diagnosed and properly treated, diabetic nephropathy eventually leads to end stage renal disease that requires dialysis or renal transplantation. multiple serum and urinary biomarkers are used to diagnose diabetic nephropathy before it is clinically evident.2 urinary microalbumin has been used as a clinical biomarker of diabetic kidney disease since 1982.4 it is used to screen both type i and type ii diabetes mellitus.5 microalbuminuria results when albumin crosses glomerular filtration barrier due to ultrastructural changes in endothelial glycocalyx.6 microalbuminuria also represents a marker of systemic endothelial dysfunction with increased risk of cardiovascular and cerebral insults in patients with diabetes mellitus.7 in addition to glomerular injury, newer biomarkers of tubular, vascular, inflammation, podocytes and oxidative stress have been verified in some patients that detect diabetic nephropathy much earlier than microalbuminuria.3 usefulness of these biomarkers is still debatable in research due to limited studies performed and requires further validation.3 microalbuminuria even disputed as biomarker of early diabetic nephropathy, is still considered as an important screening test to detect glomerular and tubular injury in diabetic population.3 american diabetes association guidelines recommend initial assessment of urinary albumin excretion in type i diabetes mellitus who have had diabetes for at least five years and in all patients with type ii diabetes mellitus at the time of presentation and during pregnancy.8 all diabetic patients with negative screening test for microalbuminuria should be assessed for kidney functions on annual basis.9 microalbuminuria (although a misnomer term) is detection of small quantity of albumin (and not small-size albumin) in the urine i.e. 30-300 mg/24 hours or 20 to 200 µg/min in the absence of clinical proteinurea as measured by standard analytical methods.7 more appropriate term for microalbuminuria is paucialbuminuria or albumin excretion rate.10 normal urinary albumin excretion is less than 30 mg/24 hours (20ug/min). this small amount is not detectable by 57 j i m d c 2 0 1 7 57 routine dipstick method of urine analysis.11 spot urinary albumin to creatinine ratio is more useful indicator and is comparable to 24 hours urine collections. measurement of albumin to creatinine ratio (acr) eliminates variations in urine flow rate on a spot urine specimen.11 albumin to creatinine ratio of 30 to 300 mg/g of creatinine suggests that albumin excretion is between 30 and 300 mg/24 hours and, therefore, microalbuminuria is present. acr value of >300 mg/g or >300 mg/24 hours are indicative of macroalbuminuria or clinical proteinurea. this classification system requires that at least two of three specimens fall within the microalbuminuric or macroalbuminuric range over a 3 to 6 months period. factors that influence urinary albumin excretion must be taken into consideration. these factors include high grade fever, sever infection exercise within 24 hours, congestive cardiac failure, severe hyperglycemia and high blood pressure.9 it is recommended that urinary protein may first be tested by routine dipstick method on spot urine sample to rule out overt proteinuria. this practice avoids loss of laboratory resources and manages work load. when urinary protein by dipstick is negative, only then spot urine sample should be tested for microalbuminuria or albumin to creatinine ratio. microalbuminuria has a variable progression. it can revert to normal, progress to macroalbuminuria or can remain static. interventions like good glycemic control, use of angiotensin converting enzyme inhibitors and angiotensin ii receptor blockers for control of blood pressure reduce microalbuminuria and prevent further loss of renal functions.3 concomitant analysis of several urinary biomarkers along with microalbuminuria can diagnose early diabetic nephropathy. however, discovery of a new and ideal urinary biomarker that is more sensitive and specific than microalbuminuria is still awaited. early detection of diabetic kidney disease with such newer biomarkers in future will minimize renal complications of diabetes mellitus by appropriate and timely interventions.3 r e f e r e n c e s 1. hafez mh, el-mougy fatma af, makar sh, abd el shaheed s s. detection of an earlier tubulopathy in diabetic nephropathy among children with normoalbuminuria. ijkd. 2015; 9:126-31 2. cohen-bucay a, viswanathan g. urinary markers of glomerular injury in diabetic nephropathy. international journal of nephrology.2012 3. gluhovschi c, gluhovschi g, petrica l, timar r, velciov s , ionita i, kaycsa a, timar b. urinary biomarkers in the assessment of early diabetic nephropathy. journal of diabetes research volume 2016 article id:4626125 4. mogensen ce. microalbuminuria as a predictor of clinical diabetic nephropathy. kidney international. 1987; 31:673— 689 5. lee sy, choi me. urinary biomarkers for early diabetic nephropathy: beyond albuminuria. pediatric nephrology. 2015; 30(7):1063–1075. 6. satchell sc, tooke je. what is the mechanism of microalbuminuria in diabetes: a role for the glomerular endothelium? diabetologia. 2008; 51(5):714–725 published online 2008 mar 18. doi: 10.1007/s00125-0080961-8 7. singh a, satchell sc. microalbuminuria: causes and implications. pediatr nephrol 2011; 26(11):1957. 8. american diabetes association. standards of medical care in diabetes. diabetes care 2007; 30(1):s4-s41 9. bangert sk, marshall wj, leonard w, editors. clinical chemistry. in: disorders of carbohydrate metabolism. 6th ed. philadelphia: elsevier mosby; 2013:205-233 10. sacks db. carbohydrates. in: burtis ca, ashwood er, bruns de, editors. tietz textbook of clinical chemistry. 6th ed. philadelphia: elsevier saunders; 2012:373-401. 11. freeman vs. carbohydrates. in: bishop ml, fody ep, schoeff le, editors. clinical chemistry techniques, principles, correlations. 6th ed. philadelphia: wolters kluwer/lippincott williams & wilkins; 2010: 326–327 https://link.springer.com/journal/467 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2292427/ https://dx.doi.org/10.1007%2fs00125-008-0961-8 https://dx.doi.org/10.1007%2fs00125-008-0961-8 https://www.ncbi.nlm.nih.gov/pubmed/?term=singh%20a%5bauthor%5d&cauthor=true&cauthor_uid=21301888 https://www.ncbi.nlm.nih.gov/pubmed/?term=satchell%20sc%5bauthor%5d&cauthor=true&cauthor_uid=21301888 j islamabad med dental coll 2023 57 open access middle ear embryonal rhabdomyosarcoma in a five years old child a rare case report asma khattak1, nosheen nabi2, summaya sohail chaudry3 1medical officer, department of pathology, pakistan institute of medical sciences, pakistan 2assistant professor, department of pathology, rawal institute of health sciences, islamabad,, pakistan 3assistant professor, department of pathology, rawal institute of medical sciences, pakistan a b s t r a c t abstract: rhabdomyosarcoma is the most common pediatric malignancy with a predilection for head and neck region. embryonal rhabdomyosarcoma is a variant of rhabdomyosarcoma which is extremely rare in middle ear. we present a case of middle year embryonal rhabdomyosarcoma in a five-year-old child who was treated as otitis media on first presentation and later misdiagnosed as a vascular aural polyp on histopathology. correspondence: nosheen nabi email: nosheennabi@yahoo.com article info: received: october 16, 2022 accepted: march 30, 2023 cite this article. khattak a, nabi n, chaudry s s. middle ear embryonal rhabdomyosarcoma in a five years old child a rare case report. j islamabad med dental coll. 2023; 12(1):57-60 funding source: nil conflict of interest: ni doi: https://doi.org/10.35787/jimdc.v12i1.923 i n t r o d u c t i o n rhabdomyosarcoma (rms) is one of the most frequently occurring malignant soft tissue sarcoma which is thought to be originated from mesenchymal stem cells showing striated muscle differentiation. based on morphology, rms is classified into embryonal rms (erms), alveolar rms (arms) and pleomorphic rms, in which arms and erms most commonly occur in children, while pleomorphic rms is mainly found in adults.1 the most commonly affected areas are head and neck, genitourinary tract, retroperitoneum and extremities. in head and neck orbit is involved in about one-third of the cases while ear is a rare site of involvement. the embryonal rms comprises about 60%-70% of rms cases.2 the diagnosis of rms of middle ear is usually delayed because it is usually misdiagnosed because of its rare location and its initial symptoms which resemble otitis media and aural polyp .3 it is thus very important to keep rms in the differentials while dealing with otitis media or aural polyp. c a s e r e p o r t a two years old girl presented in outpatient department with the complain of ear discharge from right ear and was treated as otitis media, she later presented with aural polyp. the biopsy was taken and diagnosis of vascular aural polyp was made on histopathology and she was given treatment for the same. after three years she presented again with a polypoidal growth involving external and middle ear c a s e r e p o r t j islamabad med dental coll 2023 58 (right ear). the biopsy was taken again and sent for histopathology. (figure 1). figure 1: the polypoidal mass projecting from external auditory meatus and involving external ear (right ear). ct scan of brain/temporal region showed a large lobulated 63.7x51.7x58.3mm soft tissue density mass, showing heterogeneous enhancement in right posterior auricular and mastoid region eroding the mastoid air cells, eam and middle ear cavity, petrous temporal and adjacent sphenoid bones. the opinion was right aural rhabdomyosarcoma extending into the right ijv, encasing the right carotid sheath and eroding the temporal bone with intracranial extension (figure 2). figure 2: a. contrast enhanced study showing mass lesion. b. bone window showing changes in bony part of ear. we received two soft tissue fragments in our laboratory, the largest one measured 2x1.5cm, the entire specimen was submitted. microscopic examination showed a tissue lined by stratified squamous epithelium. the underlying tissue was loose and edematous with areas of hyper and hypocellularity. the neoplastic cells were stellate shape and hyperchromatic. marked proliferation of thin-walled medium sized vessels were noted. few atypical mitoses were seen. cambium layer was not identified (figure: 3) figure 3: microscopic features of embryonal rhabdomyosarcoma: a: tumor with stratified squamous epithelial lining b: tumors had areas of hyper and hypocellularity shows stellate shape cells c: hypocellular areas, d: hypercellular areas. immunohistochemical stains were done which showed strong membranous and nuclear positivity for desmin and myogenin respectively, sma, cd 31, cd 34 stain was observed only in the endothelial lining of blood vessels, ck 1/3 was seen only in stratified squamous epithelium, lca was negative (figure 4) a a b c d j islamabad med dental coll 2023 59 a figure 4: strong immune positivity was observed for a. desmin 10x. b. desmin 40x. c. myogenin 10x, myogenin 40x. e and f. sma was seen in vessels only. g. ck 1/3 was positive in stratified squamous epithrlial lining only h. lca was negative a&b. cd 31 is positive in blood vessels only (h&e 10x, 40x) c&d. cd 34 was positive in blood vessel only (h&e 10x, 40x) d i s c u s s i o n rhabdomyosarcoma is an aggressive malignancy and 40 percent cases occur in head and neck region.4 there are three histological types; embryonal, alveolar and pleomorphic, of which embryonal type is most commonly found in head and neck region where its common location is nasopharynx and orbits.5 very few cases arise from middle ear. clinical presentation depends upon the structures involved but they usually present as chronic otitis media or aural polyps and treated as such thus delaying diagnosis and leading to advanced disease at diagnosis, when total resection is nearly impossible in most of the cases.6 it is diagnosed with the help of radiological scans and histopathological examination with immunohistochemical stains. mri usually reveals expansile lytic lesion with low to intermediate signal on t1w and high signal intensity on t2w. histopathological examination shows round blue cell morphology with positive desmin and myogenin stains. the treatment usually is chemoradiotherapy. 7 they have poor prognosis.8 the proximity to the brain and other vital structures makes its poor survival. 9 patients with stage 1 and stage 2 have good prognosis while intracranial invasion (stage 3) is a factor for poor prognosis.10 c o n c l u s i o n a d b a b c d a b c d j islamabad med dental coll 2023 60 rhabdomyosarcoma of the ear is a rare entity but it should be considered in young children with otitis media or aural polyp as early diagnosis is essential for preventing local spread and metastasis and proper treatment. r e f e r e n c e s 1. drabbe c, benson c, younger e, zaidi s, jones rl, judson i, et al. embryonal and alveolar rhabdomyosarcoma in adults: real-life data from a tertiary sarcoma centre. clin oncol. 2020 1;32(1):e27-35. doi: 10.1016/j.clon.2019.07.007. epub 2019 jul 23 2. ragab aa, fakoury mm, kassouma j, moustafa k, al salem fa. botryoid rhabdomyosarcoma in mastoid and middle ear in a 4-year-old boy: a rare case report. hamdan med j. 2018. 1;11(3):130. doi: 10.4103/hmj.hmj_6_18 3. bhandarkar a, menon a, kudva r, pujary k. embryonal rhabdomyosarcoma-a mimicker of squamosal otitis media. iranian j otorhinolaryngol. 2020;32(108):57. doi: 10.22038/ijorl.2019.38807.2280 4. sun x, guo w, shen jk, mankin hj, hornicek fj, duan z. rhabdomyosarcoma: advances in molecular and cellular biology. sarcoma. 2015 ,1;2015. doi: 10.1155/2015/232010. epub 2015 sep 1. 5. attakkil a, thorawade v, jagade m, kar r, rohe d, hanowate r, et al. our experience with embryonal rhabdomyosarcoma presenting as aural polyp. int j otolaryngol and head & neck surgery. 2014 dec 24;4(01):1. doi: 10.4236/ijohns.2015.41001 6. hayes sm, biggs tc, bird jh, hellier wp. rhabdomyosarcoma of the middle ear cavity presenting with horner’s syndrome. anns r coll engl 2019 jan;101(1):e8-10. doi:10.1308/rcsann.2018.0157 7. bhandarkar a, menon a, kudva r, pujary k. embryonal rhabdomyosarcoma-a mimicker of squamosal otitis media. iranian j otorhinolaryngol. 2020;32(108):57-61. 8. vasiwala r, burud i, lum sk, saren rs. embryonal rhabdomyosarcoma of the middle ear presenting with aural polyp and facial nerve palsy. med j malaysia. 2015 oct;70(5):314-5. doi: 10.22038/ijorl.2019.38807.2280 9. menzies-wilson r, wong g, das p. case report: case report: a rare case of middle-ear rhabdomyosarcoma in a 4-year-old boy. f1000research. 2019;8. doi: 10.12688/f1000research.20558.2 10. beghdad m, mkhatri a, berrada o, abada r, mahtar m. embryonal mastoid rhabdomyosarcoma in a three years old child: a case report. int j surg case reports. 2020 jan 1;75:108-11. https:/ doi.org/10.1016/j.ijscr.2020.08.060 https://doi.org/10.22038%2fijorl.2019.38807.2280 https://doi.org/10.1308/rcsann.2018.0157 https://doi.org/10.22038%2fijorl.2019.38807.2280 https://doi.org/10.12688/f1000research.20558.2 https://doi.org/10.1016/j.ijscr.2020.08.060 https://doi.org/10.1016/j.ijscr.2020.08.060 235 j islamabad med dental coll 2022 open access nutritional status of pediatric cancer patients and its association with repeated hospitalizations hijab shaheen1, nuzhat yasmeen2, ruqaya manzoor3, syeda itrat fatima4, sumbal saeed5 1medical officer, pediatric hematology, pims, islamabad, pakistan. 2professor, pediatric hemato – oncology, pims, islamabad, pakistan. 3assistant professor, pediatric oncology, pims, islamabad, pakistan. 4assistant professor, bmt, pims, islamabad, pakistan. 5postgraduate trainee, pediatric oncology, pims, islamabad, pakistan. a b s t r a c t background: malnutrition is known to be a poor prognostic factor affecting the outcome of pediatric cancers. the objective of this study was to assess the pre-existing malnutrition in newly diagnosed pediatric cancer patients presenting at the pediatric oncology department, children hospital, pims and their number of hospital admissions due to causes other than chemotherapy. methodology: data of 44 newly diagnosed children with cancer was analyzed to find out the association of nutritional status according to z-score for weight and height for age, body mass index (bmi) and mid-upper arm circumference (muac) with their number of hospital admissions for 6 months since their date of diagnosis. results: the mean age of the study subjects was 4.25 ± 2.85 years, out of which 33(75%) were males and 11(25%) females. most of the patients were diagnosed with leukemia or lymphoma. nutritional status evaluation of thirty patients who got admitted was mild to moderate wasting in 24(80%) assessed by weight for age, mild to moderate stunting in 21 (70%) according to height for age and mild to severe malnutrition in 10 (33%) based on body mass index and mid upper arm circumference (muac). there was significant association between nutritional status of patients at the time of diagnosis with additional hospitalization with p value less than 0.05 conclusion: malnutrition at the time of diagnosis is significantly associated with an increase in the number of hospital admissions in pediatric cancer patients. key words: hospitalization, malnutrition, oncology, pediatric authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; ,4,5data analysis; manuscript editing. correspondence: hijab shaheen email: drhijabshaheen@gmail.com article info: received: september 7, 2022 accepted: december 20, 2022 cite this article.shaheen h, yasmeen n, manzoor r, fatima s i, saeed s . nutritional status of pediatric cancer patients and its association with repeated hospitalizations.j islamabad med dental coll. 2022;11(4): 235-240. funding source: nil conflict of interest: nil doi: https://doi.org/10.35787/jimdc.v11i4.908 o r i g i n a l a r t i c l e 236 j islamabad med dental coll 2022 i n t r o d u c t i o n malnutrition is a major problem in children with cancer in developing countries and significantly affects their survival.1,2 the cause of malnutrition can be primary or secondary due to malignancy itself or its aggressive multimodal treatment. it has been shown that both the relapse and mortality rates of undernourished children with malignancies are higher than the rest of the population. it is suggested that socioeconomic and nutritional factors should be considered in the prognostic evaluation of children with cancer in developing countries.3 malnutrition causes a decrease in cytokines, complement and immunoglobulin levels that leads to a deficient immune system.4 this makes the child prone to infections, cytopenias and poor response to chemotherapy that initiates the cycle of repeated hospital admissions. nutritional assessment must be a vital component of the history and physical examination of children with cancer. nutritional imbalance in children can be measured using various indicators such as z-score, who recommended growth charts for weight-forage, height-for-age, body mass index, mid-upper arm circumference and skin fold thickness.5,6 poor dietary intake is associated with an increased risk of infections and febrile neutropenia in pediatric cancer patients. therefore, the chances of hospital admissions increase causing more treatment cost, poor quality of life and higher mortality compared to age and sex matched oncological children with good nutritional status.7 m e t h o d o l o g y this prospective observational study was conducted on 44 newly diagnosed cancer patients in pediatric oncology unit, children hospital, pims from april 2021 to march 2022, after approval of institutional ethical review board. inclusion criteria was pediatric patients with newly diagnosed malignancies, however pediatric oncology patients with preexisting illnesses like nephropathy, an inborn error of metabolism, cardiac, neurological or gastrointestinal diseases were excluded from the study. after informed consent from parents/ guardian, the demographic and clinical data was collected on a pre designed proforma. patients were assessed for their nutritional status at the time of diagnosis by bmi, weight-for-age and height-for-age on standard who z-score charts, appropriate for their age and gender. the mid-upper arm circumference was measured by standard muac measuring tape and plotted on the who standard z-score chart. who classification for nutritional assessment according to z-score was used as under;7  well-nourished (z score <-1 to 0)  mildly malnourished (z-score -2 to -1)  moderately malnourished (z-score -3 to -2)  severely malnourished (z-score<-3) the patients were started on chemotherapy protocols according to their oncological diagnoses. all cases were managed indoor or in daycare facilities according to their respective chemotherapy regimens. the patients were hospitalized immediately in case of febrile neutropenia or any other infection like pneumonia, urinary tract infection, meningitis, acute gastroenteritis and managed according to standard treatment guidelines. data was analyzed by spss (version 20). data of categorical variables was presented in frequencies and percentages, and continuous variables in mean ±sd. chi-square test was used to determine association of nutritional status with hospitalization in addition to chemotherapy. r e s u l t s the mean age of study subjects was 4.25 ± 2.85 years, out of which 33(75%) were males and 11(25%) females. most of the patients were diagnosed cases of leukemia or lymphoma. out of 44 patients, 29 (65.9%), had mild to severe wasting, 31 (70.45%) had 237 j islamabad med dental coll 2022 mild to moderate stunting and 11 (25%) had mild to severe malnutrition based on bmi (table 1) table i: diagnosis and nutritional status at time of presentation diagnosis frequency (%) acute b lymphoblastic leukemia (b-all) 23 (52.3) acute t lymphoblastic leukemia (t-all) 6 (13.6) hodgkin’s lymphoma 6 (13.6) wilm’s tumor 6 (13.6) langerhans cell histiocytosis (lch) 2 (4.5) burkitt’s lymphoma 1 (2.3) nutritional status frequency (%) weight for age normal 15 (34.1) mild wasting 19 ((43.2) moderate wasting 8 (18.2) severe wasting 2 (4.5) height for age normal 13 (29.5) mild stunting 19 (43.2) moderate stunting 10 (22.7) severe stunting 2 (4.5) mid upper arm circumference normal 33 (75) mild malnutrition 11 (25) bmi normal 33 (75) mild 8 (18.2) severe 3 (6.52) out of forty-four patients, 30 (68.18%) needed hospitalization in addition to chemotherapy due to pneumonia (25%), uti (13%), meningitis (19%), acute gastroenteritis (25%) and other causes (18%). nutritional status evaluation of thirty patients who got admitted was mild to moderate wasting in 24(80%) assessed by weight for age, mild to moderate stunting in 21 (70%) according to height for age and mild to severe malnutrition in 10 (33%) based on bmi and muac. there was significant association between nutritional status of patients at the time of diagnosis with additional hospitalization at p value less than 0.05 (table 2). table ii: association of nutritional status with hospitalization in addition to chemotherapy nutritional status no. of hospitalization 0 n (%) 1 n (%) 2 n (%) >2 n (%) p-value weight for age normal (15) 9 (60) 6 (40) 0 (0) 0(0) 0.00* mild wasting (19) 5 (26) 9(47) 5(26) 0(0) moderate wasting (8) 0(0) 1(13 ) 4(50) 3 (37) severe wasting (2) 0 (0) 0 (0) 0 (0) 2 (100) height for age normal (13) 8(61) 4(31) 0(0) 1(7) 0.01* mild stunting (19) 6(32) 10(53) 3(15) 0(0) moderate stunting (10) 0(0) 2(20) 5(50) 3(30) severe stunting (2) 0(0) 0(0) 1(50) 1(50) mid upper arm circumference normal (33) 13(39) 14(43) 4(12) 2(6) 0.03 mild malnutrition (11) 1(9) 2(18) 5(45) 3(28) bmi z score normal (33) 13(39) 13(39) 6(19) 1(3) 238 j islamabad med dental coll 2022 mild malnutrition (8) 1(12) 2(25) 3(38) 2(25) 0.05* severe malnutrition (3) 0(0) 1(33) 0(0) 2(66) total 14 16 9 5 duration of admission/ hospitalization (mean ± sd) 8 ±5.4 9±5.1 6±3.9 d i s c u s s i o n pediatric cancer is related to severe morbidity and mortality in children.1 malnutrition has been recognized as a poor prognostic indicator for pediatric oncology patients.1,8 moreover, there is a correlation of poorer survival outcomes and treatment-related toxicity both short and long term for those who are underweight at diagnosis.9,10 according to the 2018 pakistan national nutrition survey (nns), four out of ten children under five years of age are stunted and 17.7% suffer from wasting. nns 2018 shows that almost one in eight adolescent girls is underweight. adolescent boys are more affected with one in five being underweight. the associated factors of child malnutrition in pakistan include poverty, maternal under nutrition, low income, poor health facilities, overcrowded houses, food taboos, lack of education and awareness.11 cancer is a catabolic state and there is a continuous wasting of the body reservoirs. the treatment of cancer whether surgery, chemotherapy or radiotherapy is an important nutritional risk factor.12 the treatment is accompanied with nausea and vomiting, oral mucositis, sepsis, diarrhea, constipation, dyspepsia and cachexia. all these factors play a fundamental role in decreased food intake, nutrient loss, alterations in energy expenditure and weight loss.12a child with malignancy undergoing treatment is therefore predisposed to malnutrition and its consequences. this study shows that the children being treated at our center are 80% wasted and 83% stunted in different categories according to the who z-score. the frequency of admissions in moderately and severely malnourished children was more than the mild group. these children were prone to having febrile neutropenia as a complication of disease and its management. almost 43.2% of the patients admitted were in the induction phase of their chemotherapy. this is due to increase tumor burden initially, high dose of chemotherapeutic drugs, neutropenia, low immunity and thus high infection rate. adequate nourishment is important for maintaining energy levels, muscle mass and a healthy weight during cancer treatment. it then improves treatment tolerance and reduces the risk of chemotherapy side effects. screening of nutritional status should be performed on all pediatric cancer patients before starting their therapy. interventions must be made to identify, improve and prevent further malnutrition in these patients. we at our center thoroughly counsel parents regarding their child’s nutritional needs during the course of treatment. they are given proper neutropenic diet plan, advised hygienic measures and their growth is monitored regularly during the hospital visits. those children with severe malnutrition are fed via nasogastric tube and oral nutritional supplements. parenteral nutrition due to its complications and lack of expertise is not routinely used at our center. nutrition is an essential factor in pediatric oncology that affects the development of the disease, symptoms, response to chemotherapy, cancer recovery and survival.14, 15, 16 therefore, it has a strong impact on the quality of life and prognosis of the disease. poor nutritional status leads to wasting https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/canjclin.53.5.268 https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/canjclin.53.5.268 https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/canjclin.53.5.268 https://www.espen.info/wp/wordpress/wp-content/uploads/2016/11/espen-cancer-guidelines-2016-final-published.pdf https://www.espen.info/wp/wordpress/wp-content/uploads/2016/11/espen-cancer-guidelines-2016-final-published.pdf https://www.espen.info/wp/wordpress/wp-content/uploads/2016/11/espen-cancer-guidelines-2016-final-published.pdf 239 j islamabad med dental coll 2022 of muscle mass, decreased functional capacity, higher incidence of infections, drug toxicity and increased hospitalization, as well as higher mortality.11 this study focuses on the need of early detection and intervention to prevent nutritional deterioration and thus lessen the burden of cancer morbidity and mortality in the pediatric population.17, 18 since it is a single centered study, the results cannot be generalized. c o n c l u s i o n malnutrition is significantly associated with an increase in the number of hospital admissions in newly diagnosed pediatric cancer patients. r e c o m m e n d a t i o n a timely intervention will not only prevent infection rate and hospitalization in pediatric cancer patients but also improve their survival and quality of life. r e f e r e n c e s 1. diakatou v, vassilakou t. nutritional status of pediatric cancer patients at diagnosis and correlations with treatment, clinical outcome and the long-term growth and health of survivors. children (basel) 2020 nov 7; 7(11): 218. doi: 10.3390/children7110218. 2. rogers p.c. importance of nutrition in pediatric oncology. indian j. cancer 2015; 52(2):176. doi: 10.4103/0019-509x.175830 3. gabriela v, jessica b ,silvia r, ana lm, nidia l, et al. nutritional status at diagnosis of cancer in children and adolescents in guatemala and its relationship to socioeconomic disadvantage: a retrospective cohort study. pediatric blood and cancer 2019; 66(6): e27647 doi: 10.1002/pbc.27647. 4. ghafoor t, ahmed s, khalil s, farah t. impact of malnutrition on treatment of outcome of pediatric acute myeloid leukemia. journal of the college of physicians and surgeons pakistan 2020; 30(10):1021-1025. doi:10.29271/jcpsp.2020.10.1021 5. ge ky, chang sy. definition and measurement of child malnutrition. biomed environ sci. 2001 dec; 14(4):283-91. pmid: 11862608. 6. shah p, jhaveri u, idhate tb, dhingra s, arolkar p, arora b. nutritional status at presentation, comparison of assessment tools, and importance of arm anthropometry in children with cancer in india. indian journal of cancer. 2015 apr 1;52(2):210-15. doi: 10.4103/0019-509x.175838 7. triarico s, rinninella e, cintoni m, capozza ma, mastrangelo s, mele mc,et al. impact of malnutrition on survival and infections among pediatric patients with cancer: a retrospective study. eur rev med pharmacol sci. 2019 jan 1;23(3):116575.doi:10.26355/eurrev.201901.17009 8. joton cn , iftekhar a, , razia sultana ch, abdur r, nimmi h, bidhan jc,et al. assessment of nutritional status and hygiene practices of primary school children at rural areas (haor) in sylhet. world journal of nutrition and health. 2019 ;7(1):1-5. doi: 10.12691/jnh-7-1-1 9. rogers, p.c. nutritional status as a prognostic indicator for pediatric malignancies. j. clin. oncol. 2014 may; 32(13), 1293–1294. doi: 10.1200/jco.2014.55.0616. 10. orsolya k, attila c, csongor k. prevalence of undernutrition and effect of body weight loss on survival among pediatric cancer patients in northeastern hungary. int j environ res public health. 2021 feb; 18(4): 1478 doi: 10.3390/ijerph18041478 11. asim m, nawaz y. child malnutrition in pakistan: evidence from literature. children. 2018 may 4;5(5):60. doi: 10.3390/children5050060. 12. henri a, tytti p, riina s, merja m, arja h, riitta n. trends in ageand sex-adjusted body mass index and the prevalence of malnutrition in children with cancer over 42 months after diagnosis: a singlecenter cohort study. eur. j. pediatr 2020 jan;179(1):91-98.doi:10.1007/s00431-019-03482w 13. triarico s, rinninella e, attinà g, romano a, maurizi p, mastrangelo s, et al. nutritional status in the pediatric oncology patients. frontiers in bioscience-elite. 2022 feb 8;14(1):4. doi: 10.31083/j.fbe1401004 14. ravasco p. nutrition in cancer patients. journal of clinical medicine. 2019 aug 14;8(8):1211. doi: 10.3390/jcm8081211 15. si tripodi , elena b , arianna p , valentina c , carlotta b , marica dc, et al. the role of nutrition in children with cancer. tumori. 2022 jun 19; 3008916221084740. doi: 10.1177/03008916221084740 https://onlinelibrary.wiley.com/action/dosearch?contribauthorraw=villanueva%2c+gabriela https://onlinelibrary.wiley.com/action/dosearch?contribauthorraw=blanco%2c+jessica https://onlinelibrary.wiley.com/action/dosearch?contribauthorraw=rivas%2c+silvia https://onlinelibrary.wiley.com/action/dosearch?contribauthorraw=molina%2c+ana+lucia https://onlinelibrary.wiley.com/action/dosearch?contribauthorraw=lopez%2c+nidia http://dx.doi.org/10.29271/jcpsp.2020.10.1021 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7914605/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7914605/ https://doi.org/10.3390%2fijerph18041478 https://doi.org/10.3390%2fchildren5050060 https://doi.org/10.3390%2fjcm8081211 240 j islamabad med dental coll 2022 16. gaynor ep, sullivan pb. nutritional status and nutritional management in children with cancer. archives of disease in childhood. 2015 dec 1;100(12):1169-72.doi: 0.1136/archdischild-2014306941. 17. fabozzi f, trovato cm, diamanti a, mastronuzzi a, zecca m, tripodi si, et al. management of nutritional needs in pediatric oncology: a consensus statement. cancers. 2022 jul 11;14(14):3378. doi: 10.3390/cancers14143378 18. karina v, ronald d, vicente o, elena jl. nutritional status at diagnosis among children with cancer referred to a nutritional service in brazil. hematol transfus cell ther. 2021; 43(4):389–395. doi.org/10.1016/j.htct.2020.04.008 https://doi.org/10.1016/j.htct.2020.04.008 j islamabad med dental coll 2023 23 open access relationship of maxillary sinus and maxillary first molar root using cone beam computed tomography hassam anjum mir1, saima shafiq2, maheen khan3, sumbal mukhtar4, ali asif5, qayyum akhter6 1,4assistant professor, department of prosthodontics, foundation university college of dentistry and hospital, islamabad, pakistan. 2house officer, department of prosthodontics, armed force institute of dentistry, pakistan. 3resident, department of prosthodontics, khyber college of dentistry, pakistan. 5resident, department of prosthodontics, armed force institute of dentistry, pakistan. 6assistant professor, department of prosthodontics, armed force institute of dentistry, pakistan. a b s t r a c t authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3,4critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: hassam anjum mir email: mirusat@gmail.com article info: received: february 15, 2021 accepted: march 20, 2023 cite this article. mir h a, shafiq s, khan m, mukhtar s, asif a, akhter q. relationship of maxillary sinus and maxillary first molar root using cone beam computed tomography.j islamabad med dental coll. 2023; 12(1): 23-28 doi: https://doi.org/10.35787/jimdc.v12i1.676 funding source: nil conflict of interest: nil background: cone beam ct (cbct) is an advancement of conventional ct that uses a divergent pyramidal or conical x-ray beam for imaging the craniofacial complex. studies on the maxillary sinus and its relationship with the roots present within its close proximity are mostly based on computed tomography imaging and rarely being based on cone-beam computed tomography (cbct). this study aims to determine the relationship of maxillary sinus and the mesiobuccal root of maxillary first molar using cone beam computed tomography (cbct). methods: the study was conducted in armed forces institute of dentistry (afid) from sept, 2019 to feb, 2020. 142 cbcts were studied in the duration of six months. the distance between the maxillary mesiobuccal root and floor of maxillary sinus was measured using the built in software. the data collected was analyzed using spss 23. p-value of <0.005 was considered significant. results: the mean distance was -0.85 mm ± 2.56 on left side and -0.74mm ± 2.40 on right side. there was no significant difference between left and right side. the correlation between age and left and right-side measurements was statistically significant, p-value 0.000. conclusion: the relationship of maxillary sinus and the mesiobuccal root of maxillary first molar is significant. the study shows that in dentate healthy patients, the maxillary mesiobuccal molar root is nearly in contact with the sinus floor. these findings lead to the conclusion that performing surgical procedures in maxillary molar region may invariably lead to sinus perforation if one is not care full. key words: cone beam computerized tomography, dental implant, maxillary sinus, molar o r i g i n a l a r t i c l e j islamabad med dental coll 2023 24 i n t r o d u c t i o n maxillary sinus is one of the four pairs of paranasal sinuses, the other three being ethmoidal, sphenoidal and frontal. maxillary sinus is mucosa-lined, air filled spaces situated in the maxillofacial area, also communicating with the nasal cavity.1 maxillary sinus is small in size at birth, and the size gradually increases with age. the growth of maxillary sinus continues until the twenties in females and thirties in males.2 the anatomical relationship between maxillary posterior teeth and maxillary sinus affects endodontics and surgical removal of posterior teeth. the roots and roots apices of maxillary molars may extend into maxillary sinus.3 there is a risk factor for maxillary sinusitis and spread of odontogenic infections due to close relation of maxillary posterior root to maxillary sinus.4 it also affects orthodontic tooth movement. during orthodontic treatment, if the root protrudes into the sinus it can result in tipping and apical root resorption during movement of teeth horizontally across the maxillary sinus floor.5 there is also a risk factor for oroantral communication due to this close proximity.6 a clinician must have an adequate knowledge regarding proximity of roots and root apices to maxillary sinus, only then he can recognize the risk of sinus perforation and manage it accordingly.7 however, use of routine dental radiographs such as panoramic radiographs and periapical radiographs is not very helpful in determining the relationship between maxillary sinus and root, mainly because of overlapping images and incomplete visualization of maxillary sinus. cone-beam computed tomography (cbct) is a valuable diagnostic aid in this regard.8,9 the aim of our study was to assess the relationship between the mesio-buccal root of maxillary first molar and the maxillary sinus using cbct in pakistani population. this study will assist the dental practitioners who are performing procedures in rural areas without the aid of proper radiographic equipment. m e t h o d o l o g y this cross-sectional descriptive study with nonprobability consecutive sampling technique was performed in armed forces institute of dentistry. the duration of the study was 06 months from sept, 2019 to feb, 2020. 142 cbcts were performed during this duration. the sample size was calculated using who calculator. the parameters used for sample size calculation were: confidence interval: 95%, anticipated population proportion: 10%, absolute precision required: 5%. although cbcts were not done for the purpose of this study, however the areas of interest for this study were present in the scan. the inclusion criteria were all patients above the age of eighteen years and bilateral presence of teeth from canine to first molar in maxillary arch. patients with history of orthodontics treatment, fracture and periapical radiolucency in premolar/molar region were excluded. approval from ethical committee was taken prior to started this study. all images were taken with a newtom vgi cbct machine (qr s.r.l, italy) in armed forces institute of dentistry, rawalpindi, pakistan. image parameters were set to 110kv and 10 ma, and an exposure time of 18s. field of view was 15x15 cm and 250µm voxel size. the images were studied using the built in software (nnt viewer). the crosssection area of interest was observed and relationship was recorded. the distance between the floor of maxillary sinus and the mesio buccal root of maxillary first molar was measured by marking the tip of the root and the floor of the maxillary sinus. the software automatically measured the distance in millimeters. the measurement was then recorded. (figure 1) the mesio buccal root was selected as it is the farthest from the sinus and its j islamabad med dental coll 2023 25 approximation to the sinus means that the other roots are already within the sinus. figure 1: image of the measurement using the built in software. mean and standard deviations were calculated for age and distance between the maxillary mesio buccal root and maxillary sinus. frequency was calculated for gender. t-test and chi square test was used to compare the distance between left and right side, and with age and gender. the data was analyzed using spss 23. r e s u l t s a total of 142 cbcts were studied. as there is one first molar per side so there were 142 first molars on right side and 142 molars on left side. mean standard deviation and standard error of mean of the age was 40.38 + 17.90, 1.50. table i shows the distribution of gender in the sample and the values of measurements of left and right side. the relationship of age with the distance between maxillary sinus and the mesiobuccal root of maxillary first molar was calculated by using t-test as shown in table ii. chi square test was used to relate gender with measurements of left and right side. the result was non-significant with p-values of 0.676 and 0.300 respectively. measurements of left side and right side were compared with each other and non-significant relation was found (p-value 0.168). table i gender distribution gender distribution %(n) male female total 58.5% (n=83) 41.5% (n=59) 100% (n=142) measurements (mm, sd, se mean) left right mean -0.85 -0.74 sd 2.56 2.40 se mean 0.24 0.22 table ii relationship of age with the distance between maxillary sinus and the mesiobuccal root of maxillary first molar mean sd se mean pvalue pair 1 age in years 37.26 16.97 1.57 0.000 distance left side -0.85 2.56 0.24 pair 2 age in years 26.45 16.43 1.53 0.000 distance right side -0.74 2.40 0.22 d i s c u s s i o n the study documents the relationship of maxillary first molar mesiobuccal root tip with maxillary sinus. mesiobuccal root is farthest away from the sinus. in case the roots of maxillary first molar are in close j islamabad med dental coll 2023 26 proximity of the maxillary sinus, it signifies that the roots of other posterior teeth are also in near or even within the sinus. cbct is the recommended radiograph for implant and sinus lifting surgeries as it provides a threedimensional picture of the region.10 unfortunately, due to economic conditions of pakistan cbct is not available everywhere. at best, panoramic radiograph (opg) is available. this provides a 2d picture which does not provide enough data. the measurements in our study will provide average readings of the relationship with the sinus which can be used in conjunction with opg for implant and sinus surgery treatment planning. it is very important to be aware of sinus proximity. involvement of sinus can cause complications in the treatment, failure of implant, sinusitis and other problems.11,12 perforation of sinus may require another surgical procedure for its repair causing pain and discomfort to the patient and prolonging the treatment time. our study shows that the majority of the cases the roots of maxillary posterior teeth are in close proximity of the sinus. the mean distance between the maxillary posterior teeth and the maxillary sinus floor was found to be 1.97 mm by orhan k.13 another study done in chinese population showed that 62% of the roots were in close proximity with sinus.14 motiwala m a found that the closest root to maxillary sinus was palatal root of maxillary first molar with a mean distance of 1.48 ± 4.01mm.15 themkumkwun et al. analyzed cbct images of 354 roots and concluded that molar roots extending beyond the sinus floor was most common.16 in another study conducted on pakistani population showed great variation. a study conducted in karachi showed that the mesio buccal root tip was away from the sinus floor with the mean of 1.41 ± 2.31 mm in below 30 years of age group and 2.85 ± 4.90mm in above 30 years of age group. whereas our study showed that the maxillary mesiobuccal roots were within the maxillary sinus as designated by the negative sign.17 in our study evaluation of proximity in both males and females show that there is no significant difference, but von arx et al found that the sinus was closer to the roots in men than women. this was due to better root formation and longer roots in men. another reason to this is that the sinus is larger and broader in males as compared to females.18 the proximity increases with age. this is due to pneumatization of the sinus with age as well as extraction of teeth creates space for the sinus to expand. there is an increased risk of sinus involvement during various procedures of the oral cavity as the patient gets older the patient. this was shown in the study by von arx when he measured the distance of premolar roots with maxillary sinus.18 due to close proximity, there is a chance of sinus membrane perforation which may cause infection and ultimately failure of the procedure.19 regarding sinus membrane perforation, a perforation rate of 4% correlated with the surgical instrumentation alone, 12% linked to the graft insertion procedure, and 24% associated with the implant placement was found.20 so it’s very important to know the position of sinus before performing surgical procedures in maxillary posterior region. sinus elevation procedures may be performed if there is close proximity of sinus and sinus perforation risk is higher. there are multiple techniques and materials that can be employed depending on the case and dentist’s preference.21 in any case, one has to take some kind of precautionary step to avoid sinus complications. limitation of this study was that the measurements were not correlated with history of respiratory diseases as they have an effect on the size of the sinuses. c o n c l u s i o n j islamabad med dental coll 2023 27 the relationship of maxillary sinus and the mesiobuccal root of maxillary first molar is significant. the study shows that in dentate healthy patients, the maxillary mesiobuccal molar root is nearly in contact with the sinus floor. these findings lead to the conclusion that performing surgical procedures in maxillary molar region may invariably lead to sinus perforation if one is not care full. r e f e r e n c e s 1. whyte a, boeddinghaus r. the maxillary sinus: physiology, development and imaging anatomy. dentomaxillofac radiol. 2019;48(8):20190205. doi: 10.1259/dmfr.20190205. 2. von arx t, fodich i, bornstein m m. proximity of premolar roots to maxillary sinus: a radiographic survey using cone-beam computed tomography. j endod. 2014;40(10):1541-8 doi: 10.1016/j.joen.2014.06.022. 3. kang sh, kim bs, kim y. proximity of posterior teeth to the maxillary sinus and buccal bone thickness: a biometric assessment using cone-beam computed tomography. j endod. 2015;41(11):1839-46. doi: 10.1016/j.joen.2015.08.011. 4. ariji y, obayashi n, goto m, izumi m, naitoh m, kurita k, shimozato k, ariji e. roots of the maxillary first and second molars in horizontal relation to alveolar cortical plates and maxillary sinus: computed tomography assessment for infection spread. clin oral investig. 2006;10(1):35-41. doi: 10.1007/s00784-005-0020-5. 5. oishi s, ishida y, matsumura t, kita s, sakaguchikuma t, imamura t, ikeda y, kawabe a, okuzawa m, ono t. a cone-beam computed tomographic assessment of the proximity of the maxillary canine and posterior teeth to the maxillary sinus floor: lessons from 4778 roots. am j orthod dentofacial orthop. 2020;157(6):792-802. https://doi.org/10.3390/app12199494 6. hasegawa t, tachibana a, takeda d, iwata e, arimoto s, sakakibara a, akashi m, komori t. risk factors associated with oroantral perforation during surgical removal of maxillary third molar teeth. oral maxillofac surg. 2016;20(4):369-75. doi: 10.1007/s10006-016-0574-1 7. lavasani sa, tyler c, roach sh, mcclanahan sb, ahmad m, bowles wr. cone-beam computed tomography: anatomic analysis of maxillary posterior teeth—impact on endodontic microsurgery. j endod. 2016;42(6):890-5. doi: 10.14744/eej.2021.40427 8. de lima co, devito kl, vasconcelos lr, do prado m, campos cn. correlation between endodontic infection and periodontal disease and their association with chronic sinusitis: a clinicaltomographic study. j endod. 2017;43(12):197883. doi: 10.1016/j.joen.2017.08.014. 9. kilic c, kamburoglu k, yukesl sp, ozen t. an assessment of the relationship between the maxillary sinus floor and the maxillary posterior teeth root tips using dental cone-beam computerized tomography. eur j dent. 2010;4(4):462–467. 10. jacobs r, salmon b, codari m, hassan b, bornstein mm. cone beam computed tomography in implant dentistry: recommendations for clinical use. bmc oral health. 2018;18(1):88. doi: 10.1186/s12903018-0523-5. 11. al-dajani m. incidence, risk factors, and complications of schneiderian membrane perforation in sinus lift surgery: a meta-analysis. implant dent. 2016;25(3):409–15. doi: 10.1097/id.0000000000000411. 12. ragucci, g.m., elnayef, b., suárez-lópez del amo, f. wang h l, alfaro fh, albiol jg et al. influence of exposing dental implants into the sinus cavity on survival and complications rate: a systematic review. int j implant dent. 2019;5(1):6 doi: 10.1186/s40729-019-0157-7 13. orhan k, kusakci sb, aksoy s, bayindir h, berberoglu a, seker e. cone beam ct evaluation of maxillary sinus septa prevalence, height, location and morphology in children and adult population. med princ pract. 2013;22(1):47-53. . doi: 10.1159/000339849 14. zhang y q, yan x b, meng y, zhao y n. morphological analysis of maxillary sinus floor and it correlation to molar roots using cone beam computed tomography. clin j dent res. 2019;22(1):29-36. 15. motiwala m a, arif a, ghafoor r. a cbct based evaluation of root proximity of maxillary posterior teeth to sinus floor in a subset of pakistani https://doi.org/10.3390/app12199494 https://doi.org/10.1007/s10006-016-0574-1 https://doi.org/10.14744%2feej.2021.40427 https://doi.org/10.1186%2fs40729-019-0157-7 https://doi.org/10.1159%2f000339849 j islamabad med dental coll 2023 28 population. j pak med assoc. 2021;71(8):1-12. doi: 10.47391/jpma.462 16. themkumkwun, s, kitisubkanchana, j, waikakul, a, et al. maxillary molar root protrusion into the maxillary sinus: a comparison of cone beam computed tomography and panoramic findings. int j oral maxillofac surg. 2019;48(12):1570–1576. doi: 10.1016/j.ijom.2019.06.011. 17. motiwala ma, arif a, ghafoor r. a cbct based evaluation of root proximity of maxillary posterior teeth to sinus floor in a subset of pakistani population. j pak med assoc. 2021 ;71(8):19921995. doi: 10.47391/jpma.462. 18. von arx, t, fodich, i, bornstein, mm. proximity of premolar roots to maxillary sinus: a radiographic survey using cone-beam computed tomography. j endod. 2014;40(10):1541–1548. doi: 10.1016/j.joen.2014.06.022. 19. antoanela g, jaime l l, christopher a c, aladdin j a, kristin a s, patrick p w, jung-wei c. the incidence of maxillary sinus membrane perforation during endoscopically assessed crestal sinus floor elevation: a pilot study. j oral implantol. 2012;38(4): 345–59. doi: 10.1563/aaid-joi-d-12-00083 20. danesh-sani sa, loomer pm, wallace ss. a comprehensive clinical review of maxillary sinus floor elevation: anatomy, techniques, biomaterials and complications. br j oral maxillofac surg. 2016;54(7):724-30. doi: 10.1016/j.bjoms.2016.05.008. 21. deng x, shi r, zhan j, yang f. application effect of external and internal elevation of maxillary sinus in implant restoration of posterior maxilla. emerg med int. 2022 sep 1;2022:7879633. doi: 10.1155/2022/7879633. 22. whyte a, boeddinghaus r. the maxillary sinus: physiology, development and imaging anatomy. dentomaxillofac radiol. 2019 dec;48(8):20190205. doi: 10.1259/dmfr.20190205. https://doi.org/10.47391/jpma.462 https://doi.org/10.1563/aaid-joi-d-12-00083 j islamabad med dental coll 2023 116 open access impact of obesity on lumbar disc herniation murtaza ahmed khan1, .abdul hameed2, abdul qadeer khan3, muhammad danish shafiq4, talha abbas5 1,5post graduate trainee, department of neurosurgery, sir ganga ram hospital, lahore 2head of department, neurosurgery, sir ganga ram hospital, lahore 3post graduate trainee, department of radiology, paf hospital, islamabad 4assistant professor, department of neurosurgery, sir ganga ram hospital, lahore a b s t r a c t background: prevalence of obesity is increasing worldwide and obese patients constitute a major portion of the spinal surgeon s practice. the patients with lumbar disc herniation present the most in the outpatient department of neurosurgery. obesity not only leads to the disc herniation but also causes a surgeon a difficult ordeal while operating as it leads to more peri operative complications than normal weight patients. this cross-sectional study was planned to see the impact of obesity on lumbar disc herniation and its association with disease outcome. methodology this study was conducted in the department of neurosurgery at sir ganga ram hospital/ fatima jinnah medical university (n=604; males: n=368 females: n=236) from december 15th 2021 to july 31st 2022. from the prospective registry, patients undergoing unilateral fenestration and discectomy, bilateral partial laminectomy and discectomy, and endoscopic discectomy were identified with complete bmi data. results: in total 604 patients, 368 were males and 236 were females, with age range 25-55 years with ± 4.9 sd. among these 187 (30.9%) were managed surgically while 417 (69.1%) patients were managed conservatively, which were assessed on vas (visual analogue score) and sciatica bothersomeness index (sbi). among them 87 patients (20.8%) patients were of normal weight, 145 (34.77%) were overweight and 185 (44.36%) were obese. among187 patients who underwent surgery; 74 (39.5%) underwent unilateral fenestration and discectomy, 113 (60.4%) underwent bilateral partial laminectomy and discectomy whereas 16 patients (8.5%) underwent endoscopic discectomy. lumber disc herniation (ldh) was more frequent in obese and overweight individuals than in normal-weight patients. conclusion it was observed that in obese and overweight patients, the severity of pain was more as compared to normal patients. higher the bmi more the excruciating pain and more neurological were seen with increasing trend of numbness and radiculopathy. hence, obesity may have a robust impact on lumbar disc herniation apart from other pathologies involved. key words: discectomy, disc herniation, laminectomy, lumbar region, obesity. cite this article.khan m a, hameed a, khan a q, shafiq m d, abbas t. impact of obesity on lumbar disc herniation.j islamabad med dental coll. 2023; 12(2): 116-121 doi: https://doi.org/10.35787/jimdc.v12i2.934 funding source: nil conflict of interest: nil i n t r o d u c t i o n the prevalence of obesity in adults is increasing and is now considered as pandemic. overweight, commonly defined as bmi ranging from 25 to 30 kg/m2 while bmi more than 30 kg/m2 is considered as obese. according to world health organization, the incidence of obesity has almost tripled since 1975 globally. it is now considered as a serious health issue as it affects quality of life and it authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5 data analysis; manuscript editing. correspondence: murtaza ahmad khan email: ma40236344@gmail.com article info: received: december 9, 2022 accepted: june 20, 2023 o r i g i n a l a r t i c l e j islamabad med dental coll 2023 117 increases mortality and morbidity. according to the world health organization, there is an emerging epidemic of obesity currently in pakistan and 26% of women and 19% of men are obese with highest prevalence in urban.1 among the spinal degenerative diseases, lumbar disc herniation is the most common pathology and is considered as the principal cause of spinal surgery in adult population.2 it is now considered as a worldwide health problem because of the debility it causes. they mostly occur in the fourth and fifth decades of life, although being described in all age groups.3 lumbar disc herniation is mostly the result of gradual age-related wear and tear phenomenon known as disc degeneration. multiple risk factors are identified in the pathogenesis like obesity, weight lifting, smoking, genetics, frequent driving, sedentary life style, incorrect posturing while working for prolonged hours, sudden straining or twisting and trauma. the most common presentation of patients with lumbar disc herniation is lumbalgia and sciatica, apart from cauda equine syndrome and focal neurological deficit.4 the link between obesity and ldh has been given a very little attention despite a strong recognized impact of obesity on multiple musculoskeletal conditions. in numerous previous studies, the impact of obesity on lumbar spinal disorders like low back pain, protruded intervertebral disc, facet joint degeneration has been reported.5,6 the patients with lumbar disc herniations are routinely encountered in outpatient department. some of them have single level herniation and some come with multiple level herniations. the management of lumbar disc herniation; whether surgical or conservative is challenging in young adults since surgical indications are restricted, even though the surgical outcome shows good result. the most frequent indications of spinal surgery are excruciating pain that hampers the daily life activities, unresponsiveness to conservative management, presenting with a neurological deficit and cauda equina syndrome.7 the impact of obesity on musculoskeletal system has significant importance, the present study was thus planned to observe the link between lumbar disc herniation and obesity. m e t h o d o l o g y this cross-sectional study was conducted in the department of neurosurgery, sir ganga ram hospital/ fatima jinnah medical university (sgrh/ fjmu) from 15th december, 2021 to 31st july, 2022. the study has considered all the ethical requirements and was approved by the institutional ethical review board. the data were collected from all the patients who were managed conservatively and from patients undergoing unilateral fenestration and discectomy, bilateral partial laminectomy and discectomy, and endoscopic discectomy. bmi from 1825 was normal while bmi>25 was defined over weight, bmi>30 as obese. the diagnosis was made on clinical evaluation and mri. all the adult patients of either gender presenting with lower back pain which were diagnosed as lumbar disc herniation after clinical evaluation and radiological investigation (mri) done. extreme of ages and other all spinal pathologies were excluded. the patients that were managed conservatively were categorized as normal, overweight and obese. backache whether radiating to the lower limb or non-radiating was used in the study to assess the rate of the symptom severity in lumbosacral radiculopathy. sciatica bothersomeness index (sbi) and sciatica frequency index were used in this study for clinical and research purpose. the score of bothersomeness and frequency of the radiating symptoms of both indices consist of 4 radiating symptoms each.8 the severity and intensity of backache and leg pain were assessed through visual analogue scale (vas). vas has a fixed straight horizontal line usually 100mm and its ends are defined as the extreme limits of the j islamabad med dental coll 2023 118 symptoms (pain) with the right end as “maximum pain “and the left end as “no disability.”9 the patients were evaluated with a comprehensive history and physical examination. the severity of disability and pain were assessed by visual analogue scale (vas) and sciatica bothersomeness index (sbi). the patients undergoing surgical management were based on (1) if the patient is unresponsive for the conservative management for 6 weeks, (2) excruciating pain hampering daily life activities, (3) cauda equina syndrome, (4) neurological deficit (mrs grade≤3) the patients who underwent surgery were also categorized as normal, overweight and obese. spss, version 23.0 was utilized to analyze data. descriptive statistics were used to summarize the demographics and clinical parameters of the participants. the shapiro-wilk test was used to assess the normality of the data, while the levene test was used to assess the homogeneity of variances among groups. internal consistency was measured using cronbach’s alpha. an independent t-test was used to compare measurable outcomes at baseline. p value of <0.05 was taken as statistically significant. r e s u l t s in total 604 patients, 368 were males and 236 were females, with age range 25-55 years with ± 4.9 sd. among these 187 (30.9%) were managed surgically while 417 (69.1%) patients were managed conservatively. table one shows baseline characteristics of patients. figure i show that the prevalence of surgery is more in overweight and obese patients in comparison to normal weight patients. figure ii shows that the prevalence of ldh is more in overweight and obese patients in comparison to normal weight patients although they were managed conservatively. table ii demonstrates the association between the outcomes of variables used in the study that were the severity of pain when compared between obese and normal patients with vas and sbi. the patient who were overweight and obese they had significantly higher values of vas and sbi table i: baseline characteristics of study patients (n= 604) age (years) 25-55 (± 4.9) gender males 368 females 236 bmi of patients managed surgically 18-25 51 25-30 71 >30 65 surgery done 187 unilateral fenestration and discectomy bilateral partial laminectomy and discectomy endoscopic discectomy level of herniations in surgical patients single level herniation l1 / l2 01 l2 / l3 0 l3 / l4 l4 / l5 03 96 l5 / s1 87 2 or more level herniations 06 treatment plan conservative management 417 single level herniation 261 l1 / l2 00 l2 / l3 03 l3 / l4 l4 / l5 01 121 l5 / s1 136 2 or more level herniations 156 table ii: comparison of ldh with respect to vas, sbi, & bmi (n=604) α normal weight overweight obese vas scores .9 5 4.81 ± 1.23 (p< .05) 6.21 ± 1.53 (p< .05) 7.49 ± 1.42 (p< .05) sbi scores .8 7 8.63 ± 3.42 (p< .05) 10.59 ± 3.59 (p< .05) 12.51 ± 4.25 (p< .05) j islamabad med dental coll 2023 119 figure 1: patients who underwent surgery for ldh with their bmi ranges figure 2: patients conservatively managed and their bmi ranges . obese and overweight patients had more severity of pain as compared to normal patients. higher the bmi more the excruciating pain and more the neurology was affected and there was seen increasing trend of numbness and radiculopathy. d i s c u s s i o n lumbar disc herniation is the important cause of radiculopathy, sometimes associated with neurological deficits. literature review has shown a positive relationship between increased bmi and lower back pain.10 the etiology of sciatica has multiple factors but the strong factors involved are the direct compression of the nerve root by mechanical stimulation caused by the protruded disc and the cascade of inflammatory phenomenon induced by extruded nucleus.11 the patients being assessed in our study on sbi and vas demonstrated that higher the weight more prone to the lumbalgia and sciatica. in our study, the patients were either managed surgically or conservatively; overweight and obese patients were more prone to the lumbar disc herniation. current literature also demonstrated a strong association between obesity and ldh. the person who has higher bmi is two folds more prone to low back pain as compared to the person with normal bmi and there is a proposed mechanism also suggested in different studies.12-14 higher the bmi, there would be increased mechanical load on spine and the higher compressive force during various different physical activities. secondly obesity makes the person vulnerable to chronic systemic inflammation and injuries that lead to the elevation of systemic proinflammatory cytokines like il-6, tnf-α etc. leading to increased pain. the results of current study also demonstrated that the patients who underwent surgical management were falling more into the category of bmi ≥ 25. in the literature review, some studies have shown the a between obesity and increased surgical management for lumbar disc herniation.15,16 higher the bmi, more neurological effects and deterioration of symptoms, that leads the management from conservative to surgery. apart from this patient who were obese mostly had multilevel issues rather than a single level herniation. the results of this study also demonstrated that overweight and obese patients had considerably higher values of vas and sbi compared to normal-weight patients. moreover, individuals with higher bmi experienced more severe pain. these findings align with previous research that has established a link between obesity and increased pain intensity in various musculoskeletal conditions, including lumbosacral radiculopathy. it was found that higher bmi was associated with greater low back pain and sciatica j islamabad med dental coll 2023 120 symptoms.17 similarly, systematic reviews showed obesity was a risk factor for the development and progression of sciatica.18 the association between bmi and neurologic symptoms, such as numbness and radiculopathy, further supports the notion that obesity can have detrimental effects on nerve function. as the bmi increases, the potential for nerve compression and irritation also rises, leading to a higher likelihood of sensory disturbances and radicular pain.19 the current study underscores the significance of weight management and addressing obesity as part of the treatment approach for patients with radicular pain. by reducing excess weight, it may be possible to alleviate the burden on the spine, mitigate nerve compression, and potentially improve symptom severity and quality of life for individuals with lumbosacral radiculopathy. c o n c l u s i o n  obesity is a significant risk factor for lumbar disc herniation, it is thus important to reduce weight so that the chances of lumbar disc herniation are minimized.  obese patients have more tendency to undergo surgical intervention than normal weight patients.  future research in this field should examine measures to minimize the complication rates in the obese patients as well as the effect of controlled weight loss before surgery on complications and outcomes. r e f e r e n c e s 1. siddiqui m, hameed r, nadeem m, mohammad t, simbak n, latif a, abubakar y, baig a. obesity in pakistan; current and future perceptions. j curr trends biomed eng biosci. 2018;17:001-4. https://doi.org/10.19080/ctbeb.2018.17.555958 2. irmola tm, häkkinen a, järvenpää s, marttinen i, vihtonen k, neva m. reoperation rates following instrumented lumbar spine fusion. spine. 2018 feb 15;43(4):295-301. https://doi.org/10.1097/brs.0000000000002291 3. roberts s, gardner c, jiang z, abedi a, buser z, wang jc. analysis of trends in lumbar disc degeneration using kinematic mri. clinical imaging. 2021 nov 1;79:136-41. https://doi.org/10.1016/j.clinimag.2021.04.028 4. rihn ja, kurd m, hilibrand as, lurie j, zhao w, albert t, weinstein j. the influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the spine patient outcomes research trial (sport). the journal of bone and joint surgery. american volume. 2013 jan 1;95(1):1.https://doi.org/10.2106/jbjs.k.01558 5. liu c, zhou y. comparison between percutaneous endoscopic lumbar discectomy and minimally invasive transforaminal lumbar interbody fusion for lumbar disc herniation with biradicular symptoms. world neurosurgery. 2018 dec 1;120:e72-9. https://doi.org/10.1016/j.wneu.2018.07.146 6. wang yp, zhang w, an jl, zhang j, bai jy, sun yp. evaluation of transforaminal endoscopic discectomy in treatment of obese patients with lumbar disc herniation. medical science monitor: international medical journal of experimental and clinical research. 2016;22:2513. https://doi.org/10.12659/msm.899510 7. peng xq, sun cg, fei zg, zhou qj. risk factors for surgical site infection after spinal surgery: a systematic review and meta-analysis based on twenty-seven studies. world neurosurgery. 2019 mar 1;123:e318-29. https://doi.org/10.1016/j.wneu.2018.11.158 8. patrick dl, deyo ra, atlas sj, singer de, chapin a, keller rb. assessing health-related quality of life in patients with sciatica. spine. 1995 sep 1;20(17):1899908. https://doi.org/10.1097/00007632-19950900000011 9. boonstra am, preuper hr, reneman mf, posthumus jb, stewart re. reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. international journal of rehabilitation research. 2008 jun 1;31(2):165-9. https://doi.org/10.1097/mrr.0b013e3282fc0f93 10. qazi ra, rehman l, javeed f, qazi sa, ahmed t, abbas a. the prevalence of low vitamin d3 levels in patients with lumbar disc herniation and its relationship with different patient parameters. pakistan journal of neurological surgery. 2022 jul 17;26(2):229-35. https://doi.org/10.36552/pjns.v26i2.637 11. rogerson a, aidlen j, jenis lg. persistent radiculopathy after surgical treatment for lumbar disc herniation: causes and treatment options. https://doi.org/10.19080/ctbeb.2018.17.555958 https://doi.org/10.1097/brs.0000000000002291 https://doi.org/10.1016/j.clinimag.2021.04.028 https://doi.org/10.2106/jbjs.k.01558 https://doi.org/10.1016/j.wneu.2018.07.146 https://doi.org/10.12659/msm.899510 https://doi.org/10.1016/j.wneu.2018.11.158 https://doi.org/10.1097/00007632-199509000-00011 https://doi.org/10.1097/00007632-199509000-00011 https://doi.org/10.1097/mrr.0b013e3282fc0f93 https://doi.org/10.36552/pjns.v26i2.637 j islamabad med dental coll 2023 121 international orthopaedics. 2019 apr;43(4):969-73. https://doi.org/10.1007/s00264-018-4246-7 12. siddiqui as, javed s, abbasi s, baig t, afshan g. association between low back pain and body mass index in pakistani population: analysis of the software bank data. cureus. 2022 mar 30;14(3). https://doi.org/10.7759/cureus.23645 13. lambrechts mj, pitchford c, hogan d, li j, fogarty c, rawat s, leary ev, cook jl, choma tj. lumbar spine intervertebral disc desiccation is associated with medical comorbidities linked to systemic inflammation. archives of orthopaedic and trauma surgery. 2021 oct 8:1-1. https://doi.org/10.1007/s00402-021-04194-3 14. taneja sg, lil na, pathria vv, umrethiya va, dave t, chaudhary k, parmar n. the association of lumbar intervertebral disc degeneration and lumbar spinal stenosis on magnetic resonance imaging with body mass index in overweight and obese adults in indian population. international journal of orthopaedics. 2021;7(4):71-8. https://doi.org/10.22271/ortho.2021.v7.i4a.2866 15. lminawy m, kerezoudis p, lu vm, yolcu y, alvi ma, bydon m. impact of obesity on outcomes following lumbar spine surgery: a systematic review and metaanalysis. clinical neurology and neurosurgery. 2019 feb 1;177:27-36. https://doi.org/10.1016/j.clineuro.2018.12.012 16. ilyas h, savage j. lumbar disk herniation and sport: a review of the literature. clinical spine surgery. 2018 nov 1;31(9):366-72. https://doi.org/10.1097/bsd.0000000000000696 17. koyanagi a, stickley a, garin n, miret m, ayusomateos jl, leonardi m, koskinen s, galas a, haro jm. the association between obesity and back pain in nine countries: a cross-sectional study. bmc public health. 2015 dec;15:1-9. https://doi.org/10.1186/s12889-015-1362-9 18. zhang tt, liu z, liu yl, zhao jj, liu dw, tian qb. obesity as a risk factor for low back pain. clinical spine surgery. 2018 feb 1;31(1):22-7. https://doi.org/10.1097/bsd.0000000000000468 19. 19. shiri r, lallukka t, karppinen j, viikari-juntura e. obesity as a risk factor for sciatica: a meta-analysis. american journal of epidemiology. 2014 apr 15;179(8):929-37. https://doi.org/10.1093/aje/kwu007 https://doi.org/10.1007/s00264-018-4246-7 https://doi.org/10.7759/cureus.23645 https://doi.org/10.1007/s00402-021-04194-3 https://doi.org/10.22271/ortho.2021.v7.i4a.2866 https://doi.org/10.1016/j.clineuro.2018.12.012 https://doi.org/10.1097/bsd.0000000000000696 https://doi.org/10.1186/s12889-015-1362-9 https://doi.org/10.1097/bsd.0000000000000468 https://doi.org/10.1093/aje/kwu007 j islamabad med dental coll 2023 4 open access clinicopathological features and expression of ki-67 in odontogenic keratocyst, dentigerous cyst and radicular cyst rabiya saif1,hafiz majid jehangir2, zainab rizvi3, faiz rasul4, sultan muhammad wahid5, khurram nadeem6 1demonstrator, oral pathology, de’montmorency college of dentistry, lahore 2professor oral pathology,azra naheed medical and dental college lahore 3associate professor oral pathology,de’montmorency college of dentistry, lahore 4demonstrator , oral pathology, de’montmorency college of dentistry, lahore 5principal dental surgeon, oral pathology, de’montmorency college of dentistry, lahore 6associate professor,oral medicine department,lahore medical & dental college a b s t r a c t background: biological behaviour of odontogenic keratocyst (okc) is aggressiveness than others odontogenic cysts (ocs) like dentigerous cyst (dcs) and periapical cyst/residual cysts (rcs). the aim of the study was to determine clinicopathological features and expression of ki-67 in odontogenic cysts of the oral cavity. methodology: this cross-sectional study was conducted at de’montmorency college of dentistry (dcd from feb, 2020 to feb, 2022 after approval from institutional review board (irb) of dcd. a total 78 cases of ocs were collected from hospitals which are affiliated with the dcd. routine lab process for hematoxylin & eosin and immunohistochemistry was performed. data entry and statistical analysis was carried out in spss 21. a chisquare test was applied to observe the association between cyst and ki-67. p value < 0.05 was taken as statistically significant. results: among total 78 cases the mean age was 25.08 ±14.5 years with an age range of 6-70 years. most ocs (64.1%) were reported in males than females (35.89%). most ocs were reported in mandible (56.4%. ki-67 expression in okc was high 7.7%, low in 76.9% and negative in 15.4%). most of the dcs and rcs expressed low expression of ki-67 (84.6% and 76.9% respectively). conclusion: most of the odontogenic cysts expressed low expression of ki-67 while few cases of okc and dc expressed high expression. key words: dentigerous cyst, odontogenic keratocyst, immunohistochemistry, ki-67, odontogenic cysts, periapical cyst, radicular cyst. authors’ contribution: 1conception; literature research; 2,3manuscript design and drafting; 4,6critical analysis and manuscript review; 6data analysis; manuscript editing. correspondence: faiz rasul email: bayfaiz871@gmail.com article info: received: march 31, 2022 accepted: march 28, 2023 cite this article. saif r, jehangir m h,rizvi z, rasul f, wahid m s, nadeem k. clinicopathological features and expression of ki-67 in odontogenic keratocyst, dentigerous cyst and radicular. j islamabad med dental coll. 2023; 12(1):4-10 doi: https://doi.org/10.35787/jimdc.v12i1.869 funding source: nil conflict of interest: nil i n t r o d u c t i o n odontogenic cysts are classified on the basis of etiology, development, and histology. world health organization (who) has also classified cysts in 2017. o r i g i n a l a r t i c l e mailto:bayfaiz871@gmail.com j islamabad med dental coll 2023 5 ocs (derived from remnants of tooth forming epithelium), include dentigerous cyst (dc), odontogenic keratocyst (okc), orthokeratinized odontogenic cyst, lateral periodontal and botryoid odontogenic cyst, gingival cyst, glandular odontogenic cyst, calcifying odontogenic cyst and radicular cyst. radicular cysts are inflammatory oc and are most common cyst of the jaw.1 epithelial lining of rc is derived from the proliferation of rests of malassez within the periodontal ligament. dc is derived from proliferation of enamel organ remnants or reduced enamel epithelium (ree) and okc from cell rests of the dental lamina.2 okc and dc have highest risk of malignant transformation.3 who reclassified okc as odontogenic keratocyst instead of odontogenic tumor due to insufficient evidences to be placed it in tumors.4 however the exact mechanism of the development and malignant transformation of these cysts is unknown.3 studies show that ki-67 and p53 reveal intense positivity in okc as compared to other ocs.5 clinicopathological features (age, gender, site, ragiographic presentation and histology) are important parameters of ocs yet ki-67 depict potential transformation of ocs into neoplasia.5,6 expression of ki-67 was variable in okc as reported by many authors, however few foci expressed higher expression of ki-67.7 orthokeratinized odontogenic cyst (ooc) revealed low expression of ki-67 as compared to okc.8 expression of ki-67 among these cyst is different in literature, however it is still a challenge to determine that which cyst has the highest expression, and highest potential of malignant ,transformation. literature shows okc has highest expression of ki-67, followed by dc, and then rc.9-11 literature about the odontogenic cysts in local setting does not reveal the behaviour, clinicopathological features and proliferative activities of ocs. the objectives of current study are to measure demographic characteristics, size, site, radiographic presentation, locularity, histopathological characteristics and ki-67 expression of common ocs (okc, dcs, and rcs) in local setting in punjab dental hospital/dcd. m e t h o d o l o g y this cross-sectional study was conducted at de’montmorency college of dentistry (dcd from feb, 2020 to feb, 2022. ethical approval was taken from institutional review board (irb) of de’montmorency college of dentistry, lahore (dcd). a total 78 cases of ocs were collected from hospitals which are affiliated with the dcd. equal cases of okcs, dcs and rcs were collected from dcd after getting written consent from all 78 cases and each group comprised of 26 cysts. males and females of all ages were included in the study, however patients having any systemic diseases were excluded from the study. recurrent cases of ocs and inadequate tissue samples were also excluded from the study. clinical data was noted on individual proforma. routine h&e staining and immunohistochemistry for ki-67 staining were performed on collected specimens. histological features of ocs were recorded on h&e staining. expression of ki-67 was recorded on 10 high-power fields (40x). positive nuclear staining of epithelial cells were counted according to the following criteria; negative (<5% cells positive), low expression (5%-50% cells positive) and high expression (>50% cells positive).7 clinicopathological features and immunohistochemical scores were analysed using spss 21. mean + s.d were given for quantitative variables like age of patient, and size of the ocs. percentages and frequencies were given for variables like gender, site of the cyst, type of cyst, locularity, microscopic features and score of ki-67. a chisquare test was applied to observe association between cyst and ki-67, p value < 0.05 was taken as significant. j islamabad med dental coll 2023 6 r e s u l t s table i: clinical o radiological features of odontogenic cysts (n=78) sr. no. variables frequency (n) percentage (%) age < 25 > 25 44 34 56.4 43.6 gender males females 50 28 64.1 35.89 type cyst radicular cyst 26 33.33 dentigerous cyst 26 33.33 odontogenic keratocyst 26 33.33 site of ocs lower jaw (mandible) 44 56.4 upper jaw (maxilla) 34 43.6 size of ocs < 2 cm 2-4cm >4 cm 60 16 02 76.9 20.5 2.6 locularity unilocular multilocular 74 04 94.9 5.1 the mean age of the patients was 25.08 ±14.5 years with an age range of 6-70 years. male were more common (64.1%) as compared to female (35.89%). in 56.0% mandible was involved while maxilla was involved in 41.1% cases. about 95% cysts were unilocular while only 5 % were multilocular. most of the odontogenic cysts were small in size (< 2 cm) 76.9%, 20.5% were of 2 -4cm, and 2.6% had size greater than 4cm (table 1). all cases of okc were lined by keratinized (parakeratinized) epithelium while all dc and all rc cases were lined by non-keratinized epithelium. okc showed epithelial hyperplasia in 20 cysts out of 26 (76.9%) while all dc and rc showed hyperplastic epithelium (table 2). table ii: histopathological features of odontogenic cysts (radicular cyst, dentigerous cyst and odontogenic keratocyst) in n=78 histopathological features cyst type frequency (%) epithelial lining okc keratinized 26 (100) nonkeratinized 00 dc keratinized 00 non keratinized 26 (100) rc keratinized 00 non keratinized 26 (100) epithelial hyperplasia okc present 20 (76.9) absent 6 (23.1) dc present 26 (100) absent 00 rc present 26 (100) absent 00 spongiosis okc present 12 (46.2) absent 14 (53.8) dc present 24 (92.3) absent 2 (7.7) rc present 20 (76.9) absent 6 (23.1) acantholysis okc present 2 (7.7) absent 24 (92.3) dc present 2 (7.7) absent 24 (92.3) rc present 22 (84.6 ) absent 4 (15.4) inflammation in connective tissue present 26 (100) absent 00 j islamabad med dental coll 2023 7 table iii: expression of ki-67 in odontogenic cysts in n=78 odontogenic cyst ki 67 expression p value negative expression (<5% cells positive) weak positive (5-50% cells positive) strong positive (>50% cells positive) total 0.9 odontogenic keratocyst 4 (15.4%) 20 (76.9%) 2 (7.7%) 26 (100%) dentigerous cyst 2 (7.7%) 22 2 (7.7%) 26 (100%) radicular cyst 6 (23.1%) 20 (76.9%) 0 (0%) 26 (100%) total 12 (15.4%) 62 (79.5%) 4 (5.1%) 78 (100%) expression of ki-67 in odontogenic keratocysts was low in 76.9%, high expression in 7.7 % and negative in 15.4%. expression of ki-67 in dcs was low in 84.6%, high in 7.7 % and negative in 7.7%. expression of ki-67 in periapical cyst was low in 76.9% and negative in 23.1%. four cases 5.1% showed high expression, however insignificant association was observed (p= 0.90) between ki-67 and type of cysts (table 3). d i s c u s s i o n world health organization classified ocs in 1992, 2005 and 2017. okc is re classified as odontogenic cyst rather than odontogenic tumor. biological behaviour of odontogenic cysts is variable according to type of cyst, among them okc shows aggressive behaviour and high recurrence rate.1, 2, 7 in the present study, 54% of the odontogenic cysts were seen in patients less than 25 years of age which means odontogenic cysts were more common in younger age group. this finding is similar to the study conducted by bhat et al in 2019, which reported that 43% cases in the age ranging from 2140 years. male gender was affected more in the present study as compared to females. posterior mandible followed by anterior maxilla was the most common site of odontogenic cysts in the present study. these findings are concordant with the study conducted by bhat et al in 2019.13 in the current study, the size was measured on radiograph, and it was found that most of the cysts (76.9%) were of small size i.e. < 2cm in diameter and 94.9% were unilocular. another local study reported a mean size of 2.24cm of ocs. radicular cysts on the whole were smaller lesions (mean=1.58 cm) as compared to dentigerous cysts (mean=3.22 cm) and odontogenic keratocysts (mean=3.67 cm). however ocs were more common in mandible than maxilla in the current study while ocs were more common in maxilla in another study conducted by ali et al.14 dentigerous cysts were the most common in the first and second decades of life (85% cases). in dentigerous cyst, posterior mandible followed by anterior maxilla was the most common site. microscopically dentigerous cyst was lined by nonkeratinized epithelium. epithelial hyperplasia (92.3%) and spongiosis (92.3%) were prominent features. no dysplastic changes were observed. all cases of dentigerous cysts showed chronic inflammation with different degrees such as mild (15.4%) and severe (15.4%) however moderate inflammation was (69.2%). in another study of dcs with a large sample size (n= 338), the mean age was 33 years and was predominantly found in males. the most prevalent site was mandible as compared to maxilla. microscopically, 317 cysts were lined by stratified squamous epithelium, 9 by mucoepidermoid-type epithelium, and 12 by ciliated pseudostratified columnar epithelium.15 j islamabad med dental coll 2023 8 in the current study rc was most common in second and third decades of life (69% cases) and the most common site was anterior maxilla. all cases of radicular cysts were lined by nonkeratinized epithelium and showed hyperplasia. however, 76.9% rc showed spongiosis and 84.6% showed acantholysis. moderate (38.5%) to severe inflammation (61.5%) was seen in all the radicular cysts. another pakistani study reported that the mean age of patients with radicular cyst was 24.81±14.8 years and was mostly seen in males (58.3%). predominant site of radicular cyst was anterior maxilla. histopathological review revealed that 65.7% cysts were lined by nonkeratinized epithelium which is different from the current study. however, 2 radicular cysts were lined by keratinized epithelium.16 in another study with large sample of rcs (n=232) mean age of patients was 40.5 years, further it was observed that 98.2 % cysts were lined by nonkeratinized stratified squamous epithelium and only 0.9% lining of rcs were of mucoepidermoid type and 0.9% of respiratory epithelium.17 in the present study most cases of okcs were lined by keratinized epithelium with 38.5% hyperplasia, 46 % spongiosis and 7.7% acantholysis. chronic inflammation was also observed in connective tissue of okcs. in 2017 a study in pakistani population also revealed that majority of okc were lined by parakeratinized epithelium which is similar to current study.18 as far as immunohistochemical expression of ki-67 is concerned, in 76.9% okc it was low (5-50% cells stained positive) in 7.7 % okc it was high expression ((>50% cells stained positive) and negative (<5% cells stained positive) in 15.4% okc. expression of ki-67 in dcs was low in 84.6%, high in 7.7 % and negative in 7.7%. expression of ki-67 in rc was low in 76.9% cysts and negative in 23.1% periapical cysts. four cases 5.1% showed high expression however insignificant association was observed (p= 0.90) between ki-67 and type of cysts (table 3). a study reported that expression of ki-67 is observed highest in okc than dc and rc (12.76 ± 4.78, 5.87 ± 4.24 and 5.08 ± 3.11) respectively. expression was more prominent in suprabasal cell layers in okc whereas it was more common in basal layer cells of dc and rc. as far as current study is concerned strong positive expression was observed same in dc and okc however in modi’s study it was more in okc than dc.19 in another study mean expression of ki-67 li was 7.7%, 1.7% and 15.3% for okc, dc and rc respectively. out of 4 cases 66.7 % weak positive expression was observed which was focal rather than diffuse, out of 8 cases of dc only one case 12.5% expressed ki-67 in mild intensity in focal pattern, and only 1/10 cases of rc expressed moderate expression of ki-67 which was diffuse in nature.9 rc when compared with residual cyst in terms of ki-67 expression (mean proliferative index) on lining epithelial cells was 1.25% for radicular cysts (ranging from 0% to 5.31%) in comparison with 3.51% in residual cyst (ranging from 0% to 16.3%) (p=0.017). this shows that duration of radicular cyst may be lesser than residual cyst.11 a recent review (meta-analysis) of ots and ocs reported that among ocs, the highest ki-67 li expression was seen in okc (3.58±0.51%), and the lowest was observed in rcs (0.98±0.47%). the order of ki-67 li expression in ocs was as follows: okc (3.58±0.51%), coc (2.43±0.65%), dcs (1.29±0.62%), and rcs (0.98±0.47%) in descending order. these findings might be useful for diagnostic purposes. it was concluded that ki-67 is expressed in docs (developmental odontogenic cysts) to a greater extent than iocs (inflammatory odontogenic cysts), such as radicular cysts (0.98±0.47%). among docs, the highest expression of ki-67 was seen in okc (3.58±0.51%) with the lowest expression in dcs (1.29±0.62%).12 expression of ki67 was greater in okc than dcs as mentioned in studies.21, 22 while in the current study both cysts have same expression of ki-67 i.e. strong positive in 7.7 %. in another study ki-67 expressed in all cases of dcs (n=15) with moderate positive j islamabad med dental coll 2023 9 (n=14) and strong positive (n=1) which is different from the current study.23 a case report of orthokeratinized odontogenic keratocyst revealed expression of ki-67 in the basal layer and also in suprabasal layer in focal area which is similar to literature and who new classification of okc.24 okcs expressed high expression of ki-67 as compared to ots.25 c o n c l u s i o n most of the odontogenic cysts expressed low expression of ki-67 while few cases of okc and dc expressed high expression. majority of ocs were having small size which may depict early diagnosis and less transformation of epithelium and less aggressiveness. r e c o m m e n d a t i o n in this study the sample size of odontogenic cysts was small. new studies may be carried out in future to observe patient health seeking behavior (early diagnosis, small size versus large size lesions) and biological behavior (strong positivity versus weak positivity) in odontogenic cysts particularly in okc. r e f e r e n c e s 1. soluk-tekkeşin m, wright jm. the world health organization classification of odontogenic lesions: a summary of the changes of the 2017 (4th) edition. turk patoloji derg. 2018 jan 1;34(1):1-8. doi: 10.5146/tjpath.2017.01410 2. iyogun ca, orikpete ev, mbagwu aa, omitola og. odontogenic cysts in port harcourt, nigeria: a 10year retrospective study. nig j dent res 2020; 5(1):16. 3. ghafouri-fard s, atarbashi-moghadam s, taheri m. genetic factors in the pathogenesis of ameloblastoma, dentigerous cyst and odontogenic keratocyst. gene. 2021 mar 1;771:145369. https://doi.org/10.1016/j.gene.2020.145369 4. jaeger f, de noronha ms, silva ml, amaral mb, grossmann sd, horta mc, et al., . prevalence profile of odontogenic cysts and tumors on brazilian sample after the reclassification of odontogenic keratocyst. j craniomaxillofac surg. 2017 feb 1;45(2):267-70. https://doi.org/10.1016/j.jcms.2016.12.011 5. boffano p, cavarra f, agnone am, brucoli m, ruslin m, forouzanfar t, et al.,. the epidemiology and management of odontogenic keratocysts (okcs): a european multicenter study. j craniomaxillofac surg. 2022 jan 1;50(1):1-6. https://doi.org/10.1016/j.jcms.2021.09.022 6. cunha jf, gomes cc, de mesquita ra, goulart em, de castro wh, gomez rs. clinicopathologic features associated with recurrence of the odontogenic keratocyst: a cohort retrospective analysis. oral surg. oral med. oral radiol. 2016 jun 1;121(6):629-35. https://doi.org/10.1016/j.oooo.2016.01.015 7. saif r, jehangir hm, nagi ah, naseem n, rizvi z, rasul f. immunohistochemical expression of ki-67 in odontogenic keratocyst: evidence of aggressive behavior. professional med j. 2020 jan 10;27(01):749. https://doi.org/10.29309/tpmj/2019.27.01.3317 8. dandena vk, thimmaiah sy, kiresur ma, hunsigi p, roy s, rashmi m. a comparative study of odontogenic keratocyst and orthokeratinized odontogenic cyst using ki67 and α smooth muscle actin. j. oral maxillofac. pathol.. 2017 sep;21(3):458. 10.4103/jomfp.jomfp_71_17 9. orikpete ev, omoregie of, ojo ma. proliferative and anti-apoptotic indices of unicystic ameloblastoma, odontogenic keratocyst, dentigerous cyst and radicular cyst. j. oral maxillofac. pathol. 2020 may;24(2):399. doi: 10.4103/jomfp.jomfp_289_19 10. jaafari-ashkavandi z, geramizadeh b, ranjbar ma. p63 and ki-67 expression in dentigerous cyst and ameloblastomas. j. dent. 2015 dec;16(4):323. 11. martins r, armada l, dos santos tc, pires fr. comparative immunoexpression of icam-1, tgf-β1 and ki-67 in periapical and residual cysts. med oral patol oral cir bucal. 2017 jan;22(1):e24. doi: 10.4317/medoral.21346 12. jabbarzadeh m, hamblin mr, pournaghi-azar f, saatloo mv, kouhsoltani m, vahed n. ki-67 expression as a diagnostic biomarker in odontogenic cysts and tumors: a systematic review and metaanalysis. j. dent. res. dent. clin. dent. prospects. 2021;15(1):66. doi: 10.34172/joddd.2021.012 13. bhat a, mitra s, chandrashekar c, solomon m, kulkarni s. odontogenic cysts and odontogenic tumors in a large rural area from india. a 10-year reflection. med. pharm. rep. 2019 oct;92(4):408. doi: 10.15386/mpr-1295 14. ali k, munir f, rehman a, abbas i, ahmad n, akhtar mu. clinico-radiographic study of odontogenic cysts at a tertiary care centre. j ayub med coll abbottabad. 2014 mar 1;26(1):92-4. https://doi.org/10.1016/j.gene.2020.145369 https://doi.org/10.1016/j.jcms.2016.12.011 https://doi.org/10.1016/j.jcms.2021.09.022 https://doi.org/10.1016/j.oooo.2016.01.015 https://doi.org/10.29309/tpmj/2019.27.01.3317 https://dx.doi.org/10.4103%2fjomfp.jomfp_71_17 https://dx.doi.org/10.4317%2fmedoral.21346 https://dx.doi.org/10.15386%2fmpr-1295 j islamabad med dental coll 2023 10 15. lin hp, wang yp, chen hm, cheng sj, sun a, chiang cp. a clinicopathological study of 338 dentigerous cysts. j oral pathol med. 2013 jul;42(6):462https://doi.org/10.1111/jop.12042 16. durrani s, ara n, ahmed mr, sarfaraz t. histopathological evaluation of odontogenic keratocysts and radicular cysts in peshawar. pak oral dental j. 2018 sep 10;38(2):164-8. 17. chen jh, tseng ch, wang wc, chen cy, chuang fh, chen yk. clinicopathological analysis of 232 radicular cysts of the jawbone in a population of southern taiwanese patients. kaohsiung j. med. sci. 2018 apr 1;34(4):249-54. https://doi.org/10.1016/j.kjms.2018.01.011 18. mohammad s, khan m, mansoor n. histopathological types of odontogenic keratocyst. pak oral dental j. 2017 jun 1;37(2). 19. modi tg, chalishazar m, kumar m. expression of ki67 in odontogenic cysts: a comparative study between odontogenic keratocysts, radicular cysts and dentigerous cysts. j oral maxillofac pathol . 2018 jan;22(1):146. doi: 10.4103/jomfp.jomfp_94_16 20. acharya s, arnold d, prabhu p, niranjan kc, hallikeri k. mcm-2 an alternative to ki-67 for assessing cell proliferation in odontogenic pathologies. j oral maxillofac surg med pathol. 2019 jan 1;31(1):52-8. https://doi.org/10.1016/j.ajoms.2018.10.002 21. jaafari-ashkavandi z, mehranmehr f, roosta e. mcm3 and ki67 proliferation markers in odontogenic cysts and ameloblastoma. j oral biol craniofac res. 2019 jan 1;9(1):47-50. https://doi.org/10.1016/j.jobcr.2018.09.003 22. brito-mendoza l, bologna-molina r, irigoyencamacho me, martinez g, sánchez-romero c, mosqueda-taylor a. a comparison of ki67, syndecan1 (cd138), and molecular rank, rankl, and opg triad expression in odontogenic keratocyts, unicystic ameloblastoma, and dentigerous cysts. dis. markers. 2018 jul 29;2018. https://doi.org/10.1155/2018/7048531 23. nafarzadeh s, seyedmajidi m, jafari s, bijani a, rostami-sarokolaei a. a comparative study of pcna and ki-67 expression in dental follicle, dentigerous cyst, unicystic ameloblastoma and ameloblastoma. int. j. mol. cell. med. 2013;2(1):27. 24. shetty dc, rathore as, jain a, thokchom n, khurana n. orthokeratinized odontogenic cyst masquerading as dentigerous cyst. int. j. appl. basic med. 2016 oct;6(4):297. doi: 10.4103/2229-516x.192597 25. martín-hernán f, campo-trapero j, cano-sánchez j, garcía-martín r, martínez-lópez m, ballestíncarcavilla c. a comparative study of the expression of cyclin d1, cox-2, and ki-67 in odontogenic keratocyst vs. ameloblastoma vs. orthokeratinized odontogenic cyst. rev esp patol. 2021 aug 28. https://doi.org/10.1155/2018/7048531. https://doi.org/10.1111/jop.12042 https://doi.org/10.1016/j.kjms.2018.01.011 https://dx.doi.org/10.4103%2fjomfp.jomfp_94_16 https://doi.org/10.1016/j.ajoms.2018.10.002 https://doi.org/10.1016/j.jobcr.2018.09.003 https://doi.org/10.1155/2018/7048531 https://dx.doi.org/10.4103%2f2229-516x.192597 https://doi.org/10.1155/2018/7048531 j islamabad med dental coll 2023 29 29 open access predictors of relapse and survival in testicular germ cell tumors in children sajid ali1, tariq latif2, muhammad ali sheikh3, shazia perveen4, muhammad bilal shafiq5, muhammad abubakar6 1fellow, pediatric surgery, shaukat khanum memorial cancer hospital and research centre, pakistan 2consultant, pediatric surgery, shaukat khanum memorial cancer hospital and research centre, pakistan 3locum consultant, pediatric surgery, shaukat khanum memorial cancer hospital and research centre, pakistan 4senior rgistrar, pediatric surgery, liaquat university of medical and health sciences, pakistan 5fellow, orthopedic surgery, shaukat khanum memorial cancer hospital and research centre, pakistan 6biostatistician, cancer registry, shaukat khanum memorial cancer hospital and research centre, pakistan a b s t r a c t background: testicular germ cell tumors are common solid organ malignancies in children with a survival rate of more than 90 %. this study aims to assess the predictors of relapse and survival in testicular germ cell tumors in children. methodology: a retrospective review was conducted on children up to the age of 18-years from january 2010 to december 2020 with a diagnosis of primary testicular germ cell tumors. factors related to relapse and survival like age, baseline levels of tumor markers in serum and on relapse, stage at diagnosis, histological type, tumor laterality & size of the tumor in testicular germ cell tumors were analyzed. the data was entered into spss version 20. statistical significance was set at a p-value ≤0.05. results: a total of 115 patients with a mean age of 5.42+ 1.54 years having testicular germ cell tumor were treated. seventeen patients (14.7 %) had relapse of disease. relapse was highest in patients with stage i disease (64.7 %). yolk sac tumor was the most common pathology that was noted in twelve (70 %) patients. the most common site of relapse was the retroperitoneum (70 %). age of patient, stage of disease, and lymphovascular invasion were significant predictors of relapse and survival in testicular germ cell tumors. conclusion: management of patients with testicular germ cell tumors requires standardized follow-up protocol for early detection and treatment of disease relapse. complete surgical excision with meticulous control of the residual disease is critical to prevent disease relapse. keywords: chemotherapy, children, outcome, relapse, testicular tumor authors’ contribution: 1,2conception; literature research; 3manuscript design and drafting; 4critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: sajid ali email: drsajidali@yahoo.com article info: received: july 6, 2022. accepted: march 27, 2023 cite this article. ali s, latif t, sheikh m a, perveen s, shafiq m b, abubakar m. predictors of relapse and survival in testicular germ cell tumors in children.j islamabad med dental coll. 2023; 12(1):29-35 doi: https://doi.org/10.35787/jimdc.v12i1.896 funding source: nil conflict of interest: nil i n t r o d u c t i o n testicular cancer is one of the common tumors in young males worldwide.1 testicular germ cell tumors are common solid organ malignancies of childhood and their incidence has been increasing over the past few decades.2 these tumors are highly curable with modern treatment modalities of o r i g i n a l a r t i c l e j islamabad med dental coll 2023 30 30 surgery and adjuvant therapy with a survival rate of more than 90 % .3 however, disease relapse related to testicular germ cell tumor (gct) is a well-known entity, which is seen during the first two years of initial diagnosis, requiring further treatment and is associated with long-term risk of second malignancy and cardiovascular disease .4 serum tumor markers like alpha-fetoprotein (afp), human chorionic gonadotropin (hcg), and ultrasound of the scrotum and abdomen are important tools in the surveillance of testicular tumors.5, 6 however, there is no clear consensus on how to follow these patients after their initial management to identify relapse reliably without causing further harm.7 standardized follow-up protocol and risk stratification are crucial to clarify the guidance for optimal surveillance of low-risk groups and adjuvant treatment for a high-risk group that results in optimizing the risk-benefit ratios for individuals and avoiding the potential consequences of disease relapse treatment-related morbidity.8 there is limited data in pediatric literature discussing factors responsible for relapse and survival in testicular gcts. although few studies in the adult population have discussed factors that predict the survival outcome in testicular germ cell tumors but they are mostly assessing stage i disease.9 o’shaughnessy proposed the late relapse after two years in germ cell tumors (gct) in the absence of a second primary tumor and determined predictors of survival outcome while another study by kvammen et al, focused on long-term relative survival (rs) for testicular germ cell tumor (tgct) patients classified by age, histology and time at diagnosis .10,11 on the other hand, wagner et al described the correlation of the prognostic factors with outcome in children with stage i malignant testicular germ cell tumors.12 therefore, the stratification of variables regarding prediction of relapse and their impact on survival outcome is important. in the literature, there are a few studies worldwide on factors influencing outcomes in testicular germ cell tumors and data related to factors associated with relapse in the paediatric population is extremely lacking, especially from developing countries like pakistan. therefore, this study was designed to assess the factors like age, levels of tumor markers in serum, stage at diagnosis, histological type, tumor laterality & size of the tumor as predictors of relapse and survival in testicular germ cell tumors in children. m e t h o d o l o g y this is a retrospective study conducted at the department of surgical oncology at shaukat khanum memorial cancer hospital & research centre, lahore from january 2010 to december 2020 after institutional review board (irb) approval. we included all male patients up to the age of 18 years (according to institutional policy) with primary testicular germ cell tumors. data was retrieved with a keyword search of "testicular germ cell tumor or malignancy", in our electronic health records. variables that were assessed included following characteristics at initial diagnosis and at relapse: age, levels of tumor markers, stage of disease, histological type, tumor laterality & size of the tumor. all findings were recorded into a pre-designed form. on initial presentation, testicular gct was staged according to children's oncology group (cog).13upfront high inguinal radical orchiectomy performed in all the patients and further treatment devised according to the stage after discussion in the weekly multidisciplinary tumor board. cisplatinbased adjuvant chemotherapy (first line chemotherapy) was given based on the high stage of the tumor, raised tumor markers, and the presence of metastatic or residual disease. completion of treatment was documented at the end of treatment scans and regular follow up was maintained with measurement of three-monthly tumor markers (serum afp & b hcg levels), an x-ray of chest and j islamabad med dental coll 2023 31 31 ultrasound of abdomen and scrotum for two years then six-monthly up to 5 years. in case of disease relapse during follow-up (diagnosed on basis of clinical assessment, tumor markers & follow-up scans) patients were restaged and chemotherapy for relapse (second line chemotherapy) was instituted. the decision to resect metastatic or residual disease after chemotherapy was individualized after discussion in the multi-specialty board. metastatectomy and retroperitoneal lymph node dissection (rplnd) were usually performed post-chemotherapy in patients with resectable residual disease and a rising pattern of serum tumor markers (afp/ b hcg). spss v.20 statistical software was used for data analysis. mean and standard deviations were used to describe quantitative data while frequencies and proportions were used to describe categorical data. survival analysis was done in terms of overall survival (os) and disease-free survival (dfs). disease-free survival (dfs) was defined from the date of completion of treatment to the date of the disease relapse, progression, or death, and overall survival (os) was the time from the initial diagnosis to the date of last follow-up or death due to any cause. dfs and os were analyzed by the kaplanmeier method. chi square test was used to consider factor associated with relapse with p values <0.05 were considered significant. data was further stratified according to stage (early stage i & ii vs late stage iii & iv), age (< 12 years vs > 12 years), time of relapse (within 6 month & more than 6 months) and vascular invasion (yes or no) for evaluating the factors associated with relapse, dfs & os. r e s u l t s one hundred and fifteen patients with primary testicular tumors were managed during the mentioned period of 11 years with the mean age at initial diagnosis being 5.42+ 1.54 years. baseline characteristics of patients at initial diagnosis of testicular germ cell tumors are detailed in table 1. table i: baseline characteristics of patients with pediatric testicular tumors characteristics number (%) duration of symptoms < 1 month 13 months 4-6 months > 6 months 04 (3.5%) 43 (37.4%) 36 (31.3%) 32 (27.8%) age 0.5 12 years 12 18 years 85 (73.9%) 30 (26.1%) clinical presentation testicular swelling testicular swelling +pain in swelling testicular swelling + distant symptoms 81 (70.4%) 12 (10.4%) 22 (19.1%) tumor laterality right testis left testis bilateral 62(54 %) 52 (45 %) 01 (0.9 %) histological type yolk-sac tumor mature teratoma immature teratoma mixed germ cell tumor embryonal carcinoma seminoma sex cord-stromal tumors choriocarcinoma 72 (62.6 %) 03 (2.6 %) 01 (0.9 %) 26 (22.6 %) 04 (3.5 %) 06 (5.2 %) 02 (1.7 %) 01 (0.9 %) stage at diagnosis stage i stage ii stage iii stage iv 53 (46.1 %) 11 (9.6 %) 17 (14.8 %) 34 (29.6 %) site of metastasis (n=51) lung lung + retroperitoneum lung + inguinal lymph nodes retroperitoneum retro peritoneum + inguinal lymph node liver inguinal lymph node 07 (6 .8%) 21 (18.2 %) 01 (0.9 %) 17 (14.7%) 01 (0.9 %) 01 (0.9 %) 03 (2.6 %) in our study all patients had undergone upfront high inguinal radical orchiectomy followed by j islamabad med dental coll 2023 32 32 14 patients of relapse had lympho-vascular invasion on primary histopathology making it a significant factor in predicting relapse (p<0.05). a summary of the factors associated with relapsed testicular germ cell tumor is outlined in table 2. table 2: characteristics of patients with relapsed testicular gct characteristics number (%) age at relapse (years) 0.5-12 years > 12 years 16 (94 %) 01 (6 %) time to relapse (months) mean 6.87+ 1.12 tumor markers (afp) baseline on relapse (9933.06) (3836.41) tumor laterality right testis left testis 11 (64 %) 06 (36 %) histological type yolk-sac tumor mixed germ cell tumor embryonal carcinoma seminoma 12 (70.5 %) 03 (17.6 %) 01 (5.8 %) 01 (5.8 %) stage stage i stage ii stage iii stage iv 11 (64.7 %) 02 (11.7 %) 02 (11.7 %) 02 (11.7 %) site of relapse lung retroperitoneum lung + retroperitoneum inguinal lymph nodes multiple organ site 04 (6.1 %) 06 (18.3 %) 04 (0.9 %) 01 (18.3 %) 02 (0.9 %) lympho vascular invasion on histology yes no 14 (82.3 %) 03 (17.6 %) adjuvant chemotherapy (first line chemotherapy) and three patients already underwent metastatectomy (rplnd) following the first line adjuvant chemotherapy according to the protocol. seventeen (14.7 %) patients developed relapse after complete remission. the mean age of patients at relapse was 8.526 + 2.72 years and the median age was 3.2 (iqr 1-13). patients in less than 12 years of age group relapsed more as compared to older age groups. (p<0.05). the mean time to relapse of disease was 6.87+ 1.12 months after completion of treatment. out of seventeen patients with relapse, eleven (64 %) presented within three months, and six (36 %) patients presented after six months of treatment. among these patients with relapse, eleven (64 %) had a right-sided tumor and 06 (36 %) had tumor on the left side. tumor marker (afp) was significantly raised in all patients but not statistically significant as compared to baseline. relapse was highest in patients with stage i disease (11 patients) followed by two patients in each stage ii, iii and iv. no statistical significance was found between stage & relapse. the most common site of relapse was retro peritoneum. yolk sac tumor was the most common pathology that was noted in twelve (70 %) patients, three (17 %) patients had mixed germ cell tumor, one had seminoma and another one had embryonal carcinoma. no correlation was found between histological sub type and relapse (p>0.05) the seventeen patients who relapsed were restaged; 06 patients had stage iii while 11 patients had stage iv disease at relapse. all of them received second line chemotherapy vip (etoposide or vinblastine plus ifosfamide and cisplatin) as per protocol. post-chemotherapy reassessment showed residual disease in six (30 %) patients who underwent surgery; one had retroperitoneal lymph node dissection (rplnd), 03 underwent inguinal lymph node excision, one had excision of the residual scrotal mass while one patient underwent video-assisted thoracoscopy (vats) & wedge excision of lung nodules. j islamabad med dental coll 2023 33 33 figure: 1: graphical representations of disease-free survival. a: stratification of data according to lymphovascular invasion. b: stratification of stage. c: stratification of age for disease free survival. regarding treatment outcome, 14 patients (82.3%) had complete remission while 03 patients (17.6%) had a second relapse. of these 3 patients, one received further chemotherapy (third line chemotherapy) that was 4 cycles of gamitabine/oxaliplatin and had remission, second patient is currently on palliative chemotherapy while the third patient expired due to rapidly progressive disease while on chemotherapy. the median duration of follow-up of the patients after relapse was 56 months. the median diseasefree survival in the vascular invasion group was 3 months while median dfs in the no vascular invasion group was 9 months with statistically significant disease-free survival (p-value 0.04) in patients with no vascular invasion (figure 1a). the median dfs in the early and advanced stage was 7 and 18 months, respectively (figure 1b). age groups (up to 12 years and above 12 years) also showed significance (0.04) and the median dfs time in both the age groups were 7 and 18 months respectively as shown in figure 1c. d i s c u s s i o n testicular germ cell tumors are common in children and adolescent age groups and treatment with modern platinum-based chemotherapy and surgery has revolutionized the overall outcome with a high cure rate.14, 15 besides delayed presentation, advanced disease stage, inappropriate treatment of the residual disease are the predictors of overall poor outcome. disease relapse related to testicular germ cell tumor (gct) is another major factor that leads to poor outcomes, therefore accurate risk prediction of relapse is essential to avoid the serious potential consequences of overtreatment. risk factors should be analyzed to predict relapse and survival in testicular germ cell tumors in children to make uniform guidelines for treating physicians. in our cohort of 115 patients who were treated for testicular gcts, seventeen (14%) patients had a relapse. the mean age at relapse was 8.526 + 2.72 years. the mean time to relapse after treatment completion was 6.87+ 1.12 months which is supported by findings of thomas et al and others who reported that recurrence rate after 24 months is less in patients with testicular germ cell tumors.16 the analysis of age groups (up to 12 years and > 12 years) showed significant difference (p-value 0.05) in the median disease-free survival (dfs) time in both the age groups that was 07 and 18 months respectively, which suggests the importance of regular follow-up for early detection and treatment. depani s et al 17 reported high recurrence rate in patients with testicular germ cell tumors of stage iiiv disease in contrast to findings in our study where patients with stage i disease were found to have more relapse probably due to higher number of patients in this age group and later presented with advanced stages of disease (stage iii & iv). the retroperitoneum was the most common site of relapse (58 %) with the majority having bulky retroperitoneal nodal size >10 cm, similar findings have been reported in the literature. 18, 19 furthermore, retroperitoneal relapse was seen even in the patients who had a prior history of retroperitoneal lymph node dissection (rplnd) in our study, comparable with results documented by moore et al 19, further emphasizing the critical role of rplnd by an experienced surgeon in the management of testicular gct. the patients who received adjuvant first line chemotherapy also had a significant disease relapse j islamabad med dental coll 2023 34 34 as compared to chemotherapy-naive patients, which are comparable with the findings addressed by friedlander et al, emphasizing that chemotherapy before relapse was a statistically significant and clinically relevant predictor of inferior outcome due to difference in the biology of chemotherapy-naive patients at late relapse from that of patients with a prior history of chemotherapy.20 the findings from another study suggest that in patients with metastatic non-seminomatous germ cell tumors after chemotherapy there was still a small, but continuing risk of recurrence even after 05 years.21 on the other hand, lu sy et al reported in their study that children who were treated with adjuvant chemotherapy had an excellent outcome with a 3year os of >90% in relapsed and metastatic disease.22 the level of serum tumor markers like alphafetoprotein (afp) is useful in diagnosing and monitoring testicular tumors. various studies have documented that patient with raised afp at baseline have a poor prognosis, which is also in consistence with our findings.23 keeping with the present study, serum afp levels were significantly elevated on presentation as well as on relapse in all the patients. regarding tumor laterality, the right side of the tumor had more relapse in eleven (64 %) patients and non-seminomatous gct (yolk sac tumor) was the most common pathology found in patients who relapsed which is comparable with the findings documented in the literature.24 on analyzing the patients with lymphovascular invasion at presentation, fourteen patients had lymph vascular invasion who later presented with disease relapse with statistically significant diseasefree survival (p-value 0.04) and median disease-free survival was (03 vs 09 months in both groups). lobo j et al documented that patients with vascular invasion have worse relapse-free survival compared to those without vascular invasion with p < 0.001. therefore, the presence of lymph vascular invasion is an important risk factor for predicting the disease relapse on histopathology 25.limitation of this study is that it was a single centered and retrospective study with a small number of patients. c o n c l u s i o n management of patients with testicular gcts requires multidisciplinary team approach and standardized follow-up protocol for early detection and treatment of relapse. complete surgical excision with meticulous control of the residual disease is critical to prevent disease relapse. the standardization of follow-up for individual patients can result in optimizing risk/benefit ratios. r e f e r e n c e s 1. pietrzyk ł, denisow-pietrzyk m, czeczelewski m, ślizień-kuczapski k, torres k: cancer education matters: a report on testicular cancer knowledge, awareness, and self-examination practice among young polish men. scientific reports. 2020, 26:1-9. 10.1038/s41598-020-77734-3 2. park js, kim j, elghiaty a, ham ws: recent global trends in testicular cancer incidence and mortality. medicine. 2018, 97:10.1097/md.0000000000012390 3. cheng l, albers p, berney dm, feldman dr, daugaard g, gilligan t, et al. testicular cancer. nature reviews disease primers. 2018 oct 5;4(1):29. 4. kozakova k, mego m, cheng l, chovanec m. promising novel therapies for relapsed and refractory testicular germ cell tumors. expert review of anticancer therapy. 2021 jan 2;21(1):53-69. 5. marshall c, enzerra m, rahnemai-azar aa, ramaiya nh: serum tumor markers and testicular germ cell tumors: a primer for radiologists. abdominal radiology. 2019, 44:1083-90. 10.1007/s00261-0181846-z 6. thomas kl, jeong d, montilla-soler j, feuerlein s: the role of diagnostic imaging in the primary testicular cancer: initial staging, response assessment, and surveillance. translational andrology and urology. 2020:9. 10.21037/tau.2019.07.01 7. nicholson bd, jones nr, protheroe a, joseph j, roberts nw, van den bruel a, et al. the diagnostic performance of current tumour markers in surveillance for recurrent testicular cancer: a diagnostic test accuracy systematic review. cancer epidemiology. 2019 apr 1;59:15-21. j islamabad med dental coll 2023 35 35 8. honecker f, aparicio j, berney d, beyer j, bokemeyer c, cathomas r, et al. esmo consensus conference on testicular germ cell cancer: diagnosis, treatment and follow-up. annals of oncology. 2018 aug 1;29(8):1658-86. 9. rescorla fj, ross jh, billmire df, dicken bj, villaluna d, davis mm, et al. surveillance after initial surgery for stage i pediatric and adolescent boys with malignant testicular germ cell tumors: report from the children’s oncology group. journal of pediatric surgery. 2015 jun 1;50(6):1000-3. 10. o’shaughnessy mj, feldman dr, carver bs, sheinfeld j. late relapse of testicular germ cell tumors. urologic clinics. 2015 aug 1;42(3):359-68. 11. kvammen ø, myklebust tå, solberg a, møller b, klepp oh, fosså sd, et al . long-term relative survival after diagnosis of testicular germ cell tumorrelative survival after testicular germ cell tumor. cancer epidemiology, biomarkers & prevention. 2016 may 1;25(5):773-9. 12. wagner t, toft bg, engvad b, lauritsen j, kreiberg m, bandak m, et al. prognostic factors for relapse in patients with clinical stage i testicular cancer: protocol for a danish nationwide cohort study. bmj open. 2019 oct 1;9(10):e033713. 13. olson ta, murray mj, rodriguez-galindo c, nicholson jc, billmire df, krailo md, dang hm, amatruda jf, thornton cm, arul gs, stoneham sj. pediatric and adolescent extracranial germ cell tumors: the road to collaboration. journal of clinical oncology. 2015 sep 9;33(27):3018. 14. khazaei z, sohrabivafa m, mansori k, naemi h, goodarzi e: incidence and mortality of cervix cancer and their relationship with the human development index in 185 countries in the world: an ecology study in 2018. advances in human biology. 2019, 1:222. 10.4103/aihb.aihb_15_19 15. smith zl, werntz rp, eggener se. testicular cancer: epidemiology, diagnosis, and management. medical clinics. 2018 mar 1;102(2):251-64. 16. thomas lj, brooks ma, stephenson aj. the role of imaging in the diagnosis, staging, response to treatment, and surveillance of patients with germ cell tumors of the testis. urologic clinics. 2019 aug 1;46(3):315-31. 17. depani s, stoneham s, krailo m, xia c, nicholson j. results from the uk children's cancer and leukaemia group study of extracranial germ cell tumours in children and adolescents (gciii). european journal of cancer. 2019 sep 1;118:49-57. 18. hamilton rj, nayan m, anson-cartwright l, atenafu eg, bedard pl, hansen a, et al. treatment of relapse of clinical stage i nonseminomatous germ cell tumors on surveillance. journal of clinical oncology. 2019 aug 1;37(22):1919-26. 19. moore ja, slack rs, lehner mj, campbell mt, shah ay, zhang m, et al . very late recurrence in germ cell tumor of the testis: lessons and implications. cancers. 2022 feb 23;14(5):1127. 20. friedlander tw, small e. testicular cancer. inabeloff's clinical oncology 2020 jan 1 (pp. 14421467). elsevier. 21. king jm, althouse s, cary c, masterson t, foster rs, ashkar r, et al. surveillance after complete response to first-line chemotherapy in patients with metastatic nonseminomatous germ cell tumor. the journal of urology. 2022 sep;208(3):641-9. 22. lu sy, sun xf, zhen zj, qin zk, liu zw, zhu j, et al . survival analysis of children with stage ii testicular malignant germ cell tumors treated with surgery or surgery combined with adjuvant chemotherapy. chinese journal of cancer. 2015 feb;34(2):86-93. 23. pedrazzoli p, rosti g, soresini e, ciani s, secondino s. serum tumour markers in germ cell tumours: from diagnosis to cure. critical reviews in oncology/hematology. 2021 mar 1;159:103224. 24. stump ja, acosta am, whaley rd, cheng l, fang am, rais-bahrami s,et al. pathologic findings and clinical outcomes in patients who required neoadjuvant chemotherapy before orchiectomy for testicular germ cell tumors. human pathology. 2022 oct 1;128:48-55. 25. lobo j, gillis aj, van den berg a, looijenga lh: prediction of relapse in stage i testicular germ cell tumor patients on surveillance: investigation of biomarkers. bmc cancer. 2020, 20:1-6. 10.1186/s12885-020-07220-6 j islamabad med dental coll 2022 169 open access an audit of laparoscopic cholecystectomy; at a tertiary care hospital in islamabad muneebullah1, romassa javed2, muhammad faisal murad3, muhammad kashif khan4, faisal nadeem5, adil shafi6 1assistant consultant,department of surgery, maroof international hospital, islamabad,pakistan. 2,4,5medical officer, department of surgery, maroof international hospital, islamabad,pakistan. 3chief of surgery, maroof international hospital, islamabad,pakistan. 6registrar, department of surgery, maroof international hospital, islamabad,pakistan. a b s t r a c t background: laparoscopic cholecystectomy is a commonly performed surgery and is a gold standard for the treatment of cholelithiasis as it has fewer side effects. this study was conducted to determine indications and complications of this surgery at a tertiary care hospital in islamabad. methodology: this retrospective study was conducted in the department of surgery, maroof international hospital from march 2017 to march 2019. a total of 250 patients who underwent laparoscopic cholecystectomy were included through consecutive sampling technique. the data regarding age, gender, mode of presentation, types of presentation, per operative findings, operative complications and duration of hospital stay was collected from patients’ medical record. statistical package for social sciences spss version 23 was used to analyze data. results: mean age of the participants was 46.24 ± 14.13 years. female to male ratio was 2.73:1. almost 38.4% patients had chronic cholecystitis, 35.2% had symptomatic gallstone disease, 24.8% had acute cholecystitis and 1.6% had gallbladder polyps. no major vascular or common bile duct injury were noted. 27.2% patients had per operative gallbladder perforation. stone spillage occurred in 8.8% patients with retrieval in all of them. 75.2% patients were discharged on day 1. per operatively, 98.4% patients had cholelithiasis, 59.6% had adhesions, 9.6% had mucocele, 1.6% had empyema and 0.8% patients had collections. conclusion: laparoscopic cholecystectomy is a safe procedure in all types of gallstone disease presentations with low complication rate. key words: cholelithiasis, gallstones, laparoscopic cholecystectomy, per-operative complications authors’ contribution: 1conception; literature research; manuscript design; 2,3 critical analysis and manuscript review; 4data collection; 5,manuscript editing;6data analysis. correspondence: muneebullah email muneebullah@gmail.com article info: received: august 28, 2021 accepted: june 27, 2022 cite this article, muneebullah, javed r, murad f m, khan k m,nadeem f, shafi a. a review of laparoscopic cholecystectomy; 250 cases at maroof international hospital, islamabad.j islamabad med dental coll. 2022; 11(3): 169-174 funding source: nil conflict of interest: nil doi: https://doi.org/10.35787/jimdc.v11i3.774 i n t r o d u c t i o n laparoscopic surgery is also known as keyhole surgery since it utilizes very small incisions (0.5cm to 1cm) through which laparoscope and working instruments are introduced.1 due to small keyhole incisions, it is associated with less pain and earlier return to normal activity.2 it is a well-established procedure with rapidly evolving indications.3 currently, laparoscopic cholecystectomy is the gold o r i g i n a l a r t i c l e mailto:muneebullah@gmail.com j islamabad med dental coll 2022 170 standard procedure for treatment of cholelithiasis and also the most commonly performed laparoscopic surgery.4,5 the main aim of laparoscopic cholecystectomy is to minimize the trauma to the patients without compromising the efficacy of the treatment. it is performed as a day case surgery in general anesthesia with lesser duration of hospital stay as compared to traditional surgery.6 overall ,less surgical morbidity and mortality is reported with this procedure.7,8 early laparoscopic cholecystectomy is still performed by minority of surgeons for acute cholecystitis.9 this preference was based on high risk of complications owing to local inflammation and difficulty in calot’s triangle dissection in acute setting.10 previous attacks of cholecystitis or episodes of biliary pancreatitis are associated with adhesions formation thus making cholecystectomy more difficult. the common complications of laparoscopic cholecystectomy include vascular injuries resulting in bleeding or visceral injuries mostly related to common bile duct.11complications also include nausea, vomiting and postoperative parietal, visceral, incisional and referred pain.12 factors involved in the development of this pain include phrenic nerve irritation resulting from the insufflation of carbon-dioxide into the peritoneal cavity, abdominal distension, port site incisions and trauma associated with removal of the gallbladder.13 with recent advances and expertise in laparoscopic surgery, the paradigm has shifted to minimally invasive surgery. nevertheless, no surgery is without risks of morbidity and mortality. the main aim of this study was to determine common indications and per operative complications of laparoscopic cholecystectomy at our tertiary care setup and compare them with local and international studies. this will help audit outcomes, flaws and weaknesses based on evidence that will eventually lead to improvement of surgical practice. m e t h o d o l o g y this retrospective study was conducted in the department of surgery, maroof international hospital from march 2017 to march 2019. a total of 250 patients who underwent laparoscopic cholecystectomy were included through consecutive sampling technique. sample size was calculated in context to another local study.14 patients were evaluated clinically, biochemically and radiologically before proceeding for surgery. those having symptomatic gallstone disease, acute calculous cholecystitis, chronic cholecystitis and gallbladder polyps were included in the study. those with previous abdominal malignancy, pre-operative diagnosis of choledocholithiasis, dilated common bile duct, cholangitis, acalculous cholecystitis or those who elected open cholecystectomy were excluded from the study. two cases were converted to open surgeries which were excluded from study sample. all surgeries were performed by chief of surgery assisted by his surgical team. prophylactic antibiotic was given to all patients intravenously. standard four port laparoscopic cholecystectomy was performed. pneumoperitoneum was established using open method in all cases. high definition camera by karl storz was used. per operative complications were assessed by reviewing recorded videos of surgery. the data was collected from medical records of the patients and it included age, gender, mode of presentation (outpatient department or emergency), types of presentation (acute cholecystitis, chronic cholecystitis, symptomatic gallstones and gallbladder polyps), per operative findings, operative complications and duration of hospital stay. per operative findings included gallstones, acute cholecystitis, adhesions, mucocele, empyema, abscess or collection around gallbladder, vascular bed anomaly or biliary tree anomaly, accessory cystic duct and others. operative complications included bleeding that was recorded in milliliters categorized into less than 50ml (that required no intervention), 51 to 150ml j islamabad med dental coll 2022 171 (that required use of gauze for cleaning) and more than 150ml (that required suctioning), bile duct injury, gallbladder perforation, clip slippage, gallstone spillage, intestinal injury and others. drains were placed in few cases in which there was gallbladder perforation, spillage of stones, empyema, bleeding or risk of cystic duct blowout. statistical package for social sciences (spss) version 23 was used to analyze data. quantitative data was entered as mean ± sd. qualitative data was expressed as number and percentages. r e s u l t s mean age of the participants was 46.24 ± 14.13 years. it ranged from 18 to 83 years. 73.2% (183) patients were females and 26.8% (67) males. female to male ratio was 2.7:1. patients admitted via opd were 88% (220) whereas 12% (30) patients were admitted via emergency. most common presentation was chronic cholecystitis (35.2%) and symptomatic gallstone disease (24.8%) as shown in table 1. most common per operative findings are documented in table 2. most common peroperative complication was gallbladder perforation that occurred in 27.2% (68) patients while stone spillage was seen in 8.8% (22) patients. suction irrigation of cavity and retrieval of stones was done in all these patients. no common bile duct injury was documented or seen in videos. drains were placed in 14.4% (36) patients. 75.2% (188) patients were discharged within 24 hours as shown in table 3. comorbid conditions included hypertension in 19.2% (48) patients, diabetes mellitus in 12% (30), hepatitis c in 3.6% (9), ischemic heart disease in 2.4% (6), tuberculosis in 1.2% (3), asthma/chronic obstructive lung disease in 0.8% (2) and hepatitis b in 0.4% (1) patients. table i : mode of presentation (n=250) chronic cholecystitis 38.4% (n=96) symptomatic gallstones 35.2% (n=88) acute cholecystitis 24.8% (n=62) gallbladder polyp 1.6% (n=4) table ii : per operative findings (n=250) blood loss less than 50ml 72% (180) 51 to 150ml 22% (55) more than 150ml 6% (15) accessory duct 0.8% (n=2) cholelithiasis 98.4% (n=246) adhesions 59.6% (n=149) mucocele 9.6% (n=24) empyema 1.6% (n=4) pus collection 0.8% (n=2) table iii: duration of hospital stay one day 75.2% (188) two days 17.2% (43) more than two days 7.6% (19) d i s c u s s i o n laparoscopic cholecystectomy is the treatment of choice and gold standard due to less pain, minimum surgical trauma, short postoperative hospital stay and early return to home. in our study, female to male ratio was 2.7:1 (73.2% vs 26.8%) which shows less female predominance as compared to another study conducted in pakistan.15 this may represent a changing trend of cholelithiasis, becoming more common in males in our region owing to dietary changes over recent times. however, the female predominance itself is consistent with international data.16 mean age in our study was 46 years which is consistent with regional and international studies.15,16 in terms of presentation or indication for surgery, 38.4% patients had chronic cholecystitis, 35.2 % had symptomatic gallstone disease, 24.8% had acute cholecystitis and 1.6% had gallbladder j islamabad med dental coll 2022 172 polyps. this is consistent with the study done in pakistan.15 mostly bleeding in laparoscopic cholecystectomy occurs from trocar site insertion, liver bed (especially in cases of acute cholecystitis and empyema gallbladder) and vascular injury (usually cystic duct or its branches or anomalous vessel). in rare cases, massive bleed can occur due to injury to abdominal aorta, vena cava, iliac vessels, hepatic artery or portal vein.17 in our study, 72% patients had less than 50ml blood loss, 22% patients had 51 to 150 ml blood loss and 6% patients had more than 150ml blood loss. there was no major vascular injury in our study. 27.2% patients had per operative gallbladder perforation resulting in bile spillage. it is less as compared to an international study that reported gallbladder perforation in 36.1% patients.18 it is variably common in 10 to 30% of laparoscopic cholecystectomies, but it is usually not associated with any dreadful outcome, surgical site infection or post-operative collection.19 suction irrigation of the contaminated area is sufficient to address it. stone spillage occurred in 8.8% patients in our study. spilled stones can be culprits for abdominal collection, abscess formation, pain ileus etc. to avoid these, stone retrieval was performed in all of such cases followed by lavage. additionally, clips were applied from where the spillage started, to prevent further contamination and spillage. acutely inflamed and over distended gall bladders were main factors for this intraoperative event. no common bile duct injury was noted. this is consistent with studies done in karachi and peshawar.20,21 the incidence of common bile duct injury is strongly related to exposure of calot’s triangle, experience, knowledge and proper training of a laparoscopic surgeon. it is one of the most dreadful complications while performing laparoscopic cholecystectomy.15 high morbidity, mortality, and prolonged hospitalization is associated with common bile duct injury.22 accessory cystic duct was noted in two cases. this is a unique finding and requires active per operative vigilance to recognize it which otherwise will present as bile leakage and related complications. there are few cases of accessory cystic duct reported internationally.23,24 75.2% patients were discharged on day 1 which is a routine worldwide in good laparoscopic centers. patients requiring two or more days were mostly cases of acute cholecystitis, biliary pancreatitis or those who needed time for decision or second opinions with family and doctors regarding surgery in acute cholecystitis, empyema gallbladder etc. comorbidities included hypertension 19.2%, diabetes mellitus 12%, hepatitis c 3.6%, ischemic heart disease 2.4%, tuberculosis 1.2%, asthma/chronic obstructive lung disease 0.8% and hepatitis b 0.4%they were optimized with proper specialist consultations accordingly prior to surgery. this was a single-center study and retrospective in nature as all the data was collected from the past records that limits its quality. multi-centered study with a larger sample size would have increased generalizability. same surgeon performing all the operations adds to benefit on one side but also adds the bias to the study. it is pertinent to see the outcomes when another specialist performs the surgery with the same team. this study has provided evidence for improving surgical practices and demonstrated that proper training and experience decreases the risk of intraoperative complications and high end laparoscopic setup and vigilance improves the outcomes. c o n c l u s i o n laparoscopic cholecystectomy is a safe procedure in all types of gallstone disease presentations with a low complication rate. r e f e r e n c e s 1. ahmad g, baker j, finnerty j, phillips k,watson a. laparoscopic entry techniques. the cochrane library. 2019;1(1):cd006583. doi: 10.1002/14651858.cd006583.pub5 j islamabad med dental coll 2022 173 2. jaschinski t, mosch c g, eikermann m, neugebauer e.a, sauerland s. laparoscopic versus open surgery for suspected appendicitis. cochrane database of systematic reviews. 2018;11(11):cd001546. doi: 10.1002/14651858.cd001546.pub4 3. balogun o s, osinowo a o, olajide t o, lawal a o, adesanya a, atoyebi o a, et al. development and practice of laparoscopic surgery in a nigerian tertiary hospital. nigerian journal of clinical practice. 2020;23(10):1368–1374. doi: 10.4103/njcp.njcp_125_20 4. târcoveanu e, vasilescu a, lupaşcu c, vlad n, moraru m, stanciu c,et al. laparoscopic cholecystectomy in cirrhotic patients. chirurgia (bucharest, romania: 1990). 2020;115(2):213-219. doi: 10.21614/chirurgia.115.2.213 5. loozen c. s, van santvoort h. c, van duijvendijk p, besselink m. g, gouma d. j, nieuwenhuijzen g. a, et al.laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (chocolate): multicentre randomised clinical trial. bmj (clinical research ed.). 2018;363:k3965 doi: https://doi.org/10.1136/bmj.k3965 6. xu y, wang h,yang, m. preoperative nursing visit reduces preoperative anxiety and postoperative complications in patients with laparoscopic cholecystectomy: a randomized clinical trial protocol: a randomized clinical trial protocol. medicine. 2020;99(38):e22314. doi:10.1097/md.0000000000022314 7. amreek f, hussain s. z. m, mnagi m. h, rizwan, a. retrospective analysis of complications associated with laparoscopic cholecystectomy for symptomatic gallstones. cureus. 2019;11(7):e5152. doi: 10.7759/cureus.5152 8. donmez, t, erdem, v. m, uzman s, yildirim d, avaroglu h, ferahman s, et al.laparoscopic cholecystectomy under spinal-epidural anesthesia vs. general anaesthesia: a prospective randomised study. annals of surgical treatment and research. 2017;92(3):136– 142. doi.org/10.4174/astr.2017.92.3.136 9. panagiotopoulou ig, carter n, lewis mc, rao s. early laparoscopic cholecystectomy in a district general hospital: is it safe and feasible? int j evid based health. 2012;10(2):112–6. doi: 10.9738/intsurg-d-1300068.1 10. hayama s, ohtaka k, shoji y, ichimura t, fujita, m, senmaru n, et al. risk factors for difficult laparoscopic cholecystectomy in acute cholecystitis. journal of the society of laparoendoscopic surgeons. 2016;20(4):e2016.00065. doi: 10.4293/jsls.2016.00065 11. dalwani ag, shaikh r, das k, devrajani t, shah sza, shah a. complications of laparoscopic cholecystectomy at liaquat university, jamshoro. world appl sci j. 2013;23(6):808–11. doi: 10.5829/idosi.wasj.2013.23.06.747 12. isazadehfar k, entezariasl m, shahbazzadegan b, nourani z, shafee y. the comparative study of ondansetron and metoclopramide effects in reducing nausea and vomiting after laparoscopic cholecystectomy. acta medica iranica. 2017;55(4):254-258. pmid: 28532137 13. protic m, veljkovic r, bilchik aj, popovic a, kresoja m, nissan a, et al. prospective randomized controlled trial comparing standard analgesia with combined intra-operative cystic plate and port-site local anesthesia for post-operative pain management in elective laparoscopic cholecystectomy. surg endosc. 2017;31(2):704-713. doi: 10.1007/s00464-016-50245. 14. farooq umar, rashid tariq, naheed asma, barkat najeeb, iqbal muhammad, sultana qamar. complications of laparoscopic cholecystectomy. j ayub med coll abbottabad 2015;27(2):407-410. pmid: 26411129 15. afzal m, rehman s, butt m. q. complications of laparoscopic cholecystectomy: an analysis of 400 consecutive cases. pak armed forces med j.2014;64(4):546-50. www.pafmj.org/index.php/pafmj/article/view/1399 16. shah my, somasundaram u, wilkinson t, wasnik n. feasibility and safety of three-port laparoscopic cholecystectomy compared to four-port laparoscopic cholecystectomy. cureus. 2021;13(11):e19979. doi: 10.7759/cureus.19979 17. desai gs, pande p, narkhede r, kulkarni dr. revision roux-en-y hepaticojejunostomy for a postcholecystectomy complex vasculobiliary injury with complete proper hepatic artery occlusion: a case report and literature review. int j surg case rep. 2019;58:6-10. doi: 10.1016/j.ijscr.2019.03.032 18. altuntas ye, oncel m, haksal m, kement m, gundogdu e, aksakal n, et al. gallbladder perforation during elective laparoscopic cholecystectomy: incidence, risk factors, and outcomes. north clin istanb. 2018;5(1):47-53. doi: 10.14744/nci.2017.88155 19. evans l, sams e, naguib a, hajibandeh s, hajibandeh s. iatrogenic gallbladder perforation during laparoscopic cholecystectomy and outcomes: a systematic review and meta-analysis. langenbeck's archives of surgery. 2022;407(3):937-946. doi: 10.1007/s00423-022-02439-2 j islamabad med dental coll 2022 174 20. kerawala aa, bakhtiar n, qureshi na. laparoscopic cholecystectomy by resident is safe. rmj. 2019;44(03):634-636. 21. shah ru, shah s, qazi m, shiraz da, ullah hn, kalim m. outcome of laparoscopic cholecystectomy in terms of complications in lady reading hospital peshawar. professional med j. 2022;29(06):859-863. doi: 10.29309/tpmj/2022.29.06.6639 22. halbert c, altieri ms, yang j, meng z, chen h, talamini m, et al. long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy. surg endosc. 2016;30:4294-4299. doi: 10.1007/s00464-016-4745-9 23. wu ch, wu pw, wong yc, kang sc. diagnosis of a single gallbladder with double cystic ducts and dominant accessory duct draining into the right hepatic duct: a case report. j int med res. 2021;49(11):3000605211053981. doi:10.1177/03000605211053981 24. munie s, nasser h, go ph, rosso k, woodward a. case report of a duplicated cystic duct: a unique challenge for the laparoscopic surgeon. int j surg case rep. 2019;56:78-81. doi:10.1016/j.ijscr.2019.02.030 j islamabad med dental coll 2021 131 o p e n a c c e s s polymers, an infrangible part of our life. taimoor hassan1, chao zhou2, sana saeed3 1lecturer, department of health professional technologies, the university of lahore 1post graduate scholar, school of pharmacy and medicine, changzhou university, jiangsu, china 2associate professor, school of pharmacy and of medicine, changzhou university, jiangsu, china 3lecturer, department of health professional technologies, the university of lahore the polymers, a most heard word in our daily life is a macromolecule or a large molecule, which is typically a combination of plethora of subunits. we live in an era of industrial revolution where we cannot imagine life without polymers.1 they are salient part of our personal, domestic and commercial life from our dna to giant spaceships. since long ago, polymers are being used in the lives of people in different aspects, but after the advent of world war ii, polymers got their recognition globally. in the past, we had very limited availability of materials to sustain a civilized life. the wood, steel, stone, glass, were specifically used for construction purposes, while cotton, jute, wood and some other agricultural products were used in textile industry for cloth production. the traditional materials that people used were heavy and brittle.2 the industrial revolution of 20th and 21st century introduced enormous other new materials. these materials are said to be polymers, and their impact on our daily life in multiple domains is incalculable. almost everything around us is made up of polymers, like; clothing is made up of synthetic fibers, the fiberglass, every type of plastic bag, paints, polystyrene based electronic devices, silicone heart valves, polypropylene based medical syringes, catheters, tubes, polyurethane based cushions and foams used in hospitals and the list is countless.3 a word ‘polymer’ or ‘macromolecule’ is of greek origin. in greek the word poly means ‘many’ and the word meres means ‘several parts’. a polymer weighs in ranges 10 000-1000 000 g/mol and further consist of longs chains and structural subunits which bind together by a covalent bond specifically.4 polymers are derived from the reactions of monomers, the sub-units. the monomers have a distinct property of reaction with same type of molecules or with different types of molecules under certain conditions to form polymer chains. the polymers like; collagen, latex, cellulose, starch etc are formed naturally while the man-made polymers are synthetic. the natural polymers are with us since the beginning, while synthetic polymers (nylon, polyvinyl chloride, polyethylene etc.) are studied widely since 20th century. today the polymer industry has taken over the other industries combined like; steel, copper, silver, gold.5 today, the polymer industry is widely used to provide comfort to humans in almost every domain of life; in fast-communications, quality agriculture, good nutrition, instant transportations, diverse clothing, business-skyscrapers, carpet highways, entertainment, advanced medical facilitation etc. in today’s world, it is very difficult for us to sustain life without polymers.6 in increasing technological world, science plays a vital role in giving the solutions to expository problems like food, clean e d i t o r i a l correspondence: taimoor hassan email: taimoorhassan408.th@gmail.com cite this editorial: hassan t, zhou c, saeed s. polymers, an infrangible part of our life. j islamabad med dental coll. 2021; 10(3): 131-132 doi: 10.35787/jimdc.v10i3.747 j islamabad med dental coll 2021 132 environment, safety, energy and ultimate health. the theory of polymers gives us a basic understanding to live a healthy life. basic life sciences define the concept of polymers thoroughly, this includes practical, factual and theoretical knowledge.5 natural and synthetic polymers can be used in organic and inorganic forms; elastomers, plastics, fibers, adhesives, ceramics, blends and composites. the basic principle applied to one polymer category is also applicable to other categories of polymers with some essential regulations and conditions.7 it is worth-mentioning that experts from all domains: doctors, pharmacists, technologists, chemical engineers, textile engineers, mechanical engineers, technicians, chemists, research experts are directly and indirectly involved in research projects related to polymers. surprisingly, in biomedicine, molecular biology, biophysics, polymer biology and pharmacy, the biopolymers have opened new horizons of researches.1 it is quite obvious that why the study of these giant molecules is catching the eyes of researchers in today’s era. therefore, it is crystal-clear that the polymer is not an interdisciplinary subject or a branch of chemistry, but it is itself a specialized, unique and broad discipline that covers parts of chemistry, medicine, biology, physics and many more. science has played a tremendous role in exploring the hidden facts of nature.3 there is no ambiguity in saying that today the biopolymer branch, is taking over the classical fields of physics, chemistry, material engineering and even polymer engineering and is widely used in treatment, diagnosis of diseases and advanced application of medical devices. keywords: polymers, biopolymers, natural, synthetic, monomer. acknowledgments: authors like to acknowledge ‘jimdc’ for the publication of this editorial r e f e r e n c e s 1. namazi h. polymers in our daily life. bioimpacts. 2017;7(2):73. doi:10.15171/bi.2017.09. 2. ramesh kumar s, shaiju p, o'connor ke. bio-based and biodegradable polymers-state-of-the-art, challenges and emerging trends. curr opin green sustain chem. 2020; 21(2):75-81. doi: 10.1016/j.cogsc.2019.12.005. 3. hong m, chen ey. future directions for sustainable polymers. trends chem. 2019;1(2). doi: 10.1016/j.trechm.2019.03.004:148-51. 4. lutz jf. can life emerge from synthetic polymers? isr j chem. 2020; 60(1-2):151-9. doi: 10.1002/ijch.201900110. 5. badia jd, gil-castell o, ribes-greus a. long-term properties and end-of-life of polymers from renewable resources. polym degrad stab. 2017; 13(7):35-57. doi: 10.1016/j.polymdegradstab.2017.01.002. 6. ma x, wen g. development history and synthesis of super-absorbent polymers: a review. journal of polymer research. 2020; 27(6):1-2. doi:10.1007/s10965-020-02097-2. 7. ramesh p, vinodh s. state of art review on life cycle assessment of polymers. international journal of sustainable engineering. 2020; 13(6):411-22. doi: 10.1080/19397038.2020.1802623. https://doi.org/10.15171/bi.2017.09 https://doi.org/10.1016/j.cogsc.2019.12.005 https://doi.org/10.1016/j.cogsc.2019.12.005 https://doi.org/10.1016/j.trechm.2019.03.004 https://doi.org/10.1016/j.trechm.2019.03.004 https://doi.org/10.1002/ijch.201900110 https://doi.org/10.1002/ijch.201900110 https://doi.org/10.1016/j.polymdegradstab.2017.01.002 https://doi.org/10.1016/j.polymdegradstab.2017.01.002 http://dx.doi.org/10.1007/s10965-020-02097-2 https://doi.org/10.1080/19397038.2020.1802623 https://doi.org/10.1080/19397038.2020.1802623 35 j i m d c 2 0 1 7 35 op e n ac c e ss f u l l l e n g t h a r t i c l e comparison of anti-diabetic activity of berberis lycium royle stem bark (barberry) and pioglitazone in type 2 diabetes induced mice model hina aslam1, akbar waheed2, muhammed nauman shad3, khalid niaz4 1assistant professor pharmacology, islamabad medical & dental college 2professor & head of pharmacology department, islamic international medical college iimc-t 3associate professor pharmacology, islam dental college, sialkot 4.assistant professor pharmacology, islamabad medical & dental college a b s t r a c t objective: to compare the anti-diabetic activity of aqueous extract of stem bark of berberis lycium royle and pioglitazone –a thiazolidinedione in a type 2 diabetes mellitus induced male mice model. material and methods: this randomized control trial was carried out in the animal house of national institute of health (nih), islamabad for 10 weeks. fifty albino balb/c male mice were divided randomly into groups i-v (10 in each group). group i served as normal control group. in rest of the forty mice from group ii-v, type 2 diabetes mellitus was induced by administration of high fat diet (hfd) for two weeks followed by low dose (40 mg/kg) intra-peritoneal streptozotocin (stz) injections for four consecutive days. group ii served as the disease control group, group iii received the aqueous extract of stem bark of berberis lycium royle in dose of 50 mg/kg body wt. while group iv received the aqueous extract of stem bark of berberis lycium royle in dose of 100 mg/kg body wt. group v was administered pioglitazone in a dose of 30mg/kg body wt. the herb extract and the drug was given orally once a day for six consecutive weeks. samples were taken at the end of ten weeks. results: the blood samples estimated for fasting blood glucose (fbg) & glycosylated hemoglobin (hba1c %) levels showed that the aqueous extract of stem bark of berberis lycium royle in a high dose (100 mg/kg body wt.) maximally lowered the fbg and hba1c% levels followed by its low dose (50 mg/kg body wt.) pioglitazone also reduced the fbg and hba1c% to normal limits but its extent was less than the aqueous extract of stem bark of berberis lycium royle. conclusion: the aqueous extract of stem bark of berberis lycium royle lowers the fbg and hba1c levels in a type 2 diabetes induced male mice in a dose dependent manner. key words: berberis lycium royle, diabetes mellitus type 2, pioglitazone, streptozotocin,. author`s contribution 1conceived the topic of research and designed the study,2literature review and manuscript writing,3data analysis and discussion address of correspondence dr. hina aslam doc.hina.aslam1@gmail.com article info. received: jan 6, 2017 accepted: mar 22, 2017 cite this article: aslam h, waheed a, shad mn, niaz k. comparison of anti-diabetic activity of berberis lycium royle stem bark (barberry) and pioglitazone in type 2 diabetes induced mice model. jimdc. 2017; 6(1):35-39. funding source: nil conflict of interest: nil i n t r o d u c t i o n around the world, diabetes affects 2-3% of the total population. so, diabetes mellitus is now a clinical syndrome.1 it is characterized by long standing hyperglycemia along with the disturbances of carbohydrate, fat and protein metabolism due to a defect in either insulin secretion, action or both.2 everyday new o r i g i n a l a r t i c l e mailto:doc.hina.aslam1@gmail.com 36 j i m d c 2 0 1 7 36 researches are taking place to discover more efficacious drugs. thus modern medicine has been famous for its efficient role but the side effects have always been a grim.3 so the trends have gradually started shifting towards the use of natural products.4 berberis lycium royle (family berberidaceae) is a famous medicinal herb.5 it is known as barberry in english.6 berberis lycium royle is found in pakistan, indian occupied kashmir, bhutan, japan, china, nepal, united kingdom, ireland, turkey and parts of asia, south america, southern argentina, chile and europe.1,2 in pakistan, it is abundantly found in margalla hills.7 it is also distributed in northern areas such as gilgit, baltistan, ghizer, astor, diamer and swat, khyber pakhtunkhwa.8 berberis lycium royle as an anti-diabetic agent has been investigated. studies have been conducted on its different parts like the root, stem, leaves, fruit and root bark, both in crude and extracted forms. its stem bark has not been investigated yet, despite the fact that the stem bark is readily available in local market. berberine-the active ingredient with the anti-diabetic potential, is present in highest concentrations in roots followed by stem bark.9,10 so far the anti-diabetic activity of berberis lycium royle has been compared with the current anti-diabetic agents like insulin, gliclazide, glibenclamide.10,11 in the present study, aqueous extract of stem bark of the herb was selected and its anti-diabtic property was compared to another oral anti-diabetic drug; pioglitazone. m a t e r i a l a n d m e t h o d s a randomized controlled study of ten weeks’ duration was carried in the animal house of national institute of health (nih), islamabad. a total of fifty healthy male albino balb/c mice, weighing 28-38g and aged between 6-8 weeks, having fasting blood glucose (fbg) levels not more than 110 mg/dl and hba1c <6.0 were included in study. all mice were acclimatized for one week and then they were randomly divided in five groups (group i-v), each group containing 10 mice in total. group i (n=10) served as the normal control group. in rest of forty mice (group ii-v), type 2 diabetes mellitus was induced by administration of high fat diet (hfd) for two weeks followed by low dose intra-peritoneal injection of freshly prepared streptozotocin (stz), once daily for four consecutive days.12,13 a persistent fbg level >250mg/dl was selected as the cut off point for the confirmation of diabetes.14 group ii was the diabetes control group to which no drug or herb was given. group iii received 50 mg/kg body wt. (low dose) of aqueous extract of stem bark of berberis lycium royle while the group iv received 100 mg/kg body wt. (high dose) of aqueous extract of stem bark of berberis lycium royle. the group v received the drug; pioglitazone in a dose of 30mg/kg body wt. the herb and the drug were given orally once daily for six consecutive weeks. mice were housed under the controlled conditions of room temperature 20+2o c, relative humidity 50%-70% and 12-h light-dark cycle. they were provided free access to water ad libitum. all mice were handled in accordance to the nih guidelines. the stem bark of berberis lycium royle was collected from village prang, charsadda. it was identified by a botanist at botany department, peshawar university. it was then washed thoroughly with water and shade dried. it was grounded into a fine powder with an electrical grinder and taken into a non-metallic jar. the bark powder was soaked in distilled water for 72 hours with periodic stirring. it was then filtered using whatmann filter paper no.1. the filtrate was evaporated at 55 0c in a rotary evaporator at the research laboratory of riphah institute of pharmaceutical sciences (rips), islamabad. the extract was obtained as a dark brown semi-solid sticky paste. it was stored in air tight glass bottles, protected from light and kept in refrigerator at 2-8 oc to be used throughout the experiment. the yield of aqueous extract of stem bark of berberis lycium royle with respect to the original dry plant material was about 25%.15 blood samples were taken at the end of week 4 for the confirmation of diabetes mellitus and at the end of week 10 for final sampling. the 6-hr fasting blood samples were preferred as blood glucose levels vary widely together with food intake during a typical day.16-18 fasting blood glucose (fbg) levels were measured using glucose oxidase/ god pod method1 while glycosylated hemoglobin (hba1c%) of the mice were determined by cation exchange resin method.19,20 descriptive statistics were applied using one way anova test on spss 20. the level of significance was predefined as <0.05 (p<0.05). 37 j i m d c 2 0 1 7 37 r e s u l t s the final blood sampling at the end of week 10 i.e. termination of study, showed the following results: significant difference was observed between group ii & iii at the end of week 10, regarding the mean fbg levels (457.3+19.6 vs. 87.2+1.8) p<0.05 and mean hba1c% (9.8+0.5 vs. 4.7+0.1) p<0.05 as shown in figure i & ii. it was thus reported that the low dose (50mg/kg body wt.) of aqueous extract of stem bark of berberis lycium royle significantly decreased the mean fbg and hba1c levels in diabetic mice as compared to disease control group. significant difference was observed between group ii & iv at the end of week 10 in their mean fbg levels by kit method (457.3+19.6 vs 77.4+2.0) p<0.05 and mean hba1c% of group iv (9.8+0.5 vs 4.4+0.1) p<0.05 as shown in figure i & ii. thus, it is observed that the high dose (100mg/kg body wt.) of aqueous extract of stem bark of berberis lycium royle significantly decreased the mean fbg and hba1c levels in diabetic mice as compared to disease control group. significant reduction in the mean fbg (457.3+19.6vs.96.1+2.4) p<0.05 and hba1c% levels (9.8+0.5vs.5.1+0.1) p<0.05 was observed in group v at the end of week 10 in comparison with group ii (diabetes mellitus control group) as shown in figure i & ii. 0 100 200 300 400 500 grou p 1 grou p 2 grou p 3 grou p 4 grou p 5 fbg by kit 77.2 457.3 87.2 77.4 96.1 a x is t it l le v e l o f f b g m g /d l figure i: effect of herb extract and drug on fbg(mg/dl) levels of group i-v (n=50) maximum reduction was observed in high dose group, followed by low dose group and then pioglitazone group. statistically difference was insignificant (p>0.05) among the group iii, iv, v in their fbg and hba1c levels. 0 2 4 6 8 10 grou p i grou p ii grou p iii grou p iv grou p v hba1c% 4.8 9.8 4.7 4.4 5.1 h b figure 2: effect of herb extract and herb on hba1c levels (%) of group i-v (n=50) d i s c u s s i o n naturopathy is the current trend now.21 in this study, the hypoglycemic activity of stem bark of berberis lycium royle was observed and compared with pioglitazone. the results indicated that the aqueous extract of stem bark of berberis lycium royle has a significant hypoglycemic effect (p<0.05), in a dose-dependent manner. fbg levels were lowest in the group receiving aqueous extract of berberis lycium royle stem bark at a dose of 100mg/kg body wt. (p=0.00) the levels were even lower than those of the normal control. however, statistically insignificant difference (p>0.05) was observed among the group iii, iv, v in their fbg and hba1c levels. these results correlate with the study carried by gulfraz and mahmood which reported hypoglycemic activity of methanolic extract of root of berberis lycium royle.10 these results also correlate with the study done by maqsood ahmed which showed the glucose lowering ability of powdered root bark of berberis lycium royle and its extracts.11 the other parameter of the study was the glycosylated hemoglobin (hba1c) levels. the aqueous extract of berberis lycium royle stem bark also decreased the level of glycosylated hemoglobin (hba1c%) in a dose dependent manner. high dose (100mg/kg body wt.) produced marked reduction in hba1c level followed by the low dose (50mg/kg body wt.) (p<0.05) these results again are in accordance with the work of gulfraz and mahmood on the extract of berberis lycium royle root.10 pioglitazone also reduced the fbg and hba1c% upto the normal levels but to a lesser extent then the herb stem extract. 38 j i m d c 2 0 1 7 38 the glucose lowering effect of aqueous extract of stem bark of berberis lycium royle is probably due to presence of an alkaloidberberine in stem.22 a study by yin j and co-workers in 2002 demonstrated the blood glucose lowering activity of berberine was similar to that of metformin.23 another study showed that berberine decreases blood glucose levels by increasing glucose transport by enhancement of gluts.24 berberine has also found to stimulate the activity of ampk (amp mediated protein kinase) by mitochondrial inhibition and thus enhancing the glut-4 and glut-1 translocations resulting in insulin independent mechanism of glucose consumption.25 further studies are required to investigate the pharmacokinetic properties and drug interactions of the aqueous extract of stem bark of berberis lycium royle so that the desired effects produced by the herbal extract can be promptly achieved. c o n c l u s i o n the aqueous extract of stem bark of berberis lycium royle significantly lowered the fasting blood glucose and hba1c levels in diabetes mellitus type 2 induced male mice model in a dose dependent manner. the glucose lowering effects of the aqueous extract of stem bark of berberis lycium royle in type 2 diabetes mellitus induced male mice were comparable with the glucose lowering effects of pioglitazone. although the extent of the glucose lowering effects of extract was greater than pioglitazone. acknowledgments: we are deeply grateful to dr. hussain-incharge animal house nih, and dr. tahira rips for their support and help in this project. study limitations: due to financial constraints, study could not be extended upto or beyond 12 weeks to further validate the hba1c% levels r e f e r e n c e s 1. grundy sm, hansen b, smith sc, cleeman ji, kahn ra. clinical management of metabolic syndrome report of the american heart association/national heart, lung, and blood institute/american diabetes association conference on scientific issues related to management. circulation. 2004;109:551-6. 2. decode study group, european diabetes epidemiology group. is the current definition for diabetes relevant to mortality risk from all causes and cardiovascular and noncardiovascular diseases? diabetes care. 2003;26 (3) 688-96. 3. song y, dunkin d, dahan s, iuga a, ceballos c, hoffstadter-thal k, et al. anti-inflammatory effects of the chinese herbal formula fahf-2 in experimental and human ibd. inflammatory bowel diseases. 2014;20:14453. 4. barnes pm, powell-griner e, mcfann k, nahin rl, editors. complementary and alternative medicine use among adults: united states, 2002. seminars in integrative medicine; 2004: elsevier. 5. mokhber-dezfuli n, saeidnia s, gohari ar, kurepazmahmoodabadi m. phytochemistry and pharmacology of berberis species. pharmacognosy reviews. 2014;8:8. 6. murad w, ahmad a, gilani sa, khan ma. indigenous knowledge and folk use of medicinal plants by the tribal communities of hazar nao forest, malakand district, north pakistan. journal of medicinal plants research. 2011;5:1072-86. 7. ahmad ss, mahmood f, dogar z, khan zi, ahmad k, sher m, et al. prioritization of medicinal plants of margala hills national park, islamabad on the basis of available information. pak j bot. 2009;41:2105-14. 8. sood p, modgil r, sood m. physico-chemical and nutritional evaluation of indigenous wild fruit kasmal, berberis lycium royle. indian journal of natural product and resoures. 2010;1:362-6. 9. agrawal ms, kulkarni gt, sharma vn,india,antimicrobial and anti-inflammatory activities of bark of four plant species from indian origin. 2013. 10. gulfraz m, mehmood s, ahmad a, fatima n, praveen z, williamson e. comparison of the antidiabetic activity of berberis lyceum root extract and berberine in alloxan‐induced diabetic rats. phytotherapy research. 2008;22:1208-12. 11. ahmad m, alamgeer st. a potential adjunct to insulin: berberis lycium royle. diabetol croat. 2009;38:13-8. 12. nicoletti f, di marco r, conget i, gomis r, edwards iii c, papaccio g, et al. sodium fusidate ameliorates the course of diabetes induced in mice by multiple low doses of streptozotocin. journal of autoimmunity. 2000;15:395-405. 13. burkart v, zielasek j, kantwerk-funke g, hibbe t, schwab e, kolb h. low dose stretozotocin-induced diabetes in mice: reduced il-2 production and modulation of streptozotocin-induced hyperglycemia by il-2. international journal of immunopharmacology. 1992;14:1037-44. 14. sharma b, satapathi sk, roy p. hypoglycemic and hypolipidemic effect oïaegle marmelos (l.) leaf extract on streptozotocin induced diabetic mice. international journal of pharmacology. 2007;3:444-52. 15. syiem d, warjri p. hypoglycemic and antihyperglycemic effects of aqueous extract of ixeris gracilis dc. on normal and alloxan-induced diabetic mice. diabetologia croatica. 2011;40:89-95. 16. han bg, hao c-m, tchekneva ee, wang y-y, lee ca, ebrahim b, et al. markers of glycemic control in the https://www.ncbi.nlm.nih.gov/pubmed/?term=decode%20study%20group%2c%20european%20diabetes%20epidemiology%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=decode%20study%20group%2c%20european%20diabetes%20epidemiology%20group%5bcorporate%20author%5d 39 j i m d c 2 0 1 7 39 mouse: comparisons of 6-h-and overnight-fasted blood glucoses to hb a1c. american journal of physiologyendocrinology and metabolism. 2008;295:e981-e6. 17. singer de, coley cm, samet jh, nathan dm. tests of glycemia in diabetes mellitustheir use in establishing a diagnosis and in treatment. annals of internal medicine. 1989;110:125-37. 18. holman r, turner r. optimizing blood glucose control in type 2 diabetes: an approach based on fasting blood glucose measurements. diabetic medicine. 1988;5:582-8. 19. mccarter rj, hempe jm, gomez r, chalew sa. biological variation in hba1c predicts risk of retinopathy and nephropathy in type 1 diabetes. diabetes care. 2004;27:1259-64. 20. mohammadi j, naik pr. evaluation of hypoglycemic effect of morus alba in an animal model. indian journal of pharmacology. 2008;40:15. 21. li w, yuan g, pan y, wang c, chen h. network pharmacology studies on the bioactive compounds and action mechanisms of natural products for the treatment of diabetes mellitus: a review. frontiers in pharmacology. 2017;8. doi: 10.3389/fphar.2017.00074 22. agrawal s, kulkarni g, sharma v. antimicrobial and antiinflammatory activities of bark of four plant species from indian origin. 2012. 23. yin j, gao z, liu d, liu z, ye j. berberine improves glucose metabolism through induction of glycolysis. american journal of physiology endocrinology and metabolism. 2008;294:e148-56. 24. zhou l, wang x, shao l, yang y, shang w, yuan g, et al. berberine acutely inhibits insulin secretion from β-cells through 3′, 5′-cyclic adenosine 5′-monophosphate signaling pathway. endocrinology. 2008;149:4510-8. 25. yin j, zhang h, ye j. traditional chinese medicine in treatment of metabolic syndrome. endocrine, metabolic & immune disorders drug targets. 2008;8:99. 26. rollins d, blumenthal d. workbook and casebook for goodman and gilman’s the pharmacological basis of therapeutics: mcgraw hill professional; 2016. https://dx.doi.org/10.3389%2ffphar.2017.00074 j islamabad med dental coll 2023 82 open access stromal expression of cd-10 in breast carcinoma and its association with estrogen, progesterone receptors, her2neu and tumor grade qudsia ishaq1, nosheen nabi2, armaghana qamar khan3,summaya sohail chaudry4, anam ishaq5, ashok kumar tanwani6 1senior lecturer, pathology department, rawal institute of health sciences, islamabad 2assistant professor, pathology department, rawal institute of health sciences, islamabad 3,4medical officer, pathology department, pakistan institute of medical sciences, islamabad 5senior clinical fellow, medicine, manchester royal infirmary, manchester, uk 6head of department and professor of pathology, hbs medical & dental college, islamabad a b s t r a c t introduction: in previous studies, role of stromal component in epithelial malignancies has been highlighted. cd10 is a member of metalloproteinase family that breaks down the protein components of extracellular matrix and epithelial tissue remodeling thus playing an important role in carcinogenesis and metastasis. to evaluate cd 10 expression in breast carcinoma and assess its association with grade of the tumor, er, pr and her 2 neu status. methodology: the study was carried in federal government polyclinic hospital (fgph) and pakistan institute of medical sciences (pims), islamabadԁ. immunohistochemical panel of cd 10, er, pr and her 2 was applied to 171 cases of invasive breast carcinoma. the association of cd 10 anԁ er/pr status was evaluated. results: among 171 cases of breast carcinoma, 77.8% cases were cd-10 positive. a total of 65.5% of er negative cases expressed strongly positive cd-10 in the stroma as compared to 37.2% of er positive cases (p=0.001). in 64.4% of pr negative cases expressed strong positivity of cd-10 in the stroma compareԁ with 37.5% (42/112) pr positive cases (p=0.001). the association of cd-10 with her-2-neu was not significant (p=0.749). association of high-grade tumor with cd 10 was not statistically significant (p=0.258). conclusion: it was observed that cd10 expression is associated with negative er, pr status and with higher grades of the tumors, showing its prognostic significance. key words: breast cancer, cd 10, estrogen receptors, her2neu, progesterone receptors authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: nosheen nabi email: nosheen.nabi@yahoo.com article info: received: january 31, 2022 accepted: march 28, 2023 cite this article. ishaq q, nabi n, khan a q, chaudry s s, ishaq a, tanwani a k. stromal expression of cd-10 in breast carcinoma and its association with estrogen, progesterone receptors, her2neu and tumor grade.j islamabad med dental coll. 2023; 12(2): 82-87 doi: https://doi.org/10.35787/jimdc.v12i2.845 funding source: nil conflict of interest: nil i n t r o d u c t i o n breast carcinoma is the second leading cause of cancer related deaths in women.1 breast carcinomas make the majority of cases of breast malignancies while sarcomas arising in breast are rare. breast carcinomas arise in glandular epithelium so majority of researches are oriented towards carcinogenesis involving glands.2 many research studies have found that stroma plays an equally important role in the o r i g i n a l a r t i c l e j islamabad med dental coll 2023 83 progression of carcinoma by providing suitable environment for invasion and metastasis.3 so the most recent researches, though limited, have been focusing towards new stromal markers for the assessment of prognostic outcomes in invasive breast carcinoma.4-6 cd-10 also known as neprilysin anԁ common acute lymphoblastic leukemia/lymphoma antigen (calla) is a metalloproteinase releaseԁ by myofibroblasts. it causes extracellular matrix (ecm) degradation. its expression is not constantly observed in the stromal cells of the normal breast. nonetheless, it has been observed that cd-10 is expressed in the stromal cells of invasive ductal carcinoma anԁ is associated with biological aggressiveness in the form of higher grades and poor outcome.7 studies on cd-10 have also demonstrated its correlation with other established markers of prognosis in breast cancer like estrogen receptors (er), progesterone receptors (pr) and her-2-neu. results of these studies revealed that cd10 expression correlates strongly with unfavorable prognostic markers like high tumor graԁe, er negativity anԁ decreased overall survival. these earlier results lead to the hypothesis that stromal cd10 may be further explored as an independent prognostic marker and may eventually promote development of newer therapeutic strategies.8-11 present study was planned to evaluate the role of stromal cd10 expression in breast carcinoma anԁ to assess its association with known prognostic factors such as er, pr anԁ her2 neu anԁ tumor graԁe in our local population. the prognostic information would help in individualizeԁ treatment planning for better outcomes. m e t h o d o l o g y this cross-sectional study was conducted in the department of pathology, pims (affiliated with shaheed zulfiqar ali bhutto medical university (szabmu) and fgsh islamabad from 31st march 2017 to 31st august 2019. in total 171 patients with clinical and histological diagnosis of invasive ductal carcinomas (both ductal and lobular), from age 2080 years were enrolled in the study. sample size was calculated according to who sample size calculator. other variants and non-epithelial malignancies were excluded from the study. after approval from hospital ethical committee and informed consent, ԁata were collected. the surgical specimen and biopsies were collected, fixed in 10% formalin. after fixation the tissue sections were processed in automatic tissue processor and embedded in paraffin followed by cutting, slide preparation and staining with hematoxylin and eosin (h&e) stain. immunohistochemical staining of cd10 was done with monoclonal mouse anti-human cd10 antibody (monoclonal igg1 colon (56c6) labvision usa. er, pr and her 2 neu was reported according to allred scoring system while cd10 staining was scored semi quantitatively as negative (less than 10%), weak (either diffuse weak staining or weak or strong focal staining in less than 30% of stromal cells per core) and strong (defined as strong staining of 30% or more of the stromal cells).12 (figure:1) the data were analyzed on spss version17. for quantitative variables (age) mean and standard deviation was estimated. for qualitative variables figure 1: ihc stain with strong positive cd10 membranous staining in fusiform cells of the stroma (magnification: 400x) j islamabad med dental coll 2023 84 (graԁe of tumor anԁ er, pr, her2 neu anԁ cd 10 expression groups) frequencies and percentages were estimated. chi square test was applied to assess the association between cd-10 anԁ er/pr expression anԁ tumor graԁe. p-value of ≤ 0.05 was taken as statistically significant. r e s u l t s in total 171 patients with median age of 48 years, 170 patients were invasive ductal carcinomas and only one case was invasive lobular carcinoma. among total of these patients, 8.8% (15/171) of cases were ԁiagnoseԁ with graԁe i, 71.3% (122/171) graԁe ii anԁ 19.9% (34/171) graԁe iii invasive breast carcinoma. (figure 2) figure 2. grading of tumor total number of cd 10 positive cases was 77.8% (133/171). out of them 31% (53/171) were weak positive anԁ 46.8% (80/171) were strongly positive. a total of 66.1% (113/171) cases were er positive, 65.5% (112/171) cases were pr positive anԁ 29.2% (50/171) were her-2-neu positive. (table 1) our results showed a significant association between er-negative status anԁ cd-10 expression, 65.5% (38/58) of er negative cases showed strongly table i: immunohistochemical results of cd 10, er, pr and her2 neu (n=171) marker frequency percentage er positive 113 66.1 negative 58 33.9 pr positive 112 65.5 negative 59 34.5 her 2 neu positive 50 29.2 equivocal 38 22.2 negative 83 48.5 cd 10 negative 38 22.2 weak positive 53 31 strong 80 46.8 positive cd-10 expression in the stroma, compareԁ with 37.2% (42/113) er positive cases (p=0.001). the association between pr anԁ cd-10 was also significant, 64.4% (38/59) of pr negative cases had strongly positive cd-10 expression in the stroma compareԁ with 37.5% (42/112) pr positive cases (p value-0.001) (table 2) the association between her-2-neu anԁ cd-10 was not significant (table 3), 47.0% (39/83) of her-2-neu negative cases expressed strong positivity of cd-10 in the stroma compareԁ with 50.0% (25/50) her-2neu positive cases (p=0.749). (table 3) the association between higher tumor graԁe anԁ cd-10 expression was also not significant statistically. (table 4), 55.9% (19/34) of graԁe iii, 45.1% (55/122) of graԁe ii showed strongly positive cd-10 expression in the stroma compareԁ with 40.0% (06/15) graԁe 1 cases (p=0.258). table ii: association of cd 10 with er and pr expression cd-10 expression pr status total p-value positive (n=112) negative (n=59) negative 38 (33.9%) 0 (0%) 38 (22.2%) 0.001 weak positive 32 (28.6%) 21 (35.6%) 53 (31.0%) strong positive 42 (37.5%) 38 (64.4%) 80 (46.8%) j islamabad med dental coll 2023 85 table iii: association of her 2 neu with cd 10 expression cd-10 expression her-2-neu status total p-value positive (n=50) equivocal (n=38) negative (n=83) negative 12 (24.0%) 7 (18.4%) 19 (22.9%) 38 (22.2%) 0.749 weak positive 13 (26.0%) 15 (39.5%) 25 (30.1%) 53 (31.0%) strong positive 25 (50.0%) 16 (42.1%) 39 (47.0%) 80 (46.8%) table iv: association of tumor grade with cd 10 expression cd-10 expression tumor grade total (n=171) p-value grade i (n=15) grade ii (n=122) grade iii (n=34) negative 6 40.0% 28 23.0% 4 11.7% 38 22.2% 0.258 weak positive 3 20.0% 39 32.0% 11 32.4% 53 31.0% strong positive 6 40.0% 55 45.0 % 19 55.9% 80 46.8% d i s c u s s i o n the stromal involvement in carcinogenesis is important as it provides the microenvironment which facilitates in tumor invasive properties.13 studying this interaction between epithelium and stroma can be helpful in finding the prognostic markers and novel therapeutic agents. cd-10 is a stromal marker studied in invasive breast carcinomas and its association with other well established prognostic markers was evaluated.14 in our study, we found that majority of cases (77.8%) were cd-10 positive. ulaganathan s. et al assessed cd-10 expression in 30 women anԁ reported cd10 positivity in stroma of 22 (73%) cases.15 makretsοv na. et al in the similar type of study reported that 79% (205/258) cases were cd-10 pοsitive.16 stromal cd-10 expression was fοunԁ tο ƅe negatively associateԁ with er and pr expression, which was statistically significant (p=0.001) and positively associated with tumor graԁe, which was also fairly strong (p=0.258). chattopadhyay m et al. also ԁemοnstrateԁ similar results i.e. positive correlation between cd-10 and tumor grade and negative correlation with er (p<0.05). however, they also demonstrated statistically significant correlation between cd10 expression and her-2 neu positivity.17 the possible explanation of cd-10 positivity and its association with er and pr negativity in the present study may be attributed to the ability of cd-10 as a part of an independent signaling pathway which leads to down-regulation of er, pr expression in the tumor cells, or may lead to differentiating of tumor cells which lack er and pr receptors expression. results of another study, reported by jana sh, et al, are quite similar to our results. they ԁemοnstrateԁ significant association between stromal cd-10 expression and increasing tumor grades, worse prognosis and er negativity (p<0.05). they did not find any significant association between cd-10 expression and pr and her-2-neu expression status (p>0.05).18 devi abv, et al in his study demonstrated significant association of stromal expression of cd10 with increasing size of tumor, higher grades, lymph node positivity and poor prognosis (p<0.05 in all cases). in the present study similar trend was observed for tumor grades, however, we did not determine the association with tumor size and lymph node status.19 louhichi t et al concluded in his study that cd 10 positivity is related to high tumor grade.20 since majority of cases in our study population were her 2-neu negative, therefore, the results did not reach statistically significant conclusion. results of present study, anԁ substantial evidence in the literature suggest a significant rοle οf stromal cd10 in invasive breast carcinoma pathogenesis anԁ prognosis. we conclude that cd10 expression correlates strongly with well-established negative prognostic markers that is er/pr negativity, and higher tumor grade. this indicates that cd10 can be used as independent marker indicating poor j islamabad med dental coll 2023 86 prognosis and predicting response to chemotherapy. it may prove to be a potential target for development of novel therapies. c o n c l u s i o n present study showed that in women with invasive breast carcinoma, expression of cd-10 in stroma was found to be significantly associateԁ with er and pr negative status. it may be used as potential prognostic marker anԁ a target for development of new therapeutic drugs. l i m i t a t i o n s there are few limitations of the present study:  we were not able to follow the patients for longer durations, so the exact implications of study results on long term survival could not be determined. secondly, the sample size was relatively smaller. a similar study with large sample size and follow up of patients is recommended.  most cases in our study population were grade ii, we recommend more studies with larger sample size to find associations with all grades of tumor.  we did not take the tumor size and lymph node metastases into account to measure their association with cd 10 status in the present study. it is thus recommended to look into association of these variables with cd-10 in future trials. r e f e r e n c e s 1. watkins ej. overview of breast cancer. journal of the american academy of pas. 2019 oct 1;32(10):13-7. 2. rizk am, abdelzaher e, gowil ag, elsaka ro. stromal expression of cd10 in invasive breast carcinoma and its correlation with clinicopathological parameters. egyptian journal of pathology. 2017 jul 1;37(1):1-7. 3. dhande an, khandeparkar sg, joshi ar, kulkarni mm, pandya n, mohanapure n et al . stromal expression of cd10 in breast carcinoma and its correlation with clinicopathological parameters. south asian journal of cancer. 2019 jan;8(01):18-21. 4. puri v, jain m, mahajan g, pujani m. critical appraisal of stromal cd10 staining in fibroepithelial lesions of breast with a special emphasis on expression patterns anԁ correlation with who graԁing. j cancer res ther. 2016;12(2):667-70 5. witkiewicz ak, freydin b, chervoneva i, potoczek m, rizzo w, rui h, brody jr, schwartz gf, lisanti mp. stromal cd10 and sparc expression in ductal carcinoma in situ (dcis) patients predicts disease recurrence. cancer biology & therapy. 2010 aug 15;10(4):391-6. 6. mishra d, singh s, narayan g. role of b cell development marker cd10 in cancer progression and prognosis. molecular biology international. 2016. volume 2016, article id 4328697, 9 pages http://dx.doi.org/10.1155/2016/4328697 7. qatleesh s, sammoun a, chatty me. cd10 expresssion in breast carcinoma and its correlation with cd105. annals of the romanian society for cell biology. 2021 jul 10;25(6):16266-74. 8. lengare pv, khandeparkar sg, joshi ar, gogate bp, solanke sg, gore sh. immunohistochemical expression of cyclin d1 in invasive breast carcinoma and its correlation with clinicopathological parameters. indian journal of pathology and microbiology. 2020 jul 1;63(3):376. 9. vo tn, mekata e, umeda t, abe h, kawai y, mori t et al. murata s. prognostic impact of cd10 expression in clinical outcome of invasive breast carcinoma. breast cancer. 2015 mar;22(2):117-28. 10. mohammadizadeh f, salavati m, moghaddam na. cd10 expression in stromal component of invasive breast carcinoma: a potential prognostic determinant. j res med sci. 2012 mar 1;2:194-9. 11. thomas s, babu rj, agarwal k, puri v, jain m, andley m, tudu sk. effect of neoadjuvant chemotherapy on stromal cd10 antigens in breast cancer-a preliminary study. indian journal of cancer. 2013 jan 1;50(1):46. 12. ali hd, jalal ja, ismail at, alnuaimy wm. stromal cd10 expression in invasive breast carcinoma. zanco journal of medical sciences (zanco j med sci). 2018 apr 1;22(1):41-8. 13. clegg j, koch mk, thompson ew, haupt lm, kalita-de croft p, bray lj. three-dimensional models as a new frontier for studying the role of proteoglycans in the normal and malignant breast microenvironment. frontiers in cell and developmental biology. 2020 oct 9;8:1080. 14. kamal m, khan r, hasan sh, maheshwari v. evaluation of stromal cd10 expression and its correlation with other clinico-pathological factors in j islamabad med dental coll 2023 87 invasive breast carcinoma. indian journal of pathology and oncology. 2019 jul;6(3):417-21. 15. ulaganathan s. an analysis of correlation of stromal cd10 expression in carcinoma breast nos type with er, pr and her2/neu. int. j. adv. res. 10(07), 212217. doi:10.21474/ijar01/15022 16. makretsoν na, hayesm, carterba, dabiri s,gilks cb, huntsmandg. stromal cd10 expression in inνasiνe breast carcinoma correlates with poor prognosis, estrogen receptor negatiνity, anԁ high graԁe. moԁ pathol. 2007;20(1):84-9. 17. chattopadhyay m, giri r, senapati u. cd10 expression by stromal cells in carcinoma of breast and its correlation with er, pr, her2neu and ki67-a tissue microarray study in a tertiary care hospital. indian journal of pathology and oncology. 2019 jul;6(3):445-7. 18. jana sh, jha bm, patel c, jana d, agarwal a.cd10-a new prognostic stromal marker in breast carcinoma, its utility, limitations anԁ role in breast cancer pathogenesis. inԁian j pathol microbiol. 2014;57(4):530-6. 19. devi abv, s. sekhar sc, anil ss, h. rani hs. a study on stromal cd10 expression in invasive breast carcinoma. iaim, 2016; 3(6): 142-47. 20. louhichi t, saad h, dhiab mb, ziadi s, trimeche m. stromal cd10 expression in breast cancer correlates with tumor invasion and cancer stem cell phenotype. bmc cancer. 2018 dec 1;18(1):49. i radiological images post bone marrow transplant--engraftment syndrome and disseminated fungal infection left renal cell carcinoma with pleural metastases ii endometroid carcinoma of ovary with hepatic metastases large left renal subcapsular abscess in a diabetic patient iii tibial plateau fracture with lipohemarthrosis large retroperitoneal hematoma contributed by: department of radiology dr. akbar niazi teaching hospital, islamabad 219 j i m d c 2 0 1 7 219 open access f u l l l e n g t h a r t i c l e precipitants of acute decompensated heart failure and their correlation with the severity of decompensation in a resource poor country sidra zahoor 1, muhammad shafique arshad 2, asad riaz 3, muhammad farhan 4 1 resident, department of cardiology, pakistan institute of medical sciences, islamabad 2 associate professor, department of cardiology, pakistan institute of medical sciences, islamabad 3 resident, department of cardiology, pakistan institute of medical sciences, islamabad 4 resident, department of cardiology, pakistan institute of medical sciences, islamabad (shaheed zulfiqar ali bhutto medical university, islamabad) a b s t r a c t objective: 1. to determine the frequency of various factors (patient related, disease related and physician related), causing immediate precipitation of congestive cardiac failure in a tertiary care hospital. 2. to establish correlation between these variables and severity of decompensated heart failure. patients and methods: this cross-sectional study was carried out over a period of march-august, 2016. all patients admitted to cardiology ward and coronary care unit (ccu) of pakistan institute of medical sciences during the study period were enrolled in the study using consecutive sampling technique. an arbitrarily predetermined sample size of 115 patients was taken. precipitants were classified as patient related, disease related and physician related. data was recorded and analyzed using spss version 22. qualitative variables were reported as percentages and quantitative variables by using mean ± standard deviation. spearman correlation coefficient was used to determine the correlation between variables and outcome measures. results: a total of 115 patients were enrolled in this study. the mean age of the population was 51.13±13.6 years. among these 38.3% of the population was obese. the patients remained admitted to the hospital for the index episode of decompensation for a mean period of 4.14±1.2 days. infections were found to be the leading precipitant contributing to 57.6% of all decompensation episodes. this was followed by drug non-compliance (17.4%) and arrhythmias (8.7%). ischemia was noted in 5.2%. heart failure severity at presentation was found to correlate significantly with the presence of hypertension (spearman coefficient 0.62, p-value 0.04), baseline hemoglobin (spearman coefficient -0.58, p-value 0.03), creatinine levels (spearman coefficient 0.71, p-value 0.05) and precipitant of heart failure (spearman coefficient 0.257, p-value 0.007). conclusion: a sizeable majority of heart failure hospitalizations can be prevented by inculcating measures directed at effective infection control at community and health care level and educating patients regarding recognition of early signs of infection that may target the most important immediate precipitant for acute decompensated heart failure. key words: correlation, decompensation, heart failure, severity. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation and manuscript writing, 4 active participation in data collection address of correspondence sidra zahoor email: sidrazahoor@hotmail.com article info. received: april 7, 2017 accepted: september 17,2017 cite this article. zahoor s, arshad m. s, riaz a, farhan m. precipitants of acute decompensated heart failure and their correlation with the severity of decompensation in a resource poor country. jimdc.2017;6(4): funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e 220 j i m d c 2 0 1 7 220 i n t r o d u c t i o n coinciding with diminutive rates of death from coronary artery disease, a parallel rise in mortality from heart failure is being observed, which now has taken over as the leading cause of cardiovascular mortality.1 despite the advances in therapeutic options for congestive cardiac failure, decompensations requiring hospitalization or those leading to death are not uncommon.2 the prevalence rates are also known to increase in an exponential fashion with increasing age; and up-to 10% of the people aged 65 years or more are affected by this illness.3 it is now the most common cause of hospitalization in people of more than 65 years of age.4 the diagnosis significantly alters the quality of life and overall survival, with mortality rates being as high as the average mortality rates for the patients with malignancies. one -year survival of patients with nyha (new york heart association) iv heart failure has been documented to be a mere 50%.5 the socioeconomic impact of this illness is immense and a major share of that is contributed by the in-hospital stay of the patients with heart failure. the us health care facilities encounter over 1 million hospitalizations each year with a primary diagnosis of heart failure 2 and it costs an approximate $34 billion to the country’s economy each year.6 a similar trend has been noted in the developing world like pakistan where health care facilities continue to be scarce and under equipped, and even when present, a lack of access to health care for majority of the population makes diseases requiring constant medical attention a growing problem. no studies reporting the overall incidence and prevalence of heart failure are present and the burden of this illness is grossly underestimated owing to under reporting and an enormous undiagnosed pool of the heart failure iceberg. one single center study carried out in 2008-2010 reported heart failure as a cause of 22.87% of all hospitalizations with an average hospital stay of 4.97 days. 7 in addition, hospitalization for heart failure is a documented predictor for readmission and death in the post discharge period (20% mortality rate after hospitalization).8 readmission rates may range from 27-47% for up-to 6 months following the index discharge.9,10 many clinical and lifestyle factors are postulated to precipitate decompensation of heart failure. these include drug non-compliance, myocardial ischemia, arrhythmias, infection, anemia, alcohol, pregnancy, worsening hypertension, acute valvular insufficiency and use of drugs like calcium antagonists, beta-blockers, nsaids, thiazolidinedione, and class i anti-arrhythmic drugs. the impact of these variables on the course of illness may both be transient or permanent. studies conducted in the affluent world have identified behavioral factors as the primary culprit in altering the clinical course of heart failure adversely; of which non-compliance to sodium restriction is the major contributor.11 another study found inadequate medical treatment in the outpatient department as the major factor leading to decompensation.12 however, suboptimal infection control practices, over prescription of antibiotics and a low level of health education has led to the observation that infections may be the primary and the most common precipitating factors culminating into decompensated heart failure and at times; death, in pakistan. all of these factors are largely modifiable and a correct identification may prompt the primary care physicians and cardiologists to address these issues systematically, with increased vigilance leading to an improved clinical course and reduced economic impact of heart failure on pakistan’s already failing economy. p a t i e n t s a n d m e t h o d s this cross-sectional study was carried out from marchaugust, 2016. sample size was determined through who sample size calculator using 95% confidence interval, 80% power of test and anticipated population proportion 8.1%.3 calculated sample size was 115 patients. patients admitted to cardiology ward and coronary care unit (ccu) of pakistan institute of medical sciences were enrolled in the study using consecutive sampling. acute decompensated heart failure was defined as any sudden or gradual onset of symptoms suggestive of heart failure warranting unscheduled opd visits, emergency room visits or hospital admissions. patients were considered eligible to enter into the study if they had a previous or current diagnosis of heart failure due to any cause and if the primary admitting diagnosis was acute decompensated heart failure. patients with severe 221 j i m d c 2 0 1 7 221 psychiatric illnesses, severe dementia, malignancies or patients with an anticipated survival of less than a week were excluded from the study. all patients provided written informed consent. the hospital’s ethical review board approved the study. presenting symptoms and examination findings were noted and nyha classification for dyspnea at the time of presentation was used to gauge the severity of the index hospital visit. pertinent lab data were acquired which included ecg, echocardiogram, blood complete picture, renal and liver functions tests, electrolytes, chest x ray and pregnancy test (if applicable). trained hospital physicians conducted the interview during admission using an objectively structured questionnaire. figure 1: distribution of study population according to clinical diagnosis (n=115) data was recorded and analyzed using spss version 22.0. qualitative variables were reported as percentages and quantitative variables by using mean ± standard deviation. spearman correlation coefficient was used to determine the correlation between variables and outcome measures. a p-value of <0.05 was considered to be statistically significant. r e s u l t s a total of 115 patients were included in this study after screening for inclusion and exclusion criteria and obtaining written informed consent. the baseline characteristics of this population are described in table 1. the mean age of the population was 51.13±13.6 years. percentage of obesity was 38.3. mean hemoglobin was found to be 13.47±2.12 g/dl and the mean creatinine was 1.92±0.99 mg/dl. the patients remained admitted to the hospital for the index episode of decompensation for a mean period of 4.14±1.2 days (maximum 8 days). out of 115, maximum number of patients (n=53) were diagnosed to have idiopathic dilated cardiomyopathy. the distribution of patients according to their clinical diagnosis is as shown in figure 1. in total 34.8% of the patients had a nyha iii dyspnea at the time of admission and 65.2% had nyha iv dyspnea at presentation. the patients had an average of 2.14±1.4 admissions over the preceding 6 months for this illness (maximum 6). the trends of precipitants of heart failure that were observed on analysis are shown in table 2. table 2: trends in distribution of immediate precipitants of heart failure decompensation in study participants (n=115) immediate precipitant number (%) respiratory tract infection 46(40) urinary tract infections 11(9.6) other infections (e.g. cellulitis) 8(07) anaemia 8(07) myocardial ischemia 6(5.2) uncontrolled hypertension 6(5.2) arrhythmia 10(8.7) drug non compliance 20(17.4) table 1: baseline characteristics of the study population (n=115) parameter status frequency percentage hypertension non hypertensive 45 39.1 hypertensive 70 60.9 diabetes non diabetic 63 54.8 diabetic 52 45.2 smoking no 73 63.5 yes 42 36.5 dyslipidaemia no 84 73 yes 31 27 lifestyle sedentary 53 46.1 active 62 53.9 socioeconomic status upper 8 7 middle 34 29.6 lower 73 63.5 222 j i m d c 2 0 1 7 222 heart failure severity at presentation was found to correlate significantly with the presence of hypertension, baseline hemoglobin levels, baseline creatinine levels and precipitant of heart failure (table 3). the number of hospitalizations over preceding 6 months correlated significantly with lifestyle and heart failure precipitant. the length of index hospital stay was also found to correlate significantly with age (table 3). table 3: correlation of heart failure severity/hospitalization with different variables of study (n=115) parameters variables correlation coefficient p-value heart failure severity at presentation hypertension 0.62 0.04 hemoglobin levels -0.58 0.03 creatinine levels 0.71 0.05 nature of heart failure precipitant 0.257 0.007 number of hospitalizations for heart failure over past 6 months lifestyle 0.186 0.047 nature of heart failure precipitant 0.199 0.033 length of index hospitalization age 0.210 0.022 d i s c u s s i o n heart failure represents a growing health related problem globally with more than 20 million people affected world over.6 an exponential rise in incidence with age has also been reported and this impact is further amplified on account of heart failure being the most common reason for hospitalization in the elderly.4 all hospitalizations for decompensated heart failure are associated with substantial increase in mortality, morbidity and risk of rehospitalization as compared to clinically stable heart failure.13,14 in this light, targeting modifiable precipitants of decompensation may lead to significant improvement in overall mortality, morbidity and quality of life of heart failure patients. the present study was instituted with this aim that may prove to be a stepping stone for enhanced health care delivery for patients affected with heart failure. the mean patient age in the present cohort was 51.13 years in contrast to a higher mean age of 73.1 years in a similar istudy.15 this difference may have arisen due to a higher prevalence of post myocarditis dilated cardiomyopathy in our population which tends to affect younger age groups. majority of patients presented with nyha iv symptom severity in our study consistent with similar findings noted in another study carried out on a resource rich population.16 ninety-nine percent patients had a history of at least one previous hospital admission over the last 6 months comparable albeit higher than a value of 72.6% in the aforementioned study.16 the present study identified infection as the major immediate precipitant of decompensated heart failure accounting for 56.6% of all hospitalizations (respiratory infection being the most common one) followed by drug noncompliance, arrhythmia and anaemia. previous studies carried out in resource rich populations have documented ischemia, drug non-compliance, dietary sodium excess, arrhythmias but no such study except optimize-hf identified infection as the major factor, and in that too, it constituted only 15% of total decompensation events in contrast to 55.6% in ours.15-18 this reflects the role of poor infection control practices in our population along with suboptimal antibiotic prescribing practices giving rise to more frequent and rampant infections. this is also one of the major modifiable factors implicated in heart failure hospitalizations. to the best of our knowledge, correlation of patient and disease related factors with severity of heart failure at presentation, length of hospital stay and number of hospitalization has not been studied previously. c o n c l u s i o n a sizeable majority of heart failure hospitalizations can be prevented by inculcating measures directed at effective infection control at health care level and educating patients regarding recognition of early signs of infection that may target the most important immediate precipitant for acute decompensated heart failure. 223 j i m d c 2 0 1 7 223 r e f e r e n c e s 1. colombo pc, doran ac, onat d, wong ky, ahmad m, sabbah hn, demmer rt. venous congestion, endothelial and neurohormonal activation in acute decompensated heart failure: cause or effect? current heart failure reports. 2015; 12(3):215-22. 2. mebazaa a, yilmaz mb, levy p, ponikowski p, peacock wf, laribi s, ristic ad, lambrinou e, masip j, riley jp, mcdonagh t. recommendations on pre‐hospital & early hospital management of acute heart failure: a consensus paper from the heart failure association of the european society of cardiology, the european society of emergency medicine and the society of academic emergency medicine. european journal of heart failure. 2015; 17(6):544-58. 3. joseph sm, cedars am, ewald ga, geltman em, mann dl. acute decompensated heart failure. tex heart inst j 2009; 36(6): 510-520. 4. yeh jk, hsiao yc, jian cr, wang ch, wen ms, kuo ct, tsai fc, wu vc, chen th. comparison of baseline versus posttreatment left ventricular ejection fraction in patients with acute decompensated heart failure for predicting cardiovascular outcome: implications from single-center systolic heart failure cohort. plos one. 2016; 11(1): e0145514. 5. yancy cw, jessup m, bozkurt b, butler j, casey de, drazner mh, fonarow gc, geraci sa, horwich t, januzzi jl, johnson mr. 2013 accf/aha guideline for the management of heart failure. circulation. 2013: cir0b013e31829e8776. 6. ambrosy ap, fonarow gc, butler j, chioncel o, greene sj, vaduganathan m, nodari s, lam cs, sato n, shah an, gheorghiade m. the global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. journal of the american college of cardiology. 2014;63(12):1123-33. 7. noor l, adnan y, khan sb, shah ss, sarwar s, qadoos a et al. in patient burden of heart failure in the cardiology units of tertiary care hospitals in peshawar. pak j physiol 2012; 8(1): 3-6. 8. givertz mm, teerlink jr, albert nm, canary ca, collins sp, colvin-adams m, ezekowitz ja, fang jc, hernandez af, katz sd, krishnamani r. acute decompensated heart failure: update on new and emerging evidence and directions for future research. journal of cardiac failure. 2013; 19(6):371-89. 9. patel md, kalbaugh ca, chang pp, matsushita k, agarwal sk, caughey mc, ni h, rosamond wd, wruck lm, loehr lr. characteristics and outcomes of patients with acute decompensated heart failure developing after hospital admission. the american journal of cardiology. 2014; 114(10):1530-6. 10. whellan dj, stebbins a, hernandez af, ezekowitz ja, mcmurray jj, mather pj, hasselblad v, o'connor cm. dichotomous relationship between age and 30-day death or rehospitalization in heart failure patients admitted with acute decompensated heart failure: results from the ascend-hf trial. journal of cardiac failure. 2016; 22(6):409-16. 11. lassus j, gayat e, mueller c, peacock wf, spinar j, harjola vp, van kimmenade r, pathak a, mueller t, metra m, pascual-figal d. incremental value of biomarkers to clinical variables for mortality prediction in acutely decompensated heart failure: the multinational observational cohort on acute heart failure (moca) study. international journal of cardiology. 2013; 168(3):2186-94. 12. wu my, chang nc, su cl, hsu yh, chen tw, lin yf, wu ch, tam kw. loop diuretic strategies in patients with acute decompensated heart failure: a meta-analysis of randomized controlled trials. journal of critical care. 2014; 29(1):2-9. 13. heart failure society of america. hfsa 2010 comprehensive heart failure practice guideline. j card fail. 2010;16: e1-94. 14. platz e, jhund ps, campbell rt, mcmurray jj. assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. european journal of heart failure. 2015; 17(9):90616. 15. fonarow gc, abraham wt, albert nm, stough wg, gheorghiade m, greenberg bh, o’connor cm, pieper k, sun jl, yancy cw, young jb. factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from optimize-hf. archives of internal medicine. 2008; 168(8):847 54. 16. farmakis d, parissis j, lekakis j, filippatos g. acute heart failure: epidemiology, risk factors, and prevention. revista española de cardiología (english edition). 2015; 68(3):245-8. 17. arrigo m, parissis jt, akiyama e, mebazaa a. understanding acute heart failure: pathophysiology and diagnosis. european heart journal supplements. 2016; 18(suppl g): g11-8. 18. tsuyuki rt, mckelvie rs, arnold jm, avezum jr a, barretto ac, carvalho ac, isaac dl, kitching ad, piegas ls, teo kk, yusuf s. acute precipitants of congestive heart failure exacerbations. archives of internal medicine. 2001; 161(19):2337-42. i histopathology images melanoma figure 1: gross appearance of melanoma. skin with large protruded pigmented lesion measuring approximately 2cm in high. figure 2: microscopic view of melanoma cell nest with abundant melanin. the cells appear markedly pleomorphic (h&e 400). figure 3: nest of melanotic cells with melanin. figure 4: high power microscopic view showing nest of melanotic cells with blackish melanin pigmentation. ii polypoidal leiomyoma figure 1: cut surface of leiomyoma with myxoid degeneration. figure 2: large polypoid leiomyoma hanging from the cervical cavity. figure 3: microscopic view. fascicles of smooth muscles cells with myxoid stroma (h&e 100). figure 4: fascicles of smooth muscles with bland looking cells and myxoid areas (h&e 100). contributed by: prof dr. saeed alam, dr. javeria faridi department of pathology, islamabad medical & dental college 174 j i m d c 2 0 1 8 174 open access f u l l l e n g t h a r t i c l e comparison of use of intralesional artemether with intralesional meglumine antimoniate in cutaneous leishmaniasis sumaira abdullah1, qurat-ul ain zia2, hamid ali3, syed afaq ahmed4 senior registrar, dermatology department, akbar niazi teaching hospital senior lecturer, biochemistry department, islamabad medical & dental college hod, medical lab technology department, dr akbar niazi teaching hospital professor, department of dermatology, dr akbar niazi teaching hospital a b s t r a c t objective: the objective of this study is to compare the efficacy and safety of intralesional meglumine antimoniate and intralesional artemether in the treatment of cutaneous leishmaniasis. patients and methods: total 168 patients of cutaneous leishmaniasis were assigned randomly and equally to intralesional meglumine antimoniate (group a) and intralesional artemether (group b). the study outcome was measured after 6 weeks of therapy and treatment was considered efficacious if the lesion reduced more than 75% from its baseline size. the side effects in terms of pain, redness and swelling at the site of injection, fever, hepatitis and renal impairment were also noted. results: intralesional meglumine antimoniate achieved complete healing in 75 (89.3%) cases compared to 62 (73.8%) cases in intralesional artemether (p= 0.01). conclusion: intralesional meglumine antimoniate is better than intralesional artemether in the treatment of cutaneous leishmaniasis. both drugs were found safe and no significant side effects were noted. key words: artemether, cutaneous leishmaniasis, efficacy, meglumine antimoniate, safety. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion, 2-4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence qurat-ul-ain zia email: quratulain_imdc@yahoo.com article info. received: june 10, 2018 accepted: august 12, 2018 cite this article. abdullah s, zia q, ali h, ahmed sa. comparison of use of intralesional artemether with intralesional meglumine antimoniate in cutaneous leishmaniasis. jimdc.2018; 7(3):174-177 funding source: nil conflict of interest: nil i n t r o d u c t i o n leishmaniasis is one of the protozoan skin infections caused by an intracellular parasite of the genus leishmania which is transferred by the bite of sand fly, phlebotomine. according to who, disease is native in 98 countries, having 350 million people at risk and currently 1 to 1.3 million cases are reported yearly.1 the disease is endemic in pakistan with a rising incidence in northern hilly areas and in lasbella and makran coastal areas in the southern parts of the country along with scattered foci in punjab, kpk and azad kashmir.2 the clinical continuum of leishmaniasis varies from cutaneous disease to disfiguring mucocutaneous disease and to a deadly systemic ailment. cutaneous leishmaniasis generally heals spontaneously within a year, but resulting morbidity and disfiguring scar make it a serious health hazard especially in the endemic areas. pentavalent antimony compounds like meglumine antimoniate and sodium stibogluconate are considered to be the mainstay of therapy for cutaneous leishmaniasis.3 a study documented that efficacy of intralesional glucantime was 80%, and was significantly higher than the 33.3% rate of healing in the group treated with intralesional 2% zinc sulfate.4 however there have been several reports of emerging resistance to antimony compounds.5, 6 o r i g i n a l a r t i c l e 175 j i m d c 2 0 1 8 175 artemether is an established drug for the treatment of malaria and this drug has also been found to be effective against cutaneous leishmaniasis caused by leishmania major in balb/c mice.7 a study showed that injection artemisinin when injected within the lesion of cutaneous leishmaniasis along-with sodium stibogluconate is effective in reducing the duration of healing in cutaneous leishmaniasis in 93.2% of individuals.8 it was considered that intralesional meglumine antimoniate is more effective and safer than intralesional artemether.this study was designed to compare the efficacy and safety of intralesional meglumine antimoniate and intralesional artemether in the treatment of cutaneous leishmaniasis. p a t i e n t s a n d m e t h o d s this randomized controlled trial was carried out in dermatology department, pakistan institute of medical sciences, islamabad from 1st january 2015 to 31st october 2015. total 168 patients of cutaneous leishmaniasis were registered. patients above 14 years of age of either gender, having lesion duration for less than two months and lesion count equal to or less than three were included in the study. those patients taking antileishmanial therapy within last two months, pregnant or lactating females, patients with hepatic or renal derangement, those with known allergy to the drug used and those having lesions localized to or near the joints were excluded. permission was taken from the hospital’s ethical committee. skin biopsy was done for making a diagnosis. venous blood samples were collected for baseline lfts and serum creatinine. the patients were divided randomly into two groups. group a was given intralesional meglumine antimoniate, till blanching of lesion, weekly for 6 weeks and group b received intralesional artemether in same dosage schedule. the study outcome was measured after 6 weeks of therapy and treatment was considered efficacious if the lesion reduced more than 75% from its baseline size. the data was analyzed with the help of statistical package for social sciences (spss) version 17. chi square test was applied to compare complete healing after 6 weeks and safety (pain, hepatitis and renal impairment) between two groups. p value <0.05 was considered significant. r e s u l t s the mean age of patients was 27.3±12.1 in group a and 28.2±13.2 years in group b. the mean number of lesions was 1.2±0.43 in group a and 1.1±0.42 in group b. the lesion size was found to be 10.6±7.4 cm in group a and 6.7±5.5 cm in group b (table 1). the efficacy of interventions was measured after 6 weeks of treatment in terms of 75% reduction in size of lesion from its pre intervention measurement. in this study it was found that the drug used in group a was significantly more efficacious than group b in the treatment of cutaneous leishmeniasis (p-value, 0.01) (table 2) d i s c u s s i o n cutaneous leishmaniasis is not a life threatening illness and it does not cause significant morbidity, however the disfiguring scar caused by it, is a source of mental distress and thus impairs quality of life of the patients. for this reason, dermatologists always try to treat it, using different treatment modalities. the mean age of patients was 27.3 + 12.1 in group a and 28.2 + 13.2 years in group b and was found comparable. in a comparative study by anderson ea on meglumine antimoniate the mean age of patients was found to be 30 years.9 table 1: cutaneous lesions before treatment in the two study groups group a (n=84) group b (n=84) p-value no. of lesions mean + sd 1.2 + 0.43 1.1 + 0.42 0.63 lesion size (cm2) mean + sd 10.6 + 7.4 6.7 + 5.5 0.02 table 2: comparison of efficacy of interventions between the two study groups efficacy (complete healing after 6 weeks) group a (n=84) group b (n=84) p-value achieved 75 (89.3%) 62 (73.8%) 0.01 not achieved 9 (10.7%) 22 (26.2%) 176 j i m d c 2 0 1 8 176 another rct (randomized control trial) by nilforoushzadeh ma on comparison of meglumine antimoniate alone with combination of trichloroacetic acid 50% and intralesional meglumine antimoniate in the treatment of acute cutaneous leishmaniasis witnessed the mean age of their patients to be 11.0 years with age range of 5 to 32 years as they also enrolled paediatric and adolescent age groups.10 a local study by jamal q et al witnessed that most of their cases of leishmaniasis were between 11 and 20 years.11 in the present study, male gender was predominantly affected by cutaneous leshmaniasis in both genders. a study by al samarai and abolaidi witnessed a similar trend with male majority in their study.12 other previous studies also reported male preponderance, however, there are contrast reports as well where both genders have been found equally affected and even in some trials female gender was found predominant.13 in this study most of the lesions were found on forearm, followed by legs and face whereas the mean number of lesions were 1.2 per patient. goyonlo vm witnessed that most of their patients had lesions on head and neck followed by upper limbs.14 in the present study intralesional meglumine antimoniate achieved complete healing in (89.3%) cases compared to (73.8%) cases in intralesional arthemeter group after 6 weeks of treatment and this difference was significant (p-value,0.01). we could not find any study comparing intralesional meglumine antimoniate and intralesional artemether in humans, however, studies on animals (mice) were available. in a study, conducted by ghaffarifar f et al, the antiparasitic activity of artemisinin on l.major, both in vitro and in vivo, was assessed by finding the cytokine pattern as well as the percentage of apoptosis induced by artemisinin. it was concluded that artemisinin induces cytotoxic effects on l.major via apoptosis related mechanism.15 it was reported that oral artemether is an effective and simple method and may be used to treat visceral leishmaniasis.16 the current study has many advantages, firstly, there have been very few studies on cutaneous leishmaniasis nationally and internationally and this study is certainly very informative in this regard. secondly, two therapeutic drugs i.e. intralesional meglumine antimoniate and intralesional artemether for the management were investigated. thirdly, a reasonable number of study population was enrolled in both study groups. although, the current study found no local side effects (pain, redness and swelling at the site of injection), fever and renal impairment with both interventions, there were 2 cases of hepatitis in meglumine antimoniate and 1 case in artemether group. intralesional artemether can be considered as a safe and effective treatment option in localized cutaneous leishmaniasis. although the cure rate was better in the intralesional meglumine antimoniate group, but intralesional artemether is much cheaper, readily available and at the same time is effective and safe. there is a need to conduct further comparative trials on artemether and meglumine antimoniate, so that findings of current study could be validated. c o n c l u s i o n intralesional meglumine antimoniate is superior to intralesional artemether in the management of cutaneous leishmaniasis. both drugs have very few toxic effects and were found safe for treatment. r e f e r e n c e s 1. salam n, al-shaqha wm, azzi a. leishmaniasis in the middle east: incidence and epidemiology. plos negl trop dis 2014; 8(10) : 445-7 2. bari au. clinical spectrum of cutaneous leishmaniasis: an overview from pakistan. dermatol online j 2012; 18(2) : 4 3. mcgwire bs, satoskar ar. leishmaniasis: clinical syndrome and treatment. qjm 2014; 10(1) : 7-14 4. maleki m, karimi g, tafaghodi m, raftari s, nahidi y. comparison of intralesional two percent zinc sulphate and glucantime injection in treatment of acute cutaneous leishmaniasis. indian j dermatol 2012; 57(2): 118-22 5. singh n, kumar m, singh rk. leishmaniasis: current status of available drugs and new potential drug target. asian pac j trop med 2012 ; 5(6): 485-97 6. h. hajjaran, b. azarian, m. mohebali, r. hadighi, a. assare, b. vazir et al. comparative proteomics study on meglumine antimoniate sensitive and resistant leishmania tropica isolated from iranian anthroponotic cutaneous leishmaniasis patients. east mediterr health j 2012; 18(2) : 165-171 7. ebrahimisadr p, ghaffarifar f, hassan zm, sirousazar m, mohammadnejad f. effect of polyvinyl alcohol (pva) containing artemether in the treatment of leishmaniasis caused by leishmania major in blab/c mice. jundishapur j microbiol 2014; 7(5): e9696 177 j i m d c 2 0 1 8 177 8. ghaffarpasand f,seraj sr,heiran hr. intralesional artemisinin for the treatment of cutaneous leishmaniasis. med hypotheses 2009 ;72(2): 233-4 9. andersen em, cruz-saldarriaga m, llanos-cuentas a, luz-cjuno m, echevarria j, miranda-verastegui c, colina o, berman jd. comparison of meglumine antimoniate and pentamidine for peruvian cutaneous leishmaniasis. the american journal of tropical medicine and hygiene. 2005 feb 1;72(2):133-7. 10. nilforoushzadeh ma, jaffary f, derakhshan r, haftbaradaran e. comparison between intralesional meglumine antimoniate and combination of trichloroacetic acid 50% and intralesional meglumine antimoniate in the treatment of acute cutaneous leishmaniasis: a randomized clinical trial. j skin stem cell. 2014; 1(1): e16633 11. jamal q, shah a, ali n, ashraf m, awan mm, lee cm. prevalence and comparative analysis of cutaneous leishmaniasis in dargai region in pakistan. pakistan j zool 2013; 45(2): 537-41 12. al samarai am, alobaidi hs. cutaneous leishmaniasis in iraq. j infect developing ctries 2009;3(2): 123–129 13. yemisen m, ulas y, celik h, aksoy n. epidemiological clinical characteristics of 7122 patients with cutaneous leishmaniasis in sanliurfa, between 2001 and 2008. int j dermatol 2012; 51(3): 300–304 14. goyonlo, v. m., vosoughi, e., kiafar, b., nahidi, y., momenzadeh, a., & taheri, a. r. efficacy of intralesional amphotericin b for the treatment of cutaneous leishmaniasis.indian j dermatology 2014;59(6): 631 15. ghaffarifar f, heydari fe, dalimi a, hassan zm, delavari m, mikaeiloo h. evaluation of apoptotic and antileishmanial activity of artemisinin on promastigotes and balb/c mice infected eith leishmania major. iran j parasitol. 2015 ; 10(2) : 258-267 16. dehkordi nm, ghaffarifar f, hassan zm, heydari e. in vitro and in vivo studies of antileishmanial effects of artemether on leishmania infantum. jundishapur j microbiol. 2013 ; 6(5) :e6379 213 j i m d c 2 0 1 8 213 open access f u l l l e n g t h a r t i c l e frequency of preterm birth in females presenting with history of domestic violence numrah afzal 1, khadija aziz 2, sualeha zulfiqar3 1 medical officer, basic health unit, sakhana bajwa 2,3 medical officer, shalamar hospital, lahore a b s t r a c t objective: to find frequency of preterm birth in females presenting with history of domestic violence. patients and methods: this cross sectional study was done at basic health unit, sakhana bajwa, district gujranwala. total 150 cases were included in the study having mean age of 20-40 years with single pregnancy or of any parity with current pregnancy of gestational age >24 weeks experiencing domestic violence. domestic violence was defined as physical violence such as beating or hurting or sexual violence. all females were followed in opd till delivery. during follow-up, ultrasound was performed to check fetal health. preterm delivery was defined as delivery occurring before completion of 37 weeks. results: the mean age of females in this study was 33.32±6.42 years (range = 23 50 years). the mean gestational age was 37.65 ± 4.3 week with minimum and maximum gestational age was 32 weeks and 41 weeks. preterm birth was seen in 20(13.33%) cases, while 130(86.67%) females had full term birth. conclusion: the current study shows high frequency of preterm birth in females experiencing domestic violence. most of the females and their husbands were less educated, belonged to lower social class and had parity < 2. key words: intimate partner violence, trauma, psychological stress, birth outcome, preterm birth. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence numrah afzal email: numrahafzal5@gmail.com article info. received: march 6, 2018 accepted: july 12, 2018 cite this article. afzal n, aziz k, zulfikar s. frequency of preterm birth in females presenting with history of domestic violence jimdc.2018; 7(3):213--216 funding source: nil conflict of interest: nil i n t r o d u c t i o n domestic violence in pakistan is an endemic social problem. according to a study carried out in 2009 by human rights watch, it is estimated that 70 90 % of women in pakistan have suffered from some form of abuse.1 over the last few years, domestic violence is on a rise in pakistan in numbers and extent. a little percentage is being reported in the media. in addition to physical violence which is the most vulnerable and obvious form, the emotional and psychological abuse through which a woman passes is also included in domestic violence.2 it is noted in this report that women were more than twice as likely as men being beaten (25% versus 10%), five times were more likely to be choked (20% versus 4%) and almost twice likely to report ,being threatened by, and having a gun or knife used against them (13% versus 7%).3 recently it has been reported that the prevalence of reported cases of violence against women in pakistan has increased by 7% as compared to the year 2011. among total number of vaw incidents, 3,153 cases were reported in punjab, 1,027 in sindh, 283 in khyberpakhtunkhwa and 78 cases were reported in baluchistan.4 domestic violence against women during pregnancy affects many women and unborn infants worldwide. pregnancy presents a window of opportunity o r i g i n a l a r t i c l e 214 j i m d c 2 0 1 8 214 for health care providers to identify domestic violence and provide appropriate intervention.5 one study has showed that in females with domestic violence, the frequency of preterm delivery was 3.65%. 6 another study has showed that preterm delivery was 6.6% with domestic violence 7 the current study was designed to find frequency of preterm birth with history of domestic violence. little is known about the extent of problems during pregnancy associated with domestic violence during pregnancy. so this study was conducted to confirm the effect of domestic violence on pregnancy outcome. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted at basic health unit, sakhana bajwa, gujranwala. duration of study was 6 months. calculated sample size was 150 cases. it was computed by using the 3.65% frequency of preterm delivery in females with history of domestic violence, 95% confidence level and 5% margin of error.6 non probability, consecutive sampling technique was used. our inclusion criteria was married females of age 20-40years with singleton pregnancy, of any parity with current pregnancy of gestational age >24 weeks experiencing domestic violence. females with language barrier, those who refused to be interviewed, with high risk pregnancy i.e. pregnancy induced hypertension (pih) (bp>140/90mmhg), pre-eclampsia (pih with proteinuria +1 on dipstick) or eclampsia (pih with or without protein urea), gestational diabetes (ogtt>7mmol/l) or with cardiac problem (abnormal ecg and medical record) were excluded from study. informed consent was taken. demographic profile (name, age, parity, gestational age) was noted. domestic violence was defined as physical violence as beating or hurting or sexual violence. all females were followed-up in opd till delivery. during follow-up, ultrasound was performed to check fetal health. preterm delivery was defined as delivery occurring before completion of 37 weeks. all the information was recorded on a prescribed proforma. collected data was entered and analyzed statistically by using spss version 20. quantitative variables like age and gestational age were presented in the form of mean ± s.d. qualitative variables like parity, preterm delivery and intrauterine death were calculated in the form of frequency and percentage. group was compared by using chi-square test. p-value<0.05 was considered as statistically significant. r e s u l t s the mean age of pregnant females in this study was 29.35±3.42 years with minimum and maximum ages of 23 and 50 years respectively. mean age of husbands in this study was 32.75±2.15 years with minimum and maximum ages of 27 and 50 years respectively. the mean age of wives at the time of marriage was 21.36±1.45 years with minimum and maximum ages of 18 and 45 years respectively. mean age of husbands at the time of marriage was 24.67±5.64 years with minimum and maximum ages of 21 and 40 years respectively (table 1). there were 110 (73.3%) females who had parity < 2 and 40 (26.66%) females had a parity of ≥2. the mean education of wives was 10.21±1.76 years and of husbands was 11.85±1.48 years. the minimum and maximum education among wives was reported to be 0 years and 16 years and among husbands was 5 years and 18 years respectively. the preterm mean gestational age was 37.65 ± 4.3 week with minimum and maximum gestational age as 32 weeks and 41 weeks. the frequency of preterm birth was seen as 13.33%, while 86.67% females had full term birth (figure 1). table-1: descriptive characteristics of participants (n=150) variables mean sd age of females (years) 29.35 3.42 age of husband (years) 32.75 2.15 age of female at marriage (years) 21.36 1.45 age of husband at marriage (years) 24.67 5.64 weight of wife (kg) 56.79 4.75 weight of husband (kg) 74.33 10.56 height of wife (feet) 5.32 0.19 height of husband (feet) 5.89 3.31 education of wife (years) 10.21 1.76 education of husband (years) 11.85 1.48 gestational age (months) 37.65 4.3 215 j i m d c 2 0 1 8 215 figure 1: frequency of preterm birth d i s c u s s i o n domestic violence (dv) against women is a significant public health issue in both developed and developing countries of the world. 8-10 according to the world health organization (who), surveys from around the world indicate that approximately 10%–69% of the women report being physically assaulted by an intimate male partner at some point in their lives. 11 dv occurs globally, irrespective of class, creed, religion and country 12. it is an increasing and important community health problem that can be seen in any area of human life. 13in a study of domestic violence perpetrated by men in pakistan, all reported ‘ever shouting or yelling’ at their wives, 32.8% and 77% reported having slapped and engaging in nonconsensual sex with their wives, respectively 14. the prevalence of abuse during pregnancy in various countries has been reported to range from 5-50%.15 in 2008, karachi, pakistan, a study of 500 women who delivered at a hospital reported that 43% reported verbal abuse and 13% reported physical abuse during their pregnancy 16. in another study from karachi, of 300 women who gave birth in a large public maternity hospital, 25% reported some form of physical abuse during a previous pregnancy 17. domestic violence during pregnancy is associated with adverse pregnancy outcomes such in which preterm delivery is at top 18. according to current study the frequency of preterm birth was seen as 20(13.33%) while 130(86.67%) females had full term birth. a study reported that women who experienced moderate or severe violence had incidences of preterm birth of 15.4% and 17.2%, respectively 19one study has showed that in females with domestic violence, the frequency of preterm delivery was 3.65%. 6one more study has shown that preterm delivery was 6.6% with domestic violence. 7 according to a study, violence is associated with preterm birth with high and significant risk of 3.14 20. another study showed, that psychological abuse (or 3.9; 95 % ci 1.19– 12.82) and mild or greater depressive symptoms (or 3.3; 95 % ci 0.99–11.17) were significantly associated with increased risk of preterm birth. physical abuse was also associated with increased risk of preterm birth, but this was not statistically significant (or 1.9; 95 % ci 0.59– 6.19). in each of the above adjusted models, low maternal education was associated with increased risk of preterm birth, in the analysis with depressive symptoms or 0.18, ci 0.04–0.86 and in the analyses with psychological abuse or 0.19, ci 0.04–0.91.21 c o n c l u s i o n the current study shows high frequency of preterm birth in female’s who experienced domestic violence. most of the females and their husbands were less educated, belonged to lower social class and had parity < 2. r e f e r e n c e s 1. haroon fr. women are falling behind in pakistan. 2015 http://www.themodernreligion.com/women/w_pak.htm 2. azam s, zahra s, zainab k, sunny r. causative factors pushed women into dar-ul-aman: a case study of dar-ulaman district gujrat, pakistan. academic research international 2013;4(3):336. 3. girls a, movement yf. survey on the perceptions and attitudes of people towards domestic abuse in pakistan. 2014. 4. o'reilly r, beale b, gillies d. screening and intervention for domestic violence during pregnancy care: a systematic review. trauma, violence, & abuse 2010. 5. zareen n, majid n, naqvi s, saboohi s, fatima h. effect of domestic violence on pregnancy outcome. j coll physicians surg pak 2009;19(5):291-6. 6. urquia ml, o'campo pj, heaman mi, janssen pa, thiessen kr. experiences of violence before and during pregnancy and adverse pregnancy outcomes: an analysis of the canadian maternity experiences survey. bmc pregnancy and childbirth 2011;11(1):42. 7. zakar r, zakar mz, krämer a. spousal violence against women in the context of marital inequality: perspectives of pakistani religious leaders. international journal of conflict and violence 2011;5(2):371. 8. khawaja m. domestic violence in refugee camps in jordan. international journal of gynecology and obstetrics 2004;86(1):67-9. 216 j i m d c 2 0 1 8 216 9. finnbogadóttir h, dykes a-k, wann-hansson c. prevalence of domestic violence during pregnancy and related risk factors: a cross-sectional study in southern sweden. bmc women's health 2014;14(1):1. 10. who. world report on violence and health: summary. geneva. online available at www.who.intviolence_injury_prevention=violence=world_r eport=en=full_en.pdf. accessed aug 2016. 2005. 11. sarkar n. the cause and consequence of domestic violence on pregnant women in india. journal of obstetrics and gynaecology 2013;33(3):250-3. 12. arslantaş h, adana f, ergin f, gey n, biçer n, kıranşal n. domestic violence during pregnancy in an eastern city of turkey a field study. journal of interpersonal violence 2012;27(7):1293-313. 13. shaikh ma. domestic violence against women-perspective from pakistan. j pak med assoc 2000;50(9):312-4. 14. karmaliani r, irfan f, bann cm, mcclure em, moss n, pasha o, et al. domestic violence prior to and during pregnancy among pakistani women. acta obstetricia et gynecologica scandinavica 2008;87(11):1194-201. 15. farid m, saleem s, karim ms, hatcher j. spousal abuse during pregnancy in karachi, pakistan. international journal of gynecology & obstetrics 2008;101(2):141-5. 16. fikree ff, jafarey sn, korejo r, afshan a, durocher jm. intimate partner violence before and during pregnancy: experiences of postpartum women in karachi, pakistan. j pak med assoc 2006;56(6):252-7. 17. yost np, bloom sl, mcintire dd, leveno kj. a prospective observational study of domestic violence during pregnancy. obstetrics & gynecology 2005;106(1):61-5. 18. shumway j, o'campo p, gielen a, witter fr, khouzami an, blakemore kj. preterm labor, placental abruption, and premature rupture of membranes in relation to maternal violence or verbal abuse. journal of maternal-fetal medicine 1999;8(3):76-80. 19. rodrigues t, rocha l, barros h. physical abuse during pregnancy and preterm delivery. american journal of obstetrics and gynecology 2008;198(2):171. e1-. e6. 20. rao d, kumar s, mohanraj r, frey s, manhart le, l. kaysen d. the impact of domestic violence and depressive symptoms on preterm birth in south india. social psychiat psychiat epidemiol 2016;51(2):225-32. 21. gosselin dk. heavy hands: an introduction to the crime of intimate and family violence. 4th ed. new york: prentice hall; 2009. journal of islamabad medical & dental college (jimdc); 1211(1):26-29 26 original article patients satisfaction levels in out patient department of a teaching hospital *muhammad afzal, **ahmad khan, **farwa rizvi, **abrar hussain *senior research officer, community medicine department, islamabad medical and dental college, islamabad **head, community medicine department, islamabad medical and dental college, islamabad ***assistant professor, community medicine department, islamabad medical and dental college, islamabad ****assistant professor, community medicine department, islamabad medical and dental college, islamabad (bahria university, islamabad) abstract objective: to evaluate patient satisfaction and its relation with different demographic factors of respondents in the outpatient department of a teaching hospital. methodology: a cross sectional study was performed between february 2011 and june 2011. a total sample size of 150 participants was collected by consecutive sampling technique. participants were interviewed privately face to face in the hospital in outpatient department of pessi hospital rawalpindi. interviews were conducted by trained interviewers using pre tested questionnaires. data was entered and analyzed by using spss v 15. descriptive statistics was used to analyze the data. percent mean score technique was used to show the satisfaction score of the participants. results: in this sample of 150 participants 89 (59.30%) were males. mean age of the sample was 38.15±10.919 years. majority of the participants [105 (70%)] were married. most of the participants [72 (48%)] were under matric and 66 (44%) were illiterate. maximum patients [72 (48%)] belonged to low income class (< 7000 rs.). the overall patient’s satisfaction in terms of mean percent satisfaction score was 61.39±9.8793 ranging from 33.5 to 84. the highest mean percent satisfaction score (64.15±11.61) was observed in age interval of 25-35 years and the higher satisfaction was noted in females (62.10±8.95). the highest satisfaction with respect to marital status was seen in widowed category and minimum in single patients. the highest mean percent satisfaction score (67.75±5.08) was in patients who had intermediate level education but the patients who were in under matric category of education had lowest mean percent satisfaction level of 58.63±9.56. similarly the highest satisfaction was observed in low income class (63.33±10.09). conclusions: in general, patients were satisfied with their hospital care; overall satisfaction level was 61%. patients’ level of satisfaction showed a relation with age, gender, education and income level. key words: patients satisfaction, mean percent satisfaction score, pessi, introduction it is easier to evaluate the patient's satisfaction towards the service than evaluate the quality of medical services that they receive. therefore, a probe into patient satisfaction can be an important tool to improve the quality of services.1 patient satisfaction is a multi-dimensional healthcare issue affected by many factors. healthcare quality affects patient satisfaction, and in result it influences on positive patient behaviour such as confidence in hospital care. patient satisfaction and healthcare service quality can be increased by using a multi-disciplinary approach that combines patient inputs as well as expert judgment.2 in a study, it was concluded that paramedical staff need to know the factors influencing the patient satisfaction in order to improve the quality of health care.3 measurement of patient satisfaction is expected to play an increasingly important role in the growing push toward accountability among health care providers overshadowed by measures of clinical processes and outcomes in the quality of care equation. patient satisfaction finding regarding inpatient and ambulatory care play a significant role in hospitals’ strategies and tactics in delivering patient services.4 every human being carries a particular set of thoughts, feelings and needs. by getting to know the patients a little more to get their views on the care, one ought to come closer to what the patients consider as good care.5 patient compliance is very important for successful treatment outcome and since clinical outcome is always attributed to the provider and never to the patient, the patient compliance with treatment becomes all the more crucial.6 working over a long period of time in hospitals, the staff may become insensitive to the pains and anxiety of the patients. there is not much emphasis on the behavioral aspects in the training programs in our medical colleges.7 different demographic aspects of patients can affect the patient’s satisfaction level but some studies showed that age, gender, income or formal education have shown no clear connection with the patient satisfaction.4 but many studies have pointed out the importance of certain variables journal of islamabad medical & dental college (jimdc); 1211(1):26-29 27 including age which consistently shows that elderly patients are more satisfied as compared with other age groups.8 in a study it was noted that efficient delivery of primary health care through the existing health system will lead to improved health conditions and improved patients’ satisfaction.9 some studies elaborated that supporting staff and paramedical staff of hospital should the factors influencing the patient satisfaction in order to improve the quality of health care.10 health care consumers today, are more sophisticated than in the past and now demand increasingly more accurate and valid evidence of health plan quality. patient-centered outcomes have taken center stage as the primary means of measuring the effectiveness of health care delivery.1,9 it is being accepted that the patient’s feedback is very important indicator for quality of healthcare. patient’s feedback is very valuable for the hospital management as a predicted for their planning as well as a guideline to improve quality of services. 11 patient satisfaction is a domain not given much importance in our part of the world, especially if we talk about tertiary care public hospitals. this study was planned to measure the patient satisfaction in opd of a tertiary care teaching hospital to assess the quality of care provided in terms of patients’ satisfaction. methodology a cross sectional study was performed between february 2011 and june 2011. a total sample size of 150 participants was collected by consecutive sampling technique. informed written consent was taken from all the participants and approval of the study was taken from the hospital ethical committee. participants were interviewed privately face to face in the hospital in outpatient department of pessi hospital rawalpindi. interviews were conducted by trained interviewers using pre tested questionnaires. information regarding demographic characteristics like age, gender, educational status, marital status and monthly income was recorded. different characteristics of hospital like behavior of doctor, paramedical staff, waiting time, etc which can affect the patient satisfaction were measured on five point scale of strongly agree (5), agree (4), uncertain (3), disagree (2), strongly disagree (1). the percent score was calculated for each patient and patient satisfaction was measured in terms of mean percent score with respect to different demographic characteristics. data were entered and analyzed by using spss v 15. descriptive statistics was used to analyze the data and results were presented by mean ± sd and frequencies with percentages in tabular form. percent mean score technique was used to show the satisfaction score of the participants. results a total of 150 patients coming to outpatient department of pessi hospital irrespective of their age, gender and ailment were included in the study by consecutive sampling technique. the detailed demographic characteristics of the participants are given in (table 1). in this study sample 61 (40.70%) were females and 89 (59.30%) were males. mean age of study participants was found to be 38.15±10.919 years ranging from 22 to 75 years. majority of the participants 105 (70%) were married. as regards educational level of the participants, most of the participants [72 (48%)] were under matric, and 66 (44%) were illiterate. maximum patients [72(48%)] belonged to low income class (< 7000 rs. per month) and 61 (41%) to middle income class (7000-15000 rs. per month) as given in table 1. the overall patients’ satisfaction score is given in table 2, which shows that mean of total mean score was 122.7±19.759 and the range was 67 to 168 and the mean of mean score was 3.07±0.4940 ranging from 1.68 to 4.20. similarly the mean of percent score was 61.39±9.8793 ranging from 33.5 to 84. table 1: demographic characteristics of respondents age of respondent (years) mean ± sd 38.15 ± 10.919 median 35 range 22 – 57 sex of respondent male 89 59.30 % female 61 40.70 % marital status of respondent single 33 22 % married 105 70 % divorced 3 2 % widow 9 6 % education level of respondent illiterate 66 44 % under matric 72 48 % matric 6 4 % intermediate 6 4 % income of respondent < 7000 rs. 72 48 % 7000 to 15000 rs. 61 41 % > 15000 rs. 17 11 % table 2: descriptive statistics for patients satisfaction patients satisfacti on scores n minimum maximum mean std. deviation total score * 150 67 168 122.78 19.759 mean score ** 150 1.68 4.20 3.07 0.4940 percent score *** 150 33.5 84.0 61.39 9.8793 *total score range: 40 to 200;** mean score range:1-5 *** percent score range: 20-100 journal of islamabad medical & dental college (jimdc); 1211(1):26-29 28 the highest mean percent satisfaction score (64.15±11.61) was seen in age interval of 25-35 years and the minimum percent satisfaction score (54.86±10.81) was seen in older age (>55) years patients. the higher satisfaction was seen in females with mean percent satisfaction score of 62.10±8.95. the highest satisfaction with respect to marital status was seen in widowed category and minimum satisfaction in single patients whose mean percent score was 60.44±11.63. the patient satisfaction depends upon educational status of the patients the results show that the rate of satisfaction increased as the educational level increased and mean percent satisfaction score (67.75±5.08) was in patients who had educational level of intermediate but the patients who had were in under matric category of education had lowest mean percent satisfaction level of 58.63±9.56. similarly highest satisfaction was seen in low income class who had mean percent satisfaction score of 63.33±10.09 and it decreased as income level increased and become minimum in highest income level of > 15000 as given in table 3. table 3: patient satisfaction score with respect to different demographic characteristics characteristics n mean satisfaction score (%)* std. deviation (%)* age of respondent (years) < 25 21 60.57 11.61 25 35 56 64.15 8.94 35 45 39 60.81 8.58 45 55 27 58.83 10.78 > 55 7 54.86 10.81 sex of respondent male 89 60.90 10.49 female 61 62.10 8.95 marital status of respondent single 33 60.44 11.63 married 105 61.18 9.63 divorced 3 62.33 8.75 widow 9 67.00 3.46 education level of respondent illiterate 66 63.33 10.09 under matric 72 58.63 9.56 matric 6 66.83 4.14 intermediate 6 67.75 5.08 income of respondent < 7000 rs. 72 63.34 10.39 7000 to 15000 rs. 61 61.37 7.84 > 15000 rs. 17 53.21 10.53  mean and std. deviation are percent scores in percentages discussion the outcome of any disease is influenced by the decisions to seek care, timely arrival at appropriate diagnostic and treatment services and the receipt of adequate care from service providers. satisfaction in service provision is increasingly being used as a measure of health system performance. satisfaction is observable itself in the distribution, access and utilization of health services. researchers have proved that satisfaction level is related to a range of factors like ethnic group, patient education, waiting times and attitudes of providers as well as patients’ perception of a relationship of trust, providers’ answering of questions and provision of adequate information, patients’ feeling of being involved in decisions about their care. 12 age is a well known determinant of patient satisfaction index with older patients scoring more highly and being more satisfied than young and middle aged patients.13 according to the results of the study the overall patient’s satisfaction in terms of mean percent satisfaction score was 61.39±9.8793 ranging from 33.5 to 84. there was no considerable relationship between age and patient satisfaction, it was seen that elder age patients were comparatively more satisfied than other groups. the highest mean percent satisfaction score (64.15±11.61) was seen in age interval of 25-35 years and the higher satisfaction was seen in females (62.10±8.95). this fact was also seen in some other studies which concluded that some demographic variable are important including age which consistently shows that elderly patients are more satisfied.6 the effect of the age variable on satisfaction was not significant in japipaul study, but it showed interesting results. the greatest level of satisfaction was in the group 15-24 years old, and then it decreased gradually and increased again in the group who were over 60 years old.14 some studies showed that age, gender, income and formal education have shown no clear connection with the patient satisfaction.4 in this study it was noted that the higher satisfaction was seen in females with mean percent satisfaction score of 62.10±8.95 as compared with male patients. in a study, contrary to present study it was noted that female patients with short duration of hospitalization were less satisfied with staff’s care than men.15 age is a well known determinant of patient satisfaction score with older patients scoring more highly and being more satisfied than young and middle aged patients. the most consistent finding has been related to age, older patients tend to be more satisfied with their health care. 16 studies on the effect of gender are contradictory, with some studies showing that women tend to be less satisfied and other studies showing the opposite.17 the results of this present study showed that the rate of satisfaction increased as the educational level increased and mean percent satisfaction score (67.75±5.08) was in patients who had educational level of intermediate but the patients who were in under matric category of education had lowest mean percent satisfaction level of 58.63±9.56. similarly highest satisfaction was seen in low income class who had mean percent satisfaction score of 63.33±10.09 and it decreased as income level increased and become minimum journal of islamabad medical & dental college (jimdc); 1211(1):26-29 29 in highest income level of > 15000. as some studies showed that age, education level, marital status, sex, work status and length of stays affected the scores of satisfaction.18 from different studies it was noted that usually, those married or cohabitating tended to have higher satisfaction scores, but in some studies those who were single or divorced had higher satisfaction scores 14 which is also supported by the results of this present study. 19 some studies reported that low income patients were more satisfied as compared with high income patients as revealed by results of this present study.20 the goal of the health care team is to provide the best quality of health care and service to the patient. it is now a worldwide trend in the healthcare system to include subjective user satisfaction into the evaluation of quality of medical service provided.21,22 conclusion as in previous studies, there is evidence that patient socio demographic characteristics affect patient satisfaction levels. similarly it was noted in this present study that age, gender, marital status, education level and income level of patients have effect on their satisfaction score. patients with elder age, female patients, middle level of education and low income patients showed higher satisfaction. references 1. kumari r, idris mz, bhushan v, khanna a, agarwal m, singh sk. study on patient satisfaction in the government allopathic health facilities of lucknow district, india. indian j community med. 2009; 34(1): 35–42. 2. naidu a. factors affecting patient satisfaction and healthcare quality. int j health care qual assur. 2009;22(4):366-81. 3. sultana a, riaz r, rehman a, sabir sa. patient satisfaction in two tertiary care hospitals of rawalpindi. jrmc 2009;13(1):41-3 4. hajifathali a, ainy e, jafari h, moghadam nm, kohyar e, hajikaram s. in-patient satisfaction and its related factors in taleghani university hospital, tehran, iran. pak j med sci. 2008; 24(2) 274-7. 5. sultana a, riaz r, rehman a, sabir sa. patient satisfaction in two tertiary care hospitals of rawalpindi. j rawal med coll. 2009;13(1):41-3. 6. jawaid m, ahmed n, alam sn, rizvi bh, razzak ha. patients experiences and satisfaction from surgical out patient department of a tertiary care teaching hospital. pak j med sci 2009;25(3):439-42. 7. saaiq m, zaman k. pattern of satisfaction among neurosurgical inpatients. j coll physicians surg pak 2006; 16(7): 455-9. 8. crow r, gage h, hampson s, hart j, kimber a, storey l. the measurement of satisfaction with health care: implication for practice from a systematic review of the literature. health technology assessment 2002;32:1-244. 9. shaikh bt. quality of health care: an absolute necessity for patient satisfaction. j pak med assoc 2005; 55(11): 51416. 10. khan mh, hassan r, anwar s, babar ts, babar ks. patient satisfaction with nursing care. rawal med j jan-jun 2007; 32(1): 28-30. 11. danish kf, chaudhry mt, khan ua, naseer m. patient satisfaction – an experience at islamic international medical college / railway hospital. jrmc 2008;12(1):4750 12. becker g, newsom e. socioeconomic status and dissatisfaction with health care among chronically ill african americans. am j public health. 2003;93:742–8 13. rahmqvist m. patient satisfaction in relation to age, health status and other background factors: a model for comparisons of care unit. int. j quality healthcare 2001;13(5):385-390. 14. japipaul ck, rosenthal ge. are older patient more satisfied with hospital care than younger patient. j general internal medicine 2003;1:23-30. 15. kuosmanen l, hatonen h, jyrkinen ar, katajisto j, valimaki m. patient satisfaction with psychiatric inpatient care. j adv nurs 2006;6:655-63. 16. thiedke cc. what do we really know about patient satisfaction? fam pract manag. 2007;14(1):33-6. 17. kersnik j, svab i, vegnuti m. frequent attenders in gen eral practice. scand j prim health care. 2001;19:174–7. 18. quintana jm, gonzález n, bilbao a, aizpuru f, escobar a, esteban c, et al. predictors of patient satisfaction with hospital health care. bmc health services research 2006, 6:102. 19. hargraves jl, wilson ib, zaslavsky a, james c, walker jd, rogers g, cleary pd: adjusting for patient characteristics when analyzing reports from patients about hospital care. med care 2001, 39:635-41. 20. thind a, hoq l, diamant a, maly rc. satisfaction with care among low-income women with breast cancer. j womens health (larchmt). 2010;19(1):77-86. 21. hudak pl, wright jg. the characteristics of patient satisfaction measures. spine 2000; 25: 3167-77. 22. urden ld. patient satisfaction measurement: current issues and implications. outcomes manag 2002; 6:125-31. . 132 j i m d c 2 0 1 8 132 open access f u l l l e n g t h a r t i c l e determination of diabetes mellitus among hepatitis c virus associated chronic liver disease muhammad saeed 1, hafiza anum basharat 2, zoyia ejaz 3, zeeshan nawaz 4, maqsood ahmad 5, muhammad iqbal javed6, ambereen anwar imran 7 1 medical lab technologist-lab manager, dhq hospital mandi bahauddin. 2 medical laboratory technologist, allama iqbal medical college lahore 3 women medical officer, tehsil head quarter hospital fatehjang 4 assistant professor of microbiology, government college university faisalabad 5 medical lab technologist-lab manager hameed latif hospital lahore 6 assistant professor of pathology, allama iqbal medical college lahore 7 professor of pathology, head dept. of pathology, allama iqbal medical college, lahore a b s t r a c t objective: determination of diabetes mellitus among hepatitis c virus associated with chronic liver disease patients. patients and methods: this cross sectional study was conducted in the central laboratory, department of chemical pathology, allama iqbal medical college, lahore, from 1stmay 2016 to 31stjanuary 2017. a total of 201 known cases of chronic liver disease were included from medical wards of the jinnah hospital, lahore. about 02 ml blood sample was collected from each individual for estimation of fasting blood glucose and hba1c. patients were labeled as diabetic or non–diabetic according to the criteria for the diagnosis of diabetes mellitus described by american diabetes association 2017. results: out of these 201 cases, 51% (n=103) were males and 49% (n=98) were females. mean age of all participants was 55.2 + 10.6 years. mean fasting blood glucose level was 201.9+111.0 mg/dl. total 24.9% patients were found nondiabetic and remaining 75.1% were declared as diabetics. conclusion: high rate of diabetes mellitus was observed among hepatitis c virus associated chronic liver disease patients. key words: chronic liver disease, diabetes, hepatitis c virus. author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-5 data analysis, interpretation and manuscript writing, 6,7 active participation in data collection. address of correspondence muhammad saeed email: mian.scientist@yahoo.com article info. received: january 10, 2018 accepted: may 3, 2018 cite this article. saeed m, basharat ha, ejaz z, nawaz z, ahmad m, javed mi, imran aa. determination of diabetes mellitus among hepatitis c virus associated chronic disease. jimdc.2018; 7(2):132-135 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus is one of the commonest diseases around the globe, and it is expected that by the year 2030 there will be 366 million people affected globally.1 in the year 2000, global mortality due to diabetes was 2.9 million.2 in pakistan, it is estimated that 6.3 million persons have an age adjusted 7.9% prevalence of persons with diabetes (pwd) among adults, 20 years or older.3 pakistan, in 2030 will have an estimated 11.4 million persons with pwd and prevalence of 8.9% in the absence of major medications.4 there are many causes for chronic liver disease (cld), from which hepatitis c virus is most common. hcv was documented in 1989 as the primary agent of non-a, non-b hepatitis, which at the time accounted for almost 90 o r i g i n a l a r t i c l e 133 j i m d c 2 0 1 8 133 percent of all transfusion transmitted hepatitis cases in the united states.5 hepatitis c infection is one of the most alarming health problems globally, with an incidence of 200 million (3.3%) of the world’s population.6 currently, about 4 million individuals in the united states are infected with hcv and 2.7 million of these people are acareers.7 nearly 30,000 new cases of hcv have been diagnosed annually, and more than two thirds appear to be related to parenteral route.8 it is estimated that >10 million peoples are infected with hcv in pakistan.9 hcv primarily affects the liver and ultimately causes cirrhosis,end-stage liver disease and hepatocellular carcinoma.10 hcv-associated cld is responsible for 8,000-10,000 mortalities per year and for 25 percent of all liver transplantations in the united states.8,11association of dm and liver cirrhosis was first described by bohan et al 12 and designated as hepatogenous diabetes in a study conducted by megyesi et al13 in which 57% of cirrhotic patients were found to have insulin resistance. near about 80% of cld patients may be glucose intolerant and between 10–20% may be clinically diabetic.14 the liver is chiefly responsible for glucose homeostasis and store or release of glucose according to metabolic needs. in diabetes or insulin resistant states, impaired hepatic glucose release contributes considerably to the pathophysiology of those conditions. hcv infection is a known risk factor for hepatocellular carcinoma (hcc) and rising risk of hcc by 2–4 folds even after adjusting for other predisposing factors.14 acute or chronic liver disease can augment insulin resistance and effects of insulin on hepatocyte are disturbed.15 in presence of hepatic disease, the metabolic homeostasis of glucose is deranged as a result of insulin resistance, glucose intolerance, and diabetes. insulin resistance develops not only in muscle but also in adipose tissue which combined with hyperinsulinemia may seem as important pathophysiologic basis of diabetes in chronic liver disease.16 glucose absorbed from the intestinal tract is transported from portal vein to liver where most of the glucose is retained by the liver so that most of the rise in peripheral glucose concentration is a reflection of only a minor component of postprandial absorbed glucose. it is suggested that liver plays a more significant role than peripheral tissues in maintaining systemic blood glucose level following a meal.14 dm in patients of cld may be subclinical hepatogenous diabetes is clinically different from type 2 dm since it is less frequently associated with microangiopathy and patients more often undergo complications of cirrhosis and increase the death rate is because of cirrhosis.16 there are several international studies, that have reported association of diabetes with cld, but very few such studies have been published from our region. the rationale behind this study was to ascertain the frequency of dm in patients of cld. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted in department of chemical pathology, allama iqbal medical college, lahore, from 1st may 2015 to 31st january 2016. study was approved by ethical review board of the institute. total 201 patients of hcv associated chronic liver diseases of either gender were inducted from medical wards of the jinnah hospital, lahore. diagnosis of cld was made by clinician of the ward on the basis of laboratory investigations and ultrasonography.18 patients with acute stage of liver disease, renal failure, known for diabetes, hbv or any other virus career and those who refused to become the part of the study were excluded from the study. all participants were requested for overnight (10–12 hours) fast. next morning 01 ml blood sample in sodium fluoride tube was collected from each individual for estimation of fbg. similarly, 01 ml blood was taken in edta tube for hba1c analysis. all specimens were transported to the lab under standardized conditions. centrifugation was done at 2500 rpm for 5-7 minutes. blood glucose was estimated by endpoint enzymatic (glucose oxidase – pap) method, using diagnostic reagents on semi-automated chemistry analyzer (microlab-300) manufactured by merck. hba1c was analyzed by beck-man coulter access 2 automatic special chemistry analyzer by using immunoassay technique. based on the findings of fbg and hba1c, patients were labeled as diabetic or non–diabetic according to the criteria for the diagnosis of dm as described by american diabetes association 2017. spss 21.0 was used for statistical analysis. frequency and percentages were calculated 134 j i m d c 2 0 1 8 134 r e s u l t s among 201 cases, 51% participants (n=103) were males and 49% (n=98) were females. mean age of all patients was 55.2 + 10.6 years. mean fbg was 201.9+111.0 mg/l. total 24.9% individuals were found non-diabetic and remaining 75.1% were declared as diabetics (table 1). thus diabetic population was 75 % (151/201) of the whole study population. among 75 % of diabetic population, 49% (74/151) were female and 51% (77/151) were male. table 1: fasting glucose and glycated hemoglobin in cld patients groups frequency percentage non-diabetic (glucose < 100 mg/dl), hba1c (<6.5%) 50 24.9 diabetic (glucose ≥ 126 mg/dl), hba1c (≥6.5%) 151 75.1 total 201 100 d i s c u s s i o n hyperglycemia is seen in patients of cld, after ingestion of oral glucose, resulting in hyperglycemia in central circulation and leading to impairment of glucose uptake by peripheral tissues due to insulin resistance.8 in our study, 250 cases of cld have been evaluated for the prevalence of dm. we found that 75% of our study population was diabetic. multiple researchers have reported the prevalence of dm (12.9 – 23.2%) from different regions of the globe.19-21 in pakistan, the previously reported prevalence of dm is 18.7 – 34.8%.22-24 this rate is low as compared to our study. the basic reason for this higher prevalence is still unknown but few researchers have reported that persons of old age 40 years or above with hepatitis c infections are more likely to have diabetes.25 our findings are in agreement with this. another reason for this highest prevalence may be due to the population difference as previous researches has been done in different areas of pakistan but our study population was patients admitted in jinnah hospital, lahore which one of the major referral/teaching hospital of the province. among 75 % (151/201) of diabetic population, 49% (74/151) were female and 51% (77/151) were male. the gender difference was not a significant factor in our study as both genders were almost equally enrolled. however, in a previous study, it was found that dm was dominant in males.26 many researchers have also reported the association of chronic liver disease and impaired glucose tolerance. a study conducted in larkana, pakistan reported 78% prevalence of dm in a population of cirrhosis.27 the exact pathophysiology underlying the association of chronic hepatitis c with dm is still unknown. a detailed knowledge of the underlying cause of hcv associated glucose metabolism disturbance is warranted, in order to improve clinical management of chronic hepatitis c patients.28,29 accumulation of fat in liver cells is also a factor for the development of insulin resistance as described by many researchers. steatosis in hcv positive cases is also closely related to expression of hcv core protein and possibly, it is related to change metabolic profile.30 all patients who are suspected for cld should be screened for dm from time to time. if management of high blood glucose level is addressed in patients of cld, this will reduce the risk of complications associated with diabetes in these patients. this study was a single center cross sectional study with small sample size. multicenter cohort studies should be conducted on a large sample size so the exact phenomena for the development of dm in chronic liver disease cases may be described. c o n c l u s i o n the frequency of diabetes mellitus in patients suffering from chronic liver disease was high. this can be controlled and managed by the early detection of blood glucose level in chronic liver disease cases. early detection of dm may avoid micro or macro angiopathic complications of dm and life expectancy of such patients can be improved. r e f e r e n c e s 1. wilds r, green a. sicreer and king h. global prevalence of diabetes: estimates for the year. 2000:1047-53. 2. roglic g, unwin n, bennett ph, mathers c, tuomilehto j, nag s, et al. the burden of mortality attributable to diabetes. diabetes care. 2005;28(9):2130-5. 3. muhammad a, farooq mu, iqbal mn, ali s, ahmad a, irfan m. prevalence of diabetes mellitus type ii in patients with hepatitis c and association with other risk factors. punjab univ j zool. 2013;28(2):69-75. 4. whiting dr, guariguata l, weil c, shaw j. idf diabetes atlas: global estimates of the prevalence of diabetes for 2011 135 j i m d c 2 0 1 8 135 and 2030. diabetes research and clinical practice. 2011;94(3):311-21. 5. choo q-l, kuo g, weiner aj, overby lr, bradley dw, houghton m. isolation of a cdna clone derived from a bloodborne non-a, non-b viral hepititis genome. science. 1989;244(4902):359. 6. saeed m, iram s, hussain s, mobeen r, ahmad m, ashraf m. hepatitis c in asymptomatic population. professional medical journal. 2016;23(5). 7. filozof cm, jones s, connelly ma, eisenberg m, goldstein bj. liver fibrosis as assessed by the fib-4 index and metabolic markers in subjects with type 2 diabetes. in hepatology 2017; 66: 1125a-1126a 8. lavanchy d. the global burden of hepatitis c. liver international. 2009;29(s1):74-81. 9. saeed m, hussain s, rasheed f, ahmad m, arif m, rahmani mth. silent killers: transfusion transmissible infections-tti, among asymptomatic population of pakistan. jpma the journal of the pakistan medical association. 2017;67(3):36974. 10. hu kq, tong mj. the long‐term outcomes of patients with compensated hepatitis c virus–related cirrhosis and history of parenteral exposure in the united states. hepatology. 1999;29(4):1311-6. 11. hoofnagle jh. hepatitis c: the clinical spectrum of disease. hepatology. 1997;26(s3). 12. bohan e. diabetes mellitus and cirrhosis of the liver; a case report. delaware medical journal. 1947;19(11):212-5. 13. megyesi c, samols e, marks v. glucose tolerance and diabetes in chronic liver disease. the lancet. 1967;290(7525):1051-6. 14. perme o, singh yi, singh kr, devi bs, rao a, singh sk. prevalence of diabetes in chronic liver disease patient admitted in medicine ward in rims hospital, imphal. journal of medical society. 2016;30(2):84. 15. schattenberg jm, schuchmann m. diabetes and apoptosis: liver. apoptosis. 2009;14(12):1459. 16. garcia-compean d, jaquez-quintana jo, gonzalezgonzalez ja, maldonado-garza h. liver cirrhosis and diabetes: risk factors, pathophysiology, clinical implications and management. world j gastroenterol. 2009;15(3):280-8. 17. vaughan jp and morrow rh. manual of epidemiology for district health management. world health organization. 1989; 175-176. 18. friedman ls, martin p. handbook of liver disease e-book: elsevier health sciences; 2017. 19. pazhanivel m, jayanthi v. diabetes mellitus and cirrhosis liver. minerva gastroenterologica e dietologica. 2010;56(1):711. 20. singal ak, ayoola ae. prevalence and factors affecting occurrence of type 2 diabetes mellitus in saudi patients with chronic liver disease. saudi journal of gastroenterology. 2008;14(3):118. 21. kobashi-margáin ra, gutiérrez-grobe y, poncianorodríguez g, uribe m, méndez-sánchez n. prevalence of type 2 diabetes mellitus and chronic liver disease: a retrospective study of the association of two increasingly common diseases in mexico. ann hepatol. 2010;9(3):282-8. 22. shahid m. diabetes mellitus: prevalence in patients of hepatitis c. professional med j jan–mar. 2012;19(1):68-72. 23. muhammad d, amin k, anjum a, javed m. chronic hepatitis c virus association with type-2 diabetes.. professional medical journal. 2010;17(4). 24. malik zi, ishtiaq o, shah nh, anwer f, baqai hz, mehboob r, et al. serum cardiac troponin-i and st segment elevtion in patients with acute pericarditis. pak j med res. 2002;41(4):137-41. 25. mehta sh, brancati fl, sulkowski ms, strathdee sa, szklo m, thomas dl. prevalence of type 2 diabetes mellitus among persons with hepatitis c virus infection in the united states. annals of internal medicine. 2000;133(8):592-9. 26. caronia s, taylor k, pagliaro l, carr c, palazzo u, petrik j, et al. further evidence for an association between non– insulin‐dependent diabetes mellitus and chronic hepatitis c virus infection. hepatology. 1999;30(4):1059-63. 27. abro h, shah a, soomro m, sheikh w, solong g, qadri h. association of diabetes mellitus type 2 with chronic hepatitis c virus infection. med channel 2005;11(1):51-4. 28. mansoor s, bhutta si. prevalence of diabetes in patients with hcv hepatitis and cirrhosis. ann pak inst med sci. 2013;9(4):172-5. 29. negro f, alaei m. hepatitis c virus and type 2 diabetes. world journal of gastroenterology: wjg. 2009;15(13):1537. 30. sougleri m, labropoulou-karatza c, paraskevopoulou p, fragopanagou h, alexandrides t. chronic hepatitis c virus infection without cirrhosis induces insulin resistance in patients with β-thalassaemia major. european journal of gastroenterology & hepatology. 2001;13(10):1195-. 195 j i m d c 2 0 1 8 195 open access f u l l l e n g t h a r t i c l e effects of febuxostat in the progression of chronic kidney disease in renal transplant recipients muhammad aqeel1, syed sohail tanvir2, mariam masud3 1 assistant professor, 2 associate professor, 3 assistant professor department of nephrology, pakistan institute of medical sciences a b s t r a c t objective: to see the effect of febuxostat in slowing the progression that treatment with febuxostat improves egfr in renal transplant recipients having asymptomatic hyperuricemia. patients and methods: this randomized controlled trial was carried out in a department of nephrology pims. a total of 106 post renal transplants recipients having asymptomatic hyperuricemia, were randomly divided into two groups of 53 each by lottery method. one group was given febuxostat for treatment of post renal transplant hyperuricemia while the other one was given a placebo. results: the mean age of patients was 48.15 years with a male to female ratio 4.6:1. treatment with febuxostat was linked significantly in lowering the mean uric acid level at 7.01mg/dl, 6.32mg/dl and 5.42mg/dl at 2, 4 and 6 months, respectively, and renal function was better preserved in the patients receiving febuxostat at mean egfr of 49.74, 48.96 & 48.89 ml/min/1.73m 2 at 2, 4 and 6 months, respectively. conclusion: in patients with postrenal transplant asymptomatic hyperuricemia, febuxostat showed significant reduction in serum uric acid level with preservation of renal function. key words: asymptomatic hyperuricemia, egfr, febuxostat, renal graft dysfunction, renal transplant author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence mariam masud email: drmariam.masud@gmail.com article info. received: august 20, 2018 accepted: september 10, 2018 cite this article. aqeel m, tanvir s.s, masud m. effect of febuxostat in progression of chronic kidney disease in renal transplant recipents. jimdc.2018; 7(3):195-198 funding source: nil conflict of interest: nil i n t r o d u c t i o n uric acid is a weak acid trioxypurine, comprising of imidazole and pyrimidine substructure with molecules of oxygen. it is made from metabolic conversion of either endogenous or dietary purines mainly in intestines, muscles and liver 1. xanthine is the predecessor of uric acid which is metabolized into uric acid by the enzyme xanthine oxidoreductase i.e., xanthine-oxidase or xanthine dehydrogenase.2 uric acid is mainly excreted by kidneys approx. 250-750 mg/day, which is about 70% of daily urate production.3 post renal transplant hyperuricemia is defined as serum uric acid level >7.0mg/dl in men and >6.0mg/dl in women, having renal transplantation.4 identification of new risk factors help in improvement of long-term outcomes. numerous factors predisposing renal transplant recipients to hyperuricemia were reported, including treatment with diuretics, insufficient allograft function and immunosuppression with cyclosporine.5 asymptomatic hyperuricemia is a risk factor for cardiovascular disease and for the onset and progression of chronic kidney disease in general population.6,7 chung et al investigated whether early-onset hyperuricemia has clinical importance irrespective of graft function.8 post renal transplant hyperuricemia is linked with the onset of o r i g i n a l a r t i c l e 196 j i m d c 2 0 1 8 196 cardiovascular disease and allograft loss in renal transplant recipients.9,10 numerous studies have been done in kidney transplant recipients to assess the role of hyperuricemia in decreased renal function, but there has been a controversy in the results. the commonly used hypouricemic agents used in general population are allopurinol and benzbromarone but both of them cannot be used in post renal transplant hyperuricemia because of toxicity of the former and reduced hypouricemic effect due to chronic renal insufficiency and renal transplantation in the latter.11 febuxostat is a non-purine selective inhibitor of xanthine oxidase and is better tolerated in patients with gout and/or moderate renal dysfunction.12,13 metabolism of febuxostat is mainly done by glucuronide formation and oxidation in the liver.14 however, the assessment of efficacy of febuxostat in kidney transplant recipients with asymptomatic hyperuricemia has not been done in local population so far. *chi-square test and independent sample t-test, observed difference was statistically insignificant p a t i e n t s a n d m e t h o d s it is a prospective randomized controlled trial conducted in department of nephrology, pakistan institute of medical sciences, islamabad, pakistan over 6 months i.e., from 18th september 2017 to 17th march, 2018. sample size was calculated using who sample size calculator. in total 106 patients (87 males and 19 females), selected by nonprobability, consecutive sampling, were enrolled, and after informed consent were divided into 2 groups of 53 each, using lottery method. all renal transplant recipients with age from 20-60 years in pims nephrology opd or ward, 3 months’ post-transplantation with asymptomatic hyperuricemia, males having serum uric acid of >7.0 mg/dl and females having serum uric acid level > 6mg/dl, egfr > 35ml/min/1.73m 2, patients with cyclosporine levels in therapeutic range and, no previous history of gout. group a was given febuxostat with adjusted dose according to individual egfr of the participant using mdrd study equation. group b was given placebo. determination of serum uric acid levels and egfr was done in both the groups at 2, 4 and 6 months and then both serum uric acid levels and egfr were compared in both the groups at 2, 4 and 6 months. nephrotoxic drugs were avoided in this time period. patients with malignancy, hypersensitivity to febuxostat, already on any of the following drugs; probenicid, benzbromarone, fenofibrate, diuretics or azathioprine, patients having alt and ast more than twice the upper limit of laboratory reference range, pregnancy and patients non-compliant to protein diet. r e s u l t s the mean age of the patients was 48.15±8.61 years, having 87 (82.1%) males and 19 (17.9%) female patients, with a male is to female ratio of 4.6:1. demographic characteristic are presented in (table 1). treatment with febuxostat was linked with significant lowering of mean serum uric acid level at 2 months (7.01±0.35 mg/dl vs 8.69±0.74 mg/dl; p < 0.001), at 4 months (6.32 ±0.33 mg/dl vs 8.78 ± 0.78 mg/dl; p < 0.001) and at 6 months (5.42 ± 0.28 mg/dl vs 8.58 ± 0.72 mg/dl; p<0.001). it preserved renal function, which was evident from significantly higher mean egfr with febuxostat at 2 months (49.74 ± 4.67 ml/min/1.73m2 vs 47.34 ± 5.10 ml/min/1.73m2; p<0.013), at 4 months (48.96 ± 4.88 ml/min/1.73m2 vs 43.00 ±5.43 ml/min/1.73m2; p < 0.001) and at 6 months (48.89 ± 4.72 ml/min/1.73m2 vs 40.92 ± 4.99 ml/min/1.73m2; p < 0.001) as compared with placebo (table 2). table 1: baseline and demographic characteristics of study groups (n=106) characteristics group a febuxostat (n=53) group b placebo (n=53) p value age (years) 48.38 ±8.61 47.92 ±8.70 0.788 <45 years 22 (41.5%) 23 (43.4%) 0.844 ≥45 years 31 (58.5%) 30 (56.6%) 0.844 gender male 43 (81.1%) 44 (83.0%) 0.800 female 10 (18.9%) 9 (17.0%) 0.800 weight (kg) 98.66 ±12.56 97.91 ±11.79 0.750 serum creatinine (mg/dl) 1.84 ±0.27 1.85 ±0.35 0.912 egfr using mdrd equation (ml/min/1.73m2) 50.38 ±5.23 50.13 ±5.10 0.807 serum uric acid (mg/dl) 8.83 ±0.71 8.80 ±0.70 0.812 197 j i m d c 2 0 1 8 197 table 2: comparison of various laboratory parameters between the groups over 2, 4 and 6 months followup (n=106) lab parameter characteristic 0 2 months 4 months 6 months p value serum creatinine(mg/dl) febuxostat 1.84±0.27 1.87±0.28 1.88±0.32 1.91±0.29 0.487 placebo 1.85±0.35 1.99±0.35 2.05±0.30 2.25±0.38 0.006* p value 0.912 0.070 0.005* <0.001* egfr (ml/min/1.73m2) febuxostat 50.38±5.23 49.74±4.67 48.96±4.88 48.89±4.72 0.788 placebo 50.13±5.10 47.34±5.10 43.00±5.43 40.92±4.99 0.028* p value 0.807 0.013* <0.001* <0.001* serum uric acid (mg/dl) febuxostat 8.83±0.71 7.01±0.35 6.32±0.33 5.42±0.28 <0.001* placebo 8.80±0.70 8.69±0.74 8.78±0.78 8.58±0.72 0.207 p value 0.812 <0.001* <0.001* <0.001* independent sample t-test, *observed difference was statistically significant d i s c u s s i o n in order to improve long-term outcomes of kidney transplantation, new risk factors are required to be recognized that result in poor outcomes.5 posttransplant hyperuricemia occurs in renal transplant recipients.4 uric acid lowering drugs help to control serum uric acid levels and improve graft function.14-17 however, the available evidence contains controversy. moreover, there was no such local published data available that triggered the need for this study. we observed that in patients on febuxostat, serum creatinine level gradually increased over 6 months but the difference was statistically insignificant. our results are comparable to those of tojimbara et al, who also reported similar insignificant difference in mean serum creatinine in renal transplant patients with asymptomatic hyperuricemia on febuxostat treatment over 3 to 6 months’ interval from baseline.14 oh et al also reported similar insignificant rise in creatinine in such patients over 6 months.16 egfr decline in our study was also statistically insignificant. however, in present study, we found that treatment with febuxostat in post renal transplant recipients lead to significant reduction in serum uric acid level over 2, 4 and 6 months’ follow-up from baseline, (8.83±0.71 mg/dl vs. 7.01 ±0.35 mg/dl vs. 6.32 ±0.33 mg/dl vs. 5.42 ±0.28 mg/dl; p<0.001). our observations are in line with tojimbara et al, who also observed similar decline in serum uric acid levels in patients with post renal transplant hyperuricemia recipients treated with febuxostat over 3 and 6 months (8.0 ±0.8 vs. 6.3 ±0.9 vs. 5.7 ±0.7 mg/dl).14 similar reduction in mean serum uric acid level has been reported by sofue et al (8.4 0.3 vs. 6.2 0.3 vs. 6.4 0.3 vs 6.2 0.3 mg/dl; p<0.05) after 1, 3 and 6 months of treatment.15 c o n c l u s i o n the present study indicates that patients with asymptomatic hyperuricemia after 3 months of renal transplantation, febuxostat treatment was linked with significant decrease in serum uric acid level with preservation of renal function evident from insignificant difference in the mean egfr. the present study is the first of its kind in local population and advocates the routine use of febuxostat in hyperuricemic post renaltransplant recipients. a very strong limitation to the present study was limited follow-up of 6 months. consequently, long term results of febuxostat treatment on serum uric acid and kidney function were not considered. studies involving long term follow-up are recommended in future research. r e f e r e n c e s 1. hediger ma, johnson rj, miyazaki h, endou h. molecular physiology of urate transport. physiology (bethesda) 2005;20(2):125-33. 198 j i m d c 2 0 1 8 198 2. schlesinger n. dietary factor and hyperuricemia. curr pharm des 2005;11(32):4133-8. 3. maesaka jk, fishbane s. regulation of renal urate excretion: a critical review. am j kidney dis 1998;32(6):917-33. 4. haririan a, metireddy m, cangro c. association of serum uric acid graft survival after kidney transplantation: a time varying analysis. am j transplant 2011; 11(9):1943 50. 5. bahn a, hagos y, reuter s. identification of new urate and high affinity nicotinate transporter, hoat10 (scl22a13). j biol chem 2008; 283(24):16332-41. 6. goicoechea m, de vinuesa sg, verdalles u. effect of allopurinol in chronic kidney disease progression and cardiovascular risk. clin j am soc nephrol 2010;5(8):1388-93. 7. miao et al. effect of reduction in uric acid on renal outcomes during losartan treatment: a post hoc analysis of the reduction of endpoints in non-insulin-dependent diabetes mellitus with the angiotensin ii antagonist losartan trial. hypertension 2011; 58(1):2-7. 8. chung bh, kang sh, hwang hs. clinical significance of early onset hyperuricemia in renal transplant recipients. nephron clin pract 2011;117(3):276-83. 9. numakura k, satoh s, tsuchiya n. hyperuricemia at 1 year after renal transplantation, its prevalence, associated factors, and graft survival. transplantation 2012;94(2):14551. 10. huang y et al. effects of hyperuricemia on renal function of renal transplant recipients: a systematic review and meta-analysis of cohort studies. plos one 2012;7(6):e39457. 11. day ro et al. clinical pharmacokinetics and pharmacodynamics of allopurinol and oxypurinol. clin pharmacokinet 2007; 46(8): 623-44. 12. uloricr full prescribing information. deerfield, il, usa: takeda pharmaceuticals north america, inc,; 2009. 13. becker ma, schumacher hr, espinoza lr. the uratelowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: the confirms trial. arthritis res ther 2010;12(2):r63. 14. tojimbara, nakajima, yashima. efficacy and safety of febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase for the treatment of hyperuricemia in kidney transplant recipients. transplant proc 2014; 46(2):511-3. 15. sofue et al. efficacy and safety of febuxostat in the treatment of hyperuricemia in stable kidney transplant recipients. drug des devel ther 2014;8:245-53. 16. oh j et al. safety and efficacy of febuxostat in advanced ckd patients with hyperuricemia. br med j 2017; 76(2): thu0467. 17. nagaruju sp, attur rp. effect of febuxostat verses allopurinol on hyperuricemia and progression of chronic kidney disease. nephrol dial transplant 2017; 32(3):2056. j islamabad med dental coll 2021 53 o p e n a c c e s s management of empyema gallbladder during covid-19 pandemic muneeb ullah1, muhammad faisal murad2, muhammad kashif khan3, faisal nadeem4 1assistant consultan surgery, maroof international, islamabad 2chief of surgery, mih 3consultan surgery, polyclinic, islamabad 4 assistant consultan surgery, mih a b s t r a c t cholecystostomy is performed in high-risk patients with gall bladder disease. these patients are generally elderly with multiple comorbidities; in particular cardiac patients with uncontrolled diabetes, and present late with acute cholecystitis with systemic inflammation. the management of such high-risk patients requires multi-departmental approach. covid-19 pandemic has widely affected the management guidelines including timing of surgery, extent of pre-operative optimization, use of laparoscopy for surgery and intensive care requirement. we report a case of elderly hypertensive and diabetic patient who presented during the first wave of covid-19 pandemic with fever, vomiting and pain abdomen. he was diagnosed with empyema gallbladder. cholecystostomy was performed as a temporizing measure which was followed by elective laparoscopic cholecystectomy as daycare admission. this averted the need for possible intensive care stay and emergency surgery whereas providing equally good outcome. keywords: laparoscopic cholecystectomy, empyema, gallbladder, cholecystostomy, cholelithiasis correspondence: muneeb ullah email: muneeb.ullah@imdcollege.edu.pk article info: received: november 13, 2021 accepted: febuary 24, 2022 cite this article: ullah m, murad mf, khan mk, nadeem f. management of empyema gallbladder during covid-19 pandemic. j islamabad med dental coll. 2022; 11(1):53-57. funding source: nil conflict of interest: nil i n t r o d u c t i o n during the first wave of covid-19 pandemic in pakistan, there was an overflow of patients in outpatient departments and emergencies as well as shortage of beds in high dependency and intensive care units. moreover covid-19 pandemic has made doctors to change management plans depending upon individual cases and available resources. empyema gallbladder is an emergency and needs intervention at earliest. gallstone impacted at neck is the common the cause of empyema gallbladder. in high-risk patients, the decision regarding management of gallstone disease can vary i.e., conservative management, surgery (open or laparoscopic), interval cholecystectomy, cholecystostomy, etc. cholecystostomy is a relatively safe and efficient temporizing measure in the treatment of acute gallstone related disease (cholecystitis, empyema, etc.) in high-risk patients averting the need for anesthesia and emergency surgery.1,2 these high-risk patients include those who are not suitable for immediate laparoscopic cholecystectomy (lc) such as elderly, severely septic patients, those admitted with shock, having poor physiologic reserve or the ones in intensive care unit.3 percutaneous cholecystostomy (pc) is performed usually by interventional radiologist using transhepatic or transperitoneal route under local anesthesia. 4 many western countries suggest that pc could be used as an alternative for cholecystectomy in patients with severe comorbidities or those unfit for surgery.5,6 the risks associated with pc in high-risk patients are minimal with postoperative morality ranging from 10 to 12% as compared to lc ranging from 5 to 30%. 7,8 these include blood loss, tube dislodgement, blockage, c a s e r e p o r t j islamabad med dental coll 2021 57 bile leakage, organ perforation etc.9,10 once cholecystostomy is performed, the patient can be optimized for elective lc that is performed usually after 6 to 8 weeks. this also allows the patient to recover from acute illness.11 pc catheter can be removed prior to or during the surgery. 2 we present a case of a patient who presented in early covid-19 pandemic wave with empyema gallbladder and was initially managed with pc in acute phase followed by elective lc. c a s e p r e s e n t a t i o n a 65-year-old retired male officer, belonging to a middle-class family residing in islamabad, presented with pain right hypochondrium that radiated to back and right shoulder, fever with chills and rigors and vomiting that was non-bilious for one day. he was a known case of hypertension and uncontrolled diabetes. family history was unremarkable. patient had no allergies, addictions and any surgical history. on examination, he was found to have tachycardia, fever of 99.50f and dehydration. abdominal examination showed mild guarding in right upper quadrant. liver function tests (lfts) and serum amylase were normal while c-reactive proteins (crp) levels were high. ultrasound showed overdistended gallbladder (110mmx60mm) with wall thickness of 10mm, a stone 10.9mm impacted at neck of gallbladder, debris in gallbladder and pericholecystic fluid. common bile duct was normal (4.1mm). d dimers, international normalized ratio and hba1c were raised. severe acute respiratory syndrome corona virus 2 (sars-cov2) was negative. computerized tomographic (ct) scan was performed that showed pericholecystic fluid/collection and stone impacted at neck of gallbladder as shown in figure 1 and figure 2. figure 1: gallstone impacted at neck of gallbladder figure 2: pericholecystic fluid/collection the diagnosis of empyema gallbladder with contained perforation was made and emergency laparoscopic cholecystectomy was planned. anesthetist considered the patient to be high risk and wanted to confirm availability of bed in high dependency unit (hdu) or intensive care unit (icu) after the surgery. due to covid-19 pandemic, all the hospitals were overwhelmed by influx of covid-19 patients. there was overcrowding of hdus and icus in hospitals all over the country. bed availability could not be confirmed nor transfer the patient in such situation to another hospital was possible. on second day, tenderness and guarding persisted in right upper quadrant. crp levels and d dimers further increased. antibiotics were upgraded. patient was discussed in multidisciplinary team meeting. it was decided that cholecystostomy j islamabad med dental coll 2021 57 should be performed considering the high-risk case and non-availability of hdu or icu. image guided cholecystostomy was performed by interventional radiologist. next day, patient’s clinical parameters improved alongside decreased tenderness. patient had fever spike of 99.50 f. crp and d dimers started decreasing after 36 hours. patient was discharged after 48hours on injectable antibiotics as per culture report. six weeks later elective laparoscopic cholecystectomy was performed with optimized glycemic control and hypertension. patient was discharged, as daycare procedure, in evening. he came for first follow up after 3 days where he had no active complaints except for mild pain on exertion. he was started on regular diet and basic routine activities. on 10th post operative day, stitches were removed and a video session of the laparoscopic procedure was done with the patient. the patient then started all his routine activities and diet without any restrictions from surgical team. table i: laboratory parameters normal values liver function tests bilirubin 0.29 mg/d l 0.2 to 1.3 aspartate aminotransfer ase 21 u/l 0 to 41 alanine transaminase 18 u/l 0 to 41 alkaline phosphatase 73 u/l 30 to 115 c reactiv e protein (high sensitiv e) da y 1 279mg/l <1.0mg/l low risk 1.0 mg/l to 3.0mg/l average risk 3.0mg/l to 10mg/l high risk >10 acute inflammati on da y 2 516.1 mg/l da y 3 226.8 mg/l d dimers da y 1 1853ng/ml <500 negative da y 2 15456ng/ml >500 positive da y 3 8994ng/ml serum amylase 43 u/l 28 to 100 international normalized ratio 1.61 0.8 to 1.2 prothrombin time 21 seconds 9 to 14 hba1c 9.2% 4.8 to 6.4 figure 3: peroperative images of cholecystostomy and drain. d i s c u s s i o n lc can be done as emergency procedure, early or interval lc. the treatment may vary from one individual to another depending upon different j islamabad med dental coll 2021 57 parameters that include age, acute presentation and presence of comorbid conditions like hypertension, diabetes, ischemic heart disease, active covid-19 infection, sepsis, etc. lc in such high-risk patients can lead to increased risk of conversion to open surgery, per operative complications and longer duration of hospital stay with need for hdu/icu. 12 in patients where the risks of morbidity and mortality outweigh the standard lc, percutaneous cholecystostomy is a safe alternative to resolve the active disease process.1,2,9 pc aids in averting the emergency situation thereby decreasing the risks of perioperative complications and planning for definitive surgery later on after optimization. 8 however patient needs to be readmitted and planned for surgery after 6 to 8 weeks. 2 there is no standardization regarding the timing of interval cholecystectomy after pc. there is no consensus on whether the catheter is to be removed during the definitive surgery or earlier. there are many who consider pc as the definitive treatment for high-risk patients.3 pc adds to medical expenses due to readmission later on for definitive surgery and removal of catheter. there is also associated risk of tube dislodgement, bleeding, tube site infection, local discomfort, tube blockage, cholangitis, etc. 1 challenges may be faced while performing pc in patients with deranged coagulation profile, those who have gallbladder full of stones, cirrhotic liver, ascites, phlegmon, etc. due to covid-19 pandemic, all hospitals were overcrowded especially the high dependency units and intensive care units. there was lack of oxygen supply, availability of ventilators, guidelines about laparoscopic and open surgeries in emergency setting and human resources. in such cases, one has to consider the optimum management plan for the patient and use multidisciplinary approach. c o n c l u s i o n percutaneous cholecystostomy helped in avoiding risks associated with emergency surgery in this highrisk patient. interval laparoscopic cholecystectomy performed later as definitive procedure improved outcomes in terms of morbidity and mortality. considering non availability of high dependency units and intensive care units during the first wave of covid-19 pandemic, this management plan helped in converting an emergency procedure to an elective planned procedure. randomized control trials should be done to establish guidelines regarding when to perform pc, when to remove the catheter and what is the optimum timing for definitive surgery. r e f e r e n c e s 1. kamer e, cengiz f, cakir v, balli o, acar t, peskersoy m, et al. percutaneous cholecystostomy for delayed laparoscopic cholecystectomy in patients with acute cholecystitis: analysis of a single-centre experience and literature review. prz gastroenterol. 2017; 250– 5. http://dx.doi.org/10.5114/pg.2017.72098 2. hung y-l, sung c-m, fu c-y, liao c-h, wang s-y, hsu j-t, et al. management of patients with acute cholecystitis after percutaneous cholecystostomy: from the acute stage to definitive surgical treatment. front surg. 2021; 8:616320. http://dx.doi.org/10.3389/fsurg.2021.616320 3. aroori s, mangan c, reza l, gafoor n. percutaneous cholecystostomy for severe acute cholecystitis: a useful procedure in high-risk patients for surgery. scand j surg. 2019; 108(2):124–9. http://dx.doi.org/10.1177/1457496918798209 4. er s, berkem h, özden s, birben b, çetinkaya e, tez m, et al. clinical course of percutaneous cholecystostomies: a cross-sectional study. world j clin cases. 2020; 8(6):1033–41. http://dx.doi.org/10.12998/wjcc.v8.i6.1033 5. sugrue m, coccolini f, bucholc m, johnston a, contributors from wses. intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a wses prospective collaborative study. world j emerg surg. 2019; 14(1):12. http://dx.doi.org/10.1186/s13017-019-0230-9 6. abe k, suzuki k, yahagi m, murata t, sako h, ishii y. the efficacy of ptgbd for acute cholecystitis based on the tokyo guidelines 2018. world j surg. 2019; 43(11):2789–96. http://dx.doi.org/10.1007/s00268019-05117-5 7. colonna al, griffiths tm, robison dc, enniss tm, young jb, mccrum ml, et al. cholecystostomy: are j islamabad med dental coll 2021 57 we using it correctly? am j surg. 2019; 217(6):1010– 5. http://dx.doi.org/10.1016/j.amjsurg.2019.04.002 8. liu p, liu c, wu y-t, zhu j-y, zhao w-c, li j-b, et al. impact of b-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy. world j gastroenterol. 2020; 26(36):5498–507. https://dx.doi.org/10.3748%2fwjg.v26.i36.5498 9. pang kw, tan chn, loh s, chang kys, iyer sg, madhavan k, et al. outcomes of percutaneous cholecystostomy for acute cholecystitis. world j surg. 2016; 40(11):2735–44. http://dx.doi.org/10.1007/s00268-016-3585-z 10. boules m, haskins in, farias-kovac m, guerron ad, schechtman d, samotowka m, et al. what is the fate of the cholecystostomy tube following percutaneous cholecystostomy? surg endosc. 2017; 31(4):1707–12. http://dx.doi.org/10.1007/s00464-016-5161-x 11. de geus t, moriarty hk, waters ps, o’reilly mk, lawler l, geoghegan t, et al. outcomes of patients treated with upfront cholecystostomy for severe acute cholecystitis. surg laparosc endosc percutan tech. 2020; 30(1):79–84. http://dx.doi.org/10.1097/sle.0000000000000747 12. hsieh y-c, chen c-k, su c-w, chan c-c, huo t-i, liu cj, et al. outcome after percutaneous cholecystostomy for acute cholecystitis: a singlecenter experience. j gastrointest surg. 2012; 16(10):1860–8. http://dx.doi.org/10.1007/s11605012-1965-8 j islamabad med dental coll 2023 125 open access relationship between inflammatory markers and disease outcome in covid-19 savida dar1, sarah azam shah2, faridullah shah3, farhan aslam4, hareema saeed khan5, anber saleem6 1physician, department of medicine, federal government polyclinic hospital. islamabad, pakistan 2medical officer, federal government polyclinic hospital. islamabad, pakistan 3consultant, department of medicine, federal government polyclinic hospital. islamabad, pakistan 4post graduate trainee, department of medicine, federal government polyclinic hospital. islamabad, pakistan 5associate physician, federal government polyclinic hospital. islamabad, pakistan 6associate professor, school of dentistry, szambu, islamabad a b s t r a c t background: coronavirus disease-2019 (covid-19) has been labelled as a global pandemic and a cause of documented high mortality rates among severe or critical patients. this has been linked with hyperinflammation of the innate and adaptive immune systems and the resulting cytokine storm. our study aims to evaluate the relationship between inflammatory markers and disease outcomes in covid-19. methodology: this cross-sectional study was conducted at federal government polyclinic (fgpc) hospital, islamabad for a period of 3 months. all the patients who had either rt-pcr for covid-19 or hrct findings suggestive of covid were included in the study. the inflammatory markers like c-reactive protein (crp), d-dimers, and lactate dehydrogenase (ldh) were done and a combined score dlc was calculated. the need for oxygen (litres/min), bilevel positive airway pressure (bipap), or mechanical invasive ventilation was documented. results: the study was conducted on 213 patients which included 119(56%) male patients and 94(44%) female patients. covid-19 pcr was positive in 193(90.6%) while 20 patients (9.4%) had a negative pcr but hrct suggestive of covid. hrct was done in a total of 46 patients out of the 213 patients and 45 had features suggestive of covid-19. the auroc was 0.686(0.61-0.75) for d dimers, 0.688(0.61-0.75) for ldh, and 0.649(0.517-0.72) for crp respectively, and spearman rho values of (0.326, 0.328 and 0.266) respectively with a p-value (0.000). conclusion: d-dimer, ldh and crp individually as well as a combined score of the inflammatory markers (dlc) and oxygen requirement had a significant correlation with the mortality of the covid-19 patients. key words: covid-19, crp, ldh, d dimers, dlc score. authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: hareema saeed khan email: hareemasaeed80@gmail.com article info: received: august 5, 2022 accepted: april 18, 2023 cite this article. dar s, shah s a, shah f, askam f, khan h s, saleem a relationship between inflammatory markers and disease outcome in covid-19 .j islamabad med dental coll. 2023; 12(2): 125-131 doi: https://doi.org/10.35787/jimdc.v12i2.943 funding source: nil conflict of interest: nil i n t r o d u c t i o n ever since the early days of the human era, a great number of deadly infectious diseases have affected people and illnesses like malaria, tuberculosis, influenza, and smallpox have killed thousands of patients over time. the infectious disease of the 21st century, caused by novel coronavirus or sars-cov2 (labelled covid-19) began in wuhan, china in december 2019 and quickly spread like wildfire to all continents. ultimately, world health organization (who) declared it a global pandemic on march 11, o r i g i n a l a r t i c l e j islamabad med dental coll 2023 126 2020.1 till december 2022, there have been approximately 651million confirmed cases with more than 6 million deaths, reported to who. 2 at present, it seems to be impracticable to curtail the disease spread, and the focus is directed towards better treatment and identification of factors that are associated with severity of the disease.3 covid19 is a highly infectious disease with variable presentation ranging from mild to critically ill patients.4,5 the symptoms vary from asymptomatic, low-grade pyrexia, dry cough, sore throat, breathlessness, tiredness, body aches, fatigue, myalgia, nausea, vomiting, and diarrhea, to severe bilateral consolidation pneumonia, acute respiratory distress syndrome (ards) and multiple organ impairment leading to death.6,7 collective evidence has suggested that inflammatory response plays a crucial role in the progression of covid-19.8 the intense viral replication of sars-cov-2 and cellular destruction cause macrophages, monocyte recruitment leading to the release of cytokines, and chemokines resulting in a cytokine storm.9 it has been postulated by several studies that raised levels of inflammatory markers such as high c-reactive protein (crp) levels, interleukin (il)-2, il6, il-10, and tumor necrosis factor (tnf) is directly proportional to worse outcome.6 reduced lymphocyte count and elevated levels of ferritin, ldh, and d-dimer were also reported to be associated with disease severity.10,11 however, the relationship between laboratory parameters and disease severity as well as riskstratification is still not well defined. the objective of this study was to understand the relationship between inflammatory markers and covid-19 and also introduce a new scoring system i.e. the dlc score for the severity of covid-19. more specifically, the study assesses their implications in determining disease progression m e t h o d o l o g y this retrospective study was conducted at federal government polyclinic (fgpc) hospital, islamabad for a period of 3 months. the study was approved by the institutional ethical review board. the record of patients with covid-19 from january 2020 onwards was analysed. all the patients who had clinical features, positive pcr for covid-19, or highresolution computed tomography (hrct) findings suggestive of covid-19 were included in the study. patients who had seasonal allergies, incomplete clinical records, neither hrct findings nor a positive covid-19 pcr, and had other systemic infections like enteric fever, malaria, and dengue fever were excluded from the study. the sample size was calculated using the who calculator by taking the total number of cases of covid 19 till date in islamabad which were 139844 for a total of 1.198 million (11.6%) population.12 keeping the confidence interval at 95% and margin of error at 5% the sample size came out to be 158. in total 213 patients were included in this study. the consecutive non-probability sampling technique was used to collect the data. after taking the demographic details of patients and defining the diagnostic criteria, which was either positive pcr for covid-19 or hrct chest findings suggestive of covid-19, all inflammatory markers which have been done for the patients were recorded that included, creactive protein (crp), d dimers, and lactate dehydrogenase (ldh) levels. the number of patients who required oxygen was also noted and the different categories depending on the amount of oxygen required were also identified with the further need for either bilevel positive airway pressure ventilation (bipap) or invasive mechanical ventilation. the final outcome of the patient in term of morbidity or mortality was recorded. covid-19 pcr was done using the standard method of taking nasopharyngeal swabs. hrct was done only in the patients who could be mobilized from the hospital to a nearby facility and those who had a negative pcr but had chest x-ray (cxr) findings suggestive of covid-19. blood samples like ldh, crp, and d dimers were done on admission and thereafter serially, to see the degree of https://www.sciencedirect.com/topics/medicine-and-dentistry/monocyte https://www.sciencedirect.com/topics/medicine-and-dentistry/chemokine j islamabad med dental coll 2023 127 inflammation. a new combined scoring system of three commonly used inflammatory markers i.e. d dimers, ldh, and crp, named dlc score was used to find its association with the oxygen requirement. oxygen requirement was titrated as per the severity of the patient and the degree of lung damage. the patient was put on either bipap or mechanical invasive ventilation when the oxygen requirement exceeded 15 litres/min. the data were analysed using spss version 23. the frequencies and percentages for the qualitative variables like gender, oxygen dependency, the need for bipap or mechanical ventilation, and the positive or negative covid -pcr and hrct findings were calculated. mean, standard deviations, minimum and maximum values for the quantitative variable like d dimers, crp, ldh, and the combined dlc score were calculated. and the intergroup comparison for the different inflammatory markers was done. the correlation between the different inflammatory markers and mortality was found using the chisquare test. the receiver operating characteristic (roc) curve analysis was carried out to determine the sensitivity and specificity of these three inflammatory markers. the combined dlc score with a cut-off value of 758 was calculated by adding the upper limits of normal values for each of the individual variables i.e ldh <248, iu/l, d dimers< 500mg/l and crp of <10 mg/l. the impact of the dlc score on the oxygen requirement and the final outcome i.e mortality was also assessed. r e s u l t s this study was conducted on 213 patients which included 119(56%) male patients and 94(44%) female patients. covid-19 pcr was positive in 193(90.6%) while 20 (9.4%) had a negative pcr (with findings suggestive of covid-19 on hrct). hrct was done in a total of 46 patients, among these 45 had features suggestive of covid-19. two hundred and eight (97.7%) were oxygen dependent while 5 (2.3%) did not need oxygen. of the 213 patients, 49 patients needed bipap (23%) while 24 patients needed invasive ventilation. the overall mortality was 46.9% (100/213). the baseline characteristics are mentioned in table 1. mean age of the patients was 59.9±15.71 years. d-dimer (2856.22±3675.25), ldh (506.92± 321.44), crp (101.66 ± 56.53), and dlc scores (3468.11±3750.70) were reported in order to find the difference in the values in relation to patient outcomes as given in table 2. the dlc score (which is a sum of the d dimers, ldh, and crp values) for all the patients showed that the p values of roc for the individual parameters as compared to the outcomes were found to be highly significant (p<0.00) as given in table 3. table 4 shows that a statistically significant difference (p ≤ 0.05) was found in age, crp, ldh, d-dimers, and dlc in relation to patient outcome. application of chisquare test showed a positive association of oxygen requirements with the patient outcome with χ2(4) = 174.62, p< 0.001(table 5). the patients with higher oxygen requirements had a higher mortality rate as shown in fig 1. the sensitivity and specificity of the dlc score for the outcome of oxygen dependency came out to be 82.2 % and 80% respectively, however, for mortality as an outcome it was found to be 96% sensitive but only 32.7% specific (fig 2). figure 1: oxygen requirement and mortality table i: characteristics of study participants (n=213) variables number (%) j islamabad med dental coll 2023 128 male female 119(59.9) 94(44.1) covid pcr status positive negative 193(90.6) 20(9.4) hrct findings suggestive of covid hrct not done atypical for covid 45 (21.1) 167(78.4) 1 (0.5%) oxygen dependence yes no 208(97.6) 05 (2.34) oxygen requirement no requirement <5l 6-10l 11-15l >15l 213 5(2.34) 78 (36.6) 16(7.5) 11(5.2) 103(48.4) bipap 49(23) invasive ventilation 24(11.3) mortality 100(46.9) table ii: mean scores of demographic and laboratory parameters of the study participants (n=213) variables n mean+ sd minimum maximum age in years 213 59.9±15.71 20 95 d-dimer ( ng/ml) 213 2856.22±3675.25 50 13800 ldh (iu/l) 213 506.92± 321.44 145 2998 crp(mg/dl) 213 101.66± 56.53 9.20 200 dlc score 213 3468.11±3750.70 218.40 3117.50 table iii: roc and p values in both the outcome groups (n=213) variable all patient outcome roc cuto ff roc range p val ue discharge death crp (mg/dl) 101.66± 56.53 88.74±56. 52 116.26± 53.13 0.64 9 0.570.72 0.0 00 ldh (iu/l) 506.92± 321.44 419.50±2 05.94 605.7±3 93.32 0.68 8 0.610.75 0.0 00 d-dimer (ug/ml) 2856.22 ± 3675.25 1961.42 ± 3136.31 3867.35 ± 3981.26 0.68 7 0.610.75 0.0 00 dlc score 3468.11 ±3750.7 2466.57± 3181.99 4599.84 ±4028.8 5 0.72 1 0.650.79 0.0 00 figure 2: roc curves for crp, d dimers, ldh, dlc score, and oxygen requirement. d i s c u s s i o n covid-19 began in december 2019, from wuhan china and thereafter it spread globally in no time and affected the lives of millions of people worldwide.13 it has been studied extensively over the last three years, and over these three years, several variants were identified among which delta variant was found to be the most lethal. the main pathophysiology includes a thrombo-inflammatory condition causing endovascular damage and release of several cytokines leading to a cytokine storm and thus the multisystem disease. 14 there are several inflammatory biomarkers that have been extensively studied in covid-19 infection and their correlation with the severity of the disease. the most commonly used being the creactive table v: oxygen requirement in association with patient outcome (n=213) variable responses frequency (percentages) of groups χ2 p valu e discharged (n = 113) death (n = 100) oxygen require ment no requirement <5l 6-10l 11-15l >15l 5 (4.4) 78 (69.0) 16 (4.2) 7 (6.2) 7 (6.2) 0 (0.0) 0 (0.0) 0 (0.0) 4 (4.0) 96 (96.0) 176. 59 .000 ** j islamabad med dental coll 2023 129 protein (crp), lactate dehydrogenase levels (ldh), ddimers, serum ferritin, and interleukin 6 levels, etc.15,16 we tried to evaluate the role of crp, d dimers and ldh on the final outcome of the hospitalized patients. ddimers are associated with an increased risk of thrombosis and had been previously studied in community-acquired pneumonia. it has also been reported to be associated with poor outcome and increased mortality in covid-19.17 ldh is an enzyme that is released into the circulation as a result of damage to cytoplasmic membrane because of either a viral infection or inflammation.18 crp is one of the proteins synthesized in the liver in response to inflammation and thus leads to activation of the complement pathway.19 in our study, we found that all these inflammatory markers i.e. d dimers, ldh and crp had a significant correlation with the final outcome i.e. mortality in the hospitalized patients with spearman rho values of (0.326, 0.328, and 0.266) respectively with a pvalue (0.000). similar findings were observed in other international and national studies as well. one study done in peshawar cmh by arshad et al showed that these three markers i.e., crp, ldh, and d dimers predict mortality in hospitalized patients. this study showed that area under receiver operating characteristic curves and 95% confidence intervals for serum creactive protein, and ldh was 0.909 (0.854-0.964) and 0.863 (0.785-0.942)5, respectively. in our study the auroc were 0.686(0.61-0.75) for d dimers, 0.688(0.61-0.75) for ldh and 0.649(0.517-0.72) for crp respectively. the values were slightly lower in our study group compared to this study. another study done by mari muthu ak et al in india in 2021 showed results that are comparable to our study with auroc curves i.e. crp 0.668(0.551-0.785) and d dimers 0.739(0.641-0.836) 20 in this study, we also tried to combine the score of these parameters and formulate a new scoring system for the impact on the overall outcomes and it was found that the combined score of dlc had a stronger correlation with mortality than the individual parameters and had a better auroc curve cut-off as compared to individual parameters i.e., roc values of 0.718(0.65-0.78). another study that used these combination scores was done by kaftan an in iraq in 2021 which used four inflammatory markers i.e. d dimers, ldh, crp, and ferritin. they used different combination scores for these four variables with the highest roc values for crp + ldh + ferritin + d dimer; auc: 0.85 75% sensitivity and 87% specificity.21 various meta-analyses have shown that high levels of crp, ferritin, ldh, and d-dimer are associated with poor outcomes in covid-19.22 similar findings showing the effect of these markers on mortality were also seen in two other studies done in lahore by junaid k, et al and mahmud t et al.23,24 another important fact is that covid-19 leads to silent hypoxia. the majority of the patients that we received in the hospital were already quite hypoxic, had higher oxygen requirements, and thus had a higher mortality rate as compared to those who had low oxygen requirements. it also suggested that higher the inflammatory burden, the greater the lung damage and oxygen requirement and thus increased risk of going either on the bipap or the mechanical invasive ventilation as seen in our study results. a meta-analysis of 26 worst affected countries by covid done by mansab et al in 2021 showed that the more the patient is hypoxic at presentation i.e. <90 spo2 the more the chances to have a poor outcome.25 our study thus highlights the importance of early recognition of hypoxia and its treatment as well as the impact of the different commonly used inflammatory markers on the outcome of hospitalized patients. it has also been reported that actively treating the patients with anticoagulants, steroids, and antivirals at the earliest possible ensures better disease outcomes. j islamabad med dental coll 2023 130 l i m i t a t i o n s hrct and ferritin levels could not be done in all patients due to financial constraints. another limitation of the study is that it was a retrospective study so the cause and effect i.e. the trend of fall in the inflammatory markers and the clinical outcome of the patient could not be assessed as well as the effect of the different treatment modalities could not be evaluated. c o n c l u s i o n d-dimer, ldh, and crp individually as well as a combined score of the inflammatory markers (dlc)score and oxygen requirement had a significant correlation with the mortality of the covid-19 patients. judicious use of these markers may help in determining the severity of covid pneumonia and thus the final outcome of the patient. r e f e r e n c e s 1. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta biomed. 2020 mar 19;91(1):157-160. doi: 10.23750/abm.v91i1.9397. pmid: 32191675; pmcid: pmc7569573. 2. covid19. whoint. who coronavirus disease (covid19) dashboard. 3. jain a, chaurasia r, sengar ns, singh m, mahor s, narain s. analysis of vitamin d level among asymptomatic and critically ill covid-19 patients and its correlation with inflammatory markers. scientific reports.2020 nov19;10(1):20191.https://doi.org/10.1038/s41598020-77093-z. 4. chen n, zhou m, dong x, qu j, gong f, han y,et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet. 2020 feb15;395(10223):507-13. https://doi.org/10.1016/s0140-6736(20)30211-7 5. arshad ar, khan i, shahzad k, arshad m, haider sj, aslam mj. association of inflammatory markers with mortality in covid-19 infection. j coll physicians surg pak. 2020:158-63. doi: 10.29271/jcpsp.2025.01.158 6. madabhavi, irappa, malay sarkar, and nagavenikadakol. 2020. “covid-19: a review”. monaldi archives for chest disease 90 (2). https://doi.org/10.4081/monaldi.2020.1298. 7. li y, yang y, shang x, song c, chen j, li y, et al.design of a novel 3d hierarchical network porous cns@ ag0. 5@ co-180-10/gnps hetero-nanostructure hybrid as an excellent electrode for supercapacitors. electrochimica acta. 2020 dec 10;363:137244. https://doi.org/10.1016/j.electacta.2020.137244 8. mehta p, mcauley df, brown m, sanchez e, tattersall rs, manson jj. covid-19: consider cytokine storm syndromes and immunosuppression. the lancet. 2020 mar 28;395(10229):1033-4. https://doi.org/10.1016/s0140-6736(20)30628-0 9. tay mz, poh cm, rénia l, macary pa, ng lf. the trinity of covid-19: immunity, inflammation, and intervention. nature reviews immunology. 2020 jun;20(6):363-74. https://doi.org/10.1038/s41577020-0311-8 10. qin c, zhou l, hu z, zhang s, yang s, tao y,et al. dysregulation of immune response in patients with coronavirus 2019 (covid-19) in wuhan, china. clinical infectious diseases. 2020 jul 28;71(15):762-8. https://doi.org/10.1093/cid/ciaa248 (2020). 11. li y, yang y, shang x, song c, chen j, li y, et al.design of a novel 3d hierarchical network porous cns@ ag0. 5@ co-180-10/gnps hetero-nanostructure hybrid as an excellent electrode for supercapacitors. electrochimica acta. 2020 dec 10;363:137244. https://doi.org/10.1016/j.electacta.2020.137244 12. https://coronalevel.com/pakistan/islamabad/ 13. wang d, hu b, hu c, zhu f, liu x, zhang j, et al.clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in wuhan, china. jama. 2020 mar 17;323(11):1061-9. 14. henry bm, vikse j, benoit s, favaloro ej, lippi g. hyper inflammation and derangement of the reninangiotensin-aldosterone system in covid-19: a novel hypothesis for clinically suspected hyper coagulopathy and microvascular immune thrombosis. clinicachimicaacta. 2020 aug 1; 507:16773. 15. singh p, kumar a, singh s, kelkar a, doshi p, nimbargi rc, et al.utility of routine hematological parameters and infectious biomarkers to assess the disease severity in covid-19 positive patients, analysis and early trend from india. 2020. doi: https://doi.org/10.21203/rs.3.rs-40378/v1. https://orcid.org/0000-0001-8017-0162 16. zhou b, she j, wang y, ma x. utility of ferritin, procalcitonin, and c-reactive protein in severe https://doi.org/10.1016/s0140-6736(20)30211-7 https://doi.org/10.4081/monaldi.2020.1298 https://doi.org/10.1016/j.electacta.2020.137244 https://doi.org/10.1016/s0140-6736(20)30628-0 https://doi.org/10.1093/cid/ciaa248 https://doi.org/10.1016/j.electacta.2020.137244 j islamabad med dental coll 2023 131 patients with 2019 novel coronavirus disease. mar 2020. doi: 10.21203/rs.3.rs-18079/v1 17. liao d, zhou f, luo l, xu m, wang h, xia j, et al. hematological characteristics and risk factors in the classification and prognosis evaluation of covid-19: a retrospective cohort study. the lancet hematology. 2020 sep 1;7(9):e671-8. https://doi.org/10.1016/s2352-3026(20)30217-9 18. yousif ng, altimimi an, al-amran fg, adrienne j, alfadhel sm, hussien sr, et al.hematological changes among corona virus-19 patients: a longitudinal study. systematic reviews in pharmacy. 2020;11(5):862-6. doi:10.31838/srp.2020.5.125 19. perez l. acute phase protein response to viral infection and vaccination. archives of biochemistry and biophysics. 2019 aug 15; 671:196-202. https://doi.org/10.1016/j.abb.2019.07.013 20. marimuthu ak, anandhan m, sundararajan l, chandrasekaran j, ramakrishnan b. utility of various inflammatory markers in predicting outcomes of hospitalized patients with covid-19 pneumonia: a single-center experience. lung india: official organ of indian chest society. 2021 sep;38(5):448. doi: 10.4103/lungindia.lungindia_935_20 21. kaftan an, hussain mk, algenabi aa, naser fh, enaya ma. predictive value of c–reactive protein, lactate dehydrogenase, ferritin and d-dimer levels in diagnosing covid-19 patients: a retrospective study. acta informatica medica. 2021 mar;29(1):45. doi: 10.5455/aim.2021.29.45-50 22. huang i, pranata r, lim ma, oehadian a, alisjahbana b. c-reactive protein, procalcitonin, d-dimer, and ferritin in severe coronavirus disease-2019: a metaanalysis. therapeutic advances in respiratory disease.2020;14:1–14 https://doi.org/10.1177/1753466620937175 23. mahmud t, saqib m, siddiqui un, khan as, aasim m. clinical characteristics of hospitalized patients with covid-19 at territory care hospital of pakistan. pakistan journal of chest medicine. 2021 jun 2;27(2):68-73. 24. junaid k, et al. clinical characteristics and prognostic factors of severity in covid-19 patients in lahore, pakistan. virolimmunol j 2022, 6(2): 000296. 25. mansab f, donnelly h, kussner a, neil j, bhatti s, goyal dk. oxygen and mortality in covid-19 pneumonia: a comparative analysis of supplemental oxygen policies and health outcomes across 26 countries. frontiers in public health. 2021 jul 13;9:580585. https://doi.org/10.3389/fpubh.2021.580585 https://dx.doi.org/10.31838/srp.2020.5.125 https://doi.org/10.1016/j.abb.2019.07.013 https://doi.org/10.4103%2flungindia.lungindia_935_20 https://doi.org/10.5455%2faim.2021.29.45-50 https://doi.org/10.3389/fpubh.2021.580585 j islamabad med dental coll 2022 211 open access effect of pretreatment of lignocaine versus midazolam in the prevention of etomidate induced myoclonus fizza batool1, ammar ali shah2, sadia lodhi3, jawad zahir4 1postgraduate trainee, department of anesthesia, holy family hospital, rawalpindi, pakistan. 2senior registrar, department of anesthesia, holy family hospital, rawalpindi, pakistan. 3consultant, department of anesthesia, holy family hospital, rawalpindi, pakistan. 4associate professor, department of anesthesia, holy family hospital, rawalpindi, pakistan. a b s t r a c t background: the myoclonus after induction of anesthesia with etomidate can lead to increased risk of regurgitation and aspiration. we conducted this study to compare the effectiveness of midazolam and lidocaine for the prevention of etomidate induced myoclonus. methodology: this randomized controlled trial was done in the department of anesthesiology and intensive care, holy family hospital, rawalpindi from january-june 2015 after approval of hospital ethical committee. informed consent (written) was taken from 224 patients. patients were allocated into 2 equal groups randomly with the help of computer-generated numbers. two minutes after induction with etomidate, group a got 1 ml of 2% lidocaine, and one ml (1 mg) of midazolam was given to group b. myoclonus was evaluated in the following one minute, after which 0.5 mg/kg of succinylcholine was given to the patient to facilitate endotracheal intubation. time of onset of induction was marked by loss of eyelash reflex. myoclonus was recorded at 20, 40, and 60 seconds. drug was found to be effective if there was no myoclonus within one minute of etomidate induction. analysis of data was done using spss 17. results: lignocaine was effective in preventing myoclonus in 55.40% of patients and midazolam prevented it in 69.60%. the variation between the results of the groups was found significant statistically. (p< 0.05) conclusion: both midazolam and lignocaine are effective in preventing the occurrence of myoclonus associated with etomidate. however, midazolam is the more effective of the two drugs. keywords: etomidate, lignocaine, midazolam, myoclonus authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4data analysis; manuscript editing. correspondence: ammar ali shah email:ammarali05.com article info: received: june 12, 2021 accepted: december 2, 2022 cite this article. batool f, shah a a, lodhi s, zahir j. effect of pretreatment of lignocaine versus midazolam in the prevention of etomidate induced myoclonus. j islamabad med dental coll. 2022;11(4): 211-215 doi: https://doi.org/10.35787/jimdc.v11i4.661 funding source: nil conflict of interest: nil i n t r o d u c t i o n choice of induction agent is important owing to pharmacodynamics and patients’ physiological condition.1 although there are concerns with myoclonus and adrenocortical suppression, etomidate is still one of the commonly used agents. for the prevention of myoclonic jerks, other used agents include benzodiazepine, lignocaine, midazolam and rocuronium etc.2 however there is still debate over the effectiveness of these medicines.3 the incidence of myoclonus is 50-80% in unpremeditated patients following the induction dose of etomidate.4 o r i g i n a l a r t i c l e j islamabad med dental coll 2022 212 myoclonus jerks increase the danger of regurgitation and aspiration.5 thus the prevention of these jerks is a major concern for the patient safety. lidocaine is a member of amide family of local anaesthetics.6 lidocaine acts by binding to the voltage gated na channels present in the neuron.7 midazolam is part of the benzodiazepine group and produces sedation.8other effects include antiseizure activity, anxiolysis and amnesia.9 drug which is short acting, with no effect on respiration and hemodynamics would be considered ideal in this case.10 singh ka et al studied the effectiveness of lidocaine and midazolam as compared to placebo for the avoiding etomidate induced myoclonus. there results indicated 44% incidence with lidocaine, 28% with midazolam and 76% with placebo.11 after the literature review, no research was found to be done in the asian population, therefore this study was conducted which will help to establish the better modality for the myoclonus prevention. m e t h o d o l o g y this randomized control trial was performed in the department of anesthesiology and intensive care at holy family hospital, rawalpindi. the study duration was 6 months between 01-012015 till 30-06-2015. american society of anesthesiology -i and ii patients aged between 20-45 years who were admitted for elective surgical procedures were included in the study. patients having drug allergies, pregnant patients or those with any neurological disease were not included in the study. after ethical committee’s approval and obtaining informed written consent, 112 patients 11 were recruited according to the inclusion criteria, using who sample size calculator. preoperative anesthesia assessment was done a day before surgery. patients were prepared by fasting and allocated to the study groups using computer generated numbers. group a got one ml of 2 % lidocaine, 120 seconds prior to the administration of etomidate while group b got one ml (one mg) of midazolam, 120 sec prior to induction. the preparation of medication was done in coded syringes. etomidate (0.3 mg/kg) was administered by team members who were blinded to group allocations of the patients. in operating room, crystalloid infusion was initiated using lactated ringers, and asa standard monitoring was initiated. heart rate, bp, oxygen saturation, and rate of respiration were recorded and taken as baseline readings. pre-oxygenation was done with 100% oxygen for all patients for 3 minutes. the time when eyelash reflex was lost, was marked as onset of induction. additional dose of etomidate was given if necessary. after induction with etomidate, the researchers waited for 60 seconds to observe for any sign of myoclonus after which succinyl choline was administered for endotracheal intubation. vital charting was done every minute for the first five minutes, every 5 minutes for the next fifteen minutes then at 15 minutes interval till the end of surgery. maintenance of anesthesia was done with isoflurane and for muscle relaxation atracurium was used. recorded data analysis was done using the spss version 17. for quantitative variables (weight, bmi and age) mean ± sd calculation was done. chi-square test was done for comparison of myoclonus frequency in the two groups, p-value less than 0.05 was considered statistically significant. results the mean age of the participants in group a was 30.61± 0.66 years and 30.16 ± 0.56 years in group b. the mean weight was 62.64 ± 0.30 kg and 61.75 ± 0.22 kg in groups a and b respectively. the mean bmi of group a was 21.87 ± 0.16 and 21.93 ± 0.15 in group b. j islamabad med dental coll 2022 213 midazolam was effective in preventing etomidate-induced myoclonus in 69.60% whereas lignocaine was effective in 55.40% patients. the difference was statistically significant with a p-value of 0.027 (table i). table i: comparison of frequency of myoclonus between group a (lignocaine group) and group b ( midazolam group) (n=112) myoclonus within 60 seconds of etomidate induction present absent count percentage count percentage p-value group a 50 44.60 62 55.40 .027 group b 34 30.40 78 69.60 group alignocaine group b midazolam d i s c u s s i o n various studies are available in the literature which explored the use of various agents for the prevention of myoclonus after induction with etomidate. ghodki ps et al 5 explored the use of dexmedetomidine and magnesium, they found that magnesium was more efficacious. however, the use of magnesium has been associated with increased duration effects of muscle relaxants, hence may prolong the duration of anesthesia. zhu y et al 9 conducted a meta-analysis in 2018 and put forward their conclusion in favor of lignocaine. they considered eight studies which concluded that lignocaine was significantly efficacious in prevention of myoclonus however still they wanted more good quality studies on the subject for a conclusive opinion. jayasingh sc et al 10 in their study compared various doses of lignocaine, they concluded that at the dose of 1 mg/kg or 1.5 mg/kg, lignocaine provided a statistically significant reduction in myoclonus. they also put forward that lignocaine was nearly the ideal agent for the purpose as it had minimal cardiac effects and also that it did not prolong the duration of anesthesia. an rct conducted by kahlon a singh and colleagues found that lignocaine and midazolam were effective in preventing the frequency and severity of etomidate induced myoclonus.11 in our study, done at the holy family hospital, we also compared the effect of lignocaine and midazolam in prevention of myoclonus with etomidate. our results indicated that midazolam was more effective as compared to lignocaine. myoclonus incidence was 44.60% in lignocaine group whereas it was 30.40% in midazolam group. furthermore, the intensity and frequency were much lower in female group than male population (p=0.04) in a randomized control study, schwarzkopf and colleagues 12 compared the efficacy of (0.015mg/kg) midazolam with etomidate 0.05 mg/kg and placebo. patients who were premedicated with midazolam (oral), were divided randomly into 3 equal groups: etomidate iv 0.05 mg/kg, midazolam iv 0.015 mg/kg, or iv normal saline (placebo). etomidate 0.3 mg/kg iv was administered after 90 seconds of premedication. induction was done with sufentanil & rocuronium after 1 minute of the onset of hypnosis. grading of myoclonic movements was done on a scale of zero to three. the results showed that the incidence of myoclonic movements in the placebo group was significantly lower as compared to patients who were premedicated with midazolam . myoclonus incidence is 20% in their study which is not comparable to our study (33.40%) possibly j islamabad med dental coll 2022 214 because the sample size used in their study was small as compared to our study. clinicians have been experimenting with other medications as well, swaminathan v et al in their study concluded that the prevalence of etomidate-induced myoclonus was significantly decreased in patients who were pre-treated with dexmedetomidine as compared with lignocaine.13 ghodki et al compared dexmedetomidine and magnesium. they found magnesium is superior to dexmedetomidine in decreasing not only the incidence but also the severity of myoclonus.14 srivastava et al worked with pregabalin, their observation was that giving 150 mg pregabalin in the morning of iv induction with etomidate, reduced the incidence and the severity of myoclonus but incidence of sedation was more.15 zhang kd et al used pretreatment with opioids and etomidate itself. according to them, both were safe and effective for making induction of anesthesia safer by preventing the myoclonus associated with etomidate.16 similarly, hüter et al 17 found the same results using low dose midazolam (0.015mg/kg) 3 minutes before etomidate induction in elective cardioversion patients. forty patients were included in their study, and all belonged to asa-iii & iv. myoclonic movements and sedation were recorded on a scale between zero and three. 2 patients (10%) had myoclonic movements in the midazolam group, whereas 10 out of 20 patients (50%) received the placebo experienced such movements (p 0.006). there were no other significant differences between the two groups; particularly, there was no difference in the time of recovery following etomidate. the frequency of myoclonus is only 10% as compared to our results which is 30%, this is a big difference and can be due to many reasons. firstly, our study has a much bigger sample size, hence making it more representative. secondly, their study was conducted on asa iii and iv patients whereas we included only asa i and ii patients. moreover, the time difference between pretreatment was different. myoclonus is a disturbing side effect associated with etomidate induction.18 midazolam (1mg) was found to be more useful in preventing myoclonus and it is recommended to use it prophylactically before etomidate induction, based on our study findings. the limitation of our study is that we did not analyze any drug-related side effects, extubation, and recovery times. also, we only observed frequency of myoclonus and not the severity. c o n c l u s i o n both midazolam and lignocaine are effective in preventing the occurrence of myoclonus associated with etomidate. however, midazolam is the more effective of the two drugs. r e f e r e n c e s 1. gupta p, gupta m. comparison of different doses of intravenous lignocaine on etomidate-induced myoclonus: a prospective randomized and placebo-controlled study. indian journal of anesthesia. 2018 feb;62(2):121. 2. lang b, zhang l, yang c, lin y, zhang w, li f. pretreatment with lidocaine reduces both incidence and severity of etomidate-induced myoclonus: a meta-analysis of randomized controlled trials. drug design, development and therapy. 2018; 12:3311. 3. devlin rj, kalil d. etomidate as an induction agent in sepsis. crit care nurs clin north am. 2018 sep;30(3): e1-e9 4. malapero rj, zaccagnino mp, brovman ey, kaye ad, urman rd. etomidate derivatives: novel pharmaceutical agents in anesthesia. j anaesthesiol clin pharmacol. 2017 octdec;33(4):429-431 5. ghodki ps, shetye nn. pretreatment with dexmedetomidine and magnesium sulphate in prevention of etomidate induced myoclonus–a double blinded randomized controlled trial. indian journal of anaesthesia. 2021 may;65(5):404. 6. lang b, zhang l, yang c, lin y, zhang w, li f. pretreatment with lidocaine reduces both incidence and severity of etomidateinduced myoclonus: a meta-analysis of https://pubmed.ncbi.nlm.nih.gov/30286947/ https://pubmed.ncbi.nlm.nih.gov/30286947/ https://pubmed.ncbi.nlm.nih.gov/29416230/ https://pubmed.ncbi.nlm.nih.gov/29416230/ https://pubmed.ncbi.nlm.nih.gov/29416230/ https://pubmed.ncbi.nlm.nih.gov/30323563/ https://pubmed.ncbi.nlm.nih.gov/30323563/ https://pubmed.ncbi.nlm.nih.gov/30323563/ j islamabad med dental coll 2022 215 randomized controlled trials. drug des devel ther. 2018 oct 4; 12:3311-3319. 7. lang b, zhang l, li f, lin y, zhang w, yang c. comparison of the efficacy and safety of remifentanil versus different pharmacological approaches on prevention of etomidateinduced myoclonus: a meta-analysis of randomized controlled trials. drug des devel ther. 2019 may 9; 13:1593-1607. 8. gupta p, gupta m. comparison of different doses of intravenous lignocaine on etomidate-induced myoclonus: a prospective randomized and placebo-controlled study. indian j anaesth. 2018 feb;62(2):121-126. 9. zhu y, yang y, zhou c, bao z. using dezocine to prevent etomidate-induced myoclonus: a metaanalysis of randomized trials. drug design, development and therapy. 2017;11:2163. 10. jayasingh sc, nanda s, mohanty r, routray ss, dalai ic. a comparative study of different doses of lignocaine on prevention of etomidate induced myoclonus during induction of anesthesia. international journal of recent surgical and medical sciences. 2021 dec 27. 11. singh ka, ruchi g, singh ka, kaur bt efficacy of lignocaine versus midazolam in controlling etomidate-induced myoclonus: a randomized placebo-controlled study. ain shams med j 2014; 7 (3):460-64 12. schwarzkopf kr, hueter l, simon m, fritz hg. midazolam pretreatment reduces etomidateinduced myoclonic movements. anaesthesia and intensive care. 2003 feb;31(1):18-20. 13. niedermirtl f, eberhardt m, namer b, leffler a, nau c, reeh pw, et al. etomidate and propylene glycol activate nociceptive trp ion channels. molecular pain. 2018 nov;14:1744806918811699. 14. ghodki ps, shetye nn. pretreatment with dexmedetomidine and magnesium sulphate in prevention of etomidate induced myoclonus–a double blinded randomized controlled trial. indian journal of anesthesia. 2021 may;65(5):404. 15. srivastava vk, agrawal s, kumar s, pandey a, garewal s, shree p. to evaluate efficacy of pregabalin for the prevention of etomidateinduced myoclonus: a prospective, randomized, placebo-controlled, double-blind study. apollo medicine. 2021 jul 1;18(3):154. 16. zhang kd, wang ly, zhang dx, zhang zh, wang hl. comparison of the effectiveness of various drug interventions to prevent etomidate-induced myoclonus: a bayesian network meta-analysis. front med (lausanne). 2022 apr 26;9:799156. doi: 10.3389/fmed.2022.799156. pmid: 35559341; pmcid: pmc9086535. 17. hüter l, schreiber t, gugel m, schwarzkopf k. low-dose intravenous midazolam reduces etomidate-induced myoclonus: a prospective, randomized study in patients undergoing elective cardioversion. anesthesia & analgesia. 2007 nov 1;105(5):1298-302. 18. swaminathan v, khalik m, arora n, ahluwalia p, gupta a, garg a. a comparison of pretreatment with lignocaine versus dexmedetomidine in prevention of etomidate induced myoclonus-a randomized comparative trial. indian journal of clinical anaesthesia. 2022;9(2):203-9. https://pubmed.ncbi.nlm.nih.gov/30323563/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/31190739/ https://pubmed.ncbi.nlm.nih.gov/29491517/ https://pubmed.ncbi.nlm.nih.gov/29491517/ https://pubmed.ncbi.nlm.nih.gov/29491517/ https://pubmed.ncbi.nlm.nih.gov/29491517/ j islamabad med dental coll 2021 186 open access adenosquamous carcinoma of gallbladder – a case report nosheen nabi1, aamer mehmood2, naseer ahmed3 1pathologist, excel laboratory, islamabad 2consultant pathologist, excel laboratory, islamabad 3ceo, chief pathologist, excel laboratory a b s t r a c t gallbladder cancer is an uncommon malignancy and majority of these carcinomas are adenocarcinomas. adenosquamous carcinoma of gallbladder is a rare histopathological subtype of gallbladder carcinoma. it usually presents with symptoms of cholelithiasis like epigastric pain, nausea and bloating. on clinical examination, tenderness is usually present. radiologically in most of the cases, gallstones are found leading to the diagnosis of cholelithiasis for which cholecystectomy is done. gallbladder carcinomas are found mostly as an incidental finding on microscopic examination of cholecystectomy specimen. this disease is curable if diagnosed earlier but in most of the cases they present at advanced stages when resection is not possible and prognosis is poor. as this disease is extremely rare so published information is largely based on the case reports and case series. this is a case of 60 years old female patient who underwent cholecystectomy for cholelithiasis with incidental finding of adenosquamous carcinoma on histopathology report. keywords: adenosquamous, carcinoma, cholelithiasis, gallbladder. cite this case report: nabi n, mehmood a, ahmed n. adenosquamous carcinoma of gallbladder – a case report. j islamabad med dental coll. 2021; 10(3): 186-189. doi: 10.35787/jimdc.v10i3.740 funding source: nil conflict of interest: nil i n t r o d u c t i o n gallbladder carcinoma is an uncommon but lethal malignancy. adenosquamous carcinoma is a rare neoplasm accounting for 1-12 % of all the gallbladder carcinomas 1. only one-third of cases are diagnosed pre operatively while the remaining are diagnosed incidentally on histopathological examination of cholecystectomy specimen 2. adenosquamous carcinoma of gallbladder is a locally aggressive neoplasm with poor prognosis 3. we present a case of 60 years old female patient who underwent cholecystectomy for cholelithiasis with final diagnosis of adenosquamous carcinoma on histopathology report. c a s e r e p o r t a 60 years old lady presented in a private clinic in a remote area of khyber pakhtunkhwah, pakistan with complain of epigastric pain. she belongs to a middle class family and her family history for any type of carcinoma was unremarkable. after clinical examination, ultrasound abdomen was suggested which gave the opinion of cholilithiasis as it showed multiple stones in the lumen. elective cholecystectomy was planned for the cure of cholilithiasis and the specimen was sent for histopathological examination. on gross examination, gallbladder measured 9x4cm and the lumen showed multiple black stones. two polypoidal nodules were seen in the body of gallbladder, the largest one measured 1.5x1.3x1.3cm while smaller one measured 0.8x0.8x0.5cm (figure 1). microscopoic examination of the large polyp revealed a well differentiated squamous carcinoma and smaller correspondence: nosheen nabi email: nosheen.nabi@yahoo.com article info: received: july 8, 2021 accepted: august 31, 2021 c a s e r e p o r t j islamabad med dental coll 2021 187 polyp showed an adenocarcinoma. the tumor was invading the muscular layer. the margins were free of tumor (figure 2). immunohistochemical stains showed ck7 and ck 20 positivity in adenocarcinoma and p 63 was negative in the polyp containing adenocarcinoma. cdx2 was focally positive (figure 3) figure 1: gallbladder on examination showed one large polyp (small arrow), small polyp (long arrow) and contained multiple small black coloured stones (arrow head). the distance between the two polyps was 2.5cm. figure 2: microscopic examination of the gallbladder showed (a) squamous cell carcinoma in the larger polyp. (b) adenocarcinoma in the smaller polyp (h&e x40). j islamabad med dental coll 2021 188 figure 3: a, b, ck7 and ck 20 immunohistochemical stains are positive in the neoplastic cells, c, p63 is negative in the polyp containing adenocarcinoma while cdx2 is focally positive in the polyp containing adenocarcinoma (40× magnification). d i s c u s s i o n gallbladder carcinoma is an aggressive malignancy with poor outcome 4. it is the most common cancer of biliary tract and 5th most common malignancy of gastrointestinal tract 5. its increased incidence is seen in india, pakistan, east asia, eastern europe, south america, chile and columbia 6. the most common histologic subtype of gallbladder cancer is adenocarcinoma which represents approximately 76–90% of total gallbladder carcinoma cases. pure squamous and adenosquamous carcinoma constitutes 2–10% of cases and papillary tumors constitute 5–6% of cases 7. adenosquamous carcinoma of the gallbladder is composed of both glandular and squamous components. if the squamous part is 25%–99% of the tumor, then it is called as adenosquamous carcinoma 8. literature on adenosquamous carcinoma is limited because of its rarity. juan c rao conducted a large cohort study on 606 cases of gallbladder adenocarcinoma in which squamous cell carcinomas constituted 1% of the total cases and 4% were adenosquamous carcinomas. in early stages (tis-t1a), cholecystectomy alone can cure the disease and for t2-t3, liver resection and lymphadenectomy is indicated 10. prognosis of adenosquamous carcinoma is worse than conventional adenocarcinoma of gallbladder because of early direct invasion of adjacent organs such as liver and duodenum etc. survival rate is approximately 16% j islamabad med dental coll 2021 189 and most of the patients succumb to disease within 6-7 months of diagnosis 11. adenosquamous carcinoma of gallbladder is a rare entity which presents like cholilithiasis. its behavior is more aggressive than adenocarcinoma of gallbladder and it is locally more invasive. because of its rarity, limited literature is available about its clinicopathological behavior and treatment options. such case reports can provide more detailed information and insight for further research. there were certain limitations regarding this case as we could not follow up the patient for further treatment and prognosis. r e f e r e n c e s 1. kendre p, kataria p, patel a, mittal l, mule t. metastasis as initial presentation of squamous cell carcinoma of gallbladder: a rare clinical entity. indian journal of pathology and microbiology. 2017 jul 1;60(3):440. 2. utsumi m, aoki h, kunitomo t, mushiake y, yasuhara i, arata t, et al. evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results. bmc research notes. 2017 dec;10(1):1-5. 3. shariff mh, bhat sp, hl kp. an unusual presentation of adenosquamous carcinoma of gallbladder. internet journal of pathology and laboratory medicine. 2016 dec 22;2(1). 4. bacalbasa n, balescu i, dima s, popescu i. surgical advances in the treatment of gallbladder carcinoma at different stages. in bile duct cancer 2019 sep 25. intechopen. 5. prasad n, sen s. gall bladder carcinoma: the facts and the mimics. egyptian journal of radiology and nuclear medicine. 2021 dec;52(1):1-9. 6. gulwani hv, gupta s, kaur s. squamous cell and adenosquamous carcinoma of gall bladder: a clinicopathological study of 8 cases isolated in 94 cancers. indian journal of surgical oncology. 2017 dec;8(4):560-6. 7. samuel s, mukherjee s, ammannagari n, pokuri vk, kuvshinoff b, groman a, et al. clinicopathological characteristics and outcomes of rare histologic subtypes of gallbladder cancer over two decades: a population-based study. plos one. 2018 jun 11;13(6):e0198809. 8. majeed nk, younes ie, karimi s, garzon s. adenosquamous carcinoma of the gallbladder with sarcomatoid features. acg case reports journal. 2020 sep 1;7(9):e00461. 9. roa jc, tapia o, cakir a, basturk o, dursun n, akdemir d, et al. squamous cell and adenosquamous carcinomas of the gallbladder: clinicopathological analysis of 34 cases identified in 606 carcinomas. modern pathology. 2011 aug;24(8):1069-78. 10. vargas a, rodarte-shade m, lopez-garnica d. adenosquamous carcinoma of the gallbladder. case report and literature review. hpb. 2017 apr 1;19:s190. 11. hong y, li x, cao d. case report: trastuzumab treatment in adenosquamous carcinoma of the extrahepatic biliary tract with her-2 amplification. frontiers in oncology. 2021 feb 25;11:268. j islamabad med dental coll 2021 206 o p en a c c es s transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women after receiving antenatal steroids saniya naheed1, sajida asghar2, dureshahwar3, seema gul4, mahwash jamil5, ayesha akram6 1,2assistant professor, department of obstetrics and gynecology, hbs medical & dental college/general hospital islamabad 3,4assistant professor, department of obstetrics and gynecology, watim medical & dental college/general hospital rawalpindi 5,6assistant professor, department of obstetrics and gynecology, hitech-institute of medical sciences, rawalpindi. a b s t r a c t background: preterm births account for increased mortality and morbidity in both developed and developing countries. the objective of this study was to determine frequency of transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women receiving antenatal steroids. methodology: this descriptive cross-sectional study was carried out in maternal and child health center unit 1 at pakistan institute of medical sciences, islamabad from january 2018 till august 2018. 370 pregnant women presenting to hospital who received dexamethasone therapy due to preterm labor, preterm premature rupture of membranes or any other conditions which require early delivery e.g., oligohydramnios etc. were included. multiple pregnancies, advanced preterm labor, gestational or chronic diabetes mellitus, and those having bsr > 126 mg/dl before first dose of dexamethasone were excluded. after ethical approval and informed consent, proformas were filled. blood sugar levels before 1st dose of dexamethasone noted and 2nd dose was given after 12 hours. blood sugar profile (fasting, 2 hours after lunch, 2 hours after dinner) was carried out till euglycemia or 5 days if sugars remain deranged. patients having deranged levels for greater than 5 days were advised 75 g oral glucose tolerance test and were labeled as having gestational diabetes mellitus. results: mean age of study participants was 28.92+5.54 years with mean gestational age of 31.19+1.92 weeks. assessment of transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality. conclusion: frequency of transient hyperglycemia and gestational diabetes mellitus increased in pregnant women receiving antenatal steroids. basic sugar profile should be carried out after dexamethasone therapy. keywords: corticosteroid, gestational diabetes mellitus (gdm), hyperglycemia, preterm authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: saniya naheed email: saniya.naheed@gmail.com article info: received: december 31, 2020 accepted: december 24, 2021 cite this article. naheed s, asghar s, dureshahwar, gul s, jamil m, akram a. transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women after receiving antenatal steroids. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n the incidence of preterm birth in developed countries is 12.7% and its rate varies with socioeconomic status.1 preterm births account for 85% of neonatal mortality and increased morbidity in both developed and developing countries.2 for better feto-maternal outcome, it is important to identify preventable and treatable causes of preterm births.3 respiratory distress syndrome (rds), a consequence of preterm delivery, due to immatur o r i g i n a l a r t i c l e j islamabad med dental coll 2021 207 lung development, is the major reason of early neonatal mortality and morbidity. the rds has dramatically reduced because of antenatal steroids and exogenous surfactant replacement. in the developing countries, with the scarce resources, especially nicu care, antenatal steroids play a very significant role. they have reduced, risk of rds from 25.8% to 9.0 % and neonatal mortality has decreased from 15.0% to 3.2%.4 to increase lung maturity, intramuscular injection of betamethasone or dexamethasone is given. these are the steroids of choice to improve fetal lung maturity.5 glucose intolerance, chorioamnionitis, puerperal sepsis, bruising, hematoma, pain at the site of injection, insomnia, gastrointestinal upset, pre-eclampsia is known side effects of steroids.6 a strict control on sugar is very important to reduce the risk of rds because fetal hyperinsulinemia is key factor in pathogenesis of rds, administration of antenatal steroids is even more recommended in diabetic women and strict insulin therapy is advised to allow beneficial effects of steroids.7 as people of south asian descent are more prone to diabetes, antenatal steroids can cause disturbance in glucose metabolic homeostasis which may have significant maternal and possibly fetal effects. this study is aimed at exploring effects of antenatal steroids on maternal glucose metabolism by finding the frequency of transient hyperglycemia and gestational diabetes mellitus after dexamethasone therapy. m e t h o d o l o g y this descriptive cross-sectional study was carried out in maternal and child health center unit (mch1) at pakistan institute of medical sciences, islamabad from january 2018 till august 2018, using consecutive nonprobability sampling technique. a total of 370 pregnant women presenting to emergency and outpatient department who received dexamethasone therapy due to either preterm labor (alive morphologically normal babies), preterm premature rupture of membranes (pprom) or any other conditions which require early delivery (e.g., preeclampsia, intra uterine growth retardation (iugr), severe oligohydramnios, antepartum hemorrhage (aph) were included. women having multiple pregnancies, advanced preterm labor (cervix > 5cm dilated), gestational diabetes mellitus (gdm) or type i/ii diabetes mellitus (dm), bsr > 126 mg/dl before first dose of dexamethasone, chorioamnionitis and those taking any medication that affects glucose metabolism were excluded from the study. after ethical approval, informed consent was taken from study participants and proformas were filled. blood sugar levels before the commencement of 1st dose of dexamethasone were noted and 2nd dose of dexamethasone was given after 12 hours of 1st dose. blood sugar profile (fasting, 2 hours after lunch, 2 hours after dinner) were carried out till euglycemia (bsf < 100 mg/dl, 2 hours post meal 140mg/dl) or 5 days if sugars remain deranged. patients were labelled as having transient hyperglycemia if their sugar profile got deranged due to dexamethasone therapy but returned to normal within 5 days. patients having deranged levels for greater than 5 days were advised 75 g oral glucose tolerance test (ogtt) and were labelled as having gestational diabetes mellitus following the nice criteria for diabetes in pregnancy (bsf > 100 mg/dl and 2 hours pp > 140 mg/dl). spss version 26 was used for data analysis, qualitative variables like: transient hyperglycemia, gestational diabetes mellitus (gdm), sugar profile derangement for greater than 5 days were calculated as frequency & percentages. quantitative variables like age, gestational age, parity was expressed as mean ± sd. r e s u l t s in our study, mean age of the patients was 28.92+5.54 years (table-1) and mean gestational age 31.19+1.92 weeks. parity distribution showed that 73.78% (n=273) were between 1-3 paras and 26.22% (n=97) were between 4-5 paras, mean ± sd was calculated as 2.77 ± 1.24 paras. assessment of j islamabad med dental coll 2021 208 transient hyperglycemia and gestational diabetes mellitus (gdm) in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality (table-2 & 3) table 1: age distribution (n=370) age (in years) no. of patients % 18-30 213 57.57 31-40 157 42.43 total 370 100 mean ± sd 28.92 ± 5.54 table 2: bsr derangement. (n=370) blood sugar random derangement no. of patients % yes 273 73.78 no 97 26.22 total 370 100 table 3:frequency of transient hyperglycemia, impaired glucose tolerance and gestational diabetes mellitus (gdm) in preterm pregnant women receiving antenatal steroids. (n=370) qualitative variable no. of patients % blood sugar derangement 273 73.78 transient hyperglycemia 250 67.56 gestational diabetes mellitus 23 6.21 no serum glucose abnormality 97 26.22 total 370 100 d i s c u s s i o n south asian descents are more prone to diabetes8 and our population has high prevalence of undiagnosed dm and impaired glucose tolerance. antenatal steroids can cause disturbance in glucose metabolic homeostasis which may have significant maternal and possibly fetal effects. locally, no or single blood sugar level done, routinely before dexamethasone therapy may be insufficient to judge the glucose metabolic status of women, so this study was aimed at exploring effects of antenatal steroids on maternal glucose metabolism. assessment of transient hyperglycemia and gestational diabetes mellitus (gdm) in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality. gdm is becoming global health burden with global prevalence of 16.9%. the highest prevalence was seen in south-asia region of 25% as compared to 10.4% in the north america and caribbean region.9 it is established in literature that maternal corticosteroids given for fetal lung maturity increase blood glucose level of the mother.10,11 from previous studies, we have identified that the effects of corticosteroids on blood glucose levels in non-diabetic mothers remain for 24 hours. however, changes in oral glucose tolerance test were noticed for three days after giving betamethasone injections. ghazala et al12 also found that the steroids have systemic metabolic side effects. the effects of single and multiple courses of dexamethasone and its effect on maternal fasting and postprandial glucose level were observed in another study. it was found that single course of dexamethasone resulted in acute increase in blood glucose level while multiple courses resulted in continuous increase in blood glucose levels.13 in our study 73.78% of study participants had deranged blood sugar level after dexamethasone therapy out of which 6.21 % developed gdm whereas 67.51% had transient hyperglycemia, similarly a study by refuerzo et al showed 16% to 33% increase in glucose level at 20,44 and 68 hours after first dose of antenatal corticosteroids in pregnant women without diabetes which may be missed with conventional monitoring.14 glucose intolerance is signficantlty higher in twins and triplets compared to singleton.15 j islamabad med dental coll 2021 209 c o n c l u s i o n frequency of transient hyperglycemia and gestational diabetes mellitus increased in preterm pregnant women receiving antenatal steroids. basic sugar profile should be carried out after dexamethasone therapy. r e f e r e n c e s 1. padula am, huang h, baer rj, august lm, jankowska mm, jellife-pawlowski ll, et al. environmental pollution and social factors as contributors to preterm birth in fresno county. environ health. 2018; 29;17(1):70-73. doi:10.1186/s12940-0180414-x. 2. huang h, woodruff tj, baer rj, bangia k, august lm, jellife-palowski ll, et al. investigation of association between environmental and socioeconomic factors and preterm birth in california. environ int. 2018; 121: 1066-78. doi: 10.1016/j.envint.2018.07.027 3. sudhir p s, mishra s. a prospective study of etiology and outcome of preterm labour in a rural medical college. obg rev: j obstet gynecol. 2016.31;2(4):448. doi: 10.17511/joog.2016.i04.01. 4. ontela v, dorairajan g, bhat vb, chinnakali p. effect of antenatal steroids on respiratory morbidity of late preterm newborn: randomized controlled trial. j trop pediatr. 2018;64(6):531-8. doi:10.1093/tropej/fmy001 5. bricena-perez c, reyana-villasmil e, vigil-de-gracia p. antenatal corticosteroids therapy: historical and scientific basis to improve preterm birth managment. ejog. 2019; 234:32-37. doi:10.1016/j.ejogrb.2018.12.025 6. street me, angelini s, bernasconi s, burgio e, cassio a, catellani c, et al.current knowledge on endocrine disrupting chemicals (edcs) from animal biology to humans, from pregnancy to adulthood: int j mol sci. 2018;19(6):1647-9. doi:10.3390/ijms19061647 7. kalra s, kalra b, gupta y. glycemic management after antenatal corticosteroid therapy. n am j med sci. 2014; 6(2): 71-76. doi: 10.4103/1947-2714.127744. 8. dornhorst a. diabetes and endocrine disease in pregnancy. in: edmonds k editor. dewhurt’s textbook of obstetrics & gynecology .uk: blackwell. 2012; 8th edition: 121-136. doi:10.1002/9781119979449.fmatter 9. guariguata l, linnenkamp u, beagley j, whiting dr, cho nh. global estimates of the prevalence of hyperglycemia in pregnancy. diabetes res clin pract. 2014; 103 (2):176-85. doi: 10.1016/j.diabres.2013.11.003. 10. schmitz t, alberti c, ursino m, baud o, et al. full versus half dose of antenatal betamethasone to prevent severe neonatal respiratory distress syndrome associated with preterm birth: bmc pregnancy childbirth. 2019;19(1):67-70. doi:10.1186/s12884-019-2206-x 11. kim ye, park ws, sung dk, ahn sy, chang ys. antenatal betamethasone enhanced the detrimental effects of postnatal dexamethasone on hyperoxia lung and brain injuries in newborn rats. plos one. 2019;14(8):194-8. doi: 10.1371/journal.pone.0221847 12. ghazala butt, faria asad, khawar khurshid. frequency of pulmonary tuberculosis in patients with skin diseases requiring high dose long-term systemic steroid therapy. j. pak assoc derma. 2013; 23(2):12632. 13. polderman ja, farhang-razi v, van dieren s, kranke p, devries jh, et al. adverse side effects of dexamethasone in surgical patients. cochrane database syst rev. 2018;11(11). doi:10.1002/14651858.cd011940.pub3 14. refuerzo js, garg a, rech b, ramin sm, vidaeff a, blackwell sc. continuous glucose monitoring in diabetes women following antenatal corticosteroid therapy: a pilot study. am j perinatol. 2012:29(5):335-8. doi: 10.1055/s-0031-1295642. 15. weissman a, drugan a. glucose tolerance in singleton, twin and triplet pregnancies. j pernat med. 2016;44(8):893-897.doi:10.1515/jpm-2016-0186. https://doi.org/10.17511/joog.2016.i04.01 113 j i m d c 2 0 1 7 113 op e n ac c e ss c a s e r e p o r t primary musculoskeletal hydatid cyst of thigh rehana shaikh 1, nasreen naz 2, rabia hafeez 3, sabiha zaheer 4, syeda erage safi 5 1 consultant radiologist, ct & mri centre, radiology department, dow medical college/civil hospital karachi, 2 assistant professor of radiology, radiology department, dow medical college/civil hospital karachi 3 -5 resident radiology department, dow medical college/civil hospital karachi (dow university of health sciences, karachi) a b s t r a c t primary musculoskeletal hydatid disease means that there is no primary focus of hydatid disease in body. it is a rare disease and present in approximately 3% of the patients. we present a case of primary hydatid cyst of thigh in 40-year female with history of swelling in left thigh for 2-years and referred for mri at ct & mri centre, at radiology department, dow university of health sciences/civil hospital karachi. this case highlights that hydatid disease should be considered in the differential diagnosis of every soft tissue cystic mass in any anatomical location. preoperative diagnosis of hydatid cyst is important for proper management and to avoid the long-term complication of recurrence. key words: echinococcosis, hydatid cyst, mri, primary, thigh. address of correspondence dr rehana shaikh email: rehanawazir@hotmail.com article info. received: april 6, 2017 accepted: may 23, 2017 cite this case report: shaikh r, naz n, hafeez r, zaheer s, safi s. primary musculoskeletal hydatid cyst of thigh jimdc. 2017; 6(2):113-115. i n t r o d u c t i o n hydatid cyst disease is a parasitic infection caused by larva of echinococcus granulosus. man is an incidental or accidental intermediate host and becomes infected by ingesting contaminated food or water.1 hydatid cysts are usually found in liver and lungs, but can affect any part of the body,2 so the differential diagnosis of hydatid disease should be considered for every soft cystic mass in any anatomical location. we present a case of an unusual primary musculoskeletal hydatid disease in 40-year female with history of a slow-growing soft tissue mass on the medial side of the left thigh with no detectable primary site in the liver, lung or other common site of involvement. to the best of authors’ knowledge, this site of localization has not been reported previously from pakistan. c a s e r e p o r t s a 40-year female referred to ct & mri centre, radiology department, dow university of health sciences/civil hospital karachi for mri with the complaint of a very slowly growing mass on the medial aspect of left thigh for the past 2 years. there was no history of pain, fever or weight loss. she had no contact with domestic livestock. there was no history of trauma. the past medical and surgical history was unremarkable. on clinical examination, a non-tender cystic swelling was noted on the medial aspect of left thigh. the swelling was firm in consistency without fluctuation and free from the skin as well as underlying structures. routine laboratory studies were normal except slight increase of eosinophil count. mri of the thigh was performed which revealed a welldefined multicystic lesion along with daughter cysts, floating membranes and hypointense peripheral ring (rim sign) involving the left adductor magnus muscle. it appeared hypointense on t1wi, hyperintense on t2wi and stir showing marginal post gadolinum enhancement (figure 1 a+ b). it measured 10.0 x 7.7 x 4.4cm. neurovascular bundle was spared. bones and muscles of the rest of the thigh were normal. ct scan of thorax and abdomen were performed to rule out any hydatid cyst of the lungs, liver, or other common sites of involvement. based on these findings the patient was c a s e r e p o r t mailto:rehanawazir@hotmail.com 114 j i m d c 2 0 1 7 114 diagnosed as primary musculoskeletal hydatid disease and advised the antibody titer (igg) for hydatosis which showed slightly increase value, which further supported the diagnosis of hydatid disease. based on the clinical, imaging and laboratory findings, preoperative diagnosis of hydatid cyst was made. to avoid complications like anaphylactic reaction, infection and recurrence. the patient underwent enucleation of cyst and was kept on adjunctive antihelmenthic therapy to eliminate any possible larvae dissemination. the post-surgical period was uneventful. there were no post-procedure complications like urticaria or anaphylactic reaction. the histopathology confirmed the diagnosis of hydatid cyst disease. figure 1(a+b): t2 and post gd t1wi show a well-defined multicystic lesion with daughter cysts and floating membranes, hyperintense on t2wi showing marginal post gd enhancement. d i s c u s s i o n hydatid disease remains a health issue in developing countries because of the lack of control programs to prevent the transmission of this infection, high populations of stray dogs, illegal butchering of animals and poor public education /awareness.3 hydatid disease is infested by the larval form of the tapeworm, echinococcus granulosus. although it can involve any part of the body, the most commonly affected organs are liver (75 %), lungs (15.4 %) and spleen (5.1%).2 primary musculoskeletal hydatid disease is a rare entity and is present in approximately 3% of the patients.4 according to various studies, the incidence of musculoskeletal hydatid disease including subcutaneous tissue ranges between 1 – 5.4% amongst all the cases of hydatid disease.5 musculoskeletal hydatid disease can be primary or secondary. in later case, there is primary location of hydatid cyst in the liver, lung or spleen that may or may not be operated.6 primary musculoskeletal hydatid disease is rare, as the parasite has to cross pulmonary and hepatic barriers to reach the muscles.6,7 the exact mechanism is unclear but a possible dissemination through lymphatic channels has also been reported.8 the muscles are supposed to be an unfavourable site for infestation because of its high lactic acid concentration as well as contractility. 6, 9 the primary soft tissue involvement of hydatid disease is very rare, so its diagnosis is challenging. imaging methods like ultrasonography (usg), computed tomography (ct), or magnetic resonance imaging (mri) especially the later, have a primary role in its preoperative diagnosis by the characteristic appearance of a unilocular or multilocular cyst with multiple daughter cysts and hypointense peripheral ring (rim sign),5,6 as seen in mri of our case. hydatid serology is only valuable and supports the diagnosis when it is positive. however negative serology does not exclude the diagnosis.10 in our case there was slight increase in both eosinophil count and echinococcal antibody titer. our patient did not give history of surgery for hydatid disease and her investigations did not reveal any hydatid cyst in liver, lung or spleen. so, she was diagnosed as having primary musculoskeletal hydatid disease and this was confirmed on histopathology. a preoperative diagnosis of hydatid cyst is based on combination of clinical, imaging and laboratory data. preoperative mri is the imaging modality of choice not only for diagnosis the hydatid cyst, but clearly identifies the involved structures and helps in surgical planning. the 115 j i m d c 2 0 1 7 115 preoperative diagnosis and avoidance of diagnostic biopsy/aspiration is crucial in preventing local recurrence, cystic infection, and anaphylactic shock. the only successful treatment is complete excision of cyst with pre and postoperative antihelmenthic treatment; as was also given to our patient. c o n c l u s i o n a hydatid cyst is rarely seen in thigh so it should be investigated with serological tests and imaging modalities. particularly in patients coming with a soft tissue cystic swelling, the possibility of hydatid cyst should be included in differential diagnosis. if possible, total surgical excision of hydatid cyst in the muscle should be performed along with antihelmenthic therapy to avoid complications like anaphylactic reaction, larvae dissemination and recurrence. r e f e r e n c e s 1. salamone g, licari l, randisi b, falco n, tutino r, vaglica a, gullo r, porrello c, cocorullo g, gulotta g. uncommon localizations of hydatid cyst. review of the literature. il giornale di chirurgia. 2016; 37(4):180. 2. safioleas m, misiakos ep, kakisis j, manti c, papachristodoulou a, lambrou p, et al. surgical treatment of human echinococcosis. int surg. 2000; 85(4): 358-65. 3. nath k, prabhakar g, nagar rc. primary hydatid cyst of neck muscles. indian j pediatr. 2002; 69(11):997-8. 4. ozkoc g, akpinar s, hersekli ma, ozalay m, tandogan r. primary hydatid disease of the quadriceps muscle: a rare localization. arch orthop trauma surg. 2003; 123(6):314– 316. 5. gupta a, singal rp, gupta s, singal r. hydatid cyst of thigh diagnosed on ultrasonography a rare case report. j med life. 2012; 5(2): 196–7. 6. bansiwal rk, sharma r, attri ak. a large primary hydatid cyst of thigh: a case report. indian journal of surgery. 2011; 73(2):158-60. 7. garcía-alvarez f, torcal j, salinas jc, navarro a, garcía-alvarez i, navarro-zorraquino m, sousa r, tejero e, lozano r. musculoskeletal hydatid disease: a report of 13 cases. acta orthopaedica scandinavica. 2002; 73(2):227-31. 8. ousadden a, elbouhaddouti h, ibnmajdoub kh, khalid m, aittaleb k. a solitary primary subcutaneous hydatid cyst in the abdominal wall of a 70-year-old woman: a case report. j med case rep. 2011; 5(1):270. 9. tatari h, baran ö, s¸ anlıdağ t, göre o, ak d, manisalı m, havıtçıoğlu h. primary intramuscular hydatidosis of supraspinatus muscle. archives of orthopaedic and trauma surgery. 2001; 121(1-2):93-4. 10. orhan z, kara h, tuzuner t, sencan i, alper m. primary subcutaneous cyst hydatic disease in proximal thigh: an unusual localisation: a case report. bmc musculoskeletal disorders. 2003; 4(1):25. 110 j i m d c 2 0 1 7 110 op e n ac c e ss f u l l l e n g t h a r t i c l e anal fissure dilatation outcome and patient satisfaction mehreen baig1, shahid mahmood2, sosan shahid3 1 assistant professor surgery, foundation university medical college, rawalpindi 2 professor & hod surgery, islamabad medical & dental college, islamabad 3 assistant professor radiology, islamabad medical & dental college, islamabad a b s t r a c t objective: to study outcome and level of satisfaction in patients of chronic anal fissure in terms of pain control and healing of fissure. patients and methods: this descriptive study was conducted in fauji foundation hospital rawalpindi. total of 100 patients who had anal fissure for more than 6 weeks and were refractory to treatment with gtn paste were included in this study. anal dilation was done in all the patients. satisfaction of patient was assessed on visual analogue scale at 48 hours, 3 weeks, 6 weeks and 6 months during opd follow up. results: total 100 patients were included in the study. among them (84%) were females, 16% were male. 3 weeks after dilatation, anal fissure was completely cured in 93% of patients. after 6 months, repetition of procedure was needed in 3% of patients. conclusion: anal dilatation is a simple and safe procedure to treat chronic anal fissure. key words: fissure in ano, rectal bleeding, painful defecation. author`s contribution 1manuscript writing of introducton 2reviewed and proof reading, data analysis, 3data collection, analysis and help in references address of correspondence dr mehreen baig drmehreenbaig@gmial.com article info. received: april 31, 2017 accepted: june 10, 2017 cite this article: baig m, mahmood s, shahid s. anal fissure dilatation outcome and patient satisfaction jimdc. 2017; 6(2):110-112. funding source: nil conflict of interest: nil i n t r o d u c t i o n anal fissure is a boat shaped ulcer in anal canal and it has almost the same incidence in both sexes. ninety percent occurs in midline posteriorly. painful defecation and bright red bleeding are usual presenting features.1-3 acute anal fissure responds to tropical ointments and medical treatment but in chronic anal fissure, no improvement in the condition has been proved beneficial.4 chemical sphincterotomy with glyceryl trinitrate gtn1 paste is intolerable to majority, as it is associated with hypotension, tachyphylaxis and headache.5 surgical treatments include lateral internal sphincterotomy (lis) and anal dilatation6, lis is also associated with considerable risk of incontinence especially in female and elderly people1. controlled gentle anal dilatation with fingers in deep neuromuscular blockade is a time-tested method which relieves pain and anal spasm within hours.7-9 this method is acceptable for majority of patients, it also avoids wound complication and perineal sepsis which is known complication of lis.6,10 surgical treatment are far more popular than medical treatment. literature review shows that anal dilatation was recommended by goodsal’ at the turn of the century and later by gabriels and others.1 surgeons have been attracted to the procedure by its extreme simplicity1 and hence it was most ancient way of dealing with anal fissure and is still widely practiced in different parts of world.11 anal dilatation is criticized in literature because it leads to tearing of internal sphincter and hence incontinence. uncontrolled force applied in anal canal in wrong direction and use of metal anal dilators were the contributors of the failure of this procedure. diagnosis of anal fissure is usually made on history. the examination is very painful, especially it is impossible to o r i g i n a l a r t i c l e 111 j i m d c 2 0 1 7 111 do proctoscopy. on per rectal examination, fissure can be seen at 12 o clock position. routine hematological test are within normal range. radiological investigations like trans rectal ultrasound & mri are extremely useful in delineating anatomy of anal canal but again transrectal ultrasound cannot be done in acute stage, nor does it help in diagnosis or treatment. though magnetic resonance imaging (mri) is the best imaging modality for preoperative assessment of patients with anal fistula, its role is not established in case of fissure in ano. mri performed adequately should be regarded as the “gold standard” for preoperative assessment, replacing surgical examination under anesthetic (eua) in this regard.12 the anatomy of the anal canal is complex but well demonstrated by mri. understanding the anatomy is a prerequisite for determining the true site and the extent of pathology, especially for surgical work up in the case of most of the anal problems except for anal fissure. other modalities of radiological diagnosis like pet/ct are useful in staging of carcinoma and are used routinely in anal cancer.13 p a t i e n t s a n d m e t h o d s this prospective study was performed at fauji foundation hospital rawalpindi, from june 2012 till march 2017. all the patients who had anal fissure for more than 6 weeks and were refractory to treatment with gtn paste were included in this study. patients with any previous history of perianal procedure or operation and suffering from any other pathology like hemorrhoids, peri-anal fistula, crohn’s disease, ulcerative colitis and tuberculosis of gut were excluded from the study. the patients were informed about the procedure and formal written consent was taken. anal dilatation was performed by the surgeon under general anesthesia. first, per rectal examination and proctoscopy was done. anal dilatation with the gentle traction of four fingers by crossed hands was done in lateral direction. hands were crossed to avoid extra force. dilatation was not done in an upward or downward direction to avoid damage to the perineal body. a vaseline and lignocaine soaked gauze was placed in anal canal for 2 hrs. one dose of iv analgesic was advised. patients were discharged on the same day and called for follow up visits after 2 days. pain and patients’ satisfaction with the procedure were assessed pre operatively and postoperatively at 48 hours, 3 weeks, 6 weeks and 6 months during opd follow up using visual analogue scale. the visual analogue scale (vas) is a simple and frequently used method for the assessment of variations in intensity of pain. in clinical practice the percentage of pain relief, assessed by vas, is often considered as a measure of the efficacy of treatment.14 r e s u l t s a total 100 patients were included in the study, among them 84% were females and 16% were male. the median age was 31 years. seventy two percent of patients had complete pain relief in 1st 48 hours, while 28% reported persistence of pain. at 3 weeks interval, fissure healing was observed in 93% patients with persistence of symptoms in 7%. during follow up at 6 weeks and 6 month, 97% of patients were symptoms free, with 3% patients reported persistence of symptoms (table 1). table 1: occurrence of post-surgical symptoms at different time intervals in patients of anal fissure (n=100) time interval pain fissure relief (%) persistent (%) healing (%) persistence of symptoms (%) 48 hours 72 28 28 72 3 weeks 100 0 93 7 6 weeks 100 0 97 3 6 months 100 0 97 3 for these 3% patients, who continued to complaint about pain during defecation or persistence of any other symptoms, same procedure was repeated. complications like permanent or temporary incontinence, peri-anal wound infection or sepsis was not seen in any patient. d i s c u s s i o n the majority of patients had used conservative and medical treatment like gtn paste before opting for the surgery. patients themselves opted for anal dilatation when the procedure was properly explained to them. in our study, we performed this procedure in deep neuromuscular blockade14, gentle controlled force applied on the side of anal canal for 4 minutes. application of these techniques lead to excellent results15. this procedure is easy for post graduate doctors and resident registrars to do independently without serious complication. there is no need of any specialized equipment, no fear of transmission of hepatitis or hiv 112 j i m d c 2 0 1 7 112 from the hospital. the patient opted for this method of treatment because no sharp cut was made on their anal canal, no wound care was required postoperatively. patients resumed their daily life activity from the first postoperative day. lateral internal sphincterotomy is compared with anal dilatation in various studies and is said to be more effective, than dilatation, but perianal sepsis and wound infection are demerits of this procedure.16 how much sphincter is to be divided is another weakness of this procedure. one study compared the results of different sphincterotomies and found incontinence in 31 percent of patients which is quite significant.14 another study showed incontinence of 30 percent by sphincterotomy, which is another argument against this procedure.15 female gender, age, and multiparity are other contributors to the failure of sphincterotomy, as female mechanism, any sharp injury to sphincter fibers can be a control of feces and flatus.16 gender suffer associated with serious continence issues. equally physiological weakening of sphincter detrimental and study published in bmj by steen lindker jensen effective in immediate pain control and healing of fissure but anal dilatation is associated with recurrence, and poor compared anal dilatation and las and found both are as the drawback of this study was that anal dilatation was performed in local anesthesia and las was done in ga. another study done by graig p et al which was published recently in colorectal disease represent that both procedures are equivalent in terms of recurrence.17 in one study on las and anal dilation the author reported that anal dilatation is least invasive and give better pain relief and symptoms.18 c o n c l u s i o n we found anal dilatation a safe, cost effective and patient preferred method for patients who suffer debilitating pain during defecation. it is not associated with any risk of sphincter injury or incontinence if performed by proper technique. patients resumed their daily life activity from next day. there is need of more prospective randomized controlled trials to reach a conclusion. r e f e r e n c e s 1. kadhem mj, ahmad ha, alwan a. a review of non-operative management of anal fissures in pediatrics: a study of 50 cases at alkarama teaching hospital. journal of health, medicine and nursing. 2016; vol 33 :75-78 2. motie mr, hashemi p. chronic anal fissure: a comparative study of medical treatment versus surgical sphincterotomy. acta medica iranica. 2016; 54(7):437-40. 3. higuero t. update on the management of anal fissure. visc surg. 2015 ; 152(2) :37-43 4. levin a, cohen mj, mindrul v, lysy j. delayed fecal incontinence following surgery for anal fissure. int j colorectal dis. 2011; 26(12):1595-9. 5. yucel t, gonullu d, oncu m, koksoy fn, ozkan sg, aycan o. comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective study. int j surg. 2009; 7(3):228-31. 6. wray d, ijaz s, lidder s. anal fissure: a review. br j hosp med. 2008; 69(8):455-8. 7. sileri p, mele a, stolfi vm, grande m, sica g, gentileschi p, di carlo s, gaspari al. medical and surgical treatment of chronic anal fissure: a prospective study. j gastrointest surg. 2007; 11(11):1541-8. 8. tamjeed gul, mah muneer khan, maryam alam khan, uzma andaleeb, sana sahar. comparison of controlled-intermitt ent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fi ssures: a prospective randomized study. pak j surg 2016; 32(4):218-222 9. altomare df, binda ga, canuti s, landolfi v, trompetto m, villani rd. the management of patients with primary chronic anal fissure: a position paper. techniques in coloproctology. 2011; 15(2):135. 10. hetzer fh, baumann m, röthlin m. anal fissure, a new therapy concept. praxis. 2000; 89(34):1317-21. 11. torkzad mr, karlbom u. mri for assessment of anal fistula. insights into imaging. 2010; 1(2):62-71. 12. qahtan a. mahdi. characteristics and clinical management of female patients with fissure in ano in al-kadhimiya city, baghdad iraqi j med sci, 2013; vol. 11(3). 13. wells it, fox bm. pet/ct in anal cancer is it worth doing? j crad 2012; 67(6): 535-40 14. elsebae mm. a study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. world j surg 2007; 31(10): 2052-57 15. nicholas farkas, j.west. are we following an algorithm for managing chronic anal fissure? a completed audit cycle. annals of medicine and surgery. february 2016; vol 5 : 38-44 16. jensen sl, lund f, nielsen ov, tange g. lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. br med j (clin res ed). 1984; 289(6444):528-30. 17. garg p, garg m, menon gr. "long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and metaanalysis". colorectal dis. march 2013 ;15 (3): 104–17 18. golfam f, golfam p, golfam b, pahlevani p. comparison of topical nifedipine with oral nifedipine for treatment of anal fissure: a randomized controlled trial. iranian red crescent medical journal. 2014; 16(8). http://www.sciencedirect.com/science/journal/20490801 http://www.sciencedirect.com/science/journal/20490801/5/supp/c j islamabad med dental coll 2021 233 o p e n a c c e s s psychological impact of covid-19 on dental surgeons and students kanwal zulfiqar1, zarnab rizwan2, syed hamza zia3, ghina rizwan4, owais khalid durani5, ulfat bashir raja6 1 assistant professor, department of orthodontics, islamic international dental hospital, riphah international university 2,3,4 house officer, department of orthodontics, islamic international dental hospital, riphah international university 5 head of the department of orthodontics, school of dentistry, shaheed zulfiqar ali bhutto medical university 6 head of the department of orthodontics, islamic international dental hospital, riphah international university a b s t r a c t background: since the start of january 2020, covid-19, has been a serious health risk concerning the wellbeing and welfare of people worldwide. health care workers are prone to more psychological problems because of their direct contact with infectious patients. owing to the disruption of educational activities worldwide, stress was common among students. the objective of this study was to determine the psychological impact of covid-19 pandemic on dental surgeons and dental students. methods: the survey was conducted at islamic international dental hospital form february 2021 to july 2021. a total of 400 questionnaires were sent to students and dental surgeons, however 340 completely filled questionnaires were returned. questionnaire using the depression anxiety stress scale (dass-21) was used to assess the psychological influence. data was compiled and independent sample t -test and pearson’s correlation were applied using the statistical package for social sciences spss version 23 to determine difference of means considering p<0.05 as cut off for significance. results: the means of stress score, anxiety score and depression were 2.24+0.5, 3.56 +0.06 and 2.83+0.06 respectively. pearson’s correlation among the dimensions of das scale showed that depression, anxiety and stress were positively and significantly correlated with each other. conclusion: there were high levels of depression, anxiety and stress among dental students during covid-19 pandemic. keywords: covid-19, depression, dental surgeons, dental students. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: zarnab rizwan email: zarnab2217@hotmail.com article info: received: september 9, 2021 accepted: december 19, 2021 cite this article. zulfiqar k, rizwan z, zia sh, rizwan g, durani ok, raja ub. psychological impact of covid-19 on dental surgeons and students. j islamabad med dental coll. 2021; 10(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n since the start of january 2020, covid-19, has been a serious health risk concerning the wellbeing and welfare of people worldwide. the viral pandemic was first identified in the chinese city of wuhan and was able to spread globally in a couple of months. this highly contagious and fatal disease prompted observable public tension and anxiety. early investigations during the first covid-19 wave of infection showed moderate or extreme psychological impacts of the outbreak on the general population. (1) notwithstanding the psychological impacts of the pandemic on everyone, health care workers were prone to more psychological problems because of their direct contact with infectious patients. (2) among all the healthcare workers, the covid-19 pandemic significantly discouraged the activities of the dental practitioners. (3) dentists, dental students, and other staff are in danger of contracting disease. (4) dental hospitals and clinics are environments where o r i g i n a l a r t i c l e j islamabad med dental coll 2021 234 disease transmission can happen easily. aerosol transmission due to routine dental methods is a potential source of transmission when there is an exposure to high concentrations of aerosols in a moderately shut climate with possible dangers to the dental specialist, dental care staff, and patients. (5) likewise, the utilization of hand pieces or ultrasonic instruments aerosolize patient secretions. the standard defensive measures in every day clinical work are not adequately effective to stop the spread of covid-19. dental surgeons and dental students working closely with patients of covid-19, both symptomatic and asymptomatic are at a much higher risk. (6) dental students are even more vulnerable to contracting covid-19 disease because of their inability, technical inadequacy, and absence of information. psychological conditions of dental students might be influenced due to the high danger of infection. covid-19 pandemic can cause significant degrees of uneasiness in dental students. owing to the disruption of educational activities worldwide, a sense of uncertainty and stress was common among students. dental students were more prone to exhibiting higher levels of anxiety firstly due to possible exposure in their clinical activities and secondly due to disturbed undergraduate educational programs. a study was done on students to examine the psychological effect of academic disruptions; it was shown that student’s anxiety level was increased especially because of interruption of education. (7) the aim of this investigation was to find out the burden of psychological impact of the covid-19 pandemic on dentists and dental students. the findings of this study can help devising effective strategies to alleviate depression, stress and anxiety among health care workers especially dentists and dental students in our region. m e t h o d o l o g y the study was a survey of psychological impact of covid-19 on dental students and dentists working at islamic international dental hospital. it was conducted from february 2021 to july 2021. ethical approval was taken from ethical review board and those that gave verbal consent to being part of the study were asked to fill the questionnaires. a total of 400 questionnaires were sent to students and dental surgeons, however 340 completely filled questionnaires were returned and data was compiled. sample size was calculated by using pmdc statistics of the total population of registered dental surgeons in pakistan till 2019 which was 25000 along with the number of students enrolled in bachelor of dental surgery in islamabad (1500). (8) confidence level was set at 95% with 5% margin of error in the who sample size calculator. the required sample size came out to be 379 which was rounded off to 400 and questionnaires were distributed. questionnaire using the depression anxiety stress scale (dass-21) was used to assess the psychological influence. (9) it is a highly reliable and consistent scale capable of producing results with high validity. data was obtained through google forms from the students and dentists working in the hospital. questionnaire was divided in two sections, demographics and dass (depression anxiety stress scale). a total of 21 questions, based on 3 sub sections of 7 questions each, evaluating depression, anxiety and stress was used up to 4-point likert scale (ranging 0 to 3). scores were summed and grouped according to the guidelines. (10) statistical package for social sciences spss version 23 was used for simple descriptive analysis, anova test was applied to determine whether there is a significant difference in stress scores among dental surgeons/clinical and preclinical year students and pearson’s correlation was applied to determine strength of association. j islamabad med dental coll 2021 235 r e s u l t s out of total sample of 340, 53 (15.58%) were dental surgeons and 84.2% were students. mean age of the participants was 20.77+1.34. 266 (78.2%) of the participants were females, 71(20.9%) were males and 3 (0.9%) participants preferred not to say. most of the participants (90%) were unmarried among the dental surgeons. based on the year of graduation of students, 30.9% belonged to pre-clinical year and 53.5% were from clinical year. table 1 shows the demographic information of the participants. the overall means of stress score, anxiety score and depression were 17.5+5.6, 15.43+5.3 and 16.49+6.2 respectively. 38.8% of the participants had moderate stress, 35.3% were severely anxious and 34.7% of the participants suffered from moderate depression. mean anxiety score among females (15.92+5.3) was more than males (13.41+5.2). mean depression score was 16.6+5.9 and 15.7+6.7 among females and males respectively. mean of stress score was 17.7+5.4 among females and 16.3+6.2 among males. there was a significant difference (p=0.033) in the mean values of depression and stress (p=0.012) among the genders (table 2). the combined scores categorized as severe and extremely severe accounted for 4 and 24 in relation to stress ,66 and 104 in relation to anxiety and 38 and 55 in relation to depression for the pre-clinical and clinical students respectively. (table 3), t-test showed statistically significant difference (p=0.005) in anxiety and stress (p=0.017) score among clinical and preclinical year students (table2). pearson’s correlation among the dimensions of das scale showed that dass was positively and significantly correlated with each other. (table 4) table 1 demographic information of the participants variable percentage % n =340 gender females males preferred not to say 78.2 20.9 0.9 266 71 3 marital status married un married 10 90 34 306 type of under graduate students pre-clinical clinical 30.9 53.5 105 182 type of graduates house-officer fcps/masters 10 5.3 34 19 table 2 mean of dass score of dental surgeons and students variables n=340 mean depression score mean anxiety score mean stress score gender males females 15.7+6.7 16.6+5.9 p=0.033 13.41+5.2 15.92+5.3 p= 0.984 16.3+6.2 17.7+5.4 p=0.012 marital status married un married 14.41+5.65 16.72+6.17 p= 0.433 14.47+5.0 15.53+5.4 p= 0.57 16.38+6.17 17.62+5.55 p= 0.085 type of undergraduate students pre-clinical clinical 17.01+6 16.52+6.3 p=0.389 15.1+4.9 15.9+5.7 p=0.005 17.3+4.9 17.9+6 p=0.017 category students dental surgeons 16.7+6.2 15.3+5.8 p=0.306 15.59+5.4 14.5+4.7 p=0.506 17.7+5.6 16.3+5.3 p=0.404 j islamabad med dental coll 2021 236 table 3 cumulative dass scores of dental surgeons, clinical and pre-clinical students according to dass-21 guidelines. levels stress n= 340 (% of total) anxiety n=340 (%of total) depression n=340 (% of total) preclinical clinical dental surgeons preclinical clinical dental surgeons preclinical clinical dental surgeons normal 32(9.4) 58(17.1) 19(5.6) 9(2.6) 11(3.2) 4(1.2) 15 (4.4) 33(9.7) 9(2.6) mild 23(6.8) 32(9.4) 15(4.4) 10(2.9) 21(6.2) 7(2.1) 15(4.4) 34(10) 12(3.5) moderate 46(13.5) 68(20) 18(5.3) 20(5.9) 46(13.5) 14(4.1) 37(10.9) 60(17.6) 21(6.2) severe 4(1.2) 24(7.1) 1(0.3) 45(13.2) 55(16.2) 20(5.9) 36 (10.6) 45(13.2) 9(2.6) extremely severe 21(6.2) 49(14.4) 8(2.4) 2(0.6) 10(2.9) 2(0.6) combined scores of the levels (severe and extremely severe) 4 24 1 66 104 28 38 55 11 table 4 correlation among stress anxiety and depression in dental surgeons and students correlation among three variables by pearson’s correlation coefficient variables r stress versus anxiety 0.783 p=0.00 stress versus depression 0.848 p=0.00 anxiety versus depression 0.751 p=0.00 p=<0.05 d i s c u s s i o n a recent study was conducted on 338 israeli dentists and hygienists who answered questions about covid 19 related factors and were assessed for psychological distress. the results revealed that dental surgeons are under high pressure and have increased levels of fear and psychological distress during the covid-19 outbreak. (11) according to our study, increased level of depression (83.23%), anxiety (92.9%) and stress (67.94%) were identified. these results are comparable with other researches that have reported the depression and anxiety among dental surgeons from 30 countries in the course of covid-19 outbreak. (12) these studies have suggested increased proportion of individuals experiencing depression, anxiety, and stress. dentists are at a high risk of being exposed to the infectious disease. the fear of being exposed at work at some point of their work hours has affected the intellectual fitness of dentists. it has been reported that dental college students also show significant stress signs all through their training and that they are extra anxious than the general population, displaying higher degrees of depression, obsessive‑compulsive problems, and interpersonal sensitivity than age‑matched norms. (13) our results are also similar to the results of another study that was conducted in israel among dental experts (10) showing high degrees of fear and psychological distress throughout covid-19 outbreak. this can be supported by different studies displaying an unwillingness on the part of dentists to deal with the patients with infectious diseases like hiv and tuberculosis. (14) a high prevalence of stress among medical students is concerning since it may damage students' behavior, learning, and ultimately patient care after graduation. (15) it has been stated that dental education is more stressful than medical education. (16) a study conducted in saudi arabia revealed that 55.9%, 66.8% and 54.7% of the respondents had experienced depression, anxiety and stress respectively. (17) another study conducted in makkah also showed that there was elevated level of depression (69.9%), anxiety (66.4%) and stress (70.9%) among dental students. (18) nevertheless, these elevated degrees of depression, anxiety and stress may be attributed to the stress exerted on dental college students during the educational time as they try to attain suitable grades, correctly meet j islamabad med dental coll 2021 237 the course requirement, and constantly perform at their best. (18) stress levels amongst dental students are higher as compared to the general population, and female students suffer more than adult males. (17) according to our study, the depression, anxiety and stress level in female participants was higher (67%, 73.9% and 55%) than male participants (15.3%, 18.2% and 12%). our findings are similar to other studies done on mental health status of dental students in several other countries. our study results are similar to those conducted in ksa and turkey during covid19, which also found that female participants showed elevated levels of depression, anxiety and stress score as compared to male participants. (20, 21,22) it has been reported that clinical factors, together with technical abilities, are the reasons of maximum stress for females. (20) previous research suggests that females are more expressive and responsive towards stimuli as compared to males, which may additionally account for the variations.(22) when marital status was examined, married participants showed lower depression having a mean value of 2.41+1.04, anxiety having mean value of 3.29+1.19 and stress showing a mean value of 2.06+0.95 as compared to unmarried participants having mean scores 2.88+1.1, 3.59+1.16 and 2.26+1.0 for depression, anxiety and stress respectively. our results are similar to the results of madhan et al study (23) and contrary to the results of study done in india in which participants who were married showed more symptoms of these emotional states. this could be because there is increased level of responsibility in balancing private and professional life simultaneously. (24) in our study when academic years were assessed, clinical year students showed more stress (p=0.023) as compared to the students who were in pre clinical years. our results are in favor with the other studies which indicate that clinical years are more stressful than non-clinical years (12) . patients; being late or absent for his or her appointment can also increase the level of stress. final year students, as they are closer to their graduation, might have felt that this pandemic would affect their study process. the limitation of this study is that it focused on dentists and dental students belonging to one institute and hospital, further research spread out across more hospitals can be done to get a better representation of the community. c o n c l u s i o n there is increased level of depression, anxiety and stress among dental students amidst the covid-19 pandemic. among the students, depression is significantly more in preclinical while anxiety and stress is more in clinical students. also, females are psychologically more affected. r e f e r e n c e s 1. wang c, pan r, wan x, tan y, xu l, ho cs, et al. immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. int. j. environ. res. public health. 2020;17(5):1729. doi: 10.3390/ijerph17051729 2. nguyen lh, drew da, graham ms, joshi ad, guo cg, ma w, et al. risk of covid-19 among front-line health-care workers and the general community: a prospective cohort study. the lancet public health. 2020;5(9):e47583.doi:10.1016/s24682667(20)3016 4-x 3. consolo u, bellini p, bencivenni d, iani c, checchi v. epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia. int. j. environ. res. public health. 2020;17(10):3459. doi: 10.3390/ijerph17103459 4. yildirim tt, kaya fa, kaya ca. assessment of hepatitis b vaccination status of students of faculty of dentistry. international dental research. 2017;7(3):46-53. doi: 10.5577/intdentres.2017.vol7.no3.1 5. ge zy, yang lm, xia jj, fu xh, zhang yz. possible aerosol transmission of covid-19 and special precautions in dentistry. j. zhejiang univ. sci b. 2020;21(5):361-8. doi: 10.1631/jzus.b2010010 6. meng l, hua f, bian z. coronavirus disease 2019 (covid-19): emerging and future challenges for j islamabad med dental coll 2021 238 dental and oral medicine. j. dent. res. 2020;99(5):481-7. doi: 10.1177/0022034520914246 7. sahu p. closure of universities due to coronavirus disease 2019 (covid-19): impact on education and mental health of students and academic staff. cureus. 2020;12(4). doi: 10.7759/cureus.7541 8. gov.pk. [cited 2021 dec 17]. available from: https://www.pbs.gov.pk/content/registered-dentaldoctors-year-registration 9. ada urges dentists to heed april 30 interim postponement recommendation, maintain focus on urgent and emergency dental care only. april , 2020. 10. osman a, wong jl, bagge cl, freedenthal s, gutierrez pm, lozano g. the depression anxiety stress scales-21 (dass-21): further examination of dimensions, scale reliability, and correlates. j clin psychol. 2012 ;68(12):1322-38. doi: 10.1002/jclp.21908. 11. shacham m, hamama-raz y, kolerman r, mijiritsky o, ben-ezra m, mijiritsky e. covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel. int. j. environ. res. public health. 2020;17(8):2900. doi: 10.3390/ijerph17082900 12. ahmed ma, jouhar r, ahmed n, adnan s, aftab m, zafar ms, et al. fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak. int. j. environ. res. public health. 2020;17(8):2821. doi: 10.3390/ijerph17082821 13. abu‐ghazaleh sb, rajab ld, sonbol hn. psychological stress among dental students at the university of jordan. j dent educ. 2011;75(8):1107-14. pmid: 21828305 14. farhanah aw, sarimah a, jafri malin a, hasnan j, siti suraiya mn, wan mohd zahiruddin wan m, et al. updates on knowledge, attitude and preventive practices on tuberculosis among healthcare workers. malays j med sci. 2016;23(6):25-34. doi: 10.21315/mjms2016.23.6.3 15. abdulghani hm, alkanhal aa, mahmoud es, ponnamperuma gg, alfaris ea. stress and its effects on medical students: a cross-sectional study at a college of medicine in saudi arabia. j health popul nutr. 2011;29(5):516-22. doi: 10.3329/jhpn.v29i5.8906. 16. prinz p, hertrich k, hirschfelder u, de zwaan m. burnout, depression and depersonalisation-psychological factors and coping strategies in dental and medical students. gms z med ausbild. 2012;29(1). doi: 10.3205/zma000780. 17. basudan s, binanzan n, alhassan a. depression, anxiety and stress in dental students. i int j med educ.2017;8:179. doi: 10.5116/ijme.5910.b961 18. aboalshamat k, hou x-y, strodl e. psychological wellbeing status among medical and dental students in makkah, saudi arabia: a cross-sectional study. medical teacher. 2015;37(sup1):s75-s81. doi: 10.3109/0142159x.2015.1006612 19. özdede m, sahin s. views and anxiety levels of turkish dental students during the covid-19 pandemic. open j. stoma. 2020;73(3):123-8. 21. hakami z, khanagar sb, vishwanathaiah s, hakami a, bokhari am, jabali ah, et al. psychological impact of the coronavirus disease 2019 (covid‐19) pandemic on dental students: a nationwide study. j dent educ. 2021;85(4):494-503. doi: 10.1002/jdd.12470 22. ersan n, dölekoğlu s, fişekçioğlu e, i̇lgüy m, oktay i. perceived sources and levels of stress, general selfefficacy and coping strategies in preclinical dental students. psychol health med. 2018;23(5):567-577. doi: 10.1080/13548506.2017.1384844. 23. madhan b, rajpurohit as, gayathri h. mental health of postgraduate orthodontic students in india: a multi‐institution survey. j dent educ. 2012;76(2):2009. doi: 10.1002/j.0022-0337.2012.76.2.tb05247.x 24. sravani a, doshi d, kulkarni s, reddy p, reddy s. depression, anxiety, and stress among undergraduate dental students in hyderabad city, telangana, india: a cross-sectional study. j indian assoc public health dent. 2018;16(1):26. doi: 10.4103/jiaphd.jiaphd_10_17 j islamabad med dental coll 2022 114 open access reference range of amniotic fluid index (afi) in primigravidae with gestational age from 37 to 42 weeks in a local (pakistani) population. abdur raheem1, rayyan pervez2, raheela aqeel3, sanam soomro4, aisha jang5, khurram khalid bhinder6 1consultant radiologist, imaging department, dorset country hospital 2consultant radiologist, radiology department, salisbury district hospital. 3,5consultant radiologist, radiology department, shifa international hospital, islamabad, pakistan. 4consultant radiologist, radiology department, dr. salman al habib medical group, ksa. 6resident radiology, radiology department, shifa international hospital, islamabad, pakistan. a b s t r a c t background: amniotic fluid index (afi) is a key element in fetal biophysical profile that predicts pregnancy outcome especially near term in primigravidae. the objective of the study was to determine a reference range of afi in primigravidae of a local population having gestational age from 37 to 42 weeks. methodology: this study was carried out from january 2019 to december 2019 after approval from institutional review board and ethical committee at shifa international hospital, islamabad, pakistan. applying inclusion and exclusion criteria, a sample of 272 was selected. afi was calculated for each subject using ultrasound and recorded on a data collection sheet. for the sake of simplicity and clinical relevance, the population was further stratified as term pregnancy (gestational age 37-39 weeks) and postdates pregnancy (40-42 weeks). the reference range of afi was then calculated using mean ±two standard deviations. results: the reference range of afi for gestational age of 37-42 weeks (population as a whole) was 6.817.2 cm. for term pregnancy, it was 7.517.5 cm, and for postdate pregnancy, it was 5.8 to 15.4 cm. conclusion: the reference range of afi for gestational age of 37 to 42 weeks in primigravida women was 6.8 to 17.2 cm. there is a decreasing trend in afi as pregnancy advances from term to postdate. keywords: amniotic fluid index, gestational age, primigravida, reference range. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5data analysis; 6manuscript editing. correspondence: raheela aqeel email: rahilakhan119@hotmail.com article info: received: february 25, 2021 accepted: march 17, 2022 cite this article. raheem a, pervez r, aqeel r, soomro s, jang a, bhinder k k. reference range of amniotic fluid index (afi) in primigravidae with gestational age from 37 to 42 weeks in a local (pakistani) population. j islamabad med dental coll. 2022; 11(2):114-119. doi: https://doi.org/10.35787/jimdc.v11i2.686 funding source: nil conflict of interest: nil i n t r o d u c t i o n measurement of amniotic fluid is considered an integral part of routine antenatal visits, especially in the last trimester and in particular when gestation is at term, where any change in volume or composition of amniotic fluid would significantly alter the outcome of pregnancy., hence amniotic fluid assessment should be done properly because of its clinical significance for the fetus and mother. [1] there are three commonly used ultrasound o r i g i n a l a r t i c l e j islamabad med dental coll 2022 115 techniques for volume measurements of amniotic fluid. one is the subjective method, in which the observer uses his or her experience in deciding about the adequacy of fluid. the other two methods are objective, namely single deepest pocket (sdp) and amniotic fluid index (afi), and results are equivocal as to which of these is superior in terms of accuracy.[2,3] however, in our setup afi is the preferred technique used. in the single deepest pocket method, the operator places the probe on the abdomen of the pregnant patient at a right angle to the couch and searches for a pocket having maximum depth. the afi is a four-quadrant technique in which the four deepest pockets are identified by the examiner after placing the probe at a right angle to the couch. these values are added together and the summed value is called afi, measured in centimeters. there should be no fetal part or umbilical cord while measuring the deepest pocket. the value of afi does not remain the same throughout pregnancy but changes on weekly basis as a result of the increasing maturity of the fetus and placenta. similarly, afi is said to be variable among different populations with different geographical and racial backgrounds. [4] based on the changing volume of amniotic fluid as the pregnancy progresses, the assessment at every stage in pregnancy has its importance but the period of utmost clinical significance is from 37 to 42 weeks, as major decisions about feto-maternal health and mode of delivery are taken into consideration at this age of gestation. this carries more weight when it comes to primigravida, as the current pregnancy’s outcome would affect the subsequent pregnancies. therefore, the accurate decision of mode of delivery based on the accurate reference of afi is vital. moreover, considering the effect of cultural and geographical variations on medical practice, some obstetricians show reluctance in following the published international afi ranges and are therefore lacking confidence in their decisions. to our knowledge, no reference range of afi has been published so far in the literature that is based on primigravidae only. hence, we believe that this study would be of great help to our obstetricians in managing their cases efficiently and confidently. m e t h o d o l o g y an observational study was carried out in the department of radiology, at shifa international hospital islamabad, from january 2019 to december 2019. a total of 272 subjects were enrolled in the study based on sample calculation by the who sample size calculator using a confidence interval of 95% and a margin of error of 4.75%. all primigravidae (regardless of their age) with normal singleton pregnancy, of gestational age 37 to 42 weeks were included in the study and were followed till their delivery to make sure they end up in normal vaginal delivery. cases excluded were those; with multiparity and previous abortions (to exclude confounding on afi if any), foreign nationals, twin pregnancy, fetal congenital anomaly, a case with intrauterine growth retardation, and small or large for gestational age. cases ending up in caesarian sections and those cases with maternal risk factors such as anemia, hypertension, diabetes, cardiac disease, chronic respiratory disorders, maternal jaundice, and kidney diseases were also excluded. approval from the institutional review board and ethical committee at shifa international hospitals, islamabad, pakistan was sought. 3.5 mhz curved transducer of xario model ssa-660a (toshiba modified system) apparatus was used. scans were done on these patients and were reviewed by the consultants to confirm the findings. statistical analysis was performed using spss (version 16). the gestational age was split into two groups, one from 37 to 39 weeks and the other from 40 to 42 weeks. the mean and standard deviation of afi for these groups were calculated. j islamabad med dental coll 2022 116 r e s u l t s the mean age of the population was 25.6 years with an age range of 17 to 41 years. fourteen percent of subjects (n=39) had an age of 27 years. a large number of subjects were falling in age group 2 (2328 years) forming 60.3% (n=164) of the total population. [table i]. the mean gestational age was 38.4 weeks with a range of 37 to 42 weeks. maximum number of pregnancies were at a gestational age of 37 weeks, comprising 29% (n=79) of the study population followed by those with a gestational age of 38 weeks [graph ii]. grouping the subjects based on gestational ages, group 1 (37 to 39 weeks) was noted to have 209 participants as opposed to 63 in gestational age group 2 [table ii]. the mean afi for gestational age of 37 to 42 weeks (studied population as one group) was 12.0 cm with a standard deviation (sd) of 2.6 and a reference range of afi (using ±2sd) as 6.8 to 17.2 cm. when the population was split into two groups, the mean afi of gestational age 37 to 39 weeks (group 1, denoting gestation at term) was found to be 12.5 cm and sd of 2.5 hence giving a reference range of 7.5 to 17.5 cm whereas the postdate pregnancies (group 2, denoting gestational age 40 to 42 weeks) had mean afi of 10.6 cm and reference range of 5.8 to 15.4 cm using sd of 2.4 [table ii]. the reference range of afi for each maternal group is as mentioned in table iii. group 4 and group 5 were outliers as there were only a few subjects in the former and one in later. figure 1 ultrasound image showing afi taken in four different quadrants by taking maximum vertical pocket excluding fetal parts and placental tissue. table :ii frequency of subjects according to gestational age no. gestational age group frequency percent mean afi (cm) std. deviation ref. range (cm). 1 group 1 ( 37 to 39 weeks) 209 76.8 12.5 2.5 7.5 17.5 2 group 2 ( 40 to 42 weeks) 63 23.2 10.6 2.4 5.8 15.4 table i: frequency of different age groups no. age groups no. of pregnant women percent 1 group 1 (17 to 22 years) 60 22.1 2 group 2 (23 to 28years) 164 60.3 3 group 3 (29 to 34years) 43 15.8 4 group 4 (35 to 40years ) 4 1.5 5 group 5 ( above 40 years) 1 0.4 total 272 100.0 j islamabad med dental coll 2022 117 d i s c u s s i o n the amniotic fluid index is a commonly used technique worldwide because of its noninvasive nature and better correlation with the actual amount of amniotic fluid. with the notable differences in normal afi ranges across the globe, obstetricians prefer to stick to their local values of afi when deciding the mode of delivery. the study addresses the different afi ranges for primigravida only, which we think is unique to this study. secondly, we expect the results to provide a base for future studies if the effects of maternal age and parity on afi are to be explored. gestational age affects the amniotic fluid volume because of certain anatomical and physiological changes in the fetus and mother. from a delivery perspective, the volume of amniotic fluid generally becomes significant around 37 weeks of gestation and beyond this gestational age. hence amniotic fluid volume needs to be well understood at the gestational age of 37 weeks and onward in the third trimester. as a common occurrence during the progress of pregnancy, the afi falls, hence its accurate record-keeping along with other denominators of the biophysical profile is important. for example, gabbay-benziv et al have seen a drop of median afi down to 13.3 cm at 40 weeks gestational age from 16.4 cm at 22 weeks of gestation. [5] kirshenbaum et al have found a similar outcome in centiles. [6] we find these values remarkably different than ours, of term pregnant women (7.5 to 17.5 cm), but there are certainly plausible explanations for it. one possibility can be geographical variation which like other medical conditions also affects the amniotic fluid volume. another reason may be of parity of pregnant women, which has not been given enough attention in international literature. there is no proper segregation of the studied population into multigravida and primigravida which makes us different as our population is entirely of primigravida. the other reason can be sample size, a variable number of subjects in different age groups, and gestational age groups. for example, in our study 79 pregnant women had a gestational age of 37 weeks and only one pregnant woman had a gestational of 42 weeks. this variation in the frequency of study population groups might affect the variable afi range. last but not the least, is standard deviation, using two standard deviations to calculate the range will be different than that obtained with one standard deviation. luntsi et al. have also described afi values in normal northern nigerian women from gestational age of 22 to 39 weeks with 206 as the sample size of the study. [7] the calculated afi range in this study is 19.84 ± 3.64 cm. the result is somewhat similar to our population keeping in view that the said study has no postdate pregnancies enrolled. our pregnant women population was grouped into two based on their gestational ages; group1 subjects were with gestational age from 37 to 39 weeks, whereas group 2 comprised of subjects having a gestational age of 40 weeks and onwards. this division was considered essential in our study as there is a difference in the management plan for pregnancies with gestation at table iii. reference range of afi for each maternal group n o age group (years) mean afi (cm) std. deviation ref. range (cm) 1 group 1 (17 to 22) 11.8 2.4 7-16.6 2 group 2 (23 to 28) 12.1 2.6 6.9-17.3 3 group 3 (29 to 34) 12.0 2.8 6.4-17.6 4 group 4 (35 to 40) 11.8 4.2 3.4-20.2* 5 group 5 ( 40 plus) 11.0 1 na* j islamabad med dental coll 2022 118 term and those with postdate pregnancies. also, it is known that amniotic fluid volume regresses with advancing gestational age beyond 36 weeks. hence, we cannot consider the afi reference range of term gestation for those with postdate pregnancies as this may potentially lead to unnecessary interventions. the effect of gravidity on afi has not been thoroughly investigated in the literature, as the acquired reference ranges in different studies do not demarcate between primigravidae or multigravida. this would need further exploration by a comparative study of afi between primigravida and multigravida keeping in view the lesser degree of confounding; for example, age, ethnicity, and gestational age. no attempts have been made in literature wherein different pregnant women’s afi was checked in different age groups. in our study, we separated the subjects into five subgroups based on their ages (of which the youngest was 17 and the eldest was 41 years old), and certain observations were made as follows. group 1 had individuals with an age range of 17 to 22 years and showed a mean afi of 11.8 cm which is not significantly changed then (12.1 cm) that of group 2 participants comprised of the maternal age range of 23 to 28 years. the third group (maternal age range of 2934 years) had a mean value of 12 cm which is almost identical to the preceding group. moreover, the population with maternal age greater than 34 was divided into two more groups – one group with maternal age 35 to 40 years and another with age more than 40 years showing a mean of 11.8 and 11cm respectively, which do not differ significantly. hence, we can postulate that maternal age might have not that profound effect on the afi considering the fact of unequal subjects in these age-wise groups. for instance, 164 out of 272 were in the age group 2 (23-28 years) whereas 60 individuals were from age group 1 (17 to 22 years). this can also be confirmed in future studies by taking an equal number of subjects in these age groups. according to hughes et al, to be accurate in calculating abnormal amniotic fluid volume, our normal reference should be accurate as well. [3] also, determining the correct estimation of afi is important as it has a vital role in depicting fetal outcomes. [8,9] there is a tendency for overestimation of the fetal weight in the case of oligohydramnios and polyhydramnios. [10, 11] the afi determined in the third trimester can be used as a means to evaluate amniotic fluid levels [12]. oligo and polyhydramnios can be established using defined values in certain populations and when correlated with doppler ultrasound, can predict adverse fetal outcomes associated with afi derangements [13,14,15]. having said this, afi values must always be correlated with clinical outcomes [16, 17] and the decision to initiate treatment [18]. the limitations in our study are not establishing any proper afi reference range for the age group 35 years and above as limited number of cases were registered in this age group. secondly, this study does not explore difference in amniotic fluid reference range between primigravida and multigravida . c o n c l u s i o n by and large, we were able to achieve a reference range of afi for our population. we wanted to target (primigravidae with a gestational age of 37 to 42 weeks) which is 6.8 to 17.2 cm and is fairly coherent to the one published in the literature. having said that we hope this study would bring confident decision making by our obstetricians (both at regional and national levels) in managing their dayto-day cases. e t h i c a l s t a t e m e n t the patient signed an informed consent form, as per the ethical guidelines of the hospital board. j islamabad med dental coll 2022 119 r e f e r e n c e s 1. cho hc, sun s, hyun cm, kwon jy, kim b, park y, et al. automated ultrasound assessment of amniotic fluid index using deep learning. medical image analysis. 2021 apr 1; 69:101951. 2. kehl s, schelkle a, thomas a, puhl a, meqdad k, tuschy b, et al. single deepest vertical pocket of the amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (safe trial), a multicenter openlabeled randomized controlled trial. ultrasound obstet gynecol. 2016 jun;47(6):674-9. 3. hughes ds, magann ef, whittington jr, wendel mp, sandlin at, ounpraseuth st. accuracy of the ultrasound estimate of the amniotic fluid volume (amniotic fluid index and single deepest pocket) to identify actual low, normal, and high amniotic fluid volumes as determined by quantile regression. journal of ultrasound in medicine. 2020 feb;39(2):373-8. 4. agwu ej, ugwu ac, shem sl, abba m. relationship of the amniotic fluid index (afi) in the third trimester with fetal weight and gender in a southeast nigerian population. acta radiol open. 2016;5(8):2058460116652651. 5. gabbay-benziv r, maor-sagie e, shrim a, hallak m. determination of reference values the third-trimester step amniotic fluid index: a retrospective analysis of a large cohort of pregnancies with comparison to previous nomograms. j matern fetal neonatal med. 2022; 35(1): 134-140. 6. kirshenbaum m, ziv-baran t, katorza e. amniotic fluid index measurements in the second and third trimester and correlation to fetal biometric parametersnew reference based on big retrospective data. j matern fetal neonatal med. 2021 sep 1:1-5. 7. luntsi g, burabe fa, ogenyi pa, zira jd, chigozie ni, nkubli fb, et al. sonographic estimation of amniotic fluid volume using the amniotic fluid index and single deepest pocket in a resource-limited setting. j med ultrasound. apr-jun 2019;27(2):63-68. 8. moin s, mushtaq r, iftikhar b, khan m, akram na, fatima s. low amniotic fluid index (afi) as a predictor of adverse fetal outcomes in the third trimester of pregnancy. pakistan armed forces medical journal. 2020 jan 27;70(suppl-1): s69-73. 9. jharwal r, meena s, meena v, meena ak. hospitalbased prospective study to determine the relationship between amniotic fluid volume as determined by ultrasound studies and perinatal outcome. international journal of health and clinical research. 2021 jan 27;4(2):199-201. 10. karahanoglu e, altinboga o, akpinar f, gultekin ib, ozdemirci s, akyol a, et al. the effect of the amniotic fluid index on the accuracy of ultra sonographicestimated fetal weight. ultrasound q. 2017 jun;33(2)148-152. 11. janas p, radon-pokracha m, nowak m, staron a, wilczynska g, brzozowska m, et al. effect of oligohydramnios on the accuracy of sonographic fetal weight estimation in at term pregnancies. taiwanese journal of obstetrics and gynecology. 2019 march;58(2): 278-281. 12. anzaku sa, gbala m, dah tw, didamson gd. third trimester reference values of amniotic fluid index in a group of healthy nigerian women in jos, nigeria. thai journal of obstetrics and gynecology. 2018 dec 28:255-61. 13. onwuzu sw, eze cu, ugwu lc, abonyi oe, adejoh t. ultrasound biometry of a normal human amniotic fluid index in a nigerian population. radiography. 2016 may 1;22(2):e86-92. 14. talukdar rk, deka n, rahman m. clinical stud regarding the significance of doppler & modified biophysical profile in the management of post dated pregnancy. sch int j obstet gynec. 2019;2(11):277283. 15. yadav p, basnet t, yadav sp. maternal and perinatal outcome in borderline oligohydramnios: a hospital-based study. international journal of medical science and diagnosis research. 2021 jan 9;5(1). 16. ali ma. assessment of amniotic fluid volume in sudanese pregnant women in second and third trimester by ultrasound imaging (doctoral dissertation, sudan university of science and technology). 17. mishra a, neupane rp, prasad pn, thakur ak. perinatal outcomes of pregnancies with borderline versus normal amniotic fluid index–a prospective study. journal of general practice and emergency medicine of nepal. 2020 jun 15;7(9):21-5. 18. zafar h, naz m, fatima u, shahzad u, fatima a, yasmeen a. oral versus intravenous maternal hydration in isolated third-trimester oligohydramnios. international journal of research in medical sciences. 2020 oct;8(10):3449. 208 j i m d c 2 0 1 7 208 open access f u l l l e n g t h a r t i c l e use of ondansetron for prevention of spinal induced hypotension rabia baig 1, ammar ali shah 2, tassaduq khurshid 3, latif abid 4, zubair tariq 5 1 post graduate trainee, holy family hospital rawalpindi 2 senior registrar holy family hospital. rawalpindi 3 assistant professor anaesthesia, isra medical college 4 assistant professor anaesthesia, rawalpindi medical college 5 consultant anaesthetist, nhs england a b s t r a c t objective: to compare the efficacy of prophylactic administration of ondansetron before induction of spinal anesthesia with placebo, in preventing spinal induced hypotension. patients and methods: this randomized control trial was carried out at holy family hospital, rawalpindi from 29 april 2015 till 28 october 2015. a total of 106 patients were enrolled in the study. patients in group a, received 6 mg ondansetron. patients in group b received normal saline. mean arterial pressure (map) and heart rate (hr) were recorded every 5 minutes after performing spinal anesthesia. the study drug was considered efficacious if absence of hypotension for 20 minutes was recorded after inducing spinal anaesthesia. data was analyzed using spss 17. results: hypotension occurred in 7.5% cases in ondansetron group compared to 28.3% in normal saline group (p=0.005). conclusion: ondansetron is effective in preventing spinal induced hypotension. key words: bupivacaine, hypotension, ondansetron, spinal anaesthesia. author`s contribution 1 conception, synthesis, planning of research and manuscript writing 2 interpretation and discussion 3 data analysis, interpretation 4,5 manuscript writing, active participation in data collection address of correspondence ammar ali shah email: ammarali05@gmail.com article info. received: june 21, 2017 accepted: 2017 cite this article. baig r, shah aa, khurshid t, abid l, tariq z. use of ondansetron for prevention of spinal induced hypotension. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n spinal anesthesia remains a popular method of anesthesia for a wide range of surgeries due to its efficacy, simplicity, safety, advent of newer drugs with reduced side effects and more benefits for certain patient populations.1 its numerous advantages include blockade of the surgical stress response, decreased intraoperative blood loss and transfusion requirements, lower incidence of venous thromboembolism and reduced morbidity and mortality in high-risk patients.2 however, it is also frequently associated with undesirable effects such as hypotension, bradycardia, and shivering.3 hypotension is the most common side effect of spinal anesthesia with a reported incidence as high as 33% in non-obstetric and 60% in obstetric, non-laboring patients.error! bookmark not defined. symapthectomy induced decreased systemic vascular resistance and reduced preload secondary to vasodilatation in the lower body are the major mechanisms for this hypotension.3 relative dominance of parasympathetic system, activation of bezold jarish reflex (bjr) and increased baroreceptor activity are also contributory factors.error! bookmark not defined. in the setting of decreased blood volume, serotonin may be an important factor inducing the bezold jarisch reflex via 5-ht3 receptors located in intracardiac o r i g i n a l a r t i c l e 209 j i m d c 2 0 1 7 209 vagal nerve endings, leading to bradycardia and hypotension.5 hemodynamic changes after spinal block are usually benign, but they may lead to serious consequences such as myocardial ischemia and increased stroke risk in certain population groups.6 in caesarean sections, hypotension results in decreased uteroplacental blood flow, detrimental effects on the fetus and maternal nausea vomiting.error! bookmark not defined. various strategies employed to prevent spinalinduced hypotension include fluid preloading and coloading, prophylactic administration of vasopressors e.g. epinephrine, trendelenburg positioning, use of lower dose of bupivacaine for subarachnoid block.error! bookmark not defined. administering fluids, vasopressors and anticholinergics for the treatment and prevention of hypotension and bradycardia can result in fluid overload, hypertension and tachycardia, which may be poorly tolerated in elderly and coronary artery disease patients.7 furthermore, administration of vasoconstrictors may have adverse effects on uterine blood flow in pregnant women. ondansetron, a selective 5-hydroxytryptamine3 (5-ht3) receptor antagonist, is an effective antiemetic drug used for the prevention and treatment of chemotherapy induced, intraoperative and postoperative nausea and vomiting.8 prophylactic administration of ondansetron has been reported to have a perioperative anti-shivering effect in patients under anesthesia. recently, it has also been demonstrated to be effective in preventing spinal induced hypotension in multiple studies, possibly by preventing serotonin-induced bezold-jarisch reflex (bjr), suppressing venodilatation and augmenting venous return.9 in a study conducted in iran by marashi et al, 12 (17%) patients in the control group had map (mean arterial pressure) < 80 mm hg and required vasopressors compared to 0 patients in ondansetron groups. (p = 0.04).3 owczuk r. et al demonstrated that the minimum diastolic and mean blood pressure values obtained over a 20-minute observation period after spinal anesthesia were significantly higher in the ondansetron group compared to the control group.9 however, none of these studies has been conducted in pakistan. the basic aim of our study was to look for the effect of prophylactic ondansetron administration on spinal induced hypotension in our population, so that ondansetron if found to be effective, may be routinely used for the prevention of hypotension after spinal anesthesia in elective surgeries. p a t i e n t s a n d m e t h o d s this randomized control trial was carried out at holy family hospital, rawalpindi from 29 april 2015 till 28 october, 2015. a total of 106 admitted elective patients were included in the study. american society of anesthesiologist’s classification i and ii between the ages of 20-50 years who presented for elective urologic, orthopedic or gynecologic surgeries were included in the study. exclusion criteria included, patient refusal or any contraindications to spinal anesthesia, any allergy to ondansetron or local anesthetics and comorbid conditions like hypertension, coronary artery disease or other cardiovascular diseases, diabetes mellitus, pulmonary, hepatic or renal diseases. patients receiving selective serotonin reuptake inhibitors or migraine medications or obesity bmi >35 were also excluded from the study. after obtaining approval from hospital ethical committee and written informed consent, patients were recruited according to selection criteria. all patients were assessed a day before surgery for anesthesia fitness. patients were prepared by fasting (8 h for solid foods, 4 hours for clear fluids). patients were randomly divided into two equal groups (group a and group b) by computer-generated random numbers. on arrival to the operating room, standard monitor was applied to all patients, including pulse oximeter, electrocardiogram and noninvasive arterial blood pressure. oxygen was delivered via a venturi facemask at a rate of 4 l/min. an 18-gauge intravenous catheter was placed and patients received 5 ml/kg lactated ringer solution over 15 minutes before spinal anesthesia. then patients in group-a was given 6 mg ondansetron diluted in normal saline to 20 ml. the patients in the control group (group-b) received 20 ml normal saline. in both groups, solutions were infused over 5 minutes just before performing spinal anesthesia. all solutions were prepared by a resident of anesthesiology who was not involved in patient’s management or data collection. baseline parameters (including heart rate, map) were recorded 5 minutes prior to induction of spinal anesthesia. subarachnoid block was performed in the lateral position with a 25-gauge needle inserted by midline approach into the l3-4 interspace. after ensuring the correct position of the needle, 15 mg of 0.75% hyperbaric 210 j i m d c 2 0 1 7 210 bupivacaine was injected. patients were immediately placed in the supine position after spinal block. the upper level of sensory blockade was evaluated by pinprick test from caudal to rostral direction at 5-min intervals up to 20 minutes. map and hr were recorded every 5 minutes up to 20 minutes by an anesthesiologist blinded to the study groups. if map dropped <80 mm hg or decreased more than 20% from baseline, 50 micrograms intravenous phenylephrine was given, and repeated if necessary. significant bradycardia (heart rate < 50 beats/min) accompanied by hypotension was treated with 0.5 mg of intravenous atropine. data was collected on a standardized performa and analyzed using spss version 17. mean±sd was calculated for quantitative variables like age, weight, bmi, and map. qualitative variables like gender and hypotension were expressed as frequencies and percentages. chi-square test was used to compare the incidence of hypotension in the two groups. effect modifiers like age, gender and indication for surgery were controlled by stratification. post stratification chi -square test was applied. p value <0.05 was considered statistically significant. r e s u l t s demographic characteristics of both group have been given in table 1. hypotension occurred in 17.92% patients in our study. in the ondansetron group, hypotension was observed in 7.5% of cases. in the normal saline group, 28.3% of patients had hypotension. frequency of hypotension was significantly lower in the ondansetron group as compared to placebo group (table 2). there was no significant difference in the map of both groups at all times (table 3). regarding gender, among females’ frequency of hypotension was lower in the ondansetron group as compared to placebo but the difference was not statistically significant among males (table 4). table 1: comparison of demographic characters between two groups (n=106) variables ondansetron group (n=53) placebo group (n=53) p-value age (years); mean±sd 34.45 ± 1.24 34.98 ± 0.96 0.10 weight (kg); mean±sd 65.15 ± 1.37 72.58 ± 1.20 0.16 bmi (kg/m2); mean±sd 23.99 ± 0.44 25.97 ± 0.48 0.48 gender; n (%) male female 27(44) 26(58) 34(56) 19(42) 0.16 table 2: frequency of hypotension between ondansetron and placebo groups groups hypertension yes no p-value n n(%) n n(%) ondansetron 4 7.5 49 92.5 .005 placebo 15 28.3 38 71.7 table 3: mean arterial pressure in ondansetron and placebo groups variable ondansetron group (n=53) mean±sd placebo group (n=53) mean±sd p-value map at baseline (5 minutes before spinal anesthesia) 106.28 ± 0.98 104.54 ± .96 0.94 map 5 minutes after spinal anesthesia 97.77 ± 0.94 93.17 ± 1.44 0.08 map 10 minutes after spinal anesthesia 93.77 ± 0.94 89.51 ± 1.28 0.20 map 15 minutes after spinal anesthesia 90.26 ± 0.81 85.92 ± 1.15 0.31 map 20 minutes after spinal anesthesia 86.74 ± 0.75 82.17 ± 0.99 0.07 211 j i m d c 2 0 1 7 211 there was statistically significant difference in the frequency of hypotension between ondansetron and placebo groups in urologic surgeries, but the difference between the two groups was insignificant in orthopedic and gynecologic surgeries (table 5). difference in frequency of hypotension was also statistically significant between ondansetron and placebo groups in patients belonging to 20-40 years of age, but the difference was insignificant in age group 41-50 years (table 6). table 5: comparison of hypotension between ondansetron and placebo groups stratified by indication for surgery (n=106) indications for surgery groups hypotension p-value yes n(%) no n(%) orthopedic ondansetron group (n=22) 2(9) 20(91) 0.06 placebo group (n=22) 7(32) 15(68) urologic ondansetron group (n=20) 0(0) 20(100) 0.03 placebo group (n=20) 4(20) 16(80) gynaecologic ondansetron group (n=11) 2(18) 9(82) 0.34 placebo group(n=11) 4(36) 7(64) table 6: comparison of hypotension between ondansetron and placebo groups stratified by age of patients age groups (years) groups hypotension p-value yes n(%) no n(%) 20 – 30 ondansetron group (n=19) 0(0) 19(100) 0.012 placebo group (n=14) 4(29) 10(71) 31 – 40 ondansetron group (n=19) 1(5) 18(95) 0.029 placebo group (n=25) 8(32) 17(68) 41 – 50 ondansetron group (n=15) 3(20) 12(80) 0.924 placebo group (n=14) 3(21) 11(79) d i s c u s s i o n it is frequently observed that spinal anesthesia produces hemodynamic effects. the most frequent of these is hypotension and bradycardia. hypotension occurs as a result of vasodilatation secondary to sympathetic blockade. sympathetic blockade spreads two segments higher than the sensory blockade, which in turn spreads two segments higher than the motor blockade. vasodilatation causes decrease in systemic vascular resistance and central venous pressure.9-12 the same mechanism can sometimes lead to bradycardia. main causes of bradycardia are shift in cardiac autonomic balance toward the parasympathetic system, activation of left ventricular mechanoreceptors from a sudden decrease in left ventricular volume (bezold-jarisch reflex) (bjr). it is suggested by pharmacological and animal studies that an important factor in initiating the bjr is 5 ht (serotonin) and blockade of 5-ht3 receptor can lead to attenuation of this reflex.6 it was shown by previous studies that ondansetron 4 mg of ondansetron administration has been occasionally used to decrease maternal hypotension and nausea.9 spinal anesthesia is the preferred anesthetic technique table 4: comparison of hypotension between ondansetron and placebo groups stratified by gender (n=106) gender groups hypotension p-value yes n(%) no n(%) male ondansetron group (n=27) 2(7) 25(93) 0.09 placebo group (n=34) 8(24) 26(76) female ondansetron group (n=26) 2(8) 24(92) 0.02 placebo group (n=19) 7(37) 12(63) 212 j i m d c 2 0 1 7 212 for caesarean section as it is simple, safe, fast and reliable technique could effectively prevent maternal hypotension and nausea secondary to spinal anesthesia. fetal morbidity increases by the decrease in cardiac output and uteroplacental flow caused by hypotension due to spinal anesthesia.2 a very high sensory block requirement (till t5) in caesarean section causes extensive sympathetic blockade and hypotension in 55 to 90% of cases. maneuvers like the partial left lateral decubitus (with the objective of limiting the aorto-caval compression caused by the gravid uterus) are partially effective. vascular filling with crystalloids or starches and use of vasopressors are mainly used to treat hypotension but many studies showed these methods ineffective. it was shown by a recent review that hypotension is not prevented reliably by any one of these methods. to decrease fetal and maternal morbidity and mortality during spinal anaesthesia, it is crucial to prevent and treat it effectively. ondansetron can be routinely used to prevent maternal hypotension and fetal compromise after spinal anesthesia in caesarean sections, as well as general surgical and other procedures performed in spinal anesthesia. it can be a good alternative for previously used methods to treat spinal induced hypotension. ondansetron does not affect the heart and blood pressure, even when it is rapidly administered intravenously. in both children and adults, this drug is widely used to prevent postoperative nausea and vomiting prevention. based on above mentioned considerations, we conducted this randomized, controlled, double-blind study, that use of intravenous ondansetron can be investigated and it can be used prophylactically for spinal induced hypotension. a total of 106 patients were enrolled in the study and were randomly divided into two equal groups. hypotension occurred in 17.92% of patients in our study. the frequency of hypotension was significantly lower in the ondansetron group (7.5%) as compared to placebo (28.3%). in a study conducted by owczuk r et al,error! bookmark not defined. two equal groups were made out of 53 patients who operated under spinal anesthesia. it was observed that 48.1% patients in placebo group and 38.5% patients in onset group developed hypotension. they made the conclusion that ondansetron is effective in preventing decrease in map and hr when compared to normal saline group. their results were comparable to those observed in our study. in our study, we compared ondansetron 6 mg with placebo. owczuk et al. compared ondansetron 8 mg with placebo. sahoo et al. compared ondansetron 4 mg with placebo.5 marashi et al. compared ondansetron 6mg and 12mg with placebo.3 ortiz-gómez et al.’s study 10 included three doses of ondansetron (2, 4, and 8 mg versus placebo). owczuk et al. and marashi et al. studied a general surgical population. sahoo et al. and ortiz-gómez et al used obstetric patients in their study. we on the other hand, studied patients undergoing urological, orthopedic and gynecological surgeries. anesthetic technique and dose is a very important factor that can cause the difference between the studies. a different dose of hyperbaric bupivacaine was used in all of these above-mentioned studies. we and marashi et al. used 15mg of hyperbaric bupivacaine for spinal anesthesia. sahoo et al. used 10 mg bupivacaine, owczuk et al used 20 mg bupivacaine. ortiz-gómez et al. personalized each dose to each patient (9.7 ± 0.4 mg in the placebo group and 9.6 ± 0.3 mg in ondansetron group), and the mean dose was smaller than our dose of 15mg. this was a good method as it can be used to prevent over or under dosing of patients. another difference is that intravenous fentanyl to treat pain and tramadol or promethazine to treat adverse effects was used by sahoo et al. blood pressure readings can be modified directly or indirectly by these medications due to a central mechanism. another difference is that we do not use intrathecal opioids for improving effect of spinal anesthesia. this is different from the study of ortiz gómez et al. in which intrathecal fentanyl was used. ondansetron may be centrally acting and its mechanism can be affected by intrathecal opioids. neither we nor ortiz-gómez et al used other supplemental analgesia, and patients who required it were not included in the study. earlier studies have suggested that when ondansetron is administered intravenously, it can antagonize sensory block produced by local anesthetics given intrathecally. this is perhaps the reason for the attenuated hemodynamic responses after spinal anesthesia. to summarize, in the current study, we investigated the effects of 6 mg of ondansetron on the patients’ map. we 213 j i m d c 2 0 1 7 213 observed that 6 mg of ondansetron intravenous, when given alongside rapid crystalloid infusion, could significantly reduce the incidence of spinal induced hypotension. however, ondansetron preloading did not appear to have any significant effect in reducing hypotension in gynecologic and orthopedic surgeries. we can assume that 6 mg of ondansetron may not be sufficient to prevent hypotension in these types of surgeries. it seems that ondansetron enhances the contractility and efficiency of the heart by acting at cardiac level and stabilizes systemic vascular resistance by acting at vascular level through vascular and/or medullary specific receptors. c o n c l u s i o n ondansetron is effective in preventing hypotension in patients undergoing spinal anesthesia. r e c o m m e n d a t i o n s we do feel the need to include other important variables like heart rate, systolic and diastolic blood pressures. the duration and type of surgery, blood loss and maintenance fluid requirements can influence results of such studies. further studies should be carried out, taking into consideration these aspects too. studies should also be done that involve more invasive hemodynamic monitoring like swan-glanz catheter. it can be helpful to properly assess decrease in venous return and cardiac filling pressures. the effect of different doses of ondansetron on reducing spinal induced hypotension also needs to be further investigated. r e f e r e n c e s 1. memary e, mirkheshti a, moghaddam mj, abtahi d, yaseri m, kamali f. comparison of the effects of preanesthetic administration of normal saline, ringer and voluven on the spread of sensory block with hyperbaric bupivacaine spinal anesthesia. anesth pain med. 2014; 4(2): e17939. 2. akhtar mn, tariq s, abbas n, murtaza g, nadeemnaqvi sm. comparison of haemodynamic changes in patients undergoing unilateral and bilateral spinal anaesthesia. j coll physicians surg pak 2012; 22(12):747-50. 3. marashi sm, soltani-omid s, soltanimohammadi s, aghajani y, movafegh a. comparing two different doses of intravenous ondansetron with placebo on attenuation of spinal-induced hypotension and shivering. anesth pain med. 2014 mar 18;4(2): e12055. 4. mitra jk, roy j, bhattacharyya p, yunus m, lyngdoh nm. changing trends in the management of hypotension following spinal anesthesia in cesarean section. j postgrad med 2013; 59(2):121-6. 5. sahoo t, sendasgupta c, goswami a, hazra a. reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: a doubleblind randomised, placebo-controlled study.int j obstetanesth. 2012; 21(1):24-8. 6. acar ns, uzman s, toptas m, vahapoglu a, akkoc i, dinc sc. spinal anesthesia with hyperbaric bupivacaine:a comparison of hypertensive and normotensive patients. med scimonit. 2013; 19:1109-13. 7. khan fa, sabbar s, ahmad j, sattar a. comparison of haemodynamic changes in unilateral and conventional spinal anaesthesia. pak j surg. 2010; 26(2):130 133. 8. demirhan a, tekelioglu yu, akkaya a, ozlu t, yildiz i, bayir h. antiemetic effects of dexamethasone and ondansetron combination during cesarean sections under spinal anaesthesia. afr health sci. 2013; 13(2):475-82. 9. owczuk r, wenski w, twardowski p, dylczyk-sommer a, sawicka w, wujtewicz ma et al. ondansetron attenuates the decrease in blood pressure due to spinal anaesthesia in the elderly –a double blind, placebo-controlled study. minerva anestesiol. 2015; 81(6):598-607. 10. spencer l, mc donald bs. current issues in spinal anesthesia. anesthesiology. 2001; 94(5):888 906. 11. heesen m, klimek m, hoeks se, rossaint r. prevention of spinal anesthesia-induced hypotension during cesarean delivery by 5-hydroxytryptamine-3 receptor antagonists: a systematic review and meta-analysis and meta-regression. obstetric anesthesia digest. 2017 jun 1;37(2):103-4. 12. friedly c, simmons s, riddle d. prophylactic ondansetron for prevention of maternal hypotension following spinal anesthesia in women undergoing cesarean section: a systematic review. international journal of evidencebased healthcare. 2016 dec 1;14(4):196-7 j islamabad med dental coll 2023 49 open access factors associated with nurses’ attitude towards patient safety culture in an international accredited tertiary care hospital, islamabad raisa kausar, kholood janjua, mainmoona siddique, gideon victor. associate chief of nursing, shifa international hospital, pakistan. biostatistician, shifa international hospital, pakistan. consultant neurologist, shifa international hospital, pakistan. assistant professor, shifa college of nursing, shifa tameer-e-millat university, pakistan. a b s t r a c t background: patient safety has emerged as a prime agenda over the past few decades to deliver safe care in increasingly complex service delivery. this study was set out to measure the factors associated with the safety attitudes of nurses. methodology: this descriptive cross-sectional research was conducted from may 2017 to june 2018 in shifa international hospital, islamabad. nurses were invited to participate in the study. the safety attitude questionnaire was used for data collection. data were analyzed using spss v23.0. results: the response rate was 86%. job satisfaction was high at 78.37±23.63 while stress recognition was low at 53.18±27.68. nurses liked their job being a nurse 79.92±28.01 and workplace conditions 80.33±26.44. whereas, hostile situations 48.92±34.95, the negative effect of fatigue 48.50±35.32, being held back to report patient problems 47.58±34.76 and discuss errors 45.42±34.79 were also highlighted. safety attitudes were statistically significant high among intensive care nurses (p-value < 0.05). safety scores of nurses with longer job duration were high than those with lesser job duration. teamwork was favorably correlated with safety climate, job satisfaction, perception of management, and working conditions (r > .466, p-value < .01). conclusion: there was a positive attitude of nurses toward patients’ safety with some areas of improvement. key words: attitude, nurse, patient safety, practice authors’ contribution: 1conception; literature research; 2manuscript design and drafting; 3critical analysis and manuscript review; 4data analysis; manuscript editing. correspondence: gideon victor email: victorgideon@gmail.com article info: received: january 15, 2022 accepted: march 20, 2023 cite this article. kausar r, janjua k, siddique m, victor g. factors associated with nurses’ attitude towards patient safety culture in an international accredited tertiary care hospital, islamabad. j islamabad med dental coll. 2023; 12(1):49-56 doi: https://doi.org/10.35787/jimdc.v12i1.839 funding source: nil conflict of interest: nil i n t r o d u c t i o n patient safety has emerged as a prime agenda over the past few decades to deliver safe care in increasingly complex healthcare delivery.1 regardless of changes in the current healthcare system to introduce quality checks and accreditations, the occurrence of errors is inevitable and may result in severe harm to the patients.2 the world health organization estimated that an average of 10% of all inpatient visits result in some kind of unintentional harm to the patient.3 o r i g i n a l a r t i c l e j islamabad med dental coll 2023 50 therefore creating a culture of safety has been accentuated as a decisive strategy to improve patient safety. the patient safety culture includes professionals’ attitudes, values, perceptions, competencies, commitment, and the ability of an organization to manage patient safety. 4 nurses play a pivotal role to exercise patient safety due to the nature of their work with patients. this encompasses nurses’ direct involvement in patient care around the clock. 5 therefore, healthcare facilities provide them with various prospects to reduce patient harm and intercept healthcare errors even before they occur. 6 studies have shown a correlation between patient safety culture with better patient outcomes including shorter length of stay, willingness to report errors, reduced number of falls among patients, and lower rates of hospital-acquired complications. 7 nurses provided with a positive organizational culture, commitment to a culture of reporting and sharing of error and adverse events improves patient safety and reduces mortality rates.8 to ensure a safe environment and quality practices, it is crucial to promote the measurement and improvement of safety attitudes among healthcare providers.9 the study from neighboring country show the need for improvement in the patient safety culture 10. very little is explored about nurses’ perception and attitude towards patient safety in the local context. 11 examining attitudes of safety culture and factors could provide useful information to hospital leadership and management to develop strategies to improve patient safety. m e t h o d o l o g y this study was approved by the institutional review board and ethics committee of the shifa international hospital (irb& ec # 821-096-2017). a descriptive cross-sectional research design was adopted to conduct the study at shifa international hospital islamabad, pakistan from may 2017 to june 2018. the registered nurses working in nonmanagerial positions in the in-patient department were our study population. the sample size was calculated using openepi online calculator using the formula, n = [deff*np(1-p)]/ [(d2/z21-α/2*(n-1)+p*(1p)]. the calculated sample size was 350 nurses based on a 95% confidence interval. nurses working in the in-patient department were invited to participate in the study using consecutive sampling. nurses in the resignation and probation period were excluded from the study. written consent was taken. questionnaires were distributed and collected on subsequent days at the convenience of the study participants. the data were collected with a structured safety attitude questionnaire (saq) short version composed of 30 items and divided into six subscales; teamwork climate, safety climate, job satisfaction, stress recognition, perception of management, and working conditions. the responses were rated on five points likert scale (1=strongly disagree, 2 = disagree slightly, 3= neutral, 4= agree slightly and 5= agree strongly) and were converted to a 100point scale as 1=0, 2=25, 3=50, 4=75, and 5=100 for scoring. the negatively worded items 2nd and 11th were reverse scored to match their valence with positively worded items. questionnaire demonstrated acceptable construct validity and internal consistency (cronbach’s alpha 0.61–0.91).12 the questionnaire was extensively used including saudi arabia13 and india14 to measure the safety attitudes. the data were analyzed using spss v23.0 (statistical package for social sciences). descriptive statistics were applied to describe the demographic characteristics. pearson’s correlation was applied to measure the correlation between dimensions of safety culture attitude. anova was used to measure differences. a p-value of < 0.05 was considered statistically significant. r e s u l t s j islamabad med dental coll 2023 51 the questionnaire was distributed among 350 nurses and the response rate was 85.7%. out of those were predominantly male 164 (55%) and obtained three years of diploma in nursing 174 (58%) as compared to their bsn counterparts. the participants were working in diverse hospital wards including medical at 29%, surgical at 31%, pediatrics at 8%, emergency department at 11%, and icu at 20%. with regards to the duration of work, the majority 139 (46%) had been working for 1-3 years in their current unit. when asked if they had received any prior training regarding patient safety 283 (94%), gave a positive response. (table – 1) job satisfaction received the highest mean score of 78.37±23.63 while stress recognition was lowest at 53.18±27.68 among the saq subscales. the highly rated safety attitudes among nurses included they liked their job being a nurse at 79.92±28.01, appreciated the workplace at 80.33±26.44, supportiveness at workplace at 79.58±26.85, working in a multidisciplinary team at 78.08±28.13, felt proud at their clinical work at 77.75±27.94, being able to ask questions at 75.67±27.27 and they would feel safe being treated as a patient at 75.58±29.02. whereas, hostile situations at 48.92±34.95, the negative effect of fatigue during emergency situations at 48.50±35.32, being held back to report patient care problems at 47.58±34.76 and discuss errors at 45.42±34.79. the tool overall showed the favorable internal consistency of cronbach's alpha 0.917 as well. table – 2 the table – 3 denotes outcomes of anova. there were no statistically significant differences regarding job duration of the nurses. however, teamwork climate, safety climate, job satisfaction, perception of management and working conditions scores of nurses with >10 years of job duration were high. whereas, stress recognition scores of nurses with <1 year of job duration were high. the workplace, safety climate, job satisfaction, perception of management, and working conditions score of intensive care unit nurses were statistically high than those in medical, surgical, pediatric and emergency units (p-value < 0.05). the teamwork showed the moderate correlation with safety climate, job satisfaction, perception of management, working conditions and low correlation with the stress recognition at 0.01 confidence level. the high positive correlation was found among job satisfaction and working conditions at 0.01 confidence level. the stress recognition showed the low positive correlation with teamwork and perception of management. table – 4 table ii: descriptive evaluation of nurses on safety attitude questionnaire items sr. safety attitude items mean±sd table i: demographic characteristics of the nurses (n=300) frequency (%) gender male 164 (55) female 136 (45) professional qualification bsn 126 (42) diploma 174 (58) workplace medical 87 (29) surgical 94 (31) pediatrics 24 (8) emergency 34 (11) icu 61 (20) job duration < 1 year 88 (29) 1 to 3 years 139 (46) 4 to 9 years 63 (21) > 10 years 10 (3) safety education yes 283 (94) no 17 (6) bachelor of science in nursing (bsn), intensive care unit (icu) j islamabad med dental coll 2023 52 teamwork climate (cronbach's alpha, 0.720) 68.08±19.50 1 nurse input at workplace 71.67±30.56 2 held back to report patient problems* 47.58±34.76 3 positive response to disagreements 65.00±30.74 4 support for patient care 70.50±29.28 5 clear response to questions 75.67±27.27 6 multidisciplinary team work 78.08±28.13 safety climate (cronbach's alpha 0.819) 67.66±21.36 7 feel safe as a patient 75.58±29.02 8 handling of medical errors 74.25±28.51 9 clear channels of communication 74.08±31.23 10 constructive performance feedback 61.67±33.12 11 difficult to discuss workplace errors* 45.42±34.79 12 encouraging environment to report errors 71.67±29.79 13 supportiveness to learn from errors 71.00±27.97 job satisfaction (cronbach's alpha 0.904) 78.37±23.63 14 likes the job 79.92±28.01 15 supportive working environment 79.58±26.85 16 a good place to work 80.33±26.44 17 i am proud to work in this clinical area. 77.75±27.94 18 morale in this clinical area is high. 74.33±29.88 stress recognition (cronbach's alpha 0.806) 53.18±27.68 19 workload effects my performance 60.33±34.18 20 fatigue negatively effects performance 55.00±34.82 21 hostile situation increases errors 48.92±34.95 22 challenges in emergency situation 48.50±35.32 perception of management (cronbach's alpha 0.740) 63.17±22.44 23 support of management at workplace 61.28±31.25 24 intentional patient safety concerns 59.50±31.57 25 management of problem personnel constructively 65.92±27.64 26 timely information of changes at workplace 66.00±29.17 working conditions (cronbach's alpha .776) 69.87±22.75 27 sufficient staffing in the unit 57.92±34.55 28 orientation and on-job training 74.08±28.28 29 participation in patient care decisions 74.83±25.78 30 supervision to trainees 72.67±28.31 overall safety attitude (cronbach's alpha 0.917) 67.30±16.53 * reverse coded, standard deviation (sd) table 3: patient safety culture differences regarding job duration and workplace j islamabad med dental coll 2023 53 job duration workplace years mean sd p-value ward mean sd p-value teamwork climate < 1 68.56 18.48 .363 medical 69.59 19.76 .118 1 – 3 66.61 21.21 surgical 63.83 21.95 4 – 9 69.25 18.04 pediatric 70.31 20.42 > 10 77.08 7.67 er 68.01 15.00 icu 71.65 16.10 safety climate < 1 69.03 19.86 .317 medical 71.55 19.13 .001* 1 – 3 66.11 22.59 surgical 59.80 23.55 4 – 9 67.52 21.16 pediatric 69.05 21.26 > 10 78.21 16.28 er 66.91 20.40 icu 74.12 18.05 job satisfaction < 1 77.33 25.79 .613 medical 82.11 21.45 .008* 1 – 3 77.94 23.73 surgical 71.60 26.57 4 – 9 79.37 21.64 pediatric 80.00 27.15 > 10 87.50 12.75 er 76.62 22.92 icu 83.85 18.27 stress recognition < 1 54.69 29.15 .812 medical 50.57 26.65 .233 1 – 3 51.53 29.00 surgical 51.66 29.70 4 – 9 54.76 23.67 pediatric 63.02 28.61 > 10 53.13 20.25 er 50.37 20.12 icu 56.97 28.76 perception of management < 1 63.73 22.35 .214 medical 65.52 19.23 .018* 1 – 3 61.37 22.41 surgical 57.18 23.65 4 – 9 62.37 21.17 pediatric 66.49 19.37 > 10 76.25 16.79 er 59.68 25.27 icu 67.72 20.80 working conditions < 1 75.92 24.21 .244 medical 79.38 19.90 .006* 1 – 3 72.66 23.42 surgical 68.35 26.00 4 – 9 75.99 19.71 pediatric 75.52 21.80 > 10 86.25 10.54 er 71.88 23.35 icu 79.41 18.59 * statistical significance p-value < 0.05 table iv: correlation among dimensions of safety attitude questionnaire’s subscales j islamabad med dental coll 2023 54 teamwork climate safety climate job satisfaction stress recognition perception of management working conditions teamwork climate pearson correlation 1 p-value safety climate pearson correlation .692** 1 p-value <.001 job satisfaction pearson correlation .572** .675** 1 p-value <.001 <.001 stress recognition pearson correlation .170** .098 .049 1 p-value .003 .091 .400 perception of management pearson correlation .466** .622** .621** .133* 1 p-value <.001 <.001 <.001 .022 working conditions pearson correlation .579** .648** .748** .044 .692** 1 p-value <.001 <.001 <.001 .448 <.001 **. correlation is significant at the 0.01 level (2-tailed). *. correlation is significant at the 0.05 level (2-tailed). d i s c u s s i o n the overall patient safety culture attitudes of nurses were positive. nurses rated their job satisfaction and working conditions high. female nurses showed significant affinity with safety climate, working conditions and stress recognition. job satisfaction was higher among diploma graduated nurse while stress recognition among degree graduated nurses. safety climate scores were high for intensive care nurses. the main results of the study indicated the positive attitudes but few concerning gaps were also highlighted. the safety scores of nurses working in arab 15 and southeast asian 16 hospitals were consistent with current study. whereas higher safety attitude scores were reported among the nurses working in the chinese 10 and indian studies 14. the difference of safety scores among these countries may due to contextual, and policy variations. arab countries mainly depend on expatriate nurses who comes from different backgrounds. therefore, adjusting to the context and policies may be a challenge as compared to india and china whose nurses graduate from their own nursing education system. the job satisfaction and working condition scores were higher. whereas, stress recognition and perception of management scores were low in current study. this finding is consistent with chinese 10 and european studies 17. generally accredited hospital offers good salary packages and working environment which may be reflected in job satisfaction of nurses. whereas demanding and high-performance routine may contribute to stress and negative perception about management. perhaps for these reasons, nurses pointed out the work overload, hostile situations and fatigue compromising their performance in emergency as well as in daily patient care activities. moreover, the j islamabad med dental coll 2023 55 need for managerial support to provide timely information, disciplining the problematic healthcare workers constructively was also indicated. the patient safety system framework based on human factors illuminatephysical and mental workload increase the likelihoods of negative patient outcomes.18 the scores of intensive care nurses were statistically significant higher in most patient safety culture dimensions. this finding is inconsistent with a tunisian 19 whose patient safety score very low due to increased nurse patient ratio. an appropriate nurse patient ratio in present study may have attributed to high safety scores as well as due to higher job satisfaction, perception of management and working conditions than those in medical, surgical, pediatric and emergency units. the dynamics of context play an important role to establish the safety attitudes among nurses. the low perception of safety culture in most dimensions shown by the surgical unit nurses is similar to that reported in a previous study.20 perhaps surgical nurse face more challenges for providing care to critically ill patients. the job duration also impacts the safety attitudes of the nurse. the nurses with greater job duration showed positive patient safety attitudes and stress perception of lower job duration. this finding is consistent with a canadian study 21 supporting due to the fact that nurses with greater job duration comprehend the organization policies and practices better than those with less job duration. on the contrary a singaporean 22 study found higher patient culture safety score among professionals with lesser job duration. bivariate correlational analysis found that teamwork, job satisfaction, working conditions and perception of management significantly and positively correlate with patient safety culture while stress recognition weakly. this fact is supported in a meta-analytical review also.23 the international accredited hospital function under high standards to provide quality care to patients as well as fringe benefits and standardized working conditions to employees. such organizations can be demanding which is exhibited by the stress recognition of study participants. there was number of limitations of the study including using of non-probability sampling and data collection from a single private hospital. therefore, results should be generalized with caution. this was a quantitative study and may have missed certain contextual factors. a qualitative or mixed methods multi-institutional research could provide more valuable findings. further multidisciplinary approach upholds the patient safety agenda which future research can focus. c o n c l u s i o n this study provides a useful insight for patient safety culture. greater job duration, job satisfaction, teamwork, perception of management and working conditions significantly contribute to the patient safety culture. the negative impacts of stress recognition should be alleviated. hospital administration can use this information to reflect upon areas highlighted by nurses to promote and improve patient safety culture. a systematic and robust in-service education can improve patient safety culture. r e f e r e n c e s 1. carthon jmb, davis l, dierkes a, hatfield l, hedgeland t, holland s, et al. association of nurse engagement and nurse staffing on patient safety. j nurs care qual. 2019;34(1):40–6. 2. ente c, ukpe m. concept of quality and safety improvement in health care. in: essentials for quality and safety improvement in health care. springer; 2022. p. 1–22. 3. world health organization. who | global ministerial summits on patient safety [internet]. 2016 [cited 2019 nov 3]. available from: https://www.who.int/patientsafety/policies/minist erial-summits/en/ 4. lee se, quinn bl. safety culture and patient safety j islamabad med dental coll 2023 56 outcomes in east asia: a literature review. west j nurs res. 2020;42(3):220–30. 5. bianchi m, bagnasco a, bressan v, barisone m, timmins f, rossi s, et al. a review of the role of nurse leadership in promoting and sustaining evidence‐ based practice. j nurs manag. 2018;26(8):918–32. 6. aouicha w, tlili ma, sahli j, dhiab m ben, chelbi s, mtiraoui a, et al. exploring patient safety culture in emergency departments: a tunisian perspective. int emerg nurs. 2021;54:100941. 7. tlili ma, aouicha w, rejeb m ben, sahli j, dhiab m ben, chelbi s, et al. assessing patient safety culture in 18 tunisian adult intensive care units and determination of its associated factors: a multicenter study. j crit care. 2020;56:208–14. 8. hessels a, paliwal m, weaver sh, siddiqui d, wurmser ta. impact of patient safety culture on missed nursing care and adverse patient events. j nurs care qual. 2019;34(4):287–94. 9. wei h, corbett rw, ray j, wei tl. a culture of caring: the essence of healthcare interprofessional collaboration. j interprof care. 2020;34(3):324–31. 10. jiang k, tian l, yan c, li y, fang h, peihang s, et al. a cross-sectional survey on patient safety culture in secondary hospitals of northeast china. plos one. 2019;14(3):e0213055. doi: https://doi.org/https://doi.org/10.1371/journal.po ne.0213055 11. jafree sr, zakar r, fischer f, zakar mz. ethical violations in the clinical setting: the hidden curriculum learning experience of pakistani nurses. bmc med ethics. 2015;16(1):2–11. 12. gambashidze n, hammer a, ernstmann n, manser t. psychometric properties of the georgian version of the safety attitudes questionnaire: a crosssectional study. bmj open. 2020;10(2):e034863. 13. aljadhey h, al-babtain b, mahmoud ma, alaqeel s, ahmed y. culture of safety among nurses in a tertiary teaching hospital in saudi arabia. trop j pharm res. 2016;15(3):639–44. 14. patel s, wu aw. safety culture in indian hospitals: a cultural adaptation of the safety attitudes questionnaire. j patient saf. 2016;12(2):75–81. 15. elmontsri m, almashrafi a, banarsee r, majeed a. status of patient safety culture in arab countries: a systematic review. bmj open. 2017;7(2):e013487. doi: https://doi.org/10.1136/bmjopen-2016013487 16. kang s, ho ttt, lee n-j. comparative studies on patient safety culture to strengthen health systems among southeast asian countries. vol. 8, frontiers in public health. 2021. p. 1–13. doi: https://doi.org/https://doi.org/10.3389/fpubh.202 0.600216 17. gurková e, zeleníková r, friganovic a, uchmanowicz i, jarošová d, papastavrou e, et al. hospital safety climate from nurses’ perspective in four european countries. int nurs rev. 2020;67(2):208–17. 18. manley k, jackson c. microsystems culture change: a refined theory for developing person-centred, safe and effective workplaces based on strategies that embed a safety culture. int pract dev j. 2019;9(2):1– 20. 19. tlili ma, aouicha w, sahli j, zedini c, ben dhiab m, chelbi s, et al. a baseline assessment of patient safety culture and its associated factors from the perspective of critical care nurses: results from 10 hospitals. aust crit care. 2021;34(4):363–9. doi: https://doi.org/https://doi.org/10.1016/j.aucc.202 0.09.004 20. farokhzadian j, dehghan nayeri n, borhani f. the long way ahead to achieve an effective patient safety culture: challenges perceived by nurses. bmc health serv res. 2018;18(1):1–13. 21. stimpfel aw, fatehi f, kovner c. nurses’ sleep, work hours, and patient care quality, and safety. sleep heal. 2020;6(3):314–20. 22. tan byq, kanneganti a, lim ljh, tan m, chua yx, tan l, et al. burnout and associated factors among health care workers in singapore during the covid19 pandemic. j am med dir assoc. 2020;21(12):1751–8. 23. alruqi wm, hallowell mr, techera u. safety climate dimensions and their relationship to construction safety performance: a meta-analytic review. saf sci. 2018;109:165–73. 214 j i m d c 2 0 1 7 214 open access f u l l l e n g t h a r t i c l e arthralgia an indicator of vitamin d3 deficiency and insufficiency nadeem islam sheikh 1, rabia farooq 2 1 senior medical consultant, social security hospital islamabad 2 medical officer, department of medicine & allied, social security hospital islamabad a b s t r a c t objective: to determine the prevalence of vitamin-d deficiency and insufficiency in patients complaining of arthralgia. patients and methods: this cross-sectional study included a group of 332 individuals complaining of arthralgia, selected by consecutive sampling technique. vitamin-d blood level was performed by elisa method. data were entered and analyzed using spss software (version 15). mean and standard deviation was calculated for quantitative variables and frequency with percentage was presented for qualitative variables. chi-square test was applied to assess any association between qualitative variables. p value less than 0.05 was considered significant. results: out of 332 individuals who had arthralgia, 9.03% (30).12% (17) and 85.84% (285) had vitamin-d sufficiency, insufficiency and deficiency. among total sample population, 75.0% (249) were females and 25.0% (83) were males. in females 8.83% (22), 6.02% (15) and 85.1% (212) had vitamin-d sufficiency, insufficiency and deficiency (p-value 0.430). out of 212 vitamin-d deficient females,48.5% (103), 16.98% (36) and 34.4% (73) had severe, moderate and mild vitamin-d deficiency(p-value=0.844). in male patients 9.63% (8),2.40% (2) and 87.95% (73) of males had vitamin-d sufficiency, insufficiency and deficiency (p-value=0.430). out of 73 vitamin-d deficient males, 45.20%(33) ,16.43% (12) and 38.3% (28) had severe moderate and mild vitamin-d deficiency(p-value=0.844). in females vitamin-d deficiency was found to be most prevalent in age groups of 41-60 years. whereas in males vitamin-d deficiency was found to be most prevalent in age groups of 31-40years. conclusion: vitamin d deficiency/insufficiency is an important factor leading to arthralgia, keeping the prevalence rate of about 90% in mind. key words: arthralgia, deficiency, eliza, prevalence, vitamin-d. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, active participation in data collection address of correspondence nadeem islam email: nadeem.islam@hotmail.com article info. received: june 7, 2017 accepted: august 20, 2017 cite this article. islam n, farooq r. arthralgia an indicator of vitamin d3 deficiency and insufficiency. jimdc.2017;6(4): funding source: nil conflict of interest: nil i n t r o d u c t i o n vitamin d commonly called the “sunshine vitamin” is synthesized in the body when the skin is exposed to sunlight directly, making it unique amongst others. it is a fat-soluble vitamin and is commonly stored in the body’s fatty tissue.1 vitamin d3, is essential for maintaining mineral homeostasis and normal skeletal architecture. vitamin d and its synthetic analogues also have antiproliferative, prodifferentiative, and immunomodulatory activities. vitamin d3 has physiological and pharmacological actions in various systems, after the recognition of vitamin d receptors (vdr) in target cells. there are potential therapeutic applications of vdr ligands in inflammation like dermatological indications, osteoporosis, cancers, secondary hyperparathyroidism, and autoimmune diseases.2-11 vitamin d3 circulating levels greater than 75 nmol/l, or 30 ng/ml, is beneficially o r i g i n a l a r t i c l e 215 j i m d c 2 0 1 7 215 required for good health, at least 800–1000 iu vitamin d3 may be required for maintaining good health. vitamin d2 when given in physiological concentrations may be equally effective for maintaining circulating concentrations of 25-hydroxyvitamin.12-17 exposure to sunlight is the major source of vitamin d for most humans. vitamin d is naturally present in oily fish like salmon and mackerel and oils from fish, including cod liver oil. dairy products like cheese, butter, cream also contain vitamin d. in developed countries fortification of milk products, juice products, breads, yogurts, and cheeses is done with vitamin d.18, 19 vitamin d deficiency is recognized as a pandemic. it causes rickets in children and osteopenia, osteomalacia, osteoporosis, and fractures in adults.30 research has linked vitamin d deficiency with increased risk of common cancers, autoimmune diseases, hypertension, and infectious diseases.19-27 inadequate nutritional intake of vitamin d along with inadequate sunlight, faulty vitamin d absorption, and failure of converting vitamin d into active form results in vitamin d3 deficiency.28-32 serum vitamin d3 concentration is the most reliable marker of vitamin d status.12 vitamin d deficiency is increasing day by day worldwide affecting individuals of all age groups. global awareness about vitamin d benefits and its deficiency is still seriously lacking. people with vitamin d deficiency may develop a feeling of being sleepy, lethargic, lazy, and tired along with body aches and muscle cramps. in addition to these signs the development and growth of body in infants and children may be affected, with delay in tooth formation and breathing difficulty.28-32 p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at social security hospital islamabad from 20-april-2011 to 20april 2012. sample size was calculated by using who sample size calculator taking confidence level of 95%, anticipated population proportion 70% and absolute precision 5%.11 sample size turned out to be 323. initially 350 individuals were included to overcome the possibility of dropouts. patients complaining of arthralgia with age range of 2-86 years were selected by consecutive non probability sampling. voluntary informed written consent was taken by all the study subjects. those individuals refused to give informed consent were excluded. the serum vitamin d3 levels were performed by elisa. according to reference ranges, “vitamin d3 concentrations >30 ng/ml are considered to be sufficient. vitamin d3 concentrations of 51–74 nmol/l, or 21–29 ng/ml, indicate insufficiency. whereas vitamin d3 concentration <50 nmol/l, or 20 ng/ml, is an indication of vitamin d deficiency”. vitamin d3 deficiency is further classified into severe, moderate and mild deficiencies. according to definition “vitamin d3 levels below 5ng/ml is considered as severe vitamin d3 deficiency, vitamin d3 levels between 5-12ng/ml is considered moderate vitamin d3 deficiency, whereas vitamin d3 levels between 1220ng/ml is considered mild vitamin d3 deficiency”.12 data was entered and analyzed using spss software (version 15). mean and standard deviation was calculated for quantitative variables and frequency with percentage was presented for qualitative variables. chisquare test or fischer exact tests was applied, to assess any association between qualitative variables. p-value less than 0.05 was considered statistically significant. r e s u l t s out of 332 participants, 83 were male and 249 were female. male female ratio was 1:3. among all patients suffering from arthralgia, 85.84% had vitamin d3 deficiency, 5.12% individuals had an insufficient levels and only 9.03% individuals had a sufficient vitamin d3 levels (figure 1). figure 1: vitamin d levels among study participants (n=332) gender wise distribution shows that (73) 87.95% of male and (212) 85.1% of female patients had vitamin d3 deficiency. among them, 45.20% males and 48.5% females had severe vitamin d3 deficiency. sufficient levels of vitamin d were found only in 9.63% males and 8.83% females (table 1). 216 j i m d c 2 0 1 7 216 figure 2: vitamin d deficiency in various age groups in females and male patients. figure 2 showed significant association (p=0.000) of vitamin d deficiency levels in different age groups among females as compared to males. among females vitamind deficiency was found to be most prevalent in age groups of 41-60 years. whereas in males vitamin-d deficiency was found to be most prevalent in age groups of 31-40 years. d i s c u s s i o n vitamin d deficiency is one the most common medical condition worldwide. according to an estimation, about one billion people in the world have vitamin d deficiency or insufficiency.19 vitamin d deficiency has a high prevalence in asian countries.36-39 a majority (90%) of islamabad and rawalpindi patients in this study were vitamin d deficient or insufficient. it is a matter of concern to see so much of vitamin d deficiency in a country with ample sunshine. increased pigmentation due to which more prolonged exposure to sun is required, inadequate dietary intake of vitamin d, use of sun block, and veil (purdah) observation, failure of conversion of vitamin d into its active form in kidney, mal-absorption diseases and obesity may be responsible for vitamin d deficiency. 38 women are more likely to have vitamin d-deficiency than men.40 the use of veil in most women or clothing habits like wearing scarf and full sleeves clothes as a religious or cultural tradition limits sunlight exposure which may be a main reason for increased prevalence of vitamin d3 deficiency in females as compared to males.37 people also use anti-solar (sun blocks) creams on the exposed area to prevent tanning. apartments living is increasing day by day due to increase in population of the country and tendency to live in big cities are among other factors which restrict exposure to sun. table:1 vitamin d levels gender of patients total p-value male female vit d deficiency 73(87.95%) 212(85.1%) 285(85.84%) 0.430 vit d insufficiency 2(2.40%) 15(6.02%) 17(5.12%) vit d sufficiency 8(9.63%) 22(8.83%) 30(9.03%) total 83(25%) 249(75%) 332(100%) severe deficiency 33(45.20%) 103(48.5%) 136(47.7%) 0.844 mild deficiency 28(38.3%) 73(34.4%) 101(35.43%) moderate deficiency 12(16.43%) 36(16.98%) 48(16.84%) total 73(25.61%) 212(74.38%) 285(100%) in females, vitamin d3 deficiency is most prevalent in age groups of 41-60 years, which depicts that vitamin d3 deficiency in females is common in middle and old age group. the reason for increased vitamin d deficiency in middle age group may be that usually requirement exceeds the intake of vitamin d in reproductive and lactation period in life of women. whereas in females of old age or post-menopausal women there is a marked decrease in oestrogen levels which may be a factor leading to vitamin d deficiency in them. in males, vitamin d3 deficiency is most prevalent in age groups of 31-40 years; however, there is no strong evidence based on previous research, which proves the actual cause of vitamin d deficiency in a certain age group in male and female. certain factors like clothing style, air pollution, skin pigmentation, insufficient vitamin d intake, lack of routine fortification of foods with vitamin d in pakistan, could be the main factors responsible for such high rate of vitamin d deficiency in our population. the limitation of our study was that we did not include the type of diet, use of food containing vitamin d, duration of exposure to sunlight, and other possible risk factors for vitamin d deficiency. in order to prevent vitamin d deficiency 10 to 15 minutes of 217 j i m d c 2 0 1 7 217 sunshine, three times a week (between 10am to 3pm), is recommended which will produce sufficient vitamin d required for normal functioning of the body.38 people who do not live in sunny places may not make enough vitamin d through sun light, must fulfil their body vitamin d requirements by diet. vitamin d is found in dairy products like cheese, butter, cream and fortified milk. fatty fish (such as tuna, salmon, and mackerel), fortified breakfast cereals, margarine, and soy milk are also a rich source of vitamin d.38,39 in case of severe deficiency vitamin d supplementation is required. depending upon age, situation and severity of the deficiency the doctor will prescribe the correct dosage of vitamin d, which will be given as a medicine in syrup or tablets form, or in injectable form during severe deficiency.39-41. c o n c l u s i o n vitamin d3 deficiency and insufficiency is prevalent in above 90 % of islamabad and rawalpindi population presenting to physicians with arthralgia. so patients suffering from arthralgia or aches and pains should be checked for vitamin d levels initially and may be given a symptomatic treatment for vitamin d3 deficiency. r e c o m m e n d a t i o n s based on the findings of the study, we recommend fortification of food with vitamin d3 and adequate exposure to sunlight to prevent vitamin d deficiency and assessment of vitamin d status in routine, especially those with complaint of pains and aches. r e f e r e n c e s 1. holick mf. the vitamin d epidemic and its health consequences.the journal of nutrition 2005; 135(11): 2739s-2748s. 2. nagpal s, songqing n a, rathnachalam r. noncalcemic actions of vitamin d receptor ligands. endocrine reviews.2005; 26(5): 662-687. 3. gandini s, boniol m, haukka j, byrnes g, cox b, sneyd mj, et al. meta-analysis of observational studies of serum 25-hydroxyvitamin d levels and colorectal, breast and prostate cancer and colorectal adenoma. int j cancer 2011; 128(6):1414-24. 4. gallagher jc, sai a, templin t 2nd, smith l. dose response to vitamin d supplementation in postmenopausal women: a randomized trial. ann intern med. 2012; 156(6):425-37. 5. meyer f, liu g, douville p, samson e, xu w, adjei a, et al. dietary vitamin d intake and serum 25-hydroxyvitamin d level in relation to disease outcomes in head and neck cancer patients. int j cancer.2011; 128(7):1741-6. 6. zittermann a, iodice s, pilz s, grant wb, bagnardi v, gandini s. vitamin d deficiency and mortality risk in the general population: a meta-analysis of prospective cohort studies. am j clin nutr. 2012; 95(1):91-100. 7. pilz s, iodice s, zittermann a, grant wb, gandini s. vitamin d status and mortality risk in ckd: a metaanalysis of prospective studies. am j kidney dis. 2011; 58(3):374-82. 8. michaëlsson k, baron ja, snellman g, gedeborg r, byberg l, sundström j, et al. plasma vitamin d and mortality in older men: a community-based prospective cohort study. am j clin nutr. 2010;92(4):841-8. 9. mezawa h, sugiura t, watanabe m, norizoe c, takahashi d, shimojima a, et al. serum vitamin d levels and survival of patients with colorectal cancer: post-hoc analysis of a prospective cohort study. bmc cancer. 2010; 10(1):347. 10. avenell a, maclennan gs, jenkinson dj, mcpherson gc, mcdonald am, pant pr, et al. long-term follow-up for mortality and cancer in a randomized placebo-controlled trial of vitamin d(3) and/or calcium (record trial). j clin endocrinol metab. 2012; 97(2):614-22. 11. trowbridge r, mittal sk, agrawal dk. vitamin d and the epidemiology of upper gastrointestinal cancers: a critical analysis of the current evidence. cancer epidemiol biomarkers prev. 2013; 22:1007-14. 12. holick mf, chen tc. vitamin d deficiency: a worldwide problem with health consequences.the american journal of clinical nutrition 2008; 87(4): 1080s-1086s. 13. tripkovic l, lambert h, hart k, smith cp, bucca g, penson s, et al. comparison of vitamin d2 and vitamin d3 supplementation in raising serum 25-hydroxyvitamin d status: a systematic review and meta-analysis. am j clin nutr. 2012; 95(6):1357-64. 14. autier p, gandini s, mullie p. a systematic review: influence of vitamin d supplementation on serum 25hydroxyvitamin d concentration. j clin endocrinol metab. 2012;97(8):2606-13. 15. bischoff-ferrari ha, willett wc, orav ej, lips p, meunier pj, lyons ra, et al. a pooled analysis of vitamin d dose requirements for fracture prevention. n engl j med. 2012; 367(1):40-9. 16. institute of medicine. dietary reference intakes for calcium and vitamin d. national academies press, 2011. 17. ross ac, manson je, abrams sa, aloia jf, brannon pm, clinton sk, et al. the 2011 report on dietary reference intakes for calcium and vitamin d from the institute of 218 j i m d c 2 0 1 7 218 medicine: what clinicians need to know. j clin endocrinol metab. 2011; 96(1):53-58. 18. holick mf. vitamin d deficiency. n engl j med 2007; 357(3): 266-281. 19. holick mf. vitamin d: a millennium perspective. j cell biochem. 2003; 88(2): 296–307. 20. sabetta jr, depetrillo p, cipriani rj, smardin j, burns la, landry ml. serum 25-hydroxyvitamin d and the incidence of acute viral respiratory tract infections in healthy adults. plos one. 2010; 5(6):e11088. 21. brondum-jacobsen p, benn m, jensen gb, nordestgaard bg. 25-hydroxyvitamin d levels and risk of ischemic heart disease, myocardial infarction, and early death: population-based study and meta-analyses of 18 and 17 studies. arterioscler thromb vasc biol. 2012; 32(11):2794802. 22. dror y, giveon s, hoshen m, feldhamer i, balicer r, feldman b. vitamin d levels for preventing acute coronary syndrome and mortality: evidence of a non-linear association. j clin endocrinol metab.2013;98(5):2160-7. 23. tomson j, emberson j, hill m, gordon a, armitage j, shipley m, et al. vitamin d and risk of death from vascular and non-vascular causes in the whitehall study and metaanalyses of 12 000 deaths. eur heart j. 2013;34(18):136574. 24. khan h, kunutsor s, franco oh, chowdhury r. vitamin d, type 2 diabetes and other metabolic outcomes: a systematic review and meta-analysis of prospective studies. proc nutr soc. 2013;72(1):89-97. 25. pilz s, iodice s, zittermann a, grant wb, gandini s. vitamin d status and mortality risk in ckd: a metaanalysis of prospective studies. am j kidney dis. 2011;58(3):374-82. 26. bolland mj, grey a, avenell a, gamble gd, reid ir. calcium supplements with or without vitamin d and risk of cardiovascular events: reanalysis of the women’s health initiative limited access dataset and meta-analysis.bmj. 2011;342:d2040. 27. herr c, greulich t, koczulla ra, meyer s, zakharkina t, branscheidt m, et al. the role of vitamin d in pulmonary disease: copd, asthma, infection, and cancer. respir res 2011;12:31. 28. johnson le. vitamin d. the merck manual of diagnosis and therapy, 19th edition 2011; 296–307. 29. khan ah, jabbar a, baig r, ul haq n, sutton ra. vitamin d deficiency osteomalacia: the continuing challenge. pakistan journal of pathology. 2016;19(4). 30. joshi d, center j, eisman j. "vitamin d deficiency in adults". australian prescriber 2010;(33): 103–6. 31. holvik k. prevalence and predictors of vitamin d deficiency in five immigrant groups living in oslo, norway: the oslo immigrant health study. european journal of clinical nutrition. 2005; 59(1): 57-63. 32. knutsen kv, brekke m, gjelstad s. vitamin d status in patients with musculoskeletal pain, fatigue and headache: a cross-sectional descriptive study in a multi-ethnic general practice in norway. scandinavian journal of primary health care 2010; 28 (3): 166-171. 33. meyer he, falch ja, søgaard aj. vitamin d deficiency and secondary hyperparathyroidism and the association with bone mineral density in persons with pakistani and norwegian background living in oslo, norway: the oslo health study. elsevier 2004; 35(2):412–417. 34. mcgillivray g, skull sa, davie g. high prevalence of asymptomatic vitamin d and iron deficiency in east african immigrant children and adolescents living in a temperate climate. archives of disease in childhood 2007; 92(12): 1088-1093. 35. calvo ms, whiting sj, barton cn. vitamin d intake: a global perspective of current status. jr nutr 2007; 135(2): 310-317. 36. mithal a, wahl da, bonjour jp, burckhardt p, dawsonhughes b, eisman ja, fuleihan ge, josse rg, lips p, morales-torres j, iof committee of scientific advisors (csa) nutrition working group. global vitamin d status and determinants of hypovitaminosis d. osteoporosis international. 2009;20(11):1807-20. 37. iqbal, r., khan, ha. possible causes of vitamin d deficiency (vdd) in pakistani population residing in pakistan. journal of pakistan medical association, 2010; 60(1):1-2. 38. brunvand l, haug e. vitamin d deficiency amongst pakistani women in oslo. acta obstet gynecol scand 1993; 72(4): 264–268. 39. grant wb, holick mf. benefits and requirements of vitamin d for optimal health: a review. alternative medicine review 2005; 10(2): 94-111. 40. stroud ml, stilgoe s, stott ve, alhabian o, salman k. "vitamin d – a review". australian family physician 2008;37 (12): 1002–5. 41. bjelakovic g, gluud ll, nikolova d, whitfield k, wetterslev j, simonetti rg, et al. vitamin d supplementation for prevention of mortality in adults. cochrane database syst rev 2011;(7):cd007470. journal of islamabad medical & dental college (jimdc); 2012(2):81-84 81 original article validation of automated esr methods with conventional method as gold standard naghmi asif*, rizwan uppal**, shaheen mehmood***, aftab ahmed****, shafquat ali *****and muhammad afzal****** *assistant prof. hematology, islamabad medical & dental college/hematologist islamabad diagnostic centre, islamabad **assistant prof. isra university, medical specialist islamabad diagnostic centre ***pathologist, islamabad diagnostic centre, islamabad ****consultant hematologist, islamabad diagnostic centre, islamabad *****islamabad diagnostic centre, islamabad ******department community medicine, islamabad medical & dental college, islamabad (*’******bahria university, islamabad) abstract objective: to compare the esr values by vesmatic easy and vacuette srs 20/11 with conventional westergren method, aiming to validate the automated methods. material and methods: a cross-sectional study was conducted at islamabad diagnostic centre, islamabad. a total of 108 blood samples were subjected to esr estimation by manual westergren method and by automated (ves-matic and vacuette srs) methods. results were analyzed on spss ver. 17. results were compared and their correlation was calculated using pearson correlation coefficient. results: there is strong positive correlation between westergren method and ves-matic easy methods with pearson coefficient of 0.97 and highly significant p value of 0.000. results also show strong positive correlation between westergren and vacuette srs methods with pearson coefficient of 0.95 and highly significant p value of 0.00. conclusion: both automated methods (ves-matic easy and vacuette srs) show good correlation to manual westergren method, and are reliable and suitable for use in high workload clinical laboratory. key words: esr, westergren method, manual esr, automated esr introduction the erythrocyte sedimentation rate (esr) is a most widely used test in clinical practice. it increases in various infectious diseases, inflammations, malignancies and autoimmune diseases reflecting both the plasma (acutephase proteins) and cellular properties (red blood cell concentration, rbc surface charge and aggregation).1-4 these combine and cause, to a greater or lesser extent a difference in the specific gravity between red cells and plasma, and dictate the degree to which the red cells form rouleaux. esr is a particularly sensitive indicator of silent and chronic inflammation that is the underlying process in many diseases.5,6 thus despite the availability of alternative inflammatory parameters such as crp level and leukocyte (neutrophil) count, it is still a frequently requested parameter and, at the moment, probably the most widely measured index of acute phase response. the method for the esr was first described in 1921 by dr r fahraeus and dr a westergren.7,8 it rapidly became a common screening test worldwide for acute phase proteins and chronic diseases. there are several different methods to determine the esr, but the conventional westergren method is still considered as the reference method. this method determines erythrocyte sedimentation after 1 hour in a vertically mounted tube of defined length and bore size. however, it is not an automated method, and also carries a risk of infection, needs relatively large volumes of blood, and, with an analysis time of 1 hour, is time-consuming.9 increased awareness of biohazards risk to laboratory staff has led to safer methods for performing the esr such as vacuum controlled aspiration of sample and automated mixing of sample with sodium citrate anticoagulant present in the tube. to overcome the practical drawbacks of the original westergren esr method, several methods were introduced. these methods measure the esr in dedicated tubes using whole blood diluted with edta or citrate. sedimentation (in mms.) of erythrocytes is recorded and subsequently recalculated to westergren units (mm/h). the advantage of these methods over a manual westergren-based method is that they provide a fully closed, automated system with results that are more readily available. as regards ves-matic journal of islamabad medical & dental college (jimdc); 2012(2):81-84 82 and vacuette srs methods, these show good correlation with the conventional westergren method.10,11 the ves-matic method uses standard blood sample tubes for direct measurement of esr. this method has the advantages of automated mixing of blood sample, shortened testing time (20 minutes), and automated end-point reading by a digital sensor. the vacuette srs 20/11 method reads the result after 30 minutes. these automated methods show good correlation with the conventional westergren reference method. this study was designed to compare the esr values by vesmatic easy vacuette srs 20/11 and with conventional westergren method, aiming to validate the automated methods. material and methods a cross-sectional study was conducted at islamabad diagnostic centre, islamabad from april to may 2012. in total 108 samples were subjected to esr estimation by westergren, ves-matic easy and vacuette srs 20/11 methods. for all three methods, blood was diluted with citrate solution. the ves-matic easy is a bench instrument designed and programmed to determine the esr in a maximum of 10 samples of blood contained in dedicated cuvettes (which contain sodium citrate as an anticoagulant), simultaneously or individually in random access mode. the instrument is controlled by a microprocessor. the cuvettes after being filled with 1.1ml carefully mixed blood to an intended height of 60 mm, are placed in the instrument. the instrument maintains the cuvettes at an angle 18° to the vertical and a photoelectric cell then passes up the outside of each cuvette to record the height of the column of red cells at which light transmission occurs. after 20 minutes of sedimentation, timed electronically, the new level at which light passes through the column is recorded and the decrease in height is corrected mathematically to give a result which is stated to be comparable with the westergren esr at one hour. to determine the accuracy and precision of the results, quality control material provided by the manufacturer was used. the vacuette srs 20/11 functioning is almost the same as ves-matic easy, but it holds 20 samples at one time, and its measuring time is 30 minutes. the westergren esr was performed according to the standardized selected method of the international council for standardization for hematology (icsh) using sodium citrate as an anticoagulant. results were entered on spss version 17 for analysis. we divided our patients into three groups on the basis of esr values obtained by westergren method: group1: esr 0-20; group2: esr 21-50; group 3: esr 51-100. means of results obtained from manual and automated methods were compared in all samples and in three groups and their p values were calculated; p value of <0.05 was taken as statistically significant. coefficient of variance was calculated for all methods. pearson correlation was calculated for both ves-matic and vacuette srs methods. results table 1 shows mean and sd values, difference of mean with p value and coefficient of variance (cv) calculated for westergren method, ves-matic easy and vacuette srs methods, in total samples and among three groups. as shown in the table cv of ves-matic method is lower pointing towards more reliability of this method. table 1 also shows the means and difference in means calculated for both the methods in comparison to that of westergren method. as shown in the table the difference of means is insignificant with ves-matic method at higher esr values. however with vacuette srs method this difference was significant with vacuette srs method in group 2 (esr 2150 mm/hr) table 1: evaluation of results of various groups by manual and automated methods (n 108) methods mean + sd (mm/time) difference of means p value cv (%) all cases (n 108) westergren 22.96 + 21.29 92.72 vest matic 21.86 +21.27 1.1 0.02 97.30 vacuette srs 20.36 + 19.96 2.6 0.00 98.03 group 1 (n 65) westergren 8.98 + 5.33 59.39 vest matic 8.28 + 4.64 0.7 0.02 56.02 vacuette srs 8.52 + 4.98 0.46 0.19 58.47 group 2 (n 29) westergren 32.90 + 7.97 24.22 vest matic 30.00 + 8.22 2.89 0.06 27.38 vacuette srs 26.28 + 8.89 6.62 0.00 33.05 group 3 (n 14) westergren 67.29 + 11.86 17.63 vest matic 68.07 + 10.49 -0.78 0.54 14.90 vacuette srs 63.08 + 15.90 4.21 0.14 25.21 significant p value: < 0.05 table 2: pearson correlation among different methods (n 108) methods correlation* p value westergren and vest matic methods r = 0.97 0.00 westergren and vacuette srs methods r = 0.95 0.00 **correlation is significant at the 0.01 table 2 shows the pearson correlation among different methods. as is shown in the table there is strong positive correlation between westergren method and ves-matic easy methods with pearson coefficient of 0.97 and highly significant p value of 0.000. results also show strong positive correlation between westergren and vacuette srs methods of 0.95 with highly significant p value of 0.00. figures 1 and 2 show that there is significant linear journal of islamabad medical & dental college (jimdc); 2012(2):81-84 83 correlation between westergren and ves-matic methods and westergren and vacuette srs methods figure 1: correlation of esr estimatiom (in mm/hr) by vest matic method and westergren method figure 2: correlation of esr estimation (in mm/hr) by vacuette srs method and westergren method discussion the erythrocyte sedimentation rate is a relatively simple and inexpensive test used to assess patients with acute or chronic inflammatory processes.12,13 it serves as a useful aid in the diagnosis of various clinical conditions, and has been shown to correlate with an unfavourable prognosis in neoplastic diseases and coronary artery disease.14-17 in recognition of the need for a standardization of the measurement of esr, the icsh has proposed a protocol for the evaluation of alternative methodologies against the reference method has also been proposed: the new technologies must be tested over a range of esr values of 2–120 mm. in this comparison, 95%of the differences should be 5 mm or less, with larger differences associated with higher esr values. the statistical methods recommended for esr evaluations are the coefficient of correlation, the passing-bablock regression and the blandaltman statistical method.18 we carried out this study to look for correlation of two automated methods (vesmatic and vacuette srs) with westergren method. we found strong positive correlation of both the methods with westergren method with highly significant p-value of 0.000. we also calculated coefficient of variance for different methods and it was found to be lower in ves-matic method indicting more reliability of this method. other studies also confirmed the excellent correlation between ves-matic and westergren. 19,20 there are some other automated methods which are in use. horsti j carried out study with starrsed and reported that starr-sed has advantages, as it offers savings of consumables, safety and fluent workflow. starrsed has many excellent technical properties and the study proved a fairly good correlation between two methods (r2 = 0.72) and found that starrsed is in better agreement with the westergren method. they reported that differences between starrsed and classic westergren method that were observed in their study were, in many cases, acceptable and clinically insignificant.21 fiorucci also compared test 1 system with westergren method but results showed a lower degree of agreement between these two methods. they proposed though the results obtained with test 1 system are within acceptable limits, the ves-matic instrument shows better correlation with the westergren method, with a consequently lower risk of false positive and false negative results.22 however curvers et al reported less correlation of ves-matic with westergren method and good correlation of sedi system and starrsed methods with conventional method. 23 in our study mean difference of three methods in three groups has shown that lower values were recorded by vacuette srs method as compared to westergren method particularly at higher esr values. however with ves-matic method this difference is less than three even at higher esr values. subramanian a. et al recommended that a correction factor be applied for the range of esr values with such discrepancies.24 there were only 14 samples in group 3 (esr 51-100 mm/hr) and 29 sample in group 2 (esr 21-50 mm/hr). since these two groups are most important as they comprise the cases with esr values indicating pathological basis. our recommendation is to carry out further studies with at-least 50 samples in each group and the third group should also contain samples with esr more than 100 according to westergren method. however with current available data both the methods show good correlation with westergren method. in conclusion, both automated method (ves-matic easy and vacuette srs) show good correlation to westergren method (as shown by pearson correlation coefficient). these findings indicate that ves-matic easy and vacuette srs are journal of islamabad medical & dental college (jimdc); 2012(2):81-84 84 reliable and suitable system for high workload clinical laboratory. the ves-matic easy method however shows a better correlation with less difference in means, particularly at higher esr values. references 1. saadeh c. the erythrocyte sedimentation rate: old and new clinical applications. south med j 1998; 91(3):220-225. 2. wolfe f, michaud k. the clinical and research significance of the erythrocyte sedimentation rate. j rheumatol 1994; 21(7):1227-1237. 3. thue g, sandberg s, fugelli p. the erythrocyte sedimentation rate in general practice: clinical assessment based on case histories. scand j clin lab invest 1994; 54(4):291-300. 4. gronlie m, hjortdahl p. the erythrocyte sedimentation rate; its use and usefulness in primary health care. scand j prim health care 1991;9(2):97-102 5. danesh j, wheeler jg, hirschfield gm, eda s, eiriksdottir g, rumley a, lowe gd, et al. c-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease. n engl j med 2004;350(14):13871397. 6. erikssen g, liestol k, bjornholt jv, stormorken h, thaulow e, erikssen j. erythrocyte sedimentation rate: a possible marker of atherosclerosis and a strong predictor of coronary heart disease mortality. eur heart j 2000; 21(19):16141620. 7. fahraeus, 1921; westergren, 1921), fahraeus r. (1921) the suspension stability of the blood. acta medica scandinavica 55, 1–7. cited by jou j.m, lewis s.m, briggs c, lee s.h, b. dela salle b.d. icsh review of the measurement of the erythrocyte sedimentation rate int. jnl. lab. hem. 2011, 33, 125–132 8. westergren a. (1921) studies of the suspension stability of the blood in pulmonary tuberculosis. acta medica scandinavica 54, 247–282. cited by jou j.m, lewis s.m, briggs c, lee s.h, b. dela salle b.d. icsh review of the measurement of the erythrocyte sedimentation rate int. jnl. lab. hem. 2011, 33, 125–132 9. international committee for standardization. recommendation of measurement of erythrocyte sedimentation rate of human blood. am j clin pathol. 1977;68:505 507 10. alfadhli dm, al-awadhi am. comparison of erythrocyte sedimentation rate measurement by the automated sedisystem and conventional westergren method using the bland and altman statistical method. med princ pract. 2005;14:241-244 11. jonge n, sewkaransing i, slinger j, et al. erythrocyte sedimentation rate by the test-1 analyzer. clin chem. 2000; 46(6 pt 1):881-882. 12. alexy t, pais e, and meiselman hj. a rapid method to estimate westergren sedimentation rates. review of scientific instruments 2009; 80: 096101-3. 13. international council for standardization in haematology, j. clin. pathol 1993; 46: 198. 14. j. g. jones and b. l. hazleman, ann. rheum. dis 1983; 42: 702 15. h. a. bird, w. esselinck, a. s. dixon, a. g. mowat, and p. h. wood, ann. rheum. dis. 1979; 38: 434 16. r. c. brooks and s. r. mcgee, arch. intern med. 1997; 157: 162. 17. j. danesh, r. collins, r. peto, and g. d. lowe, eur. heart j. 2000; 21: 515 18. jou j.m, lewis s.m, briggs c, lee s.h, b. dela salle b.d. icsh review of the measurement of the erythrocyte sedimentation rate int. jnl. lab. hem. 2011, 33, 125–132 19. fiorucci g, camogliano l and massacane r. comparison of two automated systems for the measurement of erythrocyte sedimentation rate: ves-matic and test 1. biochemica clinica 2000;24(3):175-179. 20. perovic e, bakovic l, valcic a. evaluation of ves-matic cube 200 – an automated system for the measurement of the erythrocyte sedimentation rate international journal of laboratory hematology 2010;32(1) :88-94 21. horsti j, rontu r and collings a. a comparison between the starrsed auto-compact erythrocyte sedimentation rate instrument and the westergren method. journal of clinical medicine research 2010; 2(6):261-265 22. fiorucci g, camogliano l and massacane r. comparison of two automated systems for the measurement of erythrocyte sedimentation rate: ves-matic and test 1. biochemica clinica 2000;24(3):175-179. 23. curvers j, kooren j, laan m and lierop e. et al. evaluation of the ves-matic cube 200 erythrocyte sedimentation method comparison with westergren-based methods am j clin pathol 2010; 134:653-660 24. subramanian a, rangarajan k, pandey rm, gandhi js, sharma v, bhoi sk. evaluation of an automated erythrocyte sedimentation rate analyzer as compared to the westergren manual method in measurement of erythrocyte sedimentation rate. indian j pathol microbiol.2011; 54(1):70-4 j islamabad med dental coll 2023 36 open access frequency of gallstones in fatty liver disease in a tertiary care of suburban islamabad iftikhar ahmed1, arslan zahid2, iram iqbal3, nauman mustafa4, asma bashir5, fauzia rashid6 1,5assistant professor of surgery, hbs medical and dental college, islamabad, pakistan 2senior registrar surgery, hbs medical and dental college, islamabad, pakistan 3assistant professor of radiology, hbs medical and dental college, islamabad, pakistan 4professor of surgery, hbs medical and dental college, islamabad, pakistan 6senior registrar radiology, hbs medical and dental college, islamabad, pakistan a b s t r a c t authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3,4 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: iftikhar ahmed email: drisoomro4u@gmail.com article info: received: march 15, 2022 accepted: march 20, 2023 cite this article. ahmed i, zahid a, iqbal i, mustafa n, bashir a, rashid f. frequency of gallstones in fatty liver disease in a tertiary hospital of suburban. j islamabad med dental coll. 2023; 12(1): 36-41 doi: https://doi.org/10.35787/jimdc.v11i3.857 funding source: nil conflict of interest: nil i n t r o d u c t i o n gallstone formation or cholelithiasis is a complex process with a number of different causative factors leading to a single common pathway of stone formation. precipitation of crystalline materials in bile forms a nidus around which further precipitation takes place, eventually resulting in the formation of a stone.1 the precipitation can be background: gallstone disease and non-alcoholic fatty liver disease (nafld) share common etiological pathways. the objective of this study was to determine the frequency of gallstones and non-alcoholic fatty liver disease (nafld) in patients undergoing abdominal ultrasounds in our hospital and to compare the frequency of gallstone disease in patients with nafld and without nafld. methodology: this cross-sectional study was carried out at hbs general hospital, islamabad from january 2020 till december 2020. patients undergoing routine ultrasounds in the out-patient department of the hospital were included in the study. patients having emergency ultrasounds, history of alcohol intake, history of chronic liver disease and pregnant patients were excluded from the study. data was analysed using microsoft excel 2016 and ibm spss 22. results: a total of 689 patients were included with a 3:1 female to male ratio. mean age was 40.65± 15.610 years. the prevalence of gallstone disease was found to be 20.9% while that of nafld 27.6%. a higher percentage of patients with nafld had gallstones as compared to those who did not have nafld (24.2% vs 19.6% respectively) however for overall data, statistical significance was not reached. a statistically significant greater number of young patients with nafld had gallstones as compared to those who did not have nafld (50% vs 6%, p<0.001). mean age was greater in patients who had nafld as well as those having gallstones. conclusion: the frequency of gallstones was greater in patients with nafld as compared to those without nafld. key words: cholelithiasis, fatty liver disease, gallstones, non-alcoholic, ultrasonogram o r i g i n a l a r t i c l e mailto:drisoomro4u@gmail.com j islamabad med dental coll 2023 37 caused by disturbances in biliary homeostasis which can be as a result of many different factors. weight, diet, drugs, age, gender, fertility, disease and extent of physical activity have been linked to gall stone disease. gall stone disease shares these predisposing factors with non-alcoholic fatty liver disease.2 non-alcoholic fatty liver disease (nafld) is usually asymptomatic in its initial stages and has a poorly understood etiology.3 links have been reported to metabolic syndromes including diabetes mellitus, obesity, dyslipidemia and hypothyroidism.4 there is ongoing research into understanding nafld. inflammation in nafld can lead to steatohepatitis and ultimately cirrhosis and chronic liver disease.4,5 while treatment of cholelithiasis is cholecystectomy, the treatment of nafld is complex and involves life style changes as well as medication.6 due to similar risk factors between the two diseases, there has been a recent interest to determine whether there is a link between the two pathologies,7 however, literature currently is scarce and controversial8, with some studies claiming that these two conditions are linked while others declare them independent of each other.5,9,10 in this study, we aim to determine the frequency of gallstones as well as nafld in our patients and to see if these two diseases are related.11 this information will help us in better understanding of relationship between these diseases and thus will lead to improved management and improved patient outcomes. we compared our results with other published literature to see whether there is an effect of ethnicity and geography on the frequency of these disease.12 this study will generate local data and will contribute to improvement in academic as well as clinical knowledge of the two diseases. m e t h o d o l o g y this descriptive study was carried out at our hospital over a period of one year (i.e. january 2020 till december 2020). ethical approval was obtained from the affiliated medical college, ethical committee. patients undergoing routine ultrasounds in the out-patient department of the hospital were included in the study after informed consent and following the inclusion and exclusion criteria. patients having emergency ultrasounds, history of alcohol intake, history of chronic liver disease and pregnant patients were excluded from the study. all ultrasounds were performed by consultant radiologists and the data were recorded on the designated proforma. a patient was labelled as having cholelithiasis on ultrasound if he/she had mobile stones casting posterior acoustic shadowing or mobile sludge in the gallbladder. a patient was labelled as having nafld on ultrasound if he/she had increased echogenicity or coarsened echotexture of liver or nodular surface of liver and no clinical or radiological signs of inflammation of liver. nafld was graded as follows: grade i: diffusely increased hepatic echogenicity but peri-portal and diaphragmatic echogenicity was still appreciable grade ii: diffusely increased hepatic echogenicity obscuring peri-portal echogenicity but diaphragmatic echogenicity was still appreciable grade iii: diffusely increased hepatic echogenicity obscuring peri-portal as well as diaphragmatic echogenicity. data were analyzed using microsoft excel 2016 and ibm spss 22. mean and standard deviation was calculated for quantitative data like age. frequency and percentages was calculated for analysis of qualitative data like gender, presence of gall stones, presence of nafld. stratification was done according to age, gender, presence and absence of gall stones and nafld. chi-square test was used to compare the frequency of nafld in patients with and without gallstones. j islamabad med dental coll 2023 38 r e s u l t s we included 689 patients in our study. there was an overwhelming female predominance in our study, n= 524 (76.1%) as compared to n= 165 (23.9%) of male patients. mean age was 40.65± 15.610 years. gallstones were found to be 20.9% (n= 144) while that of fatty liver disease was found to be 27.6% (n= 190). chi-square test was applied to compare frequencies of presence of gall stones in patients who had fatty liver disease with those who did not, and it was found, this was not statistically significant. this is illustrated in table i. figure i depicts the frequency of different grades of fatty liver disease found in our patients. mean age was compared between patients who had fatty liver disease versus patients who did not have fatty liver disease and patients with gallstones versus patients without gallstones, using t-test. mean age was found to be significantly lower in patients who did not have fatty liver disease as compared to those who had fatty liver disease (38.78±16.44 years vs 45.57±11.882 years, p<0.001). a similar finding was noted based on the presence and absence of gallstones (39.25±15.64 vs 45.94±14.32 years, p<0.001). table i: frequency of fatty liver disease in patients according to gender and presence of gallstones (n=689) non-alcoholic fatty liver disease p value absent present g a ll sto n e s absent 401 (58.2%) 144 (20.89% 0.187 present 98 (14.22%) 46 (6.67%) g e n d e r male 110 (15.9%) 48 (6.9%) 0.332 female 381 (55.29%) 137 (19.88% stratification was done according to age as well. this yielded results which showed that the frequency of both gallstones and fatty liver disease increased with age. subgroup analysis of younger patients also revealed that patients who had fatty liver were more likely to have gallstones as compared to those who did not have fatty liver disease (50% vs 6%, p<0.001). figure ii shows frequency of gallstones and fatty liver disease stratified according to age. figure 1: presence and absence of gallstones in patients according to grades of fatty liver disease figure 2: shows frequency of gallstones and fatty liver disease stratified according to age d i s c u s s i o n gallstone disease is one of the most common disease affecting humans. it has a common etiology which has common causative factors with nonalcoholic fatty liver disease. the frequency of j islamabad med dental coll 2023 39 gallstones and nafld in our study to be 20.9% (n=144) and 27.6% (n=190) respectively. this demonstrates that both of these diseases are common among our population while nafld is slightly more common than gallstones. as these disease have some common etiological pathways, interest has been generated to investigate whether these two disease have other correlations. in our study, we compared the frequency of gallstones in patients having nafld and those not having nafld and found that although patients having nafld had higher frequency of gallstones (nafld group= 24% vs non-nafld group 19%, p= 0.187), it did not reach statistical significance. singh k et. al in their study described the prevalence of nafld in 101 patients undergoing cholecystectomy for gallstones.4 the gender distribution and mean age in their study is comparable to our study as their study also had a female predominance (75% female patients vs 25% male patients) and mean age was close to the mean age in our study (42.37±13.21 years in their study). the prevalence of nafld on ultrasound in their study was found to be 34.7%, keeping in mind that they only included patients who were undergoing cholecystectomies for cholelithiasis in their study, while in our study this was found to be 31.9% (n=46 out of 144 patients who had gallstones). the similarities in our data might be explained by relatively close geographical location as their study was carried out in chandigarh, india. the diet and eating habits of both these regions are also quite similar because of a shared culture before the creation of pakistan and india. li x and gao p in their cross-sectional study carried out in china included 897 patients.9 they found that the prevalence of gallstone disease was similar in men and women. they also reported that younger patients who had fatty liver disease had a higher frequency of gallstone disease as compared to young patients who did not have fatty liver disease. they also found that the frequency of gallstones increased with age. a similar finding was also noted in our study, as the frequency of gallstones increased with age, with the prevalence at 8.7% in patients younger than 25 years old, 19.9% in 25-50 years old, 33.8% in 50-75 years old and 31% in patients older than 75 years. we also found that the frequency of gallstones in patients younger than 25 was higher in nafld group as compared to nonnafld group. this finding is in line with the finding of li x and gaop, that in young patients, fatty liver disease may be a risk factor for developing gallstone disease. this may be due to the common etiological factors associated with both diseases as well as a probability that those young patients who have nafld also have dysfunctional bile homeostasis leading to the development of gallstones. another study done by qiao q et. al in china described the correlation between gallstones and nafld in their population.13 they found that the prevalence of nafld was significantly higher in patients having gallstones as compared to those without gallstones (58.98% vs 46.58%, p <0.001). although we found a similar finding, our results did not reach statistical significance (31.9% in gallstone group vs 26.4% in non-gallstones group, p = 0.187). this might be due to the difference in sample size of the two studies as well as geographical and demographic factors. qiao q et. al included 7583 subjects in their study, whereas our study had a sample size of 689 patients, which is roughly 10% of their sample size. an increase in the sample size also raises the possibility of detecting a statistically significant difference between the frequency of nafld in patients with gallstones and those without gallstones. in our results, although the frequencies of nafld and gallstones appeared to be greater in patients who had the other disease, this was not found to be statistically significant, apart from young patients. one of the possible deductions might be that our sample size was underpowered to detect the difference between the groups.13 previously published literature demonstrates that there is a j islamabad med dental coll 2023 40 relationship between these two diseases having common causes and etiological pathways.14 arrese m15 stated that there is a complex but definite relationship between fatty liver & gall stone disease, whether the patient takes alcohol or not. hung mc et al calculated the relationship between gall stones and number of metabolic risk factors including lipid profile, ultrasound scan findings and weight of the patient16. his team showed invariably increased incidence of gall stones in fatty liver and obese patients. chang y et al conducted a study in korea concluding that increased non-invasive fibrosis markers of nafld were positively associated with an increased frequency of gallstones in a graded and doseresponsive manner (p-value <0.01). this large-scale cohort study of young and middle-aged individuals demonstrated a bidirectional association between nafld and gd. nafld and its severity were independently associated with an increased incidence of gallstones.17 another study published in world journal of gastrointestinal pathophysiology has proposed that gall stones and cholecystectomy are risk factors for non-alcoholic fatty liver disease.18 similar results were shown by summart u et al19 from thailand. kakati d from us found out that nafld does not worsen the symptoms or disease progression20. c o n c l u s i o n the frequency of gallstones was greater in patients with nafld as compared to those without nafld, but it was not statistically significant. r e f e r e n c e s 1. ioannou gn. cholelithiasis, cholecystectomy, and liver disease. am j gastroenterol. 2010;105(6):136473. 2. alvaro d. gallstones: bad company for the steatotic liver. gastroenterology. 2017;152(6):1284-6. 3. lonardo a, nascimbeni f, maurantonio m, marrazzo a, rinaldi l, adinolfi le. nonalcoholic fatty liver disease: evolving paradigms. world j gastroenterol. 2017;23(36):6571-92. 4. singh k, dahiya d, kaman l, das a. prevalence of nonalcoholic fatty liver disease and hypercholesterolemia in patients with gallstone disease undergoing laparoscopic cholecystectomy. pol przegl chir. 2019;92(1):18-22. 5. kim yk, kwon os, her kh. the grade of nonalcoholic fatty liver disease is an independent risk factor for gallstone disease: an observational study. medicine (baltimore). 2019;98(27):e16018. 6. arrese m, cortés v, barrera f, nervi f. nonalcoholic fatty liver disease, cholesterol gallstones, and cholecystectomy: new insights on a complex relationship. curr opin gastroenterol. 2018;34(2):906. 7. rodríguez-antonio i, lópez-sánchez gn, garridocamacho vy, uribe m, chávez-tapia nc, nuñolámbarri n. cholecystectomy as a risk factor for nonalcoholic fatty liver disease development. hpb (oxford). 2020;22(11):1513-20. 8. yilmaz y, ayyildiz t, akin h, colak y, ozturk o, senates e, et al. gallstone disease does not predict liver histology in nonalcoholic fatty liver disease. gut liver. 2014;8(3):313-7 9. li x, gao p. fatty liver increases gallstone disease risk in younger chinese patients. medicine (baltimore). 2019;98(22):e15940. 10. ahmed mh, ali a. nonalcoholic fatty liver disease and cholesterol gallstones: which comes first? scand j gastroenterol. 2014;49(5):521-7. 11. hajong r, dhal mr, naku n, kapa b. incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy. j family med prim care. 2018;7(6):1375-8. 12. liu j, lin h, zhang c, wang l, wu s, zhang d, et al. non-alcoholic fatty liver disease associated with gallstones in females rather than males: a longitudinal cohort study in chinese urban population. bmc gastroenterol. 2014;14:213. 13. qiao qh, zhu wh, yu yx, huang ff, chen ly. nonalcoholic fatty liver was associated with asymptomatic gallstones in a chinese population. medicine (baltimore). 2017;96(38):e7853. https://pubmed.ncbi.nlm.nih.gov/?term=arrese+m&cauthor_id=29266009 j islamabad med dental coll 2023 41 14. reddy sk, zhan m, alexander hr, el-kamary ss. nonalcoholic fatty liver disease is associated with benign gastrointestinal disorders. world j gastroenterol. 2013;19(45):8301-11. 15. arrese m , cortés v , barrera f , nervi f . nonalcoholic fatty liver disease, cholesterol gallstones, and cholecystectomy: new insights on a complex relationshipcurr opin gastroentero 2018 mar;34(2):90-96. 16.hung mc, chen cf, tsou mt, lin hh, hwang lc, hsu cp. relationship between gallstone disease and cardiometabolic risk factors in elderly people with non-alcoholic fatty liver disease. diabetes metab syndr obes. 2020 oct 9;13:3579-3585. doi: 10.2147/dmso.s266947. pmid: 33116709; pmcid: pmc7553650. 17. chang y, noh yh, suh bs, kim y, sung e, jung hs, kim cw, kwon mj, yun ke, noh jw, shin h. bidirectional association between nonalcoholic fatty liver disease and gallstone disease: a cohort study. journal of clinical medicine. 2018 nov 21;7(11):458. 18. kichloo a, solanki s, haq kf, dahiya d, bailey b, solanki d, singh j, albosta m, wani f, aljadah m, shah h, khan h, jafri sm. association of non-alcoholic fatty liver disease with gallstone disease in the united states hospitalized patient population. world j gastrointest pathophysiol. 2021 mar 22;12(2):14-24. 19. summart u, thinkhamrop b, chamadol n, khuntikeo n, songthamwat m, kim cs. gender differences in the prevalence of nonalcoholic fatty liver disease in the northeast of thailand: a population-based crosssectional study. f1000res. 2017;6:1630. 20. kakati d, kumar u, russ k, shoreibah m, kuo yf, jackson b, singal ak. cholecystectomy does not worsen progression or outcomes in non-alcoholic fatty liver disease. transl gastroenterol hepatol. 2020;5:3. https://pubmed.ncbi.nlm.nih.gov/?term=arrese+m&cauthor_id=29266009 https://pubmed.ncbi.nlm.nih.gov/?term=cort%c3%a9s+v&cauthor_id=29266009 https://pubmed.ncbi.nlm.nih.gov/?term=barrera+f&cauthor_id=29266009 https://pubmed.ncbi.nlm.nih.gov/?term=nervi+f&cauthor_id=29266009 49 j i m d c 2 0 1 7 49 op e n ac c e ss f u l l l e n g t h a r t i c l e frequency of dry eye disease in elderly population and their associated risk factors munir amjad baig1, shahid mahmood2, rabeeya munir3, nazzuk shahid4 1assistant professor ophthalmology, ajk medical college, muzaffarabad 2 professor & hod surgery, islamabad medical & dental college, islamabad 3 demonstrator, rawal institute of health science islamabad 4 final year mbbs, islamic international medical college, rawalpindi a b s t r a c t objective: to know the pattern of dry eye disease (ded) in a tertiary care hospital and its association with various clinicoepidemiological factors. patients and methods: this one-year cross sectional study was conducted at federal government services hospital from 1st january 2012 to 31st dec 2012. about 1600 patients above 40 years of age were screened randomly for ded and included in the study. a 5-item standardized questionnaire (deq 5), schirmer's test (st), tear film breakup time (tbut), corneal fluorescein staining (cfs) for the presence of conjunctival injection, punctate epithelial erosions (pee), and meibomian gland dysfunction (mgd) were used. the diagnosis was made on the presence of three out of five parameters. spss 17 was used to analysed the data. results: about 1600 willing patients were screened for ded. among them four hundred and eighty-six (486) (30.37%) patients were diagnosed on the basis of symptoms and signs as ded. out of them, 261(53.7%) were males and 225(46.25%) were females, 288(59.2%) were urban and 198(40.7%] belong to rural areas. conclusion: ded constitutes a major proportion of patients attending the ophthalmology department in a tertiary care hospital. it is a multifactorial disease, is frequent in an elderly male who are using drugs like an antihistamine, anti-bph, antidepressant, and in postmenopausal women. key words: dry eye, meibomian gland dysfunction, schirmer test. author`s contribution 1 conception, synthesis, and planning of the research,2 active participation in active methodology & discussion, 3data analysis, 4helped in references and literature search address of correspondence dr. munir amjad baig drmuneeramjad@yahoo.com article info. received: jan 28, 2017 accepted: mar 24, 2017 cite this article: baig ma, mahmood s, munir r, shahid n. incidence of dry eye disease in elderly population of islamabad 2017; 6(1):49-52. funding source: nil conflict of interest: nil i n t r o d u c t i o n the swedish ophthalmologist henrick sjogren used the term “kerato conjunctivitis sicca” comprising the triad of kerato conjunctivitis sicca, dry mouth, and joint pains.1 in 1946, wolff described that the meibomian glands are essentially the proper glands of the cornea, which in the interests of vision have been moved out of the way.2 in 1950 de roth used the term “dry eye”.3 in 1955 it was named as a problem due to decreased tear production.4 in 2006 delphi panel proposed dysfunctional tear syndrome (dts) with the remarks that inflammation plays a role in the disease.5 in 2007, the international dry eye workshop (dews) developed a new definition as “dry eye is a multifactorial disease of tear and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. it is accompanied by increased osmolarity of the o r i g i n a l a r t i c l e mailto:drmuneeramjad@yahoo.com 50 j i m d c 2 0 1 7 50 tear film and inflammation of ocular surface.6 about 4.7% of american men and 7.8% of american women aged 50 years and older had ded7, about 3.2 million women and about one million men are involved in united states.8 only a few population-based studies are available. salisbury eye study in us shows the prevalence of ded to be 14.6%.9 one study carried out in a tertiary care hospital in pakistan showed the prevalence as 16%.10 a study conducted on elderly korean population found that female sex, age, and hormonal influence were risk factors for ded.11 in indonesia, prevalence is 27.5% in older age group especially those who are smokers. in taiwan, its prevalence is 33.7% with women involved more,13 while in india it is 29.25%.14 kanski describes the importance of humidity and temperature which is responsible for the integrity of the tear film.15 the goal of this study was to know the pattern of ded and its associated risk factors like smoking and medications in elderly people of islamabad. some known risk factors of ded such as diabetes, arthritis, thyroid disease, hyperlipidemia, and multivitamins were not investigated in this study. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted in department of ophthalmology, federal government services hospital islamabad from 1st jan 20l2 to 31st dec 2012. only those patients who consented for the study were included in the study. mentally handicapped patients, patients with corneal and conjunctival problems, patients with contact lens, intraocular surgeries during six months and any ocular surface disease were not included. written permission was taken from ethical committee. a trained interviewer filled 5 items dry eye questionnaire (deq5). after that, the score was calculated. all participants had a general physical and a thorough ophthalmologic examination. tear film breakup time (tbut] and schirmer's test were performed each at 10minute intervals. corneal fluorescein staining, punctate epithelial erosions, conjunctival injection, papillary hypertrophy, follicles and examination of lids for plugging and mucous strands were considered as indicators of dry eye. patients already using tear substitutes, medications were stopped for an overnight. the diagnosis was made on the presence of three out of five parameters, dry eye questionnaire scores >6, tfbut <10 seconds, schirmer's test <5 mm in 5 minutes and at least two of the dry eye signs. the presence of pterygium was also recorded. spss 17 was used to analyzed the data. r e s u l t s in this study, the percentage of male patients were slightly higher than females. among 1600 patients, 52.6% (843/1600) were male and 47.4% (757/1600) were female. sixty two percent (992/1600) belonged to urban while 38% (608/1600) from rural areas. dry eye was present in 30.3% (486/1600), among these, 261(53.7%) were males and 225(46.25%) were females (table 1). a maximum number of patients in this study was more than 50 years old. sixty percent (133/225) of females were post-menopausal. about 29% (140/486) patients were on antihistamines. 21% (102/486) were on an antidepressant. 17% (82/486) patients were on medication for benign prostatic hypertrophy and 36.4% (177/486) of the dry eye cases were smokers (table 2). table 2: risk factors associated with ded risk factor n (%) antihistamine 140 (29%) antidepressants 102(21%) medication for bph 82 (17%) smokers 177 (36.4%) most common symptoms in our study were watering 31.6%, gritty/irritation 22.8% and redness 19.9%. among symptomatic patients, 81.4% (396/486) had a low tfbut (< 10 seconds), 60.6% (295/486) had a low schirmer test result (<5 mm), 36% (174/486) had fluorescein scoring 1 or greater, and 58.8% (286/486) had abnormal anatomic features of the meibomian glands. among symptomatic patients, 57.6%(280/486) had visited an eye clinic, 27%(131/486) had been diagnosed as a patient of ded and 15.4%(74/486) already been using eyedrops. blepharitis was detected in 51.4% (250/486) of the dry table 1. gender wise frequency in study population male n(%) female n(%) total (n=1600) 843 (52.6%) 757 (47.4%) ded(n=486 ) 261 (53.7%) 225 (46.3%) 51 j i m d c 2 0 1 7 51 eye cases. in our study 27% (131/486) subjects were having uncorrected refractive errors. d i s c u s s i o n our study in this population shows a higher prevalence of ded in males 53.7% (261/486) than females 46.2% (225/486) and in urban residents 59.2% (288/486) than 40.7%(198/486) rural subjects which is not consistent with other studies.17 islamabad, being the city of government servants, male are more exposed to external environments like light/temperature and strong wind mccarty dj while females are mostly housewives. gupta et al (2000) suggested that long-term exposure to air pollution leads to ded.14 in our study, 30.3% 486 patients presented in eye unit were diagnosed as dry eyes. this is consistent with international dews which states that global prevalence of ded is about 17% while in asia it is higher about 30%.16 other report showed that ded increased with age is consistent with our study. in our study, low tfbut and schirmer's values with advancing age were consistent with studies conducted by shaumberg et al (2009)18 and moss et al (2008).19 in the present study 60%(135/225) females had menopause, 40%(90/225) were otherwise normal. blepharitis was present in 51.4% (250/486), 36.4% (177/486) of the de cases were smokers.20 systemic medications menopausal hormone therapy, which involves oestrogen and other hormones, has been shown to cause dry eye. medications that reduce androgens, e.g. for prostate disease, also can cause dry eye. our study also supported the association between several medications and ded, 29% (140/486) patients were on antihistamines while 10% (48/486) were not. in a survey conducted by mccarty dj on dry eye symptoms in australian pilots, it was concluded that self-reported symptoms of dry eye were common in australian pilots and were associated with aero plane class and flying time.21 in our study, 17% (102/486) were in use of antidepressant and 10% (40/486) were not. moss se et al in their study of ded in elderly population and their associated risk factors, reported that some drugs (e.g., diuretics and antihistamines) are associated with a greater risk, whereas others (angiotensin-converting enzyme inhibitors) are associated with lower risk.22 in another study on longterm incidence of dry eye in an older population by moss se et al, incidence was found greater (p < 0.05) in subjects with arthritis, allergy or thyroid disease not treated with hormone, using antihistamines, antianxiety medications, antidepressants, oral steroids or vitamins, and poorer self-rated health. however, incidence was less (p < 0.05) in subjects consuming alcohol. it was not significantly associated with blood pressure, hypertension, serum total or high density lipoprotein cholesterol, body mass, diabetes, gout, osteoporosis, cardiovascular disease, smoking, caffeine use, or taking calcium channel blockers or anticholesterol medications in their study. in a multivariable model with time-varying covariates, increased incidence was associated with age, female gender, poorer self-rated health, antidepressant or oral steroid use, and thyroid disease untreated with hormone. again it was found lower in those using angiotensinconverting enzyme inhibitors or with a sedentary lifestyle.23 in our study, 17% (82/486) patients were on anti benign prostatic hyperplasia (anti-bph) drugs showed a higher prevalence of ded. other studies show a 1.7 to 1.9 increased risk of ded in patients using antidepressant medications.24 in our study, 27% (131/486) subjects with uncorrected refractive errors had ded, which may be due to the habit of rubbing their eyes. strengths of our study is that we used a five items questionnaire to detect de symptoms and it was a large population-based study. moreover, trained interviewer reduces scoring bias. c o n c l u s i o n there is a link between dry eye disease and our modern lifestyle. it is seen more commonly seen in patients taking anti-depressants, anti-bph and antihistamine medicines. dry eye is rarely sight-threatening. apprehensive patients can be easily counselled and referred to tertiary care unit. r e f e r e n c e s 1. sjögren hsc. zurkenntnis der keratoconjunctivitissicca (keratitis filiformisbeihypofunktion der tränendrüsen) acta ophthalmol. 1933;(supp. ii):1–151. 52 j i m d c 2 0 1 7 52 2. wolff e. the mucocutaneous junction of the lid margin and distribution of the tear fluid. trans ophthalmo lsoc uk. 1946;66:291-308. 3. galor a, feuer w, lee dj. prevalence and risk factors of dry eye syndrome in a united states veterans affairs population. am j ophthalmol. 2011;152(3):377–384 4. lemp ma. report of the national eye institute/industry workshop on clinical trials in dry eye. clao j. 1995;21(4):221–232 5 behrens a, doyle jj, stern l, chuck rs, mcdonnell pj, azar dt, dua hs, hom m, karpecki pm, laibson pr, lemp ma. dysfunctional tear syndrome: a delphi approach to treatment recommendations. cornea. 2006 ;25(8):900-7. 6. international dry eye workshop (dews) the definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye workshop. ocul surface. 2007;5:75– 92. http://www.tearfilm.org/dewsreport/pdfs/tos-0502-dewsnoads.pdf 7 schaumberg da, dana r, buring je, sullivan da. prevalence of dry eye disease among us men: estimates from the physicians health studies. arch ophthalmol. 2009;127(6):763–768. 8. schaumberg da, sullivan da, buring je, dana mr. prevalence of dry eye syndrome among us women. american journal of ophthalmology. 2003;136(2):318-26. 9. munoz b, west sk, rubin gs, schein od, quigley ha, bressler sb, et al. causes of blindness and visual impairment in a population of older americans: the salisbury eye evaluation study. archives of ophthalmology. 2000 ;118(6):819-25. 10 malik tm, naqvi sa, shahid m. dry eye syndrome frequency in adult patients attending the eye clinic in military hospital rawalpindi. professional medical journal. 2009;16(1):145-8. 11 han sb, hyon jy, woo sj, lee jj, kim th, kim kw. prevalence of dry eye disease in an elderly korean population. archives of ophthalmology. 2011 ;129(5):6338. 12. lee aj, lee j, saw sm, gazzard g, koh d, widjaja d, et al. prevalence and risk factors associated with dry eye symptoms: a population based study in indonesia. british journal of ophthalmology. 2002;86(12):1347-51. 13 lin py, tsai sy, cheng cy, liu jh, chou p, hsu wm. prevalence of dry eye among an elderly chinese population in taiwan: the shihpai eye study. ophthalmology. 2003;110(6):1096-101. 14 gupta sk, gupta v, joshi s, tandon r. subclinically dry eyes in urban delhi: an impact of air pollution?. ophthalmologica. 2002 ;216(5):368-71. 15 kanski jj. the lacrimal system. in kanski jj.ed. clinical ophthalmology: a systematic approach. windsor: butterworth co. 1991: 46-52 16. dieckow j. 6th international conference on the tear film & ocular surface: basic science and clinical relevance (florence, italy, september 2010) ocul surf. 2011;9:3–12 17. begley cg, chalmers rl, mitchell gl, nichols kk, caffery b, simpson t, dutoit r, portello j, davis l. characterization of ocular surface symptoms from optometric practices in north america. cornea. 2001 aug 1;20(6):610-8. 18 schaumberg da, dana r, buring je, sullivan da. prevalence of dry eye disease among us men: estimates from the physicians' health studies. arch ophthalmol. 2009;127(6):763–768. 19. moss se, klein r, klein be. long-term incidence of dry eye in an older population. optometry & vision science. 2008;85(8):668-74. 20. sahai a, malik p. dry eye: prevalence and attributable risk factors in a hospital-based population. indian journal of ophthalmology. 2005 ;53(2):87. 21. mccarty dj, mccarty ca. survey of dry eye symptoms in australian pilots. clin experiment ophthalmol. 2000;28(3):169–171 22. moss se, klein r, klein be. incidence of dry eye in an older population. arch ophthalmol.2004;122(3):369–373. 23. moss se, klein r, klein be. long-term incidence of dry eye in an older population. optom vis sci.2008;85(8):668– 674. 24. galor a, feuer w, lee dj, florez h, carter d, pouyeh b, prunty wj, et al. prevalence and risk factors of dry eye syndrome in a united states veterans affairs population. american journal of ophthalmology. 2011;152(3):377-84. j islamabad med dental coll 2022 49 o p e n a c c e s s nasopharyngeal angiofibroma ahmad liaquat1, nabeela riaz2, tahmasub faraz tayyab3, ayaz mehmood4 1,3assistant professor, oral and maxillofacial surgery, university college of dentistry, university of lahore a b s t r a c t nasopharyngeal angiofibroma (na) is a rare, highly vascular, benign lesion typically affecting young males. it is prone to spontaneous bleeding even after minor trauma. reported here is a case of an 18 years old male with almost 8x8cm swelling in the left cheek. there was nasal obstruction due to mass in the left nostril and he had a history of obstructive sleep apnea and frequent epistaxis. case was treated with surgical resection of tumor using weber-ferguson approach. histopathology report revealed it to be nasopharyngeal angiofibroma. keywords angiofibroma, tumor, vascular correspondence: ahmad liaquat email: ahmadliaquat@hotmail.com article info: received: september 1, 2021 accepted: january 25, 2022 cite this article. liaquat a, riaz n, tayyab tf, talpur ta, mehmood a nasopharyngeal angiofibroma. j islamabad med dental coll. 2022; 11(1):49-52. doi:10.35787/jimdc.v11i1.776 funding source: nil conflict of interest: nil i n t r o d u c t i o n nasopharyngeal angiofibroma is a benign lesion with high vascularity. its a rare tumor that was first documented in the fifth century bc.1 it was later called juvenile nasopharyngeal angiofibroma by friedberg in 1940. the most probable reason for declaring it juvenile nasopharyngeal angiofibroma was that most of the cases were between the age of 14-25 years, but occasional cases occur in older patients as well.2 other terminologies are also used for nasopharyngeal angiofibroma such as juvenile angiofibroma (jaf) or fibromatous.3 it is also called angiofibromatous hamartoma of the nasal cavity since some researchers believe that na is hamartomatous in nature, leading to a debate about the origin of na, that is hamartoma and vascular malformation theories.4 it is remarkable to note that na is prevalent in the male population owing to the presence of high androgen receptor (ar) expression, signifying that na proliferation depends on androgen hormone.1,2 it is uncommon, comprising only 0.05% to 0.5% of all tumors of the craniofacial and neck region.5 on histopathological evaluation, most of the cases are found to be benign, however, it frequently expresses aggressive pattern, locally invading orbital and intra-cranial region in about 10% to 37% of all cases of na.6,7 reported here is a case of an 18-year-old male patient with nasopharyngeal angiofibroma on the left side of the face. c a s e r e p o r t an 18-years-old boy, belonging to low socioeconomic status, presented with a mass in the left side of his cheek and nose. he had a history of frequent epistaxis, snoring and obstructive sleep apnea. there was a soft to the firm, well-demarcated tumor on the left side of the cheek. superio inferiorly, it was extending almost 3cm away from the left infraorbital margin and going down till the base of the mandible. mediolaterally, it was extending from the left nasolabial fold and ending almost 3cm interior to the posterior ramal margin. overlying skin color, temperature and texture were c a s e r e p o r t j islamabad med dental coll 2022 52 normal (figure-1). the left nostril was obliterated with the mass whereas right nostril was clear. intraoral examination showed a bimanual palpable mass in the left cheek extending to the left side of the soft palate. the soft palate was bulging down due to the mass and causing the oronasal obstruction. the overlying mucosa was normal. all cranial nerves were intact. there was no significant past medical and surgical history. family history was also insignificant. figure-1 clinical picture figure-3 per operative pic figure-4 resected specimen a contrast-enhanced ct scan of the face in all three planes was carried out, which revealed a hyperdense mass occupying entire left maxillary sinus, eroding the posterior maxillary wall and extending into the soft palate. the left nostril was fully obliterated with the mass eroding the nasal septum and extending in the right nostril (figure-2). informed consent was taken from the patient prior to surgery. under general anesthesia, left weberferguson incision was made to expose the tumor. osteotomy of the lateral antral wall was done to expose the lesion. the lesion was removed by finger dissection and it was pulled out in total with slight pressure (figure-3). irrigation was done and maxillary anterior wall was fixed back with mini plates. the incision was closed with proline. postfigure2 axial view of ct scan showing the tumor j islamabad med dental coll 2022 52 operative antibiotics and analgesics were given. the patient’s obstructive sleep apnea was immediately corrected postoperatively. the resected specimen (figure-4) was subjected to histopathology which revealed it to be nasopharyngeal angiofibroma. there was no recurrence after a followup of five years. d i s c u s s i o n our patient was 18 years old male that is in correspondence with the reported literature.1, 2 aggressive expansion of nasopharyngeal angiofibroma is well documented.7 our patient also reported rapid progression of the tumor, obliterating the right maxillary sinus and right nostril. profuse bleeding was noted during the operation, which is one of the features of such tumors because of high vascularity, as also documented in other researches.8 since na is a vascular lesion; it has one or multiple feeding arteries making the tumor prone to bleed profusely. the primary vascular supply is the internal maxillary artery. lesions with increased size involve large arteries and, in some cases involving vessels bilaterally. the second most common artery of notable size is the ascending pharyngeal artery. the most common internal carotid artery branch recruited for feeding the lesion is the internal maxillary artery and the second most common is the ophthalmic artery.9 other characteristics of this tumor include unilateral swelling of the cheek region with congestion of the nasal cavity and hyposmia, similar to this case. for diagnosis of na, ct scan and mri are considered reliable diagnostic radiological imaging modalities. with the aid of a ct scan, the extent of the tumor along with bone destruction can be seen. if soft tissue invasion of the intracranial region is suspected, mri should be considered and preferred over ct imaging, the reason being its capability to visualize the soft tissues.10 however, the diagnosis would only be confirmed after histopathological examination of the excised specimen. the biopsy specimen shows the presence of a fibrous stroma interspersed with spindle cells and irregularly arranged collagen. the scattered vascular component is also noted containing irregular clusters of blood vessels with absent or incomplete lining, dilated or fissured, having different diameters. an increase in vascular constituent is present in the peripheral part of the tumor.6 surgical resection of the tumor remains the best treatment of choice for na. we treated this case using the weber-ferguson approach. the advantages of using this apprioach were; a good surgical exposure and ease to control the hemorrhage. however a surgical scar mark on the face is the limitation of this approach. c o n c l u s i o n nasopharyngeal angiofibroma is rare, a benign tumor affecting mostly young males. because of its aggressive nature, it needs the urgent attention of health care professionals; delay in the treatment of na can result in irreversible damage to olfactory and ophthalmic function. the best imaging modality for na is ct scan and mri. surgery remains the treatment of choice for na however special consideration must be given to the bleeding tendency of the tumor. r e f e r e n c e s 1. makhasana ja, kulkarni ma, vaze s, shroff as. juvenile nasopharyngeal angiofibroma. j oral maxillofac pathol. 2016;20(2):330. doi: 10.4103/0973-029x.185908 2. schick b, rippel c, brunner c, jung v, plinkert pk, urbschat s. numerical sex chromosome aberrations in juvenile angiofibromas: genetic evidence for an androgen-dependent tumor? oncol rep. 2003;10:1251. doi:10.3892/or.10.5.1251 3. lópez f, triantafyllou a, snyderman ch, hunt jl, suárez c, lund vj, et al. nasal juvenile angiofibroma: current perspectives with emphasis on management. head neck. 2017;39(5):1033-1045. doi: 10.1002/hed.24696 4. alshaikh na, eleftheriadou a. juvenile nasopharyngeal angiofibroma staging: an overview. ear nose throat j. 2015 jun;94(6). doi: 10.1177/014556131509400615 5. allensworth jj, troob sh, lanciault c, andersen pe. high-grade malignant transformation of a radiationj islamabad med dental coll 2022 52 naïve nasopharyngeal angiofibroma. head neck. 2016;38 suppl 1. doi: 10.1002/hed.24378 6. zhang m, sun x, yu h, hu l, wang d. biological distinctions between juvenile nasopharyngeal angiofibroma and vascular malformation: an immunohistochemical study. acta histochem. 2011; 113:626–30. doi: 10.1016/j.acthis.2010.07.003 7. park ck, kim dg, paek sh, chung ht, jung hw. recurrent juvenile nasopharyngeal angiofibroma treated with gamma knife surgery. j. korean med. sci. 2006; 21(4):773-7. doi: 10.3346/jkms.2006.21.4.773 8. overdevest jb, amans mr, zaki p, pletcher sd, elsayed ih. patterns of vascularization and surgical morbidity in juvenile nasopharyngeal angiofibroma: a case series, systematic review, and metaanalysis. head neck. 2018;40(2):428-443. doi: 10.1002/hed.24987 9. mehan r, rupa v, lukka vk, ahmed m, moses v, shyam kumar nk. association between vascular supply, stage and tumour size of juvenile nasopharyngeal angiofibroma. eur arch otorhinolaryngol. 2016;273(12):4295-4303. doi: 10.1007/s00405-016-4136-9 10. acharya s, naik c, panditray s, dany ss. juvenile nasopharyngeal angiofibroma: a case report. j clin diagn res 2017;11(4):3–4. doi: 10.7860/jcdr/2017/23729.9630 31 j i m d c 2 0 1 7 31 op e n ac c e ss f u l l l e n g t h a r t i c l e frequency of feeding problems in children with cerebral palsy hira usman1, maria asghar2 1speech therapist at sharif memorial hospital gujrat 2 medical officer, basic health unit rangpur gujrat a b s t r a c t objective: to determine the frequency of feeding problems in children with cerebral palsy. patients and methods: this cross-sectional study was conducted at developmental department of children hospital lahore. total 30 children with cerebral palsy were evaluated. the objective was to see the frequency of feeding problems in children suffering from cerebral palsy with age ranges between 1-9 years. a performa was used for each patient, which was filled on the basis of history and clinical observation. feeding skill assessment was based on gisel and patrick’s feeding behavior skill score. score of 4 or less was regarded as normal, score of 5-8 was defined as marginal problem & score of 9 or more was regarded as inadequate feeding skills. all the collected data was entered in spss (statistical package for social sciences) for analysis. results: out of total 30 patients, maximum (60%) were between 1-3 years of age. feeding skill score was normal in 50% children. about 20% had marginal feeding skills and 30% inadequate feeding skills. regarding frequency distribution of feeding problems due to oral motor dysfunction, drooling of saliva was most common complaint (66.7%) followed by absent tongue lateralization (63.3%) an hypertonic tongue (60%). the most common complication that was found due to feeding problems was recurrent chest infection (53.3%). conclusion: the present study concludes that in children with cerebral palsy, feeding problems due to oral motor dysfunctions are common and feeding problems produce different complications in these children. keywords: cerebral palsy, children, oral motor dysfunction. author`s contribution 1&2active participation in research, interpretation, and analysis of results. address of correspondence dr. maria asghar faiza_asghar50@yahoo.com article info. received: feb 22, 2017 accepted: mar 26, 2017 cite this article: usman h, asghar m. frequency of feeding problems in children with cerebral palsy.jimdc. 2017; 6(1):31-34. funding source: nil conflict of interest: nil i n t r o d u c t i o n the term cerebral palsy (cp) was first coined in 1862 by, an orthopedic surgeon named, william james little. a recent study describes cp as “a group of disorders concerning the development of movement and posture, causing activity limitation, that are attributable to nonprogressive disturbances that occur in the developing infant or fetal brain”.1 the worldwide incidence of cp is approximately 2 to 2.5/1000 live births. the incidence is strongly associated with gestational age, occurring in 1 of 20 surviving preterm infants.2 in cp, speech is affected due to oral motor dysfunction. additionally, both receptive and expressive language deficits are common in patients with cp along with mental retardation. feeding difficulties, swallowing dysfunction and drooling are also present.3 this can result in nutritional problems affecting physical growth.4 this study, however, is focusing on the feeding disorders in children with cp. it is estimated that the prevalence ratios are quite high, in children with cp, in regards to feeding difficulties. in 2000, the oxford feeding study evaluated 271 children with cp and o r i g i n a l a r t i c l e mailto:faiza_asghar50@yahoo.com 32 j i m d c 2 0 1 7 32 feeding problems. it was found that feeding difficulties occur in 30–40% of children with cp and are the most common among children with severe motor impairment .5 studies have indicated numerous feeding problems in children with cp. some common problems includes requirement of help during feeding, choking during feeding, feeding time greater than 3 hour per day, constipation, frequent vomiting. impaired oral sensorimotor function can result in drooling that in turn results in impaired hydration, chronic aspiration is often common and may be difficult to delineate when there is no cough response to aspiration events. difficulties in children with cp result from damage and disruption to the central nervous system (cns) and enteric nervous system (ens).6-10 problems with feeding are associated with specific medical problems such as aspiration, chest infections, gastroesophageal reflux (gor) and constipation. feeding difficulties may cause inadequate fluid intake resulting in dehydration. consequently, early involvement of a skilled multi-professional team is essential to reduce the impact of feeding difficulties.11 it is possible that nutritional deficits may exacerbate the effects of primary brain injury in children with cp. feeding difficulties can have a psychosocial impact for child. feeding dependence may also, have an impact on parents and other family members in other ways. evidence to support the use of feeding intervention strategies for children with cp is limited. in spite of this, some suggested potential benefits from interventions include individualized positioning for feeding, alteration of food consistency and use of oral appliances. independent sitting on the floor was the commonly used feeding position in children with neurological dysfunction. feeding devices are unlikely to be helpful in enhancing feeding efficiency. oral feeding interventions for children with cp may promote oral motor function, but these interventions have not been shown to be effective in promoting feeding efficiency or weight gain.12 this study was planned to find out the severity of feeding problems in children with cp. this study would also help to know the frequency of feeding problems generated due to oral motor dysfunction p a t i e n t s a n d m e t h o d s this cross-sectional observational study was conducted at department of developmental pediatrics at children hospital lahore over a time period of three months. total 30 diagnosed patients of cp from age 1 to 9 years without gender discrimination were inducted. all other patients, not fulfilling the above-mentioned criteria were excluded for evaluation purpose, a performa based on history and examination of the patient was used. the feeding skills assessment tool, advocated by patrick and gisel, was adopted and used by the researcher to investigate the feeding problems in the recruited patients. parents of the patients were engaged to obtain the answers of the questions in the tool. questions were phrased to parents of the patients in a succinct and consistent manner. parents’ consent was obtained before asking the questions. parents were assured that the responses would be confidential and the results would be anonymized in the finalized version of the research. all the data was analyzed using statistical package for the social sciences (spss) version 17.0. all the qualitative variables were expressed in form of frequency and percentage. r e s u l t s we segregated patients in different groups based on their age ranges. most recruited patients, with cp, were in the age group of 1-3 years (60.0%). the least number of patients were in the age range of 7-9 years (13.3%). amongst the 30 patients selected, in terms of gender, 47% were male and 53% were female patients (table 1). table 1: distribution of age and gender among patients of cerebral palsy (n=30) variables no. percentage age (years) 1-3 4-6 7-9 18 8 4 60.0 26.7 13.3 gender male female 14 16 46.7 53.3 33 j i m d c 2 0 1 7 33 as shown in table 2, the results also of this study revealed that 50% of patients had normal feeding skills. this implied that most patients could cope with activities related to feeding. the results displayed that 20.0% had marginal feeding skills and 30.0% of patients had inadequate feeding skills. feeding problems that were associated with oral motor dysfunctions have been shown in table 3. the most severe problem was drooling that was found in 20 patients (66.7%) followed by other complaints. complications that arise due to feeding problems have been displayed in table 4. the results found that significant number of patients had complications related with chest infection, constipation and choking. d i s c u s s i o n cp is a common pediatric disorder. it is a chronic motor disorder resulting from a nonprogressive insult to the developing brain. children with cp suffer from multiple problems and potential disabilities such as mental retardation, epilepsy, feeding difficulties and ophthalmologic and hearing impairments.13 disorders of feeding and swallowing are common in children with cp. feeding gastrostomy tubes are a reasonable alternative for children with severe feeding and swallowing problems who have had poor weight gain.14 in the current study, we explored various feeding problems prevalent in children with cp. as shown in the results section, it is evident that out of 30 patients, 30.0% showed inadequate feeding skills. the most severe problem reported in present study, of children with cp, was drooling 66.7%. the frequency of patients who were unable to self-feed was 56.7%. additionally, 30.0% reported choking and vomiting during feeding. a similar study conducted in india reported that out of 33 patients, the maximum number of patients showed inadequate feeding skills. other problems were the inability to selffeed 48.5%, coughing and choking during feeding 6.1% and vomiting 3.0%.15 in the present study, 40.0% patients reported chewing and swallowing problems. a similar study conducted at queen’s university of belfast, uk reported that out of 1357 children with cp, 21% had chewing & swallowing problems and 22% demonstrated excessive drooling, respectively.16 in the current study, in the frequency of constipation was found in 43.3% cases. a study conducted on 152 children with cp at netherland showed that frequency of patients with the problem of constipation was 57.0%. 17 in the current study, our findings highlighted that oral motor dysfunction was prevalent in all cases. one main problem, due to oral motor dysfunction, was sucking problem; the frequency of sucking problem was found to be 36.7%. a similar study conducted from behavioral sciences unit, institute of child health, uk reported that amongst 49 subjects, the frequency of sucking problem was 57%. further, 90% had significant oral motor dysfunction.3 another study conducted in china reported that out of 59 patients, 51 cases had oral motor dysfunction. 18 in our study out of 30 patients, 20.0% showed marginal feeding skills. in contrast to this a study conducted by gangil in india, of participants 70% were males and 30% table 2: distribution of feeding skill scores among patients of cerebral palsy (n=30) feeding behavior skills score n(%) normal feeding skill score (nfss) 15(50.0) marginal feeding skill score (mfss) 6(20.0) inadequate feeding skill score (ifss) 9(30.0) table 3: pattern of feeding problems due to oral motor dysfunction in patients of cerebral palsy (n=30) oral motor dysfunctions n (%) absent tongue lateralization 19(63.3) hypertonic tongue 18(60.0) restricted temporomandibular joint movement 13(43.3) inappropriate wide mouth opening 6(20.0) no closure of lips around spoon 12(40.0) inability to self-feed 17(56.7) chewing problem 12(40.0) swallowing problem 12(40.0) drooling 20(66.7) sucking problem 11(36.7) inability to take solid food 12(40.0%) table 4: complications arising due to feeding problems in patients of cerebral palsy (n=30) complications n (%) recurrent chest infections 16(53.3) chocking during feed 9(30.0) vomiting 9(30.0) constipation 13(43.3) cry during feeding 6(20.0) 34 j i m d c 2 0 1 7 34 females, maximum number of patients showed marginal feeding skills (62.0%) and 8.0% demonstrated inadequate feeding skills.19 findings of present studies were different from the previous studies. one potential rationale could be a different geographical distribution and sample size. c o n c l u s i o n the results of this study showed that fifty percent of children suffering with cp had marginal or inadequate feeding skills. the feeding problems associated with oral motor dysfunction are common in patients of cp. feeding problems are also responsible to produce different complications in these children. limitations of study: limitations of our study were decrease time period to conduct this research, and small sample size. r e f e r e n c e s 1. bax mc, flodmark o, tydeman c. definition and classification of cerebral palsy from syndrome toward disease. dev med child neurol suppl. 2007;109(6): 39-41. 2. taft lt. cerebral palsy. pediatr rev.1995;16(11): 411-8. 3. reilly s, skuse d, poblete x. prevalance of feeding problems and oral motor dysfunction in children with cerebral palsy: a community survey. j pediatr.1996; 129(6): 877-22. 4. srivastava vk, laisram n, srivastava rk. cerebral palsy. indian pediatr.1992;29(8): 993-6. 5. fung eb, samson fl, stallings va, conaway m, liptak g, henderson r, etal. feeding dysfunction is associated with poor growth and health status in children with cerebral palsy. j am diet assoc.2002;102(3): 361-73. 6. sullivan pb, lambert b, rose m, adams m, johnson a, griffiths p. prevalence and severity of feeding and nutritional problems in children with neurological impairment: oxford feeding study. dev med child neurol.2000;42(10): 674-80. 7. santos mt, batista r, previtali e, ortega a, nascimento o, jardim j. oral motor performance in spastic cerebral palsy individuals: are hydration and nutritional status associated? j oral pathol med. 2012;41(2): 153-7. 8. arvedson j, rogers b, buck g, smart p, msall m. silent aspiration prominent in children with dysphagia. int j ped otorhinolaryngol. 1994,28(2): 173-81. 9. rogers bt, arvedson j, msall m, demerath rr. hypoxemia during oral feeding of children with cerebral palsy. dev med child neurol.1993;35(1): 3-10. 10. delaney al, arvedson jc. development of swallowing and feeding: prenatal through first year of life. dev disabil res rev.2008;14(2): 105-17 11. archand v, motil kj. nutrition support for neurologically impaired children: a clinical report of the north america society and nutrition. j. pediatr gastroenterol nutr.2006;43(1): 123-35. 12. larnet g, ekberg o. positioning improves the oral and pharyngeal swallowing in children with cerebral palsy. acta paediatr.1995;84(6): 689-92 13. jan mm. cerebral palsy: comprehensive review and update. ann saudi med.2006;4(26): 123-32. 14. rogers b. feeding method and health outcomes of children with cerebral palsy. j pediatr.2004;145(2): 28-32. 15. diwan s, diwan j. a study of feeding problems in children with cerebral palsy. njirm.2013;4(1):78-86. 16. clancy kj, hustad kc. longitudinal changes in feeding among children with cerebral palsy between the ages of 4 and 7 years. dev neuro rehabil.2011; 114(4): 191-8. 17. veugelers r, benninga ma, calis ea, willemsen sp, evenhuis h, tibboel d, penning c. prevalence and clinical presentation of constipation in children with severe generalized cerebral palsy. dev med child neurol. 2010; 52(9): 216-21. 18. hou m, fu p, zhao jh, lan k, zhang h. oral motor dysfunction, feeding problems and nutritional status in children with cerebral palsy. chinese j pediatr.2004;42(10): 765-8. 19. gangil a, patwari ak, aneja s, ahuja b, anand vk. feeding problems in children with cerebral palsy. indian pediatr.2001;38(8):839-46. j islamabad med dental coll 2022 127 o p e n a c c e s s inflammatory myofibroblastic tumour of lung, a rare entity bilal umair1, sohail saqib2, rashid hussain3, raheel khan4, farhanullah5. 1professor and head of department, combined military hospital, rawalpindi, pakistan. 2,4,5 3consultant thoracic surgery, combined military hospital, rawalpindi, pakistan. a b s t r a c t inflammatory fibroblastic tumour of lung is a rare mesenchymal tumour usually affecting the children and young adults. it is usually considered as a benign entity however it has high potential for recurrence and local invasion. exact pathogenesis of tumour is not known. complete surgical excision is the treatment of choice. due to high chance of recurrence, patients are usually kept on close follow up. here we present a case of inflammatory myofibroblastic tumour of lung , who presented with history of pain and shortness of breath.she was diagnosed a case of inflammatory myofibroblastic tumour with the help of ct scan chest and ct guided biopsy.she underwent right sided pneumonectomy and remained symptom free on follow up. key words. inflammatory, myofibroblasts, pneumonectomy, tumour. correspondence: sohail saqib email: drsohailchatha@hotmail.com article info: received: february 2, 2022 accepted: june 13, 2022 cite this article. umair b, saqib s, hussain r, khan r, farhanullah. inflammatory myofibroblastic tumour of lung, a rare entity. j islamabad med dental coll. 2022; 11(2):127-131 doi: https://doi.org/10.35787/jimdc.v11i2.846 funding source: nil conflict of interest: nil c a s e r e p o r t j islamabad med dental coll 2022 128 i n t r o d u c t i o n inflammatory myofibroblastic tumour (imt) is a rare mesenchymal tumour that usually involves lungs, abdominopelvic organs and maxillofacial structures. they constitute less than 1% of adult lung tumours.1the tumour usually occurs in paediatric population and young adults.2 inflammatory myofibroblastic tumour is also known as inflammatory pseudotumour or plasma cell granuloma.it is usually classified as a benign tumour.3,4 however, tendency for local invasion or recurrence is present and in few reports, rare metastasis has also been reported.5.pulmonary imt usually presents as a solitary pulmonary nodule or as a mass on chest radiography.6,7preop diagnosis is usually difficult to establish and often possible after resection of the tumour. the treatment of choice is complete surgical excision. here we present a case of a pulmonary imt in a 21 year old lady, involving the right lung who underwent successful surgical excision. c a s e r e p o r t a 21 year old, unmarried lady, resident of rawalpindi presented to our opd with 6 months history of pain right side of chest and shortness of breath on minimal exertion. there were no associated complains of haemoptysis, cough or weight loss. on examination, her vitals were normal and there were decreased breath sounds on right side of the chest. her chest x-ray revealed a mass involving right hemithorax. ct chest showed a large mass occupying whole of right hemithorax and compressing right mainstem bronchus.(fig.1). fig.1 pre op ct scan chest ct guided biopsy of the mass revealed it to be inflammatory myofibroblastic tumour, so surgical excision of the mass was planned after discussion in multidisciplinary meeting including oncologist,histopathologist and radiologist. patient was counselled regarding treatment plan and prepared for surgery. standard right sided posterolateral thoracotomy was done and mass was found to be involving whole of the right lung along with involvement of right main stem bronchus, however there was no extension of the mass into the chest wall(fig.2).right sided pneumonectomy was performed. j islamabad med dental coll 2022 129 fig.2 post operative specimen post operatively, patient remained in icu for 1 day and later on shifted to ward. post op recovery was uneventful and patient was discharged on 4th post operative day. she was followed up after 1 week with histopathology report. patient remained asymptomatic in follow up period and histopathology report confirmed the preop diagnosis(fig.3).she was again discussed in oncology meeting and is placed on close observation and follow up due to high recurrence tendency of the tumour. fig.3 histopathology report d i s c u s s i o n inflammatory fibroblastic tumours of the lung are considered as a rare entity with reported incidence of less than 1 % of all lung tumours in literature.8 imt is considered as a mesenchymal tumour which is composed of fibroblastic and myofibroblastic spindle cell along with plasma cell,eosinophils and lymphocytes etc. a vast variety of nomenclature has been used in the literature to describe these set of lesions depending upon the predominant cell type. various names used in literature include plasma cell granuloma, xanthogranuloma, inflammatory myofibroblastic proliferation, inflammatory pseudotumor, fibrous histiocytoma, plasma cell histiocytoma complex and inflammatory j islamabad med dental coll 2022 130 fibrosarcoma.9. matsubara et al used the term inflammatory pseudotumor10 whereas pettinato et al were among the first ones to use the term imt due to the immunohistochemical features of the spindle cells in these lesions resembling those of myofibroblasts.11exact etiology and pathogenesis are unknown. though imt are considered as benign entity, however, malignant transformation has also been reported in the literature including recurrence and rarely metastatic disease. 12 patients usually present with diversity of symptoms ranging from being asymptomatic and discovered incidentally 13 to various symptoms such as cough, chest pain, shortness of breath, hemoptysis, fever and fatigue, with manifestations depending on the size and location of the tumor.14our patient presented with symptoms of pain and shortness of breath. imaging findings are nonspecific and range from benign looking solitary peripheral lung nodules to heterogeneous mass with variable contrast enhancement. when imt present as central masses, there is often involvement of hilar structures and the mediastinum and so was the finding in our case. calcification and lymphadenopathy are rare.4 pet can be helpful in distinguishing benign imt from malignant lesions. preop diagnosis of imt is usually difficult and always require histological examination.15mostly, diagnosis requires surgical excision. treatment of choice is complete surgical resection of the tumor. various therapies such as chemotherapy, radiation and corticosteroids are recommended for patients who have incomplete resection, have multifocal disease, irresectable tumors or when surgery is contraindicated .prognosis of the disease depends on completeness of surgical excision an size of the tumour. due to high potential for recurrence of the tumour, patient should be followed up closely even for years to detect local or distant recurrence. c o n c l u s i o n pulmonary inflammatory fibroblastic tumour,is a rare entity but should always be considered in diagnosis of pulmonary tumours, especially in children and young adults. despite being considered as a benign entity ,complete surgical exicision and close follow up is required due to high risk of local and rarely distant recurrence. r e f e r e n c e s 1. a. al-obaidi, c. buess, j. mogire, p.s. reddy.inflammatory myofibroblastic tumor of the lung: an extremely rare condition in adults, cureus 11 (12) (2019) 6432. 2. coffin cm, fletcher ja. inflammatory myofibroblastic tumour. in: world health organization classification of tumours of soft tissue and bone. 4th edition. fletcher cdm, bridge ja, hogendoorn pcw, mertens f, editors. lyon: international agency for research on cancer; 2013. p. 83-4. 3. n. marwah, n. bhutani, s. dahiya, r. sen. inflammatory pseudotumour: a rare tumor of lung, ann med surg 36 (2018) 106–109. 4. y. na, s. park. inflammatory myofibroblastic tumor of the pleura with adjacent chest wall invasion and metastasis to the kidney: a case report, j. med. case rep. 12 (2018). 5. panagiotopoulos n, patrini d, gvinianidze l, woo wl, borg e, lawrence d. inflammatory myofibroblastic tumour of the lung: a reactive lesion or a true neoplasm?. journal of thoracic disease. 2015 may;7(5):908-11. 6. yu y, wang x, shi c, hu s, zhu h, hu c. spectral computed tomography imaging in the differential diagnosis of lung cancer and inflammatory myofibroblastic tumor. journal of computer assisted tomography. 2019 mar 1;43(2):338-44. 7. karapolat s, seyis kn, ersoz s, buran a, karadeniz zm. lung image: inflammatory myofibroblastic tumor. lung. 2017 jun;195(3):387-8. 8. t. tsuchiya, m. tanaka. pulmonary inflammatory myofibroblastic tumor: a case report, asian cardiovasc. thorac. ann. 26 (2018) 317–319. j islamabad med dental coll 2022 131 9. surabhi vr, chua s, patel rp, takahashi n, lalwani n, prasad sr. inflammatory myofibroblastic tumors: current update. radiologic clinics. 2016 may 1;54(3):553-63. 10. matsubara o, tan-liu ns, kenney rm, mark ej. inflammatorym pseudotumors of the lung: progression from organizing pneumonia fibrous histiocytoma or plasma cell granuloma in 32 cases. hum pathol 1988;19:807–814. 11.pettinato g, manivel jc, de rosa n, dehner lp. inflammatory myofibroblastic tumor (plasma cell granuloma). clinicopathologic study of 20 cases with immunohistochemical and ultrastructural observations. am jclin pathol 1990;94:538 –546. 12. sagar ae, jimenez ca, shannon vr. clinical and histopathologic correlates and management strategies for inflammatory myofibroblastic tumor of the lung. a case series and review of the literature. medical oncology. 2018 jul;35(7):1-0. 13. al-obaidi a, buess c, mogire j, reddy ps. inflammatory myofibroblastic tumor of the lung: an extremely rare condition in adults. cureus. 2019 dec 20;11(12). e6432. doi:10.7759/cureus.6432 14. braham y, migaou a, njima m, achour a, saad ab, mhamed sc, fahem n, rouatbi n, joobeur s. inflammatory myofibroblastic tumor of the lung: a rare entity. respiratory medicine case reports. 2020 jan 1;31:101287.15. 15.sachdev r, mohapatra i, goel s, ahlawat k, sharma n. core biopsy diagnosis of alk positive inflammatory myofibroblastic tumor of lung: an interesting case. turk. j. pathol. 2018;36:173-7. j islamabad med dental coll 2022 71 open access post-traumatic stress disorder and post-traumatic growth among police officials; role of coping self efficacy and hope azra azeem1, nelofar kiran2 1,2assistant professor, clinical psychology, national institute of psychology, quaid-e-azam university, islamabad, pakistan. a b s t r a c t background: post traumatic stress disorder in the after math of trauma is common. the objective of this study was to find correlation between post-traumatic stress disorder and contributing factors of growth after trauma in active duty officials of police having direct exposure of trauma during war against terror in pakistan. methodology: the cross-sectional study was done on active-duty police officials from federally administered tribal areas (fata) of pakistan in three years duration from jan, 2019 till december 2021. non probability purposive sampling technique was used for selection of participants. post-traumatic stress diagnostic scale (pds-5), short form of comprehensive trauma inventory, adult hope scale and perceived coping self-efficacy scale were used for data collection. spss version 21 was used for data analysis. after descriptive analysis, correlation of variables was checked by pearson correlation and moderation analysis was done. results: age range of the participants was 33.6 ± 6.3 years. there was a significant strong positive correlation of hope and perceived self-efficacy with post traumatic growth and negative correlation with post traumatic stress disorder. there was a significant increase in post-traumatic growth in presence of hope and perceived self-efficacy. conclusion: relationship between post-traumatic stress disorder and post-traumatic growth was moderated by perceived coping self-efficacy and hope. keywords: hope, post-traumatic growth, stress. authors’ contribution: 1conception; literature research; 1manuscript design and drafting; 1,2critical analysis and manuscript review; 1,2data analysis; manuscript editing. correspondence: azra azeem email: azra.azeem@nip.edu.pk article info: received: april 1, 2022 accepted: june 21, 2022 cite this article. azeem a, kiran n. post-traumatic stress disorder and post-traumatic growth among police officials; role of coping self efficacy and hope. j islamabad med dental coll. 2022; 11(2):71-76. doi: https://doi.org/10.35787/jimdc.v11i2.870 funding source: nil conflict of interest: nil i n t r o d u c t i o n adversities in life can be disruptive in nature and there can be considerable variation in psychological reactions to stressful and tragic events with responses ranging from mild psychological symptoms to severe psychological symptoms like distress. 1 important events that can be traumatic in nature and can leave long lasting effects on the exposed population are war, personal (violent) assault (e.g., sexual assault, and physical attack), being hostage or kidnapped, being in prison, torture, being victim of terrorist attack, exposure to severe car accidents and natural disasters. post-traumatic o r i g i n a l a r t i c l e j islamabad med dental coll 2022 72 stress disorder (ptsd) is most common in the population exposed to tragic events.2 previous research showed that individuals who had higher exposure of trauma experience showed higher levels of distress. the level of distress can be measured by the severity of the symptoms like feeling of chronic sadness, worthlessness and loss of interest in interaction with other people. 3 traumatic exposure can be a precondition for severe psychological reactions like posttraumatic stress, but not all individuals who face trauma suffer from ptsd. posttraumatic growth is also reported in after math of trauma. 4 posttraumatic growth includes positive consequences like positive change in social interaction, like improved relationship with others, improvement in personal strength and selfassurance and an increased sense of appreciation of life and change in priorities of life. there are many studies which have reported post-traumatic growth in the survivors of trauma. post-traumatic growth and ptsd may co-exist after trauma exposure. there are factors that can be positively associated with one out of the two outcomes but negatively with the other. 5 coping self-efficacy and hope are important in after math of trauma. coping self-efficacy is the belief that reflects control of personal actions and a personal and future view that is more optimistic. 6 after traumatic or tragic incidents, some individuals are more likely to find benefit and gains if they have strong self-efficacy and can avoid negative effects like post traumatic stress disorder. 7 hope also plays a role between ptsd and ptg. hope is a personal strength factor. this can prove a shield against post traumatic stress disorder. 8 post-traumatic stress disorder development can be affected by the process adopted in face of adversities. use of avoidant coping is linked with increased ptsd symptoms following a trauma, but on the other hand, use of active coping in relation with ptsd is equivocal. 9 present study was conducted to investigate the under lying relationship between ptsd, war trauma and ptg and to explain the role of coping self-efficacy and hope among active duty police officials who have participated in war against terror and were directly exposed to trauma. pakistan has played an important role in global war against terror and being front line state has faced effects of this war by conducting combined operations to remove insurgency from the tribal areas and from the whole country.10. pakistani police officials have played tremendous role along army in this war. the police troops present in federally administered areas of pakistan remained closely engaged in combat. police officials who participated in this war exhibited resilience in this war against terror, scarifying much more than any other police agency of any other country in the world. 11 m e t h o d o l o g y this cross-sectional study was conducted on activeduty police officials from federally administered tribal area (fata) in 3 years duration (jan 2019 to dec 2021). study participants were selected by using non probability purposive sampling technique. inclusion criteria was police officials who had actively participated in war against terror and had direct exposure of trauma and were on post deployment in peaceful areas for 1 year. sample size was calculated by open epi calculator, and was estimated to be 192, with anticipate frequency of 50%, confidence limit 5 % and design effect 0.5. 200 police officials fitting in this inclusion criteria were included in the study with the response rate of 97%. data was collected after approval of ethical committee of nip (national institute of psychology), permission from the concerned authorities, and after taking informed consent from the participants. personal identity information was not taken and the confidentiality of the data was ensured. demographic data was collected by structured questionnaire. to determine the level of war related stress, posttraumatic stress diagnostic scale pds j islamabad med dental coll 2022 73 5(22 items) and short form of comprehensive trauma inventory (20 items) were used. hope and self-efficacy were assessed by adult hope scale (12 items) and perceived coping self-efficacy scale (26 items). posttraumatic growth was assessed by post traumatic growth inventory (ptgi-sf). urdu versions of all tools were used. analysis was done by using amos and spss version 21. internal reliability was checked by cronbach α, which was found satisfactory (> 0.6). after descriptive analysis of socio demographic variables such as education, age, marital status, duration spent in combat area, family system etc, correlation of variables was checked by pearson correlation and moderation analysis was done. r e s u l t s mean age of study participants was 33.6±6.3 years (21-56 years). descriptive analysis of demographic variables is given in table 1. the internal consistency of all translated and adapted scales like comprehensive trauma, pds-5 and adult hope scale showed acceptable internal consistency. moss et al., (1998) has recommended the cutoff of α ≥ .60 for acceptable reliabilities. skewness and kurtosis were all in the acceptable range as suggested by bulmer (2012) data, between -1 to +1 and -2 to +2 is considered as normally distributed. the ranges of the values of reliabilities were 0.84 to 0.93. these ranges were at satisfactory level. the skewness values also lied in acceptable range. this table shows the demographic variables, i.e. age, level of education, marital status, family system ( extended or nuclear) , category, and duration spent in war. table i: descriptive analysis of demographical variables variables frequency (percentage) age 21-35 36 and above 126 (63%) 74 (37 %) level of education matric 123 (61.5%) intermediate 50 (25 %) graduate 17 (8.5 %) post graduate degree 10 (5%) marital status married 154 (77%) un married 46(23%) family system extended family system 106(53 %) nuclear family system 94 (47 %) category officers 9(4.5%) other ranks 191(95.5%). duration spent in war 1 year or more 26 (13.0 %) 2 years or more 46 (23.0%) 3 years or more. 128 (64%) table ii : correlation between study variables (n=200) variables wt ptsd hope pse ptg mean± sd 1 wt .49** .37 .56 .53* 30.78 ±16.4 2 ptsd -.61* -.08 .44 28.16±18.9 3 hope .75** .98** 33.63±7.6 4 pse .99** 28.35±6.2 5 ptg 97.74± 31.8 j islamabad med dental coll 2022 74 *p < .05, **p < .01* note. wt= wartrauma, ptsd= posttraumatic stress disorder, hope = hope, pse= perceived self efficacy, ptg = post traumatic growth study showed significant strong positive correlation of hope and perceived self-efficacy with post traumatic growth and negative correlation with post traumatic stress disorder (ptsd).war trauma and ptsd were positively correlated and ptsd and ptg marginally positively correlated. *p < .05. **p < .01. ***p < .001. study confirmed moderating effects of perceived coping self-efficacy on war trauma and post traumatic growth. moderation was found satisfactory for perceived and self-efficacy. findings suggested a significant increase in post-traumatic growth after math of exposure of trauma in presence of hope and perceived coping self-efficacy. table iv : moderating role of hope in contributing post traumatic growth after trauma (n=200) post traumatic growth b ll uu p constant 35.52*** 27.98 45.07 .00 hope (moderator) -2.16*** -4.59 -.64 .01 war trauma (predictor) .22*** .44 .90 .01 hope x ptg .02*** .09 .01 .01 r2 .30*** f 9.12*** r2 .01 f 4.32 *p < .05.**p < .01.***p < .001. study confirmed moderating effects of hope on war trauma and post traumatic growth. moderation was found satisfactory for hope. findings suggested a significant increase in post-traumatic growth in after math of exposure of trauma in presence of hope. d i s c u s s i o n this study was conducted to investigate the effects of war trauma exposure among police officials who participated in war against terror. different studies have identified that war exposure is a significant predictor of post-traumatic stress disorder among affected population. but post-traumatic stress is not the only outcome, sometimes experiencing such an event may result in greater motivation to make positive meaning of traumatic event, which leads to experience of positive consequences like post traumatic growth.12 factors which play protective role against post-traumatic stress disorder among the affected population are still understudied. 13, 14 different expert studies have suggested that there are a multitude of factors that contribute for growth and boost resilience building among trauma survivors. in the present study, identification of the contributing factors of growth like hope and coping self-efficacy (which play a protective role against post traumatic stress disorder) suggests the direction of the future research as well as potential areas like educating the exposed population to overcome the traumatic events. 15 despite the reported negative reactions to tragic events, findings of different studies have proved that some people maintain psychological stability and different factors play important role in a meaningful positive change. 16 the study indicates that trauma exposure results in stress which can end into post-traumatic table 3 moderating role of perceived coping selfefficacy in contributing post traumatic growth after trauma (n=200) post traumatic growth b ll uu p constant 35.64*** 29.23 42.04 .00 perceived coping self-efficacy (moderator) -2.61*** -4.59 -.64 .00 war trauma (predictor) -.27*** -.44 -.99 .00 perceived coping self-efficacy x ptg .04*** .01 .01 .00 r2 .12*** f 9.42*** r2 .02 f 6.16 j islamabad med dental coll 2022 75 stress or growth. the moderating role of hope and coping self-efficacy positively predict growth in the after math of direct exposure of war trauma. use of positive approach in coping leads the individuals to think positive about the trauma and promotes feelings of personal strength which turns into post traumatic growth and reduces the chances of posttraumatic stress disorder. results are consistent with the previous findings. 17,18. it was also confirmed from the findings that stress and ptg are positively correlated. these findings of the present study are in line with the previous studies. present findings have confirmed that the coexistence of stress and growth is possible. 19. a growing body of research has identified variables that affect the relationship between trauma exposure, post-traumatic stress disorder and growth. these variables may be conceptualized as social and personal strength factors. studies on the personal strength factors suggest that veterans with strong coping self-efficacy and hope suffer less from ptsd. 19,20,21 war against terror was not a traditional war. the active-duty officials of police who had participated in this war and had direct and repeated exposure of trauma showed high levels of ptg and scored high in personal strength factors like hope and coping selfefficacy, results are persistent with previous research. 22, 23. the cross-sectional nature of the study, utilization of the self-report measures and use of non-probability sampling technique for sample selection are the limitations of the study. family history of psychopathology was not included. use of random sampling and longitudinal study design provides better qualification to generalization of the findings but due to time limitations and complex sample it was not possible to conduct longitudinal study. findings have implications for soldier’s fitness programs, psychological intervention planning and health care programs for the active-duty officials of police who had faced tragedies during war on terror and other trauma survivor population. conclusion relationship between post-traumatic stress disorder and post-traumatic growth was moderated by perceived coping self-efficacy and hope. r e c o m m e n d a t i o n more consideration is required to be given to enhance the role of the factors like perceived coping self-efficacy and hope as these factors may foster post traumatic growth in individuals and target stress and reduce the chances of ptsd. r e f e r e n c e s 1. bromet ej, atwoli l, kawakami n, navarro-mateu f, piotrowski p, alonso j, et al. post-traumatic stress disorder associated with natural and human-made disasters in the world mental health surveys. j of psy med. 2017 jan; 47(2):227 doi: 10.1017/s0033291716002026 . 2. shalev a, liberzon i, marmar c. post-traumatic stress disorder. new england j of med. 2017 jun; 376(25): 2459 doi: 10.1056/nejmra1612499. 3. sepahvand h, hashtjini mm, salesi m, sahraei h, jahromi gp. prevalence of post-traumatic stress disorder (ptsd) in iranian population following disasters and wars: a systematic review and metaanalysis. iranian j of psych and beh sci. 2019; 13(1):12. doi: 10.5812/ijpbs.66124. 4. shuwiekh h, kira ia, ashby js. what are the personality and trauma dynamics that contribute to posttraumatic growth? intl j of stress management. 2018 may; 25(2):181. https://doi.org/10.1080/0000054 . 5. larocca ma, scogin fr, hilgeman mm, smith aj, chaplin wf. the impact of posttraumatic growth, transformational leadership, and self-efficacy on ptsd and depression symptom severity among combat veterans. military psychology. 2018 mar 4;30(2):16273. https://doi.org/10.1037/str0899605.2018./425 0734 6. tedeschi rg, shakespeare-finch j, taku k, calhoun lg. posttraumatic growth: theory, research, and https://doi.org/10.1017%2fs0033291716002026 https://doi.org/10.1080/0000054 https://doi.org/10.1037/str0899605.2018./4250734 https://doi.org/10.1037/str0899605.2018./4250734 j islamabad med dental coll 2022 76 applications. routledge; 2018 jun 12.https://doi.org/ 10.4324/9781315527451 7. taku k, tedeschi r g, shakespeare-finch j, krosch d, david g, kehl d, et al. posttraumatic growth (ptg) and posttraumatic depreciation (ptd) across ten countries: global validation of the ptg-ptd theoretical model. j of pers. individ differ. 2021 feb 1;169. https://doi.org/10.1016/j.paid.2020.110222 8. zhou x, wu x, zhen r. self-esteem and hope mediate the relations between social support and post-traumatic stress disorder and growth in adolescents following the ya’an earthquake. anxiety, stress, &coping. 2018 jan 2; 31(1):32-45. https://doi.org/10.1080/10615806.2017./1374376 9. cushing re, braun kl. mind–body therapy for military veterans with post-traumatic stress disorder: a systematic review. the jan of alternative and complementary med. 2018 feb 1;24(2):106-14. doi: 10.1089 /acm.2018.0176 10. khan r. national security imperatives of pakistan peace in fata and afghanistan. j pak army g book. 2016; 97-103. 11. soherwordi h. pakistan’s baneful courtship: no more frontline ally of us. j pak army g book. 2016; 12-22. 12. tamiolaki a, kalaitzaki ae. “that which does not kill us, makes us stronger”: covid-19 and posttraumatic growth. psych research. 2020 jul; 289:113044. doi ;10.1016 /j.psychers.2020.113044 13. foa eb, mclean cp, zang y, zhong j, powers mb, kauffman by, et al. psychometric properties of the posttraumatic diagnostic scale for dsm–5 (pds5).psychological assessment.2016oct;28(10):1166.https://doi.org/1 0.1037/pas0000258. 14. gori a, topino e, sette a, cramer h. pathways to post-traumatic growth in cancer patients: moderated mediation and single mediation analyses with resilience, personality, and coping strategies. j of affect disord.2021 jan 15;279:692-700. https://doi.org/10.1016/j.jad.2020.10.044. 15. thompson nj, fiorillo d, rothbaum bo, ressler kj, michopoulos v. coping strategies as mediators in relation to resilience and posttraumatic stress disorder. j of affect. disord. 2018 jan 1; 225:153-9. doi: 10.1016/j.jad.2017.08.049. 16. finstad gl, giorgi g, lulli lg, pandolfi c, foti g , león-perez jm, et al. resilience, coping strategies and posttraumatic growth in the workplace following covid-19: a narrative review on the positive aspects of trauma. int j of environmental research and public health. 2021 jan; 18(18):9453. https://doi.org/10.3390/ijerph18189453 17. raghavan ss, sandanapitchai p. cultural predictors of resilience in a multinational sample of trauma survivors. frontiers in psychology. 2019 feb 5;10:131.https :// doi.org / 10.3389 /fpsyg.2019.0031 18. hokes ke, adams lm. the longitudinal development of posttraumatic growth among us adult burn injury survivors. rehab psy. 2022 apr 14. https://doi.org/10.1037/rep0000447 19. henson c, truchot d, canevello a. what promotes post traumatic growth? a systematic review. european j of trauma & dissociation. 2021 nov 1;5(4):100195. https://doi.org/10.1016/j.ejtd.2020.100195. 20. park cl, wilt ja, russell bs, fendrich mr. does perceived post-traumatic growth predicts better psychological adjustment during the covid-19 pandemic? results from a national longitudinal survey in the usa. j of psych research. 2022 feb 1; 146:179-85. doi: 10.1016/j.jpsychires.2021.12.040 21. chasson m, taubman-ben-ari o, abu-sharkia s. posttraumatic growth in the wake of covid-19 among jewish and arab pregnant women in israel. psy trauma: theory, research, practice, and policy. 2022 feb 3; https://doi.org/10.1037/tra0001189. 22. sadaghiyani s, belgrade a, kira m, lee f. finding strength in adversity: exploring the process of posttraumatic growth among multicultural individuals. cultural diversity and ethnic minority psychology. 2022 jan 27; https://doi.org/10.1037/cdp0000517. 23. montalvo-ortiz jl, gelernter j, cheng z, girgenti mj, xu k, zhang x, et al. epigenome-wide association study of posttraumatic stress disorder identifies novel loci in us military veterans. translational psych. 2022 feb 17; 12(1):1-9; https://doi.org/10.1038/s41398-022-01822-3. https://doi.org/10.1016/j.paid.2020.110222 https://psycnet.apa.org/doi/10.1037/pas0000258 https://psycnet.apa.org/doi/10.1037/pas0000258 https://doi.org/10.1016/j.jad.2020.10.044 https://doi.org/10.1016%2fj.jad.2017.08.049 https://doi.org/10.3390/ijerph18189453 https://psycnet.apa.org/doi/10.1037/rep0000447 https://doi.org/10.1016/j.ejtd.2020.100195 https://doi.org/10.1016%2fj.jpsychires.2021.12.040 https://psycnet.apa.org/doi/10.1037/tra0001189 https://psycnet.apa.org/doi/10.1037/cdp0000517 j islamabad med dental coll 2022 259 o p e n a c c e s s primary diffuse large b cell lymphoma presenting as chest wall mass: a case report shajee ahmed siddiqui1, muhammad zeeshan2, muhammad azhar jamil3, ghazal iftikhar4, adil farooq5 1professor and head of department of medicine, pakistan institute of medical sciences, islamabad. 2,3,5resident, pakistan institute of medical sciences, islamabad. 4medical officer, shifa international hospital. islamabad. a b s t r a c t primary chest wall masses or tumors can be of two types, either benign or malignant. diffuse large b cell lymphoma (dlbcl) is an aggressive type of non-hodgkin lymphoma (nhl). though an aggressive malignancy, with timely and appropriate treatment, approximately two-third of all patients can be cured. we present a rare case of dlbcl presenting as chest wall mass. this case suggests the possibility of the presence of primary malignant b cell lymphoma, with the presentation as a chest wall lesion. keywords: chest mass, diffuse large b cell lymphoma, mass, nonhodgkin’s lymphoma. correspondence: muhammad zeeshan email: zeeshanchaudhry23.zc@gmail.com article info: received: august 9, 2022 accepted: december15, 2022 cite this article. siddique s a, zeeshan m, jamil m a, iftikhar g, farooq a.primary diffuse large b cell lymphoma presenting as chest wall mass: a case report j islamabad med dental coll. 2022; 11(4): 259-262 https://doi.org/10.35787/jimdc.v11i4.903 funding source: nil conflict of interest: nil i n t r o d u c t i o n diffuse large b cell lymphoma (dlbcl) is one of the most common types of non-hodgkin lymphoma (nhl).1 though they mostly involve lymph nodes, extra nodal involvement is seen in 30% of the cases.2 among these extra-nodal sites, soft tissue involvement is rarely seen and very rarely as chest wall mass. soft tissue masses are sometimes misdiagnosed as soft tissue sarcoma. since these two disease entities differ in treatment and prognosis, their timely diagnosis is essential for management.3,4 this case report highlights the importance of including dlbcl in differential diagnosis of chest wall mass. c a s e p r e s e n t a t i o n a 65-year-old male resident of rawalpindi, city of pakistan, with no previous known comorbidities, but smoker (35 pack year), presented in emergency department with the history of chest wall mass for the past 2 months, undocumented weight loss and shortness of breath with complain of stridor for 3 days. the mass was on left side of the chest wall and was progressively increasing in size. shortness of breath progressed from mmrc grade 2 to grade 4, associated with stridor. there was no history of chest pain, cough, hemoptysis, fever, orthopnea, paroxysmal nocturnal dyspnea (pnd), night sweats or trauma. on arrival, patient was in distress and was having stridor with 94% oxygen saturation at room air, tachycardia (126 beats/min) and tachypnea (30 breaths /min). systemic examination revealed c a s e r e p o r t j islamabad med dental coll 2022 260 swelling of 7 into 8 cm size, extending from 2nd to 8th left intercostal space upon inspection, non-tender, firm to hard in consistency, immobile, with overlying skin non adherent with irregular margins upon palpation, resonant though-out the lung field and dull over the swelling upon percussion and bilateral monomorphic wheeze more on left side along with stridor upon auscultation. indirect laryngoscopy was done which showed right vocal cord fixed and left vocal cord mobile. in addition to this, there was one more swelling observed on anterior aspect of right thigh, 3 into 4 cm in size, firm in consistency, irregular margins, fixed to underlying tissue with overlying skin pinch able. during admission, multiple laboratory blood tests were done including total leukocyte count which was slightly raised (15000 cells/mm3 with 96% neutrophils and 2% lymphocytes), raised serum uric acid levels 13.6 mg /dl (reference:3.5-7.2 mg/dl) , and slight decrease in serum albumin levels 3.1g/dl (reference:3.4-5.4 g/dl), normochromic normocytic blood picture with neutrophilic leukocytosis on blood peripheral film. rest of the lab values including hemoglobin, platelet count, esr, cpk, serum calcium, serum electrolytes, liver function tests and renal function test, were within normal ranges. as an initial imaging, chest x-ray was done which showed enlarged cardiac silhouette and left sided extra pleural opacification. ultrasound chest was done which revealed minimal right sided pleural effusion along with the streak of free fluid in left pleural cavity. computed tomography of chest with contrast showed heterogeneous soft tissue density area measuring 23x18 (apxt) in dimensions involving right sided vocal cord causing narrowing of laryngeal lumen (residual lumen of 10mm at this site) and extend caudally involving right lobe of thyroid gland which appears enlarge. no surround erosion or distortion noted. a heterogeneous soft tissue density area measuring 15x5x12mm (ccxapxt) was noted involving left hemithorax, it was insinuating between anterior muscles of chest wall and reaching upto anterior aspect of pleura of left lung, also involving all muscles of left hemithorax. another heterogeneous mass soft tissue density lesion approximately measuring 10x6x7cm (ccxapxt) was noted involving right hemipelvis, involving right iliopsoas muscle and causing elevation and abutting right common iliac vessels and its branches. under lying bone appeared normal and no erosion was noted. ultrasound of right leg showed soft tissue swelling anterior to tibia with internal blood flow and no adjacent bony reaction. given the patients symptoms of painless progressive mass, combined with findings on chest imaging, the provisional diagnosis was deduced to be a lymphoma. figure 1: chest x-ray pa view j islamabad med dental coll 2022 261 figure 2: ct scan chest with contrast trucut biopsy of chest mass revealed patchy infiltrates of cells with hyper chromic friable nuclei and minimal cytoplasm. immunohistochemical staining was positive for (cd-45, lca) and negative for epithelium maker cytokeratin, representing atypical lymphoid infiltrate. additional immunestains were taken on this small biopsy (cd-3 and cd20), which indicated cellular infiltrate composed of cd-20 positive in b-cells, with possibility of malignant b-cell lymphocytes. figure 3: histopathological and immunohistochemistry sections d i s c u s s i o n chest wall tumors are of various entities and may be both benign and malignant. primary chest wall lymphoma is a very rare, yet a treatable condition.5 in a retrospective study found in a literature, out of total 157 patients with non-hodgkin lymphoma, only 7 presented with large chest wall mass.6 few reports state that dlbcl is most common type of primary chest wall lymphoma.5 there is mostly some predisposing disease like chronic tuberculous pyothorax or tuberculous pleuritis, our case however had no predisposing disease or any comorbidities.7 majority of cases of nhl are of b cell origin, especially in adults.8 single chest wall masses are uncommon, but those appearing mostly represents non hodgkin lymphoma, commonly large cell type.9 majority of chest wall masses presents as metastasis.5 patients always present with nonspecific symptoms which is the most common reason for delay in a diagnosis until radiology and histopathology confirm the diagnosis.10 surgical treatment including local excision, chest wall resection followed by reconstruction surgeries, j islamabad med dental coll 2022 262 along with chemotherapy can result in good prognosis in some of the cases.11,.12 c o n c l u s i o n diffuse large b cell lymphoma presenting as a chest wall mass, is a rare entity but should always be considered in differential diagnosis of chest wall, so that it can be treated early with a better prognosis. r e f e r e n c e s 1. le huy t, manh pd et al.primary diffuse large bcell lymphoma, presenting as a chest wall mass: a case report. jmr 2022; 154 e10 (6):131-136 2. li s, young kh, medeiros lj. diffuse large b-cell lymphoma. pathology (phila). 2018; 50(1): 74-87. doi:10.1016/j.pathol.2017.09.006. 3. shah b. primary chest wall lymphoma: a rare entity. journal of cancer research and therapeutics. 2015;11(3):661-. 4. ahuja a, mirchandani lv, kamath s, jayalakshmi t. diffuse large b-cell lymphoma presenting as a chest wall mass: case report with review of literature. international journal of current research. 2015;7(11):22667-9. 5. hsu pk, hsu hs, li af, wang ls, huang bs, huang mh, et al. non-hodgkin's lymphoma presenting as a large chest wall mass. the annals of thoracic surgery. 2006;81(4):1214-8. 6. qiu x, liu y, qiao y, chen g, shi t, chen j, et al. primary diffuse large b-cell lymphoma of the chest wall: a case report. world journal of surgical oncology. 2014;12:104. 7. kitada s, komuta k, takatsugi k, maeda k, kimura r, igarashi t. [primary non-hodgkin's lymphoma in the chest wall without preceding disease]. nihon kyobu shikkan gakkai zasshi. 1996;34(5):592-6. 8. gaynor er, fisher ri. recent advances in the management of non-hodgkin's lymphomas. disease-a-month : dm. 1989;35(9):597-650. 9. lau mc, mhandu p, parissis h, mcguigan j. primary diffuse b-cell lymphoma presenting as a solitary chest-wall lesion. journal of surgical case reports. 2015;2015(6). 10. navejar ca, morris mj. diffuse large b-cell lymphoma presenting as an anterior chest wall mass: a case report and literature review. current respiratory medicine reviews. 2009;5(4):239-41. 11. foroulis cn, kleontas ad, tagarakis g, nana c, alexiou i, grosomanidis v, et al. massive chest wall resection and reconstruction for malignant disease. oncotargets and therapy. 2016;9:2349. 12. zhang q, ju y, qu t, wang t, liu x. primary diffuse large b-cell lymphoma as a chest-wall mass: a case report. medicine. 2018;97(47). 44 j i m d c 2 0 1 7 44 op e n ac c e ss f u l l l e n g t h a r t i c l e association of diabetes with various risk factors nadia tariq1, samiha mirza2, muhammad afzal3, abdul majid rajput 4 1assistant professor, dept. of community medicine, islamabad medical and dental college, islamabad 2 demonstrator dept. of community medicine, islamabad medical and dental college, islamabad 3 bio statistician, shaheed zulfiqar ali bhutto medical university, islamabad 4 professor and head dept. of community medicine, islamabad medical and dental college, islamabad a b s t r a c t objective: to investigate the association of possible risk factors with diabetes mellitus in population of rawalpindi. patients & methods: this case control study was conducted in rawalpindi. a total of 99 cases of diabetes from opd and 101 healthy controls from blood banks were included in the study. self-developed closed ended questionnaires were used for data collection. statistical analysis was performed using spss version 16. results: a total of 200 respondents (cases and controls) were selected for this study. results were interpreted in the form of odds ratio (or) and p-value. a p-value < 0.05 was considered significant. or for age group (41-50 yrs) was 8.3 indicating that there were 8.3 times more chances of having diabetes mellitus in this age group as compared to age group of 21-30 years. males had a 4.4 times higher chances of getting diabetes mellitus as compared to females. while or revealed that there were 12.7 times more chance of getting diabetes mellitus with positive family history as compared to negative family history. conclusion: main risk factors identified in this study were age group 41-50 years, male gender and positive family history of diabetes mellitus. keywords: age, diabetes mellitus, family history, male gender, risk factors. author`s contribution 1conception, synthesis and planning of the research, interpretation and analysis 2manuscript writing, discussion,3 data analysis, 4supervision &review the study address of correspondence dr. nadia tariq nadiatariq_81@hotmail.com article info. received: dec 11 2016 accepted: mar 29, 2017 cite this article: tariq n, mirza s, afzal m, rajput am. association of diabetes with various risk factor. jimdc. 2017; 6(1):44-48. funding source: nil conflict of interest: nil i n t r o d u c t i o n over the recent decades, the alarming increase in the prevalence of diabetes mellitus (dm) has lead it to become a global public health epidemic. it is leading to significant personal, social and economic burden worldwide. the world health organization has predicted that the major burden will occur in the developing countries (170% increase) as compared to 42% in the developed countries.1 diabetes mellitus is typically characterised by persistent hyperglycaemia and impaired carbohydrate, lipid and protein metabolism due to insufficient insulin secretion and or action. diabetes has two main types, type 1 dm (insulin dependent diabetes) and type 2 dm (non-insulin dependent diabetes). type 2 dm is the more common form, accounting for 90-95% of all the diabetic patients.2 according to who, “the global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.1 meanwhile, type 1 dm is also showing an increase of 2% to 5% annually worldwide. this rapid and constant increase in type 1 dm suggests a somewhat geneticenvironmental interaction; rather than genetic shift alone in such a short time period.3 well known risk factors associated with diabetes are increased body mass index (bmi), hypertension, smoking, physical inactivity, low education, inappropriate eating habits, high serum lipids, family history, genetics and o r i g i n a l a r t i c l e 45 j i m d c 2 0 1 7 45 even specific ethnicities. stressful life events and psychological stress is also intimately linked to poor blood sugar control. also, differences in the availability or affordability of healthy food, which includes fresh food rather than processed/ fast foods is a cause for intake of excessive refined sugars. availability of places to exercise due to urbanization especially for the females is another leading cause in conservative societies.4 social inequalities in the form of access to health care facilities exists both in developed and developing countries. thus, those attending specialised care centers are offered better care and information as compared to those attending general clinics. recently a cross sectional study in uk in 2016 has revealed the combination of little physical activity, prolonged hours spent on watching television and internet and poor sleep duration as important unaddressed highrisk characteristics of both cardiovascular diseases and type 2 dm.5 public health policies are emphasizing the need for the early identification of the risk factors for dm and combating the modifiable risk factors, alongside implementing appropriate preventive interventions. this strategy is aimed to slow down the manifestations of the disease and eventually reduce public health expenditure. the present study was aimed to find out the association between diabetes and various risk factors such as age group, gender, education, socioeconomic status, family history, duration of diabetes, dietary intake and physical activity etc. p a t i e n t s a n d m e t h o d s this study was conducted in holy family hospital and social security hospital of rawalpindi from february 2016 to july 2016. a total of 99 cases of type 2 diabetes from opd of the hospitals and 101 healthy controls from blood bank were included in the study. age group, gender, socioeconomic status and educational status were matched between cases and controls. cases and controls were selected by non-probability consecutive sampling. both cases and controls either aware of or having record of their blood groups and rh type. admitted cases of dm and cases or controls not aware of their blood groups or rh type were excluded from the study. data was collected through a self-developed, close ended questionnaire. pilot study was carried out and in the light of it, necessary amendments were made in the data collecting tool. the questionnaire was administered to both cases and controls. it included information on demographic profile, whether they were diabetic or not. if diabetic, the type of dm and the duration since their diagnosis. rest of the questions including dietary habits (intake of food rich in fats or carbohydrates), physical activity (minimal with most of the time spent sitting or no), and blood group were same for both cases and controls. the statistical package for social sciences (spss version 16) was used to enter and analyze the data. mean and standard deviation were calculated for quantitative variables and frequency with percentages were presented for qualitative variables. multivariate logistic regression was used to assess impact of different independent variables on outcome variable of diabetes status. results were interpreted in the form of odds ratio and p-value. a pvalue < 0.05 was considered significant. r e s u l t s in this study, a total of 99 cases of dm and 101 healthy controls were included. overall mean age was 50.8 + 7.3 years. mean age in cases was 52.3 + 6.75 years and controls was 47.8 + 7.32 years. among cases, 56 were males and 43 were females. while, among the controls, 67 were males and 34 were females. about 20 cases and 15 controls belonged to rural areas, whereas 77 cases and 84 controls belonged to urban areas. amongst cases, 41 cases were diagnosed within last five years, 37 within 5-10 years and 21 for more than 15 years. according to the results of multivariate logistic regression; overall age of the patient had significant (p-value < 0.05) effect on having diabetes. although results showed a very large odds ratio (or) in the age group ranging from 31-40 years, but it is not statistically significant (p-value > 0.05). the age group 41-50 years is a significant contributor for acquiring dm. the or for this age group is 8.3 which shows that there are 8.3 times more chances of having diabetes in this age group as compared to age group of 20-30 years. gender played a significant (p-value < 0.05) role in acquiring dm. males have a 4.4 times higher chances of getting dm as compared to females. educational status of a person did not show any relationship with dm. there 46 j i m d c 2 0 1 7 46 was no significant (p-value > 0.05) effect of education on diabetes status. furthermore, the study revealed that residence was found to be an insignificant (p-value > 0.05) contributor in acquiring dm, indicating that dm is not necessarily a disease affluent in urban localities. a key contributor for dm established in this study was the family history. a positive family history had significant (p-value < 0.05) effect on having diabetes. the odds ratio shows that there are more chances of diabetes with positive family history as compared to negative family history. physical activity and meal intake did not show any significant (pvalue > 0.05) impact on getting diabetes on the basis of this study. (table 1) blood group as a whole had no impact diabetes. according to the results overall, there was no significant (p-value > 0.05) effect of blood group on having diabetes, but individually blood group o negative showed significant (p-value < 0.05) relationship with diabetes when multivariate logistic regression model was applied, and having o negative blood group had 10.28 times more chances of acquiring diabetes as compared to a positive blood group. (table 2) multivariate logistic regression analysis of different factors with diabetic is shown in table 3. d i s c u s s i o n the results of this study revealed that age, family history and gender have a positive relationship in the acquisition of type 2 dm and unfortunately, all three of these are nonmodifiable risk factors. the increasing insulin resistance with age, decreased physical activity and emergence of elderly diabetic patients due to improved healthcare are the reasons given for the rising prevalence of type 2 dm with age in developed countries.6-9 this study has revealed that age group of 41-50 years are the significant contributors to the non-insulin dependent diabetes mellitus load. previous research has supported this finding showing that incidence of type 2 dm increases with age universally, however, it occurs at lower ages among pakistanis compared to western developed countries.10,11. two probable justifications might be provided. firstly, pakistan is a low income developing country with limited resources and healthcare facilities, thus the average life expectancy is 66 years compared to 81 years (in a developed country such as united kingdom).12 secondly, the growth rate of pakistan (2.1%) exceeds those of many developed nations (uk 0.8%, table 1. demographic data in study groups. characteristics cases (n=99) control (n=101) frequency percent frequency percent age categories n(%) 20-30 0 0 2 2.0 31-40 3 3.0 10 9.9 41-50 38 38.4 56 55.4 51-60 53 53.5 31 30.7 > 60 5 5.1 2 2.0 total 99 100.0 101 100.0 educational status matric 35 35.4 28 27.7 inter 18 18.2 25 24.8 graduate 30 30.3 21 20.8 post graduate 16 16.2 25 24.8 total 99 100.0 99 98.0 residence rural 20 20.2 15 14.9 urban 77 77.8 84 83.2 total 97 98.0 99 98.0 family history of diabetes yes 73 73.7 33 32.7 no 25 25.3 67 66.3 total 98 99.0 100 99.0 table 2. frequency of various risk factors in study groups. characteristics cases control frequency percent frequency percent meals rich in fats and carbohydrates? yes 55 55.6 52 51.5 no 44 44.4 49 48.5 minimal physical activity yes 55 55.6 56 55.4 no 44 44.4 45 44.6 blood group a positive 12 12.1 6 5.9 a negative 5 5.1 3 3.0 b negative 41 41.4 32 31.7 b negative 6 6.1 6 5.9 ab negative 9 9.1 18 17.8 ab negative 6 6.1 2 2.0 o positive 16 16.2 29 28.7 o negative 3 3.0 4 4.0 total 98 99.0 100 99.0 47 j i m d c 2 0 1 7 47 china 0.5%), leading to a surge of young population.13 the present study also showed a significant association between family history and incidence of dm, thus complimenting with previous findings in other studies.14,15 a study conducted in rawalpindi revealed similar findings.16 research reveals that individuals with family history of dm have six fold chances of acquiring dm as compared to those with negative family history.17 this association could be derived partly from a genetic transmission and partly from unhealthy eating habits being passed from generation to generation in a cultural group suffering from dm.18 this study also revealed that males have 4.4 times more chance of having dm. this result is supported by international diabetes federation (idf), which indicated that the prevalence of diabetes in pakistan is higher in males, while the prevalence of impaired glucose tolerance (igt) is higher in females.19 this result may be attributable to specific cultural and geographic factors also; as literature has shown impact of geographic location on variety of diseases. a cross sectional survey published in 2011 conducted within the same geographical location i.e. rawalpindi; revealed that prevalence of dm was more in males than females i.e. 15.41% vs. 12.31% respectively.20 according to a case control study conducted in malaysia, a and o blood groups were negatively associated with diabetes mellitus. 21 blood group b was associated with high incidence of type 2 diabetes according to a study conducted in riyadh, saudi arabia.22 whereas our study revealed blood groups o negative is positively associated with diabetes mellitus. a sub saharan meta-analysis published in 2013 revealed men to have significantly more impaired fasting glucose table 3: multivariate logistic regression for association of different characteristics with diabetes characteristics regression coefficient s.e. wald df sig. (or) exp (b) age of participant 13.573 4 .009 31-40 yrs 22.119 28420.72 .000 1 .999 403 41-50 yrs 2.120 1.065 3.967 1 .046 8.333 51-60 yrs 1.304 .863 2.285 1 .131 3.684 > 60 yrs .380 .867 .192 1 .661 1.462 gender 1.487 .444 11.217 1 .001 4.425 education 1.872 3 .599 matric -.536 .577 .865 1 .352 .585 inter -.046 .566 .007 1 .935 .955 graduate -.590 .556 1.127 1 .288 .554 family history -1.780 .315 32.019 1 .000 .169 meals intake rich in fat and carbohydrate -.691 .398 3.024 1 .082 .501 lifestyle with minimum physical activity .056 .397 .020 1 .887 1.058 blood group 13.658 7 .058 a neg -.363 1.125 .104 1 .747 .696 b pos .241 .691 .122 1 .727 1.272 b neg .669 .921 .527 1 .468 1.952 ab pos 1.269 .791 2.571 1 .109 3.558 ab neg -1.450 1.179 1.511 1 .219 .235 o pos 1.346 .772 3.044 1 .081 3.844 o neg 2.330 1.150 4.104 1 .043 10.280 constant -3.475 1.432 5.890 1 .015 .031 reference categories for: age (20-30 yrs), gender (female), education (post graduation), residence (urban), family history (negative), meals (no), physical activity (yes), blood group (a+). 48 j i m d c 2 0 1 7 48 levels as compared to women. one possible justification for these different levels was said to be the lower hepatic sensitivity to insulin leading to higher fasting glucose levels in men. while, another justification provided was that men are more likely to smoke than women, and smoking decreases insulin sensitivity leading to impaired fasting glucose levels and eventually dm.21 this explanation matches the conservative setup in pakistan also where men are regular smokers compared to women. another possibility for the increased cases of dm amongst the males may be due to the fact that women in a low-income country such as pakistan have poor access to health care services and therefore little chances of being diagnosed with dm .22,23 c o n c l u s i o n diabetes mellitus is an important public health threat specially in a resource poor country such as pakistan. the age shift of dm is towards younger population, especially. family history is a significant contributor for diabetes mellitus. a non-modifiable risk factor, but screening in relatives of known patients of dm can reveal many hidden cases, and its early management. r e f e r e n c e s 1. who, global report on diabetes, 2016. 2. wu y, ding y, tanaka y and zhang w. risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. int. j. med. sci. 2014; 11(11): 1185-1200. 3. maahs dm, daniels sr, ferranti sd, dichek hl, flynn j, goldstein bi, et al. cardiovascular disease risk factors in youth with diabetes mellitus: a scientific statement from the american heart association. circulation. 2014; 130:1532– 1558. 4. lima acs, araújo mfm, freitas rwjf, zanetti ml, almeida pc, damasceno mmc. risk factors for type 2 diabetes mellitus in college students: association with sociodemographic variables. rev latino-am enfermagem.2014; 22(3):484-90. 5. cassidy s, chau jy, catt m, bauman a, trenell mi. cross-sectional study of diet, physical activity, television viewing and sleep duration in 233110 adults from the uk biobank; the behavioural phenotype of cardiovascular disease and type 2 diabetes. bmj open 2016; 6. 6. laura d. what is insulin resistance? about. com guide 2011. 7. zhou x,et al. prevalence and awareness of diabetes mellitus among a rural population in china: results from liaoning province. diabetic med.2015; 32, 332–342. 8. liu x, li y, li l, zhang l, ren y, zhou h, et al. prevalence, awareness, treatment, control of type 2 diabetes mellitus and risk factors in chinese rural population: the ruraldiab study. sci. rep.2016; 6:31426. 9. ding d, chong s, jalaludin b, comino e, bauman ae. risk factors of incident type 2-diabetes mellitus over a 3year follow-up: results from a large australian sample. diabetes res clin pract. 2015 ;108(2):306-15. 10. hakeem r, fawwad a. diabetes in pakistan: epidemiology, determinants and prevention. journal of diabetology.2010; 3:4. 11. shrivastava u, misra a. need for ethnic-specific guidelines for prevention, diagnosis, and management of type 2 diabetes in south asians. diabetes technol ther. 2015 ;17(6):435-9 12. life expectancy at birth, total (years). the world bank. 2016. 13. population growth (annual %). the world bank. 2016. 14. ekpenyong ce, akpan up, ibu jo, nyebuk de. gender and age specific prevalence and associated risk factors of type 2 diabetes mellitus in uyo metropolis, south eastern nigeria. diabetologia croatica.2012; 41-1. 15. mcdonald posso aj, bradshaw meza ra, mendoza morales ez, jaen y, ortega ac, mendoza posada ej. diabetes in panama: epidemiology, risk factors, and clinical management. ann glob health. 2015; 81(6):75464. 16. zafar j, nadeem d, khan sa, abbasi mmj, aziz f, saeed s. prevalence of diabetes and its correlates in urban population of pakistan: a cross-sectional survey. jpakmedassoc.2011; 66(8):922-7. 17. harrison ta, hindorff la, kim h, wines rc, bowen dj, mcgrath bb, et al. family history of diabetes as a potential public health tool. am j prev med. 2003; 24:152-9. 18. gutiérrez-pliego le, camarillo-romero es, montenegromorales lp, & garduño-garcía jj. dietary patterns associated with body mass index (bmi) and lifestyle in mexican adolescents. bmc public health.2016; 16:850. 19. international diabetes federation: idf diabetes atlas 6th ed. brussels, belgium: international diabetes federation, 2013. 20. zafar j, bhatti f, akhtar n, rasheed u, bashir r, humayun s, et al. prevalence and risk factors for diabetes mellitus in a selected urban population of a city in punjab. jpma.2011; 61:40. 21. kamil m, al jamal h, yusoff nm. association of abo blood groups with diabetes mellitus.libyan j med.2010,5:4847. 22. meo sa, rouq fa, suraya f, zaidi sz.association of abo and rh blood groups with type 2 diabetes mellitus.eur rev med pharamacol sci.2016; 20(2): 237-42. 23. hilawe eh, yatsuya h, kawaguchi l & aoyama a. differences by sex in the prevalence of diabetes mellitus, impaired fasting glycaemia and impaired glucose tolerance in sub-saharan africa: a systematic review and metaanalysis. bulletin of the world health organization.2013; 91:671-682. http://www.ncbi.nlm.nih.gov/pubmed/?term=ding%20d%5bauthor%5d&cauthor=true&cauthor_uid=25737033 http://www.ncbi.nlm.nih.gov/pubmed/?term=chong%20s%5bauthor%5d&cauthor=true&cauthor_uid=25737033 http://www.ncbi.nlm.nih.gov/pubmed/?term=jalaludin%20b%5bauthor%5d&cauthor=true&cauthor_uid=25737033 http://www.ncbi.nlm.nih.gov/pubmed/?term=comino%20e%5bauthor%5d&cauthor=true&cauthor_uid=25737033 http://www.ncbi.nlm.nih.gov/pubmed/?term=bauman%20ae%5bauthor%5d&cauthor=true&cauthor_uid=25737033 http://www.ncbi.nlm.nih.gov/pubmed/25737033 http://www.ncbi.nlm.nih.gov/pubmed/?term=shrivastava%20u%5bauthor%5d&cauthor=true&cauthor_uid=25826391 http://www.ncbi.nlm.nih.gov/pubmed/?term=misra%20a%5bauthor%5d&cauthor=true&cauthor_uid=25826391 http://www.ncbi.nlm.nih.gov/pubmed/25826391 http://data.worldbank.org/indicator/sp.pop.grow http://www.ncbi.nlm.nih.gov/pubmed/27108143 http://www.ncbi.nlm.nih.gov/pubmed/?term=zafar%20j%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=nadeem%20d%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20sa%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=jawad%20abbasi%20mm%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=aziz%20f%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=saeed%20s%5bauthor%5d&cauthor=true&cauthor_uid=27524520 http://www.ncbi.nlm.nih.gov/pubmed/?term=saeed%20s%5bauthor%5d&cauthor=true&cauthor_uid=27524520 j islamabad med dental coll 2023 140 open access a descriptive correlational study of vascular foramina in adult human femora in cadavers in pakistan arsalan manzoor mughal1, tehzeeb ul hassan2 ,beenish sabir3, hafsa arshad azam raja4, sheikh mohammad ahmad5 1assistant professor, department of anatomy, rawalpindi medical university, pakistan 2head of department, anatomy, rawalpindi medical university, pakistan 3,4,5 2nd year mbbs, rawalpindi medical university, pakistan a b s t r a c t authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4,5 data analysis; manuscript editing. correspondence arsalan manzoor email: arsalanmanzoor@gmail.com article info: received: november 5, 2022 accepted: june 1, 2023 cite this article. mughal a m, hassan t u, sabir b, raja h a a, ahmad s m. a descriptive correlational study of vascular foramina in adult human femora in cadavers in pakistan .j islamabad med dental coll. 2022; 12(2): 140-146 doi: https://doi.org/10.35787/jimdc.v12i2.927 funding source: nil conflict of interest: nil i n t r o d u c t i o n in humans, the femur is a long bone that articulates with the acetabulum to form the hip joint. blood supply to the femur is via epiphysial arteries & nutrient arteries. the femur is well supplied by many arterial groups named diaphyseal, epiphyseal, metaphyseal, and periosteal arteries.1 the main blood supply for the femoral shaft is the nutrient artery, a branch of the second perforating branch of the profunda femoris artery or from the 1st o r i g i n a l a r t i c l e background: this study was conducted to study the variations in the number and location of nutrient and epiphyseal vascular foramina of the femur in the pakistani population methodology: this descriptive cross-sectional study was conducted from april -june '2022 after getting ethical approval. data collection tool: 24-gauge hypodermic needles & measuring tapes. data collection and analysis: spss & excel inclusion & exclusion criteria: anatomically sound bones were included from the bone bank of rmu; pathological, deformed bones were excluded results: out of 80 bones 66.6% had single nutrient foramina, whereas 31.3% had two on the shaft. 82.05% of foramina were type ii, 16.67% were type i and 1.26% were type iii. only 2.5% had no foramina. majorly the nutrient foramina were found on the medial surface, medial lips or between the lips of linea aspera. there was no significant difference bilaterally in the mean foraminal index, foraminal length, or several epiphyseal vascular foramina, which were 18.65 cm, 42.66 cm, and 16 cm respectively. conclusion: most of the nutrient foramina in the femora were found in the middle third of the shaft, either on the medial lip of the linea aspera or on the shaft’s medial surface; however, variations in their location have been found. the mean epiphyseal vascular foramen ranged from 6 to 26. the article finds its implications in orthopaedic surgery and osteogenesis. key words: epiphyses, diaphysis, femur, long bones, hip joint, arteries, pathology, research, osteogenesis, population j islamabad med dental coll 2023 141 perforating branch. sometimes, additional nutrient arteries may supply the femur from either of the rest of the perforating arteries.2 it permits the nutrient artery to enter obliquely piercing the bone’s periosteum and entering the osteon via the haversian system reaching the medullary cavity. the diaphyseal artery’s entry and angulation is specific representing the direction of the growing end in most long bone.4 nutrient foramen are usually located on the shaft and may be up to three for a single bone usually near the linea aspera in the upper 2/3rd region.5,6 aging and certain pathological conditions such as anaemias, diabetes, chronic airway diseases, tumours, as well as immobility result in a decline in the quality of blood supply to all bones including the femur. the position of the nutrient foramen is significant for morphological, pathological, and operative procedures such as microvascular bone grafts.8 additionally, the femur’s upper end is rich in blood supply due to the many branches of several main arteries that anastomose with each other. the head of the femur gets its blood supply mainly via retinacular arteries from the medial circumflex branch of the profunda femoris artery.9 the other source to the head are the vessels from the obturator artery and the pericapsular anastomoses that provide blood supply to the hip joint too.10 retinacular arteries that are derived from trochanteric anastomosis around the greater trochanter supply the intra-capsular part of the femoral neck. the cruciate anastomosis is another source which is formed by the ascending branch of 1st perforating artery, the inferior gluteal artery’s descending branch, and the circumflex femoral arteries. the rich vascular supply through the retinacula of weitbrecht via a large number of retinacular vascular foramina in the neck region can be explained based on the fact that these vessels ensure the optimal vascularity of the hip joint.2 although much research has been done on the diaphyseal nutrient foramina of the femur, scant literature is available on the locations and number of epiphyseal vascular foramina a few of which are from our region. so, this research was designed to study the variations in nutrient and epiphysial vascular foramina of the femur in the pakistani population. m e t h o d o l o g y for this descriptive cross-sectional study, pakistani femora of unspecified gender and age were acquired. data was collected from april 2022 to june 2022. only anatomically sound bones were used in the study. bone having anatomical or physical pathology and deformity were not used in the study. 24-gauge hypodermic needles and magnifying hand lenses were used for determining the diaphyseal nutrient foramina and epiphyseal vascular foramen. all the bones were examined macroscopically in a well-illuminated area. the nutrient foramen was identified as it has a distinct groove along with a little-raised area at the beginning of the canal.11 this was verified by passing a 24-gauge needle from the cortex into the medullary. (fig. 1a) for the bone having two foramina, the bigger and more prominent one was considered the primary or dominant and the smaller one was considered the secondary foramen. passed through the canal. epiphyseal vascular foramina were counted using a handheld magnifying lens. (fig. 1d). it was calculated by hughes's formula. for femora having two nutrient foramen, the larger one was considered to calculate the foraminal index.12 the distance of the nutrient foramen was calculated by marking the upper margin of the head and measuring the distance to the location of the nutrient foramina. if a femur had two nutrient foramina, the larger one was considered for the calculation. the distance between these two points was marked using markers and measured with a measuring tape. (fig. 1b) j islamabad med dental coll 2023 142 diaphyseal nutrient foramen on the posterior aspect of the femur. distance between the proximal end of the femur and the diaphyseal nutrient artery measurement of total femur length counting the epiphysial nutrient foramen the total bone length was calculated by marking two points on the plane paper that indicated the outermost margin of the bone. the upper margin was drawn at the superior-most limit of the head, while the lower margin was drawn from the inferiormost level of the medial condyle of the bone. the distance between these two points indicated the total femur length, which was then measured in centimetres using the meter rule. (fig. 1c) according to the foraminal index, the nutrient foramina were divided into three main categories; type 1 with a foraminal index of less than 33.3%, type 2 with a foraminal index between 33.33% 66.66% and type 3 with a foraminal index above 66.66%. frequency and percentages were calculated for qualitative variables such as the location of diaphyseal nutrient foramen and foraminal position type. means and standard deviations were calculated for quantitative variables such as the distance of nutrient foramen from the proximal end, the number of epiphyseal vascular foramen, and the foraminal index. student’s t-test was used to compare the difference in means between the left and right femora for these variables. pearson’s correlation was used to determine the association between the number of vascular foramina and shaft length. r e s u l t s eighty anatomically intact adult femora were taken from the rawalpindi medical university’s bone bank and the location of nutrient foramina was studied. thirty-five bones were on the right side and fortyfive bones were on the left side. fifty-three bones (66.6%) had single nutrient foramina whereas twenty-five bones (31.3%) had two nutrient foramina on the shaft. most (82.05%) of foramina were type ii, 16.67% were type i and 1.26% were type iii. (fig 2) only two bones (2.5%) had no nutrient foramina. figure 2: foraminal position type according to foraminal index j islamabad med dental coll 2023 143 table i: location of nutrient foramen of femur location of nutrient foramen frequency percentage linea aspera 12 11.7 linea aspera’s medial lip 29 28.6 medial surface 26 25.2 between medial and lateral lips of linea aspera 20 19.1 linea aspera’s lateral lip 10 9.7 on lateral surface 6 5.8 total 103 100.0 table ii: the number of epiphyseal vascular foramen, distance of nutrient foramen from the proximal end, and foraminal index. vascular foramen parameters side n mean std. deviati on p-value nutrient foramen distance from proximal end (cm) right 35 18.39 5.46 0.709 left 45 18.85 5.49 total 80 18.65 5.45 foraminal index right 35 42.69 12.50 0.983 left 45 42.63 12.06 total 80 42.66 12.18 epiphyseal vascular foramen (neck) right 35 16 10 0.964 left 45 16 11 total 80 16 10 table iii: correlation between the number of vascular foramina and shaft length variable nutrient foramina on diaphysis epiphysial vascular foramen on neck shaft length(cm) pearson correlation -.034 .082 p value .770 .468 n 78 80 from the proximal end, the mean distance of the nutrient foramen was 18.65±5.45 cm difference between the sides being insignificant. the mean foraminal index was 42.66±12.18 with the difference between the sides being insignificant. the mean number of epiphyseal vascular foramen was 16±10 which was also not significant between the right and left sides. (table 2) the correlation between shaft length and the number of vascular foramina in the shaft or the epiphysis was also not significant. (table 3) d i s c u s s i o n despite the immense popularity of open reduction surgery in femoral shaft fracture, there’s little research on all the required details of the femoral blood supply. an adequate knowledge of the nutrient vessels' anatomy and their entry into the bone is of great significance as the success of these operations depends significantly upon the preservation of the bone’s blood supply. according to hughes, femur is a long bone with the most varied nutrient foramen. 13 these range from absent nutrient foramina to a maximum of three. most researchers have reported that femora often contain single nutrient foramen.14 in our study a single nutrient foramen was found in 66.6% of the femora. mysorekar, prashanth and others have reported two nutrient foramina in 42 to 55% of femora contain double nutrient foramina, 15,16 however, our research on pakistani femora revealed that 31.3% of bones had two nutrient foramina, indicating that two main diaphyseal nutrient arteries are supplying the shaft in these bones. few studies have reported up to three nutrient foramen with an only 3.5% of incidence; however, none of the bones we studied had three nutrient foramina.12 maximum number of reported foramina is nine but this is extremely rare. 17 we found only two bones (2.5%) that had no nutrient foramina. in another research, 4.6% of 86 femora had absent foramina.16 the absence of nutrient foramen is not enigmatic; it’s indicative of the fact that a nutrient artery might not have developed during intrauterine life. there might have been defects in vasculogenesis and angiogenesis j islamabad med dental coll 2023 144 during embryonic life that prevented the development of diaphyseal nutrient arteries in 2.5% of the femora. when a bone lacks the main nutrient artery, it’s usually supplied by the periosteal arteries.12 however, due to rich anastomosis between periosteal, epiphyseal, and other small diaphyseal arteries, adequate nutrition to the bone is maintained through it. although the compensation is done well by these vessels it still may not supply the bone optimally. it results in impaired osteogenesis and avascular necrosis during the fractures of the femur.1 to minimize the chances of delayed or non-union fracture, an orthopaedic surgeon must have adequate knowledge regarding the morphology of nutrient foramen.18 the geographical area also has a subjective influence on the nutrient foramina location. we found nutrient foramen mostly on the medial surface, medial lips of linea aspera or between the lips of linea aspera. none were found on the lateral surface with the difference between the sides being insignificant. similarly, in north indians, the nutrient foramen is found in abundance in the interstice, followed by on the linea aspera’s medial lip, which is in congruence with our study. 19 in the black south african population reported a similar pattern but in the white south africans, most nutrient foramina are placated on the linea aspera and sometimes on the posterolateral surface.20 in the turkish population, the right femora have a higher frequency of nutrient foramen on the medial lip whereas it changes to the lateral lip in the left femora.21 in the nepalians, the nutrient foramina are found abundantly on the lateral surface. 22 this precise knowledge about epiphyseal retinacula foramen is important in performing surgeries around the upper end of the femur i.e., hip fracture and hip dislocation surgeries. lateral ascending cervical branches of the medial circumflex humeral artery can be disrupted easily and can cause avascular osteonecrosis. in a sample of 76 chinese cadaveric bones, they counted 2417 vascular foramina most of which were on the superior aspect, anterior and posterior surfaces of the neck.7 this study complies with reports from lavigne et al.23 these studies reported the presence of nutrient foramina in the anterolateral regions of the neck; however, lavigne et al. also have reported that 71% of femora contain no nutrient foramina in the anterior regions. we found 1303 vascular foramina on the neck region in 80 bones -which is markedly less than the chinese. most of these retinacular foramina were found on the neck’s posterior side whereas some were located on the superior surface and intertrochanteric crest. it’s likely to hypothesize that these variations in chinese could be due to greater physical activity compared to our population. having a better nutritional status can also be a factor as meiguei angel medina and ana r. quesada have suggested a correlation between the modulatory effects of dietary protein and angiogenesis.24 different opinions exist regarding the relationship between the total bone length to the size or number of vascular foramina in the femoral neck. some have reported that there is no association between the distribution of nutrient foramen with the length of the bone.12,21 however, jiong mei has reported that the length of the bone and the number of vascular foramina on the neck are positively correlated. 25 no correlation between the two variables was found in our study. larger prospective studies should be done to study this phenomenon. the number of retinacular foramina has clinical significance because, in individuals with fewer vascular foramina located near the articular cartilage, even a mild fracture i.e., valgus-impacted fractures of the neck may lead to the head’s avascular necrosis. limitations of our study were that age and gender differences were not taken into account as these bones were obtained from the bone bank. further study can be done to study these parameters where data is available. j islamabad med dental coll 2023 145 c o n c l u s i o n nutrient foramen in the femora of the pakistani population is commonly found on the shaft’s middle third, lina aspera’s medial lip, the shaft’s medial surface or between the two lips of linea aspera. however, some variations in their location have been found in this study. the mean epiphysial vascular foramen per bone ranged from six to twenty-six but no correlation was found with bone length. r e f e r e n c e s 1. arias dg, marappa-ganeshan r. anatomy, bony pelvis and lower limb, arteries. 2. susan s. gray’s anatomy: the anatomical basis of clinical practice. https://doi.org/10.1002/ca.22677 3. karmali nk, chouhan sk. a morphological study of position of nutrient foramen in dry human femur. international journal of scientific study. 2019;7(3):75-8. 4. paul rg, navin kumar balla i, sailajat k. variations of the nutrient foramina in dried human femur. orig res artic. 2019;7(1):6780–5. https://doi.org/10.16965/ijar.2019.224 5. dervisevic l, dervisevic a, ajanovic z, hasanbegovic i. analytical and morphometric study of nutrient foramina of femur and its clinical implications. international journal of research in medical sciences. 2019 apr;7(4):1324. https://doi.org/10.18203/2320-6012.ijrms20191347 6. murali krishna s, kumar u, sirisha v, rajesh v. morphologic and morphometric study of the nutrient foramina in dry human femur bones of telangana region. int j anat res. 2016;4(2):2464-68. https://doi.org/10.16965/ijar.2016.239 7. mei j, ni m, wang g, jia g, liu s, cui x, et al. number and distribution of nutrient foramina within the femoral neck and their relationship to the retinacula of weitbrecht: an anatomical study. anat sci int. 2017 jan;92(1):91–7. https://doi.org/10.1007/s12565-015-0319-5 8. marenzana m, arnett tr. the key role of the blood supply to bone. bone res. 2013 sep;1(3):203. https://doi.org/10.4248/br201303001 9. the developing human: clinically oriented embryology 9th edition keith l. moore, t. v. n. persaud, mark g. torchia. https://doi.org/10.1016/b978-1-4377-20020.00028-x 10. gadinsky ne, klinger ce, sculco pk, helfet dl, lorich dg, lazaro le. femoral head vascularity: implications following trauma and surgery about the hip. orthopedics. 2019 sep 1;42(5):250-7. https://doi.org/10.3928/01477447-20190723-03 11. m murlimanju bv, prashanth ku, prabhu lv, saralaya vv, pai mm, rai r. morphological and topographical anatomy of nutrient foramina in human upper limb long bones and their surgical importance. rom j morphol embryol. 2011 mar;52(3):859-62. 12. prashanth ku, murlimanju b v., prabhu l v., kumar cg, pai mm, dhananjaya kvn. morphological and topographical anatomy of nutrient foramina in the lower limb long bones and its clinical importance. australas med j. 2011;4(10):530–7. https://doi.org/10.4066/amj.2011.725 13. pereira ga, lopes pt, santos am, silveira fh. nutrient foramina in the upper and lower limb long bones: morphometric study in bones of southern brazilian adults. int j morphol. 2011 jun 1;29(2):51420. https://doi.org/10.4067/s071795022011000200035 14. karmali nk, chouhan sk. a morphological study of position of nutrient foramen in dry human femur. international journal of scientific study. 2019;7(3):75-8. 15. denisiuk m, afsari a. femoral shaft fractures. instatpearls [internet] 2022 feb 4. statpearls publishing. 16. prashanth ku, murlimanju b v., prabhu l v., kumar cg, pai mm, dhananjaya kvn. morphological and topographical anatomy of nutrient foramina in the lower limb long bones and its clinical importance. australas med j. 2011;4(10):530. https://doi.org/10.4066/amj.2011.725 17. santolini e, goumenos sd, giannoudi m, sanguineti f, stella m, giannoudis pv. femoral and tibial blood supply: a trigger for non-union?. injury. 2014 nov 1;45(11):1665-73. https://doi.org/10.1016/j.injury.2014.09.006 18. perumal v, roberts cs. (ii) factors contributing to non-union of fractures. curr orthop. 2007 aug;21(4):258–61. https://doi.org/10.1016/j.cuor.2007.06.004 19. verma p, mahajan a, gandhi d. variation in the number and position of nutrient foramina of long bones of lower limb in north indians. | imsear. 2015. https://doi.org/10.16965/ijar.2015.285 20. mazengenya p, fasemore md. morphometric studies of the nutrient foramen in lower limb long bones of adult black and white south africans. eur j anat. 2015;19(2):155–63. j islamabad med dental coll 2023 146 21. ukoha uu, umeasalugo ke, nzeako hc, ezejindu dn, ejimofor oc, obazie if. a study of nutrient foramina in long bones of nigerians. national journal of medical research. 2013 dec 31;3(04):304-8. 22. ak g, mn a, kumar gupta a. study of nutrient foramina in adult human femur bones. j nepalgunj med coll. 2016 oct;14(2):44–9. https://doi.org/10.3126/jngmc.v14i2.21538 23. lazaro le, klinger ce, sculco pk, helfet dl, lorich dg. the terminal branches of the medial femoral circumflex artery: the arterial supply of the femoral head. the bone & joint journal. 2015 sep;97(9):120413. https://doi.org/10.1302/0301-620x.97b9.34704 24. medina má, quesada ar. dietary proteins and angiogenesis. nutr 2014, vol 6, pages 371-381. 2014 jan;6(1):371–81. https://doi.org/10.3390/nu6010371 25. mei j, quan k, wang h, dai y, zhang f, ni m. total cross-sectional area of the femoral neck nutrient foramina measured to assess arterial vascular beds in the femoral head. j orthop surg res. 2019 dec;14(1):1–7. https://doi.org/10.1186/s13018-0191480-7 40 j i m d c 2 0 1 7 40 op e n ac c e ss f u l l l e n g t h a r t i c l e frequency of candidiasis, trichomoniasis and pyogenic infection causing pelvic inflammatory diseases shazia azhar1, mamoona shafiq2, summayah niazi3 1assiatant professor, medical technology, baqai institute of medical technology, baqai medical university karachi 2 associate professor, dept. of physiology, islamabad medical and dental college, islamabad 3assistant professor, dept. of physiology, fazaia medical college, islamabad. a b s t r a c t objective: to determine the frequency of candida, trichomonas and pyogenic infection, in pelvic inflammatory diseases (pid) patients and methods: this cross-sectional study was carried out in gynecology opd of abbasi shaheed hospital karachi and baqai hospital karachi from november 2013 to january 2014. the study included 100 females of 20-40 years and above with history of vaginal discharge, low back pain, itching, bleeding. the subjects were divided on the basis of various socioeconomic status (poor, middle, rich) groups. females who were pregnant or had recent history of abortion were excluded from the study. for assessment, pap smear, wet preparation and high vagina swab was collected from cervix and vagina. results: in our study candida albican 35%, trichomonas infection 30% and pyogenic infection 35% were seen in various age groups. majority of the cases were between 20-40 years. it was also observed that trichomoniasis was observed in lower and middle class females and not in upper class females. conclusion: trichomonas, candida and pyogenic infections were found to be most commonly associated with pelvic inflammatory diseases. a relatively higher frequency of candidiasis, and pyogenic infections were observed in upper and middle class, whereas high frequency of trichomoniasis was found in lower and middle class women. key words: candidiasis, pelvic inflammatory disease, pyogenic infection, trichomoniasis. author`s contribution 1conception, synthesis and planning of the research,2 active participation in active methodology & interpretation, analysis and discussion, 1,3active participation in active methodology address of correspondence dr. mamoona shafiq e-mail: dr_mamoona78@hotmail.com article info. received: aug 8, 2016 accepted: feb 4, 2017 cite this article: azhar s, shafiq m, niazi s. frequency of candidiasis, trichomoniasis and pyogenic infection causing pelvic inflammatory disease.jimdc. 2017; 6(1):40-43. funding source: nil conflict of interest: nil i n t r o d u c t i o n pelvic inflammatory disease (pid) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. infection and inflammation may spread to the abdomen, including perihepatic structures. pid is initiated by infection that ascends from the vagina and cervix into the upper genital tract. vaginitis is defined as a spectrum of condition that cause vaginal and sometimes vulvar symptoms, such as itching, burning, irritation, odor, and vaginal discharge. the most common causes of vaginitis and cervicitis are candidiasis, trichomoniasis and bacterial vaginosis.1 the symptomatic infection by these etiological agents arises when there is an excessive proliferation of these microorganism in the vaginal flora, ceasing the colonization and starting to achieve outright adherence to the vaginal cells, consequently causing infection.2 in o r i g i n a l a r t i c l e mailto:dr_mamoona78@hotmail.com 41 j i m d c 2 0 1 7 41 candidiasis infective patient presents with thick, fetid vaginal secretions which may have granular appearance and an itchy vulva..3 the vagina becomes hyperemic and the vulva becomes erythematous, and there may be excoriation and dyspareunia.4 a patient with trichomoniasis presents with intense frothy yellowgreenish vaginal discharge, irritation and pain in the vulva, perineum and thighs, along with dyspareunia and dysuria.5 trichomonas vaginalis is a flagellate protozoan considered to be sexually transmittable and usually seen in low socioeconomic class.6 in bacterial vaginosis foulsmelling vaginal secretion, is associated with a high incidence of endometritis and pelvic inflammatory disease following abortion and late miscarriages, premature rupture of membranes, and preterm birth.7 among women with bacterial vaginosis, no overall increased risk of developing pelvic inflammatory disease has been found.8 bacterial vaginosis is also associated with both symptomatic and asymptomatic conditions. bacterial vaginosis have been strongly linked with an increased risk of human immunodeficiency virus transmission.9 clinical manifestations of pid vary widely, however: many patients exhibit few or no symptoms, whereas others have acute, serious illness. the most common presenting complaint is lower abdominal pain. many women report an abnormal vaginal discharge. for situations where onsite microscopy is not available, the world health organization has developed algorithm for management of vaginal discharge.10 p a t i e n t s a n d m e t h o d s this cross-sectional study was carried out in 100 females (20 years and above) attending gynae opd of abbasi shaheed hospital and baqai hospital karachi from november 2013 to january 2014. patients with history of discharge, low back pain, itching were included in the study. patients were also asked for history of bleeding, pregnancy and medication. patients with present pregnancy and abortion were excluded from the study. for the assessment of pap smear, wet preparation and high vagina swab was collected from cervix and vagina. wet preparation in normal saline for the identification of trichomonas was also done. high vaginal swab was inoculated in maconkey`s agar for the isolation of type of bacteria. in our study, we found the colonies of e. coli which showed indole positivity, pink rod were shows in gram staining. pap staining was used to find out the candida albican and cell morphology. all values were entered on spss version 10 for evaluation of frequency of etiological agents in the study population. moreover, their frequency was also assessed in various socioeconomic groups. r e s u l t s among total of 100 cases, 35 cases were found to have candidiasis, 30 cases trichomoniasis, and 35 cases were found to have pyogenic infection. our study also showed that candidiasis was found in 57% of cases in 20-40 years’ age group. whereas it was 43% in 50 years and above. trichomoniasis was found in 100% cases between 20-40 years. none of the females 50 years and above were found to be infected with it (table1 & 2). pyogenic infection was found in 94 in 20-40% years and 6% of cases in age groups of 50 years and above. our data was also categorized according to socioeconomically table 1. demographic characteristics of participants (n=100) variables number age limits 20-30years 31-40yrs 41yrs & above no 58 25 17 marital status married unmarried 60 40 education educated uneducated 60 40 occupation house wife working ladies 60 40 socioeconomic status according to area poor middle rich 40 30 30 family life cycle satisfactory unsatisfactory 60 40 42 j i m d c 2 0 1 7 42 status into poor, middle and rich classes (table 3); we found in poor class 40% cases had infection whereas in middle class and upper class it was seen in 30% cases each. frequency of various infections in different socioeconomic groups is shown in table 3; as shown in table no case of trichomoniasis was found in upper class. d i s c u s s i o n pelvic inflammatory disease comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.11 microorganisms that comprise the vaginal flora (e.g., anaerobes, g. vaginalis, haemophilus influenzae, enteric gram-negative rods, and streptococcus agalactiae) have been associated with pid.12 in addition, cytomegalovirus (cmv), m. hominis, u. urealyticum, and m. genitalium have also been found to be associated with some pid cases.13-16 sexually transmitted organisms, especially n. gonorrhoeae and c. trachomatis, are implicated in many cases. screening and treating sexually active women for chlamydia reduces their risk for pid.17 according to epidemiological studies three main causes of vaginitis all over the world are; candidiasis, trichomoniasis and pyogenic infections.18 these etiological agents are associated with a high incidence of endometritis and pelvic inflammatory disease. our study also correlates with another study which was conducted on infection and infertility in india, and it revealed that candidiasis, trichomoniasis, and pyogenic infections are the most common opportunistic infections in the female genital system.19 they also reported 35% candidiasis, 30% trichomoniasis infection and 35% other pyogenic infections in their study. they isolated other pyogens like sp.staphylococci, chlamydia, and nesisseria gohorrhoeae sp, species, besides escherichca coli, a finding which is not comparable with our study. many cases of pid go unrecognized. reason being as some of the cases are asymptomatic, others are not diagnosed because the patient or the health-care provider fails to recognize and investigate for mild or nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and vaginal discharge) and thus many cases remain undiagnosed. it has also been observed that even women with mild or asymptomatic pid might be at risk for infertility, so it is very much important that all cases with even mild and nonspecific symptoms be investigated meticulously. another study was also conducted on sexually transmitted diseases, and it revealed that trichomonas infection was frequently observed in poor and middle class, because of poor hygiene.20 this theory correlates with our study as we also observed that poor class and middle class are most commonly infected with trichomonas infections due to improper hygiene. c o n c l u s i o n trichomonas, candida and pyogenic infections were found to be most commonly associated with pelvic inflammatory diseases and trichomoniasis was more frequently observed in poor and middle class females due to poor hygenic. r e f e r e n c e s 1. rutvij dalal. infection and infertility, genital infections and infertility.2016; intech, doi: 10.5772/64168. available from: http://www.intechopen.com/books/genital-infectionsand-infertility/infection-and-infertility. 2. hughes jp, baeten jm, lingappa jr, et al. determinants of per-coital-act hiv-1 infectivity among african hiv-1– serodiscordant couples. j infect dis. 2012; 205:358–365. table 2. frequency of etiological agents in various age groups (n=100) etiological agents 20-30years (n=58) n(%) 30-40yrs (n=25) n(%) 50 yrs & (n=17) n(%) candida albicans (n=35) 10 (28.5) 10(28.5) 15(43) trichomoniasis (n=30) 20(6.7) 10(33) __ pyogenic (n=35) 28(80) 5(14) 2(6) table 3. frequency of etiological agents in various socioeconomic groups (n=100) etiological agents lower class (n=40) n(%) middle class (n=30) n(%) upper class (n=30) n(%) candida albicans (n=35) 10 (28.5) 10 (28.5) 15 (43) trichomoniasis (n= 30) 20 (67) 10 (33) -- pyogenic (n= 35) 10 (28.5) 10 (28.5) 15 (43) 43 j i m d c 2 0 1 7 43 3. falahati m, akhlaghi l, abianeh m, assadi m, nami s, fateh rvaginitis. am j obstet gynecol. 2012 ;152:247-51. 4. baron ej, miller jm, weinstein mp, richter ss, gilligan ph, thomson rb, et al. a guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the infectious diseases society of america (idsa) and the american society for microbiology (asm). clin infect dis.2013; 57 (4): e22-e121. 5. coleman js, gaydos ca, witter f. trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. obstetrical & gynecological survey. 2013 ;68(1):43. 6. conrad md, gorman aw, schillinger ja, fiori pl, arroyo r, malla n, et al. extensive genetic diversity, unique population structure and evidence of genetic exchange in the sexually transmitted parasite trichomonas vaginalis. plos negl trop dis. 2012;6(3):e1573 7. nielsen tj, pradhan p, brittingham a, wilson wa. glycogen accumulation and degradation by the trichomonads trichomonas vaginalis and trichomonas tenax. journal of eukaryotic microbiology. 2012 ;59(4):359-66. 8. carlton jm, hirt rp, silva jc, delcher al, schatz m, zhao q, et al. draft genome sequence of the sexually transmitted pathogen trichomonas vaginalis. science. 2007;315(5809):207-12. 9. conrad md, gorman aw, schillinger ja, fiori pl, arroyo r, malla n, dubey ml, gonzalez j, blank s, secor we, carlton jm. extensive genetic diversity, unique population structure and evidence of genetic exchange in the sexually transmitted parasite trichomonas vaginalis. plos negl trop dis. 2012;6(3):e1573 10. ginocchio cc, chapin k, smith js, aslanzadeh j, snook j, hill cs, et al. prevalence of trichomonas vaginalis and coinfection with chlamydia trachomatis and neisseria gonorrhoeae in the united states as determined by the aptima trichomonas vaginalis nucleic acid amplification assay. j. clin. microbiol. august 2012;50 (8): 2601-2608. 11. wiesenfeld hc, sweet rl, ness rb, krohn ma, amortegui aj, hillier sl. comparison of acute and subclinical pelvic inflammatory disease. sex transm dis 2005;32:400–5. 12. ness rb, kip ke, hillier sl, soper de, stamm ca, sweet rl. a cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. am j epidemiol. 2005;162:585–90. 13. cohen cr, mugo nr, astete sg. detection of mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. sex transm infect 2005;81:463–6. 14. haggerty cl, totten pa, astete sg, ness rb. mycoplasma genitalium among women with nongonococcal, nonchlamydial pelvic inflammatory disease. infect dis obstet gynecol 2006:30184. 15. short vl, totten pa, ness rb, astete sg, kelsey sf, haggerty cl. clinical presentation of mycoplasma genitalium infection versus neisseria gonorrhoeae infection among women with pelvic inflammatory disease. clin infect dis. 2009;48:41–7. 16. jurstrand m, jensen js, magnuson a, et al. a serological study of the role of mycoplasma genitalium in pelvic inflammatory disease and ectopic pregnancy. sex transm infect 2007;83:319–23. 17. oakeshott p, kerry s, aghaizu a, et al. randomised controlled trial of screening for chlamydia trachomatis to prevent pelvic inflammatory disease: the popi (prevention of pelvic infection) trial. bmj 2010;340:c1642. 18. silk bj, date ka, jackson ka, pouillot r, holt kg, graves lm, et al. invasive listeriosis in the foodborne diseases active surveillance network, 2004–2009: further targeted prevention needed for higher-risk groups. clin infect dis. 2012;54(suppl 5): s396-404. 19. reighard sd, sweet rl, miguel cv, miguel rd, chivukula m, krishnamurti u, et al. endometrial leukocyte subpopulations associated with chlamydia trachomatis, neisseria gonorrhoeae, and trichomonas vaginalis genital tract infection. am j obstet gynecol .2011;205(4):324-e1. 20. schwebke jr, hobbs mm, taylor sn, sena ac, catania mg, weinbaum bs, et al. molecular testing for trichomonas vaginalis in women: results from a prospective us clinical trial. j. clin. microbiol. 2011 ;49(12):4106-11. 154 j i m d c 2 0 1 8 154 op e n ac c e ss c a s e r e p o r t primary malignant melanoma of adrenal gland usman hassan1, mudassar hussain2, hamna salahudin3, sheeba ishtiaq4, noreen akhtar5 1,2,5 consultant histopathologist, shaukat khanum memorial cancer hospital and research centre, lahore 3 resident histopathology, shaukat khanum memorial cancer hospital and research centre, lahore 4 assistant professor of histopathology and consultant histopathologist gulab devi hospital, lahore a b s t r a c t a 49 years old male presented with abdominal pain for two months. abdominal examination revealed slight tenderness in the right lumbar region. on radiological examination an abnormal lesion, measuring 5.5cm x 4.5cm, involving the right adrenal gland was found. it was biopsied and histological and immunohistochemical features were consistent with malignant melanoma. after meticulous physical examination, the patient did not have ocular or muco-cutaneous melanoma and he did not have any past significant medical or surgical history. we labelled this case as primary malignant melanoma of adrenal gland. unfortunately, the patient died two months after the detection of tumor and before the start of treatment. key words: abdominal pain, adrenal mass, malignant melanoma address of correspondence usman hassan email: drusmanhassan256@gmail.com article info. received: march 24, 2018 accepted: may 12, 2018 cite this case report: hassan u, hussain m, salahudin h, ishtiaq s, akhtar n. primary malignant melanoma of adrenal gland. 2018; 7(2):154-156. funding source: nil conflict of interest: nil i n t r o d u c t i o n malignant melanoma is a neoplasm of skin. apart from the skin and choroid plexus, primary malignant melanoma at other sites is a rare entity.1 documented sites where malignant melanoma can occur are lung2, genitourinary tract3, and git4. it is very rare in adrenal gland. only 12 well-documented cases of primary malignant melanoma of adrenal gland have been reported.5 in the adrenal gland it originates from neural crest cells present in adrenal medulla.6 it is difficult to differentiate between primary and metastatic malignant melanoma in adrenal gland. histological and immunohistochemical studies are not helpful in differentiating between primary and metastatic malignant melanomas.6 therefore meticulous physical examinations is necessary to rule out the possibilities of primary ocular or mucocutaneous melanomas. up till now, primary malignant melanoma of adrenal gland has not been reported from pakistan. c a s e r e p o r t a 49 years old male presented with the complaints of abdominal pain, anorexia and weight loss for two months. he did not have any significant past medical or surgical history. on general physical examination patient was emaciated and pale. abdominal examination only revealed slight tenderness in right lumbar region. laboratory investigations showed haemoglobin of 10.0 g/dl with mcv and mchc 78.6 fl and 30.6g/dl respectively. renal function tests, liver function tests, and electrolytes were normal. abdominal ultrasound showed a solid hypoechoic mass of 5.5cm x 4.5cm, above the upper pole of right kidney. it did not show increased flow on doppler. left kidney, liver, gall bladder, bile duct, spleen and pancreas were normal. no pleural effusion, ascites or para aortic lymphadenopathy was noted. 3d ct abdomen with iv contrast revealed a dense abnormal lesion, measuring 5.5cmx4.5cm, involving the right adrenal gland. both kidneys showed multiple cysts with no solid mass or obstructive changes. liver, gall bladder, spleen, c a s e r e p o r t 155 j i m d c 2 0 1 8 155 pancreas, aorta and ivc were normal. no ascites was seen. patient underwent diagnostic laparoscopy and an incisional biopsy was taken from right adrenal mass. on gross examination, we found multiple fragments measuring 2.0cm x 1.0cm x 1.0cm in aggregate. specimen weighed 8 grams. cut surface revealed hemorrhagic and necrotic areas. microscopic examination revealed a malignant neoplasm, comprising of polygonal cells arranged in diffuse sheets. the cells showed marked pleomorphism, atypia, atypical mitoses (11/10 hpf) and few cells showed intracytoplasmic melanin pigment (fig 1). few areas showed necrosis. figure 1(a): low power view shows sheets and clusters of medium to large sized atypical polygonal cells with focal areas of pigmentation (arrow) [h&e 10x100]. figure 1(b): high power view shows atypical tumor cells with rounded vesicular nuclei, prominent nucleoli, intra cytoplasmic melanin pigment [h&e 40x100]. tumour cells revealed positive expression for melan a, s100, hmb-45 (fig 3\2) and negative staining for synaptophysin, calretinin, inhibin, cytokeratin, lca. figure 2: positive immunohistochemical staining for melan a ,hmb-45 and s100. based on above-mentioned results, an initial diagnosis of malignant melanoma was made and patient was evaluated for any possible primary site of malignant melanoma. on meticulous evaluation, physicians did not find any ocular or mucocutaneous melanoma. patient was diagnosed as case of primary malignant melanoma of adrenal gland. he was referred to oncologist for further management. however, patient died before the start of treatment, two months after diagnosis of adrenal malignant melanoma. autopsy was not performed due to lack of attendant’s consent. d i s c u s s i o n malignant melanoma comprises of 2% of all body tumours.7 primary and metastatic melanomas of the adrenal gland are rare and are incidental findings. pain is the most common manifestation along with gastrointestinal symptoms caused by the compression of the structures adjacent to the tumour.8 primary melanoma of the adrenal gland is usually a voluminous, nonfunctional tumor showing heterogeneous contrast enhancement on the computed tomographic (ct) scan and diagnosis is made on the basis of immunohistochemical studies and criteria led by carstens et al.2 adrenal glands can be the sites of metastatic deposits from cutaneous or visceral melanomas in up to 50% of cases.9,10 the presence of melanoma in both adrenal glands favors metastatic melanoma over a primary adrenal melanoma.11 156 j i m d c 2 0 1 8 156 histopathological and immunohistochemical studies cannot usually differentiate between primary and metastatic malignant melanomas. primary melanoma of adrenal gland is a very rare entity.12 only 12 cases have been reported to date.13 it is important to rule out possibilities of adrenocortical carcinoma, pheochromocytoma and metastatic melanoma before a diagnosis of primary malignant melanoma of adrenal gland is made. the patients presented by parker and vincent et al,12 kinseley and baggentons et al,14 dick et al 15 sasidharam et al,16 granero et a 17 and luis gonzález-sáez et al had more than 50years of age while our patient was 49 years old similar to the cases presented by dao et al, liatsikos et al, and zalatnai et al respectively. 6,18,19 the previously reported cases as well as our case had a tumor size of more than 5 cm. the largest reported adrenal tumor measured 17cm x 12cm x 10cm. the cases presented by kniseley and baggentoss et al,14 parker and vincent et al,12 dao et al 6 and zalatnai et al,19 died shortly after detection of disease. our patient also died after two months of detection. this indicates poor prognosis of the disease. in one study of 31 patients who underwent adrenal surgery for metastasis at a single institution over 10 years’ period (1999-2008), the primary tumor diagnosis was nonsmall cell lung carcinoma in 20, colorectal carcinoma in 5, renal cell carcinoma in 2 and malignant melanoma and breast carcinoma in one case each.20 in our case there was a unilateral adrenal involvement. there was no ocular or muco-cutaneous melanoma. this highly favors primary malignant melanoma of adrenal gland. out of 279929 samples processed at our institute for various diseases during last five years, 429 cases were diagnosed as malignant melanoma. only one out of these 429 cases was adrenal malignant melanoma. r e f e r e n c e s 1. das p, kumar n, ahuja a, jain a, ray r, sarkar c et al. primary malignant melanoma at unusual sites: an institutional experience with review of literature. melanoma res. 2010; 20:233-239. 2. carstens ph, kuhns jg, ghazi c. primary malignant melanomas of the lung and adrenal. hum pathol. 1984; 15:910-914. 3. sutton b, chan r, sutton m, boone t. primary malignant melanoma of the genitourinary tract with upper and lower tracts involvement. case rep urol. 2013; 2013:217254. 4. suganuma t, fujisaki j, hirasawa t, ishiyama a, yamamoto y, tsuchida t et al. primary amelanotic malignant melanoma of the small intestine diagnosed by esophagogastroduodenoscopy before surgical resection. clin j gastroenterol. 2013; 6:211-216. 5. gonzález-sáez l, pita-fernández s, lorenzo-patiño mj, et al. primary melanoma of the adrenal gland: a case report and review of the literature. j med case rep. 2011 ; 5:273-280. 6. dao ah, page dl, reynolds vh, adkins rb jr. primary malignant melanoma of the adrenal gland. a report of two cases and review of the literature. am surg. 1990; 56:199-203. 7. rodríguez aa, miñana lb, fernández at, et al. melanoma in urology: our experience and review of the literature. actas urol esp. 1991; 15:361-365. 8. pfister c. adrenal biopsy is recommended to differentiate benign versus malignant metastasis of primary adrenal lesions. ajr am j roentgenol. 2014 sep; 203(3):w340-1. 9. dasgupta t, brasfield r, paglia m: primary melanomas in unusua sites. surg gynecol obstet. 1969; 128:841-848. 10. wegnerove h, lazurova, felsoci m. adrenal metastasis. bratisl lek listy. 2013; 114:237-240. 11. blanco r, rodriguez v d, fernandez-pello s, et al. massive bilateral adrenal metastatic melanoma of occult origin: a case report. anal quant cytopathol histpathol. 2014; 36:51-54 12. parker la, vincent lm.detection of adrenal melanoma with computed tomography.urol radiol. 1986; 8:209-210. 13. ainsworth am, clark wh, mastrangelo m, conger kb.primary malignant melanoma of the urinary bladder.cancer. 1976; 37:1928-1936. 14. kniseley rm, baggentoss ah. primary melanoma of the adrenal gland. arch pathol. 1946; 42:345–349. 15. dick jc, ritchie gm, thompson h. histological differentiation between phaeochromyocytoma and melanoma of the suprarenal gland. j clin pathol. 1955; 8:89–98. 16. sasidharan k, babu as, pandey ap, rao mm, walter a. primary melanoma of the adrenal gland: a case report. j urol. 1977; 117:663–664. 17. granero l, al-lawati t, bobin j. primary melanoma of the adrenal gland, a continuous dilemma: report of a case. surg today. 2004; 34:554–556. 18. liatsikos e, papathanassiou z, voudoukis t, et al. case report: laparoscopic adrenalectomy in a patient with primary adrenal malignant melanoma. j endourol. 2006; 20:123–126. 19. zalatnai a, szende b, tóth m, rácz k. primary malignant melanoma of adrenal gland in a 41-yr-old woman. endocr pathol. 2003; 14:101–105. 20. paunovic i, zivalijevic v, diklic a, tausanovic k, stojanic r, sipetic s. prognostic parameters after surgery for adrenal metastasis: a single institution experience. acta chir belg. 2014; 114: 198-202. http://www.ncbi.nlm.nih.gov/pubmed/?term=gonz%26%23x000e1%3blez-s%26%23x000e1%3bez%20l%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=das%20p%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=kumar%20n%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=ahuja%20a%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=jain%20a%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=ray%20r%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=sarkar%20c%5bauthor%5d&cauthor=true&cauthor_uid=20386135 http://www.ncbi.nlm.nih.gov/pubmed/20386135 http://www.ncbi.nlm.nih.gov/pubmed?term=carstens%20ph%5bauthor%5d&cauthor=true&cauthor_uid=6479972 http://www.ncbi.nlm.nih.gov/pubmed?term=kuhns%20jg%5bauthor%5d&cauthor=true&cauthor_uid=6479972 http://www.ncbi.nlm.nih.gov/pubmed?term=ghazi%20c%5bauthor%5d&cauthor=true&cauthor_uid=6479972 http://www.ncbi.nlm.nih.gov/pubmed/6479972 http://www.ncbi.nlm.nih.gov/pubmed/6479972 http://www.ncbi.nlm.nih.gov/pubmed?term=sutton%20b%5bauthor%5d&cauthor=true&cauthor_uid=24066255 http://www.ncbi.nlm.nih.gov/pubmed?term=chan%20r%5bauthor%5d&cauthor=true&cauthor_uid=24066255 http://www.ncbi.nlm.nih.gov/pubmed?term=sutton%20m%5bauthor%5d&cauthor=true&cauthor_uid=24066255 http://www.ncbi.nlm.nih.gov/pubmed?term=boone%20t%5bauthor%5d&cauthor=true&cauthor_uid=24066255 http://www.ncbi.nlm.nih.gov/pubmed/24066255 http://www.ncbi.nlm.nih.gov/pubmed?term=suganuma%20t%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=fujisaki%20j%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=hirasawa%20t%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=ishiyama%20a%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=yamamoto%20y%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=yamamoto%20y%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=tsuchida%20t%5bauthor%5d&cauthor=true&cauthor_uid=23766824 http://www.ncbi.nlm.nih.gov/pubmed/23766824 http://www.ncbi.nlm.nih.gov/pubmed/23766824 http://www.ncbi.nlm.nih.gov/pubmed?term=gonz%c3%a1lez-s%c3%a1ez%20l%5bauthor%5d&cauthor=true&cauthor_uid=21722390 http://www.ncbi.nlm.nih.gov/pubmed?term=pita-fern%c3%a1ndez%20s%5bauthor%5d&cauthor=true&cauthor_uid=21722390 http://www.ncbi.nlm.nih.gov/pubmed?term=lorenzo-pati%c3%b1o%20mj%5bauthor%5d&cauthor=true&cauthor_uid=21722390 http://www.ncbi.nlm.nih.gov/pubmed/21722390 http://www.ncbi.nlm.nih.gov/pubmed?term=dao%20ah%5bauthor%5d&cauthor=true&cauthor_uid=2194410 http://www.ncbi.nlm.nih.gov/pubmed?term=page%20dl%5bauthor%5d&cauthor=true&cauthor_uid=2194410 http://www.ncbi.nlm.nih.gov/pubmed?term=reynolds%20vh%5bauthor%5d&cauthor=true&cauthor_uid=2194410 http://www.ncbi.nlm.nih.gov/pubmed?term=adkins%20rb%20jr%5bauthor%5d&cauthor=true&cauthor_uid=2194410 http://www.ncbi.nlm.nih.gov/pubmed/2194410 http://www.ncbi.nlm.nih.gov/pubmed?term=rodr%c3%adguez%20antol%c3%adn%20a%5bauthor%5d&cauthor=true&cauthor_uid=1772050 http://www.ncbi.nlm.nih.gov/pubmed?term=mi%c3%b1ana%20l%c3%b3pez%20b%5bauthor%5d&cauthor=true&cauthor_uid=1772050 http://www.ncbi.nlm.nih.gov/pubmed?term=fern%c3%a1ndez%20aparicio%20t%5bauthor%5d&cauthor=true&cauthor_uid=1772050 http://www.ncbi.nlm.nih.gov/pubmed/1772050 http://www.ncbi.nlm.nih.gov/pubmed/1772050 https://www.ncbi.nlm.nih.gov/pubmed/25148194 https://www.ncbi.nlm.nih.gov/pubmed/25148194 https://www.ncbi.nlm.nih.gov/pubmed/25148194 http://www.ncbi.nlm.nih.gov/pubmed?term=parker%20la%5bauthor%5d&cauthor=true&cauthor_uid=3798606 http://www.ncbi.nlm.nih.gov/pubmed?term=vincent%20lm%5bauthor%5d&cauthor=true&cauthor_uid=3798606 http://www.ncbi.nlm.nih.gov/pubmed/3798606 http://www.ncbi.nlm.nih.gov/pubmed?term=ainsworth%20am%5bauthor%5d&cauthor=true&cauthor_uid=1260695 http://www.ncbi.nlm.nih.gov/pubmed?term=clark%20wh%5bauthor%5d&cauthor=true&cauthor_uid=1260695 http://www.ncbi.nlm.nih.gov/pubmed?term=mastrangelo%20m%5bauthor%5d&cauthor=true&cauthor_uid=1260695 http://www.ncbi.nlm.nih.gov/pubmed?term=conger%20kb%5bauthor%5d&cauthor=true&cauthor_uid=1260695 http://www.ncbi.nlm.nih.gov/pubmed?term=conger%20kb%5bauthor%5d&cauthor=true&cauthor_uid=1260695 http://www.ncbi.nlm.nih.gov/pubmed/1260695 j islamabad med dental coll 2023 61 open access large gall bladder removed by laparoscopic cholecystectomy a case report muneeb ullah1, muhammad faisal murad2, adil shafi3, aqsa adeel4 1,4assistant consultant, general surgery, maroof international hospital, islamabad, pakistan 2chief of surgery, department of surgery, maroof international hospital, islamabad, pakistan 3registrar, department of surgery, general surgery, maroof international hospital, islamabad, pakistan a b s t r a c t correspondence: muneeb ullah email: muneebullah@gmail.com article info: received: january 31, 2023 accepted: march 30, 2023 cite this article. ullah m, murad f m, shafi a, adeel a. long gallbladder removed by laparoscopic cholecystectomy a case report. j islamabad med dental coll. 2023; 12(1):61-63 funding source: nil conflict of interest: nil https://doi.org/10.35787/jimdc.v12i1.946 i n t r o d u c t i o n diseases of gallbladder have a wide spectrum that includes asymptomatic gallstones, biliary colic, cholecystitis, mucocele, empyema gallbladder, gangrene, perforation, peritonitis, polyps and malignancy.1 the definitive treatment warrants surgical intervention in the form of laparoscopic or open cholecystectomy.2 one of the emergency presentations is acute calculous cholecystitis which, if associated with gallstone impacted at neck, would require emergency surgery.3 this impaction can also result in over-distended mucocele gallbladder or empyema gallbladder. laparoscopic cholecystectomy is performed in routine, for such patients with aim to minimize the trauma without compromising the efficacy of the treatment. it also leads to lesser pain, shorter hospital stay and early return to routine activity.4 we present a case of overdistended huge mucocele of gallbladder secondary to acute calculous cholecystitis successfully managed by laparoscopic cholecystectomy at maroof international hospital, islamabad. c a s e p r e s e n t a t i o n our patient was a 45 years old female who presented with pain in right upper quadrant of abdomen with nausea for the last six days. it was sudden and started after she had a pizza with cheese topping. there was no vomiting, anorexia or fever. the pain remained constant with bouts in between and some decrease in intensity with oral analgesics. there was no pruritis, discoloration of eyes, dark urine or clay-colored stools. she initially went to a gallbladder stones impacted at neck of gallbladder can result in acute calculous cholecystitis with mucocele gallbladder. laparoscopic cholecystectomy is performed in such cases as an emergency surgery. we present a case long gallbladder with mucocele formation that was managed by laparoscopic approach. the gallbladder removed was 27.8cm in length. this is the longest gallbladder removed by laparoscopic cholecystectomy in pakistan so far. the patient had uneventful recovery. c a s e r e p o r t j islamabad med dental coll 2023 62 general physician who then referred the patient to us. on examination, the patient had tender right hypochondrium with positive murphy’s sign and a palpable gallbladder. while the liver function tests were normal, the hepatobiliary ultrasound reported a solitary 12mm stone impacted in the neck of overdistended gallbladder as well as increased gallbladder wall thickness of 4.5mm. the patient was planned for laparoscopic cholecystectomy in acute calculous cholecystitis. standard four ports were used. diagnostic laparoscopy revealed acutely inflamed overdistended gallbladder (figure 1 and 2). figure 1: peroperative image of gallbladder figure 2: peroperative image of gallbladder gallbladder contents were aspirated using aspiration needle that revealed mucocele gallbladder. afterwards laparoscopic cholecystectomy was completed. the size of gallbladder (postoperative) was 27.8cm (figure 3) figure 3: postoperative image of gallbladder patient was discharged the next day. follow up consultations revealed uneventful recovery. d i s c u s s i o n gallbladder is situated on the undersurface of segment iv and v of liver and has a peritoneal attachment to liver.5 the critical knowledge of anatomy, its variations and clinical experience is necessary for a safe and uneventful surgery.3 the gallbladder is a pear shaped organ with an average length of 4.5 to11.6 cm and capacity of 30 to 50ml.6 acute calculous cholecystitis is accompanied by inflammation of gallbladder that presents as a combination of right upper quadrant pain that may radiate to the back or right shoulder, nausea, vomiting and fever.7 in cases where the gallbladder stone is impacted at the neck of gallbladder, cystic duct is blocked that results in the mucus accumulation within the gallbladder. this leads to over distended gallbladder i.e. mucocele.8 prolonged obstruction of cystic duct leads to continuous mucin secretion that ultimately overdistends the gallbladder causing gallbladder wall edema, dilation, inflammation, infection or perforation. in patients with diabetes mellitus especially who have poor control, there is autonomic neuropathy and cholecystoparesis that causes cholecystomegaly.6 in our case, stone impacted at neck caused overdistension of gallbladder. mucocele itself is not an infective pathology but if bacterial contamination occurs, it can lead to empyema gallbladder.9 empyema gallbladder and mucocele are emergency j islamabad med dental coll 2023 63 pathologies that require early intervention in the form of laparoscopic cholecystectomy unless there is some definitive contraindication. the advantage of laparoscopy in such cases is that, it yields minimal scar, less pain and early mobilization. the huge sized or overdistended gallbladders are attributed to congenital anomalies, acquired or obstructive causes as per literature review.10 previously, in pakistan, the largest gallbladder removed via laparoscopic cholecystectomy was 25.5cm at capital hospital islamabad as reported by taj n et al. 6 currently the largest gallbladder removed laparoscopically by laparoscopic cholecystectomy is 30cm.3 in our case the length of the gallbladder was 27.8cm which is the longest documented gallbladder removed laparoscopically so far in pakistan to date. this case report shows that apart from pathological variation, laparoscopic cholecystectomy is still the choice for operating acute or mucocele gallbladders. patient mobilizes early and is discharged as per routine and large scars can be avoided. c o n c l u s i o n huge gallbladders, although difficult to handle but can safely be removed via laparoscopic cholecystectomy with good outcomes. a sound knowledge of gallbladder anatomy, experience of surgeon and good team are corner stones in such surgeries. r e f e r e n c e s 1. atif qaa, khan ma, nadeem f, ullah m. healthrelated quality of life after laparoscopic cholecystectomy. cureus. 2022; 14(7):e26739. https://doi:10.7759/cureus.26739 2. almas t, murad m, khan m, ullah m, nadeem f, ehtesham m, et al. the spectrum of gallbladder histopathology at a tertiary hospital in a developing country: a retrospective study. cureus 12(8): e9627. https://doi:10.7759/cureus.9627 3. yadav r, kankaria j. longest gallbladder: a case report. int j surg case rep. 2017; 33:127-129. https://doi:10.1016/j.ijscr.2017.02.024 4. muneebullah, javed r, murad fm, khan km, nadeem f, shafi a. a review of laparoscopic cholecystectomy; 250 cases at maroof international hospital, islamabad. j islamabad med dental coll. 2022; 11(3):169-174. https://doi.org/10.35787/jimdc.v11i3.774 5. almas t, murad mf, mansour e, khan mk, ullah m, nadeem f, et al. look, but to the left: a rare case of gallbladder sinistroposition and comprehensive literature review. ann med surg (lond). 2021; 71:103016. https://doi:10.1016/j.amsu.2021.103016 6. jahantab mb, salehi v, mehrabi s, abedini l, barhaghtalab mjy. cholecystomegaly: a case report and review of the literature. case rep gastrointest med. 2020; 8825167. https://doi.org/10.1155/2020/8825167 7. ishii h, noguchi a, onishi m, takao k, maruyama t, taiyoh h, et al. true left-sided gallbladder with variations of bile duct and cholecystic vein. world j gastroenterol. 2015; 21(21):6754-6758. https://doi:10.3748/wjg.v21.i21.6754 8. singh sa. the longest gallbladder with mucocele from the arabian peninsula a case report. international journal of development research. 2018; 8(3):1958719588. https://www.journalijdr.com/longestgallbladder-mucocele-arabian-peninsula-case-report 9. khomusi mm, parveen s, iqbal m, ahmed t, husain r, seth us, et al. prevalence of empyema or mucocele or other histological diagnoses in patients undergoing cholecystectomy with diagnosis of chronic cholecystitis. cureus. 2022; 14(4):e23773. https://doi:10.7759/cureus.23773 10. kuznetsov av, borodach av, fedin en, khromova ad. giant gallbladder: a case report and review of literature. int j surg case rep. 2014; 5(10):673-676. https://doi:10.1016/j.ijscr.2014.08.005 j islamabad med dental coll 2021 164 open access parotidectomy and facial paralysis, a retrospective review at a tertiary care hospital israr ud din1, muhammad junaid1, imran khan1, arshad aziz2, sakhawat khan3, aafia afridi4, ihtisham ul haq2 1assistant professor, department of ent, head & neck surgery, khyber medical college/ kth, peshawar, pakistan 2registrar, department of ent, head & neck surgery, khyber medical college/ kth, peshawar, pakistan 3senior registrar, department of ent, head & neck surgery, khyber medical college/ kth, peshawar, pakistan 4registrar, department of accident & emergency, khyber teaching hospital, peshawar a b s t r a c t background: facial nerve is in close proximity with parotid gland and encountered during parotid surgery. facial nerve paralysis has 15 to 66% occurrence rate after parotidectomies. the objective of this study was to find out the frequency of facial paralysis resulting from superficial or total parotidectomies done for various parotid tumors. material and methods: this retrospective study was conducted at the department of ent, khyber teaching hospital, peshawar from january 2018 to may 2020. a total of 203 patients were reviewed for data on demographics, parotidectomies, histopathology and facial paralysis. the information on facial paralysis was compared against various parameters. results: the mean age of the participants was 46.12 ± 11.11 years. the most common parotid tumor was pleomorphic adenoma (68.9%) followed by mucoepidermoid carcinoma. 57 (28.07%) patients showed facial paralysis with a higher rate of occurrence in total parotidectomy (40.90%). among 57 patients with facial paralysis, 6 (10.53%) showed permanent facial paralysis. conclusion: tendency of permanent facial paralysis is high with total parotidectomies. female population and elderly have a slightly higher rate of facial paralysis. the duration of procedure has no effect on the occurrence of facial paralysis. keywords: facial paralysis, mucoepidermoid carcinoma, parotid tumors, pleomorphic adenoma, parotidectomy. cite this article. din iu, junaid m, khan i, aziz a, , khan s et al. parotidectomy and facial paralysis, a retrospective review at a tertiary care hospital. j islamabad med dental coll. 2021; 10(3): 164-168. doi: 10.35787/jimdc.v10i3.705 funding source: nil conflict of interest: nil i n t r o d u c t i o n parotid pathologies, especially benign and malignant tumors mostly require surgery as the modality of treatment which may be superficial, subtotal or total parotidectomy. parotidectomy of any kind carries a high risk of damage to the facial nerve. the less conservative procedures warrant a lesser chance of recurrence but have a higher rate of complications. in fact, one of the most common complications associated with the procedure tends to be facial paralysis, either temporary or permanent. temporary facial paralysis occurs at a rate of 15% to 66% while permanent facial paralysis is relatively infrequent 2.5% to 5%.1 neuropraxia has been reported in approximately 8% to 46% of parotidectomies done for benign parotid pathologies. 2 authors’ contribution: 4conception; literature research; manuscript design and drafting; 1,2, critical analysis and manuscript review; 3 data analysis; manuscript editing. correspondence: muhammad junaid email: drjunaident@gmail.com article info: received: april 17, 2021 accepted: september 19, 2021 o r i g i n a l a r t i c l e j islamabad med dental coll 2021 165 to date, facial paralysis remains one of the greatest fears of the procedure for the patient where they are anxious about ending up with facial dysfunction upon waking from the procedure. this happens to be one of the reasons for patients with massive parotid swellings to appear at a late stage for medical consultation. the incidence of facial paralysis resulting from parotidectomies has shown a significant decrease over the past few decades. this decline in facial weakness is mainly attributed to advancement in the field of bioinformatics and bioengineering with instruments like nerve monitors providing the surgeon with vital information regarding imminent danger in the proximity of the facial nerve. 3,4 the objective of this study was to assess and compare the post operative occurrence rate of facial paralysis in patients with benign and malignant parotid pathologies in order to reflect on the need for improvement in surgical practice to reduce its risk. m a t e r i a l a n d m e t h o d s this retrospective study was conducted at the department of ent, khyber teaching hospital after approval from the institutional ethical review board. duration of the study was two and a half years from january 2018 to may 2020. a sample size of 203 was calculated with open epi sample size calculator version 3.01, using 80% power of study, 95% confidence interval, 5% margin of error and 15.6% anticipated frequency of facial paralysis in parotidectomies.1 sampling technique was nonprobability convenient. records of all patients approaching the outpatient department of ent with parotid swelling showing fnac report of neoplastic activity from january 2018 to may 2020 were included in the study. patients were excluded on the basis of having either previous surgery, pre-operative facial paralysis or insufficient data in their records. the information acquired from the clinical records comprised of demographic data, histopathological outcome, type of procedure performed and occurrence of post-operative facial paralysis. furthermore, information about the facial nerve such as degree of facial paralysis, duration of facial paralysis and degree of recovery was also recorded. parotidectomy was performed in all the patients. the extent of procedure was either superficial or deep, depending upon the nature of the disease. identification of the facial nerve was done by employing an antegrade technique. this was achieved by using 3 surgical landmarks; tragal pointer, styloid process and posterior belly of digastric muscle. no nerve stimulator or monitor had been used in any of the cases. functional integrity of the facial nerve was monitored visually by the assisting surgeon. at the end, wound and skin closure was performed using polyglactin 910 [vicryl® johnson-johnson]. data analysis was performed using spss 26.0. qualitative data was presented as number and percentages. quantitative data was summarized as means and standard deviations. chi-square test was used to determine the association of facial paralysis with age, gender, type and duration of surgery. moreover, association of type of facial paralysis with type of parotidectomy was also analyzed. the significance level was set at p<0.05. r e s u l t s among the total sample of 203 patients, the number of male patients was 110 (54.18%) and female patients was 93 (45.82%) giving a male to female ratio of about 1.18:1. mean age of the patients was 46.12 ± 11.11 years (range:24-69). the mean age of males was 46.8 ± 11.19 years and females 45.3 ± 11.02 years. statistics related to age and gender are given. (table i) j islamabad med dental coll 2021 166 among 203 patients, large number of patients 159(78.32%) underwent a superficial parotidectomy and 44(21.68%) total conservative surgery. among patients having superficial parotidectomy, 24.52% developed temporary facial palsy which was resolved within two months after the procedure. out of patients who underwent total conservative type of surgery, 12(27.27%) developed temporary and 6 (13.63%) permanent facial palsy. (table ii) the duration of the procedure from first incision to closure of the wound ranged from 75 minutes to 150 minutes with an average of about 134.3 ± 12.2 minutes. table ii: data of facial paralysis reported in study participants (n=203) type of parotid surgery number of patients n (%) number of facial palsy n (%) temporary facial palsy n (%) permanent facial palsy n (%) superficial 159 (78.32) 39 (24.52) 39 (24.52) 0(0) total conservative 44 (21.68) 18 (40.90) 12 (27.27) 6 (13.63) total 203 57 (28.07) 51 (89.47) 6 (10.53) a significant association of facial palsy was found with increased age and female gender. the association of facial palsy with type and duration of surgery was non-significant. (table iii) the study found a strong association between type of facial paralysis and the type of procedure performed. it showed a higher occurrence of permanent facial paralysis in superficial parotidectomy. (table iv) table iii: association of facial palsy with age, gender, age and duration of surgery (n=203) variable facial palsy absent (n=146) n (%) present (n=57) n (%) p value age above 60 years 19(13.01) 22 (38.59) 46 – 60 years 46 (31.51) 19 (33.33) 0.03 31 – 45 years 73(50) 13 22.80) 30 years and below 8(5.48) 3 (5.26) gender female 60(41.09) 33(57.89) 0.04 male 86(58.90) 24(42.10) surgery total parotidectomy 30(20.55) 13(22.81) 0.34 superficial parotidectomy 116(79.45) 44(77.19) duration of surgery ≤120 minutes 41(28.08) 14 (24.56) 0.43 >120 minutes 105(71.91) 43 (75.43) table iv: association of degree of facial palsy with type of surgery (n=57) facial palsy p value temporary (n=51) n (%) permanent (n=6) n (%) type of surgery total parotidectomy 12 (23.53) 0 (0) superficial parotidectomy 39(76.47) 6 (100) 0.001 table i: age and gender distribution of study participants according to type of neoplasm (n=203) age benign malignant total 30 years and below male female 4 4 2 1 6 (2.9%) 5 (2.46%) 31 – 45 years male female 28 43 18 6 46 (22.66%) 49 (24.13%) 46 – 60 years male female 32 19 7 7 39 (19.21%) 26 (12.81%) above 60 years male female 14 10 5 3 19 (9.36%) 13 (6.40%) total 154 (75.86%) 49 (24.14%) 203 j islamabad med dental coll 2021 167 according to histopathological analysis, total 154 (75.86%) cases reported as benign while the remaining 49 (24.14%) reported as malignant. among benign cases, pleomorphic adenoma was found in 140 (68.9%) patients followed by warthin’s tumor 6 (3%). in malignant cases, mucoepidermoid was the most common tumor accounting for 37 cases (18.1%) followed by carcinoma ex pleomorphic adenoma, 3 cases (1.5%). d i s c u s s i o n parotid tumors are quite uncommon and comprise of about 0.8% of all the tumors in the body with an annual global incidence of about 3-4/100,000 people.5 at the same time, they make up a 2-10% fraction of the head and neck tumors.6 surgical procedures of the parotid usually end with a variety of complications among which transient facial paralysis is the most common. hence, one of the most important concerns during the procedure is to maintain anatomical and functional integrity of the facial nerve. in order to ensure this, an important step of the procedure is facial nerve identification which is done using either of the two techniques; antegrade or retrograde techniques. the antegrade technique is mostly practiced in majority of the facilities.7,8 this study of 203 patients showed a male to female ratio of 1.18:1 with the mean age at which parotidectomy was performed to be 46.12 ± 11.11 years. the male to female ratio is comparable of those reported by siddiqui1, hussain2 and thamim6 that were 1:1, 1.2:1 and 1.3:1 respectively. ali9 reported a mean age of 45.75 years while rahman10 and siddiqui1 reported ages of 40.63 and 38.75 years respectively. a majority of the patients in this study had gone through superficial parotidectomy amounting to be 78.32% while only 21.68% had total parotidectomies. however, the fraction of patients getting facial paralysis after parotidectomy was 28.07% compared to the 25.71%, 28.08% and 36.66% reported in studies by siddiqui1, musani10 and rahman11 respectively. in this study, the occurrence of facial paralysis resulting from superficial parotidectomy was 24.52% compared to 40.90% with total parotidectomies. this was significantly less than the incidence of 34.72% and 50% with superficial and total parotidectomies respectively, reported by rahman et al.10 histopathology of these tumors shows a variety of benign and malignant types. according to the literature, almost 80-85% of the parotid tumors are benign in nature while the remaining 15-20% are malignant.10 the percentage of benign tumors found in this study is comparable to the 74%, 81.2% and 82.6% reported by ali9, siddiqui1 and musani11, respectively. various methods have been developed to check for post operative facial nerve paralysis, the most effective one is subjective and objective clinical assessment.12 children are more at risk to develop facial nerve palsy due to variable location with respect to deep lobe pathologies and small size of the nerve and gland.13 carter jm, reported 94% temporary and 2% permanent nerve palsy in children with the mean age of 8.3 years after being operated as compared to this study.14 experience of the surgeon, pre-operative imaging and intraoperative nerve monitoring greatly reduces the risk of nerve palsy 15 but in this study, only magnifying lups and operative microscope were used. study of bovenzi cd et al shows much improved results with 3.7% facial nerve palsy as they performed reconstructive measures of the nerve, like anastomosis, interpositional grafting and nerve transfer to restore functions of the nerve that we did not offer to our patients.16 for patients with malignant tumors, large in size, hard fixed with deep lobe involvement, facial nerve injury remains more common. duration of surgical procedure have direct effect on facial nerve functions. bittar rf, reported temporary facial nerve palsy in 16.6 % and no permanent as most of the surgeries were j islamabad med dental coll 2021 168 performed by senior surgeons.17 conclusion facial paralysis is more common with total parotidectomies. female gender and age above 60 years are more likely to have facial paralysis while the duration of the procedure shows no association. early identification and careful exploration of the facial nerve is the key to preserving facial nerve function. r e f e r e n c e s 1. siddiqui ah, shakil s, ur rahim d, shaikh ia. post parotidectomy facial nerve palsy: a retrospective analysis. pak j med sci. 2020;36(2):126-130. doi: 10.12669/pjms.36.2.1706 2. thahim k, udaipurwala ih, kaleem m. clinical manifestations, treatment outcome and postoperative complications of parotid gland tumoursan experience of 20 cases. j pak med assoc. 2013;63(12):1472-5. pmid: 24397087 3. ruohoalho j, mäkitie aa, aro k, atula t, haapaniemi a, keski–säntti h, et al. complications after surgery for benign parotid gland neoplasms: a prospective cohort study. head & neck. 2017;39(1):170-6. doi: 10.1002/hed.24496 4. sethi n, tay p, scally a, sood s. stratifying the risk of facial nerve palsy after benign parotid surgery. the journal of laryngology & otology. 2014;128(2):15962. doi: 10.1017/s0022215113003502 5. stathopoulos p, igoumenakis d, smith wp. partial superficial, superficial and total parotidectomy in the management of benign parotid gland tumors: a 10-year prospective study of 205 patients. journal of oral and maxillofacial surgery. 2018 1;76(2):455-9. doi: 10.1016/j.joms.2017.06.018 6. hussain a, farid a, uddin w. superficial parotidectomy by retrograde approach through marginal mandibular nerve dissection. journal of islamabad medical & dental college. 2019;8(4):1715. doi: 10.35787/jimdc. v8i4.431 7. anjum k, revington p, irvine gh. superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. the british journal of oral and maxillofacial surgery. 2008;46(6):433-4. doi: 10.1016/j.bjoms.2008.03.018 8. yuan x, gao z, jiang h, yang h, lv w, wang z, et al. predictors of facial palsy after surgery for benign parotid disease: multivariate analysis of 626 operations. journal for the sciences and specialties of the head and neck. 2009;31(12):1588-92. doi: 10.1002/hed.21134 9. ali ns, nawaz a, rajput s, ikram m. parotidectomy: a review of 112 patients treated at a teaching hospital in pakistan. apjcp. 2010;11(4):1111-3. pmid: 21133633 10. rahman m, alam m, joarder a. study of the nerve injury in parotid gland surgery. nepalese journal of ent, head and neck surgery. 2011;2(1):17-9. doi: 10.3126/njenthns.v2i1.6779 11. musani ma, zafar a, suhail z, malik s, mirza d. facial nerve morbidity following surgery for benign parotid tumours. j coll physicians surg pak. 2014;24(8):569-72. pmid: 25149836 12. wang t, zhang s, dong j, liu la, yu h. automatic evaluation of the degree of facial nerve paralysis. multimedia tools and applications. 2016 oct 1;75(19):11893-908. doi: 10.1007/s11042-0152696-0 13. maddalozzo j, johnston dr, isaac a, bhushan b, rastatter jc. displacement of the facial nerve by deep parotid lobe lesions in the pediatric population. laryngoscope investigative otolaryngology. 2019;4(5):550-3. doi: 10.1002/lio2.302 14. carter jm, rastatter jc, bhushan b, maddalozzo j. thirty-day perioperative outcomes in pediatric parotidectomy. jama otolaryngology–head & neck surgery. 2016;142(8):758-62. doi: 10.1001/jamaoto.2016.1031 15. jin h, kim by, kim h, lee e, park w, choi s, et al. incidence of postoperative facial weakness in parotid tumor surgery: a tumor subsite analysis of 794 parotidectomies. bmc surgery. 2019;19(1):1-8. doi: 10.1186/s12893-019-0666-6 16. bovenzi cd, ciolek p, crippen m, curry jm, krein h, heffelfinger r, et al. reconstructive trends and complications following parotidectomy: incidence and predictors in 11,057 cases. journal of otolaryngology-head & neck surgery. 2019 dec 1;48(1):64. doi: 10.1186/s40463-019-0387-y 17. bittar rf, ferraro hp, ribas mh, lehn cn. facial paralysis after superficial parotidectomy: analysis of possible predictors of this complication. brazilian journal of otorhinolaryngology. 2016 jul 1;82(4):447-51. doi: 10.1016/j.bjorl.2015.08.024 136 j i m d c 2 0 1 8 136 open access f u l l l e n g t h a r t i c l e prevalence of dyslipidemia among diabetic patients in a tertiary care hospital muhammad rehan1, saman waqar2, haroon khan3 1 house physician, pakistan institute of medical sciences, islamabad. 2 assistant professor, department of chemical pathology, federal medical and dental college islamabad. 3 professor, department of chemical pathology, rawal institute of health sciences, islamabad a b s t r a c t objective: to identify the frequency of dyslipidemia in diabetic patients. patients and methods: a cross sectional study was conducted among the patients visiting pathology laboratory in pakistan institute of medical sciences (pims). after taking informed consent from the patients, a brief history was taken from the patients with the help of a questionnaire. lipid profiles for these patients were analyzed using the same samples as of hba1c to determine diabetic dyslipidemia. results: a total number of 206 diabetic patients were inducted in this study. out of the total sample, 179 (72.7%) respondents were on anti-diabetic therapy alone. about 31 (17.3%) were on antihypertensive therapy along with antidiabetic therapy. only 36 (20.1%) patients were on lipid lowering medication along with anti-diabetic and antihypertensive treatment. dyslipidemia was more common in patients that were only on anti-diabetic therapy. conclusion: annual screening for dyslipidemia and management were not practiced according to guidelines for diabetic patients. combination therapy comprising anti-diabetic and anti-dyslipidemia medications should be considered by clinicians instead focusing only on diabetes. key words: diabetes mellitus, dyslipidemia, lipid profile, treatment. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence saman waqar email: samanwaqar@yahoo.com article info. received: september 10, 2017 accepted: april 24, 2018 cite this article. rehan m, waqar s, khan h. prevalence of dyslipidemia and assessment of treatment regimens among diabetic patients in a tertiary care hospital. jimdc.2018; 7(2):136-139 funding source: nil conflict of interest: nil i n t r o d u c t i o n in year 2014 global prevalence for diabetes was estimated to be 9% in young adults.1 about 1.5 million deaths in year 2012 were directly because of diabetes.2 the relationship between diabetes, diabetic dyslipidemia and cardio vascular diseases(cvs) has been established long ago. vascular diseases have a major share in lowering quality of life and death.3 a number of risk factors have been determined for coronary artery and cardiovascular diseases, among these deranged lipid profiles are a major contributor to the development of coronary artery disease.4 lipoproteins increase is associated with significant risk of atherosclerosis.5 globaly dyslipidemia results in 4 million deaths per annum.6 dyslipidemia means the derangement in body lipid levels, but most of the time dyslipidemia presents as hyperlipidemia. hyperlipidemia may be due to hyperlipoprotinemia i.e. increased levels of low density lipoprotein (ldl), hypercholesterolemia or as hypertriglyceridemia or may be all combined. these were defined according to fredrickson classification.7 but dyslipidemia may present as hypolipidemia i.e. low levels of high density lipoproteins (hdl).8 a number of risk o r i g i n a l a r t i c l e 137 j i m d c 2 0 1 8 137 factors has been identified that leads to dearrangements in body lipids. these include lifestyle, obesity, high insulin and a number of other genetic and environmental factors. in present situation clinicians are focusing more on diagnosis and treatment of diabetes only. dyslipidemia associated with this condition is usually given lesser attention by the clinicians. lipid profiles are not done frequently for diabetic patients. in this study we planned to identify the frequency of dyslipidemia in diabetic patients and to know if the population is taking only anti diabetic treatment or a combination with lipid lowering drugs. p a t i e n t s a n d m e t h o d s a cross sectional survey was conducted among the patients visiting pathology laboratory in pakistan institute of medical sciences (pims), shaheed zulfiqar ali bhutto medical university (szambu), islamabad from may, 2016 to july, 2016 by convenient sampling technique. a study sample of 222 patients was obtained using who calculator taking prevalence 17.5%, confidence level 95% and absolute precision of 5%.9 a total 250 diabetic patients were inducted in the study. out of 250, total 4 patients lost the study follow up and were excluded. after induction, patients were divided into three groups. group 1 comprised of patients only on antidiabetic therapy. group 2 comprised of patients receiving antihypertensive therapy along with antidiabetic medications. group 3 included patients on lipid lowering medication along with antidiabetic and antihypertensive therapy. group 1 patients were further divided into three sub-groups on the basis of their hba1c levels. group 1a comprised of good glycemic control with normal hba1c levels (hba1c ≤6.5%), group 1b included patients with average glycemic control (hba1c 6.6-9%) and group 1c with poor glycemic control (hba1c > 9%). all subgroups of group 1 were then considered for lipid profile evaluation. dyslipidemia was defined according to the national cholesterol education program adult treatment panel (atp) iii. presence of dyslipidemia was identified when ldl ≥ 130mg/dl, hdl <40 mg/dl, tc ≥200 mg/dl and triglycerides were ≥150 mg/dl. after taking informed consent from the patients, a brief history including drug details was taken with the help of a questionnaire. total 3 ml fasting blood sample was taken to analyze hba1c levels. by using the same fasting samples lipid profile was also calculated to determine diabetic dyslipidemia. patients with deranged lipid profiles were identified and their drug therapy was assessed according to the history. patients were followed by their phone numbers. nominal data was collected and analyzed using spss version 20. r e s u l t s total number of 246 participants included this study. mean age of the respondents was 57.5 ± 15.2 years. mean hba1c value was 8.7 ± 2.5 %. male patients were 132 (53.6%) and females were 114 (46.3%). out of 246 diabetic patients, total 179 (72.7%) respondents were in group 1 (anti diabetic therapy alone), 31 were in group 2 (anti diabetic + anti-hypertensive therapy) and 36 were in group 3 (anti diabetic+ anti-hypertensive +lipid lowering medications). after further sub division of group 1, total 82 (45.8%) patients were in group 1a (good glycemic control), 53 (29.6%) were in group 1b (average glycemic control) and 44 (24.5%) patients were in group 1c (poor glycemic control) (figure 1). figure 1: comparison of glycemic control in patients only on anti-diabetic therapy (n=179) in group 1, regarding lipid profile, hdl levels were deranged in large number of participants (70.3%). prevalence of other lipid parameters with percentage derangements is shown in (table 1). family history for diabetes and hypertension was found positive among 65 (36.3%) of the respondents. only 48 (26.8%) had their lipid profile done in the past one year. 138 j i m d c 2 0 1 8 138 lipid parameters were maximally deranged in patients having poorly controlled diabetes (table 2). d i s c u s s i o n this study was conducted to evaluate the prevalence of dyslipidemia in our population along with treatment regimens for diabetic patients. the study concluded that most of the population is unaware of association between diabetes with dyslipidemia. only a small population had lipid lowering drugs prescribed along with anti-diabetic therapy (20.1%). only anti-diabetic regimen was also observed among people of czech republic.10 dyslipidemia screening practices were not adequate in diabetic patients of our study (26.8%). annual screening of diabetics by lipid profiles is the recommended guidelines by american association of clinical endocrinologists (aace). 11 contrary to this monotherapy approach was prevalent in our population. combination regimens to control dyslipidemia was found in very few. a statin should be prescribed to a patient of age greater than 40 years with diagnosed diabetes.12 stone et. al. in their guidelines also highlighted the use of statin therapy in a patient with diabetes and age 40 to 75 years or the ldl > 190 mg/dl.13 more than 50% of our population had uncontrolled diabetes mellitus. this is a factor that contributes to increased number of complications including vascular diseases and atherosclerosis.14 in our neighboring country the percentage of uncontrolled diabetes exceeds 80% and due to uncontrolled diabetes, lipids are more deranged in indian population.15 tc and tgs values of our population (22.9% and 40.7%) were more than chinese population data (16.4% and 7.6%). 16 values of these parameters were less when compared to turkish population.17 ldl values for our population was far less than turkish population17 (13.4% versus 36.2%). surprisingly hdl levels of our population were significantly reduced (in about 70%). these values did not coincide with any of other populations viewed in literature. c o n c l u s i o n annual screening for dyslipidemia and management was not practiced according to guidelines among diabetic patients. combination therapy comprising anti-diabetic and anti-dyslipidemia medications should be considered by clinicians instead focusing only on diabetes. low levels of hdl require special attention. further studies are required with large sample size and multi-center surveys to identify the causes of such low hdl prevalence among our population. r e f e r e n c e s 1. global status report on non-communicable diseases 2014. geneva, world health organization, 2012. 2. world health organization. global health estimates: deaths by cause, age, sex and country, 2000-2012. geneva, who, 2014. 3. mozaffarian d, benjamin ej, go as, arnett dk, blaha mj, cushman m, de ferranti s, després jp, fullerton hj, howard vj, et al. heart disease and stroke statistics--2015 update: a report from the american heart association. circulation. 2015;131:e29–322. 4. r c turner, h millns, h a w neil, i m stratton, s e manley, d r matthews, r r holman, risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: united kingdom prospective diabetes study (ukpds: 23). bmj 1998; 316:823. 5. nicholls s, lundman p. the emerging role of lipopro-teins in atherogenesis: beyond ldl cholesterol. semin vasc med. 2004; 4:187-195. 6. quantifying selected major risks to health. in: the world health report 2002—reducing risks, promoting healthy table 1: deranged lipid parameters in patients only on anti-diabetic therapy (n=179) lipid parameters n(%) low density lipoprotein (ldl-c) 24 (13.4) total cholesterol 41 (22.9) triglycerides 73 (40.7) high density lipoprotein (hdl-c) 126 (70.3) table 2: lipid profile according to hba1c values (n=179) hba1c values (%) ldl n (%) cholesterol n (%) triglycerides n (%) hdl n (%) ≤ 6.5 2 (1.1) 5 (2.79) 9 (5.02) 32 (17.87) 6.6 – 9 7 (3.91) 7 (3.91) 21 (11.73) 27 (15.08) > 9 15 (8.37) 29 (16.2) 43 (24) 67 (37.43) 139 j i m d c 2 0 1 8 139 life. chapter 4: geneva: world health organization; 2002:4797. 7. fredrickson ds, lees rs. a system for phenotyping hyperlipoproteinemia. circulation 1965;31:321-327. 8. ronald m. lipid and lipoproteins in type 2 diabe-tes. diabetes care. 2004;27:1496-504 9. sarfraz m, sajid s, ashraf ma. prevalence and pattern of dyslipidemia in hyperglycemic patients and its associated factors among pakistani population. saudi j biol sci 2016;23:761-6. 10. šnejdrlová m, češka r, janíčková-žďárská d, honěk p, dušek p, pavlík t, kvapil m. hypolipidemic and antihypertensive therapy in diabetic patients in the czech republic: notes on the vzp (general health insurance company) data. vnitr lek. 2015; 61(11 suppl 3):3s30-7. 11. jellinger p, smith d, mehta a, ganda o, handelsman y, rodbard h, shepherd m, seibel j. american association of clinical endocrinologists' guidelines for management of dyslipidemia and prevention of atherosclerosis. endocrine practice. 2012. 12. walker br, colledge nr. davidson's principles and practice of medicine. elsevier health sciences; 2013. 13. stone nj, robinson jg, lichtenstein ah, merz cn, blum cb, eckel rh, goldberg ac, gordon d, levy d, lloyd-jones dm, mcbride p. 2013 acc/aha guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the american college of cardiology/american heart association task force on practice guidelines. journal of the american college of cardiology. 2014; 63(25_pa):2889-934. 14. shera a, jawad f. prevalence of chronic complications and associated factors in type 2 diabe-tes. j pak med assoc 2004; 54:54-9. 15. pandya h, lakhani jd, dadhania j, trivedi a. the prevalence and pattern of dyslipidemia among type 2 diabetic patients at rural based hospital in gujarat, india. indian j clin pract. 2012;22(12):36-44. 16. sun gz, li z, guo l, zhou y, yang hm, sun yx. high prevalence of dyslipidemia and associated risk factors among rural chinese adults. lipids in health and disease. 2014; 13(1):1. 17. bayram f, kocer d, gundogan k, kaya a, demir o, coskun r, sabuncu t, karaman a, cesur m, rizzo m, toth pp. prevalence of dyslipidemia and associated risk factors in turkish adults. journal of clinical lipidology. 2014; 8(2):20616. 118 j i m d c 2 0 1 8 118 open access f u l l l e n g t h a r t i c l e emergence of tigecycline resistance among extended spectrum beta lactamases producing gram-negative organisms nameerah muhammad saleem 1, najeeha saleem 2, amna hafeez 3, sahil shaheen 4 1 m.phil scholar, lahore college for women university, lahore 2 women medical officer, rural health centre, warburton, nankana sahib 3 assistant professor of pathology, central park medical college, lahore 4 phd scholar, punjab university lahore a b s t r a c t objective: to highlight the emergence of tigecycline resistance among esbl producer gram negative organisms. patients and methods: this cross-sectional study was conducted in lahore college for women university lahore pakistan from 1st october 2015 to 20th march 2016. a total of 360 isolates of gram-negative rods were selected and processed for identification of esbl producers via double disc synergy technique. in total 100 isolates were identified as esbl producing gram-negative rods (escherichia coli, klebsiella spp., proteus spp. and acinetobacter spp.) and were further processed for antimicrobial resistance testing against tigecycline disks (30ug) via kirby bauer disc diffusion method. results: out of 360 identified gram-negative rods, 100 (27.7%) were esbl producers. among these total 46% samples were from male patients and 54% from female patients. a maximum number of esbl producers were recovered from pus & wound samples (54%). the most common esbl producer was escherichia coli followed by klebsiella spp., proteus spp. and acinetobacter spp. overall susceptibility rate of tigecycline was 54%. tigecycline resistance was greatest for esbl producing acinetobacter (n=8), followed by proteus (n=14), escherichia coli (n=18) and klebsiella (n=6) (p=0.004). conclusion: although tigecycline showed very good results against esbl producers, emergence of tigecycline resistant esbl producers is an alarming situation. key words: drug-resistance, extended spectrum beta lactamase, tigecycline. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence najeeha saleem email: najeehamsaleem@gmail.com article info. received: march 10, 2018 accepted: may 14, 2018 cite this article. saleem nm, saleem n, hafeez a, shaheen s. emergence of tigecycline resistance among extended spectrum beta lactamases producing gram-nagitive organisms. jimdc.2018; 7(2):118-122 funding source: nil conflict of interest: nil i n t r o d u c t i o n infections caused by gram-negative bacteria have continued to be a major problem, especially in hospitalized patients. these are responsible for serious bloodstream infections, respiratory tract, skin and skin structure infections. carbapenemases are a major cause of carbapenem resistance in enterobacteriaceae.1 extended-spectrum beta-lactamases are mainly produced by the enterobacteriaceae family (and nonfermentative gram-negative organisms) and are capable of hydrolyzing extended-spectrum beta-lactam antibiotics o r i g i n a l a r t i c l e 119 j i m d c 2 0 1 8 119 like cephalosporin, monobactam and penicillin.2,3 the efforts to treat multidrug-resistant (mdr) microorganisms are mainly focused on gram-positive bacteria, evident by the development of novel antimicrobial agents like linezolid.4 infections caused by mdr gram-negative bacilli have become a growing problem. resistance to fluoroquinolones, co-trimoxazole and trimethoprim is frequently observed among esbl producers, resulting in treatment failure and also greatly limiting the choice of antibiotics that can be used for treatment.5 carbapenems have been important drugs for the treatment of infections caused by esbl producing e. coli and k. pneumoniae, however, carbapenem resistance is emerging in many areas of the world.6-8 tetracycline derivative, tigecycline has proved a remarkable drug, having in vitro activity against many of these mdr organisms.9 tigecycline is the first in a new class of antibiotics, the glycylcyclines, licensed by the us food and drug administration (fda) in june 2005 for intravenous use in adults. protein synthesis is ultimately inhibited, thereby exerting a bacteriostatic effect.10 tigecycline exhibits potent in vitro activity when tested against a broad spectrum of both tetracycline-susceptible and tetracycline-resistant gram-positive and gramnegative bacteria. there is a lack of data on the treatment of severely ill patients from the pivotal trials with tigecycline. available data on the use of tigecycline in severely ill patients are mostly from retrospective analyses of studies with a focus on identified pathogens rather than the clinical picture.11 this study aimed at determining the resistance rate of esbl producing bacteria to tigecycline. as the prevalence of esblproducing bacteria is on the rise, newer choices of antibiotics for such organisms will help in treating critically ill patients infected by them. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted in government college for women under lahore college for women university lahore pakistan during the period of 1st october 2015 to 20th march 2016. standard microbiological procedures like gram staining, colony morphology, biochemical tests and analytical profile index (api) were applied to differentiate the strains of gram-negative bacteria. total 360 isolates of gramnegative rods were selected from tertiary care hospital lahore by using convenient sampling technique. these isolates were processed for the identification of esbl producers via double disc synergy technique. then esbl producing gram-negative rods were further processed for antimicrobial resistance testing against tigecycline disks (30ug) via kirby bauer disc diffusion method. tigecycline susceptibility of different esbl-producing gram-negative rods was compared by pearson's chi-square. their respective inhibition zone diameters were compared by anova, keeping a value of p≤0.05 to be statistically significant. r e s u l t s out of 360 identified gram-negative rods, 100 (27.7%) isolates were esbl producers. out of 100 esbl producing gram-negative rods, 46% samples were from males and 54% from female patients. regarding samplewise distribution, esbl producers were most commonly found in pus & wound (54%), followed by urine samples (22%) (figure 1). the most common esbl producer was escherichia coli 50% (n=50) followed by klebsiella spp. 20% (n=20), proteus spp. 20% (20%) and acinetobacter spp 10% (n=10). overall susceptibility rate of tigecycline was 54% (figure 2). figure1: sample wise isolation rate of esbl producers. figure 2: overall tigecycline resistance rate. 120 j i m d c 2 0 1 8 120 figure 3: organisms wise resistance pattern to tigecycline. tigecycline resistance rate was significantly different among four strains (p=0.004). resistance was greatest for esbl producing acinetobacter (80% [n=8]), followed by proteus ([70%] n=14), escherichia coli (36%/ n=18) and klebsiella (30%/n=6) (figure 3). the mean clearance zone diameter was 19 ± 2 mm (95% cis 18.4, 19.6). the four strains did not differ significantly in terms of mean inhibition zone diameters (p = 0.827) (table 1). d i s c u s s i o n there are serious concerns regarding increasing trend of antimicrobial resistance among gram-negative bacteria as there has been little successful development of new antimicrobial agents targeting this group of organisms. keeping in view this increasing burden of multi-drug resistant gram-negative rods and limited treatment options available, our study aimed to determine tigecycline susceptibility in one major subgroup responsible for multi-drug resistance among gramnegative rods, i.e. esbl-producing gram-negative rods, to widen the treatment options available for treating infections with such organisms and to prevent treatment failure. in a recent report, the infectious diseases society of america specifically addressed three categories of mdr gram-negative bacilli, namely, extended-spectrum cephalosporin-resistant e. coli and klebsiella spp., mdr p. aeruginosa and carbapenem-resistant acinetobacter spp.12 contrary to what happened with gram-positive bacteria, no antibiotic from a new class has been developed specifically for mdr gram-negative bacilli. the glycylcyclines, tigecycline is an exception, although was not developed specifically for the purpose of treating infections caused by such bacteria, this drug was found to have effective in-vitro activity against many of the mdr gram-negative bacilli.13 in our study, 80% of the acinetobacter strains were resistant to tigecycline. this finding is slightly higher than observed by navon-venezia et al 6, reporting 78% of the multidrug-resistant a. baumannii isolates were resistant to tigecycline. it is in complete agreement with liu et al., a study that compared the in vitro activity of tigecycline against 3,014 isolates of clinically important drug-resistant bacteria using disk diffusion methods, they included esbl -producing e. coli (n = 602), k. pneumoniae (n = 736) and also a. baumannii (n = 726) that had been collected from patients, treated between 2008 and 2010 at 20 hospitals in taiwan. they suggested tigecycline resistance rate of 30.1% in the disk diffusion testing method found among the esbl-producing k. pneumoniae isolates.14 in present study e. coli showed the highest rate of esbl production which is similar to the study of pallett and hand15, in which it was concluded that ctx-m-producing e. coli often occurs in the community and e. coli is one of the commonest organisms causing urinary tract infections (utis) the choice of agents to treat these infections is diminishing. in the setting of infections by multi-drug resistant organisms like esbl producers, tigecycline remains our most reliable resort among all extendedspectrum antimicrobials. nandi et al reported out of 82 e.coli, 14 (17.0%) were esbl producers, none of them showed resistance to tigecycline and out of 67 klebsiella isolates, 21 (i.e 31.34%) were esbl producers out of which only 1 (4.7%) was resistant to tigecycline. out of 19 acinetobacter spp isolated 3 (15.7%) were resistant to tigecycline.16 gill et al reported that 56.4% of the isolates were escherichia coli, 28.2% were klebsiella pneumoniae, 10.26% were enterobacter species, and 2.6% were each klebsiella oxytoca and acinetobacter species. esbls were found to be most sensitive to table 1: inhibition zone diameter of four strains strains inhibition zone diameter mean±sd p-value escherichia coli (mm) 19±2 0.274 klebsiella spp (mm) 19±1 proteus spp (mm) 18±1 acinetobacter spp (mm) 19±2 121 j i m d c 2 0 1 8 121 tigecycline, intermediate in susceptibility to minocycline while least sensitive to doxycycline and tetracycline.17 khalid et al reported that out of 826 clinical isolates of gram negative bacilli, 364 were esbl producers. escherichia coli was the most frequent esbl producer followed by klebsiella pneumoniae and enterobacter spp. carbapenems were found to be the most effective drug followed tigecycline then amikacin and nitrofurantoin.18 naz et al reported 100% resistance in mβl positive isolates for imipenem, piperacillin + tazobactum, ceftriaxone, co-amoxyclav, cefoperazone+sulbactam, ciprofloxacin, and amikacin, doxycycline, and gentamicin showed 91.2%, 94.0%, and 97.5% resistant rate respectively. no resistance was observed against colistin.1 although the research is going on in developing newer antimicrobial agents, yet their rate of development is quite slow.19 hence, judicious use of antibiotics and appropriate antiseptic measures are the prime requirements in order to curtail the ever increasing resistance.19 the broad-spectrum antibiotics should be used empirically only in the serious infections and when the facility for susceptibility testing is not available.19 the authors further recommend a large scale in vivo study in order to establish the in vivo efficacy of tigecycline against esbl producing gram-negative rods. c o n c l u s i o n although tigecycline showed very good results against esbl producers, however, emergence of tigecycline resistant esbl producers is an alarming situation. r e f e r e n c e s 1. naz s, rasheed f, saeed m, iram s, imran aa. bad bugs and no drugs: activity of colistin as waging war against emerging metallo-β-lactamases producing pathogens. annals of king edward medical university. 2018;24(1):1-7. 2. paterson dl, bonomo ra. extended-spectrum βlactamases: a clinical update. clinical microbiology reviews. 2005;18(4):657-86. 3. falagas m, karageorgopoulos de. extended-spectrum βlactamase-producing organisms. journal of hospital infection. 2009;73(4):345-54. 4. schito g. the importance of the development of antibiotic resistance in staphylococcus aureus. clinical microbiology and infection. 2006;12(s1):3-8. 5. colodner r, samra z, keller n, sprecher h, block c, peled n, et al. first national surveillance of susceptibility of extended-spectrum β-lactamase–producing escherichia coli and klebsiella spp. to antimicrobials in israel. diagnostic microbiology and infectious disease. 2007;57(2):201-5. 6. leavitt a, navon-venezia s, chmelnitsky i, schwaber mj, carmeli y. emergence of kpc-2 and kpc-3 in carbapenem-resistant klebsiella pneumoniae strains in an israeli hospital. antimicrobial agents and chemotherapy. 2007;51(8):3026-9. 7. navon-venezia s, chmelnitsky i, leavitt a, schwaber mj, schwartz d, carmeli y. plasmid-mediated imipenemhydrolyzing enzyme kpc-2 among multiple carbapenemresistant escherichia coli clones in israel. antimicrobial agents and chemotherapy. 2006;50(9):3098-101. 8. paterson dl. resistance in gram-negative bacteria: enterobacteriaceae. the american journal of medicine. 2006;119(6):s20-s8. 9. morosini m-i, garcía-castillo m, coque tm, valverde a, novais â, loza e, et al. antibiotic coresistance in extended-spectrum-β-lactamase-producing enterobacteriaceae and in vitro activity of tigecycline. antimicrobial agents and chemotherapy. 2006;50(8):26959. 10. mullangi pk, pankey ga. tigecycline in critical care. critical care clinics. 2008;24(2):365-75. 11. castanheira m, sader hs, deshpande lm, fritsche tr, jones rn. antimicrobial activities of tigecycline and other broad-spectrum antimicrobials tested against serine carbapenemase-and metallo-β-lactamase-producing enterobacteriaceae: report from the sentry antimicrobial surveillance program. antimicrobial agents and chemotherapy. 2008;52(2):570-3. 12. lin m-f, huang m-l, lai s-h. risk factors in the acquisition of extended-spectrum β-lactamase klebsiella pneumoniae: a case–control study in a district teaching hospital in taiwan. journal of hospital infection. 2003;53(1):39-45. 13. rubinstein e, vaughan d. tigecycline. drugs. 2005;65(10):1317-36. 14. liu j-w, ko w-c, huang c-h, liao c-h, lu c-t, chuang y-c, et al. agreement assessment of tigecycline susceptibilities determined by the disk diffusion and broth microdilution methods among commonly encountered resistant bacterial isolates: results from the tigecycline in-vitro surveillance in taiwan [tist] study, 2008-2010. antimicrobial agents and chemotherapy. 2011:aac. 05879-11. 15. pallett a, hand k. complicated urinary tract infections: practical solutions for the treatment of multiresistant gramnegative bacteria. journal of antimicrobial chemotherapy. 2010;65(suppl_3):iii25-iii33. 16. nandi p, kumar s, biswas t, mitra g, chejara sk, roy s. in vitro susceptibility pattern of tigecycline against mrsa, esbl producing escherichia coli, klebsiella species and acinetobacter isolates in a rural tertiary care hospital. 2015. 17. gill mm, usman j, hassan a, kaleem f, shaheen n. in vitro susceptibility pattern of extended spectrum β 122 j i m d c 2 0 1 8 122 lactamase producing gram negative bacilli against tetracyclines. journal of ayub medical college abbottabad. 2015;27(4):788-90. 18. khalid a, usman j, kaleem f, hassan a, omair m, anjum r. the frequency and antimicrobial sensitivity pattern of extended spectrum-lactamase (esbls) producing gram negative bacilli isolated from urine in a tertiary care hospital of pakistan. african journal of microbiology research. 2013;7(19):2040-3. 19. gupta k, kaushal s, chopra s. tigecycline: a novel glycylcycline antibiotic. indian journal of pharmacology. 2006;38(3):217. j islamabad med dental coll 2022 175 open access comparative benefits of tissue marking by poster ink in histopathology ayesha sarwar1, ashok kumar tanwani2, anum usman3, khalida moeed4. 1assistant professor, department of pathology, hbs medical and dental college, islamabad. 2hod pathology, hbs medical and dental college, islamabad. 3associate professor, department of pathology, al nafees medical college, islamabad. 4assistant professor, department of anatomy, loralai medical college, balochistan a b s t r a c t background: tissue margin marking with india ink is important in decision making for surgeons. the present study was conducted to examine the reliability of different shades of locally available poster colours in tissue marking and to evaluate the colour perceptibility microscopically in comparison with similar tissues marked by india ink. methodology: this experimental study was conducted at department of pathology, hbs medical & dental college & hospital, islamabad from 27th february 2021 to 29th april 2021. sample size was fifty, collected through convenient sampling technique. five types of formalin fixed tissue specimens were selected for the study so as to evaluate the effectiveness of poster ink marking on different tissue surfaces. from each specimen, four sections were taken from the margins. three shades of poster colour (black, blue and green) were used to ink three sections while one section from each tissue type was marked with india ink. after complete tissue processing and routine haematoxylin and eosin (h&e) staining, slides were examined microscopically. scoring was done on a scale 0 to 3 on the basis of visibility. results: the present study showed that poster colours inking of the tissues was quite reliable as compared to india ink. most consistent results were achieved with black and blue colours as compared to green colour. conclusion: poster colours are reliable tool for tissue marking when india ink is not available. their availability in a variety of colours provides them an edge over india ink. key words: eosin, india ink, resection margins authors’ contribution: 1conception; literature research; manuscript design; 2critical analysis and manuscript review; 3data collection; ,manuscript editing;4data analysis. correspondence: anum usman email dranumusman@gmail.com article info: received: august 4, 2021 accepted: september 22, 2022 cite this article: sarwar a, tanwani k a, usman a, moeed k. comparative benefits of tissue marking by poster ink in histopathology.j islamabad med dental coll. 2022; 11(3): 175-181 doi: https://doi.org/10.35787/jimdc.v11i3.751 funding source: nil conflict of interest: nil i n t r o d u c t i o n the first step in the evaluation of a surgical specimen is its gross or macroscopic examination. it is not infrequent during this process that there is a need to identify the resection margins or to identify small tissue pieces at embedding station and also to accurately orient a specimen. use of tissue marking ink greatly facilitates all these processes. accurate evaluation of stained tissue is essential for many clinical decisions and also improves intra observer and inter observer reliability.1,2 india ink is routinely used for this purpose. but india ink is available only in black colour. during routine histopathology, frequently there is a need for different colour ink when different surfaces/margins are to be studied or laterality of specimens needs to be identified. differently coloured inks also help in reducing identification error that may happen as in o r i g i n a l a r t i c l e mailto:muneebullah@gmail.com j islamabad med dental coll 2022 176 prostate needle biopsy when multiple samples are taken from different sites in an enlarged prostate gland or during research similar specimens of different patients can be coloured differently and put in one cassette.3 tissue marking dyes (tmd) have been used as an alternate to india ink in tissue marking. they are available in many colours. but they are expensive and not always readily available especially in small laboratories in developing countries.4 other alternate marking techniques are gelatin, oil paints, acrylic paints, and also eosin and alcian blue which are commonly used dyes in histopathology lab.5 the accurate histopathological evaluation of surgical margins is very important especially when there is a need to decide the type of surgery to be performed like whether an organ sparing or complete resection is required based on the fact that the tumour borders are infiltrative, irregular, or excision margins are close to the line of resection.4 the present study aims to examine the reliability of locally available poster colours in different shades for tissue inking and to evaluate the colour perceptibility microscopically in comparison with similar tissues marked using india ink. this will lead to generation of more reliable histopathology reports which is beneficial for the patients. m e t h o d o l o g y the study was conducted in the department of pathology, hbs medical & dental college & hospital, islamabad from 27 february 2021 to 29 april 2021 after approval of the ethical review board of hbs medical and dental college, islamabad. five different tissue specimens fixed in formalin were included in the study (breast, colon, skin, thyroid and testis) to represent different consistency and surfaces for inking while improperly processed or oriented specimens or improperly stained slides were excluded from the study. for the study, sections were taken from the selected specimen (breast, colon, skin, thyroid and testis) after routine grossing for histopathology was done. from each of the selected specimen, four sections were taken from the margins. three shades of poster colour (black, blue and green) were used to ink the three sections while one section from each of the tissue type was marked with india ink. fifty samples were collected by convenient sampling technique. the tissues were wiped dry using a piece of gauze before and after applying the ink. no other technique or chemical was used for inking. colours were directly applied with a brush. cassettes were processed in automated tissue processor and blocks were prepared after standard paraffin embedding. sections were cut at 3mm thickness and routine haematoxylin and eosin (h&e) was used for staining purpose. to evaluate the colour perceptibility and sharpness, slides were examined microscopically. scoring was done on a scale 0 to 3 as (0-no colour visible; 1colour is perceptible only faintly; 2colour is perceptible more clearly than 1 but less than 3, 3colour perceptibility is clear and sharp)6. r e s u l t s four sections were taken, one each from colon, breast, skin, thyroid and testis. there were 9 specimen of breast, 5 of colon, 14 of skin, 4 of testis and 18 of thyroid. sections from each of the organ was coloured with black, blue, green and india ink. the colour perceptibility as observed under microscope is shown in the table 1 table i: scoring of colour perceptibility in different types of tissues inked with poster colours and india ink under light microscope tissue type colours poster colour visibility score india ink visibility score breast black blue 3 (100% cases) 3 (100% cases) 2 (55% cases) j islamabad med dental coll 2022 177 score: 0-no colour visible; 1colour is perceptible only faintly; 2colour is perceptible more clearly than 1 but less than 3, 3-colour perceptibility is clear and sharp the results of black and blue colour were comparable to that of india ink in all types of tissue; in fact poster colours were sharper and easily visible in breast and colon specimen than india ink (all sections of blue and black poster colour gave score 3 visibility as compared to india ink in which only 4/9 (45%) cases of breast and 2/5 (40%) cases of colon gave score 3 visibility) blue colour yielded the most consistent results in all types of tissues and the results of green colour were poor. figure 1 shows the visibility of different poster colours in different tissues. green 1 (77% cases) colon black blue green 3 (100% cases) 3 (100% cases) 0 2 (60% cases) skin black blue green 3 (100% cases) 3 (100% cases) 1 3 (100% cases) testis black blue green 2 (50% cases) 1 (75% cases) 0 1 (75% cases) thyroid black blue green 3 (100% cases) 3 (100% cases) 0 3 (100% cases) b a j islamabad med dental coll 2022 178 fig1: (h&e 100x) shows the surgical specimen margins marked with poster colours as seen under the microscope. a: colon (blue), b: fat (black), c: skin (green), d: thyroid (blue) fig2: the poster paint of blue, black and green colours is clearly visible by the naked eye on the section margins d i s c u s s i o n in the present study, the poster colours successfully marked the tissue margins of routine histopathology specimens and yielded results comparable to that of similar tissues marked with india ink. india ink is the most well known tissue marking dye. kizhakkoottu s (2021)7 conducted a large scale study on 1325 specimens to compare the properties of india ink, acrylic colours and tissue marking dyes in inking of tumour resection margins. they concluded that india ink is the best tissue marking dye but the advantages of acrylic paints compete with that of india ink and require much larger studies to prove their reproducibility. our study also yielded similar results with additional benefit of less cost and multiple colours. poster colour is a type of acrylic paint and it is commonly used in artwork and painting. it is a distemper paint which has gum water as its binder and has water soluble characteristics; while acrylic paints are particulate pigments suspended in acrylic c d j islamabad med dental coll 2022 179 polymer emulsion which along with a mixture of multiple chemicals forms a thick emulsion. poster paints can be used in the same way as acrylic paints; except poster paints are more economical and dries more quickly than regular acrylic paints. acrylic paints were first introduced around 1950, and have become increasingly popular with multiple uses, as these paints are easy to apply, dry and are long lasting.8 aziz a (2019) & pursnani d (2015) used acrylic colours on breast and colon specimen and concluded that use of acrylic colours has many benefits over india ink. they also studied three different methods of colour application and found that best results were achieved when the sections were taken after inking and overnight fixation.6,9 tampi c. (2012) concluded that the easy availability and application of acrylic colours mark them as a good alternate inking technique in india that gives reliable results on microscopic examination and use of coloured inks provides precision to the examination of the tissue margins.10 sarode sc et al (2015) used acrylic paint for margin inking in oral squamous cell carcinoma and concluded that acrylic colours are better than india ink as surgical ink because they are available in a variety of colours, are easy to apply, quickly dry, and withstand the processing procedures. they also have an advantage of being easily available and of being clearly visible on paraffin blocks and under microscope. they further suggested use of multiple colours will aid in reassessment of resection margins of the gross specimens in the future.11 we also experienced similar advantages as the studies mentioned though our sample size was much less. vatsyayan a (2019)12, criswell (2021)13, mardiana aa (2019)14 are of the same view regarding the usefulness of poster colours in marking of surgical specimen. mardiana aa (2019) conducted his study in malaysia and used poster colours which is a cheaper version of acrylic paints and found it to be a reliable alternate to india ink and strongly recommended its use in routine histopathology. many studies are available that showed the benefits of acrylic paints for margin inking but only a few; as the present study, are about the application of poster paints for this purpose. we favour poster paints as their less cost and a good comparable yield makes them more suitable for long term use. however, tampi c. (2012) showed that not all shades of acrylic colours suffice as grossing ink because of their poor visibility in slides as happened in the present study, the green colour was not visible on colonic serosa and testicular biopsy.10 much larger studies are needed, especially in tissues requiring decalcification to assess the reliability of poster paints as tissue markers in routine histopathology, as is pointed out by williams as et al (2014)15 and keifer s (2021)16 in their research. jennifer s (2019)17 and kamat m (2019)18 studied the importance of resection margin in oral squamous cell cancer. they recommended the use of acrylic paints as substitute for india ink and tissue marking dyes. according to them, coloured ink is more useful for better orientation, post grossing reconstruction of the specimen and reducing the identification error. the ease of use, quick drying and easy availability of acrylic paints favours their use. fei b (2017)19 and hon jd (2019)20 emphasized the need of accurate resection margins in oral cancers. molecular assessment of resection margins is a novelty. among the available tools they preferred the use of coloured inks for surgical resection margin assessment. local data mentions the use of india ink for evaluation of surgical resection margins but not the use of any other multicolour inks like acrylic paints or poster paints.21 but there are studies from india, singapore and malaysia which highlight the utility of coloured inks in surgical specimens.6,9,10 we used poster paints for inking of surgical resection margins while mostly available data is of the use of acrylic paints. the advantages of using poster colours in this study were that black poster colour was more reliable than india ink in case of colonic mucosa, there was minimal seepage of colour into j islamabad med dental coll 2022 180 the underlying tissue and margin staining with poster colours did not affect the quality of tissue sections or staining when compared with other noninked tissues processed on the same day. the limitations of the study are it is a single centred study with a small sample size. the use of poster colours as a routine technique requires a much larger study with a greater sample size. c o n c l u s i o n poster colours are available in most stationery shops. they seem to be a reliable tool for tissue marking when india ink is not available. their availability in a variety of colours provides them an edge over india ink. to ensure reproducibility of the results these alternative paints should be tested in individual laboratories before applying in routine use. r e f e r e n c e s 1. shah k. postoperative pathologic assessment of surgical margins in oral cancer: a contemporary review. j oral maxillofac pathol. 2018; 22(1):7885. doi: 10.4103/jomfp.jomfp_185_16. 2. sarode g , sachin c , pankaj s and shankargouda p. histopathological assessment of surgical margins of oral carcinomas and related shrinkage of tumour. oral oncol. 2017;2(1):1-4. doi: 10.1177/2057178x17708078 3. chen y, xie w, adam k. rapid pathology of lumpectomy margins with open-top light-sheet (otls) microscopy. biomed opt express. 2019; 10(3): 1257-72. doi.org/10.1364/boe.10.001257 4. hon d, chen w, minerowicz c. analysis and comparison of tissue-marking dye detection via light microscopy, telemicroscopy, and virtual microscopy. am j clin pathol. 2019; 151(1): 95–9. doi: 10.1093/ajcp/aqy117 5. alturkistani a, tashkandi m, mohammedsaleh m. histological stains: a literature review and case study. glob j health sci. 2015;8(3):72-79. doi: 10.5539/gjhs.v8n3p72. 6. aziz a, bakar s, kornain n. poster colours: pocketfriendly alternative to tissue marking dyes. turk patoloji derg. 2019;35(1):170–171. doi: 10.5146/tjpath.2017.01394 7. kizhakkoottu s, jayaraj g, sherlin hj, don kr, santhanam a. inking of gross specimens: a systematic review. arkh patol. 2021;83(1):49-52. doi: 10.17116/patol20218301149 8. khramtsov ai, khramtsova gf, asaulenko zp. application of tissue-marking dyes for pathologic examination of surgical and autopsy specimens. arkh patol. 2019; 81(1):40-45. russian. doi: 10.17116/patol20198101140. pmid: 30830104. 9. pursnani d, arora s, katyayani p, ambica c, yelikar b. inking in surgical pathology: does the method matter? a procedural analysis of a spectrum of colours. turk j pathol. 2016; 32(2):112-8. doi: 10.5146/tjpath.2015.01351 10. tampi c. in search of the rainbow: colored inks in surgical pathology. indian j pathol microbiol. 2012; 55(1):154-7. doi: 10.4103/03774929.97843 11. sarode c, sarode s, patil s. comparative study of acrylic color and india ink for their use as a surgical margin inks in oral squamous cell carcinoma. world j dent. 2015; 6(1):26-30. doi: 10.5005/jp-journals-10015-1308. 12. vatsyayan a, patel p, mandlik . surgery is an art, live yours in colors: specimen color coding in head and neck oncology. indian j surg oncol. 2019; 10(4):618-619. doi: 10.1007/s13193-01900941-6. epub 2019 may 28. pmid: 31866729; pmcid: pmc6895368. 13. criswell s, sutton j. application of dyes to cytology cell blocks and biopsy tissues before processing enhances specimen visualization during embedding and microtomy. j histotech.2021. doi: 10.1080/01478885.2021.1909357. 14. mardiana a, bakar s, kaslina n. poster colours: pocket-friendly alternative to tissue marking dyes. turk patoloji derg. 2019; 35(2): 170-71. doi: 10.5146/tjpath.2017.01394. 15. williams s, dakin hache k. variable fidelity of tissue-marking dyes in surgical pathology. histopathol. 2014; 64(3):896–900. doi: 10.1111/his.12328. 16. kiefer s, huber j, fullgraf h, sorensen h, csanadi a, stillger n, et al. alteration of tissue marking dyes depends on used chromogen during http://dx.doi.org/10.1177/2057178x17708078 https://doi.org/10.1364/boe.10.001257 https://doi.org/10.1093/ajcp/aqy117 https://doi.org/10.5539/gjhs.v8n3p72 https://doi.org/10.5146/tjpath.2017.01394 https://doi.org/10.17116/patol20218301149 https://doi.org/10.4103/0377-4929.97843 https://doi.org/10.4103/0377-4929.97843 http://dx.doi.org/10.5005/jp-journals-10015-1308 https://doi.org/10.1080/01478885.2021.1909357 https://doi.org/10.5146/tjpath.2017.01394 j islamabad med dental coll 2022 181 immunohistochemistry.cells.2021;10(1):83542. doi:10.3390/cells1004083 17. jennifer s, kwesi k. india ink: a time-tested histological marker. asra. 2019; 44(7): 755-57. doi: 10.1136/rapm-2019-100553 18. kamat m, rai bd, puranik rs, datar uv. a comprehensive review of surgical margin in oral squamous cell carcinoma highlighting the significance of tumor-free surgical margins. j can res ther. 2019;15:449-54. doi: 10.4103/jcrt.jcrt_273_17. 19. fei b, lu g, wang x. tumor margin assessment of surgical tissue specimen of cancer patients using label-free hyperspectral imaging. proc spie int soc opt eng. 2017;10054:100540. doi:10.1117/12.2249803 20. hon jd, chen w, minerowicz c, thomas s, barnard n, gilbert n,et al. analysis and comparison of tissue-marking dye detection via light microscopy, telemicroscopy, and virtual microscopy. am j clin pathol. 2019 jan 1;151(1):95-99. https://doi.org/10.1093/ajcp/aqy117. 21. sattar, ak, ali b, masroor i. feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study. pilot feasibility stud 6, 140 (2020). https://doi.org/10.1186/s40814-020-00682-2 https://doi.org/10.1136/rapm-2019-100553 https://doi.org/10.1093/ajcp/aqy117 88 j i m d c 2 0 1 8 88 open access f u l l l e n g t h a r t i c l e comparison of effectiveness of topical versus oral nifedipine for treatment of chronic anal fissure ahsan ali mirza 1, muhammad asif 2, uzma javed gul 3, aysha saeed 4, kashif jamil 5 1 head department general surgery paec general hospital islamabad 2 -5 department of general surgery, paec general hospital, islamabad a b s t r a c t objective: to compare the effectiveness of topical and oral nifedipine in the treatment of chronic anal fissure. patients and methods: in this randomized control trial total of 124 patients with chronic anal fissure (caf) were selected through opd and divided randomly into two equal groups. in group a the topical nifedipine (2%) was applied, while in group b the oral nifedipine 10mg tds was used. both groups were compared in terms of pain and healing measured one month after starting treatment. results: mean age of the patients was 38.81±11.81 years. in both groups there was statistically significant difference for the age but no difference was found regarding gender and baseline visual analogue scale. group a had better healing rate and pain relieve as compared to group b. there was no difference between groups regarding the effectiveness of treatment. conclusion: the topical nifedipine has better healing effects as compared to the oral nifedipine. the oral form is better in relieving pain after one month of treatment. there was no difference between oral and topical form in terms of overall effectiveness. key words: fissure in ano, nifedipine, pain. author`s contribution 1,2conception, synthesis, planning of research and manuscript writing interpretation and discussion 3,4 data analysis, interpretation and manuscript writing, 5 active participation in data collection. address of correspondence muhammad asif email: dr.asif394@yahoo.com article info. received: september 20, 2017 accepted: january 11, 2017 cite this article. mirza aa, asif m, gul uj, saeed a, jamil k. comparison of effectiveness of topical nifedipine with oral nifedipine for treatment of chronic anal fissure. jimdc.2018; 7(2):88-91 funding source: nil conflict of interest: nil i n t r o d u c t i o n anal fissure is one of the most common and painful proctologic disease in general surgery. it occurs mostly between the second and fourth decades of life with a lifetime incidence of 11%.1 frequency of anal fissure is approximately equal between men and women.1 up to 11% of women develop this condition after childbirth. approximately 90% of anal fissures in both men and women are located posteriorly in the midline. anterior fissures occur in 10% of patients and is more common in women.2 less than 1% of fissures are located off a midline position or is multiple in number.3 raised resting sphincter pressure leads to relative ischemia especially in posterior midline ulceration, which results in persistence of internal sphincter hypertonia.4 lateral internal sphincterotomy (lis) is a surgical treatment, considered as the ‘gold standard’ therapy for chronic anal fissure5 and less than 10% long term recurrence6 but associated with postoperative incontinence in 30% (or even more) o r i g i n a l a r t i c l e 89 j i m d c 2 0 1 8 89 patients which can become permanent.7 most previous national and international researches were based on the efficacy of topical agents in anal fissure management. topical ccbs (calcium channel blockers) have been shown to be better than both lignocaine ointment and hydrocortisone cream.7 usage of oral nifedipine was suggested in some studies for anal fissure therapy.8 topical nifedipine is better in terms of wound healing for treatment of anal fissure as compared to oral nifedipine whereas oral therapy is better in terms of pain reduction.4 since no national trial was found comparing the two forms of nifedipine and international data is conflicting in support of both forms of treatment. this trial was conducted to compare topical nifedipine with oral nifedipine in chronic anal fissure in terms of healing and pain relief after 1 month in our population so that better treatment option could be adopted which would help in decreasing morbidity and hospital visits. p a t i e n t s a n d m e t h o d s this randomized control trial was conducted at department of surgery paec general hospital islamabad. duration of the study was 6 months (20 december 2015 to 20 june 2016). total calculated sample size was 124 patients, 62 in each group. sample size was calculated through who sample size calculator by using 5% level of significance, 80% power of test, 95% confidence level, 49.5% anticipated population mean pain score (p1) and 73.3% anticipated target population mean pain score (p2).4 both male and female patients, who presented with anal fissure having age range between 18 to 60 years and baseline pain score ≥ 4 on vas were included in study. patients with history of sexually transmitted disease (stds), tuberculosis, irritable bowel disease or anal cancer, presence of medical related problems such as diabetes mellitus, migraine and cardiovascular diseases, pregnancy and lactation, hypersensitivity to nifedipine or calcium channel blockers and cirrhosis were excluded from the study. after taking the ethical approval, all the patients fulfilling the selection criteria were included in the study. informed written consent was taken and patients were randomly divided into two equal groups, a & b. randomization was done through lottery method. in group a, patients were prescribed to apply topical nifedipine cream (2%) at the anal margin 8 hourly. patients in the second group were given 10 mg oral nifedipine tds, for four weeks. all patients were advised to increase their intake of fiber and usage of sitz bath for 10-15 minutes, 2-3 times daily. on the first visit and follow-up visit at 4th week, wound healing and pain relief were recorded on performa. for pain measurement, a visual analogue scale was devised between 0 and 10. patients were asked to give 0 point to no pain and 10 for the worst pain they ever experienced. wound healing was assessed by naked eye examination of wound for the development of granulation tissue and re-epitheliazation of the wound. overall effectiveness was assessed by patient feedback in terms of no pain while passing stool and on local inspection of wound healing on follow up. all the data was entered and analyzed using statistical package for social sciences (spss version 17). means and standard deviations were presented for numerical values i.e., age and visual analogue scores for pain. frequency and percentages were presented for categorical data like gender and wound healing. to compare the proportions of the patients with effectiveness in both the groups, chi square test was applied. p< 0.05 was considered statistically significant. r e s u l t s out of 124 patients, 60(48.4%) were male and 64 (51.6%) were female patients. mean age of the patients was 38.81 ± 11.815 years. the baseline pain score was 5.97 ± 1.41 at the start of the treatment. when the baseline pain scores were compared between groups at start of the treatment, then there was no statistically significant difference between groups (table 1). at the end of one month, pain was relieved (vas ≤ 2) in 59 patients (47.6%). healing was observed in 64 patients (51.6%). overall, the treatment was effective in 28 patients table 1: baseline vas score comparison between groups (n=124) group pain score (mean ± sd) p-value a 6.02 ± 1.38 0.704 b 5.92 ± 1.44 90 j i m d c 2 0 1 8 90 (22.6%). both the groups were compared regarding the pain and healing at the end of one month. regarding pain and healing, group a had significantly better effects as compared to group b. there was no significant difference between groups when the effectiveness of the treatment was compared (table 2). d i s c u s s i o n chronic anal fissure (caf) is a condition when the anal fissure is there for more than six weeks at anoderm. most of the time acute stage is usually treated with conservative management but the chronic condition usually needs surgical intervention. various drugs used have variable results in terms of symptoms and healing rates.9 glyceryl trinitrate (gtn) is smooth muscle relaxant and vasodilator and it is more effective when it is used topically for treatment of caf.10,11 ccbs are good alternative for those who did not tolerate the gtn. ccbs can be used topically as well as orally. the ccbs have some side effects like headache, dizziness, itching and burning at the site of application.12, 13 the local injection of the botox toxin is effective in short term for the treatment of caf.14 cook, t. a., et al showed that the resting anal pressure is reduced by taking the nifedipine orally and it results in the quick healing of caf.15 similar results were shown by the other studies later on.16,17 ho, k. s. and y. h compared the lis and oral nifedipine and the results showed that lis was significantly more effective than oral nifedipine in providing pain relief (p = 0.004) and better patient satisfaction (p = 0.020) at 4 weeks.18 another study showed that the lis and topical form of nifedipine showed similar results in terms of healing and pain relief.19 golfam, f., et al. concluded that topical nifedipine has a superior role for anal fissure treatment with higher healing rate and lower side effects as compared to oral one.4 c o n c l u s i o n the topical nifedipine is more effective in relieving the pain and healing as compared to oral form in caf. multicenter research work on large scale is recommended to evaluate the oral and topical forms of nifedipine for the treatment of caf. r e f e r e n c e s 1. altomare df, binda ga, canuti s, landolfi v, trompetto m, villani rd. the management of patients with primary chronic anal fissure: a position paper. tech coloproctol. 2011;15(2):135-41. 2. zaghiyan kn, fleshner p. anal fissure. clin colon rectal surg. 2011;24(1):22-30. 3. agrawal v, kaushal g, gupta r. randomized controlled pilot trial of nifedipine as oral therapy vs. topical application in the treatment of fissure-in-ano. am j surg. 2013;206(5):748-51. 4. golfam f, golfam p, golfam b, pahlevani p. comparison of topical nifedipine with oral nifedipine for treatment of anal fissure: a randomized controlled trial. iran red crescent med j. 2014;16(8):e13592. 5. perry wb, dykes sl, buie wd, rafferty jf, standards practice task force of the american society of c, rectal s. practice parameters for the management of anal fissures (3rd revision). dis colon rectum. 2010;53(8):1110-5. 6. aivaz o, rayhanabad j, nguyen v, haigh pi, abbas m. botulinum toxin a with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure. am surg. 2009;75(10):925-8. 7. madalinski mh. identifying the best therapy for chronic anal fissure. world j gastrointest pharmacol ther. 2011;2(2):9-16. 95. 8. golfam f, golfam p, khalaj a, sayed mortaz ss. the effect of topical nifedipine in treatment of chronic anal fissure. acta med iran. 2010;48(5):295-9. 9. van outryve m. physiopathology of the anal fissure. acta chir belg. 2006;106(5):517-8. table 2: comparison of outcomes between groups at end of month (n=124) groups status pvalue yes n (%) no n (%) healing group a 40(64.5) 22(35.5) 0.004 group b 24(38.7) 38(61.3) pain group a 36(58.1) 26(41.9) 0.019 group b 23(37.1) 39(62.9) overall effectivenes s (pain relief + healing ) group a 13(21) 49(79) 0.668 group b 15(24.2) 47(75.8) 91 j i m d c 2 0 1 8 91 10. garrido r, lagos n, lagos m, rodriguez-navarro aj, garcia c, truan d, et al. treatment of chronic anal fissure by gonyautoxin. colorectal dis. 2007;9(7):619-24. 11. husberg b, malmborg p, strigard k. treatment with botulinum toxin in children with chronic anal fissure. eur j pediatr surg. 2009;19(5):290-2. 12. hashmi f, siddiqui fg. diltiazem (2%) versus glyceryl trinitrate cream (0.2%) in the management of chronic anal fissure. j coll physicians surg pak. 2009;19(12):750-3. 13. jawaid m, masood z, salim m. topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. j coll physicians surg pak. 2009;19(10):614-7. 14. piccinni g, poli e, angrisano a, sciusco a, testini m. botox for chronic anal fissure: is it useful? a clinical experience with mid-term follow-up. acta biomed. 2009;80(3):238-42. 15. cook ta, humphreys mm, mc cmnj. oral nifedipine reduces resting anal pressure and heals chronic anal fissure. br j surg. 1999;86(10):1269-73. 16. brisinda g, maria g. oral nifedipine reduces resting anal pressure and heals chronic anal fissure. br j surg. 2000;87(2):251. 17. agaoglu n, cengiz s, arslan mk, turkyilmaz s. oral nifedipine in the treatment of chronic anal fissure. dig surg. 2003;20(5):452-6. 18. ho ks, ho yh. randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure. br j surg. 2005;92(4):403-8. 19. katsinelos p, papaziogas b, koutelidakis i, paroutoglou g, dimiropoulos s, souparis a, et al. topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up. int j colorectal dis. 2006;21(2):179-83. j i m d c 2 0 1 8 178 178 objective: to assess the diagnostic accuracy of aetiology scoring system for diagnosing variceal bleeding in patients presenting with upper gastrointestinal bleeding using endoscopy as gold standard. material and methods: this cross sectional study was conducted at department of medicine unit, jinnah hospital lahore (jhl) from 19th december 2015 to 20th may 2016. in total 230 subjects, fulfilling the inclusion criteria were selected by non-probability consecutive sampling technique and informed consent were obtained. patients were evaluated for variceal bleeding on the basis of aetiology scoring system and then confirmed with endoscopy. data was analyzed by using spss 21.0 and sensitivity, specificity, positive and negative predictive value of aetiology score was calculated taking endoscopy as gold standard. results: out of 230 patients presenting with upper gastrointestinal bleeding, males and females were 48.3% and 51.7% respectively. the mean age was 41.64 + 10.53 years, the mean upper gastrointestinal bleeding ateiology score system was 3.23+ 1.55. the sensitivity, specificity, positive predicted value and negative predicted value at a cutoff value of etiological score > 3.1 for variceal bleeding were 90.70%, 82.18%, 86.67% and 87.37% respectively. it was observed that there was statistically significant association between etiological score > 3.1 and endoscopy. conclusion: the ugib aetiology score, composed of 3 parameters, using a cut-off ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for ugib before endoscopy. key words: aetiology, endoscopy, scoring system, upper gastrointestinal bleeding. author`s contribution address of correspondence article info. open access f u l l l e n g t h a r t i c l e o r i g i n a l a r t i c l e diagnostic accuracy of aetiology score for predicting variceal bleed in patients of upper gastrointestinal bleeding. talha khalid 1, fahad aman khan 2, imran khan 3, mukhtar ahmed 4, khawar siddique 5, asad ullah mahmood 6 1,6 senior registrar, 2,3,4 assistant professor, 5 medical officer medical unit ii, jinnah hospital lahore a b s t r a c t 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3-5 data analysis, interpretation and manuscript writing, 6 active participation in data collection. talha khalid email: drtalhakhalid@gmail.com received: february 8, 2018 accepted: july 12, 2018 cite this article. khalid t, khan fa, khan i, ahmed m, siddique k, mahmood au. diagnostic accuracy of aetiology score for predicting variceal bleed in patients of upper gastrointestinal bleeding. jimdc.2018; 7(3):178-182 funding source: nil conflict of interest: nil i n t r o d u c t i o n upper gastrointestinal bleeding (ugib) is defined as bleeding derived from a source proximal to the ligament of treitz. patients with upper gastrointestinal bleeding (ugib) commonly present with hematemesis (vomiting of blood or coffee-ground like material) and/or melena (black tarry stools).1 the initial evaluation of a patient with a suspected clinically significant acute upper gastrointestinal (ugi) bleeding includes a history, physical examination, laboratory tests, and in some cases, nasogastric lavage. the goal of the evaluation is to assess the severity of the bleed, identify potential sources of the bleed, and determine if there are conditions present that may affect subsequent management. the information gathered as a part of the initial evaluation is used to guide decisions regarding triage, resuscitation, empiric medical therapy, and diagnostic testing.2,3 patients should be asked about prior episodes of upper gi bleeding, since up to 60 percent of patients with a history of an upper gi mailto:drtalhakhalid@gmail.com j i m d c 2 0 1 8 179 179 bleed are bleeding from the same lesion.4 in addition, the patient's past medical history should be reviewed to identify important comorbid conditions that may lead to upper gi bleeding or may influence the patient's subsequent management. a thorough history of medication should be obtained. finally, as with the past medical history, the physical examination should include a search for evidence of significant comorbid illnesses. laboratory tests include a complete blood count, liver function tests, and coagulation studies.5 whether all patients with suspected acute upper gi bleeding require nasogastric tube (ngt) placement is controversial, in part, because the studies have failed to demonstrate a benefit with regard to clinical outcomes.6 more often, ngt lavage is used when it is unclear if a patient has ongoing bleeding and thus might benefit from an early endoscopy. in addition, nasogastric tube lavage can be used to remove particulate matter, fresh blood, and clots from the stomach to facilitate endoscopy. the presence of red blood or coffee ground material in the aspirate also confirms an upper gi source of bleeding and predicts whether the bleeding is caused by a lesion at increased risk for ongoing or recurrent bleeding.7 however, lavage may not be positive if bleeding has ceased or arises beyond a closed pylorus. the presence of nonbloody bilious fluid suggests that the pylorus is open and that there is no active upper gi bleeding distal to the pylorus.8 early endoscopy (within 24 hours) is recommended for most patients with acute ugi bleeding, though whether early endoscopy affects outcomes and resource utilization is unsettled.9 other diagnostic tests for acute upper gi bleeding include angiography and a tagged red blood cell scan, which can detect active bleeding.10 there is also interest in using wireless capsule endoscopy for patients who have presented to the emergency department with suspected upper gi bleeding. an oesophageal capsule (which has a recording time of 20 minutes) can be given in the emergency department and reviewed immediately for evidence of bleeding. confirming the presence of blood in the stomach or duodenum may aid with patient triage and identify patients more likely to benefit from early endoscopy.11 for locating and identifying bleeding lesions in the upper gi tract, upper endoscopy is highly sensitive and specific diagnostic modality.12 however as aetiology scoring system is a widely used method,13 the present study was planned to evaluate diagnostic accuracy of aetiology scoring system for diagnosing variceal bleeding in patients presenting with upper gastrointestinal bleeding using endoscopy as a gold standard. m a t e r i a l a n d m e t h o d s this cross sectional study was performed at department of medicine unit ii jinnah hospital lahore (jhl) from 19th december 2015 to 20th may 2016. calculated sample size was 230. it was computed on the basis of 95% confidence interval with expected percentage of variceal bleeding in 15% of cases. taking confidence interval at 95%, 10 % margin of error for 85% sensitivity and 9% margin of error for 81% specificity, taking expected percentage of variceal bleeding in 15% of cases, the sample size was calculated 230. patients with age 18 65 years of either gender with history of upper gastrointestinal bleeding (ugib) during last 24 hours were included. diagnosed cases of peptic ulcer, patients whose definite cause of ugib was undetermined or inconclusive on previous endoscopy (on previous medical record) were excluded from study. non-probability consecutive sampling technique was used. informed consent was taken. patients were evaluated for variceal bleeding on the basis of ugib aetiology scoring system and then confirmed with endoscopy. ugib aetiology score was calculated by: aetiology score system = (3.1 x previous diagnosis of cirrhosis) + (1.5 x red vomitus) + (1.2 x red ng aspirate). where 1 and 0 are used for the presence and absence of previous diagnosis of cirrhosis, red vomitus and red ng aspirate. total ugib aetiology score ranges from 1.2-5.8 with a positive cut off value of > 3.1. varices in the lower third of the oesophagus or in the stomach confirmed on direct visualization on endoscopy, was labelled as “positive” for endoscopy. subjects positive for variceal bleed on endoscopy and ugib aetiology score > 3.1 were tagged as true positive, subjects negative for varices on endoscopy and ugib aetiology score < 3.1 were labelled as true negative. individuals having ugib aetiology score > 3.1 but no varices on endoscopy were called as false positive, subjects with ugib aetiology score < 3.1 but positive variceal bleed on endoscopy were labelled as false j i m d c 2 0 1 8 180 180 negative. all the data was entered into a predesigned structured performa and analysed by using spss 21. quantitative variables like gender, presence of variceal bleed on aetiology score and on endoscopy were presented as frequency and percentage. quantitative continuous variable data such as age and ugib aetiology score was noted as mean and standard deviation. diagnostic accuracy, sensitivity, specificity, positive and negative and predictive value were calculated considering variceal bleed endoscopy as gold standard. sensitivity: a / (a + c) x 100 or tp / (tp + fn) x 100 specificity: d / (d + b) x 100 or tn / (tn + fp) x 100 positive predictive value: tp/tp+ fp x 100 negative predictive value: tn / fn +tn x 100 accuracy: tp+ tn / tp+fp+fn+tn x 100 data was stratified for age, gender, duration of disease (cirrhosis) to deal with effect modifier. post-stratification chisquare test was used. p-value < 0.05 was considered as statistically significant. r e s u l t s out of 230 patients presented with ugib, male and females were 111(48.3%) and 119(51.7%) respectively. mean age was 41.64 + 10.53 years and mean ugib aetiology score system was 3.23+ 1.55. frequency of cirrhosis, red vomitus, red nasogastric aspirate, ugib aetiology score > 3.1 and frequency of positive endoscopy were shown in figure 1. sensitivity, specificity, positive predictive value, negative predictive and diagnostic accuracy were computed. (table 1) statistically significant association was found between etiological scores and findings of endoscopy (table 2) figure 1: frequency distribution of variables (n=230) table 1: sensitivity and specificity of ugib aetiology score system variables result (percentage) sensitivity 90.70 specificity 82.18 positive predictive value 86.67 negative predictive value 87.37 diagnostic accuracy 86.9 table:2 association of aetiology scores and endoscopy findings (n=230) variable endoscopy total p value pos neg aetiolog y score positive 117 18 135 0.000 negative 12 83 95 total 129 101 230 d i s c u s s i o n the initial evaluation of patients with acute upper gastrointestinal bleeding involves an assessment of hemodynamic stability and resuscitation if necessary.14 gi bleeding is a potentially life-threatening abdominal emergency, that remains a common cause of hospitalization.15,16 bleeding from the upper gastrointestinal tract is about four times as common as bleeding from the lower git. it is important to identify patients with a low probability of re-bleeding from patients with a high probability of re-bleeding.3,17 the purpose of the present study was to evaluate the diagnostic accuracy of aetiology scoring system for diagnosing variceal bleeding in patients presenting with upper gastrointestinal bleeding.a large number of patients having ugib due to multiple causes (both variceal and nonvariceal) for which endoscopy is indicated but facilities are not usually available due to limited recourses (only tertiary care hospital had these diagnostic facility) may get benefit from this scoring system. in this regard we collected the data from 230 cases presenting with upper gastrointestinal bleeding after fulfilling the inclusion criteria. out of 230 patients presenting with upper gastrointestinal bleeding, male and females were 48.3% and 51.7% respectively. the mean age was 41.64 + 10.53 years, the mean ateiology score system was 3.23+ 1.55. a j i m d c 2 0 1 8 181 181 comparable study reported out of 101 patients, 56% were males while the remaining 44% were females.18 similar study conducted by chasawat et al reported that among 261 patients with ugib 47 (18%) were variceal and 214 (82%) were non-variceal bleeding. previous diagnosis of cirrhosis or presence of signs of chronic liver disease (or 22.4, 95% ci 8.3-60.4), red or bloody vomitus (or 4.6, 95% ci 1.7-11.9), and red or bloody ng aspirate (or 3.3, 95% ci 1.3-8.3). variceal bleeding predicting scoring model was developed as: z = (3.1 ×previously diagnosed cirrhosis or presence of signs of chronic liver disease) + (1.4 ×red or bloody vomitus) + (1.2 ×red or bloody ng aspirate) 4.1, while 1 and 0 are used for the presence and absence of each factor, respectively. the probability of variceal bleeding is calculated from 1/(1+e -z) or by plotting to the exponential graph. the probabilities of variceal bleeding are >90%, >60%, <10% and <5% for the presence of 3, 2, 1 and 0 factors, respectively. they concluded that three clinical parameters and variceal bleeding predicting score are useful to predict the types of ugib and may aid clinical judgment for the initial management of ugib before endoscopy.16 the present research revealed that previous diagnosis of cirrhosis was observed in 58.7% patients presenting with upper gastrointestinal bleeding. there were 46.1% patients in which red vomitus was present, 60% patients in which red nasogastric aspirate was present. existing literature showed that from the patients of upper gastrointestinal bleeding there were 60% patients that have the history of red vomitus, previously diagnosed cirrhosis was found in 36% and red nasogastric aspirate was present in 60%.13 similarly another study conducted by matei d, et al revealed that previously diagnosed cirrhosis was observed in 35.8% patients presenting with upper gastrointestinal bleeding.19 we observed that there were 58.7% patients in which aetiology score was greater than 3.1 and 41.3 % patients in which aetiology score was less than 3.1. on the other hand, there were 56.1% patients in which endoscopy showed positive results. the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) at a cut-off value of etiological score > 3.1 for variceal bleeding were calculates as 90.70%, 82.18%, 86.67% and 87.37% respectively. similar results were found in a previous study, it was noticed that the ugib aetiology score by using a cut-off ≥ 3.1, the sensitivity, specificity, accuracy, ppv), and npv in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. the score was prospectively validated in another set of 195 ugib cases (46 variceal and 149 non-variceal bleeding). the ppv and npv of a score ≥ 3.1 for variceal bleeding were 79% and 97%, respectively.13 in another study, the ugib aetiology score by using a cut-off value of 0.968, higher values being predictive of variceal bleeding. ppv and npv were: 82.7% and 97%, respectively. the score was validated prospectively in another group of 162 patients: ppv and npv were 72.7% and 95.3%, respectively.(19) existing literature showed that the sensitivity of the ugib score was 78.2% and the specificity was 84.3%. the positive predictive value (ppv) was 91.5% and negative predictive value (npv) was 64.2%. the overall diagnostic accuracy of ugib score in determining variceal bleeding was found to be 80.2%.18 c o n c l u s i o n the sensitivity, specificity, positive predicted value and negative predicted value at a cut-off value of etiological score > 3.1 for variceal bleeding were found as 90.70%, 82.18%, 86.67% and 87.37% respectively. a significant association was found between etiological score > 3.1 and endoscopy. the ugib aetiology score, composed of 3 parameters, using a cut-off ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for ugib before endoscopy. r e f e r e n c e s 1. kim jj, sheibani s, park s, buxbaum j, laine l. causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding. journal of clinical gastroenterology. 2014;48(2):113-8. 2. khamaysi i, gralnek im. acute upper gastrointestinal bleeding (ugib)–initial evaluation and management. best practice & research clinical gastroenterology. 2013;27(5):633-8. 3. strate ll, gralnek im. acg clinical guideline: management of patients with acute lower gastrointestinal bleeding. the american journal of gastroenterology. 2016;111(4):459-74. 4. palmer ed. the vigorous diagnostic approach to upper gastrointestinal tract hemorrhage: a 23-year prospective study of 1,400 patients. jama. 1969;207(8):1477-80. 5. simon tg, travis ac, saltzman jr. initial assessment and resuscitation in nonvariceal upper gastrointestinal j i m d c 2 0 1 8 182 182 bleeding. gastrointestinal endoscopy clinics. 2015;25(3):429-42. 6. pallin dj, saltzman jr. is nasogastric tube lavage in patients with acute upper gi bleeding indicated or antiquated? gastrointestinal endoscopy. 2011;74(5):981-4. 7. huang es, karsan s, kanwal f, singh i, makhani m, spiegel bm. impact of nasogastric lavage on outcomes in acute gi bleeding. gastrointestinal endoscopy. 2011;74(5):971-80. 8. jensen dm, machicado ga. diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge. gastroenterology. 1988;95(6):1569-74. 9. yanar h, taviloglu k. upper gastrointestinal endoscopy. emergency surgery course (esc®) manual: springer; 2016. p. 103-8. 10. barth kh. 4 radiological intervention in upper and lower gastrointestinal bleeding. baillière's clinical gastroenterology. 1995;9(1):53-69. 11. gralnek i, ching j, maza i, wu j, rainer t, israelit s, et al. capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. endoscopy. 2013;45(01):12-19. 12. jutabha r, jensen dm. management of upper gastrointestinal bleeding in the patient with chronic liver disease. medical clinics of north america. 1996;80(5):1035-68. 13. pongprasobchai s, nimitvilai s, chasawat j, manatsathit s. upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding. world journal of gastroenterology: wjg. 2009;15(9):1099-1100 14. bunchorntavakul c, yodket y, singhasena n. clinical characteristics, treatment outcomes and risk assessment of patients with acute upper gastrointestinal bleeding in rajavithi hospital, thailand. journal of the medical association of thailand. 2017;100(2): s104-115. 15. tang y, shen j, zhang f, zhou x, tang z, you t. scoring systes used to predict mortality in patients with acute upper gastrointestinal bleeding in the ed. the american journal of emergency medicine. 2018;36(1):27-32. 16. chasawat j, prachayakul v, pongprasobchai s. upper gasrointestinal bleeding score for differentiating variceal and nonvariceal upper gastrointestinal bleeding. thai j gastroenterol. 2007;8(2):44-50. 17. peralta jv, freeman ml. upper gastrointestinal bleeding. management of bleeding patients: springer; 2016. p. 215 23. 18. ali f, bhatti ab, satti sa, satti tm. the clinical significance of upper gastrointestinal bleeding etiology score in determining variceal bleeding. open journal of gastroenterology. 2014;4(01):45. 19. matei d, groza i, furnea b, puie l, levi c, chiru a, et al. predictors of variceal or nonvariceal source of upper gastrointestinal bleeding. an etiology predictive score established and validated in a tertiary referral center. journal of gastrointestinal & liver diseases. 2013;22(4). 379-384 journal of islamabad medical & dental college (jimdc); 1211(1):1 1 editorial journal of imdc‘inaugural issue’ khalid hassan professor and head, department of pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) it is a matter of great pleasure and honour for islamabad medical and dental college to launch the inaugural issue of its official journaljournal of islamabad medical college (jimdc). the main aim of launching this journal is not only to promote the trend of medical writing in the college, but also to effectively support research activities at both faculty as well as students’ levels. jimdc will publish original (research) articles, review articles, case reports, brief communications, interesting images, abstracts from contemporary journal, and literature related to continued medical education. the last two decades have witnessed a surge of medical publications at national level, mainly as a result of the introduction of criteria of mandatory research publications for promotions in the cadres of medical teachers. with the introduction of these rules, the medical teachers were compulsorily pushed into research activities. as a consequence, the few existing journal in the country were choked with research articles submitted for publication. with the passage of time many new journals were introduced. most of these journals were published by professional societies and various institutions. in an attempt to maintain uniformity with the international practices of medical publications, pmdc and higher education commission (hec) implemented strict regulations for peer review of the journals as an essential requirement for their approval. although the steps taken by the pmdc and hec have resulted in a general trend of medical writing, yet the ‘quantity as well as quantity’ of research in the country are far from satisfactory. reasons are multiple, and some of these are as under: 1. a big percentage of publications are based on retrospective studies in a setup where record keeping is not optimally standardized, and as a result the inferences derived are more presumptive than absolute. 2. the studies designed are usually based on data obtained from hospital population, and many a time, the values thus obtained are related to general population. 3. there is still a dearth of true epidemiological studies, and therefore a true picture of disease pattern in various sets of population is not exactly documentable. 4. the research is generally not problem-based; on the contrary, emphasis is mostly on verification of already published national and international data. 5. the researchers are generally handicapped by paucity of funds and lack of diagnostic facilities. there is a need to address all these issues systematically. although it may be difficult initially, yet it will be rewarding if a consolidated effort is made to develop habit of proper and regular record keeping. the tertiary care hospitals and medical institutions and professional societies may establish research forums, which should develop their own research guidelines. imdc has taken a step in this regard, and has established a research forum for the medical students. the students interested in participating in research have been enrolled; the students thus registered will conduct epidemiological and clinical studies under the supervision of their teachers. for the students as well as faculty members workshops will be arranged especially regarding development of research proposals, research methodology, statistical analysis and medical writing. it is hoped that these steps will contribute in capacity-building at both student as well as faculty level. it is my foremost duty to thank the editorial committee of the journal who made a team effort in bringing out the inaugural issue. i am indebted to dr ghulam akbar niazi, the chairman imdc and prof muhammad naseemullah, dean imdc, who guided and encouraged us at every step. i am also thankful to bahria university for their coordination. it is further presumed that the journal of imdc will play a significant role in projecting and disseminating research in the years to come. 73 j i m d c 2 0 1 8 73 op e n ac c e ss c a s e r e p o r t rhinophyma causing feeding difficultya rare case report with review of literature ghulam saqulain 1, jawwad ahmed 2, zeba ahmed 3 1 head of department of ent, capital hospital, islamabad, pakistan 2 associate surgeon ent department, capital hospital, islamabad, pakistan 3 associate professor, ent department, civil hospital, karachi, pakistan a b s t r a c t rhinophyma is a rare chronic progressive disease of phymatous type of rosacea and commonly affects males in their fifth to seventh decades. diagnosis is based on clinical features. it commonly results in cosmetic deformities; however rarely functional issues have been reported like nasal obstruction and feeding difficulty. medical treatment is usually ineffective in reducing the size of rhinophyma and moderate and severe cases of rhinophyma give reasonably good results to surgical intervention using different modalities. we report a rare case of rhinophyma in a 72-year-male with an unusual presentation of a large rhinophyma with a long hanging tumorous tip presenting with functional issues including partial nasal obstruction and feeding difficulty especially liquids from a cup of glass for which he was adamant to get it operated. tumor was successfully removed with electrosurgical knife combined with excision and primary repair of nodular growth at the lower end to the satisfaction of the patient. this case highlights that rhinophyma can rarely enlarge in a way that it can result in feeding difficulty posing a challenge in management. the relevant literature is discussed. key words: acne, feeding difficulty, phymatous rosacea, rhinophyma address of correspondence ghulam saqulain email: ghulam_saqulain@yahoo.com article info. received: december 24, 2017 accepted: january 12, 2018 cite this case report: saqulain g, ahmed j, ahmed z. rhinophyma causing feeding difficultya rare case report with review literature. 2018; 7(1)73-77 funding source: nil conflict of interest: nil i n t r o d u c t i o n rhinophyma is a greek word (rhis: nose, phyma: growth) first coined by von hebra in 1856.1 it is a chronic progressive disease, a manifestation of phymatous subtype of acne rosacea.2 though rosacea shows a near equal gender distribution, however rhinophyma is more common in caucasian males, in their fifth to seventh decades of life.3 diagnosis is based on clinical findings using rhinophyma severity index score (rhisi).4 this subtype of acne rosacea initially shows swelling and prominence of follicular pores with patulous follicles however, in advanced cases there is skin thickening along with hyperemia and irregular nodularities, representing hypertrophy of sebaceous gland and finally distortion of shape of the nose occurs.5 the exact pathogenesis of rhinophyma and rosacea is still uncertain. medical treatment is usually ineffective in reducing the size of rhinophyma and reasonably good results are obtained from surgical excision, electro-cautery excision, cryo-excision and laser therapy in moderate and severe cases.6,7 we, present an unusual rare case of large rhinophyma in a 72-year-old male with a number of co morbidities and having functional issues specially feeding difficulty causing embarrassment, for which patient demanded surgical intervention. literature review reveals only a few cases of rhinophyma resulting in functional issues.8,9 the objective of this case report is to highlight c a s e r e p o r t 74 j i m d c 2 0 1 8 74 the fact that deformities caused by rhinophyma may result in functional issues like breathing and feeding difficulties as well as embarrassment due to feeding difficulties. reduction of tumorous growth is the treatment of choice in such cases, which may be accomplished with surgical, electrocautery and other modalities or a combination of the modalities. c a s e r e p o r t s a 72-year-old male, a known case rhinophyma with diabetes mellitus, hypertension and reduced renal function, presented to the otolaryngology outpatient with recurrence of rhinophyma following electrocautery excision 5 years back. he reported painless slowly growing swelling on the nose so much so that now the nose appeared grossly enlarged with a long hanging tumorous tip. for the last six months’ patient had started having functional issues with slight difficulty breathing and difficulty taking food especially difficulty to drink liquids from a cup of glass. this caused him alot of embarrassment due to the fact, which his nose would always dip into the liquid food while drinking and made the patient sought surgical intervention. his personal history was insignificant except that he was a smoker taking 2-3 packs a day for the last 40 years. examination revealed a grossly enlarged nose especially the lower part and the nasal tip reaching up to the margin of the upper lip revealing nodular surface and growth with soft lobulated skin colored nodules with some overlying dilated pores encompassing the entire lower part of nose especially tip and right nasal ala compressing the right nares (figure 1). figure 1: preoperative photographs showing a) lateral view b) inferior view and c) anterior view the left nasal ala was not much affected. on examination of the remainder of his face, his bilateral cheeks showed sebaceous skin with multiple scattered dilated pores and open comedones. no palpable lymphadenopathy was found. systemic examination also revealed a blood pressure of 190/100 mm hg. laboratory analysis revealed a blood sugar ranging from 200 to 400 mg/dl with a blood urea level of 40 to 60 mg/dl and creatinine 1.8 to 2.5 mg/dl. with the difficulty in taking food, the patient was adamant to get himself operated. due to age and with comorbidities like diabetes mellitus, hypertension, renal issues, patient was a high-risk case for general anesthesia being asa iii, therefore he was offered surgery under local anesthesia. keeping in view the increased nasal tip length the nasal tumor was removed with electrosurgical knife combined with excision and primary repair of nodular growth at the lower end, including nasal tip without the need of grafting. this resulted in patient’s satisfaction with good post-operative evolution and re-epithelialization in 2 weeks with reasonable cosmetic and functional outcome, given the patient's age, and associated comorbidities (figure 2). the patient was later referred to dermatologist for medical treatment to prevent recurrence. figure 2: post-operative clinical photograph showing a) lateral view 3 days’ post op, b) inferior view and c) 10 days’ post op. d i s c u s s i o n although prevalence of rosacea is estimated to range from 1% to 20%, it is highly prevalent in germany (12.3%) and less prevalent in russia (5%).10 the phymatous type is quite uncommon.11 according to sibenge and 75 j i m d c 2 0 1 8 75 gawkrodger, 14% cases of rosacea suffer from rhinophyma.3 rhinophyma is the most prevalent presentation of the type 3 rosacea (phymatous rosacea), others being gnathophyma, metophyma, otophyma and blepharophyma.12 rhinophyma is graded according to its severity. grade 1 (mild) shows slight puffiness and patulous follicles, while grade 2 (moderate) shows bulbous nasal swelling, moderately dilated patulous follicles with mild hypertrophy of glands or connective tissue and change in nasal contour. grade 3 (severe variety) is characterized by marked nasal swelling, large dilated follicles, distortion of nasal contour due to hypertrophy and presence of nodular component and usually causes disfiguration of the nose.12 accordingly, our case was grade 3 severe varieties, which also resulted in increased length of the nasal tip that almost reached the upper lip margin. severity of rhinophyma doesn’t seem to be related to the duration of disease and other factors may be involved.13 like rosacea, the pathogenesis of its phymatous stage is also obscure with a number of factors proposed 3. in severe cases of rhinophyma, the fibroplasia may block the lymphatic drainage leading to persistence of edema resulting in destruction of skin adnexal structures and production of glycosaminoglycans and collagen resulting in further fibrosis.13 rosacea including rhinophyma is usually diagnosed on clinical grounds using rhinophyma severity index score (rhisi).4 however, to rule out other causes, biopsy is warranted especially with rapid growth, ulceration, discharge and unilateral changes.5,14 it may be helpful in distinguishing atypical rhinophyma from conditions like lupus, malignancies like basal cell carcinoma, squamous cell carcinoma, lymphoma, angiosarcoma and even sebaceous carcinoma.15,16. bandyopadhyay et al, diagnosed a case of cutaneous leishmaniasis presenting as rhinophyma using needle sampling technique.17 usually seen histopathological findings include hyperplasia of sebaceous glands, abundance of sebum with dilatation of sebaceous ducts and dermal thickening with fibromatous changes. however according to schuurman et al 4, histopathological features do not correlate with clinical expression of rhinophyma. in contrast to rosacea where medical treatment is the treatment of choice including tetracycline and metronidazole,14,18 surgeries is the gold standard for reduction of rhinophyma.7 a number of options give fairly good results including surgical excision, electro-cautery excision, carbon dioxide (co2) laser 6,19 and diode laser 8. excision and grafting has also been used for advanced rhinophyma especially with maximum rhisi score 20,21. high pre-operative rhisi score has been reported to be a risk factor for recurrence.4 according to bogetti et al, scalpel in association with electrocautery along with local infiltration of diluted epinephrine was the safest method to save gland (sebaceous) fundi allowing scar free epithelialization.22 this method was safely and effectively used in our case along with excision of part of rhinophyma and primary repair. even cases of rhinophyma with suspicious giant nodules may be treated with surgical excision taking safety margin especially in cases where benign or malignant nature of the tumor is not known.20 shave excision of rhinophyma under tumescent anesthesia control has also been reported to have high patient satisfaction.23 hassanein et al used a new novel subunit excisional approach to correct the severely deformed rhinophymatous nose.24 recently ozkan et al, have advocated a new approach in which total deep excision of rhinophymatous tissue is done in a single session using plasma blade and covered with acellular dermal matrix for substitution of dermal tissue and split thickness skin grafting in single session preventing recurrence.25 kahn et al used excisional debulking and electrosurgery.26 yildiz et al has reported good results with versajet hydrosurgery system and autologous cell suspension with less complications and good wound healing.27 faris et al reported very good results with use of powered microdebrider.28 the peculiarity of the present case represented is that, it was large rhinophyma resulting in functional issues of partial obstruction of right nostril and the nasal tip length was such that the patient sought surgical intervention as he had difficulty in taking liquids with a glass or cup as his nasal tip would dip into liquid and caused him alot of embarrassment. following electrosurgical treatment combined with excision and primary repair of nodular growth at the lower end including nasal tip without the need of grafting resulted in good evolution and very short time of spontaneous epithelization, given the patient's age, and associated comorbidities. 76 j i m d c 2 0 1 8 76 c o n c l u s i o n rhinophyma needs surgical intervention mostly for aesthetic reasons, but definitely required for rare cases with functional issues like nasal obstruction or feeding issues. excision of tumorous growth of nose and reduction using electrocautery can result in good functional outcome with primary wound healing and spontaneous epithelialization. r e f e r e n c e s 1. oswal v, remacle m, jovamvic s. principles and practice of lasers in otorhinolaryngology and head & neck surgery – 2nd ed. kugler publications, amsterdam. 2014: 467-74. 2. crawford gh, pelle mt, james wd. rosacea: i. etiology, pathogenesis, and subtype classification. j am acad dermatol 2004; 51(3):327-41. 3. sibenge s, gawkrodger dj. rosacea: a study of clinical patterns, blood flow, and the role of demodex folliculorum. j am acad dermatol. 1992;26(4):590-3. 4. schüürmann m, wetzig t, wickenhauser c, ziepert m, kreuz m, ziemer m. histopathology of rhinophyma a clinical-histopathologic correlation. j cutan pathol. 2015;42(8):527-35. 5. powell fc, raghallaigh sn. rosacea and related disorders. in: bolognia jl, schaffer jv, jorizzo jl. dermatology. 3rd ed: elsevier saunders; 2012:561-70 6. el-azhary ra, roenigk rk, wang td. spectrum of results after treatment of rhinophyma with the carbon dioxide laser. mayo clin proc. 1991;66(9):899-905. 7. elliott jr, r.a., hoehn, j.g. and stayman iii, j.w. rhinophyma: surgical refinements. ann plast surg. 1978;1(3):298-301. 8. gubitosi a, ruggiero r, docimo g, esposito a, esposito e, villaccio g,et al.treating rhinophyma: a case report illustrating decortication/vaporization with an 808-nm diode laser. photon lasers med. 2012: 1(1): 51–55 9. lomeo pe, mcdonald je, finneman j. obstructing rhinophyma: a case report. otolaryngol head neck surg. 2005;133(5):799-800. 10. tan j, schöfer h, araviiskaia e, audibert f, kerrouche n, berg m et al. prevalence of rosacea in the general population of germany and russia – the rise study. j eur acad dermatol venereol. 2016; 30(3): 428–34. 11. tan j, berg m. rosacea: current state of epidemiology. j am acad dermatol. 2013;69(6):s2735. 12. f. c. powell “clinical practice. rosacea,” n engl j med.2005; 352(8):793–803. 13. aloi f, tomasini c, soro e, pippione m. the clinicopathologic spectrum of rhinophyma. j am acad dermatol. 2000;42(3):468-72 14. tüzün y, wolf r, kutlubay z, karakuş o, engin b. rosacea and rhinophyma. clin dermatol. 2014; 32(1):35-46 15. murphy a, o’keane jc, blayney a, powell fc. cutaneous presentation of nasal lymphoma: a report of two cases. j am acad dermatol. 1998;38(2):310-3. 16. kavoussi h, ramazani m, ebrahimi a. case report nasal deformity accompanying upper lip sebaceous carcinoma without neoplasm extension. journal of pakistan association dermatologists. 2012;22(1):7072. 17. bandyopadhyay a, bose k. a rare case of cutaneous leishmaniasis presenting as rhinophyma. iran j pathol. 2015;10(2):155-9. 18. nasir ma. treatment of rosacea with tetracycline and metronidazole-a comparative study. jpma. 1985; 35(5):148-49. 19. kraeva e, ho d, jagdeo j. successful treatment of rhinophyma with fractionated carbon dioxide (co2) laser in an african-american man: case report and review of literature of fractionated co2 laser treatment of rhinophyma. j drugs dermatol. 2016;15(11):1465-68. 20. al-falah, k., jecan, c.r., lascăr, i., marcu, i.g., mirea, l.e., neagu, t.p., & ţigliş, m. a curious case of rhinophyma in a 73-year-old patient. modern medicine. 2017; 24(2):111-15 21. malone ch, decrescenzo aj, subrt ap, wagner rf. rhinophyma graft for repair of the phymatous nasal ala. j am acad dermatol. 2017;76(4):e123. 22. bogetti p, boltri m, spagnoli g, dolcet m. surgical treatment of rhinophyma: a comparison of techniques. aesthetic plast surg. 2002;26(1):57-60. 23. wetzig t, averbeck m, simon jc, kendler m. new rhinophyma severity index and mid-term results following shave excision of rhinophyma. dermatology. 2013;227(1):31-6. 24. hassanein, aladdin h. et al. the subunit method: a novel excisional approach for rhinophyma. j am acad dermatol. 2016;74(6):1276 – 78. 77 j i m d c 2 0 1 8 77 25. özkan a, topkara a, özcan rh, şentürk s.the use of the plasmablade and acellular dermal matrix in rhinophyma surgery: a case report. j cutan med surg. 2016;20(2):155-8 26. kahn sl1, podjasek jo, dimitropoulos va, brown cw. excisional debulking and electrosurgery of otophyma and rhinophyma. dermatol surg. 2016;42(1):137-9. 27. yıldız k, kayan br, dulgeroglu t, guneren e. treatment of rhinophyma with the versajet™ hydrosurgery system and autologous cell suspension (recell®): a case report. j cosmet laser ther. 2017;5 :1-3. 28. c. faris, j. g. manjaly, h. ismail-koch, and s. caldera, “rapid treatment of rhinophyma with powered microdebrider,” case reports in otolaryngology. 2013; article id 621639. j islamabad med dental coll 2023 64 open access multiple inflammatory fibroid polyps in a female; a case report ayesha iftikhar1, usman hassan2, hina maqbool3, mudassar hussain4, sheeba ishtiaq5 1resident histopathology, shaukat khanum memorial cancer hospital and research centre, pakistan 2,4consultant histopathology, shaukat khanum memorial cancer hospital and research centre, pakistan 3senior instructor, shaukat khanum memorial cancer hospital and research centre, pakistan 5consultant histopathology, gulab devi hospital, pakistan a b s t r a c t cite this article. iftikhar a, hassan u, maqbool h hussain m, ishtiaq s. multiple inflammatory fibroid polyps in a female; a case report. j islamabad med dental coll. 2023; 12(1):64-68 doi: https://doi.org/10.35787/jimdc.v12i1.973 funding source: nil conflict of interest: nil i n t r o d u c t i o n the inflammatory fibroid polyp (ifp) is a benign lesion that arises from submucosa of the gastrointestinal tract most commonly in the antrum (70 %), ileum (20 %) and only occasionally in the duodenum and jejunum.1,2 vanek was the first to describe it as eosinophilic submucosal granuloma followed by helwing who established the term inflammatory fibroid polyp in 1953.3 these polyps occur more commonly in males, and stomach is the favored site followed by ileum, colon and duodenum.1 morphologically, ifp shows spindle cell proliferation with marked eosinophilia and prominent small blood vessels. a characteristic feature is “onion skin” arrangement of spindle cells around blood vessels.5 immunohistochemically ifp shows reactivity for cd34, smooth muscle actin, and cd68 and shows negative expression for cd117, dog1, s100 and cytokeratin.1 the exact etiopathogenesis of ifp is still controversial. an autoimmune etiology superimposed with an environmental trigger, such as local infection stimulating an allergic reaction or an exaggerated host response to unknown stimulus is suggested.5 recent research has shown mutations in exon 12 or 18 and, less frequently, in exon 14 of the inflammatory fibroid polyp (ifp) usually presents as a solitary benign polyp that arises from the submucosa of the gastrointestinal tract. it occurs more commonly in males and stomach is the favored site followed by ileum, colon and duodenum. multiple inflammatory fibroid polyps (ifps) is a rare occurrence, so we thought of presenting a case of a 40 years old female with multiple inflammatory fibroid polyps (ifps). she presented with abdominal pain and abdominal fullness. her c.t. abdomen showed multiple lobulated soft tissue masses causing intussusception. surgical resection was done, and histopathological examination of these polyps showed features of ifps. a literature review of 9 cases (including ours) between 2000-2022 is also presented. to our knowledge this is the third female patient with multiple ifps. c a s e r e p o r t j islamabad med dental coll 2023 65 platelet derived growth factor receptor alpha gene indicating a possible neoplastic etiopathogenesis of the lesion.3 there are numerous case reports of solitary ifp, but there are very few case reports of patients presenting with multiple inflammatory fibroid polyps (ifps).we are presenting our case report of multiple ifps in a female patient with the review of literature. c a s e r e p o r t a 40 years old non-diabetic and non-hypertensive lady presented with complaints of abdominal pain, vomiting indigestion, anorexia and abdominal fullness for 15-20 days. x-ray abdomen demonstrated air fluid levels. her abdominal ct scan report showed multiple lobulated soft tissue masses serving as a lead point and causing intussusception. she had a past history of cholecystectomy appendectomy, two caesarean sections and laparotomy for intestinal obstruction. she had a family history of intestinal obstruction in father, grandfather, aunt from father side and sister for which they underwent laparotomy. histopathology report of sister was available in which diagnosis of inflammatory fibroid polyp was given. however, histopathology reports of father, grandfather and aunt from father side are not available. laparotomy was planned for this patient. intraoperative findings included multiple variable sized masses related to bowel along mesentery at various foci. small gut resection was done and resection specimen was sent to us. gross examination of small gut resection specimen revealed, iatrogenically incised bowel specimen. opening of bowel revealed multiple polyps in the lumen ranging in size from 5 to 100 mm. further slicing of these polyps revealed a fleshy cut surface (figure 1 and figure 2). figure 1: small gut resection specimen showing multiple polyps figure 2: cut section of polyp showing fleshy appearance histological examination revealed exuberant, nonencapsulated, submucosal proliferation of mononuclear spindle shaped cells with an inflammatory infiltrate dominated by eosinophils. a network of variably sized blood vessels in background noted. arrangement of spindle shaped cells was concentric giving “onion-skin” like appearance (figure3 and figure 4). to differentiate this lesion from gastrointestinal stroma tumor, cd117 and dog1 were performed which were negative. hence the diagnosis of multiple inflammatory fibroid polyps was made. j islamabad med dental coll 2023 66 figure 3: ifp at 10x showing spindle cell proliferation in a background of inflammation and vascular proliferation figure 4: ifp at 40x showing spindle cells with prominent eosinophils table i: comparison of ifp cases reported during 2000-2022 sr. no. author year/ref sex age clinical presentation family hx no of polyps location 1 m hussain 2008 1 f 30 years small bowel obstruction +ve 3 mid ileum 2 j.fazzio 2015 3 f 70 years nausea, vomiting bloody stool -ve 1 antrum 3 wysocki a.p 2007 4 f 53 years right upper quadrant pain radiating to back -ve 1 duodenum 4 afroditi kourti 2022 5 f 12 months rectal bleeding and polypoidal mass protruding from anus -ve 1 anorectal junction 5 srikantaiah 2015 6 m 46 fever, constipation and abdominal distension -ve 1 distal ileum 6 jun sang bae 2014 7 f 48 abdominal pain -ve 1 ileum 7 yifan md 2022 8 f 41 abdominal pain, distension -ve 3 esophagus, gastric horn, duodenal bulb 8 ki bun park 2022 9 m 23 abdominal pain, squeezing epigastric pain, fever, constipation -ve 1 jejunum 9 iftikhar a et al 2022 f 40 abdominal fullness, anorexia pain +ve multiple ileum j islamabad med dental coll 2023 67 d i s c u s s i o n multiple ifps is a rare entity. its incidence is 0-2 %. ifp was first described in 1920 as “polypoid fibroma”. in 1949, vanek described the term “submucosal granuloma” and described six cases. later it became recognized by different names; eosinophilic granuloma, inflammatory pseudotumor and vanek polyps.3 ifps occur most commonly in stomach followed by small intestine leading to intestinal obstruction with a slight predominance in males.1 ifp lesion causes intussusception which is the main cause of intestinal obstruction, however the sign and symptoms differ according to the site of origin. macroscopically ifps are either sessile or pedunculated, usually solitary and nonencapsulated.4 histologically these lesions are composed of spindle cell proliferation, small blood vessels, inflammatory infiltrate comprising of lymphocytes, plasma cells and predominantly eosinophils and a myxoid edematous stroma. four distinct histological patterns have been described, i.e., classical fibrovascular, nodular, sclerotic, and oedematous.4 differential diagnoses include gastrointestinal stromal tumor, inflammatory myofibroblastic tumor, schwannoma, solitary fibrous tumor and inflammatory pseudotumor.3,4 immnonohistochemically spindle cells of ifps are positive for cd34, vimentin and cyclin d1 (suggesting a defect in cell cycle regulation) hence, concluding proliferating stromal cells are of dendiritic cell origin with myofibroblastic differentiation and negative for smooth muscle markers, neural markers (s100) and gist markers (cd117, dog1).5-7 there are numerous case reports of solitary ifp, but very rare case reports of multiple ifps. our case is reported with multiple ifps. when we reviewed the literature, we found that there are only 2 cases of multiple ifps reported between 2000-2022. the first case reported by m hussain et al in 2008 was of 30year-old female patient who presented with small bowel obstruction.1 she had three polyps in mid ileum with a positive family history. this case differs from our case in that aspect our female patient was ten years older than this patient and more than three polyps were present in ileum. however, our patient had family history of ifp as the patient reported by m hussain et al. second case compared was reported by yifan md in 2022, who reported a case of 41-year-old female who presented with abdominal pain. she had three polyps in esophagus and stomach with negative family history.8 this case differs from our in that aspect, the location of polyps in our case is ileum and a there is a positive family history. other cases reported have solitary ifp with negative family history (table 1) c o n c l u s i o n multiple ifps is a rare entity. as it is a spindle cell lesion, it can be misdiagnosed as other spindle cell lesions like gastrointestinal stromal tumor, inflammatory myofibroblast tumor etc. knowledge of this lesion is therefore important as treatment and prognosis of all these lesions differ from each other. correct diagnosis of inflammatory fibroid polyp is essential to avoid over or undertreatment and better patient outcome. r e f e r e n c e s 1. morales-fuentes ga, de arino-suarez m, zarateosorno a, rodriguez-jerkov j, terrazas-espitia f, perez-manauta j. vanek’s polyp or inflammatory fibroid polyp. case report and review of the literature. cir. 2011;79:242–5, 63–7. 2. vanek j. gastric submucosal granuloma with eosinophilic infiltration. am j pathol. 1949;25:397– 411. 3. fazzio, c. s. j., & madeira, e. b.. (2015). inflammatory fibroid polyp (vanek’s polyp): a case report and literature review. jornal brasileiro de patologia e medicina laboratorial, 51(j. bras. patol. med. lab., 2015 51(2)). https://doi.org/10.5935/16762444.20150021 j islamabad med dental coll 2023 68 4. wysocki a, p, taylor g, windsor j, a: inflammatory fibroid polyps of the duodenum: a review of the literature. dig surg 2007;24:162-168. doi: 10.1159/000102099 5. kourti a, dimopoulou a, zavras n, sakellariou s, palamaris k, kanavaki i, fessatou s. inflammatory fibroid polyp of the anus in a 12-month-old girl: case report and review of the literature. j paediatr child health. 2022 aug;58(8):1313-1316. doi: 10.1111/jpc.16080. epub 2022 jun 21. pmid: 35730111. 6. hiremath s, nanjappa n, kamath s. inflammatory fibroid polyp (ifp) of the terminal ileum presenting as acute intestinal obstruction without intussusception. bmj case rep. 2015 sep 7;2015:bcr2015211029. doi: 10.1136/bcr-2015-211029. pmid: 26347236; pmcid: pmc4567766. 7. bae js, song js, hong sm, moon ws. an unusual presentation of an inflammatory fibroid polyp of the ileum: a case report. oncol lett. 2015 jan;9(1):327329. doi: 10.3892/ol.2014.2674. epub 2014 nov 5. pmid: 25435986; pmcid: pmc4246614. 8. xv y, tao q. a rare case report of recurrent inflammatory fibroid polyp in the ileum. gastroenterol nurs. 2022 nov-dec 01;45(6):454-458. doi: 10.1097/sga.0000000000000667. epub 2022 jul 21. pmid: 35877955. park kb, jee ys, kim dw. laparoscopic resection of two inflammatory fibroid polyps: an unusual cause of jejunojejunal intussusception. int j surg case rep. 2020;69:20-23. doi: 10.1016/j.ijscr.2020.03.029. epub 2020 mar 28. pmid: 32248011; pmcid: pmc7132045. 169 j i m d c 2 0 1 8 169 open access f u l l l e n g t h a r t i c l e comparison of septoplasty with and without nasal packing: its association with post-operative nasal adhesion formation ghafoor shah 1, muhammad junaid 2 , anjum khawar 3 1 consultant, 2 senior registrar, 3 chairperson (department of ent, head & neck surgery, pakistan institute of medical sciences) a b s t r a c t objective: to compare the septoplasty with and without nasal packing in patients having deviated nasal septum in terms of frequency of post-operative nasal adhesion. patients and methods: in this randomized control trial, total 180 patients of deviated nasal septum (dns) associated with persistent nasal obstruction, breathing difficulty, sinonasal infections were enrolled and admitted in the department of ent, head and neck surgery, pakistan institute of medical sciences, islamabad. patients were randomly divided into “group a” (septoplasty with nasal packing) and “group b” (septoplasty without nasal packing) by lottery method. demographic data was recorded. septoplasty was performed under general anaesthesia. nasal splints were applied at the end of procedure. packing was removed postoperatively from „group a‟ patients after 24 hours. development of post-operative nasal adhesion was calculated superlatively for both the groups. data was recorded and analysis was done using spss version 19. chi square test was used to compare the two groups. p value < 0.05 was taken as significant. results: our study comprised 180 patients which were divided into 2 groups equally (n=90 each). patient‟s age ranged from 17– 45 years. mean age was 22.77±6.038. male to female ratio was 2:1. total males were 125 (69.4%) and females were 55 (30.6%). in “group a” 64 (71.1%) were male and 26 (28.9%) were female while in “group b” 61 (67.8 %) were male and 29 (32.2%) were females. septoplasty was done in all 180 patients out of which 125 (64 in group a and 61 in group b) were male whereas 55 (26 in group a and 29 in group b) were female. nasal adhesion was seen in 13 (14.44%) patients of group a, while 3 (3.33%) patients of group b developed the same. p value was 0.005 which is statistically significant. conclusion: septoplasty with nasal packing has more chances to develop nasal adhesion as compared to septoplasty done without packing. key words: septoplasty, nasal packing, nasal adhesion. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence muhammad junaid email: dr_junaid86@yahoo.com article info. received: june 8, 2018 accepted: july 22, 2018 cite this article. shah g, junaid m, khawar a. comparison of septoplasty with and without nasal packing: its association with post-operative nasal adhesion formation. jimdc.2018; 7(3):169-173 funding source: nil conflict of interest: nil i n t r o d u c t i o n deviation of nasal septum is a common problem which can be congenital, developmental, and traumatic. it can be present in any gender and age group, with predominance in males. usually symptoms develop in adults and adolescent age. different types of nasal septal deformities are simple septal deviation, spur formation, with or without external deformity of the nose.1 septoplasty is a common surgical procedure for deviated o r i g i n a l a r t i c l e 170 j i m d c 2 0 1 8 170 nasal septum 2. septoplasty is a conservative method in which correction of the deviated part of nasal septum is accomplished with minimum loss of septal cartilage and possible septal framework is conserved. it is done to resolve obstruction of the nose, caused by deviated nasal septum.3 following septoplasty, nasal packing is routinely done to avoid hemorrhage and septal hematoma. 4 pain and discomfort is a common problem after septoplasty with nasal packing which is increased during removal of the pack. it is reported that nasal packing can also cause nasal and periorbital edema, epiphora, sleep disturbance, dry mouth, allergy, toxic shock syndrome and increase the chances of cardiopulmonary problems e.g. cardiac arrhythmias, apnea, hypoxemia, hypotension.5,7 considerably less portoperative pain, headache, epiphora, dysphagia and sleep disturbance can occour in septoplasty without nasal packing. nasal packing after septoplasty is considered unnecessary. frequency of bleeding after septoplasty without nasal packing is very low. surgery of septoplasty can be safely carried out without postoperative nasal packing.6,8 studies have been done to compare the development of post-operative nasal adhesion in septoplasty with and without packing but showing variability of the results. muhammad sa, mughira i, showed percentage of nasal adhesion in packing group as 6.8% and 0% in nonpacking group 6 and ali maeed s, al-shehri studied that percentage of nasal adhesion in non-packing group was 5.7% and 0% in packing group. 9 while percentage of nasal adhesion was same according to the study of naghibzadeh b et al. 10 according to studies septal hematoma might be prevented by nasal packing, but these results need to be confirmed by studies with larger samples. 10 jason g. et al, identified a total of 279 studies and systematically analyzed 17 meeting the inclusion criteria, to assess the relative rates of septal hematomas, synechiae and septal perforations associated with methods commonly used to manage the nasal septum after septoplasty. they concluded that this review fails to demonstrate a clear benefit among all of the postseptoplasty management techniques.11 due to variability of the results of development of nasal adhesion in the post-operative periods and failure to get clear benefit of the techniques of post-operative septoplasty, we carried out this research to compare septoplasty with and without nasal packing in terms of post-operative nasal adhesion development. p a t i e n t s a n d m e t h o d s this randomized controlled trial was conducted at department of ent, head and neck surgery, pakistan institute of medical sciences, islamabad. patients of both genders and age between 17 – 45 years, with deviated nasal septum (dns) who had persistent nasal obstruction, breathing difficulty and sinonasal infections were included in the study. patients with upper respiratory tract infection, hypertrophied turbinates, requiring second procedure, diabetic, hypertensive and patients with bleeding diathesis, pregnant ladies and those who have previous history of nasal surgery were excluded from the study. a total of 180 patients having dns were enrolled in the study and admitted in the department of ent. patients were randomly divided into “group a” (septoplasty with nasal packing) and “group b” (septoplasty without nasal packing) by lottery method. demographic data was recorded. relevant history was taken. clinical and ent examination was done and findings were noted. baseline investigations and per-operative anesthesia fitness for surgery was done. informed written consent with research inclusion consent was taken from all patients preoperatively. general anesthesia was given to all patients. local anesthesia with 2% lignocaine & 1:200,000 adrenalines was infiltrated submucosally. xylometazoline was sprayed in each nostril, 7 minutes prior to the incision. standard septoplasty was done. nasal splints were applied at the end of procedure. nasal packing was done in “group a” patients with lubricated petroleum based antibiotic ointment and it was avoided in “group b” patients. post operatively patients were nursed in semi sitting position. soft diet was permitted in first post-operative day. analgesics if required, in the form of paracetamol injection, were given slow intravenously during nil per oral (npo) post-operative period and tab paracetamol 1000mg orally after npo break. antibiotics were given postoperatively for 7 days. decongestant nasal spray and nasal douches with normal saline and baking soda was given post operatively to „group a‟ after removal of pack and to „group b‟ 6 hours after surgery. nasal pack was removed in the „group a‟ after 24 hours 171 j i m d c 2 0 1 8 171 postoperatively. nasal splints were removed after 1 week. development of post-operative nasal adhesions were calculated superlatively for both the groups at 30th day (post operatively). the data were recorded in spss version 19. quantitative variable like age was presented by mean and standard deviation. the qualitative variables like gender and post-operative nasal adhesions were expressed by calculating frequencies and percentages. nasal adhesions were compared between the two groups by applying chi-square test. p-value ≤ 0.05 was taken as statistically significant. r e s u l t s among 180 participants, 125 (69.4%) were males and 55 (30.6%) were females. male to female ratio was 2:1. mean age was comparable in both groups. in both groups, male were more as compared to female (table 1). patients of group a developed more nasal adhesions. p-value was statistically significant i.e. 0.005(table 2). d i s c u s s i o n septoplasty is a conservative method in which correction of the deviated part of the nasal septum is accomplished with minimum loss of septal cartilage with conservation of possible septal framework. it is done to resolve obstruction of the nose caused by deviated nasal septum. 3 this prospective, randomized controlled trial study was performed on 180 patients, age ranged between 15 – 45 years with mean age as 22.77 and standard deviation (sd) was 6.038. male to female ratio was 2.27: 1. the sample size of the “group a” was (n) 90, age ranging from 15 – 45 years with mean age as 22.70 and sd was 6.773 while the sample size of the “group b” was also (n) 90, age ranged from 17 – 45 years and the mean age was 22.84 + 5.238, which is comparable with national and international research studies. behroz et al reported the mean age as 22.44 years.12 a research study conducted by ardehali4, he reported the mean age as 24.6 years. another study was published by awan, where the mean age of patients was 27.63 years in packing group and in no packing group the mean age was 25.34 years. 6 ardehali4 in his study published that the male patients were 78 and female were 27 and the male to female ratio was 2.88:1. while awan reported in his study that in the packing group 27 were males and 17 were females and in non-packing group, 30 patients were males and 14 patients were females.6 in another study reported by ardehali the postoperative septal hematoma was not detected in either group. two (3%) patients had septal perforation in the packing group, and 01 (2%) patients in the non-packing group (p=0.56). 04 (7%) patients in the packing group had purulrnt nasal secretion while no secretions were seen in the nonpacking group (p=0.08). in the packing group, 2 (3%) patients had mucosal adhesions, whereas there was only 1 (2%) patient with mucosal adhesion in the non-packing group (p = 0.56). there were 6 (10%) patients with residual deviation in the packing group and 5 (10%) patients with deviation in the non-packing group (p = 0.98). the comparison of postoperative pain and discomfort, revealed that the average vas score was 5 in the packing group and 2.1 in the non-packing group (p = 0.01).3 a study conducted by awan et al reported the adhesion formation. synechiae developed in 8 of the packing patients and none of the no-packing patients (18.2 vs. 0%; p > 0.05).7 the present study showed that 15 patients had nasal adhesions after 4th postoperative week. there were 13 (14.44%) patients in group a and only 2 (2.22) patients were in group b (p = 0.005) which is comparable with other studies. in a study reported by iqbal et al on 200 patients, the complication of septoplasty in which nasal packing was performed routinely; synechiae formed in 14 of these patients (7.0%).13 table 1: demographic characteristics of participants (n=180) variables group a (n=90) group b (n=90) gender male; n(%) 64(71.1) 61(67.8) female; n(%) 26(28.9) 29(32.2) male:female 2.46:1 2.10:1 age mean±sd 22.70±6.77 22.84±5.24 minimum 17 17 maximum 45 45 172 j i m d c 2 0 1 8 172 adhesions can be prevented without packing by careful handling of the septal mucosa, by avoiding manipulation of the turbinates, and by meticulous placement of instruments in the surgical site.14,15 according to ardehali two (3%) patients had septal perforation in the packing group, and 1 (2%) patients in the non-packing group (p = 0.56) postoperatively.4 four (7%) patients in the packing group had infected nasal secretions and there were none in the nonthe postoperative group (p = 0.08). packing group showed, 2 (3%) patients had nasal adhesion, whereas there was only 1 (2%) patient with mucosal adhesion in the non-packing group (p = 0.56). there were 6 (10%) patients with residual dns in the packing group and 5 (10%) patients with deflected septum in the nonpacking group (p = 0.98). the evaluation of postoperative pain and discomfort, showed that the average vas score was 5 in the packing group and in the non-packing group, the score was 2.1(p = 0.01).4 in awan‟s experience, only 3 patients developed nasal adhesions and was drained by incision and drainage method in the packing group (6.8 vs. 0%; p > 0.05)6 siegel et al stated 77% upgrading in rhino logical symptoms following septoplasty,50 and iqbal et al revealed 69% results of septoplasty.16 makitie et al carried a study on 100 patients, he reported that septoplasty has 88% fruitful results in nasal block and also there is an improvement in dismissing nasal discharge, sneezing, recurrent headache and chronic rhinosinusitic.17 the septoplasty is a successful surgery to eradicate the bad symptoms of dns. these symptoms are also seen in patients with a straight septum and equally, deviated septa without symptoms is also a joint finding. bitzer et al, done septoplasty in 334 patients, in his study, he expressed the complete resolution of the symptoms in 10.6% while 45.2% were satisfied with the outcome, 36.5% were partly satisfied and 19.2% were dissatisfied.18 baumann et al, carried out research ten years after septoplasty, he expressed 84% of satisfaction. literature shows satisfaction of the patients range from 70.5% to 86%. jessen revealed 74% at nine months post operative septoplasty and 69% were satisfied after nine years of septoplasty, while the percentage of patients reporting to be free of nasal obstruction was from 51% to 26%.19,20 considerably less postoperative pain, headache, epiphora, dysphagia, and sleep disturbance can occur in septoplasty without nasal packing. nasal packing after septoplasty is considered unnecessary. frequency of bleeding after septoplasty without nasal packing is very low. surgery of septoplasty can be safely carried out without postoperative nasal packing.6,8 c o n c l u s i o n frequency of nasal adhesion is statistically significant in packing group. septoplasty with nasal packing is unnecessary and is a cause of patient‟s discomfort. septoplasty can be safely performed without nasal packing. nasal packing should be reserved only for those who excessively bleed after the surgery or present with unreasonable bleeding or septal hematoma. more studies are recommended to generalize the results. r e f e r e n c e s 1. gandomi b, bayat a, kazemei t. outcome of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study. am j otolaryngol. 2010; 31(3):189-92. 2. walikar bn, rashinkar sm, watwe mv, fathima a, kakkeri a. a comparative study of septoplasty with or without nasal packing. indian j otolaryngol head neck surg. 2011;63(3): 247–8. 3. fettman n, sanford t, sindwani r. surgical management of the deviated septum: techniques in septoplasty. otolaryngo clin of north am. 2009; 42(2):241-52. 4. ardehali mm, bastaninejad s. use of nasal packs and intranasal splints following septoplasty. int j oral maxillofac surg. 2009; 38(10):1022-4. 5. muluk nb, apan a, özçakır s, arıkan ok, koç c. risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery. auris nasus larynx. 2008; 35(4):521-6. 6. awan ms, iqbal m. nasal packing after septoplasty: a randomized comparison of packing versus no packing in 88 patients. ear nose throat j. 2008;87(11):624-7. table 2: post-operative nasal adhesions at 30th day between both groups (n = 180) variable group a (n=90) group b (n=90) p-value post-operative nasal adhesions no. of patients percentage no. of patients percentage 0.005 13 14.44 3 3.33 173 j i m d c 2 0 1 8 173 7. bajaj y, kanatas an, carr s, sethi n, kelly g. is nasal packing really required after septoplasty? int j clin pract. 2009; 63(5):757-9. 8. hafeez m, ullah i, iqbal k, ullah z. septoplasty without nasal packing. gomal j med sci. 2010;8(2):141-2 9. ali maeed s, al-shehri. assessment of complications of nasal packing after septoplasty. med j cairo univ. 2011; 79(2):111-3. 10. naghibzadeh b, peyvandi aa, naghibzadeh g. does post septoplasty nasal packing reduce complications? acta med iran. 2011;49(1):9-12 11. quinn jg, bonaparte jp, kilty sj. postoperative management in the prevention of complications after septoplasty: a systematic review.laryngoscope. 2013;123(6):1328-33 12. aronson nl, vining em. correction of the deviated septum: from ancient egypt to the endoscopic era. int forum allergy rhinol. 2014;4(11):931-6. 13. fettman n, sanford t, sindwani r. surgical management of the deviated septum: techniques in septoplasty. otolaryngol clin north am. 2009;(2):241-52 14. muhammad ia, nabil-ur rahman. complications of the surgery for deviated nasal septum. j coll physicians surg pak. 2003;13(10):565-8 15. pirsig w. septum deviation 1882: beginning of systematic submucous septum surgery. laryngol rhinol otol (stuttg). 1982;61(10):547-51. 16. wexler mr. surgical repair of the caudal end of the septum. laryngoscope. 1977;87(3):304-9. 17. rudert h. killian's submucous septum resection and cottle's septoplasty to modern plastic septum correction and functional septo-rhinoplasty. hno. 1984;32(6):230 3. 18. zoumalan ra, morris lg, zeitler dm, shah ar. effects of various submucous resection techniques of septal cartilage on nasal tip projection. int forum allergy rhinol. 2011;1(1):78-82. 19. tasman aj. rhinoplasty – indications and techniques. gms curr top otorhinolaryngol head neck surg. 2007; 6. 20. gubisch w. twenty-five years‟ experience with extracorporeal septoplasty. facial plast surg. 2006 ;22(4):230-9. http://www.ncbi.nlm.nih.gov/pubmed?term=quinn%20jg%5bauthor%5d&cauthor=true&cauthor_uid=23625653 http://www.ncbi.nlm.nih.gov/pubmed?term=bonaparte%20jp%5bauthor%5d&cauthor=true&cauthor_uid=23625653 http://www.ncbi.nlm.nih.gov/pubmed?term=kilty%20sj%5bauthor%5d&cauthor=true&cauthor_uid=23625653 http://www.ncbi.nlm.nih.gov/pubmed/23625653 108 j i m d c 2 0 1 8 108 open access f u l l l e n g t h a r t i c l e validity and accuracy of fnac in the diagnosis of pleomorphic adenoma of salivary gland: a clinico-pathological study jawwad ahmed 1, ghulam saqulain 2 1 associate surgeon ent department, capital hospital, cda, islamabad, pakistan 2 head of department of ent, capital hospital, islamabad, pakistan a b s t r a c t objective: the first objective of the study was to analyze frequency of pleomorphic adenoma with reference to site involvement (i.e., parotid, submandibular, sublingual and minor salivary glands). second objective was to determine sensitivity and specificity of fine needle aspiration cytology (fnac) for diagnosis of pleomorphic adenoma considering histopathology report as gold standard patients and methods: this cross sectional study of pleomorphic adenoma of salivary glands was conducted at the department of otolaryngology, capital hospital, islamabad over a period of 5 years from may 1st, 2007 to april 30th 2012. this study included 50 diagnosed cases of pleomorphic adenoma, of either gender above 30 years of age. cases who had already received treatment and those in which histopathology reports were not available were excluded from the study. clinical data included parameters like age and sex distribution, site/ gland involvement, fnac and histopathology reports were collected. data was tabulated and analyzed using microsoft excel worksheet. qualitative data was presented by frequency and percentage and quantitative was calculated as mean + sd. variables specially studied included frequency of site involvement, and sensitivity and specificity of fnac. results: this study included a total of 50 patients, out of which 20 (40%) were males and 30 (60%) were females with a male female ratio of 1:1.5. age range was 30 to 50 years with mean age of 37.92 + 6.26 years. sites involved were, parotid in 24 (48%) patients, submandibular in 12 (24%) patients, and minor salivary glands in 14 patients (28%). fnac done for diagnosis, had a sensitivity and specificity of 87.5% and 40% respectively with an accuracy rate of 78%. conclusion: fnac is highly sensitive for the diagnosis of pleomorphic adenoma and should be performed in all such cases without undermining the importance of imaging studies. key words: fine needle aspiration cytology, pleomorphic adenoma, salivary glands author`s contribution 1,2conception, synthesis, planning of research and manuscript writing interpretation and discussion data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence ghulam saqulain email: ghulam_saqulain@yahoo.com article info. received: october 17, 2017 accepted: january 6, 2017 cite this article. ahmed j, saqulain g. validity and accuracy of fnac in the diagnosis of pleomorphic adenoma of salivary gland: a clinico-pathological study. jimdc.2018; 7(2):107111 funding source: nil conflict of interest: nil i n t r o d u c t i o n among the head and neck malignancies, salivary gland tumors account for around 3-6 %.1 it is commonly seen in fifth and sixth decades in both genders.2 pleomorphic adenoma (pa) being the commonest benign salivary gland tumour,3,4 is characterized by long quiescent periods with short growth spurts and has a clinically benign course.5 it is a morphologically complex tumor having both epithelial and myoepithelial elements in mucopolysaccharide stroma and has a false capsule. fnac based pre-operative diagnosis improves surgical outcome.6 it is best treated by parotidectomy, since enucleation has a high recurrence rate. the commonest o r i g i n a l a r t i c l e 109 j i m d c 2 0 1 8 109 site of involvement is usually the parotid gland followed by submandibular gland.4,7 pleomorphic adenomas may rarely become malignant after several years of growth. the purpose of the study was to analyze pleomorphic adenoma of salivary glands in our setup with reference to age and sex distribution, frequency of site involvement (i.e., parotid, submandibular, sublingual and minor salivary glands) and sensitivity and specificity of fnac for diagnosis of the condition. this study will contribute to local data and by comparing it with international data, it will help the clinicians in early detection leading to a better outcome. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted at department of otorhinolaryngology, capital hospital islamabad from 1st may 2007 to 30th april 2012. both male and female patients, more than 30 years of age with pleomorphic adenoma were included in the study. patients who had already received treatment and those who did not have histopathology reports were excluded from the study. medical record charts of these patients were reviewed to obtain history and other clinical data. parameters specially noted were age and sex of patients, site/ gland involved, fnac and histopathology reports. data were collected, tabulated and analyzed using microsoft excel worksheet. gender was presented by frequency and percentage. age of presentation was mentioned by mean + sd. area of involvement (i.e., parotid, submandibular, sublingual or minor salivary gland) was represented by frequency and percentage. results of fnac and histopathology were presented by frequency and were cross tabulated. sensitivity and specificity of fnac keeping histopathology as gold standard were calculated. following formulas were used to calculate accuracy, sensitivity, specificity, and likelihood of positive and negative test results. accuracy= true positive (tp) + true negative (tn)/ tp+ tn+ false positive (fp)+ false negative (fn) sensitivity= tp/tp+fn; specificity= tn/tn+fp; positive predictive value= tp/tp+fp × 100 negative predictive value=tn/tn+fn × 100 likelihood of positive test result = sensitivity/1specificity likelihood of negative test result=1sensitivity/specificity. r e s u l t s out of total 50 cases of pleomorphic adenoma, there were 20(40%) males and 30 (60%) females. male to female ration was m:f= 1:1.5. their age ranged from 30 to 50 years with mean age of 37.92 + 6.26 years. (table 1) illustrates the frequency distribution of site involvement, where parotid gland is on the top of the list. histologic evaluation with fnac and post-operative histopathologic confirmation was done in all patients. (table 2) shows cross tabulation of fnac and post-operative histopathology test results. histopathological result reveal nests and tubules of epithelial and myoepithelial cells with chondromyxoid (figure1). table 1: sites of origin of pleomorphic adenoma (n=50) s. no site involvement number of cases (n) percentages (%) 1 parotid gland 24 48 2 submandibular gland 12 24 3 sublingual 0 0 4 minor salivary glands 14 28 table 2: cross tabulation of histopathology and fnac results histopathology result n(50) positive negative total fnac result positive 35 6 41 negative 5 4 9 total 40 10 50 table 3: evaluation of fnac results test percentage (%) sensitivity 87.5 specificity 40 likelihood of positive test result 2.24 likelihood of negative test result 2.16 positive predictive value (ppv) 85.36 negative predictive value (npv) 44.44 accuracy 78 110 j i m d c 2 0 1 8 110 statistical analysis showed that fnac had a high sensitivity along with medium specificity (table 3). figure1: micrograph revealing nests and tubules of epithelial and myoepithelial cells with chondromyxoid background. (h&e: 100x) d i s c u s s i o n among head and neck neoplasms, salivary glands tumours are the most heterogeneous pathologies. they constitute around 3% of head and neck tumours, 60 to 90% being benign and pleomorphic adenoma being the commonest.8-11 arshad ar et al, in a twelve-year study of 97 cases of parotid tumours reported 75% as benign of which 80% were pleomorphic adenomas.12 out of 50 patients of pleomorphic adenoma, included in this study female preponderance was seen with 20 males (40%) and 30 females (60%), with a male to female ratio of 1: 1.5.similarly most studies report female preponderance with slight variation with a male-to-female ratio of 1:1.1 by zaman et al,8 1: 1.3 by memon et al,11 1: 1.8 by bobati et al.10 in contrast some studies show male preponderance.1,13 the age of presentation in our study varied between 30 to 50 years with mean age of 37.92 + sd 6.26 years which is in conformity to most studies like gill et al, reported median age of 34 years,13 luksic et al, 50 years14 and bouaity et al, 44 years.7 pleomorphic adenomas usually have a unilateral presentation, however, rarely may be seen bilaterally.15 however, no case of bilateral pleomorphic adenoma was noted in our study. the commonest site of involvement is usually the parotid,4,8,13,14,16 followed by submandibular glands 4 with minor salivary gland, reported as second commonest site by some.8,14 in this study parotid gland was most common gland involved in 48% (24 patients) followed by minor salivary glands of palate in 28% (14 patients) and submandibular gland 24%(12 patients) including a rare case of pleomorphic adenoma of minor salivary tissue in the par pharyngeal space. a similar picture is reported by lusic et al,14 gbotolorun also reported palate as the commonest site of minor salivary benign tumour,17 though other sites are also reported.18 also in a local study done over 8-year period, including 379 cases, parotid was the commonest site (82.85%) and five cases of minor salivary gland tumours were reported.13 computed tomography scanning is the gold standard imaging for determination of site, size, shape, extent, margins and relationship to neighboring structures19, however, according to bouaity et al, mri is methodology of choice for assessment of benignity and malignancy.7 in spite of available imaging techniques, the diagnosis of pleomorphic adenoma requires histologic confirmation. fnac is simple and cheap tool to diagnose pleomorphic adenoma. a study carried out by abid et al recommends that fnac is a reliable procedure for initial evaluation in benign lesions with specificity of 83.33%.20 fnac under ultrasound guidance is also recommended by the specialty associations involved in head and neck cancer patients in uk.2 in this study the statistical analysis showed that sensitivity and specificity of fnac was 87.5% and 40% respectively. the ppv was 85% and npv was 44% with accuracy rate of 78%. in a study by piccioni et al, comprising 176 cases, the sensitivity and specificity of fnac was even higher than our study i.e., 81% and 99% and ppv and npv were 93% and 98% respectively with accuracy rate of 83%.6 mamoon n et al in their study concluded that cystic changes in malignancy and overlapping cytological features of some tumours can cause misdiagnosis on fnac.22 different authors have worked on fnac on individual glands as well. ali et al, in their study on parotid lesions compared preoperative fnac with final histopathology and found correlation of results in 86% and concluded that fnac was quite accurate in differentiating of benign from malignant parotid lesions.23 similarly, lee et al, in their study found the diagnostic accuracy of fnac in pleomorphic adenoma of submandibular gland, diagnosed pleomorphic adenoma in 25 of the 29 cases with 85.7% sensitivity and accuracy of 82.8% and recommended fnac as initial evaluation 111 j i m d c 2 0 1 8 111 investigation for submandibular masses.24 gahine et al, have advocated repeated aspirations with multipole sampling from different parts of the lesion so as to avoid misdiagnosis, and recommend a diagnostic approach in which presence of 3-dimensional cohesive clusters of ductal cells, background plasmacytoid myoepithelial cells and dense fibrillary brightly metachromatic stroma with partially obscured entrapped myoepithelial cells is necessary.25 however, imaging studies have their own importance with mri being imaging study of choice for masses with suspicion of malignancy.26 c o n c l u s i o n in our setup, pleomorphic adenoma is more common in females. the commonest site being parotid. in all such cases presenting with non-inflammatory swellings of the area, pleomorphic adenoma should also be considered in the differential diagnosis. fnac is highly sensitive for the diagnosis of pleomorphic adenoma and should be performed in all such cases without undermining the importance of imaging studies. r e f e r e n c e s 1. guzzo m, locati ld, prott fj, gatta g, mcgurk m, licitra l. major and minor salivary gland tumors. crit rev oncol hematol. 2010;74(2):134-38. 2. rice dh. malignant salivary gland neoplasms. otolaryngol clin north am.1999;32(5): 875 – 86 3. fonseca fp, carvalho mde v, de almeida op, rangel al, takizawa mc, bueno ag, et al. clinicopathologic analysis of 493 cases of salivary gland tumors in a southern brazilian population. oral surg oral med oral pathol oral radiol. 2012;114(2):230-39. 4. laishram rs, kumar ka, pukhrambam gd, laishram s, debnath k. pattern of salivary gland tumors in manipur, india: a 10 year study. south asian j cancer. 2013;2(4):250-53. 5. watkinson j c,gaze m n,wilson j a. stell and maran head and neck surgery.4th ed.oxford:butterworth heinemann;2000 : 44158. 6. piccioni lo, fabiano b, gemma m, sarandria d, bussi m. fine-needle aspiration cytology in the diagnosis of parotid lesions. acta otorhinolaryngol ital. 2011; 31(1): 1–4. 7. bouaity b, darouassi y, chihani m, touati mm, ammar h. predictors of malignancy in the management of parotid tumors: about 76 cases. pan afr med j. 2016; 23:112. 8. zaman s, majid s, chugtai o, hussain m, nasir m. salivary gland tumours: a review of 91 cases. j ayub med coll. 2014;26(3):361-63. 9. dzaman k, pietniczka-załęska m, piskadło-zborowska k, siek m, zebrowska j. parotid gland tumours in the ent department in międzyleski hospital in warsaw between 2007 and 2014. otolaryngol pol. 2016;70(1):34-40. 10. bobati ss, patil bv, dombale vd. histopathological study of salivary gland tumors. j oral maxillofac pathol. 2017;21(1):46-50. 11. memon a r. pattern of malignant tumours seen at dow medical college and civil hospital karachi during 1987 to 1996. pak j med sci.2000;16;129-34. 12. arshad ar. parotid swellings. report of 110 consecutive cases.med j malaysia, 1998;53:417-22. 13. gill ms, muzaffar s, soomro in, kayani n, hussainy as, pervez s, et al. morphological pattern of salivary gland tumours. j pak med assoc.2001;51(10):343-46 14. luksic i, virag m, manojlovic s, macan d. salivary gland tumours: 25 years of experience from a single institution in croatia. j craniomaxillofac surg. 2012;40(3):75-81. 15. yu gy, ma dq, zhang y, peng x, cai zg, gao y, et al. multiple primary tumours of the parotid gland. int j oral maxillofac surg. 2004;33(6):531-34. 16. eneroth cm, blanck c, jakobsson pa. carcinoma in pleomorphic adenoma of the parotid gland. acta otolaryngologica. 1968; 66(1-6):477-92. 17. gbotolorun om, arotiba gt, effiom oa, omitola og. minor salivary gland tumours in a nigerian hospital: a retrospective review of 146 cases. odontostomatol trop. 2008; 31(123):17-23. 18. vaughan ed. management of malignant salivary gland tumours. hosp med.2001; 62:400-5. 19. shaheen oh. tumours of the infratemporal fossa and parapharyngeal space. in: hibbert j, kerr ag. scott-brown’s otolaryngology. 6th ed. oxford: butterworth heinemann; 1997; 1-19. 20. abid kj, iqbal j.role of fnac in parotid tumours. ann k e med coll. 2000; 6(4): 351-3. 21. sood s, mcgurk m, vaz f.management of salivary gland tumours: united kingdom national multidisciplinary guidelines j laryngol otol. 2016; 130(suppl 2): s142–s49 22. mamoon n, amin nk, mushtaq s.fine needle aspiration of salivary gland lesions. pakistan pathol, 1998; 9: 25-8. 23. ali ns, akhtar s, junaid m, awan s, aftab k. diagnostic accuracy of fine needle aspiration cytology in parotid lesions. isrn surgery. 2011; 2011:721525. doi:10.5402/2011/721525. 24. lee dh, yoon tm, lee jk, lim sc. diagnostic accuracy of fine needle aspiration cytology in pleomorphic adenoma of submandibular gland. austin j otolaryngol. 2015;2 (2): 1031. 25. gahine r, sudarshan v, hussain n, krishnani c. pleomorphic adenoma: a diagnostic pitfall in the diagnosis of salivary gland lesions on fnac: case reports with review of the literature. cyto journal. 2010; 7:17. 26. barakos ja, dillon wp, chew wm. orbit, skull base, and pharynx: contrast-enhanced fat suppression mr imaging. radiology. 1991;179:191–198. j i m d c 2 0 1 8 199 199 objective: to evaluate the frequency of cryptosporidiosis among children presenting to a tertiary care hospital with persistent diarrhea. materials and methods: this cross-sectional study was conducted from september 2016 to february 2017 at microbiology department, allama iqbal medical college, lahore. non-probability consecutive sampling technique was used and a total of 71 stool samples were collected from children admitted to paediatric ward of jinnah hospital, lahore, and full filling the inclusion criteria. every sample was collected according to standard protocol, brought to the lab within 3 hours, and processed for modified zn staining. cryptosporidium oocysts (bright red against a blue background) were identified. results: among 71 enrolled children (male=41, female =30) cryptosporidium was detected in 9.85% (n=7) stool samples via modified zn stain. majority of the children with cryptosporidium species cyst infection were less than 5 years old age. all the children presented with watery diarrhea abdominal pain and fever. only one case of cryptosporidium species cyst in diarrheal stools of children below 6 months of age was presented. the frequency of cryptosporidium infection was twice in males 12.5% as compared to females 6.6 %. conclusion: the present study highlights the importance of cryptosporidium detection as a cause of diarrhea, especially in children. key words: cryptosporidium, modified zn staining, persistent diarrhea. author`s contribution address of correspondence article info. open access f u l l l e n g t h a r t i c l e o r i g i n a l a r t i c l e cryptosporidiosis: an ignored cause of persistent diarrhea among children faryal manzoor 1, farhan rasheed 2, muhammad saeed 3, junaid rashid 4, nazia mahmood 5, ambereen anwar imran 6 1 medical lab technologist, department of pathology, shaukat khanum memorial cancer hospital lahore 2 assistant professor, department of pathology, allama iqbal medical college and jinnah hospital lahore 3 medical technologist, manager-pathology department, dhq hospital mandi bahauddin pakistan 4 professor, department of paediatrics, the children’s hospital and the institute of child health, lahore 5 assistant professor, department of paediatrics, allama iqbal medical college and jinnah hospital lahore 6 professor, department of pathology, allama iqbal medical college and jinnah hospital lahore a b s t r a c t 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2-4 data analysis, interpretation and manuscript writing, -5,6 active participation in data collection. muhammad saeed email: mian.scientist@yahoo.com received: june 3, 2018 accepted: july 29, 2018 cite this article. manzor f, rasheed f, saeed m, rashid j, mahmood n, imran aa. cryptosporidiosis: an ignored cause of persistent diarrhea among children. jimdc.2018; 7(3):199-203 funding source: nil conflict of interest: nil i n t r o d u c t i o n cryptosporidiosis is a highly contagious intestinal infection caused by, emerging pathogen, tiny microscopic parasite cryptosporidium. a protozoan among the phylum apicomplexa. early human cases were detected in 1976 at united states (us) among immuno-compromised adults and normal or immunocompetent children.1 among mailto:.scientist@yahoo.com j i m d c 2 0 1 8 200 200 young children cryptosporidiosis typically presents with watery diarrhea. passage of abnormally liquid or unformed stools at an increased frequency.2 in the early 1980s, diarrheal disorders were the biggest child killers, responsible for an estimated 4.6 million deaths worldwide every year. despite widespread use of oral rehydration therapies and an increased understanding of the pathogenesis of diarrhea, 2.5 million children still die from these illnesses every year, almost all of them in developing countries. cryptosporidium species are leading agents of chronic or persistent diarrhea worsened by specific risk factors such as malnutrition or immune deficiency. outbreaks of cryptosporidiosis have been reported in several countries. in 1993, more than 400,000 peoples were affected by the waterborne outbreak in milwaukee-wisconsin.3 numerous of cryptosporidium hominis cases are reported from developed nations like north and south america, australia and among developing countries 4 pediatric populations very high prevalence is reported from perù 5 malawi 6 kenya 7 india8 haiti 9 and brazil.10 in case of children, adults and hospitalized hiv-infected children south africa11,12 and uganda.13 whereas cryptosporidium parvum infection reported from europe, especially in uk.4 the mechanism of cryptosporidium associated diarrhea includes a combination of increased intestinal permeability, chloride secretion, and malabsorption. characteristics of cryptosporidium associated infection consist of prolonged persistent diarrhea, abdominal cramps, vomiting, low-grade fever, generalized malaise, weakness, fatigue, loss of appetite and nausea.14 the genus cryptosporidium has 14 well-defined species, while cryptosporidium parvum, cryptosporidium muris, cryptosporidium felis, cryptosporidium meleagridis, cryptosporidium canis, cryptosporidium suis, and cryptosporidium cervine are generally pathogenic for human beings.15 however, cryptosporidium hominis and cryptosporidium parvum are a common cause of human cryptosporidiosis both in immunocompetent and in immunocompromised individuals, with the difference in prevalence in different regions around the globe.16 diagnosis can be made by several techniques, such as histopathology, modified acid-fast stains, fluorescent stains, immunofluorescent assays using oocyst-specific monoclonal antibodies, antigen-detection assays and molecular techniques like polymerase chain reaction (pcr) for cryptosporidium parvum dna. although pcr is most sensitive and specific technique, however, these techniques are unavailable in developing countries due to high cost and lack of expertise. most diagnostic laboratories in developing countries are using conventional techniques, modified ziehl neelsen (zn) stain for the detection of cryptosporidium oocyst, as it is rapid, easiest and cheapest method. the present study was planned to evaluate the frequency of cryptosporidiosis among children presenting to a tertiary care hospital with persistent diarrhea. material s a n d m e t h o d s this cross-sectional study was conducted from september 2016 to february 2017 at microbiology lab, allama iqbal medical college, lahore. the sample size was calculated with the help of formula stated below:17 (ci 95%) n= pq/ (e/1.96)2 non-probability consecutive sampling technique was used and a total of 71 stool samples were collected from patients admitted in pediatric wards of jinnah hospital, lahore. children with persistent diarrhea (>14 days and >3 episodes per day): up to 12 years and both genders were included in the study. duplicate samples from the same patient during the same episode of illness were excluded. specimen processing delayed for more than three hours after collection were also excluded. every sample was collected according to standard protocol, brought to the lab within 3 hours, and processed by modified zn staining. cryptosporidium oocysts appear bright red against a blue background in this method. modified zn staining method appropriate smears were prepared on glass slides from stool specimens with the help of wire loop, air dried it, fixed with 70% ethanol and finally covered with carbol fuchsin stain. the slide was heated until vapors begin to rise. the stain was allowed to cover the smear for 5 minutes and washed in running tap water, decolorized with 3% sulphuric acid for 30 seconds and again wash with running tap water. the smear was then covered with methylene blue for 5 minutes and wash in running tap water, dry the slide and examined under oil immersion objective (100x). cryptosporidium oocysts appear bright red against a blue background in this method.18 (figure 1) j i m d c 2 0 1 8 201 201 figure 1: cryptosporidium oocyst in modified zn stain r e s u l t s among 71 enrolled children, 41 were males and 30 were females cryptosporidium was detected among 9.85% (n=7) stool samples via modified zn stain. majority children with cryptosporidium species cyst infection were more than 5 years old age, mean age was 4+1. all the children presented with watery diarrhea abdominal pain and fever. only one case of cryptosporidium species cyst in diarrheal stools was below 6 months of age. frequency of cryptosporidium infection was twice in males 12.5% as compared to females 6.6%. age group wise frequency distribution is showed in table:1. table1: age group wise frequency distribution of cryptosporidium infection age group gender total sample crypto <5 years n(48) male 28 3(10.7%) female 20 0(0.0%) >5 years n(23) male 13 2(15.4%) female 10 2 (20.0%) total male 41 5(12.1%) female 30 2(6.6%) d i s c u s s i o n intestinal parasites are very common in developing countries and cryptosporidium has revealed to be one of the most common parasites. cryptosporidium infests the small intestinal epithelium, thereby, resulting in an accelerated loss of villous enterocytes, severe villous atrophy, malabsorptive and secretory diarrhea which is the most pronounced clinical feature of the infection. the present study reported 9.85% cryptosporidium among children; similar rate (9%) was reported in a five year study reported from peshawar.14 ullah, et al. from skardu pakistan reported a higher frequency of cryptosporidium among children (20.8%) 19 while very low rate was reported in a study from karachi 1.7% .20 another study was conducted in barazjan, iran in 2012, out of 373 samples the frequency of cryptosporidium among 5 years old children was 13.1%.2 haque et al from bangladesh reported 8.4% cryptosporidium diarrhea.21 another study reported 16.3% cases ofcryptosporidium diarrhea.22 in previous studies using microscopy, approximately 3% of indian children were found to be asymptomatically infected with cryptosporidium spp.23 nkem et al from nigeria reported very similar results as cryptosporidium was reported infection 14.3%.24 male children were more prevalent for cryptosporidium infection (15.4%) than female (13.4%) (p<0.05). shalash et al from egypt reported 52 (72.2%) cryptosporidium infection.1 these sample size was nearly same as that of our study and cryptosporidium was detected by three different methods including modified zn staining and antigen detection by elisa. geographical distribution and methods of detection of cryptosporidium also vary. although modified zn staining is a less sensitive method for detection of cryptosporidium but still a useful and cheap tool for detection. the occurrence of cryptosporidium infection is similar to that reported in children in other studies in sub-saharan africa, both in the global enteric multicenter study (gems), and in the study of mbae et al. in kenya.25,26 the results of this study highlight the fact that unusual pathogens like cryptosporidium should not be overlooked while treating cases with diarrhea with prolonged duration cryptosporidium has emerged as an important cause of diarrhea worldwide. this parasite has been reported not only from western countries but also from nigeria, sudan, srilanka, bangladesh, and india with a strong possibility also in pakistan.27 the difference in the reported prevalence may be attributed to differences in the study population (considering age range), diagnostic methods, environmental risk factors (public water supply), time of the study (summer vs winter), nutritional status of the children, and other risk factors including the immune status of the study population. j i m d c 2 0 1 8 202 202 cryptosporidium is transmitted through multiple sources. the infection may be transmitted by direct person to person, contact with infected animal or by ingestion of contaminated food, or water 28 the oocysts are highly resistant to common household disinfectants and survive for long periods in the environment. it has major public health implication because the infection can result from exposure to low doses of cryptosporidium oocyst.6 cryptosporidium oocysts are very resistant to most environmental factors, with an exception of heat and desiccation. oocysts can persist for months in water and in soil and have been shown to survive for hours on wet surfaces, including stainless steel. however, they are not resistant to drying and die rapidly on dry surfaces. temperature sensitive cryptosporidium oocysts are not especially heat resistant and are destroyed by conventional milk pasteurization. a temperature of greater than 73oc will cause instantaneous inactivation of oocysts. oocysts can survive for short periods at temperatures below 0oc, especially in water, but the commercial ice cream freezing process has been shown to cause inactivation and eventual die-off occurs at temperatures below -15oc.29 c o n c l u s i o n the prevalence of cryptosporidiosis in children presenting with persistent diarrhea is considerable and we suggest routine stool examination for cryptosporidium in these children for early diagnosis and treatment to prevent it. modified zn staining is a cheap and less time-consuming method for diagnosis of cryptosporidiosis. r e f e r e n c e s 1. shalash ira, zalat r, el-enain g, el-mohandes m, mohamed e-f, aly e. comparison between modified acid fast staining and antigen detection assay as diagnostic techniques for cryptosporidium parvum. world journal of medical sciences. 2016;13(1):72-8. 2. saneian h, yaghini o, yaghini a, modarresi m-r, soroshnia m. infection rate of cryptosporidium parvum among diarrheic children in isfahan. iranian journal of pediatrics. 2010;20(3):343. 3. huang m-z, li j, guan l, li d-q, nie x-m, gui r, et al. therapeutic effects of acetylspiramycin and garlicin on cryptosporidiosis among drug users. international journal for parasitology: drugs and drug resistance. 2015;5(3):185-90. 4. xiao l, bern c, limor j, sulaiman i, roberts j, checkley w, et al. identification of 5 types of cryptosporidium parasites in children in lima, peru. the journal of infectious diseases. 2001;183(3):492-7. 5. cama va, bern c, roberts j, cabrera l, sterling cr, ortega y, et al. cryptosporidium species and subtypes and clinical manifestations in children, peru. emerging infectious diseases. 2008;14(10):1567. 6. gatei w, wamae cn, mbae c, waruru a, mulinge e, waithera t, et al. cryptosporidiosis: prevalence, genotype analysis, and symptoms associated with infections in children in kenya. the american journal of tropical medicine and hygiene. 2006;75(1):78-82. 7. ajjampur ssr, gladstone bp, selvapandian d, muliyil jp, ward h, kang g. molecular and spatial epidemiology of cryptosporidiosis in children in a semiurban community in south india. journal of clinical microbiology. 2007;45(3):915-20. 8. raccurt cp, brasseur p, verdier ri, li x, eyma e, stockman cp, et al. human cryptosporidiosis and cryptosporidium spp. in haiti. tropical medicine & international health: tm & ih. 2006;11(6):929-34. 9. bushen oy, kohli a, pinkerton rc, dupnik k, newman rd, sears cl, et al. heavy cryptosporidial infections in children in northeast brazil: comparison of cryptosporidium hominis and cryptosporidium parvum. transactions of the royal society of tropical medicine and hygiene. 2007;101(4):378-84. 10. samie a, bessong p, obi c, sevilleja j, stroup s, houpt e, et al. cryptosporidium species: preliminary descriptions of the prevalence and genotype distribution among school children and hospital patients in the venda region, limpopo province, south africa. experimental parasitology. 2006;114(4):314-22. 11. leav ba, mackay mr, anyanwu a, o'connor rm, cevallos am, kindra g, et al. analysis of sequence diversity at the highly polymorphic cpgp40/15 locus among cryptosporidium isolates from human immunodeficiency virus-infected children in south africa. infection and immunity. 2002;70(7):3881-90. 12. tumwine jk, kekitiinwa a, bakeera-kitaka s, ndeezi g, downing r, feng x, et al. cryptosporidiosis and microsporidiosis in ugandan children with persistent diarrhea with and without concurrent infection with the human immunodeficiency virus. the american journal of tropical medicine and hygiene. 2005;73(5):921-5. 13. kosek m, bern c, guerrant rl. the global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. bulletin of the world health organization. 2003;81(3):197-204. 14. mumtaz s, ahmed j, ali l. frequency of cryptosporidium infection in children under five years of age having diarrhea in the north west of pakistan. african journal of biotechnology. 2010;9(8). 15. ryan u, fayer r, xiao l. cryptosporidium species in humans and animals: current understanding and research needs. parasitology. 2014;141(13):1667-85. j i m d c 2 0 1 8 203 203 16. cacciò sm, thompson ra, mclauchlin j, smith hv. unravelling cryptosporidium and giardia epidemiology. trends in parasitology. 2005;21(9):430-7. 17. vaughan jp and morrow rh. manual of epidemiology for district health management. world health organization. 1989; 175-176. 18. organization wh. basic laboratory methods in medical parasitology. 1991. 19. khushdil a, murtaza f, chattha mn. cryptosporidiosis among children of district skardu, pakistan. journal of ayub medical college abbottabad. 2016;28(3):575-7. 20. shoaib s, tauheed s, hafiz a. frequency of cryptosporidium in childhood diarrhoea importance of modified acid fast technique. j ayub med coll abbottabad. 2003;15:3-5. 21. haque r, mondal d, kirkpatrick bd, akther s, farr bm, sack rb, et al. epidemiologic and clinical characteristics of acute diarrhea with emphasis on entamoeba histolytica infections in preschool children in an urban slum of dhaka, bangladesh. the american journal of tropical medicine and hygiene. 2003;69(4):398-405. 22. tellevik mg, moyo sj, blomberg b, hjøllo t, maselle sy, langeland n, et al. prevalence of cryptosporidium parvum/hominis, entamoeba histolytica and giardia lamblia among young children with and without diarrhea in dar es salaam, tanzania. plos neglected tropical diseases. 2015;9(10):e0004125. 23. palit a, sur d, mitradhar k, saha mr. asymptomatic cryptosporidiosis in a periurban slum setting in kolkata, india––a pilot study. japanese journal of infectious disease. 2005;58:110-1. 24. benjamin n, uchechukwu c, ikechukwu d, oliver a, muodebe n. cryptosporidiosis among children in some rural parts of imo state, nigeria. journal of public health and epidemiology. 2013;5(11):440-4. 25. kotloff kl, nataro jp, blackwelder wc, nasrin d, farag th, panchalingam s, et al. burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the global enteric multicenter study, gems): a prospective, case-control study. the lancet. 2013;382(9888):209-22. 26. mbae ck, nokes dj, mulinge e, nyambura j, waruru a, kariuki s. intestinal parasitic infections in children presenting with diarrhoea in outpatient and inpatient settings in an informal settlement of nairobi, kenya. bmc infectious diseases. 2013;13(1):243. 27. baqai r, anwar s, kazmi s. detection of cryptosporidium in immunosuppressed patients. j ayub med coll abbottabad. 2005;17(3):38-40. 28. khan nu, saleem mh, durrani az, ahmad n, hassan a, ayaz s, et al. cryptosporidium: an emerging zoonosis in southern khyber pakhtunkhwa (kpk), pakistan. pakistan journal of zoology. 2017;49(4):1455-61. 29. li x, atwill er, dunbar la, tate kw. effect of daily temperature fluctuation during the cool season on the infectivity of cryptosporidium parvum. applied and environmental microbiology. 2010;76(4):989-93. j islamabad med dental coll 2022 135 o p e n a c c e s s universal health coverage in pakistan: a call for health system reforms babar tasneem shaikh director technical/deputy chief of party,jsi research & training institute inc. the sustainable development goal 3.8, adopted in 2015 by the united nations advocated the need for ‘universal health coverage’ (uhc), a roadmap promising that all people, particularly those in need, have access to essential health services when and where they need, without any financial hardship.1 uhc is not a new lexicon, it was outlined in the founding constitution of the world health organization (who) that has stipulated health as a fundamental and universal right of every human being without distinction of race, religion and political belief, economic and social condition.2 who defines ‘maximum’ population coverage, health service coverage, and financial protection, as three dimensions of uhc. the first dimension is relatively simpler to understand: what proportion of the people in the catchment of a health facility are covered for health services, and how many are left out. the second dimension delineates the range of essential health services made available to the people e.g. immunization, family planning, antenatal care, delivery by skilled birth attendant, treatment of common ailments, and services for hiv/aids, tuberculosis and malaria etc. third dimension is about the expenditure incurred while seeking the healthcare, especially the out of pocket expenditure or the cost sharing by the patient, which is supposed correspondence: babar tasneem shaikh email: shaikh.babar@gmail.com cite this editorial: shaikh t b. universal health coverage in pakistan: a call for health system reforms j islamabad med dental coll. 2022; 11(3): 135-137 doi: https://doi.org/10.35787/jimdc.v11i3.910 to be minimal or zero at the point of service delivery. 3 the question is whether the health system in pakistan is ready and responsive to pursue the ambitious agenda of uhc. all three dimensions would ned reforms as pre-requisites to make genuine progress towards uhc. with the gdp allocation consistently of less than 1% for health4, pakistan’s health indicators have improved in the last one decade miraculously; yet the progress is diminutive vis-à-vis other neighbouring and regional countries. covid-19 pandemic has further contributed in worsening of the health indicators particularly those related to maternal, new-born and child health. although the country has a vast health system infrastructure, the operationalization of primary health care remains a challenge due to shortage of health workforce and lack of conducive environment to work.5 amidst this state of affairs, the private sector in pakistan has taken over as the preferred health service provider of all levels of health care, of course with a price tag.6 when the oop is almost 2/3rd of the total expenditure on health7, it is likely to compound impoverishment of the already poor families, subjecting them to health shocks. the current social health protection program of the government presents a silver lining, henceforth. this program must sustain and should be given a legal cover through parliamentary legislation. contrary to the present design of the program, health system should move towards the implementation of a progressive income-rated contributions to health financing, with focus on need e d i t o r i a l j islamabad med dental coll 2022 136 based entitlements to health services, and pursuit of the concept of income and risk cross-subsidization, whereby the rich cross-subsidize the poor, whilst the healthy cross-subsidize the sick. this approach will ensure the element of equity and fairness in health. otherwise, the health status variance between the different socioeconomic population groups, and limited access to primary education, safe drinking water, sanitation and hygiene conditions are some of the daunting challenges. for improving the state of public sector health service delivery, the district health system must be strengthened and empowered, administratively as well as financially.8 uhc requires a new leadership agenda for public health action, through the creation of an effective mechanism of training and supportive supervision in the district health system, forging the necessary inter-sectoral collaboration and coordination at all operational levels, including a meaningful participation of the community-the ultimate beneficiary of the health system.9 improvement in access to essential health care necessitate establishing 24/7 basic health care units, and the gaps in the human resource for health can be addressed to some extent through task shifting and expansion of the lady health workers and community midwives network in the uncovered areas of pakistan. moreover, it is important to increase the budgetary allocation for health as percentage of gdp to fulfil the mandate of effective service delivery. the reform of public health financing should be focused on the district health system, instituting output based budgeting and promoting performance based budgeting. policy makers need to understand the drivers of health seeking behaviour of the population in an increasingly pluralistic health care system. there is no denial on the significance of achieving uhc, however, optimal utilization of health services will happen only with ensuring adequate human resource and quality health care. it is to be noted that social health protection and uhc contribute not only to health; but also to poverty reduction and to the advancement of many sdgs that are linked with health.10 government of pakistan has announced that it will implement the uhc reforms agenda on fast track basis once the pandemic is in control. it is needless to say that in present times it is not only the virus which was killing people, it’s the poverty, lack of access and years and years of living with health conditions and health systems which have not been properly managed. the health disparities have widened because of the socio-economic class and many other factors which pushed people below the poverty line. progress towards uhc is directly linked to country's health budget allocated for public sector health care delivery as well as health insurance scheme in years to come. 11 covid-19 pandemic has unearthed the capacity of not only developing but many developed countries i.e., failure to deliver an equitable healthcare and to acknowledge that health security is not a nonfigurative concept, it is about fairness and equity. hope, pakistan will soon come out of this pandemic crisis, safeguarding its poor segments of population by expanding its safety net for health, and thus achieving the uhc agenda by 2030. j islamabad med dental coll 2022 137 r e f e r e n c e s 1. united nations. the 17 goals. department of economic and social affairs. https://sdgs.un.org/goals [accessed on december 19, 2021] 2. world health organization. constitution of the world health organization. geneva: 1948. https://www.who.int/governance/eb/who_con stitution_en.pdf 3. world health organization. universal health coverage: five questions. geneva. http://www.who.int/health_financing/ universal_health_coverage_5_questions.pdf [accessed december 20, 2021] 4. ahmed j, shaikh bt. an all-time low budget for health care in pakistan. j coll physicians surg pak 2008; 18(6): 388-391. 5. world health organization. global health observatory data repository. health worker density: pakistan. https://apps.who.int/gho/data/view.main.uhc hrhv [accessed december 21, 2021] 6. shaikh bt. private sector in health care delivery: a reality and a challenge in pakistan. j ayub med coll abbottabad. 2015; 27(2):496-8. 7. world bank. out-of-pocket expenditure (% of current health expenditure) – pakistan. https://data.worldbank.org/indicator/sh.xpd.o opc.ch.zs?locations=pk [accessed july 20, 2022] 8. fetene n, canavan me, megentta a, linnander e, tan ax, nadew k, et al. district-level health management and health system performance. plos one 2019; 14(2): e0210624. 9. editorial. social participation, universal health coverage and health security. bull world health organ 2021; 99:846–846a. 10. mao w, tang y, tran t, pender m, khanh pn, tang s. advancing universal health coverage in china and vietnam: lessons for other countries. bmc public health 2020; 20(1):1791. 11. shaikh bt, ali n. covid-19 and fiscal space for health system in pakistan: it is time for a policy decision. int j health plann manage 2020; 35(4):813-817. https://sdgs.un.org/goals https://www.who.int/governance/eb/who_constitution_en.pdf https://www.who.int/governance/eb/who_constitution_en.pdf http://www.who.int/health_financing/universal_health_coverage_5_questions.pdf http://www.who.int/health_financing/universal_health_coverage_5_questions.pdf https://apps.who.int/gho/data/view.main.uhchrhv https://apps.who.int/gho/data/view.main.uhchrhv https://data.worldbank.org/indicator/sh.xpd.oopc.ch.zs?locations=pk https://data.worldbank.org/indicator/sh.xpd.oopc.ch.zs?locations=pk j islamabad med dental coll 2022 164 open access high resolution computed tomography chest findings among post-covid patients rabia shahid1, muhammad saleem akhter2, muhammad waseem3, maryam rafiq3 1house officer, department of pulmonology ,sahiwal teaching hospital, sahiwal. 2assistant professor and head of department, radiology, sahiwal teaching hospital, sahiwal. 3assistant professor and head of department, pulmonology, sahiwal teaching hospital, sahiwal. 4assistant professor, department of chemical pathology, sahiwal teaching hospital, sahiwal. a b s t r a c t background: high resolution computed tomography (hrct) chest has proven to be a helpful radiological modality to assess the course of disease. the main objective of the study was to analyze the pattern of lung involvement on hrct chest among post-covid patients. methodology: this cross-sectional study was carried out in the post covid patients (30 days after discharge) from nov 2020 to july 2021 in sahiwal teaching hospital, pakistan. total 180 patients were selected through non probability consecutive sampling technique. whole body multi slice ct scan, 128 slices by ge discovery was used to get hrct of chest and to document various patterns and stages of pulmonary fibrosis in the post-covid patients. the data was analyzed using the ibm spss 28.0.0 2021. various radiological findings were expressed in percentages. results: a total of 77.8% patients had bilateral lung involvement, while 22.2% had unilateral lung involvement after one month of disease. ground glass haze was the commonest radiological pattern, found in 140 (77.8%) cases. other radiological patterns were air space opacification (47.2%), septal thickening (20%) and fibrotic bands (26.1%). traction bronchiectasis (10%) and honey combing (7.8%) were among the lesser ones reported. about 62% patients had mixed findings on hrct chest. diagnosis of organizing pneumonia was made in 166 (92.22%) patients while 14 (7.78%) patients were labelled as usual interstitial pneumonia (uip) with honey-combing in hrct chest. the involvement of right lower lobe was in 165 (91.7%) of cases. right middle lobe remained fairly spared and was seen in 120 (66.7%) cases. conclusion: patchy ground glass haze seen bilaterally in lower lung lobes are the commonest abnormalities in hrct chest of post-covid patients. keywords: covid-19, pneumonia, radiology authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4data analysis; manuscript editing. correspondence: maryam rafiq email: mariamsheikh15@yahoo.com article info: received: september 21, 2021 accepted: september 9, 2022 cite this article. shahid r, akhter s m, waseem m, rafiq m. high resolution computed tomography (hrct) chest findings among post-covid patients. j islamabad med dental coll. 2022;11(3): 164-168 doi: https://doi.org/10.35787/jimdc.v11i3.789 funding source: nil conflict of interest: nil i n t r o d u c t i o n the modern-day world is plagued by many disease epidemics. once every few decades, there comes a microorganism that puts human life at halt. arising from wuhan, china in december 2019, the disease caused by novel coronavirus or sars-cov-2 was declared as a public health emergency of international concern on 30th january 2020. it was o r i g i n a l a r t i c l e j islamabad med dental coll 2022 165 labelled a global pandemic by the world health organization on 11th march 2020. 1 while the leading researchers and scientists took it upon themselves to serve humanity by developing cure and preventive vaccines within record time, the virus had already wreaked havoc. as of august 2021, there have been a total of more than 200 million confirmed cases and over 4 million deaths worldwide. 1 the disease presents itself as a respiratory tract infection with symptoms such as fever, cough, dyspnea, muscle pain and fatigue.2 with the newer variants, such as, delta, the symptoms had broadened to include diarrhea and flu.3 diagnosis is made chiefly, based on a combination of history of exposure, symptoms and radiological and laboratory findings. chest x-rays are helpful in establishing diagnosis; however, high resolution computed tomography chest has been employed as a useful tool in observing the course of disease recovery and/or fibrosis in post-covid patients.4 a raised crp (c-reactive protein) and ldh (lactate dehydrogenase) along with a low lymphocyte count have been found to be associated with severe disease and predict poor prognosis.5 though the death rate of the disease is still around 2%, the after-effects of covid continue to alarm the world.6 moving forward, more and more research is being conducted and proving that this is deadlier than the infectious diseases that normally prevail in the community, with an increased propensity of harming the old and the immunocompromised. the burden on healthcare has been crippling for even the most developed of nations. the most worrisome part remains to be the fact that long after the virus leaves the person’s body, its damaging effects persist. those with pre-existing comorbidities are thought to be somewhat more susceptible than those who have a perfectly healthy immune system.7 the various stages of lung parenchymal involvement in post covid-19 patients are documented in this study using hrct chest, to better visualize lung damage in affected individual after hospital discharge. there are limited studies which involve radiological follow up of covid patients so this study will add to the existing body of knowledge by detecting post covid changes in lung parenchyma these may help health care providers to detect those adverse changes timely and treat them effectively. m e t h o d o l o g y this cross-sectional study was conducted in the pulmonology department of sahiwal teaching hospital, sahiwal, after approval from the institutional ethical review board through letter no 155/dme/slmc/swl dated 08-10-2020. the study was conducted from nov 2020 to july 2021 in district sahiwal, punjab, pakistan. a sample size of 151 was calculated through open epi website by taking confidence level as 95%, level of precision as 5% and prevalence of post covid hrct changes in covid patients as 89 %. 8 in total 180 patients of both genders were included by non-probability consecutive sampling technique. inclusion criteria was covid pcr positive patients admitted in hospital with follow up hrct chest done 30 days after discharge. patients with active covid-19 virus, pregnant females and those with history of chronic interstitial lung disease and preexisting lung conditions like allergic alveolitis, tuberculosis or other infections were excluded from the study. whole body multi slice ct scan 128 slices by ge discovery was used to get hrct of chest and to visualize and document various patterns and stages of pulmonary fibrosis in the post-covid patients. the changes on hrct chest were evaluated and reported by three consultant radiologists, having experience of more than five years in reporting hrct chest. the data was documented and analyzed using the ibm spss 28.0.0 2021. various radiological findings were expressed in percentages. j islamabad med dental coll 2022 166 r e s u l t s out of 180 post-covid patients, 108(60%) were males and 72(40%) females. the mean age of the participants was found to be 54.1 ± 14.525 years. a wide array of radiological findings was seen in the hrct chest of 1-month post-covid patients. these varied from slight ground glass haze or mild air space opacification to traction bronchiectasis and honeycombing. the frequency of these changes, as seen in the hrct chest of patients has been tabulated below in table 1. table i: radiological findings in hrct chest of post-covid patients. (n= 180) radiological findings no. of cases (percentage) ground glass haze 140 (77.8) air space opacification 85 (47.2) fibrotic bands 47 (26.1) septal thickening 36 (20.0) mediastinal lymphadenopathy 23 (12.8) consolidation 22 (12.2) traction bronchiectasis 18 (10.0) honeycombing 14 (7.8) 140 out of 180 patients (77.8%) had bilateral lung involvement, while 40 (22.2%) had unilateral lung involvement after one month of the disease. right lower lobe was found to be the most commonly involved, with involvement in 165 (91.7%) cases. right middle lobe was the least commonly involved, with changes shown in only 120 (66.7%) out of 180 cases. different patterns of distribution were also observed, with patchy distribution being the most common ( 85.3% ). the different patterns of distribution, along with the frequency of involvement of various lung lobes are shown in table 2. table ii: distribution of histological changes in hrct chest of post-covid patients. pattern distribution no. of cases (percentage) patchy 151(85.3%) diffuse 15(8.5%) sub-pleural 75(42.4%) peripheral 76(42.9%) lobes involved right upper lobe 159(88.3%) right middle lobe 120(66.7%) right lower lobe 165(91.7%) left upper lobe 137(76.1%) left lower lobe 145(80.6%) radiological diagnosis of 166 (92.22%) patients was,made to be organizing pneumonia while 14 (7.78%) patients were labelled as usual interstitial pneumonia (uip) with honey-combing depicted in their hrct chest. j islamabad med dental coll 2022 167 figure 1: radiological diagnosis on the basis of hrct chest in post-covd patients. d i s c u s s i o n covid-19 has trapped the world in a frenzy, where scientific knowledge is limited and our resources are being exhausted at an alarming rate. it is imperative to play our part in these trying times and gather enough reliable information for the betterment of humanity. this study is one of few conducted in pakistani patients. covid-19 is posing enormous threat to our healthcare system because of the continued damage that might lead to lung fibrosis in the absence of timely intervention. 9,10 as shown by previous research data, males are at an increased risk of developing covid and resultantly post-covid interstitial lung disease (ild)/fibrosis.11 60% of the cases were males while 40% were females, which is consistent with similar studies conducted worldwide. increased age has been shown to be a significant risk-factor via different studies.12 the mean age of affected patients was 54.1 + 14.52 years consistent with study reported by shi in which mean age of infected individuals was reported to be 49 years.13 role of repeat ct scan in follow up of lung disease has been well-established now and hrct chest is far superior to the conventional cxr.14,15 hrct chest was repeated at a one-month interval post-covid. individuals with known ild such as hypersensitivity pneumonitis (hp) were excluded from this study to allow a clear deduction of results. various histological changes were apparent in the hrct chest. the most common finding was a ground glass haze (seen in 77.8% of cases), which is consistent with the findings of previously conducted similar studies.16 few other studies revealed similar results with ground glass opacites being the commonest finding.17,18 a spectrum of radiological changes was reported, from air space opacification (47.2%) to septal thickening (20%) and fibrotic bands (26.1%). traction bronchiectasis (10%) and honey combing (7.8%) were relatively rare and can be considered to be more late/severe changes on the path to lung fibrosis. the criteria used for various radiological findings such as ground glass haze and air space opacification was according to fleischner society glossary of terms for thoracic imaging.19 bilateral lower lobe involvement was seen most commonly, while the right middle lobe remained relatively spared. there is a lot of room for further key variables to be explored in future studies. there might be a correlation in the lobes being involved and gender, occupation or smoking status of an individual. we can save the crippling healthcare infrastructure by adequately treating and dealing with all the complications associated with this deadly pandemic. hrct chest can be used as a very helpful radiological tool for close follow-up of improvement or deterioration in a post-covid patient. the goal is to predict, investigate and then intervene timely to j islamabad med dental coll 2022 168 reduce morbidity and mortality. furthermore, the small number of patients recruited at a single facility limit any definitive conclusions, although they do indicate the necessity for a more thorough follow-up of covid-19 patients. c o n c l u s i o n  patchy ground glass haze seen bilaterally in lower lung lobes are the commonest radiological abnormalities in hrct chest of post-covid patients.  timely identification of post-covid interstitial lung disease can help in prompt interventions in the form of drugs like corticosteroids to save a patient from complications like lung fibrosis. r e f e r e n c e s 1. covid19.who.int. 2022. who coronavirus (covid-19) dashboard. [online] available at: <https://covid19.who.int/> [accessed 4 june 2022]. 2. hassan sa, sheikh fn, jamal s, ezeh jk, akhtar a. coronavirus (covid-19): a review of clinical features, diagnosis, and treatment. cureus. 2020 mar;12(3). doi:10.7759/cureus.7355 3. herlihy r, bamberg w, burakoff a, alden n, severson r, bush e, et al. rapid increase in circulation of the sars-cov-2 b. 1.617. 2 (delta) variant—mesa county, colorado, april–june 2021. morbidity and mortality weekly report. 2021 aug 13;70(32):1084. doi: http://dx.doi.org/10.15585/mmwr.mm7032e2 external icon 4. kanne jp. chest ct findings in 2019 novel coronavirus (2019-ncov) infections from wuhan, china: key points for the radiologist. radiology. 2020 apr;295(1):16-17 doi: 10.1148/radiol.2020200241 5. zhang zl, hou yl, li dt, li fz. laboratory findings of covid-19: a systematic review and meta-analysis. scand. j. clin. lab. invest. 2020 oct 1;80(6):4417. doi: 10.1080/00365513.2020.1768587 6 covid.gov.pk. 2022. covid-19 health advisory platform by ministry of national health services regulations and coordination. [online] available at: <https://covid.gov.pk/stats/pakistan> [accessed 3 june 2022]. 7. beckman mf, mougeot fb, mougeot jl. comorbidities and susceptibility to covid-19: a generalized gene set data mining approach. journal of clinical medicine. 2021 jan;10(8):1666. doi:10.3390/jcm10081666 8. van gassel rj, bels jl, raafs a, van bussel bc, van de poll mc, simons so, et al. high prevalence of pulmonary sequelae at 3 months after hospital discharge in mechanically ventilated survivors of covid-19. am. j. respir. crit. care med. 2021 feb 1;203(3):371-4. 9. liu d, zhang w, pan f, li l, yang l, zheng d, et al. the pulmonary sequalae in discharged patients with covid-19: a short-term observational study. respir res. 2020 may 24;21(1):125. doi: 10.1186/s12931020-01385-1. 10. rai dk, sharma p, kumar r. post covid 19 pulmonary fibrosis. is it real threat? indian j tuberc. 2021 jul;68(3):330-333. doi:10.1016/j.ijtb.2020.11.003 11. bienvenu la, noonan j, wang x, peter k. higher mortality of covid-19 in males: sex differences in immune response and cardiovascular comorbidities. cardiovascular research. 2020 dec 1;116(14):21972206. doi:10.1093/cvr/cvaa284 12. ho fk, petermann-rocha f, gray sr, jani bd, katikireddi sv, niedzwiedz cl, et al. is older age associated with covid-19 mortality in the absence of other risk factors? general population cohort study of 470,034 participants. plos one. 2020 nov 5;15(11):e0241824. doi: 10.1371/journal.pone.0241824 13. shi h, han x, jiang n, cao y, alwalid o, gu j, et al. radiological findings from 81 patients with covid19 pneumonia in wuhan, china: a descriptive study. the lancet infect. dis. 2020 apr 1;20(4):425-34. doi: 10.1016/s1473-3099(20)30086-4 14. mahdavi a, haseli s, mahdavi a, bakhshayeshkaram m, foroumandi m, nekooghadam sm, et al.the role of repeat chest ct scan in the covid-19 pandemic. academic radiology. 2020 jul;27(7):1049. doi:10.1016/j.acra.2020.04.031 15. pal a, yadav mk, pant c, shrestha bk. high resolution computed tomography and chest radiography findings among interstitial lung disease patients. j chitwan med coll. 2019 dec 27;9(4):24-7. doi:10.3126/jcmc.v9i4.26895 16. salehi s, abedi a, balakrishnan s, gholamrezanezhad a. coronavirus disease 2019 (covid-19): a systematic review of imaging findings in 919 patients. am j roentgenol 2020 jul;215(1):87-93. doi: 10.2214/ajr.20.23034 17. wang y, dong c, hu y, li c, ren q, zhang x, et al. temporal changes of ct findings in 90 patients with covid-19 pneumonia: a longitudinal study. http://dx.doi.org/10.15585/mmwr.mm7032e2 http://dx.doi.org/10.15585/mmwr.mm7032e2 https://doi.org/10.1148/radiol.2020200241 https://doi.org/10.1080/00365513.2020.1768587 https://doi.org/10.1371/journal.pone.0241824 https://doi.org/10.1016/s1473-3099(20)30086-4 http://dx.doi.org/10.3126/jcmc.v9i4.26895 https://doi.org/10.2214/ajr.20.23034 j islamabad med dental coll 2022 169 radiology. 2020 aug;296(2):e55-64. doi: 10.1148/radiol.2020200843 18 ajlan am, ahyad ra, jamjoom lg, alharthy a, madani ta. middle east respiratory syndrome coronavirus (mers-cov) infection: chest ct findings. am j roentgenol. 2014 oct;203(4):782-7. doi: 10.2214/ajr.14.13021 19. hansell dm, bankier aa, macmahon h, mcloud tc, muller nl, remy j. fleischner society: glossary of terms for thoracic imaging. radiology. 2008 mar;246(3):697-722 doi: 10.1148/radiol.2462070712 https://doi.org/10.1148/radiol.2020200843 https://doi.org/10.2214/ajr.14.13021 https://doi.org/10.1148/radiol.2462070712 j islamabad med dental coll 2023 88 open access peripheral arteriovenous malformations and their response to treatment modalities: experience at tertiary care hospitals rashid usman1, duaa ajaz hussain2, muhammad jamil3, muhammad waseem anwar4, muhammad faheem anwer5, amna shahab6 1,5,6 associate professor of surgery, combined military hospital, lahore pakistan 2 medical officer, combined military hospital, multan, pakistan 3professor of surgery, combined military hospital, lahore pakistan 4assistant professor of surgery, combined military hospital, lahore pakistan a b s t r a c t background: arteriovenous malformations result in abnormal communication between veins and arteries. treatment of avms can be surgical or non-surgical. this study aimed to assess the response of peripheral arteriovenous malformations (avms) to various treatment modalities. methodology: this cross-sectional study was performed at combined military hospital lahore, rawalpindi, and midcity hospital, lahore pakistan, from january 2016 to june 2020. patients were divided into two groups based on gender. their demographic data, clinical presentation, and treatments provided were assessed and comparison was done using chi-square test. results: of the 43 patients, 74.4% (n=32) were females with a male-to-female ratio of 1:3. mean age was 27± 6 years (males) and 17± 4 years (females). low-flow avms were more prevalent in females (81%, n=27). in males, 50% (n=5) avms were on the trunk whereas in females 93.9% (n=31) avms were on limbs. doppler-guided foam sclerotherapy (dgfs) as the sole treatment was used in 95.3% (n=41) patients while 32.5% (n=14) patients underwent dgfs followed by surgical excision. in 4.6% (n=2) cases, angioembolization followed by surgical excision was done. one patient was treated with sirolimus. recurrence was found in 20.9% (n=9) cases, of which 66.6% (n=6) had high-flow avms. conclusion: male patients presented late and with mostly high-flow head and neck avms. sclerotherapy alone or surgical excision with preoperative sclerotherapy or embolotherapy is an efficacious curative treatment for avms while sirolimus can be offered as a palliative option. key words: arteriovenous malformations, enbucrilate, sclerotherapy, vascular malformations authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: rashid usman email:drrashidusman@yahoo.com article info: received: december 1, 2021 accepted: april 12, 2023 cite this article. usman r, hussain a d, jamil m, anwar m w, anwer m f, shahab a. peripheral arteriovenous malformations and their response to treatment modalities: experience at tertiary care hospitals. j islamabad med dental coll. 2023; 12(2):88-94 doi: https://doi.org/10.35787/jimdc.v12i2.817 funding source: nil conflict of interest: nil i n t r o d u c t i o n avms are found as congenital defects which arise due to errors in embryogenesis resulting in abnormal communication between veins and arteries.1 in the centre of the av malformation lies the nidus, which is the tangle of abnormal vessels of the avm. according to the international society of o r i g i n a l a r t i c l e j islamabad med dental coll 2023 89 the study of vascular anomalies, avms are benign lesions that directly connect the arterioles and venules and they lack intervening capillaries, thus causing dilation of veins which become tortuous over a period causing deformity of that body region. 1,2 avms belong to a group of defects known as congenital vascular malformations (cvms), which also include other more common defects like venous malformations.1,2 treatment of avms can either be surgical or nonsurgical.3 nonsurgical options are sclerotherapy, angioembolization, and immunomodulation. avms are uncommon, accounting for 10-15% of cvms having a prevalence of 5 to 613 in 100,000.4,5 over 90% of avms are intracranial, which makes peripheral avms even rarer.6 these lesions are known to develop during early gestation and can be evident at birth. they tend to grow over time and become more prominent under the influence of trauma or hormonal changes during puberty or pregnancy. although there are a substantial number of studies on cerebral avms, there is insufficient data regarding peripheral avms. this study was intended as a pilot project. patients presenting with peripheral avms were assessed whether there were any gender differences in disease presentation and the response of avms to various available treatment modalities. m e t h o d o l o g y this cross-sectional study was performed at combined military hospital lahore, rawalpindi, and midcity hospital lahore pakistan, from january 2016 to june 2020. the formal approval for the study was obtained from the institutional ethical review committee (irb number: 68/18/05/21). all patients diagnosed with an avm and willing to undergo treatment were included. informed consent was taken from all patients. children less than five years of age, unwilling patients, patients who had documented complications of the sclerosant, and pregnant patients were excluded from the study. furthermore, patients who did not complete a minimum of six months of follow-up were excluded. doppler guided foam sclerotherapy (dgfs) was performed using a 30mg/ml injection of sodium tetradecyl sulfate (sts). the foam was prepared in a ratio of 1:2:2 of sts: water: air using tessari’s method. all patients received compression on the injected area for at least 2 weeks. patients were counselled regarding the importance of strict postprocedure compliance to instructions such as those for compression therapy. regular follow-ups were done for a minimum of 6 months. at each visit, clinical evaluation along with doppler was done with the logiq book ge medical ultrasound system to assess treatment efficacy in terms of the requirement of further sessions. total treatment sessions and treatment modalities offered were recorded. other treatment modalities used were surgical excision alone or in combination with dgfs and immunotherapy with silolimus followed by dgfs. recurrence of avm was defined as re-growth after a doppler recorded complete healing. recurrence and other complications were also recorded. statistical analysis was done using statistical package for the social sciences version 24 (spss© inc., il, usa). quantitative variables were expressed as mean ± standard deviation (sd). qualitative variables were expressed as frequency and percentage. based on gender, patients were divided into two groups. the comparison was done using chi-square test and a pvalue of ≤ 0.05 was considered statistically significant. r e s u l t s a total of 49 patients diagnosed with an avm were initially included in the study. however, 12.2% (n=6) of patients did not complete the mandatory 6 months follow-up and hence were excluded. j islamabad med dental coll 2023 90 of the 43 total cases, there were 23.2% (n=10) males and 74.4% (n=32) females (m: f ratio 1:3). mean age in males was 27± 6 years (range 19 -40) and in females 17± 4 years (range 11-22) with a statistical difference (p value 0.003); suggesting that a younger population of females presented with avms [table 1]. in terms of avm type, in males, 60% (n=6) avms were high flow while in females low flow avms were more prevalent (81%, n=27). moreover, 50% (n=5) of avms in males were on the trunk followed by the head and neck (30%) and limbs (20%). however, in females, this ratio was reversed with the limb being the most prevalent site (93.9%) and the trunk being the least affected site (3%). dgfs was performed in 95.3% (n=41) of patients. dgfs was employed as monotherapy in 63.4% (n=26) of these patients [figure a]. all had low-flow avms and 53.8% (n=14) of them showed complete recovery after a single session of dgfs. 30.7% (n=8) patients needed two sessions and 15.3% (n=4) patients needed more than two sessions; however, complete healing was achieved in all cases. a total of 32.5% (n=14) patients underwent dgfs followed by surgical excision [figure b]. of these, 35.7% (n=5) patients had low-flow avms while the remaining 64.2% (n=9) patients had high-flow avms. it is worth noting that all those patients who had high-flow avms needed multiple sessions of dgfs [figure c] one patient had a high-flow avm involving the entire side of his face which was not amenable to formal excision. he opted for novel immunotherapy and therefore underwent 2 sessions of intravenous sirolimus which were followed by 3 sessions of dgfs. on follow-up, small remnant pockets of active blood flow were still present. however, there was a significant size reduction of the avm which was cosmetically acceptable. in 4.6% (n=2) of cases, preoperative angio embolization was performed followed by surgical removal within the same week. recurrence was recorded in 20.9% (n=9) cases, in these 66.6% (n=6) patients were having high-flow avms. hence the recurrence rate was 50% (n=6) in high-flow avm patients while it was 9.6% (n=3) in the low-flow avms. in patients undergoing dgfs, there was local pain and swelling in noted 51.2% (n=21), skin necrosis/ulceration in 19.5% (n=8), and superficial local thrombophlebitis in 17% (n=7) patients. however, none of these complications needed further treatment. other minor complications included small hematoma formation in 27.9% (n=12), seroma in 23.2% (n=10), and superficial surgical site infection in 6.9% (n=3) cases. table i: types and location of avm male (n=10) females (n=33) p value age in years (mean sd) 27 +/6 17 +/4 0.003 type of avm high flow (%(n)) 50 (6) 50(6) 0.322 low flow [%(n)] 12.9 (4) 87.1 (27) 0.005 site of avm limbs [%(n)] 6.2 (2) 93.9 (31) 0.005 head and neck [%(n)] 75 (3) 25 (1) 0.07 trunk [%(n)] 83.3 (5) 16.7 (1) 0.04 figure a: avm of lip presenting with ulceration and bleeding (left). one month post-dgfs (right) j islamabad med dental coll 2023 91 figure b: avm in upper calf treated with surgical excision (note the aberrant arterial connection arising from the popliteal artery). figure c: high flow avm involving the right pinna and postauricular region. d i s c u s s i o n although avms are present at birth, these lesions may only clinically appear later in life, as their growth tends to parallel that of the rest of the child’s body. the male to female ratio is commonly reported as a 1:1 ratio for avms however we found a higher number of females in our study group.7 moreover the average age of presentation in females was much less as compared to males. there may be more than one plausible factor for this. as avms tend to grow under hormonal influences, they enlarge at puberty and in pregnancy.8 this could be a reason why it becomes apparent and is picked up early in females. males were more likely to have an avm involving the trunk whereas avms on the limbs were more prevalent in females. while the such difference in gender on the presentation of intracranial avms was found in some studies but further studies are needed before the same can be concluded for non-intracranial avms.9 the diagnosis of avms is made based on imaging findings. mri, which has a wider observable range than ultrasound, is better suited for initial workup and to rule out vascular neoplasms such as hemangiomas. invasive investigations such as selective angiography are also used in the workup of avms. avms are the only cvms requiring a diagnostic angiography.3, unlike other cvms that can be monitored closely and left untreated if asymptomatic, avms require early and aggressive treatment. this is because avms can threaten life or limb. avms if large enough, are also found to cause high-output cardiac failure, which usually accounts for most of the capacitance in a vascular circuit. artery steal syndromes can also occur resulting in under-perfusion of tissues leading to skin ischemia and soft tissue and muscle necrosis with resulting gangrene. a large avm in close vicinity of a long bone can also cause limb-length discrepancy.10 endovascular techniques which include sclerotherapy and angio embolization have long been used as a 2nd line of treatment for those lesions which are unsuitable for formal excision, but currently, these are often combined with surgical excision for higher success rates.11 sclerotherapy has been used for the treatment of vascular malformations. the sclerosing agent used in our study was sts, which is a fatty acid salt with detergent properties that allow it to modify the surface tension around endothelium, resulting in vascular injury.12 such injury to the vessel then results in fibrotic changes and occlusion of the j islamabad med dental coll 2023 92 lesions.13 side effects of sts are self-resolving swelling and skin necrosis and these were noted in more than 50% of cases in our study. an important but uncommon adverse effect is hemoglobinuria which arises due to self-limiting hemolysis and can be prevented by prophylactic hydration before the procedure and the use of diuretics if required. no such case developed in our study. sts has been found a very effective option for the treatment of avms since there was complete resolution in the 26 patients in our study who underwent dgfs as monotherapy. similar results have been procured by other studies using sts for the treatment of avms elsewhere.14,15. many types of embolics may be used for embolic therapy, starting from mechanical coils to particles such as pva and liquid embolics such as nbca (nbutyl cyanoacrylate) and onyx.16 the agent used in our study was nbca, a cyanoacrylate glue which polymerizes on contact with any ionic solution such as blood or contrast solution, forming a caste of the vessel instantly.17 there is no evidence that nbca causes endothelial injury, which means that although it is associated with a reduced risk of complications, the risk of recanalization is higher. embolization before surgery results in a reduction of blood flow in the avm, hence also resulting in less bleeding during surgery.18 moreover, it eliminates deep feeding arteries that are thought to be the limiting factor in the surgical respectability of large avms. the most important complication that is worth mentioning is that after the embolization procedure, there could be a blockade of non-target vessels, which can potentially result in ischemia and sepsis. other, less devastating adverse effects include microcatheter blockage and catheter retention, both of which are due to premature polymerization of nbca. awareness of factors, for instance, the technique of injection and strength of nbca dilution is paramount to minimize damage, since nbca glue deposition is very unpredictable when tested in vivo.19 sirolimus (rapamycin), an mtor inhibitor can be used in the treatment of vascular malformations. mtor is a kinase that promotes protein synthesis when activated. furthermore, activation of mtor results in the removal of inhibitory influences on protein translation, making it a very important regulator of cell multiplication.20 this makes mtor a plausible target for the treatment of avms, as its inhibition can potentially prevent angiogenesis.21 sirolimus can be combined with other modalities, such as sclerotherapy in our study. sole treatment with sirolimus does not offer a complete cure, as evident by the persistence of positive blood flow pockets in the avm of the patient who underwent treatment with sirolimus in our study. this is consistent with the findings of many other studies which also showed no or very small improvements with sirolimus.22,23 however, it can be considered a palliative option, especially in such cases where formal excision is not possible. an important limitation of our study was the sample size, and this was due to the rarity of the disease. considering that it is a pilot study, our objective was to note any differences where present in the patient groups studied. however, we fully agree that all the findings in this study cannot be generalized to the overall population. for such, we need much larger and more powerful studies. c o n c l u s i o n there is notable variance in avms in terms of size and type based on gender, with males having more prevalence of mainly high flow avms on the trunk while females have low flow avms mostly on limbs. sclerotherapy or embolotherapy should be performed before a planned surgical excision since they reduce peri-operative complications and future recurrence. j islamabad med dental coll 2023 93 r e f e r e n c e s 1. trotter jw, kirkpatrick jp. arteriovenous malformation: a real can of worms. int j radiat oncol biol phys. 2021; 111(4):851-3. https://doi.org/10.1016/j.ijrobp.2018.08.068 2. polubothu s. genothype-guided medical treatment of arteriovenous malformation. clin exp dermatol. 2021; 46(4):800-1. https://doi.org/10.1111/ced.14439 3. mulligan pr, prajapati hjs, martin lg, patel th. vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches. br j radiol. 2014; 87(1035):1–18. https://doi.org/10.1259/bjr.20130392 4. alshamekh s. arteriovenous malformations. dermatol clin. 2022; 40(4):4458.https://doi.org/10.1016/j.det.2022.06.012 5. fernandez-alvarez v, suarez c, bree r, nixon ij, makitie aa, rinaldo a, et al. management of extracranial arteriovenous malformations of the head and neck. auris nasus larynx. 2020; 47(2): 18190. https://doi.org/10.1016/j.anl.2019.11.008 6. soulez g, gilbert p, giroux mf, racicot jn, dubois j. interventional management of arteriovenous malformations. tech vasc interv radiol. 2019; 22(4): 100633.https://doi.org/10.1016/j.tvir.2019.100633 7. lee bb, baumgartner i, berlien hp, bianchini g, burrows p, do ys, et al. consensus document of the international union of angiology. current concept on the management of arterio-venous management. int angiol. 2013; 32(1):9–36. https://doi.org/10.1007/s00547-003-0844-2 8. lee bb, villavicencio jl. rutherford's vascular surgery and endovascular therapy. 9th ed. philadelphia: elsevier; 2018. p. 2236-50. https://doi.org/10.1177/153100358900200209 9. tong x, wu j, lin f, cao y, zhao y, ning b, et al. the effect of age, sex, and lesion location on initial presentation in patients with brain arteriovenous malformations. world neurosurg. 2016; 87(2):598606. https://doi.org/10.1016/j.wneu.2015.10.060 10. bertino f, frederic ka, hawkins cm, gill ae, briones ma, swerdlin r, et al. congenital limb overgrowth syndromes associated with vascular anomalies. radiographics. 2019; 39(2):491-515. https://doi.org/10.1148/rg.2019180136 11. sohail m, bashir m, ansari h, khan fa, assumame n, awan nu, et al. the outcome of management of vascular malformations of lip. j craniofacial surg. 2016; 27(6):e520e524.https://doi.org/10.1097/scs.000000000000282 4 12. ahmad s. efficacy of percutaneous sclerotherapy in low flow venous malformations-a single centre series. neurointervention. 2019; 14(1):53. https://doi.org/10.5469/neuroint.2019.00024 13. stuart s, barnacle a, smith g, pitt m, roebuck dj. neuropathy after sodium tetradecyl sulfate sclerotherapy of venous malformations in children. radiology. 2015; 274(3):897-905. https://doi.org/10.1148/radiol.14132271 14. kirkpatrick dl, frenette a, hasham ha, custer b, lemons s, collins z, et al. successful percutaneous treatment of an arteriovenous malformation of the toe. ann vasc surg. 2020; 65(1):288.e5-288.e8. https://doi.org/10.1016/j.avsg.2019.11.034 15. sitra g,kayalvizhi ab, sivasankari t, vishwanath r. a new venture with sclerotherapy in an oral vascular lesion. j basic clin pharm. 2015; 6(1):40. https://doi.org/10.4103/0976-0105.145778 16. vollherbst df, chapot r, bendszus m, mohlenbruch ma. glue, onyx, squid or phil? liquid embolic agents for the embolization of cerebral arteriovenous malformations and dural arteriovenous fistulas. clin neuroradiol. 2022; 32(1):25-38. https://doi.org/10.1007/s00062-021-01066-6 17. khurana a, hangge p, albadawi h, knuttinen mg, alzubaidi sj, naidu sg. the use of transarterial approaches in peripheral arteriovenous malformations (avms). j clin med. 2018; 7(5):109.https://doi.org/10.3390/jcm7050109 18. kansy k, bodem j, engel m, freudlsperger c, mohlenbruch ma, herweh c, et al. interdisciplinary treatment algorithm for facial high-flow arteriovenous malformations, and review of the literature. j craniomaxillofac surg. 2018; 46(5):76572. https://doi.org/10.1016/j.jcms.2018.03.002 19. hill h, chick jfb, hage a, sirinivasa rn. n-butyl cyanoacrylate embolotherapy: techniques, complications, and management. diagnostic interv j islamabad med dental coll 2023 94 radiol. 2018; 24(2):98– 103.https://doi.org/10.5152/dir.2018.17432 20. ji y, chen s, yang k, zhou j, zhang x, jiang x, et al. a prospective multicenter study of sirolimus for complicated vascular anomalies. j vasc surg. 2021; 74(5): 1673-81. https://doi.org/10.1016/j.jvs.2021.04.071 21. maruani a, tavernier e, boccara o, mazereeuwhautier j, leducq s, bessis d, et al. sirolimus (rapamycin) for slow-flow malformations in children: the observational – phase randomised clinical performus trial. jama dermatol. 2021; 157(11):1289-98. https://doi.org/10.1001/jamadermatol.2021.3459 22. gabeff r, boccara o, soupre v, lorette g, bodemer c, herbreteau d, et al. efficacy and tolerance of sirolimus (rapamycin) for extracranial arteriovenous malformations in children and adults. acta derm venereol. 2019; 99(12):1105–9. https://doi.org/10.2340/00015555-3273 23. freixo c, ferreira v, martins j, almeida r, caldeira d, rosa m, et al. efficacy and safety of sirolimus in the treatment of vascular anomalies: a systematic review. j vasc surg. 2020; 71(1):318-27. https://doi.org/10.1016/j.jvs.2019.06.217 j islamabad med dental coll 2022 62 open access impact of extroversion on oral health-related quality of life in prosthodontic patients waleed ishaq1, hira riaz2, muhammad amir ghafoor chaudhary3, rida anjum4, salman ahmad5, sara bano6. 1,2assistant professor, department of prosthodontics, islamic international dental college, riphah international university. 3associate professor and hod, department of prosthodontics, islamic international dental college, riphah international university. 4senior registrar, department of prosthodontics, azra naheed dental college, superior university, lahore. 5professor and hod, department of prosthodontics, foundation university college of dentistry. 6demonstrator, department of operative dentistry, shifa tameer –emillat university. a b s t r a c t background: oral health-related quality of life (ohrqol) is a compound model comprising individualized evaluation of one’s emotional, functional and oral health. it is easily influenced by multiple variables including oral problems, cultural differences and personality traits. where other personality traits negatively influence ohrqol, extroversion exhibits a positive association. contrarily, conflicting results have been reported in literature. the inconsistent results, insufficient local data and cultural differences make it imperative to further investigate. the objective of the study was to determine a correlation between extroversion and ohrqol in prosthodontic patients. methodology: this cross-sectional study was conducted in prosthodontics department of islamic international dental hospital, islamabad from may 2018 to april 2019. sample size was calculated to be 270 with 5% significance level and spearman correlation coefficient of 0.17. however, 305 patients were included in this study. after obtaining informed consent and recording demographic data, oral health impact profile-14 (ohip-14) and eysenck personality questionnaire–revised short-scale (epq-rs) were used to collect the required data and categorize patients. results: the bivariate correlation analysis revealed extroversion to be negatively associated (r = -0.220) with ohip score. it depicts that the more extrovert an individual, the lower the ohip score (better ohrqol) and vice versa. effect modifier analysis revealed inconsistent correlation results for extroversion. conclusion: a positive correlation has been established between extroversion and ohrqol, with inconsistent results after controlling effect modifiers. keywords: extroversion, oral health, personality, quality of life authors’ contribution: 1conception; literature research; manuscript design; 2,3 critical analysis and manuscript review; 4data collection; 5,manuscript editing;6data analysis. correspondence: waleed ishaque email: waleed.ishaque.warraich@gmail.com article info: received: october 20, 2021 accepted: may 27, 2022 cite this article. ishaq w, riaz h, chaudhary mag, anjum r, ahmed s, bano s. impact of extroversion on oral health-related quality of life in prosthodontic patients. j islamabad med dental coll. 2022; 11(2):62-70. doi:https://doi.org/10.35787/jimdc.v11i2.800. funding source: nil conflict of interest: n o r i g i n a l a r t i c l e mailto:waleed.ishaque.warraich@gmail.com j islamabad med dental coll 2022 63 i n t r o d u c t i o n oral health-related quality of life (ohrqol) is a compound model comprising individualized evaluation of one’s emotional, functional and oral health.1 ohrqol measures have been used in dentistry to determine the inter-play between personality traits, quality of life, patient’s dental perceptions and satisfaction level.2 it is important to consider ohrqol because oral problems have been known to influence the psychosocial and functional health of a person considerably. owing to its dynamic nature, ohrqol is influenced by socio-demographic factors, cultural variances and personality traits and therefore may change with time.3 personality has been reported to consistently relate with quality of life. interestingly, the moderate impact of personality usually prevails over that of socio-demographic and even clinical variables.4 this highlights the predictive value of personality traits towards quality of life and general functioning in the discipline of medicine.5 several studies showed relationship between quality of life and patient personality in the field of dentistry. the study conducted by takeshita et al.2 reported an association between personality traits and ohrqol, irrespective of the dental status and oral function. ohrqol is reported to be negatively associated with neuroticism and positively associated with extroversion. such impact of personality traits may be caused by their strong correlation with sense of purpose, which itself is positively associated with self-reported health. this makes the patients prone to oral disease and alters their disease perceptions.6 another study conducted on undergraduate medical students found personality traits to be influencing both self-esteem and ohrqol significantly.7 similar results have been reported in the field of orthodontics by al nazeh et al. 8 who found extroversion, openness, and conscientiousness personality factors contributing towards ohrqol. in the field of prosthodontics, reissmann, et al 9 concluded that substantially improved ohrqol, usually observed with implant treatment, is not independent of patient's clinical and psychosocial characteristics. however, contrary to all the above mentioned studies, menassa et al. 10 found no such correlation. they found that in patients receiving implant-supported mandibular overdenture, ohrqol improved regardless of their personality traits or other clinical variables. the objective of the study was to determine a correlation between extroversion and ohrqol in prosthodontic patients. the gathered information will provide an insight into the importance of evaluating patient personality traits prior to comprehensive prosthodontic treatment, since they may be influential to their ohrqol, by either altering their perspectives, expectations, or treatment outcomes. since more dental visits could also be expected from people with certain personality traits, this investigation will further aid in understanding a public health burden. it will therefore be advantageous if the dental practitioner can foresee these problems, predict patient’s tolerance and responses to a prescribed therapy and ultimately improve their ohrqol. m e t h o d o l o g y this cross-sectional study was conducted at prosthodontics department of islamic international dental hospital islamabad from may 2018 till april 2019. with reference to the correlation coefficient values from the study by takeshita et al.2, sample size for extroversion was calculated to be 270 with significance level 5% and spearman correlation coefficient of 0.17. however, 305 patients were included in this study. the sampling technique followed was consecutive non-probability. j islamabad med dental coll 2022 64 formal approval was obtained from the ethical review committee of the institute. the study sample was collected from the patients referred to the department of prosthodontics for treatment purpose. informed consent was obtained from the patients before being included in the study and interviewed. male and female patients ranging in age from 21 years to 65 years presenting with partial or complete tooth loss were included while patients who were old-denture wearers, mentally handicap, non-cooperative, unable to comprehend or respond to questions efficiently and those undergoing antidepressant therapy were excluded from the study. after relevant clinical and radiographic examination, a provisional diagnosis was made followed by a tentative treatment plan. all interviews were conducted by the principal investigator prior to any prosthodontic procedure to overcome any treatment-related bias. first, basic demographic information was recorded in a self-designed proforma. patients were inquired about their education level, socioeconomic status and locality. the data helped to place patients into their corresponding groups. according to age, patients were categorized into three groups: group i (21-35 years), group ii (36-50 years) and group iii (51-65 years). four groups were proposed on the basis of education level: illiterate, under-graduate, graduate and post-graduate. similarly, socioeconomic status was categorized into three groups: low class (monthly income less than 50k), middle class (monthly income from 50k to 150k) and high class (monthly income above 150k). after the first proforma, the following 2 questionnaires were filled: oral health impact profile-14 (ohip-14) and eysenck personality questionnaire–revised short-scale (epq-rs). all the questions were translated and explained to the patients in urdu language. in order to assess the ohrqol, every patient was asked 14 questions from the ohip-14 standard questionnaire. patients responses were recorded on a four-point likert scale, either as never (frequency = 0%), sometimes (frequency ≤ 50%), often (frequency = 50-75%) or always (frequency = 75-100%). each question was scored independently. final ohip score was obtained by summing up the individual scores of all the questions. it could range from minimum of 0 to maximum of 42. this ohip score was used to categorize ohrqol into three groups i.e. good (score of 0 14), average (score of 15 28) and poor (score of 29 42). after the completion of the first questionnaire, every patient was asked questions from the epq-rs standard questionnaire which originally consists of 48 questions for assessment of four major personality traits (12 questions per trait) including neuroticism, extroversion, psychoticism and lie. only extroversion was assessed for this study. the data was recorded and analyzed on spss (version 23). descriptive statistics were calculated for both quantitative and qualitative variables. means with standard deviations were calculated for the quantitative variables i.e. age, ohip score, and extroversion score. frequencies with percentages were calculated for qualitative variables i.e. gender, age groups, education level, socioeconomic status, locality, oral health-related quality of life (ohrqol) and extroversion. bivariate correlation analysis was done between extroversion and ohip score. poststratification correlation was used to evaluate underlying influence of the effect modifiers on the statistically obtained relationship between oral health related quality of life and extroversion. p value of 0.05 or less was considered statistically significant. j islamabad med dental coll 2022 65 r e s u l t s the 305 patients in the age range of 21 years to 65 years, with a mean age of 40.47 years and standard deviation of 15.84 participated in the study. the ohip score obtained by the participants ranged from 0 to 37 with a mean of 12.26 and standard deviation of 8.67. the extroversion score ranged from 0 to 12 with a mean of 7.16 and standard deviation of 3.15. the study included 122 (40%) male and 183 (60%) female participants. according to age groups, more than half participants i.e. 159 (52%) were from group i (21-35 years) followed by 113 (37%) participants from group iii (51-65 years). least participation was from group ii (36-50 years) which comprised of only 33 (11%) patients. based on education level, majority of the sample swas well educated. only 16 (5.2%) participants were illiterate and 94 (30.8%) were under-graduates. 137 (45%) were graduates while 58 (19%) were post-graduates. on the basis of socioeconomic status, majority of the sample size i.e. 181 (59.3%) candidates belonged to the middle class families, 89 (29.2%) participants were from poor socioeconomic background while only 35 (11.5%) were from high class status. quality of life assessment returned promising results. good ohrqol was observed in majority of participants i.e. 188 (61.7%), whereas only 19 (6.2%) showed poor ohrqol. average ohrqol was exhibited by 98 (32.1%) participants. in the five categories of extroversion, 32 (10.5%) participants were assessed as ‘introvert’, 57 (18.7%) showed ‘tendency towards introversion’, 32 (10.5%) were ‘average’, 99 (32.4%) showed ‘tendency towards extroversion’ while 85 (27.9%) were ‘extrovert’. in order to find out the relationship between ohrqol and extroversion, a bivariate correlation analysis was performed in spss (version 23) between ohip score and the personality trait under observation i.e. extroversion. extroversion was found to be negatively associated with ohip score (rs = -0.220). it shows that the more extrovert the individual, the lower the ohip score which in turn represents a better ohrqol. p-value (0.000) depicts the highly significant relationship between these two variables. in order to address the influence of effect modifiers, stratification of data was done followed by correlation analysis of ohrqol with extroversion. the first effect modifier under observation was gender. as depicted in table i, association of ohrqol with extroversion remained significant after data stratification. table ii depicts the correlation analysis after data stratification according to the three devised age groups. unlike the significant association observed in two age groups i.e. group ii (36-50 years) and group iii (51-65 years), group i (21-35 years) showed insignificant association between extroversion and ohrqol. after data stratification into four groups according to education level, correlation analysis revealed that ohrqol was still significantly associated with extroversion in two groups i.e. undergraduates and postgraduates (table iii). illiterates and graduates did not exhibit significant association between extroversion and ohrqol. as shown in table iv, correlation analysis revealed that ohrqol was still significantly associated with extroversion in two groups (middle class and high class). individuals from low class socio-economic status did not exhibit significant association between extroversion and ohrqol. j islamabad med dental coll 2022 66 table i: correlation between ohrqol and extroversion with gender as effect modifier extroversion ohrqol in males (n = 122) ohrqol in females (n = 183) good average poor good average poor introvert 7 (5.7%) 4 (3.3%) 0 (0.0%) 6 (3.3%) 7 (3.8%) 8 (4.4%) tendency introversion 18 (14.8%) 6 (4.9%) 2 (1.6%) 12 (6.6%) 16 (8.7%) 3 (1.6%) average 6 (4.9%) 2 (1.6%) 3 (2.5%) 15 (8.2%) 6 (3.3%) 0 (0.0%) tendency extroversion 30 (24.6%) 7 (5.7%) 2 (1.6%) 34 (18.6%) 25 (13.7%) 1 (0.5%) extrovert 33 (27.0%) 2 (1.6%) 0 (0.0%) 27 (14.8%) 23 (12.6%) 0 (0.0%) total 94 (77.0%) 21 (17.2%) 7 (5.7%) 94 (51.4%) 77 (42.1%) 12 (6.6%) correlation coefficient rs = -0.348 rs = -0.161 significance p = 0.000 p = 0.030 table ii: correlation between ohrqol and extroversion with age group as effect modifier extroversion ohrqol in group i (n = 159) ohrqol in group ii (n = 33) ohrqol in group iii (n = 113) good avg. poor good avg. poor good avg. poor introvert 9 (5.7%) 0 (0.0% 1 (0.6%) 0 (0.0%) 2 (6.1%) 6 (0.0%) 4 (3.5%) 9 (8.0%) 1 (0.9%) tendency introversion 15 (9.4%) 9 (5.7%) 0 (0.0%) 6 (18.2%) 2 (6.1%) 2 (6.1%) 9 (8.0%) 11 (9.7%) 3 (2.7%) average 15 (9.4%) 3 (1.9%) 0 (0.0%) 2 (6.1%) 2 (6.1%) 0 (0.0%) 4 (3.5%) 3 (2.7%) 3 (2.7%) tendency extroversion 36 (22.6%) 19 (11.9%) 0 (0.0%) 3 (9.1%) 5 (15.2%) 0 (0.0%) 25 (22.1%) 8 (7.1%) 3 (2.7%) extrovert 33 (20.8%) 19 (11.9%) 0 (0.0% 2 (6.1%) 1 (3.0%) 0 (0.0%) 25 (22.1%) 5 (4.4%) 0 (0.0%) total 108 (67.9%) 50 (31.4%) 1 (0.6%) 13 (39.4%) 12 (36.4%) 8 (24.2%) 67 (59.3%) 36 (31.9%) 10 (8.8%) correlation coefficient rs = 0.132 rs = -0.563 rs = -0.533 significance p = 0.096 p = 0.001 p = 0.000 j islamabad med dental coll 2022 67 table iii: correlation between ohrqol and extroversion with education level as effect modifier extroversion ohrqol in illiterates (n = 16) ohrqol in undergraduates (n = 94) ohrqol in graduates (n = 137) ohrqol in postgraduates (n = 58) good avg. poor good avg. poor good avg. poor good avg. poor introvert 0 0.0% 1 6.3% 0 0.0% 1 1.1% 3 3.2% 7 7.4% 10 7.3% 5 3.6% 1 0.7% 2 3.4% 2 3.4% 0 0.0% tendency introversion 0 0.0% 2 12.5 % 0 0.0% 5 5.3% 6 6.4% 5 5.3% 19 13.9 % 7 5.1% 0 0.0% 6 10.3 % 7 12.1 % 0 0.0% average 1 6.3% 0 0.0% 0 0.0% 5 5.3% 4 4.3% 3 3.2% 12 8.8% 4 2.9% 0 0.0% 3 5.2% 0 0.0% 0 0.0% tendency extroversion 2 12.5 % 5 31.3 % 1 6.3% 22 23.4 % 16 17.0 % 1 1.1% 24 17.5 % 7 5.1% 1 0.7% 16 27.6 % 4 6.9% 0 0.0% extrovert 2 12.5 % 2 12.5 % 0 0.0% 15 16.0 % 1 1.1% 0 0.0% 29 21.2 % 18 13.1 % 0 0.0% 14 24.1 % 4 6.9% 0 0.0% total 5 31.3 % 10 62.5 % 1 0.6% 48 51.1 % 30 31.9 % 16 17.0 % 94 68.6 % 41 29.9 % 2 1.5% 41 70.7 % 17 29.3 % 0 0.0% correlation coefficient rs = -0.215 rs = -0.552 rs = -0.034 rs = -0.269 significance p = 0.425 p = 0.000 p = 0.695 p = 0.041 table iv: correlation between ohrqol and extroversion with socioeconomic status as effect modifier extroversion ohrqol in low class (n = 89) ohrqol in middle class (n = 181) ohrqol in high class (n = 35) good avg. poor good avg. poor good avg. poor introvert 1 (1.1%) 3 (3.4%) 1 (1.1%) 9 (5.0%) 5 (2.8%) 7 (3.9%) 3 (8.6%) 3 (8.6%) 0 (0.0%) tendency introversion 10 (11.2%) 4 (4.5%) 1 (1.1%) 15 (8.3%) 15 (8.3%) 4 (2.2%) 5 (14.3%) 3 (8.6%) 0 (0.0%) average 5 (5.6%) 2 (2.2%) 1 (1.1%) 11 (6.1%) 5 (2.8%) 2 (1.1%) 5 (14.3%) 1 (2.9%) 0 (0.0%) tendency extroversion 21 (23.6%) 16 (18.0%) 2 (2.2%) 40 (22.1%) 14 (7.7%) 1 (0.6%) 3 (8.6%) 2 (5.7%) 0 (0.0%) extrovert 9 (10.1%) 13 (14.6%) 0 (0.0%) 42 (23.2%) 11 (6.1%) 0 (0.0%) 9 (25.7%) 1 (2.9%) 0 (0.0%) total 46 (51.7%) 38 (42.7%) 5 (5.6%) 117 (64.6%) 50 (27.6%) 14 (7.7%) 25 (71.4%) 10 (28.6%) 0 (0.0%) correlation coefficient rs = 0.059 rs = -0.316 rs = -0.445 significance p = 0.580 p = 0.000 p = 0.007 j islamabad med dental coll 2022 68 d i s c u s s i o n the correlation between qol and personality has rarely been explored in the discipline of oral health as opposed to multiple researches encompassing various medical conditions which emphasize the role of personality in shaping a patient’s qol. the personality trait under observation i.e. extroversion is linked with a sociable nature and lack of stressful sentiments. extroverts tend to exhibit a positive perception of their health status. the influence of extroversion on ohrqol fluctuates across existent researches but is generally theorized to improve coping and dealing with bothersome symptoms.11 on the basis of gender, this study returned consistent findings with many other investigations depicting a poorer oral health perception in women.12 on the contrary, sierwald et al.13 published research advocating males to be more sensitive to oral problems. the same research also concludes that ohrqol assessment is independent of age which contradicts the findings in this study where a significant relationship between age groups and ohrqol was observed. the middle age group i.e. group ii (36-50 years) exhibited poorer ohrqol in comparison to the age groups at both extremes. this finding has questionable validity due to least representation of participants in this age group. however, it does contradict the results of lodhi et al.14 who found geriatric individuals to be having poorer ohrqol. the relationship between the education level and ohip score is in line with past researches representing a significant role of education to predict ohrqol.2 education level was found to be directly related to ohip score with educated individuals exhibiting better ohrqol. on the contrary, the association between the ohip score and socioeconomic status is insignificant, making it inconsistent with previous studies which indicated its role in the prediction of ohrqol.2 it has been an established fact that particular personality traits exhibit a significant impact on responses to self-reported items. in this study, it was found that an association between oral health related quality of life and extroversion does exist. extroversion did affect the ohrqol but with inconsistent results after controlling effect modifiers. the inconsistency can be explained by the findings of bonafe et al.15 who reported no significant association between extroversion and ohrqol. multiple studies advocate that extrovert people, regardless of oral status, tended to score high on ohrqol index.2, 16 however this recommendation was inconsistent with the surprising observation by lin et al.12 who found no significant correlation between all dimensions of ohip-14 and extroversion. perhaps such contradicting studies explain the mixed results obtained in our study when the initially significant positive correlation established between ohrqol and extroversion disappeared after the application of poststratification effect modifier analysis. after adding effect modifiers, extroversion showed inconsistent results with all effect modifiers except gender. however, the disappearance of significant association observed in younger individuals ‘group i’ (21-35years) is in line with the findings of aydogan17, clijmans et al.18, gabriella et al.16 and takeshita et al.2 where the first researcher found no significant effect of extroversion on ohrqol in adolescents while the rest reported significant association in adults and elderly. these results should be taken into account when considering the approach towards a patient. the data contributes a clearer understanding of personality traits specifically extroversion and its impact on qol in the field of oral health. personality traits may influence an individual’s reaction to symptoms, contributing to sickness state and, thus relating to one’s ohrqol. with the passage of time, the demands of dental patients especially geriatric individuals are turning out to be ever more complex, so it is valuable to evaluate personality traits of a j islamabad med dental coll 2022 69 patient before dental treatment in order to foresee patient response and expectations affiliated with the devised treatment plan. another characteristic that may be influenced by personality traits is the compliance exhibited by the patient. understanding patient personality traits may aid to determine the most feasible therapy in accordance with their tolerance threshold, since more dental visits could also be expected from people with certain personality traits e.g. introversion. this will help us formulate a better approach in prevention of public health burden and efficient utilization of health resources. some limitations of this study must be considered. cross-sectional study design, although less demanding and low-cost, can only establish relation between a condition and one of its possible causative factor, rather than a “cause-and-effect” association. had the financial resources and time allowed, a longitudinal study would have been more appropriate to capture the change in attitude and behavior over time, enabling better identification of the relationships among different variables. another limitation was the exclusion of handicapped, noncooperative and patients who were unable to respond, making it impossible to collect a sample data that truly represents general population. further studies need to be conducted to confirm the modification of relationship between extroversion and ohrqol by other variables along with assessment of other personality traits as well. c o n c l u s i o n correlation existed between personality traits and oral health-related quality of life in prosthodontics patients. extroversion correlates positively with the ohrqol but with inconsistent results after controlling effect modifiers r e f e r e n c e s 1. john mt. foundations of oral health-related quality of life. j oral rehabil. 2021; 48: 355– 359. doi: 10.1111/joor.13040 2. takeshita h, ikebe k, kagawa r, okada t, gondo y, nakagawa t, et al. association of personality traits with oral health-related quality of life independently of objective oral health status: a study of communitydwelling elderly japanese. j dent. 2015;43(3):342-9. doi: 10.1016/j.jdent.2014.12.011. 3. sun l, wong hm, mcgrath cpj. the factors that influence oral health-related quality of life in 15-yearold children. health qual life outcomes. 2018 jan 18;16(1):19. doi: 10.1186/s12955-018-0847-5. 4. huang i, lee jl, ketheeswaran p, jones cm, revicki da, wu aw. does personality affect health-related quality of life? a systematic review. plos one. 2017 mar 29;12(3):e0173806. doi: 10.1371/journal.pone.0173806. 5. ridgewell c, blackford ju, mchugo m, heckers s. personality traits predicting quality of life and overall functioning in schizophrenia. schizophr res. 2017 apr;182:19-23. doi: 10.1016/j.schres.2016.10.007. 6. hill pl, edmonds gw, hampson se. a purposeful lifestyle is a healthful lifestyle: linking sense of purpose to self-rated health through multiple health behaviors. j health psychol. 2019;24(10):1392-1400. doi: 10.1177/1359105317708251. 7. oancea r, timar b, papava i, cristina ba, ilie ac, dehelean l. influence of depression and self-esteem on oral health-related quality of life in students. j int med res. 2020;48(2):1-11. doi: 10.1177/0300060520902615. 8. al nazeh aa, alshahrani i, badran sa, almoammar s, alshahrani a, almomani ba, et al. relationship between oral health impacts and personality profiles among orthodontic patients treated with invisalign clear aligners. sci rep. 2020;10(1):20459. doi: 10.1038/s41598-020-77470-8. 9. reissmann dr, dard m, lamprecht r, struppek j, heydecke g. oral health-related quality of life in subjects with implant-supported prostheses: a systematic review. j dent. 2017 oct;65:22-40. doi: 10.1016/j.jdent.2017.08.003. 10. menassa m, de grandmont p, audy n, durand r, rompre p, emami e. patients' expectations, satisfaction, and quality of life with immediate loading protocol. clin oral implants res. 2016;27(1):83-9. doi: 10.1111/clr.12515. 11. herzberg py, lee sj, heussner p, mumm fha, hilgendorf i, von harsdorf s, et al. personality influences quality-of-life assessments in adult patients j islamabad med dental coll 2022 70 after allogeneic hematopoietic sct: results from a joint evaluation of the prospective german multicenter validation trial and the fred hutchinson cancer research center. bone marrow transplant. 2013;48(1):129-34. doi: 10.1038/bmt.2012.83. 12. lin f, ye y, ye s, wang l, du w, yao l, et al. effect of personality on oral health-related quality of life in undergraduates. angle orthod. 2018;88(2):215-20. doi: 10.2319/051017-322.1. 13. sierwald i, reissmann d, john mt. assessing ohrqol using ohip: impact of age and gender. iadr/aadr/cadr general session. 2011 san diego, california. 14. lodhi fs, montazeri a, nedjat s, mahmoodi m, farooq u, yaseri m, et al. assessing the quality of life among pakistani general population and their associated factors by using the world health organization’s quality of life instrument (whoqol-bref): a population based cross-sectional study. health qual life outcomes. 2019;17(1):9. doi: 10.1186/s12955018-1065-x. 15. bonafé e, rezende m, machado mm, lima snl, fernandez e, baldani mmp, et al. personality traits, psychosocial effects and quality of life of patients submitted to dental bleaching. bmc oral health. 2021;21(1):7. doi: 10.1186/s12903-020-01370-6. 16. gabriella d, klemens r, xiao-hui rf, corinna b, eva h. effect of personality traits on the oral health related quality of life patients with oral lichen planus undergoing treatment. clin oral investig. 2021;25(4):2381-9. doi: 10.1007/s00784-020-035615. 17. aydoğan c. extraversion and openness to experience moderate the relationship between orthodontic treatment need and oral health related quality of life in adolescents. angle orthod. 2018;88(5):617-23. doi: 10.2319/103117-737.1. 18. clijmans m, lemiere j, fieuws s, willems g. impact of self-esteem and personality traits on the association between orthodontic treatment need and oral healthrelated quality of life in adults seeking orthodontic treatment. eur j orthod. 2015;37(6):643-50. doi: 10.1093/ejo/cju092. j islamabad med dental coll 2022 82 open access functional outcome of distal femur fracture treated with retrograde nailing technique muhammad azfar khanzada1, muhammad tahir lakho2, zulfiqar ali memon3, syed alam zeb4, bashir ahmed5, rajesh kumar6 1,4specialist, department of orthopedic surgery, alhabib hospital, riyadh, kingdom of saudi arabia 2assistant professor, department of orthopedic surgery, dr. ruth k. m. pfau, civil hospital, karachi 3senior registrar, department of orthopedic surgery, liaquat university of medical and health sciences, jamshoro 5surgeon, department of orthopedic surgery, jinnah postgraduate medical center, karachi 6medical officer, dr. ruth k. m. pfau, civil hospital, karachi a b s t r a c t background: management of distal femur fractures is always challenging for the surgeons. retrograde interlocking nailing is one of the effective methods with minimal complications for treatment of such fractures. the objective of the study was to evaluate the functional outcome of retrograde interlocking nailing technique in patients with distal femur fractures. methodology: this interventional study was conducted at the department of orthopedic surgery, liaquat university hospital, hyderabad from march 2017 to december 2019. patients of either gender, between 30 to 65 years age, who presented with acute fracture of distal femur, as a result of trauma within 12-96 hours, requiring surgical intervention were included. lysholm scoring system was used to evaluate the functional outcome of patients treated with retrograde interlocking nailing technique. data was analyzed using spss version 24. results: total 102 patients gave consent of participation. the mean age of study participants was 43.50±7.26 with the age range from 40-65 years. male patients were 76.47% and female 23.53%. in majority (63.73%) of cases, mode of injury was road traffic accidents. statistically significant difference in functional mobility score between the age groups and gender (p < 0.05) was found. statistically significant (p < 0.05) decline in mean lysholm score was observed in participants who had been bearing full weight for 3 months. excellent functional outcome was achieved by 49.02% patients while 34.31% patients achieved good functional outcome. conclusion: retrograde interlocking nailing for fracture of distal femur is an effective fixation surgical technique with minimal complications and excellent to good functional outcome. key words: accidents, femur fractures, fracture fixation, functional performance authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 4data analysis; 5,6manuscript editing. correspondence: zulfiqar ali memon email: memon.zulfi9326@gmail.com article info: received: february 26, 2021 accepted: may 17, 2022 cite this article. khanzada ma, lakho mt, memon za, zeb sa, ahmed b, kumar r. functional outcome of distal femur fracture treated with retrograde nailing technique. j islamabad med dental coll. 2022; 11(2):82-88. doi: https://doi.org/10.35787/jimdc.v11i2.687 funding source: nil conflict of interest: nil i n t r o d u c t i o n distal femur fractures (dff) are the fractures that occur upto 15cm from the articular surface of distal femur. these are infrequently occurring fractures o r i g i n a l a r t i c l e j islamabad med dental coll 2022 83 that constitute around 4-6% of all femur fractures.1 globally, the dff usually results from high energy trauma such as motor vehicle accidents, frequently seen in males between their 15 to 50 years of age. while dff resulting from low energy trauma like simple fall commonly occurs in females more than 50 years of age. moreover, patients suffering from osteoporosis and/or having previous knee arthroplasties are at higher risk of these fractures.2,3 globally, in elderly people, dff are the second most common cause of mortality after hip fractures.3 fractures of distal femur are usually treated by using different surgical techniques like; internal fixation by 95 degree angle blade plate, cancellous screws, dynamic condylar screw and plate, condylar buttress plates, distal femoral locking plate and retrograde intramedullary nail.3,4 while conservative methods include traction and plaster immobilization of joint, the ultimate goal of restoration of alignment is to preserve the function of extremity which is a crucial step in the definitive treatment of distal femur fracture.4 in addition to this, early knee range of motion (rom) is the key to achieve acceptable outcomes. whereas, loss of knee rom and subsequent stiffness of the knee joint may result in immobilization and often contribute to poor outcome. understanding the characteristics, principles and challenges in the management of dff is important in optimizing their outcomes.5,6 closed intramedullary implants not only respect soft tissue envelope and periosteum but can achieve this goal without increasing the risk of infection and prolonged immobilization. retrograde interlocking nail is associated with swift recovery, early union and lesser complications.6 this implant is preferable to plate and screws because it is load sharing, minimum soft tissue dissection and periosteal stripping is done during its application, chances of union are more and patient is mobilized earlier.(5, 7) while some very minimal complications like knee pain, nonunion, and arthrofibrosis are also associated with this technique. the current interventional study was designed to evaluate the functional outcome of retrograde interlocking nailing technique in patients with distal femur fracture presented in liaquat university hospital hyderabad. the findings of the present study can help in formulating the standard guidelines for the effective and efficient surgical technique for dff. m e t h o d o l o g y the interventional study was conducted at the orthopedic surgery unit of liaquat university hospital, jamshoro, hyderabad from march 2017 to december 2019. all the patients of either gender, between ages 40 to 65 years, who presented with acute fracture of distal femur close extra-articular and intra-articular fractures (diagnosed by radiograph) resulting from the trauma within 12– 96 hours, requiring surgical intervention were included. while patients, presenting with gunshot injury, previous knee injury, fracture involving nerve, vascular and/or head injury, poly trauma of other bones of same side, previous interventional femoral surgery of same side, having evidence of infected wound or existence of purulent discharge on examination and with lost follow-up were excluded from the study. the sample size of 102 was calculated by setting confidence interval at 95%, margin of error at 8% and taking 23% of anticipated proportion knee range pain using open epi. online calculator.8,9 non-random consecutive sampling technique was applied for selection of the participants. ethical approval was sought from the ethical review board of liaquat university of medical and health sciences, jamshoro. an informed consent was taken from the patients after briefing them about the risks and benefits, as well as purpose of the study. a predesigned written proforma was used to collect the detailed information of all the participants relating to the age, sex and occupation, mode of j islamabad med dental coll 2022 84 injury, past and associated medical illness.10 after collection of information, all the patients were assessed and treated for any life-threatening conditions. detailed physical examination was done in all the patients to observe the condition of skin, any swelling or edema, vascular involvement etc. upon arrival, patients were kept on skeletal pin traction or below knee skin traction application and limb put over bohler-braun cradle till the time of operation while in some cases, a skin traction or a long slab was applied. x-ray of the affected limb was taken in anterior-posterior and lateral views at the time of admission. distal femur fracture was classified according to the arbeitsgemeinschaft für osteosynthesefragen (ao) classification system.11 all surgeries were performed under general or spinal anesthesia on radiolucent traction table. preoperative prophylactic antibiotic (second generation cephalosporin) was administered to all the patients at the time of induction. all surgeries were performed in a standard and uniform manner. open reduction and internal fixation were done using standard lateral approach. patients were kept in supine position, on radiolucent table with knee in slight flexion. the femoral condyle was exposed through a central 5 cm incision starting from lower pole of patella and just medial to the patellar tendon. the inter condylar notch was palpated and under image intensifier (anterior-posterior and lateral fluoroscopy) proper entry point was made and guide wire was passed while maintaining reduction and alignment. a proper length and maximum diameter of nail was inserted closely and locked at both ends. the medullary canal was reamed and the nail of appropriate size was reinserted. to encourage the early range of motion of knee, physiotherapy was initiated on the first postoperative day. patients were called for follow up at 2nd, 4th and 6th week initially and then monthly for one year. in each visit, patients were clinically assessed for knee range of motion, measured by goniometer and ability to tolerate weight. xrays were done to evaluate the bony union. the functional outcome was assessed on the 36th week post-operatively with radiological healing through x ray ap/lateral view and lysholm gillquist scoring system (lgss). the lysholm knee scoring system comprise of eight components to measure: pain, instability, limp, swelling, locking, squatting, support and stair climbing. for each question response, an arbitrary score has been assigned. the random lgss has a maximum score of 100. the scores >90 is graded as excellent, while 84-90 considered as good, it is categorized as fair, if score is 65-83 and poor if the score is <65.12 data was entered and analyzed using spss ver. 24. the relationship between age of all participants (≤ 45 and over 45 years), gender, the duration of immobilization (up to 6 and ≥ 6 weeks), time to start full weight-bearing (≤ 3 months and over 3 months) were also analyzed.13 qualitative variables are presented as frequency and percentages while quantitative variables demonstrated as means and standard deviation. student’s t-test was applied for the statistical analysis of qualitative variables. significance level was kept at p-value < 0.05. r e s u l t s total 102 patients participated in the study. the mean age of study participants was 43.50±7.26 with the age range from 30-65 years. male patients were 78(76.47%) and female 24(23.53%). according to stratified groups, 43(42.15%) patients were aged ≤45years and 59(57.84%) patients were aged >45 years. mean age of patients aged ≤45 years was 37.83±3.07 years and for patients aged >45 years the mean age was 53.42±3.14 years. most of participants had right side of knee involved (61.76%) compared with left side (38.23%). in majority of cases, mode of injury was road traffic accidents (rta) (63.73%) while second highest number of patients sustained fractures due to fall on ground. (36.27%) j islamabad med dental coll 2022 85 on radiological examination, majority 36(35.30%) of patients had type a1, 26(25.50%) a2, 21(20.58%), a3 and 19(18.62%) patients had c1 type of femur fracture on ao classification. total 48 (47.07%) patients underwent surgery within three days of admission while 39 (38.23%) patients underwent surgery in 3-7 days after initial stabilization and 15 (14.70%) underwent surgery after 7 days of admission after extensive treatment for controlling infection. after completion of one year, out of total patients, ≥110° flexion was achieved by 75 (73.53%) patients, 91°-109° flexion achieved by 16(15.68%) patients and ≤ 90° of knee flexion was achieved by 11 (10.78%) patients. the knee flexion was assessed for all the patients and the mean flexion at knee on different duration is mentioned in table i. table i: mean flexion at knee joint on different follow-up visits monthly follow-ups mean degree of flexion first 42.10° ± 5.26° third 89.62° ± 10.81° sixth 111.87° ± 9.21° twelfth 120.50° ± 11.87° the findings of functional outcome for all the patients is shown in the figure below. majority of patients showed excellent functional outcome on lgss. (figure 1) figure 1: functional outcome on lysholm gillquist scoring system (lgss) table ii below is demonstrating the relationship between the age, gender, immobilization time and weight bearing time with functional scores of the patients. there was a statistically significant difference between the two age groups (< 45 and >45) and gender (p < 0.05), while no statistically significant difference between the affected side of the patients and functional outcomes. table ii: differences in mean lysholm knee scoring among study participants lysholm knee scoring mean± sd p-value age  ≤ 45 years  > 45 years 90.71±7.34 80.11±9.78 0.0001* gender  male  female 91.24±6.45 85.13±7.08 0.0003* immobilization time  < 6 weeks  ≥ 6 weeks 87.81±10.68 81.32±13.22 0.054 weight-bearing time  ≤ 3 months  > 3 months 87.54±13.27 79.48±13.54 0.010* radio-graphical presentation of fracture of distal femur at the time of admission and after application of retrograde femoral nail. 1a-pre-operative radiographic scan j islamabad med dental coll 2022 86 1bpost-operative retrograde femoral nailing d i s c u s s i o n the patterns and spectrum of distal femur fractures are so diverse that no single treatment option has proven consistently successful. the management of dff using surgical techniques with the ultimate goal of restoration of alignment is preservation of the function of extremity, promotion of early motion of knee and restoration of articular surfaces.5 moreover, preservation of soft–tissue envelope by durable fixation techniques allows the functional recovery throughout the bone healing.7,14 the present study was designed with an objective of the evaluation of functional outcome of dff using retrograde nailing technique. the male to female ratio in our study is 3:1 while more patients belong to age > 45 years. the demographic profile of the present study participants is almost identical to those reported in previous studies by shah et al and prasanna et al.14, 15 in this study, the retrograde nailing technique was being used. the advantages of closed intramedullary nailing act as a load sharing device range from providing the favorable intramedullary stability, early mobilization to lesser complications as compared to other treatment options. it is a closed treatment option without interrupting the fracture hematoma and leads to early callus formation.16 in order to preserve the soft-tissue envelope and for achieving the closed indirect fracture reduction, the nail was inserted at a correct insertion point, so that it may leave the soft-tissue envelope intact. moreover, the intramedullary fixation not only allows to achieve the multi-angle interlocking but also protects blood circulation around the fracture at the utmost extent. in our study, significantly higher union rate of dff with minimal complications was achieved. atef et al. also endorsed these findings in his study and reported the 100% union rate of dff in their study participants.12 a study by dileep et al. reported that retrograde nailing is the reliable technique for dff with higher rate of union, with very limited complications that don’t affect the movement of knee.17 two other local studies by habib et al and shafiq et al also reported excellent functional outcome, union rate and minimal complications using retrograde nailing technique in dff in majority of their study participants.7, 9 most 60(61.9%) of the participants in our study had right side of knee involved compared with left side 37(38.1%). rta was the most common mode of injury in this study as more than 60% patients suffered from rta while 36.27% of patients sustained fractures due to fall on ground. prasanna et al and jillala et al also reported similar proportion of mode of injury in their study participants with rta more predominant mode of injury.15, 18 several rating scales are available and have been used to determine the functional outcomes after surgical treatment of fractures of femur yet none of the scale is validated to be superior to other. the most commonly used rating scales for functional outcome assessment include; lysholm gillquist scoring system (lgss), neer’s score, schaztker and lambert score, rand knee society score (kss) etc. in our study, we used lysholm gillquist scoring system for the assessment of functional outcome of patients with dff undergoing retrograde intramedullary nailing technique.19 in the present study, excellent functional outcome was demonstrated in 49.02%, good in 34.21% and j islamabad med dental coll 2022 87 fair in 9.80% patients with dff type a1, a2, a3 and c1 according to the lysholm knee scoring system. poor functional outcome due to non-union and breakage of nail was demonstrated in 6.86% patients in our study. moreover, prasanna et al also reported consistent findings as over two-third of their patients had excellent to good functional outcome using same technique and scoring system.(15) shah et al. also reported an excellent to good functional outcome in majority of their study participants after retrograde nailing for dff using schatzker and lambert criteria.14 few complications are observed in patients of the present study, the most common complication was anterior knee pain followed by superficial infection at the site of nail insertion and delayed union. similar findings have been reported by prasanna et al. while another study reported more serious complications including pulmonary embolism, knee stiffness and shortening of size of femur.15 this study evaluated the functional outcome of intramedullary retrograde nailing technique for dff, comparative analysis of different surgical techniques may provide more detailed information regarding effectiveness of the surgical techniques. c o n c l u s i o n intramedullary retrograde nailing for fracture of distal femur is reliable and effective fixation surgical technique. excellent to good functional outcome with minimal complications and disruption to the soft tissues, as well as higher union rate and fast recovery is achieved in distal femur fracture patients. r e f e r e n c e s 1. rathi nb, solanki ra, patel ha, tank pj. study of retrograde intramedullary nailing in distal one third shaft femur fracture. journal of dental and medical sciences. 2016;15(4):18-23. 2. elsoe r, ceccotti aa, larsen p. population-based epidemiology and incidence of distal femur fractures. international orthopaedics. 2018;42(1):191-6. doi: 10.1007/s00264-017-3665-1. 3. meluzio m, oliva m, minutillo f, ziranu a, saccomanno m, maccauro g. the use of knee megaprosthesis for the management of distal femoral fractures: a systematic review. injury. 2020;51:s17s22. doi: 10.1016/j.injury.2019.08.011. 4. metwaly rg, zakaria zm. single-incision doubleplating approach in the management of isolated, closed osteoporotic distal femoral fractures. geriatric orthopaedic surgery & rehabilitation. 2018;9:2151459318799856. 5. agrawal ak, bansal a, rawat s, kapadiya s, desai s, golwala p. surgical management of distal femur fracture using anatomical locking compression plate. int j cur res rev| vol. 2021;13(02):176. 6. albareda-albareda j, gabarre-raso s, rosell-pradas j, puértolas-broto s, ibarz-montaner e, redondotrasobares b, et al. biomechanical behavior of retrograde intramedullary nails in distal femoral fractures. injury. 2021. 10.1016/j.injury.2021.01.052. 7. habib mk, niazi a. outcome of retrograde interlocking nail in supracondylar femur fracture. journal of pakistan orthopaedic association. 2018;30(01):05-8. 8. sullivan km, dean a, soe mm. on academics: openepi: a web-based epidemiologic and statistical calculator for public health. public health reports. 2009;124(3):471-4. 9. shafiq m, ahmed a, akram r, javed s, aziz a. retrograde femur nail:outcome of retrograde femur nail, is it implant of choice for distal shaft of femur fracture? the professional medical journal. 2018;25(03):364-70. doi:https://doi.org/10.29309/tpmj/2018.25.03.370 10. wang w, liu l, chang x, jia z, zhao j, xu w. crosscultural translation of the lysholm knee score in chinese and its validation in patients with anterior cruciate ligament injury. bmc musculoskeletal disorders. 2016;17(1):1-8. doi: 10.1186/s12891-0161283-5 11. el mwafy hm, abd el gawad mm, el din afs, youssef wm. surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate. menoufia medical journal. 2015;28(4):948. doi: 10.4103/1110-2098.173681 12. atef m, hamoda ai. management of distal femoral fractures: a comparative study between open reduction and internal fixation by distal femur locked plate and retrograde nailing. al-azhar international medical journal. 2020;1(4):144-8. doi: 10.21608/aimj.2021.35593.1284 j islamabad med dental coll 2022 88 13. ahmed b, lakho mt, khanzada ma, memon za, karim m, bhatti a. functional and radiological outcome of condylar buttress plate in patients with intra-articular distal femoral fracture. rawal medical journal. 2021;46(1):98-101. 14. shah sgm, ahmed a, shaikh sa, ahmed n, jamali ar. outcome of fracture distal femur treated with retrograde nailing. journal of pakistan orthopaedic association. 2019;31(4):149-52. 15. prasanna a, jeyaraman m, chaudhari k, ajay s, sabarish k. prospective study on functional outcome of retrograde femoral nailing in distal third femoral fractures. j clin exp orthop. 2019;5. doi: 10.36648/2471-8416.5.2.65 16. hoskins w, sheehy r, edwards e, hau r, bucknill a, parsons n, et al. nails or plates for fracture of the distal femur? data from the victoria orthopaedic trauma outcomes registry. the bone & joint journal. 2016;98(6):846-50. doi: 10.1302/0301620x.98b6.36826. 17. dileep k, mahesha k. retrograde intramedullary nailing for fractures of distal femur: a prospective study. int j res orthop. 2016;2(4):276-9. doi: http://dx.doi.org/10.18203/issn.24554510.intjresorthop20164003 18. jillala sr, ahmed sw, shruthi a, gajul r, katikitala a, rakesh k. a comparative study of supracondylar nail versus locking compression plate in distal femur fractures. annals of international medical and dental research. 2017;3(4):35-41. 19. samuel aj, kanimozhi d. outcome measures used in patient with knee osteoarthritis: with special importance on functional outcome measures. international journal of health sciences. 2019;13(1):52. pmcid: pmc6392485 pmid: 30842718 157 j i m d c 2 0 1 8 157 open access leucodepletion in thalassaemia major patients in pakistan kaenat nasir 1, usman waheed 2, saira tahir 3, hassan abbas zaheer 4 safe blood transfusion programme, ministry of national health services, islamabad, pakistan thalassaemia is a blood disorder in which an abnormal form of haemoglobin is made due to genetic aberration. although no national database exists to calculate the exact number of thalassaemics, but it is estimated that there are 9.8 million carriers of the disease in pakistan [1]. consanguineous marriage is the leading cause for this high prevalence rate due to which the thalassaemia gene is trapped within the affected families. these patients are dependent on regular blood transfusions to sustain life in addition to expensive chelation therapy and other medical management. as a result, thalassaemia is a major healthcare challenge and places great psychological and financial trauma on the affected families and is a huge burden on the national healthcare delivery system [2]. as the thalassaemia major patients are dependent on regular transfusions to sustain life [1], a common adverse effect of chronic transfusions in these patients is febrile non-haemolytic transfusion reaction (fnhtr) with an occurrence rate of about 0.5-6.8% [3]. the fnhtrs occur due to immune reaction of the recipient against donor leucocytes [4]. leucodepletion is a process of removing leucocytes from the donated blood either during blood collection, processing or at the bedside. the average amount of leucocytes present in donated human blood is estimated to be 109 per unit. according to the guidelines, the total amount of leucocytes present in a blood unit should be less than 5 x 106 per unit after preparation [5]. a pilot study was carried out in three major thalassaemia centres of islamabad and rawalpindi (pakistan institute of medical sciences thalassaemia centre; pakistan bait ul mal thalassaemia centre; jamila sultana thalassaemia centre) on 120 thalassaemic patients with history of mild to moderate transfusion reactions. the study was conducted from january – april 2018, and the ethical consent was given by the ethical review board of pakistan institute of medical sciences, islamabad. written consent was taken from patients (or their parents) before the start of transfusions and the results were analyzed using microsoft excel 2013. leucolitetm filters (by glt medical co., ltd.) were used during transfusion to the selected 120 patients. in the past, these patients were routinely given pre-medication [solu-cortef (100 mg) and avil injections] to avoid transfusion reactions but with the leucofilter use, no premedications was given to observe the effectiveness of the leucofilters. the age of transfused red cell concentrates ranged from 5-27 days. no transfusion reaction of any kind was observed in any of the patients using the leuofilters. a study conducted by waheed et al., [6] on thalassaemia major cases, reported an incidence of 26.3% transfusion associated reactions in a total of 2,193 red cell transfusions, with fnhtr being the most common reaction. in the present study, reaction rate declined to 0%, when bedside filter was used and no fnthrs were documented on cases which had earlier reported high incidence of fnthrs. on the other hand, use of non leuco-reduced blood resulted in the occurrence of febrile non-haemolytic transfusion reactions with a reaction rate of 100%. this shows that a remarkable reduction occurs in fnthrs when bedside filter leuco-reduced blood is transfused as compared to non-leucoreduced blood. hence, leucoreduction of blood components in thalassaemic patients can be helpful in preventing transfusion reactions. anecdotal evidence claims no effect on the rate of fnhtrs but that is invariably in those centres where the sub-standard filters are being used. the leucofilters sale thus needs to be regulated by the government. this is an on-going study, leucofilters will be used consistently on thalassaemics and other chronic recipients to assess the effectiveness of e d i t o r i a l 158 j i m d c 2 0 1 8 158 leucodepletion and co-relate it with financial impact including prolonging duration of interval of transfusion. r e f e r e n c e s 1. ahmed s, saleem m, modell b, petrou m. screening extended families for genetic hemoglobin disorders in pakistan. n engl j med. 2002;10;347(15):1162–8. 2. zaheer ha, waheed u. development of a national thalassemia policy in pakistan. glob j transfus med. 2017;2:69-70. 3. perrotta pl, snyder el. non-infectious complications of transfusion therapy. blood rev. 2001;15(2):69– 83. 4. menis m, forshee ra, anderson sa, mckean s, gondalia r, warnock r, et al. febrile non-haemolytic transfusion reaction occurrence and potential risk factors among the u.s. elderly transfused in the inpatient setting, as recorded in medicare databases during 2011-2012. vox sang. 2015;108(3):251-61. 5. brecher me. american association of blood banks. technical manual. bethesda, md.: american association of blood banks; 2008. 6. waheed u, wazeer a, qasim z, iqbal z, zaheer ha. surveillance of adverse transfusion reactions in multi transfused thalassaemia patients in mirpur, azad jammu and kashmir, pakistan. 2016; 12(1):27-30 j islamabad med dental coll 2021 190 o p e n a c c e s s health care challenges in pakistan nadia tariq1 associate professor, islamabad medical and dental college, islamabad pakistan is a low-income country having poor infrastructure of health care, face shortage of health professionals and lacks accessibility and affordability to health care services. the country’s health profile is described by high population growth, double burden of disease, high maternal mortality and high infant and child mortality.1 the budget allocated for healthcare facilities is only 3.4% of the total. the health policies mainly focus on curative healthcare with little emphasis on preventive, environmental, social and cultural aspects of healthcare. also, there is a gap between policy making and its implementation. unfortunately, the developing countries like pakistan, while formulating policies, toe the line of developed countries without consideration of ground realities of its weak health care infrastructure. pakistan, like many other developing countries, has poor healthcare access, as health care system is highly reliant on out-of-pockets costs. about 75% of the population in pakistan is using healthcare services from private sector while only 25% is using free health services from public sector hospitals, including government employees and armed forces personnel. developed countries due to better living standards, well-structured systems and rich resources, enjoy higher life expectancy and can afford to invest heavily on health and its determinants including better access to health care. some countries such as ethiopia and brazil have better life expectancy when seen with respect to their gross national income as they have struggled for better health care coverage. on the other hand, a developed country such as usa does not have a life expectancy worth of its gni which can be due to its market-based health care and less political commitment. standards of population health is directly related to broad based policies, investment in phc and universal health coverage in order to achieve positive and equitable population health outcomes in all countries regardless of their wealth.2 there is an increased healthcare demand with the subsequent shortage of healthcare workers globally. it necessitates to put emphasis on recruitment, training, deployment and management of health workforce all over the world.3 in pakistan, competence and productivity of health workers is questionable as only a few medical schools are providing quality education and training. health care workers have very less incomes and are forced to do double jobs affecting service delivery. there is also depletion of health workforce due to emigration. lack of knowledge and robust management leads to low utilization and lapse of funds. despite inadequate infrastructure, inequitable access between rural and urban areas, political instability and natural disasters, pakistan has shown improvement in healthcare indicators in the last 25 years. life expectancy in pakistan was 59 years in the year 1990 and now it is 66.6 years but there is a way forward for improvement. health management information system needs to be strengthened that would impact decisions and policies. in providing preventive, therapeutic and e d i t o r i a l correspondence: nadia tariq email: nadia.tariq@imdcollege.edu.pk cite this editorial: tariq n. polymers, health care challenges in pakistan. j islamabad med dental coll. 2021; 10(4): 190-191.doi: 10.35787/jimdc.v10i4.770 j islamabad med dental coll 2021 191 rehabilitative amenities, healthcare organization requires various forms of equipment, diagnostic devices, vaccines, drugs and modern technology which is not existing in health care delivery system of pakistan. political will and support in formulating policies and writ in its implementation will indeed play a pivotal role in uniform distribution of resources and delivering universal health coverage for all populace. adequate budget allocation, based on peculiar requirements of both urban as well as rural areas is required. all stakeholders should be involved in formulating policies. there must be an initiative for the quality production and development of health professionals according to the population ratio. there must be more solidification of primary health services and a robust referral system must be implemented for the efficient use of amenities.4 r e f e r e n c e s 1. punjani ns, shams s, bhanji sm. analysis of health care delivery systems: pakistan versus united states. int j endorsing health sci res. 2014;2(1):38-41. issn 2310-3841 2. freeman t, gesesew ha, bambra c, giugliani er, popay j, sanders d, macinko j, musolino c, baum f. why do some countries do better or worse in life expectancy relative to income? an analysis of brazil, ethiopia, and the united states of america. int j equity health. 2020;19(1):1-9. doi: 10.1186/s12939020-01315-z 3. gedik fg, buchan j, mirza z, rashidian a, siddiqi s, dussault g. the need for research evidence to meet health workforce challenges in the eastern mediterranean region. eastern mediterranean health j. 2018;24(9): 811. doi:10.26719.2018.24.9.811 4. akram m, inayat s, hussain m. analysis of the health care delivery system in pakistan and nepal. ijahs. 2021;4(01):22-8. 22 j i m d c 2 0 1 7 22 op e n ac c e ss f u l l l e n g t h a r t i c l e c reactive protein as a predictor of sepsis in children up to 5 years of age itrat fatima1, gulbin shahid2, syeda sana ali3, nasera bhatti4 1assistant professor, bone marrow transplant, children’s hospital, pakistan institute of medical sciences, islamabad 2assistant professor, dept. of pediatrics, children’s hospital, pakistan institute of medical sciences, islamabad 3postgraduate trainee, children`s hospital, pakistan institute of medical sciences, islamabad 4 professor of pediatrics, children`s hospital, pakistan institute of medical sciences, islamabad a b s t r a c t objective: to determine frequency of raised crp levels in children clinically diagnosed to have sepsis. patients and methods: in this cross-sectional study, a total of 91 children up to 5-year age, clinically diagnosed as having sepsis, were enrolled and were screened for a raised crp level. the outcome of the study was recorded as the frequency of raised crp level in children clinically suspected of having sepsis. results: the results of the study showed that 95.6% (87/91) of our patients had a raised crp level. conclusion: crp can be used as an early sensitive tool for diagnosis of bacterial sepsis. key words: biomarkers, creactive protein, sepsis. author`s contribution 1conception, synthesis and planning of the research, interpretation and analysis 2,3active participation in active methodology & discussion,4 review the study. address of correspondence dr. itrat fatima itratfatima012@gmail.com article info. received: feb 14, 2017 accepted: mar 15, 2017 cite this article: fatima i, shahid g, ali ss, bhatti n c reactive protein as a predictor of sepsis in children up to 5 years of age. jimdc. 2017; 6(1):22-26. funding source: nil conflict of interest: nil i n t r o d u c t i o n c-reactive protein (crp) is an acute-phase reactant whose level in the serum rises with inflammation. it is of hepatic origin and is a protein that increases following il-6 secretion by macrophages,1 in response to a wide range of acute and chronic inflammatory conditions such as bacterial, viral or fungal infections, rheumatic disorders, autoimmune disorders, malignancies and conditions causing tissue injury and necrosis.2 crp rises within 6 hours of the onset of inflammation and may rise up to 10, 000 folds peaking at 48 hours. it has a half-life of about 19 hours which is constant and hence its level is determined by its rate of production and therefore by the severity of the precipitating cause.3 it may be concluded that crp is a good indicator of inflammation and may be used to screen for inflammation. evaluations have been done to determine its diagnostic strength in this context.2 crp is an abnormal protein as it is not found in the serum of a healthy person, but increases in a matter of hours after onset of tissue damage or destruction, regardless of the cause, and disappears equally rapidly after the destructive process has ceased. crp is not subject to normal variation, as is the erythrocyte sedimentation rate (esr) and is independent of the hematocrit. in this respect, it is generally found to be more useful and sensitive marker of acute inflammatory disease than esr.4 combined usage of total leucocyte count (tlc) and crp gives a better positive predictive value in the diagnosis of inflammatory conditions.5 crp is not only useful in determining the presence of an inflammatory disease but is also helpful in following its progress and effectiveness of treatment. in particular serial measurements of crp is o r i g i n a l a r t i c l e mailto:itratfatima012@gmail.com 23 j i m d c 2 0 1 7 23 very useful, for instance when one has to decide about the duration of antibiotic therapy in infections.6-10 the present study was conducted to determine the frequency of raised levels of qualitative crp in children clinically suspected of having sepsis in our setup. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at the children’s hospital, pakistan institute of medical sciences (pims), islamabad. the sample size was calculated as 91 by who sample calculator with an anticipated population of 17% at 95% confidence level and absolute precision of 0.07. a total of 91 children up to 5 years of age clinically suspected of having septicemia were enrolled by nonprobability consecutive sampling. children with liver disease, trauma, chronic kidney disease, suspected rheumatic disease or other focal infections like pneumonia, urinary tract infections were excluded from the study. clinical impression of sepsis was made if the patient had several of the considered signs and symptoms of sepsis namely fever, reluctance to feed, lethargy, purpura/bleeding or altered level of consciousness. approval from the hospital ethical committee was taken. an informed written consent was taken from parent/caregiver after explaining the importance of the study. patient profile including name, age sex, address, hospital number, serial number, date of inclusion in the study were noted. if the patient was sick, he /she was first stabilized before blood samples were taken for tlc and crp levels. all information was collected and entered into a proforma especially designed for this study. the data was analyzed on a computer using spss version 10. mean was calculated for numerical variables like age and total leukocyte count. frequency and percentages were presented for categorical variables i.e. gender, positive crp. crp >5mg/dl was taken as positive. r e s u l t s in our study a total of 91 cases clinically suspected of having sepsis were enrolled. the mean age of the patients was 2.6 years ranging from 0.1 to 5 years. among these, 41 (45%) of the patients were between 3 and 5 years, 24(26.4%) were less than 1 year and 26(28. 5%) were between 1 to 3 years. there were 54 (59%) males and 37 (41%) females with a male to female ratio of 1.4:1. as regards clinical signs and symptoms of sepsis, almost all patients 88(96.7%) had a fever. other significant clinical findings were purpura/bleeding from different sites in 57 (62.2%), reluctance to feed in 51(56%), lethargy also in 51 (56%), poor tolerance to feeding in 33(36.2%) and altered level of consciousness in 24(26.3%)–figure 1. 88 51 51 24 33 57 0 10 20 30 40 50 60 70 80 90 n o o f p a ti e n ts fever reluctant to feed lethargic altered level of consciousness poor tolerance to feed bruising or bleeding from any site clinical findings figure 1: clinical findings in study patients (n = 91) total leucocyte count was measured in all the study patients. the mean tlc was 18713/cmm ranging from 13400 to 30000/cmm. majority of the patients56(61.5%) had tlc between 15001 and 20000cmm, 19(20.8%) had tlc between 13000 and 15000/cmm whereas 10(10.9%) had tlc between 20001 and 25000/cmm and 6 (6.5%) were found to have tlc between 25001 and 30000/cmm table 1. as per our study objective the frequency of raised crp was measured in all the patients. vast majority of the patients87(95.6%) were found to have an increased crp level while in only 4(4.4%) patients, crp was not raisedtable 2. table 1. total leukocyte count in the study patients (n = 91) tlc (cmm) number (%) 13000 to 15000 19 (20.9) 15001 to 20000 56 (61.5) 20001 to 25000 10 (11) 25001 to 30000 6 (6.6) table 2: crp findings in study patients (n = 91) c-reactive protein number (%) increased not increased 87 (95.6) 04 (4.4) 24 j i m d c 2 0 1 7 24 d i s c u s s i o n crp has been fairly extensively studied as a useful marker of bacterial sepsis in neonates and children. 11-15 other studies which have also reviewed the same.16, 17 ammo k et al prospectively studied the utility of crp and esr as a diagnostic marker for sepsis in neonates, evaluating 293 episodes of sepsis in 163 infants.18 complete blood counts with differentials, blood cultures, crp and esr were measured. as expected hematologic profile of sepsis episodes were characterized by higher white blood cell counts among other indices. in their study the crp and esr in combination with absolute neutrophil count had the highest negative predictive value (93%) for ruling out sepsis and 95% sensitivity for diagnosing sepsis. they concluded that crp and esr are highly sensitive markers for neonatal sepsis and recommended prospective studies incorporating crp and esr into a sepsis scoring system. in comparison, our study though not confined to neonates, had a number of neonates as part of the study population. though we did not evaluate the data of neonates separately but in general we also concluded that raised tlc and crp levels were present in the vast majority of patients clinically diagnosed to have sepsis. sidra younis et al also studied the diagnostic accuracy of crp in neonatal sepsis.12 they enrolled 59 consecutive patients with risk factors and clinical features suggestive of sepsis. crp and blood cultures were taken from all patients. in their study, the sensitivity, specificity, positive predictive value and negative predictive value of raised crp were found to be 97.3%, 95.2%, 97.3% and 95.2% respectively. blood cultures were positive in 64.4% and raised crp was found in 64.5% cases. they concluded that crp has high sensitivity and specificity for establishing the diagnosis of neonatal sepsis which is comparable to that of blood culture results. in comparison, our study only included patients who were clinically diagnosed to have sepsis and crp was not compared to blood cultures and this was a limitation of our study. michal kyr et al studied the role of the time course of crp levels in association with clinical outcomes in children with different septic conditions in an intensive care environment.19 they performed a retrospective analysis of 99 patients with inflammatory response syndrome, sepsis or septic shock syndrome. they monitored the crp level for 10 days following the onset of the septic condition and determined that there is a significant effect of septic condition and diagnosis on the course of crp levels. in patients who did not progress to septic shock, crp blood levels decreased rapidly after reaching peak values in contrast to the values in patients with septic shock in whom crp levels decreased slowly. they concluded that the more severe the systemic reaction to the insult, the higher and the more prolonged the crp levels. their study population had an average age of 7.6 years with a range of 0.1-18.5 years an age range which was much higher than in our study (mean age, 2.6 years with a range of 0.1-5 years). moreover, we did not do quantitative or serial crp levels in our study. both studies emphasize the role of crp in sepsis, however, the study by michal kyr et al goes a step further in evaluating the role of serial measurements of crp and understanding the pattern of change in levels of crp and relating it to sepsis severity. lanziotti et al published an excellent review on the use of biomarkers in the screening, diagnosis, prognosis (risk stratification), monitoring of therapeutic response and rationale use of antibiotics (e.g. determining the adequate treatment length) in children with sepsis.20 their emphasis was on evaluating the role of crp, procalcitonin, interleukin 6, 8 and 18 and a few other markers in this context. they evaluated five main publications on the use of crp in pediatric infection/sepsis and concluded that the use of biomarkers, including crp, in pediatric sepsis cases is promising, although their use should always be correlated with clinical evaluation.21-25 they emphasized that combined use of multiple biomarkers has a much better sensitivity and specificity in the diagnosis and prognosis of sepsis compared to the use of a single biomarker. in their view biomarkers, such as crp and procalcitonin have shown a key role in clinical practice and crp is especially useful for the evaluation of the response to antibiotic treatment when evaluated serially. other advantages of crp that they enumerated were that it is easily available, has low cost, peaks 36-50 hours after an inflammatory trigger and is not affected by immunosuppression, renal dysfunction or corticosteroid use. they also sited limitations of crp testing in that it has variable sensitivity for detecting bacterial infections (lower when a single level is measured) and also that it 25 j i m d c 2 0 1 7 25 has low accuracy. thus, they concluded that the dynamic and judicious use of crp combined with clinical criteria and/or other biomarkers has great value and should be considered in sepsis diagnosis and especially in sepsis treatment evaluation where it probably has a better role than in the diagnosis. our study certainly had a number of limitations. firstly, it was a descriptive series only looking at the frequency of raised crp levels in children clinically suspected of having sepsis. a control group or a validating test like blood culture would have helped to measure actual accuracy. selection bias always remains a possibility in observational studies with convenient sampling procedures. moreover, we did not do quantitative or serial crp measurements as were done in most of the abovecited studies. however, our study did carry the advantages of being the first study of its kind in our local setting, including a number of neonatal and preschool children in the study population and using an easily available low cost test like crp and determining whether it could be used as an early surrogate marker of infection in children clinically suspected of having sepsis. c o n c l u s i o n in children, up to 5 years of age clinically suspected of having sepsis a raised total white cell count along with a raised crp are present in the vast majority and therefore these two indicators together may be used as early surrogate markers of sepsis in this paediatric age group. better powered studies are needed in our setup to validate this conclusion. r e f e r e n c e s 1. pepys mb, hirschfield gm. c-reactive protein: a critical update. j. clin. invest. 2003 ;111(12):1805-12. 2. chandrashekara s. c-reactive protein: an inflammatory marker with specific role in physiology, pathology, and diagnosis. internet j rheumatol clin immunol. 2014;2(s1). 3. mitaka c. clinical laboratory differentiation of infectious versus non-infectious systemic inflammatory response syndrome. clinica chimica acta. 2005;351(1):17-29. 4. liu s, ren j, wu x, ren h, yan d, wang g, gu g, li j, xia q, han g. preliminary case-control study to evaluate diagnostic values of c-reactive protein and erythrocyte sedimentation rate in differentiating active crohn’s disease from intestinal lymphoma, intestinal tuberculosis and behcet’s syndrome. the american journal of the medical sciences. 2013 ;346(6):467-72. 5. caldas jp, marba s, blotta mh, calil r, morais ss, oliveira rt. accuracy of white blood cell count, c-reactive protein, interleukin-6 and tumor necrosis factor alpha for diagnosing late neonatal sepsis. journal de pediatria. 2008 ;84(6):53642. 6. parviz a, mahdi dm, jahani hh. the role of serial serum creactive protein level in the diagnosis of neonatal infection. j. compr. ped. 2007(1):47-51. 7. lobo sm. sequential c-reactive protein measurements in patients with serious infections: does it help? crit.care. 2012 ;16(3):130. 8. póvoa p, coelho l, almeida e, fernandes a, mealha r, moreira p, et al. pilot study evaluating c-reactive protein levels in the assessment of response to treatment of severe bloodstream infection. clin. infect. dis. 2005;40(12):1855-7. 9. schmit x, vincent jl. the time course of blood c-reactive protein concentrations in relation to the response to initial antimicrobial therapy in patients with sepsis. j. infect. 2008 ;36(3):213-9. 10. póvoa p, teixeira-pinto am, carneiro ah. c-reactive protein, an early marker of community-acquired sepsis resolution: a multi-center prospective observational study. crit. care. 2011;15(4):r169. 11. hisamuddin e, hisam a, wahid s, raza g. validity of creactive protein (crp) for diagnosis of neonatal sepsis. pak j med sci. 2015 ;31(3):527. 12. younis s, sheikh ma, raza aa. diagnostic accuracy of creactive protein in neonatal sepsis. jbm. 2014;1(1):1. 13. himayun m, ahmad s, rasool a. role of c-reactive protein in early onset neonatal sepsis. internet j pediatr neonatol. 2009;11(2). 14. loni r, sengupta a, jaganathan g, singh pk. the evaluation of c-reactive protein as a screening tool for neonatal sepsis. int j of contemp pediatr. 2016 dec 22;3(4):1329-33. 15. póvoa p. c-reactive protein: a valuable marker of sepsis. intensive care med. 2002 ;28(3):235-43. 16. lai my, tsai mh, lee cw, chiang mc, lien r, fu rh, et al. characteristics of neonates with culture-proven bloodstream infection who have low levels of c-reactive protein (≦ 10 mg/l). bmc infectious diseases. 2015 ;15(1):320. 17. isaacman dj, burke bl. utility of the serum c-reactive protein for detection of occult bacterial infection in children. arch pediatr adolesc med. 2002;156(9):905-9. 18. ammo k, salacity g.crp and esr as a diagnostic marker in detection of neonatal sepsis. pak paed j 2008; 32(1):15-22. 19. kyr m, fedora m, elbl l, kugan n, michalek j. modeling effect of the septic condition and trauma on c-reactive protein levels in children with sepsis: a retrospective study. crit. care. 2007 ;11(3):r70. 20. lanziotti vs, póvoa p, soares m, silva jr, barbosa ap, salluh ji. use of biomarkers in pediatric sepsis: literature review. revista brasileira de terapia intensiva. 2016 ;28(4):472-82. 21. riordan a, mcwilliam s. how to use crp. arch. dis. child educ. pract. ed. 2010;95:55-8. 22. sanders s, barnett a, correa-velez i, coulthard m, doust j. systematic review of the diagnostic accuracy of c-reactive protein to detect bacterial infection in nonhospitalized infants and children with fever. j. pediatr. 2008 ;153(4):570-4. 26 j i m d c 2 0 1 7 26 23. santolaya me, alvarez am, avilés cl, becker a, venegas m, o’ryan m, et al. prospective validation of a risk prediction model for severe sepsis in children with cancer and high-risk febrile neutropenia. pediatr infect dis j. 2013 ;32(12):131823. 24. kitanovski l, jazbec j, hojker s, derganc m. diagnostic accuracy of lipopolysaccharide-binding protein for predicting bacteremia/clinical sepsis in children with febrile neutropenia: comparison with interleukin-6, procalcitonin, and c-reactive protein. support care cancer. 2014;22(1):269-77. 25. lanziotti vs, póvoa p, pulcheri l, meirelles pz, guimarães g, mendes as, et al. c-reactive protein ratio response patterns in pediatric sepsis: a cohort study-preliminary results. intensive care medicine exp. 2015 ;3(1):a787. 27 j i m d c 2 0 1 7 27 op e n ac c e ss f u l l l e n g t h a r t i c l e management of fistula-in-ano: a local experience m fahim ahsan1, haider darain2, aatik arsh3, muhammad ibrar4 1 senior registrar, general surgery department pakistan institute of medical sciences, islamabad 2 assistant professor, khyber medical university institute of physical medicine and rehabilitation 3 paraplegic center peshawar 4 isra university, islamabad campus a b s t r a c t objective: to evaluate short and long-term outcomes of complex fistula surgery. patients and methods: this cross-sectional study was conducted on all patients, both male and female admitted to general surgery department of pims, islamabad who underwent surgery for fistula-in-ano from 1st january 2010 to 31st december 2015. a total of 65 patients, who underwent surgery for fistula-in-ano in the hospital were included in this study. they were assessed by case review supplemented by opd follow up and telephonic interview when necessary. results: a total of 65 cases of fistula-in-ano were operated in the surgical unit of the hospital. out of the total patients, 27 patients were operated once, 29 patients were operated twice and 9 patients had surgery three times. almost about half of the patients (45 %) had trans sphincteric complex fistula with secondary tract identified in 40% cases, 16 % cases with intra sphincteric, 36% cases with extra sphincteric, 3% case with horseshoe shaped and 5% with a combination of two. in 45 % of the cases, excision of primary and secondary tracts were done with loose seton placement while preserving the sphincter complex. about 36 % cases had excision of the tract while in horseshoe cases fistulotomy was done. in 4 % of cases primary excision of the tract and repair of the sphincter complex was performed. in two patients, drainage and curettage of presacral abscess was done. we made colostomy in one patient after 4th recurrence while one patient was having colostomy before operation that was operated 6 times for fistula. no incontinence was reported for solid and liquid, while 12.3 % cases had transient flatus incontinence, 9.2 % cases presented post-operative bleeding in which 4 % of patients settled with pressure dressing while 5.2 % required control of bleeding under ga. conclusion: majority of the complex fistula in-ano treated by primary fistulotomy or stage fistulotomy with a loose seton are followed by good clinical and functional result. key words: fistula in ano. fistulotomy, fistulectomy, loose seton author`s contribution 1conception, synthesis and planning of the research, 2,3,4interpretation, analysis and discussion address of correspondence dr haider darain email: haider.kmu@hotmail.com article info. received: nov 28, 2016 accepted: mar 18, 2017 cite this article: ahsan mf, darain h, ibrar m. management of fistula-in-ano: a local experience.jimdc. 2017; 6(1):27-30. funding source: nil conflict of interest: nil i n t r o d u c t i o n fistula-in-ano (fia) has been a common surgical ailment reported since the time of hippocrates but little systematic evidence exists on its management.1 a complex fia is defined as a fistula whose treatment poses an increased risk of change incontinence, multiple external openings, indurations felt above the puborectalis, on probing from external opening tract travel towards the levatorani instead of anus, when tract involve greater than 30% to 50% of the sphincter mechanism and is anterior in woman or the patient has a history pre-existing incontinence, crohn’s disease or local irradiation.2 infection developing in an anal gland lying within the submucosa of the anal canal is a direct cause of most fia(cryptoglandular fistula).3 it can be associated with number of conditions, including tuberculosis, crohn’s disease and malignancy.4 o r i g i n a l a r t i c l e mailto:haider.kmu@hotmail.com 28 j i m d c 2 0 1 7 28 the estimated prevalence of nonspecific fia is 8.6 to 10/100,000 of the population per year, with a male to female ratio of 1.8:1.5 it is a distressing condition for the patient and can be surgically challenging.6 in 1976, sir alan parks classified fia depending on the relationship of the tract to the anal sphincter. in total, four types of tracks were described, inter-sphincteric (45%), trans-sphincteric (29%), supra-sphincteric (20%) and extra-sphincteric (5%).6 results of treatment of fia are still far from satisfactory, even in centers experienced in its treatment.7 recurrence rate varies from 0% to 32% and the incidence of postoperative gas and stool incontinence may reach 63%.7 present study was designed to evaluate, the short and long term outcomes of complex fistula surgery. p a t i e n t s a n d m e t h o d s a total of 65 consecutive patients who underwent surgery for fia between 1st january 2010 to 31st december 2015 were included in the study. our analysis included the following parameters: patient’s gender and age, duration of symptoms, types of fia and also the number of single and multi-tract fias (including horseshoe-shaped fistulas). detailed medical history was obtained prior to surgery, focusing on previous proctological procedures for conditions other than fia. we analyzed the kind of surgical procedures most often associated with particular types of fia, other proctological procedures performed simultaneously for concomitant diseases, as well as types and incidence of early and late postoperative complications. we also assessed the effectiveness of surgical techniques implemented in the treatment of particular fia types and duration of hospital stay associated therewith. prior to surgery, all patients underwent digital rectal examination and proctoscopy to localize the internal opening of their fistula and to evaluate large-bowel mucosa for any coexisting diseases. whilst most complex fistulae require the use of imaging modalities such as contrast fistulography, or magnetic resonance imaging to correctly classify the primary and secondary tract, the level of internal opening and associated pathology. almost 85% can be correctly diagnosed by careful examination under anesthetic and the judicious use of probes. all procedures were performed by a specialist general surgeon. early in the series, spinal anesthesia was predominated; full relaxation was avoided to enable the surgeon to appreciate the extent of the anorectal ring. when the internal opening was difficult to identify, either dilute methylene blue or hydrogen peroxide was injected through the external opening to assist its localization. the operative procedures included simple fistulotomy (layingopen technique), fistulectomy of secondary tract cutting seton technique (sequential office-based seton advancement), and draining seton technique. the draining seton patient had placement of the seton as if prepared for the cutting technique. however, the fistulotomy was maintained without tightening for at least 5 weeks or until the inflammatory response receded. at this point, eua was done and the seton was removed, and the patient was followed-up expectantly. postoperatively, the wounds were managed by twice-daily digitation and irrigation rather than by tight packing. patients were followed up on the ward 3rd day and 1st week after surgery. this allowed the wound to be inspected and checked for postoperative bleeding and infection. thereafter, patients were seen in outpatients on weekly basis for 1st month than fortnightly up to 6-monthly interval at our outpatients’ clinic, until fistula was healed. thereafter, patients were assessed for symptoms and signs of recurrence and also for incontinence if needed. there was a template for the examining doctor to fill in when the patient attended for review. it included wound infection, wound healing period, digitations done continence disturbances, stenosis and recurrence of fistula. r e s u l t s a total of 65 patients underwent surgery for complex fistula during 5 years’ study. they were assessed by case review supplemented by opd follow up and telephonic interview when necessary. the mean age of these patients was 45.3 years ± 9.3 sd. out of total, 58 (89%) patients were male while remaining 11% (n=7) were female. the patients were clinically proven to fia for a mean of 11.5 month. (range =1 to 60 months). most of the patients presented with perianal discharge (97%), itching and discomfort (60%). few patients presented with pain. on examination, external opening was found, 80% posteriorly, while 20% it was anteriorly. on digital rectal 29 j i m d c 2 0 1 7 29 examination internal opening was found, 61% at the dentate line and 39% above the dentate line. majority of the patients (45 %) had transsphincteric complex fistula with secondary tract identified in 40% cases, 16 % cases with intra sphincteric, 36% cases with extra sphincteric, 3% cases with horseshoe shaped and 5% with a combination of two. in 45 % of the cases, excision of primary and secondary tracts were done with loose seton placement while preserving the sphincter complex. a total of 21 patients of over series with recurrent disease, 90% of recurrent fistula were tertiary referrals from other hospitals and the nature of any previous fistula surgery was, therefore, difficult to ascertain (see table 1 for details of the patients). we also tried to find out the total number of operations, 27 patients operated one time, 29 patients operated twice, while 8 patients were operated more than two times, though one of our patient was operated 9 times. about 45% of our patients were operated by stage fistulectomy; that is excision of the lower fistula tract and placement of the seton, followed by daily dressing and digitations of the wound. we came across bleeding in six patients, in which four were managed by pressure dressing and two were explored under anesthesia and bleeding was controlled. in our series the transient flatus incontinence was the commonest (12.3%) complication which got settled with passage of time. recurrence of disease was found in 7 patients, out of them 2 were re-operated and found to have low fistula-in-ano, while 5 patients were not operated at the time of data collection and were at waiting list. d i s c u s s i o n surgical treatment of fia should aim at the complete elimination of the fistula while maintaining sphincter muscle function as much as possible.8 the criteria of determining success or failure of surgery are the incidence of recurrence or incontinence.9 in this trial a total of 65 patients were treated for complex fistula. mean age of the patients was 45.3 ± 9.3, while in study of 54 cases, khalid et-al observed a high incidence in 3rd and 4th decades.10 in a study of 85 cases, takayuki et-al found that mean age incidence was 42.5 years which is comparable to that observed in our study. in this study there were 58 male and 7 female patients, with male to female ratio of 9:1. a similar ratio was reported by saif etal, in their study, 41 males and 4 females underwent the process.12 in another study conducted by buchanan et al. it was found that 17 males and 3 females were having the problem.13 these results show that male are approximately 9-10 folds at high risk of developing the condition compared to females. this proves male predilection because males have more intramuscular gland than female and they are more ramifying and more cystic. most common symptom was perianal discharge 97 % followed by itching and discomfort 60%. pain, bleeding p/r, and altered bowel habits were other presentations in some patients. mean duration of symptoms before surgery was 11.5 months (range 1 to 60 months). khalid and takayuki et al reported that mean duration of symptoms before surgery was 18 months and 11 months respectively which is nearly comparable to mean duration of symptoms in our study.10,11 in current study 21 (32.30%) patients were found previously operated for fia, 90% of recurrent fistula were tertiary referrals from other hospitals. g.n buchanan et al reported in their study that 19 patients out of 20, had previously undergone fistula surgery.13 in another study, 29 patients (64 %) out of 45, had previously undergone fistula surgery.12 in this study, in majority of cases the fistula was found posteriorly (80 %). in another study of 199 cases, external opening of fistula were found posteriorly observed by sainio and husa.14 in this case series, majority of the table 1. findings and management of patients of fistula-in ano (n 65) characteristics n (%) male 58 (89) female 07 (11) post. ext opening 52 (80) ant. ext opening 13 (20) sec. tract involvement 26 (40) intra sphincteric 10 (16) extra sphincteric 23 (36) horseshoe shaped 02 (3) combination 03 (5) patient operated once 27 (42) patient operated twice 29 (45) patient operated more than twice 09 (13) 30 j i m d c 2 0 1 7 30 patients (45%) had transsphincteric complex fistula with secondary tract identified in 40% cases, 16 % cases with intra sphincteric, 36% cases with extra sphincteric, 3% case with horseshoe shaped and 5% with a combination of two. while in the study of 160 patients, vasilevsky et-al reported 41% cases of inter sphinteric,52 trans sphincteric and 1.3 % suprasphincteric.15 some surgeons use a seton to drain fia, whereas others believe that seton placement stimulates fibrosis and therefore promotes healing.16,17 when a seton is used to mark the primary track the subsequent decision whether or not to lay it open, can be made easier by palpating the seton in relation to the anal sphincter complex.16 chemical seton placement may cause more pain than fistulotomy, and there is little difference in functional outcome between the two methods.18 use of a cutting seton is also effective, but this too may cause minor disturbance of continence and may necessitate tightening. about 45% of our patients were operated by stage fistulectomy; that is excision of the lower fistula tract and placement of the seton followed by daily dressing and digitations of the wound. however, in 36% cases, fistulectomy was performed. in 9% cases, fistulotomy was done. while 4% of patients were dealt with excision of the fistula tract and sphincteric repair, and colostomy done in one patient. we come across the bleeding in six patients (9.2%), in which four were managed by pressure dressing and two were explored under anaesthesia and bleeding was controlled. in our study, transient flatus incontinence was the commonest complication seen in 12.3% cases and it got settled with the passage of time. in another study conducted by takayuki et al, incontinence was found in 20.3% of their cases.11 recurrence of disease was found in 7 patients out of them 2 were re-operated and were found to have low fia while 5 still unoperated. c o n c l u s i o n the majority of complex fia patients were treated by fistulotomy and staged seton fistulotomy with a low recurrence rate and low morbidity. r e f e r e n c e s 1. malik a, nelson r. surgical management of anal fistulae: a systematic review. colorectal disease. 2008;10(5):420-30. 2. song kh. new techniques for treating an anal fistula. journal of the korean society of coloproctology. 2012;28(1):7-12. 3. ortiz h, marzo j, ciga m, oteiza f, armendáriz p, de miguel m. randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. british journal of surgery. 2009;96(6):608-12. 4. chowdri na, parray fq, editors. benign anorectal disorders: a guide to diagnosis and management. springer; 2015 nov 9.. 5. cadeddu f, salis f, lisi g, ciangola i, milito g. complex anal fistula remains a challenge for colorectal surgeon. international journal of colorectal disease. 2015;30(5):595603. 6. davies m, harris d, lohana p, sekaran tc, morgan a, beynon j, et al. the surgical management of fistula-in-ano in a specialist colorectal unit. international journal of colorectal disease. 2008;23(9):833-8. 7. sygut a, zajdel r, kędzia‐budziewska r, trzciński r, dziki a. late results of treatment of anal fistulas. colorectal disease. 2007;9(2):151-8. 8. toyonaga t, matsushima m, tanaka y, suzuki k, sogawa n, kanyama h, et al. non-sphincter splitting fistulectomy vs conventional fistulotomy for high trans-sphincteric fistula-inano: a prospective functional and manometric study. international journal of colorectal disease. 2007;22(9):1097102. 9. murugesan j, mor i, fulham s, hitos k. systematic review of efficacy of lift procedure in crpytoglandular fistula-in-ano. journal of coloproctology. 2014;34(2):109-19. 10. khalid hussain qureshi mk mhas, naseer ahmed tariq, salman ahmad tipu. management of fistula-in-ano. j coll physicians surg pak, jun 2002; 12: 361-3 11. takayuki toyonaga yt, makoto matsushima. evidence based treatment strategy for anorectal sepsis and anal fistula. nippon daicho komonbyo gakkai zasshi. 2008; 61 (7): 364-377 12. saif ahmad rn, talat mahmoud. use of seton in complicated anal fistula: a study at sindh govt. qatar hospital, karachi. pak j surg .2003;19(1):25-9. 13. buchanan g, owen h, torkington j, lunniss p, nicholls r, cohen c. long‐term outcome following loose‐seton technique for external sphincter preservation in complex anal fistula. british journal of surgery. 2004;91(4):476-80. 14. sainio p, husa a. fistula-in-ano. clinical features and longterm results of surgery in 199 adults. acta chirurgica scandinavica. 1984;151(2):169-76. 15. vasilevsky c-a, gordon ph. results of treatment of fistula-inano. diseases of the colon & rectum. 1985;28(4):225-31. 16. pearl rk, andrews jr, orsay cp, weisman ri, prasad ml, nelson rl, et al. role of the seton in the management of anorectal fistulas. diseases of the colon & rectum. 1993;36(6):573-9. 17. williams j, macleod c, rothenberger d, goldberg s. seton treatment of high anal fistulae. british journal of surgery. 1991;78(10):1159-61. 18. subhas g, singh bhullar j, al-omari a, unawane a, mittal vk, pearlman r. setons in the treatment of anal fistula: review of variations in materials and techniques. digestive surgery. 2012;29(4):292-300. j islamabad med dental coll 2022 188 o p e n a c c e s s endometriotic stones; can they exist? a case report muneeb ullah assistant consultant, department of surgery, maroof international hospital, islamabad. a b s t r a c t endometriosis is a gynecological pathology that manifests as pelvic pain, infertility and cyclical issues. the presence of endometriotic tissue outside the uterus is the hallmark of endometriosis and commonest sites are ovaries, fallopian tubes, uterosacral ligaments and lateral pelvic peritoneum. ovarian endometriotic cyst (ec) is typically a chocolate cyst that is often diagnosed by a combination of clinical history, examination and radiological imaging. however, the definitive diagnosis requires histopathological confirmation. the management is complex and requires long term suppression of menstrual cycle and ovarian cystectomy. we hereby illustrate a case of a young female who presented with ec. during a routine daycare laparoscopic cystectomy, a rare finding of endometriotic stones was ascertained peroperatively. patient remained well post operatively and was discharged in the evening. keywords: cystectomy, cyst, endometriosis, laparoscopic correspondence: muneeb ullah email: muneebullah@gmail.com article info: received: june 24, 2022 accepted: august 3, 2022 cite this article. ullah m. endometriotic stones; can they exist? a case report. j islamabad med dental coll. 2022; 11(3): doi: https://doi.org/10.35787/jimdc.v11i3.891 funding source: nil conflict of interest: nil i n t r o d u c t i o n endometriosis is a chronic gynecological disease that occurs as a result of endometriotic tissue outside the uterus. 1 common sites are ovaries, fallopian tubes, uterosacral ligaments and lateral pelvic peritoneum. 2,3 in ovaries, it frequently presents as endometriotic cyst (ec) that is non-cancerous and contains chocolate like fluid. 4 ec is often the underlying culprit responsible for chronic pelvic pain associated with ovulation and menstruation in females of reproductive age. 5 the diagnosis of ec requires a combination of good history, clinical examination and investigations such as cancer antigen 125 (ca125) and ultrasound imaging. 1 although the ultrasonography is generally able to identify ec but definitive diagnosis is based on laparoscopy and histological confirmation. 1,6 differentials while managing such cysts must include dermoid cyst, hemorrhagic cyst, neoplasms and uncommonly, abscesses and ectopic pregnancy. 7 management of ec is controversial and depends upon size, symptoms and patient preferences especially when there are concerns for fertility. long term suppression of menstrual cycle is the mainstay of management for cysts smaller than 3cm while those greater than 3cm are dealt with laparoscopic ovarian cystectomy. 8,9 patients who have fertility problems are predominantly planned to proceed for ovarian cystectomy. this aids in assisted reproductive methods, alleviates pelvic pain and improves likelihood of successful oocyte retrieval procedure. 10 by virtue of this platform, we hereby report a case of a laparoscopic endometriotic cystectomy which per-operatively revealed endometriotic stones within the cyst cavity, a rare occurrence. it has not been reported previously as per our knowledge. c a s e r e p o r t c a s e r e p o r t https://doi.org/10.35787/jimdc.v11i3.891 j islamabad med dental coll 2022 189 a 30 years old young female, resident of rawalpindi, presented with cyclical menstrual and pelvic pain in right lower quadrant, dysmenorrhea and irregular cycles for the last two years. pain aggravated during menstruation and relieved by taking oral non steroidal anti-inflammatory drugs. it was not associated with any physical activity, food, anorexia, weight loss, fever, any symptoms related to gastrointestinal or urinary tract. for the past six months, she was under medical management for endometriosis and right ovarian ec. recently after her wedding, she and her husband had planned for conception. there were no clinical findings except right sided uterosacral ligament tenderness on pelvic examination. ca-125 levels were slightly raised to 58 u/ml. recent ultrasound showed right adnexal ec of 5.8 x 4.9 x 6.6 cm in size as depicted by figure 1. figure 1: ultrasound showing right endometriotic cyst (red arrows) due to failure of medical management, chronic pain and fertility related concerns; patient was planned for diagnostic laparoscopy and to proceed for laparoscopic cystectomy. prior to surgery, informed consent was taken for oophorectomy, cystectomy and deroofing of cyst with possibility of recurrence and insufficient ovarian tissue preservation for fertility. laparoscopy was performed in trendelenburg’s position. operative findings were consistent with right ec but additionally a rare finding of endometriotic stones was discovered, shown in figure 2 and figure 3. j islamabad med dental coll 2022 190 figure 2: per-operative image of right endometriotic cyst (red arrow) figure 3: per-operative image of endometriotic stones (red arrows) laparoscopic cyst deroofing, followed by cystectomy was performed. remnant tissue was packed with adrenaline soaked gauze for five minutes. hemostasis was secured using bipolar electrocautery. specimen including stones was delivered in bag. picture of specimens is shown in figure 4. j islamabad med dental coll 2022 191 figure 4: post operative image showing cyst wall (blue arrows) and endometriotic stones (red arrows) cyst wall was sent for histopathology. patient was discharged within 24 hours and had unremarkable post-operative recovery. histopathology report was consistent with ec. d i s c u s s i o n endometriosis has variable presentations and diagnosis is often delayed. this causes hindrance in proper management and results in vast implications especially on quality of life and daily routine. 11 laparoscopic ovarian cystectomy is recommended for a symptomatic ec that is without a widespread disease and is greater than 3cm size. although this provides lowest recurrence rates and highest possibility of spontaneous conception, the risk of insufficient ovarian reserve persists. this is attributed to inadvertent removal of normal ovarian tissue during cystectomy and cauterization to control the bleeding. 9 first choice of imaging in pelvic adnexal pathologies is ultrasonography which is cheap, effective and without any radiation or contrast exposure. ct scan and mri are superior to ultrasound in assessing the adnexal masses as they help in correlation of surrounding structures and surgical planning. 6 additionally they are able to differentiate complex cysts, septated lesions, solid masses and benign from malignant pathologies. we did not perform a ct scan or mri since the clinical diagnosis was quite evident and the size of cyst was not a huge one. patient was planned for laparoscopic intervention which is considered gold standard for the diagnosis of endometriosis and has the therapeutic advantage of treating endometriotic cysts as well. 12 our patient had concerns for fertility since she was planning for conception, and endometriosis at any stage is known to decrease fertility. 11 treatment modalities were discussed with the patient and her husband, and consensus was reached to proceed surgically. laparoscopically, the cyst is usually aspirated under vision to confirm the diagnosis and to take the sample. later, suction and irrigation is performed multiple times before proceeding for cystectomy to avoid contamination. in our case, aspiration needle was used to take the sample as well as for suction and irrigation, before carrying out cystectomy. the stones were thus easily seen after deroofing, else they could have easily been missed. bleeding from the ovarian tissue was packed with adrenaline-soaked gauze, later, hemostatsis was achieved using bipolar cautery. monopolar or bipolar cautery is an effective method for controlling hemostasis but results in damage to ovarian follicles causing insufficient ovarian reserve.13 adrenaline-soaked gauze decreases the need for bipolar cautery and its extent, thus improving outcomes related to ovarian reserves. histopathological confirmation is a requisite for definitive diagnosis and also rules out any underlying malignancy. although laparoscopy has the advantage of speedy recovery, minimal scar, diagnostic evaluation of the whole abdominal cavity and staging of the disease, j islamabad med dental coll 2022 192 but it has the disadvantage of decreased depth perception of the cyst, loss of tactile feedback, risk of spillage and implantation especially at the port sites. laparoscopic technique has the advantage of being diagnostic and therapeutic modality. in addition, it has the capability to stage the disease and identify uncommon findings that can easily be missed otherwise. ec can be managed laparoscopically if the expertise is available. care must be taken to avoid port site implantation. r e f e r e n c e s 1. foti pv, farina r, palmucci s, vizzini iaa, libertini n, coronella m, et al. endometriosis: clinical features, mr imaging findings and pathologic correlation. insights imaging. 2018; 9:149-172. https://doi.org/10.1007/s13244017-0591-0 2. katsoulis ie, katsoulis ie. retrorectal endometrioid cyst: a case report. j med case reports. 2010; 4:389-10. https://doi.org/10.1186/1752-1947-4-389 3. jiao y, lu b. poorly differentiated mucinous carcinoma with signet ring cells in an ovarian endometriotic cyst: a case report. diagn pathol. 2019; 14:73. https://doi.org/10.1186/s13000019-0850-0 4. hingankar y, taksande v and mahakarkar m. chocolate endometrial cyst: a case report. journal of pharmaceutical research international. 2021; 33(40b):1-6. https://doi.org/10.9734/jpri/2021/v33i40b32 254 5. bulun se, yilmaz bd, sison c, miyazaki k, bernardi l, liu s, et al. endometriosis. endocr rev. 2019; 40(4):1048-1079. https://doi.org/10.1210/er.2018-00242 6. yaşar l, sönmez as, zebitay ag, neslihan g, yazıcıoğlu hf, mehmetoğlu g. huge ovarian endometrioma—a case report. gynecol surg. 2010; 7:365-367. https://doi.org/10.1007/s10397-009-0482-6 7. asani l, nikolova d, madzunkova k, karanfilovski v, pandilov s, janevska v. osseous metaplasia in ovarian endometrial cyst: a case report. 2019; 23(5):17729-17732. http://dx.doi.org/10.26717/bjstr.2019.23.00 3959 8. vercellini p, viganò p, somigliana e, fedele l. endometriosis: pathogenesis and treatment. nat rev endocrinol. 2014; 10:261-275. https://doi.org/10.1038/nrendo.2013.255 9. akkaranurakkul p, lertvikool s, hongsakorn w, vallibhakara o, tantanavipas s, paiwattananupant k, et al. effects of intravenous tranexamic acid on ovarian reserve and intra-operative blood loss during laparoscopic cystectomy of endometriotic cyst: a pilot randomized controlled trial. pilot feasibility stud. 2021; 7:171. https://doi.org/10.1186/s40814-021-00907-y 10. dunselman gaj, vermeulen n, becker c, calhaz-jorge c, d’hooghe t, bie bd, et al. eshre guideline: management of women with endometriosis. human reproduction. 2014; 29(3):400-412. https://doi.org/10.1093/humrep/det457 11. frankel lr. a 10-year journey to diagnosis with endometriosis: an autobiographical case report. cureus. 2022; 14(1):21329. https://doi.org/10.7759/cureus.21329 12. young h, bui t, cramer se, o’connell r, houshyar r. ruptured endometrioma in a nonpregnant patient: a case report. j med case reports. 2022; 16:161. https://doi.org/10.1186/s13256-022-03361-3 13. sugita a, iwase a, goto m, nakahara t, nakamura t, kondo m, et al. one-year followup of serum antimüllerian hormone levels in patients with cystectomy: are different https://dx.doi.org/10.1007/s13244-017-0591-0 https://dx.doi.org/10.1007/s13244-017-0591-0 https://dx.doi.org/10.1007/s13244-017-0591-0 https://dx.doi.org/10.1186/1752-1947-4-389 https://dx.doi.org/10.1186/1752-1947-4-389 https://dx.doi.org/10.1186/s13000-019-0850-0 https://dx.doi.org/10.1186/s13000-019-0850-0 https://dx.doi.org/10.1186/s13000-019-0850-0 https://dx.doi.org/10.9734/jpri/2021/v33i40b32254 https://dx.doi.org/10.1210/er.2018-00242 https://dx.doi.org/10.1007/s10397-009-0482-6 https://dx.doi.org/10.1007/s10397-009-0482-6 https://dx.doi.org/10.26717/bjstr.2019.23.003959 https://dx.doi.org/10.26717/bjstr.2019.23.003959 https://dx.doi.org/10.1038/nrendo.2013.255 https://dx.doi.org/10.1186/s40814-021-00907-y https://dx.doi.org/10.1186/s40814-021-00907-y https://dx.doi.org/10.1186/s40814-021-00907-y https://dx.doi.org/10.1186/s40814-021-00907-y https://dx.doi.org/10.1186/s40814-021-00907-y https://dx.doi.org/10.1093/humrep/det457 https://dx.doi.org/10.1093/humrep/det457 https://dx.doi.org/10.7759/cureus.21329 https://dx.doi.org/10.7759/cureus.21329 https://dx.doi.org/10.7759/cureus.21329 https://dx.doi.org/10.7759/cureus.21329 https://dx.doi.org/10.1186/s13256-022-03361-3 https://dx.doi.org/10.1186/s13256-022-03361-3 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 j islamabad med dental coll 2022 193 sequential changes due to different mechanisms causing damage to the ovarian reserve?. fertil steril. 2013; 100(2):516-22. https://doi.org/10.1016/j.fertnstert.2013.03.0 32 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 https://dx.doi.org/10.1016/j.fertnstert.2013.03.032 j islamabad med dental coll 2022 182 open access attitude of physical therapy students towards their profession and education in punjab tahir mahmood1, abdulsalam2, iqra waseem3, aqsa khalid4, umer maqsood5 1senior lecturer, physical therapist, imran idrees institute of rehabilitation sciences, sialkot, pakistan. 2assistant professor and head of department, imran idrees institute of rehabilitation sciences, sialkot, pakistan. 3assistant professor, university institute of physical therapy, lahore, pakistan. 4medical officer, sundas foundation, sialkot, pakistan. 5assistant professor, department of physical therapy, azra naheed medical college, lahore, pakistan. a b s t r a c t background: the quality of medical teaching can be refined based on the attitude of the students towards their clinical and teaching environment. the objective was to determine student attitudes towards their profession and education in punjab. methodology: this cross-sectional survey was conducted from 20th july to december 2021 after taking ethical approval. the data was collected through an online google document from physical therapy undergraduates and post graduates from different institutes of punjab. the outcome was measured using “physical therapy student attitudes questionnaire (psaq)”.it had four sections, section a is about the knowledge of the profession, section b includes beliefs about future, section c is about patient exposure in clinical trainings and section d is about level of satisfaction from the learnings. the data was encoded and analyzed using spps v.23. the descriptive statistics and mean+ standard deviations were used to present the scores. the independent sample t-test was used to find the difference in mean scores of males and females with p value ≤ 0.05 taken as significant. results: the current study comprised of 82(32.15%) males and 173(67.84%) females with mean age of 24.4 +6.5 years. the overall satisfaction level regarding knowledge, future beliefs, clinical exposure and learning was good with total mean± sd of 87.62+17.64 for males and 87.97+18.67 for females. there was no statistically significant difference of satisfaction among male and female students with p >0.05 conclusion: the student attitude was quite satisfactory regarding their choice of physical therapy profession, good future, patient exposure and learning skills. there was no statistically significant difference based on the gender. keywords: education, patients, physical therapy, satisfaction, training. authors’ contribution: 1conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review;4 ,5data analysis; manuscript editing. correspondence: tahir mahmood email: tahirmahmoodphysio@gmail.com article info: received: february 16, 2022 accepted: september 14, 2022 cite this article. mahmood t, salam a, waseem i, khalid a, maqsood u. attitude of physical therapy students towards their profession and education in punjab. j islamabad med dental coll. 2022;11(3): 182-187 doi: https://doi.org/10.35787/jimdc.v11i3.851 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e https://doi.org/10.35787/jimdc.v11i3.851 j islamabad med dental coll 2022 183 i n t r o d u c t i o n physical therapy is a health care profession and a part of the health care in multi-disciplinary rehabilitation. it has an integral role in health care system for decades. (1)this profession was started as a three years diploma in 1963. however, there was a demand for higher education and improved healthcare services.(2) to meet this need, universities started offering bachelor's degree programs in physical therapy (pt) in the late nineteenth century.(3) good quality education is necessary and reflected in the quality of physical therapy services. to have a good physical therapy program, it is necessary to have diverse courses, qualified teaching staff, and well-organized clinical training. it is shown that almost 71% of undergraduate pt students feel that the difficulty level of course is greater than expected. the current educational system focuses on an important concept called student’s satisfaction.(4) as an academician, we can enhance students' understanding and learning by estimation of their satisfaction levels during their education and learning along with clinical trainings, tools for effective communication and proper time management.(5) this will enable us to modify the physical therapy program curriculum, clinical trainings and adopt new learning strategies in our institutions.(6) interest in student satisfaction at undergraduate and graduate level is wellestablished within higher education in many countries but depends upon several factors. (7)the students’ attitude and knowledge about their profession, results in good reputation and a positive impact leading to social awareness and it is other way with decreased satisfaction.(8) in this era of emerging professions and advancement, physical therapy profession has gained importance. there is a need of educational foundations that enable students to build up their skills based knowledge and attitudes.(9, 10) not much studies done in pakistan have addressed students’ attitudes in knowledge about the profession, beliefs about future, patient exposure in clinical trainings and level of satisfaction from the learnings. the objective was to estimate students’ attitudes towards their profession and education in punjab and find any gender-based difference. this will help to implement new strategies for further improvement in the profession of physical therapy. m e t h o d o l o g y this cross-sectional survey was conducted from 20th july, 2021 to 15th december 2021 after taking ethical approval (ref# iirs/dpt/ierc-372). the data was collected online using google document. we included physical therapy undergraduates and post graduates from different private institutes of punjab including agile institute rehabilitation sciences bahawalpur, bakhtawar amin college of rehabilitation sciences, multan, imran idrees institute of rehabilitation sciences, sialkot, azra naheed medical college, lahore and university institute of physical therapy, lahore. the calculated sample size was 255 by applying parameters, 𝑍1 − 𝛼/22 𝑃(1−𝑃) 𝑑2 where, 𝑍1 − 𝛼/22= 1.96 (standard normal variants at 5% type i error (p<0.05), p= 0.79 (expected proportion in population) and d= 0.05 (absolute error). (11)the online google document was prepared based on the mentioned outcome tool with addition of basic details and informed consent, ensuring the privacy and confidentiality of the provided responses. the outcome tool was “physical therapy student attitudes questionnaire (psaq).”it had four sections including a, 6 questions related to the knowledge about the profession, 5 questions in j islamabad med dental coll 2022 184 b related to beliefs about future, 7 questions in c related to patient exposure in clinical trainings and 7 questions in d is related to level of satisfaction from the learnings. the responses were based on likert scale; absolutely agree, agree, neutral, disagree and absolutely disagree. the outcome tool had 0.71 content validity and 0.69-0.75 for its subdivisions. the cronbach’s alpha coefficient for reliability was 0.86 and 0.32-0.86 for its sub divisions. ( 12) the responses were added according to scale in each column to measure the average response of the students. after that, the scores were added up for each of the four domains to summarize the total scores using likert scale. the data was encoded and analyzed using spps version 23 .the descriptive statistics included mean ±standard deviations that were used to present the scores , independent sample t-test was used to estimate and compare the scores based on gender with significance set at <0.05 (95% ci). r e s u l t s the mean age of the participants was 22.5+6.5years. the current study comprised of more females as compared to males, participants belonging to middle class were 226 (88.62%). 71.36% of the participants were from 2nd to 4th professional year . (table 1) the sum of all domains of psaq were calculated separately. the combined scoring showed no significant gender-based difference with p value >0.05. (table *this scoring is sum of all boxes within male and females the response of the students showed that 120 (47.05%) agree that they were willing to be physical therapist in future and 140 (54.90%) had good theoretical background, others are presented. (figure 1) table: idemographics of the participants (n=255) descriptive statistics frequency (%ages) gender male 82(32.15%) female 173(67.84%) socioeconomic status upper class 19(7.45%) middle class 226(88.62%) lower class 10(3.92%) professional year 1st year 45(17.64%) 2nd year 88(34.50%) 3rd year 56(21.96%) 4th year 38(14.90%) 5th year 23(9.01%) masters/mphi l 5(1.96%) age groups 19-21 181(70.97%) 22-24 68(26.66%) 25-27 03(1.17%) 28-30 03(1.17%) table :ii sum of scores and their means group statistics domain gender n mean + sd std. error mean p –value knowledge about the profession male 82 21.82 + 3.84 .42 0.604 female 173 21.54 +4.10 .31 future beliefs male 82 16.63+5.44 .60 0.244 female 173 17.45+5.11 .39 patient exposure in clinical trainings male 82 24.55+5.60 .62 0.873 female 173 24.43+5.68 .43 alevel of satisfaction from the learnings. male 82 24.62+5.56 .61 0.944 female 173 24.57+6.08 .46 all male 82 87.62+17.64 1.95 0.844 female 173 87.98+18.67 1.42 j islamabad med dental coll 2022 185 pt=physical therapist figure 1: students response about their profession d i s c u s s i o n this cross-sectional survey was conducted on 255 physical therapy undergraduates and post graduates to find out students’ attitudes towards their profession and education. the student attitude was quite satisfactory regarding their choice of physical therapy profession, good future, patient exposure in clinical trainings and learning skills. this study reports satisfactory males and females mean scores in domain a which includes choice of profession and happiness after getting admission. according to another study, the students from spain and czech republic were found to be happy in getting admission in physical therapy profession and working as physiotherapist.(13) in our study, more than half of the students were satisfied with the clinical and patient exposure in their institutes and hospitals. the students in saudi arabia had good satisfaction level regarding clinical and practical sessions at individual level but the sample size was less as compared to this study.(14) the mean satisfaction score was 24.62±5.56 for males and 24.57±6.08 for females with no difference of satisfaction regarding their learning. they were willing to work as physical therapist in future with no difference of response based on the gender. the level of satisfaction had an impact on the academic performance and choice of career and the respondents were in favor of the physical therapy as a choice of profession in line with findings of you lim. (15) in brazil, 1st year students were more satisfied compared to 3rd,2nd and 4th year physical therapy students. (16)a recent study in chili reported positive perception of undergraduate students about their learning environment with less positive attitude of first year students. literature favors that most of the students choose this profession because of their interest in it. ( 12)the high rate of admissions can be due to a perception that a physical therapist helps others , encourages sports related activities, works manually and this profession has multiple job 0 20 40 60 80 100 120 140 160 180 want to be pt potentials rightly utilized aware of the job prospects recommend to others good theoretical background teaching is mostly associated with patient assessment and treatmentabsolutely agree agree j islamabad med dental coll 2022 186 opportunities.(17) the performance is based on clinical trainings and patient exposure during study years, which is predictor of license exams in different countries.(18) the overall satisfaction of students was good regarding knowledge, future beliefs, patient exposure and learnings in their institutes. the evidence supports that organization and teaching are the actual factors that influence the students level of satisfaction.(19) in contrast, according to a recent finding in ethiopia, student satisfaction was low as compared to the current study.(20) the current study highlighted student perception and their level of satisfaction. there is further need to enhance the skills of the enrolled students, so that better future clinicians can serve the community. the online data has affected generalization of the results and there were fewer respondents from the master class which can further affect the external validity of the study. c o n c l u s i o n the student attitude was quite satisfactory regarding their choice of physical therapy profession, good future, patient exposure in clinical trainings and learning skills. there was no statistically significant difference based on the gender. r e f e r e n c e s 1. leeftink a, bikker i, vliegen i, boucherie r. multidisciplinary planning in health care: a review. health systems. 2020;9(2):95-118. doi: 10.1080/20476965.2018.1436909 2. sana a, rashid h, ilyas m, danish h, sheraz m, atif a. swot analysis of physiotherapy profession in pakistan. res j pharm technol. 2018;11(10):4553-8. doi:10.5958/0974-360x.2018.00833.8 3. babur n, ashfaq m. a journey from post matriculation diploma to post professional clinical doctorate: a historical perspective of physical therapy profession in pakistan. int j rehab sci. 2012;1(1):8-9.[ available at : https:// www. academia .edu/47594523/a_journey_ from_ post _matriculation _diploma _to_post professional_ clinical_ doctorate_ a_historical_ perspective_of_ physical_therapy_profession_in_pakistan] [ cited 16 september ,2022] 4. siddiqi fa, azim me, babur mn, osama m, waheed a, memon ar. psychological stress and satisfaction with life among physical therapy students of rawalpindi / islamabad, pakistan. j pak med assoc. 2019 jul;69(7):973-975. pmid: 31308565 5. chan zc, chan hy, chow hc, choy sn, ng ky, wong ky, et al.academic advising in undergraduate education: a systematic review. nurse educ. today. 2019 apr 1;75:58-74. https://doi.org/10.1016/j.nedt.2019.01.009 6. fidalgo p, thormann j, kulyk o, lencastre ja. students’ perceptions on distance education: a multinational study. int. j. educ. technol. high. educ2020;17(1):1-18. doi.org/10.1186/s41239-02000194-2 7. muskens m, frankenhuis we, borghans l. lowincome students in higher education: undermatching predicts decreased satisfaction toward the final stage in college. j youth adolesc . 2019;48(7):1296-310. doi: 10.1007/s10964-01901022-1 8. van schalkwyk sc, hafler j, brewer tf, maley ma, margolis c, mcnamee l, et al. transformative learning as pedagogy for the health professions: a scoping review. med educ. 2019;53(6):547-58. doi: 10.1111/medu.13804. 9. worum h, lillekroken d, roaldsen ks, ahlsen b, bergland a. physiotherapists’ perceptions of challenges facing evidence-based practice and the importance of environmental empowerment in fall prevention in the municipality–a qualitative study. bmc geriatrics. 2020;20(1):1-17. doi: 10.1186/s12877-020-01846-8 10. timmerberg jf, dole r, silberman n, goffar sl, mathur d, miller a, et al. physical therapist student readiness for entrance into the first full-time clinical experience: a delphi study. phyl thera. 2019 feb 1;99(2):131-46. doi.org/10.1093/ptj/pzy134 11. khan m, maqsood u, saleem n, mahmood t, arshad hs. knowledge, experience, attitude and barriers of postgraduate physiotherapy students toward extracurricular research activities. rawal med j. 2021;46(1):118-22. 12. tedla js. construction of a new questionnaire for assessing physical therapy student attitudes towards their education and profession and testing its validity and reliability. phys. ther. rehabil. sci. 2017;6(1):20-5. doi.10.14474/ptrs.2017.6.1.20 13. gotlib j, białoszewski d, opavsky j, garrod r, fuertes ne, gallardo lp, et al. attitudes of european https://doi.org/10.1080%2f20476965.2018.1436909 http://dx.doi.org/10.5958/0974-360x.2018.00833.8 https://doi.org/10.1016/j.nedt.2019.01.009 https://doi.org/10.1007/s10964-019-01022-1 https://doi.org/10.1007/s10964-019-01022-1 https://doi.org/10.1093/ptj/pzy134 j islamabad med dental coll 2022 187 physiotherapy students towards their chosen career in the context of different educational systems and legal regulations pertaining to the practice of physiotherapy: implications for university curricula. physiotherapy. 2012;98(1):76-85. doi: 10.1016/j.physio.2011.02.003 14. alahmari k, shanker j, gular k. pysical therapy student’s satisfaction during their practical and clinical training sessions at abha, saudi arabia. a cross-sectional study. general and professional education. 2017;2017(1):3-7. 15. kim yl, lee sm. effect of satisfaction in major at university on academic achievement among physical therapy students. j. phys. ther. sci.2015;27(2):4059. doi: 10.1589/jpts.27.405 16. czapievski fdn, sumiya a. assessment of the degree of satisfaction of physical therapy students with the academic experience. fisioterapia em movimento. 2014;27:119-25. doi.org/10.1590/01035150.027.001.ao13 17. fuente-vidal a, march-amengual j-m, de souza dlb, busquets-alibés e, sole s, cañete s, et al. factors influencing student choice of a degree in physiotherapy: a population-based study in catalonia (spain). peerj. 2021;9:e10991. doi: 10.7717/peerj.10991. 18. kume j, reddin v, horbacewicz j. predictors of physical therapy academic and npte licensure performance. health prof. educ.2019;5(3):185-93. doi.org/10.1016/j.hpe.2018.06.004 19. sofroniou a, premnath b, poutos k. capturing student satisfaction: a case study on the national student survey results to identify the needs of students in stem related courses for a better learning experience. j. educ. sci2020;10(12):378. doi.org/10.3390/educsci10120378 20. temesgen mh, girma y, dugo t, azeze g, dejen m, deres m,et al. factors influencing student’s satisfaction in the physiotherapy education program. adv med educ pract. 2021;12:133. doi: 10.2147/amep.s289134. https://doi.org/10.1590/0103-5150.027.001.ao13 https://doi.org/10.1590/0103-5150.027.001.ao13 https://doi.org/10.1016/j.hpe.2018.06.004 https://doi.org/10.3390/educsci10120378 journal of islamabad medical & dental college (jimdc); 1211(1):30-32 30 original article frequency of hepatitis c virus infection and estimation of serum alanine aminotransferase in hcv positive patients * salma guhlam nabi,** ghazal zaffar,*** zaheer ahmed,****shamim mumtaz * assistant professor, department of pathology, islamabad medical and dental college, islamabad ** student 4th year mbbs, yusra medical college, rawalpindi *** associate professor, department of pathology. yusra medical college, rawalpindi **** prof of pathology, islamabad medical and dental college, islamabad (bahria university, islamabad) abstract background: hepatitis c virus (hcv) has emerged as a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. hepatitis c is rapidly emerging as a major health problem in developing countries including pakistan. serum alanine aminotransferase (alt) is the most frequently utilized screening test in routine evaluation of liver damage. this study was conducted to determine the seroprevalence of hepatitis c virus infection and its association with serum alanine aminotransferase. objective: determination of the seroprevalence of hepatitis c virus infection and its association with serum alanine aminotransferase in patients at social security hospital, islamabad. material and methods: a cross sectional study was conducted at clinical laboratory of social security hospital islamabad, from may 2009 to october 2009. all samples referred to social security hospital for hepatitis profile were included in the study. all patients were screened serologically for hepatitis c virus antibodies and serum alanine aminotransferase was determined in selected hcv positive patients only. results: out of 1006 blood samples 146 were positive for anti-hcv antibodies with an overall positivity of 14.5%. out of these 55% cases were males and 45% were females. seroprevalence of hcv was found to be 8% in the age group of <20 years, and almost equal i.e. 46% and 49% in 20-40 years and >40 years age groups respectively. serum alt was determined in total 83 patients only: they showed levels less than 30u/l in 25% patients, 30-45u/l in 15% patients, 46-60u/l in 19% patients, 61-100u/l in 29% patients and more than 100u/l in 12% patients. conclusion: the present study revealed that prevalence of hcv was 14.5% and alt levels were found to be more than 45u/l in 75% of the anti hcv positive cases, showing the significance of this biochemical marker as diagnostic tool in such patients. introduction hepatitis c is rapidly emerging as a major health problem in developing countries including pakistan.1-5 it is estimated that 3–4 million people are infected with hcv each year. some 130–170 million people are chronically infected with hcv and at risk of developing liver cirrhosis and/or liver cancer. more than 350,000 people die from hcv-related liver diseases each year. countries with high rates of chronic infection are egypt (22%), pakistan (4.8%) and china (3.2%).6 in pakistan 10 million people are presumed to be infected with hcv. 7, 8 seroprevalence studies of anti-hcv antibodies in the general population of pakistan have been recorded as 5.31% to 7.5%.9-11 serum alanine aminotransferase (alt) is the most frequently utilized screening test in routine evaluation of liver damage.12, 13 alt is most concentrated in liver and released into the bloodstream as the result of liver injury. it, therefore, serves as a fairly specific indicator of liver status.14,15 however, there are conflicting reports on the relationship between the biochemical markers of inflammation and alt.16 hence this study was designed with an aim to determine the seroprevalence of hepatitis c virus infection and its association with serum alanine aminotransferase in our population. material and methods a cross-sectional study was conducted at clinical laboratory of social security hospital islamabad, for a period of six months from may 2009 to october 2009. all blood samples referred for hcv profile were checked for anti hcv. serum alanine aminotransferase was tested in those patients who were found positive for anti hcv. samples were subjected to serological analysis for anti-hcv antibodies using rapid immune chromatography kits (ict, australia and abbott, usa) and positive samples were confirmed by elisa (imx, abbott, usa). alt was performed by standard biochemical method on microlab. results were entered on spss version 14 for final analysis. journal of islamabad medical & dental college (jimdc); 1211(1):30-32 31 results total number of cases referred for hcv profile was 1006. out of these 146 cases were positive for anti-hcv antibodies; hence overall positivity was 14.5%. among these 55.5% were males and 44.5 % were females with male to female ratio of 1.2:1. prevalence of hepatitis c was found to be 8% in the age group of <20 years, and almost equal i.e. 46% and 49% in 20-40 years and more than 40 years groups respectively (table.1). table 1: hcv positivity in relationship with age (n=146) age in years no. (%) <20 20-40 >40 8 (5.48) 67 (45.89) 71 (48.63) table 2: alt levels in anti-hcv positive patients serum alt level (u/l) no. (%) mean ±s.d <30 30-45 46-60 61-100 >100 21(25.30) 12(14.46) 16(19.28) 24(28.92) 10(12.05) 21.81± 4.26 35.17± 4.60 53.38± 5.71 78.58± 9.72 250.1± 186 serum alt was checked in total 83 patient’s blood samples. our study showed levels less than 30u/l in 21 patients, 30-45u/l in 12 patients, 46-60u/l in 16 patients, 61-100u/l in 24 patients and more than 100u/l in 10 patients (table.2). reference ranges for alt established in our lab are 3-33u/l. discussion prevalence of hcv may be different in different regions and various groups of the same community. 17 in our hospital based study seroprevalence of hcv was 14.5%. hospitalbased studies revealed seroprevalence rates of anti-hcv as 5.31% in islamabad,18 2.45%-20.89% in various parts of the punjab province. 4,19-20 seroprevalence of hcv was 4-6% in karachi, 5 5%-9% in north west frontier province (nw.f.p) 21,22 and 25.7% in northern areas. 23 our study is partially in agreement with another study, in which prevalence of active hcv infection in district mansehra pakistan was 7%1. slightly higher prevalence of hcv was recorded in the earth quake affected areas of pakistan in 2005. 3 high prevalence of hcv infection in male population has earlier been recorded by other studies from pakistan and around the globe. in our hospital based study males were more commonly affected than females, the results comparable with another study conducted by ahmed et al at jinnah postgraduate medical centre, karachi as 55% hepatitis c cases were males and 45 % females. 24 in relation to age group we also observed a high prevalence of hcv among adults i.e. more than 40 years (48.63%) followed by individuals between 20-40 years (45.89 %). on the other hand, the prevalence in less than 20 year age group was significantly low (5.48%). this shows that the prevalence of hcv increased with increasing age. this was in agreement with another study that showed high prevalence of hcv among middle-aged (40-50 years) group and lowest between 21-30 years. 1 in developing countries, alt testing continues to be employed as a diagnostic marker for hcv infection based on the assumption that recent hcv infection can be detected earlier by alt than by anti-hcv. the serological screening test may miss a hepatitis c virus infection before hepatitis c virus antibodies are detected. 12, 25 in 63% of patients in our study value of alt were found to be between 30-100u/l. this study is in agreement with a study conducted in postgraduate institute of peshawar which showed that majority of hcv-positive patients in different stages of infection had alt levels between 41-80u/l; the study also showed that there is a close correlation between elevation of alt and hcv infection.26 this pattern is strongly supported by the works of wang, rodger, and shang who found a strong correlation between the prevalence of an elevated serum alt level and hcv positivity.26-29 this finding suggests that we can use the prevalence of an elevated serum alt level for identifying the communities with high prevalence of hcv infection. considering that the per unit cost of the anti-hcv test is 5 to 25 times that of the serum alt level test , the overall cost for conducting such regional or national survey of hvc infection can be significantly reduced using the serum alt levels. moreover, performing serum alt levels in the field is much more feasible than performing the anti-hcv test. our data has important implications in terms of cost, and feasibility for monitoring a communicable disease in communities, particularly in hyper endemic areas. in summary, the prevalence of an elevated serum alt level is a valuable index for identifying the communities at the high risk of hcv infection. population with elevated serum alt levels may then be checked for hcv infection. 26, 27 conclusion the present study revealed that prevalence of hcv was 14.5% and that there was a close correlation of alt with anti hcv positivity. it is recommended that if screening for hcv is not possible then alt should be checked and a mild elevation in alt should be taken as a base for hcv screening. journal of islamabad medical & dental college (jimdc); 1211(1):30-32 32 references 1. ali a, ahmad h, ali i, sheema khan4, gulshan zaidi5 and muhammad idrees5 prevalence of active hepatitis c virus infection in district mansehra pakistan. virology j 2010, 7:334 2. raza sa, clifford gm, franceschi s: worldwide variation in the relative importance of hepatitis b andhepatitis c viruses in hepatocellular carcinoma: a systematic review. br j cancer 2007, 96(7):1127-1134. 3. khan s, rai ma, khan a, farooq a, kazmi su, ali sh: prevalence of hcv and hiv infections in 2005earthquak areas of pakistan. bmc infect dis 2008, 8:147. 4. hashmie zy, chaudhary ah, ahmad m, ashraf m: incidence of healthy voluntary blood donors at faisalabad. the prof med j 1999, 6:551-555 5. kazmi k, sadaruddin a, dil as, zuberi sj: prevalence of hcv in blood donors. pak j med res 1997, 36:61-62. 6. available from: http://www.who.int/topics/hepatitis/factsheets/en/index .html fact sheet n°164 june 2011 7. waheed y, shafi t, safi sz, qadri i. hepatitis c virus in pakistan: a systematic review of prevalence, genotypes and risk factors. world j gastroenterol 2009, 7: 5647-5653 8. hamid s, umar m, alam a, siddiqui a, qureshi h, butt j. psg consensus statement on management of hepatitis c virus infection--2003. j pak med assoc 2004; 54: 146-150 9. khokhar n, gill ml, malik gj: general seroprevalence of hepatitis c and hepatitis b virus infections in population. j coll physicians surg pak 2004, 149:534-536. 10. luby sp, qamruddin k, shah aa: the relationship between therapeutic injections and high prevalence of hepatitis c infection in hafizabad, pakistan. epidemiol infect 1997, 119:349-356 11. syed aa, rafe mj, qureshi h, vermund sh: hepatitis b and hepatitis c in pakistan. int j infect dis 2009, 13:9-19. 12. ali n, moiz b, moatter t, ahmed s, adil sn, khurshid m. correlation of hepatitis c rna and serum alanine aminotransferase in hepatitis b and c seronegative healthy blood donors. 2010, 53:480 485 13. ozer j, ratner m, shaw m, bailey w, schomaker s. the current state of serum biomarkers of hepatotoxicity. toxicology 2008, 245:194-205. 14. chakravarti a, dogra g, verma v, srivastava pa. distribution pattern of hcv genotypes & its association with viral load. indian j med res. 2011 march; 133(3): 326-331. 15. lee ys, yoon sk, chung es, bae sh, choi jy, han jy, et al. the relationship of histologic activity to serum alt, hcv genotype and hcv rna titers in chronic hepatitis c. j korean med sci.2001;16:585– 91 16. strader db, wright t, thomas dl, seeff lb. diagnosis, management, and treatment of hepatitis c. hepatology 2004, 39:1147–71. 17. idrees m, riazuddin s: frequency distribution of hepatitis c virus genotypes in different geographical regions of pakistan and their possible routes of transmission. bmc infect dis 2008, 8:69 18. farhana m, hussain i, haroon ts: hepatitis c: the dermatologic profile. j pak assoc derm 2008, 18:171-181 19. chaudhary ia, samiullah u, khan ss, masood r, sardar ma, mallhi aa. seroprevalence of hepatitis b and c among the healthy blood donors at fauji foundation hospital, rawalpindi. pak j med sci 2007, 23:64-67. 20. jehangir w, ali f, shahnawaz u, iqbal t, qureshi hj: prevalence of hepatitis b, c and hiv in blood donors of south punjab. esculapio 2006, 2:6-7. 21. khan msa, khalid m, ayub n, javed m: seroprevalence and risk factors of hepatitis c virus (hcv) in mardan, n.w.f.p. rawal med j 2004, 29:57-60 22. muhammad n, jan a: frequency of hepatitis c in bunir, nwfp. j coll physicians surg pak 2005, 15:11-14. 23. tariq wu, hussain ab, karamat ka, ghani e, hussain t, hussain s: demographic aspects of hepatitis c in northern pakistan. j pak med assoc 1999, 49:198-201. 24. ahmed w, arif a, alam se, qureshi h, changing trend of viral hepatitis — “a twenty one year report from pakistan medical research council research centre, jinnah postgraduate medical centre, karachi’ 25. krajden m. hepatitis c virus diagnosis and testing. can j public health 2000; 91:34-9, 6-42. 26. akhtar t, lutfullah g, rahim a, nazli r. serum alanine aminotransferase levels in hepatitis c patients in teaching hospital of peshawar. j chem soc pak, 2008, 30:106-109. 27. wang cs, wang st, p chou. using the prevalence of an elevated serum alanine aminotransferase level for identifying communities with a high prevalence of hepatitis c virus infection. arch intern med. 2001;161:392-39 28. j. rodger, s. roberts, a. lanigan, s. bowden, t. brown, n.crofts. assessment of long-term outcomes of community-acquired hepatitis c infection in a cohort with sera stored from 1971 to 1975. hepatology; 2000, 32:582-587. 29. chong-shan wang, md, mph; shan-tair wang, phd; ting-tsung chang, md; wei-jen yao, md; pesus chou. smoking and alanine aminotransferase levels in hepatitis c virus infection implications for prevention of hepatitis c virus progression. arch intern med. 2002;162:811-81. 8 j i m d c 2 0 1 7 8 op e n ac c e ss f u l l l e n g t h a r t i c l e role of probiotics in prevention of necrotizing enterocolitis in preterm infants mehreen batool bukhari1, saba naim khan2, mohsin butt3 1-3assistant professor, department of pediatrics, islamabad medical and dental college, social security hospital, islamabad a b s t r a c t objective: to compare the efficacy of prophylactic enteral probiotic administration versus placebo in the prevention of necrotizing enterocolitis in preterm infants. patients and methods: this randomized control trial was carried out at paediatric department of holy family hospital, rawalpindi. a total of 154 preterm infants, 28-33 weeks’ gestational age and <2500 grams at birth were enrolled after informed parental consent a donation of for 6 months. they were randomized in to 2 groups with 77 in each group. the infants in the study group were given bilus (b.bifidus & l.acidophilus) with breast milk twice a day. the infants in the control group were given breast milk alone. physical and radiological signs of necrotizing enterocolitis (nec) were observed and nec was staged according to modified bell’s criterion. results: the frequency of necrotizing enterocolitis was lower in the study group as compared to the control group; 4 of 77 (5.2%) versus 6 of 77(7.8%) but the results were not statistically significant (p value = 0.25) key words: necrotizing enterocolitis, preterm infants, probiotics. author`s contribution 1 conception, synthesis and planning of the research,2 active participation in active methodology, 3active participation in active methodology, interpretation, analysis and discussion address of correspondence dr. mohsin butt proudpakistani65@hotmail.com article info. received: oct 7, 2016 accepted: mar 6, 2017 cite this article: bukhari mb, khan sn, butt m. role of probiotics in prevention of necrotizing enterocolitis in preterm infants.jimdc. 2017; 6(1):8-13 funding source: nil conflict of interest: nil i n t r o d u c t i o n necrotizing enterocolitis (nec) is one of the most common gastrointestinal emergencies in the newborn infants. it is one of the most devastating life-threatening diseases affecting 7 to 14% of preterm infants.1 not only is it associated with high mortality but also with long-term adverse outcomes such as neurodevelopmental impairment in the survivors.2 the precise pathogenesis is unknown and it is considered as multifactorial disease. three major factors are thought to contribute i.e. presence of pathogenic organisms, altered enteric mucosal integrity and the challenge of enteral feeding.3 a better understanding of the intestinal ecosystem in preterm babies may hold the key to prevention of nec. the microflora in the gut of preterm baby lacks the biodiversity that is seen within days in a healthy baby born at term.4 one factor may be the late introduction of breast milk, that contains bifidobacteria which promote healthy microbiota development.5 probiotics are live microbial agents that are delivered enterally, colonize the gut and provide benefits to the host. as it takes time for the gut of preterm babies to be colonized by beneficial bacteria that contribute to healthy gut function, early prophylactic treatment with probiotics seems a very logical strategy.6 probiotics may assist in establishing a normal nonpathologic flora by preventing the binding of pathogenic bacteria to the enterocyte, local production of antimicrobial products or by altering the intestinal luminal o r i g i n a l a r t i c l e 9 j i m d c 2 0 1 7 9 ph, by producing potentially microbicidal short chain volatile fatty acids.7 genomic studies of the probiotic lactobacillus rhamnosus have revealed that it contains pilus fibers with mucus binding predisposition by which it displaces pathogenic bacteria.8 these data suggest that probiotics by modifying the occurrence of cascade of events may play a major role in reducing the incidence of nec. various probiotics have been used for this purpose but the most commonly employed are species of bifidobacteria and lactobacillus.9 in this study, we evaluated the role of probiotics (bifidobacteria and lactobacillus) in the prevention of necrotizing enterocolitis in preterm infants. the results of some previous studies are quite encouraging but more studies are needed so that probiotic administration can be made a routine protocol in the care of preterm infants. p a t i e n t s a n d m e t h o d s this randomized control trial was carried out in the nursery of paediatric department of holy family hospital, rawalpindi from 10th september 2010 to 9th march 2011. premature infants with gestational age between 28 and 33 weeks, weighing <2500 grams who started to feed enterally and survived beyond the seventh day after birth were included in the study and those with necrotizing enterocolitis developed within 7 days of birth were excluded. approval of this study was taken by the ethical committee of rawalpindi medical college and allied hospitals. informed parental consents were taken. about 154 preterm infants were randomized into the study group and control group with 77 in each group. randomization was done by consecutive non-probability sampling. the study group was given bilus which contains bifidobacterium bifidus and lactobacillus acidophilus 1 x 106 cfu each. this was mixed with expressed breast milk and given twice a day. the control group received breast milk alone. this was administered by the nursing staff via nasogastric tube. feeding was started when the infant had stable vital signs, active bowel sounds, visibly normal abdomen and with no dirty or bloody aspirate. strict feeding protocol was followed. depending on the birth weight and gestational age feeding was started. the feeding was advanced slowly with daily increment of 15-20ml/kg. the probiotic was added when feeding was tolerated usually by fifth or sixth day of life. during this time infants’ vitals, i.e. heart rate, respiratory rate, the temperature was taken daily and were examined for feeding intolerance, abdominal distension, bloody stools, and emesis. abdominal distension and any residual feed were checked by nursing staff before each feed. if present, was reported to doctor and feeding was stopped if residual feed was more than 30% of last feed. laboratory parameters that were done in all cases were complete blood count, electrolytes, and stool routine examination. blood and stool cultures along with x-rays were done in suspected cases of nec. nec was categorized according to modified bell’s criterion. patients were monitored for a period of two weeks or until discharge/death. a proforma was filled for all of the study participants. spss version 14.0 was used to enter and analyze the data. chi-square test was used on categorical variables like efficacy in both groups. the significance level was assumed to be any value less than 0.05. r e s u l t s in probiotic group, the mean age of patients was 5.29 days + 0.51 sd and was 5.30 days + 0.54 sd in the control group. the average birth weight was 1498.7 grams + 214.3 sd in the probiotic group and 1461.0 grams + 206.6 sd in the control group. when birth weight was compared in categories, 42 (54.5%) in probiotic group had low birth weight while in control group 32(41.6%) had low birth weight. similarly, in probiotic group 35 (45.5%) had vlbw while in the control group 45 (58.4%) had vlbw. (table 1). table 1. baseline characteristics of patients in the two study groups probiotic group control group (n = 77) (n = 77) age (days) mean + sd 5.29 + 0.51 5.30 + 0.54 birth weight (grams) mean + sd 1498.7 + 214.3 1461.0 + 206.6 weight in categories lbw n (%) 42 (54.5) 32 (41.6) vlbw n (%) 35 (45.5) 45 (58.4) the mean gestational age in the probiotic group was 31.5 + 1.5, weeks compared to 31.3 + 1.5 weeks in the control 10 j i m d c 2 0 1 7 10 group. the categories according to gestational age were also compared. (table 2) table 2. gestational age of preterm babies in the two study groups probiotic group (n = 77) control group (n = 77) gestational age (weeks) mean + sd 31.5 + 1.5 31.3 + 1.5 gestational age in categories (n%) < 30 weeks 30 – 31 weeks 32 – 33 weeks 11 (14.2) 16 (20.8) 50 (65.0) 11 (14.2) 29 (37.7) 37 (48.1) the clinical signs like temperature, heart rate and respiratory rate were compared in both study groups, and were found to be statistically insignificant. similarly, lethargy, feeding intolerance and abdominal distension were compared. emesis and bowel sounds were also noted (table 3). table 3. comparison of clinical signs of patients in the two study groups clinical signs probiotic group (n = 77) control group (n = 77) pvalue temperature normal hyperthermia hypothermia unstable n (%) 74 (96.1) 2 (2.6) 0 (0.0) 1 (1.3) n (%) 71 (92.2) 0 (0.0) 2 (2.6) 4 (5.2) 0.21 respiratory rate n(%) normal 73 (94.8) 72 (93.5) 0.45 apnea 1 (1.3) 0 (0.0) tachypnea 3 (3.9) 5 (6.5) heart rate n(%) normal 74 (96.1) 71 (92.2) 0.58 bradycardia 2 (2.6) 4 (5.2) tachycardia 1 (1.3) 2 (2.6) lethargy n(%) 5 (6.5) 6 (8.0) 0.72 feeding intolerance 5 (6.5) 6 (8.0) 0.72 abdominal distension 5 (6.5) 6 (8.0) 0.72 emesis 4 (5.2) 6 (8.0) 0.48 bowel sounds 3 (3.9) 2 (2.7) 0.67 bleeding p/r 5 (6.5) 5 (6.5) 0.96 comparison of haemoglobin, serum electrolyte and total leukocyte count in both groups, was also statistically insignificant. (table 4) investigations on stool and abdominal x-rays were done in both study groups; though the difference in proportions of stool r/e results between both the study groups was evident, still it could not be proven statistically. on stool culture, growth of klebsiella and e-coli were noted. x-ray abdomen findings were almost similar among study groups (table 4). table 4. comparison of pathological investigations in the two study groups investigations probiotic group (n=77) n (%) control group (n=77) n (%) pvalue hemoglobin normal abnormal serum electrolytes normal abnormal tlc normal decreased increased 75 (97.4) 2 (2.6) 73 (94.8) 4 (5.2) 73 (94.8) 3 (3.9) 1 (1.3) 72 (93.5) 5 (6.5) 71 (89.6) 6 (7.8) 71 (92.2) 6 (7.8) 0 (00) 0.51 0.28 0.49 stool r/e normal abnormal 73 (94.8) 4 (5.2) 69 (89.6) 8 (10.4) 0.27 stool culture no growth e-coli klebsiella 76 (98.7) 0 (0.0) 1 (1.3) 73 (94.8) 2 (2.6) 2 (2.6) 0.4 abdominal x-ray normal distended bowel loops pneumatosis intestinalis ascites 72 (93.5) 3 (3.9) 2 (2.6) 0 (0.0) 71 (92.2) 3 (3.9) 2 (2.6) 1 (1.3) 0.43 in group study 4 (5.2%) patients developed nec, while in the control group 6(7.8%) patients developed nec and all of these were in 2nd stage of necrotizing enterocolitis. the difference in the proportions was evident, however, was statistically insignificant. (table 5) table 5. comparison of stages of necrotizing enterocolitis between the two study groups probiotic group control group (n=77) n(%) (n=77) n(%) p-value without nec 73 (94.8) 71 (92.2) 0.74 nec stages* stage 1 1 (1.3) 0 (0.0) stage 2 2 (2.6) 6 (7.8) 0.25 stage 3 1 (1.3) 0 (0.0) * probiotics decreases the risk of nec rr (95% ci) 0.67 (0.20 – 2.27) 11 j i m d c 2 0 1 7 11 d i s c u s s i o n our study shows that prophylactic probiotics (bifidobacterium bifidus and lactobacillus acidophilus) are not effective in reducing the frequency of nec. although the difference in cases of nec in both groups is evident (5.2% in the study group as compared to 7.8% in control group) but this was not statistically significant. a total of 10 patients developed nec out of which 8 had stage 2 nec, 1 had stage 1 nec and 1 had stage 3. the results imply that larger sample size may be required to prove that probiotics reduce the incidence of nec and achieve significant results. however, there could be other factors to account for these results. firstly, the study was not powered to detect stool colonization by probiotic bacteria. stool colonization by probiotic bacteria is the means of assessing the viability of probiotic species. this can be equated for checking the bioavailability of a drug. the viability of probioic bacteria was checked by this method by lin et al in their pilot study.10 secondly, there are many variables associated with the development of nec. the consistent ones are prematurity and low birth weight.11 the other risk factors that are associated with increased risk of nec are vaginal delivery, need for ventilatory support, low apgar score at 5 minutes.12 the study was randomized but these risk factors were not accounted for, as all preterm infants in the study were not hospital born and thus the complete data was not available in those cases. thirdly, the difference in results could be because of the dose used. the dose used in our study was 1x 106 cfu. although there is no fixed dose of the probiotics used in various studies nor is the dosing interval determined but it seems that increasing the dose to 109 cfu has better results. in his first study lin et al used probiotics in a dose of 1 x 106 cfu, however in the second study by lin et al the dose used was 2 x 109 cfu and samanta et al also gave a probiotic mixture in a dose of 2.5 x 109 cfu but the probiotics used were also different.10,13 the results of our study are in accordance with the study done by dani et al in which although nec was found less frequent in the probiotic group i.e. 1.4% in the probiotic group versus 2.7% in the study group, the results were not significant.14 another study was done in usa in 2009, in which the effect of two probiotic and prebiotic products on weight gain, stool microbiota and stool short chain fatty acids was assessed. nec was a secondary outcome. there were 3 groups, 2 of which received probiotic preparation but the probiotic did not decrease the incidence of nec.15 the results of our study are also in accordance with the study in turkey in 2011, in which lactobacillus sporogenes was given to 110 infants until discharge. it was seen that there was no difference in the incidence of nec in the probiotic supplemented as compared to the control group.16 in our study, it was seen that most cases of nec i.e. 5 out of 10 (50%) occurred in one month, the month of november. it has been reported in different studies that many cases of nec occur sporadically, however, nec epidemics have also been reported in literature. in a retrospective study carried out at two neonatal intensive care units in cincinatti usa, data regarding the occurrence of nec was analyzed over an 8-year period. it was found that there were 12 temporal clusters of nec which comprised 18% of total 203 cases.17 our study did not focus on improvement in feeding tolerance with probiotics, but a number of studies have focussed on this aspect and provide encouraging results. a study done by samanta et al showed that the number of days required to reach full feeds was significantly lower in babies who received probiotics (13.76 vs. 19.2).13 therefore feeding tolerance was better. another study was carried out in china, which focused on the same subject. the incidence of feeding intolerance in the probiotics treatment group was lower than that in the conventional treatment group (4% vs 14%; p <0.01) in their study.18 the time to regain birth weight (6.8±1.2 days vs 7.7±1.6 days; p<0.05) and the time to reach full enteral nutrition (8.0±1.4 days vs 9.0±2.0 days; p<0.05) in the probiotics treatment group were shorter than those in the conventional treatment group. the extensive and safe use of commercial probiotics worldwide over several decades alongside clinical trials to assess potential adverse effects, provide the most compelling evidence for the safety of probiotics for the general population.19 to date over 2,000 premature neonates have been exposed to prophylactic probiotics in different prospective studies and no adverse short term effects have been noted.20 this history of safe consumption of some probiotics has generally been considered proof of short term safety for this vulnerable 12 j i m d c 2 0 1 7 12 population of infants but the proof of safety of a specific strain requires study of that strain rather than extrapolation from related strains. the trials mentioned earlier did not report any cases of sepsis secondary to probiotic use; however, they were not powered to detect such cases. the european society for paediatric gastroenterology, hepatology and nutrition’s committee on nutrition found limited high-quality data on the safety of probiotics added to infant formulas and no long-term studies on benefits and adverse effects of such supplementation.21 furthermore, the potential for sepsis from probiotics is unknown because the culture media used in most diagnostic laboratories do not support the fastidious anaerobic probiotic growth.22 it is not known that which probiotic or probiotic combination is best to use. it seems that double or triple probiotic strains provide the greatest effect. the appropriate dose and the frequency of dosing also need to be addressed. the quality of probiotics available is also unknown. each probiotic strain is a unique component itself and each strain has specific properties that cannot be extrapolated from other, even closely related strains. the specific properties of probiotic bacteria need to be characterized.22 thus there are still a lot of things unknown about probiotics and concerns regarding its safety. some of the trials done so far, have shown definite benefits but other trials like ours have shown inconclusive results. currently, there are 16 randomized controlled trials studying 12 different probiotic preparations in preterm infants which report data on clinically important outcomes such as nec, mortality, sepsis, or feeding advancement. although the results from these trials are encouraging, there is no evidence to recommend that all preterm infants should be fed probiotics routinely.23 the ability to manipulate enteric microbial flora in preterm, very low birth weight infants towards a normal nonpathogenic microenvironment addresses one of the fundamental issues in the pathogenesis of nec.8 the current study is, therefore, an important one and it is recommended that further studies are done with a larger sample size and enhanced scientific methods. c o n c l u s i o n prophylactic probiotics bilus (bifidobacterium bifidus and lactobacillus acidophilus) given twice a day in a dose of 1x106 with breast milk for two weeks is not effective in reducing the frequency of nec in preterm infants. to unequivocally prove the clinical efficacy of probiotics in nec large multicenter trials are needed. our results suggest for more research regarding appropriate bacterial strain, dose, and timing of administration to achieve clinically robust effects and also include analysis of possible adverse effects of probiotic administration, such as probiotic-associated sepsis and tolerance of milk feeding. r e f e r e n c e s 1. hintz, sr., kendrick, de., stoll, bj., vohr, br., fanaroff, aa. and donovan, ef et al. neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis. pediatrics.2005 115(3), 696-703 2. rees cm, pierro a, eaton s. neurodevelopmental outcomes of neonates with medically and surgically treated necrotizing enterocolitis. arch dis child fetal neonatal ed 2007; 92: f193-f198. 3. gaul j. probiotics for the prevention of necrotizing enterocolitis. neonatal network. 2008;27(2):75-80. 4. munyaka pm, khafipour e, ghia je. external influence of early childhood establishment of gut microbiota and subsequent health implications. frontiers in pediatrics. 2014; 2:109. 5. gueimonde m, laitinen k, salminen s, isolauri e. breast milk: a source of bifidobacteria for infant gut development and maturation? neonatology. 2007; 92(1): 64-6. 6. claud ec, walker wa. bacterial colonization, probiotics and necrotizing. (review) in gastroenterol enterocolitis(review) j clin gastroenterol 2008; 42: suppl 2: s46-52. 7. millar m, willkes m. costeloe k. probiotics for preterm infants? arch dis child fetal and neonatal ed. 2003; 88: f354-f358. 8. von ossowski i, reunanen j, satokari r, vesterlund s, kankainen m, huhtinen, et al. mucosal adhesion properties of the probiotic lactobacillus rhamnosus gg spacba and spafed pilin subunits. applied and environmental microbiology. 2010;76(7):2049-57. 9. petrof eo. probiotics and gastrointestinal disease: clinical evidence and basic science. anti-inflammatory & anti-allergy agents in medicinal chemistry (formerly current medicinal chemistry-anti-inflammatory and anti-allergy agents). 2009;8(3):260-9. 10. lin hc, su bh, chen ac, lin tw, tsai ch, yeh tf, et al. oral probiotics reduce incidence of necrotizing enterocolitis in very low birth weight infants. pediatrics. 2005; 115(1): 1-4. 11. lee js, polin ra. treatment and prevention of necrotizing enterocolitis. semin neonatol. 2003; 8: 449-459. 12. guthrie so, gordon pv, thomas v, thorp ja, peabody j, clark rh. necrotizing enterocolitis among neonates in the united states. j perinatol 2003; 23: 275-278. 13. samanta m, sarkar m, ghosh p, kr ghosh j, kr sinha m, chatterjee s. prophylactic probiotics for prevention of 13 j i m d c 2 0 1 7 13 necrotizing enterocolitis in very low birth weight newborns. j trop pediatr. 2009; 55(2); 128-131. 14. dani c, biadaioli r, bertini g, martelli e, rubaltelli ff. probiotics feeding in prevention of urinary tract infection, bacterial sepsis and necrotizing enterocolitis in preterm infants. neonatology. 2002 ;82(2):103-8. 15. underwood ma, salzman nh, bennett sh, barman m, mills d, marcobal a, et al. a randomized placebo-controlled comparison of two prebiotic/probiotic combinations in preterm infants: impact on weight gain, intestinal microbiota, and fecal short chain fatty acids. journal of pediatric gastroenterology and nutrition 2009;48(2):216. 16. awad h, mokhtar g, imam s.s. comparison between killed and living probiotic usage versus placebo for the prevention of necrotizing enterocolitis and sepsis in neonates. pakistan journal of biological sciences 13 (6):253-262, 2010. 17. meinzen-derr j, morrow al, hornung rw, donovan ef, dietrich kn, succop pa. epidemiology of necrotizing enterocolitis temporal clustering in two neonatology practices. the journal of pediatrics. 2009;154(5):656-61. 18. hu xy, zhou yx, xu sz, lin yy. effects of probiotics on feeding intolerance in low birth weight premature infants. zhongguo dang dai er ke za zhi. 2010 ;12(9):693-5. 19. lahtinen sj br, margolles a, frias r, gueimonde m. safety assessment of probiotics. in: chcaralampopoulos drr, ed. prebiotics and probiotics science and technology. new york: springer 2009; 1193-235. 20. sanders me, akkermans lm, haller d, hammerman c, heimbach jt, hörmannsperger g, et al. safety assessment of probiotics for human use. gut microbes 2010;1(3): 164-185 21. agostoni c, axelsson i, braegger c, goulet o, koletzko b, michaelsen kf, et al. probiotic bacteria in dietetic products for infants: a commentary by espghan committee on nutrition. j pediatr gastroenterol nutr 2004; 38: 365-74. 22. garland sm, jacob se, tobin jm. a cautionary note on instituting probiotics into routne clinical care for preterm infants. pediatrics. 2010; 126: e741-e742. 23. mihatsch wa. what is the power of evidence recommending routine probiotics for necrotizing enterocolitis prevention in preterm infants? curr opin clin nutr metab care. 2011; 14(3): 302-6. file:///g:/pubmed%3fterm=%22hu%20xy%22%5bauthor%5d file:///g:/pubmed%3fterm=%22zhou%20yx%22%5bauthor%5d file:///g:/pubmed%3fterm=%22xu%20sz%22%5bauthor%5d file:///g:/pubmed%3fterm=%22lin%20yy%22%5bauthor%5d file:///g:/nec%202/l javascript:al_get(this,%20'jour',%20'curr%20opin%20clin%20nutr%20metab%20care.'); j islamabad med dental coll 2023 42 open access medicolegal aspect analysis of burn cases in liaquat university hospital, hyderabad hari ram1, jamshed ul qadir memon2, amna mangi3, mir ghulam ali talpur4, naveed ali qadri5, salman ahmed farsi kazi6. 1assistant professor, forensic medicine & toxicology department, shaheed mohtarma benazir bhutto medical college, lyari, karachi. 2lecturer, forensic medicine & toxicology department, liaquat university medical health science jamshoro, pakistan. 3senior lecturer, forensic medicine and toxicology department, isra university hyderabad, pakistan. 4assistant professor, forensic medicine and toxicology department, ghulam mohammad mahar medical college sukkur, pakistan. 5assistant professor, forensic medicine and toxicology department, isra university hyderabad, pakistan. 6professor, forensic medicine and toxicology department, isra university hyderabad, pakistan. a b s t r a c t background: owing to the high potential of physical injuries, disabilities and even deaths resulting from burn-related injuries, these are considered as injuries of medico-legal importance. the study aims to investigate the medico-legal aspects of selective cases of burn victims admitted to the burn unit of liaquat university hospital, hyderabad. methodology: this study was conducted at the burn unit of liaquat university hospital, hyderabad. the information on burn patients was collected retrospectively from the record for the period of three years from january 2018 to december 2020 from the burn unit. the data related to socio-demographic details, site, cause, severity and outcome of burn cases was recorded. results: total 418 victims record was evaluated; the highest prevalence of cases was in the age group of 0-10 years (60.6%). majority; 58.8% of the victims were males. in more than half (52.6%) of the victims, 20% or less body area was burnt. in 34.2% cases, 21-40% area was burnt. about 48.1% of cases were of wet scalds and 40.2% dry flame burns. about 7.6% were cases of electrocution. male and female burn victims demonstrated statistically significant difference (p<0.05) regarding site of burn, side, source, manner and survival from burn injuries. conclusion: males are more affected by burns than their counterpart while children ≤ 10 years are most co mmonly reported with burn injuries. wet scald is the most common type of burn while most victims present with ≤20% burnt body area. key words: accidental injuries, burns, suicide authors’ contribution: 1conception; literature research; 3manuscript design and drafting; 4critical analysis and manuscript review; 5,6data analysis; manuscript editing. correspondence: amna mangi email: amna.mangi1985@gmail.com article info: received: april 13, 2022 accepted: march 26, 2023 cite this article. ram h, memon j uq, mangi a, talpur m g a, qadri n a, qazi s a f medicolegal aspect analysis of burn cases in liaquat university hospital, hyderabad.j islamabad med dental coll. 2023; 12(1): 42-48 doi: https://doi.org/10.35787/jimdc.v11i2.873 funding source : nil conflict of interest: nil i n t r o d u c t i o n burn is defined as an acute injury to the skin and or organic tissues resulting from the application of heat to external or internal body surfaces of a person. it o r i g i n a l a r t i c l e j islamabad med dental coll 2023 43 includes all types of thermal lesions whether produced by heated metallic objects, flames, fluids at or near boiling point and pressure steam.(1) the burn-related injuries may also occur due to direct or indirect contact with extremely cold materials, corrosive chemicals, and electric as well as radioactive rays that may cause significant morbidity as well as mortality.(2) the burn-related injuries are unique traumas recognized as a serious global health problem and are the common method of suicide and homicide. the global incidence of burn-related injuries is over 25 million deaths each year. whereas, over 11 million patients necessitate medical attention and millions are left with lifetime disabilities and skin disfigurements that further result in stigma and rejection.(3) following road traffic accidents, falls and interpersonal violence-related injuries, these injuries are the commonest,accounting for 12% of all injuries worldwide and accounting for over 1% of the global burden of diseases. according to the world health organization, two-thirds of burn injuries (approximately 96% of fatal fire-related burns) occur in the african, eastern mediterranean and south-east asia regions.(4-6) owing to the high potential of physical injuries, disabilities and even deaths resulting from burnrelated injuries, these are considered as injuries of medico-legal importance. moreover, these injuries also follow psychological sequelae (affecting psychosocial and functional aspects of patients) and pose a considerable associated health-economic impact on victims and their families. these injuries are responsible for significant burden to healthcare system, as the burn victim stays for a longer duration in hospitals.(7, 8) majority of incidents of burn injuries happen in domestic settings of developing countries like pakistan because of household appliances, ironing, cooktops, boiling water, inflammable agents at home. in pakistan, these injuries might be deliberated as the common causes of unnatural deaths with higher incidence reported among children that occur at home as an accident.(2, 9) despite the medico-legal as well as clinical importance, burn injuries are under-researched area in pakistan. keeping this concern in view, it is important to investigate the different aspects of burn injuries as this can give us more insight about the factors responsible for such injuries. m e t h o d o l o g y this retrospective study was conducted at the burn unit of liaquat university hospital, hyderabad after getting the approval from the ethical review committee of isra university, hyderabad (erc no: iu/rr-15-irc-21/n/2021/1767). the information on selective medico-legal cases of burns was collected and analyzed retrospectively from the burn unit record for the period of three years from january 2018 to december 2020. information of all admitted burn victims of any age, gender, occupation etc. with available medico-legal reports were included in the study. while record of burn victims with minor burns, incomplete record of victims and those without any medico-legal report were excluded from the study. sample size was calculated using open-epi sample size calculator. using confidence interval (ci) of 95% and an anticipated frequency (p) of 41%, the sample size of 418 was calculated.(10, 11).the selection of the participants was through non-probability purposive sampling technique. the data of all victims related to age, gender, socioeconomic condition, source of injury, site, cause, severity (percent of area burnt), duration of injury, general physical appearance at the time of admission and outcome of burn cases were recorded in a prepared checklist. the collected data of burn victims was entered and analyzed in statistical package for social sciences (spss) version 22. all the categorical data was presented as frequency and percentages while continuous data tabulated as mean and standard deviation. chi-square test was applied for comparing the data. significance level was set at p value <0.05. j islamabad med dental coll 2023 44 r e s u l t s total 418 burn cases records were collected from the burn unit of luh and evaluated at the department of forensic medicine and toxicology, isra university, hyderabad. out of total, majority of the victims were males compared to their counterparts. it was demonstrated that higher number of burn victims was from the age group of 01-10 years while the victims belonging to age group of 30’s (from 30 to 39 years) were least affected. (table i) table i: socio-demographic details of burn victims (n=418) socio-demographic variables n (%) gender  male  female 245 (58.6) 173 (41.4) age group  01-10 years  11-19 years  20-29 years  30-39 years  40 and above 187 (44.7) 61 (14.6) 139 (33.3) 10 (2.4) 21(5.0) residential status  rural  urban 152 (36.4) 266 (63.6) economic background  middle class  low/ very low class 170 (40.6) 248 (59.3) admission season  summer  autumn  winter  spring 98(23.5) 165(39.5) 110(26.3) 45(10.7) majority of the victims 306(73.2%) presented in the emergency / burn unit within 6 hours of the injury while 112(26.8%) reported after 10 hours of the incident. when comparison between age groups and gender was made, majority 137(56.0%) victims were from age group 01-10 years, 39(16.0%) were adolescents from age 11-19 years, 58(23.6%) were from age group 20-29 years and 06(2.4%) belonged to age group 30-39 years. while 05(2.0%) male victims were from age 40 years and above. among female victims, 50(29.0%) were from age group 01 table ii: gender wise distribution of characteristics of burn injuries among burn victims (n=418) gender total pvalue male 245 female 173 site of injury head & face 20(8.2) 35(20.2) 55 (13.2) 0.01* thorax 47(18.8) 31(18.5) 78(18.6) upper limb 58(23.7) 24(13.9) 82(19.7) pelvis 18(7.8) 09(4.6) 27(6.4) abdomen 51(20.8) 30(17.3) 81(19.3) lower limb 40(16.3) 36(20.8) 76(18.3) back/ buttocks 9(3.6) 5(2.9) 14(3.3) full body 2(0.8) 3(1.7) 5(1.2) side of injury bilateral 145(59.2) 115(66.4) 260(62.2) 0.00* left 38(15.5) 43(25.0) 81(19.3) right 62(25.3) 15(8.6) 77(18.5) source of injury flame 79 (32.2) 89 (51.4) 168 (40.2) 0.02* scald 136 (58.5) 65 (37.5) 201 (48.1) electrocutio n 18 (7.3) 14 (8.1) 32 (7.6) gas explosion 12 (5.1) 05 (3.0) 17 (4.1) mann er of injury suicidal 23(9.4) 46(26.6) 69(16.5) 0.00* accidenta l 200 (81.6) 102(59.0) 302(72.2) homicidal 22(9.0) 25(14.4) 47(11.2) place of injury domestic 181(74.0) 151(87.3) 332(79.4) 0.00* occupati onal 64(26.0) 22(12.7) 86(20.6) * statistically significant p value < 0.05 (chi square) 10 years, 22(12.7%) were from age 11-19 years, 81(47.0%) were adults from age group 20-29 years and 16(9.2%) were from age 40 years and above. while 04(2.3%) belonged to age group 30-39 years. table ii demonstrates the characteristics of injuries among the victims. based on the findings, most common site of injury was upper limb while back/buttocks and full body was least affected. j islamabad med dental coll 2023 45 bilateral injuries were more prominent among the victims. majority of victims were suffering from the wet type of burn. accidental and domestic burn injuries were more common. there was a statistically significant difference (p<0.05) in site, side, source and manner of burn injuries between male and female victims.(table ii)figure 1 is showing the proportional distribution of victims according to the degree of burns. based on the record, majority of victims were presented with 2nd degree of burn while smaller proportion of victims were presented with 4th degree burn. (figure 1) figure 1: proportional distribution of degree of burns in victims (n=418) based on the findings, over half of the 220 (52.6%) of the burn victims had a common occurrence of minor burns with 20% body surface area burnt while 143 (34.2%) of cases had 21-40% surface area burnt. moreover, 36(8.6%), 10 (2.5%) and 9(2.1%) victims had burnt area of 41-60%, 61-80%, and 81-100% respectively. majority of burn victims were cured after sustaining burn injuries. out of all victims, majority of male victims were cured from the injuries compared with their counterparts. there was statistically significant difference (p<0.05) between male and female in survival from burn injuries. (figure 2) figure 2: frequency of outcome of burn injuries among male and female victims (n=418) the study found that majority, 32(39.0%) of deaths occurred due to septicemia followed by cases of respiratory tract issues 27(33.0%) and shock 23(28.0%). d i s c u s s i o n in the present study, the data of total 418 burn victims were evaluated admitted/ presented during three-year period. our study findings revealed the male preponderance among the burn victims. these findings are consistent with other studies by hassan q. et al., naeem m. et al. and wardhana a. et al.(2, 12, 13) this may be due to fact that males are more exposed to the industrial work and other fire causing activities like smoking.whereas, our findings are relatively inconsistent to the studies conducted in other south asian countries that reported female predominance.(14, 15) the females are mostly burnt due to household explosions or cooking oil burns. main reasons are inexperience with cooking, use of risky fire appliances and use of conventional synthetic clothing that catch fire quickly as well as spread it throughout the body of victim. sometimes the burns are inflicted upon by the partner and could be owing to intentional burning owing to family feuds.(16) lower prevalence of females in this study may be because majority of victims were from urban setting where most of females are educated and do not frequently use liquid fuel for domestic purposes. 1st degree, 17.5% 2nd degree, 40.2% 3rd degree, 33.3% 4th degree, 9.1% 218 118 336 27 55 82 0 100 200 300 400 male female total outcome of burn injuries cured death j islamabad med dental coll 2023 46 our study observations discovered that the most common age group in burnt victims was 1 to 10 years. this high incidence can be explained by unawareness of children, their curiosity, and lack of natural instinct to understand the hazard of certain objects as well as their exploring nature and activity. the findings consistent with our study are reported by ahmed a. et al., george s. et al. and ebrahem n. et al. (17-19) scalds resulting from spillage or immersion in hot water baths, hot cooking oils and hot food and liquids account for one-half of all burns in high and middle-income countries and globally account for approximately 5% of all burn-related deaths. (18, 19) children are more vulnerable to the effects of scalds due to their thinner skin. present study exhibited that during the period of three years, out of 418 burn cases; 201(48.1%) had scald as the source of injury. these findings are consistent with the findings of bangladeshi, egyptian and pakistani studies by george s. et al, ebrahem n. et al and ahmed a. et al.(17-19) while the findings of kandeel et al, hassan q et al. and bailey et al. were inconsistent to our study findings where flame was the major cause of burn in their studies.(2, 5, 20) furthermore, our study findings are in agreement with bailey et al., george s. et al and ebrahem n et al where scald was the the most common cause of burn among infants, while flame was the most common of cause of burn injuries among adult and elderly. this may be due to the fact that infants display careless behavior and adults in addition to their occupational exposure to burn injuries, make use of domestic gas stoves.(5, 18, 19) the current study also revealed that over two third (79.4%) of burns occurred at home. this could be attributed to the fact that the vast majority of burnt victims in the present study were children who spent the majority of their days at home and were at high risk of burn injury. moreover, majority of adult females in our setting are housewives that spend maximum time in front of stoves for cooking purpose where hot foods, liquids, and hot cooking oils spillage result in domestic burn cases. these findings are consistent with studies by george s. et al, ebrahem n et al. and ali et al.(18, 19, 21) in the present study based on manner of injury, 72.2% of cases were accidentally injured with burn. while suicide cases account for 16.5% of total cases. this is probably due to the fact that suicide burns are uncommon method for suicide in pakistan, as evidenced by the low number of suicidal cases compared to accidental instances. moreover, this goes against religious principles, as suicide is considered a criminal act against oneself under islamic law.(22) it could also be attributed to an underestimating of suicidal burn, as incident reporters may not record the exact method of burn for fear of legal responsibility. the same findings were observed kandeel et al. and hashish et al.(20, 23) burnt area percentage or degree depends upon situation created when the incident occurred. in an oil spill or an industrial burn, the burns are usually gross bodily burns involving mostly a large part of the body and sometimes permanent damage ensues in a vital organ that may take the life of a person. however, we did not study the postmortem cases but the medico-legal cases of burns on the account to chart out the demographics of different parameters. according to our study the percentage area burnt is classified into 5 broad ranges among which the most frequent range group is under 20%. this finding is in agreement with ahmed a et al.(17) the biggest limitation of this study was that the data was collected retrospectively and information given in the records had to be relied on. conclusion infants, toddlers and children (≤ 10 years) are the most vulnerable individuals with burns. males are more affected by burns than their counterpart. wet scalds are the most common type of burns, while majority of victims get cured. majority of cases are accidentally affected with burn and the most common cause of death is septicemia. j islamabad med dental coll 2023 47 a c k n o w l e d g m e n t we would like to acknowledge the support of the staff members of the burn unit of liaquat university of medical and health sciences, hyderabad. r e f e r e n c e s 1. jeschke mg, van baar me, choudhry ma, chung kk, gibran ns, logsetty s. burn injury. nature reviews disease primers. 2020;6(1):1-25. doi: 10.1038/s41572-020-0145-5 2. hassan q, ali mi, mirza f. burns: epidemiology and distribution pattern in karachi–a one-year survey. pakistan journal of medicine and dentistry. 2018;7(4):6-. doi:10.36283/pjmd.v7i4.146 3. noorbakhsh si, bonar em, polinski r, amin ms. educational case: burn injury—pathophysiology, classification, and treatment. academic pathology. 2021;8:23742895211057239. doi: 10.1177/23742895211057239 4. james sl, lucchesi lr, bisignano c, castle cd, dingels zv, fox jt, et al. epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the global burden of disease 2017 study. injury prevention. 2020;26(suppl 2):i36-i45. doi: 10.1136/injuryprev-2019-043299 5. bailey m, sagiraju h, mashreky s, alamgir h. epidemiology and outcomes of burn injuries at a tertiary burn care center in bangladesh. burns. 2019;45(4):957-63. doi: 10.1016/j.burns.2018.12.011 6. zia n, latif a, mashreky sr, al-ibran e, hashmi m, rahman a, et al. applying quality improvement methods to neglected conditions: development of the south asia burn registry (sabr). bmc research notes. 2019;12(1):1-6. doi:10.1186/s13104-0194063-0 7. cariello an, perrin pb, tyler cm, pierce bs, maher ke, librandi h, et al. mediational models of pain, mental health, and functioning in individuals with burn injury. rehabilitation psychology. 2021;66(1):1. doi: 10.1037/rep0000359. 8. lerman sf, sylvester s, hultman cs, caffrey ja. suicidality after burn injuries: a systematic review. journal of burn care & research. 2021;42(3):357-64. doi: 10.1093/jbcr/irab014 9. riaz l, shahid ra, rashid mn, batool r, abro su, saleem q. high-risk factors causing mortality in pediatric burn patients, admitted in burns centre of karachi. journal of rawalpindi medical college. 2021;25(4). doi:10.37939/jrmc.v25i4.1583 10. kevin m, sullivan a. openepi-toolkit shell for developing new applications.[online] 2019 [cited 2019 october 05]. 11. siddiqui e, zia n, feroze a, awan s, ali al, razzak ja, et al. burn injury characteristics: findings from pakistan national emergency department surveillance study. bmc emergency medicine. 2015;15(2):1-7. doi:10.1186/1471-227x-15-s2-s5 12. naeem m, shah m. medico-legal review of burns a retrospective study in forensic department of kemu lahore. jpsim. 2019;03(01):69-73. 13. wardhana a, basuki a, prameswara adh, rizkita dn, andarie aa, canintika af. the epidemiology of burns in indonesia’s national referral burn center from 2013 to 2015. burns open. 2017;1(2):67-73. doi: 10.1016/j.burnso.2017.08.002 14. bansude m, kadavkar s, umbare r, dode c. a prospective study of medicolegal autopsies to establish profile of burn deaths. ip international journal of forensic medicine and toxicological sciences. 2021;6(3):95-101. 15. goudar bv, agarwal s, lamani yp, gururaj s, gouda v. the problem of burns. international surgery journal. 2017;4(2):500-5. 16. van niekerk a, govender r, kimemia d. assault burn injuries in adolescents and adults in south africa: risk factors and characteristics. international journal of injury control and safety promotion. 2022:1-7. doi: 10.1080/17457300.2022.2061517 17. ahmed a, khan aa, arif s, tahir h, malik ar. analysis of 300 medico legal cases of burn in lahore in 2018 a retrospective study. pakistan postgraduate medical journal. 2018;29(2):45-51. 18. george s, abdellah n. the medicolegal aspects of burn cases admitted to assiut university hospitals during years of 2015 and 2016. zagazig journal of forensic medicine. 2017;15(1):60-75. 19. ebrahem n, shaltout e, ali wm. study of medicolegal aspects of burnt cases admitted to burn unit, assiut university hospitals: retrospective study. zagazig journal of forensic medicine. 2022;20(1):82-98. doi: 10.21608/zjfm.2021.86904.1085 20. kandeel f. a study of some medico-legal aspects of fatal burn cases admitted to menofia university hospital over five years. ain shams journal of forensic medicine and clinical toxicology. 2019;32(1):57-64. doi: 10.21608/ajfm.2019.25004 21. ali s, hamiz-ul-fawwad s, al-ibran e, ahmed g, saleem a, mustafa d, et al. clinical and demographic features of burn injuries in karachi: a six-year j islamabad med dental coll 2023 48 experience at the burns centre, civil hospital, karachi. annals of burns and fire disasters. 2016;29(1):4. 22. shekhani ss, perveen s, hashmi d-e-s, akbar k, bachani s, khan mm. suicide and deliberate selfharm in pakistan: a scoping review. bmc psychiatry. 2018;18(1):1-15. doi:10.1186/s12888-017-1586-6 23. hashish rk, abdel-karim ri. a study of burn injuries in patients admitted to the burn unit, suez canal university hospital: medico-legal perspectives. mansoura journal of forensic medicine and clinical toxicology. 2017;25(1):79-91. doi:10.21608/mjfmct.2018.47272 78 j i m d c 2 0 1 8 78 op e n ac c e ss c a s e r e p o r t a rare variant of acute open fracture dislocation of knee joint faaiz ali shah 1, main amjad ali 2, abdur rehman qureshi 3, naeemullah 4, umar zia khan 5, muhammad sarwar khan 6 1, 3-5 assistant professor orthopaedic a unit, lady reading hospital peshawar 2 associate professor/head of department orthopaedics & traumatology, lady reading hospital peshawar 6 post graduate trainee, orthopaedic a unit, lady reading hospital peshawar a b s t r a c t acute knee dislocation usually results from high-energy trauma like motor vehicle accidents, fall from significant height and sports related injuries. early intervention to reduce joint and recognize any limb threatening vascular injury and repair is mandatory. knee dislocations are usually closed and very rarely associated with proximal tibia or patella fractures. we presented a very unique case of open posterior dislocation of knee joint with medial hoffa fracture and avulsion of ligamentum patellae without any neurovascular injury. we reduced the knee joint, fixed the fracture and stabilized the patellar tendon. the fracture achieved union and patient had full range of knee motion and full weight bearing without any support or pain. to our knowledge this is the first case in the literature which does not fit into any classification system and not yet reported. key words: knee dislocation, multi ligament injury, neurovascular injury, periarticular fractures address of correspondence mian amjad ali email: drmianamjadali@gmail.com article info. received: august 24, 2017 accepted: september 12, 2017 cite this case report: shah fa, ali ma, qureshi ar, naeemullah, khan uz, khan ms. a rare variant of acute open fracture dislocation of knee jointa case report. 2018; 7(1)78-82 funding source: nil conflict of interest: nil i n t r o d u c t i o n acute knee joint dislocation is the disruption of knee ligaments resulting in loss of contact between the tibial and femoral condyles on x-ray.1 however, if the tibiofemoral alignment on x-ray is maintained after acute knee injury but stress radiographs reveal malalignment, this entity will be termed spontaneous reduction of a dislocated knee joint.1 knee joint dislocation constitute 0.02% to 0.2% of all orthopaedic traumas.2,3 the usual victims of acute knee dislocation are younger patients with road traffic accidents and sports injuries. male female ratio is 4:1 and 20% to 30% of knee dislocations are open.4 kennedy proposed the first classification of acute knee dislocation in 1963.5 in this classification five types had been described based upon the displacement of tibia on femoral condyles: anterior, posterior, lateral, medial and rotatory. anterior knee dislocation account for 40%, posterior 33%, lateral 18%, medial 4% and rotatory type 5% of all knee dislocations.6 kennedy’s classification was not comprehensive because approximately 50% of the spontaneously reduced knee dislocations were unclassified.7 therefore an improved classification by wascher7 and modified by schenck8 was proposed which includes ligaments injuries, associated peri articular fractures and neurovascular injuries. wascher (modified by schenck) classified knee dislocation into five types, i.e., kd i (multi ligaments rupture with either acl or pcl rupture), kd ii (both cruciate rupture but collateral intact), kd iiim (both cruciate and medial collateral ligament rupture), kd iiil (both cruciate and lateral collateral ligament rupture), kd iv (all ligaments rupture) and kd v(knee dislocation with periarticular fracture). arterial and nerve injuries when present with the above types are denoted with c and n respectively. the reported incidence of vascular injury with knee dislocation is 18% c a s e r e p o r t 79 j i m d c 2 0 1 8 79 but it can be as high as 64%.9,10 the incidence of common peroneal nerve injury was reported in 14% to 41% cases specially after posterolateral complex injuries.11 knee dislocation can be associated with fracture of proximal tibia, patella and distal femur. these fractures usually need operative treatment and make the overall management difficult.12 we present a very unique case of open posterior dislocation of knee joint with medial hoffa fracture and avulsed ligament patella tendon in a 25 year old man, who was hit by high speed car. to our knowledge, this is the first case of this type in the literature. c a s e r e p o r t s a 25 years old man had a road traffic accident with highspeed car hitting his left knee joint while he was riding his motorbike. he was received in accident & emergency department of lady reading hospital where he was resuscitated according to atls protocol. the patient’s vital signs were stable on admission. he complained of severe pain in his left knee joint. local examination showed swollen deformed left knee joint with a large circular 7 cm wound around the patella (figure 1). distal neurovascular status was intact. no other significant systemic or associated musculoskeletal injuries were noted. x ray of the knee joint showed posterior dislocation of the knee joint with medial hoffa fracture. (figures 2 & 3). figure 1: photograph showing wound of posterior dislocated knee joint figure.2: x ray showing posterior dislocation of knee joint with hoffa fracture. figure. 3: lateral radiograph showing posterior dislocation of knee joint with hoffa fracture. the patient was taken to the operation theatre. wound was examined under general anaesthesia. patellar tendon was found to be avulsed from tibial insertion. the knee joint was relocated and wound was thoroughly washed with normal saline and closed. the limb was splinted and intravenous antibiotics started. angiography of the knee joint was done to exclude vascular injury (figure 4). figure 4: post reduction angiography of popliteal artery the case was discussed in the trauma meeting of our department for definitive management. in the second stage after three days under general anaesthesia with a tourniquet, the previous wound was incorporated into an incision and the knee joint was opened. medial hoffa fracture was fixed with 3 cancellous screws, two screws directed from posterior side of the femoral condyles and one from anteromedial side. the ligamentum patellae was fixed with a small plate and protected with a circumferential cerclage wire. the knee joint was stabilized with a stemin pin passed from patella to tibial 80 j i m d c 2 0 1 8 80 plateau. the fixation was checked under image intensifier per operatively (figure 5 & 6). figure. 5: fixation of hoffa fracture with cancellous screws, patellar ligament with plate and cerclage wire and knee stabilized with stemin pin checked under image intensifier in ap view per operatively. figure 6: fixation of hoffa fracture with cancellous screws, patellar ligament with plate and cerclage wire and knee stabilized with stemin pin checked under image intensifier in lateral view per operatively. the wound was closed and long back slab was given. check x ray was done on the first post-op day (figure. 7). distal neurovascular status was intact post operatively. wound was examined on third day and dressing was changed. supervised physiotheraphy was started. the patient was discharged home. stitches and stemin pin was removed at 2 weeks (figure. 8 & 9). figure 7: post op xray showing fracture fixation and patellar tendon and knee joint stabilization. range of motion exercises started at 4th weeks and crutch walking was allowed. regular follow up at monthly interval was done. the hoffa fracture healed at 3rd month (figure 10) and the patient started partial weight bearing. the cancellous screws and cerclage wire was removed at 6th month (figure.11). the patient had full range of knee motion (figure 12,13,14) and had full weight bearing without any pain or support. the patient was offered acl and pcl reconstruction surgery, which he refused. figure 8: photograph of wound at 02 weeks follow up. figure 9: photograph at 2 weeks post op after stitch removal and stemin pin removal. figure 10: three months follow up radiograph figure 11: radiograph after removal of metal works 81 j i m d c 2 0 1 8 81 figure 12: knee scar and extension after removal of implants. figure 13: knee flexion after removal of implants. figure 14: knee range of motion at last follow up visit. d i s c u s s i o n in our case report, we treated the patients in two stages; first, we reduced the knee joint, washed the wound with saline and gave the antibiotic cover. in the second stage, we did the definite fixation followed by intense physiotherapy and the patient regained full knee range of motion. the patient was then offered ligament reconstruction surgery. literature supports our treatment protocol.13,14 the most frequent early complication of knee dislocation is popliteal artery disruption.15 in the presence of palpable distal pulses and absence of “hard signs” of vessel injury many researchers advise measuring anklebrachial index (abi) and if <0.90,angiography is suggested.16 others advocate routine angiography for recording partial tear of popliteal artery which is usually missed.17 computed tomographic angiography (cta) is a less invasive investigating tool for diagnosing arterial injury in such cases and has sensitivity and specificity of nearly 100%.18 early recognition of vascular injuries are very important as the limb ischemia time is directly related to the rate of above knee amputation and amputation rates were reported to be only 11% if repair was done within 8 hours compared to amputation rate of 86% when repair was delayed beyond 8 hours.6,19 our patient had medial hoffa fracture alongwith posterior dislocation knee. hoffa fracture refers to an isolated intra articular fracture of femoral condyle in coronal plane and equivalent to the orthopaedic trauma association type 33-b3 fracture.20,21 this fracture needs early open reduction and internal fixation to achieve excellent long term functional outcome.22 we fixed the hoffa fracture with 3 cancellous screws, two screws directed from posterior side and one from antero-medial direction. we could not find comparison of various methods of fixation in literature but most surgeons prefer fixation with cancellous or cannulated screws.22-24 since our case report is unique and similar case report has not been found in literature, we expect that if similar case reports are documented elsewhere it might help us in classifying accurately such fracture dislocation. moreover, a standard method of treatment can evolve to achieve excellent long-term functional outcome. c o n c l u s i o n acute knee dislocation must be diagnosed promptly, relocated immediately with careful evaluation of neurovascular status. effective physiotherapy and regular follow up is advised. we suggest strict vigilance in any high trauma knee injury cases, so that one does not miss any knee dislocation specially the spontaneously reduced knee. r e f e r e n c e s 1. schenck rc, richter dl, wascher dc.knee dislocations: lessons learned from 20 year follow up. orthop j sports med 2014;2(5):67-72. 2. howells nr, brunton lr, robinson j, porteus aj, eldridge jd, murray jr. acute knee dislocation: an evidence based approach to the multiligament injured knee.injury 2011;42(11):1198-1204. 3. levy ba, giuseffi sa, bishop at, shin ay, dahm dl, stuart mj.surgical treatment of peroneal nerve palsy after knee dislocation. knee surg sports traumatol arthrosc 2010;18(11):1583-1586. 4. manske rc, hosseinzadeh p, giangarra ce. multiple ligament knee injury. complications.n am j sports phys ther 2008;3(4):226-233. 5. kennedy jc. complete dislocation of the knee joint. j bon joint surg am 1963;45(5):889-904. 6. reen ne, allen bl. injuries associated with dislocation of the knee.j bone joint surg am 1977;59(2):236239. 7. wascher dc,dvirnak pc, decoster ta. knee dislocation:initial assessment and implication for treatment. j orthop trauma 1997;11(7):525-529. 8. schenck r.classification of knee dislocation.oper tech sport med 2003;11(3):193-198. 9. medina o, arom ga, yeranosian mg, petrigliano fa, mcallister dr.vascular and nerve injury after knee 82 j i m d c 2 0 1 8 82 dislocation: a systematic review. clin orthop relat res. 2014; 472(9):2621-9. 10. seroyer st, musahl v, harner cd. management of the acute knee dislocation:the pittsburgh experience. injury 2008;39(7):710-8. 11. niall dm, nutton rw, keating jf.palsy of the common peroneal nerve after traumatic islocation of the knee.j bone joint surg br. 2005 ; 87(5):664-7. 12. peskun cj, levy ba, fanelli gc, stannard jp,stuart mj, macdonald pb et al. diagnosis and management of knee dislocations. the physican and sprtsmedicine 2010;4(38):101-111. 13. jiang w, yao j, he y, sun w, huang y, kong d. the timing of surgical treatment of knee dislocations: a systematic review.knee surg sports traumatol arthrosc. 2015 oct; 23(10):3108-13. 14. pardiwala, dn, rao nn, anand k, raut a. knee dislocations in sports injuries.indian j orthop 2017;51(5):552-562. 15. leonardi f, zorzan a, palermo a, molfetta l. neglected posterior knee dislocation:an unusual case report.joints 2017;5(4):253-255. 16. nicandri gt, chamberlain am, wahl cj. practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. clin j sport med 2009;19(2):125129. 17. douma mr, burg md, dijkstra bl knee dislocation: a case report, diagnostic vascular work-up, and literature review. case reports in emergency medicine 2017;25-28. 18. inaba k, potzman j, munera f, mckenney m, munoz r, rivas l et al. multi-slice ct angiography for arterial evaluation in the injured lower extremity. j trauma 2006;60(3):502-507. 19. patterson bm, agel j, swiontkowski mf, mackenzie ej, bosse mj. knee dislocations with vascular injury: outcomes in the lower extremity assessment project (leap) study. j trauma. 2007; 63:855-858. 20. mak w, hunter j, escobedo e. hoffa fracture of the femoral condyle. radiol case rep 2008;3(4):231-33. 21. marsh jl, slongo tf, agel j. fracture and dislocation classification compendium -2007. j orthop trauma. 2007;21(suppl.):s1–s133. 22. gao m, tao j, zhou z, liu q, du l, shi j. surgical treatment and rehabilitation of medial hoffa fracture fixed by locking plate and additional screws: a retrospective cohort study. international journal of surgery 2015; 19:95-102. 23. cheng pl, choi sh, hsu yc. hoffa fracture: should precautions be taken during fixation and rehabilitation? hong kong med j 2009; 15(5):385-387 24. chang jj, fan jc, lam hy, cheung ky, chu vw, fung ky. treatment of an osteoporotic hoffa fracture. knee surg sports traumatol arthrosc., 2010;18(6):784-786. j islamabad med dental coll 2023 71 open access genotyping of platelet alloantigens by dna sequencing in pakistani population inam ullah,1 abida arshad2, usman waheed3, noore saba4, zahida qasim5, muhammad arshad6 . 1 phd scholar, department of biological sciences, international islamic university, islamabad 2 associate professor, department of zoology, pmas arid agriculture university, rawalpindi 3 department of pathology and transfusion medicine, shaheed zulfiqar ali bhutto medical university, islamabad 4 consultant haematologist, peshawar regional blood centre, department of health, khyber pakhtunkhwa 5 consultant haematologist, mirpur regional blood centre, department of pathology, divisional headquarters teaching hospital, mirpur, ajk 6associate professor, department of biological sciences, international islamic university, islamabad a b s t r a c t authors’ contribution: 1,2conception; literature research; manuscript design and drafting; 2,3 critical analysis and manuscript review; 5,6 data analysis; manuscript editing. correspondence: muhammad arshad email: m.arshad@iiu.edu.pk article info: received: april 11, 2023 accepted: june 12, 2023 cite this article. ullah i, arshad a, waheed u, saba n, qasim z, arshad m. genotyping of platelet alloantigens by dna sequencing in pakistani population. j islamabad med dental coll. 2023; 12(2): 71-81. doi: https://doi.org/10.35787/jimdc.v12i2.981 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e introduction: single-nucleotide polymorphism (snp) in human platelet antigens (hpas) glycoproteins leads to alloimmunizations and platelet disorders such as posttransfusion purpura, neonatal alloimmune thrombocytopenia, and refractoriness to platelet transfusion. to study the prevalence in a particular ethnic group, genomic dna is used to genotype hpas. detection of these polymorphisms is imperative to identify the risk of alloimmunization and the provision of hpas. current study was planned to determine the frequency of hpas in the pakistani population of blood donors. methodology: genomic dna was extracted from blood samples of 300 randomly selected platelet donors from five major cities of pakistan (islamabad, peshawar, karachi, quetta, and mirpur). this study was approved by the ethical committee of shaheed zulfiqar ali bhutto medical university, islamabad, pakistan. prior informed consent was taken from all the participants. sequence-specific primers for platelets glycoprotein genes were designed using primer 3 online software. the distinct targets were amplified through pcr. amplified pcr products were eluted from the gel after electrophoresed, purified and sequenced. all the sequences and data obtained were analyzed through spss version 25. results: genotyping of samples showed that among the subjected hpa systems, hpa-1, hpa-5, hpa-7w, hpa-19w, and hpa-21w systems were found to have both a and b alleles in the pakistani population while only aa genotype was found in hpa-4, hpa-6w, hpa-8w, hpa-10w, hpa-11w, hpa-16w, and hpa-23w. the frequency of hpa-1a was 0.9333 and hpa1b was 0.0666, hpa-5a was 0.8033 and hpa-5b was 0.1966, hpa-7wa was 0.98 and hpa-7wb was 0.02, hpa-19wa was 0.95 and hpa-19wb was 0.05 and hpa-21wa was 0.9866 and hpa-21wb was 0.0133. among the analyzed hpas, the mismatch probability was higher in hpa-5 while it was lower in hpa-21w. conclusion: hpa-4b, hpa-6b, hpa8b, hpa-10b, hpa-11b, hpa-16b and hpa-23b were absent. no homozygosity was found in the remaining genotyped hpas. our study suggests that it is necessary to establish hpa screening sites in blood banks to have hpa typed donor registry providing compatible therapeutic platelets to all unimmunized patients. our data will be useful to understand and better treat the alloimmune-mediated platelet disorders. key words: alloantigens, genotyping, sequencing, platelets, platelet alloantigens j islamabad med dental coll 2023 72 i n t r o d u c t i o n platelets are 3-5μm, anucleated cell fragments in blood and critical for hemostasis.1 over the last five decades, the transfusion of platelet concentrates is being regularly used for the treatment of thrombocytopenic patients, reducing the incidence and severity of bleeding disorders.2 the human platelet antigens (hpas) result from single nucleotide polymorphisms (snps) in the genes that encode glycoprotein,3 expressed on platelet surface membranes, frequently on gpiib/iiia.4 in addition to the hpa, the platelet surface membrane comprises of other antigenic molecules namely abo blood group antigens,5 human leukocyte antigens (hla),6 and the naka antigen present on cd36.7 hpa polymorphism results in the development of human platelet antibodies following alloimmunization,8 leading to the destruction of platelets.9 these alloantibodies develop in response to exposure to the alloantigens after blood transfusion and during pregnancy or transplantation. this may result in platelet disorders including neonatal alloimmune thrombocytopenia (nait), posttransfusion purpura (ptp), and refractoriness to platelet transfusion. in nait, pregnant women become immunized to alloantigens of fetus platelets, resulting in thrombocytopenia in the infant.10 the ptp is an infrequently reported adverse reaction of blood transfusion characterized by severe thrombocytopenia within two weeks of transfusion.11,12 refractoriness to platelets, on the other hand, occurs when the patient’s circulating platelet levels regularly fail to rise after transfusion of an adequate dose of platelets.13 until now, 41 human platelet alloantigens have been identified14 on six platelet glycoprotein (gp) complexes which are functionally significant; gpiib, gpiiia, gpiba, gpibb, gpia and cd109.15 the hpa with a higher frequency is labeled as “a” while with low frequency is labeled as “b”. a word “w” attribution is added after the name of antigen if there is no reported alloantibody against antithetical antigen.5 the genotyping for hpa is required to identify the risk of alloimmunization and the provision of hpa-matched platelets for patients with alloimmune-mediated platelet disorders. hpa typing was formerly performed by serologic techniques.16 the current methods are based on genomic dna, such as pcr sequence-based typing,17 pcr sequence-specific primers,18 restriction fragment length polymorphism‐pcr),19 real-time pcr,20 beadchip microarray technology,21 matrixassisted laser ionization or desorption time of flightmass-spectrometry.22,23 the platelet antigen frequency is different among populations around the globe. most of the existing data have been reported from north american and western european regions. however, the incidence of hpa in other regions is still not studied extensively. in particular, data among pakistani population, are still insufficient and so far, only one study has been published.24 this current study was performed to determine the frequency of human platelet antigens (hpa) in pakistani blood donors to be able to provide hpamatched platelets for patients with immune platelet disorders. m e t h o d o l o g y this cross-sectional study was performed from october 2019 to february 2020, at the department of pathology and transfusion medicine, pakistan institute of medical sciences (pims), shaheed zulfiqar ali bhutto medical university (szabmu), islamabad, pakistan. a total of 300 regular healthy blood donors were recruited in this study. these donors were randomly selected following careful selection criteria,25 from five major cities including islamabad (pims/szabmu), peshawar (regional blood centre), karachi (regional blood centre), quetta (regional blood centre), and mirpur j islamabad med dental coll 2023 73 (department of pathology and transfusion medicine, divisional headquarters teaching hospital). from each centre, blood samples were collected in edta tubes and transported to the study site, following standard protocols of cold chain maintenance. written informed consent was obtained from all study participants. this study was approved by the ethical committee of the szabmu, islamabad, pakistan. laboratory analyses dna extraction genomic dna from the whole blood of all samples was extracted using the inorganic method.26 the dna concentration was maintained to 20–50 ng/µl. the extracted dna was stored at 4ºc for further use. to determine the quality of dna, the extracted dna was detected through uv light after performing agarose gel electrophoresis. 2µl dna was mixed with 1µl bromophenol dye and was loaded onto 1 percent agarose gel. 0.5-gram agarose was dissolved in 50 ml of 0.5x tbe buffer and was placed in a microwave oven until it started boiling. it was then placed at room temperature for cooling. 2 µl ethidium bromide was added and was mixed well. it was poured in gel tray with comb placed in it and placed for solidification at room temperature. after 20 – 30 minutes, comb was removed carefully, and the gel was ready with wells for loading dna. 2 µl dna was dissolved with 1 µl bromophenol dye and then each sample of extracted dna was loaded separately in wells. electrophoresis was performed for 30 minutes at 90 volts/cm (45 ma). the dna was then visualized under uv lights by performing gel documentation assay. designing sequence-specific primers hpa polymorphism of nucleotide sequences was obtained from the hpa immuno polymorphism database.27 sequence-specific primers were designed (table 1) according to hpa nucleotide polymorphism and sequence obtained of gp1ba, itgb3, itga2, itga2b, cd109 and gp1bb gens in the ncbi genbank database using primer 3 online software.28 a pair of primers was used to amplify those hpa nucleotide polymorphisms which are located nearer to each other in the same gene. different primers were designed for different hpa systems. all the designed pairs of primers had a different range of amplification product lengths. the location of primer attachment to the complementary sequence was kept 50 base pairs away from the hpa system polymorphism site. table i: details of primers used for hpa n a m e p rim e r s e q u e n ce (5 '-> 3 ') t m (℃ ) le n g th a m p lico n (b p ) f in a l co n ce n tra tio n (m o l/l) hpa1 and hpa10w forward tgctccaatgtac ggggtaa 58.72 424 0.5 reverse tcccaccccatttc cattctg 59.99 hpa5 forward agacgtgctcttg gtaggtg 59.40 231 0.5 reverse tggggacatcctc aaaaatga 57.18 hpa6w and hpa7w forward ctgggcccaactg tgtctaa 59.60 529 0.5 reverse gcaggtatatgag ggggtgtg 59.93 hpa4, hpa16w and hpa19w forward ggtggaggatta ccctgtgg 59.45 239 0.5 reverse cgtctggaggag ggacttac 58.90 hpa8w, hpa11w, hpa21w and hpa23w forward agctggactggg atacgctt 60.98 254 0.5 reverse acaggtgggagt tggataggt 60.20 j islamabad med dental coll 2023 74 table ii: pcr conditions for hpa-1, -5, -6,-7,-9,-10,-11,-21 and 23 hpa initial denaturation denaturation annealing extension final extension hpa-1 and hpa-10w temp (℃ ) 95 95 58 72 72 time (sec) 300 60 60 60 600 repeats 35 hpa-5 temp (℃ ) 95 95 59 72 72 time (sec) 180 30 30 60 600 repeats 35 hpa-6w and hpa-7w temp (℃ ) 95 95 61 72 72 time (sec) 180 30 30 60 600 repeats 35 hpa-8w, hap-11w, hpa21w and hpa-23w temp (℃ ) 95 95 60 72 72 time (sec) 180 30 30 60 600 repeats 35 table iii: pcr conditions for hpa-4, hpa-16w and hpa-19w hpa initial denaturation denaturation touch down annealing extension denaturation annealing extension final extension temp (℃ ) 95 95 65 72 95 63 72 72 time (sec) 240 60 60 60 60 60 60 600 repeats 15 25 amplification of required region using polymerase chain reaction (pcr) the required amplicon was amplified through pcr using the designed sequence-specific primers. positive and negative control pcr reactions were also conducted. for this purpose, pcr tubes were used. all the reactions were performed in t100tm thermal cycler (bio-rad). mixture for each pcr was made by adding 25 µl master mix (thermo genotyping of amplicon (thermo scientific), 5 µl forward primer, 5 µl reverse primer, and 5 µl dna sample. the final volume was set to 50 µl by adding 10 µl pcr water. all these were properly mixed. different conditions were set to carry out pcr for each pair of primers. normal pcr was carried out for all pairs of primers (table 2) except designed for hpa-4, hpa-16w, and hpa-19w, which were amplified through touch-down pcr (table iii) amplicons were purified and were sent for genotyping to macrogen inc, korea. after genotyping, all the sequences were analyzed and then blasted with standard sequences of hpa polymorphism reported to immuno-polymorphism database.27 statistical analyses statistical analyses were carried out using spss version 25.0 (ibm corporation, usa). tests for hardy-weinberg equilibrium in the population were performed by x2 test. chi-square test was used to calculate expected and observed. p values were assigned statistically significant which were less than 0.05. r e s u l t s amplicon confirmation all the pcr products were confirmed by performing gel electrophoresis. samples were run with a dna ladder. all the pcr products were randomly loaded to confirm their molecular weight according to the specifically designed primers for pcr. the dna j islamabad med dental coll 2023 75 ladder used was of 3000, 2000, 1500, 1200, 1000, 900, 800, 700, 600, 500, 400, 300, 200 and 100 from top to bottom respectively. all pcr products had durable and exact single bands (fig 1). figure 1: the electropherogram for the hpa system. 231 bp (hpa-5), 239 bp(hpa-4, hpa-16w and hpa-19w), 254 bp (hpa-8w, hpa-11w, hpa-21w and hpa-23w), 424 bp (hpa-1 and hpa-10w) and 529 bp (hpa-6w and hpa-7w) . l: dna ladder genotyping of the amplified region genotyping was performed of the pcr products to view the polymorphism of the nucleotide at the polymorphism for each hpa system. fig 2 shows the sectional sequencing chromatograms of samples. site of polymorphism is shown in each sequenced segment by an arrow. the frequencies of hpa-1, 4, 5, 6w, 7w, 8w, 10w, 11w, 16w, 19w, 21w and 23w genotype and alleles in pakistani population are shown in table 4. distribution of these hpa genotype loci were compatible with hardy weinberg equation (p> 0.05). hpa-4, hpa-6w, hpa-7w, hpa-8w, hpa-10w, hpa11w, hpa-16w and hpa-23w were perfect aa homozygous while there was polymorphism in hpa1, hpa-5, hpa-7w, hpa-19w and hpa-21w systems. hpa mismatch probability mismatch probability in pakistani population were found in hpa-1, hpa-5, hpa-7w, hpa-19w and hpa21w system. among those analyzed, hpa-5 showed higher mismatch probability while the least mismatch probability was found hpa-21w. mismatch probability was low in hpa-1, hpa-7w and hpa-19w system as much of the individuals were aa homozygote. j islamabad med dental coll 2023 76 figure 2: chromatograms of dna sequencing for hpafrequency j islamabad med dental coll 2023 77 table iv: distribution of hpa-1, hpa-5, hpa-7, hpa-19 and hpa-21 in pakistani population. (n=300) hpa n observed n expected hardy˗weinbrg genotype frequency allele frequency mismatch probability aa ab bb aa ab bb x 2 p aa ab bb a b hpa-1 261 37 2 260.40 38.19 1.400 0.2952 >0.05 0.871 1 0.1244 0.0044 0.9333 0.066 6 0.1167 hpa-5 193 95 12 192.80 95.39 11.800 0.0052 >0.05 0.645 3 0.3159 0.0386 0.8033 0.196 6 0.2660 hpa-7w 288 12 0 288.12 11.76 0.12 0.1249 >0.05 0.960 4 0.0392 0.0004 0.98 0.02 0.0384 hpa-19w 270 29 1 269.80 29.39 0.800 0.0551 >0.05 0.902 5 0.095 0.0025 0.95 0.05 0.0904 hpa-21w 292 8 0 292.05 7.89 0.053 0.0548 >0.05 0.973 5 0.0263 0.0002 0.9866 0.013 3 0.0259 d i s c u s s i o n hpas are expressed on platelets and also other cells such as monocytes and endothelial cells. human platelet antigens (hpas) play a critical role in numerous immune platelet disorders such as nait, ptp, and refractoriness. about 10% to 20% of nait patients have postnatal intercranial hemorrhage (ich) with a fatality of 5%. although patients may have internal organs bleeding, but ich is the feared cause of death. ich may have a mortality rate of up to 48%.29 the reoccurrence of nait among consequent siblings having positive platelets antigens is about to 100%.30 according to national blood collection and utilization survey (nbcus), in 2015, 305 cases of ptp were confirmed in the united states. about 30% of ptp patients have major hemorrhage with 10% rate of mortality. women having children with ptp may have an increased risk of nait during their following pregnancy.31 clinical studies suggest that 27% to 34% of platelets transfusion have unsatisfactory responses.32 the knowledge of antigen frequencies in a population is essential for the medical management of patients with immune-mediated platelet disorders. the pattern of hpa frequency varies in different countries globally. partial data on hpa frequency in the pakistani population exist. the current study assessed the gene frequency of hpa for 300 blood donors from five large blood centers in the country. pakistani people belong to different origins and cultures. although there are many ethnic groups living in pakistan, the most known are panjabis, pashtuns, sindhis, balochis, and kashmiris. the current study focused on punjabis, pashtuns, and kashmiris. in pakistan, the rate of consanguineous marriages is very high.29-31 consanguineous marriages cause to have greater chances of many abnormalities which also affect platelets glycoprotein. it may also cause the production of isoantibodies.32 so platelets glycoprotein is also affected due to consanguineous marriages. dna-based techniques have become a standard after the discovery that the determination of molecular hpa type is due to the substitution of the amino acid at a specific location. alleles of hpa systems are different on the basis of snp except for hpa-14w which is due to the deletion of aag nucleotide. in this study, we analyzed the frequency distribution of hpa system including, hpa(1,4,5,6w,7w,8w,10w,11w,16w,19w,21w,23w) using pcrsequence-based typing method. all the snp containing regions of subjected hpa systems were amplified using ssp. primers were designed to be away more than 50 nucleotides from the site of snp. targeted regions were amplified, purified and sequenced. hpa mismatch increases the likelihood j islamabad med dental coll 2023 78 of alloimmunization during pregnancy, allogeneic stem cell transplantation and platelets transfusion. a study from indonesia revealed that alloimmunization against hpa-1, 2 and 6w is uncommon; whereas hpa-1 is the prevalent alloantigen in caucasians.33 our study has reported mismatch probability in hpa-1, 5, 7w, 19w and 21w, which can be a risk for alloimmunization. a study performed in germany on the turkish and caucasian populations, compared the hpa between both groups and observed no statistical differences.34 similarly, a study from brazil showed no statistical difference between the reported alleles frequencies of different ethnic groups.35 two more studies compared blood donors and platelet donors of southern brazil and found statistical significance for hpa-1, hpa-2, hpa-5 and hpa-15.36,37 a study from algeria have similarity in alleles frequencies of hpa4 and 5, but had difference of hpa-1, when compared to our study.38 the allele frequencies of hpa-1, 4, 8w, 10w, 11w, 16w and 21w in our study were similar to the reported frequencies in chinese population.39 there is great difference of hpa-5 genotyping distribution among the population of pakistan and iran.40 an earlier study from pakistan24 reported a hardyweinberg equilibrium deviation towards alleles hpa-3b and hpa-5b, due to increased consanguinity rates. in our study, aa genotypes were observed in all hpa systems except hpa-1, -5,-7w,-19w and hpa21w. when compared to a previous study,24 there was a significant difference (p < 0.05) in hpa-1a. no significant difference (p < 0.05) was seen between the reported and observed hpa-4a and hpa-5a in the pakistani population. hpa gene frequencies in the population of different countries are shown in table 5. table v: frequency distribution of hpa system reported in different countries of the world27 pakistan argentina austria brazil china denmark germany italy spain saudi arabia hpa-1a 0.9333 0.878 0.852 0.925 0.993 0.83 0.84 0.85 0.81 0.809 hpa-1b 0.0666 0.122 0.148 0.075 0.007 0.17 0.16 0.15 0.19 0.191 hpa-4a 1 1 1 1 0.997 1 1 1 0.997 hpa-4b 0 0 0 0 0.003 0 0 0 0.003 hpa-5a 0.80 0.927 0.892 0.920 0.991 0.92 0.917 0.9 0.88 0.934 hpa-5b 0.20 0.037 0.108 0.080 0.009 0.08 0.083 0.1 1 0.066 hpa-6a 1 1 1 1 0.980 1 0 hpa-6b 0 0 0 0 0.020 0 hpa-7a 0.980 1 hpa-7b 0.020 0 hpa-8a 1 1 hpa-8b 0 0 hpa-10a 1 1 1 1 hpa-10b 0 0 0 0 hpa-11a 1 1 1 1 hpa-11b 0 0 0 0 hpa-16a 1 1 hpa-16b 0 0 hpa-19a 0.950 hpa-19b 0.050 hpa-21a 0.986 0.994 hpa-21b 0.013 0.006 hpa-23a 1 hpa-23b 0 j islamabad med dental coll 2023 79 in conclusion, it is imperative to have a first-hand knowledge of the frequency of hpa to provide a safe platelet concentrates transfusion to the patients, particularly to those who are refractory or alloimmunized. c o n c l u s i o n this is the first study to genotype hpa systems in blood donors from the five major cities of pakistan. our study has reported that hpa-1, -5, -7w, -19w, and hpa-21w systems were found to have both a and b alleles in the pakistani population while only aa genotype was found in hpa-4, -6w, -8w, -10w, 11w, -16w, and -23w. the study will be important to provide information to prevent and treat alloimmunization triggered by hpa. it will also help to improve blood component therapy. it is necessary to establish hpa screening sites in blood banks to have hpa typed donor registry providing compatible therapeutic platelets to all unimmunized patients. future research can study possible feasible and effective methods of hpa screening and also provide a guideline for potential hpa screening during pregnancy. a c k n o w l e d g e m e n t we wish to thank all blood bank staff of pakistan institute of medical sciences, shaheed zulfiqar ali bhutto medical university, islamabad, pakistan. r e f e r e n c e s 1. schiffer ca, bohlke k, delaney m, hume h, magdalinski aj, mccullough jj, et al. platelet transfusion for patients with cancer: american society of clinical oncology clinical practice guideline update. j clin oncol. 2018;36(3):283-299. doi: 10.1200/jco.2017.76.1734. 2. zhang jc, ni lh, tu y, hu hx. related donor platelet transfusion improves platelet transfusion refractoriness in hematological patients. front med (lausanne). 2023;10:983644. doi: 10.3389/fmed.2023.983644. 3. van der meijden pej, heemskerk jwm. platelet biology and functions: new concepts and clinical perspectives. nat rev cardiol. 2019;16(3):166-179. doi: 10.1038/s41569-018-0110-0. 4. regan f, lees cc, jones b, nicolaides kh, wimalasundera rc, mijovic a; royal college of obstetricians and gynaecologists. prenatal management of pregnancies at risk of fetal neonatal alloimmune thrombocytopenia (fnait): scientific impact paper no. 61. bjog. 2019;126(10):e173-e185. doi: 10.1111/1471-0528.15642. 5. o'donghaile d, jenkins pv, mcgrath rt, preston l, field sp, ward se, o'sullivan jm, o'donnell js. expresser phenotype determines abo(h) blood group antigen loading on platelets and von willebrand factor. sci rep. 2020;10(1):18366. doi: 10.1038/s41598-020-75462-2. 6. song x, qi j, fang k, li x, han y. a meta-analysis of risk factors associated with platelet transfusion refractoriness. int j hematol. 2023;117(6):863-875. doi: 10.1007/s12185-023-03557-3. 7. kashiwagi h, honda s, take h, mizutani h, imai y, furubayashi t, tomiyama y, kurata y, yonezawa t. presence of the entire coding region of gp iv mrna in nak(a)-negative platelets. int j hematol. 1993;57(2):153-61. 8. pai sc, burnouf t, chen jw, lin li. human platelet antigen alleles in 998 taiwanese blood donors determined by sequence-specific primer polymerase chain reaction. biomed res int. 2013;2013:973789. doi: 10.1155/2013/973789. 9. allan he, vadgama a, armstrong pc, warner td. platelet ageing: a review. thromb res. 2022 :s00493848(22)00481-9. doi: 10.1016/j.thromres.2022.12.004. 10. donato h. neonatal thrombocytopenia: a review. i. definitions, differential diagnosis, causes, immune thrombocytopenia. arch argent pediatr. 2021;119(3):e202-e214. english, spanish. doi: 10.5546/aap.2021.eng.e202. 11. hawkins j, aster rh, curtis br. post-transfusion purpura: current perspectives. j blood med. 2019;10:405-415. doi: 10.2147/jbm.s189176. 12. goel r, tobian aar, shaz bh. noninfectious transfusion-associated adverse events and their mitigation strategies. blood. 2019;133(17):18311839. doi: 10.1182/blood-2018-10-833988. 13. jiang d, panch sr. evidence-based minireview: strategies to manage a severely hla-alloimmunized patient with refractory thrombocytopenia. hematology am soc hematol educ program. j islamabad med dental coll 2023 80 2022;2022(1):437-441. doi: 10.1182/hematology.2022000416. 14. dutra vf, bub cb, costa th, santos ld, bastos ep, aravechia mg, kutner jm. allele and haplotype frequencies of human platelet and leukocyte antigens in platelet donors. einstein (sao paulo). 2019;17(1):eao4477. doi: 10.31744/einstein_journal/2019ao4477. 15. saris a, pavenski k. human leukocyte antigen alloimmunization and alloimmune platelet refractoriness. transfus med rev. 2020;34(4):250257. doi: 10.1016/j.tmrv.2020.09.010. 16. jovanovic srzentic s, lilic m, vavic n, radovic i, djilas i. genotyping of eight human platelet antigen systems in serbian blood donors: foundation for platelet apheresis registry. transfus med hemother. 2021;48(4):228-233. doi: 10.1159/000514487. 17. pai sc, lin li. sequence-based typing for platelet alloantigens. methods mol biol. 2015;1310:167-74. doi: 10.1007/978-1-4939-2690-9_14. 18. zhou h, ding h, chen y, li x, ye x, nie y. simultaneous genotyping of hpa-17w to -21w by pcr-ssp in chinese cantonese. platelets. 2015;26(2):186-9. doi: 10.3109/09537104.2014.887668. 19. wu gg, kaplan c, curtis br, pearson ha. report on the 14th international society of blood transfusion platelet immunology workshop. vox sang. 2010;99(4):375-81. doi: 10.1111/j.14230410.2010.01348.x. 20. kengkate m, butthep p, kupatawintu p, srisuddee a, chantratita w, nathalang o. comparison of a simpleprobe real-time pcr and multiplex pcr techniques for hpa-1 to hpa-6 and hpa-15 genotyping. j clin lab anal. 2015;29(2):94-9. doi: 10.1002/jcla.21734. 21. bertrand g, conti f. genotyping of human platelet antigens by beadchip microarray technology. methods mol biol. 2015;1310:149-65. doi: 10.1007/978-1-4939-2690-9_13. 22. kim ty, yu h, phan mt, jang jh, cho d. application of blood group genotyping by next-generation sequencing in various immunohaematology cases. transfus med hemother. 2021;49(2):88-96. doi: 10.1159/000517565. 23. garritsen hs, fan ax, bosse n, hannig h, kelsch r, kroll h, holzgreve w, zhong xy. matrix-assisted laser desorption/ionization time-of-flight mass spectrometry for genotyping of human plateletspecific antigens. transfusion. 2009;49(2):252-8. doi: 10.1111/j.1537-2995.2008.01953.x. 24. bhatti fa, uddin m, ahmed a, bugert p. human platelet antigen polymorphisms (hpa-1, -2, -3, -4, -5 and -15) in major ethnic groups of pakistan. transfus med. 2010;20(2):78-87. doi: 10.1111/j.13653148.2009.00982.x. 25. zaheer ha, ahmed s, waheed u, wazeer a, et al., (2020). national guidelines for quality control in transfusion medicine. safe blood transfusion programme, ministry of national health services, regulations & coordination, government of pakistan. 3rd edition. isbn 978 969 9881 47 3 26. koshy l, anju al, harikrishnan s, kutty vr, jissa vt, kurikesu i, jayachandran p, jayakumaran nair a, gangaprasad a, nair gm, sudhakaran pr. evaluating genomic dna extraction methods from human whole blood using endpoint and real-time pcr assays. mol biol rep. 2017;44(1):97-108. doi: 10.1007/s11033016-4085-9. 27. immuno polymorphism database. available from https://www.ebi.ac.uk/ipd/ accessed on june 30, 2022 28. rozen s, skaletsky h. primer3 on the www for general users and for biologist programmers. methods mol biol. 2000;132:365-86. doi: 10.1385/159259-192-2:365. 29. bussel jb, vander haar el, berkowitz rl. new developments in fetal and neonatal alloimmune thrombocytopenia. am j obstet gynecol. 2021;225(2):120-127. doi: 10.1016/j.ajog.2021.04.211. 30. de vos tw, winkelhorst d, de haas m, lopriore e, oepkes d. epidemiology and management of fetal and neonatal alloimmune thrombocytopenia. transfus apher sci. 2020;59(1):102704. doi: 10.1016/j.transci.2019.102704. 31. cortes ma, romon i, gomez d. purpura mimicking posttransfusion purpura. transfusion. 2019;59(8):2504-2505. doi: 10.1111/trf.15392. 32. prodger cf, rampotas a, estcourt lj, stanworth sj, murphy mf. platelet transfusion: alloimmunization and refractoriness. semin hematol. 2020;57(2):9299. doi: 10.1053/j.seminhematol.2019.10.001. 33. darr a, modell b. the frequency of consanguineous marriage among british pakistanis. j med genet. 1988;25(3):186-90. doi: 10.1136/jmg.25.3.186. 34. bittles ah, grant jc, shami sa. consanguinity as a determinant of reproductive behaviour and mortality in pakistan. int j epidemiol. 1993;22(3):463-7. doi: 10.1093/ije/22.3.463. 35. afzal m, ali sm, siyal hb, hakim a. consanguineous marriages in pakistan [with comments]. the pakistan development review. 1994;33(4):663-76. 36. botero jp, lee k, branchford br, bray pf, freson k, lambert mp, luo m, mohan s, ross je, bergmeier w, di paola j; clingen platelet disorder variant curation expert panel. glanzmann thrombasthenia: genetic basis and clinical correlates. haematologica. 2020;105(4):888-894. doi: 10.3324/haematol.2018.214239. https://www.ebi.ac.uk/ipd/ j islamabad med dental coll 2023 81 37. asmarinah, dharma r, ritchie nk, rahayu s, putricahya e, santoso s. human platelet-specific antigen frequencies in indonesian population. transfus med. 2013;23(4):250-3. doi: 10.1111/tme.12039. 38. hauck-dlimi b, hammon k, eckstein r, ott s, zimmermann r, dengler t, ringwald j. human platelet antigen genotypes in turkish and caucasian blood donors in germany. tissue antigens. 2012;80(3):214-8. doi: 10.1111/j.13990039.2012.01908.x. 39. castro v, origa af, annichino-bizzacchi jm, soares m, menezes rc, gonçalves ms, costa ff, arruda vr. frequencies of platelet-specific alloantigen systems 1-5 in three distinct ethnic groups in brazil. eur j immunogenet. 1999;26(5):355-60. doi: 10.1046/j.1365-2370.1999.00174.x. 40. kuniyoshi am, chiba ak, vieira filho jp, castro bs, bordin jo. hpa-9 and hpa-3 allelic frequencies in brazilian blood donors and amazon indians. transfus med. 2010;20(5):354-5. doi: 10.1111/j.13653148.2010.01018.x. 41. merzoni j, fagundes is, lunardi lw, lindenau jd, gil bc, jobim m, dias vg, merzoni l, sekine l, onsten tg, jobim lf. human platelet antigen genotyping of platelet donors in southern brazil. int j immunogenet. 2015;42(5):329-35. doi: 10.1111/iji.12220. 42. brouk h, halle l, bertrand g, neche fz, ouelaa h, kaplan c. human platelet antigen allele frequencies in different algerian populations. tissue antigens. 2010;75(6):673-8. doi: 10.1111/j.13990039.2009.01429.x. 43. hong x, chen s, ying y, liu y, xu x, he j, zhu f. simultaneous genotyping of human platelet alloantigen-1 to 28bw systems by multiplex polymerase chain reaction sequence-based typing. vox sang. 2017;112(4):360-366. doi: 10.1111/vox.12507 44. kazemi mh, malakootikhah f, momeni-varposhti z, falak r, delbandi aa, tajik n. human platelet antigen 1-6, 9 and 15 in the iranian population: an anthropological genetic analysis. sci rep. 2020;10(1):7442. doi: 10.1038/s41598-020-64469-4. 123 j i m d c 2 0 1 8 123 open access f u l l l e n g t h a r t i c l e association of childhood asthma control with parental socioeconomic status imran mahmood khan1, muhammad waqas ashfaq2, mohsin butt3, aamir afzal4 1,2 assistant professor, pediatric department, islamabad medical & dental college, islamabad 3 associate professor, pediatric department, islamabad medical & dental college, islamabad 4 biostatistician, foundation university medical college, islamabad a b s t r a c t objective: to evaluate association of childhood asthma control with parental socioeconomic status. patients and methods: this cross sectional study was conducted in four hospitals of rawalpindi and islamabad from 1st february, 2017 to 31st january, 2018. total 151 patients, aged 6 months to 15 years were enrolled in study through nonrandomized, simple consecutive sampling. after informed consent doctor filled the structured proforma by taking short interview of parents about their socioeconomic status, drug compliance and level of asthma control of their child. data was entered and analyzed on spss version 21.0. chi-square test was applied for association among categorical variables. p-value less than 0.05 was considered significant. results: among total of 151 children, 37 (24.5%) children had well controlled asthma while 69 (45.7%) had partially controlled and 45 (29.8) had uncontrolled asthma. children from low socioeconomic families had poor asthma control than children from high socioeconomic families. conclusion: there is statistically significant association of poor asthma control with low parental education and income status. therefore, more asthma education, frequent follow-ups and provision of free of cost medicines are needed in order to achieve good asthma control in such children. key words: asthma control, childhood, socioeconomic status author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3,4 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence imran mahmood khan email: lifesaverforu@yahoo.com article info. received: february 9, 2018 accepted: may 24, 2018 cite this article. khan im, ashfaq mw, butt m, afzal a. association of childhood asthma control with parental socioeconomic status. jimdc.2018; 7(2):123-127 funding source: nil conflict of interest: nil i n t r o d u c t i o n asthma is a chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction. the exact cause of asthma has not been determined; a combination of environmental exposures (viruses and home allergens) and genetic susceptibilities has been implicated.1 asthma is the most common chronic disease among children and is associated with morbidity, school absenteeism, substantial healthcare resource use and parental absence from work.2 ,3 a study of childhood asthma prevalence in 233 centers in 97 countries (international study of asthma and allergies in childhood, phase 3) found a wide range in the prevalence of asthma in 6-7 years (2.4-37.6%) and 13-14 years old children (0.8-32.6%) with mean prevalence of 11.6% and 13.7% respectively worldwide.1,3,4 in india, the mean asthma prevalence is 7.1% in children 6-7 years of age and 6.5% in children 13-14 years of age. in bangladesh m e a n prevalence i s 9.1% among 6-7 years old children and in pakistan mean prevalence is 10.1% among 13-14 years old children.5 in individual cities of pakistan, asthma prevalence is 6% in multan, 10.2% in karachi and 31.5% in islamabad.6-8 asthma prevalence is increasing in o r i g i n a l a r t i c l e 124 j i m d c 2 0 1 8 124 indian subcontinent at the rate of 0.06% per year in 6-7 year old children and 0.02% per year in 13-14 year old children.3there are various studies done in european and american countries regarding association of socioeconomic status with incidence and control of asthma in adults and children. most of the studies reported that asthma prevalence is higher in children and youth belonging to low socioeconomic status especially first year of life 9,10 and children from lower socioeconomic status have poor asthma control.11-14 while other studies showed that asthma prevalence is higher in children from higher socioeconomic groups especially after 1st year of life.9,14,15 another study showed that socioeconomic status had no significant effect on prevalence of childhood asthma.16 studies done in pakistan showed asthma risk is higher in adult population belonging to middle socioeconomic status and children from low socioeconomic status.17,18 very few such studies are conducted in pakistan. thus this study was conducted in various hospital of rawalpindi and islamabad to know exact relationship of parental income status and maternal education with control of childhood asthma. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted in pediatric department, dr. akbar niazi teaching hospital, islamabad, and three other private hospitals of rawalpindi and islamabad from 1st february, 2017 till 31st january, 2018. ethical permission was taken from institutional ethical review board. patients, aged 6 months to 15 years, coming to opd clinics, admitted in emergency or pediatric wards with physician-diagnosed asthma on basis of history were included in this study. children who had any other chronic disease (cardiovascular, git or seizures, endocrine, delayed milestones) along with asthma were excluded from study. total 151 patients were inducted. sample size was calculated by using who sample size calculator with following values of calculations; confidence level = 95%, anticipated population proportion =11%, absolute precision required= 5%.11 patients coming from islamabad and various cities of punjab and khyber pakhtunkhwa were recruited through a non-randomized, simple consecutive sampling. parents were verbally briefed about the study and written consent was taken. doctors filled the structured proforma by taking short interview of parents about their socioeconomic status, drug compliance and level of asthma control of their child. level of asthma control was categorized into controlled, partially controlled and uncontrolled depending on asthma symptoms in last 4 weeks according to latest gina guidelines 2015 (figure 1).19 in socioeconomic status, education of mother and household income were considered. education of mother was categorized according to “national qualification framework of pakistan” approved by higher education commission of pakistan on 11th january, 2016. these education categories are (1) primary (1-5 years), (2) middle (6-8 years), (3) matriculation (9-10 years), (4) intermediate (11-12 years) and (5) higher education levels (13-21 years).20 for purpose of data analysis, we divided them into three groups: low education group (uneducated, primary and middle), medium education group (matriculation and intermediate) and higher education group (graduation and above). household income was grouped according to national income tax slab year 2016. these groups were as follows; low income group (annual income up to 4 lac rupees), medium income group (annual income from 4 lac to 7.5 lac rupees) and higher income group (annual income above 7.5 lac rupees).21 data were entered and analyzed in spss version 21.0. mean and standard deviation was calculated for age of children in years. frequencies and percentages were calculated for patient’s gender, income status of parents, maternal education and asthma control. chi-square test/fischer exact test were applied for association among categorical variables. p-value less than 0.05 was considered statistically significant r e s u l t s total 151 cases were included in the study. mean age (years) was 3.77+2.94 sd. males were more in number (71.5%) as compared to females. a large number of children belonged to families having higher income (41.1%) and higher education levels (57.6%). children having partial control of asthma were more in number (45.7%) as shown in table 1. association of socioeconomic status in terms of low income group and higher income group was observed significantly with uncontrolled 125 j i m d c 2 0 1 8 125 and well controlled asthma; 16 (35.6%) & 18 (48.6%) respectively. low education was associated significantly with uncontrolled asthma level 11 (24.4%) whereas association of well controlled asthma 26 (70.3%) was observed with higher education of mother as shown in table 2. there was no statistically significant association of drug compliance with socio economic status. good drug compliance was observed in medium and higher income group 53 (43.1%) and 49 (39.8%) respectively. similarly, there were more mothers having medium and higher education, [40(32.5%) and 71 (57.7%) respectively], who followed good drug compliance (table 3). d i s c u s s i o n nowadays infectious diseases are decreasing due to prevention by vaccination and allergic diseases are constantly on rise and are becoming major health problems affecting all age groups. poorly controlled asthmatic children cannot carry out their usual activities during play and education. it also results in parental loss of work and productivity due to frequent emergency visits and admissions resulting in more expensive treatment. in our study, 20.5% children belong to low income families, 38.4% to medium and 41.1% to high-income families. this is in contrast to study done in karachi which showed 60% patients belong to poor income levels.18 in our study children belonging to low, medium and higher education families are 12.6%, 29.8% and 57.6% respectively which is also in contrast to the study done in karachi, in which 86.7% children belong to low education families.18 in our table 1: descriptive statistics of asthma patients (n=151) characteristics of patients mean+sd age (years) 3.77+2.94 characteristics of patients n (%) gender male female 108 (71.5) 43 (28.5) income level low medium higher 30(19.9) 59 (39.1) 62 (41.1) education level low medium higher 19 (12.6) 45 (29.8) 87 (57.6) asthma control well control partially control uncontrolled 37 (24.5) 69 (45.7) 45 (29.8) table 3: comparison of parental socioeconomic status with drug compliance (n=151) parental socioeconomic status drug compliance total n (%) p-value* good n (%) poor n (%) income of parents low 21 (17.1) 09 (32.1) 30 (19.9) 0.061 medium 53 (43.1) 06 (21.4) 59 (39.1) higher 49 (39.8) 13 (46.4) 62 (41.1) education of mother low 12 (9.8) 07 (25.0) 19 (12.6) 0.053 medium 40 (32.5) 05 (17.9) 45 (29.8) higher 71 (57.7) 16 (57.1) 87 (57.6) table 2: comparison of parental socioeconomic status with asthma control (n=151) parental socioeconomic status level of asthma control total n (%) p-value* well controlled n (%) partly controlled n (%) uncontrolled n (%) income of parents low 01 (2.7) 13 (18.8) 16 (35.6) 30 (19.9) 0.001 medium 18 (48.6) 32 (46.4) 09 (20.0) 59 (39.1) higher 18 (48.6) 24 (34.8) 20 (44.4) 62 (41.1) education of mother low 02 (5.4) 06 (8.7) 11 (24.4) 19 (12.6) 0.013 medium 09 (24.3) 27 (39.1) 09 (30.0) 45 (29.8) higher 26 (70.3) 36 (52.2) 25 (55.6) 87 (57.6) 126 j i m d c 2 0 1 8 126 study, 24.5% children have well controlled asthma while 45.7% had partly controlled and 29.8% have uncontrolled asthma. these results are comparable to those of study conducted in canada and san francisco which showed two thirds of children did not achieve good asthma control.11,13 our study showed that children belonging to low income and low education groups had poor control of asthma as compared to children from higher income and higher education groups. these results are similar to study done in adult population (18-44years) in denmark.12 study done in san francisco in 2014, in african american youths (8-21years) also showed association of poorly controlled asthma with low maternal education and low parental income status.13 study done in south africa in 13-14 year old school children also showed similar results in which asthma control was poor in children from poor societies who rely less on controller treatment and more on episodic care of asthma exacerbations.14 study done in boston and san francisco showed that factors through which socioeconomic status influence asthma prevalence and severity include indoor and outdoor air quality, smoke exposure, access to health care facility, psychological and cultural factors.22,23 indoor allergens like cockroach, dust mites and moulds, cooking fuels, proximity to pets, overcrowding and infections are higher in low income areas as compared to higher income areas. smoking, violence, stress and depression are more prevalent in poor families.24 all these factors contribute to poor asthma control. mostly low-income families live in areas with more outdoor pollutants, which trigger asthma exacerbations. lack of insurance and low income results in negative impact to access health care, diagnosis and management of asthma. gong and mielick found less use of controller medications as a cause of poor asthma control in families with lower education.10,25 our study also supports above finding as drug compliance is poor in low socioeconomic families as compared to higher socioeconomic families although it is not statistically significant. this can be because controller medicines are costly, moreover mothers with low education do not know the importance of continuing medicines even when children are apparently well. as a result, they stop controller medicines of their children and asthma control worsens resulting in frequent exacerbations. previous studies in pakistani population showed that there are myths in society regarding use of inhalers. people think that inhalers are used only in advanced stages of asthma and their regular use may result in inhaler addiction.17, 26 same attitude of parents towards inhalers was observed in our study when they tried to avoid use of inhalers and requested health care providers to prescribe oral medicines despite proper education and counseling. with oral medicines only, asthma control is rarely achieved as they have low efficacy and more side effects than inhalers. this misconception is another cause of less use of controller medications resulting in poor control of asthma in our study. due to poor knowledge about asthma, most people in pakistani society have false belief that milk, egg and rice trigger asthma attack which result in avoidance of these diets leading to malnutrition in asthmatic children.26 c o n c l u s i o n low socioeconomic status is associated with poor asthma control. it should be kept in mind while managing asthmatic patients and more time should be spent in educating such families regarding asthma allergens, triggers and importance of controller medications especially inhalers and their proper use. false beliefs regarding inhalers and diet should be properly addressed. maximum efforts should be done to provide free of cost medicines to such families through medical insurance or other means to increase drug compliance. frequent follow-ups should be advised in such children to check compliance and assess asthma control. by taking these measures, percentage of children with good asthma control can be increased which is our goal in asthma management. acknowledgements we are thankful to all patients and their parents who participated in our study. r e f e r e n c e s 1. liu ah, covar ra, spahn jd. childhood asthma. in: kliegman rm, behrman re, stanton bf, editors. nelson textbook of pediatrics. 20th ed. philadelphia: elsevier; 2016.1095-1115. 2. fleming, l., n. wilson, et al. difficult to control asthma in children. curr opin allergy clin immunol. 2007;7(2):190-5. 3. braman ss. the global burden of asthma. chest 2006;130(1 suppl):4s-12s. 127 j i m d c 2 0 1 8 127 4. pearce, n., n. ait-khaled, et al. worldwide trends in the prevalence of asthma symptoms: phase iii of the international study of asthma and allergies in childhood (isaac).thorax 2006;62(9):758-766. 5. zamank,takeuchih,yonusm,arifeense,choudharyhr,baqui ,etal.asthmainruralbangladeshchildren.indianj of pediatrics.2007;74:539-43. 6. mustafa, g., p. a. khan, et al. nocturnal asthma in school children of south punjab, pakistan. j ayub med coll abbottabad. 2008;20(3):36-9. 7. khanaa, tanzil s,jamalit,shahida,naeem s,sahitoa,etal. burdenofasthma among children ina developing megacity: childhoodasthmastudy,pakistan.j asthma.2014;51(9):8919 8. waqar, m. a., k. muneeba, et al. prevalence of allergy and asthma in school children of islamabad, pakistan.world applied sciences journal 2009;6(3):426-432. 9. almqvist, c., g. pershagen, et al. low socioeconomic status as a risk factor for asthma, rhinitis and sensitization at 4 years in a birth cohort. clin exp allergy. 2005;35(5):612-618. 10. gong t, lundholm c, rejnö g, mood c, långström n, almqvist c. parental socioeconomic status, childhood asthma and medication use–a population-based study. plos one. 2014;9(9):e106579. 11. shannon f, wendy j, richard h. socioeconomic factors and asthma control in children. pediatr pulmonol. 2008;43(8):745-752. 12. von bülow a, kriegbaum m, backer v, porsbjerg c. poor asthma control is associated with low socio-economic status: results from a nationwide cross sectional study of danish patients with asthma. european respiratory journal 2015;46(59).2024 13. thakur, n., m. martin, et al. socioeconomic status and asthma control in african american youth in sage ii. j asthma. 2014;51(7):720-8. 14. poyser, m. a., h. nelson, et al. socioeconomic deprivation and asthma prevalence and severity in young eur respir j. 2002;19 (5):892 15. thakur, n., s. s. oh, et al. socioeconomic status and childhood asthma in urban minority youths. the gala ii and sage ii studies. am j respir crit care med. 2013;188(10): 1202-1209. 16. hancox, r. j., b. j. milne, et al. relationship between socioeconomic status and asthma: a longitudinal cohort study. thorax 2004;59(5):376-380. 17. iqbal, z., saleem a. a local experience of bronchial asthma. j allama iqbal med coll. 2009;7(4):64-64. 18. rais h, arif f, santosh s. asthmatic children; knowledgeand practices in theparents.professionalmedj.2014;21(4):739-744. 19. global initiative for asthma . global strategy for asthma management and prevention. updated 2015.http://www.ginasthma.org/local/uploads/files/gina_r eport_2015.pdf . 20th may 2015. 20. higher education commission, pakistan. national qualifications framework of pakistan [internet]. 2016 [updated 2016 08 04]. available from: http://hec.gov.pk/english/services/universities/pqf/pages/d efault.aspx 21. income tax slabs in pakistan 2016-17: income tax rates for salaried persons [internet]. 2016 [updated 2016 july 19]. available from: https://ww.web.pk/2016/income-taxslabs-in-pakistan-2016-17-income-tax-rates-for-salariedpersons/ 22. forno, e. and j. c. celedon. asthma and ethnic minorities: socioeconomic status and beyond. curr opin allergy clin immunol. 2009; 9(2):154-160. 23. neidell, m. j. air pollution, health, and socio-economic status: the effect of outdoor air quality on childhood asthma. j health econ. 2004;23(6):1209-1236. 24. awasthi s, kalra e, roy s, awasthi s. prevalence and risk factors of asthma and wheeze in school-going children in lucknow, north india.indian pediatr. 2004;41(12):1205-10. 25. mielck, a., p. reitmeir, et al. severity of childhood asthma by socioeconomic status. int j epidemiol. 1996;25(2):388393. 26. irfan o, irfan b, khan za, tahir m, sarwar zubairi ab, khan ja. knowledge about asthma: a cross-sectional survey in 4 major hospitals of karachi, pakistan.j pak med assoc. 2017; 67(11):1787-90. http://www.ginasthma.org/local/uploads/files/gina_report_2015.pdf http://www.ginasthma.org/local/uploads/files/gina_report_2015.pdf 140 j i m d c 2 0 1 8 140 open access f u l l l e n g t h a r t i c l e clinical pattern and management of typhoid ileal perforation faiza hameed 1, fida hussain shah 2, muhammad hanif 3 1 senior registrar, department of general surgery liaquat university of medical & health sciences jamshoro 2 assistant professor, department of general surgery liaquat university of medical & health sciences jamshoro 3 assistant professor, department of general surgery indus medical college sindh a b s t r a c t objective: to determine the clinical presentation of typhoid ileal perforation and its outcome after treatment at tertiary care hospital. material and methods: this cross-sectional study was carried out in the department of general surgery, lumhs/jamshoro from october 2010 to september 2011. all the cases that presented with typhoid perforation on clinical basis and had x-ray demonstration of air-fluid and gas under the diaphragm were included in the study. all the cases underwent surgical emergency with coverage of broad spectrum antibiotic, nasogastric suction, and correction of fluid. electrolyte imbalance was cured and blood transfusion was done before the surgery. all the data regarding clinical presentation, postoperative complications and mortality was recorded in the proforma. data was analyzed by spss version 16. results: total 40 patients were studied. mean age of the patients was 27.08+22.0 years with the range of 10 to 60 years. most common 82.5% were male and 17.5% were female. abdominal pain and tenderness was found in all the cases. regarding signs and symptoms, abdominal distension (97.5%) and fever (95%) were the most common presenting complaints. primary closure in two layers was done in 40.0% cases, segmentation resection end to end anastomosis procedure was done in 10.0% cases and primary repair with proximal ileostomy was done in 50.0% cases. wound infection developed in 62.5% patients followed by wound adhesion in 30.0% cases. mortality rate of 10.0%. conclusion: we observed wound infection and wound adhesion were the commonest complications with mortality rate was 10%. key words: clinical presentation, ileal perforation, treatment, typhoid. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, active participation in data collection. address of correspondence faiza hameed email: dr.saeedarain786@gmail.com article info. received: march 10, 2018 accepted: may 14, 2018 cite this article. hameed f, shah fh, hanif m. clinical pattern and management of typhoid ileal perforation. jimdc.2018; 7(2):140-144 funding source: nil conflict of interest: nil i n t r o d u c t i o n typhoid fever is a systemic illness caused by salmonella enterica serovar typhi, a gram-negative bacterium. transmission mostly occurred by the ingestions of food and water contaminated by feces from acutely infected or improving cases or asymptomatic carriers. incubation period is of 1 2 weeks usually, while its range may be from 3 60 days.1 this disease presents with sustained fever and many other sign and symptoms as dry cough, abdominal pain, fatigue, constipation and the diarrhea.2 disease causing organism is a multi-organ pathogen which inhabited the lymphatic tissue in small intestine, spleen, liver and bloodstream in the infected persons.3 enteric fever is more frequent in children older than five years and its complications have been seen in o r i g i n a l a r t i c l e 141 j i m d c 2 0 1 8 141 more than one third cases reported.4 the reported incidence in children with 2–5 year is 573.2 in pakistan, 340.1 in india and 148.7 in indonesia per 100,000 person per year respectively. it was estimated 451.7 out of 100,000 cases per years in children from age 2–15 year. its rate was higher significantly in countries of south asia including pakistan as compared to south-east countries and north-east countries of asia.5 many complications are associated with typhoid fever. ileal perforation is one of the most fatal complication 6 and is frequent surgical emergency. however surgery is recognized as definite management and exact surgical procedure choice remains controversial.7 mostly studies reported that simple closure of perforation and its resection, and anastomosis in the cases having multiple perforations showed satisfactory outcome.8,9 these surgical procedures though appear interesting, particularly in the emergency setup, while it is not free from complications.7 nowadays, the mortality rate is decreasing, but still it is very higher as 1 to 39% with the significant morbidities inspite of the progression of therapies.10 however surgeries associated with higher rate of morbidity and mortality, offer great survival hope.11 though insufficiency of incidental data and inadequate resources of financial status in developing countries such as ours preclude the effective applications of preventative strategies.6 this study has been conducted to determine the clinical pattern of ileal perforation and its outcome after treatment in term of postoperative complications and mortality. m a t e r i a l a n d m e t h o d s this cross sectional study was conducted in the department of general surgery lumhs jamshoro from october 2010 to september 2011. sample size was calculated by raosoft-software. anticipated proportion of typhoid perforation was used as 9.2% with 95% confidential level and 9% marginal error.18 calculated sample size was 40 patients. all the cases that presented with typhoid perforation on clinical basis and had x-ray demonstration of air-fluid and gas under the diaphragm were included in the study. cases with non-typhoid ileal perforations including tuberculosis and traumatic perforations including perforated appendicitis, duodenal ulcer perforation, tuberculosis, bacterial peritonitis and meckle’s diverticulum perforation were excluded from the study. all the cases underwent surgical emergency with coverage of broad spectrum antibiotic, nasogastric suction and correction of fluid balance. in all patient’s electrolytes were balanced and blood transfusion was done before the surgeries. exploratory laparotomy was carried out under general anesthesia. operative procedures were decided according to condition of disease and operative findings. all the cases were followed for outcome in terms of complications. parenteral antibiotics were continued in all the cases for five days. the data was entered and analyzed by spss version 16. r e s u l t s total 40 patients were included in this study. mean age of the patients was 27.08+22.0 years with the range of 10 to 60 years. majority of cases 70.0% were with in age group of 26 to 40 years. male gender was most common 82.5% as compared to female 17.5% (table 1). table1: distribution of study participants according to age and gender (n=40) age groups (year) frequency percentage 10 to 25 07 17.5 26 to 40 28 70.0 41 to 50 05 12.5 >50 0 0 gender male 33 82.5 female 07 17.5 abdominal pain and tenderness were found in all the cases. regarding sign and symptoms, abdominal distension was present in 97.5% patients and fever in 95% (table 2). perforations were surgically treated depending upon the number of perforations, general health status of patient and degree of faecal contamination. primary closure in two layers was done in 40.0% cases, segmentation resection end to end anastomosis procedure was done in 10.0% cases and primary repair with proximal ileostomy was done in 50.0% cases (figure 1). wound infection was present in 62.5% patients followed by wound adhesion in 30.0% (table 3). majority of the patients (37.5%) were discharged between 142 j i m d c 2 0 1 8 142 5 to 15 days including 1 death, remaining 30.0% patients were discharged between 16 to 25 days and 25.0% were discharged between 26 to 30 days including 1 death, while only 3 cases were discharged after 30 days and out of them 2 died (table 3). figure 1: different surgical approaches opted in study patients table 3: post-operative complications in hospital stay (n=40) variables frequency percentage complications wound infection 25 62.5 wound dehiscence 12 30.0 ileostomy 03 07.5 retraction 03 07.5 herniation 04 10.0 intra-abdominal abscess 06 15.0 septicemia 04 10.0 mortality 04 10.0 hospital stay (in days) 5 to 15 15 37.5 16 to 25 12 30.0 26 to 30 10 25.0 > 30 03 07.5 d i s c u s s i o n typhoid fever and its complications are serious public health issues. this study has been conducted to determine clinical presentation and treatment outcome in patients with typhoid ileal perforation and perforations were surgically treated depending upon the number of perforations, general health status of patient and degree of faecal contamination. in this study primary closure in two layer was done in 40.0% cases, 10% cases underwent segmentation resection end to end anastomosis and primary repair with proximal ileostomy was done in 50.0% cases. similar findings were reported by ansari ag et al.11 on other hand ugochukwu ai et al6 reported that 60.5% underwent simple closure, 21% underwent ileal resection and entero-anastomosis, 8.1% were treated by tube ileostomy, primary suture and proximal ileo-transverse anastomosis were done in 5.8% cases and 4(4.7%) cases underwent right hemicolectomy. surgical treatment is associated with many complications and mortality. in the present study according to the complications wound infection was found in 62.5% patients, wound adhesion in 30.0%, development of table 2: clinical presentation of study participants (n=40) sign and symptoms frequency percentage sign anaemia 29 72.5 pedal edema 05 12.5 dehydration 07 17.5 distention 39 97.5 tenderness 40 100.0 guarding 04 10.0 symptoms abdominal pain 40 100.0 fever 38 95.0 constipation 30 75.0 diarrhea 02 05.0 vomiting 25 62.5 143 j i m d c 2 0 1 8 143 herniation was found in 10.0% patients, intra-abdominal abscess was noted in 15.0%) cases and septicemia was found in 10.0% of the patients. mortality rate was found 10.0%. ansari ag et al.11 in their study reported that wound infection in 68.18% of cases, wound dehiscence in 27.27%, intra-abdominal abscess in 9.09% patients and entero-cutaneous fistula was found in 13.36% patients. in this study mortality rate was 10.0%. ugochukwu ai et al6 reported that overall death ratio was 18.6%. ansari ag et al.11 reported mortality rate 13.36%. these studies showed high mortality rate as compared to our study. malik am et al12 reported that mortality rate was 6.25% siddiqui fg et al7 also reported death rate in 8.3% patients. in this study herniation developed in 5(10.0%) patients. ansari ag et al.11 stated that 36.36% cases had developed incisional hernia. farooq u et al13 reported that herniation developed in 10.0% cases. in this study mean age of the patients was 27.08+22.0 years with the range of 10 to 60 years. ansari ag et al11 reported mean age was 29.36 years, ranged from 10 to 45 years, in another previous study also found comparable findings regarding age.14 majority of cases 38 (76.0%) were between 13 to 45 years of age. in this study male gender was most common (82.5%) as compared to female (17.5%). ansari ag et al11 reported that 63.63% males and female were 36.36%. some other studies of kouame j et al,15 malik am et al,16 and chanh nq et al17 reported comparable findings. typhoid ileal perforation still found higher in male gender in our population, this may be because young males are more involved in outdoor activities and utilize unhygienic food and water outside of home. according to the clinical presentation, all the patients presented with abdominal pain and tenderness, signs as distension in 97.5%, anaemia 72.5%, pedal edema in 12.5%, dehydration in 17.5%, and guarding in 10.0%, fever in 95.0%, constipation in 75.0%, diarrhea in 5.0% and vomiting was in 62.5%. ansari ag et al11 reported fever, abdominal pain and distension were in all study subjects followed by diarrhea 5 (11.36%), vomiting and constipation in 12 (27.27%) and 4 (9.09%) cases respectively. kabwama sn et al1 also stated that fever was found in all cases including abdominal pain in 72.72% and headache in 69.69% cases. siddiqui fg et al 7 reported that presenting symptoms were abdominal pain was in all cases. he further reported that the mostly 87% cases were anemic and had haemoglobin level <10 g/dl. ugochukwu ai et al6 also did a study on typhoid ileal perforation and reported that mostly cases 90.7% presented with pain of abdomen, abdominal distention was found in 75.6% cases, 70.9% cases had nausea and vomiting, 54.7% had history of constipation, while fever was found in 50.1% cases. farooq u et al13 conducted study on ileac perforation and reported that postoperative complications were as; infection 66.0%, wound dehiscence 34.0%, stenosis 6.0%, intra-abdominal abscess 10.0% and septicemia was seen in 8.0% patients. in this study according to the hospital stay majority of the patients (37.5%) were discharged between 5 to 15 days including 1 death, remaining 30.0% patients were discharged between 16 to 25 days and 25.0% were discharged between 26 to 30 days including 1 death, while only 3 cases were discharged after 30 days and out of them 2 died. c o n c l u s i o n abdominal pain, distension, fever, vomiting and anemia were the commonest clinical features. wound infection and wound adhesion were the commonest complications and 10% was mortality rate. primary ileostomy is optional surgical procedure in late admitted patients with massive fecal contamination. segmental resection and end-to-end anastomosis is optional for multiple perforations. primary repair is reliable surgical procedure for single perforation. early diagnosis and treatment of enteric fever may reduce the morbidity and mortality. r e f e r e n c e s 1. kabwama sn, bulage l, nsubuga f, pande g, oguttu dw, mafigiri r, et al. a large and persistent outbreak of typhoid fever caused by consuming contaminated water and streetvended beverages: kampala, uganda, january–june 2015. bmc public health. 2017; 17(1):23. 2. world health organization. the diagnosis, treatment and prevention of typhoid fever. world health organisation, department of vaccines and biologicals: ch-1211 geneva 27; 2003. who/v&b/03.07. 3. thong kl, bhutta za, pang t. multidrug-resistant strains of salmonella enterica serotype typhi are genetically homogenous and coexist with antibiotic-sensitive strains as distinct, independent clones. int j infect dis. 2000; 4:194– 197. 4. malik as, malik rh. typhoid fever in malaysian children. med j malaysia. 2001; 56:478–90. 144 j i m d c 2 0 1 8 144 5. ochiai rl, acosta cj, danovaro hmc, baiqing d, bhattacharya sk, agtini md. a study of typhoid fever in five asian countries: disease burden and implications for control. bulletin of the world health organization. 2008; 86:260–68 6. ugochukwu ai, amu oc, nzegwu ma. ileal perforation due to typhoid fever–review of operative management and outcome in an urban centre in nigeria. international journal of surgery. 2013; 11(3):218-22. 7. siddiqui fg, shaikh jm, soomro ag, bux k, memon as, ali sa. outcome of ileostomy in the management of ileal perforation. jlumhs. 2008; 7:168-72. 8. richens j. management of bowel perforation in typhoid fever. trop doct 1991; 21:149-51. 9. na’aya hu, eni ue, chama cm. typhoid perforation in maiduguri, nigeria. ann of af med 2004; 3 (2): 69-72. 10. naorani m, sial i, pain v. typhoid perforation of small bowel: a study of 72 cases. jr coll surg edinb 1997; 42: 274-6. 11. ansari ag, naqvi sq, ghumro aa, jamali ah, talpur aa. management of typhoid ileal perforation: a surgical experience of 44 cases. gomal journal of medical sciences. 2004; 7(1). 12. arshad m. malik, laghari aa, mallah q, qureshi ga. different surgical options and ileostomy in typhoid perforation. world j. med. sci.2006;1(2):112-16. 13. farooq u, farooq s, zahir s. risk factors of typhoid ileal perforation. p j m h s 2012;6;1;69-74 14. talwarr s, sharmad a, mittala ind, prasad p. typhoid enteric perforation. aust n z j surg 1997; 67: 351-3. 15. kouame j, kouadio l, turquin ht. typhoid heal perforation, surgical experience of 64 cases acta chir belg 2004; 104: 445-7. 16. malik am, laghari aa, mallah q, qureshi gah, talpur ah, effendi s, et al. different surgical options and ileostomy in typhoid perforation world journal of medical sciences 2006; 1:112-6. 17. chanh nq, everest p, khoa tt, house d, murch s, parry c, et al. a clinical, microbiological, and pathological study of intestinal perforation associated with typhoid fever. clinical infectious diseases 2004; 39: 61-7. 18. na’aya hu, eni ue, chama cm. typhoid perforation in maiduguri, nigeria. annals of african medicine 2004;3; 69 72. 92 j i m d c 2 0 1 8 92 open access f u l l l e n g t h a r t i c l e effect of beclomethasone dipropionate versus mast cell stabilizer on mucociliary clearance in patients of allergic rhinitis muhammad ramzan 1, nasir iqbal 2, arslan karim 3 1 ex house officer nishtar hospital multan 2 ex house officer, medical officer bhu wandher multan 3 ex house officer, medical officer bhu qadir pur multan a b s t r a c t objective: the study was conducted to compare the effect of beclomethasone dipropionate with mast cell stabilizer on mucociliary clearance in patients of allergic rhinitis. patients and methods: a randomized trial was carried out in ent department of nishtar hospital multan from december 2016 to february 2017. patients of allergic rhinitis from both genders were included in the study after written consent. mucociliary transport velocity was measured by saccharine dye test. the collected data was processed and analyzed by spss software 23 version and presented in tabulation form. qualitative variables were analyzed in percentage and frequency form. the main outcome variable, mucociliary transport velocity, age and weight of patients were presented as mean and stranded deviation. students’ test was applied to calculate p value. p value <0.05 was taken as significant. results: a total number of 140 patients were included in the study and were divided in two main groups. there were 70 volunteers in each group. one group was provided beclomethasone and other group was given mast cell stabilizer for one week. after careful analysis and calculation, it was observed that the mean of mucociliary transport velocity after one week of beclomethasone dipropionate treatment was 7.33±1.27 mm/minute with p value 0.558 and mean of velocity after mast cell stabilizer (nedocromil sodium) was 7.82±1.2 mm/minute with p-values 0.304. conclusion: no statistical significance was found with both treatment regimens. key words: allergy, beclomethasone dipropionate, mucociliary clearance, nedocromil sodium, rhinitis, saccharine dye test. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence arslan karim email: ziali43@hotmail.com article info. received: september 20, 2017 accepted: december 19, 2017 cite this article. ramzan m, iqbal n, karim a. to compare effect of beclomethasone dipropionate with mast cell stabilizer on mucociliary clearance in patients of allergic rhinitis. jimdc.2018; 7(2):92-96 funding source: nil conflict of interest: nil i n t r o d u c t i o n in upper respiratory disorders, allergic rhinitis has important correlation with asthmatic complications.1 its prevalence in united states ranges between 5 to 22 percent. major symptoms of allergic rhinitis are pruritus of nose and eyes, rhinorrhea, nasal congestion and sneezing. less common symptoms include popping of ears, coughing and throat clearing.2 chronic breathing disease and the consequences of allergic rhinitis complications like sinusitis, eustachian tube dysfunction and sleep disturbances are major complications which result in morbidity.3 parental history of atopic disease increases the chance of disease occurrence in next generation by 30 percent and even more risk when both parents have such disease.4 allergic rhinitis as itself o r i g i n a l a r t i c l e 93 j i m d c 2 0 1 8 93 explains is the hypersensitivity response to the external allergens mediated by ige antibodies. its outcomes are nasal symptoms or upper respiratory tract disturbances presenting as its main hallmarks. there is a list of allergens, which are the cause of this hypersensitivity. these include trees and small plants pollens, house dust, insects and some foods.5 in allergic rhinitis, mast cells and basophils are first line of defense, which has high affinity receptors for ige antibodies and second line of defense are eosinophils, monocytes and platelets with low affinity receptors.6 it is not necessary that all the subjects having ige serum level show clinical significance. it is also understood that there is no probability of any specific organ to be effected by increase in ige serum level. although in allergic rhinitis patients mast cells degranulate, causing release of inflammatory mediators, which ultimately lead to stimulation of nasal end organs, producing different symptoms like sneezing, itching, nasal congestion and rhinorrhea.7 among the persons with raised ige serum level and positive skin sensitivity test, about 90 percent population show immediate hypersensitivity response followed by the symptoms stated above. mediators released by first and second line defenders show collective symptomatic response with less information about individual exact response, although some individual response has been discussed on the base of nasal provocation tests. histamine causes acute antigen antibody response, serotonin causes sneezing and rhinorrhea without congestion while leukotrienes and prostaglandins cause rhinorrhea and congestion both.8 to cope with this nasal disease there are different ways of therapy. before treatment, avoidance from the causative factors are more important as care is the best health remedy. all the sources of pollens, dust and other hypersensitive allergens must be avoided to cope with this disease. otherwise frequently used medicines for the treatment of allergic rhinitis are antihistamines, decongestants, nedocromil sodium (nds) and glucocorticoids.9 immunotherapy is also preferred to lower the threshold for development of clinical symptoms by injecting a series of injections with allergens. antihistamines provocation includes rapid onset and reducing sneezing, rhinorrhea and pruritus but not congestion. decongestants like pseudoephedrine hydrochloride with alpha-adrenergic agonist properties constrict the nasal vascular bed, which results in decreased blood supply, and thus lowering of mucosal edema. nedocromil sodium (nds), a frequently used mast cell stabilizer is also the same in effectiveness as antihistamines.10 glucocorticoids that include flunisolide, beclomethasone dipropionate and dexamethasone are very potent and preferred drugs for the treatment of allergic rhinitis. there mode of action is the same as that of antihistamines with rapid onset reducing hypersensitivity symptoms. to evaluate the efficacy and to find out the significant difference in treatment effects, different drugs have been compared in different studies. in this study, two drug groups discussed above have been focused to evaluate their therapeutic efficiency by certain tests. the two drugs are beclomethasone dipropionate (bdp) a glucocorticosteroid and nedocromil sodium (nds) a mast cell stabilizer, both provocation results effect on mucociliary clearance.11 there are many tests used to evaluate the mucociliary clearance like saccharine test, dye method and radiographic method. saccharine test is inexpensive and reliable technique frequently preferred for the mucociliary clearance measurement.12 the study was conducted to evaluate the difference between the efficacies of two drugs on allergic rhinitis. p a t i e n t s a n d m e t h o d s this prospective study was conducted in ent department of nishtar medical college and hospital multan from december 2016 to february 2017 on patients of allergic rhinitis. after proper approval from institutional ethical committee, a total 140 patients, of both gender were included in this study. sample size was calculated by using online software raosoft by using reference study of svendsen and colleagues with confidence interval 95%.13 a written consent was taken from the participants with verbal briefing about procedure, purpose and protocol of study. patients were divided into two main groups randomly by lottery method and allocated to drugs beclomethasone dipropionate and nedocromil sodium (nds) in equal ratio.14 inclusion criteria was nonsmokers, no history of asthma, no previous chronic upper and lower respiratory disease, no nasal structural abnormality. only 94 j i m d c 2 0 1 8 94 patients with acute allergic rhinitis were included in the study.15 patients already treated with beclomethasone dipropionate and nedocromil sodium (nds) were excluded from the study. all selected patients were gone through mucociliary function test to measure mucociliary transport velocity at baseline and after treatment with beclomethasone dipropionate and nedocromil sodium (nds). to measure mucociliary transport velocity (mm/min), saccharine dye test was applied.16 the test was preferred as it was inexpensive, readily available, easy to perform and reproducible. a particle of saccharine with special blue dye was placed on the anteriomedial portion of the inferior turbinate at the point 4 cm apart from the nasal tip. the transport time was measured from the time of application of saccharine with dye up to the sweet taste in mouth. it was further confirmed by blue dye in the pharynx. the length of nasal cavity was measure with the help of cotton swab from the nasal tip to the pharyngeal wall.17 with the help of measured transport time and length of nasal cavity mucociliary transport velocity (mm/min) was calculated. the same procedure was repeated on the same nostrils after one-week treatment of both medicine groups i.e. 1st group treated with beclomethasone dipropionate and 2nd group treated with nds. mucociliary transport velocity was calculated according to same method as before treatment. the daily dose during treatment was, 4 mg nedocromil sodium (2 mg per puff) and 0.1 mg beclomethasone dipropionate (0.05 mg per puff) two time each medicine daily. treatment was continued for one week on each group.18 all the data were collected and saved in excel spreadsheets and spss version 23. main outcome variable of current study was mucociliary transport velocity, which was calculated by transport time, and nasal length expressed as mm/min. qualitative data like gender were analyzed in percentage and frequency. the main outcome variable mucociliary transport velocity, age and weight of patients were presented as mean and standard deviation. paired sample t-test was applied to calculate p value and p-value ≤ 0.05 was taken as statistically significant. r e s u l t s total 140 patients of both genders were included in this study. gender distribution showed that there were more males (69.3%) than females (30.7%). mean age and weight of the patients was 32.65±4.93 years and 62.22±4.93 kg respectively. majority of the patients (65.7%) were in age group 31-45 years. weight distribution showed that large number of patients (61.4%) had weight between 61-70 kg (table 1). mean age and weight of the patients treated with beclomethasone was 29.81±3.25years and 60.64±3.40 kg respectively. while the mean age and weight of the patients treated with nds was 35.48±4.69 years and 63.8±5.68 kg respectively (table 2). mean mucociliary transport velocity of the patients in two groups at baseline and after one week of table 1: demographic characteristics of study participants (n=140) characteristics frequency percentage gender male 97 69.3 female 43 30.7 stratified age (years) 20-30 48 34.3 31-45 92 65.7 stratified weight (kg) 50-60 54 38.6 61-71 86 61.4 descriptive statistics age (years) mean±sd 32.65±4.93 weight (kg) 62.22±4.93 table 2: group wise demographic characteristics of participants groups variable mean±sd beclomethasone (n=70) age (years) 29.81±3.25 weight (kg) 60.64±3.40 nedocromil sodium (n=70) age (years) 35.48±4.69 weight (kg) 63.80±5.68 95 j i m d c 2 0 1 8 95 treatment was statistically insignificant with p-values 0.558 and 0.304 respectively (table 3). d i s c u s s i o n allergic rhinitis is directly correlated with different upper respiratory complications leading to acute or chronic respiratory diseases. therefore, different treatment strategies are implemented to overcome this disease. antihistamines, decongestants, nedocromil sodium (nds), glucocorticoids and immunotherapy are the preferred modes of treatment. above all self-care and health consciousness are also very important factors to avoid these kinds of diseases. in current study, the two groups of drugs used in the treatment of this disease have been compared in their efficacy. many studies have been presented by different researches on the effects of drugs discussed above, over different aspects of treatment outcome. ratner et al in 2002 had conducted a research on the effect of cromolyn sodium on allergic rhinitis, which showed positive results of drug relieving the major symptoms caused by allergic rhinitis.19 we focused on the comparison of treatment efficacy of glucocorticoids (beclomethasone dipropionate) and mast cell stabilizer (nedocromil sodium (nds). the treatment efficacy was evaluated on the basis of mucociliary transport velocity in nasal cavity by saccharine dye test. pelucchi et al in 1995 described the effectiveness of intranasal azelastine and beclomethasone dipropionate on seasonal nasal symptoms which showed that the later drug had better treatment outcome.20 a study presented by watson et al in 1993 showed the effects of beclomethasone on treatment of allergic rhinitis with asthmatic complications compared with placebo. the results concluded the direct effect on upper respiratory symptoms due to allergic rhinitis and indirect positive effect on lower respiratory complications like asthma.21 svendsen et al in 1989 proposed in their research there was no significant difference in efficacy of nedocromil sodium and beclomethasone dipropionate in the treatment of allergic rhinitis accompanied by asthmatic respiratory disorders.21 another study by stafanger et al in 1987 showed effect of beclomethasone dipropionate and flunisolide on the movement of nasal cilia obtained from healthy volunteers by gentle scraping. the results showed a minor but irreversible decrease in ciliary beating frequency (cbf) of the cilia by both drugs.22 rudd et al in 1983 described the effect of orally taken mast cell stabilizers on exercise-induced asthma. the results showed that m&b 22,948 (z-0-propoxyphenyl8azapurin-6-one) a mast cell stabilizer had no significant effect on histamine hypersensitivity but significant effect on exercise induced asthmatic complications.23 in another study, holmberg et al in 1986 demonstrated the effects of beclomethasone on mucociliary activity in comparison with placebo which revealed no significance in the results.24 the current study is in comparison with that study, especially focusing on outcome variable. the results showed that mucociliary transport velocity after one week of bechlomethasone treatment was 7.33±1.27 mm/minute and of mast cell stabilizer (nedocromil sodium) treatment was 7.82±1.2 mm/minute with p-values 0.558 and 0.304 showing no significant difference. c o n c l u s i o n there was no significant difference between the mucociliary transport velocity after treatment of beclomethasone and mast cell stabilizer. this shows the same effectiveness of both drugs in treatment of allergic rhinitis. r e f e r e n c e s 1. marogna m, braidi c, colombo c, colombo f, palumbo l. a randomized controlled trial of a phytotherapic compound containing boswellia serrata and bromeline for seasonal allergic rhinitis complicated by upper airways recurrent table 3: comparison of two groups before and after treatment groups time mucociliary transport velocity(mm/ minute) mean±s.d pvalue bechlomethasone before treatment 7.46±1.43 0.558 after 1 week of treatment 7.33±1.27 nedocromil sodium before treatment 8.01±0.93 0.304 after 1 week of treatment 7.82±1.2 96 j i m d c 2 0 1 8 96 respiratory infections. journal of allergy and clinical immunology. 2015;135(2): ab271. 2. cardell lo, olsson p, andersson m, welin ko, svensson j, tennvall gr, hellgren j.total high cost of allergic rhinitis—a national swedish population-based questionnaire study. npj primary care respiratory medicine. 2016; 26: article number:15082. 3. bergmann kc, demoly p, worm m, fokkens wj, carrillo t, tabar ai, nguyen h, montagut a, zeldin rk. efficacy and safety of sublingual tablets of house dust mite allergen extracts in adults with allergic rhinitis. journal of allergy and clinical immunology. 2014; 133(6):1608-14. 4. seo jh, kim hy, jung yh, lee e, yang si, yu hs, kim yj, kang mj, kim hj, park ks, kwon jw. interactions between innate immunity genes and early-life risk factors in allergic rhinitis. allergy, asthma & immunology research. 2015; 7(3):241-8. 5. woodfolk ja, commins sp, schuyler aj, erwin ea, plattsmills ta. allergens, sources, particles, and molecules: why do we make ige responses?. allergology international. 2015; 64(4):295-303. 6. metcalfe dd, pawankar r, ackerman sj, akin c, clayton f and falcone fh et al. biomarkers of the involvement of mast cells, basophils and eosinophils in asthma and allergic diseases. world allergy organization journal. 2016; 9(1):7. 7. undem bj, taylor-clark t. mechanisms underlying the neuronal-based symptoms of allergy. journal of allergy and clinical immunology. 2014; 133(6):1521-34. 8. chhabra n, lujan js, houser sm. allergic rhinitis and migraine headache. insinus headache, migraine, and the otolaryngologist 2017 (pp. 111-120). springer international publishing. 9. church ds, church mk, scadding gk. allergic rhinitis: impact, diagnosis, treatment and management. clin pharmacist. 2016; 8(8):249-55. 10. incorvaia c, moingeon p, buttafava s, frati f. focusing the mechanism of action to dissect the different treatments of respiratory allergy. expert review of clinical immunology. 2015; 11(9):1005-13. 11. workman ad, cohen na. the effect of drugs and other compounds on the ciliary beat frequency of human respiratory epithelium. american journal of rhinology & allergy. 2014; 28(6):454-64. 12. al ahmari m. non-invasive respiratory support is a proinflammatory stimulus to the upper and lower airways (doctoral dissertation, ucl (university college london)).2013. 13. svendsen ug, frølund l, madsen f, nielsen nh. a comparison of the effects of nedocromil sodium and beclomethasone dipropionate on pulmonary function, symptoms, and bronchial responsiveness in patients with asthma. journal of allergy and clinical immunology. 1989; 84(2):224-31. 14. kim yh, kim m, yang hj, choi jh, kim dk, yoo y, lee b, kim bs, kim wy, kim jh, park sy. crinical diagnostic guidelines for allergic rhinitis: medical treatment. journal of the korean medical association. 2017; 60(2):183-93. 15. trikojat k, buske‐kirschbaum a, plessow f, schmitt j, fischer r. memory and multitasking performance during acute allergic inflammation in seasonal allergic rhinitis. clinical & experimental allergy. 2017; 47(4):479-87. 16. deborah s, prathibha km. measurement of nasal mucociliary clearance. clin res pulmonol. 2014;2(2):1019. 17. aroor r, ali zs, somayaji kg. do nasal surgeries affect mucociliary clearance?. indian journal of otolaryngology and head & neck surgery. 2017; 69(1):24-8. 18. gupta r, fonacier ls. adverse effects of nonsystemic steroids (inhaled, intranasal, and cutaneous): a review of the literature and suggested monitoring tool. current allergy and asthma reports. 2016; 16(6):44. 19. ratner ph, ehrlich pm, fineman sm, meltzer eo, skoner dp. use of intranasal cromolyn sodium for allergic rhinitis. inmayo clinic proceedings. elsevier. 2002; 77(4):350-354. 20. pelucchi a, chiapparino a, mastropasqua b, marazzini l, hernandez a, foresi a. effect of intranasal azelastine and beclomethasone dipropionate on nasal symptoms, nasal cytology, and bronchial responsiveness to methacholine in allergic rhinitis in response to grass pollens. journal of allergy and clinical immunology. 1995; 95(2):515-23. 21. watson, wade ta, allan b. becker, and f. estelle r. simons. "treatment of allergic rhinitis with intranasal corticosteroids in patients with mild asthma: effect on lower airway responsiveness." journal of allergy and clinical immunology.1993; 91(1): 97-101. 22. stafanger g. in vitro effect of beclomethasone dipropionate and flunisolide on the mobility of human nasal cilia. allergy. 1987; 42(7):507-11. 23. rudd rm, gellert ar, studdy pr, geddes dm. inhibition of exercise-induced asthma by an orally absorbed mast cell stabilizer (m & b 22,948). british journal of diseases of the chest. 1983; 77:78-86. 24. holmberg k, pipkorn u. influence of topical beclomethasone dipropionate suspension on human nasal mucociliary activity. european journal of clinical pharmacology. 1986; 30(5):625-7. 145 j i m d c 2 0 1 7 145 open access f u l l l e n g t h a r t i c l e properties and applications of biodentine in restorative dentistry and endodontics: a review saqib arshad khan 1, saima azam 2, beenish qureshi 1 post graduate trainee, mds operative dentistry 2 head of department, operative dentistry 3 associate professor, operative dentistry (islamabad medical and dental college, islamabad) a b s t r a c t recently, a new calcium silicate based cement known as “biodentine” or “dentin in capsule” has been introduced. it is a biocompatible and bioactive material. it consists of tricalcium silicates, dicalcium silicates, calcium carbonate and zirconium oxide. it has many promising characteristics including antibacterial activity, high compressive strength and chemical bonding to tooth structure. additionally, it also has the ability to initiate reparative dentine formation. these properties allow their use for various restorative and endodontic procedures such as management of deep carious lesions, vital pulp therapies, perforation repair, retrograde fillings, apexogenesis, and apexification. key words: calcium silicate based cements; deep carious lesions; pulp capping author`s contribution 1,2conception, synthesis, planning of research and manuscript writing interpretation and discussion data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence saqib arshad khan email: sakib_khan@live.com article info. received: october 17, 2017 accepted: january 6, 2018 cite this article. properties and application of biodentine in restorative dentistry and endodontics: a review. jimdc.2018; 7(2): funding source: nil conflict of interest: nil with the advent of biotechnology and its applications in various fields, including medicine; new techniques and materials are constantly formulated for the improvement of health care system. today, dentists use different synthetic and natural substances for various restorative and endodontic procedures, such as, protection of pulpdentine complex, management of open root apices, repair of root and furcation perforations and as a retrograde filling material.1 ideally, these materials should be bioactive and biocompatible. they should have low solubility, adequate setting time, antibacterial activity, and ability to bind to dental tissues.2 in order to develop a material that meets all these requirements, various materials have been introduced over the years which include calcium hydroxide [ca(oh)₂] cement, glass ionomer cement (gic), zinc oxide eugenol (zoe) cement, resin composites and mineral trioxide aggregate (mta).3 although each material has few advantages over the other, no material meets the criteria completely and therefore cannot be used for multiple clinical procedures. recently, biomaterial scientists have introduced new calcium silicate based cement known as “biodentinetm”. biodentine resembles mta, but the manufacturer claims better handling and physical characteristics, and therefore better performance than other materials.4 since "biodentine" has gained considerable popularity in recent years, this comprehensive review will evaluate the existing literature about the properties and clinical applications of biodentine in comparison to existing materials and will provide a basic guideline to the clinician r e v i e w a r t i c l e 146 j i m d c 2 0 1 7 146 in selecting an appropriate material for a particular situation. composition biodentine is manufactured as powder and liquid. its chemical composition and properties of each component are shown in table 1 .5 setting reaction biodentine sets via hydration reaction as shown in equation below. 2(3cao.sio2) + 6h2 o→3cao.2sio2 .3h2 o + 3ca (oh) 2 water interacts with tricalcium silicate and results in the formation of calcium silicate gel (c-s-h) and a calcium hydroxide.6 the hydrated gel precipitates on the surfaces of the remaining silicate particles (figure 1) and in the spaces between the particles, gradually filling spaces between the unreacted tricalcium silicate.6 clinical applications of biodentine the integrity of the teeth can be compromised in several ways including trauma, abrasion, attrition, dental caries and iatrogenic factors.2 once damaged, restorative and endodontic intervention is required to replace the lost tooth structure, not only to preserve the vitality of pulp but also to restore tooth anatomy and its function. for this reason, many materials have been introduced over the years, making it challenging for a dental clinician to choose the most suitable material for the desired procedure biodentine has been specifically formulated to be used as a dentine substitute material. however, due to its many promising characteristics compared to other materials, it can also be used for vital pulp therapies and retrograde filling materials.7 biodentine as lining material biodentine has been specifically formulated to be used as a dentine substitute material. it has been used as a lining material under direct resin composite restorations. the high compressive strength, color stability and its ability to resist masticatory forces makes it a favorable lining material.8 it has been reported that enhanced strength is attributed to the low powder/liquid ratios of biodentine.9 in a study, kayahan et al evaluated the effect of acid etching on the compressive strength of biodentine. acid etching is an important step in the placement of composite restorations. the authors concluded that acid etching did not significantly affect the compressive strength of biodentine.10 therefore, the author suggested that biodentine could serve as a lining material under light cured resin materials in an esthetically sensitive area.10 figure 1: precipitates of hydrated gel on particles surface biodentine in vital pulp therapies: vital pulp therapy includes conservative management of deep carious lesions either by placing biologically compatible material on the residual affected dentin, called indirect pulp capping or on the exposed pulp, called direct pulp capping. additionally, pulpotomy is another widely accepted vital pulp therapeutic procedure. this method is widely used in pediatric dentistry and involves removal of inflamed and infected pulp tissue, followed by placement of a biocompatible and bioactive material, which not only preserves vitality but also promotes root formation in immature permanent teeth.1 calcium hydroxide is considered as a “gold standard” for vital pulp therapies.7 its two most important properties are antibacterial activity and its ability to form reparative dentine. however, it lacks adhesion to dentine, has high solubility and reduced mechanical strength.11-13 literature shows that the antibacterial property and enhanced mechanical strength of biodentine with its ability to attach firmly to underlying dentin induces formation of reparative dentin which makes it superior medicament for vital pulp therapies.7 moreover, biodentine has the ability to stimulate odontoblasts and increase secretion of tgf-b1 from pulp cells that induces reparative dentin synthesis. in a study, tran et al. compared biodentine, mta and calcium hydroxide in terms of reparative dentine formation when applied to mechanically exposed rat pulps.14 they noted that reparative dentine induced by ca(oh)2 had several tunnel defects, as reported previously by cox et 147 j i m d c 2 0 1 7 147 al. these tunnel defects are described as the presence of porosities or voids in newly formed reparative dentin, which may act as portal of entry for pathogenic microorganisms, thus predisposing tooth to an endodontic infection.12,15 in contrast, the dentine bridge formation induced by biodentine showed a much favorable pattern compared to calcium hydroxide.14 in addition, biodentine maintains a marginal integrity due to the formation of hydroxyapatite crystals at the surface, thereby reducing risk of microleakage that may jeopardize the success of vital treatment procedures.8 in another study, the biological effect of biodentine and mta on pseudoodontoblastic and pulp cells was evaluated. it was established that both mta and biodentine can alter the proliferation of pulp cell lines and therefore, biodentine can be considered an alternative to mta for vital pulp therapies.16,17 in a similar study, cbct analysis of teeth capped with biodentine and gic (fuji ix) showed that majority of teeth with healing / healed lesion received biodentine while majority of teeth with fuji ix showed new/progressing lesions.4 it has been established that the high alkaline nature of biodentine promotes degeneration of the collagenous component of the dentin. this leads to the formation of porosities in developing reparative dentine which permits diffusion of a high concentration of calcium, hydroxyl, and carbonate ions, leading to an increased mineral deposits and a better reparative dentine formation.18,19 studies on biodentine versus formocresol pulpotomy of primary teeth shows that biodentine requires less procedural time.20 it also eliminates the use of additional filling material and reduces the risk of recurrence of bleeding during treatment.1,21 in a study, biodentine was used for partial pulpotomy in an immature tooth, and successful formation of the dentinal bridge with root development was observed.21 biodentine for repair of perforations perforation is a common procedural error encountered in endodontic procedures and post placement or removal. it results in communication between the root canal system and the surrounding connective tissues, thus compromising the success of the treatment.22 it is essential that a perforation repair material is biocompatible, easy to place, chemically bond to the tooth structure, has the ability to induce osteogenesis and cementogenesis, is radio-opaque, dimensionally stable and has high push-out bond strength with dentinal walls.8,22,23 the biocompatibility of a dental material is an important property that must be taken into account when used in direct contact with connective tissue or pulpal tissue and has the potential to affect the viability of periradicular cells and pulp cells.8 available data shows that gic has good biocompatibility, good affinity to bond with tooth structure, provides excellent bacterial seal, but lacks dentin regeneration effect and has low fracture resistance and sensitivity to moisture during setting that has limited its use as a repair and retrograde filling material.3,24 literatures show that biodentine is a favorable repair material. its biocompatibility is attributed to the deposition of hydroxyapatite crystals on the surface of the material when it is in direct contact with tissue fluids.8 in addition, this also contributes to improved dimensional stability as there is no loss of particulate matter.8 additionally it has high push-out bond strength with dentinal walls, which guarantees a hermetic seal to prevent microleakage and dislodgement of material from the repair site.8,22,23 in one of the study aggarwal et al. evaluated the push-out bond strengths of biodentine, pro root mta, and mta table 1: composition of biodentine (septodont, france) according to manufacturer’s specification powder liquid tricalcium silicate (3cao.sio2) main component and regulate the setting reaction calcium chloride (cacl2 2h2o) accelerator dicalcium silicate (2cao.sio2) second main component superplasticizer (water reducing agent) improves handling calcium carbonate (caco3) filler water hydration zirconium dioxide (zro2) radio pacifier 148 j i m d c 2 0 1 7 148 plus. it was observed that the 24 h push-out strength of mta was lower than that of biodentine. moreover, it was observed that blood contamination affected the push-out bond strength of mta plus irrespective of the setting time whereas no effect on the push-out bond strength of biodentine was observed.25 in a similar study, guneser et al. evaluated the effect of different types of endodontic irrigants on the push out bond strength of biodentine and mta. they concluded that biodentine exhibited considerable performance as a repair material even after being exposed to various endodontic irrigation solutions.26 radiopacity, another important property for repair and retrograde filling materials, allows differentiation of the material from the surrounding tissues.8 biodentine has zirconium oxide as a radio pacifier unlike bismuth oxide, which is preferred radiopacifier for other materials. in a study done by tanalp et al, the radiopacity of biodentine was found to be lower than that of the other repair materials(mm-mta, and mta angelus).27 despite this, the reason for preferring zirconium oxide was due to its bioinertness and favorable mechanical properties and corrosion resistance.28 biodentine as retrograde filling material in periradicular surgeries such as apicoectomy, the most important step is to create an adequate apical seal. in the past, several materials were used including, amalgam; reinforced zinc oxide eugenol cements, glass-ionomer cement, and composite resin.1 yet, an ideal retrofilling material for endodontic surgeries has not been found. recently, mta, a less cytotoxic material with better microleakage protection has been used to give more clinically favorable results over the traditional root-end filling materials.nevertheless, mta has some drawbacks including difficult manipulation; extended setting time, and less compressive and flexural strengths than dentin. biodentinehas similar properties to those of mta with better manipulation therefore, it is considered as a better alternative to mta as a retrograde filling material.8 initial setting time of biodentine was determined as 15 minutes. this short setting time was attributed to the addition of calcium chloride to the mixing liquid.8 biodentine meets most requirements of retrograde filling materials including biocompatibility, radiopacity, antimicrobial activity, dimensional stability, good marginal integrity, and induction of hard tissue regeneration. it has an added advantage of being less porous. in a study, biodentine showed considerable performance as a retrograde filling material and complete healing of a cystic lesion with an eighteen months of follow up period.29 in a similar study with two year follow up period there was complete absence of clinical and radiographic signs and symptoms along with regeneration of the apical tissues.30 another in-vitro study evaluated microleakage of biodentine as a retrograde filling material in 60 single rooted human maxillary permanent teeth and concluded minimal microleakage with biodentine.31 c o n c l u s i o n although studies on biodentine are limited and additional research is needed; all literature shows that the material offers a favorable and promising alternative to other commonly used materials. therefore, biodentine appears to be a promising material for various restorative and endodontic procedures. r e f e r e n c e s 1. allazzam sm, alamoudi nm, el meligy oaes. clinical applications of biodentine in pediatric dentistry: a review of literature. journal of oral hygiene & health. 2015;2015. 2. patel u, hughes j. preserving pulp vitality. dent health (london). 2013;52: 26-9. 3. hilton tj. keys to clinical success with pulp capping: a review of the literature. operative dentistry. 2009;34(5):615-25. 4. hashem d, mannocci f, patel s, manoharan a, brown je, watson tf, et al. clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomized controlled clinical trial. journal of dental research. 2015;94(4):562-8. 5. kaup m, schäfer e, dammaschke t. an in vitro study of different material properties of biodentine compared to proroot mta. head & face medicine. 2015;11(1):1. 6. singh h, kaur m, markan s, kapoor p. biodentine: a promising dentin substitute. jbr journal of interdisciplinary medicine and dental science. 2014;2014. 7. bakopoulou a, about i. biodentine™, a promising bioactive material for the preservation of pulp vitality in restorative dentistry. international dentistryafrican edition. 2014;4. 8. malkondu, #xd6, zlem, kazanda, #x11f, m, et al. a review on biodentine, a contemporary dentine replacement and repair material. biomed research international. 2014;2014:10. 149 j i m d c 2 0 1 7 149 9. grech l, mallia b, camilleri j. investigation of the physical properties of tricalcium silicate cement-based root-end filling materials. dental materials. 2013;29(2):e20-e8. 10. kayahan mb, nekoofar mh, mccann a, sunay h, kaptan rf, meraji n, et al. effect of acid etching procedures on the compressive strength of 4 calcium silicate–based endodontic cements. journal of endodontics. 2013;39(12):1646-8. 11. barnes ie, kidd ea. disappearing dycal. br dent j. 1979;147(5):111. 12. cox cf, subay rk, ostro e, suzuki s, suzuki sh. tunnel defects in dentin bridges: their formation following direct pulp capping. operative dentistry. 1996;21(1):4-11. 13. goracci g, mori g. scanning electron microscopic evaluation of resin-dentin and calcium hydroxide-dentin interface with resin composite restorations. quintessence international (berlin, germany: 1985). 1996;27(2):129-35. 14. tran x, gorin c, willig c, baroukh b, pellat b, decup f, et al. effect of a calcium-silicate-based restorative cement on pulp repair. journal of dental research. 2012;91(12):1166-71. 15. cox c, sübay r, ostro e, suzuki s, suzuki s. tunnel defects in dentin bridges: their formation following direct pulp capping. operative dentistry. 1996;21(1):4-11. 16. pérard m, le clerc j, meary f, pérez f, tricot-doleux s, pellen-mussi p. spheroid model study comparing the biocompatibility of biodentine and mta. journal of materials science: materials in medicine. 2013;24(6):1527-34. 17. nowicka a, lipski m, parafiniuk m, sporniak-tutak k, lichota d, kosierkiewicz a, et al. response of human dental pulp capped with biodentine and mineral trioxide aggregate. journal of endodontics. 2013;39(6):743-7. 18. atmeh ar, chong ez, richard g, festy f, watson tf. dentin-cement interfacial interaction: calcium silicates and polyalkenoates. journal of dental research. 2012;91(5):454-9. 19. watson tf, atmeh ar, sajini s, cook rj, festy f. present and future of glass-ionomers and calcium-silicate cements as bioactive materials in dentistry: biophotonics-based interfacial analyses in health and disease. dental materials. 2014;30(1):50-61. 20. shayegan a, jurysta c, atash r, petein m, abbeele av. biodentine used as a pulp-capping agent in primary pig teeth. pediatric dentistry. 2012;34(7):202e-8e. 21. priyalakshmi.s mr. review on biodentine-a bioactive dentin substitute. iosr journal of dental and medical sciences. jan 2014; 13(1): ver. ii:p-issn: 2279-0861. 22. hartwell gr, england mc. healing of furcation perforations in primate teeth after repair with decalcified freeze-dried bone: a longitudinal study. journal of endodontics. 1993;19(7):357-61. 23. kakani ak, veeramachaneni c, majeti c, tummala m, khiyani l. a review on perforation repair materials. journal of clinical and diagnostic research: jcdr. 2015;9(9):ze09. 24. khoroushi m, keshani f. a review of glass-ionomers: from conventional glass-ionomer to bioactive glass-ionomer. dental research journal. 2013;10(4):411. 25. aggarwal v, singla m, miglani s, kohli s. comparative evaluation of push-out bond strength of proroot mta, biodentine, and mta plus in furcation perforation repair. journal of conservative dentistry: jcd. 2013;16(5):462. 26. guneser mb, akbulut mb, eldeniz au. effect of various endodontic irrigants on the push-out bond strength of biodentine and conventional root perforation repair materials. journal of endodontics. 2013;39(3):380-4. 27. tanalp j, karapınar-kazandağ m, dölekoğlu s, kayahan mb. comparison of the radiopacities of different root-end filling and repair materials. the scientific world journal. 2013;2013. 28. piconi c, maccauro g. zirconia as a ceramic biomaterial. biomaterials. 1999;20(1):1-25. 29. pawar am, kokate sr, shah ra. management of a large periapical lesion using biodentine tm as retrograde restoration with eighteen months evident follow up. journal of conservative dentistry. 2013;16(6):573. 30. caron g, azérad j, faure m-o, machtou p, boucher y. use of a new retrograde filling material (biodentine) for endodontic surgery: two case reports. international journal of oral science. 2014;6(4):250-3. 31. gupta pk, garg g, kalita c, saikia a, srinivasa t, satish g. evaluation of sealing ability of biodentine as retrograde filling material by using two different manipulation methods: an in vitro study. journal of international oral health: jioh. 2015;7(7):111. 183 j i m d c 2 0 1 8 183 open access f u l l l e n g t h a r t i c l e effect of antiepileptic drugs (valproate vs phenytoin) in patients of traumatic brain injury alamgir khan1, muhammad nawaz2, juwayria omar3 1 post graduate resident fcps neurosurgery, pims hospital islamabad 2 post graduate resident ms neurosurgery, pims hospital islamabad 3 assistant professor community medicine, fazaia medical college, air university, islamabad a b s t r a c t objective: to determine the effect of valproate as compared to phenytoin in patients with traumatic brain injury to prevent early seizures. patients and methods: this randomized controlled trial (rct) was conducted at pakistan institute of medical sciences (pims) islamabad from march to september 2015. a total of 100 cases of traumatic brain injury were enrolled in this study; which were randomly divided into two groups a and b. gender distribution was similar in both a & b groups, with 36 (72%) males and 14 (28%) females. consecutive (non-probability) sampling technique was used. group a patients received valproate as anti-epileptic agent, while in group b, phenytoin was given. in group a there were 45 (90%) patients with no seizures, 1 (2%) with simple partial, 1(2%) with complex partial and 3 (6%) with generalized tonic clonic seizures. in group b there were 40 (80%) patients with no seizures, 1 (2%) with simple partial, 5(10%) with complex partial and 4 (8%) with generalized tonic colonic seizures. in group a seizures were low (10 %) as compare to group b (20%), with statistically insignificant difference (p= 0.161). results: conclusion: in this study, valproate was found to be effective as a prophylactic anti-epileptic agent as compared to phenytoin. new drugs need to be studied on larger scale to find more effective and safe drug for prophylactic use in post-traumatic seizures. key words: phenytoin, post-traumatic seizures traumatic brain injury, valproate. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence alamgir khan email: @yahoo.com article info. received: june 3, 2018 accepted: july 29, 2018 cite this article. khan a, nawaz m, omar j. effect of antiepileptic drugs (valproate vs phenytoin) in patients of traumatic brain injury. jimdc.2018; 7(3):183-188 funding source: nil conflict of interest: nil i n t r o d u c t i o n throughout the world, traumatic brain injury (tbi) is a great health and socio-economic burden.1 besides being one of the major contributor to death and disability, it puts burden of huge costs on individuals and society.2 every year worldwide an estimated 10 million people are affected by traumatic brain injury (tbi). surgical care is primary option of treatment. tbi results in conditions such as epilepsy which need constant medical and supportive care.3,4 the frequency of early seizures in post-traumatic brain injury ranges from 4-25%.5,6 trauma is responsible for 20% of symptomatic epilepsy in the general population and 5% of all epilepsy. early post-traumatic seizures occur in more than 20% of patients in the intensive care unit and are related to secondary brain injury and even worse patient results 4 after trauma, seizures can occur early (within 1 week) as well as late (1 week to years, post injury).7 early seizures, occurring within first 24 hours post trauma are third in line of post-traumatic seizures o r i g i n a l a r t i c l e 184 j i m d c 2 0 1 8 184 category. due to secondary brain damage in early posttraumatic seizures it is related to high morbidity and mortality rates.5 besides contusion on ct scan, pre-hospital hypoxia, young age, severe tbi, acute epidural, subdural or intracerebral hemorrhage, open depressed skull fracture with parenchymal injury and penetrating brain injury, all increase the risk of seizures early after injury.8 electrographic seizures can result in increased intracranial pressure, late increases in intracranial pressure (icp) that is after 96 hours can increase mortality rate. continuous use of electroencephalography (eeg) to spot seizures may result in better icp control.4,9 glasgow scale (gcs) is used to classify head injury into grades; mild head injury is classified between score of 13 to 15, whereas gcs score of 9 to 12 is defined as moderate head injury. some investigators consider gcs of 13 as moderate head injury; the point in favor of this change is that prognosis of patients with gcs 13 is similar to moderate gcs score category.10-12 the terms cerebral concussion and mild tbi are used under similar considerations in medical literature, whereas concussion is almost always taken as lightest form of cerebral lesion. post traumatic seizures are mostly witnessed after head injury of severe nature and the prevalence of posttraumatic seizures decreases substantially to below 5% in cases of mild to moderate head trauma. most common cause of post traumatic seizure after head injury is observed as presence of intracranial hematoma. approximately 50% occurs within initial 24 hours of event; 25% occurs within first hour.13,14 early seizures elevate risk of post-traumatic epilepsy four times to > 25%.14 however, among patients with depressed skull fracture and intracerebral hematoma; up to 30% patients can suffer from early seizures.14,15 study results done on patients with mild tbi have reported presence of early seizures in 5-10% patients. similar study which included mild head injury cases who underwent ct scan brain and ct was normal; still seizures were reported in such patients in early period.15-17 time interval has proved to be important criteria for presence of post traumatic seizures. the more the time passes lesser is the incidence of post traumatic early seizures. 50% of early post-traumatic seizures occurred within initial 24 hours and 25% occurred within initial first hour.18 it has been observed that, mostly type of seizures is dependent on time duration. mostly seizures occurring within 24 hours of trauma (72 to 84 percent) were of generalized tonic clonic variety.17 the later seizure begins with head injuries; it is more likely to be focal in onset; 50% of seizures occurring after 24 hours are simple partial (pure motor) or focal convulsions.19 complete medical assessment should be done in all patients presenting with mild tbi or any concussion. immediate assessment of patients involves thorough neurologic and mental status examination. neurological findings need early neuroimaging and neurosurgical evaluation. mild tbi and concussion can sometimes be missed both by patients and para-medical staff, especially when history shows absence of loss of consciousness.25 studies have shown that > 80% of patients with past history of concussion did not realize the nature of injury leading to such condition.20,21 when ct scan and mri are compared, mri is more sensitive in finding and pointing out minor locations with contusion or petechial hemorrhage, axonal injury and small extra-axial hematomas.17,22,23 administering an anti-epileptic drug (aed) within 24 hours of injury and maintaining high therapeutic levels is protective and decreases the risk of early seizures by up to 73%.24,25 phenytoin, carbamazepine and valproate are commonly used aeds in reducing the risk of early seizures.26 now a days it has been recommended that aeds should be prescribed to all such patients as they have significant risk of status epilepticus or aggravation of a systemic injury. such practice of prescribing antiepileptic drugs has prophylactic role as well as recurrent seizures can result in heavy cerebral blood flow resulting in increased intracranial pressure and brain edema leading to comatose state of the patient. prophylactic use of all such drugs has been advocated even in patients who haven’t suffered from early seizures but are at high risk for early fits due to presence of intracerebral hemorrhage, brain edema or ventricular compression, it has been advocated that treatment given in aed decreases the occurrence of early fits and can be used due to high risk for secondary complications.27,28 185 j i m d c 2 0 1 8 185 seizures which occur > 7 days’ post head trauma are considered as post traumatic epilepsy which indicate towards permanent structural and physiologic changes inside brain parenchyma. it has been established that anticonvulsants are beneficial in the first 7 days after injury.29 studies have shown that tonic and tonic-clonic seizures are dependent on voltage gated sodium channels and this knowledge has resulted in acknowledging the fact that drugs like carbamazepine and phenytoin inhibit sodium channels voltage gated channels which can be effectively used for such fits control. advantage of valproate over other aeds is that it is available in both intravenous and oral form, has less adverse effects (cognitive), is economical and levels can be determined easily. the main purpose of this trial was to determine effect of valproate as compared to phenytoin as prophylaxis in patients with traumatic brain injury to prevent early seizures. this will help in better management of the patients and devise a plan for proper prophylaxis of seizures. this will, in turn, help in better outcome of the patients with brain contusion. p a t i e n t s a n d m e t h o d s this randomized controlled trial was carried out at pakistan institute of medical sciences (pims) islamabad from march to september 2015. study permission was taken from the hospital's ethical committee. calculated sample size was 50 patients in each group. it was computed through raosoft software by taking the least proportion of early seizures in post-traumatic brain injury ranging from 4-25% with 95% confidence interval and 5% margin of error.6,7 all patients with age range of 18-60 years, having head injury, who presented to neurosurgery department, pims were included. neonates with head injuries, diagnosed case of epilepsy, patients with space occupying lesion of the brain, patients with previous history of brain surgery, head injury patients who were pregnant and all patients with any co-morbidities were excluded from study. a written informed consent was administered to the patient or caretakers in case of unconscious patients. all the patients were divided in two groups: group a was comprised of patients having traumatic brain contusion with valproate cover. group b patients had traumatic brain contusion with phenytoin cover. both groups were observed from second to seventh day for the occurrence of seizures. data was collected through a proforma. demographic characteristics of the patients were recorded and relevant examination was carried out. computerized tomography (ct) scan of the head was done on all patients with head injury. types of seizure, whether focal or generalized were recorded. data were entered and analyzed on spss 17. mean and standard deviation were measured for the numerical values like age and gcs, whereas categorical variables like gender, mode of trauma, ct scan brain findings, location of the contusion, and type of seizures and day of seizures after head injury were measured as frequency and percentage. occurrence of early seizures was compared between the two groups using chi-square. p-value of ≤ 0.05 was considered statistically significant. results were presented in graphical or tabulated forms. r e s u l t s total of 100 patients having tbi were randomly divided into two equal groups. in group a mean age was 42.5 + 8.3 years. in group b mean age was 43.5+7.5 years. proportion of male and female was equal in both groups. in group a as well as in group b main cause of head injury was road accident, 66% and 74% respectively followed by fall from height in group a and b, the minimum gcs at arrival was 8 and 7 respectively. mean gcs in group a was 12.62±1.68. in group b mean gcs was 12.36+ 2.06. in both groups, large number of patients (56%) were in category of 13-15 gcs. in group a, main area of head injury was temporal (38%) while in group b it was parietal 34% (table 1). in group a, there were 90% patients with no seizures while in group b patients with no seizures were 80%. but this difference was insignificant (p=0.161) (figure 1). figure 1: distribution of cases according to type of seizures (n=100) 186 j i m d c 2 0 1 8 186 table 1: baseline characteristics of patients (n=100) variables group a (n=50) group b (n=50) age (years) mean±sd 42.5±8.3 43.5±7.5 range 22-57 27-58 gender; n(%) n(%) male 36(72) 26(72) female 14(28) 14(28) cause of injury, n(%) road accident 33(66) 37(74) fall from height 12(24) 8(16) assault 2(4) 2(4) fire injury 2(4) 2(4) others 1(2) 1(2) gcs category; n(%) 4-8 2(4) 3(6) 9-12 20(40) 19(38) 13-15 28(56) 28(56) head injury; n(%) frontal 13(26) 14(28) temporal 19(38) 14(28) parietal 14(28) 17(34) occipital 2(6) 4(8) cerebellum 1(2) 1(2) d i s c u s s i o n review articles have been written based on randomized controlled trials to see effect of prophylactic antiepileptic drugs in traumatic head injury for cessation of fits. the findings of these trials reported that prophylactic use of antiepileptic drugs can be done in high risk patients during initial week after trauma.30,31 phenytoin has been commonly and thoroughly studied drug for the prophylaxis of pts. there have been very few or no studies on phenobarbital, valproate and carbamazepine use due to their complications and pharmaco-dynamic property, it has not proved to be beneficial using these agents as compared to phenytoin.32 use of phenytoin for prophylaxis of early pts is recommended by brain trauma foundation as well. the guidelines say that valproate has shown same effectiveness as compared to phenytoin. the fda approved use of phenytoin for prevention and stoppage of complex partial seizures and generalized tonic–clonic state as well as for the prevention and treatment during and after neurosurgery seizures. in a study which was conducted on 244 blunt and penetrating tbi patients (intracranial hematoma; depressed skull fracture of frontal, temporal or parietal regions; major focal deficit or unconsciousness for > 6 hours). patients in group a category; were administered phenytoin and group b category patients were given placebo for 7 days. the mean number of seizures was 2.8 in phenytoin and 5.0 in placebo group (p = 0.06).33 another study included 214 tbi patients with blunt and penetrated injuries. group a patients were administered phenytoin with initial dose of 11 mg/kg i.v. and then followed by 13 mg/kg intramuscularly once per day and group b patients were administered placebo for 18 months. this study also showed no difference between phenytoin vs. phenobarbital in terms of frequency of pts (12.9% vs. 10%, respectively). there was also no difference in late pts between placebo and phenytoin groups (10.8% and 12.9%, respectively).34 a randomized control double blind trial was conducted by temkin and colleagues. this rct included 379 tbi patients with moderate or severe injuries. patients were selected in first 24 hours of tbi and were randomized to either phenytoin or valproate. the study revealed that frequency of early pts was similar among the phenytoin and valproate groups (1.5% versus 4.5%, respectively). these findings are continuous with the current study results.35 a randomized double blind study included 279 moderate to severe tbi patients who were given either phenytoin or valproate within 24 hours after tbi were evaluated at 1, 6, and 12 months for neuropsychological effects from either medication. at any point, no difference in neuropsychological or cognitive measures was seen among the groups.36 c o n c l u s i o n valproate was found to be effective as a prophylactic antiepileptic agent as compared to phenytoin, however this difference was statistically insignificant. seizure is a common phenomenon seen in patient after traumatic brain injury. antiepileptic drugs have been used frequently to prevent or stop these seizures but with little effect. new 187 j i m d c 2 0 1 8 187 larger scale studies are needed to find an effective and safe drug for prophylactic use in post-traumatic seizures. r e f e r e n c e s 1. maas ai, stocchetti n, bullock r. moderate and severe traumatic brain injury in adults. the lancet neurology. 2008;7(8):728-41. 2. finkelstein e, corso ps, miller tr. the incidence and economic burden of injuries in the united states: oxford university press, usa; 2006. 3. zheng p, he b, tong w. decrease in pituitary apparent diffusion coefficient in normal appearing brain correlates with hypopituitarism following traumatic brain injury. j endocrinol invest. 2014;37(3):309-12. 4. zimmermann ll, diaz-arrastia r, vespa pm. seizures and the role of anticonvulsants after traumatic brain injury. neurosurg clin n am. 2016;27(4):499-508. 5. chan kh, tharakan j, pal hk, khan n, tan yc. risk factors and phenytoin prophylaxis for early post-traumatic seizures among patients with traumatic brain injury. the malaysian journal of medical sciences: mjms. 2010;17(4):36. 6. annegers jf, grabow jd, groover rv, laws er, elveback lr, kurland lt. seizures after head trauma a population study. neurology. 1980;30(7):683-. 7. abdelhak t, abrego gc. traumatic brain injury. neurointensive care: springer; 2015. p. 219-48. 8. statler kd. pediatric posttraumatic seizures: epidemiology, putative mechanisms of epileptogenesis and promising investigational progress. dev neurosci. 2006;28(4-5):35463. 9. vespa pm, miller c, mcarthur d, eliseo m, etchepare m, hirt d, et al. nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis. critical care medicine. 2007; 35(12):2830. 10. stein sc, ross se. the value of computed tomographic scans in patients with low-risk head injuries. neurosurgery. 1990;26(4):638-40. 11. servadei f, teasdale g, merry g. neurotraumatology committee of the world federation of neurosurgical s. defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. j neurotrauma. 2001;18(7):657-64. 12. uchino y, okimura y, tanaka m, saeki n, yamaura a. computed tomography and magnetic resonance imaging of mild head injury–is it appropriate to classify patients with glasgow coma scale score of 13 to 15 as “mild injury”? acta neurochir (wien). 2001;143(10):1031-7. 13. annegers jf, hauser wa, coan sp, rocca wa. a population-based study of seizures after traumatic brain injuries. n engl j med. 1998;338(1):20-4. 14. frey lc. epidemiology of posttraumatic epilepsy: a critical review. epilepsia. 2003;44(s10):11-7. 15. tecoma es. oxcarbazepine. epilepsia. 1999;40(s5). 16. reinikainen kj, keranen t, halonen t, komulainen h, riekkinen pj. comparison of oxcarbazepine and carbamazepine: a double-blind study. epilepsy res. 1987;1(5):284-9. 17. schachter s, vazquez b, fisher r, laxer k, montouris g, combs-cantrell d, et al. oxcarbazepine double-blind, randomized, placebo-control, monotherapy trial for partial seizures. neurology. 1999;52(4):732-. 18. kim dw, gu n, jang ij, chu k, yu ks, cho jy, et al. efficacy, tolerability, and pharmacokinetics of oxcarbazepine oral loading in patients with epilepsy. epilepsia. 2012;53(1). 19. crespel a, genton p, berramdane m, coubes p, monicard c, baldy-moulinier m, et al. lamotrigine associated with exacerbation or de novo myoclonus in idiopathic generalized epilepsies. neurology. 2005;65(5):762-4. 20. delaney js, abuzeyad f, correa ja, foxford r. recognition and characteristics of concussions in the emergency department population. the journal of emergency medicine. 2005;29(2):189-97. 21. delaney js, lacroix vj, leclerc s, johnston km. concussions during the 1997 canadian football league season. clin j sport med. 2000;10(1):9-14. 22. post rm, uhde tw. treatment of mood disorders with antiepileptic medications: clinical and theoretical implications. epilepsia. 1983;24(s2). 23. rose fc, johnson f. carbamazepine in the treatment of non-seizure disorders: trigeminal neuralgia, other painful disorders, and affective disorders. reviews in contemporary pharmacotherapy. 1997;8:123-43. 24. liesemer k, bratton sl, zebrack cm, brockmeyer d, statler kd. early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. j neurotrauma. 2011;28(5):755 62. 25. vespa pm, miller c, mcarthur d, eliseo m, etchepare m, hirt d, et al. nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis. crit care med. 2007;35(12):2830. 26. treatment-of-seizures-and-epilepsy-in-the-elderly-patient. 2010:461. 27. schmidt d, jacob r, loiseau p, deisenhammer e, klinger d, despland a, et al. zonisamide for add-on treatment of refractory partial epilepsy: a european double-blind trial. epilepsy res. 1993;15(1):67-73. 28. marson a, kadir z, hutton j, chadwick d. the new antiepileptic drugs: a systematic review of their efficacy and tolerability. epilepsia. 1997;38(8):859-80. 29. kirmani bf, robinson dm, fonkem e, graf k, huang jh. role of anticonvulsants in the management of posttraumatic epilepsy. front neurol. 2016;7(32). 30. task force of the american association of neurological surgeons and joint section in neurotrauma and critical care. guidelines for the management of severe head injury. brain trauma foundation, 1995. 188 j i m d c 2 0 1 8 188 31. temkin n, haglund m, winn h. post-traumatic seizures. chapter 77. in: youmans jr, ed. youmans neurological surgery, 4th ed. philadelphia: wb saunders, 1996:1834–9. 32. dilantin (phenytoin) package insert. new york: pfizer, inc.; 2011 oct. 33. temkin nr, dikmen ss, anderson gd et al. valproate therapy for prevention of posttraumatic seizures: a randomized trial. j neurosurg. 1999; 91(4):593-600. 34. dikmen ss, machamer je, winn hr et al. neuropsychological effects of valproate in traumatic brain injury: a randomized trial. neurology. 2000; 54(4):895-902. 204 j i m d c 2 0 1 8 204 open access f u l l l e n g t h a r t i c l e diagnostic accuracy of trans-abdominal ultrasonography in urolithiasis, keeping ct kub as gold standard maryam javed1, faran nasrullah2, shahlisa hameedi3 1 trainee radiology, armed forces institute of radiology and imaging, rawalpindi 2 consultant radiologist, dept of radiology, paf hospital rafiqui, shorkot 3 assistant professor, islamabad medical & dental college, islamabad a b s t r a c t objective: to determine the diagnostic accuracy of trans-abdominal ultrasonography in urolithiasis, keeping ct kub as gold standard. material and methods: this cross-sectional validation study was conducted at armed forces institute of radiology and imaging, military hospital (mh) rawalpindi from 15 july 2015 to 14 july 2016. in total 115 patients with expected urolithiasis were evaluated with transabdominal ultrasonography and the findings were documented. ct kub of these patients was carried out. the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of transabdominal ultrasonography were calculated, keeping findings of ct kub as gold standard. results: among total of 115 patients, 54.78% (n=63) were males and 45.22% (n=52) were females. mean age was 35.69 ± 5.91 years. frequency of urolithiasis on ct kub was recorded in 62.61% (n=72). the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of transabdominal ultrasonography in urolithiasis was calculated as 65.27%, 72.09%, 79.66%, 55.36% and 67.83% respectively. conclusion: the diagnostic accuracy of trans-abdominal ultrasonography in urolithiasis is acceptable for diagnosing urolithiasis and hence it may serve as an alternative in case of unavailability or contraindication to ct scan. key words: ct kub, diagnostic accuracy, tans-abdominal ultrasonography, urolithiasis. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence faran nasrullah email: faran.nas@gmail.com article info. received: january 12, 2018 accepted: july 12, 2018 cite this article. javed m, nasrullah f, hameedi s. to determine diagnostic accuracy of trans-abdominal ultrasonography in urolithiasis keeping ct kub as gold standard. jimdc.2018; 7(3):204-207 funding source: nil conflict of interest: nil i n t r o d u c t i o n urinary tract calculi are solid concretions found in the urinary tract from dissolved urinary minerals.1 they may be found in the kidneys, ureters, urinary bladder or urethra and represent one of the major diseases affecting the population since ancient ages.2 a study calculated the prevalence of urinary tract calculi to be greater in males (15% ) and lesser in females (8%) with an annual incidence of 131 per 100,000.3,4 urolithiasis, presenting as renal colic, flank pain, dysuria or hematuria, is one of the commonest causes to seek medical attention. stone disease may cause longstanding obstruction and infection, ultimately leading to renal failure 5 thus, early accurate diagnosis with appropriate treatment of urolithiasis is paramount for prevention of complications and maintenance of renal function.6 male gender, nsaid (non-steroidal anti-inflammatory drugs) usage, intestinal surgery, crohn’s disease, reduced physical activity, hospitalization and gallstones are significant risk factors for urolithiasis along with metabolic disturbances such as gout, renal tubular acidosis and hypercalciuria.7 o r i g i n a l a r t i c l e 205 j i m d c 2 0 1 8 205 acute renal colic is one of the frequent causes of presentation to the surgical department. over the years, there has been a drastic change in the preference of investigations used to diagnose urolithiasis, so it is not always clear in which order the investigations should be carried out, especially if there is a contraindication to contrast administration or ionizing radiations. historically, kub radiography in the form of plain x-rays and intravenous pyelography (ivp) was used, but this had the disadvantages of radiation exposure, patient preparation and contrast administration (in cases of ivp). a study established kub radiography to be 57 % sensitive and 76 % specific.8 ultrasound (us) has emerged as a leading imaging modality for diagnosis of urinary tract calculi , as it is non-invasive, free from ionizing radiation, easily available and cost-effective.9 the disadvantages may include inter-operator variation and difficulty in diagnosing ureteric calculi. the sensitivity and specificity of ultrasound for urolithiasis is variable, depending upon various factors like patient habitus, operator capability, and the site and size of the calculus. the sensitivity of ultrasonography for ureteric calculi increases on addition of x-ray kub abdomen.10 ct kub is the most sensitive investigation for identification of urolithiasis.11 however, it has some weaknesses like limited spatial of resolution, due to which it may wrongly predict small calculi and stone fragments. similarly, due to use of ionizing radiation, repeated ct scans can result in a substantial cumulative dose during short-term follow up. low-dose protocols allow patient to be exposed to low dose causing reduced biological risk.11 in pakistan, the usage of ct kub for diagnosis of urinary tract calculi is relatively new with the lack of availability, its cost and lack of technical expertise being the main causes of its limited use. so this study has been carried out to assess the diagnostic accuracy of ultrasonography in detecting urolithiasis in comparison with ct, for the reason that it has the advantage of lower radiation dose and easy availability in our setups. m a t e r i a l a n d m e t h o d s the cross sectional study was carried out at armed forces institute of radiology and imaging, military hospital (mh) rawalpindi, from 15 july 2015 to 14 july 2016. total 115 patients with expected urolithiasis were included in the study. non-probability, purposive sampling was done. all the patients, reporting to the hospital during the duration of the study, who fulfilled the inclusion criteria, were included in the study. the study was approved by institute’s ethical committee for research. patients of either gender having age between 18 to 45 years, visiting to the outpatient department due to flank pain with any of the following associations like increased frequency of urination (more than twice of previous), oliguria (<400ml/24hrs), dribbling of urine (on history) or hematuria were incorporated in the study. any patient with known pelvic pathology, pregnant patients, patients who refused to give consent and non-cooperative patients (psychiatric patients) were eliminated from the study. all participants were briefed about the purpose of the study and informed written consent was taken. history and physical examination was done. ultrasonography was done, through the transabdominal approach for all patients with full urinary bladder, using toshiba nemio xg® doppler ultrasound scanner with 4.2mhz frequency transducer. the kidneys were visualized in both sagittal and coronal planes. ureters were also traced down up to the urinary bladder with emphasis to the ureterovesical junction. ct scan was carried out with acquilion multislice (64) ct scanner, by the trainee researcher. all findings of computed tomography scan were substantiated by the opinion of consultant radiologist data was entered and interpreted using spss version 15. sensitivity, specificity, ppv, npv and accuracy were calculated as: sensitivity: a / (a + c) x 100 or tp / (tp + fn) x 100 specificity: d / (d + b) x 100 or tn / (tn + fp) x 100 positive predictive value: a/a+ b x 100 negative predictive value: d / c + d x 100 accuracy: a+ d / a+b+c+d x 100 r e s u l t s age of study participants ranged between 19 to 54 years with mean age calculated as 35.69 ± 5.91 years. large number of patients (46.9%) were in 31-45 years of age group (table 1). out of total 115 patients, 63 were male and 52 were females (figure 1). on ct kub, total 72 patients (62.61 %) were positive while 43 patients (37.39 %) were negative for urolithiasis. keeping ct kub as gold standard, trans-abdominal ultrasonography revealed 206 j i m d c 2 0 1 8 206 40.87 % patients as true positive cases (table 2).the sensitivity was 65.27 %, specificity was 72.09 %, ppv was 79.66 %, npv was 55.36 % and diagnostic accuracy was 67.83 % (figure 2). d i s c u s s i o n renal colic resulting due to urinary tract calculi may present as acute abdomen and leads to a significant burden on the a & e (accident and emergency) and surgical opd. guidelines of the american college of radiology (acr), american urological association (aua), and european association of urology (eau) propose different investigations for further assessment of these cases.12 table 1: age distribution of patients (n=115) age of patients (years) frequency percentage 16 30 22 19.1 31 45 54 46.9 46 – 60 39 33.9 total 115 100 table 2: cross tabulation of findings of ct kub and trans abdominal ultrasonography in study participants (n=115) trans-abdominal ultrasonography urolithiasis ct-kub positive ct-kub negative positive a (true positive) 47 (40.87%) b (false positive) 12(10.43%) negative c (false negative) 25 (21.74%) d (true negative) 31(26.96%) figure 1: graphical representation of gender distribution in study participants (n=115) the acr and aua nominate ct kub as modality of choice for urolithiasis while eau favors ultrasound.12-14 low dose noncontrast ct, due to its high diagnostic accuracy, is taken as the gold standard in patients with suspected urolithiasis, as it can accurately delineate the site and size of calculus (including ureteric calculi), reveal complications and unfold alternative causes of abdominal pain like appendicitis or intestinal obstruction.15 in our study, the sensitivity, specificity and diagnostic accuracy of transabdominal ultrasonography in cases of urolithiasis was calculated to be 65.27%, 72.09 % and 67.83 % respectively. the findings of our study are closely in agreement with most studies performed in this regard. kanno t et al 16, with a sample size of 856 patients, showed that ultrasonography had a sensitivity of 78.9 % and specificity of 83.7 % for renal calculi, confirmed by non-enhanced ct. the study proved ultrasonography to be an accurate modality for detection of urolithiasis. another study conducted by smith-bindman r et al 17 (conducted on 2759 patients) showed that ultrasonography as first-line investigation produced lower radiation exposure as compared to ct scan without any significant change in diagnostic ability or any other untoward effect. transabdominal sonography may be used effectively to detect calculi in kidneys, proximal ureter, vesicoureteric junction or urinary bladder. it also gives information regarding the extent and severity of the resulting obstruction. mid ureter is usually obscured by bowel gas shadows and visualization of this region is limited. in this regard, findings of ultrasonography may be combined with findings of x-ray abdomen to give better diagnostic accuracy. similarly, use of contrast medium or performing transrectal or transvaginal sonography are newer avenues which can be explored to enhance the diagnostic accuracy, but due to the limitation of the study, we did not use these techniques in this study. in our view transabdominal ultrasonography provides many benefits as an effective diagnostic modality for urolithiasis, especially in pregnant patients and children. newer techniques and equipment as well as use of intravenous contrast media can provide additional information and lead to even greater improvements in the diagnostic potential of ultrasonography for urolithiasis. 207 j i m d c 2 0 1 8 207 not much data is available when determining the diagnostic accuracy of transabdominal ultrasonography in urolithiasis, keeping ct kub as gold standard; however, further trials are required to validate our findings c o n c l u s i o n diagnostic accuracy of transabdominal ultrasonography in urolithiasis is acceptable for diagnosing urolithiasis. hence, it may serve as an alternative in case of unavailability or contraindication to ct scan like pregnant patients. moreover, ultrasonography has the advantage of lower radiation dose and easy availability in our setups. r e f e r e n c e s 1. ahmad f, nada mo, farid ab, haleem ma, razack sm. epidemiology of urolithiasis with emphasis on ultrasound detection: a retrospective analysis of 5371 cases in saudi arabia. saudi j kidney dis transpl. 2015; 26(2):386-91. 2. nasim mj, bin asad mh, durr-e-sabih, ikram rm, hussain ms, khan mt et-al. gist of medicinal plants of pakistan having ethnobotanical evidences to crush renal calculi (kidney stones). acta pol pharm. 2014; 71(1):3-10. 3. lee m-c, bariol sv. epidemiology of stone disease in australia. in: talati jj, tiselius hg, albala dm, ye z, editors. urolithiasis: basic science and clinical practice. london: springer london, 2012; p. 73–76. 4. romero v, akpinar h, assimos dg. kidney stones: a global picture of prevalence, incidence, and associated risk factors. rev urol. 2010;12(2–3): e86-96. 5. rafi m., shetty a., gunja n. accuracy of computed tomography of the kidneys, ureters and bladder interpretation by emergency physicians. emerg med australas. 2013; 25(5):422–426. 6. soomro hu, hammad ather m, salam b. comparison of ureteric stone size, on bone window versus standard softtissue window settings, on multi-detector non-contrast computed tomography. arab j urol. 2016; 14(3):198-202. 7. fagagnini s, heinrich h, rossel jb, biedermann l, frei p, zeitz j, et al. risk factors for gallstones and kidney stones in a cohort of patients with inflammatory bowel diseases. plos one. 2017; 12(10):e0185193. 8. fulgham pf, assimos dg, pearle ms, preminger gm. clinical effectiveness protocols for imaging in the management of ureteral calculous disease: aua technology assessment. j urol. 2013; 189(4):1203–1213. 9. mills l, morley ej, soucy z, vilke gm, lam shf. ultrasound for the diagnosis and management of suspected urolithiasis in the emergency department. j emerg med. 2017 pii: s0736-4679(17):30877-6. 10. m hammad ather, aftab h jafri, m nasir sulaiman. diagnostic accuracy of ultrasonography compared to unenhanced ct for stone and obstruction in patients with renal failure. bmc med imaging. 2004; 4(1): 2. 11. villa l, giusti g, knoll t, traxer o. imaging for urinary stones: update in 2015. eur urol focus. 2016; 2(2):122129. 12. coursey ca, casalino dd, remer em, arellano rs, bishoff jt, dighe m, et al. acr appropriateness criteria® acute onset flank pain--suspicion of stone disease. ultrasound q. 2012; 28(3):227-33. 13. fulgham pf, assimos dg, pearle ms, preminger gm. clinical effectiveness protocols for imaging in the management of ureteral calculous disease: aua technology assessment. j urol. 2013; 189(4):1203 13. 14. türk c, petřík a, sarica k, seitz c, skolarikos a, straub m, knoll t. eau guidelines on interventional treatment for urolithiasis. eur urol. 2016; 69(3):475-82 15. brisbane w, bailey mr, sorensen md. an overview of kidney stone imaging techniques. nat rev urol. 2016; 13(11):654-662. 16. kanno t, kubota m, sakamoto h, nishiyama r, okada t, higashi y, et al. the efficacy of ultrasonography for the detection of renal stone. urology. 2014; 84(2):285-8. 17. smith-bindman r, aubin c, bailitz j, bengiamin rn, camargo ca jr, corbo j, et al. ultrasonography versus computed tomography for suspected nephrolithiasis. n engl j med. 2014;371(12):1100-10. journal of islamabad medical & dental college (jimdc); 2012(2):72-76 72 original article demographic profile of keratinocyte tumours muhammad usman shams*, usman hassan*, farid ahmed khan** and sabrina suhail pal*** *department of pathology, shaukat khanum memorial cancer hospital, lahore **department of plastic surgery, king edward medical university, lahore ***department of dermatology, king edward medical university, lahore abstract background: keratinocytic tumours of epidermis constitute the bulk of neoplastic lesions of the skin, and comprise benign, borderline and malignant lesions. objective: to study the characteristics of keratinocytic tumours in our hospital population and compare the collected local data with the available international data. materials and methods: this cross-sectional, descriptive study was conducted in university of health science and mayo hospital, lahore from march 2010 to october 2010. a total of 112 consecutive cases of histologically diagnosed keratinocytic tumours were included in the study. age, gender, histologic types and site distribution of these tumours were recorded and analyzed. results: among keratinocytic tumours, basal and squamous cell carcinomas were the most frequent malignant lesions and viral warts were the commonest benign lesion. males were affected more commonly than females. patients were in the age range of 13-85 years. head and neck region was the most frequent site of involvement. conclusion: the results of the study are comparable with international data regarding age, gender and site distribution of keratinocytic tumours. key words: keratinocytic tumours; squamous cell carcinoma, basal cell carcinoma introduction skin is a remarkable organ being the largest in human body accounting for 15% of the total body weight in adults.1 it has 6 million cells, 5000 sensory points and 150 glands in each square centimeter.2 epidermis of skin is a continuously regenerative tissue. this dynamicity makes it a ‘fertile land’ for neoplastic lesions. in fact, the tumours derived from epidermal keratinocytes i.e. keratinocytic tumours account for most of the neoplastic lesions of skin. skin tumours are much common than those occurring in any other organ. according to american cancer society, number of new cases of skin cancer diagnosed each year is more than the combined number of cancers of the breast, prostate, lung and colon.3 melanoma and other skin cancers are ranked 12th most common in men and 15th most common in women by a who report.4 these were found in 706,000 persons out of a total population of 6,437 million. in a local study conducted at ayub medical college, skin cancers were found to be just 1.04% of the total cancers reported over a period of nine years indicating low incidence in the region.5 keratinocytic tumours account for approximately 90% or more of all skin malignancies. among keratinocytic tumours, basal cell carcinomas constitute the major bulk i.e. 70% of all keratinocytic tumours and 50% of all skin malignancies according to different studies.5,6 keratinocytic tumours pose a significant public health problem and a financial burden. fortunately these tumours have low mortality rate and are mostly curable on complete excision. these facts necessitate a better approach towards the early diagnosis and a deeper understanding of the pathogenesis of these lesions. the main aetiological factor is solar radiation which causes dna damage. especially ultraviolet b radiation (uvb, 290320 nm) is found to contribute in the formation of squamous and basal cell carcinomas.7,8 other carcinogenic agents include tobacco, human papilloma viruses, arsenic, industrial chemicals such as vinyl chloride, polycyclic aromatic hydrocarbons, and exposure to gasoline.6 the purpose of this study was to study different characteristics of keratinocytic tumours including gender, age, histological types and site distribution and to compare our data with international studies. this study will help in understanding the keratinocytic tumours found in our local population. materials and methods study design, setting and duration: this cross-sectional, descriptive study was conducted in the department of dermatology and the department of plastic and reconstructive surgery, mayo hospital, lahore and the department of pathology, university of health sciences, lahore. histologically diagnosed cases of keratinocytic tumours were selected and data regarding age, gender and site was recorded and analyzed. the study was completed in eight months, march 2010 to october 2010. sample size: one hundred and twelve new and old diagnosed cases of keratinocytic tumours of skin were included in the study. sampling technique: convenient non-probability sampling journal of islamabad medical & dental college (jimdc); 2012(2):72-76 73 inclusion criteria: histologically diagnosed cases of keratinocytic tumours of skin, belonging to all age and both genders results a total of 112 cases of keratinocytic tumours were selected according to inclusion criteria. all the six types of keratinocytic tumours according to who classification were included. as shown in table 1, basal cell carcinoma (bcc) and squamous cell carcinoma (scc) were the commonly observed types of keratinocytic tumours with 36 (32.1%) cases each (fig 2). the next common type was verrucas with 29 (25.9%) cases (fig 4). the other three types were relatively uncommon with 6 (5.4%) cases of acanthomas, 3 (2.7%) cases of bowen’s disease (fig 1) and only 2 (1.8%) cases of actinic keratosis. table1: histological types of keratinocytic tumours (n 112) type of keratinocytic tumour no. (%) acanthomas 06 (5.36) actinic keratosis 02 (1.79) verrucas 29 (25.89) bowen's disease 03 (2.68) basal cell carcinomas 36 (32.14) squamous cell carcinomas 36 (32.14) various subtypes of keratinocytic tumours were found during the study. these are shown in graph 1. association of keratinocytic tumours with gender: keratinocytic tumours were diagnosed more commonly in men. among the 112 cases, 70 (64.3%) were males and 42 (35.7%) were females. among different types of keratinocytic tumours, all the six types showed male preponderance. in fact, 66.7% cases of acanthoma, 100% cases of actinic keratosis, 55.6% cases of bcc, 66.7% cases of bowen’s disease, 63.9% cases of scc and 72.4% cases of verrucas were males. in case of pinkus bcc and moderately differentiated scc, female patients were more frequent. association of keratinocytic tumours with age: among 106 cases for which age data was available, the youngest patient was 13 years old and the eldest one was 85 years. most of the patients presented in 3rd and 6th decades of life. lesser number of keratinocytic tumours was found in 2nd and 4th decade (table 2). the median age for patients of keratinocytic tumours was 50 years. among different types, all patients except those of verrucas had median age of 50 or more. for verrucas, the median age was 25 years. for bowen’s disease and actinic keratosis, all the patients were older than 55 years. for other types, the age distribution was diverse. the youngest patients of the two cancers i.e. scc and bcc were 13 years old and 22 years old respectively. frequency of different keratinocytic tumours 1 4 1 1 1 3 6 3 1 2 12 3 3 3 3 19 7 3 1 6 2 4 4 19 keratoacanthoma seborrheic keratosis lichen‐planus like keratosis actinic keratosis arsenical keratosis adenoid basosquamous infiltrative metatypical micronodular nodular pigmented pinkus superficial bowen's disease well‐differentiated moderately‐differentiated poorly‐differentiated spindle cell verrucous condyloma accuminatum plana plantaris vulgaris 6 2 3 6 3 3 6 2 9 a c a n th o m a a k b c c b d s c c v e rr u c a graph 1: frequency of different types and subtypes of keratinocytic tumours. table 2: age distribution of patients (n 112) age range (years) no. (%) 11-20 11 (9.82) 21-30 24 (21.43) 31-40 8 (7.14) 41-50 13 (11.60) 51-60 26 (23.21) 61-70 19 (16.96) above 70 05 (4.46) data missing 06 association of keratinocytic tumours with site: keratinocytic tumours were found in all parts of body. among the sites, the data of 104 cases showed that 69.23% (72 cases) of tumours were present in head and neck region. nose was the most frequently involved site with 15 (13.4%) cases. the second and third most common sites were also from head and neck region i.e. face (not otherwise specified) and head. besides head and neck region, upper limbs were also involved in 13 cases with hands being the most common site of occurrence. the site distribution among different types of keratinocytic tumours showed that head and neck region was most commonly involved by all types except verrucas. verrucas most commonly occurred on hands. the two cancers among keratinocytic tumours i.e. scc and bcc were most journal of islamabad medical & dental college (jimdc); 2012(2):72-76 74 frequently seen on different parts of face. nose was the most frequent site of involvement for bcc whereas ear was the most common site for scc. chest, abdomen and back were less commonly involved sites with one case each. table 3: frequent sites of different types and subtypes of keratinocytic tumours* type of total frequent sites of 1. acanthoma 6 back , chin keratoacanthom 1 chin seborrheic 4 back , chin, thigh lichen-planus 1 hip 2. actinic keratosis 2 head, hand actinic keratosis 1 head arsenical 1 hand 3. bcc 36 nose , cheek adenoid 3 cheek, face, nose basosquamous 6 cheek , nose infiltrative 3 eyelid, nose metatypical 1 head micronodular 2 cheek, face nodular 12 nose, eye pigmented 3 face, head, eyelid pinkus 3 back, cheek, nose superficial 3 nose, back 4. bowen's disease 3 face, forearm, leg 5. scc 36 ear, nose well19 ear, hip, lip, nose moderately7 ear, flank, head, poorly3 face , ear spindle cell 1 nose verrucous 6 head, mouth, ear, 6. verruca 29 hand, face condyloma 2 genital area plana 4 arm , chest, plantaris 4 hand, foot vulgaris 19 face, hand, lip, *valid percentage is used. single cases are not assigned percentage considering the sub-types of different keratinocytic tumours, there is great diversity among sites of occurrence. seborrheic keratosis, the most frequent acanthomas in our study, commonly involved skin of back. nose was the most frequent site of nodular and superficial bccs, whereas figure1. bowen’s disease showing full thickness epidermal atypia and lichenoid upper dermal chronic inflammatory infiltrate (h & e stain, 10x) fig.2. adenoid bcc showing strands of basaloid cells in a reticulate pattern. (h&e stains, 4x) fig.3. verrucous scc showing bulbous nature of squamous downgrowths and mild atypia of keratinocytes (h&e stains, 4x) journal of islamabad medical & dental college (jimdc); 2012(2):72-76 75 fig.4: verruca vulgaris showing papillomatosis, parakeratosis and hyperkeratosis. (h&e stains, 4x) micronodular and basosquamous bccs most commonly involved cheek. the aggressive variant of bcc i.e. infiltrative bcc was most commonly found on eyelids. ear was the frequent site of well-differentiated and moderately differentiated sccs. the most common sites of poorlydifferentiated scc and verrucous scc were face and head respectively. among verrucas, vulgaris type was the most common on face while planatris and plana types were the most frequent at hand and arm respectively (table 3). discussion keratinocytic tumours are a diverse group of lesions derived from proliferation of keratinocytes and behaviour ranging from benign entities to highly aggressive carcinomas. these tumours impose a common public health problem, but fortunately have low mortality and morbidity rate. in present study, bcc and scc which are the two malignant entities in keratinocytic tumours’ category were found to be equal in frequency with each comprising 32.1% of the cases. however, previously done local studies have shown contradicting results. mansour et al.9, baloch et al.10 and yasmeen et al.11 found bcc to be more frequent than scc whereas the study by ahmed et al.5 found more scc than bcc. globally bcc is the more frequent keratinocytic malignancy and bcc constitutes 60% of keratinocytic malignancies according to who6. the difference might be due to limited sample size, duration and population representation in different studies. as regards the other keratinocytic lesions, no comparative reference could be found. in our study, verrucas were the commonest nonmalignant keratinocytic lesion comprising 25.9% of total cases, and this may be due to the fact that viral warts are quite frequent in children and adolescents6. among the different subtypes of bcc, nodular or solid bcc is the most frequent type constituting 56% and 30-75% of the total cases seen in two different studies12,13. our results are compatible with these studies with nodular bcc constituting 33.3% of total bcc cases. the second most frequent type of bcc found was basosquamous bcc but this is in contrast to the studies of vantochuva et al. and bircon et al.12, 13 who found superficial bcc and adenoid bcc as second most frequent bcc types respectively. the histoogical subtypes of scc have not been found to be studied for comparison of frequencies, however, literature favors well-differentiated or conventional scc to be most frequent6,14 and the same was the result that we found with well-differentiated scc constituting 52.8% of total scc. regarding gender distribution, we found keratinocytic tumours to be more frequent in males. most keratinocytic tumours also showed male predominance. in present study, keratoacanthoma, lichen-planus like keratosis and actinic keratosis were found only in males. le boit et al.6 quoted similar results in case of keratoacanthoma and actinic keratosis but contradictory results for lichen-planus like keratosis where it was reported to be more in females. however, a study from china showed the results matching with ours with lichen planus like keratosis (lplk) more frequent in males15. we found equal gender distribution for seborrheic keratosis and this matches with the literature as well6. different local and international studies found bcc to be more common in malesas seen in our study.5,6,11,16,17 in bowen’s disease, scc and verrucas, our study revealed male predominance with 66.7%, 63.9% and 72.4% of total cases respectively. these results are comparable with the available literature; local5,11 and international6. in present study, the youngest patient having keratinocytic tumour was 13 years old and the eldest one was 85 years old. this wide range of age distribution is most likely due to the diversity of keratinocytic lesions with verrucas more common in younger age group and carcinomas being a problem of old age. keratoacanthoma is found in older individuals6 and the only patient in our study was 83 years old. it is unusual to have seborrheic keratosis in children6 and we found this lesion in the age range of 42-68 years. in present study, age range for actinic keratosis was found to be 60-85 years that matches with the literature6. if we look at the age range of bcc in our study i.e. 22-85 years, there exists some differences. in previous local studies, the age ranges for bcc were found to be 50-70 years from jamshoro16, 30-90 years from chandka medical college larkana18, 51-60 from faisalabad17, 8-92 years jpmc karachi11 and 15-103 years from abbotabad5. these differences might be because different sample size and populations employed for various studies. in literature, the average age for bowen’s disease is 48 years, but we found the median age to be 61.5 years. this contrast might be because of limited no. of cases included in our study i.e. only 3 cases. among scc cases, we found a few cases in young patients with minimum age in cases of welldifferentiated, moderately-differentiated and poorlydifferentiated sccs to be 13, 18 and 13 years respectively. in literature, scc is more of a lesion of older age group6,19. in our study, the majority of scc cases were of older age group and the few unusual younger age group cases might be related to familial disorders or syndromes like xeroderma journal of islamabad medical & dental college (jimdc); 2012(2):72-76 76 pigmentosa in which scc appears at young age. another unusual result in our study was a very wide age range (1270 years) for verrucas. viral warts are usually common among school going children i.e. below and /or around 10 years. we have no case of school going age group because of the fact that children and their parents were found to be less compliant towards getting biopsies done. skin is everywhere on our body, so keratinocytic tumours could be present on any body part. our study validates this fact and we found these lesions in all parts of the body. however, head and neck region was found to be the most favoured site with 72 (69.2%) out of total 112 cases; perhaps this is the most frequent site exposed to solar radiations or sun exposure. keratoacanthomas are usually present on face6 and our only case had this lesion on chin. the only case of lichen planus like keratosis in our study had this lesion on hip and le boit et al.6 found the same with predilection for upper trunk and extremities. seborrheic keratosis could occur anywhere6 and in our cases, the lesions were present in diverse locations as well. palms and soles are the common sites for arsenical keratosis and our result is comparable with the only case having the lesion on hand. regarding bcc, memon et al.16 found nose as commonest site while fayyaz et al.17 reported cheek and eyelids as most frequent sites. in our study, nose was the commonest site for bcc and cheek was the second most frequent site of involvement. our results regarding sites of different bcc subtypes are comparable with literature. for instance, head is the favored site for nodular bcc6 and we found the same with nose and eye being the commonest sites. bowen’s disease can occur on both exposed and nonexposed parts of body6 and we found compatible results with this disease found at face, forearm and leg in our three cases. in present study, scc was found mostly on exposed parts with only a few cases on non-exposed parts like hip, flank or leg. these results match with the who results6. dotto and glusac20 reported nose as the commonest site for spindle cell scc and our only case had the lesion on nose too. we found verrucous scc to be more common on head and around mouth and according to le boit et al6; buccal mucosa is the favored site for verrucous scc. verruca vulgaris is found more commonly on exposed parts particularly fingers and dorsum of hand6. in present study, the results are comparable, with face (21.1%) and hands (15.8%) being the two most frequent sites of involvement for verruca vulgaris. conclusion the characteristics of keratinocytic tumours found in local population are similar to those found in other regions of world. in pakistan, this is the first study analyzing various types and subtypes of keratinocytic tumours in local population. our data regarding age, gender and site distribution is comparable with international data. this data will help in better understanding of the epidemiology of keratinocytic lesions present in our country. references 1. kanitakis j. anatomy, histology and immunohistochemistry of normal human skin. eur. j. dermatol. 2002;12(4):390 -9. 2. zeligman i. the skin as a physiologic organ. j. natl. med. assoc. 1971;53:148-150. 3. american cancer society: cancer facts and figures 2009. [online] available: http://www.cancer.org/research/cancer facts figures cancerfactsfigures/cancer-facts-figures-2009. html> [accessed 23 may 2010] 4. who. the global burden of disease: 2004 update. switzerland 2008: who press. 5. ahmed a, alam mb, khan w, badara and shah sh.frequency and characteristics of skin cancers diagnosed at ayub medical college, abbottabad pakistan from 1995-2003. j. ayub med. coll. abottabad 2007;19(4):3-6. 6. leboit pe, burgg, wooden d and sarasin a (eds.).world health organization classification of tumours. pathology and genetics of skin tumours. lyon 2006: iarc press. 7. kuboy, murao k, matsumoto k and arase s. molecular carcinogenesis of squamous cell carcinomas of the skin. j. med. invest. 2002; 49:111-7. 8. de-gruijlfr, longstreth j, norval m, cullen ap, slaper h, kripke ml, takizawa y and der leun jc. health effects from stratospheric ozone depletion and interactions with climate change. photochem. photobiol. sci. 2003;2:16-28. 9. 9. mansour al, naveed ia, kamal f, et al profile of malignant skin tumours over a period of five years at the department of pathology, king edward medical college, lahore. biomedica. 1999; 15:5-8. 10. baloch q, siyal ar, annasi sa and zubairi bf. pattern of malignant tumors of skin at larkana. jcpsp 2000;10(5):155-7. 11. yasmeen n, saeed s, kanjee a, sadiq s. a study of 75 cases of malignant skin tumors. j. pak. assoc. derma. 2002;12(3):130-4. 12. vantuchov y and �u�ík r.histological types of basal cell carcinoma. scripta medica (brno) 2004;79:261 70. 13. bircan s, candir o, kapucoglu n and baspinar s.the expression of p63 in basal cell carcinomas and association with histological differentiation. j. cutan. pathol. 2006;33:293–8. 14. rosai j. (ed.). rosai and ackerman's surgical pathology. 9th ed. philadelphia 2004: mosby. 15. zhang q, wang wh, zhao m, shen l, cheng jh, zhang by and fi l. clinical and pathological study of lichen-planus-like keratosis in china. j. dermatol. 2006;33(7): 457-61. 16. memon ga, memon ar and kumar m. basal cell carcinoma in our population: a study of 21 years experience. j. liaquat uni. med. health sci. 2002;1(1):7-10. 17. fayyaz ga, asim m and nagra zm. basal cell carcinoma; experience at the department of plastic surgery, allied hospital faisalabad. professional med. j. 2002;9(3):236-40. 18. abro h, soomro ah, abbasi s and baloch q. basal cell carcinoma. j. surg. pak. 2003;8(1):19-21. 19. elder de. (eds.)lever’s histopathology of skin. 10th ed. (2009). philadelphia: lippincott williams and wilkins. 20. dotto je and glusac ej. p63 is a useful marker for cutaneous spindle cell squamous cell carcinoma. j. cutan. pathol. 2006;33:413-17. 112 j i m d c 2 0 1 8 112 open access f u l l l e n g t h a r t i c l e antibiotic susceptibility pattern of gram negative bacilli isolated from different clinical specimens in a tertiary care hospital lubna ghazal 1, ayaz hussain qureshi 2, naila iqbal 3 1 assistant professor, 2 professor /head of department 3 registrar (department of microbiology, wah medical college) a b s t r a c t objective: to find out the antibiotic susceptibility pattern of gram-negative bacilli isolated from different clinical specimens received in a tertiary care hospital at wah. material and methods: this cross-sectional study was carried out to determine antibiotic susceptibility pattern of gramnegative bacilli, cultured from different clinical specimens received in pof hospital laboratory at wah. one hundred and forty-four clinical isolates of gram-negative rods from different clinical specimens from april 2015 to march 2016 were included in the study. all the isolates were processed by standard microbiological methods. the antibiotic susceptibility pattern was carried out by disk diffusion method as recommended by clinical laboratory standard institute guidelines (clsi). results: out of one hundred and forty-four gram-negative bacilli, one hundred (69.44%) were from enterobacteriaceae family and forty-four (30.56%) were from non-enterobacteriaceae group. the commonest isolated organism was escherichia coli (47.3%), followed by pseudomonas aeruginosa (17.36%) and acinetobacter baumannii (13.19%). these isolates were highly resistant to the most of the commonly prescribed antibiotics. the members of the family enterobacteriaceae showed better sensitivity for amikacin and cefoperazone-sulbactam. resistance rate for carbapenems was significantly high for k.pneumoniae and proteus mirabilis. among non-enterobacteriaceae, p.aeruginosa showed better susceptibility for cefoperazone-sulbactam, amikacin, imipenem and meropenem. the multidrug resistant pattern was observed for acinetobacter.baumannii. conclusion: the isolates depict highly resistant patterns to available oral antibiotics as well as commonly prescribed injectable third generation cephalosporins and carbapenems. establishment and implementation of infection control practices are required to combat this grave situation. key words: antibiotics, antibiotic susceptibility, enterobacteriaceae, gram negative bacilli, non-enterobacteriaceae. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence lubna ghazal email: doctor.lubna@yahoo.com article info. received: july 28, 2017 accepted: december 12, 2017 cite this article. ghazal l, qureshi ah, iqbal n. antibiotic susceptibility pattern of gram negative bacilli isolated from different clinical specimens in a tertiary care hospital. jimdc.2018; 7(2):112-117 funding source: nil conflict of interest: nil i n t r o d u c t i o n antibiotics have enabled tremendous advances in the discipline of infectious diseases since their emergence in 1930. unfortunately, the occurrence of resistant bacteria is endangering the efficacy of antibiotics, which have transformed medicine and saved millions of lives.1 the infections caused by multiple-drug resistant (mdr) gramnegative organisms have created entire classes of antibiotics redundant and threatened to bring about the end of the 'antibiotic era'. 2,3 extended-spectrum betalactamases, metallo-beta-lactamases and amp-c o r i g i n a l a r t i c l e 113 j i m d c 2 0 1 8 113 mediated beta-lactamases produced by enterobacteriaceae and other non-lactose fermenters are increasingly implicated in outbreaks through the dissemination of mobile genetic elements rendering emergence of resistant mutants.4 this grave situation demands optimization of therapy primarily because of substantial increases in the frequency with which these organisms affect the health care settings as well as the community acquired infections. the challenge of heightened antimicrobial resistance among gram-negative pathogens has been exacerbated by the stagnation in the development of novel antimicrobials. studies have provided convincing evidence that effective initial empirical antibiotic therapy, based on ultimate drug susceptibility results, improves survival.2 the constantly evolving antimicrobial resistance patterns render antibiotic susceptibility profile in one region at a specific period, inapplicable to other region or in another period. thus, antimicrobial susceptibility data from any given regional, national, or international surveillance study cannot reliably predict the drug resistance profiles of pathogens isolated from an individual patient.5 the current study was designed to document the commonly isolated gram-negative bacilli from different clinical specimens and their susceptibility patterns in tertiary health care hospital at wah. this will be an effort to rationalize the empirical treatment by clinicians resulting in evidence-based practice and better results in terms of early recovery from infections, shorter duration of hospitalization and cost effectiveness. moreover, this effort will contribute to safeguard the remaining therapeutic options for the clinicians and encourage a focused, concerted effort against key human pathogens. m a t e r i a l a n d m e t h o d s this cross-sectional study was carried out at microbiology section of pakistan ordinance factories hospital laboratory from april 2015 to march 2016. one hundred and forty-four clinical specimens from patients either gender, of all ages, yielding growth of gram-negative bacilli were included in the study and selected by convenient sampling. duplicate samples of the same patient from the same site were not included.the specimens were inoculated on appropriate culture medium like blood agar, macconkey agar, chocolate agar (sputum) and cysteine lactose electrolyte deficient agar (urine) and incubated at 35-37˚c under aerobic conditions for 24 hours. after overnight incubation, the agar plates were examined for growth of bacteria and their colonial morphology. gram-negative rods were identified based on gram staining, catalase test, oxidase test and motility.6 microbact gram-negative 24e identification kits (oxoid, basingstoke, uk) were used for confirmation of isolates. antimicrobial susceptibility tests were performed on the muller–hinton agar plates with disk diffusion method, as recommended by clinical laboratory standards institute.7 the bacterial suspensions of isolates equivalent to 0.5 mcfarland standard turbidity were applied on muellerhinton agar (oxoid, basingstoke, uk). the antimicrobial disks (oxoid, basingstoke, uk) were evenly placed on the inoculated plates and included ampicillin (10 µg), amoxicillin-clavulanate (20/10 µg), trimethoprinsulfamethoxazole (1.25/ 23.75 µg), ceftriaxone (30 µg), ciprofloxacin (5 µg), gentamicin (10 µg), amikacin (30 µg), cefoperazone-sulbactam (75/ 30 µg), imipenem (10 µg) and meropenem (10 µg). concurrent quality control testing was performed with escherichia coli atcc 25922 and pseudomonas aeruginosa atcc 27853. after overnight incubation, the diameter of each zone of inhibition around the antimicrobial disk was measured. the susceptibility results were interpreted according to recommendations of clsi as sensitive, intermediate and resistant.7 the data were entered and analyzed using spss version 19. for qualitative variables (gramnegative bacilli, gender, type of samples and organisms isolated) frequencies and percentages were calculated. mean ± sd was presented for age. r e s u l t s a total of one hundred and forty-four (144) isolates of gram-negative bacilli were included in the study. majority of isolates were yielded from urine (n=83, 57.6%), followed by pus (n=23, 16%) and respiratory specimens (n=17, 11.9%). the other isolates were from blood, high vaginal swabs, catheter tips, ear swabs, tissue and body fluids. the distribution of specimens along with their breakup is presented in table 1. out of one hundred and forty-four (144) gram-negative bacilli, one hundred (69.44%) were members of the family enterobacteriaceae 114 j i m d c 2 0 1 8 114 figure 1: frequency of isolated gram-negative bacilli (n=144) and forty-four (30.56%) were from nonenterobacteriaceae. and forty-four (30.56%) were from non-enterobacteriaceae. the commonest isolated organism was escherichia coli (47.3%), followed by pseudomonas aeruginosa (17.36%) and acinetobacterbaumannii (13.19%). (figure-1) out of one hundred and forty-four isolates, 53.47% were recovered from male patients and 46.53% from female patients. mean age of the patients was 49.32years+ 23.72 sd. age distribution of different age groups which yielded gram-negative isolates is shown in figure-2. figure 2: distribution of different age groups, which yielded gramnegative bacilli thirty-seven isolates (33.3%) were isolated from outdoor patients, while the remaining (n=107, 66.7%) were from patients admitted in different wards. their distribution is presented in figure 3. the resistance frequency of e.coli against ampicillin, amoxicillin-clavulanate and trimethoprimsulfamethoxazole was 93.3%, 81.3% and 76% respectively. none of the isolates was 100% susceptible to any of the antimicrobials assessed in the study. table 1: break up of clinical specimens yielding gram-negative bacilli (n=144) frequency percentage blood 8 5.6 tracheostomy discharge 8 5.6 endotracheal tubes 6 4.2 cvp 1 .7 csf 1 .7 vitreous tap 1 .7 bile 1 .7 tissue 1 .7 bronchoalveol ar lavage 1 .7 peritoneal fluid 2 1.4 urine 83 57.6 high vaginal swabs 1 .7 sputum 2 1.4 catheter tips 4 2.8 pus 23 16.0 ear swab 1 .7 115 j i m d c 2 0 1 8 115 table 2: antimicrobial resistance pattern in enterobacteriaceae escherichia coli (n=75) klebsiella pneumonia (n=15) enterobacter spp (n=08) proteus mirabilis (n=02) n r% n r% n r% n r% amp 70 93.3 15 100 7 87.5 2 100 amc 61 81.3 14 93.3 7 87.5 2 100 ak 14 18.6 7 46.6 3 37.5 2 100 g 32 42.6 8 53.3 3 37.5 1 50 cot 57 76 11 73.3 6 75 2 100 cro 51 68 11 73.3 4 50 1 50 imp 17 22.6 8 53.3 1 12.5 1 50 mnp 21 28 8 53.3 2 25 1 50 scf 10 13.3 5 33.3 2 25 1 50 cip 51 68 8 53.3 3 37.5 1 50 the antibiotic susceptibility pattern of members of enterobacteriaceae, including e.coli, k.pneumoniae, enterobacter sp and proteus mirabilis has been shown in table 2. figure-3: sites of collection of gram-negative bacilli. the susceptibility pattern of members of nonenterobacteriaceae including pseudomonas aeruginosa and acinetobacter baumannii is displayed in table 3. table 3: antimicrobial resistance pattern in nonenterobacteriaceae pseudomonas aeruginosa (n=25) acinetobacter baumannii (n=19) n r% n r% amp _ _ 19 100 amc _ _ 19 100 ak 13 52 15 78.9 g 20 80 17 89.4 cot _ _ 18 94.7 cro _ _ 17 89.4 caz 24 96 _ _ imp 13 52 18 94.7 mnp 13 52 18 94.7 cip 18 72 17 89.4 scf 12 48 12 63.1 dox _ _ 13 68.4 amp-ampicillin, amc-amoxicillin-clavulanate, akamikacin, g-gentamicin, cot-trimethoprimsulfamethoxazole , croceftriaxone, cazceftazidime, impimipenem , mnpmeropenem, scfcefoperazonesulbactam , cipciprofloxacin ,doxdoxycycline, r resistant 116 j i m d c 2 0 1 8 116 d i s c u s s i o n the susceptibility pattern of gram-negative isolates revealed an alarming resistance ratio to commonly used antibiotics. in the present study, e.coli, klebsiella pneumoniae, enterobacter spp and proteus mirabilis are highly resistant to first-line drugs including ampicillin, trimethoprim-sulfamethoxazole and amoxicillinclavulanate. these findings are in agreement with a study carried out at fauji foundation hospital rawalpindi by nabi et al.8 it is worrisome to note the high rates of resistance of members of enterobacteriaceae to the third generation cephalosporins (ceftriaxone) and also to the commonly used flouroquinolone (ciprofloxacin) in our study. similar resistance patterns have been reported in other studies from rawalpindi4 as well as from iran.9 this situation is much different when compared to the resistance rate prevailing in england as published in english surveillance programme for antimicrobial utilization and resistance (espaur) report, 2014.10 the contrasting results provide an evidence of injudicious and imprudent use of these antibiotics in our setup. the resistance frequency of e.coli against gentamicin (42.67%) and amikacin(18.67%) is comparable to a study conducted on uropathogens by nabi et al in dhaka in 2014.11 a low percentage of resistance of e.coli against amikacin indicate that this antibiotic may be a useful therapeutic agent in our setup when considered as empirical choice. klebsiella pneumoniae is fairly resistant to gentamicin and amikacin. this finding is in concordance with those reported by bhat et al.12 a high and moderate level of resistance of proteus mirabilis against amikacin and gentamicin respectively are depicted in our study, a situation different from the one reported by bahashwan et al.13 a disturbing situation existing in our hospital is 53.3% resistance against imipenem and meropenem conferred by k.pneumoniae, and 50% for both members of carbapenems by p.mirabilis. similar results have been reported from other parts of the subcontinent.11,13 poor infection control measures contribute to the development of high-level resistance to these relatively safe and effective antibiotics. resistance of e.coli and enterobacter spp against carbapenems are also significantly high when compared to studies conducted in two different institutions at rawalpindi.4,8 our study also revealed a.baumannii is significantly resistant (89.4%) to each of ceftriaxone, gentamicin and ciprofloxacin. this bug shows 94.4% resistance to carbapenems and trimethoprimsulfamethoxazole. the resistance pattern in our settings is in accordance when compared to data by fayyaz et al16 in rawalpindi and sohail et al in lahore.17 cefoperazonesulbactam and doxycycline are relatively effective drugs against a.baumannii (63.1% & 68.4% respectively) in our setting , which is a similar finding as demonstrated by fayyaz et al.16 our data suggests 96% resistance of p.aeruginosa against ceftazidime, 72% against ciprofloxacin and 52% against amikacin , imipenem and meropenem respectively. comparison with espaur report revealed a stupendous difference in susceptibility pattern of p.aeruginosa, indicative of a failure of antibiotic stewardship in our settings.10 antibiograms in context to local data unveiled an increased resistance ratio to antipseudomonal antibiotics as compared to our clinical settings.4,18 our study is laboratory-based and has no correlation with the clinical outcomes after antibiotics administration to treat the specific pathogen. despite this limitation, the study will be helpful for local clinicians to make an appropriate choice of antibiotic for empirical therapy. c o n c l u s i o n e.coli is the most common gram-negative bacillus, followed by p.aeruginosa and a.baumannii isolated from the culture of clinical specimens in pof hospital, wah. the isolates depict highly resistant patterns to available oral antibiotics as well as commonly prescribed injectable third generation cephalosporins and carbapenems. 1. gram-negative bacilli reveal relatively better susceptibility against cefoperazone-sulbactam. 2. antibiotic resistance is a dynamic phenomenon which emphasizes continuous monitoring of infection control practices and regular surveillance of antibiotics susceptibility patterns in our health care setting. 3. strict implementation of polices for judicious use of antibiotic and efficient infection control practices are strongly recommended. 117 j i m d c 2 0 1 8 117 r e f e r e n c e s 1. boucher hw, talbot gh, bradley js et al. bad bugs, no drugs: no eskape! an update from the infectious diseases society of america. clin. infect. dis. 2009;48(1):1–12. 2. centers for disease control and prevention, office of infectious disease antibiotic resistance threats in the united states, 2013. 3. pendleton jn, gorman sp, gilmore bf. clinical relevance of the eskape pathogens. expert rev anti infect ther. 2013; 11(3): 297-308. 4. khan iu, mirza ia, ikram a, afzal a, ali s, hussain a, et al. antimicrobial susceptibility pattern of bacteria isolated from patients with urinary tract infection. j coll physicians and surg pakistan. 2014; 24 (11): 84044. 5. balank1 ,sujitha k2 , vijayalakshmi ts. antibiotic susceptibility pattern of gram negative clinical isolates in a teaching tertiary care hospital. sch. j. app. med. sci., 2013; 1(2):76-79. 6. schreckenberger pc, janda jm, wong jd, baron ej. algorithms for identification of aerobic gram-negative bacteria. manual of clinical microbiology. 1999; 7:438-52. 7. murray pr, baron ej, jorgensen jh, landry ml, pfaller ma (editors). manual of clinical microbiology. 9thed. washington, d.c: asm press 2007. 371-6. 8. clsi. performance standards for antimicrobial susceptibility testing; twenty-fifth informational supplement. clsi document m100–s25. wayne, pa: clinical and laboratory standards institute; 2015. 9. nabi sg, zaffar g, mumtaz s. antimicrobial resistance pattern of gram negative bacilli isolated from clinical samples. jimdc. 2014; 3(1):25-28. 10. rabiradi n, mohammad pm, lari r, shojaie a, bayat r, alebouyeh m. antimicrobial susceptibility patterns of the gram-negative bacteria isolated from septicemia in children's medical center, tehran, iran. j prev med hyg. 2014; 55(1): 23-26. 11. public health england: english surveillance programme antimicrobial utilization and resistance (espaur) report publications gov.uk. 2014. 12. nabi sn, haider kmts, rahimgir m, uddin mn, shapla nr. current trends of urinary pathogens and their antimicrobial susceptibility pattern in a tertiary care hospital. jafmc. 2015;10(2): 71-74. 13. bhat v, gupta s, kelkar r, biswas s, khattry n, moiyadi aa, et al. bacteriological profile and antibiotic susceptibility patterns of clinical isolates in a tertiary care cancer center. indian j med paediatroncol. 2016; 37(1): 20-4. 14. bahashwan sa, el shafey hm. antimicrobial resistance patterns of proteus isolates from clinical specimens. european scientific journal. 2013; 9(27): 188-202. 15. kalam k, qamar f, kumar s, et al. risk factors for carbapenem resistant bacteraemia and mortality due to gram-negative bacteraemia in a developing country. j pak med assoc. 2014;64(5): 530-6. 16. kim yj, kim si, hong kw, kim yr, park yj, kang mw. risk factors for mortality in patients with carbapenemresistant acinetobacterbaumannii bacteremia: impact of appropriate antimicrobial therapy. j korean med sci. 2012; 27(5):471-5. 17. fayyaz m, khan iu, hussain a, mirza ia, ali s, akbar n. frequency and antimicrobial susceptibility pattern of acinetobacter species isolated from pus and pus swab specimens. j coll physicians surg pak. 2015; 25(5): 346349. 18. sohail m, rashid a, aslam b, waseem m, shahid m, akram m, et al. antimicrobial susceptibility of acinetobacter clinical isolates and emerging antibiogram trends for nosocomial infection management. rev soc bras med trop. 2016; 49(3): 300-304. 14 j i m d c 2 0 1 7 14 op e n ac c e ss f u l l l e n g t h a r t i c l e y chromosome microdeletions in pakistani infertile men atif mahmood1, syeda nuzhat nawab2, saima ejaz3, masood anwar qureshi4, fauzia imtiaz5, abid azhar6 1. associate professor, department of physiology, bhitai dental and medical college 2. scientific officer, khan’s institute of biotechnology and genetic engineering (kibge), university of karachi. 3. lecturer, northern border university, arar, saudia arabia 4. chairman/head physiology department, dow university of health sciences; director, institute of basic medical sciences (duhs) 5. associate professor, department of biochemistry, dow university of health sciences 6. director general, khan’s institute of biotechnology and genetic engineering (kibge), university of karachi. a b s t r a c t objective: to determine the prevalence of y chromosome microdeletions in pakistani idiopathic infertile men, using multiplex polymerase chain reaction. patients and methods: a case control study was conducted on the infertile male patients attending opd’s of aziz medical hospital and national center for fertility control, jinnah post graduate medical center (jpmc), karachi. a total of 220 primary infertile men, of which 150 (68.2%) had azoospermia, 40 (18.2%) had severe oligozoospermia and 30 (13.6%) had oligozoospermia and 220 fertile men as control group were studied. six sequence-tagged sites: sy84 and sy86 for azfa, sy127 and sy134 for azfb, and sy254 and sy255 for azfc were used for amplification of the azoospermia factor region of y chromosome according to the recommendations of european academy of andrology and the european quality monitoring network group. results: yq microdeletions were found in (12) 5.45% cases, while none in the control group (p =<0.007). all the microdeletions were found in azoospermics 12/150 (8.0%). among patients with microdeletions, the azfa region was found to be deleted in 1 (8.33%), azfb in 2 (16.67%), azfc in 6 (50%), azfb+c in 2 (16.67%) and complete azf deletions in 1 (8.33%) patients. identification of y chromosome microdeletions in pakistani infertile males was found to have significant diagnostic and prognostic value and provides useful information for genetic counseling in patients choosing assisted reproductive treatments. key words: azoospermia, azoospermia factor, male infertility, oligozoospermia, polymerase chain reaction, y chromosome microdeletions. author`s contribution 1conceived the topic of research and designed the study 2literature review and manuscript writing 3data analysis and discussion address of correspondence dr. atif mahmood atif_mahmood20@yahoo.com article info. received: oct 16, 2016 accepted: feb 7, 2017 cite this article: mahmood a, nuzhat s, ejaz ns, qureshi ma, imtiaz f, azhar a. y chromosome microdeletions in pakistani infertile. jimdc. 2017; 6(1):14-21. funding source: nil conflict of interest: nil i n t r o d u c t i o n approximately 10–15% of couples are affected by infertility which come into consideration when the couples fail to conceive after unprotected coitus for more than one year. a male factor can be diagnosed in approximately 50% of them. the main causes of this disorder for men are associated with various factors, among them are genetic, physio-pathologic and anatomo-pathologic abnormalities, intense and prolonged physical exercises, aging, drugs, and even excessive time of sexual abstinence.1 in almost 20% of cases in which male infertility cannot be attributed to any other cause, the role of genetic alterations is being increasingly scrutinized.2 this form of infertility can be classified as a genetic disorder, where structural chromosomal alterations, o r i g i n a l a r t i c l e 15 j i m d c 2 0 1 7 15 acquired or congenital, have been one of the main etiologic factors.3 little is known about the reproductive genetic disorders that cause disruption of spermatogenesis. early cytogenetic studies showed that microscopic deletions in the long arm of y chromosome are responsible for azoospermia and structural alterations in the y chromosome have been the principal reason for male infertility.4 numerous investigations have documented interstitial microdeletions in azfc region in both azoospermics and mild oligospermics. such microdeletions have been reported with varied prevalence in different populations. for example, the studies in brazilian population reported both low (6.7%) as well as high (44%) prevalence of yq microdeletions in the azfc region in infertile males.5,6 likewise, low frequency (5.1%) as well high frequency (17.4%) has been shown in chinese population.7,8 further the range of frequency of azfc region deletion in indian population has been 5.3% -15%.9,10 azfc deletions and partial azfb deletions are associated with sperm retrieval in 50% of cases, while in cases of azfb deletions, probability of finding sperm is virtually nil. however, retrieved sperms are found to be fully fertile in both intracytoplasmic sperm injection (icsi) and in vitro fertilization (ivf) procedures. icsi allows partners of infertile men to become pregnant; however, it is possible that y deletions may be transmitted to the male offspring. substantial prevalence of y deletions in infertile men and the potential risk of transmitting this genetic disorder to their offspring provide a compelling rationale for screening of infertile men prior to icsi.11 the status of azfc in the genetic involvement of male infertility has been documented in many countries with varying frequency. so far only two studies have reported y chromosome microdeletions in pakistani infertile men. one of these studies was conducted in lahore and has not reported any microdeletions, whereas another study which was conducted in islamabad reported an overall prevalence of 11.6% yq microdeletions in pakistani infertile men.12,13 thus, it becomes imperative to investigate the deletions of azfc region localization in pakistani population. the aim of this study was to detect genetic defect in male infertile patients attending infertility clinics and to evaluate it for etiological diagnosis in cases of idiopathic male infertility. p a t i e n t s a n d m e t h o d s a case control study was conducted on the infertile male patients attending opd’s of aziz medical hospital and national center for fertility control, jinnah post graduate medical center (jpmc), karachi. the bench work was carried out at khan institute of biotechnology and genetic engineering (kibge), university of karachi from june 2012 to may 2013. a purposive non probability sample of 220 idiopathic infertile men with a normal karyotype aged between 21 and 60 years (mean ± sd = 33.54 ± 6.57) were screened for the presence of y chromosome microdeletions. two hundred and twenty age-matched (mean ± sd = 37.24 ± 5.65 years) fertile men with proven fertility and sperm count > 20 million/ml were considered as control group; also a female sample was used as negative control. informed written consent was obtained from each and every subject included in the study and confidentiality and anonymity of the data was ensured. the study was approved by the institutional review board (irb) of dow university of health sciences (duhs). a detailed history and physical examination was done on all the subjects. semen analysis was performed according to normal standard parameters using the world health organization (who) criteria. infertile men (n=220) were divided into 3 groups on the basis of sperm count: azoospermic (no spermatozoa), severe oligozoospermic (less than 5 million/ ml) and oligozoospermic (less than 20 million/ml). five microlitre of venous blood was also collected in a tube containing ethylene diamine tetraacetate (edta) as an anticoagulant for dna extraction. genomic dna was extracted utilizing phenol chloroform method. polymerase chain reaction (pcr) was performed according to the standard protocol for analysis of the azf region of the y-chromosome. three sub-regions were analyzed: azfa, azfb and azfc, where sequence tagged site (sts) markers were used. as positive control, fertile men with naturally conceived children were used. these sts markers were suggested by the european academy of andrology which are able to detect 90% of the deletions in the loci of azf.2 the pcr amplification reaction mix comprised a total volume of 15μl, which contained 1.5μg of 50ng/μl human genomic dna as template, 1 μl of 2mm dntp’s (fermentas), 5μl of 100 μm each of the forward and 16 j i m d c 2 0 1 7 16 reverse primers (pennicon), 0.3μl of 50mm mgcl2 (geneaid) and 0.1μl of 5 units/μl taq dna polymerase (geneaid), 1.5μl of 10x pcr buffer (geneaid) and 0.6μl of deiodinized water. the conditions for thermocycling were standardized for the sub-regions, utilizing a thermo hybaid mbs 0.2s pcr thermal cycler. two sets of multiplex pcr were used; multiplex a (sy86, sy127, sy254) and multiplex b (sy84, sy134, sy255). in addition, two sets of primers (zfx/zfy and sy14) were used to amplify sry and zfy regions as internal controls as shown in table 1. the cycling conditions for multiplex a pcr amplifications were: 35 cycles at 95ºc 78 ºc and 52 ̊ºc for 45 seconds each. initial denaturation was done at 94 ºc for 4 min and final extension at 72 ºc for 10 min. the cycling conditions for multiplex b pcr amplifications were: 35 cycles at 95̊c, 78 ºc and 52ºc for 45 seconds each in cycle. initial denaturation was done at 94ºc for 4 min and final extension at 72ºc for 10 min in both the multiplex. the amplified pcr product (15ul) was loaded in 2% agarose gel in 1x tris-borate edta (te) buffer and was run by gel electrophoresis in gel assembly for 30 minutes at 200 volts. the gel was stained with ethidium bromide (5ug/100ml) and the results were visualized by gel documentation system under uv light and photographed. the size of the dna bands was identified by comparing with the molecular weight marker (100bp dna ladder) (fermentas, 0.5μg/μl) loaded in a separate lane. this analysis was performed at least three times on samples with microdeletions. in each multiplex pcr essay, one sample from healthy female was used as negative control, and healthy fertile male was used as positive control. statistical analysis was carried out by the statistical package for social science version 16.0. the student’s t test and chi-square were used to determine the associations among the different parameters. p value of less than 0.05 was considered to be significant. r e s u l t s among total of 220 subjects of the study group, mean age of the patients was found to be 33.54 ±6.57 years whereas it was 37.24 years ± 5.65sd for the control group. the mean age of their wives was 28.15 years ± 4.63sd, whereas mean age in control group was 27.99 years ± 5.05 sd. the average time since the marriage in table 1. sequence-tagged sites (sts) used in the detection of y chromosomal microdeletions multiplex sts locus region sequence 5’ to 3’ bp a and b zfx/zfy zfx/zfy xq34 495 yp22.3 a and b sy14 sry yp11.3 472 a sy254 daz azfc f 5′-ggg tgt tac cag aag gca aa-3′ 380 r 5′-gaa ccg tat cta cca aag cag c-3′ a sy86 dys148 azfa 318 a sy127 dys218 azfb f 5′-ggc tca caa acg aaa aga aa-3′ 274 r 5′-ctg cag gca gta ata agg ga-3′ b sy84 dys273 azfa f 5′-aga agg gtc ctg aaa gca ggt-3′ 326 r 5′-gcc tac tac ctg gag gct tc-3′ b sy134 dys224 azfb 301 b sy255 daz azfc 123 17 j i m d c 2 0 1 7 17 study group was 6.98 years ± 4.85 sd and was 5.39 years ± 5.26 sd in control group (table 2). the semen of the enrolled patients was analyzed for the number of sperms as per who criteria as shown in figure 1. figure 1. distribution of the infertile men and healthy fertile controls on the basis of sperm counts (million/ml) amongst the total of 220 subjects (shown in red) that were included in the study, 68.2% males (n=150) were found to be azoospermic i.e. having no sperm in their semen. about 18.2% cases (n=40) were found to be severely oligospermic i.e. having sperm count less than 5 million/ml, while 13.6% patients (n=30) were found to be oligospermic having sperm count less than 20 million/ml. amongst the control group (shown in blue), 99.1% (n=218) individuals had their sperm count greater than 20 million/ml while only 0.9% (n=2) were found oligospermic. the sperm counts for the two groups had significant difference with p value of <0.01. table 3 shows that the microdeletions in the y-chromosome were found in 5.45% cases (12 individuals out of 220) while no microdeletion was detected in controls. (p =<0.007). amongst the microdeletions that were reported during the study, 2.73% were isolated azfc deletions; 0.91% were azf b and azfb+c deletions each while 0.45% deletions were found in azfa and azfabc regions. these microdeletions were observed in azoospermics only. of all the microdeletions, the azfa region was found to be deleted in 8.33% (1/12), azfb in 16.67% (2/12), azfc in 50% (6/12), azfb+c in 16.67% (2/12) and azfa+b+c in 8.33% (1/12) patients. figure 2 represents optimization of the primers of multiplex pcr: 100 bp, ladder; 1, primer 1 (495 bp); 2, primer 2 (475 bp); 3, primer 3 (320 bp); 4, primer 4 (274 bp); 5, primer 5 (380 bp); 6, primer 6 (326 bp); 7, primer 7 (301 bp); 8, primer 8 (123 bp). figure 3 shows the absence of band of 380 bp in lane 5, 6 and 7 which corresponds to azfc region. band of 274 bp and 380 bp are absent in lane 8 and 9 showing deletion in the azfb + c region whereas lane 10 shows complete deletion of the entire azf region. figure 4 shows the absence of band of 123 bp in lane 5, 6 and 7 which corresponds to azfc region. band of 301 bp and 12 bp are absent in lane 8 and 9 showing deletion in the azfb + c region whereas lane 10 shows complete deletion of the entire azf region table 2: age of the couples and duration of marriage parameter cases (n=220) control (n=220) mean ± sd 95% ci (lower – upper) mean ± sd 95% ci (lower – upper) age of the patients (years) 33.54 ± 6.57 32.67 – 34.41 37.24 ± 5.65 36.49 – 37.99 age of the wife (years) 28.15 ± 4.63 27.53 – 28.76 27.99 ± 5.05 27.32 – 28.66 years since married 6.98 ± 4.85 6.34 – 7.63 5.39 ± 5.26 4.69 – 6.09 table 3. deletion rate and distribution of observed microdeletions of azf region on y chromosome in infertile men azf region azoospermia (n=150) severe oligozoospermia (n=40) oligozoospermia (n=30) total (n=220) deletion rate (%) azfa 1 1 0.45 azfb 2 2 0.91 azfc 6 6 2.73 azf b+c 2 2 0.91 azf a+b+c 1 1 0.45 total (%) 12 (8%) 12 5.45 18 j i m d c 2 0 1 7 18 figure 2: optimized multiplex pcr with all the eight primers figure 3: multiplex a: lane 1, 100bp dna ladder; lane 2, dna of normal fertile male as +ve control; lane 3, female dna; lane 4, water as –ve control; lane (5, 6, 7), dna of azfc deleted patient; lane (8, 9), dna of azfb+c deleted patient; lane 10, dna of azfa, b, c deleted patient. figure 4: multiplex b: lane 1, 100bp dna ladder; lane 2, dna of normal fertile male as +ve control; lane 3, female dna; lane 4, water as –ve control; lane (5, 6, 7), dna of azfc deleted patient; lane (8, 9), dna of azfb+c deleted patient; lane 10, dna of azfa, b, c deleted patient. d i s c u s s i o n among numerous etiologic factors, genetics play a key role in male infertility with abnormal semen parameters.1416 spermatogenesis is regulated by a number of genes on the y chromosome and by autosomes that act at different stages of germ cell development.16 previous reports have revealed that y chromosome microdeletions vary from 1 to 55% among infertile men all over the world, but most studies have reported an incidence below 15%.2 in the present study, the estimated frequency was 8% among azoospermic patients and an overall prevalence of 5.45% which is well within the range of the published data. no microdeletion was reported in a study conducted in lahore city in 53 idiopathic azoospermic infertile men while using european academy of andrology (eaa) recommended sts markers.12 another study conducted in islamabad city for y chromosomal microdeletions in oligozoospermic and azoospermic men reported an overall prevalence of 11.8% in 51 patients.13 these deletions were found solely in non-obstructive azoospermic patients which is also the case in our study as no microdeletion was found in the oligozoospermic or severe oligozoospermic patients. wide variations in deletion frequency that are reported in previous published works could be caused by geographic and ethnic differences, genetic background, and environmental influences, different patient selection criteria, study designs, sample size and partly by methodological aspects.17,18 however, there are studies that suggest that the major factor influencing deletion frequency was the composition of study population and ethnic or geographical differences apparently had no influence on it.19,20 they found that the highest deletion frequency was in the group defined as idiopathic azoospermic with the incidence of 17 percent and the incidence decreases progressively with the inclusion of less severe phenotypes.20 it seems that the discrepancy in reported deletion frequencies in pakistani population could be explained by (i) differences in the sample size, and (ii) ethnic variations since our samples were collected from karachi which is a metropolitan city and accommodates people from many different ethnic groups and races. 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 19 j i m d c 2 0 1 7 19 it has been reported that azfc microdeletion constitutes a progressive and deteriorating effect on spermatogenesis leading to a steady and methodical decline in spermatogenesis and deterioration in sperm quality.21 but, a clinical study of azoospermic and oligospermic men, did not agree to this concept as they found that the azfc deleted men had their baseline sperm production potential stable over time.22 it has been shown that chromosome y microdeletions are much less frequent when sperm concentration is less than 2 million/ml.23,24 this may be one of the reasons for the failure to detect y microdeletions in the non-azoospermic groups which is also observed in our study where complete azf deletion and the deletions of azfa, azfb, azfb+c and all the azfc deletions were all found only in azoospermic male. deletions in azfc region are the most commonly reported deletions among azf microdeletions and its complete deletion is one of the most frequent genetics causes of severe male infertility. in a study conducted on 247 saudi men with idiopathic azoospermia or oligospermia, 3.2% had y chromosome microdeletion, consisted of 6 in the azfc, 1 in the azfb, and 1 in both azfa and azfc.15 azfa contains single copies of dffry (usp9y) and dby (ddx3y) genes. it is suggested that complete deletion of azfa region may result in complete sco syndrome and azoospermia.2,4,25,26 identification of deletions in this region is very important since it is impossible to retrieve testicular sperm for icsi.2,25 in our study, azfa region was involved in a total of 8.33% (1/12) of the observed y chromosome microdeletions using sy84 and sy86 sequence tagged sites. deletion in this region was observed in combination with complete deletions of azf region in one patient (8.33%). this is slightly higher than the percentage of deletions reported in literature in azfa region, which is 2 -5%.19,27 this higher percentage was also reported by the another study conducted in our country, in which one patient out of six with microdeletions showed azfa deletion (16.67%).13 a study conducted in india reported 2% azfa region deletion.28 azfb deletion was involved in 41.7 % of the total deletions of which azfb alone was involved in 16.67 %. selected sts markers for detecting deletions in azfb region in the present study were located in the median and distal part of azfb and in the most cases the deletion of sy127 and sy134 markers, indicated a complete deletion of the azfb region which may cause sco syndrome or spermatogenetic arrest resulting in azoospermia.2 two patients showed complete deletion of azfb whereas two patients showed partial deletion in azfb region. rbmy genes, including rbm1 and rbm2, located in azfb region, are specifically expressed in testis and germ cells. the gene encodes a rna binding protein that localizes to the nucleus of all spermatogenic cell types.25,29 since several copies of these genes are located in the azfb region, it is not clear whether the loss of the rbmy genes in men may result in male infertility or not, therefore, the role of deletion in these genes is not clear in the process of spermatogenesis.30 several reports have shown that complete deletions in azfb region will have the same results as deletions in azfa region for testicular sperm extraction (tese).2,25 patients with complete or partial azfb deletion in our study also showed maturation arrest in their testis biopsy; therefore, attempts for retrieving sperm were not successful. c o n c l u s i o n y chromosome microdeletions proved to be the second most common etiology among genetic causes of male infertility after klinefelter’s syndrome. however, men with microdeletions will presumably transmit the deletion, as well as the related fertility problem, to their sons. it is, therefore, very important not only to routinely screen for yq microdeletion but also to offer proper genetic counseling to the couples particularly those who wish to undergo assisted reproductive techniques. r e f e r e n c e s 1. pasqualotto ff. investigation and assisted reproduction in the treatment of male infertility. revista brasileira de ginecologia e obstetrícia. 2007;29(2):103-12. 2. simoni m, bakker e, krausz c. eaa/emqn best practice guidelines for molecular diagnosis of y-chromosomal microdeletions. state of the art 2004. international journal of andrology. 2004;27(4):240-9. 3. stankiewicz p, lupski jr. genome architecture, rearrangements and genomic disorders. trends in genetics. 2002;18(2):74-82. 4. vogt ph, edelmann a, kirsch s, henegariu o, hirschmann p, kiesewetter f, et al. human y chromosome azoospermia factors (azf) mapped to different subregions in yq11. human molecular genetics. 1996;5(7):933-43. 5. saopedro sl, fraietta r, spaine d, porto cs, srougi m, cedenho ap, et al. prevalence of y chromosome deletions 20 j i m d c 2 0 1 7 20 in a brazilian population of nonobstructive azoospermic and severely oligozoospermic men. brazilian journal of medical and biological research = revista brasileira de pesquisas medicas e biologicas / sociedade brasileira de biofisica,et al. 2003;36(6):787-93. 6. arruda jt, bordin bm, santos pr, mesquita we, silva rc, maia mc, et al. y chromosome microdeletions in brazilian fertility clinic patients. genet mol res. 2007;6(2):461-9. 7. yang y, zhang sz, peng lm, ding xp, lin l, wang j. studies on molecular epidemiology of y chromosome azoospermia factor microdeletions in chinese patients with idiopathic azoospermia or severe oligozoospermia. zhonghua yi xue yi chuan xue za zhi = zhonghua yixue yichuanxue zazhi = chinese journal of medical genetics. 2003;20(5):385-9. 8. liu xz, tang yg, zheng lx, zhou by, liu h, li mz, et al. chromosome abnormalities and y chromosome microdeletions in patients with the azoospermia and cryptozoospermia. zhonghua yi xue yi chuan xue za zhi = zhonghua yixue yichuanxue zazhi = chinese journal of medical genetics. 2010 aug;27(4):460-2. 9. mitra a, dada r, kumar r, gupta np, kucheria k, gupta sk. screening for y-chromosome microdeletions in infertile indian males: utility of simplified multiplex pcr. the indian journal of medical research. 2008 feb;127(2):124-32. 10. babu sr, swarna m, padmavathi p, reddy pp. pcr analysis of yq microdeletions in infertile males, a study from south india. asian journal of andrology. 2002 ;4(4):265-8. 11. van landuyt l, lissens w, stouffs k, tournaye h, liebaers i, van steirteghem a. validation of a simple yq deletion screening programme in an icsi candidate population. molecular human reproduction. 2000;6(4):2917. 12. siddique a, qureshi hj, siddique s, husnain a. y chromosomal microdeletions in a local infertile male population of pakistan. pak j physiol. 2009;5(1):29-33. 13. siddiqi s, siddiq a, majeed k, mansoor a, qamer r, mazhar k, et al. y-chromosomal deletionsa risk factor for male infertility. international journal of agriculture and biology [short communication]. 2009;11(1):110-2. 14. samli h, solak m, imirzalioglu n, samli m. genetic anomalies detected in patients with non-obstructive azoospermia and oligozoospermia. med j kocatepe. 2005;6:7-11. 15. hellani a, al-hassan s, iqbal ma, coskun s. y chromosome microdeletions in infertile men with idiopathic oligoor azoospermia. journal of experimental & clinical assisted reproduction. 2006;3:1. 16. dada r, gupta np, kucheria k. cytogenetic and molecular analysis of male infertility: y chromosome deletion during nonobstructive azoospermia and severe oligozoospermia. cell biochemistry and biophysics. 2006;44(1):171-7. 17. zhu yj, liu sy, wang h, wei p, ding xp. the prevalence of azoospermia factor microdeletion on the y chromosome of chinese infertile men detected by multi-analyte suspension array technology. asian journal of andrology. 2008 ;10(6):873-81. 18. vutyavanich t, piromlertamorn w, sirirungsi w, sirisukkasem s. frequency of y chromosome microdeletions and chromosomal abnormalities in infertile thai men with oligozoospermia and azoospermia. asian journal of andrology. 2007 ;9(1):68-75. 19. krausz c, forti g, mcelreavey k. the y chromosome and male fertility and infertility. international journal of andrology. 2003;26(2):70-5. 20. krausz c, rajpert-de meyts e, frydelund-larsen l, quintana-murci l, mcelreavey k, skakkebaek ne. double-blind y chromosome microdeletion analysis in men with known sperm parameters and reproductive hormone profiles: microdeletions are specific for spermatogenic failure. the journal of clinical endocrinology and metabolism. 2001;86(6):2638-42. 21. simoni m, gromoll j, dworniczak b, rolf c, abshagen k, kamischke a, et al. screening for deletions of the y chromosome involving the daz (deleted in azoospermia) gene in azoospermia and severe oligozoospermia. fertility and sterility. 1997;67(3):542-7. 22. oates rd, silber s, brown lg, page dc. clinical characterization of 42 oligospermic or azoospermic men with microdeletion of the azfc region of the y chromosome, and of 18 children conceived via icsi. human reproduction. 2002;17(11):2813-24. 23. ferlin a, moro e, garolla a, foresta c. human male infertility and y chromosome deletions: role of the azfcandidate genes daz, rbm and dffry. human reproduction (oxford, england). 1999;14(7):1710-6. 24. mclachlan ri, o'bryan mk. clinical review: state of the art for genetic testing of infertile men. the journal of clinical endocrinology and metabolism. 2010 ;95(3):101324. 25. sadeghi-nejad h, farrokhi f. genetics of azoospermia: current knowledge, clinical implications, and future directions. part ii: y chromosome microdeletions. urology journal. 2007;4(4):192-206. 26. krausz c, quintana-murci l, mcelreavey k. prognostic value of y deletion analysis. human reproduction. 2000;15(7):1431-34. 27. krausz c, degl'innocenti s, nuti f, morelli a, felici f, sansone m, et al. natural transmission of usp9y gene mutations: a new perspective on the role of azfa genes in male fertility. human molecular genetics. 2006;15(18):2673-81. 28. mahanta r, gogoi a, roy s, bhattacharyya ik, sharma p. prevalence of azoospermia factor (azf) deletions in idiopathic infertile males in north-east india. int j hum genet. 2011;11(2):99-104. 29. elliot dj, millar mr, oghene k, ross a, kiesewetter f, pryor j, et al. expression of rbm in the nuclei of human germ cells is dependent on a critical region of the y 21 j i m d c 2 0 1 7 21 chromosome long arm. proceedings of the national academy of sciences of the united states of america. 1997;94:3848-53. 30. delbridge ml, harry jl, toder r, o’neill rjw, ma k, chandley ac, et al. a human candidate spermatogenesis gene, rbm1, is conserved and amplified on the marsupial y chromosome. nature genetics. 1997;15:131-6. 83 j i m d c 2 0 1 8 83 address of correspondence: rehmah sarfraz email: rehmah.sarfraz@imdcollege.com the changing role of a teacher: a paradigm shift rehmah sarfraz head, department of medical education, professor of anatomy, islamabad medical and dental college, islamabad recent advances and refinements are continuously changing the face of medical education with the paradigm shift in the role of teacher. the use of information technology and research has opened a big window through which the teaching and learning can be modified. the shifting of onus of learning from teachers to students and replacement of compartmentalized and disciplinebased curriculum by integrated one require change in curriculum content, design and delivery. as albert einstein once said “the measure of intelligence is the ability to change”; the changes in the field of medical education can be implemented in true spirit only if the teachers adapt to change. the fact cannot be denied that the successful implementation of curriculum depends upon the quality of teaching. nowadays teacher centered learning is being replaced by student centered approach with focus on student collaboration and team work instead of creating competitive environment for individual student. small group discussions, simulation and e-learning along with community-based learning has been added to lectures and bed-side teaching. early exposure to clinical sciences has provided relevance to the basic sciences curriculum. the skills and attitudes have gained importance in assessment with more focus on evidence-based practice. these global changes in the world of medical education led to the changing role of a teacher. ronald harden, a renowned medical educationist summarized the qualities of a good teacher in following formula encompassing the three main areas: good teacher = teaching competencies x approach to learning x personal development the teaching competencies include the responsibility of teacher as curriculum planner, information provider, learning resource developer and a role model for the students. facilitation of students and assessment of teaching and learning activities are part of this domain; quality is the key feature of all roles and responsibilities. however, teaching competencies alone are not enough unless the flavor of approach to learning is added to it. the delivery of content on the basis of understanding of scientific principles, taking informed decision and working as a team member along with demonstration of appropriate ethics and attitudes are the main features of teacher’s approach to learning. in the last part of the formula, emphasis is on the continuing personal and professional development of medical teachers with the aim to improve knowledge, skills and attitudes with the help of which they can reflect upon their own competencies. the two underlying motivational facts of personal development are the life-long learning and improvement in the professional quality. the teacher acts as a pivot around which all the teaching and learning activities rotate. following the principles of andragogy and with passion of teaching and commitment, the teacher becomes the source of motivation and inspiration for the students and plays a major role in the life of a doctor b i b l i o g r a p h y 1. harden rm, laidlaw jm. the changing role of the teacher. in: editors. essential skills for a medical teacher: the changing role of the teacher. united kingdom: elsevier churchill livingstone; 2012. p. 223-225. 2. harden rm, crosby j. a good teacher is more than a lecturer-the twelve roles of the teacher. amee guide no. 20.2003:334-347 e d i t o r i a l 159 j i m d c 2 0 1 7 159 open access f u l l l e n g t h a r t i c l e effect of aloevera whole leaf extract in combination with rosiglitazone on oxidative stress and lipid profile levels in type-2 diabetic rats meena gul 1, sadia moazzam 2, ifthikar adil 3 1 associate professor, department of physiology, gajju khan medical college, swabi 2 professor, department of physiology, fazaia medical college islamabad 3 assistant professor, department of pharmacology, gajuu khan medical college, swabi a b s t r a c t objective: to measure the synergistic effects of aloevera and rosiglitazone on plasma glucose, oxidative stress and lipid profile in type-2 diabetic sprague-dawley rats. subjects and methods: a randomized control trail was carried out in physiology department of army medical college, rawalpindi. twenty healthy rats were made diabetic according to srinivasan model. after confirmation of type 2 diabetes, they were randomly segregated into two equal groups. groups were named as diabetic control group and diabetic treatment group. control group was injected normal saline and treatment group was given 150 mg/kg body weight of aloevera extract and 2.5mg/kg body weight of rosiglitazone. it was half of the effective doses which were calculated through pilot study. results: plasma glucose, malondialdehyde and lipid profile were significantly reduced (p<0.000) in diabetic treatment group as compared to diabetic control group. conclusion: a significant reduction in plasma glucose, oxidative stress and lipid profile was obtained in diabetic treatment group although half of the effective doses were used. it would also be help in reducing side effects associated with use of rosiglitazone. key words: aloevera, diabetes mellitus type 2, oxidative stress, rosiglitazone. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence sadia moazzam email: sadiamoazzam1@yahoo.com article info. received: september 15, 2017 accepted: july 12, 2018 cite this article. gul m, moazzam s, adil i. effect of aloevera whole leaf extract in combination with rosiglitazone on oxidative stress and lipid profile levels in type-2 diabetic rats. jimdc.2018; 7(3):159-164 funding source: nil conflict of interest: nil i n t r o d u c t i o n diabetes mellitus (dm), the third killer of the mankind, is increasing with alarming rate throughout the world especially in developing countries.1 dm is a continuous source of oxidative stress to the body. oxidative stress is an imbalance between production of free radical generation and scavenging system2. it is relevant to the both types of diabetes and its associated complications. the increased production of free fatty acid (ffas) in diabetes can directly increase reactive oxygen species (ros) via lipid peroxidation reactions and mitochondrial production.3 chronic hyperglycemia causes oxidative stress by degrading antioxidant defense system and oxidation of glutathione pool.4 malondialdehyde (mda) is considered as an adequate indicator of lipid peroxidation caused by free radicals and its level is increased in diabetes.5 the amount of mda is then determined by thiobarbituric acid (tbars) levels.6 to protect themselves against harmful effects of ros, cells may reduce the o r i g i n a l a r t i c l e 160 j i m d c 2 0 1 7 160 formation of ros and/or enhance ros removal.7 managing diabetes is difficult due to its chronic nature and number of side effects associated with drugs used for its treatment. complementary and alternative medicine (cam) for the treatment of diabetes mellitus is becoming popular. it is claimed that dietary supplements and herbal remedies are safer than conventional drugs. studies have revealed that aloevera is rich in polysaccrides and flavonoids and can be used effectively against diabetes.8 clinical trials have indicated that supplementation with antioxidant is associated with reduction in the incidence of chronic disease morbidity and mortality. previous results revealed aloevera as hypoglycemic and antilipidemic in its gel extract, which may also contribute to its antioxidant potential. aloevera whole leaf has about three to five times more constituents than gel.9 rosiglitazone is a known antidiabetic drug of thiazolidinediones family. it works by binding to peroxisome proliferators activated receptor gamma (pparγ), nuclear regulatory protein and regulate glucose and fat metabolisms by improving insulin sensitivity in muscles and liver. these drugs decrease plasma triglyceride (tg) levels but are associated with weight gain, an increased in low density lipoprotein (ldl)cholesterol levels, congestive heart failure and left ventricular dysfunction.10 literature survey does not reveal work on antidiabetic effect of aloevera whole leaf extract, used in combination with rosiglitazone. therefore, in present study aloevera whole leaf extract was used in combination with rosiglitazone in half of its effective dose to overcome the side effects associated with drug and to look for its synergistic effects. s u b j e c t s a n d m e t h o d s the randomized control trial (rct) was carried out at physiology department army medical college, rawalpindi in collaboration with national institute of health (nih) islamabad for one year. young aloevera plant due to their high medicinal quantities was purchased from commercial nursery in lahore. plant material identification was carried out at herbarium of quaid-eazam university islamabad, by the department of plant sciences. accession number 46624 and voucher specimen number 157 was obtained. a whole leaf process was employed in making the aloe juice. leaves were cut into sections and were pulverized into a soup like structure by placing them in a grinding unit. the filtered juice was passed through an activated charcoal column, which was prepared in a central funnel, to remove the unwanted laxative agents, aloin and aloe emodin which is a byproduct of rind and latex.11 pilot study was performed on a group of ten rats to find the effective dose of aloe vera whole leaf extract to achieve normoglycemia in diabetic rats. it was found that aloe vera whole leaf extract in the dose of 300 mg/kg body weight effectively lowered plasma glucose levels in type 2 diabetic rats. dose of rosiglitazone was taken from literature. half their effective doses were used in our study. in rct, twenty sprague dawley rats, about 90 days old with average weight 220±50 grams were taken from national institute of health (nih), islamabad. animal house facility of nih, islamabad was used which has a setup according to international standards for breeding and housing of experimental animals. normal pellet diet (npd) was `prepared at nih according to the standard approved by the universities federation for animals welfare. high fat diet (hfd) was specially prepared at nih according to the standard used elsewhere.12 twenty animals were fed with high fat diet for 2 weeks after which a single intra-peritoneal injection of streptozotocin (available as 1-gram vial, bioworld pharmaceutical) in the dose of 35 mg/kg body weight was given.12 their fasting blood glucose and mda levels along with total lipid profile were measured after 72 hours to confirm type 2 diabetes mellitus (t2dm).13 after confirmation of t2dm, twenty sprague dawley rats were randomly divided into two groups as their plasma glucose and tg: high density lipoprotein (hdl) ratio was comparable to each other. cages were labeled as control group and treatment group. now each group having 10 rats was introduced to treatment for next 21 days. diabetic control group was administered 0.1ml normal saline intraperitoneally (i/p) daily and diabetic treatment group was given half the effective dose of aloevera 150mg/kg and rosiglitazone 2.5mg/kg body weight i/p. after 21 days of treatment, overnight fasted rats were anesthetized and 5 ml of intra-cardiac blood was collected to analyze plasma glucose, mda, lipid profile. analysis of samples was done at centre for research in 161 j i m d c 2 0 1 7 161 experimental and applied medicine (cream), army medical college, rawalpindi, pakistan. estimation of glucose was done by enzymatic colorimetric (trinder’s) method.14 tg, total cholesterol and hdl were estimated simultaneously on automated chemistry analyzer (vitalab selectra e). ldl was calculated by using friedewald formula and very low density lipoprotein (vldl) by triglyceride/5.15 mda levels were estimated through thiobarbituric acid reactive substances (tbars) assay by elisa. data were entered into spss version 16.0. mean and standard deviation was employed for all the values. data between groups were analyzed by using independent sample t test. the p value <0.05 was considered statistically significant. r e s u l t s at the start of study, levels of plasma glucose, mda and lipid profile were comparable to each other in both groups. after 21 days of treatment, a marked reduction in plasma glucose, mda and lipid profile was noted in treatment group as compared to baseline (table 1). after treatment plasma glucose, serum tg, cholesterol, ldl and vldl were significantly reduced in diabetic control group as compared to diabetic treatment group. serum hdl levels were noted to be significantly increased in treatment group (table 2). after three weeks, mda level in the control group was 10.06 ± 1.07 µmol/l and in treatment group it was significantly (p<0.000) reduced i.e. 3.65 ± 0.39 µmol/l (figure 1). d i s c u s s i o n the srinivasan animal model of t2dm was used in this study because it closely resembled the natural course and metabolic characteristics of the disease.12 the animal models constructed with alloxon and streptozotozin resulted in extreme insulin deficiency and overt table 1: percent reduction in treatment group as compared to baseline (n=10) variables percentage blood glucose 73 malondialdehyde 64 triglyceride 50 total cholesterol 46 high density lipoprotein 25 low density lipoprotein 51 very low density lipoprotein 49 figure-1: effect of aloevera and rosiglitazone on mda levels in type 2 diabetic treatment group as compared to control group (n=20) hyperglycemia features similar to type dm-1 than to dm2. models. administration of high fat diet for 2 weeks followed by low dose of streptozotocin resulted in frank hyperglycemia, hyperinsulimemia and insulin resistance. these findings were consistent with the published data of different studies.12 we used tg: hdl ratio of 1.8 as cut off point for presence of insulin resistance. in both groups after inducing t2dm it was more than 1.8. however, in a study by srinivasan, hyperinsulinemia (467.50 ± 32.43 pmol/l) was taken as the indicator of insulin resistance in high fat fed rats.12 aloevera and rosiglitazone combine supplementation in the present study has resulted in statistically significant (p<0.00001) reduction in plasma glucose levels when compared with diabetic control group even when half of their effective doses were used. to latest literature, survey has revealed that no study has so far been conducted in which aloevera extract and rosiglitazone are used in combination to treat type 2 diabetes mellitus. however, our results are encouraging when compared with studies where these drugs are used alone for t2dm. the work of tanka et al on diabetic mouse strain bks cg-m lepr (db/db) with aloe vera gel extract resulted in significant (p<0.05) reduction in fasting plasma glucose level by 64% in diabetic mice when treated for 35 days.16 our study revealed 73%% reduction in plasma glucose level in combined group. the desired results in tanka study were obtained after 35 days of treatment, while duration of our study was shorter (21 days) with much better results. this may be due to synergistic effects of aloevera and rosiglitazone in combined group. 162 j i m d c 2 0 1 7 162 table 2: after treatment comparison of plasma glucose, mda and lipid profile between groups (n=20) variables diabetic control group (n=10) mean±sd treatment group (n=10) mean±sd p value plasma glucose (mmol/l) 19.05 ± 1.70 5.14 ± 0.25 <0.000 mda (µmol/l) 10.06 ±1.07 3.65 ± 0.39 <0.000 triglyceride (mmol/l) 3.96 ± 0.41 1.98 ± 0.14 <0.000 cholesterol (mmol/l) 4.54 ± 0.21 2.45 ± 0.13 <0.000 hdlcholesterol (mmol/l) 0.40 ± 0.08 0.50 ± 0.07 0.0005 ldlcholesterol (mmol/l) 3.26 ± 0.40 1.6± 0.22 <0.0000 vldl – cholesterol (mmol/l) 0.79 ± 0.07 0.4± 0.71 <0.000 in our study whole leaf extract rather than only gel part of aloevera. was used which may also contribute towards better results in short time of 21 days rather than 35 days taken by tanka study. in their study, they also identified five phytosterol but all did not show antihyperglycemic effects, supporting the documented observation regarding the synergistic action of number of constituents rather than one component alone.17 in present study, oxidative stress was measured by estimating the levels of mda in plasma. the concentration of mda in diabetic group was 10.06 ±1.07 µmol/l which could be due to high fat diet (hfd) and streptozotocin treatment which generally induces oxidative predominance in tissue by generating reactive oxygen species.18 the mda levels decreased by 64% in combined group which could be due to its antioxidant properties as aloe vera has been reported to have strong antioxidant potential than alpha tocopherol.19 it has been documented that aloevera extract normalized the deranged plasma glucose and lipid status and improved the antioxidant status, which may also contribute in lowering oxidative stress.20 aloevera can contribute to its antioxidant status due to presence of vitamins (c, e,) enzymes (gpx, sod, catalase).21 the combined group results can be attributed to its synergistic action. in a study conducted by can et al reported the effect of aloevera leaf gel and pulp extract had reduced the mda levels by 18% and 13% respectively. they attributed the antioxidant effect to alerosin derivative present in latex.22 plasma mda levels of our study were more profound than cans’ study. this may be due to the longer duration of treatment in our study design. secondly, they had used gel and pulp of aloevera separately while we used whole leaf extract. the antioxidant potency of aloevera is already known which was attributed to the presence of aloe emodin present in the gel.23 however in our study we had removed aloe emodin and still a significant (64%) decrease in mda level was observed despite half the effective dose of drug was used. this could be due to synergistic action of aloevera and rosiglitazone when used in combination. in the present study, after intake of hfd for three weeks the diabetic rats showed severe derangements in plasma lipid profile because intake of high fat diet was associated with increase in plasma triglycerides, cholesterol, ldl, vldl and decrease in hdl levels, similar to previous studies.24 combined group supplementation in the present study has resulted in statistically significant (p<0.00001) improvement in plasma tg, cholesterol, ldl, vldl and hdl levels when compared with diabetic control group. combined group reduced the levels of tg’s by 50%, cholesterol 46%, ldl 51%, vldl 49% and increased hdl by 25% as compared to diabetic rats at the end study. these results were better than when aloevera was used alone. no study is available, in which aloevera and rosiglitazone is used in combination in half of their effective dose. however, aloevera used alone showed antilipidemic effects. the findings are supported by the published data of different studies. a study by kim et al revealed that processed aloevera gel has significantly reduced tg and raised hdl with no effects on cholesterol despite 8 weeks of treatment. they attributed this effect to reduced lipogensis and which was assessed/analyzed by the decrease in adipocyte size.25 our study results were much better due to usage of whole leaf extract as well as synergistic action of two drugs despite their usage in half of their effective dose. a study on aloe vera gel high molecular weight fractions (ahm), 163 j i m d c 2 0 1 7 163 given to fifteen patients with uncontrolled t2dm.the results revealed a significant reduction in tg with no effect on cholesterol level.26 however our study in combined group showed statistically significant results on tg, cholestrol, vldl and ldl while rise in hdl level. in combined group. this may be due to the fact that only a fraction from aloevera gel was separated and used in this study. it has been reported that despite small solid contents of aloevera, its multiple therapeutic effects of aloevera are due to the synergestic effects of its components. phenolic compounds and saponins are known to reduce hyperlipidemia in diabetes.27 the hypoglycemic effect of aloevera extract may be implicated as the major reason for the observed antihyperlipidemic effect of the extract because glycemic control is the major determinant of total cholesterol, vldl, and triglyceride levels. aloe chrome increases insulin sensitivity by increasing adiponectin level. five chromones have been identified in aloe vera extract.28 phytosterol, lophenol (lo) and cycloartanol (cy), may act as ligand for ppar.29 rosiglitazone is a known antidiabetic drug of thiazolidinediones family. it has been used for the treatment of type 2 dm since 1991. it increases insulin sensitivity and improves glycemic control. it also acts as a ligand for the gamma subtype of peroxisome proliferators activated receptor (ppargamma), which is directly involved in the regulation of genes controlling glucose homeostasis and lipid metabolism. 30 in our study the plasma glucose levels are reduced by 73%%, tg 50%, cholesterol 46%, ldl 51%, vldl 49% with concomitant increase in hdl by 25% despite the fact that half of its effective dose were used. these findings of combined are similar to many clinical trials carried in the past when rosiglitazone were used alone. however, no study is available in literature for using alevera and rosiglitazone in combination. in a study conducted by atanasovska et al, rosiglitazone treatment in a dose of 5mg/kg body weight to fructose induced metabolic syndrome winstar rats resulted in a statistically significant (<0.001) decreased in plasma glucose and tg.31 they concluded that these effects may probably involve a regulation of the enzyme lipoprotein lipase in the adipose tissue.32 it has been reported in that a patient receiving 4mg/kg body weight of rosiglitazone showed signs and symptoms of hepatocellular injury. discontinuation of treatment was advised to him.33 the volume overload is responsible for heart failure associated with thiazolidines rather than direct effect on cardiac function.34 however in our study with 2.5mg/kg body weight of rosiglitazone along with aloevera in combination resulted in effective reduction in glucose lipids and mda level. this will help in reducing the side effects associated with drug. c o n c l u s i o n the data of our study has revealed encouraging results which could help evolve new strategy of treatment for t2dm. the use of natural herb with synthetic drug may help to lessen the financial burden associated with this disease. in addition, the side effects associated with prolong use of rosiglitazone such as myocardial infarction and heart failure due to high ldl. it has been suggested that use of lipid lowering drug may reduce this risk. our study has beneficial effect on normalizing the oxidative stress and lipid profile, in type 2 diabetics. it demands for a study on human t2dm patients by using aloevera with rosiglitazone in half the effective dose to explore a new combination of treatment. r e f e r e n c e s 1. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care 2010; 33(1): 562–569. 2. moussa, s. a. oxidative stress in diabetes mellitus, romanian j. biophys. bucharest.2008; 18(3): 225– 236. 3. kumawat. m. pahwa m. b. gahlaut, v.s. and singh, n. status of antioxidant enzymes and lipid peroxidation in type 2 diabetes mellitus with microvascular complications. open. endo. j. 2009; 3(1): 12-15. 4. yoshida, k., hirokawa, j., tagami, s., kawakami, y., urata, y. and kondo, t. weakened cellular scavenging activity against oxidative stress in diabetes mellitus: regulation of glutathione synthesis and efflux. diabetologia, 1995; 38(2): 20110. 5. dey. s. k., jayashree, d. sanjukta, p. and debasmita, p. changes in the antioxidative enzyme activities and lipid peroxidation in wheat seedlings exposed to cadmium and lead stress. braz. j. plant physiol. 2007; 19(1): 53 60. 6. armstrong, d. and browne, r. the analysis of free radicals, lipid peroxides, antioxidant enzymes and compounds to oxidative stress as applied to the clinical chemistry laboratory. adv. exp. med biol. 1994; 366: 4358. 164 j i m d c 2 0 1 7 164 7. maritim, a.c., sanders, r.a. and watkins, j. b. diabetes, oxidative stress and antioxidants: a review, j. biochemi. mol. toxicol.2003; 17(1): 24– 38. 8. zaman k. medicinal plants with hypoglycemic activity. journal of ethnopharmacology. 1989 jun 1;26(1):1-55. 9. yeh y, kaptchuk t, eisenberg m. systemic review of herbs and dietary supplements for glycemic control in diabetes. diabetic care 2003; 26(4):127-94 10. kaul s, bolger af, herrington d, giugliano rp, eckel rh. thiazolidinedione drugs and cardiovascular risks: a science advisory from the american heart association and american college of cardiology foundation. journal of the american college of cardiology. 2010; 55(17):1885-94. 11. qiu, z., jones, k. wylie, m. jia, q. and orndorff, s. modified aloe barbadensis polysaccharide with immunor egulatory activity. planta med. 2000; 66(2), 152–156. 12. srinivasan. k, viswanad b, asrat l, kaul c.l and ramarao p. combination of high-fat diet-fed and low-dose streptozotocin-treated rat: a model for type 2 diabetes and pharmacological screening. pharmacol. res. 2005; 52(4): 313-20. 13. mclaugin t, abbasi f, cheal k, chu j, lamendola c, reaven g.use of metabolic markers to identify overweight individuals who are insulin resistant. ann intern. med. 2003;139(10): 8029. 14. trinder p. determination of blood glucose using 4-amino phenazone as oxygen acceptor. j. clin. pathol.1969; 22(2): 246-49. 15. friedewald, w.t., levy, r.i. and fredrickson, d.s. estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. clin. chem.1972; 18(6): 499-502 16. shera. a. s, fawad f and maqsood, a. prevelance of diabetes in pakistan. diabetes.res.clin practice.2007; 76(2): 219-222. 17. tanka. m. misawa. e. ito,y. habara, n. nomaguchi, k. yamada, m. toida,t. hayasawa,h. takase, m. masanori, i. and ryuuichi, h. identification of five phytosterol from aloe vera gel as antidiabetic compounds. bio. pharm. bull. 2000; 29(7): 1418 22. 18. choi. s., and chung m. h. a review on the relationship between aloe vera components and their biological effects. semin. integr. med. 2003; 1(1): 53-62. 19. kamal, a. and mohamed, a. n. effect of carnitine and herbal mixture extract on obesity induced by high fat diet in rats. diabetology metabolic syndrome.2009; 1(17): 1-14. 20. saritha. v., anilakumar. k. r. and farhath. k. antioxidant and antibacterial activity of aloe vera gel extracts. int. j. pharm. bio. arc. 2010; 1(4): 376-384 21. rajasekaran s, sivagnanam. k. and subramanian. s. antioxidant effect of aloe vera gel extract in streptozotocininduced diabetes in rats. pharmacol reports.2005; 57(1): 90-96. 22. shane-m.w. l. biological complementary therapies: a focus on botanical products in diabetes. diabetes spectrum.2001; 14(4):199–208. 23. can. a. akev. n. ozsoy. n. bolkenet.s. pelin. a. effect of aloe vera leaf gel and pulp extracts on the liver in type-ii diabetic rat models. biol. pharm.. bull.2004; 27(5): 694— 98. 24. chandan. a.b., saxena, z. sukla, s. sharma, n. gupta, k. suri, k. and singh. b. hepatoprotective potential of aloe barbedensis mill. against carbon tetrachloride induced hepatotoxicity. j. ethnopharmacol. 2007; 111(3): 560 -66. 25. parveen, k. and siddiqui, w. protective effect of butea monosperma on high fat diet and streptozotocin induced non genetic rat model of type 2 diabetes: biological and histological evidences. int. j. pharm. pharm. sci.2011; 3(3): 74-81. 26. kim, k., kim, h. kwon,.j. lee, s. kong,.h. lee, y. young,.l. oh, s. chong, k. kyungjae, k. hypoglycemic and hypolipidemic effects of processed aloe vera gel in a mouse model of non-insulin-dependent diabetes mellitus., phytomedicine.2009; 16(9): 856–63. 27. yagi. a. hegazy, s. kabbash, a. and wahab, e. (2009). possible hypoglycemic effect of aloe vera high molecular weight fractions on type 2 diabetic patients. saudi. pharma. j.2009; 17(3): 20915. 28. nimenibo-uadia r. effect of vernonia amygdalina in alloxan induced diabetic albino rats. j. med. lab. sci. 2003; 12(1): 25-31. 29. mesfim. a., yiman, jifu, z. jennifer, h. yuan, and et al. aloe chrome improve sensitivity by increase of adiponectin level and their potential in maintaining healthy blood glucose level. j. pharmacol. exp. ther. 2008; 298(1): 2408. 30. nomaguchi.k., miyuki tanaka, m. misawa, e. yamada, m. toida, t. iwatsuki, k. and et al. aloevera phytosterols act as ligands for ppar and improve the expression levels of ppar target genes in the livers of mice with diet-induced obesity. obes. res.clini. pract. 2011; 5(3): e190 e201. 31. day, c.thiazolidinediones: a new class of antidiabetic drugs. diabet. med. 1999; 16(3): 17992 32. atanasovska. e., jakovski, k.. kostova, e. petlichkovski, .a. dimitrovski, c. bitovska, i. and et al. effects of rosiglitazone on metabolic parameters and adiponectin levels in fructose-fed rats. maced. j. med. sci.2009; 2(1): 22-29. 33. laplante. m., festuccia w.t. and soucy g. i.mechanisms of the depot specificity of peroxisome proliferator-activated receptor gamma action on adipose tissue metabolism. diabetes. 2006;55(10):2771-78. 34. salman, j., kemp. g. arjom. h. mitta. m. hepatocellular injury in a patient receiving rosiglitazone. ann. intern. med.2006; 132 (2): 118-121. 150 j i m d c 2 0 1 7 150 op e n ac c e ss c a s e r e p o r t lingual thyroid presenting as an asymptomatic pedunculated oropharyngeal mass ghulam saqulain1, jawwad ahmed2, muhammad mumtaz khan3, nahida nawaz4 1 head, department of ent, capital hospital, islamabad 2 associate surgeon ent department, capital hospital, islamabad 3 professor, department of pathology, peshawar medical college, peshawar 4 postgraduate trainee ent department, capital hospital, islamabad, a b s t r a c t lingual thyroid is a rare developmental anomaly and constitute 90% of ectopic thyroids, first described by hickman in 1869. lingual thyroid are usually symptomatic and commonly cause dysphagia and dyspnea and are rarely asymptomatic. they are usually seen arising from the tongue base in the midline. we report a very rare case of lingual thyroid in a 38-year-female presenting as an asymptomatic pedunculated mass in the oropharynx arising from the tongue base from the left side. the occurrence of lingual thyroid as a pedunculated virtually asymptomatic mass is very rare and literature search did not reveal a case of pedunculated lingual thyroid in this region. this case report highlights that lingual thyroid very rarely can present with pedunculated superficial mass and should be considered in the differential diagnosis of oropharyngeal masses. key words: ectopic thyroid, lingual thyroid, pedunculated mass address of correspondence ghulam saqulain email: ghulam_saqulain@yahoo.com article info. received: january 24, 2018 accepted: may 12, 2018 cite this case report: saqulain g, ahmed j, khan mm, nawaz n. lingual thyroid presenting as an asymptomatic pedunculated oropharyngeal mass. 2018; 7(2):150-153. funding source: nil conflict of interest: nil i n t r o d u c t i o n ectopic thyroid is a rare developmental anomaly first documented by hickman in 1869, which results from fault in descent from the foramen cecum to the pre-tracheal position (in front of 2nd, 3rd and 4th tracheal rings) and the thyroid tissue may be sequestered anywhere along this embryologic path.1 in case of lingual thyroids (lts) which constitute 90% of ectopic thyroids, a remnant or whole of the thyroid fails to descent and is found at the base of tongue.2 microscopic thyroid tissue is present in 10% population at this location of which 0.01% develop lingual thyroids. usually lts are asymptomatic are very rare and incidentally found.3 we present a very unusual and rare case of lingual thyroid, which presented to us without any classic symptoms and as a pedunculated swelling from the tongue base from the left side. the unusual presentation, diagnosis and management is described. literature search did not reveal any case presenting as an asymptomatic pedunculated lt, however a case of lt placed superficially on tongue which posed a threat to the airway was noted.4 the rarity is worth documenting this case, and highlights the importance of considering lt in the differential diagnosis of oropharyngeal masses. c a s e r e p o r t a 38-year-old diabetic female presented to the otolaryngology outpatient with a 3 days’ history of sore throat. intraoral examination was consistent with acute pharyngitis and interestingly a post lingual swelling, which was provisionally diagnosed as a vallecular cyst. an endoscopic examination a week later following treatment c a s e r e p o r t 151 j i m d c 2 0 1 7 151 of the acute pharyngitis revealed a pedunculated 2 cm diameter mass arising from the tongue base on the left side with smooth surface (figure 1). other intraoral structures were normal, with palatine and lingual tonsils situated at their normal locations. with a barely palpable thyroid in its normal anatomical location, no other swelling/ palpable lymph nodes was noted in the neck. figure 1: photograph of lt a) preoperative endoscopic view showing lt arising from tongue base with a peduncle and b) peroperative view with dingman’s mouth gag in place and showing lt (1) ready to be removed patient’s baseline laboratory investigations, including thyroid function tests were within normal limits. radio nucleotide imaging with tc 99m-pertechnetate revealed a normal-sized thyroid image with homogenous radiotracer uptake in the pre-tracheal location, however swelling at the base of tongue showed tracer uptake suggestive of lt (figure 2). figure 2: thyroid scan with technetium (tc 99m) showing isotope uptake at the normal thyroid location in the neck as well as uptake at the tongue base. magnetic resonance imaging (mri) scan with contrast (figure 3) revealed a soft tissue density lesion measuring 12 mm tr x 13 mm ap x 16 mm ccl in oropharynx arising from the left side of the base of tongue and projecting within oropharyngeal cavity. it demonstrated intermediate signal on t1w and high signals on t2w sequences with significant post contrast enhancement, consistent with lingual thyroid. thyroid gland was also seen located in its pre-tracheal location. no cervical lymphadenopathy noted. keeping in view the posterior placement on tongue base and pedunculated nature of the swelling, fnac was not considered. figure 3: mri scan (gadolinium enhanced) with both sagittal view (a) and axial view (b), showing a soft tissue density lesion (lt) measuring 12 in transverse, 13 mm in anterio-posterior and 16 mm in craniocaudal direction, arising from left side of the tongue base and projecting into the oropharynx. after taking informed consent, trans-oral surgical removal of the mass was done under general anaesthesia and endotracheal intubation. the mass was carefully approached in tonsillectomy position with dingman’s mouth gag in place followed by removal of the mass with ligation of the pedicle arising from the tongue left side of the tongue base (figure 4). figure 4: surgical specimen of lt, measuring approx. 2 cm craniocaudally and transversely with a pedicle. 152 j i m d c 2 0 1 7 152 post-operative recovery was uneventful and diet restored 6 hours post operatively. the diagnosis was supported by histopathological examination, which revealed normal thyroid tissue (figure 5). no evidence of malignancy noted. one-year follow-up was maintained with no recurrence. figure 5: photomicrograph, showing thyroid follicles which are lined by columnar cells. follicles are filled with eosinophilic colloid (h&e: 10x100). d i s c u s s i o n ectopic thyroid is a developmental anomaly, commonly occurring at four areas of the aerodigestive tract including lingual, sublingual, thyroglossal and intra-laryngotracheal, with lingual location being the commonest with prevalence between 1:100000 to 1:300000.5 patil ys et al., noted a prevalence of lingual thyroid of 1:2400.1 ting gu et al., reported a frequency of lt as 64 %, sublingual 17 %, in 12 % it was found at two locations and, other locations in 7 % cases.6 a female predominance is noted6 with a male to female ratio of 1: 5.1 usual age of occurrence is between 5 months to 40 years of age7 and commonly arising at growth spurts like puberty and menstrual age. in 70 -80% cases, ectopic thyroid is the only functional thyroid tissue.8 pathogenesis is uncertain.9 ting gu et al., in a study found high levels of marker, ttf-1(thyroid transcription factor-1) in ectopic tissue and postulated that this could be related to abnormal development of embryo leading to the ectopy.6 lts are usually symptomatic. symptoms include swallow difficulty in swallowing,1,9,10, dysphonia,1,8 pain, cough, airway difficulty,11 hemorrhage,12 and patient may also present with symptoms of hypothyroidism 12. rashid et al., in a local study have reported a case of snoring and sleep apnea 13, and severe sleep apnea may also result.14 very rarely it may be asymptomatic and found incidentally 3, as in our case. presence of a mass at the foramen cecum should raise suspicion and warrant thorough head and neck evaluation, which must include neck palpation for thyroid gland, neck nodes and laryngeal examination. when available endoscopic examination can give important information like status of larynx and hypopharynx, exact site and size of the mass including surface characteristics like ulceration, bleeding etc.12 in this case endoscopic examination was rewarding and site, size, surface and a peduncle was outlined, making surgical decision easier. literature highlights role of preoperative imaging modalities like thyroid scintigraphy and ultrasonography.1 according to fiaschetti et al., radionucleotide imaging with tc 99m-pertechnetate can be confirmatory for diagnosis of lt. it can detect ectopic thyroid tissue including lt and confirm presence or absence of thyroid in the normal pre-tracheal location 3, 7. ultrasonography (us) has contributory role.7,15 in one study color doppler us showed a sensitivity of 90% compared to 70% for grayscale us and mri 16. mri, and ct are useful modalities in doubtful cases. mri has been used for the diagnosis of lingual thyroid18 and displays higher density for thyroid tissue on t1 and t2-weighted images.15 in our case thyroid scintigraphy revealed the thyroid gland in its normal location as well as the lt and an mri scan demonstrated the size of the pedunculated lt and contrast enhancement. fine needle aspiration cytology (fnac) is helpful in differentiation between benign and malignant lesions.18 keeping in view the pedunculated nature of the mass, need of fnac was not felt rather excision biopsy was preferred. differential to be considered with lingual thyroid include other tongue base swellings like vallecular cyst, lingual tonsils, mucous retention cysts, hemangioma, lymphangioma, thyroglossal cysts and salivary tumors,19 however in this case, rare conditions like lingual osseous choriostoma, that can present as pedunculated mass were also considered.20 rarely carcinoma may also develop in a lt.2 surgical removal is the preferred treatment option for symptomatic cases like those having airway compromise, severe dysphagia and hemorrhage.12 thyroid hormone suppression therapy for early cases12,21 and in refractory cases, levothyroxine for suppression and 153 j i m d c 2 0 1 7 153 radioiodine ablation is considered.1 a number of surgical approaches are advocated, depending upon the size, extent and symptomatology including endoscopic, transoral, and trans-cervical and combined approaches.22 trans-oral approach is the least traumatic and provides reasonable approach with better recovery,1 it also proved most suitable for the present case. the present case is very rare and unusual, with an asymptomatic, pedunculated lt measuring 12 mm tr x 13 mm ap x 16 mm ccl length arising from the left side of the base of tongue and projecting within oropharyngeal cavity along with a normal thyroid in the pre-tracheal location on mri scan and thyroid scintigraphy in a 38year-female who visited the otolaryngology outpatients for upper respiratory tract infection, and thus incidentally picked and diagnosed to have lt. though asymptomatic, with thyroid in normal location and normal hormone analysis, keeping in view the pedunculated nature a transoral surgical excision was done without any complication and recurrence. c o n c l u s i o n lingual thyroid may rarely be encountered as asymptomatic pedunculated mass arising from the tongue base and should be considered in the differential diagnosis of oropharyngeal masses. r e f e r e n c e s 1. patil ys, rajashekhar rp, karodpati ns, thomas j. lingual thyroid. a case series of six lingual thyroid with incidence and different treatment modalities. int j head neck surg. 2015; 6(3):103-8 2. massine re, durning sj, koroscil tm. lingual thyroid carcinoma: a case report and review of the literature. thyroid. 2001; 11(12):1191-6. 3. fiaschetti v, claroni g, scarano al, schillaci o, floris r, diagnostic evaluation of a case of lingual thyroid ectopia. radiology case reports. 2016; 11(3):165-70 4. buckland rw, pedley j. lingual thyroid – a threat to the airway. anesthesia.2001; 56(4):386. 5. sauk jj. lingual thyroid. j pathol. 1970; 102(4):239-43. 6. gu t, jiang b, wang n, xia f, wang l, gu a et al. new insight into ectopic thyroid glands between the neck and maxillofacial region from a 42-case study. bmc endocr disord. 2015; 15(1): 70. 7. noussios g, anagnostis p, goulis dg, lappas d, natsis k. ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity. eur j endocrinol. 2011; 165(3):375-82. 8. yoon js, won kc, cho ih, lee jt, lee hw. clinical characteristics of ectopic thyroid in korea. thyroid. 2007; 17(11): 1117-21. 9. amr b, monib s. lingual thyroid: a case report. int j surg case rep. 2011; 2(8):313-15. 10. gallo a, leonetti f, torri e, manciocco v, simonelli m, devincentiis m. ectopic lingual thyroid as unsusual cause of severe dysphagia. dysphagia. 2001;16(summer 3):220-23 11. buckland rw, pedley j. lingual thyroid a threat to the airway. anaesthesia. 2000; 55(11):1103-5 12. williams jd1, sclafani ap, slupchinskij o, douge c. evaluation and management of the lingual thyroid gland. ann otol rhinol laryngol. 1996;105(4):312-6. 13. rashid m, majeed s, tariq km, inam-ul-haq, niwaz a, saeed a. lingual thyroid as a cause of snoring and sleep apnoea. j coll physicians surg pak. 2004; 14(11):681-2 14. manzi b, henry ho. non-functional lingual thyroid presenting with severe obstructive sleep apnea, acta oto-laryngologica case reports. 2016; 1(1):8-11. 15. bersaneti ja, silva rd, ramos rr, matsushita mde m, souto lr. ectopic thyroid presenting as a submandibular mass. head neck pathol. 2011; 5(1):63–66. 16. ohnishi h, sato h, noda h, inomata h, sasaki n. color doppler ultrasonography: diagnosis of ectopic thyroid gland in patients with congenital hypothyroidism caused by thyroid dysgenesis. j. clin. endocrinol. metab. 2003; 88(11): 5145– 49. 17. khamassi k, jaafoura h, masmoudi f, lahiani r, bougacha l, ben salah m. ectopic lingual thyroid. case rep pediatr. 2015:252357. doi: 10.1155/2015/252357. 18. wang cy & chang tc. preoperative thyroid ultrasonography and fine-needle aspiration cytology in ectopic thyroid. american surgery. 1995; 61(12):1029–31. 19. chawla m, kumar r & malhotra a. dual ectopic thyroid: case series and review of the literature. clin nucl med. 2007;32(1):1-5. 20. davidson s, steiner m, nowichi m. lingual osseous choristoma. j pediatr.2016;168:247. 21. castro ph, volpato le, tramujas j, borges ah. ectopic thyroid at the base of the tongue of a young patient. case rep dent. 2016:9174970. 22. toso a, colombani f, averono g, aluffi p, pia f. lingual thyroid causing dysphagia and dyspnoea. case reports and review of the literature. acta otorhinolaryngologica italica. 2009; 29(4):213-17. 97 j i m d c 2 0 1 8 97 open access f u l l l e n g t h a r t i c l e frequency of surgical site infection in response to single dose antibiotic prophylaxis in lumbar intervertebral disc excision rayif rashid kanth1, muhammad mujahid sharif2, masood mukhtar3, ahsan akhtar khan4 1 assistant professor, department of neurosurgery, akbar niazi teaching hospital islamabad 2,3 consultant neurosurgeon, fauji foundation hospital rawalpindi 4 assistant professor, ortho and spinal surgery, fauji foundation hospital rawalpindi a b s t r a c t objective: to measure the frequency of infection with single dose antibiotic prophylaxis in surgery for intervertebral disc prolapse. patients and methods: this cross-sectional study was conducted at the department of neurosurgery, pakistan institute of medical sciences, islamabad for ten months. in total 400 patients both male and female, undergoing surgery for lumbar disc herniation (single level lumbar intervertebral disc), meeting inclusion criteria, were selected for the study. postoperative frequency of surgical site infection was measured using redness, pain, raised local temperature and wound discharge as diagnostic criteria. postoperative surgical site infection was measured using the above criteria scale on 3rd postoperative day and 15th postoperative day. the frequency of infection in the studied patients on day 3 and day 15 was calculated. p-value of <0.05 was considered as statistically significant. results: out of total 400 patients, 290 were males and 110 were females, the age distribution was from 24 to 70 years. mean age was 48.2± 10.8 sd. esr for the patients ranged from 2 to 36 with a mean of 11±4.6. white cell count of the patients ranged from 2900 to 20100 with a mean of 7342±2100. only 7 patients (1.7%) developed infection on third day of surgery and it persisted in only 4 patients (1%) till day 15 of surgery. conclusion: single dose preoperative antibiotic is effective in postoperative wound infection prophylaxis. this protocol if followed can prevent drug resistance and multiple doses related side effects and can cut hospital cost. key words: antibiotic prophylaxis, infection, intervertebral disc prolapse, single dose antibiotics, surgical site. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2,3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence rayif rashid kanth email: rayif.kanth@gmail.com article info. received: december 10, 2017 accepted: april 14, 2018 cite this article. kanth rr, sharif mm, mukhtar m, khan aa. incidence of surgical site infection in response to single dose antibiotic prophylaxis in lumber intervertebral disc excision. jimdc.2018; 7(2):97-101 funding source: nil conflict of interest: nil i n t r o d u c t i o n disc prolapse is the most common cause of sciatica with lesions occurring most often at l4-l5 and l5-s1 segments.1 approximately 12–33% of the adult work force is affected by low back pain each year. 2 it has been suggested that between 70 95% of adults will suffer from low back pain at some time during their life time.3 unlike other orthopedic disorders, the expenses associated with management of back pain have increased over the last 20 to 30 years.4 despite continuous clinical and scientific efforts, low back pain remains an ever-present, quality-oflife-related, health problem.5 the lumbar intervertebral disc is susceptible to injury and early degeneration, which often results in pain and disability.6 to effectively cure these problems, treatment of symptomatic lumbar disc o r i g i n a l a r t i c l e 98 j i m d c 2 0 1 8 98 herniation has continuously evolved.7 surgeons have tried to reduce operative trauma to the spine by adopting minimally invasive techniques which are used to treat single-level disc injury in working-age adults.8-10 despite widespread use of this technique, there are few reports of long-term results.11 early success rates ranging from 70– 91% have been reported.12 with proper patient selection, surgery for lumbar disc herniation and sciatica can be expected to lead to excellent results in the majority of patients.13-15 surgical site infection is one of the most common complications that a surgeon encounters, with an infection occurring after approximately 780,000 operations in the united states each year.16 the use of antibiotic prophylaxis in orthopedic surgery has been shown to be beneficial.17 the incidence of postoperative infections has been estimated at 0.7 to 11.9% of spinal operations.18 several factors are known to increase rates of postoperative infections in common procedures, such as spinal fusions and laminectomies, according to the national nosocomial infection surveillance report. instrumentation has been shown to increase the rate of infection to 3 to 6%, as has malnutrition, extended pre-surgical hospital stay, and increased blood loss.19-21 postoperative spinal wound infections are painful and can lead to poor cosmetic outcomes if allowed to heal by secondary intention.22 the expense is considerable as well. the cost of medical care incurred during the course of a lumbar fusion, complicated by deep wound infection may be three or four times higher than the cost of an uncomplicated fusion.23 antibiotics should be administered within sixty minutes prior to the incision and, ideally, as near to the time of the incision as possible.24 a single dose of antibiotics may be adequate for prophylaxis against perioperative infection.25 the objective of this study is to measure the frequency of wound infection following lumbar disc surgery in patients receiving a single dose of antibiotic prophylaxis. decrease in frequency can lead to shorter hospital stay, fewer costs to the health care facilities, and lesser chances of antibiotic adverse reactions and resistance to antibiotic therapy, thus reducing costs and more free beds available to our overcrowded and overburdened health care system. p a t i e n t s a n d m e t h o d s this cross-sectional study was conducted at the department of neurosurgery, pakistan institute of medical sciences islamabad from march 2013 to february 2014. sample size was calculated through who calculator with the 95% confidence level, 4.3% anticipated population proportion and 2% absolute precision. calculated sample size was 396 individuals.7 total four hundred patients, of both sexes, undergoing surgical intervention for lumbar disc surgeries and meeting inclusive and exclusive criteria were included in the study. all patients having prolapsed inter vertebral disc of either gender and of any age diagnosed on mri scans having significant prolapsed intervertebral disc were included in the study. these patients were operated under same type of anesthesia and antibiotic protocol. the patients who had co morbid conditions including malnutrition, diabetes mellitus, endstage renal disease, cirrhosis of liver, ischemic heart disease, those receiving immunosuppressant drugs, aids, patients with multiple level disc disease, patients with pre-operative symptoms and signs of any infection, patients with csf leaks, patients undergoing reexploration were excluded from the study. the study was approved by hospital ethical committee. informed consent was taken from the patient or guardian. the data on each of the patient was collected using predesigned proforma. each patient was given broad spectrum antibiotics i.e. inj. ceftriaxone 1gm intravenous (third generation cephalosporins) as per study protocol. the surgery was performed by a consultant neurosurgeon. each patient was examined for clinical features of infection on 3rd and 15th postoperative day. clinically suspected cases were confirmed by local wound examination and complete blood picture with esr. the complication free patient was discharged on 3rd postoperative day and considered normal if no clinical features of infection appear till 15th postoperative day. telephonic contact and address of the patient was taken to ensure follow up. data was analyzed using spss version 12. mean ± s.d were calculated for numerical variables. frequencies and percentages were calculated for categorical variables. 99 j i m d c 2 0 1 8 99 r e s u l t s out of 400 patients, 290 (72.5%) were males and 110 (27.5%) were females. age range of the patients was 24 to 70 years.highest number of patients were between the ages of 45 years to 54 years and lowest number of patients were between 24 years to 34 years. the esr of the patients ranged between 2-36 mm/hour. the wbc counts ranged from 2900 to 20100 / cmm (table 1). infection status at day 3 and day 15 of surgery was obtained using the proforma charting and categorizing the patients according to their findings. at day 3, pain was present in large number of patients (29.75%) followed by raised temperature (21.25%), redness (16.25%) and discharge (3%). at day 5, frequency of these symptoms decreases. pain was present in 3.75% patients followed by raised temperature (2%), discharge (1.5%) and redness (0.25%) (table 2). table 2: frequency of clinical features in study participants at day 3 and day 15 (n=400) day 3 day 15 variables n(%) n(%) redness yes no 65 (16.25) 335 (83.75) 1(0.25) 399(99.75) pain yes no 119 (29.75) 281 (70.25) 15(3.75) 385(96.25) raised temperature yes no 85(21.25) 315(78.75) 8(2) 392(98) discharge yes no 12(3) 388(97) 6(1.5) 394(98.5) based upon these findings, at day 3, infection was declared in 7 patients (1.7%). later on at day 15, infection was present only in 4 patients (1%). these patients were continued with their admission. wound toilet and re suturing was done once the infection was cleared. table 3 shows gender-wise status of patients at day 3 and day 15. mean age of patients having infection at day 3 and day 15 was 44.3±8.1 and 46±7.2 years respectively. at day 15, mean esr and wbc count were more 21.1±11 mm/hour and 13400±4390 /cmm respectively in patients suffering from infection, as compared to patients having no infection (table 4). d i s c u s s i o n surgical site infection is a devastating complication in spine surgeries.1 it prolongs the duration of the hospital stay, increases medical expenditures, the likelihood of an intensive care unit stay, and the incidence of readmission as well as increases the risk of mortality and worsens the quality of life.2 a vast majority of surgical infections can be preventable with appropriate interventions. evidencebased practices resulted in three main focuses for antibiotic administration: appropriate selection of antibiotics, administration of antibiotics within 30-60 min before incision, and discontinuation of prophylactic antibiotics within 24 hours of surgery.3-5 despite the knowledge about preventing infection and despite the progress of contemporary surgery, infection is still one of the most feared complications of a surgical procedure.6-8 perioperative antimicrobial prophylaxis has long been advocated in certain types of clean and cleancontaminated surgical procedures to decrease the incidence of surgical site infections (ssis).9-11 with increasing health care costs, hospitals and clinics should review procedures to adjust their budgets. concerns of table 1:descriptive characteristics of study patients (n=400) variables mean±sd median min max age of patients (years) 48.2±10.8 47 24 70 esr (mm/hour) 11±4.6 11 2 36 wbc count (/cmm) 7342±2100 7100 2900 20100 table 3: gender and age wise infection status of patients at day 3 and day 15 (n=400) variables day 3 day 15 no infection infection present no infection infection present n (%) n (%) n (%) n (%) gender male female 284 (71) 109 (27.25) 6 (1.5) 1(1.25) 287(71.75) 109(27.25) 3(0.75) 1(0.25) 100 j i m d c 2 0 1 8 100 antimicrobial resistance puts pressure on infection control specialists to decrease antimicrobial usage.12-15 the “ideal” antibiotic for prophylaxis of wound infections in clean surgery should have a relatively low cost, limited toxicity, long half-life in both serum and bone, adequate penetration in subcutaneous and muscular tissues and intervertebral disc, and should be sufficiently broad to be effective but limited enough to avoid resistance and superinfections.21 gram-positive staphylococci are the most common causative pathogens for postoperative infections.22 a first-generation cephalosporin is the most widely accepted choice in spinal surgery because it is active against staphylococcal species, is relatively nontoxic and inexpensive, and it provides good soft tissue and bone penetration. also, first generation cephalosporin has been proved to be more cost-beneficial compared with other wide-spectrum antibiotics such as ampicilinsulbactam.23 ceftriaxone was the suggested prophylactic antibiotic in our hospital. average savings per patient in my study was approximately rs 5000. the remarkable decrease in antibiotic use and costs per procedure was due to no requirement for post-operative doses, in countries with limited resources such as pakistan; even relatively modest savings can have an impact. anderson pa et al 8 conducted a study to provide a narrative review of practical solutions to reduce ssi (surgical site infection) in spine surgery. ssi prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. preoperative warming of patients and timely administration of antibiotics are critical to prevent ssi. radcliff xe et al 21 conducted a study to identify and summarize the recent literature on the incidence, risk factors, diagnosis, prevention, and treatment of ssis after adult spine surgery. they concluded that there are a number of patient and procedure-specific risk factors for ssi. surgical site infection appears to have significant implications from the patients' perspective on outcome of care. diagnosis of ssi appears to rely primarily on clinical factors, while laboratory values such as c-reactive protein are not universally sensitive. similarly, novel methods of perioperative infection prophylaxis such as local antibiotic administration appear to be modestly effective. this study also signifies the importance of single dose of antibiotic in controlling the infection rate. c o n c l u s i o n this study proves that single dose antibiotic is enough for postoperative lumbar wound infection prophylaxis. wound infection must be prevented not managed with multiple dose regimens. these results are comparable to international studies. the choice of antibiotic may vary from hospital to hospital and region to region. r e f e r e n c e s 1. takemoto rc, lonner b, andres t, park j, ricart-hoffiz p, bendo j, goldstein j, spivak j, errico t. appropriateness of twenty-four-hour antibiotic prophylaxis after spinal surgery in which a drain is utilized: a prospective randomized study. jbjs. 2015 ;97(12):979-86. 2. parchi pd, evangelisti g, andreani l, girardi f, darren l, sama a, lisanti m. postoperative spine infections. orthopedic reviews. 2015 ;7(3). 3. bakhsheshian j, dahdaleh ns, lam sk, savage jw, smith za. the use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. world neurosurgery. 2015; 83(5):816-23. 4. martin jr, adogwa o, brown cr, bagley ca, richardson wj, lad sp, kuchibhatla m, gottfried on. experience with intrawound vancomycin powder for spinal deformity surgery. spine. 2014; 39(2):177-84. 5. salsgiver e, crotty j, larussa sj, bainton nm, matsumoto h, demmer rt, thumm b, vitale mg, saiman l. surgical site infections following spine surgery for nonidiopathic scoliosis. journal of pediatric orthopaedics. 2017;37(8): e476-83. 6. warner sj, uppstrom tj, miller ao, o’brien st, salvatore cm, widmann rf, perlman sl. epidemiology of deep surgical site infections after pediatric spinal fusion surgery. spine. 2017 ;42(3): e163-8. 7. alexander gj, butler j, and john. negative-pressure wound therapy in the treatment of complex postoperative spinal wound infections: complications and lessons table 4: laboratory findings of patients receiving a single dose of antibiotic therapy at day 15 (n=400) variables no infection infection present mean±sd mean±sd esr (mm/hour) 10.9±4.1 21.1±11 wbc count (/cmm) 7300±1800 13400±4390 101 j i m d c 2 0 1 8 101 learned using vacuum-assisted closure. j neurosurg spine 2007:6;407–11. 8. devin cj, chotai s, mcgirt mj, vaccaro ar, youssef ja, orndorff dg, arnold pm, frempong-boadu ak, lieberman ih, branch c, hedayat hs. intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery: a multicenter analysis. spine. 2018; 43(1):65-71. 9. anderson pa, savage jw, vaccaro ar, radcliff k, arnold pm, lawrence bd, shamji mf. prevention of surgical site infection in spine surgery. neurosurgery. 2017; 80(3s): s114-23. 10. ramo ba, roberts dw, tuason d, mcclung a, paraison le, moore iv hg, sucato dj. surgical site infections after posterior spinal fusion for neuromuscular scoliosis: a thirtyyear experience at a single institution. jbjs. 2014; 96(24):2038-48. 11. elgafy h, hamilton r, peters n, paull d, hassan a. critical care of obese patients during and after spine surgery. world journal of critical care medicine. 2016; 5(1):83. 12. shearwood mcclelland iii rc, lonner bs, andres tm, park jj, ricart-hoffiz pa, bendo ja, goldstein ja, spivak jm, errico tj. analysis of postoperative thoracolumbar spine infections in a prospective randomized controlled trial using the centers for disease control surgical site infection criteria. international journal of spine surgery. 2016;10 13. oksuz e, deniz fe, gunal o, demir o, barut s, markoc f, erkorkmaz u. which method is the most effective for preventing postoperative infection in spinal surgery?. european spine journal. 2016; 25(4):1006-11. 14. lewkonia p, dipaola c, street j. incidence and risk of delayed surgical site infection following instrumented lumbar spine fusion. journal of clinical neuroscience. 2016; 23:76-80. 15. liu w, neidert mc, groen rj, woernle cm, grundmann h. third-generation cephalosporins as antibiotic prophylaxis in neurosurgery: what's the evidence?. clinical neurology and neurosurgery. 2014; 116:13-9. 16. thakkar v, ghobrial gm, maulucci cm, singhal s, prasad sk, harrop js, vaccaro ar, behrend c, sharan ad, jallo j. nasal mrsa colonization: impact on surgical site infection following spine surgery. clinical neurology and neurosurgery. 2014; 125:94-7. 17. kobayashi k, imagama s, ito z, ando k, yagi h, hida t, ito k, ishikawa y, tsushima m, ishiguro n. is a drain tip culture required after spinal surgery? clinical spine surgery. 2017; 30(8):356-9. 18. swann mc, hoes ks, aoun sg, mcdonagh dl. postoperative complications of spine surgery. best practice & research clinical anaesthesiology. 2016; 30(1):103-20. 19. blumstein gw, andras lm, seehausen da, harris l, ross pa, skaggs dl. fever is common postoperatively following posterior spinal fusion: infection is an uncommon cause. the journal of pediatrics. 2015; 166(3):751-55. 20. boody bs, jenkins tj, hashmi sz, hsu wk, patel aa, savage jw. surgical site infections in spinal surgery. clinical spine surgery. 2015; 28(10):352-62. 21. nandyala sv, marquez-lara a, lee yp. strategies to prevent infection after spine surgery. contemporary spine surgery. 2014; 15(6):1-5. 22. radcliff ke, neusner ad, millhouse pw, harrop jd, kepler ck, rasouli mr, albert tj, vaccaro ar. what is new in the diagnosis and prevention of spine surgical site infections. the spine journal. 2015; 15(2):336-47. 23. pawar ay, biswas sk. postoperative spine infections. asian spine journal. 2016; 10(1):176-83. 24. cassir n, de la rosa s, melot a, touta a, troude l, loundou a, richet h, roche ph. risk factors for surgical site infections after neurosurgery: a focus on the postoperative period. american journal of infection control. 2015; 43(12):1288-91. 25. chen sh, lee ch, huang kc, hsieh ph, tsai sy. postoperative wound infection after posterior spinal instrumentation: analysis of long-term treatment outcomes. european spine journal. 2015; 24(3):561-70. 26. ehlers ap, khor s, shonnard n, oskouian jr rj, sethi rk, cizik am, et al. intra-wound antibiotics and infection in spine fusion surgery: a report from washington state's scoap-certain collaborative. surgical infections. 2016: 17(2):179-86. 59 j i m d c 2 0 1 8 59 open access f u l l l e n g t h a r t i c l e a pattern of antimicrobial sensitivity and resistance in large series of indoor patients at a tertiary care hospital azmat ali 1, fyza saleem 2, awais saeed abbasi 3 1 head of department, medicine department, khan research laboratory hospital, islamabad 2,3 pg medicine khan research laboratory hospital islamabad a b s t r a c t objective: in the era of increasing antibiotic resistance, associated with increasing hospital stay and morbidity, the purpose was to define guidelines for antibiotics in different clinical situations. patients and methods: this study was conducted at khan research laboratories hospital, islamabad, pakistan, from july 2014 to december 2016. 3277 patients admitted in medical, surgical, gynaecology & obstetrics, ent, eye and dental departments were included. positive cultures from different sources including blood, urine, pus, central venous lines, bronchial washings and cervical swabs were taken. age, gender, common pathogens, their sensitivity and resistance to 27 antimicrobial drugs were taken into account. statistical package for social sciences (spss) version 20 was used for data analysis. results: 53.1% (n=1738) were females while 46.9% (n=1539) were males.2800 samples were available for analysis. majority of the patients belonged to medical ward, 56.9% (n=1864). major source of culture was urine, 38.3% (n=1073). escherichia coli (e. coli) was the most common isolate 51.3% (n=1436) followed by staphylococcus aureus 19.9% (n=558). e. coli showed maximum sensitivity to imipenem i.e. 94% (n=1349) followed by amikacin, 93% (n=1335). it was resistant to ceftriaxone (77%).staphylococcus aureus showed maximum sensitivity to linezolid and vancomycin i.e. 98% (n=548) followed by chloramphenicol 84% (n=470), while being resistant to ciprofloxacin and levofloxacin (54%). klebsiella pneumoniae showed maximum sensitivity to imipenem i.e. 75%, while showing resistance to amoxicillin/clavulanic acid (95%) and ceftriaxone (80%).staphylococcus epidermidis showed maximum sensitivity to linezolid i.e.99%. pseudomonas aeruginosa showed maximum sensitivity to piperacillin and tazobactam i.e. 76% . acinetobacter baumannii showed maximum sensitivity to colistin i.e. 91%.salmonella typhi showed maximum sensitivity to ceftriaxone i.e. 99% while resistance to ciprofloxacin (94%).enterococcus faecalis showed maximum sensitivity to linezolid i.e.100% and salmonella paratyphi a showed maximum sensitivities to cefixime and ceftriaxone i.e 100% conclusion: antibiotic resistance is emerging. rationale use of antibiotics is required to curtail the surge of antibiotic resistance. there is also a need to modify treatment guidelines in different clinical situations based on local sensitivity and resistance patterns in order to reduce hospital stay, morbidity and mortality. key words: antimicrobials, bacteria, blood culture, culture, e. coli; imipenem, resistance, sensitivity, urine culture. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence azmat ali email: ali99azmat@gmail.com article info. received: august 20, 2017 accepted: september 11, 2017 cite this article. ali a, saleem f, abbasi as. a pattern of antimicrobial sensitivity and resistance in large series of indoor patients at a tertiary care hospital. jimdc.2018; 7(1):5966 funding source: nil conflict of interest: nil o r i g i n a l a r t i c l e 60 j i m d c 2 0 1 8 60 i n t r o d u c t i o n antimicrobial resistance is recognized as one of the greatest threats to human health worldwide.1 drugresistant infections take a staggering toll in the united states (us) and across the globe. just one organism, methicillin-resistant staphylococcus aureus (mrsa), kills more americans every year (∼19,000) than emphysema, hiv/aids, parkinson's disease, and homicide combined.2 antibiotic resistance is an increasing crisis as both the range of microbial antibiotic resistance in clinical settings expands and the pipeline for development of new antibiotics contracts.3 the first isolation of a bacterium, enables the design of experimental models to analyze virulence and to complete koch's criteria, thereby establishing a link between microorganisms and infectious diseases.4 antimicrobial agents have been greatly important cornerstones of clinical medicine since the second half of the 20th century and have saved a great number of people from life-threatening bacterial infections. however, the last decade of 20th century and the first decade of the 21th century have witnessed the emergence and spread of antibiotic resistance in pathogenic bacteria around the world, and the consequent failure of antibiotic therapy, especially in intensive care units (icus), which has led to hundreds of thousands of deaths annually.5 a pure bacterial culture remains essential for the study of its virulence, its antibiotic susceptibility, and its genome sequence in order to facilitate the understanding and treatment of caused diseases. the first culture conditions empirically varied incubation time, nutrients, atmosphere, and temperature; culture was then gradually abandoned in favor of molecular methods. the rebirth of culture in clinical microbiology was prompted by microbiologists specializing in intracellular bacteria.6 bacterial culture also enables the study of the antibiotic susceptibility of bacteria and is the first step in establishing recommendations for effective treatment. 7,8 a recent study of antibiotic prescribed in primary care for urinary tract infection(uti) in ireland identified that only 55% of antibiotic prescriptions could be interpreted as appropriately targeted when evaluated against the laboratory report on the urine sample.9 the theme of world health day 2011 “antimicrobial resistance: no action today, no cure tomorrow” highlighted antimicrobial resistance as a major issue. the pathogens currently presenting the biggest problem in terms of antimicrobial resistance as the eskape pathogens: enterococcus faecium (e. faecium), staphylococcus aureus (s. aureus), klebsiella pneumoniae (k. pneumoniae), acinetobacter baumannii (a. baumannii), pseudomonas aeruginosa (p. aeruginosa), and enterobacter species.10,11 multiple drug resistance (mdr) is defined as non-susceptibility to at least one agent in three or more antimicrobial categories. extensively drug resistant (xdr) is defined as nonsusceptibility to at least one agent in all but two or fewer antimicrobial categories (i.e. bacterial isolates remain susceptible to only one or two categories). pan-drug resistant (pdr) is defined as non-susceptibility to all agents in all antimicrobial categories.12 there has probably been a gene pool in nature for resistance to antibiotics. for most microbes that are antibiotic producers are resistant to their own antibiotic. in retrospect, it is not surprising that resistance to penicillin in some strains of staphylococci was recognized almost immediately after introduction of the drug in 1946. likewise, very soon after their introduction in the late 1940s, resistance to streptomycin, chloramphenicol and tetracycline was noted. by 1953, during a shigella outbreak in japan, a strain of the dysentery bacillus (shigella dysentery) was isolated which was multiple drug resistant, exhibiting resistances to chloramphenicol, tetracycline, streptomycin and the sulfonamides. over the years, and continuing into the present almost every known bacterial pathogen has developed resistance to one or more antibiotics in clinical use.13 a study conducted in ethiopia showed that 54.2% of eye swab cultures were positive for different bacterial pathogens.14 p.aeruginosa found in urinary tract infections showed 19% multi-drug resistant strains in a german study.15 in a study conducted in china, an opportunistic pathogen, a. baumannii showed more than 30% drug resistance to most of the antibiotics tested in the study.16 in a study conducted in karachi pakistan, out of 312 cultured specimens, 272 (87.17%) were found to be infected with 437 microbial organisms.17 while in a study 61 j i m d c 2 0 1 8 61 on blood cultures, out of 1824 blood cultures, 508 (27.9%) yielded microorganism growth.18 in another study, the frequency of mdr p. aeruginosa among all the pseudomonas strains isolated was found to be 22.7%.19 in view of emerging resistance, we conducted our study to ascertain the presence of pathogens in different human sources, and their antimicrobial sensitivity and resistance. p a t i e n t s a n d m e t h o d s this study was conducted at khan research laboratories hospital, islamabad, pakistan, from july 2014 to december 2016. in total 3277 patients admitted in medical, surgical, gynaecology & obstetrics, ent, eye and dental departments were included. positive cultures from different sources including blood, urine, pus, central venous lines, bronchial washings and cervical swabs were taken. age, gender, common pathogens, their sensitivity and resistance to 27 antimicrobial drugs were taken into account. the tested antimicrobials included imipenem, meropenem, cefoperazone/sulbactam, pipercillin/tazobactam, trimethoprim/sulfamethoxazole (tmp/smx), pencillin g, ampicillin, amoxicillin/clavulanic acid, chloramphenicol, vancomycin, linezolid, amikacin, gentamicin, nalidixic acid, ciprofloxacin, levofloxacin, ofloxacin, cefixime, ceftriaxone, ceftazidime, cefoperazone, cephradine, tigecyclin, doxycycline, colistin, nitrofurantoin and fosfomycin. the bactec blood culture system produced by becton dickinson (mountain view, ca, united states) was used. the kirby-bauer (kb) method was used for drug sensitivity testing on müllerhinton agar. the results of the drug sensitivity tests were assessed according to the standards of the us clinical and laboratory standards institute (clsi). all urine samples were cultured on cysteine lactose electrolyte deficient (cled) medium. the plates were incubated at 37 c for 24 hours and using gram staining, morphology and biochemical characteristics, bacteria was identified. antimicrobial susceptibility testing was performed on all isolated bacteria by kirby bauer's disc diffusion method as per clinical and laboratory standards institute (clsi) recommendations. isolates were declared as sensitive or resistant on the basis of zone of inhibition following the laboratory standards. bronchial washing’s samples were weighed and processed with a 4-fold volume of dithiothreitol (sputasol, oxoid ltd., hants, uk) and were cultured. sputum samples were serially diluted and plated on chocolate agar enriched, chocolate agar with bacitracin, haemophilus-selective agar, blood agar, and macconkey agar. plates were incubated for 24-48 hours at 37°c and in 5% co2 atmosphere. microorganisms were identified by colony morphology, gram staining and specific culture conditions. for csf culture, 0.15 ml of uncentrifuged csf specimen was inoculated onto each of one 5% sheep blood plate and one chocolate agar plate (becton dickinson microbiology systems, cockeysville, md.), and 1.0 ml was inoculated into 5 ml of bd blood culture bottles. agar plates were incubated at 37°c in 5% carbon dioxide and examined daily for 3 days. broth cultures were incubated at 37°c. cervical swab specimens were placed in blood agar (ba) and sabouraud agar (sa) for 18-24 hr in 5% co2 atmosphere at 37℃. statistical package for social sciences (spss) version 20 was used for data analysis. data of study patients were stated as number of patients and percentages. r e s u l t s present study comprised of 3277 patients. total 1738(53.1%) were females while 1539 (46.9%) were males. only 176 (5.4%) patients were below 20 years of age, 1081 (32.9%) patients were between 20 to 50 years, 1143 (34.9%) patients were between 50 to 70 years and 877 (26.8%) patients were above 70 years. more than half 1864 (56.9%) patients were admitted in medical ward (figure 1). figure 1: distribution of patients in different wards 62 j i m d c 2 0 1 8 62 figure 2: source of cultures out of 3277 patients, culture samples of 2769 (84.5%) patients were available for analysis (figure 2) table 1 illustrates frequency of microorganisms isolated. as shown in the table, escherichia coli (e. coli) was the most common isolate 51.3% (n=1436), followed by s. aureus 19.9% (n=558) (table 1) table: 1 frequency of common isolates organism frequency (%) escherichia coli 1436 (51.3) staphylococcus aureus 558 (19.9) klebsiella pneumonia 405 (14.5) staphylococcus epidermidis 325 (11.6) pseudomonas aeruginosa 244 (8.7) acinetobacter baumannii 233 (8.3) salmonella typhi 228 (8.1) enterococcus faecalis 121 (4.3) salmonella paratyphi a 59 (2.1) antimicrobial sensitivity and resistance of the above mentioned microorganisms have been shown in table 2 d i s c u s s i o n we conducted our study to determine sensitivity and resistance patterns of microorganisms in different clinical settings. susceptibility pattern of pathogens has been changing over the years, implying the need for periodic monitoring in order to decrease the number of therapeutic failures and boost an effort to arrest the growing occurrence of antibiotic resistance. proper collection, transportation and inoculation are other steps required for enhancing bacterial growth on culture media. microbiologists have to work in collaboration with clinicians in installing newer and appropriate antibiotic discs according to emerging resistance patterns and local antibiogram. in our study, e. coli was found to be the most predominant isolated organism (51.3%). in a study conducted in saudi arabia, e. coli was found to be the most common isolate (38.3%).20 in another study conducted in india, e. coli was also the most common isolate having frequency of 59.6%.21 this warrants the need of suspecting e. coli in different clinical conditions and starting appropriate empiric treatment targeting e. coli apart from other microorganisms. e. coli and k. pneumoniae showed greater resistance to ampicillin, amoxicillin and tmp/smx, these results are comparable to another study in which e.coli (34.6%), coagulasenegative staphylococci (19.2%), p. aeruginosa (15.4%), and klebsiella spp. (11.5%) were common bacterial isolates, where most of them were resistant against ampicillin, amoxicillin, tetracycline, tmp/smx, and chloramphenicol.22 of particular interest is the resistance to ceftriaxone of e.coli(77%) and k.pneumoniae(80%) in this study. these two gram negative organisms showed greater sensitivity to three commonly chosen antibiotics imipenem, amikacin and meropenem.according to a study conducted in quaid-i-azam university, islamabad, the antibiotics showing greater susceptibility towards e. coli and k. pneumoniae isolates were imipenem, piperacillin-tazobactam, ampicillin-sulbactam and amikacin. the antibiotics having the highest resistance, particularly against the extended spectrum beta lactamases (esbls) producers were amoxicillin/clavulanic acid, tmp/smx, cefuroxime, cefpirome, ceftriaxone and ciprofloxacin and should be removed from the line of treatment for common urinary tract infections23, while a study conducted in saudi arabia showed that e.coli is more than 78% resistant to amikacin.20 p. aeruginosa showed alarming resistance to the once commonly prescribed antibiotics including 63 j i m d c 2 0 1 8 63 table 2: sensitivity and resistance pattern of various organism escherichia coli (e.coli) (n=1436) sensitivity resistance antibiotic n % antibiotic n % imipenem 1349 94 ampicillin 1293 90 amikacin 1335 93 cefixime 1136 79 meropenem 1250 87 amoxicillin/clavulanate 1111 77 cefoperazone/sulbactam 1045 73 ceftriaxone 1105 77 pipercillin/tazobactam 979 68 tmp/smx 1082 75 staphylococcus aureus (n=558) linezolid 548 98 penicillin g 535 96 chloramphenicol 470 84 ampicillin 532 95 amikacin 457 82 ciprofloxacin 304 54 doxycycline 447 80 levofloxacin 299 54 vancomycin 548 98 ofloxacin 245 44 klebsiella pneumoniae (n=405) imipenem 304 75 ampicillin 395 98 meropenem 297 73 amoxillin/clavulanic acid 384 95 amikacin 270 67 cefixime 336 83 cefoperazone/sulbactam 210 52 ceftriaxone 326 80 pipercillin/tazobactam 181 45 tmp/smx 300 74 staphylococcus epidemidis (n=325) linezolid 323 99 ampicillin 316 97 amikacin 294 90 penicillin g 314 97 vancomycin 277 85 ciprofloxacin 208 64 chloramphenicol 270 83 levofloxacin 207 64 gentamicin 215 66 ofloxacin 177 54 pseudomonas aeruginosa (n=244) piperacillin/tazobactam 186 76 levofloxacin 95 39 amikacin 183 75 ciprofloxacin 90 37 cefoperazone/sulbactam 182 75 ceftazidime 80 33 imipenem 179 73 cefoperazone 80 33 gentamicin 164 67 gentamicin 74 30 acinetobacter baumannii (n=233) colisitin 213 91 amoxillin/clavulanic acid 231 99 tigecycline 187 80 ceftriaxone 227 97 gentamicin 91 39 ampicillin 226 97 amikacin 70 30 cefixime 225 97 cefoperazone/sulbactam 60 26 ciprofloxacin 224 96 ceftazidime (33%), ciprofloxacin (37%) and gentamicin (30%). similar pattern of resistance was observed in another study with resistance to ceftazidime (41%), gentamicin (27%) and ciprofloxacin (26%).24 in our study s. aureus was sensitive to vancomycin & linezolid (98%). s. epidermidis showed 99% sensitivity to 64 j i m d c 2 0 1 8 64 table 2a: sensitivity and resistance pattern of various organism (n=228) sensitivity resistance antibiotic n % antibiotic n % salmonella typhi (n=228) ceftriaxone 227 99 ciprofloxacin 214 94 cefixime 222 97 levofloxacin 212 93 ampicillin 99 43 naladixic acid 200 88 tmp/smx 95 42 ofloxacin 179 79 chloramphenicol 77 33 tmp/smx 133 58 enterococcus faecalis (n=121) linezolid 121 100 ceftriaxone 108 89 vancomycin 109 90 ciprofloxacin 108 89 amoxillin/clavulanic acid 74 61 levofloxacin 108 89 ampicillin 70 58 cefixime 107 88 nitrofurantoin 55 45 cephradine 94 78 salmonella paratyphi a (n=59) cefixime 59 100 ciprofloxacin 57 97 ceftriaxone 59 100 levofloxacin 57 97 ampicillin 54 92 naladixic acid 57 97 tmp/smx 53 90 ofloxacin 56 95 chloramphenicol 50 85 ampicillin 5 8 linezolid and 85% to vancomycin. however, in a study conducted in saudi arabia it was found that resistant and susceptibility profile of s. aureus showed high resistance to both ampicillin and linezolid (94.1%) and high sensitivity to more than one antibiotic such as daptomycin, penicillin, synercid, teicoplanin, vancomycin, and tmp/smx, which have sensitivity rate more than 88%.21 e. faecalis which frequently cause urinary tract infection, endocarditis and bacteremia, showed resistance to generally prescribed empiric antibiotics regimen like ceftriaxone, levofloxacin and ciprofloxacin (89%). e. faecalis was sensitive to linezolid (100%), vancomycin (90%) and amoxicillin/clavulanic acid (61%). linezolid, vancomycin and teicoplanin are currently widely used drugs for the effective treatment of enterococcal infections.25-27 a baumannii showed sensitivity to colistin (91%) and tigecyclin (80%), while is resistant to amoxicillin/clavulanic acid (99%), ceftriaxone, ampicillin and cefixime (97%). therefore, it is sensitive to antibiotics prescribed for ventilator associated pneumonia(vap) (a. baumannii is a common cause of vap). colistin and tigecycline are in many cases the unique options for the treatment of many episodes of vap caused by multiple drug resistantgram negative bacteria (mdr-gnb ).28 s. typhi and s. paratyphi a showed high degree of resistance to quinolones. ciprofloxacin (94%), levofloxacin (93%) for s.typhi; ciprofloxacin and levofloxacin (97%) for s.paratyphi a. both these organisms showed almost no resistance to ceftiaxone and cefixime. according to a study conducted in islamabad the prevalence of mdr and fluoroquinolone resistance was very high among salmonella serovars. no resistance was found to third-generation cephalosporins.29 c o n c l u s i o n antibiotic resistance is an emerging problem. rationale use of antibiotics is required to curtail the surge of antibiotic resistance. there is also a need to modify treatment guidelines in different clinical situations based on local sensitivity and resistance patterns. emphasis 65 j i m d c 2 0 1 8 65 stays on reducing hospital stay, morbidity and mortality. acknowledgement: dr. syed kamran majeed, dr. masood iqbal satti, muhammad farhan. r e f e r e n c e s 1. walker b, barrett s, polasky s, galaz v, folke c, engström g, et al. environment. looming globalscale failures and missing institutions. science. 2009; 325(5946):1345–6. 2. klevens rm, morrison ma, nadle j, petit s, gershman k, ray s, et al. invasive methicillinresistant staphylococcus aureus infections in the united states. jama. 2007; 298(15):1763–71 3. cooper ma, shlaes d. fix the antibiotics pipeline.nature 2011 ;472(7341):32. 4. marshall bj, armstrong ja, mcgechie db, glancy rj. attempt to fulfil koch's postulates for pyloric campylobacter. med j aust 1985; 142(8):436–439. 5. palmer a.c., kishony r. understanding, predicting and manipulating the genotypic evolution of antibiotic resistance. nat. rev. genet. 2013;14(4):243–248. 6. lagier jc, edouard s, pagnier i, mediannikov o, drancourt omd, and raoul d.current and past strategies for bacterial culture in clinical microbiology. clin microbiol rev. 2015; 28(1): 208– 236. 7. boulos a, rolain jm, mallet mn, raoult d. molecular evaluation of antibiotic susceptibility of tropheryma whipplei in axenic medium. j antimicrob chemother 2005; 55(2):178–181. 8. boulos a, rolain jm, raoult d. antibiotic susceptibility of tropheryma whipplei in mrc5 cells. antimicrob agents chemother 2004; 48(3):747– 752. 9. vellinga a, cormican m, hanahoe b, bennett k and murphy aw. antimicrobial management and appropriateness of treatment of urinary tract infection in general practice in ireland. bmc fam prac 2011;12(1):108. 10. boucher h., talbot g.h., bradley j.s. bad bugs, no drugs: no eskape! an update from the infectious diseases society of america. clin. infect. dis. 2009; 48(1):1–12. 11. rice l.b. federal funding for the study of antimicrobial resistance in nosocomial pathogens: no eskape. j. infect. dis. 2008;197 :1079–1081. 12. magiorakos ap, srinivasan a, carey rb, carmeli y, falagas me, giske cg.multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance.clinical microbiology and infection, 2011; 8(3):2 68-81. 13. http://textbookofbacteriology.net/resantimicrobial.html. 14. anagaw b, biadglegne f, belyhun y, anagaw b, mulu a. bacteriology of ocular infections and antibiotic susceptibility pattern in gondar university hospital, north west ethiopia. ethiop med j. 2011;49(2):117–123. 15. narten m, rosin n, schobert m, tielen p. susceptibility of pseudomonas aeruginosa urinary tract isolates and influence of urinary tract conditions on antibiotic tolerance. curr microbiol. 2012; 64(1):7–16 16. chang-tai z, yang l, zhong-yi h, chang-song z, yin-ze k, yong-ping l, et al. high frequency of integrons related to drug-resistance in clinical isolates of acinetobacter baumannii. indian j med microbiol. 2011;29(2):118–123. 17. sabir r,alvi sfd, fawwad a.antimicrobial susceptibility pattern of aerobic microbial isolates in a clinical laboratory in karachi – pakistan.pak j med sci. 2013; 29(3): 851–855. 18. shahla l, saeed a, ishtiaq a. bacterial pathogens responsible for blood stream infection (bsi) and pattern of drug resistance in a tertiary care hospital of lahore. biomedica. 2009;25(2):105–109. 19. gill mm, usman j, kaleem f, hassan a, khalid a, anjum r, et al. frequency and antibiogram of multidrug resistant pseudomonas aeruginosa. j coll physicians surg pak. 2011; 21(9):531–534. 20. al yousef sa. surveillance of antibiotic-resistant bacteria in king khalid hospital, hafr al-batin, saudi arabia, during 2013. jundishapur j microbiol. 2016; 9(9): e19552. 21. chatterjee n, chatterjee c, ghosh s, mukhopadhyay m, brahmachari r, patar k. pattern of urinary antibiograms in a tertiary care hospital of eastern india. j assoc physicians india. 2016;64(4):26-30. 22. derese b, kedir h, teklemariam z, weldegebreal f and balakrishnan s. bacterial profile of urinary tract infection and antimicrobial susceptibility pattern among pregnant women attending at antenatal clinic in dil chora referral hospital, dire dawa, eastern ethiopia. ther clin risk manag. 2016; 12: 251–260. 23. ahmed i, sajed m, sultan a, murtaza i, yousaf s, maqsood b,et al. the erratic antibiotic susceptibility patterns of bacterial pathogens causing urinary tract infections. excli j. 2015; 14: 916–925. 66 j i m d c 2 0 1 8 66 24. said kb, al-jarbou an, alrouji m, and al-harbi ho. surveillance of antimicrobial resistance among clinical isolates recovered from a tertiary care hospital in al qassim, saudi arabia. int j health sci (qassim). 2014; 8(1): 3–12. 25. arias c.a., murray b.e. emergence and management of drug-resistant enterococcal infections. expert. rev. anti. infect. ther. 2008;6(5):637–655. 26. arias c.a., murray b.e. emergence and management of drug-resistant enterococcal infections. expert. rev. anti. infect. ther. 2008;6(5):637–655. 27. el-khoury j., fishman j.a. linezolid in the treatment of vancomycin-resistant enterococcus faecium in solid organ transplant recipients: report of a multicenter compassionate-use trial. transpl. infect. dis. 2003;5(3):121–125. 28. josé garnacho-montero j, yael corcia-palomo y, amaya-villar r, and martin-villen l.how to treat vap due to mdr pathogens in icu patients. bmc infect dis. 2014; 14(1): 135. 29. ali a, ali ha, shah fh, zahid a, aslam h,javed b.pattern of antimicrobial drug resistance of salmonella typhi and paratyphi a in a teaching hospital in islamabad.j pak med assoc. 2017;67(3):375-379. 165 j i m d c 2 0 1 8 165 open access f u l l l e n g t h a r t i c l e clinical and morphological aspects of celiac disease anum usman, noor khan lakhanna, mudassira zahid, humaira zafar 1,3 assistant professor, 2 professor/head of department, 4 associate professor department of pathology, al-nafees medical college and hospital islamabad a b s t r a c t objective: to assess the clinical and morphological aspects of celiac disease. patients and methods: this cross sectional study was conducted at department of pathology, al nafees medical college & hospital for a period of 8 months. after taking approval from institutional review board, a written informed consent was taken from all the enrolled patients depending upon inclusion and exclusion criteria. clinical data including the symptoms and signs and their severity was collected and entered on a specially designed proforma. morphological data was collected with the help of patient’s endoscopic biopsy. histopathological biopsies were graded according to modified marsch grading system. for qualitative variables frequencies and percentages were calculated. quantitative variables were measured in terms of mean and standard deviation. results: there were 77 patients with suspicion of celiac disease whose endoscopic biopsy was done. among these 42% were males and 58 % were females. maximum number of patients were in the age group of 13-30 years. among symptoms, diarrhea was present in 83.11% (n=64) patients, abdominal distention and pain was present in 53% and 63.6% patients respectively. lesser frequent symptoms including vomiting and weight loss was significant in only 16.9% patients and constipation in 14.3% patients. according to modified marsch grades, maximum celiac patients were graded in marsch-3a (15.6%) and marsch-3b (19.5%). conclusion: majority of patients with celiac disease presented with typical gastrointestinal signs and symptoms in which diarrhea was the commonest complaint. the disease is more common in adults with female predominance. majority of patients belong to the 3a and 3b type lesion of the modified marsch grading system. key words: celiac disease, malabsorption, morphology, modified marsch grades. author`s contribution 1 conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 3 data analysis, interpretation and manuscript writing, 4 active participation in data collection. address of correspondence mudassira zahid email: mudassirazahid@gmail.com article info. received: may 17, 2018 accepted: august 22, 2018 cite this article. usman a, lakhana nk, zahid m, zafar h. clinical and morphological aspect of celiac disease. jimdc.2018; 7(3):165-168 funding source: nil conflict of interest: nil i n t r o d u c t i o n celiac disease (cd) is a chronic disease of the small intestine in which intake of gluten found in rye, wheat and barley determines the injury of the intestinal mucosa in genetically susceptible individuals.1 it is an inflammatory process which mainly involves the mucosa of small intestine resulting in atrophy of intestinal villi along with clinical manifestations. gluten proteins are resistant to digestive enzymes resulting in peptide derivatives leading to immunogenic response in cd patients.2 celiac disease affects 0.6-1.0% people worldwide and different studies showed the prevalence of 0.3% in germany and 2.4% in finland.3-5 celiac disease affects around 1% of the general population with increasing prevalence over time as reported in the united states and europe.6-8 diagnosis of celiac disease is based on clinical manifestations, laboratory tests, histological aspects of small intestine o r i g i n a l a r t i c l e 166 j i m d c 2 0 1 8 166 mucosa and serological markers.9-10 patients suffering from celiac disease usually present with features of malabsorption represented by diarrhea, steatorrhea, weight loss or failure to thrive. cd patients can also present with variety of extraintestinal symptoms and signs including anemia, vague abdominal symptoms, ataxia, neuropathy, depression, short stature, osteoporosis, osteomalacia, liver diseases and lymphoma.11-15 characteristic histopathological changes in the mucosa of small intestine are taken as the standard criteria for diagnosis of celiac disease. according to the modified marsch grading system, histopathological changes are categorized as 0-4.16 the severity of mucosal changes in celiac disease is variable ranging from almost normal to total atrophic villi.17 marsh proposed histopathological classification system which was later modified by oberhuber. marsh-oberhuber grading system includes five grades of lesions as type 0 with normal histology, type 1 with increased intraepithelial lymphocytes (iel) only; type 2 with increased iel and crypt hyperplasia, type 3 with increased iel, crypt hyperplasia and villous atrophy which is further classified as 3a, 3b and 3c for mild, marked and total villous atrophy and type 4 lesion with flat atrophic villi.18 the current study is aimed at determining how patients with celiac disease present to the physicians and what are the morphological attributes in these patients. this study will help identify the current trends of presentation of celiac disease patients in our settings. p a t i e n t s a n d m e t h o d s this cross sectional study was conducted over a period of eight months from may 2015 to december 2015 in department of pathology, al nafees medical college and hospital. both males and females from all age groups, having symptoms of malabsorption and later labeled as celiac disease patients on intestinal biopsy were included in the study. patients diagnosed with other causes of malabsorption, improperly processed samples and improperly stained slides were not included in the study. written and informed consent was taken from all patients. data regarding procedure performed and history of patient was collected along with each specimen. proforma was filled. surgically removed endoscopic duodenal biopsy specimens, placed immediately in 10% buffered formalin, were received in the pathology lab. after fixation the gross examination of biopsy was carried out. these gross specimens were sent for processing and hematoxylin & eosin staining. the stained sections of the specimen were examined microscopically at low power (4x, 10x objective), medium power (20x objective) and high power (40x objective). the microscopic details were analyzed by using modified marsch grading system. data was computed using spss version 20. qualitative variables were analyzed in terms of frequencies and percentages. for quantitative variables mean and standard deviation was calculated. r e s u l t s total 77 patients were enrolled in the study. among them, 39% were male and 61% were female. the stratification of patient data according to patient age group is shown in table-1. maximum number of patients were between ages 13 to 30 years. among all symptoms, diarrhea was the commonest in both male and female (figure 1), noted in 83.11% (n=64) patients. abdominal distention and pain were present in 67.53 % (n=52) and 63.6% (n=49) patients respectively. vomiting was noted in 16.9% (n=13) patients and constipation was present in 14.3% (n=11) patients. endoscopic duodenal biopsy findings of all patients were recorded and grouped into different grades as per modified marsch grading system. marsch-0 included 28.6% (n=22) patients, marsch-1 consisted of 9.1%(n=7) patients and marsch-2 included 13%(n=10) patients. whereas, marsch-3a, marsch-3b and marsch-3c comprised of 15.6% (n=12), 19.5% (n=15) and 14.3% (n=11) patients respectively as shown in graph-2. figure1: percentage distribution of patients according to symptoms 167 j i m d c 2 0 1 8 167 figure 2: gender distribution according to marsch grades d i s c u s s i o n celiac disease is known as one of the most important gastrointestinal diseases. diagnosis of celiac disease is difficult because of the unusual presentation of large number of patients with intestinal and extraintestinal signs and symptoms.19 in the current study, findings about distribution of patients according to age shows that maximum number of patients lie in the age group of 13 to 30 years while pediatric (n=6) and old (n=5) age group has lesser number of patients. in contrast a study conducted by rashtak s et al showed that median age of patients at the time of diagnosis was under the age of 50 while one third of patients were diagnosed above the age of 65.20 another study carried out by marine m et al reported that the prevalence of celiac disease in the pediatric age group had increased fivefold as compared to the adult age group.21 the current study reveals that female adults are more commonly affected by celiac disease as compared to males. these findings are in favor of other study conducted by makharia g which revealed that celiac disease is more frequent in adult women than in men with a ratio of 4:1.22 in another study done by thomas h also showed similar results that the prevalence of celiac disease was high in women to that in men.23 in current study, amongst all symptoms, diarrhea, abdominal pain and abdominal distention are maximally present in the patients and also in the same group of 13 to 30 years. a study conducted by santiago v et al reported that diarrhea, malnutrition, bloating and vomiting table-1: distribution of patients according to age groups gender males females total age n(%) n(%) n <13 years 2(6.7) 4(8.5) 6 13-30 years 15(50.0) 24(51.1) 39 30-50 years 10(33.3) 17(36.2) 27 >50 years 3(10.0) 2(4.3) 5 total 30(100) 47(100) 77 were more prevalent in children less than 2 years while dyspepsia, iron deficiency anemia and constipation were maximally present in adult age group.24 another study conducted by kivela l revealed that the clinical presentation of celiac disease in children were minor especially in the 1990s while most of these changes had reached a peak in recent years.25 histopathological findings graded by modified marsch revealed that maximum number of both male and female patients suffered from 3a and 3b type lesion of the celiac disease among all marsch categories. study conducted by parveen malothra et al in 2015 also had similar findings, which revealed that maximum number of patients belonged to grade 3a of modified marsch grading system.26 c o n c l u s i o n majority of patients with celiac disease present with typical gastrointestinal signs and symptoms in which diarrhea is the commonest finding. majority of patients were adults with female predominance. histopathological findings showed that 3a and 3b type lesion of the modified marsch grading system were the commonest. r e f e r e n c e s 1. timothy d. pelkowski..celiac disease: diagnosis and management. am fam physician. 2014;89(2):99-105. 2. ivarsson a, myléus a, norström f. prevalence of childhood celiac disease and changes in infant feeding. pediatr.2013;131(1):687–94. 3. white le, merrick vm, bannerman e. the rising incidence of celiac disease in scotland. pediatr.2013; 132(2):924– 31 4. kang jy, kang ahy, green a. systematic review: worldwide variation in the frequency of coeliac disease 168 j i m d c 2 0 1 8 168 and changes over time. aliment pharmacol ther. 2013; 38(1):226–45. 5. mustalahti k, catassi c, reunanen a, fabiani e, heier m, mcmillan s et al. the prevalence of celiac disease in europe: results of a centralized, international mass screening project. annals med. 2010; 42(8):587-95. 6. alessandrini s, giacomoni e, muccioli f. mass population screening for celiac disease in children: the experience in republic of san marino from 1993 to 2009. ital j pediatr. 2013; 39(3):67-71. 7. kochhar r, dachdev s, aggarwal a. prevalence of coeliac disease in healthy blood donors: a study from north india. dig liver dis. 2012; 44(1):530–32. 8. bai jc, fried m, corazza gr. world gastroenterology organization global guidelines on celiac disease. j clin gastroenterol. 2013; 47(4):121–6. 9. schuppan, d., & zimmer, k. the diagnosis and treatment of celiac disease. dtsch ärztebl int.2013. 110(49), 835– 46. 10. rubio-tapia a .acg clinical guidelines: diagnosis and management of celiac disease. am j gastroenterol.2013;108(1):656–76. 11. ludvigsson jf, leffler da, bai jc. the oslo definitions for coeliac disease and related terms. gut.2013;62(1):43–52 12. vanga r.ex vivo gluten challenge differentiates patients with celiac disease on a gluten free diet from healthy individuals.gastroenterol.2014;146(5):471-4 13. leffler d. schuppan d & pallav k et al. kinetics of the histological, serological and symptomatic responses to gluten challenge in adults with coeliac disease.gut.2013;62(1):996–1004. 14. bao f.green p, bhagat g. an update on celiac disease histopathology and the road ahead. arch pathol lab med.2012;136(2):735–45. 15. green ph, lebwohl b, greywoode r. celiac disease. j allergy clin immunol. 2015;135(5):1099-106 16. kelly cp, bai jc, liu e, leffler da. advances in diagnosis and management of celiac disease. gastroenterol.2015;148(6):1175-86 17. rosen a, sandstrom o, carlsson a et al. usefulness of symptoms to screen for celiac disease. pediatr. 2014;133(2):211-8 18. squires je, fei l, cohen mb. role of celiac disease screening for children with functional gastrointestinal disorders. jama pediatr.2014;168(6):514-5 19. gujral n. celiac disease: prevalence, diagnosis, pathogenesis and treatment. world j gastroenterol.2012;18(42):6036-40. 20. rashtak s, murray ja. celiac disease in the elderly. gastroenterol clin north am.2009;38(3):433-46. 21. marine m, farre c, alsina m. the prevalence of celiac disease is significantly higher in children compared with adults. aliment pharmacol ther. 2011;33(4):477 86. 22. makharia, g. current and emerging therapy for celiac disease. front med. 2014;1(1):6-10 1. 23.thomas h, ahmad t, rajaguru c et al. contribution of histological, serological, and genetic factors to the clinical heterogeneity of adult-onset celiac disease. scand j gastroenterol. 2009;44(1):1076–83. 23. santiago v,luis v, laura r et al. age-related differences in celiac disease: specific characteristics of adult presentation. world j gastrointest pharmacol ther. 2015;6(4): 207–12. 24. kivela l, kaukinen k, lähdeaho ml et al. presentation of celiac disease in finnish children is no longer changing: a 50-year perspective. j pediatr. 2015;167(5):1109 15. 25. parveen m, pansi, sonia c, vani m, ajay c, abhishek c et al. spectrum of celiac disease at tertiary care center of northeren india. adv res gastroenterol hepatol.2015;1(2):1-5. 84 j i m d c 2 0 1 8 84 open access f u l l l e n g t h a r t i c l e effect of an artificial sweetener on rat’s pancreas and body weight hina kundi 1, naureen waseem 2, maria yousaf 3 1 assistant professor of anatomy, fazaia medical college, air university. islamabad 2 assistant professor of anatomy, islam medical and dental college. sialkot 3 assistant professor of anatomy, army medical college, rawalpindi a b s t r a c t objective: to observe the effects of an artificial sweetener on rat’s pancreas and body weight. material and methods: this laboratory based randomized control trial was carried out at anatomy department, army medical college rawalpindi, in collaboration with nih, islamabad, from march to may 2014. forty male and female sprauge dawley rats were used in the experiment. ten males and 10 female served as control group c and 10 males and 10 female served as an experimental group e (n = 20 animals in each group). the rats were randomly allocated by using a random selection table. control group c was given normal diet for two months whereas experimental group e was provided artificial sweetener (sodium cyclamate) 60mg/kg/day through oral gavage tube for two months. animals were weighed before and at the end of experiment. pancreas were dissected out, examined and weighed. histological sections of pancreas were studied under light microscope. fatty infiltration was calculated in three slides per specimen. results were analyzed on spss version 20. results: the pancreas of rats showed fatty infiltration and weight of animals were significantly higher in experimental group.(p-value<0.001) conclusion: artificial sweetener brings significant fatty infiltrations in rat’s pancreas and also induces weight gain in animals. key words: artificial sweetener, fatty infiltration, pancreas, sodium cyclamate. author`s contribution 1conception, synthesis, planning of research and manuscript writing interpretation and discussion 2 data analysis, interpretation and manuscript writing, 3 active participation in data collection. address of correspondence hina kundi email: drhinazaid@gmail.com article info. received: september 20, 2017 accepted: january 11, 2017 cite this article. kundi h, waseem n, yousaf m. effect of an artificial sweetener on rat’s pancreas and body weight. jimdc.2018; 7(2): 84-87 funding source: nil conflict of interest: nil i n t r o d u c t i o n humans have a sweet tooth for deserts and sweet items. it is for this reason that such products are consumed much more than the body’s nutritional requirement. natural sugars and sweeteners are a part and parcel of human diet and having them in appropriate amount is very important as it may influence health.1 over the last few decades, a wide range of sweeteners has been introduced in market. 2 among food additives, artificial sweeteners are considered most important as they are low in calories, intensely sweet and maintain the taste of sweet foods and drinks.3 the first generation sweeteners are saccharine, cyclamate and aspartame while acesulfame-k, sucralose, alitame and neotame are referred as second or new generation artificial sweeteners.4 they bind with taste receptors and exceed sweetness of sucrose from 30 to o r i g i n a l a r t i c l e 85 j i m d c 2 0 1 8 85 13000 times.5 artificial sweeteners are widely used in beverages, multivitamins, breakfast cereals, dairy products and pharmaceuticals. the safety for the consumption of products like artificial sweeteners, coloring, flavoring agents and preservatives is still controversial.6 it is generally thought that artificial sweeteners are not harmful and are helpful in weight reduction but few recent studies showed alteration in glucose metabolism and appetite by the use of these sweeteners. there are various studies, which showed unfavorable metabolic effects, and included increase in weight, diabetes mellitus and other metabolic disorders.7 sodium cyclamate is being used in several artificial sweetened foods, beverages, medicines and cosmetics since it is easily available and cheap.8 not much work has been done regarding its effect on histology of pancreas. a long-term study on primates showed alteration in blood glucose levels as well as histology of pancreas showed hyalinization of pancreatic islets of langerhans.9 a study conducted on children by giving them sodium cyclamate sweetened beverages showed no alteration in diet, hunger or body weight. the effects of sodium cyclamate on body weight and weight of pancreas have not been seen simultaneously. the rationale of current study was to identify the effects of sodium cyclamate on the body weight and weight of pancreas. m a t e r i a l a n d m e t h o d s this randomized control trial was carried out at the anatomy department, army medical college rawalpindi, in collaboration with nih (national institute of health) islamabad. the duration of study was three months from march 2014 to may 2014. forty sprauge dawley rats, both male and female, were used in the experiment.1 weight of the experimental animals was between 175gm to 205gms. they were kept in controlled environment of animal house of nih, islamabad. pelleted diet prepared in nih was given to them for two months. rats were randomly divided into two groups, each having equal number of male and female rats by using a random selection table. they were kept in separate cages to avoid pregnancy. group c served as control group in which animals were given 1ml plain water with normal diet. group e served as experimental group in which animals were given 60mg/kg body weight sodium cyclamate once daily orally for two months by a gavage tube.10,11 after two months, the animals were weighed and dissected. pancreas was removed and their weight was recorded. specimens were fixed and three sections/specimen (intestine, middle and spleen region) were placed in tissue cassettes.12 automated processing of all the sections obtained was done. sections were cut and stained with routine hematoxylin and eosin to observe the histology of pancreas. four fields were selected per slide randomly and images were taken at 10x. fatty infiltration in pancreas was observed. the fatty infiltration was scored as global score by adding the scores of (a) perilobular fat and (b) intralobular fat.13 for perilobular fat, zero score was marked for no fat cells, score one was given to few fat cells and score two was assigned to more than 10 fat cells between two lobules. for intralobular fat zero score was given to no fat cells, one score was marked for few scattered fat cells and two score was given to numerous fat cells within lobules in the form of clusters of more than 10 cells. global score was given by adding (a) and (b). global score 0 to 2 indicate fatty infiltration. global score 3 to 4 indicate fatty infiltration. statistical package spss version 20 was used to analyze data. to find out intergroup differences, independent sample t test was applied on quantitative data and chi square was applied on qualitative data. p value < 0.05 was considered significant. results were represented as mean ± standard deviation (mean ±sd) and number with percentages. r e s u l t s at the start of study, weight of the experimental animals was between 175gm to 205gms and it was statistically non-significant between two groups. after two months, the mean change in weight of animals in control and experimental group was found be statistically significant with p value ˂0.001 (table 1). histologically the pancreas of group c showed normal architecture consisting of glandular parenchyma and stroma. there was a loose connective tissue capsule covering the gland. the glandular parenchyma was divided into irregular lobules by septa originating from the capsule. lobules showed tubuloacinar gland consisting of pancreatic acinar cells and duct system. the small islets of langerhans of variable sizes were scattered through the pancreatic parenchyma. (figure 1a). the stroma comprising of large 86 j i m d c 2 0 1 8 86 amount of loose connective tissue was present between each lobule containing arteries, vein, nerves, ducts and few fat cells. fat cells present between lobules were considered as perilobular fatty infiltration. while the fat cells present in the lobule were considered as intralobular fatty infiltration. perilobular fatty infiltration was present in 5 animals of control group, whereas intralobular fatty infiltrate was present in 2 animals of control group. global scoring showed no fatty infiltration in any animal of control group. in experimental group e, perilobular fatty infiltration was found in 13 animals, whereas intralobular fatty infiltration was found in 9 animals. global scoring showed that fatty infiltration was present in 6 (30%) rats, while it was absent in 14 (70%) rats. frequency of fatty infiltration was significantly higher in experimental group e as compared to control group c (p = 0.020) (figure 1b, table 1). figure 1 (a) photomicrograph of histological section of pancreas of control group showing; pancreatic acinus (a), islets of langerhans (i), duct (d) and connective tissue septa (s). [h&ex300] figure 1 (b) photomicrograph of histological section of pancreas of animal in experimental group showing; fatty infiltration with perilobular fat cells (pf), intralobular fat cells (if), connective tissue septa (s) and acinus (a). [h&ex300] d i s c u s s i o n sugar free food items are gaining a lot of attention these days for being low in calories but with sweet taste. it is for this reason many artificial sweeteners are being used by the food industry as a substitute of sugars. diseases like hypertension, diabetes, obesity and other cardiovascular diseases are growing day by day. high sugar content in diet could be alarming to health.14 sugar sweetened beverages are considered to play a negative impact on weight and health. non-caloric sweeteners are grabbing more attention in order to avoid the risks of these out comes. however evidences have proved that regular users of these non-caloric sweeteners may also be at a high risk of diseases like metabolic syndrome, diabetes mellitus, obesity and heart disease.15 the change in body weight of rats was statistically significant when both the groups were compared. it has been reported that artificial sweeteners may induce hunger and thus encourage food intake, which may affect the body weight.16,17 use of artificial sweeteners and weight gain are positively correlated in a prospective cohort study.18 a review on artificial sweeteners suggested that non nutritive sweeteners intensify the appetite especially when it is taken with other non-caloric products. the reason being when artificial sweeteners are replaced by nutritive sweeteners they are unable to provide energy to the body which leads to increased hunger and appetite.19 a perspective study carried out on table 1: comparison of weight and fatty infiltration in control and experimental groups (n=40) variable group c (n = 20) group e (n = 20) p value mean±sd animal weight (gms) 291.18±10.82 307.64±7.05 < 0.001* number (%) fatty infiltration yes no 0(0%) 20(100) 6(30%) 14(70) 0.020 87 j i m d c 2 0 1 8 87 women showed that intake of artificial sweetener such as sodium cyclamate and saccharin for one year didn’t help in weight reduction when compared with non user group. the study proved a negative correlation between longterm use of sodium cyclamate and weight reduction.20 the pancreases of experimental group showed significant fatty infiltration. which has also caused increase in organ weights, as shown in previous study.21 the results of the current study were in agreement with the findings of gaujoux et al, reporting that increase in the body weight and obesity leads to increase in weight of abdominal organs and risk of morbidity.13 in the current study, fatty infiltration also caused increase in weight of pancreas as well as of the animals. the mean weight of six cases with pancreatic fatty infiltration in experimental group was higher than that of six cases without fatty infiltration in control group. this lipomatosis of pancreas is directly related to increase in body weight.22 this study has shown that the artificial sweetener tends to increase body weight as well as induce fatty infiltration in pancreas, may thus induce obesity. c o n c l u s i o n the use of artificial sweeteners like sodium cyclamate induces fatty infiltration in rat’s pancreas and is also responsible for weight gain. future recommendations: the artificial sweeteners effects can also be seen in other organs like kidney and liver. acknowledgment: special thanks to dr hussain ali, scientific officer animal house, national institute of health, for his support in animal handling and care. r e f e r e n c e s 1. dell rb, holleran s, ramakrishnan r. sample size determination. ilar journal. 2002;43(4):207-13. 2. o'donnell k, kearsley m. sweeteners and sugar alternatives in food technology. 2nd ed: wiley blackwell; 2012.137-163 3. abhilash m, paul mv, varghese mv, nair rh. effect of long term intake of aspartame on antioxidant defense status in liver. food and chemical toxicology : an international journal published for the british industrial biological research association. 2011;49(6):1203-7. 4. weihrauch mr, diehl v. artificial sweeteners--do they bear a carcinogenic risk? annals of oncology : official journal of the european society for medical oncology / esmo. 2004;15(10):1460-5. 5. shastry cs, yatheesh ck, aswathanarayana bj. comparative evaluation of diabetogenic and mutagenic potential of artificial sweeteners aspartame, acesulfame-k and sucralose. nitte university journal of health science. 2012;2(3):80-4. 6. soffritti m, belpoggi f, esposti dd, lambertini l, tibaldi e, rigano a. first experimental demonstration of the multipotential carcinogenic effects of aspartame administered in the feed to sprague-dawley rats. environmental health perspectives. 2006;114(3):379-85. 7. brown rj, rother ki. non-nutritive sweeteners and their role in the gastrointestinal tract. the journal of clinical endocrinology and metabolism. 2012;97(8):2597-605. 8. o'brien-nabors l. alternative sweeteners, third edition, revised and expanded: taylor & francis; 2001.63-66 9. takayama s, renwick a, johansson s, thorgeirsson u, tsutsumi m, dalgard d, et al. long-term toxicity and carcinogenicity study of cyclamate in nonhuman primates. toxicological sciences. 2000;53(1):33-9. 10. reagan-shaw s, nihal m, ahmad n. dose translation from animal to human studies revisited. the faseb journal. 2008;22(3):659-61. 11. martins at, santos fdsd, scannavino flf, pires jr, zuza ep, padovani junior ja, et al. effect of sodium cyclamate on the rat fetal exocrine pancreas: a karyometric and stereological study. international journal of morphology. 2010;28(3):899-904. 12. farrokhi b, rostamkhani f, zahediasl s, zardooz h. effects of acute and chronic psychological stress on isolated islets' insulin release. 2012.11: 163-175 13. gaujoux s, cortes a, couvelard a, noullet s, clavel l, rebours v, et al. fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. surgery. 2010;148(1):15-23. 14. chattopadhyay s, raychaudhuri u, chakraborty r. artificial sweeteners–a review. journal of food science and technology. 2011:1-11. 15. swithers se. artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements. trends in endocrinology & metabolism. 2013;24(9):431-41. 16. fowler sp, williams k, resendez rg, hunt kj, hazuda hp, stern mp. fueling the obesity epidemic? artificially sweetened beverage use and long‐term weight gain. obesity. 2008;16(8):1894-900. 17. kroger m, meister k, kava r. low‐calorie sweeteners and other sugar substitutes: a review of the safety issues. comprehensive reviews in food science and food safety. 2006;5(2):35-47. 18. yang q. gain weight by “going diet?” artificial sweeteners and the neurobiology of sugar cravings. the yale journal of biology and medicine. 2010;83(2):101-8. 19. mattes rd, popkin bm. nonnutritive sweetener consumption in humans: effects on appetite and food intake and their putative mechanisms. the american journal of clinical nutrition. 2009;89(1):1-14. 20. vermunt s, pasman w, schaafsma g, kardinaal a. effects of sugar intake on body weight: a review. obesity reviews. 2003;4(2):91-9. 21. kundi h, butt sa, hamid s. variation in the area of islets of langerhans in sodium cyclamate treated rats. pakistan armed forces medical journal. 2015;65(5):656-9. 22. schmitz-moormann p, pittner p, heinze w. lipomatosis of the pancreas: a morphometrical investigation. pathology-research and practice. 1981;173(1):45-5 102 j i m d c 2 0 1 8 102 open access f u l l l e n g t h a r t i c l e effect of lead toxicity and its correlation with different variables of dna damage fahmida khatoon1, ayesha pervez2, fozan ahmad ³, zamir ahmed ⁴, muhammad humayun⁵, sadia mahmood 6 1 associate professor, united medical and dental college, karachi 2 assistant professor, amna inayat medical college, sheikhupura 3,4 assistant professor, fatima memorial college of medicine and dentistry lahore 5 professor, allama iqbal medical college, lahore 6 associate professor, rashid latif medical college, lahore a b s t r a c t objective: to establish correlations of blood lead levels with dna damage in population frequently exposed to lead in urban city. patients and methods: this cross-sectional study was carried out in 60 traffic police wardens working in nine different administrative towns of lahore. cases were selected according to inclusion and exclusion criteria through stratified random sampling using proportional allocation. total 30 healthy controls were taken from university of health sciences. blood samples were drawn after informed consent. blood lead concentration was determined by atomic absorption spectrometer and dna damage by comet assay method. data analysis was done by spss version 18. correlation between lead level and dna damage was studied. results: police wardens working in open environment had significantly higher mean values of blood lead. mean serum lead levels in study group exposed to lead were significantly elevated as compared with control group. their blood lead levels were correlated with different variables of dna damage. conclusion: as a result of industrial development, individuals exposed to lead due to their professional work, had significantly higher mean values of blood lead. key words: hemoglobin, lead, reactive oxygen species. author`s contribution 1 conception, synthesis, planning of research and manuscript writing, 2,3interpretation and discussion 4,5 data analysis, interpretation and manuscript writing, 6 active participation in data collection. address of correspondence fahmida khatoon email: drfahmida1@gmail.com article info. received: december 19, 2017 accepted: may 2, 2018 cite this article. khatoon f, pervez a, ahmad f, ahmed z, humayun m, mahmood s. effect of lead toxicity and its correlation with different variables of dna damage. jimdc.2018; 7(2):102-107 funding source: nil conflict of interest: nil i n t r o d u c t i o n lead is a poisonous metal and is widely used in daily life for its good chemical properties. increased use of lead in industry, its excessive inhalation and ingestion can adversely affect major biological functions in the human body. heavy metals are among environmental factors that may contribute to (asd) autism spectrum disorder.1 organic lead, such as tetra-ethyl lead, is a central nervous system toxin that is absorbed through the skin and into the brain; toxicity may occur through handling objects contaminated with organic lead.2 children absorb 40% of a dose of lead compared to 10% in adults and retain 30% of lead absorbed compared to 1% in adults. blood levels of 10 μg/dl or more in children are proved to be toxic, but even lower levels may impair o r i g i n a l a r t i c l e 103 j i m d c 2 0 1 8 103 development and cognition. blood lead levels in the general population of developed countries have fallen significantly over the past 20 years due to phasing out of lead petrol and bans on the use of lead in paints.2-4 lead absorption occurs in two forms. inorganic lead, oxidizes immediately, and can be absorbed through the respiratory tract as lead dust particles and inhalation from lead-containing objects such as paints and lead pipes, through the gastrointestinal tract from water and foods affected by lead contents in the soil, particularly as industrial waste and also from processes such as glazing ceramics, or manufacture of lead accumulators and as a product of lead-containing petrol from atmosphere.5-7 in the body 95–99% of ingested lead is sequestered in erythrocytes and dispersed through soft tissues and bone and is also found in hair and nails.1 lead after getting absorbed from gastrointestinal tract or lungs enters the blood stream. it attaches to the blood proteins that carry it to various tissues or organ systems in the body.5 the largest amounts are stored in bone tissue where lead is deposited initially as a colloidal compound and then as a crystalline material. very low concentrations of lead are found in kidney and liver.6 in children approximately 65 % is found in skeleton.7,8 the elimination of lead from the body is mainly through urine which is 76 % and by gastrointestinal tract is 26 %. about 8% lead is excreted by the sweat, skin exfoliation and hair.4 lead is excreted in urine and feces regardless of the route of exposure. the urinary lead excretion rate depends on renal blood flow and glomerular filtration rate. minor routes of excretion include sweat, saliva, hair, nails, and breast milk.6-8 fecal excretion accounts for approximately one-third of total excretion of absorbed lead. the elimination half-life for inorganic lead in blood and bone is approximately 30 days and 20 years, respectively, whereas its half-life in soft tissues accounts for forty days.9 sources of lead exposure and toxicity include old piping, and working in certain occupations such as printing, plumbing, the destruction of old houses, and the use of lead-contaminated vessels in olive oil production, wine flour and canned food. it is also used in ammunition in army, lead dust increases during daily firearm training in an indoor range; it was shown that blood lead levels doubled within the 6-week duration.10 it is very important to identify the probable sources of lead exposure. lead based paints were the supreme source of the lead poisoning before 1978, now lead is banned to be used in paint industries in developed countries though it is still being consumed in developing countries. in united state about 74 % of private housing units built before 1980 contain lead based paints.11-12 plumbism or lead toxicity is defined as a toxic condition caused by the ingestion or inhalation of the heavy metal lead. in 1991, the centers for disease control and prevention of the united states department of health and human services recommended that lead toxicity occurs when blood lead levels are equal to or greater than 10 μg/dl.13 reproductive toxicology lead effects both male and female reproduction adversely. at high concentrations in blood lead acts as a powerful abortificient. at lower levels, it has been associated with miscarriages, and low birth weights of infants. males may have decreased sperm counts motility, and teratospermia, altered sperm morphology and function.14,15 neurotoxicity lead has miscellaneous impacts on the cns. immature astrocytes are receptive to lead, and it interferes with myelin formation and of the blood-brain barrier integrity. when the barrier is disrupted, molecular proteins like albumin enter the cns, resulting in edema, increased intracranial pressure, and encephalopathy.16 the most commonly predictable adult neurological symptom of lead exposure is peripheral neuropathy.17 patients with high blood lead levels may present with severe colic, motor disturbances, altered consciousness, paralysis of limbs and weakness.18 hypertension and cardio vascular affects studies have been carried out in animals and humans showing that in animals exposed to lead in drinking water, lead affected the renin–angiotensin system, inducing hyperactivity of sympathetic system and increasing sensitivity to stimulation of cardiac vascular and dopaminergic receptors.15 high blood lead levels have been associated with high blood pressure.19,20 lead, gout and renal disease glycosuria and aminoaciduria (saturnine gout) are produced from long term exposure of this heavy metal along with damage to the renal tubules. lead 104 j i m d c 2 0 1 8 104 nephropathy has been well documented in occupationally exposed workers manifesting as interstitial fibrosis, proximal tubular damage and sclerosis of glomeruli.21 dna backbone damage backbone damages include single and double-strand dna breaks. abasic sites can be generated spontaneously, by the formation of unstable adducts or by base excision repair. ssbs are produced directly by detrimental agents, or the intermediates of base and nucleotide excision repair can give rise to single-strand breaks in the range of 1–30 nucleotide.22 along with that when a damaged dna effort to replicate it brings along with it certain errors or mutations into the genetic code.23 p a t i e n t s a n d m e t h o d s this case control comparative study was conducted in the department of biochemistry, university of health sciences lahore. study was completed in 12 months after the approval from institutional ethical committee. there are 1600 traffic police wardens in lahore working in 9 administrative towns namely ravi town, shalimar town, aziz bhatti town, wagah town, data ganj bakhsh town, gulberg town, allama iqbal town, samanabad town and nishtar town. one hundred sixty traffic wardens work in each town and out of them 100 work in field. total 60 traffic wardens from nine administrative towns of lahore, working in morning shift, age range between 25-40 years and having at least 1 year of service in field were selected. they were nominated through stratified random sampling using proportional allocation after taking permission from police central line. wardens working in closed offices or patrolling in cars, known case of any chronic inflammatory disease such as asthma, known case of any autoimmune disease and smokers were excluded from study. thirty age and sex matched controls were taken who volunteered for giving blood. control group was consisted of healthy office workers and students who had never been occupationally exposed to known genotoxic agent. after an informed consent, blood samples were collected from traffic wardens and controls fulfilling the inclusion criteria. all the blood samples were drawn under aseptic conditions from the median cubital vein from anterior aspect of forearm. total 5 ml blood was obtained. for cell extraction, 2.5 ml of heparinized blood was collected in heparin containing vials and mixed properly and 2.5ml of blood sample was taken in black top metal free nitric acid treated tube. the sample was transported to uhs in a cool box containing ice bags. cell isolation was performed on the same day of blood collection. blood lead concentration was determined by atomic absorption spectrometer regarding comet assay method for dna detection, a modified version by singh and colleagues in 1988, introduced a microgel technique. this involves electrophoresis under alkaline (ph 13) conditions for detecting dna damage in single cells. the comet assay is a method in which the basic principle is to determine the dna breaks by measuring the dna damage which is quantified by the proportion of dna, which migrates out of the nuclei towards the anode when individual cells or isolated nuclei is subjected to electrophoresis. the image obtained with this technique looks like a comet like shape with an intact head, the nuclear region and a tail which contains dna fragments of nuclei followed by electrophoresis. the amount of dna liberated from the head of the comet during electrophoresis depends on the level of effect of the mutagen under evaluation. images were captured using charge-coupled device (ccd) camera attached with the microscope (figure 1). figure 1. dna migration pattern produced by the single cell gel/comet assay. (carcin.oxfordjournals.org). the data were entered and analyzed using spss version 18.0. for quantitative variables (lead level, dna damage, and age), mean ± s.d was given. distribution of variables was checked using the 105 j i m d c 2 0 1 8 105 shapiro-wilk test. because of non-normal distribution of parameters, the differences between mean values were tested with nonparametric tests the, mannwhitney u test. spearmen correlation was applied to observe correlation between quantitative variables (dna damage parameters and lead level). correlation coefficient (r) was determined. p value of ≤ 0.05 was considered as statistically significant. r e s u l t s out of total 90 participants, 60 were cases and 30 were control. the age range of cases and control was 24-39 years and 25-35 years respectively. mean age in cases and control was 27.62±2.15 years and 28.13±2.33 years respectively. mean levels of lead in both cases and control groups were 18.76±8.84 μg/dl and 12.00±3.552 μg/dl respectively. blood lead levels were significantly increased in cases as compared to controls (table 1). variables of dna damage, tail moment and tail length were significantly increased in cases. difference of % dna in tail was non-significant between cases and control (table 2). table 1: age and blood lead levels of cases and controls (n=90) variables cases (n=60) median (iqr) controls (n=30) median (iqr) pvalue age (years) 27.50(26-28) 28.00(27-29) 0.241 blood lead levels (µg/dl) 17.00(12-22) 11.50(10-13.25) 0.000 table 2: variables of dna damage in cases and controls (n=90) variables cases (n=60) mean±sd controls (n=30) mean±sd pvalue tail moment (%) 0.0583±1.960 0.045±0.108 0.04 tail length (μm) 7.156±12.56 1.50±2.12 0.03 % dna in tail 4.101±5.87 2.055±2.481 0.136 difference of other parameters of dna damage including % dna in head was non-significant (p=0.16) and comet length was statistically significant between cases and controls (p=0.005). among cases, lead levels were significantly correlated with tail moment, % dna in tail and % dna in head while lead association was nonsignificant with comet length and tail length (table 3). among control, correlation of lead levels was significant with tail moment (r=0.407, p=0.026) while non=significant association was found with comet length (r=0.191, p=0.313), tail length (r=0.226, p=0.231), %dna in tail (p=0.926) and % dna in head (p=0.926). d i s c u s s i o n air pollutants generated from traffic and industrial plants are believed to be one of the major causes of dna damage in living species. because of rapid urbanization, air pollution and environmental quality deterioration have been affecting our daily lives as well as the nature. several experimental studies have reported that lead has a moderate genotoxic potential. in a study conducted by valverde and colleagues 24 a lead inhalation model in mice was used to detect the induction of genotoxic damage as single-strand breaks and alkali-labile sites in several mouse organs (nasal epithelial cells, lung, whole blood, liver, kidney, bone marrow, brain, and testes), assessed by the comet assay. following single and subsequent inhalations, differences were found among the organs studied. a positive induction of dna damage in the liver and the lung after a single inhalation was observed. the response was positive in all organs, except the testicle, in subsequent inhalations. dna damage induction over time varied for each organ. the brain and bone marrow showed the table 3: correlation of lead levels with variables of dna damage in cases (n=60) variables correlation coefficient p-value tail moment 0.337 0.008 % dna in tail 0.380 0.03 % dna in head -0.380 0.03 comet length 0.134 0.306 tail length 0.185 0.15 106 j i m d c 2 0 1 8 106 highest damage induced. differences in dna damage occurred in organs when lead was administered acutely or sub-chronically. our study revealed a significant increase in the blood lead level of study group and controls (p value 0.000). the mean pb in our study was 18.76±8.8 and controls mean pb was 12±3.5 as compared to study in islamabad that was carried out in 2005 in which blood lead levels of wardens were 27.27 ±4.04 and a similar study on traffic wardens in karachi indicated a value of lead in wardens of 47.7±15.8. micrograms /dl.another study in alexandrria eygpt reported that their traffic constables had a higher blood lead level than our study.25 blood lead levels were analyzed in nigerian traffic wardens, comprising sixty from lagos, thirteen from the sparsely populated university town of ile-ife and a control group of twenty-four subjects. the mean lead level in lagos wardens was 18.1 ± 6.4 μg/dl, which was significantly higher than the level of 10.2 ± 2.7 μg/dl in ife wardens and 12.9 ± 7.0 μg/dl obtained in the controls (p < 0.001). however, there was no significant difference between the levels of blood lead in ife traffic wardens and normal controls.26,27 nigeria wardens had almost similar values as our study but their study was conducted 17 years ago and since that time urbanization and population has increased tremendously. alexandria and karachi both are populated cities and have more traffic congestion that is why their lead levels were high as compared to our study. also after 2005 when the law of using unleaded petroleum was introduced no study had been conducted since then on this occupationally exposed group. our study indicated that law had actually been implemented that has reduced lead from the atmosphere and from this exposed group. the mean age in cases in our study was from 24-39 years and in controls was 25-35 years. there was no statistical difference in the mean age of cases and controls in our study (p value 0.241). the mean age of wardens in the study of islamabad and karachi had a mean value of 2145 years and 20-52 years respectively, not comparable with our study. the various parameters of comet assay that is mean tail moment, % dna in tail and mean tail length in our study had values of 0.0583 ±1.960 (p valve 0.04),4.101 ±5.87 (p value 0.136) and7.156 ±12.56 (p value 0.003) respectively in cases and 0.045±0.108 ,2.055 ±2.481 and 1.50±2.12 respectively in controls. there was a significant correlation of lead with tm, but no statistically significant correlation of lead with tail length in cases. the mean % dna in tail in cases gave a mild positive correlation with lead. the other parameters given in our study were % dna in head with a difference in the mean value of cases and controls with a (p value 0.16). the % dna in head gave a mild negative correlation with lead in cases (p value 0.03 and rho -0.380). comet length in our study had a difference in the means of two groups having a p value 0.005 that was statistically significant but it gave no significant correlation with lead in cases. the homeopathic preparation plumbum metallicum had no effect, in a study conducted by riera in 2011, in terms of reducing serum lead in workers exposed to lead.28 a study of dna damage by comet assay in traffic wardens in china 29 showed that occupational exposure to traffic exhaust significantly increased tail length 4.20µm, (3.98 4.42) µm in outside ones vs. 3.23 µm, (2.82 3.7) µm in office work policemen, p < 0.001. the p value of mean tail length is 0.003 in our cases and controls that is statistically significant and comparable to their study however our study did not give a significant correlation of lead with tail length in cases. the results confirm that inhaling lead induces systemic dna damage, but certain organs, such as the lung and the liver, are special targets of this metal, partly depending on the duration of exposure. c o n c l u s i o n because of industrial development, individuals exposed to industrial areas or lead due to their professional work, had significantly higher mean values of blood lead. the correlation coefficient of pb with comet length in cases was statistically insignificant and rho of lead with percentage of dna in head of cases was mild negative correlation and rho of lead with percentage of dna in tail of cases was positive correlation and p value in controls was not statistically significant. r e f e r e n c e s 1. saghazadeh a, rezaei n. systematic review and metaanalysis links autism and toxic metals and highlights the impact of country development status: higher blood and erythrocyte levels for mercury and lead, and higher hair 107 j i m d c 2 0 1 8 107 antimony, cadmium, lead, and mercury. prog neuropsychopharmacol biol psychiatry. 2017;79(pt b):34068. 2. advisory committee on childhood lead poisoning prevention (acclpp)”. cdc. 2012 retrieved. 2014. 3. yeoh b, woolfenden s, lanphear b, et al. household interventions for preventing domestic lead exposure in children. cochrane database syst rev. 2014;(12):cd006047. 4. centers for disease control and prevention (cdc). adult blood lead epidemiology and surveillance: united states, 2003-2004. mmwr morb mortal wkly rep. 2006; 55(32):876879 5. rosin, a.the long-term consequences of exposure to lead. isr med assoc j. 2009; 11:689-94. 6. bellinger, d.c. lead. pediatrics, 2004; 113(4): 1016-22. 7. boreland f, lesjak m, lyle d. evaluation of home and lead remediation in an australian mining community. science of the total environment 2009;408(2):202-8 8. phillip,a.t. gerson,b lead poisoning – part i. incidence, etiology, and toxicokinetics. clin la med, 1994; 14(2):423444. 9. dietrich kn, ware jh, salganik m, radcliffe j, rogan wj, rhoads gg, et al. for the treatment of lead-exposed children clinical trial group. effect of chelation therapy on the neuropsychological and behavioral development of leadexposed children after school entry. pediatrics 2004;114(1):19-26 10. who, world health organization. environmental health criteria 3: inorganic lead, international programme on chemical safety, geneva, switzerland: world health organization. 1997. 11. counter sa, buchanan lh, ortega f, rifai n, shannon mw. comparative analysis of zinc protoporphyrin and blood lead levels in leadexposed andean children. clin. biochem. 2007;40(11):787–792. 12. rabinowitz, m.b., wetherill, g.w. and kopple, j.d. (1976). kinetic analysis of lead metabolism in healthy humans. jclin invest, 1976; 58(2):260-270. 13. soldina qp, miller m, soldin sj. pediatric reference ranges for zinc protoporphyrin. clin. biochem. 2003;36(1):21–25. 14. olewińska, e., kasperczyk, a., kapka,l., kozłowska, a., pawlas, n. and dobrakowski, m. et al. level of dna damage in lead-exposed workers. ann agric environ med.2010; 17(2):231–236. 15. vivante, a., hirshoren, n., shochat, t.and merkel, d. 1. association between acute lead exposure in indoor firing ranges and iron metabolism imaj isr med assoc j, 2008; 10(4): 292-5. 16. clark,c.s., rampal,k.g., thuppil,v., chen, c.k.,clark,r. and roda,s. the lead content of currently available new residential paint in several asian countries. environ res,2006; 102(1): 9–12. 17. eugenious,o., adebamow,c., clark,s., roda,s,. agbede,o.a.,sridhar, m.k.c.and adebamowo, c.a. lead content of dried films of domestic paints currently sold in nigeria. sci total environ.2007; 388(1-3): 116-120. 18. reenan,j. diagnosing pediatric lead toxicity. virtual mentor . ama.2005; 7(12). 19. gidlow, d.a. lead toxicity. occupational medicine. 2004; 54(2):76–81. 20. patrick, l. lead toxicity part ii: the role of free radical damage and the use of antioxidants in the pathology and treatment of lead toxicity. altern med rev.2006; 11(2): 114–127. 21. phillip,a.t. and gerson,b. lead poisoning – part i. incidence, etiology, and toxicokinetics. clin la med. 1994; 14(2):423444. 22. needleman, h. lead poisioning. annu. rev. med.2004; 55:209–22. 23. sancar, a., laura, a., lindsey-boltz., keziban., unsalkacmaz., and linn, s. molecular mechanisms of mammalian dna repair and the dna damage checkpoints. annu. rev. biochem.2004; 73(1):39–85. 24. valverde, m., fortoul, t.i., diaz-barriga,f., mejia, j. and rojas del castillo, e. genotoxicity induced in cd-1 mice by inhaled lead: differential organ response. mutagen.2002; 17(1):55–61. 25. toshihiro, o., tokishita,s.i., mochizuki,k,. kawase,j., sakahira,m. and yamagata,h. uv sensitivity and mutagenesis of the extremely thermophilic eubacterium thermus thermophilus hb27. genes and environment.2006; 28(2):56–61. 26. fracasso, m.e., perbellini, l., sold`a, s., talamini, g., franceschetti, p. lead induced dna strand breaks in lymphocytes of exposed workers: role of reactive oxygen species and protein kinase c. mutat. res.2002; 515 (1):159– 169. 27. agha,f., sadaruddin, a. and khatoon, n. effect of environmental lead pollution on blood lead levels in traffic police constables in islamabad, pakistan. j pak med assoc. 2005; 55(10):410. 28. zhu, c.q., lam, t., jiang, c.q., wei, b.x., chen, y.h. and xu, q.r. a study on lymphocyte dna damage in traffic policemen in guangzhou. zhonghua lao dong wei sheng zhi ye bing za zhi, 2003; 21(1):41-4. 29. padilha rq, riera r, átallah an. homeopathic plumbum metallicum for lead poisoning: a randomized clinical trial. homeopathy. 2011;100(3):116-121. 67 j i m d c 2 0 1 8 67 open access f u l l l e n g t h a r t i c l e tensile strength of novel experimental hydrophilic vinyl polysiloxane impression materials compared to control and commercial vps impression materials shahab ud din1, nouman noor 2, sadaf humayoun3, sadia khalid4, sandra parker5, mangala patel6 1,5,6 department of oral growth and development (dental physical sciences unit), bart’s and the london school of medicine and dentistry, queenmary, university of london, uk 2,3 rawal institute of health sciences (rihs), islamabad, pakistan 4 dentistry and allied disciplines, shaheed zulfiqar ali bhutto medical university (szabmu), pakistan institute of medical sciences (pims), islamabad, pakistan a b s t r a c t objective: to measure the tensile strength of novel experimental hydrophilic (medium bodied) vinyl polysiloxane impression materials developed from ab initio in comparison to control and commercial vinyl polysiloxane impression materials. materials and methods: this experimental study was conducted at the department of oral growth and development, bart’s and the london school of medicine and dentistry, queen mary, university of london, uk from 1st oct 2010 to 28th february 2014. five novel experimental (medium bodied) vps impression materials (exp-i, ii, iii, iv and v) were developed and evaluated for their effect as crosslinking agent and surfactant on the tensile strength and percent elongation-at-break in comparison to control and three commonly used commercial (medium bodied) vps impression materials (aquasil ultra monophase, elite hd monophase, extrude. these properties were evaluated using tenius olsen (mechanical testing machine). results: aquasil ultra monophase (aq m) had a significantly higher ultimate tensile strength (uts) compared to all commercial and experimental vps. although exp-iii showed the lowest uts among all the materials but this was only significant for aq m. on comparing exp-i (control) with exp-ii, after adding tfdmsos into exp-ii there was a slight, but not significant, increase in uts. after adding the surfactant to hydrophilic exp-iii, iv and v, the uts decreased slightly, but not significantly, compared to exp-ii. after addition of cross-linking agent (tfdmsos) there was a significant increase in elongation-at-break of exp-ii compared to the control (exp-i), which was further significantly increased after incorporating the surfactant (rhodasurf cet-2) in the exp hydrophilic vps formulations (exp-iii, iv and v). elongationat-break was significantly increased after incorporating the surfactant (rhodasurf cet-2) in the exp hydrophilic vps formulations (exp-iii, iv and v) compared to exp-ii. conclusion: all exp vps had significantly higher % elongation-at-break (more than double) than commercial vps. percentage elongation-at-break further increased significantly after adding rhodasurf cet-2 (surfactant). key words: impression materials, rhodasurf cet surfactant, tensile strength, vinyl polysiloxane (vps) author`s contribution 1,2 conception, synthesis, planning of research and manuscript writing interpretation and discussion 3,4 data analysis, interpretation and manuscript writing, 5,6 active participation in data collection. address of correspondence sadaf humayoun email: sadaf.humayoun@gmail.com article info. received: december 20, 2017 accepted: february 10, 2018 cite this article. shahab ud din, noor n, humayoun s, khalid s, parker s, patel m. tensile strenghth of novel experimental hydrophilic vinyl polysiloxane impression materials compared to control and commercial vps impression materials. jimdc.2018; 7(1):69-72 o r i g i n a l a r t i c l e mailto:sadaf.humayoun@gmail.com 68 j i m d c 2 0 1 8 68 funding source: nil conflict of interest: nil i n t r o d u c t i o n prosthetic rehabilitation of a dental patient is dependent on many elements. sufficient clinical practices, cautious tooth preparation and luting procedures prove to be the crucial elements in such rehabilitations.15. similarly, the accuracy and detailed reproduction of the impression is also critical for a successful prosthesis and therefore the properties of an impression material from which an impression and then a corresponding cast is made are of utmost importance. an ideal impression material should therefore be able to withstand various forces that are available during different clinical procedures.3 impressions materials come under tensile stresses when they are being removed from the mouth over undercuts. tensile strength is the maximum amount of stress that a material can bear under tension before failure.6,7 the elongation (elongation-at-break) is the amount, a material deforms before its failure (figure 1). impression materials are more prone to tearing in specific areas such as gingival crevices and interproximal areas and such tearing produces a defected impression, which eventually leads to the construction of an ill-fitting prostheses.8 fig 1 shows schematic representation of tensile testing of a typical specimen of impression material. elastomeric impression materials are known for their higher elastic properties on removal of impression from the mouth six. elastomeric impression materials differ from each other in regards to their ultimate tensile strength (uts) and percent elongation-at-break. klooster, logan studied the effects of strain rate on the uts and elongation-at-break of five elastomeric dental impression materials; two polysulphides (coe-flex and omniflex), one condensation silicone (accoe), one vps (reprosil) and one polyether (impregum), all medium-bodied, with the exception of omniflex, which was light-bodied.7 they used three variable crosshead speed rates (100, 200, and 500 mm min-1) for each material. specimens were stretched axially by applying a tensile load in tension until rupture. the polysulphide impression materials showed the lowest uts compared to all materials tested. generally, materials showed higher uts with the higher strain rates. the polysulphide materials showed the greatest amount of % elongation-at-break followed by polyether then vps and finally condensation silicone. generally, materials demonstrated higher values for uts and percent elongation-at-break occurring at the higher strain rates. for this reason, it is recommended that an impression should be removed from the mouth with a snap, in order to minimize permanent deformation. by rapidly removing the materials from the mouth the polymer chains stretch for a shorter period of time, thus there are less chances of tearing and also better elastic recovery. hence, impressions should be removed from the mouth and from the cast rapidly. there is very less information about the tensile strength of vps impression materials and studies available are lacking any quest to improve the tear strength and percent elongation of the material. the objective of this investigation was to comprehensively study five novel experimental vps impression materials (from 113 pilot studies) for their tensile strength and percent elongation-at-break and to evaluate the effect of crosslinking agent and surfactant on the tensile strength and percent elongation-at-break in comparison to control and three commonly used commercial vps impression materials. m a t e r i a l s a n d m e t h o d s this experimental study was conducted at the department of oral growth and development, bart’s and the london school of medicine and dentistry, queen mary, university of london, uk from 1st oct 2010 to 28th february 2014. five novel experimental (medium bodied) vps impression materials (exp-i, ii, iii, iv and v) were developed and evaluated for their effect as crosslinking agent and surfactant on the tensile strength and percent elongation-at-break in comparison to control and three commonly used commercial (medium bodied) vps impression materials (aquasil ultra monophase, elite hd monophase, extrude. these properties were evaluated using tenius olsen (mechanical testing machine). following were the commercial vps impression materials used and included in this study, which were randomly selected: (i) aquasil ultra monophase (medium-bodied), (aq m), purchased from dentsply, usa. ../../../sadaf/desktop/abstract.docx#_enref_2 69 j i m d c 2 0 1 8 69 (ii) elite hd monophase (medium-bodied), (elt m), purchased from zhermack, italy. (iii) extrude (medium-bodied), (extr m), purchased from kerr, usa. the ingredients used for preparation of exp (exp-i, ii, iii, iv and v) vps were: vinyl-terminated poly (dimethylsiloxane) (pre-polymer; molecular weight-mw 62700; fluorochem, uk), aerosil r812s (filler from lawrence industries, uk), rhodasurf cet-2 (ethoxylatedcetyl-oleyl alcohol; non-ionic surfactant, from rhodia, uk) and the following were purchased from sigma aldrich, uk, poly(methylhydrosiloxane) (mw 2270; conventional crosslinking agent), tetra-functional (dimethylsilyl) orthosilicate (tfdmsos; mw 328.73; novel cross-linking agent), platinum catalyst (0.05 m), palladium (˂1 µm; scavenger). preparation of experimental vps impression materials five exp compositions (exp-i, ii, iii, iv and v) appeared as the most favorable formulations out of the 113 formulations.the main differences between these five formulations included the incorporation of a novel crosslinking agent, tfdmsos, to improve the tear strength and a novel non-ionic surfactant (rhodasurf cet-2; ethoxylatedcetyl-oleyl alcohol) to improve wetting properties of the material. exp-i was used as a control for exp-ii. the catalyst paste was same for both the formulations (exp-i and ii). exp-ii was used as a control for exp-iii, iv and v. the catalyst paste was same for all the hydrophilic formulations (exp-iii, iv and v). measurement of tensile strength tensile testing was carried out on the tinius olsen which was calibrated before use. the specimens (n=12 per material) were held in self-tightening grips and then extended at a constant test speed of 500 mm min-1 until rupture, and the force (n) required to break the specimen, and the extension (mm) of the specimen at failure were recorded (12,13) (figure 2). stress and strain values were calculated using equations 1 and 2 respectively. where σ is the stress (mpa), f represents the force (n), a is the sample cross-sectional area (m2) where ε represents the strain (%), l₀ is the original length (mm) at rest, l is length (mm) after applied stress. r e s u l t s figure 3 shows the results for the mean ultimate tensile strength (uts) and % elongation-at-break for all commerciand exp vps impression materials. all comml and exp vps impression materials demonstrated significant differences (p<0.05) in uts. aq m had a significantly higher (tukey’s hsd test) uts (3.31 mpa ± 0.19 mpa) compared to all comml and exp vps. although exp-iii showed the lowest uts (2.19 mpa ± 0.21 mpa) among all the materials, this difference was only significant for aq m. elt m, extr m and exp-i had relatively similar mean values, which were not significant (p˃0.05). on comparing exp-i (control) with exp-ii, it was noticed that after adding tfdmsos into exp-ii there was a slight, but not significant, increase in uts. it was also observed that after adding the surfactant to hydrophilic exp-iii, iv and v, the uts decreased slightly, but not significantly, compared to exp-ii (control; figure 3). all exp vps showed significantly higher elongation-atbreak (%) than the comml vps. exp-v exhibited significantly higher values (981.92 % ± 51.08 %) for % elongation-at-break, while significantly lower values were shown by elt m (114.88 % ± 15.05 %) compared with all materials; these were not significantly different for aq m. on comparing the comml vps with each other, extr m had significantly higher % elongation-at-break followed by aq m and then elt m, and the difference between aq m and elt m was not significant. on comparing the exp vps with each other, exp-i demonstrated significantly lower elongation-at-break. it is worth noting that on addition of cross-linking agent (tfdmsos) there was a significant increase in elongation-at-break of exp-ii compared to the control (exp-i), which was further significantly increased after incorporating the surfactant (rhodasurf cet-2) in the exp hydrophilic vps formulations (exp-iii, iv and v; figure 3). generally, materials with high uts had lower 70 j i m d c 2 0 1 8 70 percent elongation-at-break. however, this trend was not strictly applicable for all comml and exp vps, such as aq m, which had the highest uts but it’s percent elongationat-break was not the lowest (second lowest). similarly, exp-ii had the second highest uts, but its elongation-atbreak was higher than all comml and exp-i materials (figure 3). figure 1: schematic representation of tensile testing of a typical specimen of impression material figure 2: a typical tensile test specimen set up (n=12) figure 3: mean (± standard errors; n=12) uts and % elongation-at-break of comml and exp vps immediately after setting. similar letters indicate no significant difference (p˃0.05) d i s c u s s i o n the uts of impression materials is an important parameter, which indicates the maximum stress that a material can withstand while being stretched before breaking. strain at failure is the percentage elongation-atbreak of the material. the uts of an impression is dependent on many factors such as the choice of material, relief properties from the tooth and the perfect timing or rate of impression removal.14 from clinical point of view, materials with higher tensile strength are considered superior than the ones with lower tensile strength and therefore an ideal impression can be taken only once the impression material is able to demonstrate maximum energy absorption without tearing and with minimal distortion. for the above reasons the tensile strength and percent elongation-at-break were evaluated in the current work and a possibility to improve them was taken as a challenge.14 uts for all comml and exp vps investigated were in the range of 2.21 to 3.31 mpa. on comparing these results with a previous study by klooster, logan, who investigated the uts and elongation-at-break of vps, condensation silicone, polyether and polysulphide impression materials, it was seen that all the comml and exp vps in this study had higher uts. the values for klooster et al’s materials were in the range of 0.96 to 2.07 mpa.7 in the case of elongation-at-break, all exp vps had significantly higher percent elongation-at-break (more than double) than comml vps. furthermore, exp-ii showed a higher % elongation-at-break (761.99%) compared to the control (exp-i; 538.44%). the former contains the novel crosslinking agent (tfdmsos), and it is assumed that this component is responsible for the increase in % elongation-at-break, due to being tetra-functional, as discussed in detail earlier in the materials and method section. 7,14 on comparing this data with lawson, burgess results, who investigated the elongation-at-break percent of six elastomeric impression materials; five vps and one hybrid, the exp vps had much higher values (more than double) for percent elongation-at-break compared to their materials. also, all exp vps of the current study showed ../../../sadaf/desktop/abstract.docx#_enref_2 ../../../sadaf/desktop/abstract.docx#_enref_8 71 j i m d c 2 0 1 8 71 much higher values for percent elongation-at-break (more than double) than those reported by klooster et al, for some elastomeric impression materials.7,15 a high percent elongation-at-break is a very clinically relevant property, provided the material has the required elastic recovery. according to mccabe and walls, polysulphide impression materials can withstand 700% elongation before failure. interestingly all the exp vps investigated in this study, with the exception of exp-i, exhibited higher percent elongations (761.99% to 981.92%). in the case of the polysulphides some of the strain is non-recoverable, which is the major drawback of these materials, while in the case of the exp vps, the elastic recovery was comparable to all comml vps. all exp vps, with the exception of exp-i, additionally contained tfdmsos as a cross-linking agent. therefore, it is inferred that this component increased cross-linking within the materials, thus contributing to the increase in their percent elongation-at-break.16 c o n c l u s i o n all exp vps had significantly higher percent elongationat-break (more than double) than commercial vps. percentage elongation-at-break further increased significantly after adding rhodasurf cet-2 (surfactant). recommendations the specific properties of an impression material dictate the choice of an impression material for a particular application. with regard to the uts and percent elongation at break tested, all exp vps had significantly higher percent elongationat-break (more than double) than commercial vps, and exp-ii showed a higher percent elongation-at-break compared to the control (exp-i). the former contained the novel cross-linking agent (tfdmsos), and it is assumed that this component is responsible for the increase in percent elongation-at-break due its’ tetra-functional structure. elongation-at-break was significantly increased after incorporating the surfactant (rhodasurf cet-2) in the exp hydrophilic vps formulations (exp-iii, iv and v) compared to exp-ii. this study can be a great help to design a new vps impression material with much better mechanical properties. r e f e r e n c e s 1. arcangelo ac, zarow m, angelis df, vadini m, paolantonio m, giannoni m, etal. five-year retrospective clinical study of indirect composite restorations luted with a light-cured composite in posterior teeth. clin oral invest. 2014;18(2):615-624. 2. arcangelo dc, angelis df, vadini m, amario dm. clinical evaluation on porcelain laminate veneers bonded with light-cured composite: results up to 7 years. clin oral invest.. 2012;16(4):1071-1079. 3. re d, de angelis f, augusti g, augusti d, caputi s, amario dm, arcangelo dc, etal. mechanical properties of elastomeric impression materials: an in vitro comparison. int j dent. 2015; 7(4):428-486. 4. wassell rw, barker d, steele jg. crowns and other extra-coronal restorations: try-in and cementation of crowns. brit dental j. 2002;193(1):17-28 5. arcangelo dc, angelis df, amario dm, zazzeroni s, ciampoli c, caputi s,etal. the influence of luting systems on the microtensile bond strength of dentin to indirect resin-based composite and ceramic restorations. operat dent. 2009;34(3):328-336. 6. lu h, nguyen b, powers j. mechanical properties of 3 hydrophilic addition silicone and polyether elastomeric impression materials. j prost dent. 2004;92(2):151-154. 7. klooster j, logan gi, tjan ahl. effects of strain rate on the behavior of elastomeric impression. the journal of prosthetic dentistry. 1991;66(3):292-298. 8. hamalian ta, nasr e, chidiac jj. impression materials in fixed prosthodontics: influence of choice on clinical procedure. journal of prosthodontics. 2011;20(2):153-160. 9. lee ea. impression material selection in contemporary fixed prosthodontics: technique, rationale, and indications. compendium of continuing education in dentistry (jamesburg, nj: 1995). 2005;26(11):780-782. website: [https://www.researchgate.net/journal/15488578_compendium_of_continuing_education_in_den tistry_jamesburg_nj_1995] retrieved on 12th dec 2017. 10. din su, parker s, braden m, tomlins p, patel m. experimental hydrophilic vinyl polysiloxane (vps) impression materials incorporating a novel surfactant compared with commercial vps. dental materials. 2017; 33(8):301-309. 11. din sh, hassan m, parker s, patel m. setting characteristics of three commercial vinyl polysiloxane ../../../sadaf/desktop/abstract.docx#_enref_15 ../../../sadaf/desktop/abstract.docx#_enref_9 72 j i m d c 2 0 1 8 72 impression materials measured by an oscillating rheometer. pak oral dental j. 2016;;36(3): 332-335. 12. parker s, meththananda i, braden m, pearson jg. characterisation of some experimental silicones. j mater sci. 2006;17(2):1255-1258. 13. walker mp, alderman n, petrie cs, melander j, mcguire j. correlation of impression removal force with elastomeric impression material rigidity and hardness. j prosthodont. 2013;22(5):362-366. 14. abdulsamee n, hussein n. wettability and tear strength of two novel materials for recording impressions of post hole spaces. ec dental sci. 2017;10(3):179-93. 15. lawson nc, burgess jo, litaker ms. tensile elastic recovery of elastomeric impression materials. j prosthet dent. 2008;100(1):29-33. 16. mccabe jf, walls awg. applied dental materials. blackwell publishing ltd; 2008; 19(9):167.