ISSN No.

2079-8547
Recognized by PMDC

KHYBER JOURNAL OF
MEDICAL SCIENCES
Patron
Professor Mohammad Noor Wazir
Principal, Khyber Girls Medical College, Peshawar
Chief Editor
Mohammad Noor Wazir
Professor of Medicine, Khyber Girls Medical College, Peshawar
Managing Editor Executive Editors
Said Amin Muhammad Usman
Muhammad Bilal Khattak Rabeea Sadaf
Tariq Mehar Imran Khan
Shams Suleman Fawad Rahim
Shahswar
Jamshad Ktk
Zahid Ullah Khan
Kalsoom Tariq
Editorial Advisory Board
Tauseef Aman Ayesha Jami Sher Rehman
Rahida Karim Ghazala Wahid Anwar ul Haq
Shahab Ud Din Khalid Shahab Amer Abbas
Naheed Siddiqui Khalid Usman Shahsawar
Saeed Ur Rehman Muhammad Ishfaq Muhammad Naeem
Jahanzeb Khan Afridi Rashid Aslam M. Zahid
Saiqa Zahoor Muhammad Asim Nadia Khattak
Khalid Khan
Muhammad Aqeel Khan Asmatullah
Ghazala Shams
Islam Gul Rubina Akhtar
Naheed Asghar
Israr Ahmad Nabila Sher Khalid Mehmood
Mehreen Samad Shakila Asif Munir Hussain
Zubia Shah
Overseas Advisors
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Zaffar (UK), M S S Hamzuni (UK), Sharif Ullah (UK), Salman Nishthar (UK),
M Saeed (UK), C Graddin (UK)
Epidemiologists: Bio Statistician:
Zahid Jadoon and Usman Raza Muhammad Iqbal

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Professor of Medicine
Khyber Girls Medical College,
Peshawar - Pakistan
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KJMS May - August, 2020, Vol. 13, No. 2
CONTENTS
EDITORIAL
SARS-CoV-2 infection and Acute Limb Ischemia: Are We Un-
derestimating the Problem?___________________________169
Muhammad Hanif, Abdul Wali Khan
Original Articles
1- Hand hygiene practices and trends in tertiary care hospitals of
Peshawar___________________________________________171
Shimee Shahzadi, Muhammad Shah, Raza Ullah, Shehzad Akbar Khan, _
Yousaf Jan, Shaukat Hussain
2- Use of chorionic villus sampling technique by mothers of
thallasemia major children for the prevention of thalassemia in
coming children in KPK_______________________________176
Abdul Wali Khan, Amjad Ali, Muhammad Ishaq, Abat Khan,
Sami Ullah Khan, Wajid Ali
3- Frequency of solid organs injuries in blunt abdominal
trauma______________________________________________180
Ali Gohar, Muhammad Yunas Khan, Muhammad Zeb, Fahad Ahmad,
Umair Shahab, Imran Khan Haider, Maaz Rehman
4- Comparative study of ringers solution vs ½ strength normal
saline (0.45%) As post operative fluid therapy in
children_____________________________________________184
Muhammad Daraz Khan, Muhammad Jehangir, Saddar Rahim,
Muhammad Uzair, Fayaz Ur Rehman, Hayat Ur Rehman
5- Survey to Assess Knowledge, Attitude and Preventive Practic-
es Regarding Dengue among Adult Population__________188
Shakila Asif, Tauseef Aman, Nida Asif, Hamana Tahir, Alia Dar Qazi
6- A Comparative Evaluation of Radiological Score (CTSI) and
Clinical Score (Ranson’s) in predicting the Severity of Acute
Pancreatitis__________________________________________193
Jamshed Alam, Muhammad Kalim, Ahmad Faraz, Junaid Shah,
Siddique Ahmad, Muhammad Iftikhar, Ayaz Gul, Sohaib Ali
7- Pattern of spinal trauma: a clinical study of 205 patients in
hayatab medical complex/ medical teaching institute Peshwar
Pakistan_____________________________________________198
Sohail Amir, Rizwan-Ullah-Khattak, Imran Khan, Ayaz Afridi,
Muhammad Nawaz Khattak, Hanif Ur Rehman, Mushtaq,
Muhammad Ali Nouman, Shahid Ayub
8- Level of Job Satisfaction among nurses working in Tertiary
Care Hospital of Faisalabad___________________________202
Aftab Nazir, Rabia Arshad Usmani, Rida Dawood,
Nargis Haider Kakar, Marriam Nazir, Zunera Tanveer, Irshad Ahmad
9- Prevalence of refractive errors in primary school going chil-
dren of sheikh maltoon town Mardan___________________207
Shafi Ullah, Shahana Nisar, Uzma Nisar, Hamza Abbas, Bakhtawara.
Nayyer zaman, Nizam ud din
10- Effectiveness and safety of Sofosbuvir and velpatasvir combi-
nation for the treatment of HCV________________________213
Dilaram Khan, Fakhre alam, Fawad raheem, Hashmatullah,
Mohammad Kamran Hassan
 11- Efficacy of harmonic scalpel versus bipolar electrocautry in
hemorroidectomy____________________________________216
Tahir Ullah, Muhammad Khan, Arshad Ali, Imran Ud Din Khan,
Annual Subscription
Ghulam Younas, Abdul Hameed
Pakistan: Rs. 1200/-
12- Epidemiology and distribution of kidney diseases and its asso-
Overseas: US $ 50/-
ciation to socio-demographic factors in patients presenting to
khyber teaching hospital, Peshawar____________________220
Muhammad Fayaz, Muhammad Umer Farooq, Mian Mufarih Shah,
Wajeeh Ur Rehman, Muhammad Tariq Shah, Muhammad Shahid,
Junaid Ali
13- Comparison of ureteroscopic laser versus extracorporeal
shock wave lithotripsy for upper ureteral stones in terms of
stone free rate_______________________________________224
Riaz Ahmed, Jamshad Alam, Ameroon Shah, Ahmad Faraz, Ayaz Gul,
Muhammad Kalim, Sohaib Ali
14- Frequency and types of anemia in patients attending antenatal
clinic in a teaching hospital of Peshawar________________229
Sadia, Shahnaz Parveen, Rabeea Sadaf, Nighat Shaheen,
Shazia Tabassum
15- Clinical outcomes of Reconstruction and Arthroscopic repair of
the cruciate ligament of the Knee joint by quadrupled semi-ten-
dinosus auto-graft____________________________________233
Javed Iqbal, Rafe-ullah, Naeem Ullah, Aimal sattar, Ehsan Ullah,
Ibrar Mohibullah Wazir
16- Induction of labour with Foley Catheter in women with previous
one caesarean section________________________________237
Shahida Sultan, Samina Sabir, Rabeea Sadaf, Ghazala Shams,
Sadia Ali
17- Prevalence and mortality due to communicable and non-com-
municable diseases in urban areas of Peshawar__________241
Sayyed Jalawan Asjad, Aamer Liaqat, Syed Shahmeer Raza,
Shakeeb Khan, Muhammad Noman
18- Frequency of Bacterial Co-infection in Patients with
Malaria______________________________________________245
Muhammad Nouman, Fawad Rahim, Huma Gul, Muhammad Ayub,
Sadaf Chiragh, Muhammad Yousaf
19- Dermatologic spectrum of patients presenting with dengue
infection and their co-relation with severity of the disease__ 248
IrfanUllah, Muhammad Majid Paracha, Mehran Khan, Hina Zahoor,
Dawood Khan, Ayesha Saleh
20- Experience of peripheral neurectomy in case of trigeminal
neuralgia treatment a retrospective analysis of 40 cases___254
Rizwan Ullah, Kamran Ullah, Mushtaq, Ayaz, Imran, Nawaz
21- Frequency of vitamin b12 deficiency in patients with type ii
diabetes mellitus with and without metformin therapy_____257
Kalim Ullah Khan, Jehan Anjum, Muhammad Fayaz,
Wajeeh Ur Rehman, Daneet Kumar, Jasvindar Kumar, Uroosa Arif
22- Relation of serum ammonia level with porto-systemic enceph-
alopathy and its short term prognostic role in patients with liver
cirrhosis_____________________________________________262
Munir Hussain, Noaman Yousaf, Afshan Bashir, Khalid Mehmood,
Khalid Javed, Arshed Parvez
23- The spaghetti wrist: management and outcome at a special-
ized hand unit in a tertiary care hospital_________________268
Firdous Khan, Mohammad Shadman, Zahid Iqbal Bhatti,
Tahseen A. Cheema, Tahmeedullah
24- Frequency and types of age related macular degeneration
(amd) in patients with decreased vision above 60 years of
age; a cross sectional study conducted at tertiary care hospi-
tal, Peshawar________________________________________274
Muhammad Numan, Muhammad Sajid Khan, Waqar Hayat,
Muhammad Saleh Faisal, Waheed Iqbal
25- Functional outcome of minimal invasive plate osteosynthesis
in peri-articular knee fractures__________________________279
Arif Kaleem, Tahir Mehmood Khattak, Basit Hussain, Zahid Askar
26- Efficacy of Laparoscopy for Impalpable Cryptorchidism___284
Jehangir Khan, Muhammad Javed Khan, Kifayat Khan
27- Risk factors for non-alcoholic fatty liver disease: a cross-sec-
tional study in Pakistani Population_____________________287
Abida Matin Ansari, Naheed Gul, Mahwish Majid Bhatti, Lubna Meraj,
Zarmast Khan, Muhammad Wajad Munir
28- Comparison of laparoscopic transabdominal preperitoneal
(tapp) versus open (lichenstein) repair of inguinal hernia in
terms of early post operative pain______________________293
Rafiullah, Razman Khan, Muhammad Ismail, Asif Mehmood,
Muhammad Kaleem, Abdul Ghafoor
29- Frequency of gestational diabetes in obese patients______300
Huma Sahibzada, Irfan Ullah, Summra Yousaf, Taskeen Rehana
30- Trigeminal Nerve Compression (TGNC) Surgical Technique
for the Treatment of Trigeminal Neuralgia; Study of 40 Cases
in 5 Years____________________________________________304
Muhammad Nawaz Khan, Mushtaq, Khalid Anwar Khanzada,
Attiya Nasir Siddique, Shahid Ayub, Rizwanullah Khattak,
Azmatullah Khattak
31- Sensitivity of nitrofurantoin in escherichia coli urinary tract
infection in khyber teaching hospital Peshawar___________309
Shandana Altaf, Mariana Amer Amer Azhar
32- Frequency of retained products of conception on ultrasound
among women presenting with spontaneous abortion____312
Samreen, Saadia Shamsher, Naila Nasr, Shadab Gul
33- To Compare the Effectiveness of Transurethral Pneumatic
Lithotripsy and Extracorporeal Shock Wave Lithotripsy: In
treatment of Lower Ureteric Stones_____________________318
Siddique Ahmad, Jamshed, Barka Sajjad, Syed Ameroon Shah,
Riaz Ahmad, Irfan Ullah, Muhammad Kalim, Muhammad Sohaib Ali,
Muhammad Ibqar
34- Incidence of low birth weight in pregnant women with isolated
oligohydramnios_____________________________________327
Shabana Yasmeen, Oreekha Amin, Ayesha Naz
35- Pregnancy rate after diagnostic hysterosalpingography in
infertile women_______________________________________331
Anjum Ara, Taskeen Rehana, Naheed, Tashfeen Irtaza Khan
36- Role of Progesterone in preventing preterm birth_________334
Shahdab, Shabana yasmeen, Ayesha Naz, Ghazala Shams
37- Frequencies of different risk factors for hemorrhagic
stroke_______________________________________________337
Himayatullah, Raza Ullah, Sami ul Huq, Shahida Naz, Rab Nawaz
38- Comparison of antipyretic efficacy of intravenous (iv) acetamin-
ophen versus oral (po) acetaminophen in the management of
fever in children______________________________________340
Khalil Ahmad, Ansar Hussain, Habib ur Rahman, Khalid Khan,
Irfan Khan, Hamayun Anwar
39- Sulfasalazine Induced Granulomatous Interstitial Nephritis: An
Unusual Case of Caution______________________________343
Muhammad Hanif, Abdul Wali Khan, FNU Sunds, Muhammad Ishaq,
Abat Khan
 SARS-COV-2 INFECTION AND ACUTE LIMB ISCHEMIA: ARE
WE UNDERESTIMATING THE PROBLEM?
Muhammad Hanif, Abdul Wali Khan
The Coronavirus disease-2019 (COVID-19), caus-
ing by SARS-CoV-2 infection, emerged as a cluster of
atypical pneumonia in December 2019, has caused
more than a million deaths, and has affected approx-
imately forty-one million people worldwide until now.
SARS-CoV-2 not only involves the respiratory system
but can affect any organ system presenting with differ-
ent complications, including myocarditis, renal failure,
neurological, and gastrointestinal complications.1 The
association between coagulopathy and COVID-19 has
been reported in the literature by the laboratory findings
of increased levels of D-dimer.2 A study conducted in
France showed that 24% of hospitalized patients devel-
op some degree of pulmonary embolism.3 Acute limb
ischemia is a limb-threatening emergency and usually
requires extensive and prompt interventions. If not
managed in time, it usually results in loss of viability of
the affected limb. During this COVID-19 pandemic, an
increased number of critical limb ischemia has been not-
ed. A study conducted in Italy demonstrated a ninefold
increase in critical limb ischemia cases compared to the
previous year (p<.001).4 Similarly, studies conducted
in other parts of the world have also demonstrated an
increase in the frequency of acute critical limb ischemia
in COVID-19 patients.
An increase in the cases of critical limb ischemia
has surfaced in recent months in Pakistan. In the
following paragraphs, we chronicle the tale of an elderly
lady with mild SARS-CoV-2 infection who presented with
acute limb ischemia.
An elderly lady was brought to the emergency
department for complaints of sudden onset pain,
numbness, and bluish discoloration of the right upper
extremity. The pain started a day ago. It was sudden
in onset and progressed over time. On examination,
the right upper extremity was cold to touch, and the
brachial pulse was palpable. Distal pulses were eval-
uated, which showed a feeble right radial pulse and
absent ulnar pulse. Pulses in the left upper extremity
were normal. His blood pressure was recorded to be
110/70, heart rate of 92, oxygen saturation of 82% on
peripheral pulse oximetry, and a temperature of 100F.
The patient was offered paracetamol for the pain, but
Postgraduate Internal Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan
.........................................................................................
Address for correspondence:
Muhammad Hanif
Postgraduate Internal Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan
E-mail: hanifafridi273@gmail.com
KJMS May - August, 2020, Vol. 13, No.2
her pain did not respond to paracetamol, necessitating
the use of opioids. Given her low oxygen saturation, she
was offered oxygen through a simple oxygen mask. All
baseline investigations were ordered, which showed a
TLC count of 16000 /cmm3 (with 88% neutrophils), Hb
of 12g/dl, Platelets of 280000/cmm3, serum ferritin 1176
ng/ml, CRP 12 mg/L, ESR 45/minute, D-Dimer of 7mcg/
ml. Her chest X-Ray demonstrated bilateral infiltrates.
To determine the cause of her right upper ex-
tremity pain, a Doppler ultrasound was ordered, which
demonstrated an absent blood flow in the right ulnar and
radial artery consistent with thrombosis. A thrombophilia
screen and anti-neutrophilic antibodies were sent for
analysis, the results of which came out negative. An
echocardiogram was done, which does not reveal any
thrombus with normal ejection fraction. Given her low
oxygen saturation and bilateral infiltrates on chest x-ray,
a nasal swab was collected for SARS-C0V-2 PCR, which
turned out positive. She was diagnosed with a throm-
botic complication, possibly secondary to SARS-CoV-2
infection. She was admitted to the COVID-19 isolation
unit, where she was commenced on low molecular
weight heparin-Enoxaparin (60mg twice a day subcu-
taneously), Ceftriaxone IV (75mg/kg/day), Azithromycin
500mg IV once a day, dexamethasone 4mg/day IV,
vitamin C and Zn supplements. A consultation from the
vascular surgery department was obtained, but due to
late presentation, surgical interventions were deferred. 
Various mechanisms have been proposed to
delineate the association between COVID-19 and co-
agulopathy. Coagulopathy has been a significant com-
plication of COVID-19, and various mechanisms have
been proposed to explain this association. Following
are a few of the possible mechanisms:
SARS-CoV-2 may directly invade the endothe-
lial cells via ACE-2 receptors leading to endothelitis
followed by vasoconstriction of the affected vessel
segment leading to ischemia and end-organ damage.5
Another proposed mechanism suggests that
COVID-19 induced inflammatory cytokines such as in
cytokine storm may induce a hypercoagulable state
leading to vessel thrombosis.6
Patients with COVID-19 are usually immobile; this
factor may contribute to the overall hypercoagulable
state in these patients.
SARS-CoV-2 infection may modify the Renin-an-
giotensin pathway that may play some role in the
development of a hypercoagulable state.7
169
 In our case, thrombotic complications developed
in a patient with mild COVID-19, which is not in line with
existing literature, where mostly thrombotic complica-
tions are presented in severe COVID-19 disease. No
significant study has been done on the said topic in this
region. Conducting large scale studies is the need of the
hour to unmask this very important association between
COVID-19 and critical limb ischemia. Furthermore,
clinicians should be aware of this unique complication
of COVID-19, and early interventions should be done
to prevent the development of detrimental effects. It is
equally important to conduct large-scale trials on the
possible therapeutic approaches to these complica-
tions. 
REFERENCES
1. Ahmed MU, Hanif M, Ali MJ, et al. Neurological
Manifestations of COVID-19 (SARS-CoV-2): A Re-
view. Front Neurol. 2020;11:518. Published 2020
May 22. doi:10.3389/fneur.2020.00518
2. Zamboni P. COVID-19 as a Vascular Disease: Lesson
Learned from Imaging and Blood Biomarkers. Diag-
nostics (Basel). 2020;10(7):E440. Published 2020
Jun 29. doi:10.3390/diagnostics10070440
170
3. Bompard F, Monnier H, Saab I, Tordjman M, Abdoul
H, Fournier L et al. Pulmonary embolism in patients
with COVID-19 pneumonia. European Respiratory
Journal. 2020;56(1):2001365.
4. Bellosta R, Luzzani L, Natalini G, Pegorer M, Attisani
L, Cossu L et al. Acute limb ischemia in patients
with COVID-19 pneumonia. Journal of Vascular
Surgery. 2020;.
5. Varga Z, Flammer AJ, Steiger P, et al. Endothelial
cell infection and endotheliitis in COVID-19. Lancet.
2020;395(10234):1417-1418. doi:10.1016/S0140-
6736(20)30937-5
6. Abou-Ismail MY, Diamond A, Kapoor S, Ara-
fah Y, Nayak L. The hypercoagulable state in
COVID-19: Incidence, pathophysiology, and
management. Thromb Res. 2020;194:101-115.
doi:10.1016/j.thromres.2020.06.029
7. Hajra A, Mathai SV, Ball S, et al. Management of
Thrombotic Complications in COVID-19: An Up-
date. Drugs. 2020;80(15):1553-1562. doi:10.1007/
s40265-020-01377-x
KJMS May - August, 2020, Vol. 13, No.2
 HAND HYGIENE PRACTICES AND TRENDS IN TERTIARY
CARE HOSPITALS OF PESHAWAR
Shimee Shahzadi, Muhammad Shah, Raza Ullah, Shehzad Akbar Khan, Yousaf Jan, Shaukat Hussain

ABSTRACT
Objective: The importance of hand hygiene cannot be under estimated in hospitals environment where there is increased
chance of nosocomial infection. Hand hygiene is the mainstay of health care and a sure measure against nosocomial
infection. The aim of our study is to observe trends of hand hygiene practices in Peshawar tertiary care hospital.
Methods and materials: this observational study was conducted in medical/surgical wards of public/private sector
hospitals of Peshawar (LRH, HMC, KTH, KTH and MTH). The duration of observation for each ward was 1 hour. Health-
care workers including professors, house officers (Hos), nurses and paramedics in respective wards were included.
Data was collected and categorized as clean and dirty activities according to the Fulkerson Scale. The data was ana-
lyzed on the SPSS-17.
Results: Total observations 228, Professors 80, HOs 74, Nurses 60 Paramedics 12. Hand hygiene action was as fol-
lows: Missed 174(76.3%), Hand Wash 25(11%) Gloves 27(11.8%). Among 92% clean activities by professors, 86 %
missed hand hygiene action while encountering 8 % of dirty activities, they used gloves and hand wash. Majority of the
house officers missed hand wash or use of gloves in clean activities while performing dirty activities they were better
comparatively. 70% of nurses encounter dirty activities, 31.6 % didn’t wash hands, 8.3% did and 26.7% used gloves.
Encountering clean activities 28.3% neglected hand wash, 3.3% washed hands and 1.7% used gloves.
Conclusion: our hospitals lack hand hygiene practices and should be properly addressed.
Key words: Hand Hygiene, tertiary care hospitals, Healthcare Workers

INTRODUCTION some countries especially the Pakistan, the situation is

The corner stone of any health practice in ancient
times as well as in the present has always been clean-
liness, mainly clean hands. And let’s not forget that
cleanliness has become corner stone of any civilized
society and is a mark of good breeding and conduct1. In
some societies the cleanliness has been so engrained
so as to the development of communal baths for the
sole purpose of a clean healthy community. In the health
care practice, clean hands are basic pillar of any type
of patient handling, if you are going to touch the patient
and anything associated with the patient or if you are
going to review a ward or handle ward equipment, or
if you are just visiting a sick patient room without the
patient in it and you get your hands on anything at all
you have to wash your hands.
It’s a common complaint of paramedical staff
specially the nursing cadre that the available resources
are limited such as running out of soap, running out of
towels, damp hands, dry hands, dermatic irritation. And
if the soaps are replaced with alcohol based hand rubs,
then there is the issue of cost and limited resources. In
Department of Surgical’ C’ Unit HMC/KGMC
.........................................................................................
Address for correspondence:
Dr Muhamad Shah
Department of Surgical’ C’ Unit HMC/KGMC
Cell: 03335829224
E-mail: drmuhammadshah@yahoo.com
much worse in the aspect of incomplete facilities2. It is
a common observation of the unhygienic conditions in
the hospital ward and the limited resources for hand
hygiene as there are not easily accessible facilities
provided to the nursing and paramedical staff.
If we assess the situation step by step we can
deduce the following:
Hospitals are not structured nor their wards to
employ hand hygiene practices in the most basic term
of wash basins, towels, soap bars. And in some setups
that we may come across it, the utilization is not ade-
quate to merit it.
There is a general lack of knowledge in all cadres
of health care practice of the best possible hand hygiene
practices
If there is some sufficient knowledge in some
cadres, the attitude and practice of that knowledge is
sufficiently lacking.
There is a general mismanagement of hand
hygiene practices at the administration levels of most
institutions. And the administration mainly focuses on
treatment and discharge.
Most of our institution of healthcare work past their
patient load capacity, and the health care workers work
load is such that the idea of hygienic practices seems
to them a luxury.

KJMS May - August, 2020, Vol. 13, No.2 171

 The most basic practice that is employed in our
health care setup is that if you are handling a wound
or an infected site or if you may come in contact with
urine and feces, first and foremost employ glove use. It
will protect you. So the basic action of our health care
workers is to protect themselves then the patient for
they do not have time for the patient and their safety.
And it is a common observation that most of the
lower staff the nursing care and the house officers only
employ strict hand hygiene when specifically ordered
by a senior professor in some instances otherwise they
consider it a triviality.
WHO recognizes that most of the developing
economies of the world and the health care institu-
tions due to lack of direction and limited resources
are a chief playing ground of nosocomial infections.
The situation becomes grim especially in the surgical
domain when the patient after undergoing surgery is
most susceptible to nosocomial infection, and most
post-surgical complications are such infections post
operatively and seriously endanger a patient life3. And
if anybody a patient is immune-comprised for him the
hospital admission could be a death sentence.
Most in our community the indiscriminate use of
antibiotics has created super bugs which are resistant
to most classes of antibiotics and if anybody gets a
hospital acquired infection it most probably is antibiotic
resistant type, which further complicates the problem,
and highlights the issue of hand hygiene practices and
how much we need them so as not to endanger the
patient lives.
OBJECTIVES
To assess and evaluate and rate a healthcare
facility for provision of Hand Hygiene Facilities, by a
scale devised by WHO for this specific measure.
To find and assess the frequency and percentage
of hand hygiene practices namely Hand Wash, Alcohol
Rub, Gloves, or Missed.
To evaluate the hand hygiene practices among
professors, house officers and nurses on the basis of
which practice they employed most, whether correctly
or incorrectly.
To evaluate all the activities per observation ac-
cording to fulkerson scale, into clean / unclean activities,
and compare and contrast that data, with which hand
hygiene practice was employed.
METHODOLOGY
We needed to observe the health care worker in
their wards, not suspecting any observer at all. Firstly,
we trained our observers in the study on how to rate a
patient on the WHO hand hygiene action scale, Then
we trained them in Fulkerson scale and how to rate an
observation and activity according to the Fulkerson
172
scale. We also printed a key for all the observers to
carry it with them on a hard card.
LOCATION
Then we selected five major hospitals from Pesha-
war, namely Lady Reading Hospital, Khyber Teaching
Hospital, Hayatabad Medical Complex, Kuwait Teaching
Hospital, Mercy Teaching Hospital. Next we decided to
select only medicine and surgical wards for our study to
limit the scope of our study. We assigned two observers
per ward to avoid single observer bias, and asked them
to observe the ward for one hour only from 9am to 10am
in the morning in all hospitals.
STUDY DESIGN
It was an observational study, with undetermined
sample size just a time constraint of one hour all obser-
vations that can be made in that time. The number of
observers was 10 who were tasked to do the survey in
two days as the number of wards was ten in total. So
they did the medicine wards on the first day and the
surgical wards on the second day.
DATA COLLECTION TOOL
The data collected was put in SPSS 17.0. And
analysis was run on the data.
ETHICAL CONSIDERATION
The next step was to write to the Heads of these
hospitals and ask permission to carry out the study,
the permission was duly granted. Observers were
coached if someone asks them what they are doing;
their response would be “collecting data on drug ad-
ministration and types of drugs commonly used”.
ANALYSIS PLAN
The data was analyzed as string variables, and
multiple cross tabulations were performed. comprehen-
sive data obtained by combining first the data from all
medicine wards in one data set and the surgical in the
another, the analysis run on them. After that both the
data sets were combined to run analysis for a more
comprehensive picture of hand hygiene practices and
its trends.
RESULTS
In 174 out of 228 observations the hand hygiene
practice was missed and the total number of clean
activities is 150 (Table 1.2), which means that in 24
dirty activities, a critical hand hygiene opportunity was
missed which amounts to 10.5% of total necessary
hand hygiene action. The maximum missing is in the
professor’s category, but on close analysis it was re-
vealed that most of their activities were clean activities.
The second group to miss Hand hygiene indication was
house officers while the nurses were in the last to miss
KJMS May - August, 2020, Vol. 13, No.2
the least. The most preferable mode of hand hygiene
action is gloves as is evident from nurses’ category as
they mostly encounter dirty activities. While in house
officers it is Hand wash compared to the gloves. It also
reflects on the issue that the nurses found it expedient
to use gloves and save time then employ Hand wash,
as their workload is more. While the house officers
employ hand wash due to less workload albeit the fact
that equal number of observations was made. On the
other hand, the professors usually performed routine
checks and did not engage in many dirty activities as
Graph.1.1: Categorized observations based on Fulk-
per Fulkerson scale.
erson Scale
Among the professors the contact according to
Fulkerson scale clean and dirty activities, mostly 92 % of
them did clean activities for which mostly 86 % of them
missed hand hygiene action but while encountering
dirty activities which was only 8 percent of total the
professors used gloves and hand wash. Among House
Officers who dealt with 25% of their 33% were dirty ac-
tivities, for which, in 9.5% they neglected hand hygiene
while in 5.5% they washed and in 6.8% used gloves but
when they dealt with clean activities, in 75% of these
they missed the hand wash practice while in 10.9 % they
washed their hands and in 1.4% used gloves.70% of
nurses encounter dirty activities for which 31.6 % didn’t
wash their hands while 8.3% did wash, 26.7% of these
used gloves while doing the activity, similarly while Graph.1.2: Surgical Wards
encountering clean activities 28.3% neglected hand
wash, 3.3% washed their hand and 1.7% used gloves.
At close observation of the comparison of the
graphs (Graph1.2 & 1.3) we begin to realize that there
are not many gross differences in hand hygiene practic-
es between the medicine and surgical wards, because
it seems that the health care workers consider clean
and dirty in general measure rather than in terms of
understood fact and protocol. When we look at the
Fulkerson readings we realize that a general category
such as urine prompted the use of hand hygiene action
but a less subtle category such as objects associated
with patient secretions did not prompted hand hygiene
measure, which reinforces the fact that knowledge
about hand hygiene and when should it be employed
is less or the attitude towards hand hygiene practices Graph.1.3: Medical Wards
is at fault.
In surgical wards, it was observed that hand hy- Table1.1: Observations based on Professional
giene action was most prevalent before the touching Category
of the patient. It was also observed that gloves use was
more in the surgical wards. Professional Category Frequency Percent
Missing Values 2 0.9
INFRASTRUCTURE SURVEY
Professors 80 35.1
In the facility infrastructure survey for hand hy-
House Officers 74 32.5
giene evaluation multiple factors were taken into ac-
count such as availability of soap, sinks, water, towels, Nurses 60 26.3
alcohol hand rub, gloves. Then there was educational Paramedics 12 5.3
material on hand hygiene in the forms of posters and
Total 228 100
guidelines and protocols. Presence or absence of which
was recorded.

KJMS May - August, 2020, Vol. 13, No.2 173

Table 1.2: Activities Categorization based on Fulker-
son Scale
Fulkerson Scale Frequency
Missing value
Sterile or autoclaved
martials
Thoroughly cleaned or
washed materials
Patient himself, but minimal
and limited
Objects intimately associat-
ed with the patients but not
known to be contaminated
Materials not necessary
cleaned but free from
pateints contact
Objects contacted by
patient either infrequently
or not expected to be con-
taminated
secretions or excretions
from infected site
patient urine
infected patient sites
infrastructure.
DISCUSSION
Percent
As is evident in the results, and much it has been
2 0.9 discussed there, but we will shed some light upon the
8 3.5 highlights of the study here. Out of the total 228 obser-
vations in the ten wards, 150 were clean activities while
78 were dirty activities according the Fulkerson scale,
15 6.6
which amounted to 34.2% of the total. While the hand
hygiene practices had a high missed ratio but looking
65 28.5 at such low percentage of dirty activities it came out as
that in 10.5% of the total observations the adoption of
31 13.6 hand hygiene was of paramount importance4. who was
the main culprit here in this was explained the results
but recapping here, professors mainly engaged in the
patient examination and let the junior staff deal with dirty
17 7.5
activities, House officers also relied mainly on nursing
staff to deal with dirty activities, and the nurses being
overloaded sometimes looked the other way in terms
12 5.3 of hand hygiene.
The most common Hand hygiene action was
gloves use, which can also be stipulated from the fact
that facilities only provided gloves as a sure shot way of
25 11.0 hand hygiene as was explained in the results of facility
infrastructure evaluation heading It was most common
7 3.1 in nurses as they were the only one who mainly engaged
6 2.6 in the apparent dirty activities5.

objects in contact with 14 6.1 But what is most important is the fact that hand
patient secretions hygiene was followed just and i mean just because,
only things or activities that were considered dirty only
patient secretions or 16 7.0
in those hand hygiene was employed which is not the
mouth, nose, genitoanal
protocol. Hand hygiene before patient and after patient
area
no matter what the activity is, the risk is there6. And it
materials contaminated by 10 4.4 was evident from the data that the hand hygiene before
patient urine patient handling was very less7.
Total 150 / 78 = 65.8 / Then comes the point of knowledge about hand
228 34.2 hygiene practices, and becomes clear that the main
culprit here is the knowledge, because in the apparently
Looking at the data one thing is clear, yes there’s
clean activities there is risk and a knowledgeable person
running water. yes some are in easy access, are there
would know that, the evidence for it in the data was
any towels no, are the taps hand operated yes, are
that everyone considered urine to be dirty and hygiene
soaps available No are they replaced in one hospital
worthy but very seldom were the objects associated with
only and only intermittently, are alcohol hand rub avail-
the urine or secretion were considered wash worthy or
able in some only,
glove use8. There is a type of self-made perception of
One thing which was a diehard constant was the what’s dirty and what’s not, and only general wisdom
availability of gloves in all hospitals at all times signi- and experience is the rule here not standards and
fying a cheap time saving alternative to hand hygiene protocols, such kind of attitude of, i know what’s dirty
practices other than it. or what’s not is a wrong attitude here. And therein lies
the second problem, no one is educating them9. In the
With regard to Posters on hand Hygiene, about facility evaluation survey it was found that not a single
the technique, and about the indication of hand hygiene, poster was present which encourages or teaches about
was non-existent in all hospitals and wards under the hand hygiene practices to health care providers10,11. It’s
study. a serious administrative lapse, and seeing that all five
Due to ethical considerations the data with regard hospitals were teaching hospitals, it strange in what is
to facility infrastructure and hospitals could not be dis- they trying to teach if not hand hygiene, a cardinal pillar
closed only their rating given per WHO scale as less of health care12.
than adequate in terms of hand hygiene practices and

174 KJMS May - August, 2020, Vol. 13, No.2

 The attitude needs to be changed it can be in-
stilled through top bottom approach, as was apparent
the professors were the most to miss on hand hygiene
opportunities13,14. Everybody follows by example and
elders are the best examples to follow if the professors
employ hand hygiene at every available opportunity
than it would be possible to change the attitude as a
whole15.
CONCLUSION
The lapse in hand hygiene could be attributed to
work burden, non-availability of facilities, inadequate
knowledge, mislead attitudes, inadequate training. Our
cordial sincere suggestion would be to organize work-
shops on hand hygiene, paste posters on technique and
indications, and provide towels soap running water, or
alcohol rub. Decrease workload on nursing staff. Pro-
vide additional training to nursing staff. Make policies
with regard to provision of accessible hand hygiene
measures or facilities with abundant stock in stores at
all times.
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1. Gidley, C. “Now, wash your hands!” Nursing times
83, no. 29 (1986): 40-42.
2. Boyce, John M. “It is time for action: improving hand
hygiene in hospitals.”Annals of internal medicine
130, no. 2 (1999): 153-155.
3. Hugonnet, Stéphane, Thomas V. Perneger, and
Didier Pittet. “Alcohol-based handrub improves
compliance with hand hygiene in intensive care
units.”Archives of Internal Medicine 162, no. 9
(2002): 1037-1043.
4. Bennett, Glynis, and Ian Mansell. “Universal precau-
tions: a survey of community nurses’ experience
and practice.” Journal of Clinical Nursing 13, no. 4
(2004): 413-421.
5. Pittet, Didier, Philippe Mourouga, and Thomas V.
Perneger. “Compliance with handwashing in a
teaching hospital.” Annals of internal medicine 130,
no. 2 (1999): 126-130.
KJMS May - August, 2020, Vol. 13, No.2
6. Larson, Elaine L. “APIC guidelines for handwashing
and hand antisepsis in health care settings.” Amer-
ican journal of infection control 23, no. 4 (1995):
251-269.
7. Pittet, Didier, StéphaneHugonnet, Stephan Harbarth,
Philippe Mourouga, ValérieSauvan, Sylvie Touve-
neau, and Thomas V. Perneger. “Effectiveness of a
hospital-wide programme to improve compliance
with hand hygiene.” The Lancet 356, no. 9238
(2000): 1307-1312.
8. Kampf, G., and H. Löffler. “Dermatological aspects of
a successful introduction and continuation of alco-
hol-based hand rubs for hygienic hand disinfection.”-
Journal of Hospital Infection 55, no. 1 (2003): 1-7.
9. Lankford, Mary G., Teresa R. Zembower, William E.
Trick, Donna M. Hacek, Gary A. Noskin, and Lance
R. Peterson. “Influence of role models and hospital
design on the hand hygiene of health-care workers.”
Emerging infectious diseases 9, no. 2 (2003): 217.
10. Won, Sau-Pin, Hung-Chieh Chou, Wu-Shiun Hsieh,
Chien-Yi Chen, Shio-Min Huang, Kuo-Inn Tsou,
and Po-NienTsao. “Handwashing program for the
prevention of nosocomial infections in a neonatal
intensive care unit.” Infection control and hospital
epidemiology 25, no. 9 (2004): 742-746.
11. Gould, D. “Nurses’ hand decontamination practice:
results of a local study.”Journal of Hospital Infection
28, no. 1 (1994): 15-30.
12. Lyle, H. “Infection control--the situation in hand.”
Nursing times 93, no. 37 (1996): 76-78.
13. Gould, D. “Hand decontamination: nurses’ opinions
and practices.” Nursing times 91, no. 17 (1994):
42-45.
14. Willis, Jenine. “Skin care: Principles of hand-wash-
ing.” Nursing times 91, no. 44 (1995): 43-44.
15. Gould D (2000) Hand decontamination. Nursing
Standards 15, 45-50.
175
 USE OF CHORIONIC VILLUS SAMPLING TECHNIQUE BY
MOTHERS OF THALLASEMIA MAJOR CHILDREN FOR THE
PREVENTION OF THALASSEMIA IN COMING CHILDREN IN
KPK
Abdul Wali Khan1, Amjad Ali2, Muhammad Ishaq3, Abat Khan4, Sami Ullah Khan5, Wajid Ali1

ABSTRACT
Objectives: To assess the awareness status and frequency of use of chorionic villus sampling among parents of thal-
assemia major children for prenatal Diagnosis of thalassemia and to study the effects of consanguineous marriages
on disease transmission.
Methods: This cross sectional descriptive study was carried out in Khyber teaching hospital and blood donation centers
including Frontier foundation, Hamza foundation and Fatmeed foundation from January 2017 to April 2017. Consecutive
sampling was done. Mothers who were having at least 1 previous thalassemic child and had either child younger than
thalassemic child or were in the last trimester of their pregnancy were included. Those mothers whose children were
having blood disorders other than thalassemia major and those who were having either no child after thalassemic child
or were not pregnant at the time of our research were excluded. Unwilling mothers were also excluded. A total of 130
mothers were selected and informed consent was obtained. Those mothers were interviewed using interview based
questionnaire. Data was manually analyzed and results were prepared with Microsoft office 2013.
Results: Of total 130 subjects, 101 (77.69%) had some knowledge of CVS while 29 subjects (22.31%) had no knowledge
of CVS. Out of 101 subjects who were aware of this procedure only 50 (49.5%) subjects had done this test at the time
of interview, while about 51 subjects (50.5%) did not undergo CVS. Those mothers who were aware of CVS but never
utilize their knowledge, stated different reasons for not undergoing this test. Among them 29.70% stated sociocultural
reasons, 14.85% stated religious reasons, 6.9% were having fear of procedure associated risks and 1.96% did not
believe in test result. Out of 130 subjects 99 subjects (76.15%) were married to their first cousins.
Conclusions: The mothers with thalassemic child(s) in KPK has comparable knowledge about the prenatal diagnosis
of thalassemia but only about half of them opt to undergo CVS. Most of the mothers terminate their pregnancies after
having a positive test result. Consanguinity is as common as other parts of this country.
Key words: Chorionic villus sampling, thalassemia, Khyber Pakhtunkhwa, prenatal diagnosis.

INTRODUCTION About 5-9 thousands of thalassemic children are

born every year in Pakistan, though exact number is not
Thalassemia is highly prevalent genetic disorder known.3An estimated carrier state of 9.8 million, which
throughout the globe, With 70,000 infants born every makes up to 5-7% of the total population, is present in
year and around 270 million carrying heterozygous Pakistan.4
mutation.1,2
Consanguinity is a major risk factor in the
causation of thalassemia. Different populations and
1
Department of Physician Hayatabad medical Complex,
ethnic groups have different proportions of consanguin-
Peshawar
eous marriages, hence different rates of thalassemia.
2
Department of Surgeon Hayatabad Medical Complex,
A study conducted in Lahore showed that thalassemia
Peshawar
was most frequently found in Rajputs followed by Jatts,
3
House officer Hayatabad Medical Complex, Peshawar
Arains, Sheikhs and Pathans. It showed that 56.7% had
4
Department of Physician Khyber teaching hospital
1stcousin marriages and 19.8% were relatives.5
Peshawar
5
Department of Physician Ayub Teaching Hospital, Many techniques have been developed for the
Abbotabad pre-natal diagnosis of thalassemia. Chorionic villous
......................................................................................... sampling (CVS), amniocentesis, cordocentesis, and
Address for correspondence: fetal blood sampling are a few to mention. CVS has an
Abdul Wali Khan added advantage i.e. can be carried out in 1st trimester
Department of Physician Hayatabad medical Complex, of pregnancy and has lesser maternal cells contam-
Peshawar ination. Detection of cell free fetal DNA in maternal
Cell: ?????? blood is another technique in developing. Needless to
Email: abdulwalikhan801@yahoo.com

176 KJMS May - August, 2020, Vol. 13, No.2

mention, the availability, knowledge, accessibility and
acceptability of these procedure to mothers or parents
at risk are still major problems to be addressed. A study
centered at Rawalpindi and Islamabad showed that
among 149 couples, 90 (60%) did not request PND. The
main reasons for not utilizing the options of PND was
lack of awareness (23%), high cost of procedure(23%),
no access (17%), delay in seeking (16%) and advice
against the test (12%).6 A study conducted in Iran
showed that only 81.4% of mothers with positive test
result undergo abortion, while 18.6% mothers enrolled
in the study choose not to undergo abortion after pos-
itive test result. The main reason for not undergoing
abortion was found to be low education level of partner.7
Greater population of Khyber Pakhtunkhwa lives
in rural areas with low literacy rate, different cultural
norms, strict religious beliefs and highly prevalent
consanguineous marriages. Educating the public about
pre-marital Hb electrophoresis, prenatal diagnosis of
thalassemia, and opting for induced abortion after a
positive PND result, seems challenging. A study con-
ducted at Armed forces institute Rawalpindi, Pakistan
showed that 72% of the couples were aware of the
prenatal testing for thalassemia. Among couples who
had a positive test result, 88.7% opted for pregnancy
termination, while 11.3% didn’t opt for pregnancy termi-
nation on religious ground.8 No study has been done
so far in KPK region to evaluate the knowledge about
the prenatal diagnosis or chorionic villus sampling for
thalassemia, its effectiveness and outcome and the pub-
lic perception about these techniques. Our study aims
at assessing the awareness level of parents regarding
PND of thalassemia, utilization of their knowledge for the
PND of thalassemia, reasons for reluctance to PND and
proportion of consanguinity in parents of thalassemic
children in KPK region.
METHODS
This cross sectional descriptive study was carried
out in Khyber teaching hospital and blood donation cen-
ters including Frontier foundation, Hamza foundation
and Fatmeed foundation where subjects were referred
from different districts of KPK including Peshawar,
Mardan, Charsadda, Buner, Bannu, Lakimarwat and
Abbotabad; from January 2017 to April 2017. Consec-
utive sampling was done. Mothers who were having
at least 1 previous thalassemic child and had either
child younger than thalassemic child or were in the
last trimester of their pregnancy were included. Those
mothers whose children were having blood disorders
other than thalassemia major and those who were
having either no child after thalassemic child or were
not pregnant at the time of our study were excluded.
Unwilling mothers were also excluded. A total of 130
mothers were included and informed consent was ob-
tained. Those mothers were interviewed using interview
based questionnaire. Sample size and time constraints
KJMS May - August, 2020, Vol. 13, No.2
were our main limitations. Data was manually analyzed
and results were prepared with Microsoft office 2013.
RESULTS
Of total 130 subjects, 76.69% (101/130) had some
knowledge of PND using chorionic villus sampling
while 23.31% (29/130) had no knowledge about it.Out
of 101 subjects who were aware of this procedure only
50 (49.5%) subjects had done this test at the time of
interview, while about 51 subjects (50.5%) declined the
procedure. Out of 50 subjects who opted for this test,
15 (30%) subjects tested positive, 11 (73.3%) subjects
having positive test result agreed to terminate their
pregnancies but 4 subjects declined pregnancy ter-
mination; 3 babies born to these subjects were found
thalassemic and 1 baby was normal despite positive test
result. Out of 50 cases who had done CVS 35 (70%)
were diagnosed as negative for thalassemia but later
on when the babies were born 3 babies were found
thalassemic.
The subjects who were aware of the procedure,
89 subjects (88.12%) were counseled by physicians,
5 (4.95%) subjects were advised by family members,
5 subjects by friends and no one had benefited from
media.
Subjects who were aware of CVS but never uti-
lized their knowledge, stated different reasons for not
doing this test; 29.70% stated sociocultural reasons,
14.85% stated religious reasons, 6.9% were having fear
of procedure associated risks and 1.96% did not trust
test result.
Out of 50 who had done this test 7 (14%) sub-
jects experienced only mild abdominal cramps with no
other complications. Of total 130 subjects 76.15% were
married to their first cousins.
DISCUSSION
Regarding knowledge about PND for thalassemia,
no significant difference was found between our study
population (KPK) compared to studies done in other
parts of the country(p = .67, α= .05).8
No significant difference for non-utilization of
knowledge of PND was found between our study pop-
ulation and other studies (p= 0.85, α= 0.05)8. Majority
of the subjects (50.5%) who are aware of the PND were
still reluctant to undergo the procedure. The reasons for
not undergoing the procedure are multifold, major be-
ing, socio-cultural and religious reasons; others include
fear of procedure associated risks and no trust in test
results. Other studies show many different reasons for
not undergoing PND services includinglack of aware-
ness (23%), high cost (23%), poor access (17%), delay
in seeking (16%) and advice against the test (12%).
Increasing mother education significantly increases the
use of PND services.9A study carried out in Thailand
shows a similar trend where 47.37% of mothers didn’t
177
opt for PND.10Interventions should be mainly focused at
educating masses regarding socio-cultural and religious
misconceptions in KPK.
A study conducted in Karachi showed that only
5% (6 of120) mothers underwent prenatal diagnostic
testing.11 In our study population, considerably higher
number of mothers (50 of 130, 38.46% ) underwent PND
testing (Z=6.30). A similar study conducted in Bangla-
desh showed that 5% (10 0f 200) mothers opted for PND
testing.12Little sensitization would increase compliance
and adherence to medical advice in the people of KPK.
Most of the mothers terminated their pregnancies
after having a positive test result in our study population.
This proportion is significantly higher as compared to
people in Iran (p<.05) and Italy (p<.001)13.However, in
china and India all of the mothers carrying a thalassemia
major fetus terminated their pregnancies.14, 15
Consanguinity is a major risk factor for thalas-
semia. Up to 76.15% subjects in our study population
were married to their first cousins, it was in line with
another study conducted in Karachi which revealed
78.5% consanguinity rate.16 a similar study conducted
in Faisalabad reported consanguinity rate of 77.3% in
parents of thalassemic children.17 It is shown that 61% of
the members in a family with thalassemia (consanguin-
ity) had haemoglobinopathies including thalassemmia
major, minor and carrier state.18Consanguinity is still
high in our population (KPK) as in other parts of this
country and is leading to thalassemia burden on the
society and already constrained health resources.
Majority of the subjects were counseled by phy-
sicians regarding thalassemia and PND services. Role
of doctors specially pediatricians and obstetricians is
pivotal in genetic counseling, referral for PND services
and public education as they are the 1st who diagnose
thalassemia or come across it. Print and electronic
media should come into play as their contribution is
minimum at this stage.
CONCLUSION
The mothers with thalassemic child(s) in KPK has
comparable knowledge about the prenatal diagnosis of
thalassemia but only about half of them opt to undergo
CVS. Most of the mothers terminate their pregnancies
after having a positive test result. Consanguinity is as
common as other parts of this country.
REFERENCES
1. Abolghasemi H, Amid A, ZeinaliS,RadfarMH,Esh-
ghiP,RahiminejadMS,etal.Thalassemia in Iran:
epidemiology, prevention, and management. J
PediatrHematolOncol 2007;29:233–8.
2. Modell B, Khan M, Darlison M, King A, Layton M, Old
J,etal.A national register for surveillance of inherited
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Bull World Health Organ 2001;79:1006–13
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3. Ansari SH, Shamsi TS, Ashraf M,BohrayM,Far-
zanaT,KhanMT,et al. Molecular epidemiology of
β-thalassaemia in Pakistan: Far reaching implication.
IntJMolEpidemiol Genet 2011;2:403–8.
4. Black ML, Sinha S, Agarwal S, Colah R, Das R,
Bellgard M, et al. A descriptive profile of β- thalas-
saemia mutations in India, Pakistan and Sri Lanka.
JCommunity Genet2010;1(3):149–57.
5. MaimoonaHafeez 1, Maleeha Aslam, Ayesha Ali,
Yasmin Rashid, Hussain Jafri. Regional and Ethnic
Distribution of Beta Thalassemia Mutations and
Effect of Consanguinity in Patients Referred for Pre-
natal Diagnosis. J Coll Physicians Surg Pak. 2007
Mar;17(3):144-7.
6. SajidaNaseem 1, Suhaib Ahmed, FarhaanVahidy.
Impediments to Prenatal Diagnosis for Beta Thalas-
saemia: Experiences From Pakistan. PrenatDiagn.
2008 Dec;28(12):1116-8. doi: 10.1002/pd.2133.
7. Moudi Z, Miri-Moghaddam E. Decisions Regarding
Pregnancy Termination Due to β-Thalassemia Major:
a Mixed-Methods Study in Sistan and Baluchestan,
Iran. Journal of Genetic Counseling. 2016;26(3):556-
566.
8. S Ahmed 1, M Saleem, N Sultana, Y Raashid, A
Waqar, M Anwar, B Modell, K A Karamat, M Petrou.
Prenatal Diagnosis of Beta-Thalassaemia in Paki-
stan: Experience in a Muslim Country. PrenatDiagn.
2000 May;20(5):378-83.
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RatanaKomwilaisak, YotsombatChangtrakul, Supan-
Fucharoen, JamrasWongkham, PilaiwanKleebkaow,
KanokSeejorn. Prenatal Prevention for Severe
Thalassemia Disease at Srinagarind Hospital. J Med
Assoc Thai. 2006 Oct;89Suppl 4:S87-93.
11. Arif F, Fayyaz J, Hamid A. Awareness among parents
of children with thalassemia major. J Pak Med Assoc.
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M Rudra, T T Mirza. Awareness Among Parents of
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KJMS May - August, 2020, Vol. 13, No.2 179

 FREQUENCY OF SOLID ORGANS INJURIES IN BLUNT
ABDOMINAL TRAUMA
Ali Gohar1, Muhammad Yunas Khan2, Muhammad Zeb3, Fahad Ahmad3, Umair Shahab3, Imran Khan Haider3,
Maaz Rehman3
INTRODUCTION
Blunt trauma is physical injury to a body part either
by effect, injury, or physical assault. Stomach injury is
viewed as one of the most widely recognized reasons
for dreariness and mortality among all age bunches
everywhere on the world. Harm to stomach organs
is normally connected with stomach trauma1. Clinical
highlights incorporate stomach torment, inflexibility,
delicacy, and wounding of the outside midsection. The
most widely recognized reasons for Blunt stomach
injury are engine vehicle impacts (MVCs), attacks, rec-
reational mishaps, or falls. Among the reasons for gruff
stomach injury, the most widely recognized reason is
Motor vehicle collisions2. Safety belts ensure the event
of head and chest wounds however may make injury
stomach organs as the pancreas and the intestines2.
Gruff injury of the lower chest might be related with
splenic or liver injuries3. The liver is the most widely
recognized stomach viscera inclined to all types of in-
jury; with an occurrence of around five percent among
all injury patients admitted to a hospital4.
The spleen is the most widely recognized strong
organ causing huge seeping in unpolished stomach
injury. In kids, Spleen is the second most regularly in-
tra-stomach harmed organ5. The kidneys may likewise
be harmed in unpolished stomach injury as they are to
some degree somewhat secured by the ribs6. A mea-
surements from the National Center for Injury Prevention
and Control, injury was one of the main sources of death
in matured 1-44 years. Among these injury patients, ob-
tuse stomach injury represented 79% of cases7. Writing
support that Blunt stomach injury is more normal in men
with a male-to-female proportion of 60:40. Analysis of
gruff stomach injury is made based on finding recom-
mended by ultrasonography, registered tomography,
and peritoneal lavage, and medical procedure might
be considered in the treatment7. The visualization of
obtuse stomach injury patients is acceptable.
1
Consultant Surgery, Fauji Foundation Hospital Pe-
shawar
2
Department of Surgery E Unit KTH,
3
Postgraduate Trainee Surgery E Unit KTH
.........................................................................................
Address for correspondence:
Dr Ali Gohar
Department of Surgery, Fauji Foundation Hospital
Peshawar
Cell: 0333-9118809
E-mail: ????
180
METHODOLOGY
This retrospective study spellbinding investigation
was directed at the careful division of Khyber Teaching
Hospital (MTI-KTH) Peshawar, over a time of a half
year from April 2019 to October 2019. Complete of
118 patients were concentrated subsequent to getting
educated assent. The incorporation models of our ex-
amination were the two sexes male and female patients
with an age scope of 18-70 years giving gruff stomach
injury. Rejection rules included patients with a past
history of laparotomy or another significant stomach
medical procedures and patients with starting systolic
pulse under 90mmhg. All the patients were exposed
to exploratory laparotomy on the following prompt OT
rundown to identify organ wounds. All the laparotomies
were done under the oversight of a specialist general
specialist with having at least five years’ insight. Strong
organ wounds including kidney, liver, spleen, and
pancreas wounds were assessed utilizing ultrasound
and CT examines. All the examinations were finished
by master Radiologists having at any rate five years of
involvement.
An information examination was completed
utilizing SPSS adaptation 20. Mean and standard de-
viation(SD) was determined for mathematical factors
like age and recurrence and rates were for downright
factors like sexual orientation, sort of injury, strong
organ wounds (liver, spleen, kidney, and pancreas).
Strong organ wounds were separated from age, sex,
sort of injury to see impact modifiers. Chi-Square test
(Post-separation) was applied with P-esteem ≤0.05 was
considered as critical. All the outcomes were introduced
as tables and diagrams.
RESULTS
The investigation was directed at the Department
of General Surgery, Khyber Teaching Hospital, Pesha-
war on 118 patients. The outcomes are as under: 75
(63.55%) patients were recorded in 18-45 years and
43 (36.44%) patients were recorded in 46-70 Years.
Mean and SDs for age was 40+12.97. (Table No. 1). 96
(81.43%) patients were male patients while 22 (18.56%)
patients were female patients. (Table No. 2). 47 (39.66%)
patients were having RTA, 38 (32.06%) patients went
under attack, 11 (9.28%) patients had an injury from fall
while 22 (18.98%) patients got wounds from a modern
mishap. (Table No. 3). 9 (07.59%) patients got pancreas
wounds, 36 (30.37%) patients got kidney wounds, and
37 (31.22%) patients got wounds in the liver though 36
(30.37%) patients got wounds in the spleen. (Table No.
KJMS May - August, 2020, Vol. 13, No.2
 Table 1: Age Wise Distribution (n=118) Table 2: Gender Wise Distribution (n = 118)

Age Group Frequency Percentage Gender Frequency Percentage

18-45 Years 75 63.29% Male 193 81.43%
46-70 Years 43 36.70% Female 44 18.56%
Mean and SD 40+12.97 Total 237 100%

Table 3: Stratification Of Solid Organ Injuries With Respect To Age (n=118)

Solid Organ Injuries Age Groups P Value

18-45 Years 46-70 Years
Pancreas Yes 07 (5.93%) 02 (1.69%) 0.066
No 67 (56.96%) 42 (35.44%)
Spleen Yes 22 (18.56%) 14 (11.8%) 0.645
No 53 (44.72%) 29 (24.89%)
Liver Yes 21 (17.79%) 16 (13.55%) 0.089
No 54 (45.99%) 27 (22.78%)
Kidney Yes 25 (21.09%) 11 (9.32%) 0.267
No 50 (42.19%) 32 (27.00%)

Table 4: Type Of Trauma (n=118) admitted to hospital4.

Type of trauma Frequency Percentage The spleen is the most well-known reason for
huge seeping in dull stomach injury. Among young-
RTA 47 39.66% sters, the spleen is the second most normally harmed
Assault 38 32.06% intra-stomach organ in children5. The kidneys may
likewise be harmed as they are mostly secured by ribs.
Fall 11 9.28%
Industrial Accident 22 18.98% In one investigation, injury to strong gooey hap-
pened in 79% of patients, 7.3% of whom had an empty
Total 118 100%
thick physical issue. The recurrence of empty thick injury
expanded with the number of strong organs injury:
Table 5: Solid Organ Injuries (n=118)
15.4% and 34.4% of patients with two strong gooey
wounds (n = 547) and three strong gooey wounds (n
Solid Organ Frequency Percentage
= 96)8respectively.
injuries
Pancreas 9 07.59% In our investigation 75 (63.55%) patients were
recorded in 18-45 years and 43 (36.44%) patients were
Spleen 36 30.37% recorded in 46-70 Years. Mean and SDs for age was
Liver 37 31.22% 40+12.97. (Table No. 1). 96 (81.43%) patients were
Kidney 36 30.37% male patients while 22 (18.56%) patients were female
patients. (Table No. 2). 47 (39.66%) patients were having
Total 118 100% RTA, 38 (32.06%) patients went under attack, 11 (9.28%)
patients had an injury from fall though 22 (18.98%)
4). The definition of strong organ wounds as for age and patients got wounds from a mechanical mishap. (Table
sex are recorded in Table No. 5 and 6 individually. No. 3). 9 (07.59%) patients got Pancreas wounds, 36
(30.37%) patients got kidney wounds, 37 (31.22%) pa-
DISCUSSION tients got wounds in the liver while 36 (30.37%) patients
got wounds in the spleen. (Table No. 4). The definition of
This retrospective study reveals insight over
strong organ wounds as for age and sex are recorded
certain fascinating perceptions which are explained
in Table No. 5 and 6 individually.
beneath as stomach injury is one of the most widely
recognized reasons for grimness and mortality among In another examination on dull stomach injury
all age bunches around the world. It might be obtuse or patients, about 70% of the injury patients were in the
entering type and may make harm the basic stomach emergency unit). The age bunch went from 6 - 74
viscera. The liver, the weakest organ to a wide range years with middle age 24 years). An examination by
of injury, is harmed in about 5%of all injury patients

KJMS May - August, 2020, Vol. 13, No.2 181

Sawhney et al indicated that around 89% and 84% of
the patients had liver splenic trauma9respectively. In
another examination which included 41 (82%) male
and 9 (18%) female patients with a proportion of 5.4:1
individually. About 15(30%) patients experienced liver
wounds. 13 patients (26%) supported splenic wounds.
Intestinal injury (from the stomach to the butt-centric
waterway) was seen in 11 patients (22%), five patients
were with small digestive tract injury, 2 with stomach
and duodenum and the staying 4 had internal organ
wounds. Pancreas was harmed in 2(4%) patients. Mes-
enteric tear in 3 (6%) patients and 2 (4%) had a cracked
stomach. Five patients (10%) supported retroperitoneal
hematoma. Renal injury was seen in 3(6%) patients
and 2 patients had wounds to the urinary bladder10.
In our examination 9 (07.59%) patients had pancreas
wounds, 36 (30.37%) patients got kidney wounds, and
37 (31.22%) patients got wounds in the liver though 36
(30.37%) patients got wounds in the spleen.
In past investigations by Ball and Croley11, Gupta
et al. and Saad and Alpar13, the male to female propor-
12
tion were 5.4:1. These findings are near the aftereffects
of studies led by Ahmed14 and Kunin et al15.
58 percent (58%) cases contained street auto
collisions (RTA). The explanation for it is the decrepit
condition of public vehicle framework in Karachi, packed
one, with travelers even on rooftop highest points of
transports, presenting an extraordinary danger to their
wellbeing. Other than this, a large portion of the trans-
port drivers are exhausted, lack of sleep, here and there
for over 24 hours at a stretch and generally are affected
by different narcotic medication misuse and cannabis or
sedative use brings about hindered judgment on their
part prompting innumerable lethal mishaps. RTA is the
most well-known reason prompting obtuse stomach
injury, as announced by different examinations, for
example, 48% by Khan13, 67% by Kunin et al.15, 30%
by Ball SK (67), and 81.8% by Ceelen et al16 next to
RTA another reason was tumble from stature (20%).
Most frequencies of these falls were discovered to be
among workers of development organizations, who are
compelled to chip away at small wages on tall structures
without proper wellbeing measures. A tumble from steps
at home or in other spots, substantial articles fall on the
midsection in mechanical mishaps were 6% where iron
bars or solid squares fell on the mid-region likewise
quality in little extent,. In different investigations, it was
accounted for 18.18%17.
In the current investigation liver was the most
well-known harmed organ including around 15 cases
(30%) out of 50 cases. 22.7% of liver wounds were ac-
counted for by Hussain et al.18 and 15% by Hoyt19. In this
examination, 73.3% of patients had grade I and grade
II liver wounds while Pouch An in Italy reported 84.75%
hepatic wounds (grade I, II, III)20. Spleen Second basic
harmed organ in 13 cases (26%). It was related to a left
lower rib crack. This shows that with the left side lower
182
rib break, splenic burst ought to likewise be thought
of. GIT (from the stomach to butt-centric trench) is the
third most normal organ to continue injury because of
obtuse injury, as found in 11 cases (19.6%), additionally
connected with other organ wounds. A retroperitoneal
hematoma for example 5 cases (8.9%) were related to
bladder and kidney wounds. Kidney and mesenteric
tear have a similar recurrence, 3 cases (5.4%) of every;
at that point pancreatic, bladder, and diaphragmatic
wounds, 2 cases each. Aftereffects of this investigation
are somewhat not quite the same as different examina-
tions result as referenced in Cuscheri essential20.
Medical clinic mortality was 10% generally speak-
ing. Interestingly death rate was 13.3%, as announced
by Hussain et al, 11% by Gupta et al.12 and 20% by
Khan and Alpar13. The death pace of this investigation
was marginally higher than 8.5% as revealed by Ball
and Croley21. Among these, the reason for death was
hemorrhagic stun, septicemia, and numerous organ
disappointment.
REFERENCES
1. Baker Q, Aldoori M. Clinical surgery: a practical
guide. CRC Press; 2009 Jul 31.
2. Fabian TC, Bee TK. “Liver and biliary trauma”.
In Moore EJ, Feliciano DV, Mattox KL. Trau-
ma. New York: McGraw-Hill, Medical Pub. Divi-
sion. 637. ISBN 0-07-137069-2. Archived from the
original on 2017-11-06.
3. Wyatt JP, Illingworth RN, Graham CA, Hogg K.
Oxford handbook of emergency medicine. Oxford
University Press; 2012 Feb 1
4. Lichtenstein R, Suggs AH. “Child abuse/assault”.
In Olshaker JS, Jackson MC, Smock WS. Forensic
Emergency Medicine: Mechanisms and Clinical
Management (Board Review Series). Hagerstown,
MD: Lippincott Williams & Wilkins. pp. 157–
9. ISBN 0-7817-9274-6. Archived from the original
on 2017-11-06.
5. Choua O, Rimtebaye K, Yamingue N, Moussa K,
Kaboro M. Epidemiological, clinical and therapeutic
aspects of blunt abdominal trauma in patients un-
dergoing surgery at the General Hospital of National
Reference of N’Djamena, Chad: about 49 cases. The
Pan African medical journal. 2017;26:50-.
6. Cunningham AJ, Lofberg KM, Krishnaswami S,
Butler MW, Azarow KS, Hamilton NA, Fialkowski EA,
Bilyeu P, Ohm E, Burns EC, Hendrickson M. Minimiz-
ing variance in Care of Pediatric Blunt Solid Organ
Injury through Utilization of a hemodynamic-driven
protocol: a multi-institution study. Journal of pediatric
surgery. 2017 Dec 1;52(12):2026-30.
7. Ong CL, Png DJ, Chan ST. Abdominal trauma--a
review. Singapore Med J. 1994 Jun. 35(3):269-70. .
8. Taviloglu K, Yanar H. Current trends in the man-
agement of blunt solid organ injuries. European
Journal of Trauma and Emergency Surgery. 2009
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 Apr 1;35(2):90-4.
9. Sawhney C, Kaur M, Gupta B. Critical care issues in
solid organ injury: Review and experience in a tertia-
ry trauma center. Saudi JAnae. 2014 8(Suppl 1)S29
10. Aziz A, Bota R, Ahmed M. Frequency and pattern
of intra- abdominal injuries in patients with blunt
abdominal trauma. J Trauma Treat 2014;3:196.
11. Ball SK, Croley GG (1996) Blunt abdominal trauma.
A review of 637 patients. J Miss State Med Assoc
37: 465-468.
12. Gupta S, Talwar S, Sharma RK, Gupta P, Goyal A,
et al. (1996) Blunt trauma abdomen: a study of 63
cases. Indian J Med Sci 50: 272-276.
13. Khan S, Alpar EK (1997) Abdominal solid organ
injuries in multi trauma patients, incidence and
etiology: a retrospective analysis of 111 cases. J
Surg14: 44-47.
14. Ahmad I (1992) Abdominal trauma:a prospective
study. Pak J Surg 8: 37-42.
15. Kunin N, Letoquart JP, La Gamma A, Chaperon J,
Mambrini A (1994) [Intestinal-mesenteric lesions
of closed abdominal traumas]. J Chir (Paris) 131:
129-134.
16. Ceelen W, Hesse U, De Hemptinne B (1995) Small
bowel perforation following blunt abdominal trauma.
ActaChirBelg 95: 187-189.
17. Brown SP, Dudley HAF (1995)Abdominal trauma.
Hamilton Bailey’s emergency surgery. (12thedn),
Oxford: Butterworth Heinemann: 474-503.
18. Hussain R, Rathore AH, Zulfiqar R (1991) Hepatic
injuries due to blunt abdominal trauma. Specialist
7: 15-17.
19. Hoyt DB (1995)Moosa AR Trauma: general consid-
eration. Essentials of surgical practice (3rd edn),
Oxford: Butterworth-Heinemann: 501-507.
20. Pouche A, Piardi T, Zorat S, Codignola C, Tiberio
GA, et al. (1995) [Hepatic injuries: diagnostic and
therapeutic features]. G Chir 16: 169-175.
21. Holmes JF, Offerman SR, Chang CH, Randel BE,
Hahn DD, Frankovsky MJ, et al. Performance of he-
lical computed tomography without oral contrast for
the detection of gastrointestinal injuries. Ann Emerg
Med. 2004 Jan. 43(1):120-8.

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KJMS May - August, 2020, Vol. 13, No.2 183

 COMPARATIVE STUDY OF RINGERS SOLUTION VS ½
STRENGTH NORMAL SALINE (0.45%) AS POST OPERATIVE
FLUID THERAPY IN CHILDREN
Muhammad Daraz Khan1, Muhammad Jehangir2, Saddar Rahim3, Muhammad Uzair4, Fayaz Ur Rehman5,
Hayat Ur Rehman6

ABSTRACT
Background: Majority of postoperative paediatric patients kept nil per oral for a variable duration after the operation
and the significance of postoperative fluid management and electrolyte monitoring cannot be stressed enough. The
optimal postoperative parenteral maintenance solution that results in least electrolyte disturbances and complications
remains controversial.
Aims &Objectives: The aim of the study was to assess the risk of electrolyte imbalance following an isotonic (ringers
solution) administration compared to a hypotonic (1/2 strength normal saline) as postoperative maintenance solution
for pediatric patients.
Methods: This randomized control trial was conducted at KGN Teaching hospital Bannu over twenty months from July
2014 to February 2016. Patients with normal electrolyte levels at the baseline were included. They were allocated to
either Ringers solution or ½ strength normal saline groups by random method. Their electrolytes were monitored till
fifth postoperative days and complications were noted.
Results: Our study included 110 children in their perioperative period. 47 (42.7%) were females and 63 (57.3%) were
males. The age ranged from 1 to 12 years. The mean age was 4.85±2.75 years. The median and mode ages were 4
and 3 years respectively. All patients underwent abdominal surgeries. On the first and second postoperative day sig-
nificantly greater number of children developed hyponatremia p <0.05. On the third, fourth and fifth days there was no
significant difference in the number of children developing hyponatremia between the Ringers and ½ strength normal
saline groups. The potassium, chloride, calcium, bicarbonate and glucose were not significantly different for both the
group till fifth postoperative day.
Conclusion: Isotonic Ringers solution is remarkably safer than hypotonic ½ strength normal saline in protecting against
acute postoperative hyponatremia in children.
Keywords: Postoperative fluids; hyponatremia, ringers solution, half strength normal saline.

INTRODUCTION The morbidity and deaths associated with severe

neurologic damage resulting from iatrogenic hypona-
Majority of postoperative paediatric surgical pa- tremia has raised questions regarding the parenteral
tients kept nil by mouth (NBM) from a few hours to at maintenance solutions (PMSs) safety by Holiday-Segar
least one to two days or even weeks postoperatively recommendations and has fueled furious debate re-
and the significance of postoperative fluid management garding the isotonic or hypotonic solutions that which
and electrolyte monitoring cannot be stressed enough. one is suitable for children who are hospitalized.1,2,3,4
Hospital-acquired hyponatremia is common, particu-
1
AP Paediatric Surgery Bannu Medical College Bannu larly in children underwent surgery are at high risk. The
2
HOD Paediatric Surgery and Dean Nowshera Medical Primary mechanisms for hyponatremia in this patient is
College Nowshera due impaired ability to excrete free water due to nonos-
3
AP Paediatric Surgery Saido Medical College Swat motic antidiuretic hormone (ADH) secretion, electrolyte
4
AP Paediatric Surgery KMC Peshawar free water (EFW) impaired clearance and hypotonic
5
MO Paediatric Surgery KTH Peshawar fluid administration is an additional risk factor,1 cerebral
6
Associate Prof Paediatric Surgery Nowshera Medical salt wasting, a “desalination” phenomenon, sick cell
College Nowshera syndrome, stress due to surgery, and translocational
......................................................................................... hyponatremia. It has been suggested widely that hy-
Address for correspondence: potonic PMS increases the risk of hyponatremia, pro-
Dr. Muhammad Daraz Khan spective evidence to compared the safety of hypotonic
Department of Paeds Surgery, Bannu medical college and isotonic fluid (PMSs) for children is limited.3 Those
Bannu who are in favor of isotonic PMS administered argument
E-mail: pedssurgery71@yahoo.com that the most important role of sodium is to maintain
Cell: 0331-2862628 plasma tonicity during acute illness, while in case of hy-

184 KJMS May - August, 2020, Vol. 13, No.2

potonic PMS argument that hyponatremia results from
excessive PMS volume with an unacceptable risks with
isotonic PMS such as hypernatremia, fluid overload,
excessive sodium excretion, and hyperchloremic met-
abolic acidosis.2,3,4 whereas hypotonic PMS results in
excess EFW in patients with an already impaired ability
to excrete EFW2 The primary objective of the present
study was to compare isotonic Ringers with hypotonic
half strength normal saline solution administered in-
travenously at a maintenance rates to children in the
early postoperative recovery period causing various
electrolyte abnormalities.
METHODS AND MATERIAL
STUDY DESIGN: Quasi-experimental study (Prospec-
tive randomized control trial)
SETTING: A study was conducted of 110 inpatient
children in the Pediatric Surgery department, Khalifa
Gul Nawaz (KGN) teaching hospital Bannu.
DURATION OF STUDY: Study was conducted from
July 2014 to Feb 2016.
SAMPLE SIZE: A total of 110 children in their postop-
erative period were included in the study.
SAMPLE TECHNIQUE: Random sampling.
SAMPLE SELECTION:
Inclusion criteria: All patients of one month to 12
years of age.
Patients of either gender
Patients undergoing major operative procedures
and will be kept on only I/V fluid for 3-5 days after sur-
gery.
A random number was generated comprising
110 random block in the study in which odd numbers
were serially allocated to group 1 and even numbers
allocated to group 2. All children were monitered daily
by measuring Sodium (Na), Potassium (K), Chloride
(Cl), Calcium (Ca) and blood sugar.
DATA ANALYSIS
Data was analyzed using SPSS version 20. A total
of 110 patient were included in the final anlaysis with
Mean and standard deviation (SD) were calculated for
numerical data e.g. age and serum electrolyte levels.
Frequencies and percentages were calculated
and presented for gender and frequencies of hypo-
natremia, hypernatremia, hypokalemia, hyperkalemia,
hyperchloremua, hypochloremia, hypocalcemia, and
hypercalcemia. Student T test was used for numerical
comparisons and Chi square test was used for categor-
ical comparisons.
RESULTS
Our study included 110 children in their periop-
erative period. The age ranged from 1 to 12 years. The
mean age was 4.85±2.75 years. The median and mode
ages were 4 and 3 years respectively. 47 (42.7%) were
females and 63 (57.3%) were males.
All patients underwent abdominal surgeries. 31
(28.2%) had colostomy/ ileostomy closure, 24 (21.8%)
had laparotomy for gut perforation and primary anas-
tomosis was done, 23 (20.9%) had surgery for appen-

Exclusion criteria
• Patients below 1 month (neonates) and above
12yrs of age.
• Patients with known cause of electrolyte imbalance.
• Patients with comorbid conditions e.g. renal hepat-
ic, cardiac or respiratory failures.

DATA COLLECTION TECHNIQUES Figure 1: Type of surgery

After getting ethical approval from the hospital
research committee an informed consent was taken
from the parents of children who had been operated
and were on one of the intravenous fluid regimes. A
detailed history and thorough physical examination
was done to exclude preexisting comorbid conditions.
Patients in the study were divided into two groups.
• Group 1: Patients who received Ringer solution
• Group 2: Patients who received ½ strength normal
saline solution.
Figure 2: complicatios

KJMS May - August, 2020, Vol. 13, No.2 185

dicitis/ appendicular perforation, 3 (2.7%) had surgery
for intussusception, 1 (0.9%) had excision of mesenteric
cyst, 27 (24.5%) had laparotomy for intestinal obstruc-
tion and 1 (0.9%) perforated Meckels diverticulum
(figure 1). The type of surgery did not differ significantly
between the two groups.
In the preoperative period the mean sodium level
was 137.98±0.35 mmol/L and 137.65±2.44 mmol/L
for Ringers lactate solution versus 1/2 strength normal
solution groups respectively. This difference was not
statistically significant; p= 0.495.
3 patients in the ringers and 5 in the ½ strength
normal saline group developed paralytic ileus; this
difference was not statistically significant; p= 0.463. 3
patients in the ½ strength normal saline group devel-
oped cloudy mental statuts. None had any neurological
complication in the ringers group; the difference in both
the solution was not statistically significant; keeping P
value ≤0.05. None had intestinal obstruction. All were
discharged safely in both groups. (figure 2)
DISCUSSION
Currently there is a shift of postoperative fluid
therapy from conventional to modern fluid therapy as
recommended by national patient safety agency (NPSA)
of United Kingdom. Basic aim of such recommenda-
tions is to avoid acute postoperative hyponatremia, a
common pitfall with conventional fluid therapy5. In our
study all patients underwent abdominal surgeries. On
the first and second postoperative day significantly
greater number of children developed hyponatremia p
<0.05. On the third, fourth and fifth days there was no
significant difference in the number of children develop-
ing hyponatremia between the Ringers and ½ strength
normal saline groups. The potassium, chloride, calcium,
bicarbonate and glucose were not significantly different
for both the group till fifth postoperative day. Hence,
isotonic Ringers solution PMS is significantly safer than
hypotonic ½ strength normal saline in protecting against
acute postoperative hyponatremia in children. Moritz
ML and colleagues also recommend the use of isotonic
solution in admitted patients who requires sole I/V fluids
to avoid hyponatremia. Iatrogenic hyponatraemia in
children may be associated with fluid therapy. Literature
review support that more than 50 cases of neurological
injury is due to hospital-acquired hyponatraemia in
children, majority of them were after common routine
surgery 5,6,7. A study by Neville et al suggested that most
cases of hospital-acquired hyponatraemia can be pre-
vented by the use of isotonic saline in the perioperative
period.8Holliday and Segar used a formula to estimate
the maintenance parenteral fluid therapy now common-
ly used to calculate maintenance postoperative fluids
since 1957. The ideal maintenance fluid in children was
hypotonic dextrose saline but volume deficits should be
replaced with a bolus of isotonic saline 20–40 ml kg−1.
Very few studies had been conducted to compare the
186
use of isotonic or hypotonic maintenance fluids in the
postoperative period in children age group. Our study
showed that a carefully conducted trial may be justified,
as the exclusive use of isotonic saline in the postopera-
tive period would be a major change in current practice,
including specialist paediatric anaesthetists. A study
conducted to investigate replacement fluid therapy in
children with gastroenteritis which showed that 0.9%
normal saline (N/S) was preferable to 0.45% N/S and
protected against hyponatraemia. Urinary sodium ex-
cretion increased in normonatraemic children receiving
0.9% saline and hypernatraemia did not occur.9 We
conclude that the risk of hyponatremia was attributable
to excess EFW intake in hypotonic PMS administration
form. This conclusion is supported by the urine electro-
lyte and ADH results.10 The incidence of hyponatremia
after isotonic PMS administration varies from 5% -20%.11
Hyponatremia occurred in 40.8% and 22.7% of
patients receiving hypotonic and isotonic fluid respec-
tively. Elevated level ADH has been observed in these
patients, which suggests the non-osmotic stimuli for
ADH contribute in causing hyponatremia. ADH levels
were raised in both groups on first postoperative day
and normalized the next day. The hyponatremia onset
occurred within first 24 hours after surgery for the ma-
jority of affected patients (59 [80.1%] of a total of 73
patients), which suggests that the risk of hyponatremia
may be greatest during this period when ADH secretion
is at its peak.
Among hospitalized children hyponatremia is the
most frequent electrolyte disorder 12 routine electrolyte
monitoring in children receiving PMS remains infre-
quent13 Despite numerous published guidelines interna-
tionally14 the implementation of their recommendations
is currently still inadequate, which partly reflects the
limited prospective evidence. In addition to others
trial, the results of this trial can provide a higher level
of evidence and contribute to more-definitive practice
recommendations for safe fluid administration in pedi-
atrics patients.
CONCLUSION
Hyponatremia is a commonly preventable con-
dition among children hospitalized for any surgical
procedure. The current standard for postoperative
fluid and electrolyte management for pediatric patients
should change as evident by the result of this currently
trial. The findings confirm that isotonic Ringers solution
is a safe empiric choice compared with hypotonic ½
strength normal saline for preventing potential harm.
Appropriate perioperative and postoperative fluid man-
agement is essential for the paediatric patient. Till now
there is no “ideal” postoperative maintenance solution
for children. With any solution either isotonic saline
or hypotonic, response both fluid therapy should be
monitored and clinician decisions with respect to the
most appropriate PMS should be individualized and
KJMS May - August, 2020, Vol. 13, No.2
goal-directed. Management must be individualized,
taking into account developmental and physiological
considerations.
REFERENCES
1. Dearlove OR, Ram AD,Natsagdoy S, Humphrey
G.Hyponatraemia after postoperative fluid manage-
ment in children. Br. J. Anaesth 2006;97:897-898.
2. Choong K, Arora S,Cheng J, Farrokhyar F, Reddy
D, Thabane L, Walton JM.Hypotonic Versus Iso-
tonic Maintenance Fluids After Surgery for Chil-
dren: A Randomized Controlled Trial. Pediatrics
2011;28 :857 –66. 
3. Duke T, Molyneux EM. Intravenous fluids for
seriously ill children: time to reconsider. Lan-
cet 2003;362:1320–23
4. Holliday M, Ray P, Friedman A. Fluid therapy for
children: facts, fashions and questions. Arch Dis
Child 2007;92:546–550
5. Moritz M, Ayus C. Hospital-acquired hyponatre-
mia: why are hypotonic parenteral fluids still being
used? Nat ClinPractNephrol 2007;3:374–82
6. Moritz ML, Ayus J. Prevention of hospital-acquired
hyponatremia: a case for using isotonic saline. Pe-
diatrics 2003;111:227–3.
7. Moritz . Preventing neurological complica-
tions from dysnatremias in children.PediatrNe-
phrol 2005;20:1687-700.
8. Brazel PW, McPhee IB. Inappropriate secretion of an-
tidiuretic hormone in postoperative scoliosis patients:
the role of fluid management. Spine1996;21:724-7.
9. N evi l l e  KA , Ver g e  CF,  R o senb er g   A R ,   O’
Meara MW, Walker JL. Isotonic is better than hypo-
tonic saline for intravenous rehydration of children
with gastroenteritis: a prospective randomised
study. Arch Dis Child 2006;91:226-32.
10. Shafiee MAS, Bohn D, Hoorn EJ, Halperin ML. How
to select optimal maintenance intravenous fluid
therapy. QJM 2003;96:601–10.
11. Brazel PW, McPhee IB. Inappropriate secretion of
antidiuretic hormone in postoperative scoliosis pa-
tients: the role of fluid management. Spine (PhilaPa
1976). 1996;21:724–27.
12. Moritz M, Ayus J. New aspects in the pathogenesis,
prevention, and treatment of hyponatremic encepha-
lopathy in children.PediatrNephrol 2010;25:1225–38.
13. Mani V, Peutrell J, Snaith R. Impact of NPSA guide-
lines on intravenous fluid prescription in children:
retrospective audit on fluid prescription in children
undergoing appendicectomy. PediatrAnesth.
2009;19:718–19.
14. National Patient Safety Agency. Reducing the risk
of hyponatremia when administering intravenous
infusions to children.London,England: National
Patient Safety Agency; 2007. Patient Safety Alert 22
NPSA/2007/22. Available at: www.nrls.npsa.nhs. uk/
resources/?EntryId45_59809. Accessed September
29, 2011

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KJMS May - August, 2020, Vol. 13, No.2 187

 SURVEY TO ASSESS KNOWLEDGE, ATTITUDE AND
PREVENTIVE PRACTICES REGARDING DENGUE AMONG
ADULT POPULATION
Shakila Asif1, Tauseef Aman1, Nida Asif2, Hamana Tahir3, Alia Dar Qazi

ABSTRACT
Background: Dengue is a common mosquito-borne disease and is one of the world’s rising and rapidly spreading viral
infection of public health importance. However in common Pakistani people there is a lack of information on knowledge,
attitudes, and practices regarding dengue.
Objectives: To evaluate the knowledge, attitude and practices regarding dengue among adult population visiting
outpatient department (OPD) of Rehman Medical Institute (RMI) Peshawar.
Material and Methodology: A cross sectional study was carried out among adult patients and their attendants visiting
medical OPD of RMI, from1st October 2016 to 30th March 2017.A sample size of 200 was selected by simple random
sampling. A structured questionnaire was used to record the information about demographic characteristics of respon-
dent, awareness about dengue symptoms, mode of transmission, mosquito habitat, attitude towards the disease and
preventive practices against it.
Result: Out of 200 subjects, 57% correctly identify fever, 20% rashes, 28% muscle pain and 26 % joint pains as typical
symptoms of dengue. Approximately 60% participants were aware that dengue is transmitted by mosquito bite. However,
most respondents of the study were aware that ticks and flies do not transmit dengue fever 80% and 83% respectively.
Approximately15% of respondents were aware that dengue mosquitoes are likely to bite during day time. Yet 75% re-
spondents knew that mosquitoes breed in standing water. Regarding the attitude of respondents overall 83 % reported
the serious nature of the disease. Only 36 % of the respondents thought that they were at risk of contracting dengue
fever. While 78 % participants agreed that the disease is preventable. Regarding Preventive practices against dengue
fever, majority of the participants of our study used effective preventive methods such as 77% window screening, 73%
covering water container in home and 91% removal of standing water, 42% bed nets,36% mosquito coils and only 19%
do not use any protective measures.
Conclusion: The knowledge about dengue symptoms was inadequate. Awareness needs to be created to identify the
clinical symptoms and mode of transmission of dengue. The overall attitude and practices of the participants towards
dengue care, prevention and control was good.
Key words: Dengue fever, knowledge, Attitude, Practices.

INTRODUCTION during day time [4].

Dengue is a common viral disease and is one Southeast Asia, North & South America, Africa
of the world’s rising and rapidly spreading infection and the Caribbean Islands are the mostly affected areas.
of public health importance [1–2]. WHO reports 50-100 Serious dengue outbreaks were reported worldwide in
million dengue cases worldwide every year [3]. It is the year 2016 with 2.38 million cases reported in the
caused by flavivirus, from family flaviridae. It has four Americas and 1.5 million from Brazil. Nearly 500, 000
serotypes, DENV-1, DENV-2, DENV-3 and DENV-4. people with severe dengue get hospitalized each year,
Female mosquito of species Aedes aegyptiand Aedes with 2.5% mortality. The disease manifest itself in two
albopictusare responsible for the transmission of virus forms i.e. dengue fever and dengue hemorrhagic fever
(DHF) with a broad range of clinical manifestations in-
1
Department of Community Medicine, Khyber Girls cluding asymptomatic infection, mild flu-like symptoms,
Medical College, Peshawar and the more severe hemorrhagic fever [3].
2
House officer, Rehman Medical Institute Peshawar
3
House officer, Hayatabad Medical Complex Peshawar A rapidly spreading viral disease in Pakistan
......................................................................................... with its first case reported in Karachi in 1994[5].Only
Address for correspondence: 699 cases of dengue were reported in three districts
Dr. Shakila Asif of Pakistan from 1995-2004. After that there was a
Department of Community Medicine, Khyber Girls substantial increase in cases and deaths i.e. 55946
Medical College, Peshawar and 539 respectively, affecting 105 out of 146 districts/
Ph: 03339402659 agencies/territories [6,7]. Reasons included rapid growth
Email. ashakila264@gmail.com of population, urbanization, poor water management,

188 KJMS May - August, 2020, Vol. 13, No.2

no mosquito control program and rise in international
trade and travel.
Although various steps has been taken by Gov-
ernment and non-governmental institutions to increase
awareness about dengue, limited studies have been
done in Pakistan specially in Khyber Pakhtunkhwa
(KPK), to determine the impact of such interventions.
Although dengue can be life threatening yet
preventable if people have the awareness of preventive
measures and adopt those measures in their routine Figure 1. Dengue mosquitoes biting pattern
lives. Because of the non-availability of a definitive
treatment and vaccine, our objective should be to im-
prove preventive strategies by assessing knowledge,
perception and behavior of population which will help in
designing effective control strategies for the near future.

OBJECTIVES
To assess the knowledge, attitude and practices
(KAP) regarding dengue among the adult population
of Peshawar district.

MATERIAL AND METHODS

A cross sectional survey was carried out in the
Medical outpatient department of RMI Peshawar from
1stOctober 2016 to 30th March 2017. A total of 200 par-
ticipants including both patients and their attendants
aged 21 years and above from both sexes, visiting Figure 2. Mosquito Breed in standing water
medical OPD of RMI were selected by simple random
sampling. Only those who belonged to Peshawar district
were included in study. Not more than one person was
interviewed from the same family. Data was collected by
using structured questionnaire. Informed consent was
obtained from each respondent. Questionnaire included
demographic information, awareness about dengue
symptoms, mode of transmission, mosquito habitat,
attitude towards the disease and preventive practices
against it. Data was analyzed in (SPSS) version 20.0.
Descriptive data was analyzed and the results were
presented as frequencies and percentages.

RESULTS Figure 4. Dengue is a serious illness

The study population consisted of 200 patients/

attendants. Among these 40% were males and 60%
females. Age of participants was between 21-50 years.
Further 16% of respondents were illiterate, 20% attend-
ed the middle school, 21% were matriculate, 30% had
intermediate education, while 13% were graduate and
above.
Knowledge was assessed based on 12 questions
grouped under the following four categories:
1) Symptoms
2) Mode of transmission.
Figure 5.You are at Risk of getting dengue
3) Dengue mosquitoes biting pattern and
4) Habitat of Mosquitoes.

KJMS May - August, 2020, Vol. 13, No.2 189

 Table1. Knowledge about Dengue fever among the respondents. (Sample size (N)=200)

Parameters No (percent) Yes No (percent) No No (percent) Total

1.Knowledge about symptomsc
Fever 114(57%) 86(43%) 200(100%)
Headache 40(20%) 160(80%) 200(100%)
Joint pain 52(26%) 148(74%) 200(100%)
Muscle pain 56(28%) 144(72%) 200(100%)
Rash 40(20%) 160(80% 200(100%)
Pain behind the eyes 30(15%) 170(85%) 200(100%)
2.Knowledge about Mode of Transmission
Do flies transmit Dengue 34(17%) 166(83%) 200(100%)
fever?
Do ticks transmit Dengue 40(20%) 160(80%) 200(100%)
fever?
Do mosquitoes transmit 120(60%) 80(40%) 200(100%)
Dengue fever?
Does person to person 68(34%) 132(66%) 200(100%)
contact transmit Dengue
fever?

dents appreciated the serious nature of the disease.

Figure 6. Dengue fever can be Prevented
Table1. depicts low percentage of the respon-
dents who were able to correctly identify typical symp-
toms of dengue such as fever 57%, rashes 20%, joint
pains26 % and muscle pain 28%, furthermore almost
60% were aware that dengue was transmitted by mos-
quito bite. On the other side, most participants knew
that flies and ticks do not transmit dengue fever; 83%
and 80% respectively. While 34% respondents were
aware that person to person contact could not lead to
transmission of the infection.
Attitude was assessed by the perception of the
subjects to the following items:
1) Dengue as a serious illness
2) Risk of getting the infection
3) Dengue as a preventable disease
As learnt from figure 4, overall 83% of respon-
While about 78 % participants agreed that the disease
is preventable as shown in figure 6. Only 36 % of the
respondents thought that they were at risk of contracting
dengue fever as indicated in figure 5.
Preventive practices were assessed on 9 ques-
tions divided into the following two categories:
1) Preventing mosquito-man contact and
2) Eliminating breeding sites of mosquitoes around
the household.
As shown in table 2, majority of the participants
of our study used effective preventive methods such as
77% window screening, 73% covering water containers
in home and 91% removal of standing water, 42% bed
nets during night and 36% mosquito coils. Only 19%
do not use any protective measures.
DISCUSSION
A survey was conducted to assess the knowledge,
attitude and practices about dengue among adult pop-
ulation visiting RMI Peshawar.
According to our results, 57% correctly identify
fever, 20% rashes, 28% muscle pain and 26 % joint pains
as typical symptoms of dengue.Results of our study
were consistent with findings of similar studies by Itrat et
al[8] and Zameer et al. [4]. Similarly in a study conducted
by Vector Control Research Centre, Puducherry, India
in 2013, it was found out that 59% of participants men-
tioned fever as the most common symptom of dengue.
[9]
Poor knowledge of symptoms of dengue fever meant

190 KJMS May - August, 2020, Vol. 13, No.2

that it might be confused with most other causes of fever
such as flu and influenza etc.
In our study approximately 60% participants were
aware that dengue is transmitted by mosquito bite. On
the other hand, most participants were also aware that
flies and ticks were not responsible for its transmission
(83% and 80% respectively). While 34% respondents
knew that person to person contact cannot lead to
acquisition of dengue. A considerable percentage of
respondents still need health education. Our study find-
ing were consistent with the results of previous studies,
done by Itrat et al, Zameer et al and Qureshi et al[8,4,10].
About 15% of respondents were aware that den-
gue mosquitoes are likely to bite during day time. in
contrast to finding in a study conducted bySamina
Qadir1et al.in 2015, where 46% acknowledged day as
usual time of biting.[11]Reducing this gap in knowledge
is a prerequisite in the design of programs to educate
people on personal protection against mosquitoes.
Regarding the attitude of respondents, almost
83% reportedthe serious nature of the disease. Similar
results were shown by previous studies[12,13,14,]. Moreover
36% thought that they are at risk of getting dengue which
is consistent with the results of a household-based sur-
vey in Yemen [15]. Furthermore 70% respondents of our
study thought that dengue is preventable. Almost similar
results were shown by Malhotra et al.[13]
Regarding Preventive practices against dengue
fever, majority of the participants of our study used
effective preventive methods such as77% window
screening, 73% Covered water containers in the home
and 91% removal of standing water,42% bed nets and
22% insecticide sprays. Similar results were reported by
a study carried out by Samina Qadiret al[11].In a study
by Begonia et al, it was found that 87.5% participants
follow the practice of keeping water containers closed
at home[16] . In our study 36% use mosquito coils while
19% used repellants, to avoid mosquito bites. Similarly
hospital based study done by Itrat et al, reported that
about 47.5% respondents use mosquito coils/ mat as
preventive measure against mosquito bite [8]. Another
hospital based study conducted in Puducherry India,
found that 43% of study population used mosquito
coils to avoid bites [12]. High cost of purchasing coils/
repellents might be responsible for their low use.  in Lahore, Pakistan. Pak J of Sci 2014; 66:7-9
CONCLUSIONS
The knowledge about dengue symptoms was
poor in our study population. However knowledge re-
garding mode of transmission of dengue was adequate.
Awareness needs to be created to identify the clinical
symptoms and mode of transmission of dengue. The
overall attitude and practices of the participants towards
dengue care, prevention and control was good. Still
negative attitudes in their perception of risk and possi-
ble prevention of the infection were common among a
KJMS May - August, 2020, Vol. 13, No.2
small proportion of the population which needs to be
targeted by educational campaigns.
The available data in Pakistan is limited; therefore
a national level survey is needed to assess the knowl-
edge, attitude and practices regarding dengue infection
in the general population.
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1. Guzman MG, Halstead, Halstead SB, Artsob H. Den-
gue: a continuing global threat. Nat Rev Microbiol
2010; 8:7-16.
2. Gunasekara TDCP, Velathantheri VGNS, Weerasee-
kara MM, Fernando SSN, PeelawattageM,Guruge
D, et al. Knowledge attitude and practice regarding
dengue fever in suburban community in Sri Lanka.
Galle Med J 2012; 17:10-6.
3. World Health Organization. Dengue and severe den-
gue. Available fromURL: http://www.who.int/media-
centre/factsheets/fs117/en . Accessed 4, July 2016.
4. Zameer M, Shuja M, Ashraf A, Mukhtar A, Ahmad
BM. Knowledge, attitude and practices study of
dengue viral infection and its association with
environmental factors and health issues, Lahore,
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7:711-7 60:243-7.
5. Rai MA, Khan H Dengue: Indian subcontinent in the
line of fire. J Clin Virol.2007; 38: 269–270.
6. National Guidelines for Dengue Vector Control in
Pakistan 2013. Available fromURL: http://www.dmc.
gov.pk/documents/GDC/introduction
7. Ahmad S, Rehmat A, Shah SS, Illahi I. To evaluate the
epidemiological trend of dengue fever in a teaching
hospital at district Swat Pakistan. App Sci Report
2014; 6:78-81.
8. Itrat A, Khan A, Javaid S, Kamal M, Khan H,Jehan I, et
al. Knowledge, awareness and practices regarding
dengue fever among the adultpopulation of dengue
hit cosmopolitan. PLosone 2008; 3:1-7.
9. Jeelani S, Sabesan S, Subramanian S. Community
knowledge, awareness and preventive practices
regarding dengue fever in Puducherry - South India.
Public Health. 2015;129(6):790-6.
10. Qureshi EMA, Vehra S, Ghafoor GZ, AliAS, AhmedF.
Community perception regarding dengue epidemic
11. Samina Qadir ,IftikharAhmad,M Naeem Akhtar,Hi-
raNaeem,KAP about dangue fever among local
population.Gomal Journal of Medical Sciences.
2015;13(2):87-90
12. Valantine B et al. Cross sectional study on KAP
regarding dengue among adult population visiting
a tertiary care hospital in Puducherry, India 2017
Mar;4(3):623-627
13. V.Malhotra, Paramjeet Kaur. The community KAP
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14. Mayxay M, Cui W, Thammavong S, Khenasakhou K,
Vongxay V, Armstrong G, et al. Dengue in periurban
Pak-Ngum district, Vientiane capital of Laos: a com-
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ani SM , Al-Mekhlafi AM, Raja YA, Shah SA, Beier
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dengue fever among local urban communities in
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16. Yboa BC, Labrague LJ. Dengue fever, dengue pre-
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quick, convenient, cheap, requirement of HEC and Paperless.
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and follow the instructions on the website. Author agreement can be easily
downloaded from our website. A duly signed author agreement must accompany
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192 KJMS May - August, 2020, Vol. 13, No.2

 A COMPARATIVE EVALUATION OF RADIOLOGICAL SCORE
(CTSI) AND CLINICAL SCORE (RANSON’S) IN PREDICTING
THE SEVERITY OF ACUTE PANCREATITIS
Jamshed Alam1, Muhammad Kalim1, Ahmad Faraz2, Junaid Shah1, Siddique Ahmad1, Muhammad Iftikhar1,
Ayaz Gul2, Sohaib Ali1

ABSTRACT
Acute Pancreatitis, commonly presenting as pain abdomen to surgical ER, with either nausea or vomiting, is a common
illness, with almost daily admissions from general population, with mild, moderate and severe forms. It is important
that patient with severe disease are identified early on, for these patients may require intensive care or an HDU care.
Methodology: This was a cross sectional study conducted in the department of general surgery, Hayatabad medical
complex Peshawar. The data was collected prospectively for each consecutive patient presenting with AP.Duration of
study was 6 months from August 2018 to February 2019. A total of 148 patients were enrolled in the study.
Results: Among 148 patients, 18(12%) were in age range 20-30 years, 47(32%) were in age range 31-40 years while
83(56%) were in age range 41-50 years. Mean age was 42 years with SD ± 2.25.41(28%) were male, 107(72%) were
female. (as shown in Table No 2). Based on etiology, n=112 were having gallstones, n=29 were idiopathic and n=7
were traumatic pancreatitis.133(90%) patients had Ranson’s score<3 while 15(10%) patients had Ranson’s score >3.
Those who underwent CECT,118(80%) had CTSI score< 5 while 30(20%) had CTSI score >5. Comparative evaluation
of CTSI vs Ranson’s score showed CTSI having the sensitivity of 58.8%, specificity of 91.2%. PPV was 66.7% while
NPV was 88.1% while diagnostic accuracy of 83.8%. During the course of hospital admission and clinical score, 90%
had mild AP while 10% went on to develop severe AP. Mortality was n=7 (4.7%). Compared to CTSI, ranson score was
a better predictor for mortality.
Conclusion: Our study didn’t find any significant difference between the clinical and radiological scoring system pre-
dicting mortality and disease severity.
Keywords: Acute pancreatitis, CTSI, Ranson Score

INTRODUCTION appraisal of management strategies. Necrotizing Pan-

Acute Pancreatitis, commonly presenting as pain
abdomen to surgical ER, with either nausea or vomit-
ing, is a common illness, with almost daily admissions
from general population, with mild, moderate and
severe forms1.The incidence of acute pancreatitis in
UK is 56 cases per 100000 per year and while in USA,
about 20000 admissions are reported to have acute
pancreatitis2. It is important that patient with severe
disease are identified early on, for these patients may
require intensive care or an HDU care. So that they can
receive aggressive fluid resuscitation and close vitals
monitoring for development of organ failure. In case
these patients have developed complication which
require interventions such as enteral feed and endo-
scopic sphincterotomy or antibiotics. It is important that
we characterize high risk group of patients for critical
1Department of General Surgery, Hayatabad Medical
Complex
2Department of General Surgery, MTI LRH
.........................................................................................
Address for correspondence:
Ahmad Faraz
Department of General Surgery, MTI LRH
E-mail: drahmadfaraz79@gmail.com
Cell: 03349899916
creatitis with an Incidence of 20% in admitted patients
have complications which include MOD (Multi – Organ
Dysfunction) or Inflammatory Cascade resulting in infec-
tion, edema, pseudocyst or necrosis of the Pancreatic
Parenchyma3. The severity of Acute pancreatitis can
be assessed by several scoring systems developed
overtime, which can be predict whether the course of
the pancreatitis will mild, moderate or severe, different
scoring systems have different accuracy profile4. Severe
acute pancreatitis is demarcated by a cascade of local
effects, pancreatic necrosis and ischemic changes
due to micro thrombi in local vasculature. Pancreatitis
severity scores were first described by Ranson in early
seventies and consisted of eleven criteria. There are
also other scores which include Glasgow, Moss Score
and acute physiological score for ICU (APACHE-II) and
a bedside score by the name of BISAP Score4. All of
these criterion developed over the years have a varying
baseline for specificity and sensitivity ranging between
55-90%, although these scores are valuable assets
as prognostic indicators but they are too complex or
require a time period (48 Hours) to elapse before they
can be implemented i.e. Ranson’s Score5. C.T Abdomen
with pancreatic protocol which uses IV Contrast has
become the basis for CTSI Score for acute pancreatitis

KJMS May - August, 2020, Vol. 13, No.2 193

graded between 1-10 and is the investigation of choice
for Physician’s to accurately assess the local inflamma-
tory and necrotizing processes and give an indication
of prognoses4,6-8 disease course, CT timing, Balthazar
CT score, and clinical management were evaluated.
RESULTS First documented hospital admissions of 166
patients were analyzed. Etiology was biliary (42.8%.
The mainstream approach advocates if the disease is
mild and patient improving then one can forego the CT
abdomen n pelvis, and only opt for the investigation
whenever there is suspicion of severe acute pancreati-
tis, Therefore, judicial use of CT is warranted9,10. Ajay
K. Khanna et al. reported a sensitivity of 87.5% and
specificity of 55.3% ICU admission with an accuracy of
64.8% for CTSI while Ranson’s Score had a sensitivity
of 88.9% and specificity of 57.1% for ICU admission
with an accuracy of 61.1%11. Although Clinical assess-
ment by a Physician to diagnose Acute Pancreatitis is
difficult at best with a specificity of 34-39% and acute
pancreatitis is sometimes mislabeled in 30-40% of the
cases with diagnoses being made on the autopsy table
post-demise5. So on admission if the patient has clinical
biomarkers for Acute-Pancreatitis, C.T Abdomen-Pelvis
with pancreatic protocol should be a modality of choice
to index the severity of Acute Pancreatitis in admitted
patient8. Recognition of Multi Organ Dysfunction in the
beginning of the disease process in Acute Severe AP,
significantly improves outcomes in such patients12.CT
severity index is still a very valuable and relatively inex-
pensive tool for assessing acute inflammation of pan-
creas and for predicting the severity of the pancreatitis8.
International studies have compared CTSI with various
scoring systems for severity of acute pancreatitis and
found CTSI to be fairly accurate5,8. There is a need for
a validation study which can safely categorize high risk
patients in AP with the aid of clinical and radiological
scoring systems in our institution.
METHODOLOGY
A cross sectional analysis of the cases in the Gen-
eral Surgery Department, Hayatabad medical complex
Peshawar. The data was collected prospectively for
each consecutive patient presenting with AP. The study
continued for almost 6 months, from August 2018 to
February 2019. A prompt approval from ethical board
was sought which was granted subsequently, followed
by informed consent from the patients both written and
oral. A total of 148 patients were enrolled in the study.
The patients were admitted through ER and OPD as a
case of diagnosed acute pancreatitis based on history,
examination and lab findings.AP was defined as 2 or
more of the following; characteristic abdominal pain,
serum amylase/lipase 3 or more times the upper limit
of normal and or CTInclusion criteria involved age 18-
50 years of either gender or patients presenting with
pain within 48 hours of onset of symptoms of acute
pancreatitis. Strict exclusion criteria was followed in
which patients presenting greater than 48 hours of on-
194
set of symptoms, patients who already had developed
complications, congenital anomalies of pancreas, and
malignancies of pancreas and peri-ampullary origin,
previous recent history of MI or surgery.. All patients
were subjected to contrast enhanced computer tomog-
raphy (CECT) by Toshiba Asteion Scanner with Pancre-
atic Protocol and the severity of Pancreatic inflammation
scored according to CTSI by the two radiologists inde-
pendently who were blinded to the clinical scores. The
review of CT scans was done on PACK work stations.
The clinical data was recorded by 2 consultant surgeons
who were also blinded to CTSI. They collected data for
Ranson score from the prospective patients. Sensitivity,
specificity, positive predictive value and negative pre-
dictive value was measured for each scoring system in
predicting the severity of Pancreatitis, and all patients
were managed according to standard protocols. The
patients were observed during their hospital stay till their
discharge or referral to otherspecialized unit, like ICU.
Statistical analysis
All data was collected, indexed and entered in
excel and exported to SPSS 18. All manner of basic
statistical analyses was carried out and values obtained
for each variable. All data was tabulated and graphed in
charts. Sensitivity, specificity, positive predictive value
and negative predictive value were calculated taking
Ranson’s score as a Gold Standard in a 2*2 table.
P value of < 0.05 was considered significant. All the
results were presented in the form of tables and charts.
RESULTS
Among 148 patients, 18(12%) were in age range
20-30 years, 47(32%) were in age range 31-40 years
while 83(56%) were in age range 41-50 years. Mean
age was 42 years with SD ± 2.25. (as shown in Table
No 1).41(28%) were male, 107(72%) were female. (as
shown in Table No 2). Based on etiology, n=112 were
having gallstones, n=29 were idiopathic and n=7 were
traumatic pancreatitis.133(90%) patients had Ranson’s
score<3 while 15(10%) patients had Ranson’s score
>3 (as shown in Table No 3). Those who underwent
CECT,118(80%) had CTSI score< 5 while 30(20%) had
CTSI score >5 (as shown in Table No 4). Comparative
evaluation of CTSI vs Ranson’s score showed CTSI
having the sensitivity of 58.8%, specificity of 91.2%.
PPV was 66.7% while NPV was 88.1% while diagnostic
accuracy of 83.8%.(as shown in Table No 5). During the
course of hospital admission and clinical score, 90%
had mild AP while 10% went on to develop severe AP.
Mortality was n=7 (4.7%). Compared to CTSI, Ranson
score was a better predictor for mortality.
DISCUSSION
Acute pancreatitis has always been a challeng-
ing disease due to its complicated disease course.
Physicians have always sought out a way to recognize
KJMS May - August, 2020, Vol. 13, No.2
 Table 1: Age distribution (n=148)

Age Frequency Percentage

20-30 years 18 12%
31-40 years 47 32%
41-50 years 83 56%
Total 148 100%
Mean age was 42 years with SD ± 2.25.
Table 2: Gender distribution (n=148)
patients at risk of developing severe disease. Multiple
Gender Frequency Percentage scoring systems have been devised overtime which
Male 41 28% included clinical scoring systems such Ranson’s,
Female 107 72% Glasgow and APACHE II and radiological scoring sys-
tems first described by Balthazar et al in 198513 50%, or
Total 148 100% greater than 50%. Since then , several radiological scor-
ing systems have come into existence8, which include
Table 3: Ranson’s Score (n=148) scoring systems such as Balthazar grade, pancreatic
size index (PSI), mesenteric oedema and peritoneal fluid
Ranson’s score Frequency Percentage
(MOP)score, extra pancreatic (EP) score and extra pan-
(>3) Positive 15 10% creatic inflammation on CT ( EPIC) score. CTSI requires
(<3) Negative 133 90% contrast enhanced CT which combines extra pancreatic
inflammation/extent with pancreatic necrosis. This was
Total 148 100%
later modified by Mortele et al termed as modified CTSI
which combined extra pancreatic complications(pleural
Table 4: Ctsi Findings (n=148)
effusion, ascites, and ischemia)with separate scoring
Ctsi Frequency Percentage points.

(>5) Positive 30 20% The radiological scoring systems have moderate

accuracy compared to clinical scoring system due to
(< 5) Negative 118 80%
the fact that the disease progress is nonlinear in nature
Total 148 100% such as a patient having low CTSI score on admission
will and can go into severe AP. This is due to the fact that
disease progression is not dictated by the morphologi-
cal features of the disease4,5,14,15. It remains a conundrum
that why some patients who have significant pancreatic
necrosis will have a mild course of disease16, nonethe-
less,it has also been clinically observed that patients
who have pancreatic necrosis do develop organ failure
and requires intervention.17-19
Papachristou et al. compared multiple scores as
predictors of SAP and mortality and found that Ranson
score compared to CTSI had sensitivity, specificity and
accuracy of 84.2%, 89.8% and 94% respectively5. While-
Bollen et al. found that CTSI had sensitivity, specificity
and accuracy of 65.4%, 50% and 57.4% respectively
for predicting severe acute pancreatitis8. Compared
to our study, the above findings correlate to our study
as CTSI having sensitivity, specificity and accuracy of
58.8%, 91.2% and 83.7% respectively.
Pancreatitis severity scores were first described
by Ranson in early seventies and consisted of eleven
criteria. There are also other scores which include
Glasgow, Moss Score and acute physiological score for
ICU (APACHE-II) and a bedside score by the name of
BISAP Score. All of these criterion developed over the
years have a varying baseline for specificity and sensi-

KJMS May - August, 2020, Vol. 13, No.2 195

tivity ranging between 55-90%, although these scores
are valuable assets as prognostic indicators but they
are too complex or require a time period (48 Hours) to
elapse before they can be implemented i.e. Ranson’s
Score.C.T Abdomen with pancreatic protocol which
uses IV Contrast has become the basis for CTSI Score
for acute pancreatitis graded between 1-10 and is the
investigation of choice for Physician’s to accurately as-
sess the local inflammatory and necrotizing processes
and give an indication of prognoses8.
Similar results were found in another study con-
ducted by Ajay K. Khanna et al11 reported a sensitivity
of 87.5% and specificity of 55.3% ICU admission with
an accuracy of 64.8% for CTSI while Ranson’s Score
had a sensitivity of 88.9% and specificity of 57.1% for
ICU admission with an accuracy of 61.1%. Although
Clinical assessment by a Physician to diagnose Acute
Pancreatitis is difficult at best with a specificity of 34-
39% and acute pancreatitis is sometimes mislabeled in
30-40% of the cases with diagnoses being made on the
autopsy table post-demise20-24. So on admission if the
patient has clinical biomarkers for Acute-Pancreatitis,
C.T Abdomen-Pelvis with pancreatic protocol should
be a modality of choice to index the severity of Acute
Pancreatitis in admitted patient(8). If a severe clinical
course is suspected for Acute AP, early recognition
of Multiorgan Dysfunction or MODI, and its treatment
significantly impacts the outcome in such patients25.
Similar results were found in another study
conducted by Srivastava A.et al.26 in which CTSI has
the sensitivity 80%, Specificity 63%, Positive predictive
value 83%, Negative predictive value 70%, Diagnostic
accuracy was 86%.
Similar results were found in another study con-
ducted by Arvanitakis M1et al.7 comparing CT and MRI
for assessment of disease severity in AP. In which MRI
and CT Scan both were done in 39 patients.Of all the
admitted patients 07 (18%) were diagnosed as Clinically
Severe Cases of Acute Pancreatitis. On admission both
MRSI and CTSI were performed and values obtained
which showed correlation between clinical severity
and radiological scores. Subsequently after a week
(07 Days) MRSI had a baseline correlation with CRP
levels, Ranson’s Score, Stay in the Hospital, Patients’
morbidity and post pancreatitis complications. Thus it
is ascertained that Ranson’s Scoring Criteria correlated
well with MRSI by detecting severe Acute Pancreatitis
with a specificity of 91% vs. 86% for C.T and sensitivity
of 83% vs. 78% for C.T.27. MRCP with IV Secretin resulted
in leak from Pancreatic Duct in three patients (08%).
Our study had limitations in the form of that on day
of admission not all patients underwent CT due to the
fact that the advisement of CT was under the discretion
of attending surgeon which he would usually advise
based on the disease severity only. It is also noted that
it was highly impractical for all patients to undergo CT
due to the fact that the procedure had a high cost and
196
the risk of needless radiation exposure.
CONCLUSION
Our study didn’t find any significant difference
between the clinical and radiological scoring system
predicting mortality and severity. It is noted that clinical
severity scores are superior to radiological scoring
system due to the ease of use and economic viability.
There is no significant advantage in performing a CT on
admission. A CT can only be performed at physicians
discretion when patient failed to respond to conservative
management or falls into a high risk group of SAP.
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197
 PATTERN OF SPINAL TRAUMA: A CLINICAL STUDY OF
205 PATIENTS IN HAYATAB MEDICAL COMPLEX/ MEDICAL
TEACHING INSTITUTE PESHWAR PAKISTAN
Sohail Amir1, Rizwan-Ullah-Khattak2, Imran Khan3, Ayaz Afridi4, Muhammad Nawaz Khattak5, Hanif Ur Rehman6,
Mushtaq7, Muhammad Ali Nouman8, Shahid Ayub9

ABSTRACT
Objective: To determine the clinical presentation and level of spinal trauma in patients presenting in teaching institute.
Study Design: Descriptive, cross-sectional study
Setting: This study was conducted at the Department of Neurosurgery, Hayatabad Medical Complex Peshawar from
September 2017 to December 2019.
Subjects: The patients in the study were of both genders, between 15 to 75 years of age (N=205, mean age was
40.15 years, SD 18.31).
Materials and Methods: A total of 205 patients were recruited in this study. Approval was obtained from hospital ethical
committee before starting the study. All patients between 15 to 75 years of age with spinal trauma admitted via Outpatient
department, emergency or referred from other unit were included in our study while those patients who have previous
spinal surgery or not willing for surgery were excluded from our study. After initial stabilization of the patient by ATLS
protocol age, sex, mode of trauma, level of injury, type of fracture and neurological status were recorded. Plain X-Ray
both Anterior posterior and lateral view were taken in all patients. 3D CT scan and MRI films were obtained in cases
where needed. Data analyze using SPSS version 20.0 and presented in form of tables.
Results: The most frequently affected age group presenting with spine trauma were young between 15 to 25 years
of age 75 (36.58%). The most frequent etiologies seen for spine injury were falls; 90 (43.9%) followed by RTA’s; 60
(29.26%). The most common level of spine trauma presentation was at the lumbar spine; 92 (44.87%) followed by tho-
racic spine fractures; 80 (25.4%). Out of 205 patients, 80 (39.02%) patients had stable spine fractures and 125 (60.9%)
patients were having unstable fractures. Majority of the patients presented with ASIA Grade - A; 86 (41.95%), followed
by Grade - E; 60 (29.2%) patients.
Conclusion: Lumbar spine and younger male people are more prone to have spinal injuries.The most frequent reason
for the trauma was due to falls followed by road traffic accidents.
Key Words: Spine trauma, spinal cord injury, ASIA impairment scale

INTRODUCTION Epidemiological patterns indicate that accidental

Spinal Trauma accounts for one of the leading
cause of hospitalization, death, social and economic
disability.1,2 Traumatic spinal cord injury accounts for an
annual incidence of 40 cases per million population. In
the US alone, approximately 11,000 new cases pres-
ent each year. Recent statistics from Australia report
an age-adjusted rate of 14.5 cases per million of the
population.2Approximately, 183,000-230,000 patients
with Spinal cord injury are alive in the United States
and 94% of patients survive the initial hospitalization.2
Department of Neurosurgery Hayatabad Medical Com-
plex, Peshawar
.........................................................................................
Address for correspondence:
Dr. Sohail Amir
Department of Neurosurgery Hayatabad Medical Com-
plex, Peshawar
Cell # 03325723653 03219181303
Email Id: dr.sohailamir@gmail.com
falls (58.9%), road traffic accidents (20.9%), assaults
(11.3%) and sports injuries (5.47%) are the common
causes of spine trauma in China.3 Using the American
Spinal Injury Association (ASIA) impairment classifica-
tion, 15.3% patients were classified as having ASIA-A
injuries, 29% as ASIA-B, C and D, and 55.7% had
ASIA-E.3 The most common area of fracture was the
dorso-lumbar spine (54.9%).3
Data from study in Brazil on cervical spine trauma
showed that 19.8% of the cases involved the cranio-cer-
vical region and 80.2% had injuries in the cervical
sub-axial region.4The high incidence of spinal injuries
in recent times is attributed to road traffic accidents,
urban violence, military conflicts and natural disasters
in different parts of the world.5 Trauma to the spine can
lead to cervical, dorsal and lumbar spine injuries. Spinal
trauma constitutes a major public health issue in the
developing world due to its devastating impact on life.6
Basic life-support along with spinal trauma evacuation

198 KJMS May - August, 2020, Vol. 13, No.2

protocols is crucial first step in the management of such A Complete No motor and sensory level preserved
patients. Immobilization of the spine is crucial so as to below level of injury
avoid inciting a secondary neurological damage. 7
B Incomplete Sensory present but no motor pre-
The epidemiology and neurological outcome of served below the level of injury
spinal cord injury(SCI) in a developing country such as
C Incomplete Motor preserved below the level of
Pakistan differs from that of developed countries and
injury but muscle power is<3
it needs consideration whilst devising a plan for SCI
management and rehabilitation. D Incomplete Motor preserved below the level of
injury and power is below norm
The rationale of conducting this study is to identify
and highlight the epidemiological pattern (etiology and E Normal Motor and sensory function are normal
frequency) of traumatic spinal cord injuries and their Fig 1: ASIA Impairment Scale
outcome based on American Spinal Injury Association
(ASIA) impairment classification, presenting at a tertiary Table 1: Age Distribution
care unit of a developing country like Pakistan. This
study shall enable us to delineate the etiology of spinal Age in years Frequency Percentage
trauma and bring into light the need to improve the
15-25 years 75 36.58%
spinal trauma management protocols so as to improve
the morbidity it imposes. It may also help the district 25-35 years 46 22.4%
and town management authorities in better planning to 35-45 years 38 18.5%
avoid these injuries.
45-60 years 30 14.6%
MATERIAL AND METHODS 60-75 years 16 7.8%
This descriptive (cross sectional) study was Table 2: Sex Distribution
conducted at Neurosurgery Department of Hayatabad
Medical complex Peshawar, from September 2018 to Sex Frequency percentage
December 2019. It was non-randomized convenience
Male 150 73.17%
sampling. The sample size was calculated by WHO
calculator. All patients between 15 to 70 years of age Female 55 26.82%
with spinal trauma admitted via Out patient department,
emergency or referred from other unit were included, Table 3: Mode of Trauma
while those patients who has previous spinal surgery
and not willing to participate in study were excluded. Mode of trauma Frequency percentage
After approval from hospital ethical and research RTA 60 29.26%
committee informed written consent was obtained from Fall 90 43.9%
each patient or their attendants. After initial stabilization
of the patient by ATLS protocol age, sex, mode of trau- Sports injury 10 4.87%
ma, level of injury, type of fracture and neurological sta- Assault 15 7.31%
tus were recorded. Plain X-Ray both Anterior posterior Miscellaneous 30 15.12%
and lateral view were taken in all patients. 3D CT scan
and MRI films were obtained in cases where needed
especially in cervical and dorsal spine. For thoracic and Table 4: Level of spinal fracture
lumbar fracture we use TLICS (Thoracolumbar injury
classification and severity score) based on three basic Level of Spinal Frequency Percentage
parameters injury morphology, posterior ligamentous Fracture
complex integrity and patient neurology. A score of 4 Lumbar spine 92 44.87%
and greater than 4 is considered unstable and need fracture
surgical intervention similarly for neurological assess-
ment of the patient we use ASIA ( American spinal injury Dorsal spine 52 25.36%
association) impairment scale. Shown in fig (1). Data fracture
analyze using SPSS version 20.0 and presented in form Lower cervical 28 13.65%
of tables. spine fracture
Upper cervical 18 8.78%
RESULTS spine fracture
A total of 205 patients with different types and Multiple fracture 15 7.31%
levels of spine trauma were included in the study.
The most frequently affected age group presenting

KJMS May - August, 2020, Vol. 13, No.2 199

 Table 5: ASIA impairment Scale
ASIA Scale Frequency Percentage
A 86 41.95%
B 13 6.34%
C 30 14.63%
D 16 7.80%
E 60 29.2%
with spine trauma were young 15 to 25years of age
75(36.58%) followed by 25 to 35years 46(22.4%) as
shown in Table I. In our study males are more prone to
have spinal trauma as compared to female probably
males are more expose to external environment heavy
work, RTA, fall and other sports injury in our society as
shown in Table II .
The most frequent etiologies seen for spine injury
were falls; 90 (43.9%) patients, followed by RTA’s; 60
(29.26%), miscellaneous causes were 30 (15.12%),
assault; 15(7.31%) and sports injuries 10 (4.87%) as
depicted in Table III. In this study the most common level
of spine trauma presentation was at the lumbar spine; 92
(44.87%) patients, followed by thoracic spine fractures;
52 (25.36%) patients, followed by lower cervical spine;
28 (13.65%) patients and upper cervical spine trauma;
18(8.78%) patients. Patients presenting with multi-level
spine fractures were 15(7.31%) as shown in Table IV.
Out of 205 patients, 80 (39.02%) patients had
stable spine fractures and 125 (60.9%) patients were
having unstable fractures. Majority of the patients pre-
sented with ASIA Grade - A; 86 (41.95%), followed by
Grade - E; 60 (29.2%) patients. 30 (14.63%) patients
were in Grade - C, 10 (7.80%) patients in Grade - D and
13(6.34%) patients in Grade – B. as depicted in Table V
DISCUSSION
Spine trauma all over the world has a significant
impact on morbidity and mortality in patients with
multiple or isolated injuries8 This may be in terms of
death, permanent or long-term disability and reduced
productivity of individuals in society9. Spine trauma
frequency, its etiology and associated neurological
status of patients at presentation follow certain trends
in a developing third world country such as Pakistan.
These trends are clear indicators that can easily be
seen by the results of this study. Of course, multi-center
studies will give a clearer picture of the problem, but
trends of spine injury will provide the impetus to plan
for an effective implementation of primary prevention
strategies, appropriate management programs and
proper allocation of health resource in this area10
In this study, it was seen that the most frequently
presenting age group with spine trauma were young,
between 15 and 25 years of age. This holds true be-
cause this age group is seen to be most active, involved
200
in falls and RTAs.11 The mean age of presentation was
41% years in which minimum age at presentation was
15 years and maximum age was 75 years. Males 150
(73.17%) were more commonly affected as compared
to females 55 (26.82%) similar syudy done by Lee
BB, Cripps RA, Fitzharris M et al in 201411,12. Lumbar
spine fractures 92 (44.8%) were most frequently seen,
followed by dorsal/thoracic spine 52 (25.36%), Lower
cervical spine 28 (13.65%), Upper cervical spine 18
(8.78%) and multi-level spine fractures 15 (7.31%) in
patients that presented during the study period. Variable
trends of the level of spine trauma are seen in different
parts of the world12
Fracture type in this study was broadly clas-
sified as stable or unstable, based on radiological
criteria combined with clinical absence or presence
of neuro-deficit. . For thoracic and lumbar fracture we
use TLICS( Thoracolumbar injury classification and
severity score) based on three basic parameters injury
morphology, posterior ligamentous complex integrity
and patient neurology. A score of 4 and greater then 4
is considered unstable and need surgical intervention.
The majority of spine fractures were of unstable type
125 (60.9%) whereas 80 (39.02%) patients had stable
spine fractures. Unstable fractures of the spine required
admission and surgical intervention. Similar results were
presented by study done in Nigeria in 201211,12,13.
Associated neurological deficit at presentation
and the corresponding ASIA grade were assessed for
every patient that presented with spinal trauma in this
study. It was seen that majority of the patients were
categorized into ASIA grade – A13. Prognosis is directly
related to the severity of injury14. These statistics vary
from the developed world where there are set stan-
dards of work related safety and traffic laws in place.
The miscellaneous causes seen in this study included
occupational and trade related hazards, notably injuries
sustained by workers in coal mines and wood-cutters15.
Another interesting and unusual observation was the
‘dopatta’ (scarf) ladies garment being a unique cause
of cervical spine trauma in accidents and has also been
reported in literature16. In today’s day and age, warfare
and acts of terrorism have also been implicated as
a significant cause of spine injury17.The incidence of
RTAs resulting in spine trauma is significant in other
parts of the world as well18. Sports related injuries,
especially contact sports such as rugby are commonly
implicated in spinal trauma but are not very popular in
Pakistan and in general there is a very low incidence of
sport related spine injury in our country probably due
to under - reporting, however, sports and recreation
related spine injury has been widely documented in
other parts of the world19. Spine trauma due to assault
and other miscellaneous causes (blunt force, firearm
related, stabs, penetrating and non - penetrating) has
also been reported and widespread but was not seen
to be frequent in our study.20
KJMS May - August, 2020, Vol. 13, No.2
 The lumbar spine followed by the thoracic spine
was the segment to be most frequently involved in
trauma due to falls and miscellaneous causes. However,
the frequency of lower cervical spine trauma was more
in RTAs when compared to falls. In fact, lower cervical
spine trauma in RTAs exceeded thoracic spine injury
and almost equaled the frequency of lumbar spine in-
jury in this etiological group. Patients having sustained
spine injury due to falls and RTAs mostly had severe
neuro-deficit (ASIA grade - A). Mild impairment (ASIA
grade - D) was seen more frequently in RTAs as com-
pared to falls. Varying degrees of impairment (ASIA
grade B, C) were seen with various modes of trauma.
Logically, in this study, it was seen that stable fractures
of the spine frequently presented with no neurological
impairment (ASIA grade - E) and unstable fractures with
complete neurological damage (ASIA grade - A).
CONCLUSION
Spinal trauma is a devastating injury that affects
mainly young male active population of our country. The
most common level of spine injury sustained is of the
lumbar spine and unstable type. Most of these patients
had severe neurological deficit at presentation and were
classified into ASIA Grade -A. The most frequent reason
for the trauma was due to falls followed by road traffic
accidents.
FUTURE PROSPECTS
A spine trauma registry with data collected from
multiple tertiary care centers dealing with such cases
will give a better picture of the trends of spine trauma
in Pakistan.
RECOMMENDATION
It is evident that in a third world country such as
Pakistan, stringent work related safety standards and
implementation of traffic safety laws are needed to
reduce the incidence of accidents and spinal trauma.
REFERENCES
1. Fildes J. Initial Assessment and Management. In:
Advanced Trauma & Life Support. 8thEdi. Chicago:
American College of Surgeons; 2008. p. 1-18.
2. Aquino Gondim FA, Stephen A Berman, Thomas FP,
Berman SA, Talavera F et al. Spinal Cord Trauma
and Related Diseases. Emedicine [Online]. 2013 Jun
[Cited: 2014 Jan 1].Available from: http://emedicine.
medscape.com/article/1149070-overview.
3. Wang H, Zhang Y, Xiang Q, Wang X, Li C, Xiong H,
Zhou Y. Epidemiology of traumatic spinal fractures:
Experience from medical university – affiliated hospi-
tals in Chongqing, China,2001 – 2010. J Neurosurg
Spine. 2012:17: 459-468.
4. Santos EAS, Filho WJS, Possatti LL, Bittencourt LRA,
Fontoura EAF, Botelho V. Epidemiology of severe
cervical spinal trauma in the north area of Sao Paulo
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City: a 10 – year prospective study. J Neurosurg
Spine. 2009: 11: 34 – 41.
5. Lodhi A, Khan SA, Ahmed E, Fatima S, Fatima F et
al. Pre-hospital management of spinal injuries in a
natural disaster. J Ayub Med Coll Abottabad. 2011;
23: 10-2.
6. Rathore FA, Hanif S, Farooq F, Ahmad N, Mansoor
SN. Traumatic spinal cord injuries at a Tertiary Care
Rehabilitation Institute in Pakistan. J Pak Med Assoc.
2008; 58: 53-7.
7. Kalani MY, Fillipidis AS, Theodore N. Spine Trauma.
In: Ellenbogen RG, Shekar LN (editors). Principles
of Neurological Surgery. 3rd edi. USA: Elsevier;
2012. p. 397-411.
8. Anwar F. Multiple trauma associated with spinal
injury. Rawal Med J 2011;36:18-21.
9. Martin ND, Marks JA, Donohue J. The mortality in-
flection point for age and acute cervical spinal cord
injury. J Trauma 2011 Aug;71(2):380-5.
10. Ibrahim A, Lee KY, Kanoo LL. Epidemiology of spinal
cord injury in Hospital Kuala Lumpur. Spine (Phila
Pa 1976) 2013 Mar 1;38(5):419-24.
11. Parenteau CS, Wang NC, Zhang P. Quantification
of pediatric and adult cervical vertebra-anatomical
characteristics by age and gender for automotive
application. Traffic Inj. Prev. 2014;15(6):572-82.
12. Hasier RM, Exadaktylos AK, Boumara O. Epidemi-
ology and predictors of cervical spine injury in adult
major trauma patients: A multicenter cohort study.
J Trauma Acute Care Surg. 2012 Apr; 72(4):975-81.
13. Tsou PM, Wang J, Khoo L. A thoracic and lum-
bar  spine  injury severity classification based on
neurologic function grade, spinal canal deformity,
and spinal biomechanical stability. Spine J. 2006
Nov-Dec;6(6):636-47.
14. Abdul-Sattar AB. Predictors of functional outcome
in patients with traumatic SCI after inpatient rehabil-
itation: in Saudi Arabia. NeuroRehabilitation. 2014
Jan 1;35(2):341-7.
15. Hoque MF, Hasan Z, Razzak AT, Helal SU. Cervical
spinal cord injury due to fall while Carrying heavy
load on head: a problem in Bangladesh. Spinal Cord.
2012 Apr; 50(4):275-7
16. Jain V, Agrawal M, Dabas V. Dupatta (scarf): A unique
cause of cervical spine injury in females. Injury. 2008
Mar; 39(3):334-8.
17. Rathore FA, Ayub A, Farooq S. Suicide bombing as
an unusal cause of SCI: a case series from Pakistan.
Spinal Cord. 2011 July; 49(7):851-4.
18. Leutand T, Ndiaye A, Frost F. A 10 - year population
survey of spinal trauma and spinal cord injuries after
road accidents in the Rhone area. J Neurotrauma.
2010 Jun; 27(6):1101-7.
19. Boran S, Lenehan B, Street J. A 10 year review of
sports related spinal injuries. Ir J Med Sci. 2011 Dec;
180(4):859-63.
20. Goh BK, Yeo AW. Traumatic pneumorrhachis. J
Trauma. 2005; 58(4):875-9.
201
LEVEL OF JOB SATISFACTION AMONG NURSES WORKING IN
TERTIARY CARE HOSPITAL OF FAISALABAD
Aftab Nazir1, Rabia Arshad Usmani1, Rida Dawood2, 3, Nargis Haider Kakar4, Marriam Nazir5, Zunera Tanveer4,
Irshad Ahmad6

ABSTRACT
Introduction: Nurses playing an important role in the provision of health service delivery. Their job satisfaction impacts
the quality of healthcare service delivery and patient outcome.
Objective: To study the level of job satisfaction among nurses working in Independent University Hospital, Faisalabad.
Material and Methods: Descriptive cross-sectional study was conducted in Independent University Hospital from
January 2018 to June 2018. All the nurses, who were working in Independent University Hospital and are willing to
take part, were included in our study through convenience sampling technique. Data was collected through structured
questionnaire. Confidence level set at 95% and p-value taken 0.05. Job satisfaction was considered low when 0-33%
respondents answered yes (satisfied) to a particular question, moderate satisfaction for a 34-67% response and high
satisfaction for 68% or more yes (satisfied) response to a particular question. A nurse was labeled as satisfied from job
if answers to more than 6 out of 12 questions was found yes (satisfied).
Results: Among 116 participants nurses, 92 (79.3%) nurses were satisfied with work load, 90 (77.6%) nurses with
their working hours, 90 (77.6%) nurses with new job skills and 88 (75.9%) nurses were satisfied with relations with
co-workers. Lowest satisfaction was found with pay 26 (39.7%) followed by satisfaction with benefits other than pay
66 (56.9%). Overall 80 (69.0%) nurses were satisfied with their job while 36 (31.0%) were not satisfied with their job at
independent university hospital.
Conclusion: Majority of the nurses working at Independent University Hospital were satisfied with their job. Pay and
job-related benefits need to be reviewed for nurses’ better job satisfaction and less job turnover.
Key words: Nurses, job satisfaction, Tertiary care hospital, healthcare

INTRODUCTION
A number of factors affect the performance and state resulting from the appraisal of one’s job or job
success of an organization. Job satisfaction of employ- experiences’.(1)
ees is an important factor which affects the organization
In healthcare setting, job satisfaction of employ-
success. Job satisfaction of employees is subjective. It
ees is very important for the better and optimal care of
can be defined as ‘a pleasurable or positive emotional
patients and provision of quality healthcare services(2,3)
Job satisfaction and organizational performance are
1Department of Community Medicine, Independent interlinked with each other as it can be said job satis-
Medical College, Faisalabad Pakistan. faction determine organizational performance.(3) Positive
2Department of Cardiology, Children Hospital Faisal- job satisfaction leads to better organizational perfor-
abad, Pakistan. mance and vice versa.(3) Nurses play an important part
3Department of Medical Education, University of Health in the provision of health services. Because of nurses
Sciences, Lahore, Pakistan. shortage, it is important to have the nurses have good
4Department of Physiology, Bolan University of Medical job satisfaction and thus retain them in the organization
and Health Sciences, Quetta, Pakistan. and reducing their turn over.(4)
5Allied Hospital Faisalabad, Faisalabad Medical Uni-
versity, Faisalabad, Pakistan. A number of factors influence the nurses’ job
6Department of Molecular Biology and Genetics, satisfaction in a healthcare setting. Educational level,
Institute of Basic Medical Sciences, Khyber Medical years of experience, personal income, work burden,
University, Peshawar, Pakistan. workplace relationship, stress, job autonomy, perceived
......................................................................................... organizational support, equity etc have their impact on
Address for correspondence: job satisfaction. (5-9)
Dr. Aftab Nazir Herzberg‘s two-factor theory also known as mo-
Department of Community Medicine, Independent tivation-hygiene theory is the most commonly theory
Medical College, Faisalabad, Pakistan. used to describe motivation and job satisfaction. (10)
Mob#: +92-345 171 62 72 It describes the factors which influence the attitude of
Email: aftab_001@hotmail.com

202 KJMS May - August, 2020, Vol. 13, No.2

people towards their work and job satisfaction. This the-
ory describe two types of factors that is hygiene factors
(extrinsic factors) and motivator (intrinsic factors).(10) A
summary of these factors is shown in the following Table
No.1
Motivation factors are intrinsic to job and aim
to improve the job satisfaction among employees. (10)
Hygiene factors are extrinsic to job and they are there in
an organization to reduce the job dissatisfaction among
employees.
Our study aims to describe the factors associated
with job satisfaction among nurses working in Indepen-
dent University Hospital (IUH), and to study the level of
job satisfaction among nurses working in Independent
University Hospital, Faisalabad
METHODOLOGY
Study design: Cross-sectional descriptive study was
done at Independent University Hospital (IUH) from
January 2018 to June 2018. All the 116 nurses working
at Independent University Hospital (IUH) were selected.
Sampling technique was convenience sampling. Con-
fidence interval set at 95%.
Sample selection: All the nurses working in the hos-
pitals affiliated with Independent Medical College Fais-
alabad and willing to participate in our study. Consent
was taken before the administration of questionnaire.
Data collection procedure: Data was collected by
self-administered structured questionnaire. Question-
naire was adapted from studies conducted previously.
Verbal and written consent was taken before adminis-
tration of questionnaire.
Study variables: include the following: Age, marital
status, boarding status, wards working, years of expe-
rience, total monthly income, working hours
Data analysis procedure: Data was entered and ana-
lyzed using the statistical package for social sciences
(SPSS) version 19.
Operational Definitions
Low satisfaction: When 0-33% respondents answered
yes (satisfied) to a particular question.
Moderate satisfaction: 34-67% respondents answered
yes (satisfied) to a particular question.
High satisfaction: 68% or more respondents answered
yes (satisfied) to a particular question.
Overall job satisfaction: There were total of 12 job
satisfaction related questions, a nurse was labeled as
satisfied from job if answer to more than 6 questions
was found yes (satisfied).
RESULTS
Among 33 nurses who aged less than 30 years,
KJMS May - August, 2020, Vol. 13, No.2
23 (69.7%) were satisfied while 10 (30.3%) were unsat-
isfied. Those aged 30 years or more, 17 (68%) were
satisfied while 8 (32%) were unsatisfied from their jobs.
100 nurses were married and only 16 were unmar-
ried. Among 100 married, 68 (68%) were satisfied and
32 (32%) were unsatisfied while among 16 unmarried
nurses, 12 (75%) were satisfied and only 4 (25%) were
unsatisfied.
Among 48-day scholar nurses, 36 (75%) were
satisfied and 12 (25%) were unsatisfied from their job.
Among 68 nurses living is nursing hostel, 44 (64.7%)
were satisfied while 24 (35.3%) were unsatisfied from
their job.
Nurses’ response to each particular job satisfac-
tion related question is shown in Table No.3.
Out of 116 nurses, 80 (69%) were found to be
satisfied from their job while 36 (31%) were unsatisfied
from their job. (Table No. 4)
DISCUSSION
Our research found that more than two third nurs-
es (69%) working at Independent University Hospital
were overall satisfied from their job. This is significant as
it has been shown that the greater the job satisfaction,
the lesser the intent to leave the job and thus reduced
employee turnover.(11) A similar study conducted on
nurses working in different hospitals in Turkey found
nurses satisfaction level at 58%.(12)
High satisfaction level was found for the work load
question as 92 (79.3%) nurses were satisfied with the
work load they face during their job followed by satis-
faction with working hours 90 (77.6%), satisfaction with
new job skills 90 (77.6%) and satisfaction with relation
with co-workers 88 (75.9%). All of these factors are im-
portant in job satisfaction of employees and motivating
them to continue their existing job.
Low level of satisfaction were found with pay
46 (39.7%), followed by satisfaction with benefit other
than pay 66 (56.9%), and by satisfaction with attitude
of hospital management 70 (60.3%). This is significant
as studies have shown that pay and job benefits have
great impact on job satisfaction of nurses and thus in
turn their intention to quit the job. (12, 13) Less pay forces
Table No.1 Factors in Herzberg two-factor theory
Motivation Factors Hygiene Factors
Advancement Interpersonal relationship
Work itself Salary
Possibility of growth Policies and administration
Responsibility Supervision
Recognition Working conditions
Achievement
203
 Table No. 2: Frequency distribution of socio demographic variables of study participants

Demographic variables Frequency Percentage

Age Group
Less than 30 years 66 56.9%
30 or more than 30 50 43.1%
Marital status
Single 16 13.8%
Married 100 86.2%
Boarding status
Day scholar 48 41.4%
Hostelite 68 58.6%
Type of family
Nuclear 88 75.9%
Extended 28 24.1%
Ward in which working
Medicine and allied 32 27.6%
Surgery and allied 84 72.4%
Years of experience
Upto 4 years 90 77.6%
More than 4 years 26 22.4%
Working at other job
Yes 98 84.5%
No 18 15.5%
Total monthly family income
Upto 40000 72 62.1%
More than 40000 44 37.9%
Participant income
Upto 15000 82 70.7%
More than 15000 34 29.3%
Number of working hours
8 hours 32 27.6%
More than 8 hours 84 72.4%
Mode of transport usage
Public transport 72 62.1%
Own transport 44 37.9%

204 KJMS May - August, 2020, Vol. 13, No.2

 Table No.3: Nurses job satisfaction with respect to particular question

Serial Statement Yes % No % Satisfaction

No. level
1 Are you satisfied with your working hours? 90 77.6 26 22.4 High
2 Are you satisfied with your workload? 92 79.3 24 20.7 High
3 Are you satisfied with your pay? 46 39.7 70 60.3 Moderate
4 Are you satisfied with the time of your pay? 72 62.1 44 37.9 Moderate
5 Are you satisfied with your working condition & 74 63.8 42 36.2 Moderate
environment?
6 Are you satisfied with the attitude of hospital man- 70 60.3 46 39.7 Moderate
agement?
7 Are you satisfied with the appreciation when you do 78 67.2 38 32.8 Moderate
good work?
8 Are you satisfied with the motivation provided by 78 67.2 38 32.8 Moderate
your supervisor?
9 Are you satisfied with your relations with your 88 75.9 28 24.1 High
co-workers?
10 Are you satisfied with any other benefit other than 66 56.9 50 43.1 Moderate
salary?
11 Are you satisfied with new skills acquired at job 90 77.6 26 22.4 High
12 Are you satisfied with security provided at work 74 63.8 42 36.2 Moderate

Table No. 4: Overall job satisfaction of nurses REFERENCES

1. Locke EA, Sirota D, Wolfson AD. An experimental
Overall job satisfaction
case study of the successes and failures of job en-
Satisfied 80 69%* richment in a government agency. Journal of Applied
Unsatisfied 36 31%** Psychology. 1976;61(6):701.

*There were total of 12 job satisfaction related ques-
tions, a nurse was labeled as satisfied from job if answer
to more than 6 questions was found yes (satisfied). **A
nurse was labeled as unsatisfied from job if answer
to 6 or more than 6 questions was found to be no
(unsatisfied).
the workers to leave the job and search for jobs having
better pay and good job-related benefits.
Research included a sample of employees from
only Independent University Hospital, so the data
cannot be generalized to whole population of nurses
working in different hospitals of Faisalabad.
CONCLUSION
80 (69%) nurses were found to be satisfied and
only 36 (31%) were unsatisfied with their job at Inde-
pendent University Hospital. High satisfaction level was
found for work load burden (79.3%) while low satisfac-
tion was found with the pay (39.7%) among nurses. Pay
and job-related benefits need to be reviewed for the
better job satisfaction of nurses working at Independent
University Hospital and thus reduced job turn over.
2. Purpora C, Blegen MA. Job satisfaction and hori-
zontal violence in hospital staff registered nurses:
the mediating role of peer relationships. Journal of
clinical nursing. 2015;24(15-16):2286-94.
3. Bakotić D. Relationship between job satisfaction
and organisational performance. Economic Re-
search-Ekonomska Istraživanja. 2016;29(1):118-30.
4. Al Maqbali MA. Factors that influence nurses’ job
satisfaction: a literature review. Nursing manage-
ment. 2015;22(2).
5. Čábelková I, Abrhám J, Strielkowski W. Factors
influencing job satisfaction in post-transition econ-
omies: the case of the Czech Republic. International
Journal of Occupational Safety and Ergonomics.
2015;21(4):448-56.
6. Alotaibi J, Paliadelis PS, Valenzuela FR. Factors that
affect the job satisfaction of S audi A rabian nurses.
Journal of nursing management. 2016;24(3):275-82.
7. Sharma J, Dhar RL. Factors influencing job perfor-
mance of nursing staff: mediating role of affective
commitment. Personnel Review. 2016;45(1):161-82.
8. Chien W-T, Yick S-Y. An investigation of nurses’ job
satisfaction in a private hospital and its correlates.
The open nursing journal. 2016;10:99.

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9. Atefi N, Lim Abdullah K, Wong LP, Mazlom R. Factors
influencing job satisfaction among registered nurses:
a questionnaire survey in Mashhad, Iran. Journal of
nursing management. 2015;23(4):448-58.
10. Alshmemri M, Shahwan-Akl L, Maude P. Herz-
berg’s two-factor theory. Life Science Journal.
2017;14(5):12-6.
11. Al-Hamdan Z, Manojlovich M, Tanima B. Jordanian
nursing work environments, intent to stay, and
job satisfaction. Journal of Nursing Scholarship.
2017;49(1):103-10.
12. Masum AKM, Azad MAK, Hoque KE, Beh L-S, Wanke
P, Arslan Ö. Job satisfaction and intention to quit:
an empirical analysis of nurses in Turkey. PeerJ.
2016;4:e1896.
13. Top M, Gider O. Interaction of organizational com-
mitment and job satisfaction of nurses and medical
secretaries in Turkey. The International Journal of
Human Resource Management. 2013;24(3):667-83.

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206 KJMS May - August, 2020, Vol. 13, No.2

 PREVALENCE OF REFRACTIVE ERRORS IN PRIMARY
SCHOOL GOING CHILDREN OF SHEIKH MALTOON TOWN
MARDAN
Shafi Ullah1, Shahana Nisar1, Uzma Nisar2, Hamza Abbas3 Bakhtawara4. Nayyer zaman5,Nizam ud din6

ABSTRACT
Objectives: To find out the prevalence of Refractive Errors and its associated risk factors in Primary school children
of Sheikh Maltoon Mardan.
Study design: Descriptive Cross sectional Study
Place and Duration of study: This study was conducted in the primary schools of sheikh Maltoon town, Mardan, in
the month of April, 2018.
Materials & Methods: A total of 250 students from class 1 to class 5 in five primary schools of Sheikh Maltoon town
Mardan, were selected through probability cluster and systemic sampling. Students were interviewed through ques-
tionnaire. Near and far vision was tested through Jagger’s and Snellen’s Chart. Those suspected of having Refractive
Errors were called for follow up in MMC Eye OPD. Those diagnosed with refractive errors were then advised glasses.
Results: Out of the total 250 students 55 were suspected for Refractive Errors on the basis of Questionnaire and
Examination. 52 students reported to MMC OPD, 7 were found to be normal and 45 had refractive errors. Hence the
prevalence of refractive errors came out to be 18% out of which the cases of Myopia, Hyperopia and Astigmatism were
48.8%, 20% and 31.1% respectively.
Conclusion: This research shows that Refractive errors specifically Myopia is very common in school children. Spec-
tacle correction of refractive errors is the cheapest and easy solution of this problem.
Key Words: Hyperopia, Myopia, Risk factors, Accommodation of lens.

INTRODUCTION ficiency and no proper visual care1. There is an easy

The awareness and health education regarding way to wear affordable glasses by which further visual
refractive errors should be considered seriously be- impairment can be prevented in that person and thus
cause one of the primary cause of visual impairment to prevent permanent visual loss.
especially in children is refractive errors. As there are many predisposing factors that
This is more common in developing countries. contribute to visual impairment some of them like close
The reason may be unawareness regarding this prob- reading distance and continuous reading without any
lem, no access to corrective measures, dietary insuf- gap in between for long time are also associated with
development of myopia in children so by emphasizing
1Department of Community Medicine, Bacha Khan on the correction of these predisposing conditions can
Medical College, Mardan, Pakistan. reduce the chances of visual impairment 2 .
2(Consultant Radiologist), Armed Forces Institute of
Radiology and Imaging, MH, Rawalpindi, Pakistan. CLASSIFICATION OF REFRACTIVE ERRORS
3Department of Community Medicine, Gajju Khan 1) Myopia
Medical College, Swabi, Pakistan
4Department of Dentistry, Bacha Khan Medical College, 2) Hyperopia
Mardan, Pakistan. 3) Astigmatism:
5Department of forensic Medicine, Gajju Khan Medical
College, Swabi, Pakistan Myopia
6Department of pharmacology Khyber girls Medical
College Hayat Abad, Peshawar It is also known as nearsightedness, is a form
......................................................................................... of refractive error in which parallel rays of light after
Address for correspondence: entering the eye are refracted and instead of focusing
Dr. Shafiullah on retina it gets focused in front of retina with accom-
Department of Community Medicine Bacha Khan Med- modation at rest .
ical College, Mardan, Pakistan.
Email:shafibkmc82@gmail.com Hyperopia
Cell: 0332-9175568

KJMS May - August, 2020, Vol. 13, No.2 207

 It is also known as farsightedness, is a form of re-
fractive error in which parallel rays of light after entering
the eye gets refracted and instead of focusing on retina
it gets focused behind the retina with accommodation
at rest.
Astigmatism
Astigmatism is a common vision condition that
causes blurred vision. It occurs when the cornea is ir-
regularly shaped or sometimes because of the curvature
of lens inside the eye. An irregularly shaped cornea or
lens prevents light from focusing properly on the retina.
The effect of outdoor activities like cricket, football,
volleyball and many others in spare time of children was
observed and compared with those of indoor activities
like book reading, use of mobile, Computer tablets
etc., it was concluded that children involved in outdoor
activities are less likely to develop refractive errors as
compared to those involved in indoor activities3. When
different age Groups were considered to look that which
age group is more affected it was observed that myopia
(a type of refractive error) is less prevalent in 3-5 years of
children and more prevalent in > 6 Years of age group
probably due to environmental factors like schooling
and associated studying which usually started after
4-5 years of age group4. Refractive errors are second
leading cause of visual impairment and blindness which
are double as compared to that cause by cataract in de-
veloping countries5. By providing health education and
awareness among population the chances of Refractive
errors can be reduced significantly. Refractive errors are
one of the greatest problems which have affected large
population irrespective of age and races6.
This is one of the major problems if left untreat-
ed. It could lead to severe damage to vision and even
can cause blindness. It could affect even the mental
level of children. They think that they cannot achieve
their goals in their lives like other children and they
get disappointed and stop their struggle for achieving
their goals and thus the person which can be otherwise
very fruitful for the society Become a burden on it7 .In
developing countries there is more problem of refractive
errors because of their reduced resources which are
required for normal vision like lack of food or availability
of improper food and also the lack of awareness.
The school age is a growing period physically as
well as mentally to transform a child in to a responsible
and promising adult. So the earliest we diagnose a
problem (disease), more it is easy to handle and solve
so that’s why our focus is on early age group. In addition
to that the problem of refractive error is common in this
age, which if undetected can cause an adverse effect
on the lives of these individuals8. In 2008 a study was
conducted on the school going children of Karachi and
prevalence of refractive errors was found to be 8.9%
among the total 940 students examined9.
208
Another study on school students conducted
in Lahore in 2007 showed prevalence of 19.8%. This
study also showed a positive relationship of refractive
errors with family history10. A cross sectional study
conducted at Al-Shifa Eye trust OPD in 2016 examined
1500 children below the age of 15 years for the pres-
ence of different types of refractive errors. In this study
astigmatism was found in 41.4%, hyperopia 36.5% and
myopia 22.1%11.
A study on the madrassa students of district Har-
ipur revealed a 41.4% prevalence of refractive errors,
out of which Myopia was present in 52.6% of students,
Hyperopia 28.4% and Astigmatism 19%12.Another study
conducted in Lahore in 3 public sector schools exam-
ined 525 students and refractive errors were found to
be present in 21.7% of students and the percentage of
Myopia, Hyperopia and astigmatism was 42.5%, 32.9%
and 24.6% respectively13.A study was conducted in a
public school of Lahore in 2012 in which 533 students
from class 6 to 10th were included. Refractive error was
found in 107 student’s i.e 20.07%. Myopia accounted for
61.70%, Hypermetropia 14% and Astigmatism 24.30%
of the total refractive errors14.
A school based cross sectional study performed
in kotabharu district of Malaysia showed the prevalence
of refractive errors to be 7.7% out of which myopia was
present in more than 75% of cases15.
In Nepal 964 school children were examined and
refractive errors were found in 62 students (6.4%) in
which also myopia was found to be the most common16.
A cross sectional study in Delhi screened 9884
children for myopia and prevalence of myopia was
found out to be 13.1% out of which only 24.7% children
were wearing glasses. (Corrected refractive error) 17.
Another research on the subject was carried out in
Kolkata among the school children aged 5-10 years.
Among 2317 students examined, 25.11% were suffering
from refractive errors, myopia being the commonest. No
significant difference between refractive errors of boys
and girls was found18.
A study done in Nigeria among children aged
between 7-17 years, the observed frequency for hy-
peropia followed a reverse pattern to that of myopia.
The prevalence of hyperopia in the 7 year old subjects
was at 26% and continued to decrease with age to 5%
among the 17 year old subjects19.
Rationale
This study was conducted to identify the children
who are unaware of their refractive errors and find the
prevalence of these refractive errors in Mardan.
MATERIALS & METHODS
This study was conducted in primary schools of
sheikh maltoon town Mardan, in April 2018. Mardan is
KJMS May - August, 2020, Vol. 13, No.2
the second biggest district of KPK in terms of popula-
tion. Sheikh Maltoon Town is located in the periphery of
Mardan, about 7 km outside main city. On one corner of
the town is Abdul Wali Khan University and on the other
is Bacha Khan Medical College and Mardan Medical
Complex. It is clean and green area with around 10
thousand population.
Sample Frame: 18 Primary Schools of Sheikh Maltoon
Town Mardan
Population Size: 2298 students Sample Size Formula:
Sample size was calculated using WHO sample size
calculator, by using the following formula;
Sample Size: 250
Sampling technique: Probability sampling was done.
Five schools were selected through cluster sampling.
In these school’s 10 students from each class were
selected through lottery method, hence 50 students
from all the five schools. Consent was sought from all
the students that fulfilled the selection criteria.
Tool for collecting the data: The tool for collecting
the data was a modified questionnaire obtained from
WHO website and modified according to the need of
my study which was verbally translated into Pashto but
the answers were written in English.
Ethical consideration: - Informed consent was ob-
tained from each student before their participation in the
study and were interviewed after their consent.
Data Analysis: Data was analyzed using SPSS version
20. The data was organized, summarized and displayed
through tables and Pie charts. Nominal data was an-
alyzed and presented in the form of frequencies and
percentages.
Inclusion Criteria: All primary Students (class 2 to
Class5) of Sheikh Maltoon Town Mardan.
Exclusion Criteria: Pre School and Students of Middle
School were excluded from the study.
Sampling Frame:
• Dr TM Khan School (122)
• The Educators (133)
• Country Grammar School (127)
• Allied School (132)
• Imperial School (130)
• Dar e Arqam Schools (124)
KJMS May - August, 2020, Vol. 13, No.2
• Pak School (129)
• Smart School (122)
• Pak Turkish School (121)
• Government Girls Primary School (127)
• Conventional School (126)
• MILS (128)
• Global School (126)
• National School (121)
• Government Primary School #2 (127)
• The NIPS (136)
• Mardan Model School (141)
• Mardan Grammar School (126)
• Total Population: 2298 (clusters=18)
RESULTS
From the total 250 students we suspected 55
students to have decreased vision based on History
and Examination (Snellen’s and Jagger’s charts). We
called those 55 students for follow up in MMC Eye
OPD. 52 out of these 55 students reported to the OPD.
7 were found to be normal while 45 had refractive errors.
Hence the Prevalence came out to be 18%. Out of those
45 students 22 had Myopia (48.8%), 9 had Hyperopia
(20%) and 14 had Astigmatism (31.1%).
We divided the students into two age groups;
Group A from age 8-10 years, and Group B from age
11-13 years. Total numbers of students in Group A were
219 (83.5%) and that in Group B were 43 (16.4%), as
shown in the figure-1
In our total sample of 262 student’s there were
130 male students (51.9%) and 120 female students
(48.1%). Total number of cases in males was 21 com-
pared with 26 in females. This shows that girls had a
high percentage of refractive errors compared to boys,
as shown in the figure- 2
Students were asked about blurring Of Vision
While reading, 54 students said Yes (20.6%), and 208
students said No (79.4%), as shown in the figure-3.
46.3% (25 out of 54) of those who said yes were
later diagnosed to have refractive errors. While those
who replied No to this question, only 10.5 percent (22
out of 208) of them had refractive errors. This clearly
shows that these symptoms are clear indicators of
the presence of RE’s and shouldn’t be ignored by the
teachers and parents.
Out of the total sample only 39 students (15%)
previously had an eye checkup as shown in figure-4.
Most of the students who were suffering from of
Refractive Errors (mild or severe) didn’t ever had an
209
 Fig 1

Fig 4

eye checkup and were unaware if they had any ocular

disease in the form of Refractive Errors.
136 students experienced pain/irritation in their
eyes. As we later analyzed our data we came to know
that 24.3% of these students had refractive errors (33
out of 136). While those who didn’t felt any pain irritation,
13.4% of them had refractive errors (14 out of 126).
64 students experienced difficulty seeing at night
while 198 didn’t. Refractive errors were more in the
former group (20/64) than in the later (27/198). Those
who experienced headache while reading had more
percentage of refractive errors than those who didn’t
experienced headache. This, and the two symptoms
discussed before, shows that ocular complaints like
“pain/irritation in bright light”, “difficulty seeing at night”
Fig 2
and “headache while reading” have a positive associa-
tion with the presence of refractive errors.

DISCUSSION
According to our study, there were more cases of
refractive errors in the lower age group, that is age group
8-10 years but in other studies the Refractive errors
prevalence increases as the age advances10. In 2008 a
study was conducted on the school going children of
Karachi and prevalence of refractive errors was found
to be 8.9% among the total 940 students examined9.
Young Children in this age group are not able to properly
communicate their problem to their parents hence the
responsibility lies on parent’s shoulders to know if their
child has a poor sight and have them clinically checked
as soon as possible.
In my study the prevalence of refractive errors
came out to be 18%, while in another study on school
Fig 3
students conducted in Lahore in 2007 showed preva-

210 KJMS May - August, 2020, Vol. 13, No.2

lence of 19.8%11, however in another study conducted
on the school going children of Karachi and prevalence
of refractive errors was found to be 8.9% among the
total 940 students examined9.
A cross sectional study conducted at Al-Shifa Eye
trust OPD in 2016 examined 1500 children below the
age of 15 years for the presence of different types of
refractive errors. In this study astigmatism was found
in 41.4%, hyperopia 36.5% and myopia 22.1%11 and in
my study cases of Myopia, Hyperopia and Astigmatism
were 48.8%, 20% and 31.1%20.
A study on the madrassa students of district Har-
ipur revealed a 41.4% prevalence of refractive errors,
out of which Myopia was present in 52.6% of students,
Hyperopia 28.4% and Astigmatism 19%12.
In Kenya, a study done by Muma et al, revealed
that the prevalence of hypermetropia among ages 12-16
years in rural Kenya showed the converse, hypermetro-
pia was found to be the commonest refractive error at
3.2% followed by myopia at 1.7 percent21.
In South African a study on refractive error and
visual impairment in African children found astigmatism
was associated with older age21.
In our total sample of 262 student’s there were
130 male students (51.9%) and 120 female students
(48.1%). Total number of cases in males was 21 com-
pared with 26 in females. This shows that girls had a
high percentage of refractive errors compared to boys.
Another research on the subject was carried out in Kol-
kata among the school children aged 5-10 years. No
significant difference between refractive errors of boys
and girls was found19.
The prevalence of Refractive errors should be
more in the higher age group because of increased
time of exposure to risk factors. We enquired the stu-
dents about other factors which are the possible risk
factors of developing refractive errors like studying in
dim light, studying for long continuous hours without
rest, and use of electronic devices for long time. All
these factors increase the strain on the eyes and are
not good for health as illustrated by previous studies14,
15
. Although in our study we did not find any; relation
of these factors with developing Refractive Errors but it
is generally advised that reading areas should be well
illuminated and classrooms should have adequate
lighting. Similarly studying for long hours without any
rest is also not advisable.
We asked students regarding taking part in
sports activities and surprisingly our results showed
no relation between outdoor games and development
of refractive errors. But playing Sports and taking part
in outdoor activities are obviously healthy for the body.
In general including the eyes and vision as shown by
previous researches. Similarly regarding eating green
vegetables, we couldn’t find any relation but it is obvi-
KJMS May - August, 2020, Vol. 13, No.2
ous that these green vegetables contain vitamin A and
other essential vitamins which are absolutely important
for good vision and children should be encouraged to
eat green vegetables.
The risk factors that we were able to identify
like posture while reading, dim lighting, continuous
study for long hours, less sleep, less physical activity
and spending more time on computer and electronic
gadgets are also widely accepted and acknowledged
as risk factors for developing Refractive Errors14.
In our last question we tried to find the relation
of refractive errors with positive family history and we
found out that those having positive family history have a
relatively higher chance of developing refractive errors.
CONCLUSION
The prevalence of 18% is quite alarming. In Paki-
stan, one of the major cause of blindness in uncorrected
refractive errors. Refractive errors are usually present in
the childhood and continue in the adult life.
Unfortunately they are not given much importance
in our society which is evident from the fact that there
is no effective system of preschool visual examination
of children either in the government or in the private
sector.
Recommendations
There should be regular screening for refractive
errors in primary and preschool children. Early detection
and management can save a child vision from further
deterioration and potential blindness. Reading areas
should be well illuminated and classrooms should have
adequate light. Similarly studying for long hours without
any rest should be avoided.
REFERENCES
1. (WHO), W. H. O. 11, October 2006. Sight test and
glasses could dramatically improve the lives of 150
million people with poor vision [Online]. Available:
http://www.who.int/mediacentre/news/releas-
es/2006/pr55/en/ 2017].
2. DANDONA, R., DANDONA, L., SRINIVAS, M., SA-
HARE, P., NARSAIAH, S., MUNOZ, S. R., POKHAR-
EL, G. P. & ELLWEIN, L. B. 2002. Refractive error in
children in a rural population in India. Investigative
ophthalmology & visual science, 43, 615-622.DAN-
DONAR, D. W. H. O. 2001. refractive error blindness.
3. IP, J. M., SAW, S.-M., ROSE, K. A., MORGAN, I. G.,
KIFLEY, A., WANG, J. J. & MITCHELL, P. 2008. Role
of near work in myopia: findings in a sample of Aus-
tralian school children. Investigative ophthalmology
& visual science, 49, 2903-2910.
4. ATTA, Z., ARIF, A. S., AHMED, I. & FAROOQ, U. 2015.
Prevalence of refractive errors in madrassa students
of haripur district. Journal of Ayub Medical College
Abbottabad, 27, 850-852.
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5. WU, P.-C., TSAI, C.-L., WU, H.-L., YANG, Y.-H. & KUO,
H.-K. 2013. Outdoor activity during class recess
reduces myopia onset and progression in school
children. Ophthalmology, 120, 1080-1085.
6. YARED, A. W., BELAYNEW, W. T., DESTAYE, S.,
AYANAW, T. & ZELALEM, E. 2012. Prevalence of
refractive errors among school children in Gondar
town, northwest Ethiopia [Online]. [Accessed 4 19].
7. Kumar, K.S. and Akoijam, B.S., 2016. Prevalence
of refractive error among school-going children of
Imphal, Manipur. International Journal of Medical
Science and Public Health, 5(7), pp.1364-1368.
8. Parmar, A., Kartha, G. and Baria, M., 2017. A study
on the prevalence of refractive errors among school
children of 10-16 years in Surendranagar district, Gu-
jarat. International Journal Of Community Medicine
And Public Health, 4(9), pp.3376-3379.
9. Haseeb Alam1, M. Irfanullah Siddiqui2, Syed Imtiaz
Ahmed Jafri3, Abdul Sattar Khan4, Syed Ishtiaq
Ahmed5, Mohammad Jafar6. Prevalence of re-
fractive error in school children of Karachi. JPMA
June-08
10. AYUB ALI, IMRAN AHMAD, SAIMA AYUB Institute
of Public Health, and Punjab Institute of Preventive
Ophthalmology, Mayo Hospital, Lahore, E:/Biomed-
ica Vol.23 Jul. – Dec. 2007/Bio-21 (A)
11. Maria Manzoor1, Hanif Malik1, Hina Sharif2. As-
sessment of Patterns of Refractive Errors: A Hospital
Based Study. Al-Shifa Journal of Ophthalmology
2016; 12(4), 195-201. © AlShifa Trust Eye Hospital,
Rawalpindi.
12. Zoia Atta, Abdus Salam Arif, Iftikhar Ahmed, Umer
Farooq. PREVALENCE OF REFRACTIVE ERRORS
IN MADRASSA STUDENTS OF HARIPUR DISTRICT.
J Ayub Med Coll Abbottabad 2015;27(4)
13. Prevalance of refractive errors in school children
of lahore a comparative study of 3 public sector
schools
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14. Muhammad Abid Latif , Muhammad Zahid Latif,
Intzar Hussain, Rahila Nizami, Khalid Jamal, Preva-
lence of Refractive Errors in a public school children
of Lahore, PJMHS Vol. 8 No.4 Oct – Dec 2014 1018
15. Hashim SE, Tan HK, Wan-Hazabbah WH, Ibrahim M.
Department of Ophthalmology, School of Medical
Sciences, Health Campus University Sains Malaysia,
Kelantan, Malaysia. (Prevalence of refractive error in
malay primary school children in suburban area of
Kota Bharu, Kelantan, Malaysia)
16. Prevalence of Refractive Errors and Number Needed
to Screen among Rural High School Children in
Southern India: A Cross-sectional Study, Deepika
Dorothy John, Padma Paul, Evon Selina Kujur, Sara-
da David, Smitha Jasper5 and Jayaprakash Muliyil
17. Niroula DR,  Saha CG. Kathmandu Univ Med J
(KUMJ). 2009 Jan- Mar;7(25):67-72. Study on the
refractive errors of school going children of Pokhara
city in Nepal.
18. J Optom. 2014 Jul-Sep; 7(3):168-76. doi: 10.1016/j.
optom.2014.02.001. Epub 2014 Mar 11. Preva-
lence of correctable visual impairment in primary
school children in Qassim Province, Saudi Arabia.
Aldebasi YH
19. Prevalence of Myopia and Its Risk Factors in Urban
School Children in Delhi: The North India Myopia
Study (NIM Study) Rohit Saxena, ,* Praveen Vash-
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20. Niroula DR,  Saha CG. Kathmandu Univ Med J
(KUMJ). 2009 Jan- Mar; 7(25):67-72. Study on the
refractive errors of school going children of Pokhara
city in Nepal.
21. Prevalence, Knowledge, Attitude and Practice on
Refractive error among Students attending Public
High Schools in Nairobi County Research disser-
tation in part fulfilment for the degree of Master of
Medicine, Ophthalmology: Principal Researcher: Dr.
Lily A. Nyamai, University of Nairobi
KJMS May - August, 2020, Vol. 13, No.2
 EFFECTIVENESS AND SAFETY OF SOFOSBUVIR AND
VELPATASVIR COMBINATION FOR THE TREATMENT OF HCV
Dilaram Khan, Fakhre alam, Fawad raheem, Hashmatullah, Mohammad Kamran Hassan

ABSTRACT
Objectives: To determine the effectiveness and safety profile of Sofosbuvir and velpatasvir for the management of HCV.
Methodology: This study was done in the IBP and OPD of Gastroenterology Unit Lady reading Hospital Peshawar from
April 1st 2019 to September 30, 2019 .
Patients having age more than 18 years, of either gender, irrespective of previous exposure to treatment, non-cirrhotics
or compensated cirrhotics were put in this study. Compensated cirrhotic with Hepatoma, HCV infected individuals hav-
ing HBV, HCV infected individuals having HIV as well, pregnant ladies having HCV and HCV patients on hemodialysis
were excluded from this study. Patients who fulfilled the criteria and gave consent. were started on Sofosbuvir and
Velpatasvir combination for 12 weeks.
Results: Total number participants were 90, 60 (67.70%) were male and 30 (33.30%) were female with a male to female
ratio of 2:1. Minimum age was 18 years while maximum was 66 with a mean age of 40.07 +_11.72. Seventy-two (80%)
patients were non-cirrhotic while 18(20%) were compensated cirrhotic as shown in table. All of the 90 (100%) patients
had undetectable Hepatitis C virus RNA at the end of treatment (ETR) while HCV RNA at 12 weeks after post treatment
(SVR) was undetectable in 88(97.77%) patients. Nine (10%) patients complained of headache and fatigue during the
treatment as shown in table.
Conclusion: The combined use of Sofosbuvir and Velpatasvir is highly effective & safe for the management of HCV
in our local set up.
Key Words: Sofosbuvir, Velpatasvir, Hepatitis C

INTRODUCTION 25%), which necessitate the demand for an increased

Hepatitis C virus is a microorganism which
spreads through blood and is a remarkable worldwide
health issue 1. After getting of the virus, acute Hepa-
titis C Virus infection can lead to chronicity2, which is
related with several morbidities, such as liver cirrhosis
and hepatoma 3-5. Roughly about 170 million people
are having infection with the virus across the globe,
and this infection is proving to be a rapidly increasing
economical, social and health burden6.
Infection with Hepatitis C is indigenous in our
country and its number is predicted to rise more in
imminent years because of extensive use of non-safe
procedures. The generality of this disease in our country
has formerly been evaluated and a systematic review
study which was published between 2010 and 2015
showed that the frequency of this virus in the general
adult population in Pakistan is about 6.8%, while the
frequency of patients actively infected with the this
virus was about 6% of the population. Studies included
in this review also showed very high viral occurrence
in rural and poorly developed peri-urban areas (up to
Gastroenterology unit LRH peshawar
.........................................................................................
Address for correspondence:
Dr Fakhre Alam
Gastroenterology unit LRH peshawar
Phone: 03339463153
attention on this formerly ignored socioeconomic group
of the population7.
 Many studies have shown that genotype 3a is the
most frequently occurring HCV genotype is in Pakistan
[8]. However, some recent studies show that, although
3a subtype might still be the most dominant HCV type
in our country, the pattern and frequency distribution of
different Hepatitis C virus genotypes have gone through
an important change. These studies have shown an
increase in the occurrence of genotype 2a, especially
in Khyber Pakhtunkhwa province9.
The combination of sofosbuvir with velpatasvir,
is a once-a-day, oral, all-genotypic, single-pill regimen
which is well-tolerated and leads to achievement of
high SVR rates (95–99%) in patients having Hepatitis C
virus infection with or without compensated cirrhosis in
clinical studies 10,11. Main advantage of sofosbuvir and
Velpatasvir combination as compared to previous oral
anti-viral drugs combination is that it can be used with-
out ribavirin in all Hepatitis C genotypes and in patients
with compensated cirrhosis. The safety and tolerability
profile of this combination suggest it could be given to
patients with minimal monitoring for toxicity, and this is
an important consideration for regions which are having
reserves limitations.
The main goal of this study was to assess safety
and effectiveness of sofosbuvir–velpatasvir combination

KJMS May - August, 2020, Vol. 13, No.2 213

for the treatment of chronic HCV irrespective of geno- Table 1: Age Wise Distribution of Patients (n=90)
typic distribution and treatment exposure.
Age Range Number Percentage
METHODOLOGY 18-30 18 20
This study was done in the institutional based 31-45 53 58.88
private practice and OPD of Gastroenterology Lady
46-66 19 21.11
reading Hospital Peshawar from April 1st 2019 to Sep-
tember 30, 2019 on those chronic HCV patients who Total 90 100
visited IBP for treatment of HCV.
Table 2: Liver Status Wise Distribution of Patients
Patients having age more than 18 years, of either (n=90)
gender, irrespective of previous exposure to anti-viral
treatment, non-cirrhotics or compensated cirrhotic Liver status Number Percentage
were put in the study. Individuals with decompensated
Non-Cirrhotics 72 80
cirrhosis liver, compensated cirrhotic patients with
Hepatoma, HCV infected individuals having HBV, HCV Compensated 18 20
infected individuals having HIV as well, pregnant ladies Cirrhotics
and HCV patients on hemodialysis were excluded from Total 90 100
the study.
Table 3: Response Wise Distribution of Patients
Proper permission was taken from all participants
and patients were assessed for treatment candidacy Response Rate Number Percentage
by doing baseline hematological tests including CBC,
LFTs, PT/INR, serum albumin, creatinine, Screening for HCV RNA at the end of 90 100
HBV and HIV, HCV RNA, US abdomen and OGD where Treatment(ETR)
considered necessary. HCV RNA at 12 weeks 88 97.77
post therapy (SVR)
The patients, who fulfilled the criteria, were given
sofosbuvir 400mg and velpatasvir 100mg in a single pill Table 4: Side Effects Wise Distribution of Patients
combination for 12 weeks. All the patients who were
started on this combination were followed during the Side effects Number percentage
treatment for compliance and any side effects.HCV RNA
was done at 12 weeks after treatment completion. Headache 9 10
fatigue 9 10
Data was analyzed by using the statistical soft
ware 21.
namely Sofosbuvir/Velpatasvir combination, represents
RESULTS a single tablet, once a day, pangenotypic combination,
demonstrated to be safe and effective in almost all
Total of 90 patients were included in this study, type of Hepatitis C Virus infected individuals. Sofos-
60 (67.70%) were male and 30 (33.30%) were female buvir which is a nucleotide inhibitor of viral NS5B RNA
with female to male ratio of 1:2. polymerase, was approved for the treatment of chronic
Minimum age was 18 years while maximum was hepatitis C in 2013, in combination with other drugs and
66 with mean age of 40.07 +_11.72. Majority of the it was the first important step in the management of
participants were having age in the range of 31-45 years CHC patients, since it was the first approved oral drug
as shown in table No.I. having high potency and high genetic barrier against
all HCV genotypes12. Velpatasvir is an NS5A inhibitor
Seventy-two (80%) patients were non-cirrhotic which was given approval in 2016 for the management
while 18(20%) were compensated cirrhotic as shown of all major genotypes hepatitis C infection.
in table II.
Our study showed that Sofosbuvir and velpatasvir
All of the 90 (100%) patients had undetectable comination was very effective against hepatitis C virus
viral RNA at the end of treatment (ETR) while HCV RNA infection irrespective of Genotype, in clinical practice in
12 weeks post treatment (SVR) was undetectable in our local population who were infected with hepatitis C,
88(97.77%) patients, shown in Table III. giving a high response rate in the form of End treatment
Nine (10%) patients complained of headache and Response and sustained virological response rate ulti-
fatigue during the treatment as shown in table IV. mately curing c HCV with less side effects occurrence
associated with this treatment regimen.
DISCUSSION This high response rate achieved in our study is
The last generation of SOF-based regimens, comparable to other studies done on similar combina-

214 KJMS May - August, 2020, Vol. 13, No.2

tion regimens like study done by Mangia A13 et al in Italy
and Hu C14 in China where an SVR of more than 98%
was achieved.
Similarly our study results are also comparable
to the open label phase III study done by Isakov V et
al in Russia in which an SVR of 99% was achieved and
this combination was also very safe and well tolerated.
However our study results are not in accordance with
the phase III study done by Sood A 15 in India where the
over all SVR rate of 93% was achieved but the safety
profile was the same as of our study. However we could
not compare our study to other studies done in our
country as there is paucity of literature regarding the
combination of sofosbuvir and velpatasvir combination.
In conclusion, the combine use of sofosbuvir
and velpatasvir is very highly effective and safe in the
management of Hepatitis C irrespective of genotype in
our local population.
Limitations of our study: the size of our sample
was small and may not be really representing the com-
munity so further large studies are needed to clearly
elaborate the safety and efficacy of this combination in
our local hepatitis C infected patients.
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infection. N Engl J Med. 2015;373:2599–2607.
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PJ, Gitlin N et al. All-oral 12-week treatment with
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N, Palmieri V, et al. (2019) SVR12 rates higher than
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215
 EFFICACY OF HARMONIC SCALPEL VERSUS BIPOLAR
ELECTROCAUTRY IN HEMORROIDECTOMY
Tahir Ullah1, Muhammad Khan1, Arshad Ali2, Imran Ud Din Khan3, Ghulam Younas4, Abdul Hameed5

ABSTRACT
Objective: To compare the effectiveness of harmonic scalpel versus bipolar electrocautery in haemorrhoidectomy in
term of postoperative pain.
Methodology: The current study was carried out at Department of general Surgery, Lady Reading Hospital, Peshawar.
Duration of the study as one year (from 1th March 2016 to 1st April 2017) in which a total of 112 patients were observed.
This was a randomize controlled trial in which 56 patients (in each group) were included and were divided into two
groups. Patients in Group A (underwent harmonic scalpel haemorrhoidectomy) while patients in Group B (underwent
bipolar electrocautery). Post operative variables (effectiveness at 48 hours) was collected from the patients and entered
on pre-tested questionnaire. When responding to a visual analogue score (VAS) item, respondents were asked to
specify their level of pain by indicating a position along a line between two end-points (zero and ten). It was considered
effective if 1-3 achieved on VAS after 48 hours.
Results: In the present study mean age in harmonic scalpel haemorrhoidectomy group was 42 years ± 12.84 while
mean age in bipolar electrocautery group was 43 years ± 12.36. In harmonic scalpel group 40% patient were male
and 60% patients were female while in bipolar electrocautery group 43% patients were male and 57% patients were
female. More over harmonic scalpel haemorrhoidectomy was effective in 70% cases while bipolar electrocautery was
effective in 57% cases.
Conclusion: Our study concludes that harmonic scalpel technique is more effective as compare to bipolar electrocau-
tery in term of pain reduction in haemorrhoidectomy.
Key Words: effectiveness, harmonic scalpel, bipolar electrocautery, haemorrhoidectomy

INTRODUCTION and rubber band ligation. Grade 3 and 4 need surgical

Haemorrhoids are a common condition encoun-
tered in surgical practice most commonly situated at 3,
7 and 11 o clock position. Haemorrhoids are classified
as internal and external with reference to dentate line.
Internal and external hemorrhoids have different presen-
tation. Constipation, prolong straining, increased ab-
dominal pressure, lack of support to pelvic tissues and
increase aging can result in haemorrhoids formation1.
Haemorrhoids are classified into four degree. Grade
1 bleed only and don’t prolapsed; grade 2 prolapses
but reduced spontaneously; grade 3 prolapses and
need manual reduction; fourth degree are permanently
prolapsed2.
Treatment options for grade1 and grade 2 haem-
orrhoides are life style modification, medical treatment
1Department of surgery Muhammad Teaching Hospital
Peshawar
2Department of Surgery LRH Peshawar
3Senior Registrar Khyber Teaching hospital Peshawar
4Medical officer LRH
5Department of Paeds Surgery LRH Peshawar
.........................................................................................
Address for correspondence:
Dr Imran Ud Din Khan
TMO Surgical B Unit Jinnah Teaching Hospital Peshawar
Cell No: 0335-5951691
E-mai: Ikmarwat47@gmail.com
procedures like Milligan Morgan or open haemorrhidec-
tomy in which ligation and excision of haemorrhoidal
tissues are done and wound is left open. Other different
techniques has been reported in litrature, like Close
haemorrhoidectomy (Ferguson technique), Stapled
haemorrhoidopexy2, Harmonic scalpel haemorrhoid-
ectomy and Bipolar electrocautry haemorrhoidectomy3.
Surgeon can use one of the above methods for hae-
morrhoidectomy according to the grade, availability,
patient interest and outcome. Each has its own pros
and cones 4,5 .
In meta-analysis (Mushaya 2014), including 8
studies and 468 patients of grade III and IV haemor-
rhoids, compared the HSH with the traditional haem-
orrhoidectomy. Four RCTs showed that patients were
able to return to work faster in the HSH group. Six RCTs
showed that the HSH has less postop pain.6
Post operative patients are given analgesic like
paracetamole, NSAID and narcotics analgesic. In most
of the studies, haemorrhoidectomy patient is judged
on pain, return to normal activity, hospital stay, patient
satisfaction, cost and complications (bleeding, anal
stenosis, urinary retention, recurrence7.
Visual analogue scale (VAS) is used for acute and
chronic pain in pre or postoperative patient which was
started by Hayes and Pattersonin 1921 . It is a subjective

216 KJMS May - August, 2020, Vol. 13, No.2

method in which a scale from 0 to 10 is assigned on
paper or laptop or mobile and present to patient for his
pain quantification. 0 is on left side which shows no pain
and 10 is on right side which shows the worst pain 8.
Harmonic scalpel device use ultrasound energy
to cut tissues and seal vessels in it. It is controled by
hand or foot with the scalpel vibration of 2000-5000hz2.
Harmonic scalpel cause very little lateral thermal inju-
ry about 1.5 mm compare to bipolar electro cautery
about 9mm. Hamonic scalpel has been reported to
as less painful as compare to bipolar electrocautry 9.
Hamorrhoidectomy done with harmonic scalpel have
better outcome regarding pain, return to normal activity,
less operative time compare to conventional excional
haemorrhoidectomy10,11. According to Bilgin et al that
harmonic scalpel compare to stapler haemorrhoidec-
tomy shows that it is easy to perform, safe, quicker
and less recurrence rate compare to harmonic scalpel
haemorrhoidectomy12.
In study conducted by Iihan Ece et al the VAS
was in Harmonic scalpel hemorrhoidectomy group
were 3.1±1.1, 2.8±0.8 and 1.1±0.3 on day 0,1 and 07
respectively 13. In study conducted by Abo Hashem AA
et al shows that in Harmonic scalpel hemorrhoidectomy
group the preoperative pain score was 3.2 ± 0.7 where
as in bipolar electrocautery the preoperative pain score
was 2.8 ± 0.4, but after surgery the pain was less in
HSH vs bipolar electrocautry 9.
OBJECTIVE
The aim and goals of our study to compare the
effectiveness of harmonic scalpel versus bipolar electro-
cautery in haemorrhoidectomy in term of postoperative
pain.
METHODOLOGY
The current study was carried out at Department
of general Surgery, Lady Reading Hospital, Peshawar.
Duration of the study as one year (from 1th March 2016
to 1st April 2017) in which a total of 112 patients were
observed. All the adult patients (male and female) in
age between 18 to 65 years presenting with grade 3
and 4 hemorrhoides were included. while patients with
grade 1 or grade 2 hemorrhoides, comorbidities, history
of previous anal surgery and known bleeding disorder
were excluded from the study so is to avoid bias in study
results.
As this was a randomize controlled trial so all the
included patients were divided into two groups (56 in
each group). Patients in Group A (underwent harmonic
scalpel haemorrhoidectomy) while patients in Group
B (underwent bipolar electrocautery). Post operative
variables (effectiveness at 48 hours) was collected from
the patients and entered on pre-tested questionnaire.
When responding to a visual analogue score (VAS)
item, respondents were asked to specify their level of
KJMS May - August, 2020, Vol. 13, No.2
pain by indicating a position along a line between two
end-points (zero and ten). It was considered effective if
1-3 achieved on VAS after 48 hours. The demographic
information like name, age, sex was recorded. All pa-
tients were assessed by proctoscopy and DRE were
recorded. The data was analyzed in SPSS-23.
Mean and SD were calculated for continuous variables
like age, visual analogue score. Frequencies and per-
centages were calculated for categorical variables like
gender, degree of hemorrhoids and efficacy. Efficacy
was stratified with effect modifiers like age, gender and
degree of hemorrhoids to see the effect modifications.
Post stratification chi square test was applied in which
P value ≤ 0.05 as considered as significant value.
RESULTS
In the current study a total of 112 patients (56
in each group) were observed. Mean age of group A
patients was 42 years ± 12.84 whereas in mean age
group B was 43 years ± 12.36. In group A (Harmonic
scalpel Haemorrhoidectomy) 22(40%) patients were
male and 34(60%) patients were female while in group
B (Bipolar Electrocautery) 24(43%) patients were male
and 32(57%) patients were female. In group A (Har-
monic scalpel Haemorrhoidectomy) 39(70%) patients
had VAS pain score range 1-3 while 17(30%) patients
had VAS pain score 4-10. Mean VAS pain score was
2.77 with SD ± 0.86 while in group B (Bipolar Electro-
cautery) 32(57%) patients had VAS pain score range
1-3 while 24(43%) patients had VAS pain score 4-10.
Mean VAS pain score was 3.98 with SD ± 1.72. In group
A (Harmonic scalpel Haemorrhoidectomy) 43(77%)
patients had grade 3 haemorrhoids and 13(23%) pa-
tients were had grade 4 haemorrhoids while in group
B (Bipolar Electrocautery) 42(75%) patients had grade
3 haemorrhoids and 14(25%) patients were had grade
4 haemorrhoids. Groups A (Harmonic scalpel Hae-
morrhoidectomy) was effective in 39(70%) patients
while group B (Bipolar Electrocautery) was effective in
32(57%) patients. (table no 1)
DISCUSSION
Haemorrhoidectomy is one of the common
procedure performed by general surgeons. Different
techniques has been reported for hemorrhoidectomy
and every procedure has its own pros and cons. The
most common procedures which are used are Maligan
Morgon haemorrhoedectomy, Furguson technique,
bipolar electro cautry and harmonic scalpel harmor-
rhoidectomy.
Our study shows that mean age in group A
(Harmonic scalpel Haemorrhoidectomy) was 42 years
with SD ± 12.84. Where as mean age in group B (Bi-
polar Electrocautery) was 43 years with SD ± 12.36. In
group A (Harmonic scalpel Haemorrhoidectomy) (40%)
patients were male and (60%) patients were female.
Where as in group B (Bipolar Electrocautery) (43%)
217
 Table 1:

Efficacy Group A (n=56) Group B (n=56) P Value

Effective 39(70%) 32(57%) 0.0001
Not effective 17(30%) 24(43%)

Table 2: Stratification of Efficacy With Age

Age Efficacy Group A n=56 Group B n=56 P Value

Effective 5 3
20-30 years 0.4285
Not effective 2 3
Effective 14 12
31-40 years 0.3929
Not effective 6 9
Effective 11 10
41-50 years 0.5536
Not effective 5 7
Effective 9 7
51-65 years 0.5706
Not effective 4 5

Table 3: Stratification of efficacy with degree of haemorrhoids

Gender Efficacy Group A n=56 Group B n=56 P Value

Effective 30 24
Grade 3 0.2267
Not effective 13 18
Effective 9 8
Grade 4 0.5158
Not effective 4 6

patients were male and (57%) patients were female. In
group A (Harmonic scalpel Haemorrhoidectomy) (77%)
patients had grade 3 haemorrhoids and (23%) patients
were had grade 4 haemorrhoids. Where as in group B
(Bipolar Electrocautery) (75%) patients had grade 3
haemorrhoids and (25%) patients were had grade 4
haemorrhoids. Mean Post operative pain (VAS Score)
in group A (Harmonic scalpel Haemorrhoidectomy)
was 2.77 with SD ± 0.86. mean pain score in group B
(Bipolar Electrocautery) was 3.98 with SD ± 1.72. More
over Harmonic scalpel Haemorrhoidectomy was effec-
tive in 70% patients. Where as Bipolar Electrocautery
was effective in 57% patients.
In another study conducted by Iihan Ece et al11 the
VAS pain scores on day 0, 1 and 7 in Harmonic scalpel
hemorrhoidectomy group were 3.1±1.1, 2.8±0.8 and
1.1±0.3. In study conducted by Abo Hashem AA et
al7 shows that in Harmonic scalpel hemorrhoidectomy
group the post operative pain score after 48 hours was
3.2 ± 0.7 where as in bipolar electrocautery the post
operative pain score after 48 hours was 2.8 ± 0.4.
Armstrong DN et al16 had shown that pain in the
Harmonic Scalpel hemorrhoidectomy group was sig-
nificantly less than in electrocautery patients on each
postoperative day studied. Analgesic requirements were
also significantly less in the Harmonic Scalpel group on
Days 1, 2, 7, and 14. There was no correlation between
postoperative pain and grade of hemorrhoid, status of
the surgical incision (open vs. closed), or any other
study variable. Fifty-five percent of Harmonic Scalpel
patients returned to work within one week of surgery,
compared with 23 percent of electrocautery patients.
Kwok et al17 reported that the postoperative pain
was less after bipolar diathermy hemorrhoidectomy than
hemorrhoidectomy with the ultrasonic scalpel, where
the wounds were left open. Because bipolar diathermy
surgery is considered as a sutureless closed hemor-
rhoidectomy18,19 and the wounds were closed in the
ultrasonic scalpel group in the present study, treatment
of wounds seemed to be identical in both groups. There
was some evidence that closed hemorrrhoidectomy was
associated with less pain compared with open controls
during the early postoperative period20 .
CONCLUSION
Our study concludes that harmonic scalpel tech-
nique is more effective than bipolar electrocautery in
term of pain reduction in haemorrhoidectomy.
REFERENCE

218 KJMS May - August, 2020, Vol. 13, No.2

1. Klingensmith, ME. The Washington manual of sur-
gery. Lippincott Williams & Wilkins. 2008.p.210-27
2. Williams NS, Bailey H, Bulstrode CJ, Love M. Bailey
& Love’s short practice of surgery. Crc Press. 2013.
3. Lohsiriwat V. Hemorrhoids: from basic pathophys-
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4. Anne L, Mounsey, Halladay J, Sadiq TS. Haemoor-
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5. Bulus H, Tas A, Coskun A, Kucukazman M. Evalu-
ation of two haemorrhoidectomy techniques: Har-
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Asian Journal of Surgery 2014;37:20-3
6. Mushaya CD, Caleo PJ, Bartlett L, Buettner PG, Ho
YH. Harmonic scalpel compared with conventional
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proctology. 2014 Nov 1;18(11):1009-16.
7. Yeo D, Tan KY. Haemorrhoidectomy-making
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8. Delgado DA, Lambert BS, Boutris N, McCulloch PC,
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10. Mushaya CD, Caleo PJ, Bartlett L, Buettner PG, Ho
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tology. 2014;18(11):1009-16
11. Tsunoda A, Sada H, Sugimoto T, Kano N, Kawa-
na M, Sasaki T, et al. Randomized control trial of
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12. Belgin Y, Hot S, Barias IS, Akana A, Erayavuz Y.
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13. Ilhan Ece* , Huseyin Yilmaz, Fahrettin Acar, Serdar
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16. Armstrong DN1, Ambroze WL, Schertzer ME,
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B, Engelhardt V, Lametschwandtner A, Wienert V,
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219
 EPIDEMIOLOGY AND DISTRIBUTION OF KIDNEY DISEASES
AND ITS ASSOCIATION TO SOCIO-DEMOGRAPHIC FACTORS
IN PATIENTS PRESENTING TO KHYBER TEACHING
HOSPITAL, PESHAWAR
Muhammad Fayaz1, Muhammad Umer Farooq2, Mian Mufarih Shah3, Wajeeh Ur Rehman4,
Muhammad Tariq Shah5, Muhammad Shahid6, Junaid Ali7

ABSTRACT
Objective: This case control study was conducted to determine the epidemiology, demographic factors and common
risk factors that were responsible for development of and estimation of fatal outcomes of kidney diseases and to create
awareness at mass level.
Materials and Methods: It was an observational case control study including 480 subjects. Data was collected from
all age groups of patients with a diagnosed kidney related illness as cases. An equal number of other participants
having no kidney disease were taken as controls. Data was collected through the non-probability convenient sampling
technique at multiple wards of Khyber Teaching Hospital, Peshawar between December 2016 and November 2019.
Results: A total of 480 individuals were studied. Out of which 240 were cases and 240 were controls. 318 out of
the 480(66.2%) were males and 162(33.8%) were females. 120(25%) individuals presented with history of allergies,
111(23.1%) showed positive family history of kidney diseases, 246(51.2%) were smokers and 255(53.1%) gave positive
history of drug-use for more than 1 month. 12(2.5%) individuals showed history of bee sting within a month.
Conclusion: Although our study failed to derive association between any of the socio-demographic factors and
development of kidney related diseases. However, allergic conditions, respiratory tract infections, smoking, alcohol
consumption and excessive use of drugs were observed to be more common in the cases. We conclude that further
extensive studies are required to be done on this topic in different hospitals.
Keywords: Kidney disease, Socio-demographic, Acute Kidney Injury, Chronic Renal Failure.

INTRODUCTION emia 2. The hyalinization of glomeruli permits molecules

Kidney diseases can lead to a significant decrease
in quality of life1. They can be classified into nephritic
and nephrotic. Kidney diseases, any disturbance in the
kidney glomerular channels prompts proteinuria, oede-
ma and in steroid-resistant nephrotic disorder causing
chronic renal failure. Affected kidneys demonstrate a
diffuse mesangial sclerosis (DMS). The cardinal features
are oedema, massive proteinuria and hypo-albumin-
1 Trainee Medical Officer, Medical C Ward Hayatabad
Medical Complex, Peshawar
2 MBBS Ayub Medical College, Abbottabad
3 Specialist Registrar Medical C Ward Hayatabad Med-
ical Complex, Peshawar
4 Trainee Medical Officer Hayatabad Medical Complex,
Peshawar
5 Medical Officer Lady Reading Hospital, Peshawar
6 Khyber Medical College Peshawar
7 Trainee Medical Officer, Medical E Ward Khyber
Teaching Hospital, Peshawar
.........................................................................................
Address for correspondence:
Trainee Medical Officer, Medical C Ward Hayatabad
Medical Complex, Peshawar
Cell No# 0341-9223332
Email: Drfayaz057@yahoo.com
like albumin, immune-globulins and anti-thrombin to be
excreted into the urine. Abnormalities from kidney dis-
eases lead to elevated levels of triglycerides, cholestrol
and apolipoprotein B containing lipoproteins VLDL and
LDL. In response to these changes the liver initiates
changes in metabolism, for example union of proteins,
alpha-2 macroglobulin and lipoprotein.3
Signs of kidney diseases include oedema man-
ifesting as periorbital oedema, pitting oedema of legs,
pleural effusion, ascites and anasarca. Other signs
include anaemia, dyspnoea and increased sedimenta-
tion rate due to increased fibrinogen. Some of the his-
tological types of kidney diseases are focal segmental
glomerulosclerosis, minimal change disease, rapidly
progressive glomerulonephritis, membrano-proliferative
glomerulonephritis and membranous glomerulonephri-
tis affecting people of different demography. Kidney
diseases can also occur secondary to other diseases
like diabetic nephropathy, systemic lupus erythromato-
sis, sarcoidosis, syphilis, hepatitis B, sjogren syndrome,
HIV, amyloidosis, multiple myeloma, vasculitis, cancer
and drugs like penicillin and captopril 1-3.
The yearly rate of nephrotic disorder per 100,000
population in each of the following categories is such
that 2 to 7 new cases occur in kids, 16 new cases

220 KJMS May - August, 2020, Vol. 13, No.2

occur in youngsters and 3 new cases occur in adults4.
The commonest chronic glomerular disease in pae-
diatric population is Idiopathic (Idiopathic Nephrotic
Syndrome) and in West it occurs at the rate of 2 out of
100,000 children5. Even though nephrotic syndrome is
found in patients of every age, it is found in significantly
large prevalence in adults such that it occurs 26 times of
as much as it occurs in children. The different types of
nephrotic syndrome can be broadly classified according
to age. The once which are common in children are
minimal change disease, focal segmental glomerulo-
sclerosis and membrano-proliferative gomerulonephritis
while those common in the eldery are focal segmental
gomerulonephritis and membrano-proliferative go-
merulonephritis. Its most common secondary cause is
diabetic nephropathy mostly occuring in adult. As far
as genders are concerned nephrotic syndrome occurs
two times as much in men as it occurs in women.
Prognosis of the kidney diseases under treatment
is good despite of the fact that it depends on many fac-
tors such as treatment response, age of the patient and
cause or type of the disease. Minimal change disease
is the most common nephrotic syndrome in children,
it occurs in 80% of children who have nephrotic syn-
drome and it responds very well to steroids therapy.
It has also been termed as steroid sensitive nephrotic
syndrome 6. The another type of nephrotic syndrome is
steroids resistant nephrotic syndrome which is defined
as proteinuria after 2 months of treatment with oral
prednisolone7. Without treatment, kidney disease has
a terrible prognosis particularly rapidly progressing
glomerulonephritis, which prompts acute renal failure
following a couple of month.
Many socio-demographic determinants are found
to be contributing towards outcomes of renal diseases,
as supported by the literature. According to studies that
relates race and socio demographic status, assessed
rate of nephrotic kidney disease is between 2- 7 for
every 100,000 kids around the world, with higher prev-
alence in kids of South Asian and African descents8.
Chronic illness in a child has adverse effects on others
in the family as well 9. Studies have been conducted
in order to find out the relation between behavioural
and socio-demographic factors and kidney diseases.
After adjusting for common socio-demographic de-
terminants the relation between nephrotic syndrome
and psychiatric diseases has been found in paediatric
population. Some of the common psychiatry diseases
which were found in nephrotic disease patients were
conduct disorder, obsessive compulsive neurosis, hy-
perkinesis and emotional disorders. Hyperkinesis was
the most common. In children with kidney disease the
prevalence was 68% while in the control group it was
21.6%10.
Derangement in renal function leads to hyperten-
sion and intravascular volume expansion because of
increase in renal tubular reabsorption. It leads to oede-
KJMS May - August, 2020, Vol. 13, No.2
ma. Excessive weight gain, and metabolic abnormalities
related to it, contributes to chronic kidney disease 11.
METHODS
It was an observational case control study in
which we collected data from diagnosed patients of
kidney diseases of all age groups as cases as well as
equal number of other participants having no kidney
disease as controls at Khyber Teaching Hospital. The
duration of study was from December 2016 to Novem-
ber 2019. We collected our data by non-probability
convenient sampling. Patients of all age and sex groups
were included. Patients who were critically ill, mentally
disabled and with no kidney disease were excluded.
The sample size was 480 (240 cases and 240 controls).
Data analysis was done with SPSS version 21.0 to cal-
culate frequencies, percentage, means and standard
deviations for the variables given in the questionnaire.
RESULTS
The cases and controls were matched for gender
and age. Descriptive analysis for every variable studied
was performed. Our study included 318 males (66%)
and 162(34%) females. Mean age of patients with
the disease was 43.15(standard deviation of 20.168)
and control was 39.19(standard deviation of 19.61).
The mean age of both the cases and control was
41.5(standards deviation of 19.89). Education of the
subjects was such that uneducated were 267(55.6%),
those with primary education were 75 (15.6%), those
with matric education were 99 (20.6%) and those with
higher education were 39(8.1%).
Table 1 demonstrates consumption of water from
different sources among the patients. The highest being
used from non -conventional sources labelled as ‘other’
in the table. The ‘other’ category consisted of sources
like stream water.
Furthermore, 117 cases and 63 controls had
pre-existing diseases. While 123 cases and 177 con-
trols did not had any pre-existing illness. The odd ratio
turns out to be 1.27(CI 95% 0.63-2.5) which means
that individual having pre-existing-illness (diabetes,
hypertension and pneumonia etc) were 1.27 times more
prone to the kidney diseases. There were 63 cases and
81 controls having history of respiratory tract infection.
Whereas 177 cases and 159 controls did not had any
history of respiratory tract infection (RTI). The odd ratio
was 0.699(CI95% 0.35-1.38). Therefore our data showed
negative association of RTI with the kidney diseases,
which was significant. 93 cases and 153 controls had
history of active or passive smoking while 147 cases
and 87 controls do not have any history of smoking.
The odds ratio was 0.36(CI95% 0.190-0.683) and it
showed that smokers were 0.36 times less prone to the
kidney diseases and showed negative relation with the
smoking.
221
 Table 1: Drinking Water Source diseases in our country thus giving it a rank of 8th in
mortality. Renal stones, low water intake, medications,
Source Frequency Percent unhealthy food intake, hypertension and diabetes are
Municipal water 48 10.0 some of the common causes of kidney diseases. To
find out the relation of kidney diseases with socio-de-
Well water 105 21.9 mographic factors, we conducted this study in Khyber
Boring 135 28.1 teaching Hospital. In our study, sample was chosen 480
Others 192 40.0 out of which, 240 were cases and 240 were control from
different wards of Khyber teaching hospital.
Total 480 100.0
Different kidney diseases are caused by medi-
cations taken for kidney infections as a wide range of
Table 2: History of any drug use for one month or
medications are used for treating pyelonephritis. Medi-
more
cations induced Acute Renal Failure (ARF) represented
Drug Use Group Total 20% of all ARF in an Indian Study of which aminogly-
cosides were responsible for 40% of total cases12. Our
Case Control data supports these results, despite the fact that we
Yes 132 123 255 have not mentioned a particular medication but rather
included medication history of all the drugs taken by the
NO 108 117 225
patients over the last month. The odds ratio is 1.16(CI,
Total 240 240 480 0.61-2.16), while study in other journals shows odds
Odds ratio 1.163 ratio of 2.1(95%CI 1.1-3.7) which support the results of
our studies13.
Table 3: Family History of Renal Disorders A group of students carried out a study in 2005 on
a small scale to discover a relationship between kidney
Family Group Total diseases occurrence in patients having positive family
history Case Control history. They discovered positive relation particularly
Yes 63 78 141 in patients who have experienced kidney biopsies14.
Our results demonstrates that there is no relationship
NO 177 162 339 between positive family history and kidney disease.
Total 240 240 480
Pre-existing debilitating diseases is also important
Odds ratio 1.42 in the development of kidney diseases. A study done in
2010 confirms this association15. But the results of our
Regarding the recent use of drugs (Table 2), there study are opposite to this which does not support this as-
were 132 cases and 123 controls having history drug sociation. The reason of this difference may be attributed
use within a month. 108 cases and 117 controls did not to poor data collection techniques or research biases.
have any history of recent use of medication. The odds
ratio was 1.163(CI 95% 0.65-1.24) which shows posi-
Describing the association of bee sting with the
tive association between recent drug use and kidney
kidney diseases, our data shows no relation between
disease
them. The odds ratio comes out to be 0.95 with the
Moreover, 63 cases and 78 controls had family confidence interval of 0.903-2.538. This data is con-
history of kidney diseases (Table 3). The odds ratio was tradictory to the other studies which show association
1.42(95%CI of 0.67-2.95) which meant that individuals of bee sting to the kidney diseases. One of which is
having family history of kidney diseases were 1.42 times mentioned here, the history of man with multiple bites
more prone to the kidney diseases which was signifi- of honey bee, developed anaphylactic shock and ended
cant. Lastly, 60 cases and 60 controls had presence of up with acute renal failure16.
allergy. The odds ratio came out to be 1 and showed
Another one of the causes of kidney diseases is
no association to the presence of allergy to the kidney
smoking. A study conducted in 1978 showed associ-
diseases.
ation between kidney disease and smoking tobacco.
The association of smoking and kidney diseases like
DISCUSSION
nephrotic syndrome has also been shown by studies
Many studies have been done to find out relation- related to American Association of Kidney Patients
ship between socio-demographic factors and kidney (AAKP) 17. Some evidence of dose-response trend was
diseases, however, kidney diseases still prevail in our also found in another study. That study showed that
country. According to Pakistan Medical Association, CKD has positive association with smoking and inverse
kidney diseases accounts for 20,000 deaths annually relation was found between CKD and smoking such
out of the 20 million people who suffer from kidney that chronic kidney disease prevalence was decreased

222 KJMS May - August, 2020, Vol. 13, No.2

with time since which smoking was quit. Many different
smoking related mechanisms have been found which
cause kidney injury. These mechanisms include the ef-
fects of smoking on endothelial function, in acceleration
of renal atherosclerosis and changes in systemic and
renal hemodynamics. 18 Our data is in contrast to the
above one, the odds ratio is 0.36 and shows negative
association with the disease under consideration. This
may be because of different demographic factors or
study differences.
Another study which had different results from
our study was conducted in rural India showed the
significance of bee sting with the Acute renal failure.
Nine cases were selected in the study, six out of them
had acute kidney injury. Bee venom contains toxic
substances like mellitin, phospholipases, apamine,
mastocytolytic peptide, hyaluronidase, histamine, do-
pamine and minimine. These substances are hemolytic,
neurotoxin, histamine releaser, vascular permeability
increaser, hemodynamic toxin and cell membrane toxin.
Among these most lethal, pain inducing and highest in
quantity is mellitin.19
CONCLUSION
Although our study fails to show these factors
as causes of kidney diseases but it finds association
between them. The literature shows that allergic con-
ditions, respiratory tract infections, smoking, alcohol
consumption, animal toxins i.e bee sting, scorpion
toxins and snake venom, excessive use of medications
are known causes of kidney diseases. So by avoiding
the above mentioned factors which are modifiable, we
can prevent the kidney diseases and can decrease
the number of mortalities and morbidities associated.
Further studies on this topic are required.
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Tract Diseases”. Archived from the original on 2008-
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in Children. J Pediatr 98:561–564
3. DURAN ALVAREZ, Sandalio. Acute complications
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5. International Study of Kidney Disease in Children
Nephrotic syndrome in children: prediction of histo-
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16. Lin HC, Chen HH, Yeh JC. Acute renal failure
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Nephrology Nursing Journal. 2003 Oct 1;30(5):578
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223
 COMPARISON OF URETEROSCOPIC LASER VERSUS
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR UPPER
URETERAL STONES IN TERMS OF STONE FREE RATE
Riaz Ahmed1, Jamshad Alam2, Ameroon Shah1, Ahmad Faraz3, Ayaz Gul3, Muhammad Kalim2, Sohaib Ali2

ABSTRACT
Background: Kidney stones are one of the commonest diseases, with increasing incidence and a major healthcare
burden. Concerning among them are large stones, which are being treated with differing treatment options, namely,
ureterolithotomy (Laproscopic / open), ESWL (Extracorporeal Shock wave lithotripsy), and Ureteroscopic Lithotripsy.
Objective: Our study is based upon proximal ureteric stones ranging from 10- 15mm, and comparison of ESWL and
Laser Ureteroscopic Lithotripsy as a treatment modality, for maximal stone free rate.
Material and Methods: This clinical trial was conducted at IKD Peshawar (Institute of Kidney Disease, HMC), it was an
RCT Cohort with 282 patients divided equally as 141 each, 5% taken as significant and power test at 80%.
Results: Male to female ratio 56 % / 43.6%. Age mean 35.34 +/-11.9. Stone free rate in ESWL group was 68.8% ( n-97),
compared to Laser Ureteroscopic Lithotripsy 80.85 (n-114).
Conclusion: Our results concluded that Laser Ureteroscopic Lithotripsy has a higher percentage of stone free rate
compared to ESWL and can be confidently adopted for stones (10-15mm) in proximal ureter.
Keywords: ESWL, Laser Ureteroscopic Lithotripsy, proximal ureteric stones

INTRODUCTION are both an equivalent option for stones greater than

Urolithiasis has a significant global health care
burden with increasing incidence especially in third to
fourth decade of life, with male predominance1,2. Uro-
lithiasis can be treated by different number of treatment
modalities namely including ESWL and Laser Uretero-
scopic Lithotripsy for stone 8-15mm in size3, but their
exist a differing of opinion on both these options as both
are minimally invasive nevertheless which one of them
is the most effective is matter of debate in endourolo-
gy4. Comparative studies so far done are inconclusive
between the two treatment option5,6. While some have
shown that Laser Ureteroscopic Lithotripsy is much
superior compared to ESWL7,8.
The European Guidelines on the matter namely
by the European Association of Urology gives recom-
mendation that for stones in proximal Ureter and less
than 10mm ESWL is preferred, but for stones greater
than 10mm in proximal Ureter Laser Ureteroscopic Lith-
otripsy is recommended, while the American Urological
Association gives a slightly different recommendation
saying that ESWL and Laser Ureteroscopic Lithotripsy
1Department of Urology, IKD
2Dept. of Surgery, HMC
3Dept. of Surgery, LRH
.........................................................................................
Address for correspondence:
Dr. Syed Ameroon Shah
Medical officer, Department of Urology,IKD
Cell: 03339712477
E-mail: Shahameroon@gmail.com
10mm in proximal ureter and for stones less than 10mm
in distal ureter 9. The literature published so far has
been quite variable on the reported stone free rate of
their respected case series, Cui y et al 160 patient case
series discovered 90% clearance for ESWL compared
to URS Lithotripsy 10. Ghoneimet et al. compared the
efficacy of ESWL in stented and non-stented groups,
and found it to be 90% and 86.7% for proximal ureter
stones, with average stone clearance rate of 88.3% 11.
Omar M Aboumarzouk et al. in his 64 patient case series
showed the efficacy of Laser lithotripsy to be 87.7% 12,
while Mohammed et al. showed a similar efficacy for
ESWL to achieve a stone free rate of 88% in his case
series 13. Furthermore, Ahmed et al in his case series
of 99 patients fond that Laser Ureteroscopic Lithotripsy
was able to achieve a stone free rate in 66% patients for
distal ureteric stones at the end of 4 weeks (p<0.05) 14,
compared to that Hafeez et al found a better efficacy
for ESWL (79.2% stone free rate) three months after
the last session 15. On contrast, Ryoji Takazawa et al
demonstrated 80.4 % clearance rate after only a single
session of Ureteroscopic Lithotripsy 16. Joshi HN et al
in his case series showed that after a single session the
clearance rate was 72% for renal and 86.6% for ureteric
stones, and in subsequent follow up three sessions
monthly after three months was 95.4% and 97.2%,
while when comparing for the stone size the clearance
rate was <10mm (97%), 10-15mm (97%) and > 15mm
(90%)17. Pearle and Lee reported an improved patient
satisfaction for ESWL rather than URS 18. In recently
conducted meta-analysis it was concluded that pa-
tients who underwent URS had to undergo some other

224 KJMS May - August, 2020, Vol. 13, No.2

subsequent intervention compared to those treated by
ESWL19.
Therein exists controversies which while being
addressed have raised some serious confusion as to
follow which protocol. Although there is a consensus
on ESWL as a first line treatment option for proximal
ureteric stones <10mm, the controversy exists about
what to do with larger stones and those of the distal
ureter, this study targets that specific quandary.
MATERIALS AND METHODS
This RCT took place in Urological Diseases
Department, in Institute of Kidney Disease, Hayatabad
Peshawar. The duration was from January July 2018 (06
Months), total cases 282, with 141 in each respective
group.
Inclusion criteria adopted was; all adult patients
of either gender between 18 to 60 years with proximal
ureteric stones ranging from 10-15mm. While Obesity,
pregnancy, solitary kidney; excretory system malforma-
tions, ipsilateral ureteric stricture; active UTI, uncorrect-
ed coagulation disorders, transplanted kidney, previous
stone manipulation and previous ureteric surgery
patients were excluded. These conditions were acting
as confounders and if included, had introduce bias in
the study results. Proximal ureter stone is described as
a stone in proximal ureter between UP Junction and SI
joint as diagnosed by X ray KUB / Ultrasound.
Patients fulfilling the above mentioned inclusion
criteria were enrolled and given consent had included
in the study through the Out Patient Department. Prior
Permission for this study was taken from the hospital
ethical committee. Patients were randomly allocated
into two equal groups by using lottery method. Com-
plete history and Physical examination was performed
in all the cases.
All patients were investigated using X-ray KUB
(Kidney, Ureter and Bladder), Ultrasound Abdomen
and Pelvis (all patients were having Ultrasound scan
done by the same and senior most sonologist of the
hospital), and intravenous urography (IVU) to confirm
the presence of stones, their size, location. Other in-
vestigations were urine routine examination and culture
and sensitivity to confirm the presence or absence of
infection; blood urea and serum creatinine to determine
the renal function; and complete blood picture.
Group A patients underwent URSL and in group
B patients underwent ESWL. In group A, patients under
anesthesia in the lithotomy position, ureteroscopy was
conducted using 7-8.9F semi rigid ureteroscope with
Ho: YAG laser. In group B, parenteral diclofenac sodium
was administered for analgesia. ESWL was performed
with patient in supine position. Plain x-rays KUB was
obtained after two, six weeks and three months, of pro-
cedure to assess the clearance of stone in each group.
Efficacy was determined in terms of stone clearance
KJMS May - August, 2020, Vol. 13, No.2
which is defined as, when patient will be completely
stone free after three months, diagnosed on x-ray KUB
and confirmed by U/S.
All the demographically data was coded for priva-
cy and strict adherence to exclusion criteria insured that
he study was not affected by bias and confounders. All
the procedures in both the groups was conducted under
supervision of an expert urologist having minimum of
five years of experience.
Data was analyzed using SPSS 18.0, Statistical
Tests run, Chi square for comparison and efficacy, and
P- Value was considered significant if equal to less than
0.05. Efficacy analyses done for Stone Size, Gender and
Age. And results presented in tabulated form.
RESULTS
Mean age was 35.34 years ± 11.9SD. Age distri-
bution among 282 patients was analyzed as 43(15%)
patients were in age range < 20 years, 42(37%) patients
were in age range 21-30 years, 96(42%) patients were in
age range 31-40 years, 46(16%) patients were in range
41-50 years, 56(19.85%) patients were in range 51-60
years. There were 159(56.38%) patients as male and
123(43.6%) patients were female.
Stone size distribution among 282 patients was
analyzed as 61(21%) patients had stone size 10mm,
98(34.7%) patients had stone size 11mm, 60(21.2%)
patients had stone size 12mm, 29(10.28%) patients
had stone size 13mm,22(7.8%) patients had stone size
14mm, 12(4.2%) patients had stone size 15mm.
Stone clearance among patients undergoing
ESWL was effective in 68.8% (n=97) and was not
successful in 31.2 %( n=44), while in the URSL group
80.85% (n=114) were treated successfully and in 19.1
%( n=27) patients there was treatment failure. The
results are highly significant for both groups in terms
of efficacy with P-Value 0.020. (as shown in Table 1).
When age was stratified among the two groups in
comparison, we got the following results. Mean age+
SD were 35.20 years + 11.96SD in the ESWL group
while the mean ages were 35.47+11.83SD in the URSL
group. The age range was from 18 to 60. Minimum age
of patient was 18 years and maximum was 55 years
among the patients having proximal ureteric stones.
The mean age comparison between the two groups
was not significant (p=0.901)
The mean Stone size among patients treated with
ESWL was 11.31mm+0.464SD, while on the other hand
mean stone size + SD were 11.80mm+1.40 respective-
ly. The most frequently occurring stone size was in the
range of 11 to 12mm. stone size distribution was also
insignificant with p-value = 1.00 (as shown in Table 5).
Gender wise stratification shows that out of 159
patients (56.4%) among male patients 80(50.3%) were
treated by ESWL and 79(49.6%) were managed by
225
 Table 1: Comparison of Effectiveness of Eswl and Ursl

Group Total p-value

ESWL URSL
Stone clear- No Count 44 27 71 0.020
ance % within Group 31.2% 19.1% 25.1%
Yes Count 97 114 211
% within Group 68.8% 80.80% 74.8%
Total Count 141 141 282

Table 2: Stratification of Eswl and Ursl in Age Distribution

Group N Stone size p-value

Mean Std. Deviation Std. Error Mean
ESWL 141 6.581 1.35307 0.11395 1.0
URSL 141 6.5816 1.40994 0.11874

Table 3: Stratification of Eswl and Ursl in Gender Distribution

Group Total p-value

ESWL URSL
Gender Male Count 80 79 159 0.905
% within Group 56.7% 56% 56.38%
Female Count 61 62 123
% within Group 43.2% 44% 43.6%
Total Count 141 141 282
% within Group 100.0% 100.0% 100.0%

Table 4: Stratification of Eswl and Ursl in Size of the Stone

Stone size Group Total

ESWL URSL
10mm Yes Count 19 26 45
% within Group 65.5% 81.2% 73.77%
11mm Stone clearance Yes Count 43 30 73
% within Group 76.8% 71.4% 74.4%
12mm Stone clearance Yes Count 11 32 43
% within Group 47.8% 86.5% 71.6%
13mm Stone clearance Yes Count 12 9 21
% within Group 75.0% 75.0% 75.0%
14mm Stone clearance Yes Count 8 8 16
% within Group 36.4% 80.0% 50.0%
15mm Stone clearance Yes Count 1 4 5
% within Group 20.0% 57.1% 31.3%

226 KJMS May - August, 2020, Vol. 13, No.2

URSL. while out of a total 123(43.6%) among female
patients 61 (49.5%) were included in ESWL group and
62(50.4%) were managed by URSL. Sex
DISCUSSION
Kidney stones are as old as the human history it-
self, a notable find by a renowned Egyptologist E. Smith
in 1901 was a bladder stone, dated to 5000 BC20,21.
Although a common affliction, there is a varia-
tion between incidence in different population groups
around the world with average incidence around 10-15
% in western hemisphere, compared to 22 % in the
Asiatic Region 22. In general practice in Pakistan it is
one the most commonly encountered complaint.
In our study we are exploring two different treat-
ment options, Extra Corporeal Shock Wave Lithotripsy
(ESWL) and Laser Ureteroscopic Lithotripsy. Use of
ESWL is quite a popular treatment for stones specif-
ically in the proximal ureteric tree, as it causes the
stones to fragment by extra corporeal shock waves in
a non-invasive manner with almost no complication, the
common complication being retainedsmaller fragment
in distal ureter post stone fragmentation, still causing
symptoms. Compared to ESWL there is the Laser Lith-
otripsy. Although, there are other forms of lithotripsy
available using mechanisms such as ultrasound, electro
hydraulic and pneumatic, but we have good experience
with excellent outcomes based on Laser Lithotripsy, so
we will focus on that.
Just to compare to the other forms of lithotripsy,
Razaghi et al. in his case series used a pneumatic
lithotripsy technique, for stone sizes 10 mm to 20mm,
and his result of stone free rate of 82.1 %, is almost
comparable to our own clearance rate of 84.1%. but
the key difference lies in the mean stone size which is
bigger 12.20mm+1.66SD in our case series compared
to his 10mm+5.6SD 24.
Compared to local data published so far on
stone clearance rates, our results are on par with the
published literature25.
Contrasting the ESWL group with international
data, Rabbani et al. in their case series of 30 patients
for stone size >12m showed a relative stone free rate
of 46.66%, compared to our 65.2% stone free rate for
141 patients who underwent ESWL 26.
Similar case series done for ESWL on the national
level, show subpar results as compared to our results
27
. Our case series could prove to be the one which
causes a paradigm shift in the treatment of proximal
ureteric stones. These study results can be translated
into the development of local management guidelines
for this urological disease.
One of the limitation we faced was of the tech-
nical nature as treatment modality differ significantly
based upon the relative hardness of the stone, which
KJMS May - August, 2020, Vol. 13, No.2
can be easily measured in the CT scan as house field
units HU, denoting the relative stone density. This is of
particular importance when we are considering ESWL
as the treatment option, as a hard stone can result in
treatment failure 28. We did not include the relative stone
density as a factor to consider in our case series. An-
other limitation in our study was a short follow up time
compared to published researched so far.
Our case series results can be a road map for all
the general practitioners, and urologist encountering
proximal ureteric stones 29,30. Some of the questions
were left unanswered while the study also raised some
new questions such as despite similar stone size some
patients (138) in both treatment groups had treatment
failure. Further research needs to be undertaken to
answer these questions.
CONCLUSION
Though ESWL is a popular choice of treatment
modality in proximal ureteric stones, Laser Ureteroscop-
ic Lithotripsy is much superior treatment modality due to
good outcomes for stone size ranging from 10-15mm.
Our research group in future would like to com-
pared the results of different intracorporeal lithotripsy
modalities in a form of an RCT, namely the Pneumatic
and Ultrasonic Lithotripsy compared to the Holmium
Laser Lithotripsy.
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28. Poletti PA, Platon A, Rutschmann OT. Low-dose
versus standard-dose CT protocol in patients with
clinically suspected renal colic. AJR Am J Roentge-
nol. 2007;188(4):927-33.
29. Walden M, Lahtinen J, Elvander E. Analgesic effect
and tolerance of ketoprofen and diclofenacc in acute
ureteral colic. Scand J UrolNephrol. 1993;27:323–5.
30. Ibrahim Al, Shelty SD, Awad RM, Patel KP. Prognos-
tic factors in the conservative treatment of ureteric
stones. Br J Urol1991;67:358–61.
KJMS May - August, 2020, Vol. 13, No.2
 FREQUENCY AND TYPES OF ANEMIA IN PATIENTS
ATTENDING ANTENATAL CLINIC IN A TEACHING HOSPITAL
OF PESHAWAR
Sadia1, Shahnaz Parveen1, Rabeea Sadaf2, Nighat Shaheen3, Shazia Tabassum4

ABSTRACT
Objective: To determine the frequency and types of anemia in patients attending an antenatal clinic in a teaching
hospital in Peshawar.
Materials and methods: The Cross Sectional study was conducted in Mercy Teaching Hospital for six months from 8th
April 2017 to 7th October 2017 .Patients at all gestational ages attending antenatal clinic for the first time were screened
for anemia by doing complete blood count (including hemoglobin , total and differential leukocyte count and platelet
count ). Anemia in pregnancy is defined as hemoglobin level below 11 gm/ dL. Mild anemia is hemoglobin concen-
tration of 10-10.9 gm/ dL, moderate anemia is 7-9.9 gm/ dL and severe anemia is <7 gm/ dL. Patients with microcytic
hypochromic picture on peripheral film were further investigated to differentiate between iron deficiency anemia and
Thalassemia trait. For this purpose, serum ferritin and hemoglobin electrophoresis were done .Normal serum ferritin level
range from 12-150ng/dL. Results were expressed in terms of mean, standard deviation, frequency and percentages.
Results: Total number of cases with antenatal visit was 1500. Out of these, 980 returned with complete blood count
report. Out of these 980 patients, 396 (40%) were anemic. 150 patients who had moderate to severe anemia were further
investigated by doing peripheral blood smear, serum ferritin and hemoglobin electrophoresis . Out of 150 patients, 75
returned with serum ferritin report . 42 (56%) out of 75 patients had iron deficiency anemia. Hemoglobin electrophoresis
is a more expensive and time consuming test so only 44 out of 150 patients returned with hemoglobin electrophoresis
report. Out of these 44 patients, 6 (13.6%) had thalassemia trait and the rest were normal. These patients were followed
to study their mode of delivery and birth weight of the baby. Out of 150 patients with moderate to severe anemia, 68
(81.9%) had normal vaginal delivery while 15 (18.06%) had cesarean delivery. Rest were lost from follow up.
Conclusion: Iron deficiency anemia is the most common cause of anemia in pregnancy. Thalassemia minor is very
common in our population.
Key words: Iron deficiency anemia, Antenatal clinic,Thalassemia trait.

INTRODUCTION illiteracy rate and lack of awareness in general popula-

Anemia is defined as a low haemoglobin level
below the normal limit for a particular age and sex1,2.
Females during pregnancy are more vulnerable to
develop anemia because of increase in the demand of
iron and also due to overall stress on the body because
of the growing fetus in the uterus3,4. Anemia during
pregnancy is a well recognized health problem all over
the world because it is associated with increased rate
of morbidity and maternal mortality5. Maternal anemia
is also a significant cause of morbidity and mortality in
the babies, especially in the developing country where
health care services are inadequate and there is high
1 Gynecology Department, Peshawar Medical College
Peshawar.
2 Gynecology Department, HMC Peshawar
3 Cantonment General Hospital, Peshawar.
4 Deptt. of Gynae & Obs, HMC Peshawar.
.........................................................................................
Address for correspondence:
Dr. Rabeea Sadaf
Associate Professor, Gynecology department, HMC
Peshawar.
Email:rabeeasadaf@gmail.com
tion5.
Worldwide, about 38% of pregnant females devel-
op anemia during the course of their pregnancy6. The
prevalence of anemia is highest in the African region
where the prevalence is 57%, and lowest in South Amer-
ican region where prevalence of anemia is reported to
be 24%5. In Asian countries, the prevalence of anemia
in pregnant females is about 48.7%6.Iron deficiency
anemia is the commonest cause of anemia all over the
world3. According to the World Health Organization
(WHO), about 35% of the pregnant females are iron
deficient3,7. Anemia during pregnancy is a well docu-
mented health problem in Pakistan8.The prevalence of
anemia during pregnancy in Pakistan varies from 30% to
50%depending on the area or socioeconomic states8. In
Karachi, it is about 64%, and in Multan it is about 76%8.
On the other hand, beta thalassemia trait commonly
occurs in the Middle East countries9. The worldwide
prevalence of beta thalassemia trait is reported to be
2.78%10.
There are multiple causes of anemia in pregnant
women1,5. The commonest one in the developing coun-

KJMS May - August, 2020, Vol. 13, No.2 229

tries is inadequate intake of iron in the diet , and other RESULTS
nutrients like vitamin B 12 and proteins1,5. Other causes
of anemia in pregnancy include infestation with intestinal A total of 1500 females attended the antenatal
parasites and inflammatory processes and infections clinic during the study duration. Out of these, 980 came
like tuberculosis5.The predominant cause of anemia in back with the complete blood count report and were in-
pregnant women may vary from region to region5.For cluded in the study. Age of the study population ranged
example , in African countries , the commonest cause from 16-40 years with the mean of 29±7.25 years.
of anemia in pregnancy is decreased intake of iron in The frequency of anemia in study population is
diet5.Iron deficiency anemia and beta thalassemia trait shown in figure 1. Frequency of iron deficiency and beta
are the causes of anemia that has significant impact on Thalassemia trait is shown in figure 3 and 4 respectively.
the outcome of pregnancy9. Mode of delivery in cases of anemia is shown in table
The routine laboratory investigations done to 1.
detect anemia in pregnancy include hemoglobin level
DISCUSSION
and examination of the peripheral blood smear by the
hematologist11. As both iron deficiency anemia and Anemia in pregnancy is a recognized cause of
beta Thalassemia trait present with low hemoglobin and fetal as well as maternal morbidity and mortality all over
microcytic hypochromic morphology, so it becomes the world5,7,14. It is reported that anemia in pregnancy
necessary to differentiation between their manage-
ment is different from each other9,11. Serum Ferritin
levels are done to confirm iron deficiency anemia while
hemoglobin electrophoresis is done to confirm beta
Thalassemia trait3,9. The cut of value of hemoglobin for
defining anemia depends on the age of patient, gender
,and pregnancy states according to the World Health
Organization (WHO)12,13.The WHO defines anemia as
a hemoglobin level below 12gm/dl in non pregnant fe-
males, while below 11 gm /dL in pregnant females5,12,13.
The serum ferritin of less than 15 μg/L indicated iron
deficient stores3. Hemoglobin A2 (Hb A2) concentration Figure 1: Frequency of anemia in patients attending
of more than 3.5% confirms beta Thalassemia trait9. antenatal clinic (n=980)
The study was done in order to determine the
frequency and types of anemia in pregnant females
attending the ante natal clinics in our region.

MATERIALS AND METHODS

This was a Cross Sectional study. It was conduct-
ed in Mercy Teaching Hospital for six months from 8th
April 2017 to 7th October 2017. Patients at all gestational
ages attending antenatal clinic for the first time were
screened for anemia by doing complete blood count
(including hemoglobin , total and differential leukocyte
count and platelet count ). Anemia in pregnancy was
defined as hemoglobin level below 11 gm/ dL (5, 12, Figure 2: Frequency of iron deficiency anemia in
13). Mild anemia is hemoglobin concentration of 10-10.9 study population (n=75)
gm/ dL, moderate anemia is 7-9.9 gm/ dL and severe
anemia is <7 gm/ dL(5,12,13) .Patients with microcytic
hypochromic picture on peripheral film were further
investigated to differentiate between iron deficiency
anemia and Thalassemia trait. For this purpose, serum
ferritin and hemoglobin electrophoresis were done .
Normal serum ferritin level were taken from 12-150ng/
dL (3).Value of Hemoglobin A2 greater than 3.5% was
taken for the diagnosis of beta Thalassemia trait [10].
Results were expressed in terms of mean, standard
deviation, frequency and percentages.

Figure 3: Frequency of beta - Thalassemia trait in the

study population (n=44)

230 KJMS May - August, 2020, Vol. 13, No.2

 Table 1: Mode of delivery in 83 cases of anemia
Mode of delivery n (%)
Normal vaginal delivery 68(81.9%)
Caesarean section 15(18.06%)
causes maternal death in about 20% of the cases1. It
is hazardous not only for the mother but also for the
developing baby7,14,15. Anemia in pregnancy causes ill
effects on the fetus such as low birth weight babies,
cognitive abnormalities and even fetal death15.
In the present study age of the pregnant females
ranged from 16-40 years with mean of 29±7.25 years.
It means that most of the pregnant females were of the
younger age group. This is similar to the age group
reported by Behre et al from Ethiopia who reports mean
age of 25.3 years in his study1. Herzog SA from Europe
reported the age range of 15-45 years7.Shukla S from
India reported a lower age of 23 years in her study9.
Qadir M from Peshawar reported the age of 27 years
[16].Similar age distribution is reported by Shams S
from Mardan and Srour MA from Palestine8,17.
In our study, the prevalence of anemia in pregnant
females was 40%, that of iron deficiency anemia was
56%, while that of beta Thalassemia minor was 13.6%.
The overall prevalence of anemia reported in our study
was higher as compared to that reported by Behre et al
from Ethopia (7.9%) , Herzog SA from Europe (13.7%)
and Srour MA from Palestine (25.7%)1,7,17. Similarly , a
lower prevalence of anemia in pregnancy was report-
ed from Debre Berhan (9.7%), Sudan (10%), Addis
Ababa(11.6%) and Iran (13.6%) as compared to our
study18-21. A figure of 28% is reported from Ethopia22.
This shows that prevalence of anemia in pregnancy
is high in our study. However, a higher prevalence of
anemia is reported in a meta-analysis done by Adam I
who report the figure of 53%5.The highest prevalence
of anemia in pregnancy so far reported was 76% from
Sudan23. The prevalence of iron deficiency anemia
reported by Srour MA from Palestine is same as that
reported by our study i.e 52%17. However, Loy SL from
Singapore and Shams S from Mardan report a higher
figure of 73.8% and 76.7% respectively for prevalence of
iron deficiency anemia in their studies3,8.The prevalence
of iron deficiency anemia in pregnancy is reported to
be 38% in a study done in Portugal24.The prevalence of
beta Thalassemia trait reported by Shukla S from India is
3.15% which is quite low as compared to that reported
by our study9. A prevalence of 8.5% was reported for
beta Thalassemia trait in pregnant females from Ban-
galore25. On the other hand, Qadir M from Peshawar
reports that 56% of the pregnant females were positive
for beta Thalassemia trait which is quite a high figure
as compared to the present study16.
Iron deficiency anemia commonly develops in
pregnancy because during pregnancy, the requirement
KJMS May - August, 2020, Vol. 13, No.2
of iron increases about ten times that of normal and thus
all the stores of iron are used up from the mother body17.
Thalassemia trait is asymptomatic hereditary hemoglo-
binopathy that often unmasks itself in pregnancy and
that’s when it is diagnosed while doing routine blood
counts for antenatal checkup9. Both iron deficiency
states and Thalassemia trait in pregnancy have hor-
rible effects on both the mother and child9. Therefore,
screening for anemia is mandatory in pregnant females9.
According to NICE guidelines, pregnant females should
be screened for anemia in early pregnancy , and then
later again at 28th week of gestation1,7,26. Screening of
pregnant females with hemoglobin level and serum
ferritin along with hemoglobin electrophoresis in cer-
tain cases should be ensured right from the start of
pregnancy3.This will enable timely detection of anemia
in pregnant females, with timely administration of treat-
ment and this will in turn lead to reduced morbidity and
mortality in pregnant females. But unluckily, illiteracy
and unawareness of the general population about iron
deficiency states and thalassemia are the main reasons
why couples fail to screen themselves9.
CONCLUSION
Iron deficiency anemia is the most common cause
of anemia in pregnancy. Beta Thalassemia minor is very
common in our population.
RECOMMENDATIONS
Routine oral iron supplementation should be done
for all pregnant women. Oral iron will not result in iron
overload as absorption is according to iron require-
ments of body.
Looking at high prevalence in our part of the
world, pre marriage screening for Thalassemia trait
should be done in all couples to be and proper coun-
seling done regarding risk of Thalassemia major in
off-springs in screening positive couples.
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7. Herzog SA, Leikauf G, Jakse H, Siebenhofer A,
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Master DC, Mahanta J, et al. Prevalence of ß-thalas-
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11. Tandon R, Jain A, Malhotra P. Management of Iron
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12. Iron Deficiency Anemia. Assessment prevention and
control. Geneva:WHO; 2001.
13. Zekarias B, Meleko A, Hayder A, Nigatu A, Yetagessu
T. Prevalence ofanemia and its associated factors
among pregnant women attendingantenatal care
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14. Stevens GA, Finucane MM, De-Regil LM, Paciorek
CJ, Flaxman SR, Branca F, et al. Global, regional, and
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and pregnant and non-pregnant women for 1995-
2011: A systematic analysis of population represen-
tative data. Lancet Glob Health. 2013;1(1):e16–25.
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sociated factors of anemia among pregnant women
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16. Qadir M., Amir S. Frequency of beta thalassemia
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17. Srour MA ,Aqel SS,Srour KM,Younis KR, Samarah
F. Prevalence of Anemia and Iron Deficiency among
Palestinian Pregnant Women and Its Association with
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doi.org/10.1155/2018/9135625
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care in North Shoa Zone, Ethiopia. RSSDIJ.2014;3:3.
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20. Gebreweld A, Tsegay A. Prevalence and factors
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KJMS May - August, 2020, Vol. 13, No.2
 CLINICAL OUTCOMES OF RECONSTRUCTION AND
ARTHROSCOPIC REPAIR OF THE CRUCIATE LIGAMENT
OF THE KNEE JOINT BY QUADRUPLED SEMI-TENDINOSUS
AUTO-GRAFT
Javed Iqbal1, Rafe-ullah2, Naeem Ullah1, Aimal sattar1, Ehsan Ullah3, Ibrar Mohibullah Wazir4

ABSTRACT
Objective: To Study the functional and clinical reconstruction and arthroscopic repair of the cruciate ligament of the
Knee joint by quadrupled semi-tendinosus auto-graft.
Methodology: This Descriptive Prospective study was carried out In Orthopedic Division of Abaseen Medical Centre,
Peshawar, and KPK Pakistan from December 2017 to December 2018. After taking permission from Hospital ethical
committee and taking an informed consent, a total of fourty two Patients included in the study. A comprehensive history
regarding the symptoms of injury, its duration, pathogenesis and nature of trauma was properly taken. Any medical
comorbidity, details of the primary treatment were also noted. Physical examination was done followed by radiograph-
ic investigation. All the patients then underwent surgical treatment of anterior cruciate ligament (ACL) reconstruction
and then post operative clinical and functional outcome was obtained using functional knee score. Data was analyzed
using SPSS version 21.
Results: Of the total 42 Patients included in the project, the mean age was 33.02+11.03years. All were male (100%).
Most common injury were caused by road traffic accidents 26(61.9%). Sports injury 11(26.2%). Fall 5(11.9%) patients.
Lachman test was positive in 37 (87.5%) patients and Pivot shift test was found to be positive in 26(62.5 %) in preoper-
ative evaluation. After 6 month follow up, Lachman test was found to be negative in all 42pts (100%) with grade 3 ACL
injury, while pivot shift test was negative in 34(81.25%) and remained positive in 8 (18.75 %) patient.
Conclusions: This study concluded that injuries to the ACL are predominant in younger patients and Reconstruction-
al Arthroscopic repair of the cruciate ligament of the Knee joint by quadrupled semi-tendinosus auto-graft has good
clinical results.
Key words: Anterior cruciate ligament, Quadrupled-semitendinosus auto-graft, Arthroscopic reconstruction.

INTRODUCTION It is also common to counteract the stress of rotation and

Knee joint is the largest joint of the body. It is one
of the strongest as well as most important joint of the
body involved with locomotion. Numerous muscles and
ligaments support the knee joint and stabilize. Injuries
and age related change of the knee joint are a rather
common presentation in clinical practice. The most
common damaged ligament of the knee in the human
body is ACL.1 The primary stabilizer of the knee is
ACLand this protects the knee from anterior translation.
1Departmnet of Orthopedic Surgery, MTI LRH Pesha-
war.
2Depatment of Orthopedic Surgery, Consultant Gurkey
Trust & Teachinng Hospital Lahore.
3Department of orthopedics, Trainee Medical Officer,
MTI Khyber Teaching Hospital
4Anatomy,Lecturer, Khyber Girls Medical College.
.........................................................................................
Address for correspondence:
Dr. Javed Iqbal
Department of Orthopedic Surgery, MO Orthopedic A
Unit, LRH Peshawar.
Email: drorthopda@gmail.com
Cell. : 0333 5311148
valgus2. In previous studies, the estimated frequency
of ACL between 0.24-0.34 /1000 population per year.
The ACLrupture is the most common serious injury of
the knee.3,4
There was a lower cumulative incidence of OA
among ACL-reconstructed patients (33.1%) than among
non-reconstructed patients (40.3%).5 Rehabilitation has
been highlighted as one of the most important factor in
ACL injury management, better to surgical reconstruc-
tion.6 ACL rehabilitation does not ensure successful
results a recovery of performance is followed.7 There
are minimal differences noted between rehab after
reconstruction or rehabilitation alone with regards
to function, and re-injury.8
ACL reconstruction with autografted tendons
(semitendinosus gracilis muscles) is a common and
successful practice frequently used now a days.9 The
semitendinosus tendon autograft is becoming the graft
of choice in ACLreconstruction. The advantages with
semitendinosus graft are availability of a greater cross
sectional area and unaffected integrity of the extensor
mechanism.10 ALC reconstruction was carried out with

KJMS May - August, 2020, Vol. 13, No.2 233

a donor autograft (hamstring tendon, patellar tendon
or quadriceps tendons) and allograft (Achilles, patellar
tendon, hamstring tendon or Iliotibial anterior tendons),
attempts have been made using synthetic graft. Silver
wire, Fascia lata, and Iliotibial band.
This study aimed at evaluation of the post-surgi-
cal function and quality of life after ACL reconstruction
arthroscopically.
METHODOLOGY
This was a Descriptive prospective study carried
out in Orthopedic Division of Abaseen Medical complex,
Peshawar, KPK, Pakistan, conducted from December
2017 to -December 2018.
42 participants were recruited into the study pro-
gram after taking informed consent and approval from
hospital ethical committee.
The patients selected by Consecutive sampling
(Non-probability sampling technique) and all those
patients were included who had complete grade 3 ACL
tear for at least 6 weeks which was confirmed on MRI.
(paired or unpaired), was appropriately applied to the
collected data. Significance was established at p<0.05,
confidence interval was 95% and margin of error 5%.
Quantitative data like age, were presented as means
and standard deviation and qualitative data like age
groups, pre and postoperative functional outcome was
presented as frequency and percentages.
RESULTS
Out of the total 42 Patients included in this study,
the mean age was 33.02±11.03 years. All the 42 pa-
tients in the study were male (100%). Most common
injury were caused by road traffic accidents 26(61.9%),
while sports activities like match, jogging and golf in
11(26.2%) patients, and 5(11.9%) with fall while doing
daily activities like slip and climbing upstairs and down
stairs. All the patients had acute ACL tear. Left knee
was affected in 26(61.9%) and right knee was affected
in 16(38.1%). Table 1
Table 1: Demographic characteristics of patients
No of Patients 42

Patients with similar comorbidities were excluded Gender Male

from the study. Joint infection and history of injury to the 42(100%)
ligaments in the same knee were also excluded from Mean Age 33.02+11.03
participating in the study.
Mechanism of Injury
Demographic details of patients (name, age)
Road Traffic Accident 26 (61.9%)
were obtained. History was taken regarding the nature
of injury with special emphasis on the mechanism of Sports 11 (26.2%)
injury, duration of injury and symptoms associated Fall 5 (11.9%)
with it. Any medical comorbidity, details of the primary
Side of Injury
treatment were also noted. Physical examination was
done followed by radiographic investigation. Two Left Knee 26(61.9%)
team’s member performed Lachman and pivot test Right Knee 16(38.1%)
on all the patients and these test were performed
on the basis of the clinical diagnosis and analysis
Table 2: Clinical Evaluation of patients
of post-surgical results. The physical evaluation and
x-ray were recorded preoperatively. After preoperative
Clinical Result Preopera- Postopera-
optimization for Anesthesia, all the patents underwent
test tive clinical tive Clinical
surgical intervention, one surgeon with the help of the
Result Result
same operating team and instruments performed all the
operations using autologous semitendinosus’ tendon Lachman Positive 37 0 / (0%)
autograft. Postoperatively, patients were evaluated for Test Negative 5 42/ (100%)
any complication and clinical and functional outcome
Pivot Positive 26 8 /(18.75%)
noted 6 months after surgery. All patients were given a
Test Negative 16 34/(81.25%
structured postoperative treatment procedure, which
was monitored by two personnel and recorded com-
pliance. In the first three weeks after the surgery, knee Table: 3 Postoperative results according to function-
braces were utilized for controlled mobilization of the al knee score
patients. Partial weight bearing assistance was per-
mitted in the first three weeks after surgery. During the Scoring No of patients (%)
last follow up of the patients, ROM, stability and knee
Excellent (80-100) 29(69.0%)
proprioception were all assessed in comparison with
the healthy side. At the last follow-up, ROM, stability Good (70-79) 8(19.05%)
and knee proprioception was measured against the Fair (60-69) 5(11.9%)
healthy side. The collected data was analyzed using
Poor (<60) 0
SPSS 21.0. Descriptive statistics were used and t test

234 KJMS May - August, 2020, Vol. 13, No.2

 Lachman test was positive in 37(87.5% and neg-
ative in 5 (12.5%) patients. Pivot test was found to be
positive in 26(62.5% and negative 16 (37.5%) pts by
preoperative evaluation. By post-operative evaluation
after 6 month follow up ,Lachman test was found to be
100% positive with grade 3 ACL injury , and pivot shift
test was negative in 34 81.25% and remained positive
in 8( 18.75% )pts. Table 2
About 68.75% patients showed that results as
excellent with score (80-100), 18.75% of the patients
gained good with score between (70-79) and 12.5%
of the patients was fair with score 60-69 and no one
patients was gained poor score. Table 3
Paired t test was applied to compare the pre and
postoperative knee scoring system. There was signifi-
cant correlation with p value < 0.05 and mean preop-
erative score was 44.46 with improved postoperative
score of 79.81 after anterior Ligament reconstruction.
DISCUSSION
With other recent advances & development, ACL
reconstruction surgery has made great progress in
the last period of ten years. A number of studies have
explored many factors that are involved in the various
technical aspects of ACL reconstruction. Our study
contain 42 cases which have been handled in last one
year. We used the Lysholm knee score to measure the
results as this is statistically verified and commonly used
as a better rating system.
Vikas et al., used combined reconstruction where
they utilized semitendinosus tendon for intra articular
and illo tibial band for extra articular augmentation.
They reported 80% excellent, 32% good, 8% fair results.
They had no poor results.11 They did however use other
scoring system. In our study, postoperative scoring
system, excellent score was 68.75%, Good score was
18.75% and fair score was 12.5%.
Six month follow up study was also done in 2015.
88% patients preoperatively showed in grade 2 posi-
tive pivot shift test while postoperatively 94% patients
improved to grade 0 in pivot shift test. Similarly, 84%
patients were having grade 2 positive lachman test
preoperatively which improved to 86%, showing grade
0 lachman test and only 10% showed grade 2 positive
lachman test.12
In present study 100% of the patients’ recovered
postoperative recovery in lachman test and 81.2% im-
proved in pivot shift test. Comparable to another study
done in 2017, 92% of the patients graded their postop-
eratively recovery as normal according to knee society
score.13 Noojin et al published findings with a difference
p< 0.05 between the clinical failure in women 23% and
men 4% in a group of sixty five participating patients who
had undergone anterior cruciate reconstruction with a
four strands hamstring auto graft. 14But in our study all
patients were males. Similar Khan et al, reported that
KJMS May - August, 2020, Vol. 13, No.2
no one female were also came with ACL rehabilitation
only male were included.12
CONCLUSION
This conclusion concluded that, among younger
generation, ACLinjuries were common. The most com-
mon cause among males was road accident, followed
by sports injuries. Arthroscopy reconstruction using
quadrupled semitendinosus autograft is a very good
treatment option in patients with complete ACL tear.
ACKNOWLEDGEMENTS
We are thankful to the staff of Abaseen Medical
Centre who help us n data collection.
REFERENCES
1. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto
H, Shinomiya K. Two-bundle reconstruction of the
anterior cruciate ligament using semitendinosus
tendon with endobuttons: operative technique and
preliminary results. Arthroscopy: The Journal of
Arthroscopic & Related Surgery 1999;15(6):618-24.
2. van der Hart CP, van den Bekerom MP, Patt TW. The
occurrence of osteoarthritis at a minimum of ten
years after reconstruction of the anterior cruciate
ligament. Journal of orthopaedic surgery and re-
search 2008;3(1):24.
3. Sajovic M. Simultaneous bilateral anterior cruciate
ligament (ACL) reconstruction with use of hamstring
tendon autografts: a case report. Journal of Surgery
2013;1(1):1-5.
4. Ajuied A, Smith C, Wong F, Hoskinson S, Back D,
Davies A. A survey of rehabilitation regimens follow-
ing isolated ACL reconstruction. JMED Research
2014;2014.
5. Lin S-H, Wang T-C, Lai C-F, Tsai R-Y, Yang C-P,
Wong C-S. Association of anterior cruciate liga-
ment injury with knee osteoarthritis and total knee
replacement: A retrospective cohort study from the
Taiwan National Health Insurance Database. PLoS
One 2017;12(5):e0178292-e.
6. Grindem H, Risberg M, Eitzen I. Two factors that
may underpin outstanding outcomes after ACL re-
habilitation. BMJ Publishing Group Ltd and British
Association of Sport and Exercise Medicine; 2015.
7. Shelbourne KD, Klotz C. What I have learned about
the ACL: utilizing a progressive rehabilitation scheme
to achieve total knee symmetry after anterior cruciate
ligament reconstruction. Journal of Orthopaedic
Science 2006;11(3):318.
8. Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler
L, Risberg MA. Nonsurgical or surgical treatment of
ACL injuries: knee function, sports participation, and
knee reinjury: the Delaware-Oslo ACL Cohort Study.
The Journal of bone and joint surgery American
volume 2014;96(15):1233.
9. Cirstoiu C, Circota G, Panaitescu C, Niculaita R. The
235
 advantage of arthroscopic anterior cruciate ligament
reconstruction with autograft from the tendons of the
semitendinosus–gracilis muscles for the recovery
of the stability of the knee. Maedica 2011;6(2):109.
10. Streich NA, Reichenbacher S, Barié A, Buchner M,
Schmitt H. Long-term outcome of anterior cruciate
ligament reconstruction with an autologous four-
strand semitendinosus tendon autograft. Interna-
tional orthopaedics 2013;37(2):279-84.
11. Negi VS, Pawar U, Pangwane S. Functional Out-
come of Arthroscopic Reconstruction of Anterior
Cruciate Ligament using Quadrupled Semitendi-
nosis Autograft. MVP Journal of Medical Sciences
2016;3(2):101-9.
12. Khan RDA, Hassan SMT, Saeed UB, Yasin A. Post-
operative range of motion and stability after anterior
cruciate ligament reconstruction using quadrupled
hamstring autograft. JPMA The Journal of the
Pakistan Medical Association 2015;65(11 Suppl
3):S215-9.
13. Padya S, Kolluri R. Functional outcome of ar-
throscopic anterior cruciate ligament reconstruction
using semitendinosus autograft–A prospective
study. International Journal of Orthopaedics
2017;3(3):353-8.
14. Noojin FK, Barrett GR, Hartzog CW, Nash CR.
Clinical comparison of intraarticular anterior cru-
ciate ligament reconstruction using autogenous
semitendinosus and gracilis tendons in men versus
women. The American journal of sports medicine
2000;28(6):783-9.

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236 KJMS May - August, 2020, Vol. 13, No.2

 INDUCTION OF LABOUR WITH FOLEY CATHETER IN WOMEN
WITH PREVIOUS ONE CAESAREAN SECTION
Shahida Sultan1, Samina Sabir1, Rabeea Sadaf2, Ghazala Shams2, Sadia Ali3

ABSTRACT
Objectives: The research aim was to determine the success ratio and safety of induction of labour via intra-cervical
Foley catheter in pregnant women with the history of a single Caesarean delivery.
Methods: This descriptive cross-sectional study was conducted in the department of Obstetrics and Gynaecology,
MTI, Lady Reading Hospital Peshawar, Pakistan, from June 2019 to December 2019. In this study 95 full-term, pregnant
women with previous one Cesarean section were included. All those patients with placenta previa, contracted pelvis,
previous two Cesarean sections and history of premature rupture of the membrane were excluded. The data obtained
was analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY).
Results: The mean age of the women was 28.60 ± 12.43, with majority i.e. 50 (52.63%) women being 25–30 years old.
67% of the women gave birth via vaginal delivery, indicating an overall 70.52% success rate of VBAC; of these women,
however, 37(67.6%) needed oxytocin administration to augment labour. Vaginal bleeding ensued after the insertion of
Foley catheter in four women. No cases of uterine rapture or scar dehiscence were observed. A considerable mean
maternal age difference was observed between the group of women who were able to have a successful VBAC, and
those who had to undergo a Caesarean delivery (p-value 0.001).
Conclusion: In the women with the history of one Cesarean section, induction of labour via Foley catheter was a risk-
free and viable option, with a good success rate as well as little fetomaternal complications.
Keywords: VBAC, C-Section, Foley Catheter, Labour

INTRODUCTION with significantly increased rates of uterine rapture. An

It has often been reported that the risk associated
with Caesarean section for women increases with each
subsequent Caesarean delivery. Some potentially fatal
complications, such as of surgical complications, pla-
centa accrete, hemorrhage can occur.1.2 Complications
of future pregnancies can be avoided by the encourage-
ment of vaginal birth after a previous caesarean (VBAC)
though attempting VBAC can end in a significantly
greater risk of serious morbidity for newborns.
Induction of labour is done in 18%–27% of women
attempting a VBAC.3,4 According to the prior studies,
60%–80% of women with one previous CS will deliver
vaginally if a trial of labour is permitted, even when
induced.5,6 In women who have had a low transverse
incision, a uterine rapture rate of approximately 0.2%–
0.5% was observed with trial of labour (TOL).7 Uterine
rupture is one of the most dreadful outcomes of the trial
of labour (TOL) and its chances increase upto six-fold
by use of prostaglandins for cervical ripening. Induction
of labour, rather than spontaneous labour is associated
1 Deptt. of Gynae & Obs, LRH Peshawar
2 Deptt. of Gynae & Obs, HMC Peshawar
3 ??????
.........................................................................................
Address for correspondence:
Dr. Rabeea Sadaf
Associate Professor, Gynecology department, HMC
Peshawar.
Email:rabeeasadaf@gmail.com
unfavorable cervix and cervical ripening methods are
also risk factors.8Secure and effective techniques have
not yet been founded for cervical ripening and induction
of labour in women with prior CS. To improve outcomes
in women with previous CS mechanical methods of
induction are becoming an option. Trials have shown
that it is effective in labour induction as pharmacological
methods with lower rates of uterine hyper-stimulation
thus minimizing the risk of uterine rupture and decrease
fetal heart rate abnormalities.9 In women with previous
CS, the use of mechanical methods may be linked with
a lower rate of uterine rupture.
There have been many studies done internation-
ally to explore the use of Foley catheter to induce labour
in patients with CS history, but locally and nationally, no
such study has been done in recent history. Our study,
thus, was done with an intention of evaluating the safety
and viability of labour induction via Foley catheter in
women with one previous Caesarean delivery present
at a tertiary center in Peshawar, Pakistan.
MATERIAL AND METHODS
This descriptive cross-sectional study was done in
the department of Obstetrics and Gynaecology “Ward
C”, Lady reading hospital Peshawar, Pakistan, from
June 2019 to December 2019. In our study 95 full-term,
pregnant patients with a cephalic presentation with the
previous one Cesarean section were included. All those
patients with placenta previa, contracted pelvis, previ-

KJMS May - August, 2020, Vol. 13, No.2 237

ous two Cesarean sections and history of premature
rupture of the membrane were excluded from the study.
The study was conducted after approval from the
Lady Reading Hospital (LRH) ethical committee. After
informed consent, all patients meeting the inclusion
criteria were included in the study. All patients were
subjected to a detailed history and clinical examination.
The cervix was cleaned in a lithotomy position by
using Cusco’s speculum, Foley catheter with 24 French
sizes was inserted in the cervix and 60 ml normal saline
was used to inflate the balloon. The device was left for
a maximum period of 24 hours and the patient’s activ-
Figure 1: showing the success of vaginal birth after
ity was not restricted. Once labour was established,
C-section. (n=95%)
patients were managed according to intrapartum care
guidelines. The success rate of VBAC was the primary Table 1: showing demographic data of patients
outcome measure of the study, while perinatal compli- (n=95)
cations such as scar dehiscence and uterine rapture
were the secondary outcomes. Variable Number (%)
Age in years
The study protocol was approved by the Ethical
Committee of Lady Reading hospital, Peshawar, and all 25-30 years 50(52.63%)
included patients provided written informed consent. 30-35 years 26(27.36%)
Patient information, including, name, age, and gender
were recorded on pre-designed forms. 35-40 years 19(20%)
Gravida
Statistical analysis Multigravida 65(68.42%)
Data were analyzed using IBM SPSS Statistics Grand multigravida 30(31.57%)
for Windows, Version 23.0 (IBM Corp., Armonk, NY).
Gestational Age:
Continuous variables will be reported as mean and
standard deviation and categorical variables as number 37-40 weeks 25(26.31%)
(percent). Chi-square test and Pearson’s correlation test 41-42 weeks 62(65.26%)
will be applied. The level of significance was set at P <
0.05. >42 weeks 8(8.42%)

RESULTS Table 2: showing indication of labour (n=95)

A total of 95 women were included in the study. Indication for induction of labour Number (%)
Majority i.e. 50 (52.63%) of the women were 25–30 years
Gestational age more than 40 70(73.68%)
old with a mean age of 28.60 ± 12.43, and mostly 62
weeks
(65.26%) were in the gestational age of 41-42 weeks.
Table 1 showing demographic data of patients in the Intrauterine growth retardation 5(5.26%)
study. Table 2 shows the various indications for induc- Pregnancy-induced Hypertension 7(7.36%)
tion of labour
Gestational Diabetes melitius 9(9.47%)
No uterine rupture or scar dehiscence cases were Fetal distress 4(4.21%)
observed. Minimal vaginal bleeding was experienced
by four women, but they underwent successful VBAC VBAC (p-value 0.001). The gestational age of delivery,
following the removal of catheter; 37 (67.6%) women, mean neonatal birth weights, Bishop score at Foley’s
however, were administered oxytocin for augmenting insertion and removal, and or Apgar Score at one and
labour. 67 women gave successful vaginal births, giving five minutes however, did not differ significantly. (Table
an overall VBAC success rate of 70.52%. (figure 1) 3)
Emergency Caesarean sections had to be performed
on the remaining women because of various reasons: DISCUSSION
failure to Progress, 21(75%), Fetal distress, 4(14.28%)
The results of our study suggest that induction of
and cord prolapse 3(10.71%).
labour using Foley catheter in women with one previous
The group of women who underwent Caesarean Caesarean section is relatively risk-free and effective in
sections had a considerable mean maternal age dif- the given clinical context. This could mean a valuable
ference from the women were able to have successful advancement for a change in the obstetric approach

238 KJMS May - August, 2020, Vol. 13, No.2

 Table 3: comparison of VBAC and C-section with different Variables. (n=95)
Variable VBAC(n=67)
Age (mean±SD) 27.15±8.65
Gestational age (mean±SD) 38.32± 3.23
Parity (mean±SD) 1.48±1.10
Bishop score(insertion) 2.47±0.81
Bishop score (removal) 4.51±1.23
Birth weight 2.97±1.27
APGAR at 1 min 8.76±1.33
APGAR at 5 min 9.32±1.84
for women with a uterine scar. The safest method to
induce delivery is a balloon catheter compared with
women who deliver by means of an elective repeated
caesarean section.
There were no cases of perinatal death or uter-
ine rapture and VBAC had a success rate of 70.52%
in our study. The previous studies on VBAC showed
a success rate of 70–78% 10,11,12. Some other studies
were conducted to determine the success rate of VBAC
subsequent to induction of labour via a Foley catheter.
In a recent study done on 208 women with a previous
history of Caesarean delivery, a success rate of 71% of
observed, with two perinatal deaths; one of them was
due to uterine rupture13,14.
While prostaglandins simultaneously affect cer-
vical ripening and uterine contractions, Foley catheter
induces cervical ripening without stimulating uttering
contractions. 15 A study done previously on VBAC
showed that by the use of Foley catheters for induction
of labour in a patient with previous CS, the risk of uter-
ine rupture in the induced TOL group was minimized.
Prostaglandin introduction during TOL, however, was
associated with a more than six-fold increase in uterine
ruptures in comparison with spontaneous labour.16,17
Our study observed no uterine raptures.
In our study, previous vaginal births, maternal
age, gestational age at delivery, body mass index, birth
weight, and Bishop score at Foley insertion and removal
were investigated in the prediction of successful VBAC.
Nevertheless, the only statistically significant differences
noted were with maternal age (p-value: 0.001), while the
rest of the parameter was not significant. Patients with
better Bishop scores were found to have a slight, but
not significant, higher rate of successful VBAC during
the introduction Foley catheter.
The use of Foley catheter for labour induction
sounds an efficient technique to bring about vaginal
delivery in women with previous CS when induction
is indicated. If the requirement of immediate delivery
arises in the women, the potential maternal and fetal
risk of repeated CS should be taken into regards, which
comprises maternal perioperative morbidity, such as
KJMS May - August, 2020, Vol. 13, No.2
C-Section (n=28) P value
30.43±5.43 0.001
38.90± 2.12 0.846
1.54± 1.87 0.539
2.10± 0.43 0.083
4.01±1.86 0.092
3.10±.45 0.312
8.43±1.15 0.749
9.20±1.77 0.523
postpartum hemorrhage, bladder and bowel lesions,
but also risks for subsequent pregnancies, such as
placenta previa and placenta accrete18,19,20
This is the first study to be done on induction of
labour using Foley catheter with the history of one Cae-
sarean section and The Lady Reading Hospital is one of
Peshawar’s first centers to use this method while most
other centers still use prostaglandins to induce labour.
More research is needed to compare success rates
and risks in VBAC patients with labour induced using
prostaglandins and Foley catheter. A small sample size
limited our current study; therefore, we recommend that
a multicenter approach be utilized in the future studies
to obtain a larger sample size of patients.
CONCLUSION
The results of our study help us conclude that the
induction of labour using Foley catheter in women with
the history of one Caesarean section is a safe and viable
option with low probability of complication. A positive
correlation was observed between the success rate and
maternal age.
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natal complications in pregnancies conceived after
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ysis. BJOG. 2017;124(4):561-572. doi:10.1111/1471-
0528.14257
2. Green L, Knight M, Seeney FM, Hopkinson C, Collins
PW, Collis RE, et al. The epidemiology and outcomes
of women with postpartum haemorrhage requiring
massive transfusion with eight or more units of
red cells: a national cross-sectional study. Bjog.
2016;123(13):2164-2170. 10.1111/1471-0528.13831
3. Vogel JP, Gülmezoglu AMM, Hofmeyr GJ, Tem-
merman M. Global perspectives on elective induc-
tion of labor. Clinical obstetrics and gynecology.
2014;57(2):331-342. 10.1097/grf.0000000000000031
4. Radan AP, Amylidi-Mohr S, Mosimann B, Simillion
C, Raio L, Mueller M, et al. Safety and effectiveness
of labour induction after caesarean section using
239
 balloon catheter or oxytocin. Swiss Med Wkly.
2017;147:w14532. 10.4414/smw.2017.14532
5. Rossi AC, Prefumo F. Pregnancy outcomes of
induced labor in women with previous cesarean
section: a systematic review and meta-analysis. Arch
Gynecol Obstet. 2015;291(2):273-280. 10.1007/
s00404-014-3444-9
6. Marconi AM. Recent advances in the induction
of labor. F1000Res. 2019;8:F1000 Faculty Rev-
1829. Published 2019 Oct 30. 10.12688/f1000re-
search.17587.1
7. Lydon-Rochelle M, Holt VL, Easterling TR (2001) Risk
of uterine rupture during labor among women with
a prior cesarean delivery. N Engl J Med 345(1): 3-8.
8. Biswas A. Management of previous cesarean sec-
tion. CurrOpin Obstet Gynecol 2003;
9. 15:123–9.
10. Jozwiak M, Dodd JM (2013) Methods of term labour
inductionfor women with a previous caesarean
section. Cochrane DatabaseSyst Rev 3:CD009792.
11. Rogers AJ, Rogers NG, Kilgore ML, Subramaniam
A, Harper LM. Economic evaluations comparing a
trial of labor with an elective repeat cesarean deliv-
ery: a systematic review. Value in Health. 2017 Jan
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12. Fobelets M, Beeckman K, Faron G, Daly D, Begley
C, Putman K. Vaginal birth after caesarean versus
elective repeat caesarean delivery after one previous
caesarean section: a cost-effectiveness analysis
in four European countries. BMC pregnancy and
childbirth. 2018 Dec;18(1):92.
13. Razzak MA, Hamdan MN, Abutiheen AA. Success
rate of vaginal birth after cesarean section in Kerbala
maternity hospital. Iraq Medical Journal. 2018 Mar
31;2(1):32-5.
240
14. Jozwiak M, van de Lest HA, Burger NB, Dijksterhuis
MG, De Leeuw JW. Cervical ripening with Foley
catheter for induction of labor after cesarean section:
A cohort study. Acta Obstet Gynecol Scand 2014;
93:296–301. doi: 10.1111/ aogs.12320.
15. Wu Y, Kataria Y, Wang Z, Ming WK, Ellervik C. Factors
associated with successful vaginal birth after a cesar-
ean section: a systematic review and meta-analysis.
BMC pregnancy and childbirth. 2019 Dec;19(1):1-2.
16. Farah Z, Seema H, Sridevi B (2013) Transcervical
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Caesarean Section-A Clinical Study. J Clin Diagn
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17. Masood A. Intracervical Foley Catheter versus Vagi-
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with Previous One Cesarean Section-A Pilot Study.
Obstet Gynecol Int J. 2015;2(5):00054.
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KJMS May - August, 2020, Vol. 13, No.2
 PREVALENCE AND MORTALITY DUE TO COMMUNICABLE
AND NON-COMMUNICABLE DISEASES IN URBAN AREAS OF
PESHAWAR
Sayyed Jalawan Asjad1, Aamer Liaqat1, Syed Shahmeer Raza1, Shakeeb Khan2, Muhammad Noman2

ABSTRACT
There is a need for healthcare authorities to forecast the special health problems associated with the urbanization due
to the increasing global burden from urbanization.
Objectives: To assess Prevalence and mortality rate due to communicable and non-communicable diseases in urban
areas Peshawar
Methodology: A cross-sectional study was conducted in Hayatabad, University town, and Cantonment board area
of Peshawar from January 2017 to May 2017. A sample size of 270 from population between age groups of 20 to 65
years old both educated and uneducated persons of urban areas was chosen. Quota sampling was done. Data was
collected through questionnaires and processed through SPSS software version 20.
Results: According to our research, the prevalence of communicable diseases before the year 2000 was 26.86% while
that of non-communicable diseases was 73.13%. The prevalence of same group of diseases between the years 2000-
2016 is 42.54% and 57.45% respectively. According to our study mortality from communicable diseases before year
2000 was 11.32% while that of non-communicable diseases was 88.67%. Mortality between the years 2000-2016 from
communicable diseases was 19.02% while that from non-communicable diseases was 80.98%.
Conclusion: Prevalence and mortality of non-communicable diseases is high as compared to communicable diseases,
showing a trend from non-communicable diseases towards communicable diseases in our study population.
Key Words: Prevalence, Communicable disease, Mortality.

INTRODUCTION A study was conducted on “Non-communicable

In modern times, when most of the rural areas
are transforming into urban areas; our health authorities
need to forecast the special health problems associat-
ed with the urbanization.The better transport facilities,
better health facilities, high level of education, high
income level, better sanitation, a good vaccination
coverage leads to a better control of communicable
disease and mortality due to these diseases; although
overcrowding still poses a constant threat for an easy
spread of communicable diseases. The World Health
Organization (WHO) reports non-communicable dis-
eases (NCDs) to be by far the leading cause of death
in the world, representing over 60% of all deaths. Out of
the 36 million people who died from NCDs in 2005, half
were under age 70 and half were women1. According
to WHO report; a total of 57 million deaths occurred in
the world during 2008. 36 million (63%) were due to
non-communicable diseases and 37% due to commu-
nicable diseases2.
1Department of Medicine HMC Peshawar
2Department of Medicine KTH Peshawar
.........................................................................................
Address for correspondence:
Dr. Aamer Liaqat
Department of Medicine HMC Peshawar
Cell No: 0342-9073205
E-mail: aamer_kmc86@yahoo.com
diseases and injuries in Pakistan: strategic priorities”3
and concluded that Non-communicable diseases, in-
cluding cardiovascular diseases, cancers, respiratory
diseases, diabetes, and mental disorders, and injuries
have become the major causes of morbidity and mor-
tality in Pakistan. Similar conclusion resulted from a
study in India4. The study on Preventable Lifestyle Risk
Factors for Non-Communicable Diseases in the Pakistan
Adolescents Schools Study 1 (PASS-1)5 was done by
students and analyzed over 80% of the adolescents
had unhealthy diets, and 54% were physically inactive.
Most adolescents were exposed to passive smoking,
and 14% were also current smokers. Only 3.1% of the
participants were without any preventable lifestyle risk
factor for NCDs, and over 80% had ≥2 factors.
Another study by the name “The prevalence of
underweight, overweight and obesity in Bangladeshi
adults: Data from a national survey”6 concluded that un-
derweight and overweight are prevalent in Bangladeshi
adults.This results in increased prevalence of NCDs.
Principal NCDs were coronary heart disease
(CHD), diabetes mellitus (DM), cancer and chronic
respiratory diseases. Nearly 80% of these NCD deaths
(29million) occurred in low and middle income coun-
tries. A research was conducted on the topic “Car-
diovascular disease(a major NCD) in the developing
world: prevalence, patterns, and the potential of early

KJMS May - August, 2020, Vol. 13, No. 2 241

disease detection”7. Over the past decade or more, the
prevalence of traditional risk factors for atherosclerotic
cardiovascular diseases has been increasing in the
major populous countries of the developing world,
including
China and India, with consequent increases in the
rates of coronary and cerebrovascular events. The oc-
currence of cardiovascular diseases (CVD) and related
risk factors was evaluated in Seychelles, a middle level
income country8, as accumulating evidence supports
increasing rates of CVD in developing countries. CVD
mortality was obtained from vital statistics for two peri-
ods, 1984-5 and 1991-3. CVD morbidity was estimated
by retrospective review of discharge diagnoses for all
admissions to medical wards in 1990-1992. Levels of
CVD risk factors in the population were assessed in
1989 through a population-based survey. In 1991-93,
standardized mortality rates were in males and females
respectively, 80.9 and 38.8 for cerebrovascular disease
and 92.9 and 47.0 for ischemic heart disease. CVD ac-
counted for 25.2% of all admissions to medical wards.
Among the general population aged 35-64, 30% had
high blood pressure, 52% of males smoked, and 28%
of females were obese. These findings substantiate the
current health transition to CVD in Seychelles. Current
health tradition in India seems to be similar to that of
Seychelles9.
As Pakistan is a low income country, the rate of
prevalence due to communicable and non-communi-
cable disease is also very high. The proportion of the
population 65 years and older are particularly prone to
non communicable diseases. Pakistan has not been
able to control the burden of communicable diseases
like tuberculosis, malaria, dengue fever, typhoid, viral
hepatitis, cholera and other infections. While at the same
time there remained a rising trend of non-communicable
diseases like heart diseases, strokes, diabetes, hyper-
tension and cancer.
A study was conducted by Indus Hospital Re-
search Center, Korangi Crossing, Karachi, Pakistan10.
Data analysis shows that Six hundred and sixty-seven
households were enrolled between March 2010 and
August 2011. A majority of households lived in per-
manent structures (85%) with access to basic utilities
(77%) and sanitation facilities (98%) but limited access
to clean drinking water (68%). Households had high
ownership of communication technologies in the form
of cable television (69%) and mobile phones (83%). Risk
factors for NCD, such as tobacco use (45%), overweight
(20%), abdominal obesity (53%), hypertension (18%),
diabetes (8%) and pre-diabetes (40%) were high. At the
same time, infectious diseases such as hepatitis B (24%)
and hepatitis C (8%) were prevalent in this population.
A research was conducted on Prevention of
non-communicable diseases in Pakistan: an integrated
partnership-based model11 and concluded that Devel-
opment and implementation of NCDs prevention polices
242
in the developing countries is a multidimensional chal-
lenge. This article highlights the evolution of a strategic
approach in Pakistan. The model is evidence-based and
encompasses a concerted and integrated approach to
NCDs. It has been modeled to impact a set of indicators
through the combination of a range of actions capital-
izing on the strengths of a public-private partnership.
The high figures of prevalence and mortality due
to NCDs demands more detailed study of the current
prevalence rates and mortality rates of non-communi-
cable diseases; so that our health authorities are not
only aware of the disease burden but also of the high
increasing rates of non-communicable diseases.
METHODOLOGY
Cross-sectional study was done. It was conducted
from January 2017 to May 2017. Our study was limited
to Hayatabad, University town and Cantonment board.
Target population was between age groups of 20 to 65
years old both educated and uneducated persons of
urban areas. Cross sectional type of descriptive study
was done. The convenient sample size initially chosen
was from 150-300 persons. As the research was carried
out, the final no of persons from whom questionnaires
were filled was 270.Quota sampling technique was
chosen. Data was collected through distribution of ques-
tionnaire which were filled by interviewers themselves.
The study population was briefed about the nature of
study and informed consent was taken. Assurance was
given to them that their identities wouldn’t be disclosed
to anyone not involved in the research project but that it
can’t be guaranteed.Data was analysed by dividing the
disease occurrence into before 2000 era and between
2000-16 era.The results were processed from 15 May
2017 to ,22 May 2017 through Statistical package for
social sciences file system also known as statistical
product and service solutions {SPSS(version 20)}. Data
was presented in the form of text and figures.
RESULTS
Communicable diseases have 26.8% and
42.54% prevalence in before 2000 group and 2000-16
group respectively. Non-communicable diseases have
73.13% and 57.45% prevalence in before 2000 group
and 2000-16 group respectively. Thus the prevalence
of communicable diseases is increasing in our study
population.
Communicable diseases have 11.3% and 19%
mortality in before 2000 group and 2000-16 group re-
spectively. Non-communicable diseases have 88.67%
and 81% mortality in before 2000 group and 2000-16
group respectively. Thus mortality from communicable
diseases is rising in our study population.
DISCUSSION
According to the results of our study, commu-
KJMS May - August, 2020, Vol. 13, No. 2

Figure 1: Prevalence rates between communicable
and non-communicable diseases before 2000 and
between 2000-16
Figure 2 showing mortality rates of communicable
and non-communicable diseases between 2000 and
2000-16
nicable diseases have 26.8% morbidity during before
2000 group. It has 42.54 % morbidity in the 2000-2016
group. It shows that communicable diseases prevalence
is increasing in this area during the study period. It also
shows that no proper attention is paid to the control
of communicable diseases in this area. This result is
somewhat similar to the results from a study conducted
in Poland by the name “Infectious diseases in Poland
in 2014”12 in which some of the common infectious
diseases were found to be again on the rise in 2014
after the decrease in 2008-2012 period. Our result can
also be compared to the study done in Pakpattan dis-
trict, Pakistan13 in which 58% of the study group were
suffering from communicable diseases. In one of the
other studies done in Mayanmar on malaria incidence
(one of the chief communicable diseases) by the name
“Malaria incidence in Mayanmar 2005-2014: steady but
KJMS May - August, 2020, Vol. 13, No. 2
fragile progress towards elimination”14 , a contrasting
result can be found to that of our study. In the mentioned
study 81.1% decline in the annual incidence was found
between the years 2005-2014.A similar result might be
suspected in case of other communicable diseases in
that country. This indicates poor health policy on part
of our government because of failure of controlling
communicable disease burden in our study area.
The increase in incidence of communicable
diseases might also be the result of better screening
programmes introduced in the health sector. A study
“Active Case Finding of Tuberculosis: Randomized
Evaluation of Simple and Infotainment Chest Camps”15
showed increased incidence of TB when asymptomatic
people were screened for TB.
Communicable diseases have 11.3% mortality
in the before 2000 group. It has 19.0% mortality in the
2000-2016 group. It shows that mortality from communi-
cable diseases have increased in the study area during
the given study time.
Overall, non-communicable diseases have 73.1%
morbidity during before 2000 group. It has 57.4% mor-
bidity in the 2000-2016 group. It shows that non-com-
municable diseases prevalence is decreasing in this
area during the study period. This result is quite similar
to the result from another study “Stroke incidence in
Victoria, Australia-Emerging improvements”16 in which
a significant decline was noticed in the stroke (a major
NCD) incidence from 2003-04 to 2007-08. But a con-
trasting result can be found to that of ours in a study
done in Karachi, Pakistan17 in which burden of diabetes
was found to be increasing.
Non-communicable diseases have 88.7% mor-
tality in the before 2000 group. It has 81% mortality
in the 2000-2016 group. It shows that mortality from
non-communicable diseases have decreased in the
study area during the given study time.
Thus our study results contradict the general
trend in the world. According to the study “Risk profiles
for non-communicable diseases in rural and urban
schoolchildren in the Republic of Cameroon”18, NCDs
are on the rise in urban schoolchildren because of
the sedentary lifestyle. Another study conducted on
Non-communicable diseases in sub-Saharan Africa19:
showed that now Sub-Saharan Africa (SSA) has a very
high burden of both infectious and chronic diseases.
Current disease estimates for SSA are based on sparse
data, but projections indicate increases in non-commu-
nicable diseases (NCDs) caused by demographic and
epidemiologic transitions. The same contradiction from
our study can also be found in the study “Estimating the
prevalence, hospitalization and mortality from T2DM in
Nigeria: a systematic review and meta-analysis”20 which
shows increased prevalence of T2DM.But our research
in the urban areas of Peshawar shows that communica-
ble diseases are on the rise which is an alarming result.
243
CONCLUSION
It was concluded that the morbidity and mortal-
ity from communicable diseases is on the rise in our
study area but overall prevalence and mortality from
non-communicable diseases is still significantly high
compared to communicable diseases. From the results
of our study we can speculate that the rest of KPK also
has same trend in the prevalence of diseases. The gov-
ernment needs to take serious steps in order to control
the rise of communicable diseases. Most important step
in this regard will be the establishment of sanitation
barrier.Pakistan needs to work out an extraordinary
strategy for the challenges ahead, as it continued to
witness a double burden of diseases including both
communicable and non-communicable diseases.
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ble diseases.Ann Trop Med Parasitol. 2006 Jul-
Sep;100(5-6):455-64.
2. Hori H1, Watanabe M, Sakurai M.Infectious dis-
eases in African children.ActaPaediatrJpn. 1993
Dec;35(6):553-8.
3. Jafar TH1, Haaland BA, Rahman A, Razzak JA, Bilger
M, Naghavi M, Mokdad AH, HyderAA.Non-commu-
nicable diseases and injuries in Pakistan: strategic
priorities.Lancet. 2013 Jun 29;381(9885):2281-90
4. Bela Shah and PrashantMathurSurveillance of car-
diovascular disease risk factors in India: The need
& scope.7 AbstractIndian J Med Res. 2010 Nov;
132(5): 634–642.
5. Ali Khan Khuwaja,corresponding author1 Saleem
Khawaja,2 Komal Motwani,2 Adeel Akbar Kho-
ja,2 Iqbal Syed Azam,3 Zafar Fatmi,4 BadarSabir
Ali,5 and Muhammad Masood Kadir6Preventable
Lifestyle Risk Factors for Non-Communicable Dis-
eases in the Pakistan Adolescents Schools Study
1 (PASS-1)J Prev Med Public Health. 2011 Sep;
44(5): 210–217.
6. Biswas T,PervinS.The prevalence of underweight,
overweight and obesity in Bangladeshi adults: Data
from a national survey.Published online 2015 Jan 16.
doi: 10.1371/journal.pone.0177395
7. Celermajer DS1, Chow CK, Marijon E, Anstey NM,
Woo KS.Cardiovascular disease in the developing
world: prevalences, patterns, and the potential of
early disease detection. J Am CollCardiol. 2012 Oct
2;60(14):1207-16.
8. Bovet P1.The epidemiologic transition to chronic
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mortality, morbidity, and risk factors in Seychelles
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9. Anand K1, Shah B, Yadav K, Singh R, Mathur P,
Paul E, KapoorSK.Are the urban poor vulnerable
to non-communicable diseases? A survey of risk
factors for noncommunicable diseases in urban
slums of Faridabad.Natl Med J India. 2007 May
Jun;20(3):115-20.
10. Khan FS1, Lotia-Farrukh I, Khan AJ, Siddiqui ST,
Sajun SZ, Malik AA, Burfat A, Arshad MH, Codlin
AJ, Reininger BM, McCormick JB, Afridi N, Fish-
er-Hoch SPmesMDThe burden of non-communi-
cable disease in transition communities in an Asian
megacity: baseline findings from a cohort study in
Karachi, Pakistan.
11. SaniaNishtarPrevention of non-communicable dis-
eases in Pakistan: an integrated partnership-based
model. Health Res Policy Syst. 2004; 2: 7.
12. Zielinski A, Sadkowska-Todys MA. Infectious diseas-
es in Poland in 20142016;70(2):167-181
13. Hassan S, Imtiaz R, IkramN Public health surveil-
lance at a mass gathering: urs of Baba Farid, Pakpat-
tan district, Punjab, Pakistan, December 2010East
Mediterr Health J, 2013;19 Suppl 2:S24-8
14. Mu TT, Sein AA, Min M. Malaria incidence in Mayan-
mar 2005-2014: steady but fragile progress towards
elimination2016 Oct 18;15(1):503
15. Khan MA, Anil S, Ahmed M. Active Case Finding
of Tuberculosis: Randomized Evaluation of Simple
and Infotainment Chest CampsPublished on 2016
Sep- Oct;82(5):813-818.
16. Clissold BB, Sundararajan V. Stroke incidence in Vic-
toria, Australia-Emerging improvementsPublished
on 2017 May 4;8:180.
17. Shera AS, Fawwad A, BasitA Prevalence of metabolic
syndrome in urban Pakistan (Karachi): comparison
of newly proposed International Diabetes Federation
and modified Adult Treatment Panel 3 criteria2009
Apr;7(2): 119-24.
18. Proctor MH1, Moore LL, Singer MR, Hood MY,
Nguyen US, Ellison RC.Risk profiles for non-com-
municable diseases in rural and urban schoolchil-
dren in the Republic of Cameroon.Ethn Dis. 1996
Autumn;6(3-4):235-43.
19. Dalal S1, Beunza JJ, Volmink J, Adebamowo C,
Bajunirwe F, Njelekela M, Mozaffarian D, Fawzi W,
Willett W, Adami HO, Holmes MD Non-communica-
ble diseases in sub-Saharan Africa: what we know
now Int J Epidemiol. 2011 Aug;40(4):885-901.
20. Adeloye D, Ige JO, Amoo EO. Estimating the prev-
alence , hospitalization and mortality from T2DM in
Nigeria: a systematic review and meta-analysis 2017
May 11;7(5):e015424.
KJMS May - August, 2020, Vol. 13, No. 2
 FREQUENCY OF BACTERIAL CO-INFECTION IN PATIENTS
WITH MALARIA
Muhammad Nouman1, Fawad Rahim1, Huma Gul2, Muhammad Ayub3, Sadaf Chiragh4, Muhammad Yousaf5

ABSTRACT
Objective: To determine the frequency of concomitant bacterial infection in patients with malaria.
Material and methods: This descriptive cross-sectional study was conducted at Department of Medicine, Hayatabad
Medical Complex, Peshawar. After informed consent, a total of 179 patients with malaria were included using consecu-
tive sampling technique Patients who have had antibiotic treatment in the last 72 hours were not included in the study.
Using aseptic technique, 10 ml blood was collected from the study participants in aerobic blood culture bottle and
was submitted in microbiology laboratory for bacterial culture. All patients received standard treatment for malaria.
Admitted patients were informed about result of their blood culture in person in ward, and outpatients were informed
on follow up visit after 3 days. Those with growth of pathogenic bacteria on blood culture, if not already on antibiotic,
were advised antibiotic treatment. Demographic parameters and result of blood culture were recorded on predesigned
proforma. Data was analyzed using SPSS version 17. Descriptive statistics were performed for age, gender and result
of bacterial culture. Results were presented as tables.
Results: The mean age of study population was 34.77±10.85 years, with male predominance (69.8%). 5.6 % (10/179)
patients with malaria had bacterial growth of on blood culture.
Conclusion: Failure to improve with optimum antimalarial therapy shall raise suspicion of concomitant/superadded
bacterial infection and further work up shall be considered in such cases.

INTRODUCTION from 4.6 to 11.7% in children.3-6 and 0.5 to 14.3% in

Malaria is endemic in over hundred countries,
making it a significant public health problem. Around
2.6 billion people are vulnerable to get Plasmodium
vivax (p. vivax) malaria, with 130-435 million projected
to get infected with P. vivax infection annually.1
Half of the world’s population is at risk from ma-
laria. n 2018, an estimated 228 million cases of malaria
occurred worldwide. Most malaria cases in 2018 were
in the World Health Organization (WHO) African Region
(213 million or 93%), followed by the WHO South-East
Asia Region. In 2018, there were an estimated 405 000
deaths from malaria globally.2
Researchers have focused on concomitant bac-
terial infection in patients with malaria. Majority of these
studies have been carried out in Africa where malaria
is endemic. Prevalence of bacterial infections ranging
adults has been reported.7-9 Other studies on patients
with malaria have found the prevalence of invasive bac-
terial infection of 0.3 % and 24 to 30% in Sweden and
Switzerland, respectively.10,11 Regionally, authors from
India have reported prevalence of bacterial infection in
adult patients with malaria between 1.3 to 6.7%.12-14
The presence of bacterial co-infection in a pa-
tient with malaria has implications for management
of these patients. These patients may have persistent
fever after adequate treatment for malaria and may
be mismanaged as cases of anti-malarial resistance.
Early diagnosis with blood culture and treatment with
appropriate antibiotics will decrease their morbidity and
mortality. The purpose of this study was to generate
local evidence in this regard. The results may help in
developing local protocol about screening patients with
malaria for concomitant bacterial infection.

1Department of Medicine, MTI/Hayatabad Medical MATERIALS AND METHODS

Complex, Peshawar
This descriptive cross-sectional study was con-
2Department of paedriatic HMC
ducted at Department of Medicine, Hayatabad Medical
3Medical ward sadu medical college swat
Complex, Peshawar. After informed consent, a total of
4Department of Oncology Hmc
179 patients with malaria were included using con-
5Medical officer tank
secutive sampling technique during the study period
.........................................................................................
of 10 months. The diagnosis of malaria was based in
Address for correspondence:
demonstration of malarial parasite on thick and/or thin
Dr. Fawad Rahim
smear. Patients who have had antibiotic treatment in
Department of Medicine, MTI/Hayatabad Medical Com-
the last 72 hours were not included in the study.
plex, Peshawar
Email: drfawadrahim@outlook.com Using aseptic technique, 10 ml blood was collect-
Cell: ????

KJMS May - August, 2020, Vol. 13, No. 2 245

ed from the study participants in aerobic blood culture
bottle and was submitted in microbiology laboratory
for bacterial culture. All patients received standard
treatment for malaria. Admitted patients were informed
about result of their blood culture in person in ward,
and outpatients were informed on follow up visit after
3 days. Those with growth of pathogenic bacteria on
blood culture, if not already on antibiotic, were advised
antibiotic treatment.
Demographic parameters and result of blood cul-
ture were recorded on predesigned proforma. Data was
analyzed using SPSS version 17. Descriptive statistics
were performed for age, gender and result of bacterial
culture. Results were presented as tables.
RESULTS
Out of total 179 patients, 125 (69.8%) were male.
Table 1: Demographic parameters of study popula-
tion (n=179)
Age in years, (Mean ± SD) 34.77±10.85
Age groups
16-25 years, No. (%) 54 (30.1%)
26-35 years, No. (%) 64 (35.8%)
Above 35 years, No. (%) 61 (34.1%)
Gender
Male, No. (%) 125 (69.8%)
Female, No. (%) 54 (30.2%)
Table 2: Frequency of positive blood culture
Bacterial culture No. % CONCLUSIONS
Positive 10 5.6 %
Negative 169 94.4 %
Total 179 100%
The mean age of study population was 34.77±10.85
years. Demographic parameters of study population
are outlined in table 1. 10 (5.6 %) out of 179 patients
had bacterial growth of on blood culture. (Table 2)
DISCUSSION
Malaria is endemic in our part of the world and
often present with fever without other focal symptoms
and signs. Certain bacterial infections like salmonellosis
can present in the same way. Researchers have docu-
mented blood stream bacterial infections in patients with
children and adults with malaria.3-5,8,10,13 particularly in
areas of holoendemic malaria transmission, are largely
unexplored, blood cultures and comprehensive clinical,
laboratory, hematological, and nutritional parameters
for malaria-infected children (aged 1 to 36 months, n
= 585 patients
In this study, 5.6% of patients with malaria had
246
systemic bacterial infection documented through a
positive blood culture. Investigators from Africa and
India have reported similar prevalence of bacterial infec-
tion.3-6,13,15particularly in areas of holoendemic malaria
transmission, are largely unexplored, blood cultures
and comprehensive clinical, laboratory, hematological,
and nutritional parameters for malaria-infected children
(aged 1 to 36 months, n = 585 patients Findings of this
study are in contrast with those reported by Nwuzo et
al.7 and Mbuh et al.8 from Africa who have reported
very low rate of positive bacterial cultures in patients
with malaria. The divergence may be due to the fact
that they have reported growth of salmonella only.
Similarly, this study has reported higher prevalence
of bacterial infection in malaria patients as compared
to those reported by Pattanaik et al.14 from India. This
disagreement may be because of difference in the study
population as they have included non-severe cases of
malaria. In the same manner, our prevalence is higher
than that reported from Sweden (0.3%)10 where they
have studied returning travelers with malaria.
A Study from Nigeria9 has reported higher prev-
alence (14.4%)of bacterial infection than this study.
This may be due to differences in study population
with regard to genetics, endemicity of salmonella and
hygienic conditions. Similarly, authors from Switzerland-
11
between one and three malaria-associated deaths oc-
cur annually in Switzerland. In this retrospective study,
33 deaths (25 men and 8 women have observed the
prevalence of bacterial co-infections up to 24 – 30%.
But they have studies only patients admitted in inten-
sive care who are anyways at higher risk of acquiring
bacterial infections.
Malaria is endemic in Pakistan and is one of the
most common differential diagnoses in patients present-
ing with fever without localizing symptoms and signs.
Lack of response to adequate antimalarial therapy shall
raise suspicion of concomitant/superadded bacterial
infection and further work up shall be considered in
such cases.
REFERENCES
1. Rizvi I, Tripathi D, Chughtai A, Beg M, Zaman S,
Zaidi N. Complications associated with Plasmodium
vivax malaria: A retrospective study from a tertiary
care hospital based in western Uttar Pradesh, India.
Ann Afr Med. 2013;12(3):155-159. doi:10.4103/1596-
3519.117624
2. Global Malaria Programme: WHO Global. World
Malaria Report 2019.; 2019. https://www.who.int/
news-room/fact-sheets/detail/malaria.
3. Bronzan RN, Taylor TE, Mwenechanya J, et al. Bacte-
remia in Malawian children with severe malaria: Prev-
alence, etiology, HIV coinfection, and outcome. J
Infect Dis. 2007;195(6):895-904. doi:10.1086/511437
KJMS May - August, 2020, Vol. 13, No. 2
4. Bassat Q, Guinovart C, Sigaúque B, et al. Severe
malaria and concomitant bacteraemia in children
admitted to a rural Mozambican hospital. Trop Med
Int Heal. 2009;14(9):1011-1019. doi:10.1111/j.1365-
3156.2009.02326.x
5. Were T, Davenport GC, Hittner JB, et al. Bactere-
mia in Kenyan children presenting with malaria. J
Clin Microbiol. 2011;49(2):671-676. doi:10.1128/
JCM.01864-10
6. Church J, Maitland K. Invasive bacterial co-infection
in African children with Plasmodium falciparum
malaria: A systematic review. BMC Med. 2014;12(1).
doi:10.1186/1741-7015-12-31
7. Nwuzo AC, Onyeagba RA, Iroha IR, Nworie O, Oji
AE. Parasitological, bacteriological, and cultural
determination of prevalence of malaria parasite
(Plasmodium falciparum) and typhoid fever co-in-
fection in Abakaliki, Ebonyi State. Sci Res Essays.
2009;4(10):966-971.
8. Mbuh FA, Galadima M, Ogbadu L. Rate of Co-In-
fection With Malaria Parasites and Salmonella Typhi
in Zaria , Kaduna State , Nigeria. Ann Afr Med.
2003;2(2):64-67.
9. Ekesiobi A, Igbodika M, Njoku O. Co-infection of
malaria and typhoid fever in a tropical community.
Anim Res Int. 2009;5(3):888-891. doi:10.4314/ari.
v5i3.48754
10. Sandlund J, Naucler P, Dashti S, et al. Bacterial
coinfections in travelers with malaria: Rationale for
antibiotic therapy. J Clin Microbiol. 2013;51(1):15-21.
doi:10.1128/JCM.02149-12
11. Christen D, Steffen R, Schlagenhauf P. Deaths
caused by malaria in Switzerland 1988-2002. Am J
Trop Med Hyg. 2006;75(6):1188-1194. doi:10.4269/
ajtmh.2006.75.1188
12. Chakrabarti D, Sah S, Trivedi AS BA. Clinical profile of
co-infections and bacterimia in adults with malaria–
An experience from a Tertiary Care Hospital in North-
eastern India. Ind Med Gaz. 2015;May:174-180.
13. Bhattacharya SK, Sur D, Dutta S, et al. Vivax malaria
and bacteraemia: A prospective study in Kolkata,
India. Malar J. 2013;12(1):10-13. doi:10.1186/1475-
2875-12-176
14. Pattanaik SS, Tripathy R, Panda AK, Sahu AN, Das
BK. Bacteraemia in adult patients presenting with
malaria in India. Acta Trop. 2012;123(2):136-138.
doi:10.1016/j.actatropica.2012.04.001
15. Berkley JA, Bejon P, Mwangi T, et al. HIV infec-
tion, malnutrition, and invasive bacterial infection
among children with severe malaria. Clin Infect Dis.
2009;49(3):336-343. doi:10.1086/600299

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KJMS May - August, 2020, Vol. 13, No. 2 247

 DERMATOLOGIC SPECTRUM OF PATIENTS PRESENTING
WITH DENGUE INFECTION AND THEIR CO-RELATION WITH
SEVERITY OF THE DISEASE
IrfanUllah1, Muhammad Majid Paracha2, Mehran Khan1, Hina Zahoor3, Dawood Khan1, Ayesha Saleh1

Abstract
Objectives: To observe dermatologic spectrum of patients presenting with dengue infection and their co-relation with
severity of the disease.
Material and Methods: This prospective cross-sectional study was conducted at Khyber teaching hospital Peshawar,
from July 2017 to January 2018. Two hundred and twenty eight patients were enrolled in the study. Patients fulfilling
the inclusion criteria were subjected to detailed history, clinical, mucocutaneous and systemic examination. Relevant
investigations were done. Data was recorded in pre-designed pro forma and analyzed.
Results: Among a total of 228 patients included in the study, 123 were male and 105 were female. The mean age was
34.57±14.9 years. There was significant association of mucosal manifestations with dengue fever and dengue hemor-
rhagic fever, while cutaneous manifestations had significant association with dengue shock syndrome with p-value of
less than 0.05. Mucosal findings in dengue disease were found to be significantly associated with headache, bleeding,
abdominal pain, epistaxis, deranged liver function tests, deranged renal function tests, thrombocytopenia, deranged
PT, deranged APTT, high hematocrit level and unfavorable outcome, while bleeding, high hematocrit, ascites, abdom-
inal tenderness and unfavorable outcome of the disease were found to have significant correlation with cutaneous
manifestations, with p-value of less than 0.05.
Conclusion: Mucocutaneous manifestations can be used as an earlier marker to predict the development of compli-
cations, laboratory abnormalities and severe dengue disease.
Key Words: Dengue fever, dengue hemorrhagic fever, dengue shock syndrome, mucocutaneous manifestations,
dermatological spectrum
Abbreviations: DF (dengue fever), DHF( dengue hemorrhagic fever), DSS(dengue shock syndrome)

INTRODUCTION DSS is 1% in treated cases, which escalates to 20% in

Dengue, described as “break bone fever” by
Benjamin Rush, is fast emerging mosquito borne
viral infection caused by dengue virus (DENV).1 The
condition is endemic in both subtropical and tropical
areas.2Dengue patients present with wide spectrum of
clinical manifestations. Patient may have silent infection
with no symptoms, or may have flu-like illness, dengue
fever (DF). Few patients, however, presents with severe
dengue disease (SDD), including dengue hemorrhagic
fever (DHF) and dengue shock syndrome (DSS).3
About 2.5 billion population worldwide are at risk
of developing this infection. In 100 endemic countries,
approximately 50 million cases have been reported,
including hospitalization of nearly half a million cases,
and death of 22,000 cases.4,5 The mortality rate of DHF/
1 ?????Khyber Teaching Hospital
2?????Lady Reading Hospital
3?????Hayatabad Medical Complex
.........................................................................................
Address for correspondence:
Mohammad Majid Paracha
?????
Cell: 03339637010
E-mail: mohammadmajidparacha@gmail.com
untreated cases.4
Dengue is febrile illness, that can affect infants,
young children and adults of all ages.6 Dengue patients
present with wide spectrum of clinical manifestations.
Patient may have silent infection with no symptoms, or
may have flu-like illness, dengue fever (DF). However,
patients may present with severe dengue disease
(SDD), including dengue hemorrhagic fever (DHF) and
dengue shock syndrome (DSS).2,3
The symptoms of dengue fever appear in 3-14
days after the bite of infective mosquito.6 It is an acute
illness, with sudden onset of high grade fever, with
headache and skin rash. This triad is called ‘dengue
triad’. There may be exhaustion, muscle aches and
severe joints pain and swollen glands. Laboratory find-
ings in dengue patients may show thrombocytopenia,
relative leukopenia, haemoconcentration, deranged
liver function tests, deranged renal function tests.7 Dis-
seminated intravascular coagulation may be mediated
in cases in which dengue antigen-antibody complexes
mediate complement activation and release of vasoac-
tive amines.8 However, most of the patients presenting
with classical dengue fever recover completely without
any complications.9 In addition to classical dengue

248 KJMS May - August, 2020, Vol. 13, No.2

fever, if there is appearance of hemorrhagic rash or
hemorrhagic manifestationsin patient, then it is called
dengue hemorrhagic fever.10 Dengue shock syndrome is
associated with low blood pressure, altered sensorium
and delayed capillary refilling. 10 Dengue hemorrhagic
fever and dengue shock fever has higher mortality rate,
unless prompt and adequately treated.6 Sequential
infection increases the chance of dengue hemorrhagic
fever and dengue shock syndrome.10
Dengue fever is diagnosed my several methods.
However, an accurate means that can help to predict the
severity and prognosis of the disease at an early stage of
disease is not available. Patients initially asymptomatic
or with mild dengue fever can develop severe dengue
disease later.3 It is important to look for those signs and
symptoms of the disease that can help to determine
the progression of disease to severe dengue disease.
This will also help to provide necessary care to patients,
who are at risk of developing SDD and to reduce un-
necessary hospitalization of stable cases.3It will also
help in reducing disease burden and will play role in
controlling the progression of disease to severe dengue
disease.11, 12 The dengue guidelines in 2009, regarded
abdominal tenderness or pain, vomiting, lethargy,
restlessness and mucosal bleeding as warning signs
and symptoms of severe dengue disease. Correlation
was found between the frequency of nausea, vomiting,
abdominal pain, cutaneous rash, bleeding and severe
dengue disease.11,12 It was also found that certain viral
factors, host immune reactions and laboratory tests
can also help in predicting severe dengue disease.13
Few studies show effect of age and sex on the clinical
presentation of disease as well.14,15,16,17
The clinical manifestations of dengue fever can
be used as an earliest marker to predict severe den-
gue disease. At their presentation, there is a need to
identify those the patients who need critical care in ICU
depending upon the presence of warning signs.18 The
reports on to predict severe dengue fever on basis of
presence or absence of warning signs are inconsis-
tent. We conducted a study to identify the cutaneous
manifestations, systemic signs and symptoms, and
laboratory tests that are associated with severe dengue
disease. This will help to find better methods to predict
the development of severe dengue disease in patients
presenting with dengue fever in both outpatient and
inpatient departments.
MATERIAL AND METHODS in 4, aphthous ulcers in 2 patients. 2 patients had any
The study was conducted in Department of Der-
matology, Khyber Teaching Hospital, Peshawar from
July 2017 to January 2018. Patients presenting with
positive NS.1 test and diagnosed with dengue fever
were enrolled in the study from outpatient and inpatient
departments. All ages and both gender were included.
Patients with other acute or chronic concurrent ailments
besides dengue fever were excluded from the study.
KJMS May - August, 2020, Vol. 13, No.2
An informed consent was taken. A detail history was
obtained. Clinical, mucocutaneous and systemic ex-
amination was carried out. Relevant investigations such
as hematocrit, platelet count, white blood cells count,
coagulation profile, liver function test, renal function
tests, dengue serology (IgG, IgM) and dengue NS.1
were done. The data was entered on pre-designed
proforma and later analyzed.
Type of study
A Prospective cross sectional study
Statistics
Analysis of results was made using SPSS version
22. Frequencies and percentages were calculated
for all the categorical variables like gender, age, skin
findings, mucosal manifestations. Mean ± standard
deviation was calculated for continuous variables like
age, temperature, onset of fever, blood pressure, pulse
etc. Post stratification Chi-square test was applied, in
which p-value less than 0.05 was considered as signif-
icant. Pearson’s correlation coefficient was calculated,
and one sample T-test was used wherever applicable.
The results were expressed as percentages and signif-
icance.
RESULTS
A total of 228 patients were included in the study.
Majority of the cases, 123 (53.9%) were males and 105
(46.1%) were females. Mean age of patients in the study
was 34.57+_14.94 years, with age range of 1 to 72
years. Maximum patients, 64 (28.1%) belonged to the
age group of 21-30 years as shown in table 1. Number
of cases reported among the under the age of 10 years
were 10 (4.4%).
Total number of patients who presented with cu-
taneous manifestations was 108(47%), while mucosal
findings were present in 59(25.9%) cases. 37(16.2%)
patients had both cutaneous and mucosal manifesta-
tion. 147(64.5%) patients had classical dengue fever,
61 (26.8%) patients had dengue hemorrhagic fever
and 20(8.7%) patients had dengue shock syndrome
as shown in table 2.
In this study, 35 patients with dengue fever had
mucosal, and 95 patients with dengue fever had cu-
taneous manifestations. Among the mucosal lesions,
erythema was present in 14, oral thrush in 13, purpura
other mucosal findings. Pruritis was present in 35 and
maculo-papular rash was present in 29 patients. 12
patients had purpura and similar number of patients
had burning sensation on skin. Only 7 patients had
other skin rash as shown in table 2.
In patients with dengue hemorrhagic fever, 17
had mucosal and 48 had cutaneous manifestations.
10 patients had erythema of mucosal surfaces, 05 had
249
 Table 1: Demographic characteristics of patients with dengue fever (n=228)

Characteristics Number Percentage

Age groups Up to 10 10 4.4%
11-20 31 13.6%
21-30 64 28.1%
31-40 53 23.2%
41-50 38 16.7%
51-60 20 8.8%
>60 12 5.3%
Gender Male 123 53.9%
Female 105 46.1%

Table 2: Mucocutaneous manifestations in patients with dengue fever, dengue hemorrhagic fever and dengue
shock syndrome.

Dengue fever Dengue hemorrhagic fever Dengue shock syndrome

Total patients 147(64.5%) 61(26.8%) 20(8.7%)
Mucosal manifestations
Erythema 14 10 5
Thrush 13 0 0
Purpura 4 0 1
Aphthous ulcers 2 5 1
Anyother 2 2 0
Total 35 (23.8%) 17 (27.8%) 7 (35%)
p-value 0.022(0.744) 0.018(0.790) 0.065(0.332)
Cutaneous manifestations
Pruritis 35 31 9
Maculopapular rash 29 15 3
Purpura 12 4 1
Burning 12 5 3
Other skin rash 7 6 1
Total 95 (64.6%) 48 (78.6%) 17 (85%)
p-value 0.163(0.014) 0.158(0.017) 0.027(0.683)

aphthus ulcers and 02 had other mucosal findings. 31
patients had pruritis, 15 had maculo-papular rash, 05
had burning and 04 had purpura on the skin. Only 6
patients had other cutaneous manifestations shown in
table 2.
Among patients with dengue shock syndrome,
mucosal erythema was present in 05 patients, while
aphthous ulcers and purpura were noted in a single
patient each. On the other hand, 09 patients had pruritis,
03 patients had maculo-papular rash, 03 had burning
sensation, with one patient having cutaneous purpura.
Only one patient in dengue shock syndrome presented
in erythroderma as shown in table 2.
The association of mucosal manifestations with
dengue fever was statistically significant, with p-value of
less than 0.05. Dengue hemorrhagic fever also had sig-
nificant association with mucosal findings as well. The
association of cutaneous manifestations was, however,
not significant with dengue fever and dengue hemor-
rhagic fever. In dengue shock syndrome, association
with cutaneous manifestations was found significant as
shown in table 2. Gender was found to have significant
association with severity of dengue disease, while age
was found to have association with mucosal and cuta-
neous manifestations of dengue disease as shown in
table 3.
In this study, Fever was present in 82 (35.96%) pa-

250 KJMS May - August, 2020, Vol. 13, No.2

 Table 3: Frequency of clinical features, complications and laboratory abnormalities in patients with dengue viral
illness and their association with mucocutaneous manifestations of dengue disease

Clinical signs and Present P-value

symptoms
Number (n=228) Frequency Mucosal manifes- Cutaneous manifes-
tations tations
Fever 82 35.96% 0.064 0.102
Anorexia 157 68.9% 0.051 0.097
Headache 155 68% 0.002 0.059
Bleeding 41 18% 0.042 0.026
Malaise 141 61.8% 0.155 0.113
Vomiting 133 58.5% 0.073 0.059
Abdominal pain 95 41.7% 0.049 0.095
Epistaxis 27 11.8% 0.031 0.116
Laboratory investi-
gations
Deranged liver func- 84 36.8% 0.026 0.059
tion tests
Deranged renal func- 6 2.6% 0.028 0.058
tion tests
Thrombocytopenia 119 83.8% 0.018 0.077
Leukopenia 94 41.3% 0.072 0.092
Deranged PT 11 4.8% 0.040 0.106
Deranged APTT 6 2.6% 0.028 0.058
High hemato- 87 38.15% 0.042 0.002
crit(>52%)
Complications
Ascites 21 9.2% 0.054 0.040
Pleural effusion 33 14.4% 0.070 0.055
Abdominal tender- 39 17.1% 0.051 0.043
ness
Pericarditis 0 0 0 0
Unfavorable out- 67 29.38% 0.009 0.011
come (admitted)

tients at the time of examination, anorexia in 157(68.9%),
headache in 155 (68%), malaise in 141(61.8%), Vomiting
in 133(58.5%), Abdominal pain in 95(41.7%), Bleeding
in 41(18%) and Epistaxis was present in 27(11.8%).
There was significant association between presence of
mucosal manifestations and abdominal pain, epistaxis,
headache and bleeding as shown in table 3. Cutaneous
manifestations of dengue viral illness was found to have
correlation with bleeding only, with p-value of <0.05, as
shown in table 3.
Hematocrit was found to be greater than 52% in
87 (38.15%) patients, and was found to have significant
correlation with both mucosal and cutaneous manifes-
tations as shown in table 3. 119 (83.8%) patients had
thrombocytopenia, with 116 (50.9%) patients having
platelets of less than 50,000/mm3. Leukopenia was
found in 94(41.3%) patients, among which 2(0.8%) pa-
tients had total leukocyte count of less than 1000/mm3.
PT was found deranged in 11 (4.8%) patients while
APTT was deranged in 6(2.6%) patients. PT, APTT and
platelets count had significant correlation with mucosal
manifestations of the disease only as shown in table 3.
Liver function tests were above the normal range in 84
(36.8%) cases and renal function tests were abnormal
in 6(2.6%) cases, with both of these biochemical ab-
normalities of the disease showing positive association
with mucosal findings of dengue viral illness as shown
in table 3.

KJMS May - August, 2020, Vol. 13, No.2 251

 Complications, like ascites were present in 21
(9.2%) patients, pleural effusion was present in 33
(14.4%) patients, and 39 (17.1%) patients had abdom-
inal tenderness. Pericarditis was not documented in any
patient. Presence of ascites and abdominal tenderness
had significant association with presence of cutaneous
manifestations of dengue disease as shown in table 3.
Among 228 enrolled patients, 151(66.2%) patients
were stable at the time of examination and were treated
as an outpatient. 67(29.38%) patients were admitted in
the hospital, while 10(4.3%) patients presented to der-
matology department at the time of discharge. Disease
unfavorable outcome like admission for the presence of
complications was found to have significant association
with cutaneous and mucosal manifestations of dengue
disease with p-value of less than 0.05, as shown in table
3.
DISCUSSION
Dengue fever incidence is increasing worldwide
and is becoming one of the most challenging problem
for public health sectors in tropical and subtropical
countries.19 Dengue has wide range of clinical presen-
tations. It can present as dengue fever (DF), with mild
flu-like symptoms, dengue hemorrhagic fever (DHF)
and dengue shock syndrome (DSS), however, the
published studies about the signs and symptoms and
their association with dengue hemorrhagic fever and
dengue shock syndrome are inconclusive. 20
A total of 228 patients were enrolled in the study.
Majority of the patients were male, with male to female
ratio of 1.17:1. This finding was consistent with Giraldo
et al in which male to female ratio of patients with fever
was 1.04:1.12 Mean age of patients was 34.57±14.9
years with maximum patients belonging to the age
group between 21-30 years which was consistent with
Afzal et al.21
Total number of patients with mucosal mani-
festations was 25.9%. Chadwich et al showed that
the mucosal involvement was found in 14% cases. In
another study it was estimated to be 15- 30%, in which
more mucosal involvement was seen in patients with
dengue hemorrhagic fever. In this study, the percentage
of patients with dengue hemorrhagic fever, the mucosal
involvement was more as compared to dengue fever,
which was again consistent with Thomas et al.22 Total
number of patients who presented with cutaneous man-
ifestations was 108(47%), which was consistent again
with Thomas et al where cutaneous manifestations was
present in 46% cases.23
This study showed that the frequency of pa-
tients developing mucocuatenous manifestations was
increasing with increase in severity of dengue viral
illness, being highest for patients with dengue shock
syndrome. Zhang et al concluded that there is 14 fold
increase in the chance of developing severe dengue
252
disease if patient develop hemorrhagic manifestations
like purpura. Zhang et al also proved that cutaneous
manifestations can be helpful to predict the progression
of dengue viral illness to severe dengue disease. 20
Similarly, in the study, there was significant correlation
between cutaneous manifestations and dengue shock
syndrome with p-value of <0.05.
The study showed significant correlation of mu-
cosal manifestations with dengue fever and dengue
hemorrhagic fever, which was similar to findings in
the study where mucocutaneous signs were used as
warning signs to help identify patients at risk of shock
in dengue viral illness.24
In the study, maximum patients had anorexia
(68.9%), followed by headache (68%), malaise(61.8),
vomiting (58.5%), abdominal pain 41.7%, bleeding
(18%) and Epistaxis (11.8%). In Kumar et al, maximum
number of patients had malaise (64.6%) followed by
headache (47.6%), vomiting (47.6%) and abdominal
pain (37.5%) in the same order which was surprisingly
consistent with the study. 25
In this study, 83.8% patients had thrombocytope-
nia and 41.3% had leukopenia, which was contrary to
Saleem et al, in which all the patients with dengue fever
presented with thrombocytopenia and leukopenia.23
Liver function tests were found to be deranged in 5.8%
patients among Thai patients in Wichkam et al, while in
this study, liver function tests were found deranged in
36.8%.26 In another study, 28% patients had deranged
liver function tests. Hematocrit was abnormal in 38.15%
which was consistent with Ali et al in which deranged
hematocrit level was a common finding.27 Only 1.5%
patients had renal failure in Kumar et al, which was
found in 2.6% in this study.25
Among the complications, pleural effusion was
present in 30.3% cases in the study while in this study
the frequency of pleural effusion in patients with dengue
disease was 14.4%.25
CONCLUSION
This study highlights that mucosal and cutaneous
manifestations has association with the severity of den-
gue disease, and can be used as one of the warning
sign to predict the prognosis of the illness at the time
of presentation. The mucocutanous manifestations are
also found to be significantly associated with labora-
tory abnormalities and organ involvement in dengue
disease, and so can help to prevent the development
of complications by managing these cases vigilantly.
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253
 EXPERIENCE OF PERIPHERAL NEURECTOMY IN CASE OF
TRIGEMINAL NEURALGIA TREATMENT A RETROSPECTIVE
ANALYSIS OF 40 CASES
Rizwan Ullah, Kamran Ullah, Mushtaq, Ayaz, Imran, Nawaz

ABSTRACT
Objective: To note the efficacy of peripheral neurectomy in 40 cases of trigeminal neuralgia for typical single branch
of fifth nerve involvement and chronic post herpetic pain.
Material And Method: There were fifteen male and 25 female patients with average age of 40 to 70 years who had
undergone neurectomy retrospectivelyanalyzed for relieve of immediate pain and to note complications and recurrence
of pain in a follow up period of 2 to 3 year
Results: No major complications occurred with the exception of two incidental cases of maxillary sinus masses and
recurrence of pain in 07 patients.
Key words: Trigeminal neuralgia,peripheral procedure, Neurectomy.

INTRODUCTION A local infiltration of nerve block involved confined

The international association for the study of
pain describes the neuropathic pain asensuing from a
disease in the central and peripheral nervous system1.
Trigeminal neuropathic pain syndrome is define as
unilateral disordered characterized by sudden severe
sharp spasmodic short duration sad stabbing(8S)usu-
allyunilateral facial pain in one of branch of the fifth cra-
nial nerve2, Started by minimal stimuli such as talking,
sneezing, eating, brushing teeth, washing face. It was
first accurate described by John fothergill in 1773 also
called fothergill disease3. It starts in second and ends
in short time to keep the patient all the time in constant
apprehension of the next similar attack. The episode of
attack increases with time if not treated properly. It oc-
curs mostly about 40 year of age and affects both male
and females. Slight increase percentage in females. The
area which is very sensitive even by puff hair touch the
pain starts is called trigger zone. The different etiological
factors are
The nerve compression by vessels loops, aneu-
rysm, AVM, tumors, multiple sclerosis,post herpetic also
postmeningitis4, 10.
Other etiological factors may be diabetes mellitus
congenital skull base deformities, non myelinating dis-
ease of pon and medulla, while in the majority of cases
the etiology is not known i-e idiopathic5.
Department of Neurosurger Hayatabad Medical Com-
plex Peshawar
.........................................................................................
Address for correspondence:
Dr. Mushtaq
Department of Neurosurger Hayatabad Medical Com-
plex Peshawar
Cell No. 0333-9342707
E mail: drmushtaqmuhammad@yahoo.com
the diagnosis as well as a treatment option for severe
acute intolerable pain12of TR neuralgia other investiga-
tion includes CT Scan brain MRIbrain to exclude CP
angle lesion like desmoid tumors or vessels abnormal-
ities.TGN is a well-recognized complication of MS in
that particular case partial sensory rhizotomy of the fifth
cranial nerve can be a good surgical option13. A large
number of drugs like anti-epileptic drugs carbazemap-
ine, topramate,phenytoin, lamitrigil,baclofen,gabapen-
tin have been used. These drugs blocks the sodium
channels and changes the conduction of Ca++, NA+
and K+ across the nerve cell membrane thus preventing
the action potentials. The sweet’s criteria can help in
diagnosis of trigeminal neuralgia is4.
1. The pain is paroxysmal
2. The pain may be provoked by light touch to the
face (trigger zone).
3. The pain is confined to trigeminal distribution.
4. The pain is unilateral.
5. The clinical sensory examination is normal.
The trigeminal neuralgia can be treated by differ-
ent surgical procedure4.
Micro vascular decompression (MVD)
Partial sensory rhizotomy( PSR)
Radio frequencythermo coagulation(RFTC)
Gasserion ganglionotomy
Percutaneous balloon compression PBC
PERIPHERAL PROCEDURE
Injections alcohol, steroids, xylocain local anes-

254 KJMS May - August, 2020, Vol. 13, No.2

thesia
Neurectomy
Neurolysis
Electro surgery
Cryo-surgery4
This article shows the author experience about
minor procedure neurectomy with follow up for two to
three year with satisfactory and good results without
any major complications.
MATERIAL AND METHOD
Retrospective analysis of 40 cases 15 male and
25 female between the age of 40 to 70 years under went
peripheral neurectomy from July 2014 to august 2018
were carried out. Post-operative result of the 40 patients
The diagnosis made by clinical history and
detailed clinical examination all patients were taking
carbamazepine analgesic anti-depressant for 1-2 years.
The branch of specific nerve involved was diagnosed by
giving injection two percent (02%) xylocain. All patients
were investigated by doing CT scan and MRI Brain to
exclude intra cranial pathology. Informed written con-
sent was taken
Involved branches of trigeminal nerve among 40
cases were Neurectomy done on Right side in 26 cases
and left side in 12 cases while in 02 cases there was
maxillary mass. There were 25 female and 15 male.
Surgical Method
For infra orbital nerve intra oral approach vestibu-
larincision were given Gingo-mucosal junction incision
made infra orbital foramen visualized the nerve identified
and separated from the tissue picked up tied with catgut
2/0 and cut.Intra foreman part caugolated with bipolar
lead and the nerve cut end turned to the opposite side
and stitched.
Superorbital nerve was approached extra orally
by incision given in the eye brow the nerve identified
cut and coagulated
Incision given over anterior border of left Ramus
of the mandible and mucoperiosteal flap raised form
the foramen and lingual nerve identified and cut.
RESULTS
40 patients underwent surgery, 25 female and
15 male at the age of 40-70 years 26 for infra orbital 08
for supra orbital 04 of which was post herpetic and 04
mandibular and 02 cases both supra orbital and infra
orbital neurectomy done. The supra orbital were done
under local anesthesia and infra orbital and mandibular
neurectomy were done under generalanesthesia. Right
side found in 26 patients (percent 65 %) and left side
in 12 Patients(30%) in two cases there were maxillary
KJMS May - August, 2020, Vol. 13, No.2
S.No Branch involved Total Percent-
age
1. Infra orbital nerve 26 65
2. Supra orbital nerve 04 10
3. Postharpetic nerve 04 10
4. Mandiblur nerve 04 10
5. Supra orbital and 02 05
infra orbital
6. Total 40 100
mass found. Total follow up period was of 03 years.
While doing infra orbital nerectomy two complications
like mass in maxillary sinus found biopsy taken and his-
topathalogy result came out adenocarcinoma. With the
exception of these two patients immediate neurogenic
pain relieves in all patients. In Seven patientsreoccur-
rence of pain occurs in one to two years follow-up and
later on converted to MVD.
DISCUSSION
The 2st division of trigeminal nerve the infraorbital
is mostly involved in our study while a study conducted
by Narayan Sharma et al, Effectiveness of peripheral
neurectomyin refractory cases of trigeminal neuralgia2
and S.M Agrawal et al6, they have the result of mostly
effecting the v3 division of trigeminal nerve .The pain
relief period post operatively in our study as three years
which comparable with the result of Narayan et all2.
Seru sing etal operated of single case of post herpetic
supra orbital branch of trigeminal nerve for chronic pain
in April20137, while we operated post herpetic supra
orbital neurectomy in 04 cases with three years follow
up with satisfactory results.We operated exposing the
nerve tying with catgut 2/0 cut and tie with soft tissue
toward other side and coagulating the intraforeminnal
part with bipolarcautery, similar method was adapted
by Priya jeyaraj in a case report Efficacy of peripheral
Neurectomy in the management of refractory cases of
trigeminal neuralgia8 .Sanjay Chandan et al reported
two cases of recurrence after a period 24 month of 20
cases but responded very well to minimum doses of
carbamazepine in these cases3, we recorded 07 cases
recurrent after two years that later on underwent MVD.
The two patients persist pain due to lesion in the max-
illary sinuses.Huang D et all in a study endoscope-as-
sisted neurectomy and inferior alveolar nerve avulsion
in treating trigeminal neuralgia9, and by W.Hitchon et
al options in treating trigeminal neuralgia: experience
with 195 patients11, results shows post-operative fascial
numbness and paresthesia while we do not have such
complication.
CONCLUSIONS
If the patient had Comorbidity, if the patient had
single branch involvement, If the patient had post her-
255
petic neuralgiatrigger zone point positive doctor is not gia. A retrospective study. Journal of maxillofacial
skilled in MVD, patient wish plus other factors like it’s and oral surgery. 2011;10(3):195-8.
cheap, less time consuming, lessfatigability of surgeon, 7. Singh S, Gupta R, Kaur S, Kaur J. Post-herpetic neu-
non availability of post-operative icu care and proper ralgia: A review of current management strategies.
equipment’s these factors give space to peripheral Indian Journal of Pain. 2013;27(1):12.
neurectomy.
8. Jeyaraj P. Efficacy of Peripheral Neurectomy in the
Management of Refractory Cases of Trigeminal
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9. Huang D, Zhu S, Guo J, Chen S. Endoscope-assist-
neuropathic pain from neuromas in the upper limb:
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surgical techniques and future directions. Plast
treating trigeminal neuralgia. Journal of Cranio-Max-
Aesthet Res. 2015;2:165.
illofacial Surgery. 2017;45(9):1531-4.
2. Michhane NS, Du X, Li S, Poudel DC. Effectiveness
10. Brisman R, editor Surgical treatment of trigeminal
of peripheral neurectomy in refractory cases of
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11. Hitchon PW, Holland M, Noeller J, Smith MC, Mori-
3. Chandan S, Halli R, Sane VD. Peripheral neurecto-
tani T, Jerath N, et al. Options in treating trigeminal
my: minimally invasive surgical modality for trigem-
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inal neuralgia in indian population: a retrospective
neurology and neurosurgery. 2016;149:166-70.
analysis of 20 cases. Journal of maxillofacial aLand
oral surgery. 2014;13(3):295-9. 12. Han KR, Chae YJ, Lee JD, Kim C. Trigeminal nerve
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trigeminal neuralgia: long-term clinical effectiveness
Neurectomy of Inferior Alveolar Nerve-A Treatment
on pain. International journal of medical sciences.
Option for Trigeminal Neuralgia: A Case Report.
2017;14(1):29.
5. Kumar P, Maleedi S, Goud S. Peripheral Neurectomy:
13. Love S, Gradidge T, Coakham HB. Trigeminal neural-
A Surgical Option for Trigeminal Neuralgia Involving
gia due to multiple sclerosis: ultrastructural findings
Inferior Alveolar Nerve. Journal of Headache & Pain.
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2017;2(2):10.
and applied neurobiology. 2001;27(3):238-44.
6. Agrawal S, Kambalimath DH. Peripheral neurectomy:
a minimally invasive treatment for trigeminal neural-

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256 KJMS May - August, 2020, Vol. 13, No.2

 FREQUENCY OF VITAMIN B12 DEFICIENCY IN PATIENTS
WITH TYPE II DIABETES MELLITUS WITH AND WITHOUT
METFORMIN THERAPY
Kalim Ullah Khan1, Jehan Anjum1, Muhammad Fayaz1, Wajeeh Ur Rehman2, Daneet Kumar1, Jasvindar Kumar3,
Uroosa Arif4

ABSTRACT
Objective: To find out the frequency of vitamin B12 deficiency in patients with type II diabetes mellitus with and without
metformin therapy.
Materials and Methods: This was a cross sectional study conducted at Department of Medicine Hayatabad medi-
cal Complex Peshawar. To find the frequency of vitamin B12 Deficiency in patients with type-II diabetes mellitus with
Metformin therapy a total of 183 patients were included in the study. There was 6 month duration of our study from
14-02-2019 to 14-08-2019. WHO sample size calculator was used to determine sample size. Sample size was taken
183 keeping proportion of 21.9% of vitamin B12 deficiency among DM patients on metformin, with 95% confidence
level & 6% absolute precision. Sampling technique was Consecutive nonprobability sampling.
Results: Age wise distribution amongst 183 patients was analyzed as n=1.5 years (29 %) 30-40 years (20.2%) 41-50
year (27.3%) 51-60 years (23.5%) 61-70 Mean age was 2.45 years with standard deviation ±1.142 .Gender distribution
amongst 183 patients was examined as n= (37.7%) were male patients and (52.30%) were female patients. 25% of
Vitamin B12 Deficiency was observed amongst type II Diabetic Patients.
Conclusion: Greater probabilities of increasing biochemical vitamin B12 deficiency in the patients of type II diabetes
mellitus, associated with the continuing cure with metformin and parallel usage of blocker of acid were confirmed from
this cross-sectional study. Medical physician should keep this in mind and it should be distinguished from other factors.
The diabetic patients on metformin treatment for secondary vitamin B12 deficiency and other patient who have any
distressed neurologic symptoms should be screened. Additionally, by the regular intake of added multivitamins and
supplements vitamin B12 deficiency can be prevented.
Key Words: Frequency, metformin therapy, type II diabetes mellitus, Vitamin B12 deficiency

INTRODUCTION 2025 3. increase in disability, reduction of life prospect

The most common non-communicable disease
on this globe is now Diabetes Mellitus (DM). In advanced
countries it is the 4th or 5th foremost cause of death1.
In the united states from 2009 to 2034, there will be
increase in the both the diagnosed and undiagnosed
people with diabetes and it will range from 23.7 million to
44.1 million 2. It is estimated that in the world, there will
be 418 million people with impaired glucose tolerance
and about 380 million people with type II diabetes by
1 Medical C Ward Hayatabad Medical Complex, Pe-
shawar
2Resident Physician, Hayatabad Medical Complex,
Peshawar
Complex, Peshawar
3 Medical Officer BHU Langow Buner
4 MBBS
.........................................................................................
Address for correspondence:
Dr. Kalim Ullah Khan
Specialist Registrar, Medical C Ward Hayatabad Medical
Complex, Peshawar
Cell No # 0332-9285524
Email: kalim83@yahoo.com
and huge health cost for every culture are resulted from
the complication due to diabetes like stroke, diabetic
neuropathy, coronary artery and peripheral vascular
disease, amputation, blindness and failure of kidneys1.
In a study from Pakistan the estimated prevalence in
urban areas in male is 6% and in female it is estimated
3.5% while in rural area it is estimated as, 6.9% in male
while in female it was 3.5%. 4 In the top ten countries,
Pakistan was on 8th in the list of diabetes with high
prevalence and there were about 4.3 million people
with diabetes mellitus in a report of WHO, though it is
estimated that there will be 14.5 million people with this
problem in Pakistan and will be on 4th in list 5.
For managing type II diabetes (T2DM) the met-
formin is the most commonly used remedy 6. People
using high dose of metformin for longer period of time
have well known vitamin B12 deficiency in the type II
diabetes patient 7. This remedy might hinder with the
calcium-dependent absorption of vitamin B12 and with
the central element in the ileum and this influence can
be retreated by increased calcium intake8. The result of
decrease in vitamin B12 concentration in case of clin-
ically important problems such as neuropathy, mental
changes and macrocytic anemia, could be irreversible

KJMS May - August, 2020, Vol. 13, No.2 257

and intense9. Moreover the deficiency of vitamin B12
symptoms can lead to unnecessary treatment if it is
misdiagnosed with peripheral diabetic neuropathy.
There should be strong consideration of Vitamin B12
concentration in blood, during the long term type II
diabetes and high dose of metformin and should be
monitored regularly. This was suggested by a recent
data including a current meta-analysis10, 11.
In one study, among T2DM patients not taking
metformin, the prevalence of B12 deficiency was 4.4%
compared with 14.1% in metformin users12. Vitamin
B12 deficiency prevalence amongst diabetic patient
on metformin remedy was 21.9% in another study13. In
another study, the B12 deficiency was present in 16.2%
T2DM patients using metformin14.
Our study was planned to define occurrence of
vitamin B12 deficiency in type II diabetes patients with
metformin therapy. Doing a systematic study search,
we establish that very infrequent data exists concerning
the occurrence of vitamin B12 deficiency between T2DM
patients with metformin therapy and literally no data
exists from the population of Pakistan. This study was
an effort to found the level of the problem in our local
diabetic population with metformin use. Consequences
of our research was guidelines for planning future re-
search plan and policies and to identify the mechanism
of vitamin B12 deficiency prevention in T2DM patients
with metformin treatment.
MATERIAL AND METHODS
Our study was cross sectional study directed at
the Department of Medicine Hayatabad Medical Com-
plex Peshawar. After synopsis approval, duration of
study was six months from 14-02-2019 to 14-08-2019.
Sample Size was 183 (21.9%) proportion of vitamin
B12 deficiency among DM patients on metformin, with
95% confidence level & 6% absolute precision. The
technique of Sampling was Non-probability consecutive
sampling. Enclosure Criteria include; All patients of type
II DM with minimum of five years duration, Patients using
Metformin for the last at least one year, Both genders
(male & females) were included, patient having age
between 30-70 years. while Exclusion Criteria include;
Patients on lipid lowering drugs on history, Patients with
renal failure on medical records, Patients with Hepatic
failure on medical records and laboratory investigations,
Patients using Multivitamins supplements, Patients with
pernicious anemia was excluded , Patients with malab-
sorption disorders was also be omitted
PROCEDURE FOR DATA COLLECTION
The study was conducted after sanction from
hospitals ethical and research team. All patients with
DM with metformin use for the last at least one year was
registered in the study through OPD. All the patients
were clarified about the benefits and purpose of our
study and we also got a written informed consent. All
258
patients were subjected to complete history and clinical
examination followed by routine baseline examinations.
After overnight fasting blood samples were obtained
from the patients and then sent to the hospital laboratory
for the measurement of the vitamin B12 concentration.
In a pre-designed proforma all the figures com-
prising age, sex, name were documented and omission
standards was followed strictly to control prejudice in
our study outcomes. A skilled microbiologist, having
experience of five years, performed all these examina-
tions in a hospital laboratory.
DATA ANALYSIS PROCEDURE
SPSS version 23 was used for the analysis of
data. For quantitative variables like age, fasting blood
glucose level, HbA1C, BMI and vitamin B12 levels, mean
+ standard deviation was calculated. For categorical
variables like gender and vitamin B12 deficiency, fre-
quencies and percentages was calculated. Vitamin
B12 deficiency was divided among age, gender, fasting
blood glucose, HbA1C, BMI and duration of diabetes
to understand the outcome of modifications using chi
square test with p value considered as < 0.05 as sig-
nificant. The presentation of all the results were done
in the form of tables and graphs.
RESULTS
This study was piloted at Department of Medicine
Hayatabad medical Complex Peshawar in which a total
of 183 patients were included to find the frequency of
vitamin B12 Deficiency in patients with type-II diabetes
mellitus with Metformin therapy and the results were
evaluated as: Age wise distribution amongst 183
patients was analyzed as n=1.5 years (29 %) 30-40
years (20.2%) 41-50 year (27.3%) 51-60 years (23.5%)
61-70 Mean age was 2.45 years with standard deviation
±1.142 (table No 1) .Gender distribution amongst 183
patients was examined as n= (37.7%) were male pa-
Figure 1: Gender Wise Distribution
KJMS May - August, 2020, Vol. 13, No.2
 Table 1: Age Wise Distribution of Sample Size tients and (52.30%) were female patients.( Figure No 1)
(n=183) 25% of Vitamin B12 Deficiency was observed amongst
type II Diabetic Patients.
Age groups Frequency Percent
30-40 53 29.0 DISCUSSION
41-50 37 20.2 The vitamin B12 deficiency in the study group
of patient having type II diabetes mellitus was deter-
51-60 50 27.3
mined by our cross-sectional study to be 29.66%. A
61-70 43 23.5 comparison of our prevalence with the results of former
Total 183 100.0 researchers is not direct and straight forward, therefore
there should be consideration of other factors. Former
Table 2: Gender Wise Distribution of Sample Size researchers obtained comparable results Previous
(n=183) researchers have come up with comparable results,
however the mechanism by which this deficiency come-
Gender Frequency Percent up has not been 18, 19.
Valid Male 69 37.7 In this concern insufficient record is available.
Female 114 62.3 Correspondingly, in Pakistan there has been no study
done for the evaluation of vitamin B12 deficiency that
Total 183 100.0 occur in diabetic patient who are on metformin remedy.
An earlier study by Jager and colleagues 20, after type II
Table 3: Frequency of BMI (n=183) diabetes taking metformin 2550 mg / day for 4.3 years
showed that metformin was associated with a normal
BMI Frequency Percent decrease of 19% in vitamin B12 levels compared to
Valid 18.4 or less(under- 20 10.9 placebo (95% confidence interval from -24% to -14%;
weight) P <0.001A
18.5 to 24.9(Nor- 53 29.0 A factor was determined that was significantly
mal) associated with vitamin deficiency includes the simul-
25.0 to 29.9(Over- 74 40.4 taneous administration of metformin with inhibitors of
weight) proton pump or blockers of H2. The concept that the
reduction of stomach acidity shows an important role
40.0 to 49.9 (Mor- 36 19.7
in malabsorption of vitamin B12 strongly support the
bidly Obese)
relationship of vitamin B12 deficiency and inhibitors of
Total 183 100.0 proton pump or H2 blockers. Reduction in acid secre-
tion by parietal cells is caused by both of these drugs.
Table 4: Mean Serum of Vitamin B 12 (n=183)
For the breakdown of vitamin B12 from the nutritional
Mean Standard Deviation sources, the release of gastric acid from these cells are
essential 16. Such type of relationship is found rarely. No
Vitamin B12 1.75 .435 connection was found between the use of omeprazole
Deficiency and the level of vitamin B12 in the serum in a study
Table 5: Mean of Serum B12 levels (n=183) done by Nervo, et al. 15 additionally we should keep in
mind the possible outcome amongst metformin, inhib-
Mean Standard Deviation itors of proton pump and H2blockers comparative to
vitamin B12 uptake. For combination therapy serious
Serum B12 128.39 36.302 cautions are advised. Vitamin B12 deficiency risk is high
levels in patient who use metformin continuously. Our study
hence suggested that in type II diabetes patients on
Table 6: Mean of HBA1C (n=183)
metformin the vitamin B12 deficiency should be find
out. Our study also suggested the use of multivitamins
Mean Standard Deviation
in daily life as it has protective role in diabetic patient by
HBA1C 7.96 .766 preventing vitamin B12 deficiency. The serum vitamin
B12 level increases by using a multivitamins suggested
Table 7: Mean of Fasting Blood Glucose Level by Literature documentation. Increased level of vitamin
(n=183) B12 in the blood of adults was observed in a randomized
controlled trial study, who take regularly use of vitamin
Mean Standard Deviation B12 from 6 to 9 microgram.
Fasting Blood 159.90 26.481
Consistency of our prevalence with previous
Glucose Level
studies is not simple and easy with placebo 17. Similarly,

KJMS May - August, 2020, Vol. 13, No.2 259

for the evaluation of the daily use of multivitamins for
the prevention of vitamin B2 deficiency no studies have
been done. Increased dosages of supplementations
administered orally or parentally for the typical manage-
ment of vitamin B12 deficiency is notable finding of our
study. Though, multivitamin preparation that have 6 to
25 microgram of vitamin B12 are adequate for vitamin
B12 deficiency. To avoid vitamin B12 deficiency, further
research and study is the need of the day for supporting
the idea of multivitamin usage. On the other hand other
risk factors like age progression and usage of blocker
of acid were not observed to have association with the
vitamin B12 deficiency.
We consider that our this study is significant
statistically and it should be used as valuable guide for
physicians appraise the vitamin B12 as a main element
for the patient specially when they are on high dose
of metformin for longer period of time. Although the
effect of inadequacy along with the precise medical
importance is unknown. Former researchers suggested
that vitamin B12 supplements should be prescribed for
avoiding neuropathic pains.18
Our study faced many limitations. . First limitation
of our study was that of external validity because study
group in our study was in a single center. This can
lead to different results and there may be considerable
variation from the diabetic patients that are present all
over the community. The second limitation of our study
is the exclusion of the measurement of methyl malonic
acid level in the blood which can recognize the defi-
ciency of vitamin B12 in the primary non-symptomatic
period. After replacement of vitamin B12 the outcome
was not followed-up. For dosage outcome and vitamin
B12 supplementation period, regular follow-up can be
helpful19, 20.
CONCLUSIONS
Greater probabilities of increasing biochemical
vitamin B12 deficiency in the patients of type II diabe-
tes mellitus, associated with the continuing cure with
metformin and parallel usage of blocker of acid were
confirmed from this cross-sectional study. Medical
physician should keep this in mind and it should be
distinguished from other factors. The diabetic patients
on metformin treatment for secondary vitamin B12
deficiency and other patient who have any distressed
neurologic symptoms should be screened. Additionally,
by the regular intake of added multivitamins and sup-
plements vitamin B12 deficiency can be prevented.
REFERENCES
1. Dunstan DW,Zimmet PZ, Welborn TA, de Courten
MP, Cameron AJ, Sicree RA. The rising prevalence of
diabetes and impaired glucose tolerance. Diabetes
Care 2012; 25(5):829-834.
2. Leong A, Porneala B, Dupuis J, Florez JC, Meigs
JB. Type 2 diabetes genetic predisposition, obesity,
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and all-cause mortality risk in the US: a multiethnic
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surgery. Diabetes care. 2016; 39(6):878-83.
4. Moradi-Lakeh M, Forouzanfar MH, El Bcheraoui C,
Daoud F, Afshin A, Hanson SW, et al. High fasting
plasma glucose, diabetes, and its risk factors in the
eastern Mediterranean region, 1990–2013: Findings
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Diabetes care. 2017; 40(1):22-9.
5. World Health Organization. The World Health Report.
Geneva World Health Organization; 2011
6. Rydén L, Grant PJ, Anker SD. ESC Guidelines on
diabetes, pre-diabetes, and cardiovascular diseases
developed in collaboration with the EASD: the Task
Force on diabetes, pre-diabetes, and cardiovascular
diseases of the European Society of Cardiology
(ESC) and developed in collaboration with the Euro-
pean Association for the Study of Diabetes (EASD).
Eur Heart J 2013; 34:3035–87.
7. Rydén L, Grant PJ, Anker SD. ESC Guidelines on
diabetes, pre-diabetes, and cardiovascular diseases
developed in collaboration with the EASD: the Task
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diseases of the European Society of Cardiology
(ESC) and developed in collaboration with the Euro-
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Eur Heart J 2014; 35:1824.
8. Turner LW, Nartey D, Stafford RS. Ambulatory
treatment of type 2 diabetes in the U.S, 1997–2012.
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9. Beulens JW, Hart HE, Kuijs R. Influence of duration
and dose of metformin on cobalamin deficiency in
type 2 diabetes patients using metformin. ActaDia-
betol 2014; 52:47–53.
10. Sato Y, Ouchi K, Funase Y. Relationship between
metformin uses, vitamin B12deficiency, hyperhomo-
cysteinemia and vascular complications in patients
with type 2 diabetes. Endocrinol J 2013;60:1275–80
11. Niafar M, Hai F, Porhomayon J. The role of metformin
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IntEmerg Med 2015; 10:93–102.
12. de Groot-Kamphuis DM, van Dijk PR, Groenier KH,
Houweling ST, Bilo HJ, Kleefstra N. Vitamin B12
deficiency and the lack of its consequences in type
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ONLINE SUBMISSION OF MANUSCRIPT

It is mandatory to submit the manuscripts at the following website of KJMS. It is
quick, convenient, cheap, requirement of HEC and Paperless.
Website: www.kjms.com.pk
The intending writers are expected to first register themselves on the website
and follow the instructions on the website. Author agreement can be easily
downloaded from our website. A duly signed author agreement must accompany
initial submission of the manuscript.

KJMS May - August, 2020, Vol. 13, No.2 261

 RELATION OF SERUM AMMONIA LEVEL WITH PORTO-
SYSTEMIC ENCEPHALOPATHY AND ITS SHORT TERM
PROGNOSTIC ROLE IN PATIENTS WITH LIVER CIRRHOSIS
Munir Hussain1, Noaman Yousaf3, Afshan Bashir3, Khalid Mehmood2, Khalid Javed1, Arshed Parvez1

ABSTRACT
Background: Porto-systemic encephalopathy (PSE) and hepatic encephalopathy (HE) are the terms used synonymously
to describe a central nervous system disturbance associated with acute or chronic failure of liver. Although PSE is sup-
posed to arise due to hepatic failure to clear the toxic products from blood yet it has not been clearly established that
which of those toxic products should be labeled as culprits in the etiology of hepatic or portosystemic encephalopathy.
Objectives: To study the relation of serum ammonia (NH3) levels with portosystemic encephalopathy and its severity
in patients with hepatic failure.
To assess the short term prognostic role of serum ammonia in hepatic encephalopathy.
Methodology: Total 100 patients having hepatic encephalopathy were selected for the study. All patients were evaluated
by detailed history and examination for signs of chronic liver disease, grades of HE and serum ammonia levels along
with other baseline investigations.
Results: This study included 70% male and 30% female patients with mean age of 50.89±12.81 years. Ninety seven
percent of patients were positive for anti HCV while 3% for anti HCV and HbsAg both. Serial estimations of serum am-
monia and evaluation of clinical grades of HE demonstrated a progressive decline in serum ammonia levels paralleled
by improvement in grades of encephalopathy on days 1, 3, 5, 7 and day 9.
Conclusion: Decrease in serum ammonia level was correlated with decrease in grades of hepatic encephalopathy.
This study showed a positive correlation between serum NH3 levels and grades of hepatic encephalopathy. The study
also revealed the short term prognostic role of NH3 levels in patients with HE.
Key words: Serum ammonia (NH3) level, hepatic encephalopahty, porto-systemic encephalopathy, liver cirrhosis.

INTRODUCTION of intellectual capability i.e. reasoning, orientation and

Porto-systemic encephalopathy or Hepatic
encephalopathy (HE) is amongst one of the most
debilitating complications of acute or chronic hepatic
failure1. Hepatic encephalopathy can be defined as a
disturbance in central nervous system function due to
acute or chronic hepatic failure.
Hepatic encephalopathy is a cluster of neuropsy-
chiatric manifestations which are present both in acute
and chronic hepatic failure and are reversible by taking
appropriate measures2. In HE, there is progressive de-
cline in the level of consciousness i.e. from lethargy to
somonolence to stupor and finally coma and hampering
1Department of Pathology, Khyber Girls Medical Col-
lege, Peshawar
2Department of Pathology Hayatabad Medical Com-
plex, Peshawar
3Mufti Mehmood Memorial Hospital, D.I. Khan
.........................................................................................
Address for correspondence:
Dr. Munir Hussain
Department of Pathology, Khyber Girls Medical College,
Hayatabad, Peshawar.
Cell # 92-3339380354
E- mail: sendtodrmunir@gmail.com
neurologic deficits like Asterixis or flapping tremors3,4.
Hepatic encephalopathy must be differentiated from
the other causes which lead to liver damage and the
manifestation of similar symptoms. These other causes
include brain and liver damage caused by alcohol and
copper (Wilson’s disease), neurologic deficits caused
by bilirubin deposition in brain (Kernicterus), cerebral
hemorrhage caused by disorders of coagulation due
to liver damage and other abnormalities that are not
associated with liver failure5.
The pathogenesis of HE is quite complex and still
it is not completely understood6. However it is clear that
there is shunting of blood from portal to systemic circu-
lation and it has got a crucial role in the etiopathogene-
sis of HE5. The toxins which are thought to be involved
in the etiology of hepatic encephalopathy actually do
so as a result of portosystemic shunting of blood and
include; ammonia, aromatic amino acids, manganese,
benzodiazepine like substances i.e. GABA, mercaptans
and pro-inflammatory cytokines leading to changes in
intestinal microbiota1,7-10. So lot of toxins have been nom-
inated that can contribute to hepatic encephalopathy yet
it is widely accepted that NH3 plays a pivotal role in the
pathogenesis of this disorder4,11,12. It is an established
fact that all these substances are produced normally

262 KJMS May - August, 2020, Vol. 13, No.2

in the body and most of them are cleared by the liver
on regular basis, so liver damage in a way which leads
to shunting of blood from liver to systemic circulation
facilitates these toxins and especially NH3 to cross blood
brain barrier leading to brain edema and HE.
Ammonia is generated by different tissues, the
principal tissues being liver and intestine while the
others include muscle and kidney. Intestinal ammonia
is derived firstly by the action of the enzyme urease
produced by colonic bacteria which degrades urea into
ammonia and secondly by deamidation of glutamine
(amino acid) in the small intestine to gluatamate and
ammonia by the help of enzyme glutaminase2. Liver
causes production of urea in an attempt to metabolize
ammonia. Liver causes production of urea in an attempt
to metabolize ammonia. Liver is the principal site of
removal of excess ammonia from the body and it does
so by converting it into urea in periportal hepatocytes
and glutamine in centrovenular hepatocytes5, the urea
is then excreted by kidneys. When there is acute or
chronic hepatic failure, there is portosytemic shunting
as well as reduced detoxification of ammonia by liver
so reduced clearance of ammonia leads to hyperam-
monemia. Hyperammonemia exerts injurious effects
on brain by causing brain edema5. Under physiological
conditions astrocytes of the brain also carry on the
function of detoxification of ammonia. Astrocytes form
one third portion of the cerebral cortex. Astrocytes per-
form detoxification of ammonia by causing amidation
of glutamate(excitatory neurotransmitter) and ammonia
to glutamine5.
In case of liver failure the additional detoxification
function is then performed by astrocytes, as a result
they become swollen, leading to cerebral edema and
altered mental function3,13. Recent studies have put light
on the precise mechanism behind astrocyte swelling
and dysfunction. In fact increased ammonia levels lead
to oxidative stress (nitrosative stress) on astrocytes by
causing production of reactive nitrogen species like
nitric oxide (NO.) and others which eventually leads to
astrocyte dysfunction, edema and HE6. Increased neu-
ronal nitric oxide synthase (nNOS) activity was found
in the brains of rats in which portacaval anastomosis
was done.14 Along with increased activity of nNOS there
was increased production of nitric oxide (NO) as well
in brains of portacaval shunted rats when they were
given an infusion of NH315. It means that in portacaval
shunting there is increased production of NO in brain
(astrocytes) due to hepatic bypassing of the blood.
Nitric oxide then being a free radical causes swelling
and astrocyte dysfunction secondary to increased NH3
levels.
A lot of research work points towards the fact
that NH3 plays a pivotal role in the pathogenesis of
portosystemic encephalopathy4,11,16,17. The role of NH3
as a crucial factor in pathogenesis of HE has been
proposed on the basis of a rise in NH3 levels of patients
KJMS May - August, 2020, Vol. 13, No.2
having cirrhosis and HE, increase in blood-brain barrier
permeability to NH3 in HE; and elevations of NH3 levels
associated with astrocyte dysfunction12,16-19.
Measuring venous ammonia levels is helpful in the
evaluation of liver disease as a cause of disturbance in
consciousness when one is suspecting other causes
for such disturbance20. Venous sampling is enough and
appropriate for measurement of ammonia and there
seems no extra advantage of measuring partial pressure
of NH17. Adult NH3 levels in plasma are 19-60 µg/dL or
15-35 µmol/L21.
The present study was conducted in order to
assess an association between hepatic encephalopahty
and serum ammonia levels and it was intended that this
would provide guidelines for improved prevention and
management of hepatic encephalopathy.
METHODOLOGY
Sampling was carried out at Gastroenterology
department of Shaikh Zayed Hospital, Lahore. It was a
descriptive, cross sectional study. Sampling was done
on Non-probability convenient sampling basis. Duration
of study was from 12th October 2017 to 11th April 2018.
A total of hundred patients with hepatic encephalopa-
thy who sought admission in Gastroenterology ward,
of Shaikh Zayed Hospital through OPD or emergency
department and fulfilled the inclusion criteria, were
selected for the study.
Adult patients with chronic liver disease, irrespec-
tive of gender, presenting with hepatic encephalopathy
were included in the study.
All cases of chronic obstructive pulmonary
disease, uremia, cardiovascular accident, fulminant
hepatic failure, meningitis, hypoglycemia, encephalitis,
Wernicke’s encephalopathy, psychiatric disturbances,
sedative intake and acute respiratory distress syndrome
were excluded from the study.
All patients underwent a detailed history and ex-
amination for signs of chronic liver disease and grades
of encephalopathy. Grading of encephalopathy was
done according to West Haven grading.
Serum ammonia of all the patients was measured
along with other baseline investigations through stan-
dard laboratory techniques. Blood samples were col-
lected in appropriate vacutainers and were processed
in pathology laboratory of the Shaikh Zayed Hospital.
Venous blood was tested for serum ammonia, full blood
count, liver function tests and renal function tests at
day 1, 3 5, 7 and 9. The kit used for the estimation of
Serum ammonia was Amon flex reagent cartridge Cat
No. DF19. All data was collected on the pre-designed
proforma.
SPSS 23 was used to derive different statistical
parameters. The study variables were age, gender,
Hemoglobin (Hb), total Bilirubin, Alanine transaminase
263
(ALT), Aspartate transaminase (AST), Alkaline phos- did not show any association with hepatic encepha-
phatase (ALP), serum Creatinine, Blood urea nitrogen lopathy, ammonia levels of 67.87±29.20 µmol/L were
(BUN), grades of hepatic encephalopahty and serum associated with Grade I and Grade II encephalopathy
ammonia levels. One way anova test was applied to while ammonia levels of 123.44±52.27 µmol/L were
evaluate changes in serum ammonia levels on different associated with Grade III HE and levels of 249.65±92.57
days. Chi Square test was applied for association with µmol/L were related to Grade IV encephalopathy.
decrease in serum ammonia levels and grades of HE.
Day wise correlation of mean serum NH3 levels
A p value of ≤0.05 at 95 % confidence interval was
and hepatic encephalopathy indicated that higher lev-
considered as significant.
els of serum NH3 were associated with higher grades
RESULTS of hepatic encephalopathy and the grades of hepatic
encephalopathy kept on decreasing with decreasing
Mean age of the patients was 50.89±12.81 years. levels of serum ammonia with the passage of time due
Minimum age range was 21-30 years while maximum
range was 71-80 years. Maximum numbers of patients
were in age range of 51-60 years, (41%).
In present study 70 (70%) patients were males
and 30 (30%) patients were females.
Mean Hemoglobin levels of the subjects (11.07 Figure 1: Conversion of NH3 and glutamate to gluta-
± 2.46 mg/dl) were low, while Bilirubin levels were high mine and vice versa
(6.17 ± 7.47 mg/dl) but not high enough. Similarly mean
ALT (120.41 ± 242.07 U/L) and AST (151.51 ± 205.53
U/L) levels were raised indicating liver injury along with
raised levels of ALP (162.95 ± 115.87 U/L) indicating
slight degree of obstruction consequent upon cirrhosis.
The Creatinine levels were within normal range, while
BUN levels were slightly raised but insignificant, indi-
cating normal renal functions.
In this study Hepatitis C was the commonest
cause of liver cirrhosis and consequent hepatic en-
cephalopathy, while Hepatitis B alone was not found
to cause the cirrhosis and its complications.
Higher ammonia levels were associated with Figure 2: Distribution of patients according to causes
higher grades of HE. Ammonia levels of 40.59±12.49 of cirrhosis and HE
Table 1: West Haven grading of Hepatic Encephalopathy(1)

Hepatic encepha- Consciousness Intellectual function Personality Behavior

lopathy
Grade 0 No detectable No detectable No detectable None
changes changes changes
Grade I (mild) Sleep disturbance, Shortened attention Euphoria, depres- Muscular incoor-
trivial lack of aware- span, mildly im- sion, irritability dination, impaired
ness paired computations handwriting, Asterixis
may be present
Grade II (moderate) Lethargy, mild disori- Amnesia of recent Overt change in Slurred speech,
entation to time events, grossly im- personality, inappro- Asterixis, hypoactive
paired computations priate behavior reflexes, ataxia
Grade III (severe) Somnolence, confu- Inability to compute, Paranoia, bizarre Hyperactive reflex-
sion, semistupor disorientation to behavior es, Nystagmus, (+)
place Babinski’s sign,
Clonus, rigidity
Grade IV (coma) Stupor None None Dilated pupils, Opist-
hotonus, coma, lack
of verbal, eye & oral
response

264 KJMS May - August, 2020, Vol. 13, No.2

Table 2: Distribution of patients according to differ- Table 6: Day wise correlation of mean serum
ent age groups NH3levels and hepatic encephalopathy

Age No. Percentage Mean ± SD Days Serum ammonia level HE p val-

(Years) (µmol/L) (Mean ± SD) grades ue
21-30 6 6% Day 296.19±106.38 Grade IV
0.001
31-40 19 19% 1

41-50 21 21% Day 203.11±78.77 Grade IV

0.001
50.89±12.81 3
51-60 41 41%
Day 123.44±52.27 Grade III
61-70 8 8% 0.001
5
71-80 5 5% Day 67.87±29.20 Grade I
0.001
7 & II
Table 3: Distribution of patients according to gender
Day 40.59±12.49 Grade 0
0.001
Gender Number Percentage 9
Male 70 70 %
Female 30 30 % In present study 70% of the patients were males
and 30% of the patients were females while in study
Total 100 100 % conducted by Wazir Mohammad Khan et al 23, 63%
were males and 37% were females, similarly in a study
Table 4: Laboratory data of different parameters
done by Abidullah khan et al24, there were 81 males as
compared to 34 females who had hyperammonemia
Investigations Mean ± SD
and HE. In both studies the number of males and fe-
Hemoglobin (mg/dl) 11.07 ± 2.46 males was comparable to present study. Moreover the
Total Bilirubin (mg/dl) 6.17 ± 7.47 number of males was more as compared to females in
all the studies.
ALT (U/L) 120.41 ± 242.07
AST (U/L) 151.51 ± 205.53 The mean total bilirubin levels of the patients
in study were 6.17±7.47 gm/dl. In a study conduct-
ALP (U/L) 162.95 ± 115.87 ed by Dasani and his co-workers25 the total bilirubin of
Serum Creatinine (mg/dl) 1.75 ± 1.22 the subjects was 2.24±0.20 gm/dl. So the total biliru-
BUN (mg/dl) 33.98 ± 25.41 bin of the patients in this study was much higher than
Dasani et al.
Table 5: Correlation of mean serum NH3 levels and In present study the mean serum ALT levels were
hepatic encephalopathy grades 120.41 ± 242.07 U/L, a value far higher than the mean
value of 82.33 ± 43.2 U/L in a study conducted by
HE grades Serum ammonia level (µmol/L)
Senthil Raj et al26.
(Mean ± SD)
Grade 0 40.59±12.49 Out of 100 patients having HE, 97 (97%) were
hepatitis C positive while 3 (3%) were both hepatitis
Grade I & II 67.87±29.20 B and C positive, and it was comparable to the study
Grade III 123.44±52.27 conducted by Wazir Mohammad Khan et23 al in which
out of a total 100 patients, 91 (91%)had hepatitis C
Grade IV 249.65±92.57
while 9 (9%) patients were having hepatitis B.
to compensation. Mean ammonia levels at day 1 and The ammonia levels showed positive cor-
3 were associated with grade IV HE, while levels on relation with the grades of HE, higher the levels
day 5 were associated with grade III encephalopathy. of serum ammonia, higher were the grades of HE.
Serum ammonia levels at day 7 corresponded to grade Patients with mean ammonia levels of 40.59±12.49
II and I encephalopathy while levels at day 9 were not µmol/L had no sign of HE while the patients with mean
associated with any grade of encephalopathy. levels of 249.65±92.57 µmol/L were having grade IV
encephalopathy. The rest of the patients had grades
DISCUSSION in between. The fact that increasing levels of ammonia
Mean age of the patients in this study was were associated with increasing grades of HE was
50.89±12.81 years. This finding was comparable consistent with the studies done by Abidullah khan et
with the study done by Queiroz et al22 in which the al (24)and Omar Qureshi et al27.
mean age of the patients was 56.3 ± 10.8 years. In this study it was found that the levels of

KJMS May - August, 2020, Vol. 13, No.2 265

ammonia kept on decreasing gradually along with
the grades of encephalopathy during the stay of
the patients in hospital that is there was a positive
correlation between the decreasing NH3 levels and
the grades of encephalopathy. This finding points
towards the fact that ammonia has got prognostic
role in the treatment of hepatic encepaholopathy
and it is in accordance with the study conducted
by Shalimar et al 28. Moreover it also strengthens
the fact that ammonia levels and grades of HE are
strongly associated with each other.
CONCLUSION
In present study it was found that NH3 levels
have strong positive correlation with the grades of
hepatic encephalopathy, as the levels of NH3 rise
the severity of encephalopathy also increases and
with decrease in serum NH3 levels the severity of
the disease also declines. Moreover it was also
concluded that serum ammonia levels can be used
as a prognostic indicator for the patients having
hepatic encephalopathy during their hospital stay.
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Vilstrup H. Brain metabolism of 13N-ammonia during
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MT, Van Lente F et al. Correlation between ammonia
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18. Kundra A, Jain A,Banga A, Bajaj G, Kar P Evaluation
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94.

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KJMS May - August, 2020, Vol. 13, No.2 267

 THE SPAGHETTI WRIST: MANAGEMENT AND OUTCOME AT A
SPECIALIZED HAND UNIT IN A TERTIARY CARE HOSPITAL
Firdous Khan1, Mohammad Shadman2, Zahid Iqbal Bhatti3, Tahseen A. Cheema4, Tahmeedullah1

ABSTRACT
Objective: To evaluate the spaghetti wrist injury pattern in our community and find ways to decrease complications
and obtain better results.
Place & Duration Of Study: This study was carried out at Burns & Plastic Surgery Centre, Hayatabad Medical Complex
Peshawar, Pakistan from March 2018 to Oct 2019.
Study Design: Prospective case series study
Methods & Materials: A total of 35 patients were registered during the study period. Selection criteria included patients
with sharp volar laceration of the wrist; patient not operated elsewhere, acute injury of < 7 days and co-operative patient
to perform the postoperative exercises. All patients were assessed thoroughly by taking proper history, clinical exam-
ination and x-rays of the injured limb. Any pre- operative deficits found were noted. Per- operatively, number and types
of structures involved and the type of repair done were documented. Patients were followed regularly for outcome in
the form of sensory recovery and range of motion and any functional deficit at 2- weeks, 1-month, 3-months, and then
at 6- months intervals. The criteria of Kleinert & Verdan were used for motor recovery and Medical Research Council
Grading System was adopted for sensory recovery.
Results: A total number of 35 patients comprising of 21 male and 14 female patients were included in the study. Mean
age was 24.5 years ranging from 8 to 62 years. The most commonly injured hand was right hand (74.9 %) and most
frequent injured tendons were Flexor Digitorum Sublimus (FDS) of third and fourth (98.3 %) digits. The ulnar nerve &
ulnar artery were more commonly injured than the median nerve and radial artery.
In the follow- up period, range of motion was excellent in 14 patients and good in 8 patients. Intrinsic muscle recovery
was good in 9 patients and fair to poor in 21 patients. Regarding sensory recovery, 17 patients recovered only pro-
tective sensation and 13 patients gained return of two-point discrimination that ranged from 7 to 13 mm in 10 patients
and from 2 to 6 mm in 3 patients.
Conclusion: Spaghetti wrist is a severe disabling injury. In spaghetti wrist injuries, functional recovery after repair is
always not complete. Accurate repair of injured structures, early movement, appropriate physiotherapy and patient
co-operation are required for better results.
Keywords: Spaghetti wrist, Injuries, Tendon, Volar, Nerve.

INTRODUCTION that lies in the distal forearms and extends from distal
wrist crease to the flexor musculo-tendinous junction1.
Verdan in 1959 described Flexor Tendon Zone 5 The wrist at this level have 16 long tubular structures
1Burns & Plastic Surgery Centre, Hayatabad Medical consisting of 2 arteries, 2 nerves and 12 flexor ten-
Complex, Peshawar, Pakistan dons1,2. All these structures are packed in a relatively
2Department of Plastic Surgery & Burns, Khyber Teach- limited but flexible space covered by thin skin. Sharp
ing Hospital, Peshawar, Pakistan laceration at this level can damage more than one struc-
3Department of Plastic Surgery & Burns, Nawaz Sharif ture3. These long tubular structures at wrist resemble
Medical College, Gujrat, Pakistan spaghetti when transected by sharp objects hence
4Diplomat of American Board of Orthopedic & Hand the term spaghetti wrist given 3, 4. Spaghetti wrist has
Surgery, Bahawalpur Medical & Dental College, Baha- got minor and major types. Minor type involves three
walpur, Pakistan transected structures including artery, nerve and any
5Burns & Plastic Surgery Centre, Hayatabad Medical tendon while major type involves at least 10 structures
Complex, Peshawar, Pakistan including both median and ulnar nerves2 5,6.
.........................................................................................
Address for correspondence: Wrist is the most frequent and exposed site for
Dr. Firdous Khan suicidal and accidental sharp cut injuries7. Trauma at
Burns & Plastic Surgery Centre, Hayatabad Medical this level has got great disability due to involvement
Complex, Peshawar, Pakistan of median and ulnar nerves3, 8. Injuries at this level are
E-mail: Dr firdouskhanpsu@gmail.com troublesome and debilitating and early management is
Mobile No +92-321-9099363 the key to good functional recovery and outcome7, 9, 10.

268 KJMS May - August, 2020, Vol. 13, No.2

Study Design: Prospective case series. band traction was started after 24 hours. This regime
was continued for 4 weeks without changing the splint.
Duration: March 2012 to Oct 2015.
At 4-6 weeks, the splint was changed keeping the wrist
Setting: Burns & Plastic Surgery Centre, Hayatabad in neutral to 10° of flexion and the Metacarpophalangeal
Medical Complex, Peshawar, Pakistan. joints in 40° of flexion using same rubber band active
extension and passive flexion exercises. At 6-8 weeks,
MATERIALS & METHODS the splint was removed and light activity of daily living
was allowed.
A total of 35 patients were registered during the
study period. Selection criteria included patients with RESULTS
sharp volar laceration of the wrist or zone 5; patient
not operated elsewhere, acute injury of < 7 days and A total number of 35 patients comprising of 21
co-operative patient to perform the postoperative exer- male and 14 female patients were included in the study.
cises. All patients were assessed thoroughly by taking Mean age was 24.5 years ranging from 8 to 62 years.
proper history, clinical examination and x-rays of the The most commonly injured hand was right hand (74.9
injured limb. Any pre- operative deficits found were %) and most frequent injured tendons were Flexor
noted. Per- operatively, number and types of structures Digitorum Sublimus (FDS) of third and fourth (98.3 %)
involved and the type of repair done were documented. digits. Most frequent cause was household accidental
Patients were followed regularly for outcome in the glass cut laceration occurring in 16 patients followed by
form of sensory recovery and range of motion and industrial glass cut laceration in 11 patients. Five cases
any functional deficit at 2- weeks, 1-month, 3-months, occurred in suicidal aggressive angry young men by
and then at 6- months intervals. The criteria of Kleinert
& Verdan were used for motor recovery and Medical Table 1: Causes and mechanism of spaghetti wrist
Research Council Grading System was adopted for in total (n=35 patients).
sensory recovery11, 12.
Cause of Mechanism of No. of patients
Operative approach injury injury (%)
Household Glass cut 13 (37%)
All patients were operated under general anes-
accidents Sharp knife 3 (9%)
thesia using tourniquet. The wound was irrigated with
normal saline and any debris removed. Wound was Industrial acci- Glass cut 11 (31%)
extended in a zig zag fashion both proximally and dents
distally to facilitate inspection and identification of cut
structures. In all cases, carpal tunnel released was also Suicidal & Glass cut 4 (11%)
done. After identification, the cut ends of involved struc- Homicidal Sharp knife 3 (9%)
tures were refreshed and tagged using prolene 6-0. The Razor blade 1 (3%)
sequence of repair was first tendon repair followed by
nerves and then vessels repair except in cases where
Table 2: Frequency of structures damaged (n=35).
both radial and ulnar arteries were cut where arteries
were repaired first. In all cases, tendons were repaired
Structures Total patients Involved n (%)
by Modified Kessler’s technique using prolene 4-0 round
transected (n=35)
body core suture followed by 5-0 epitenon sutures. The
cascade of fingers was checked after completion of all Ulnar nerve 35 24 (69%)
affected fingers before proceeding to the next step. In Ulnar artery 35 25 (71%)
four cases, the arterial repair was performed following
Flexor carpi 35 27 (77%)
the finger tendons repair. Arteries were repaired using
ulnaris
prolene 7-0 round body. The tourniquet was released
and vascularity rechecked for adequate flow followed Flexor digito- 140 30 (86%)
by nerve repair under loupe magnification using 8-0 rum sublimus
prolene suture. Flexors of the wrist were repaired in Flexor digito- 140 24 (68%)
the last using 3-0 prolene core suture and 5-0 prolene rum profundus
epitenon repair. After gaining good haemostasis, the
Flexor pollicis 35 21 (60%)
wound closure was done in 2 layers.
longus
The hand was dressed in a three layered bulky Flexor carpi 35 19 (54%)
dressing extending upto the tips of digits and a dorsal radialis
splint given with the wrist in 30° of flexion, the Metacar-
pophalangeal joints in 70° of flexion and the interpha- Palmaris longus 30 23 (66%)
langeal joints in neutral position. Kleinert protocol of Median nerve 35 20 (57%)
early passive flexion and active extension using rubber Radial artery 35 18 (51%)

KJMS May - August, 2020, Vol. 13, No.2 269

Figure1. Glass injury with transected FCU, ulnar artery & nerve, median N, FDS & FDP Pre- operative (a), (b) & Post-
operative (c), (d), (e)

270 KJMS May - August, 2020, Vol. 13, No.2

 Figure2. Child hand glass injury with transected ulnar triad and PL & FDS Pre- operative (a), (b) & Post- operative
(c), (d), (e)

hitting door and windows made up of glass materials
and 3 cases because of knives cut in young women
due to some domestic issue as a suicidal attempt. Most
frequently injured tendons were FDS (86 %) and Flexor
Carpi Ulnaris FCU (77 %). Structures located in the ulnar
triad were more commonly injured including ulnar artery
and nerves than the radial artery and median nerve.
Regarding the functional outcome as measured
by Kleinert and Verdan criteria, range of motion was
graded as excellent, good, fair and poor. ROM was
excellent in 16 patients, good in 10 patients, fair in 3
and poor in 6 patients. Recovery of intrinsic muscle was
good in 11 patients and fair to poor in 24 patients. Sen-
sory recovery was measured by MRC grading system.
Nineteen patients gained only protective sensation and
10 patients demonstrated return of two-point discrimi-
nation that ranged from 7 to 13 mm in 9 patients and 2
to 6 mm in 5 patients. During the follow-up period, there
were no tendon rupture or gapping and any neuroma
formation. Our results are depicted in the following
tables and figures.
DISCUSSION
Spaghetti wrist also known as full house syn-

KJMS May - August, 2020, Vol. 13, No.2 271

drome involves transaction of at least 3 structures at
wrist including one major artery, nerve and tendon3.
Pucket and Meyer used the term “spaghetti wrist”
when tendon, nerve or artery are simultaneously cut13.
These injuries mainly occur accidentally in industries
or at home due to sharp objects like glass and knives3.
Suicidal attempts by cutting wrist with knife are also
common in our society7. These are serious injuries with
potentially devastating disabilities14. Clinically these
injuries are significant due to overcrowded tendons and
involvement of major neurovascular structures5, 6. The
hand has been identified as an important component
of human anatomy, unique in structure and function15.
Because the hand is frequently used as a nonverbal
medium of communication, a disfigured hand results
in negative changes in self image16. Patients with these
injuries needs good patient IQ level for post operative
rehabilitation.
In managing these injuries, primary repair of
nerves and tendons has been demonstrated to im-
proved results than secondary repair1,3. There is no
significant difference between epineural and group
fascicular nerve repair17,18. In tendon repair, 4 strand
cruciate repairs provide good strength for early range
of motion (ROM) exercises. Splints with controlled early
ROM exercises are the key to good functional recov-
ery18,19.
The causative agent in most cases in our study
was glass cut injury. This finding was also observed by
Gloria Chins who conducted study on 60 patients8. The
most common cause in their study was laceration from
glass cut. Puckett et al studied 38 patients and found
that glass laceration is the main cause for spaghetti
wrist13. In another study by Carolyn VJ et al, glass cut
was the main causative agent in spaghetti wrist20. In our
study, the main mode of injury was accidental trauma
by falling on table and window glass at home or at in
industry. This fact was also observed by Carolyn VJ et
al who found that 50 % of trauma was accidental glass
injury20. El-Lamie KK and Younes TB and Bukhari et al,
also observed in their studies that accidental glass cut
laceration is the most frequent mechanism of injury2,10.
Apart from accidental trauma, there were 8 cases (23%)
of suicidal glass cut laceration in our study. All these
patients used either sharp glass piece or knife to cut
their wrist while attempting suicide. All these were young
emotionally unstable and highly aggressive patients.
This finding in our study is similar to the study of Car-
olyn VJ et al, 20. Raza MS, et al also observed suicidal
attempts at wrist in 10 % of their patients.
The most frequent structures damaged in our
study were on the ulnar side at wrist involving the
ulnar artery, ulnar nerve and FCU. FDS was the most
common tendon involved in 86% of our cases. Mafi
P. and Beikpour H. also found that FDS was the most
common transected tendon in their study17. In another
study conducted by Raza MS et al, the most common
272
injured structures were FDS, FCU, ulnar artery and ulnar
nerve7. This finding was also observed by El-Lamie KK
and Younes TB in their study of 124 patients2.
The study conducted by Bukhari et al is contradic-
tory to our results as there was predilection of injury for
medial structures10. In their study, the injury involved
median nerve in 70% and ulnar nerve in 60% while in
our study, ulnar nerve was transected in 24 patients
(68%) and median nerve in 20 patients (58%). There
was combined nerve involvement in 16 patients (46%) in
our series. This finding is similar to the study of Carolyn
VJ et al, who found combined median and ulnar nerve
transaction in 39 % of cases20.
Nerve injury causes motor and sensory loss of
the hand. Several previous studies reported on motor
recovery following nerve injury8,13,22,23. Our results are
comparable with findings in these studies, although
reports on grip and tip pinch strength recovery vary. We
found overall recovery of intrinsic muscles to be better
than reported by others8,13,22,23.
Functional outcome was measured by Kleinert
and Verdan criteria for motor recovery and was grad-
ed as excellent, good, fair and poor 11. We obtained
excellent and good motor nerve recovery in 48% and
28% respectively which is comparable to other similar
studies 2, 7, 10. Jaquet JB et al, in their study also showed
same comparable results for motor recovery3. Hung
et al, also found in their study sub optimal results of
motor recovery21. Sensory recovery was measured by
MRC grading system12. Reports on sensory recovery
vary but are overall dissatisfying, with most patients
recovering only gross protective sensation8,13. In our
study, 19 patients (54%) gained only protective sensa-
tion and only 10 patients (28%) demonstrated return of
two-point discrimination. These results in our study are
comparable to similar studies conducted by Widgerow
AD and Chin G, et al 5,8.
CONCLUSION
Spaghetti wrist is a severe disabling injury. Func-
tional recovery after repair in “spaghetti wrist” is gener-
ally sub-optimal. Accurate repair of injured structures,
early movement, appropriate physiotherapy and patient
co-operation are required for better results.
REFERENCES
1. Verdan CE. Primary repair of flexor tendons. J Bone
Joint Surg 1960; 42A: 647-57.
2. El-lamie KK, Younes TB. Spaghetti Wrist: Good
Prognosis with Adequate Surgical Technique and
Early Physiotherapy. Egypt J Plast Reconstr Surg
2010; 34(2): 161-66.
3. Jaquet JB, Van der Jagt I, Kuypers P, Schreuders T,
Kalmijn S, et al. Spaghetti Wrist Trauma: Functional
Recovery, Return to Work, and Psychological Effects.
Plast Reconstr Surg 2005; 115: 1609-17.
KJMS May - August, 2020, Vol. 13, No.2
4. Yuksel F, Pecker F, Acikel C, Cellkoz B. Second hand
management of Spaghetti wrist: do not hesitate to
explore. Ann Plast Surg 2002; 49: 500-4.
5. Widgerow A.D. Full-house/spaghetti wrist injuries. S
Afr J Surg 1990; 28: 6-10.
6. Hudson D, de Jager L. The spaghetti wrist: Simul-
taneous laceration of the median and ulnar nerve
with flexor tendons at the wrist. J Hand Surg (Br.)
1993; 18: 171-3.
7. Raza MS, Jaffery SAY, Khan FA. Flexor Zone 5 Cut
Injuries: Emergency Management and Outcome.
J Coll Physicians Surg Pak 2014; 24(3): 194-197.
8. Chin G, Weinzweig N, Mead M, Gonzalez M.
‘’Spaghetti Wrist’’ Management and results. Plast
Reconstr Surg 1998; 102: 96- 102.
9. Yrjana N, Nina CL, Sauli P, Sanna R, Nadja R. Flexor
tendon injuries in pediatric patients. J Hand Sur Am
2007; 32: 1549-57.
10. Bukhari AJ, Saleem M, Bhutta AR, Khan AZ, Abid KJ.
Spaghetti wrist: management and outcome. J Coll
Physicians Surg Pak 2004; 14(10): 608-11.
11. Kleinert HE, Verdan C. Report of the committee on
tendon injuries. J Hand Surg 1983; 8: 794-8.
12. MacKinnon SE, Dellon AL. 1988c. Nerve repair
and grafting. In: Mackinnon SE, Dellon AL, editors.
Surgery of the peripheral nerve. New York: Thieme.
P 89–129.
13. Puckett CL, Meyer VH. Results of treatment of ex-
tensive volar wrist lacerations: The spaghetti wrist.
Plast Reconstr Surg 1985; 75 (5): 714- 21.
14. Tate DG. Workers’ disability and return to work. Am
J Phys Med Rehabil 1992; 71: 92- 96.
15. Haese JB. Psychological aspects of hand injuries:
Their treatment and rehabilitation. J Hand Surg (Br.)
1985; 10: 283- 87.
16. Grunert BK, Smith CJ, Devine CA, et al. Early psy-
chological aspects of severe hand injury. J Hand
Surg (Br.) 1988; 13: 177- 80.
17. Mafi P, Beikpour H. Management and results of ex-
tensive volar wrist lacerations: “the spaghetti wrist“in
124 patients during a 5 year period in 15th khordad
hospital Tehran. MJIRI 2006; 20(1): 5-7.
18. Strickland JW. Development of flexor tendon sur-
gery: twenty-five years of progress. J Hand Surg
Am 2001; 25A:214-35.
19. Kabak S, Hallici M, Baktir A, Turk CY, Avsarogullari L.
Results of treatment of extensive volar wrist lacera-
tions: the Spaghetti wrist. Eur J Med 2002; 9: 71- 6.
20. Carolyn VJ, Shyam SR, Scot LH, Michael JT. Out-
comes of spaghetti wrist injuries at a country hospi-
tal. P145. AAHS Annual meeting: Atlantis Paradise
Island, Bahamas; Jan 21- 24, 2015.
21. Hung LK, Pang KW, Yeung PLC, Cheung L. Active
mobilization after flexor tendon repair following
injuries in zone 2 and other zones: comparison of
results. J Orthopaed Surg 2005; 13: 158- 63.
22. Vastamaki M, Kallio P, Solonen K. The results of
secondary microsurgical repair of ulnar nerve injury.
J Hand Surg (Br.) 1993; 18: 323- 6.
23. Kallio P, Vastamaki M. An analysis of the results of
late reconstruction of 132 median nerves. J Hand
Surg (Br.) 1993; 18: 97- 105.

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KJMS May - August, 2020, Vol. 13, No.2 273

 FREQUENCY AND TYPES OF AGE RELATED MACULAR
DEGENERATION (AMD) IN PATIENTS WITH DECREASED
VISION ABOVE 60 YEARS OF AGE; A CROSS SECTIONAL
STUDY CONDUCTED AT TERTIARY CARE HOSPITAL,
PESHAWAR
Muhammad Numan1, Muhammad Sajid Khan2, Waqar Hayat3, Muhammad Saleh Faisal4, Waheed Iqbal5

ABSTRACT
Objective: To determine the frequency and types of age related macular degeneration (AMD) in patients with de-
creased vision above 60 years of age presenting to out patient and inpatient department of Ophthalmology at tertiary
care hospital of Peshawar.
Methodology: A consecutive cross-sectional study was carried out in the Department of Ophthalmology at Hayatabad
Medical Complex, Peshawar from May, 2018 to December, 2018. 138 consecutive patients presented with decreased
vision were part of this study. A detailed history was taken and an ocular examination was conducted. The diagnosis
and classification of age related macular degeneration (AMD) was made on the basis of slit lamp indirect fundus
examination, fundus fluorescein angiography (FFA) and optical coherence tomography (OCT) according to standard
protocol. The data was entered and analyzed through statistical package for the social sciences (SPSS).
Results: As per frequencies and percentages for AMD, 25 (18.11%) patients had AMD while for gender wise distribution,
17 (68%) were male and 8 (32%) were females. As per descriptive statistics, Mean and SD for age was recorded as
59±1.7. Among 25 (18.11%) patients, 18 (32%) patients had Dry AMD and 7 (5.07%) patients had Wet AMD. Among
patients with Wet AMD, 5 (3.62%) were males and 2 (1.44%) were females whereas among patients with Dry AMD,
12 (8.69%) were males and 6 (4.34%) were females. Although frequency of male patients was higher in our data but
there was no statistically significant association between AMD vs gender and AMD vs quality of life with p-value 1.00.
Conclusion: The incidence of AMD increases with age and males are more affected than females. AMD (particularly
wet type) appeared to have negative impact on the quality of life, patient’s mental health and dependence.
Keywords: Age Related Macular Degeneration (AMD), Age Related Maculopathy (ARM), Retinal Pigment Epithelium
(RPE)

INTRODUCTION causes the death of photoreceptors and results in loss

of central vision (1). RPE degeneration is accompanied
Age related macular degeneration (AMD) is ba- by variable loss of both the overlying photoreceptors
sically a degenerative disorder involving central retina and the underlying choroidal perfusion. When the loss
and ultimately ends up with severe visual deterioration. of visual field, visual acuity or other visual functions
These deteriorative changes in retinal pigment epithe- are accompanied by advanced age and typical clinical
lium (RPE), chorio-capillaris and neurosensory retina findings, the condition is termed as AMD. In elderly
1Medical Officer, Health Department, KPK population, AMD is one of the major causes of blindness
2Trainee Vitreo Retinal Ophthalmology, Hayatabad and affect around 21 million elderly people globally (2).
Medical Complex, Peshawar Prevalence of AMD increases with advancing age.
3Senior Registrar, Department of Medicine, Fauji Foun- Overall, the prevalence of AMD among US population
dation Hospital, Peshawar of age above 40 years has been found to be 6.5% (1).
4Assistant Professor, Department of Pharmacology, According to Beaver Dam offspring study, early AMD
Khyber Medical College was present in 3.4% of population age between 21-34
5Pharmacist, Department of Pharmacology, Khyber years while an increase to 9.8% was observed in pop-
Medical College ulation of 65 years and above (2). Fridbert Jonasson et
......................................................................................... al reported that prevalence of AMD was 12.4% in age
Address for correspondence: group of 66-74 years, with increase to 36% in population
Waheed Iqbal of 85 years and above (3).
Pharmacist, Department of pharmacology, Khyber
Medical College, Peshawar AMD is usually manifested after fifth decade of life.
Contact No: 0347-5244271 The disease may be asymmetrical but is usually bilat-
Email: waheediqbal4200@gmail.com eral and most of the times the affected patients shows

274 KJMS May - August, 2020, Vol. 13, No.2

positive family history. It is one of the leading causes
of irreversible blindness in the developed world. Visual
loss has not been observed in early phase but central
retinal degeneration and retinal atrophy is often seen
as the disease progresses over years and associated
with loss of central vision.
AMD has two major types i.e. Dry and Wet AMD.
The early form of dry/non exudative AMD is char-
acterized by small to intermediate sized druses, without
significant loss of vision. The intermediate form of dry/
non-exudative AMD is characterized by atrophy of over-
lying retinal layers, loss of retinal pigment epithelium,
difficulty in light adaptation and loss of contrast sensi-
tivity. The advanced dry/non-exudative form of AMD is
associated with atrophic changes resulting in severe
loss of central visual field. It must be remembered that
in all sub-types of dry AMD, peripheral visual acuity is
intact.
More than 90% of patients diagnosed with AMD
are affected by Dry/Non-exudative type, which is mostly
accompanied by very slowly progressive visual loss i.e.
occurs over period of decades in comparison to Wet/
exudative type, where the visual loss is usually very
rapid i.e. occurs within months.
Moreover, around 10-20% of patients with non-ex-
udative AMD transforms into exudative form (4).Thus,
significant visual loss in at least 1.75 million patients
who currently have advanced AMD is secondary to the
effects of choroidal neovascularization from AMD (5, 6).
AMD is generally considered a disease of devel-
oped world due to greater life expectancy and it has not
been studied much in our region. But due to convinc-
ing evidence and supporting association of other risk
factors such as smoking, hypertension, hyperlipidemia
and diabetes mellitus with AMD, it is suggested to be
more prevalent in our region as well. So, we carried
out this study to see if the results coincide with that
of international studies, and if so, it would raise our
concern about the disease and would warrant proper
evaluation of the patients presenting with decreased
vision, especially their macular status.
MATERIAL AND METHODS
A cross sectional study was conducted at the
Department of Ophthalmology, Hayatabad Medical
Complex, Peshawar from May, 2018 to December, 2018
using non-probability consecutive sampling technique.
Sample size of 138 was calculated using WHO
calculator, based on 12.4% prevalence (3) at 95 con-
fidence level, 5.5% absolute precision and population
proportion (P) of 0.12 (12.4%).
Patients of either gender, presented with de-
creased vision to outpatient and inpatient department of
ophthalmology having age between 60 to 85 years, with
clear fundus view on slit lamp indirect ophthalmoscopy
KJMS May - August, 2020, Vol. 13, No.2
were included in the study.
Patients allergic to fluorescein dye, unfit for FFA
due to renal failure, having comorbid retinal diseases
like diabetic retinopathy, hypertensive retinopathy, pos-
terior uveitis, retinitis or any other maculopathies, patient
with mature cataracts or corneal opacities causing
hazy fundus view were excluded from study to control
biasness and confounders.
After taking proper approval from the hospital
ethical committee and written informed consent from
patients, a detailed history and clinical examination in-
cluding ophthalmological examination were carried out
followed by said investigations to rule out confounders.
The diagnosis and classification of age related macular
degeneration was made on the basis of slit lamp indirect
fundus examination, fundus fluorescein angiography
(FFA) and optical coherence tomography (OCT) ac-
cording to standard criteria (7) i.e.
• Presence of significant multiple drusen are charac-
teristic features of Early Dry AMD.
• Presence of drusen with associated pigment accumu-
lation in the posterior pole, atrophic changes in
retinal pigment epithelium (RPE) and easier de-
marcation of underlying choroid vascular plexus
are observed in Intermediate Dry AMD.
• Coalescence of atrophic focal islands to form large
zonal colonies of atrophy with severe visual alter-
ation are features of Advanced stage Dry AMD.
• Appearance of RPE elevation, Choroidal neo-vascular-
ization, exudate, sub-retinal fluid or hemorrhage
are seen in Advanced Wet AMD.
DATA ANALYSIS
Data was analyzed using SPSS version 20. Fre-
quency and percentages were calculated for categorical
variables like gender, AMD and its types. Mean ± S.D
were calculated for continuous variables like age. AMD
and its types were stratified among age and gender to
see effect modifiers. Post stratification Chi Square test
were applied among different groups and P value was
calculated. P value less than 0.05 was considered as
significant.
RESULTS
As per frequencies and percentages, of 138 pa-
tients, 25 (18.11%) patients had AMD including 17 (68%)
males and 8 (32%) females. Overall 18 (32%) patients
had Dry AMD and 7 (5.07%) patients had Wet AMD. In
order to find out the role of gender in the development
of AMD, fisher’s exact test was carried out. The results
are summarized in Table 1 while graphically shown
in Figure 1 in which 12 males were suffered from dry
AMD while 5 males had wet AMD. On the other hand, 6
females had dry AMD and only 2 females had wet AMD.
275
 Table 1: Association of gender with AMD

Gender Dry AMD Wet AMD p-value OR (95% CI)

Males 12 5 1.0 0.80(0.11-5.40)
Females 6 2

Table 2: Association of AMD with quality of life

Quality of life Dry AMD Wet AMD p-value OR (95% CI)

Fair 13 4 0.63 1.95 (0.31-12.01)
Poor 5 3

patients were spending poor quality of life. Similarly,

in wet AMD, patients with fair and poor quality of life
were 4 and 3 respectively as mentioned in Figure 3. It
affected many daily life activities like driving, reading,
computer use, mobility, face recognition etc.
To find out difference between quality of life in
patients with either wet or dry AMD, fisher’s exact test
was applied. The results are shown in Table 2.

Figure 1: Gender distribution among wet and dry
AMD
Figure 2: Age wise distribution of AMD
Figure 3: Quality of life in AMD
Age wise distribution of AMD is given in Figure 2,
showing increase in incidence with progression in age.
The quality of life was also assessed in patients
suffering with either dry or wet AMD. In our data, 13
patients with dry AMD had fair quality of life while 5
DISCUSSION
The study was conducted at the Department of
Ophthalmology, Hayatabad Medical Complex, Pesha-
war. 138 patients were included in this study of which
25 (18.11%) were diagnosed with AMD, comprising 17
(68%) males and 8 (32%) females.
Population based studies on AMD documented
various prevalence rates i.e. 3.5% from Tromso Eye
Study in Norway (8), 9.8% from the Blue Mountains Eye
Study in Australia (9) and 12.3% from Rotterdam Study
in Netherlands (10).
In Asia, data available regarding this topic is
mostly derived from Eastern countries, while reports
from western Asian countries are very limited. The
AMD prevalence according to Singapore Malay Eye
Study was 9.9% (11), Beijing Eye Study was 5.4% (12),
Hisayama Study in Japan was 13.5% (13) and Andhra
Pradesh Eye Disease Study was 10.7% (14). In our
study, the prevalence of AMD among >70 years was
11.15%.
According to Indian Sub-continent studies, the
prevalence of late AMD was found to be 0.6% in the
Aravind Eye Survey, which was less than our obser-
vation in the present study i.e. 1.6% (15).  The reason
for this difference could be inclusion of the older age
population in Aravind’s study, but it is worth mentioning
here that in the Aravind’s Survey, prevalence of late AMD
increased from 1.3% in the age range of 40-49 year to
6.9% in those with age more than 70 years. 
In the present study, it is also inferenced that
AMD incidence increases with advancement in age.
This finding is consistent with many other studies thus,

276 KJMS May - August, 2020, Vol. 13, No.2

there is strong association between AMD and increasing
age (16-18). Since it is a disease of elderly population,
AMD may co-exist with other ocular ailments such as
cataract, diabetic retinopathy, hypertensive retinopathy
etc. Therefore, it is important to diagnose and specify
the type of disease on routine fundus examination.
In our study, among 25 patients, 18 patients had
Dry AMD (12 males and 6 females) and 7 patients had
Wet AMD (5 males and 2 females) which is consistent
with the results of a study done by Dr. D.Y. Patil Medical
College & Research Centre, Pune in which Dry AMD was
much more common than Wet AMD and the frequency
of both types increased with advancing age. Moreover,
in this study the AMD incidence was higher among
males than females i.e. males were 15 times at higher
risk of developing AMD, resembling our study. But in
some studies, AMD was found to be more prevalent in
women than men (19, 20).
We also determined the effect of AMD upon
patient’s quality of life where 17 patients were having
fair quality of life (4 with wet AMD and 13 with dry
AMD) while 8 patients were having poor quality of life
(3 patients with wet AMD and 5 with dry AMD). These
results were derived from different parameters i.e. 18.9%
patients were having no ocular pain, 62.2% were having
mild to moderate while 18.9% were having severe ocular
pain.
Some patients were having moderate to extreme
difficulty in reading newspaper with respective percent-
ages of 27% and 54.1%. 16.2% patients were having
slight difficulty in reading street signs and bus number
plates while some were having moderate to extreme
difficulty with respective percentages of 13.5% and
62.2%.
Only 2.7% patients were having mild difficulty in
going up and downstairs, 43.2% patients were having
moderate and 40.5% patients were having extreme
difficulty.
Keeping these facts in mind, it is important to
focus not only on treatment modalities but also on
steps to be taken for improving patient’s quality of life
and prevention of limitations associated with AMD.
CONCLUSION
The incidence of AMD increases as age progress-
es and males are more affected than females. Moreover,
AMD negatively affects the quality of life particularly in
patients with wet type AMD. Although available treat-
ment modalities are limited but early diagnosis and
continuing support can improve prognosis and quality
of life of patients. Our data needs further validation with
large sample size from multiple centers.
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ONLINE SUBMISSION OF MANUSCRIPT

It is mandatory to submit the manuscripts at the following website of KJMS. It is
quick, convenient, cheap, requirement of HEC and Paperless.
Website: www.kjms.com.pk
The intending writers are expected to first register themselves on the website
and follow the instructions on the website. Author agreement can be easily
downloaded from our website. A duly signed author agreement must accompany
initial submission of the manuscript.

278 KJMS May - August, 2020, Vol. 13, No.2

 FUNCTIONAL OUTCOME OF MINIMAL INVASIVE PLATE
OSTEOSYNTHESIS IN PERI-ARTICULAR KNEE FRACTURES
Arif Kaleem, Tahir Mehmood Khattak, Basit Hussain, Zahid Askar

ABSTRACT
Background: Fractures around the knee are common, and are caused by high energy trauma[1,2] such as road traffic
accidents. Such fractures are difficult to treat because of its unique characteristics such as fracture extension into joint,
precarious blood supply and operative treatment is usually recommended for good outcome [3,4,5,6]. The use of MIPO
technique for peri-articular knee fractures has been extensively studied in western literatures but the studies in local
literatures are limited. There is little evidence regarding use of MIPO technique in local literature. Our patient population
is unique as most of the injuries are due to high velocity trauma like gunshot wounds along withroad traffic accidents.
The present study is designed to determine the functional outcome of MIPO technique in Peri-articular knee fractures..
Objective: To determine the functional outcome of MIPO (Minimal invasive plate osteosynthesis) in peri-articular knee
fractures.
Setting: Department of Orthopedics and Traumatology, Khyber Teaching Hospital, Peshawar.
Study Design: Descriptive case series
Materials And Methods: In this examination an aggregate of 65 patients were watched. All patients with peri-articular
knee breaks requiring MIPO and patients between age 18 and 60 years with ASA I-II were remembered for the inves-
tigation. Postoperatively, Patients were assembled dependent on the crack example and obsession. As a rule, weight
bearing on peri-articular knee breaks was deferred till indications of recuperating with callus development or goal of crack
line showed up. Exercise based recuperation was established taking a shot at center fortifying, scope of movement,
reinforcing and molding. Patients were continued in the workplace on customary premise at time periods, 6, 12 weeks,
and a half year. Grumbles of agony was evaluated with visual simple score (VAS) and issues with ambulation (limp and
required guides) was recorded. Clinical assessment of incisional mending, engine assessment, tactile assessment,
knee soundness, scope of movement (ROM) and ambulation was performed. Radiographs comprising of AP and LAT
perspectives on distal femur, knee joint and proximal tibia were gotten and assessed by muscular specialists during
development. Actual assessment discoveries and radiological appraisal was utilized to ascertain the KNEE SOCIETY
SCORE at half year follow up visit.
Results: The present study shows that among 65 patients, 72% patients were in age range 18-40 years and 28%
patients were in age range 41-60 years. Mean age was 37 years with SD ± 9.91. 76% patients were male and 24%
patients were female. More over 21% patients had excellent outcome, 38% patients had good outcome, 33% patients
had fair outcome while 8% patients had poor outcome.
Conclusion: Our study concludes that functional outcome of MIPO (Minimal invasive plate osteosynthesis) was excellent
in 21%, good in 38%, fair in 33% and poor in 8% in patients presenting with peri-articular knee fractures.
Key Words: Functional outcome, Minimal invasive plate osteosynthesis, peri-articular knee fractures

INTRODUCTION screws allows direct fracture visualization, reduction and

Fractures around the knee are common, and
caused by high energy trauma[1,2] such as road traffic
accidents. Such fractures are difficult to treat because of
its unique characteristics such as fracture extension into
joint, precarious blood supply and for good outcome
operative treatment is usually recommended [3,4,5,6].
Open reduction and internal fixation, with plates and
1????????????
.........................................................................................
Address for correspondence:
Dr Arif Kaleem
Senior Registrar, Fouji Foundation Hospital Peshawar
Email: drarifkaleem@gmail.com
Cell: 03331979790
fixation but also has the adverse effects like periosteal
stripping, soft tissue dissection, wound breakdown,
fracture hematoma disruption, joint stiffness and deep
infections. These problems can be avoided by circular
ring fixator, but have the risks of non-union and pin-
tract infection [7,8]. Minimal invasive plate osteosynthesis
(MIPO) improves farcture healing by preserving the
blood supply of the fracture fragments, minimizing
soft tissue dissection and avoiding fracture hematoma
disruption [9,10]. The anatomically designed locking plate
allows for its easy and quick application with screws
fixed only proximally and distally from the fracture site
in a bridging mode, and allows early functional rehabil-
itation. The pullout strength of locking plates is higher

KJMS May - August, 2020, Vol. 13, No.2 279

than the conventional plates, making it particularly
useful in osteoporotic bones [11,12]. Treatment goals of
periarticular knee fractures are to restore joint congru-
ity, limb alignment and stable fixation [13-14]. Functional
outcome mainly depends on range of motion , and
extensor mechanism strength of knee.
In a study done by Nayak 2011 15 on 31 patients
with distal femur fractures, the results were good or
excellent in 93.54%. In another study done by Walia
on distal femur fractures (50 patients), 18 had excellent
and 28 had good results.[16] In 4 patients, the results
were poor. Singh[17] compared the results of Buttress
plate and MIPO in 40 patients with proximal tibia frac-
tures and his results showed that operative time and
post-operative complications were less in the MIPO
group and results were better compared to the Buttress
plate group. Clinical results in study by Dr Muhammad
Shoaib khan were good or excellent in 83.6% patients
(n=22), while functional results were good or excellent
in 88.5% (n=23) patients.[18]
There is limited local data on the management of
periarticular knee fractures treated by MIPO technique.
The purpose of this study was to evaluate the outcome
of MIPO in periarticular knee fractures.
OBJECTIVE
To determine the functional outcome of MI PO
(Minimal invasive plate osteosynthesis) in periarticular
knee fractures, at Department of Orthopedics And
Traumatology, Khyber Teaching Hospital, Peshawar.
MATERIAL AND METHODS
SETTING: Department of Orthopedics and Traumatol-
ogy, Khyber Teaching Hospital, Peshawar.
STUDY DESIGN: Descriptive case series.
DURATION OF STUDY: 7 months 20/12/2019 to
20/7/2020.
SAMPLE SIZE: Sample size was calculated using the
WHO software for sample size calculation. The param-
eters used for calculation included: confidence interval
of 94%, margin of error 6%, effectiveness of 93.5%.[15]
The sample size was 65.
SAMPLING TECHNIQUE: Non probability consecutive
sampling.
Inclusion criteria
• All patients with peri-articular knee fractures re-
quiring MIPO.
• Patients between age 18 and 60 years with ASA I-II.
Exclusion criteria
• Patients with intramedullary fixation, metastatic
disease.
280
• Impaired lower extremity motor or nerve function
prior to injury and supplemental methods for bone
healing were excluded.
DATA COLLECTION PROCEDURE
All the patients with peri-articular knee fractures
satisfying the inclusion criteria were included in the
study through OPD and ER department. The purpose
and benefit of study was explained to all patients and
written informed consent were obtained (attached as
annexure)
All patients were subjected to detailed history,
complete routine examination and appropriate baseline
investigations .
Investigations such as plain radiographs with AP
and LATERAL views were done to delineate the fracture
pattern. Other investigations like complete blood count,
virology profile, ECG, echocardiography, renal function
tests etc were done for evaluation of fitness for surgery
by anesthesiologist.
The patient was given either general anesthesia
(GA) or spinal anesthesia depending upon fitness as-
sessed by anesthesiologist. Indirect Fracture reduction
was done under fluoroscopic guidance with patients in
supine position. The operative approach to peri-articular
knee fractures was tailored according to each patient
based on particular pattern of injury, location of fracture,
associated injuries and soft tissue involvement. Expe-
rienced orthopedic surgeon, having minimum 5 years’
experience in orthopedics was performing the surgeries.
All patients were have postoperative radiographs (AP,
LAT) imaging to confirm reduction quality and implant
position.
Postoperatively, patients had received antibiotic
and deep vein thrombosis prophylaxis. Patients were
mobilized based upon the fracture pattern and fixa-
tion. IN general, weight bearing on peri-articular knee
fractures was delayed until signs of healing with callus
formation or resolution of fracture line. Physical therapy
was instituted working on core strengthening, range of
motion, strengthening and conditioning.
Patients were followed up in the office on regular
basis at intervals of 2 weeks, 6 weeks, 12 weeks, and
6 months. Complains of pain was assessed with visual
analogue score (VAS) and problems with ambulation
(limp and required aids) was recorded. Clinical exam-
ination of incisional healing, motor examination, sensory
examination, knee stability, range of motion (ROM) and
ambulation was performed. Radiographs consisting of
AP and LAT views of distal femur, knee joint and prox-
imal tibia was obtained and evaluated by orthopedic
surgeons during follow-up. Physical examination find-
ings and radiological assessment was used to calculate
the KNEE SOCIETY SCORE at 6 month follow up visit.
KJMS May - August, 2020, Vol. 13, No.2
RESULTS Status of loss of flexion was analyzed as 21(32%)
patients had loss of flexion while 44(68%) patients didn’t
In this study age distribution was analyzed as had loss of flexion. (see Table No 5)
47(72%) patients were in age range 18-40 years while
18(28%) patients were in age range 41-60 years. Mean Status of varus/valgus deformity was analyzed
age was 37 years with SD ± 9.91. as 40(61%) patients had varus/valgus deformity while
25(39%) patients didn’t had varus/valgus deformity.
Gender distribution was analyzed as 49(76%)
patients were male while 16(24%) patients were female. OA/OTA fracture classification was analyzed as
13(20%) patients had extra articular distal femur frac-
Duration of disease was analyzed as 38(59%) ture, 22(34%) patients had complete articular distal
patients had duration of disease ≤ 24 hours while femur fracture, 8(12%) patients had extra articular prox-
27(41%) patients had duration of disease > 24 hours. imal tibia fracture, 16(25%) patients had partial articular
Mean duration of disease was 24 hours with SD ± 2.33. proximal tibia fracture, 6(9%) patients had complete
Status of pain in term of visual analogue score articular proximal tibia fracture.
was analyzed as 22(34%) patients had moderate pain Mechanism of injury was analyzed as 43(66%)
(VAS score 4-7) while 43(66%) patients had severe pain patients had RTA, 16(25%) patients had fall, 6(9%)
(VAS score 8-10). Mean VAS was 8 with SD ± 4.572. patients had fire arm injury.
(see Table No 4)
Functional outcome was analyzed as 14(21%)
patients had excellent, 25(38%) patients had good,
Table No 4: Visual Analogue Score
21(33%) patients had fair, 5(8%) patients had poor. (see
Table No 9)
Visual analogue Frequency Percentage
score
DISCUSSION
4-7 22 34%
Breaks around the knee are normal, and are
8-10 43 66% brought about by high energy trauma [1,2], for exam-
Total 65 100% ple, street auto collisions. Such breaks are hard to treat
Mean VAS = 8 in view of its interesting qualities, for example, crack
SD± 4.572 augmentation into joint, tricky blood gracefully and
usable treatment is generally suggested for good result
Table No 5: Loss Of Flexion [3,4,5,6]. Open decrease and inward obsession, with
plates and screws permits direct crack representation,
Loss of flexion Frequency Percentage decrease and obsession yet it additionally has the
900 - 1100 21 32% unfavorable impacts like periosteal stripping, delicate
tissue analyzation, danger of wound breakdown, crack
1110 - 1300 44 68%
hematoma interruption, joint solidness and profound
Total 65 100% diseases. These issues are dodged by round ring
Mean loss of flexion = 1100 fixator, however have the dangers of non-association
SD± 38.101 and pin-parcel disease [7,8]. Insignificant obtrusive
plate osteosynthesis (MIPO) improves break recu-
Table No 6: Varus / Valgus Deformity perating by safeguarding the blood gracefully of the
crack pieces, limiting delicate tissue dismemberment
Deformity Frequency Percentage and staying away from crack hematoma interruption
Yes 40 61% [9,10]. The anatomically planned bolting plate takes
No 25 39% into account its simple and snappy application with
screws fixed just proximally and distally from the break
Total 65 100% site in a connecting mode, and permits early practical
recovery. The pullout quality of locking plates is higher
Table No 9: Functional Outcome than the ordinary plates, making it especially helpful
in osteoporotic bones [13,14]. Treatment objectives of
Functional out- Frequency Percentage
periarticular knee breaks are to reestablish joint con-
come
gruity, appendage arrangement and stable obsession
Excellent 14 21% [13-14]. Practical result mostly relies upon scope of
Good 25 38% movement, and extensor system quality of knee.
Fair 21 33% The current examination shows that among 65
Poor 5 8% patients, 72% patients were in age range 18-40 years
and 28% patients were in age range 41-60 years. Mean
Total 65 100% age was 37 years with SD ± 9.91. 76 percent patients

KJMS May - August, 2020, Vol. 13, No.2 281

were male and 24% patients were female. More over
21% patients had great result, 38% patients had great
result, 33% patients had reasonable result while 8%
patients had helpless result.
Comparative outcomes were seen in another
examination led by Nayak RM et al18 in which the
mean working time was 70 (territory, 60-100) minutes.
The mean length of medical clinic remain was 9 (6-
14) days. The interim to association was 3.7 (territory,
2.8-4.6) months. The mean subsequent period was 18
(14-26) months. At the one-year development, 29 of the
patients had great or magnificent results. No patient had
rakish or rotational distortion of >10º. One osteoporotic
lady with a sort A1 break had embed disappointment
at 10 weeks and went through correction medical
procedure. Another patient with a kind A1 break had
diligent torment on the parallel part of the distal thigh
and went through embed evacuation at 22 months. No
patient grew profound disease, malunion or nonunion.
31 patients with distal femur breaks, the outcomes were
acceptable or brilliant in 93.54%.
Comparative outcomes were seen in another
examination directed by Walia JP et al19 in which there
was a general decrease of 26.4% in the extent of patients
alluded for knee radiography in the mediation gathering
(77.6% versus 57.1 %; P<.001), yet an overall decrease
of just 1.3% in the benchmark group (76.9% versus
75.9%; P=.60). These progressions after some time
were critical when the mediation and control bunches
were thought about (P<.001). The standard was found
to have an affectability of 1.0 (95% certainty span [CI],
0.94-1.0) for recognizing 58 knee cracks. The K coeffi-
cient for understanding of the standard was 0.91 (95%
CI, 0.82-1.0). Contrasted and nonfracture patients who
went through radiography during the after-mediation
time frame, those released without radiography invested
less energy in the crisis division (85.7 minutes versus
118.8 minutes) and acquired lower assessed complete
clinical charges for doctor visits and radiography (US
$80 versus US $183).
Comparative outcomes were seen in another
investigation led by Singh S et al20 in which looked at
the aftereffects of Buttress plate and MIPO in 40 patients
with proximal tibia breaks and his outcomes demon-
strated that employable time and post-usable difficulties
were less in the MIPO gathering and results were better
contrasted with the Buttress plate gathering. Clinical
outcomes in concentrate by Dr Muhammad Shoaib
khan were acceptable or magnificent in 83.6% patients
(n=22), while utilitarian outcomes were acceptable or
brilliant in 88.5% (n=23) patients.
In another investigation led by Ramseier LE et al21
had announced that man time to association was 3.7
(territory, 2.8–4.6) months. The mean subsequent period
was 18 (14–26) months. At the one-year development,
93.5% of the patients had great or phenomenal results
in the wake of exposing them to MIPO for femur breaks.
282
In another investigation directed by Lee SH et
al79 had revealed that mean age was 40 years with
SD ± 3.18. 70% patients were male and 30% patients
were female. Insignificantly intrusive percutaneous
osteosynthesis strategy utilizing securing plates was
compelling 90% patients and was not powerful in 10%
patients.
CONCLUSION
Our study concludes that functional outcome of
MIPO (Minimal invasive plate osteosynthesis) was ex-
cellent in 21%, good in 38%, fair in 33% and poor in 8%
in patients presenting with peri-articular knee fractures.
REFERENCES
1. Virk JS, Garg SK, Gupta P, Jangira V, Singh J, Rana
S. Distal Femur Locking Plate: The Answer to All
Distal Femoral Fractures.J Clin Diagn Res. 2016
Oct;10(10):RC01-RC05.
2. Agrawal A, Kiyawat V. Complex AO type C3 distal
femur fractures: Results after fixation with a lateral
locked plate using modified swashbuckler approach.
Indian J Orthop. 2017 Jan-Feb;51(1):18-27.
3. Wähnert D, Hoffmeier K, Fröber R, Hofmann G,
Mückley T. Distal femur fractures of the elderly--dif-
ferent treatment options in a biomechanical com-
parison. Injury. 2011 Jul;42(7):655-9.
4. Jahangir AA, Cross WW, Schmidt AH. Current man-
agement of distal femoral fractures. Curr Orthop
Prac.2010,21:193-197.
5. Kregor PJ, Stannard J, Zlowodzki M, Cole PA,
Alonso J. Distal femoral fracture fixation utilizing
the Less Invasive Stabilization System (L.1.S.S.):
The technique and early results.Injury.2001,32(Sup-
pl3):SC32-SC47.
6. Andalib A, Sheikhbahaei E, Andalib Z, Tahririan
MA. Effectiveness of minimally invasive plate osteo-
synthesis (MIPO) on comminuted tibial or femoral
fractures. Archives of Bone and Joint Surgery. 2017
Sep;5(5):290.
7. Gupta P, Tiwari A, Thora A, Gandhi JK, Jog VP.
Minimally Invasive Plate Osteosynthesis (MIPO) for
Proximal and Distal Fractures of The Tibia: A Bio-
logical Approach. Malaysian orthopaedic journal.
2016 Mar;10(1):29.
8. Anwar LC, Amin CM. Clinical Outcome of MIPO
Technique in Complex Multi-fragmentary Distal
Femoral Fractures. Journal of Pakistan Orthopaedic
Association. 2015 Mar 30;27(1):21-7.
9. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey
W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B,
Henley B, Audigé L. Fracture and dislocation
classification compendium-2007: Orthopaedic
Trauma Association classification, database and
outcomes committee. Journal of orthopaedic trau-
ma. 2007;21(10 Suppl):S1-133.
10. Kim JW, Oh CW, Jung WJ, Kim JS. Minimally inva-
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 sive plate osteosynthesis for open fractures of the
proximal tibia. Clinics in orthopedic surgery. 2012
Dec 1;4(4):313-20.
11. Da-ke T, Fang J, Xiao-bing C, Jun-lan L. Locking
internal fixator with minimally invasive plate os-
teosynthesis for the proximal and distal tibial frac-
tures. Chinese Journal of Traumatology. 2011 Aug
1;14(4):233-6.
12. Byun YS, Park KC, Bong HJ, Lee CH. Minimally in-
vasive plate osteosynthesis for proximal tibial shaft
fracture. Journal of the Korean Fracture Society.
2011 Jan 1;24(1):23-7
13. Ramesh G, Kumar NR. Study of complications and
functional outcome of fixation of distal tibial fractures
with anatomical locking plate using mipo technique.
Journal of Evolution of Medical and Dental Sciences.
2017 Apr 17;6(31):2489-93.
14. Morgan SJ, Jeray KJ. Minimally invasive plate os-
teosynthesis in fractures of the tibia. Operative Tech-
niques in Orthopaedics. 2001 Jul 1;11(3):195-204.
15. Nayak RM, Koichade RM, Umre AN, Ingle MV. Mini-
mally invasive plate osteosynthesis using a locking
compression plate for distal femoral fractures. Jour-
nal of orthopaedic surgery. 2011 Aug;19(2):185-90.
16. Walia JP, Malu G, Walia SK, Gupta AC, Sethi S, Singh
S. Minimally Invasive Plate Osteosynthesis for Distal
Femoral Fractures. JIMSA 2014; 27 (4): 197.;198.
17. Singh S, Arora KK, Chaudhary P, Kapila R, Shar-
ma R. Role of locking compression plate (LCP) in
periarticular fractures knee. International Journal of
Orthopaedics. 2017;3(4):697-703.
18. Khan MS, Jamal A, Ali A, Hussain B, Askar Z. Re-
sults of Minimally Invasive Plate Osteosyntheses
in Periarticular Knee Fractures. Journal of Pakistan
Orthopaedic Association. 2017 Mar 30;29(1):29-32.
19. Walia JP, Malu G, Walia SK, Gupta AC, Sethi S, Singh
S. Minimally Invasive Plate Osteosynthesis for Distal
Femoral Fractures. JIMSA 2014; 27 (4): 197.;198.
20. Singh S, Arora KK, Chaudhary P, Kapila R, Shar-
ma R. Role of locking compression plate (LCP) in
periarticular fractures knee. International Journal of
Orthopaedics. 2017;3(4):697-703.
21. Ramseier LE, Janicki JA, Weir S, Narayanan UG.
Femoral fractures in adolescents: a comparison
of four methods of fixation. J Bone Joint Surg Am.
2010;92(5):1122-9.

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KJMS May - August, 2020, Vol. 13, No.2 283

 EFFICACY OF LAPAROSCOPY FOR IMPALPABLE
CRYPTORCHIDISM
Jehangir Khan1, Muhammad Javed Khan2, Kifayat Khan3

ABSTRACT
Background: Undescended testes in male child are a very common abnormality in which one or both testis does not
reach the bottom of scrotum at birth. In case of impalpable testes, ultrasound is often used to find the testis which fre-
quently gives false results. Recently laparoscopy has become popular in diagnosis and treatment of impalpable testes.
We performed the study to determine the sensitivity and specificity of laparoscopy and determine the conversion rates
i.e., efficacy, in our local children presenting with impalpable testes undescended testes.
Material and methods: This Descriptive cross-sectional study was conducted in department of Paediatric surgery unit
Lady Reading Hospital from June 2015 to December 2016 with age range 2 to 14 years. The patients were admitted
from outpatient department after detailed history, physical examination and ultrasonography.
Results: A total of 98 patients with 115 undescended testes i.e., 17 with bilateral undescended testes underwent
Diagnostic laparoscopy and therapeutic surgery. In 12 undescended testes vas and vessel were entering the inguinal
ring for which inguinal exploration was performed, thus the conversion rates to open surgery was 10% in our study.
Conclusion: Our study showed laparoscopy is diagnostic in 100% while effective in 90% with the conversion rates of 10%.

INTRODUCTION formed by Chang et al showed 5% canalicular testes,

Cryptorchidism is the most common anomaly of
genito-urinary system in male children.1, 2 The testes in
these children may be palpable or impalpable.2,3 The
overall incidence of cryptorchidism is 3% which may be
upto 30% in premature infants.3,4 The incidence of pal-
pable testes is about 80% and these testes are located
in inguinal region or upper part of scrotum, while the
impalpable testes is about 20%.1, 3
For diagnosis of impalpable testes the investiga-
tion modalities could not reach 100% in the past. These
modalities include Ultrasound, Computed tomography,
Magnetic resonance imaging, angiogram as these have
limitations.3, 5 The abdomino-pelvic ultrasound locates
intra-abdominal testes accurately in only 18% while
MRI detect in only 37%.3,4 Diagnostic laparoscopy has
been recommended for the detection of impalpable
undescended testes, with a sensitivity and specificity
of more than 90%. 2, 5, 6
The success rate of laparoscopy for impalpable
testes is as high as >95% in various series.5 Study per-
1Department of Paediatric surgery unit Gajju Khan
Medical College, Swabi
2Department of Paediatric Surgery Unit Nowshera
Medical College.
3Department ofPaediatric Surgery unit, Lady Reading
Hospital Peshawar
.........................................................................................
Address for correspondence:
Dr Muhammad Uzair
Department of Paediatric Surgery Unit Nowshera Med-
ical College.
E-mail: ?????????
Cell: ????
another study conducted by Ahmed et al showed 15%
patient with vas and vessel entering the deep ring.
The present study is designed to determine the
sensitivity and specificity of laparoscopy and determine
the conversion rates i.e., efficacy, in our local children
presenting with impalpable testes undescended testes.
This study will help us to highlight the importance of
laparoscopy not only in diagnosis of undescended testis
but also its treatment in the form of bringing it down to
scrotum.
MATERIAL AND METHODS
Descriptive cross-sectional study was conducted
in Paediatric surgery unit of Lady Reading Hospital Pe-
shawar for a period of 18 months extending from June
2015 to December 2016 The study was conducted after
approval from hospitals ethical and research committee.
During this period a total 98 patients with 115 impalpa-
ble undescended testes underwent laparoscopy and
laparoscopic orchidopexy. Patients with age range
from 2 years to 14 years. The patients were admitted
from outpatient department after physical examination
and ultrasonography to confirm absence of testes in
inguinal canal and ectopic locations. Investigations like
Hemoglobin were performed to see fitness for surgery,
average Hemoglobin was 10.8g/dl. Patient with previous
history of surgery were excluded from study. Informed
consent before surgery was taken from the parents. All
the results were analyzed in SPSS 20.0
RESULTS
Age distribution among 98 patients was analyzed
as 82(84%) patients were in age range 4-8 years,

284 KJMS May - August, 2020, Vol. 13, No.2

16(16%) patients were in age range 9-14 years. Mean Table No 1: Age Distribution (n=98)
age was 6 years with SD 2.73. (as shows in table no 1)
Age Frequency Percentage
98 patients with 115 undescended testes under-
went diagnostic laparoscopy and therapeutic surgery. 2 - 8 years 82 84%
Patients with bilateral impalpable cryptorchidism were 9-14 years 16 16%
17 while 81 patients had unilateral impalpable testes.
Total 98 100%
(as shown in table 2)
Mean age was 6 years with SD ± 2.73
Ultrasound performed before the operation
localized 52 of the 115 testes (42%). In the group of Table No 2: Laterality (n=98)
patients where the gonads were really absent (17 testes)
the sensitivity of US was 100%. Thus sensitivity of US Laterality Frequency Percentage
was 42%. In the group of patients where the gonads Unilateral 81 83%
were really absent (17 testes) the sensitivity of US was
Bilateral 17 17%
100%. Laparoscopy was helpful in determining the
location and morphology of all the testes(100%). The Total 115 100%
laparoscopic findings in these patient were categorized
according to the findings and location of testes (as Table No 3: Category Of Impalpable Testis (n=115)
shown in table 2).
Categories Frequency Percentage
Category 1: Vas and vessel entering inguinal ring
Category 1 12 10%
Category 2:intra-abdominal testes Category 2 95 83%
Category 3: Testicular vessel and vas ending blindly Category 3 8 7%
(vanishing testes) Total 115 100%
Findings were as follow
Table No 4: Efficacy (n=115)
Efficacy of laparoscopy was determined by the
number of patients requiring inguinal exploration after Efficacy Frequency Percentage
laparoscopy i.e., conversion rate.(as shown in table 3)
Effective 103 90%
Out of 115 testes inguinal exploration was performed
in 12 cases as the vas and vessel were entering the Not effective 12 10%
deep inguinal ring. Out of those 12, 3 had hypo trophic Total 115 100%
testes and orchidopexy was done, while remaining
had vas and vessel ending blindly or atrophic testes the diagnostic laparoscopy is able to confirm the pres-
and orchidectomy was performed. Overall success of ence or absence of testes in 100%. 9, 10
laparocopy for impalpable testes was 90% preventing
unnecessary exploration of inguinal canal. Study conducted by Ahmed dar et al showed vas
and vessel entering the deep ring in 9.09% while study
DISCUSSION conducted by Sangrasi AK et al showed vas vessel
entering the deep ring in 6(15%) patient which are com-
In 20% of patients with cryptorchidism the testis
parable with our study.11,12 Inguinal canal exploration
is impalpable and that group of patients is presently
reveals a blind-ended vas deferens, although 9 of the
treated usually using laparoscopic techniques. Orchi-
12 testes in our group showed remnants of atrophic
dopexy in cryptorchid child should be done before 1
gonads histologically that, in our opinion, should be
year of age. The mean age of presentation in our study
removed. Our practice is open exploration, which
was 6 year with SD 2.5 which is more as there is delayed
definitely resolves the problem and provides definitive
presentation and lack of awareness in local population.
management; this is very important for parents who are
However we recommend orchidopexy in impalpable
usually afraid of malignant transformation
testes be performed at standard age i.e., before 1 year,
as laparoscopy is safe in any age. Patient with bilaterality CONCLUSION
in our study were 17% which is comparable with study
by Ismail 13% and Hassan 21%8,9 In our study the sensitivity and specificity of lap-
aroscopy was 100% while efficacy of laparoscopy for
The sensitivity of radiological diagnosis of impal- impalpable testes was 90% preventing unnecessary
pable testis of 42% in our series which is comparable exploration of inguinal canal in 103 cases. The main
with Nijs et al 48%.10 This is too low to exclude the advantage of laparoscopy lies in the fact that it can be
presence of testes in the abdomen. The US is able to used as a diagnostic tool and as well as therapeutic
localize testes in the abdomen, but when they are not tool.
visualized, this does not exclude their presence, while

KJMS May - August, 2020, Vol. 13, No.2 285

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1514–1519, 2009.
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scopic management of impalpable tes-
tes in children–new classification; lessons
learned and rare anomalies,” Journal of Laparo-
endoscopic and Advanced Surgical Techniques
2010.;20(3):265-269,
10. Nijs SM, Eijsbouts SW, Madern GC, et al. Nonpal-
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286 KJMS May - August, 2020, Vol. 13, No.2

RISK FACTORS FOR NON-ALCOHOLIC FATTY LIVER DISEASE:
A CROSS-SECTIONAL STUDY IN PAKISTANI POPULATION
Abida Matin Ansari1, Naheed Gul, Mahwish Majid Bhatti, Lubna Meraj, Zarmast Khan, Muhammad Wajad Munir1

ABSTRACT
Objective: Fatty Liver is seen with increasing pervasiveness in daily clinical routine but the ubiquity of its risk
factors is undiscovered. This study evaluates the clinical features and commonness of risk factors for fatty
liver disorder.
Methods: This descriptive study was carried out at the Medical Unit of Pakistan Institute of Medical Sciences,
Islamabad from January to July, 2015.Hundred patients who had abnormal ALT, negative screening for hepatitis
B and C virus and fatty liver identified on ultrasound were examined for the manifestation of diabetes, obesity,
hypercholesterolemia, hypertriglyceridemia and the metabolic syndrome. The demographic, anthropometric
and laboratory data were recorded in a proforma. Statistical analysis was done using SPSS version 18.
Results: The mean age of the study population was 45.39±14.16 years. Females were 63%. Most (63%) patients
were asymptomatic, 28% had dyspepsia, 5% had right hypochondrial pain and 36% had fatigue. Only 19% patients
had hepatomegaly and none had signs of portal hypertension. The mean ALT of the study population was 83±28.5
IU/L. Thirty-four percent were found to be diabetic, 66% were obese, 28% had hypercholesterolemia, 48% had
hypertriglyceridemia and 26% had metabolic syndrome.
Conclusion: Nonalcoholic fatty liver disease is interconnected with a high occurrence of obesity, female gender, hy-
percholesterolemia, hypertriglyceridemia, and diabetes. Patients are usually asymptomatic and most have no clinical
signs on examination.
Key words: Fatty liver, diabetes, Hyperlipidemia, metabolic syndrome, obesity.

INTRODUCTION nonalcoholic steatohepatitis (NASH), may progress

Nonalcoholic f a t t y liver disease also referred
to as NAFLD is a clinicohistopathological entity with
histological features that resemble alcohol-induced
liver injury but by definition occurs in patients with
little or no history of alcohol consumption. It encom-
passes a histological spectrum that ranges from fat
accumulation in hepatocytes without concomitant
inflammation or fibrosis called hepatic steatosis to
steatohepatitis which is steatosis with a necroinflam-
matory component that may or may not have asso-
ciated fibrosis1. The latter condition, referred to as
1Department of Medicine Nafees medical college,
Islamabad, Isra University.
2Department of Medicine, Shifa College of Medicine,
Islamabad.
3Department of Pathology Shifa College of Medicine,
Islamabad.
4DHQ department of Medicine, Rawalpindi medical
College
5Depatment of Pediatrics, Shifa College of Medicine
Islamabad.
.........................................................................................
Address for correspondence:
Dr. Naheed Gul
Department of Medicine, Shifa College of Medicine,
Islamabad.
E-mail: doctornaheed@live.com
Cell: +92 3215248081
to cirrhosis in up to 20 percent of patients. NASH is
now recognized to be a leading cause of cryptogenic
cirrhosis2. Regarding pervasiveness, studies have sug-
gested that up to 24% of the population bear NAFLD in
different countries3 but a more convincing information
comes from the third National Health and Nutrition
Examination Survey (NHANES III) which indicated
that between 3-6% of the US population have some
degree of NAFLD with the diagnosis based on raised
aminotransferases in the absence of any alternative eti-
ologies4. This affirmation has come from a histological
review of 354 patients having abnormal liver function
tests defined as alanine transaminase or a r-glutamyl
transferase more than twice the upper limit of normal
for minimum of 6 months of unknown etiology. Two-
thirds of the patients had NAFLD, one-third simple
steatosis and one-third a more advanced disease
non-alcoholic steatohepatitis (NASH) either with or
without fibrosis5. Diagnosis of NAFLD is based on a
combined clinical and histological criteria incorporating
absent/ low alcohol consumption with a comparable
liver biopsy revealing steatosis, Mallory bodies, he-
patocyte ballooning and inflammation with or without
fibrosis and cirrhosis. Radiological imaging is less
invasive and also help to identify patients with NAFLD.
All three imaging modalities including ultrasound, CT
scan and MRI are sensitive (93-100%) for identifying
a fatty liver significantly3. NAFLD is among the most
common etiologies of altered liver function tests and

KJMS May - August, 2020, Vol. 13, No.2 287

otherwise unexplained alanine aminotransferase (ALT)
elevation has been adopted as a surrogate marker
of NAFLD in epidemiological studies6. In the past few
years an increasing amount of research effort has
been expended on various aspects of non-alcoholic
fatty liver disease for at least two main reasons. First
is the recognition that NAFLD is extremely common,
and second the accumulating body of evidence that
a proportion of patients with NAFLD can progress to
cirrhosis, liver failure and hepatocellular carcinoma.
NAFLD is now a growing problem in Asian coun-
tries including pakistan7,8. The traditional risk factors
for NAFLD are generally considered to be female sex,
type 2 diabetes mellitus, obesity, and hyperlipidemia.
The reported prevalence of obesity in several series
of NAFLD varied between 30 and 100 percent, type
2 diabetes varied between 10 and 75 percent and
dyslipidemias varied between 20 and 94% respective-
ly3,4. Little is known about the association of these risk
factor with fatty liver in our population. This study was
carried out to find out the association of NAFLD with
diabetes, obesity, female gender, hypertriglyceridemia,
hypercholesterolemia and the metabolic syndrome in
Pakistani population.
MATERIAL AND METHODS
This study to determine the frequency of various
risk factors in patients o f Non-alcoholic fatty liver dis-
ease ( NAFLD) was carried out at Pakistan Institute of
Medical Sciences, Islamabad which is a 1,000 bedded
hospital affiliated with Quaid-e-Azam Post Graduate
Medical College, Islamabad and recruits’ patients from
most of Northern Punjab and Northern areas of Paki-
stan. Hundred patients were included in the study using
non-probability sampling technique. The demographic
details, clinical presentation, investigations and risk
factors of NAFLD were recorded on a Proforma. This
descriptive study was completed in a period of six
months from January to July, 2015. Patients of all age
groups with fatty liver on ultrasound or elevated ALT
were included. Patients with alcoholic hepatitis, au-
toimmune hepatitis and drug induced hepatitis were
excluded from the study.
NAFLD was diagnosed to be present in patients
with elevated ALT in the presence of fatty liver on
ultrasound (suggested by features of a diffuse hyper
echoic echo texture, bright liver, increased liver echo
texture compared with the kidneys, vascular blurring,
deep attenuation), exclusion of excessive alcohol
intake, positive hepatitis B or C serology and other
known etiologies of liver disease. Liver biopsy was
used to confirm the diagnosis only in those patients
who gave consent. The histopathological criteria of
diagnosis of NAFLD were macrovascular fatty change
in hepatocytes with displacement of the nucleus to the
edge of the cell. Additional presence of features like
Mallory bodies, balloon degeneration, predominantly
288
lobular neutrophilic inflammation, and Rappaport zone
III per sinusoidal fibrosis were considered as supportive
of diagnosis of fatty liver.
Viral hepatitis was defined as a positive HBsAg or
HCV antibodies by ELISA and they were excluded from
the study. Alcoholic hepatitis was defined as convincing
evidence of ongoing alcohol consumption of >40 g/
week, with changes suggestive of fatty liver on ultra-
sound. Obesity was defined by a body mass index (BMI)
>30 kg/m2 and hypertriglyceridemia as triglyceride level
of > 150 mg/dL or > 1.7 mmol/L after an overnight fast.
Diabetes mellitus type 2 was defined as patients already
taking an oral hypoglycemic drug or insulin or are
shown to have a fasting blood sugar > 126 mg/dL
o r / and a random blood sugar >200mg/dL on two
separate occasions. Hypertension was defined as pa-
tients already taking an anti-hypertensive drug or are
shown to have a blood pressure of >140/90 mmHg on
at least 2 occasions. Drug Induced NAFLD was defined
as features of fatty liver on ultrasound a n d history if
intake of amiodarone, tamoxifen, steroids or diltiazem.
Metabolic syndrome was defined according to the
Guidelines developed by “ T h e National Cholesterol
Education Program Adult treatment panel” also known
as the A TP III criteria.9 The presence of any three of
the following five traits (1. Abdominal obesity, defined
as a waist circumference in men more than 102 cm and
in women more than 88 cm. 2. Triglycerides level more
than 150 mg/dL or drug treatment for high triglycerides.
3. HDL cholesterol of less than 40 mg/dL in males and
less than 50 mg/dl in women or drug treatment for
low HDL-C. 4. Blood pressure 130/85 mmHg or drug
treatment for elevated blood pressure. 5. Fasting blood
glucose over 100 mg/dl or drug treatment for elevated
blood glucose. For obesity however we used BMI >30
kg/m2 instead of waist circumference in our study.
Data Collection Procedure
Patients were registered from the medical out-
patient department. Patients were screened with ALT.
Those with elevated ALT were evaluated with Hepatitis
B surface antigen (HBsAg) and antibodies to HCV.
Patients having a negative viral serology were sent for
an ultrasonography. Those patients with fatty liver on
ultrasound and elevated ALT were subjected to further
testing by Kayser Fleischer ring on slit lamp exam-
ination by the eye department, and ANF. Patients with
evidence of Wilson’s disease, or autoimmune hepatitis
were excluded from the study. Patients were ques-
tioned about alcohol intake and an attempt was made
to quantify the weekly intake in grams. Detail history
and physical examination was carried out according
to Proforma. This included demographic details of age,
gender, contact information and hospital registration
number. Patients were asked about history of diabetes,
hypertension or intake of oral hypoglycemics, insulin,
anti-hypertensives, amiodarone, diltiazem, steroids or
tamoxifen. Blood pressure and BMI was recorded in
KJMS May - August, 2020, Vol. 13, No.2
a proforma. Weight was done on the same weighing
machine with the shoes, sweaters, coats shawls and
hats off. The height was calculated in centimeters and
BMI was calculated as kg/m2. After the initial screening
patients were explained about the importance, tech-
nique and possible complications of liver biopsy. Those
who consented to biopsy had their blood samples
sent for blood complete picture, coagulation profile.
Fasting blood sugar, and fasting lipid profile was
done for all patients. A biopsy was taken using the
surecut liver biopsy needle under ultrasound guidance.
The samples were sent to department of pathology
for reporting. Figure 1:NAFLD Patients with Metabolic Syndrome

Statistical Methods Table 1: Descriptive statistics of study population

with NAFLD (n=100)
The data was analyzed using SPSS version 18.
Descriptive statistics including continuous variables VARIABLES
of age, AL T, BMI, fasting triglycerides and fasting Age (years) 45.39 +14.16
blood sugar levels were expressed as mean with
standard deviation.Categorical data including gender Cholesterol (mg/dL) 197.44+43.34
and presence or absence of symptoms (like anorexia, Triglyceride (mg/dL) 181.15+57.56
dyspepsia, right upper quadrant pain), fatty liver on BMI (kg/m2) 30.03+5.25
ultrasound, obesity, hypertension, hypercholesterol-
emia, hypertriglyceridemia and diabetes were reported Gender (Females) 63(63%)
as frequencies and percentages. Difference between Diabetes Mellitus 34(34%)
different variables was assessed using chi square test.
Hypertriglyceridemia 48(48%)
Logistic regression analysis was used to see association
of risk factors with NAFLD. P values lesser than 0.05 was Hypercholesterolemia 28(28%)
regarded as meaningfully significant. Obesity 66(66%)
Grade 1 obesity 48(48%)
RESULTS
Grade 2 obesity 17(17%)
Our study enrolled about 210 patients with el-
evated ALT and negative viral serology. They were Grade 3 obesity 1(1%)
sent for ultrasound and 107 patients were found to Overweight 21(21%)
have bright liver suggestive of fatty liver on ultrasound.
Normal weight 13(13%)
Three patients were excluded due to positive serology
for autoimmune hepatitis and one due to suspicion of Metabolic Syndrome 26(26%)
Wilsons disease. Three patients were ruled out due to Metabolic Syndrome Components
use of drugs known to cause fatty liver. Two of them
None 17(17%)
were using diltiazem and one was on tamoxifen. The
remaining 100 patients were evaluated for presence One component 21(21%)
of risk factors of obesity, diabetes, dyslipidemias and Two components 36(36%)
hypertension. They were counselled to undergo liver
Three components 18(18%)
biopsy and only patients who consented were sub-
jected to undergo the biopsy procedure. Descriptive Four components 8(8%)
statistics of the study population are detailed in Ta-
ble-1. none had signs of portal hypertension.

Age of the patients scaled between 15 and 76
years with a mean age of 45.39± 14.16years. Subse-
quent analysis showed however that the mean age did
not vary among males and females (46.37 versus 44.21;
p= 0.547). Females were 63% and males were 37% in
the study group.
Symptoms and Signs when analyzed, most of
t h e patients ( 63%) were asymptomatic, 28% had
dyspepsia, 5% had right hypochondrial pain and 36%
had fatigue. Only 19% patients had hepatomegaly and
The mean ALT of the study population was
83±28.5 IU/L. All patients had normal serum bilirubin
and albumin.
Thirty-four percent of the study population had
diabetes. Diabetes was more prevalent among the
obese (39.39% patients were diabetic among obese as
opposed to 23.5% among non-obese) but the variance
was not materially significant (p= 0.113). Similarly,
diabetes was more common among females (39.7%
among the females versus 24.32% diabetics in males)

KJMS May - August, 2020, Vol. 13, No.2 289

but the difference however was not statistically signifi-
cant (p= 0.118).
For hyperlipidemia, 48% patients with NAFLD had
hypertriglyceridemia and 28% had hypercholesterol-
emia. The dyslipidemias happened to be more frequent
among the obese patients (hypertriglyceridemia was
present in 59% versus 26.4% of obese and non-obese
respectively, p=0.002; and hypercholesterolemia was
present in 34.8% versus 14.7 of obese and non-obese
patients respectively, p=0.03). Similarly, these dyslip-
idemias were more common in patients with diabetes
(hypertriglyceridemia was present in 61.76% versus
40.9% in diabetic and non-diabetic patients respective-
ly, p= 0.048; and hypercholesterolemia was present in
47% versus 18.18% in diabetic and non­diabetic patients
respectively (p= 0.002). Mean triglyceride levels of
females was 186.23 mg/dl versus 172.4865 in males
(p= 0.251). Thirty-four females (54%) and 14 males
(37.8%) had hypertriglyceridemia. This difference was
not meaningfully significant (p=0.119) although females
had hypertriglyceridemia 1.9 times more common as
compared to men (OR= 1.96; 95% CI 0.841- 4.412).
Mean cholesterol level among females was recorded as
199.47 mg/dl in contrast to193.97 in males (p= 0.543).
Sixteen of the females (25.4%) had hypercholesterol-
emia against 12 males (32.4%). This variance was not
statistically decisive (p= 0.449) although females were
less likely to have hypercholesterolemia as compared
to men (OR= 0.709; 95% CI 0.291- 1.73).
Obesity is a key risk factor when considering
fatty liver. When analyzed, Only 13% patients of NAFLD
had normal weight (BMI 18-25 kg/m2) and 21% were
overweight (BMl 25-30 kg/m2). The rest of 66% patients
were obese with 48% having grade I obesity (BMI 30-35
kg/m2), 17% having grade II obesity (BMI 35- 40 kg/m2)
and only 1% being morbidly obese (BMI >40 kg/m2).
Among the 66 obese patients 26 (39.4%) were diabetic,
23 (34.8%) had hypercholesterolemia, 39 (59%) had
hypertriglyceridemia and 24 (36.7%) had metabolic
syndrome. On the other hand, among the 34 non-obese
patients only 8 (23%) were diabetic, 5 (14.7%) had
hypercholesterolemia, 9 (26.4%) had hypertriglycer-
idemia and 2 (5.8%) had metabolic s y n d r o m e .
Obesity was much more common among females
with NAFLD. Forty-nine females (77.8%) as compared
to 17 males (46%) were obese (BMI >30 kg/m2). This
difference was statistically significant (p= 0.001).
Females were 4 times more likely to be obese i f they
have fatty liver on ultrasound (OR= 4.118; 95% CI
1.711-9.907). Mean BMI of females was 31.35 kg/m2
and that of males was 27.78 kg/m2. The difference
was statistically significant ( p= 0.001).
For the existence of metabolic syndrome in the
study group, we documented the presence of diabe-
tes, obesity, hypertriglyceridemia and hypertension.
Figure-1 shows that 26% of the patients had metabolic
syndrome (defined as co-existence of three of more
290
of these traits). Seventeen percent, 21 % and 36% had
none, one and two traits respectively. The frequen-
cy of metabolic syndrome was higher in females in
whom 21 out of 63 (33.3%) had at least 3 traits of the
“deadly quartet” as compared to males in which 5 out
of 37 (13.5%) had metabolic syndrome. This difference
between the two genders was statistically significant
(p=0.029). Females were 3.2 times more likely to have
metabolic syndrome if diagnosed with fatty liver on
ultrasound (OR=3.2; 95% CI 1.089-9.4).
DISCUSSION
NAFLD has landed up to increasing pervasive-
ness among different communities all over the world.
This study documents the frequency of various known
risk factors in NAFLD patients. Early identification of its
risk factors and hence their timely management can
help to reduce the fraction of patients progressing to
cirrhosis. The most commonly associated risk factors
with fatty liver identified in our study were female gender,
obesity, diabetes, and hypertriglyceridemia which were
comparable to local published data10,11,12.
Our study showed 63% of females patients to
have NAFLD. Previous studies have reported compa-
rable results 10, 11. In various studies, nonalcoholic fatty
liver disease is reported to be common in middle-aged
woman, but few have shown more pervasiveness of
nonalcoholic fatty liver disease in males13, 14.
In our study obesity was present in 66% of the
patients. Data over the last few years reports fifty seven
to seventy four percent of obese persons, and ninety
percent of morbidly obese persons to possess NAFLD15.
The prevalence of NAFLD increases by a factor of 4.6 in
obese people. The pervasiveness of obesity in patients
with NAFLD ranged from 30 to 100 percent in a study16.
The NAFLD was observed in 76% of obese individuals
in contrast to 16% of non-obese individuals. Unexpect-
edly in patients with a normal body-mass index, central
obesity is identified to be a key predisposing factor
for nonalcoholic fatty liver disease17. The frequency of
obesity was probably underestimated in our study as
we evaluated obesity by BMI only. Measuring the waist
to hip ratio to estimate central obesity would probably
have affected the outcome for obesity.
Thirty four percent of patients in our study man-
ifested diabetes. It is becoming more common as
obesity becomes a major medical problem18.A study
at Saudi Arabia have documented a prevalence of 33%
for diabetes in obese patients19. A study reported even
children having type I diabetes mellitus to have fatty
liver 20. Type 2 diabetes mellitus tremendously increases
the occurrence of NAFLD irrespective of high or normal
body-mass index15.A study revealed the occurrence of
NAFLD to rise with increasing levels of sugar. It rose from
27% in population with normal blood sugar to 43% in
patients having impaired fasting glucose. This further
landed up to 62% in those having diabetes21. Mean ALT
KJMS May - August, 2020, Vol. 13, No.2
level in our study was 83+28.5 U/L which is comparable
to local data which reported it as 88.4+38.3 22.
Forty-eight percent patients with NAFLD in
our study had hypertriglyceridemia and 28% had
hypercholesterolemia. Silverman et al have reported
a prevalence of 21-60% of hyperlipidemia in NAFLD.
Obese patients, patients with diabetes and females
commonly exhibited the various dyslipidemias 16.
Similar pattern was observed in our study. In patients
with radiological evidence of fatty liver, approximately
half of the patients demonstrated hyperlipidemia pre-
viously. Hypertriglyceridemia was more frequent than
hypercholesterolemia in our study group and a study
have shown that hypertriglyceridemia compared to
hypercholesterolemia enhance the likelihood of fatty
liver disease23.
The association of NAFLD and metabolic syn-
drome is obvious from observational studies with
NAFLD being considered as the hepatic element of
this syndrome. For metabolic syndrome, over 90%
of subjects with NAFLD have at least one component
of metabolic syndrome and round one third have the
complete set of syndrome. As the number of metabolic
predisposing factors rise, the probability of NAFLD rises.
NAFLD patients with metabolic syndrome are expected
to have more severe disease imparting an odds ratio
of 3.2 for existence of Nonalcoholic steatohepatitis
and 3.5 for advanced fibrosis24. In our study 26% had
complete metabolic syndrome and 83 % had at least
one component of metabolic syndrome emphasizing
screening for other risk factors when you find one risk
factor for NAFLD.
Limitations: It was a cross-sectional study so
causal relationship was difficult to corroborate. A com-
parative study comparing NAFLD patients with normal
subjects would have provided a strong study design.
Moreover, extensive work is required on a larger levels
to document the prevalence of various risk factors for
NAFLD.
CONCLUSIONS
Non-alcoholic fatty liver disease is associated
with high occurrence of obesity, diabetes and metabolic
syndrome. Hypertriglyceridemia, hypercholesterolemia
and female gender are also closely interconnected with
fatty liver disease. Awareness and early identification
of these predisposing factors will lead to a holistic ap-
proach for management of patients with nonalcoholic
fatty liver disease.
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292 KJMS May - August, 2020, Vol. 13, No.2

 COMPARISON OF LAPAROSCOPIC TRANSABDOMINAL
PREPERITONEAL (TAPP) VERSUS OPEN (LICHENSTEIN)
REPAIR OF INGUINAL HERNIA IN TERMS OF EARLY POST
OPERATIVE PAIN
Rafiullah1, Razman Khan1, Muhammad Ismail2, Asif Mehmood3, Muhammad Kaleem4, Abdul Ghafoor5

ABSTRACT
Background: Inguinal hernia is very common presentation to general surgeons and their repair is indeed very common
surgical operation among surgeons. From the last several decades Lichtenstein mesh hernioplasty is the acceptable
and gold standard technique for inguinal hernia repair. Now a days surgeons are slowly adopting technique of laparo-
scopic inguinal hernia repair TAPP and TEP. There is an increasing evidence that laparoscopic inguinal hernia repair
is associated with less post-operative pain as compared to Lichtenstein mesh hernioplasty.
Objective: To compare laparoscopic transabdominal preperitoneal (TAPP) versus open (Lichtenstein) repair of inguinal
hernia in terms of early post-operative pain .
Material and Methods: This prospective randomized controlled trial was conducted at the Department of Surgery,
Khyber Teaching Hospital, Peshawar over a period of 2.5 years from January 2016 to July 2018. Total of 106 patients
presenting with inguinal hernia were divided into two groups A and B, 53 patients in each group. Patients in group
A were subjected to undergo Laparoscopic (TAPP) mesh hernia repair while patients in group B underwent open
Lichtenstein mesh hernioplasty. Patients from both groups were observed for 48-72 hrs. in post-operative period and
severity of early post-operative pain was assessed by using visual analogue scale. Statistical analysis of the recorded
data was done by using SPSS version 20.
Results: Total of 106 patients with inguinal hernia were included in the study. There were 53 patients in group A under-
going transabdominal preperitoneal (TAAP) mesh hernioplasty and 53 in group B undergoing open mesh hernioplasty.
Male to female distribution in group A was 47 (44.34%) and 6 (5.66%) respectively while in group B it was 46 (43.40%)
and 7 (6.60%) respectively (Graph No.1). p value was 0.08 which was not significant. Maximum patients in group A and
B presented with inguinal hernia were in the age of 31-50 years i.e. 21 (39.62%) and 19 (35.84%) respectively. While
minimum patients in both group A and B were in the age of 17-30 years i.e. 12 (22.64%) and 16 (30.18%) respectively.
p value was 0.31 which was statistically insignificant. Post-operative pain within 24 hrs. was measured in both groups
using visual analogue scale. It was divided into No pain (VAS =0) mild (VAS = 1-3), moderate (VAS =4-6) and sever
(VAS = >6). Statistical data was plotted into SPSS version 20 and results were obtained. Overall 41 (77.35%) patients
in group A experienced no post-operative pain as compared to 30 (56.60%) patients in group B. 12 (22.64%) patients
from group A and 23 (43.3%) patients from group B experienced some degree of pain within 24 hrs. p value was 0.023
which is statistically very much significant (<0.05).
5 (9.4%) patients in group A and 16 (30.18%) patients in group B experienced mild pain that required simple analgesics
like paracetamol or NSAIDs. Comparing both groups in terms of mild pain yield p value of 0.013 that is again statistically
very significant. In terms of moderate pain 5 (9.4%) patients from group A and 4 (7.54%) patients from group B expe-
rienced moderate pain that required strong analgesics like opioids e.g. tramadol. p value calculated was 1.000 that is
statistically not significant showing no significant difference in both groups in terms of moderate pain. 2 (3.7%) patients
in group A and 3 (5.6%) in group B experienced severe pain that required strong opioids like nalbuphine. P value cal-
culated was 1.000 that is statistically not significant showing no difference between two groups in terms of severe pain.
Mean visual analogue scale calculated was 0.86 ± 1.66. Minimum score was 0 and maximum score calculated was 7.
Conclusion: Laparoscopic (TAPP) inguinal hernia repair is associated with less early post-operative pain as compared
to open Lichtenstein mesh hernioplasty.
Key Words: Inguinal hernia, Transabdominal preperitoneal (TAPP), Lichtenstein mesh hernioplasty

Department of Surgery, Khyber Teaching Hospital Pe- INTRODUCTION

shawar, Pakistan Hernia (Latin, disruption; Greek, bud) it’s defined
......................................................................................... as the visceral protrusion through a defect in the abdom-
Address for correspondence: inal wall. The hernias are among one of the most antique
Ramzan Khan disease that affect men, being one of the first diseases
Department of Surgery, Khyber Teaching Hospital Pe- to be detected due to the obvious signs1. Inguinal hernia
shawar, Pakistan is very common presentation to general surgeons and
Cell: 0311-9585511 their repair is indeed very common surgical operation
E-mail: ramzan92080@yahoo.com among surgeons. In USA alone, about 700,000 cases

KJMS May - August, 2020, Vol. 13, No.2 293

are performed each year2. It has been estimated that
worldwide over 20 million operations of inguinal hernia
are performed every year, the specific operation rates
varying between countries from around 100–300 per
100 000 population per year. Fortunately, most inguinal
hernias are repaired electively. Inguinal hernia repair
accounting for 10 to 15% of all surgical procedures
and is the second most common surgical procedure
after appendectomy3. Open surgery for inguinal hernia
has gone through many stages of development after
its first description by an Italian surgeon Edoardo Bas-
sini (1844-1924) in 18894. Bassini discovered that the
inguinal floor played an important role in the etiology
of inguinal hernias. He approached the hernia at the
anterior side, resected the hernia sac, incised the fas-
cia transversalis and reconstructed the posterior wall
of the inguinal canal by a triple layer method. Bassini
published his results showing a recurrence rate of 2.8
% after 5 years of follow-up. In 1945 Canadian surgeon
Earle Shouldice (1890-1965) opened a small hospital
treating only inguinal hernias. His surgical technique
resembled the Bassini technique, but did have some
alterations and reconstructed the posterior wall of the
inguinal canal by a four-layer method. By this operation
recurrence rate decreased impressively to 1% in expe-
rienced hands and specialized clinics5. Since 1940s
various types of synthetic polymers are being used in
inguinal hernia repair. In 1987 Lichtenstein published
the results of 6,321 patients followed for 2-14 years
after repair with polypropylene mesh. This approach
revolutionized hernia repair. Despite passing 28 years
this Lichtenstein tension free mesh repair is still a gold
standard because this technique is simple, safe and
effective, with relapse rate of 0.7%.4 The advantages
of this repair were its association with less pain, rapid
postoperative recovery, early return to normal activity
and very low recurrence rate. Complications seen with
this procedure may be foreign body reaction, infection,
pain (The incidence of chronic groin Pain following this
procedure is reported to be as high as 75.5%), fistula
formation, migration, shrinkage, and recurrence. Other
complications include skin anesthesia, bruising and
hematoma formation, seroma formation, orchitis and
testicular atrophy6.
Soon after the establishment of laparoscopic
cholecystectomy some surgeons began laparoscopic
inguinal hernia repair however unlike laparoscopic cho-
lecystectomy, which was very quickly accepted by the
surgical community, laparoscopic hernia repair has re-
mained a controversial issue since its commencement7.
Ger was the first surgeon to attempt the laparoscopic
hernia repair.4 Evidence comparing laparoscopic and
open hernia repairs has varied with time and with chang-
es in techniques used but despite all these advances,
the best method for inguinal hernia repair has not yet
been established.2 Both methods have their positive and
negative aspects in terms of hospital stay, recurrence,
post-operative pain and cost effectiveness8.
294
Pain is a recognized complication after inguinal
hernia repair, but it should subside within an expected
time interval of about 2–3 months. A presumptive di-
agnosis of post herniorrhaphy neuralgia can be made
when the pain persists for more than 3 months after
hernia repair and is not related to other causes9. Early
uncontrolled trials claimed that laparoscopic repair was
superior to the conventional open repairs regarding
postoperative pain, resumption of normal activities, and
return to work. It started an era of real controversy in
1990 when tension free laparoscopic repair of inguinal
hernia was routinely practiced and aggressively market-
ed by promising less pain and shorter recovery period.3
However later on studies shown that laparoscopic
inguinal hernia repair specially TAPP was also associ-
ated with long term post-operative discomfort such as
inguinal or scrotal pain in up to 28.7% of patients10. In
one study Akhtar Ghani et all compared both techniques
in terms of post-operative pain, mean hospital stay and
operative duration, they stated that in laparoscopic
(TAPP) group 64.8% patients didn’t experienced any
pain as compared to 34.1% with a p-value of <0.001
which is quite significant.2
The present study was designed to determine
and compare the severity of pain among patients under-
going inguinal hernia repair surgeries by laparoscopic
transabdominal preperitoneal technique and open
Lichtenstein technique. The idea behind conducting this
study came into mind because of controversies both in
literature and among surgeons regarding early post-op-
erative pain in open Lichtenstein mesh hernioplasty and
laparoscopic TAPP. Some studies have shown increase
pain after Lichtenstein mesh hernioplasty while other
have shown no any significant differences between
two procedures. Also no any local data is available so
there was need to conduct a study and comparing both
procedures in our local population.
MATERIAL AND METHODS
This randomized controlled trial was conducted
at the Department of Surgery, Khyber Teaching Hospi-
tal, Peshawar over a period of 2.5 years from January
2016 to July 2018. Total of 106 patients presenting with
inguinal hernia were divided into two groups A and B,
53 patients in each group. Sample size was calculated
through the WHO software for sample size determina-
tion in health studies, using the formula for hypothesis
testing of two proportions (one sided) with the following
assumptions:
Significance Level = 5% Statistical Power = 80%
Anticipated proportion of mild and moderate pain in
group A (TAPP) = 32.9%
Anticipated proportion of mild and moderate pain in
group B (Lichtenstein) = 56.9% 1
Patients were divided into two groups A who
undergone laparoscopic (TAPP) repair and B who
KJMS May - August, 2020, Vol. 13, No.2
undergone open (Lichtenstein) repair. Blocked random
sampling technique in which first patient was asked
to select a block by lottery method. Each block was
consisting of four random combinations of both group
A and B so first four patients were included according
to that combinations. All patients above the age of 14
years, either gender with primary inguinal hernia were
included and patients with obstructed inguinal hernia,
recurrent inguinal hernias, uncontrolled diabetes or
having focus of infection e.g. abscess, sore throat etc.
were excluded. The study was conducted after ap-
proval from hospitals ethical and research committee.
All patients meeting the inclusion criteria and presenting
with inguinal hernia were admitted from OPD in Surgical
department Khyber teaching Hospital Peshawar. The
purpose and benefits of the study was explained to all
patient’s attendants if agreed upon a written informed
consent was obtained from attendant. All patients were
provided a printed pro forma.
All patients were subjected to detailed history and
clinical examinations followed by routine investigations. Graph 1: gender distribution of patients treated by
Patient remained in ward on the day of admission and tapp (group a) and open lichtenstein (group b) in the
surgery was done on next day elective list by general treatment of inguinal hernia
surgery team.
Procedure A was performed under general
anesthesia by 3 port technique. Procedure B was per-
formed under general or spinal anesthesia and a drain
was placed to prevent Seroma formation. After wound
closure and complete recovery from general anesthesia
patients were shifted to general ward. Patients from both
groups were observed for 48-72 hrs. and severity of
early post-operative pain was assessed by using visual
analogue score. After discharge patients were followed
at 1-4 weeks post operatively and severity of their pain
was assessed by using visual analogue score at each
follow up visit.
Statistical analysis of data was performed using
SPSS software version 20. Mean and standard deviation
were calculated for numerical variables like age and
weight. Frequency and percentage were computed in
both groups for categorical variables like gender and
pain. Outcome variable early post-operative pain was Graph 2: Comparisson of Pain in Post operative Pe-
stratified among age, weight and gender to see the riod Experienced by Patients in Taap (Group-A) and
effect modifiers. Data was calculated using chi square open Lichtenstein (Group-B) Mesh Hernioplasty
test and p-value calculated as <0.05 was considered
as significant. Both groups were compared using chi No.1). p value was 0.08 which was not significant.
square test. The data results were expressed in the form
Maximum patients in group A and B presented
of tables and charts.
with inguinal hernia were in the age of 31-50 years i.e. 21
(39.62%) and 19 (35.84%) respectively. While minimum
RESULTS
patients in both group A and B were in the age of 17-30
Total of 106 patients with inguinal hernia were years i.e. 12 (22.64%) and 16 (30.18%) respectively. p
included in the study. There were 53 patients in group A value was 0.31 which was statistically insignificant. Full
undergoing transabdominal preperitoneal (TAAP) mesh detail is shown in the table no 2.
hernioplasty and 53 in group B undergoing open mesh
Post-operative pain within 24 hrs. was measured
hernioplasty. Male to female distribution in group A was
in both groups using visual analogue scale. It was divid-
47 (44.34%) and 6 (5.66%) respectively while in group
ed into No pain (VAS =0) mild (VAS = 1-3), moderate
B it was 46 (43.40%) and 7 (6.60%) respectively (Graph

KJMS May - August, 2020, Vol. 13, No.2 295

 (VAS =4-6) and sever (VAS = >6). Statistical data was
plotted into SPSS version 20 and results were obtained.
Overall 41 (77.35%) patients in group A experienced
no post-operative pain as compared to 30 (56.60%)
patients in group B. 12 (22.64%) patients from group
A and 23 (43.3%) patients from group B experienced
some degree of pain within 24 hrs. p value was 0.023
which is statistically very much significant (<0.05).
results are shown in table no 2 and bar chart no 2.
5 (9.4%) patients in group A and 16 (30.18%)
patients in group B experienced mild pain that required
simple analgesics like paracetamol or NSAIDs. Com-
paring both groups in terms of mild pain yield p value of
0.013 that is again statistically very significant as shown
in table no 3.

Graph 3: Comparison of Pain in Post Operative In terms of moderate pain 5 (9.4%) patients from
Period According to Gender Distribution in Taap group A and 4 (7.54%) patients from group B experi-
(Group-A) And Open Lichtenstein (Group-B) Mesh enced moderate pain that required strong analgesics
Hernioplasty (Ghraph) like opioids e.g. tramadol. p value calculated was 1.000

Table 4: Age Distribution of Patients Treated By Tapp (Group A) and open Lichtenstein (Group B) in the Treatment
of Inguinal Hernia

SURGERY Mean N Std. Deviation

TAAP 42.40 53 13.443
OPEN 40.26 53 14.999
Total 41.33 106 14.214

Table 5: distribution of age groups of patients in taap (group-a) and open lichtenstein (group-b)

Age Groups Group A Group B

17-30 years 12 (22.64%) 16 (30.18%)
31-50 years 21 (39.62%) 19 (35.84%)
51-60 years 20 (37.73%) 18 (33.96%)
p value = 0.31

Table 6: Comparison Of Pain In Post Operative Period Experienced By Patients In Taap (Group-A) And Open
Lichtenstein (Group-B) Mesh Hernioplasty

Pain Group A Group B P value

Yes 12 (22.64%) 23 (43.3%) 0.023
No 41 (77.35%) 30 (56.60%)

Table 7: Comparison Of Mild Pain In Post Operative Period Experienced By Patients In Taap (Group-A) And Open
Lichtenstein (Group-B) Mesh Hernioplasty

MILD PAIN P value

Group A Group B
YES 5 (9.4%) 16 (30.18) 0.013
NO 48 (90.56%) 37 (6.81%)

296 KJMS May - August, 2020, Vol. 13, No.2

 Table 8: Comparison Of Moderate Pain In Post Operative Period Experienced By Patients In Taap (Group-A) And
Open Lichtenstein (Group-B) Mesh Hernioplasty

MODERATE PAIN P value

Group A Group B
YES 5 (9.4%) 4 (7.54%) 1.000
NO 48 (90.56%) 49(92.45%)

Table 9: Comparison Of Sever Pain In Post Operative Period Experienced By Patients In Taap (Group-A) And
Open Lichtenstein (Group-B) Mesh Hernioplasty

SEVER PAIN P value

Group A Group B
YES 2 (3.7%) 3 (5.6%) 1.000
NO 51 (96.22%) 50 (94.33%)

Table 10: Distribution Of Visual Analogue Scale Among Patients Undergoing Taap (Group-A) And Open Lichten-
stein (Group-B) Mesh Hernioplasty

SURGERY VAS Total

.00 1.00 2.00 3.00 4.00 6.00 7.00
TAAP 41 4 2 2 2 1 1 53
OPEN 30 12 2 2 4 2 1 53
Total 71 16 4 4 6 3 2 106

Table 11: Comparison Of Pain In Post Operative Period According To Gender Distribution In Taap (Group-A) And
Open Lichtenstein (Group-B) Mesh Hernioplasty

Gender PAIN EXPERIENCED P value

Group A Group B
MALE 6 (12.76%) 20 (43.47%) 0.001
FEMALE 6 (100%) 3 (42.85%) 0.070

that is statistically not significant showing no significant
difference in both groups in terms of moderate pain.
Results are shown in table no 4.
2 (3.7%) patients in group A and 3 (5.6%) in
group B experienced severe pain that required strong
opioids like nalbuphine. P value calculated was 1.000
that is statistically not significant showing no difference
between two groups in terms of severe pain. Results
are shown in table no5.
Mean visual analogue scale calculated was 0.86
± 1.66. Minimum score was 0 and maximum score
calculated was 7. Details of the visual analogue scale
in both groups are shown in the table no 6.
DISCUSSION
The hernias are among one of the most antique
disease that affect men, being one of the first diseases
to be detected due to the obvious signs.1 Inguinal hernia
is very common presentation to general surgeons and
their repair is indeed very common surgical operation
among surgeons.2 Inguinal hernia repair accounting for
10 to 15% of all surgical procedures and is the second
most common surgical procedure after appendectomy.3
Worldwide two types of procedures are under practice
now a days i.e. open Lichtenstein mesh hernioplasty
and laparoscopic mesh hernioplasty that either is done
by totally extraperitoneal approach (TEP) or transab-
dominal preperitoneal approach (TAAP). Both methods
have their positive and negative aspects in terms of
hospital stay, recurrence, post-operative pain and cost
effectiveness.8
Pain is a recognized complication after inguinal
hernia repair, but it should subside within an expected
time interval of about 2–3 months. A presumptive di-
agnosis of post herniorrhaphy neuralgia can be made
when the pain persists for more than 3 months after
hernia repair and is not related to other causes.9 Early

KJMS May - August, 2020, Vol. 13, No.2 297

uncontrolled trials claimed that laparoscopic repair was
superior to the conventional open repairs regarding
postoperative pain, resumption of normal activities, and
return to work. It started an era of real controversy in
1990 when tension free laparoscopic repair of inguinal
hernia was routinely practiced and aggressively market-
ed by promising less pain and shorter recovery period.3
However later on studies shown that laparoscopic
inguinal hernia repair specially TAPP was also associ-
ated with long term post-operative discomfort such as
inguinal or scrotal pain in up to 28.7% of patients.10
In our study we compared TAAP and open
Lichtenstein mesh hernioplasty in terms of early
post-operative pain. We included 106 patients that
were distributed in two groups A (TAAP group) and B
(Lichtenstein group), each group comprising 53 pa-
tients. Both groups included male and female patients
with male predominance in both groups (88.67% vs
11.32% and 86.79% vs 13.20%). Both groups had
maximum patients in age group between 17-30 years
(22.64% and 30.18%). Early post-operative was mea-
sured in both groups using visual analogue scale within
24-72 hours and patients were first divided into patients
having some degree of pain (VAS ≥1) and those having
no pain (VAS =0). It was noted that patients in group
A who have undergone TAAP experienced less pain
as compared to patients in group B who undergone
open Lichtenstein mesh hernioplasty i.e. 12 (22.64%)
vs 23 (43.3%). P value was 0.023 which was statistically
significant and showing that laparoscopic approach for
mesh hernia repair was superior and effective in terms
of post-operative pain.
Laparoscopic group was also superior is terms of
pain in male gender where only 6 patients experienced
pain as compared to 20 patients in open group while in
female gender open group was more effective where 3
patients experienced pain as compared to 6 in laparo-
scopic group. Pain was divided into mild, moderate and
sever grades on the basis of VAS. Laparoscopic group
was more effective in terms of mild pain where only 5
(9.4%) patients experienced mild pain as compared to
16 (30.18%) patients in open group. P value was 0.013
which was statistically significant. The groups were
statistically similar regarding age, moderate and sever
pain.
Akhtar Ghani et all compared both techniques in
terms of post-operative pain, mean hospital stay and
operative duration, they stated that in laparoscopic
(TAPP) group 64.8% patients didn’t experienced any
pain as compared to 34.1% with a p-value of <0.001
which is quite significant.2
A study by L Neumayer et al stated that patients in
the open-repair group had significantly greater levels of
pain (at rest, at work or during exercise, and during nor-
mal activities) than did those in the laparoscopic group
during the two-week postoperative assessment period.
On the day of surgery, the difference in the mean score
298
on the visual analogue scale was greatest (10.2 mm [95
percent confidence interval, 4.8 to 15.6]), but the score
decreased to 6.1 mm (95 percent confidence interval,
1.7 to 10.5) by the time of the two-week assessment.
The two treatment groups were similar with respect to
all pain assessments by the time the three-month visit
took place11.
Kumar et al.23 reported 12.3% chronic pain after
open mesh repair and 4.3% after laparoscopic total
extraperitoneal (TEP) repair12. Poobalan et al. reported
a 30% incidence of chronic pain after open hernia repair,
although this postal questionnaire only achieved 53%
follow up13.
The etiology of pain is multifactorial. Although
there is a mix of nociceptive pain (related to tissue
injury) and neuropathic pain (related to nerve injury),
the latter is predominant and its intensity seems to be
aggravated when numbness is also present14. Dam-
age to a nerve in the groin region may occur due to
stretching, contusion and crushing or thermal injury
due to electrocautery or injury due to entrapment while
suturing. The nerves that are usually injured are the
Ilioinguinal nerve, Iliohypogastric nerve, both the genital
and femoral branches of the genitofemoral nerve, and
the lateral femoral cutaneous nerve of the thigh. The
first two are especially prone to injury during an open
hernioplasty, with the most frequent site of involvement
being the suture line of external oblique near the su-
perficial inguinal ring while the latter are more likely to
be damaged during laparoscopy15,16. To minimize the
development of pain, Lichtenstein et al recommend the
preservation of the nerves in the inguinal canal17, while
some surgeons prefer to sacrifice these nerves. The
result of this maneuver is a region of sensory deprivation
in the distribution of these nerves. However, it is thought
to be better tolerated by the patient than the chronic
and persistent pain attributed to nerve entrapment in
scar or mesh18.
In our study we had identified all three nerves
specially in open Lichtenstein mesh hernioplasty and
tried to preserve all of them. In both groups meticulous
dissection was performed so that all aspects that can
lead to post-operative pain could be minimized. Anchor-
ing the mesh in both groups was done very carefully
so that no nerve was entrapped in suture material or
endotackers. With all these maneuvers results showed
that less number of patients in laparoscopic group
had experienced some degree of pain as compared to
patients in open Lichtenstein group (12 [22.64%] vs 23
[43.3%] with p value of 0.023).
CONCLUSION
From the results of our study it is concluded that
the incidence of post-operative in laparoscopic (TAPP)
and open Lichtenstein mesh hernioplasty in our local
adult populations is 22.64% and 43.3% respectively. Sta-
tistics showed that laparoscopic approach is associated
KJMS May - August, 2020, Vol. 13, No.2
with less post-operative pain as compared to open.We
recommend that this new minimal invasive technique
should be practiced and adopted by our surgeons so
that complications related to open invasive technique
can be minimized
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299
 FREQUENCY OF GESTATIONAL DIABETES IN OBESE
PATIENTS
Huma Sahibzada1, Irfan Ullah2, Summra Yousaf3, Taskeen Rehana4

ABSTRACT
Objective: To estimate incidence of GDM at different BMIs in pregnant women of different ethnic/racial groups.
Methods: A descriptive observational study wherein Non-probability sampling technique was used to assess GDM in
pregnant obese patients. Whole performa were filled about patient’s demography, obstetrical history and laboratory
investigations. SPSS vers. 16 was employed for data entry and analysis. Frequency and percentages were determined
for categorical variables. -value ≤0.05 was kept significant for the applied post-stratification Chi-square test.
Results: Total of 187 obese patients observed, mean age was 28 ± 2.17. Majority patients were within age bracket
of 26-35 years which was 97(52%); whereas patients in 15-25 years and 26-35 years age brackets were 34(18%) and
56(30%), respectively. Status of parity among 187 patients was analyzed as 56(30%) patients were primipara and
131(70%) patients were multipara. Gestational diabetes was found in 41(22%) patients. In Gestational diabetes, more
were within age of between 26-35 years which was 21 patients. Multipara and multigravida patients having diabetes
were 29 and 31, respectively while primipara and primigravida were 12 and 10, respectively.
Conclusion: GDM is found more in pregnant women having high BMI and with increasing gravidity and parity.
Key words: Pregnancy, Parity, Gestational diabetes, Body mass index.

INTRODUCTION and previous diagnosis of GDM7. Obesity on its own is

Gestational diabetes mellitus (GDM) refers to
occurrence of impaired glucose tolerance found for the
first time during second or third trimester of gestation,
a common metabolic disorder during pregnancy1. Ex-
posure of pregnant women to GDM is considered to be
directly in association with adverse perinatal and later
life complications among newborns2.
GDM has been found to affect 1-14% of pregnan-
cies3. GDM is mostly diagnosed by using the 75gm, 2
hours Oral Glucose Tolerance Test (OGTT)4. The risk
of Diabetes Mellitus (DM) development at later stages
is enhanced in women with GDM3. It is also associated
with adverse outcomes such as high rates of stillbirth,
hydramnios, gestational hypertension, macrosomia
and caesarian section5. GDM affected infants have
enhanced risks of peripartum complications including
mortality, birth trauma, hypocalcemia, polyhydramnios,
hypoglycemia and macrosomia6.
Reported risk considerations in GDM are ad-
vanced maternal age, ethnicity, multigravida state,
1Senior Registrar, Naseer Teaching Hospital, Peshawar
2MBBS student, Kabir Medical College, Peshawar
3Senior Registrar, Naseer Teaching Hospital, Peshawar
4Assistant Professor, Naseer Teaching Hospital, Pe-
shawar
.........................................................................................
Address for correspondence:
Huma Sahibzada
Senior Registrar, Naseer Teaching Hospital, Peshawar
Email: ???
Cell: ????
a risk element for GDM whereby GDM increases with
increase in BMI4,8-11. The ethnic composition in the study
area (District Peshawar) is distinct from those studied in
previous research and therefore merits an independent
study to confirm/validate and/or highlight differences
with the findings of research carried out elsewhere. This
study is aimed at estimating the incidence of GDM at
different BMIs in pregnant women of different ethnic/
racial groups within and around the Peshawar district.
MATERIAL AND METHOD
A cross-sectional study was performed in the
Department of Obstetrics and Gynaecology, Hayatabad
Medical Complex Peshawar from 17th August 2015 to
17th February 2016. Non probability sampling technique
were used in order to assess GDM in 187 patients us-
ing 22.58% proportion of GDM in obese patients, 95%
confidence level and 6% margin of error with the help of
WHO software for sample size determination. All those
women whose age was within the range of 15-45 years,
all parity and of BMI greater than or equal 23 kg/m2 were
included in the study. Women having Type – I Diabetes
Mellitus, hypertension or family history were excluded
from the study. Data was collected from out-patient
department (OPD) and Emergency Room (ER) after
approval from ethical committee. Data were collected
after taking consent and explaining purpose of study,
the benefits and risks involved. Patients were assured
that information collected was strictly to be used for
research purposes only and would remain confidential.
Whole performa were filled about patient’s demography,
obstetrical history and laboratory investigations meeting
the inclusive criteria. SPSS vers. 16 was employed for

300 KJMS May - August, 2020, Vol. 13, No.2

data entry and analysis. Frequency and percentages Table 1: Baseline features of pregnant patients
were determined for categorical variables. -value ≤0.05
was kept significant for the applied post-stratification Characteristics N=187 (%)
Chi-square test. Mean Age (Years) 28 ± 2.17

RESULTS 15-25 years 34 (18.0)

26-35 years 97 (52.0)
GDM is diagnosed if the woman has either: plas-
ma glucose level at fasting of 100 mg/dl (5.6 mmol/l) or 36-45 years 56 (30.0)
above; or a plasma glucose level (2-hour) of 140 mg/ Parity
dl (7.8 mmol/l) or above. A total of 187 obese patients
Primipara 56 (30.0)
were observed with a mean age of 28 ± 2.17.
Multipara 131 (70.0)
Majority patients were in the age bracket of 26-35
years which was 97(52%); whereas patients in 15-25 Gravida
years and 26-35 years age brackets were 34(18%) Primigravida 47 (25.0)
and 56(30%), respectively. Status of parity among 187 Multigravida 140 (75.0)
patients was analyzed as 56(30%) patients were prim-
ipara and 131(70%) patients were multipara. Among Body Mass Index (BMI)
187 patients, 47(25%) patients were primigravida and ≤ 27 kg/m2 112 (60.0)
140(75%) patients were multigravida. Mean Body
> 27 kg/m2 75 (40.0)
Mass Index (BMI) of all patients was 26 ± 12.82 kg/
m2. 112(60%) patients out of 187 had BMI ≤ 27 kg/m2
whereas 75(40%) patients had BMI greater than 27 kg/ Table 2: Stratification of gestational diabetes with
m2 (see Table 1). respect to various parameters

Gestational diabetes was found in 41(22%) pa- Parame- GDM, N:41 Non-GDM, Signifi-
tients. In Gestational diabetes, more were within ages ters (%) N:146 (%) cance
between 26-35 years which was 21 patients. Multipara Primipara 12 44 0.915
and multigravida patients having diabetes were 29 and
31 while primipara and primigravida were 12 and 10 Multipara 29 102 0.915
respectively (as shown in Table 2). Primi grav- 10 37 0.901
ida
DISCUSSION
Multi grav- 31 109 0.901
Obesity has been defined as “abnormal or ex- ida
cessive fat accumulation that may impair health”12. Age
It is one of today’s most glaringly visible, yet most groups
neglected, public health problems. In most of Asia,
incidence of excessive weight and obesity has grown 15-25 7 27 0.954
widespread especially in recent decades. Studies have 26-35 21 76 0.954
found that when compared on the basis of weight with 36-45 13 43 0.954
white populations, Asian populations usually possess
more body fat13. High risk BMI is 23 kg/m2 or higher GDM= Gestational diabetes mellitus
(as per WHO’s suggested guideline for South Asian
populations instead of the standard cut-off point of 25 multipara. Twenty-five percent patients were primigrav-
kg/m2 or higher)14. Little work has been done on normal ida and 75% patients were multi gravida. Sixty percent
weight obesity in Asia except China where significant patients had BMI ≤ 27 and 40% patients had BMI >27.
importance has been given to this part of population. A Mean BMI was 26 with SD ± 12.82. Moreover 22%
large study was carried out in China on 52,023 adults patients had gestational diabetes while 78% patients
and data were collected from 1993 to 2009. The study did not have gestational diabetes.
showed an upward trend in normal weight obesity in Our results are similar to those of Zaman et al8
the Chinese, with an overall rate of 21.1% of abdominal whose study included obese women with a mean age
obesity in adults with normal body mass index15. of 28.12±2.72 years and non-obese to be 27.89±2.34
Our study shows that among the observed 187 years old. The most common parity among both groups
patients, 18% patients were within the age range of 15- was 3-4 (n=31, 50% for obese and n=29, 47% for
25 years, another 52% patients within 26-35 years, and non-obese). This study found that GDM incidence was
remaining 30% patients were within the age range of more than 3 times higher in the obese group (22.58%)
36-45. Mean age was 28 years with SD ± 2.17. Thirty as compared to the non-obese group (6.45%).
percent patients were primipara and 70% patients were Logistic regression was used in another study

KJMS May - August, 2020, Vol. 13, No.2 301

to estimate risk of GDM due to overweight and obesi-
ty16. It was reported that extreme obesity, obesity and
overweight contributed to 21.1%, 9.7% and 15.4%
GDM prevalence rates, respectively. While the overall
population percentage attributable was 46.2%.
Meta-analysis of the published literature suggests
that high maternal BMIs are associated with an higher
risk of GDM17. Similar findings have also been reported
by Martin et al.18 who studied a cohort of 1030 pregnant
women. They found that the percentage increase in
GDM was 6.74%, 13.74%, 12.79% and 20% for over-
weight, obese subclass 1, obese subclass 2 and obese
subclass 3, respectively. Further, they observed that
women with GDM had lesser chances of giving birth to
a macrosomic infant when compared with women who
did not have GDM, they attributed this to the possible
effect of GDM treatment18.
A review study provided further supports the
association between prevalence of GDM and obesity19.
It has been reported that while the background rate
of GDM varies between 2 and 14 percent, in obese
population the incidence can approach 40%. However,
the same study also suggests that lifestyle changes for
GDM patients can possibly avoid the need for therapy
by medications such as metformin or insulin.
In a recent study carried out in Turkey, the re-
searchers found that predictors for GDM include waist
circumference (WC) at 20-24 weeks of gestation besides
prepregnancy and gestational BMI. Among these WC
had the highest sensitivity at 84% while prepregnancy
BMI had highest specificity at 76%20.
CONCLUSION
Our study concludes that the incidence of gesta-
tional diabetes was found to be 22% in obese patients
in our setup. GDM is found more in pregnant women
having high BMI and with increasing gravida and para.
Recommendation
All women should be screen for diabetes, at least
those having higher BMI and, high gravida and parity.
Also, women should be advised for appropriate diet
during pregnancy.
REFERENCES
1. Liu, L., Hu, J., Wang, N. et al. A novel association
of CCDC80 with gestational diabetes mellitus in
pregnant women: a propensity score analysis from a
case-control study. BMC Pregnancy Childbirth 20, 53
(2020). https://doi.org/10.1186/s12884-020-2743-3
2. Lowe WL, Scholtens DM, Lowe LP, Kuang A,
Nodzenski M, Talbot O, Catalano PM, Linder B, Brick-
man WJ, Clayton P, Deerochanawong C. Association
of gestational diabetes with maternal disorders of
glucose metabolism and childhood adiposity. Jama.
2018 Sep 11;320(10):1005-16.
302
3. Kim SY, England L, Wilson HG, Bish C, Satten GA,
Dietz P. Percentage of gestational diabetes mellitus
attributable to overweight and obesity. Am J Public
Health. 2010;100(6):1047-52.
4. Coustan DR. Diagnosis of gestational diabetes.
Scand J Clin Lab Invest. 2014;74(244):27-33.
5. Catalano PM, McIntyre HD, Cruickshank JK, Mc-
Cance DR, Dyer AR, Metzger BE, et al. The hyper-
glycemia and adverse pregnancy outcome study.
Diab Care. 2012;35:780-86.
6. Ferrara A., Kim C. Gestational diabetes mellitus:
diagnosis, maternal and fetal outcomes, and man-
agement, Diabetes in Women. 2009; 239-253.
7. Getahun D, Fassett MJ, Jacobsen SJ. Gestational
diabetes: risk of recurrence in subsequent pregnan-
cies, Am J Obstet Gynecol. 2010;203(5):467.e1-6.
8. Zaman N, Taj N, Nazir S, Ullah E, Fatima N. Gesta-
tional diabetes mellitus and obesity: an experience
at a teaching hospital in Bahawalpur, Pakistan. Rawal
Med J 2013;38(2):165-8.
9. Athukorala C, Rumbold AR, Willson KJ, Crowther
CA. The risk of adverse pregnancy outcomes in
women who are overweight or obese, BMC Preg
Childbirth 2010;10:56.
10. Torloni MR, Betran AP, Horta BL, Nakamura MU,
Atallah AN, Moron AF, et al. Prepregnancy BMI and
the risk of gestational diabetes: a systematic review
of the literature with meta-analysis, Obesity Rev.
2009;10:194-203.
11. Kim SY, Saraiva C, Curtis M, Wilson HG, Troyan J,
England L, et al. Fraction of gestational diabetes
mellitus attributable to overweight and obesity by
race/ethnicity, California 2007-2009. Am J Public
Health. 2013;103(10):65-72.
12. McClean KM, Kee F, Young IS, Elborn JS. Obesity
and the lung: 1. Epidemiology, Thorax. 2008; 63(7):
649-654. Percentage of gestational diabetes mellitus
attributable to overweight and obesity. Am J Public
Health. 2010;100(6):1047-1052.
13. Anoop M. Ethnic-specific criteria for classification of
body mass index: a perspective for Asian Indians
and American Diabetes Association position state-
ment. Diab Tech & Therap. 2015; 17(9): 667-671.
14. Anjana M, Sandeep S, Deepa R. Visceral and
central abdominal fat and anthropometry in rela-
tion to diabetes in Asian Indians. Diabetes Care
2014;27(12):29-48.
15. Du T, Sun X, Yin P, Huo R, Ni C, Yu X. Increasing
trends in central obesity among Chinese adults with
normal body mass index, 1993–2009. BMC Public
Health. 2013; 13: 327.
16. Kim SY, England L, Wilson HG, Bish C, Satten GA,
Dietz P. Percentage of gestational diabetes mellitus
attributable to overweight and obesity. Am J Public
Health. 2010;100(6):1047-1052.
17. Torloni MR, Betran AP, Horta BL, et al. Prepregnancy
KJMS May - August, 2020, Vol. 13, No.2
 BMI and the risk of gestational diabetes: a systematic
review of the literature with meta-analysis. Obes Rev
2009;10(2):194–203.
18. Martin KE, Grivell RM, Yelland LN, Dodd JM. The
influence of maternal BMI and gestational diabetes
on pregnancy outcome. Diab Res & Clin Pract. 2015;
108(3): 508-513
19. Kennelly MA, McAuliffe FM. Prediction and preven-
tion of gestational diabetes: an update of recent
literature. Europ J of Obs & Gynae and Repro Bio.
2016; 202: 92-98
20. Takmaz T, Yalvac ES, Ozcan P, Coban U, Karasu AFG,
Unsal M. The predictive value of weight gain and
waist circumference for gestational diabetes mellitus.
Turk J Obstet Gynecol. 2019; 16(3): 199-204.

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KJMS May - August, 2020, Vol. 13, No.2 303

 TRIGEMINAL NERVE COMPRESSION (TGNC) SURGICAL
TECHNIQUE FOR THE TREATMENT OF TRIGEMINAL
NEURALGIA; STUDY OF 40 CASES IN 5 YEARS
Muhammad Nawaz Khan1, Mushtaq1, Khalid Anwar Khanzada2, Attiya Nasir Siddique3, Shahid Ayub1,
Rizwanullah Khattak1, Azmatullah Khattak2

ABSTRACT
Background : To evaluate the outcome of an innovative surgical aproach i-e compression technique of trigeminal nerve
at the intra- cisternal part of the nerve for relief of trigeminal neuralgia pain.
Methods: This observational study was conducted in Hayatabad Medical Complex and Lady Reading hospital Peshawer
from Jun 2014 to Jun 2019. After Ethical Committee permission all cases of Trigeminal Neuralgia operated via TGNC
Technique were studied and followed Post operatively for maximum 1 year.
Results: During our study period 40 patients were operated. There were 25 (62.5%) female & 15(37.5%) male patient
with male to female ratio of 3:5. The patients ages were in the range of 34 to 84 years with mean of 54.76 ± 9.6 SD .
Majority of the patients were complaining of pain in the right side of the face having frequency of 33 (82.5%) and both
V2 , V3 were involved in the facial pain with greatest proportion almost frequency of 16 (40%). Total 38 patients were
completely pain free at 1year post op .However 2 patients presented with recurrent pain in the same area and same
side of the face .
Conclusion: Compression of intra-cisternal component of trigeminal nerve for trigeminal neuralgia is the safe and
effective procedure and potentially alternative to MVD procedure or at least the only gold standard option in cases
where no significant vascular loop conflict is found .It has the potential to be performed endoscopically via single bur
hole in the near future .
Key Words: Compression, Intracisternal component, Trigeminal nerve, Trigeminal Neuralgia.
Abbreviations: TGNC: Trigeminal Nerve Compression. CBC: Complete Blood Count.

INTRODUCTION up. In 1756 Andre coined the name “ tic douloureux”.

Trigeminal Neuralgia is a painful condition of the
face in which the patient experiences sudden, severe,
shock like pain for short duration and is distributed in
one or more sensory branches of trigeminal nerve.1
Every year 4.3 new cases of trigeminal neuralgia are
diagnosed per 100,000 population . It is more common
in females as compared to the males.2 The incidence
increases after the age of 40 years.One series has
showed higher incidence in older population(>60yrs
age) group i-e 25.9 cases every year per 100,000 .3
Galen, Aretaeus and Hippocrates termed this condition
as “kephalalgia”. During 1661-67 this condition was
studied extensively & a lot of new information came
Jhon hunter described trigeminal neuralgia more clearly
stating,” it is the disease of nervous system in which
pain is referred to the teeth, gums and tongue in the
absence of obvious organic lesion”.4
Peter jenneta proposed the pathophysiology of
trigeminal neuralgia is the indenting SCA(or any other
nearby vessel) which causes demyelination of the nerve
causing ephatic nerve impulse at DREZ of trigeminal
nerve but there are very strong counter arguments and
evidences one of them is Adams et al/Sunderland et al
proving in their large series of cadveric dissections vas-
cular compression in asymptomatic cadaver disection
is as frequent as 70%.

1Department of Neurosurgey, Hayatabad Medical At some point in 1989 Adams et al compromised

Complex,Peshawar. with jenita to propose MVD operation probably works
2Department of Neuroaurgery Lady Reading Hospital by causing slight injury to the nerve while unintentional
Peshawar. manipulation
3Resident Surgical unit,Hayatabad medical complex The same was inference of Gardener et al.Trigem-
Peshawar. inal neuralgia can be treated by atraumatic manipulation
......................................................................................... of trigeminal nerve.” Gardenr published 112 cases in
Address for correspondence: 1960 , he gently brushed the trigeminal nerve with cotton
Khalid Anwar Khanzada pledget and ringer irrigation without removing vascular
Assistant Professor Neuroaurgery Deptt Lady Reading loop.
Hospital Peshawar. Cell: 03005902918
E-mail: ????????? Nowadays ,Trigeminal neuralgia is treated by both

304 KJMS May - August, 2020, Vol. 13, No.2

pharmacological and surgical methods. Carbamaze-
pine and ox-carbamezapine are the firstline drugs which
gives good to excellent pain control in 50% of patients
baclofen and gabapentine are only recommended as
a co-therapy.5- 8
All trigeminal neuralgia cases refractory to the
medical management or those unable to tolerate side
effects of carbamazepine are subjected to one of various
surgical procedures which includes the gold standard
MVD procedure or nerve destructive procedures i-e
peripheral neurectomy , glycerol rhizotomy and radiof-
requency ablation,balloon compression rhizotomy,
stereotactic radiosurgery.In 1967 Dr. Peter Jannetta was
the person who performed first MVD for trigeminal neu-
ralgia by separating the 5th nerve from offending vessel
(SCA,AICA and other least common vessels) by means
of the Teflon sponge , in comparison to other surgical
techniques microvascular de-compression is safe and
effective procedure( currently termed a Gold Standard)
indeed.9-13 There is often a tricky intraoperative situation
which every surgeon might have faced i-e when NO
obvious/significant vascular loop is found compressing
the nerve, various methods are devised to overcome
this tricky situation. In 2013 Revuelta – Gutierrez R and
colleagues introduce a technique for these cases i-e
gentle Compression of intra-cisternal part of trigeminal
nerve was done by Mallis forcep to give iatragenic neu-
ropraxia which showed results comparable to MVD.15
They Stated “Pain control of trigeminal neuralgia for
prolong periods can be obtained by this novel technique
of intracisternal compression of trigeminal nerve with
minimum morbidity and mortality in the experienced
hands”.16 The same technique is followed by us since
last five years as a surgical protocol for any MVD case
in which loup couldn’t be found or was technically dif-
ficult to separate from the nerve.And for documentation
and registration purposes this modification to the MVD
procedure is termed as TGNC(Trigeminal Nerve Com-
pression Technique).
Rationale of the current study is to evaluate the
outcome of TGNC Technique. This study is important
because there is only one study published uptill now
and by doing this study in our set -up it will open a
gateway for future researchers to evaluvate TGNC
procedure as potential alternative to MVD.
METHODOLOGY
This observational study was conducted in
Hayatabad Medical Complex Hospital Peshawar,and
Lady Reading Hospital Peshawar from Jun 2014 to Jun
2019 for total duration of 5 years.All cases operated via
TGNC technique were followed to assess the safety and
efficacy of the procedure excluding re-do and trigeminal
neuralgia secondary to MS. Pre operative management
included history, detailed clinical examination and
relevant investigations including MRI of the brain with
and without contrast to exclude other causes of facial
KJMS May - August, 2020, Vol. 13, No.2
pain and establishing diagnosis. All data of the cases
including patient’s age, gender, pre operative symptoms
and signs, post operative pain control and complica-
tions were recorded in the pre designed proforma.
Post operatively patients were followed for 1 year for
pain recurrence in the distribution of trigeminal nerve
by using visual analogue scale. Results were analyzed
by SPSS version 20.
Surgical Technique
Position: All the patients were placed in the park
bench position. Portal (Incision): Linear paramedian
incision having dimensions of 5 × 6 × 4 (5 mm medial
to the mastoid notch, 6 cm above it and 4 cm below it)
was used.
Procedure: 3 × 3 cm retro-mastoid craniectomy
was made followed by inverted Y shaped dural opening
having vertical limb towards the transverse and sigmoid
junction. CSF was drained from the CP angle cisterns.
Then petro-tentorial corridor was followed to visualise
petrosal vein, which was not coagulated in majority
of the cases . 5th nerve was identified and Arachnoid
was separated from it and intracisternal part was gently
compressed twice by bayonet forcep at two different
sites to give neuropraxia to the nerve without searching
for vascular loop or inserting Teflon between vascular
loop and fifth nerve. Wound was closed in the water
tight fashion.
Post-operative Care: All the patients were kept
in ICU for first 24 hours for monitoring , later shifted to
ward. All patients were discharged on post op day 2 or
3.
Post-operative follow-up: All the patients were
followe upto 1 year.
RESULTS
During our study period 40 patients were oper-
ated. There were 25 (62.5%) female & 15(37.5%) male
patient with male to female ratio of 3:5. The patients
ages were in the range of 34 to 84 years with mean of
54.76 ± 9.6 SD
Majority of the patients were complaining of
pain in the right side of the face having frequency of
33 (82.5%) and both V2 , V3 were involved in the facial
pain with greatest proportion almost frequency of 16
(40%)
Total 38 patients were completely pain free at
1year post op .However 2 patients presented with
recurrent pain in the same area and same side of the
face .
The most common post-op complication was
Temporary/Transient facial hypoesthesia which oc-
curred in 26(65%) patients and other less common
complications were recurrence of pain, facial nerve
paresis, CSF rhinorrhea, (by temporary facial hypoes-
305
 Table 1: Age Distribution of Cases

Age of patients Frequency Percent Valid percent Cumulative percent

34-44 yrs 20 50.0 50.0 50.0
45-54 yrs 13 32.5 32.5 82.5
55-64 yrs 4 10 10 92.5
65-74 yrs 1 2.5 2.5 95
75-84 yrs 2 5 5 100
Total 40 100.0 100.0 100.0

Table 2: Preoperative Trigeminal Nerve Division Involvement

Branch Frequency Percent Valid percent Cumulative percent

V1 1 2.5 2.5 2.5
V2 11 27.5 27.5 30
V3 4 10 10 40
V1,V2 5 12.5 12.5 52.5
V2,V3 16 40 40 92.5
V1,V2,V3 3 7.5 7.5 100.0
Total 40 100.0 100.0 100.0

Table 3: Pain Relief at 1year Post OP

Characteristic Frequency Percent Valid percent Cumulative percent

Complete pain relief 38 95% 95% 95%
Recurrence 2 5% 5% 100.0
Total 40 100.0 100.0 100.0

Table 4: Post Operative Complications

Complication Frequency Percent Valid percent Cumulative percent

No complication 8 20% 20% 20%
Recurrence 2 5% 5% 25%
Facial nerve paresis 3 7.5% 7.5% 32.5%
Temporary facial 26 65% 65% 97.5%
hypoesthesia
Csf rhinorrhea 1 2.5% 2.5% 100%
Total 40% 100% 100% 100%

thesia we mean self resolving condition i-e none of the
patient had any degree of numbness at face at one
month follow up).
DISCUSSION
History of diseases dates back to 1756 when
Nicolas Andre defined this facial pain syndrome .After
him it took almost a century for Victor Horsely proposed
first surgical procedure as treatment option ,but it in-
volved transaction of trigerminal nerve root which was
associated with dreadful complication of hemifacial
anesthesia , corneal anesthesia & corneal ulceration .In
1925 Walter Dandy suggested partial sectioning of tri-
germinal nerve to minimize the complication associated
with earlier procedure .In 1967 Peter Jenneta described
& proposed MVD procedure which is nowdays gold
standard surgical option .
Recently a novel technique is published by
Revuelta – Gutierrez R and colleagues in 2013 for the
treatment of trigeminal neuralgia in which there was no
vascular conflict at the area of DREZ involving compres-
sion of intracisternal part of trigeminal neuralgia 15. They

306 KJMS May - August, 2020, Vol. 13, No.2

collected data of 44 patients treated by this technique
over period of 10 years from 2000 to 2010 in these
patients no vascular conflict was found .This method
was found highly effective in terms of pain control,
recurrence and post operative morbidity and mortality.
Furthermore this technique was highly appreciated by
Broggi G16 and Chen KS et al,18 in their articles.Khattak
A,Haider A.et al has published 80 cases in 2016 with
excellent post operative pain control 96.2% and recur-
rence rate 3.8%33
We applied same method to a total of 40 cases
for treatment of Trigerminal Neuralgia during a total time
span of 5 years . All the patients were in the age range
of 34- 84 years with the mean age range of 54.76 ± 9.6
years SD while the females were predominantly affected
with the male to female ratio of 3:5. Intra-operatively all
our patients had undergone compression of intra-cis-
ternal part of 5th nerve(as standard TGNC protocol)
without decompression of any vascular loop or inserting
muscle or Teflon patch.In majority of cases right side
was involved .Most frequently involved branches were
V2, V3 in 16 cases followed by V2 only in 11 cases . In se-
ries of Revuelta – Gutierrez R and colleagues the mean
age of the patients was 49 years which is slightly more
than the mean age of the patients in our series(54yrs).
We found the complete pain relief in 38 (95%) patients
out of 40 patients at 1year and recurrence of pain in
the same branch of 5th nerve in 2 (5%) cases but the
initial pain relief was noted in all 40 (100%) patients by
using the visual analogue scale. Revuelta – Gutierrez R
and colleagues series15, initial pain relief was excellent
in all 44 (100%) patients but their recurrence rate was
12 (27.2%). The rate of recurrence of pain in the series
of Rev-uelta – Gutierrez R et al,15 is slightly more as
compared to our series. This may be due to the shorter
post operative follow-up in our study.
MVD Procedure efficacy in immediate pain relief
ranges from 76.4 to 98.2% while its recurrence rate
increases with increase in the post operative duration.
In international series the rate of recurrence has been
mentioned in the range of 8.3 to 30 % based on different
durations of post operative follow-ups from 5 months
to 120 months21-25,27-31 . This shows TGNC Technique is
more effective and safer than MVD in terms of excellent
initial pain relief and lesser recurrence rate.
Searching for offending/indenting vascular loup
in MVD procedure requires significant retraction on cer-
ebellum due to medial anatomical location of the loup
and coagulation/cutting of petrosal veins is advisable.
Since TGNC Technique does not involve the identi-
fication and removal of offending/indenting vascular
loup hence minimal cerebelar retraction is required
in comparison to MVD procedure .TGNC Technique
can be perforormed using endoscope with a smaller
corridor/a bur hole even.and it often does not require
coagulation and cutting of petrosal venous complex.
KJMS May - August, 2020, Vol. 13, No.2
CONCLUSION
Compression of intra-cisternal component of
trigeminal nerve for trigeminal neuralgia is the safe and
effective procedure and potentially alternative to MVD
procedure or at least the only gold standard option
in cases where no significant vascular loop conflict is
found .
It has the potential to be performed endoscopi-
cally via single bur hole in the near future.
REFERENCES
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KJMS May - August, 2020, Vol. 13, No.2
 SENSITIVITY OF NITROFURANTOIN IN ESCHERICHIA
COLI URINARY TRACT INFECTION IN KHYBER TEACHING
HOSPITAL PESHAWAR
Shandana Altaf1, Mariana Amer2, Amer Azhar3

ABSTRACT
Objectives: To find the sensitivity of Nitrofurantoin against Escherichia – Coli in urinary tract infection.
Materials and Method: It was a observational study done in the department of Nephrology Khyber Teaching Hospital
Peshawar from December 2016 to March 2018. Inclusion criteria was patient having urinary tract infection caused by
Escherichia – Coli. We looked at the sensitivity of Nitrofurantoin against E-Coli in urinary tract infection.
Results: Hundred patients were included in the study. Male to Female ratio was 1:1.5. Age range was 11-90 years with
mean age of 50.06%. Overall sensitivity of Nitrofurantoin against E-Coli was 85%.
Conclusion: UTI is more common in females. In the era of decreased sensitivity of oral anti-biotics against E-Coli in
urinary tract infection, Nitrofurantoin still has got very good sensitivity against E-Coli.
Key Words: Nitrofurantoin, Escherichia – Coli, Urinary Tract Infection.

INTRODUCTION of Nitrofurantoin is only achieved in Urinary Tract,

In United States of America 8 million visits to
physician and antibiotic prescribed are for Urinary Tract
Infection (UTI) 1. In 75 to 95% of cases Escherichia Coli
is the organism causing UTI 2 .Resistance to antibiotics
is increasing around the world, resulting in infections
with are hard to treat causing increase motility and
cost of treatment 3-5. Infectious Disease Society of
America (IDSA) has recommended Nitrofurantoin and
trimethoprim/sulfamethoxazole as initial drugs to treat
uncomplicated cystitis empirically 6. Unfortunately, the
guidelines are not properly followed and fluroquinolo-
nes are prescribed frequently as first line drugs 7. In the
recent past only few antibiotics have been approved
but most of them are for intravenous use, therefore old
drugs are reconsidered for treatment of UTI. One of
the old drugs is Nitrofurantoin. Nitrofurantoin was first
introduced in 1953. Oral bioavailability of Nitrofurantoin
is 80%. Twenty five percent of the drug is excreted in the
urine unchanged. The mechanism of action is probably
multi factorial it causes inhibition of protein synthesis of
bacterial enzymes through interference with bacterial
ribosomal proteins 8. As the therapeutic concentration
1Department of Pharmacology, Khyber Medical Col-
lege, Peshawar.
2 Khyber Medical College, Peshawar.
3 Division of Nephrology, Khyber Teaching Hospital,
Peshawar.
.........................................................................................
Address for correspondence:
Shandana Altaf
Department of Pharmacology Khyber Medical College,
Peshawar
Cell: 00923018852090
Email:shandanaaltaf@hotmail.com
therefore it is mainly used to treat uncomplicated uri-
nary infections especially in women 9, and due to this
there are less chances of developing resistance against
Nitrofurantoin. The objective of this study was to find
the sensitivity of Nitrofurantoin against E-coli. this will
create awareness among the medical practitioners for
selecting appropriate antibiotics. We have seen that
resistance to oral anti-biotics is increasing day by day
and there are very few choices in oral antibiotics left to
treat UTI empirically. So this is most important to use
antibiotic rationally and try to prevent UTIs. The abuse
and misuse of any drug causes resistance through
developing mutant strains.
MATERIAL AND METHODS
A single center observational study was done in
the Department of Nephrology Khyber Teaching Hos-
pital Peshawar Pakistan from December 2016 to March
2018. Midstream sample was collected for culture and
sensitivity in sterilized bottle from patients suffering
from urinary tract infection. MacConkey agar medium
was used for culture and the samples were incubated
for 24-48 hours. Kirby-Bauer disk diffusion method was
used to test Antibiotic susceptibility. Patients having
E.coli growth on culture and sensitivity were included
in the study. Sensitivity pattern of different antibiotics
were noted with main emphasis on nitrofurantoin. Total
100 cases were included in the study.
RESULTS
Out of 100 patients, 40 (40%) were male and 60
(60%) were female, with male to female ratio of 1:1.5
(Table 1). Patient age was in the range of 11 to 90 years
with mean age of 50.06%.Majority of patients that is

KJMS May - August, 2020, Vol. 13, No.2 309

50% were more than 50 years old. Thirty Six percent as females are more prone to UTI’s after menopause.
of patients were up to 50 years old and only 14% were Overall sensitivity of Nitrofurantoin against UTI was 85%.
less than 25 years old (Table 2). Highest sensitivity to Nitrofurantoin is available for the last several decades
Nitrofurantoin was 92.85% in the age group up to 25 but its resistance remained low. In United States of
years old (Table 3). Over all sensitivity of Nitrofurantoin America, a population-based study of invitro antibiotic
against E-Coli was 85%. Sensitivity of other oral antibi- resistance was 1.6% to E-Coli isolates11. Australian data
otics against E-Coli is shown is Table 4. also suggests resistance to E-Coli of 1 to 4% against Ni-
trofurantoin12,13. In comparison to Nitrofurantoin sensitiv-
DISCUSSION ity of ciprofloxacin and trimethoprim/sulfamethoxazole
was 14.80% and 19.41% respectively. Ciprofloxacin is
Our study shows that UTI is more common in
still most commonly prescribed antibiotic in the outpa-
females (60%) as compared to males (40%). Sixty
tient departments for the treatment of UTI7. Regarding
percent of female will have UTI in their lifetime 10. In
trimethoprim/sulfamethoxazole, it is recommended to
50% of patients UTI occurred after 50 years of age,
treat UTI if resistance is less than 20% 6. Sanchez G.V
et.al has shown that resistance to trimethoprim/sulfame-
Table 1: Distribution of Patients on sex
thoxazole is highly prevalent 14. Most of the organisms in
Urinary Tract Infections remain sensitive to Nitrofuranto-
Characteristics Number % of Total
in and its resistance is uncommon 15-17. A meta-analysis
All Patients 100 100 regarding Nitrofurantoin showed cure rate of 74 to 92%
Male 40 40
18
. A head to head comparison with Fosfomycin showed
cure rate of 70% 19. In 2010 Nitrofurantoin was included
Female 60 60
as preferred drug to treat UTI 20. In Pakistan according
Table 2: Distribution of Patients according to age to drug information system there are hardly five brands
groups of nitrofurantoin registered. In contrast there are hun-
dreds of ciprofloxacin brands available in the market.
Num- Age Group Number of Percent- There is also lack of awareness among the general
ber (Years) Patients age practitioners regarding use of nitrofurantion. Probably
all this is causing less use of nitrofurantion and reduce
1 Upto 25 years 14 14%
rate of resistance to it.
2 Upto 50 years 36 36%
It is also one of the most commonly used drugs
3 More than 50 50 50% for long term prophylaxis of UTI. There are some lim-
years itations regarding use of Nitrofurantoin. One of this is
Table 3: Sensitivity of Nitrofurantoin in different age acute bacterial pyelonephritis, because it does not
groups achieve therapeutic concentration in kidneys 11. Previ-
ously Nitrofurantoin was contra indicated if creatinine
Age Total Number Sensi- Percent- clearance was below 60ml per minute. Recently it has
Group of Patients tive age been allowed to use Nitrofurantoin cautiously if creat-
inine clearance is between 30 to 60ml per minute and
Upto 25 14 13 92.85% no other antibiotic is available 21, 22. Nitrofurantoin is
years contra indicated in pregnant women from 38-42 weeks
Upto 50 36 32 88.88% of pregnancy. It is also contra indicated in children less
years than 1 month of age, as it increases the chances of He-
More 50 40 80.00% molytic anemia in new born 11. As Nitrofurantoin does
than 50 not penetrate prostate effectively therefore its use is also
years limited in men with urinary tract infection. It’s used in
patients older than 65 years of age increases chances
Table 4: Sensitivity pattern of Antibiotic against of neuropathy, pulmonary and hepatic toxicity, espe-
E-Coli cially given for a long-time 11. Therefore , Nitrofurantoin
should be used cautiously and future will tell us whether
Num- Antibiotic % sensitivity there is increase in its resistance as a result of recent
ber recommendations of its use showing high sensitivity
1 Nitrofurantoin 85.00 against E-Coli in UTI.

2 Ciprofloxacin 14.80 CONCLUSION

3 Clavulanic Acid / 16.63
Nitrofurantoin has got high rate of sensitivity
Amoxicillin
against E-Coli, it is safe and effective drug for the treat-
4 Trimethaprim+sulpha- 19.41 ment of uncomplicated UTI. The hepatic and pulmonary
methoxazole toxicity is usually seen in elderly in long term use only.

310 KJMS May - August, 2020, Vol. 13, No.2

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311
 FREQUENCY OF RETAINED PRODUCTS OF CONCEPTION
ON ULTRASOUND AMONG WOMEN PRESENTING WITH
SPONTANEOUS ABORTION
Samreen1, Saadia Shamsher1, Naila Nasr2, Shadab Gul3

ABSTRACT
Background: Spontaneous abortion or miscarriage is an early loss of pregnancy before or within 24th gestation weeks.
In many cases, it usually happened into 12 weeks recorded as early abortion and, in some cases, its interval lies into
13-24 weeks. Global statistics reflect that every year 44 billion abortion is performed and half of them performed un-
safely. From this ratio 26 million abortion cases are legal and 20 million illegal abortion cases performed with 70,000
maternal deaths every year.
Objective: To determine the frequency of retained products of conception on ultrasound among women with sponta-
neous abortion
Settings: Department of Obstetrics and Gynecology, Hayatabad Medical Complex, Peshawar.
Study Design: Descriptive, Cross-sectional study.
Duration: 6 months, From 24/9/2018 to 24/3/2019.
Material and Methods: In this study, 132 patients were observed. All women were subjected to a detailed history and
clinical examination regarding Spontaneous abortion. All the patients were subjected to abdominal greyscale ultrasound
to detect Retained Products of Conception. All the observations were analyzed through SPSS 20.0. Chi-square test
was performed on the results.
Results: Obesity is the leading factor of spontaneous abortion in our research. Female who entered into mature
adulthood have more chances of miscarriage than the younger ones. Cross marriages are found insignificant in our
research. Only 41% of cases have RPOC.
Conclusion: Our study concluded that in mature adulthood frequency of retained products of conception was highly
(41%) observed on ultrasound machines.
Key Words: Retained products of conception, spontaneous abortion, obesity, cross marriages

INTRODUCTION heavy bleeding, and clots. In some researches, it is

Spontaneous abortion or miscarriage is an early
loss of pregnancy before or within 24th gestation weeks.
In many cases, it usually happened into 12 weeks re-
corded as early abortion and, in some cases, its interval
lies into 13-24 weeks. Ectopic pregnancy Gestational
trophoblastic disease (GTD) is not currently categories
into spontaneous abortion. The physician reported
bleeding after 24 weeks as an antepartum hemor-
rhage1. After these symptoms and gathered information
miscarriage is defined as a complete miscarriage if no
pregnancy tissue in the uterine cavity with the help of an
ultrasound machine with intrauterine pregnancy history,
1Department of Gynae HMC Peshawar
2Department of Gynae Kuwait Teaching Peshawar
3Depatment of KTH Peshawar
.........................................................................................
Address for correspondence:
Dr Saadia Shamsher
Department of Gynae HMC Peshawar
Cell: 0333-9176031
E-mail: saadia.shamsher@yahoo.com
also defined as a pregnancy of unknown location after
confirmation of no signs of Intrauterine pregnancy2.
In some researches, early miscarriage was
clinically diagnosed when the POC (products of con-
ceptions) expelled, contracted uterus, and cervical os
of women is closed. Researcher observed abortion in
12 or above gestational period including expelled POC
retained fetal membrane, and placental tissues inside
the vagina which results in incomplete abortion after
the clinical diagnosis of the condition3. Some studies
demonstrate the clinical signs of miscarriage as vaginal
bleeding, worsen pain that differentiate the condition
from the menstruation pain, internal complexities that
threatened women for future miscarriage4. Many stud-
ies observed that most of the women passed through
the period where their predictable miscarriage con-
verted into complete abortion. In some other cases,
the physician reported heavy bleeding and clots as
compared to the bleeding in the menstruation cycle.
Researchers demonstrate that in an early pregnancy,
woman having a history of continued pregnancy, along
with vomiting had decreased 30% risk of miscarriage as

312 KJMS May - August, 2020, Vol. 13, No.2

compared to the women having bleeding in her early
pregnancy interval5.
In all around the world, every miscarriage case
needs to be examined under the transvaginal ultrasound
(TVS). In many countries 98% of complete miscarriage
cases were diagnosed under transvaginal ultrasound
according to statistics. But some studies explored the
resistance of women for the transvaginal scan after
this resistance diagnosis takes place under the super-
vision of physicians with the help of a transabdominal
ultrasound machine. Physicians should be aware of
the limitations of transabdominal ultrasound. A visible
heartbeat can be easily shown via this ultrasound. In
the first trial, if a heartbeat is not visible then the physi-
cian should move on to other trials. Ultrasound can be
performed for the period of 7 to 14 days. This duration
depends on the mean measurements of the gestational
sac and length of crown-rump length. Physicians must
be aware of the women’s body structure because
unknown location pregnancy might be an ectopic
pregnancy7.
According to multiple research reports almost
20% of pregnancies go through the miscarriage stage
which causes psychological distress among female
population. Another significant research observed
the relationship between psychological morbidity and
the miscarriage rate. Researchers Friedman and Gath
found out that almost 50% of miscarriages are the result
of women’s depressive disorders and this has been
increasing with time8.
Other studies demonstrate the 18.6% ratio of
depression among women after spontaneous abortion.
Whereas some statistics reflect 26% of cases of de-
pression with grief. This ratio was found higher among
childless women, or women with poor social support,
relationship complexities, further reasons are under
observation9.
Global statistics reflect that every year around
44 million abortions are performed and half of them
are performed unsafely. 26 million abortion cases are
legal and 20 million illegal abortion cases are performed
with 70,000 maternal deaths every year. Similarly, only
30 to 50% pregnancies pass the first trimester whereas
80% spontaneous abortions noticed where in the first
trimester women lost their babies before physicians
detect the embryo10. Psychological distress, excessive
usage of alcohol, vascular diseases, diabetes, hormonal
problems, infection, double uterus, age, accidental trau-
ma are the leading reasons for spontaneous abortion.
In a study researcher demonstrate that 30% cases of
spontaneous abortion were due to the retained POC
(RPOC) in the first trimester11. Early symptoms of RPOC
include fever, abdominal pain, and vaginal bleeding
which cause hemorrhage, endometritis, and even
Asherman’s syndrome. RPOC can easily be treated
after diagnosis through expectant management, use
of uterotonic medications such as prostaglandin E1
KJMS May - August, 2020, Vol. 13, No.2
analogs, and surgical interventions such as dilation and
curettage or hysteroscopic removal12. Esmaeillou H
observed in his study that 67.4% of cases have RPOC
after spontaneous abortion13.
A large number of studies have already been
conducted on this topic in our population for the last five
years thus the present study is designed to determine
the frequency of RPOC on ultrasound among women
presenting with first-trimester spontaneous abortion.
Spontaneous abortion is not uncommon in our popula-
tion owing to the high burden of most of its risk factors.
This study will be an attempt to highlight the magnitude
of RPOC among women with spontaneous abortion as
mentioned above, failure to diagnose in time, this can
lead to life-threatening complications. The results of
this study provide us the latest and updated information
about retained products of conception on ultrasound
which will be shared with other obstetricians to make
aware the gravity of the problem and for future research
recommendations.
OBJECTIVE
The objective of this study was to determine the
frequency of retained products of conception on ultra-
sound among women with spontaneous abortion.
METHODOLOGY
This descriptive cross-sectional research was
conducted in Department of Obstetrics and Gynecolo-
gy, Hayatabad Medical Complex, Peshawar. Research
was conducted within 6-months’ time period. Data was
collected during 24/9/2018 to 24/3/2019. The study was
conducted after approval from the hospital’s ethical
and CPSP research committee. All women meeting the
inclusion criteria (as per operational definition) were
included in the study through OPD or ER department.
Written informed consent was taken from the patient.
All women were subjected to a detailed history and
clinical examination regarding Spontaneous abortion.
All patients were subjected to abdominal greyscale
ultrasound to detect Retained Products of Conception.
All observations were recorded in the presence of expert
obstetrician fellow of CPSP and the ultrasound was
done by an expert radiologist having a minimum expe-
rience of five years. Women from 15-45 years of age
group with spontaneous abortion before 24 completed
weeks of gestation; and suffering from any parity was
selected for this research. On the other hand, those
women who have a history of trauma, bleeding disor-
ders, diabetes, hypothyroidism, or any immune system
disorder before and during pregnancy were excluded
from this research. All basic information of selected
participants was recorded on pre-designed Performa by
the trainee herself. Confounders and other biases were
controlled by strictly following exclusion criteria. Data
were analyzed using SPSS 20.0. Quantitative variables
like age, BMI was be described as mean ± SD. Cate-
313
gorical variables like the previous history of miscarriage, Table 1: Age Distribution (n=132)
obesity, RPOC was described in terms of frequencies
and percentages. RPOC was stratified with age, previ- Age Frequency Percentage
ous history of miscarriage, obesity, cousin marriage, 15-30 years 48 36%
previous or family history of abnormal babies to see the
effect modifiers. A post-stratification chi-square test was 31-45 years 84 64%
applied for this study. P-value ≤0.05 was considered a Total 132 100%
significant value for this research. Actual statistics were
presented in the form of tables and diagrams. Table 2: History Of Miscarriage (n=132)

RESULTS History Frequency Percentage

A total of 132 females was selected for this Yes 36 27%

study. All cases of spontaneous abortion were critically No 95 72%
diagnosed. Each and every lab report was analyzed, Total 132 100%
factors and reasons were discussed and presented in
the form of tables. In this study age distribution was Table 3: Status of Obesity (n=132)
analyzed as 48(36%) patients were in age range 15-30
years while 84(64%) patients were in age range of 31-45 Obesity Frequency Percentage
years. Mean age was 32 years with standard deviation
Nonobese 57 43%
± 11.98. (as shown in Table 1). History of miscarriage
was analyzed as 36(27%) patients had positive history Obese 75 57%
of miscarriage while 95(72%) patients had no history Total 132 100%
of miscarriage. (as shown in Table 2). Status of obesity
was examined as 57(43%) patients were non-obese Table 4: Cousin Marriage (n=132)
while 75(57%) patients were obese. (as shown in Table
3). Status of cousin marriage was analyzed as 16(12%) Cousin mar- Frequency Percentage
patients were in a cousin marriage while 116(88%) pa- riage
tients didn’t have cousin marriage. (as shown in Table Yes 16 12%
4).
No 116 88%
Previous or family history of abnormal babies
Total 132 100%
was analyzed as 11(8%) patients had a family history
of abnormal babies while 121(92%) patients didn’t. (as
Table 5: Previous or Family History of Abnormal
shown in Table 5). The frequency of retained products
Babies (n=132)
of conception was analyzed as 54(41%) patients had
retained products of conception while 78(59%) patients Abnormal Frequency Percentage
didn’t. (as shown in Table 6). Stratification of retained babies
products of conception with respect to age, previous
history of miscarriage is given in tables 5,6,7. Further Yes 11 8%
information was discussed under the given tables. No 121 92%
From the selected population 27% (36) of females Total 132 100%
already had a miscarriage whereas the majority of the
population 72% (95) in our studies were first timers. Psy- Table 6: Retained Products of Conception (n=132)
chological distress after miscarriage was much higher
among the group having first experience of miscarriage. Retained products Frequency Percentage
of conception
Our research demonstrates that obesity is one
Yes 54 41%
of the leading reasons for spontaneous miscarriage.
Women beyond the ideal BMI have more chance of No 78 59%
spontaneous abortion. 57% (75) cases were reported Total 132 100%
due to obesity in pregnancy. Some of them having a
bulky body before pregnancy and some reported gain-
cases of cousin marriages were reported.
ing weight due to unhygienic food during pregnancy.
Mean BMI was 27 Kg/m2 with SD ± 3.64 From 132 selected females, only 8% (11) females
came from families with the history of abnormal babies.
Cross marriages are one of the common practices
Rest 92% (121) cases identify with normal and healthy
in our culture. It has adverse effects on the offspring and
childbirth.
the couple. But in our studies 88% (116) miscarriage
cases were not family marriages whereas only 12% (16) We explored cases of retained products of

314 KJMS May - August, 2020, Vol. 13, No.2

 Table 7: Stratification of Retained Products Of Conception W.R.T Age Distribution (n=132)
Retained Products Of Conception 15-30 years
Yes 19
No 29
Total 48
Table 8: Stratification of Retained Products Of Conception W.R.T History of Miscarriage (n=132)
Retained Products of Conception Yes
Yes 15
No 21
Total 36
conception 41% (54) in the uterus after spontaneous
abortion in most cases. These cases were handled
by unprofessional nurses which threatened the life of
females. From these statistics, we explored that un-
professional ways of abortions are still practiced in our
country. People use remedies even for legal abortion
procedures. The socio-economic status of families
forced females to use tablets for abortion. Unplanned
pregnancy was also the major reason for RPOC in our
research.
In our study ultrasound demonstrated that after
30 years, the heavy chance of RPOC occurs among
females. Obesity, socio-economic pressure, unplanned
pregnancies are one of the major reasons that leaves
retained products of conceptions in the uterus. But in
some cases, we also found fewer cases of RPOC among
females. A chi-square test was applied in which P-value
was 0.8148.
Among 54 cases of RPOC, we found 15 cases
that describe the association of retained products of
conception with a history of miscarriage. Whereas 39
cases had no previous occurrence of miscarriages.
From the non-RPOC cases, we observed that the ratio
of no previous miscarriage experience is still high, only
21 cases were reported with previous miscarriage ex-
perience. Chi-square test was applied in which P-value
was 0.9491.
DISCUSSION
Spontaneous abortion or miscarriage is an ear-
ly loss of pregnancy before or within 24th gestation
weeks. In many cases, it usually happened into 12
weeks recorded as early abortion and, in some cases,
its interval comes into 13-24 weeks. Ectopic pregnancy
Gestational trophoblastic disease (GTD) is not currently
categorized into spontaneous abortion. The physician
reported bleeding after 24 weeks as an antepartum
hemorrhage1. After these symptoms and gathered infor-
mation miscarriage is defined as a complete miscarriage
if no pregnancy tissue in the uterine cavity with the help
of an ultrasound machine with intrauterine pregnancy
KJMS May - August, 2020, Vol. 13, No.2
31-45 years Total
35 54
49 78
84 132
No Total
39 54
56 78
95 132
history, heavy bleeding, and clots. In some researches,
it is also defined as a pregnancy of unknown location af-
ter confirmation of no signs of Intrauterine pregnancy2.
Researchers demonstrate that in an early pregnancy,
women having a history of continued pregnancy, along
with vomiting had decreased 30% risk of miscarriage
as compared to the women having bleeding in early
pregnancy interval5.
Our study shows that the mean age was 32 years
with standard deviation ± 11.98. Twenty seven percent
patients had positive history of miscarriage while 72%
patients had history of miscarriage. Forty three percent
patients were non obese while 57% patients were
obese. Moreover 41% patients had retained products
of conception while 59% patients didn’t have retained
products of conception.
Studies demonstrate that pregnancy after 26
years increased the risk of abortions in 57% cases14
whereas our statistics also revealed high percentage of
spontaneous abortion (64%) among the age group >
30 years.
Obesity is one of the leading causes of infertility
in women. In our study, we found 58% obese cases of
spontaneous abortion. These results are consistent with
previous studies conducted by Boots et al15 (58%) and
Broughton16 (59%). But we did not find consistency for
BMI rate in previous studies. Almost all previous studies
observed BMI rate greater than 30 but our study found
an opposite BMI rate. A retrospective study conducted
by Matjila et al17 somehow reflects consistency in which
he found 29 BMI with 6.96 kg/m2 standard deviations
whereas we found 27 BMI with SD ± 3.64.
Marriage is considered a basic institution through
which the breed extends in different Asian and Arab
countries. consanguineous is defined as the same
gene locus of both mother and father which sometimes
creates complications in their breed18. Still 20% pop-
ulation of world practice consanguineous19. Studies
conducted by Bachir predicts that the abortion risk is
high among the consanguinity than the non-consan-
315
guineous couples20. Similar findings were observed
in other studies conducted in Iraq and Turkey where
researchers found two times the risk of early and late
abortion in consanguineous communities21,22. But
our studies reflect no correlation between these two
variables. We observed a high risk of miscarriage into a
non-consanguineous group (88%). Only 12% of females
suffering from spontaneous abortion who belong to the
cousin marriage group. These statistics are quite near
to the Turkish study23 conducted in 2016. They found
18% abortion cases of cousin marriages and we found
only 12%.
In 1-5% of pregnancy cases, retained products of
conception caused severe complications. Women who
faced miscarriage in their second trimester are at high
risk of RPOC24. Studies explored that the median time
of RPOC from delivery was 11 days in which women
suffer from heavy vaginal bleeding, fever, and pelvic
pain25. In a study conducted by Esmaeillou H13, he
observed 46 cases underwent dilation and curettage
where 61% of cases of the retained product of con-
ception in the first-second trimester. Kamya at el found
vascularity as a major reason for RPOC in 96% cases.
Studies conducted by Smorgick N7 examined
19.3% of cases of spontaneous abortion. From this
ratio, he further examined 15.5% recurrent retained
products of conception while in 44 cases he found the
third stage of labor placental problem. In other studies,
retained products of conception found in 40% first
trimester cases and 45% of cases of RPOC belong to
spontaneous abortion27,28. These results are consis-
tent with our studies. Mature adulthood increases the
risk of spontaneous abortion along with the retained
products of conception.
CONCLUSION
Legal abortions need proper care but an unpro-
fessional way of abortions is still practiced in Pakistan
that causes retained products of conception and
threatens female health. People use tablets without
their physicians advise in order to prevent unplanned
pregnancies. Obesity and socioeconomic factors also
trigger spontaneous abortion. Cross marriages are a
major practice in our region but we did not find any re-
lationship between cousin marriages and spontaneous
abortion. Hormonal imbalance in mature adulthood was
also one of the major causes of spontaneous abortion.
Our study concluded that in mature adulthood frequen-
cy of retained products of conception was high (41%),
observed on ultrasound machines. It is highly recom-
mended that the sensitivity of these processes should
be known to people so that they can find physicians in
time, in order to prevent abortion complications.
ACKNOWLEDGEMENT
I am extremely thankful to my teacher and su-
pervisor PROF. DR. BUSHRA RAUF for her guidance,
316
sympathetic attitude, moral support and advice in the
preparation of this dissertation.
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317
 TO COMPARE THE EFFECTIVENESS OF TRANSURETHRAL
PNEUMATIC LITHOTRIPSY AND EXTRACORPOREAL SHOCK
WAVE LITHOTRIPSY: IN TREATMENT OF LOWER URETERIC
STONES
Siddique Ahmad1, Jamshed1, Barka Sajjad2, Syed Ameroon Shah2, Riaz Ahmad2, Irfan Ullah2, Muhammad Kalim1,
Muhammad Sohaib Ali1, Muhammad Ibqar2

ABSTRACT
Ureteric calculi are a common reason for presenting to the emergency department (ED), with more than a million ED
visits per year. Most pass out spontaneously but Calculi greater than 5 mm in diameter frequently require intervention.
ESWL and TPL are one of the treatment options.
Objectives: To compare the effectiveness of transurethral pneumatic lithotripsy (TPL) and extracorporeal shock wave
lithotripsy(ESWL) in treatment of lower ureteric stones.
Methodology: This study was conducted in the Department of General Surgery HMC & Department of Urology, IKD,
Peshawar from July 2018 to January 2019, 06 months in duration. A group of 70 patients presenting with ureteric
calculi were randomly allocated in two groups. Group A underwent TPL while Group B ESWL. Follow up was done to
determine the effectiveness with regards to stone clearance.
Results: The mean age of the whole study sample was 35.6 + 8.5 years. The difference between mean age of both
groups was statistically not significant (p 0.665). there were 70% males compared to 30% females in the overall sample
and the difference of gender across both groups was comparable (p 0.192). The mean size of stone of the whole study
sample at presentation was 6.4 + 2.5mm and the duration of illness was 4.8 + 1.8months. On follow up, the effectiveness
of the procedure in terms of stone clearance was recorded in 88.6% of TPL group and 77.1% of ESWL group (p 0.205).
Conclusion: TPL is comparable to the ESWL in terms of its effectiveness for ureteric calculi of size less than or equal
to 10mm. More research trials need to be done for conclusive outcome.
Key Words: urolithiasis, ureteric calculi, transurethral pneumatic lithotripsy, extracorporeal shock wave lithotripsy,
stone clearance

INTRODUCTION on spontaneous passage rates of ureteric calculi, but

Ureteric calculi are a common reason for present-
ing to the emergency department (ED), with more than a
million ED visits per year.1 Ureteric calculi are estimated
to affect up to 12% of men and 6% of women in their
lifetime and typically affect young and healthy adults.
Common symptoms of ureteral stones include renal
colic, dark or bloody urine, painful urination, nausea,
vomiting, and fever. When conservative treatment fails,
the two most common treatments are extracorpore-
al shock wave lithotripsy (ESWL) and transurethral
pneumatic lithotripsy (TPL). There are limited data
1Department of General Surgery, Hayatabad Medical
Complex
2Department of Urology, Institute of Kidneys Disease
Hayatabad
.........................................................................................
Address for correspondence:
Dr. Syed Ameroon Shah
Department of Urology, Institute of Kidneys Disease
Hayatabad
Cell No.0333-9712477
Emailameroonshah@yahoo.com
factors such as stone size, location, smooth muscle
spasm, edema, and anatomy are known to affect pas-
sage. Calculi greater than 5 mm in diameter frequently
require intervention.2,3 ESWL uses high-energy sound
waves projected from outside the body through the
intervening tissue to break up the stone with no need
to insert an instrument through any tissue. Frequently
cited advantages of ESWL include noninvasiveness,
safety, and a lack of need for anesthesia. Moreover,
ESWL does not require significant surgical skills and can
be performed as an outpatient procedure. In contrast,
transurethral pneumatic lithotripsy depends on a uret-
eroscope inserted into the affected ureter by way of the
urethra and bladder. In addition to a camera and other
operating equipment, a pneumatic lithotripter device
is passed through the ureteroscope to break up the
stone. It is also associated with complications such as
postoperative bleeding, thrombosis and emboli, infec-
tion, and ureteral stricture.4 Razzaghi et al, in their study
comparing pneumatic lithotripters versus holmium laser
for ureteral calculi, concluded that immediate stone-free
rate in pneumatic lithotripsy group was 82.1 % while in
17.9 % patients stone was pushed backward. Three of

318 KJMS May - August, 2020, Vol. 13, No.2

them were managed with conservative measures while
the remaining patients needed extracorporeal shock
wave lithotripsy. Mean duration of pneumatic lithotripsy
was 7.9+4.2 minutes for this group. Mucosal damage &
postoperative fever occurred in 1.8% &3.6% of patients’
respectively.5 A study on the comparison of efficacies
of holmium YAG laser, and pneumatic lithotripsy in the
endoscopic treatment of ureteral showed that transure-
thral pneumatic lithotripsy has 98.4% stones-free rate for
distal ureter. The operation time was significantly shorter
with less postoperative analgesics requirement & short-
er hospital stay for transurethral pneumatic lithotripsy.6
In a prospective study for management of distal ureteric
stone Etafy M et al. noted that in the ESWL group, the
operative time was 43.13 +22.5 min; the average num-
ber of sessions/patients was 1.5 sessions; the average
number of SW/patients was 4500 SW/patients; the aver-
age energy was 16.5 kV; the average stone burden was
7.8/mm; the overall stone–free rate was 75% (36/48);
and the average radiation exposure time was 3.5 min.7 A
prospective randomized study by Verze P et al. showed
that stone-free rate for distal ureteric stones treated with
ESWL was 92.70% with a 44.88% re-treatment rate and
an 11.02% auxiliary procedure rate.8 The rationale of
the current study is to know about the effectiveness of
transurethral pneumatic lithotripsy and extracorporeal
shock wave lithotripsy in treatment of lower ureteric
stones cases in our population because there is not any
recent research available in local adult population as
limited number of prospective studies comparing ESWL
and transurethral pneumatic lithotripsy are available,
and most published reports are mostly retrospective in
design. The current study will contribute to serve as a
platform in devising local guidelines for adopting one
technique in preference to the other, affecting patient
management. The study will lead us towards the better
management of patients with lower ureteric stone cases.
METHODOLOGY
This study was conducted in Department of
General Surgery and Department of Urology, Institute
of Kidney Diseases, Hayatabad, Peshawar, from July
2018, to January 2019, a total duration of 06 months.
Study design was randomized controlled trial. Total
number of patients was 70 , 35 in each group. Keeping
a stone free rate in pneumatic lithotripsy as 98.4% and
p2 75% as stone free rate in extracorporeal shock wave
lithotripsy based on previous study.6,7 significance level
was 5% and power was 90% under WHO sample size
calculation formula.
SAMPLING TECHNIQUE
Consecutive non-probability sampling
Inclusion criteria
1. Both genders
2. Age 18 to 50
KJMS May - August, 2020, Vol. 13, No.2
3. Patients with single lower ureteric stone of 10
mm or less in size being unilateral or bilateral
as evident on radiographs or ultrasound & with
symptoms of flank pain radiating to genitalia for
at least 2 weeks.
Exclusion criteria
1. Patients with solitary kidney as evident on ultra-
sonography.
2. Renal insufficiency i.e. serum creatinine more
than 3mg/dl.
3. Ipsilateral ureteric stricture on IVU.
4. Active renal tract infection on urine examination.
5. Transplanted kidney or previous surgery for
ureteric stones known from patient history &
examination.
6. Morbid obesity or pregnancy confirmed on ultra-
sound.
7. Bleeding diathesis as evident on clotting profile.
DATA COLLECTION PROCEDURE
All the patients coming to out-patient department,
diagnosed as having lower ureteric calculi & meeting
the selection criteria, was included in the study. They
were randomly distributed into two groups (A & B)
each group having equal number of patients. A written
consent both for the procedure & inclusion in the study
was taken, followed by detailed history and thorough ex-
amination. X-ray KUB, intravenous urography (IVU) and
ultrasonography was done & examined by a consultant
radiologist having at least 2 years of experience, for the
diagnosis of ureteric stone. Group A being treated with
transurethral pneumatic lithotripsy and group B being
treated with ESWL. The first group was admitted and
procedure was done the next day, while the patients in
group B was treated as outpatients on day care basis.
All the patients was given intravenous a single dose of
diclofenac sodium 50mg post procedure for pain control
in both groups. All patients were given prophylactic
oral ciprofloxacin 500mg twice a day for 5 days. After
completion of the procedure, at-hand fluoroscopy was
performed to know the stone-free status of the ureter
for both groups. Presence of no stone in ureter on
fluoroscopy was termed as treatment success (100%
stone clearance). Following the procedures, complete
stone clearance was further confirmed by X-ray KUB &
ultrasound which was reported by the same consultant
radiologist. A pre-designed proforma was used for data
collection.
STATISTICAL ANALYSIS
Descriptive statistics for data was computed using
(SPSS) version 19. Frequency and percentage were
calculated for categorical variables like gender & effec-
319
tiveness. Mean + S.D. were calculated for continuous
variables like age, stone size and duration of illness.
Chi-square test was used to compare the effectiveness
in both the groups. P-value < 0.05 was considered sig-
nificant. Effectiveness is stratified among age, gender
and duration of illness to see the effect modifiers using
chi square test with P-value < 0.05 was considered
significant. All the results are presented in the form of
tables and charts.
RESULTS
The study was conducted on 70 patients urolithi-
asis of size less than 10mm. All patients were randomly
allocated in two groups. Patients in group A were sub-
jected to tranuretheral pneumatic lithotripsy (TPL) while
patients in group B were subjected to extracorporeal
shock wave lithotripsy (ESWL).
The mean age of the whole study sample was 35.6
+ 8.5 years. Minimum age of 21 years and maximum
age of 50 years. The difference between mean age of
both groups was statistically not significant (p 0.665).
Table 1
While distributing the patients with regards to gen-
der, there were 70% males compared to 30% females in
the overall sample. The difference of gender between
both groups was statistically not significant (p 0.192).
Table 2
The mean size of stone of the whole study sample
at presentation was 6.4 + 2.5mm. We categorized the
stones between 1-5mm and > 5-10mm and compared
between both groups which was statistically not signifi-
cant (p 0.212). Table 3
The mean duration of illness of the whole study
sample was 4.8 + 1.8months. we categorized the du-
ration of illness as 2-5 months and > 5-8 months and
Table 1: Comparison of age Between Both Groups (n = 35 each)
Treatment n Mean
Groups
Age of patient
TPL 35
ESWL 35
Age Groups 20 to 30 years
> 30 to 40 years
> 40 to 50 years
Total
320
compared between both groups (p 1.0). Table 4
On follow up, the effectiveness of the procedure
in terms of stone clearance was recorded in 88.6% of
TPL group and 77.1% of ESWL group (p 0.205). Table
5
In our study, age wise distribution showed treat-
ment effectiveness of 100% for ESWL in age group
20-30 years while TPL showed a higher success rate in
patients aged 30 years and above of 83.3% compared to
63.6% failure of ESWL (table 6-8).Gender wise, females
had a higher success rate with TPL( 84.6%) compared to
a failure rate of ESWL (62.5%) while in male gender, TPL
and ESWL had comparable 90.9% & 88.9% success rate
respectively(table 9-10).In terms of stone size(5mm),
TPL had a 100% treatment effectiveness compared to
ESWL (70%) while stone sized 5-10mm, TPL and ESWL
had equal 80% treatment effectiveness (table 11-12).
Treatment effectiveness of both procedures was
assessed by total duration of illness which show that
in a shorter follow up of 2-3 months, TPL had treatment
effectiveness of 81.8% compared to ESWL(77.3%) but
when the patients were followed up to 5-8 months, TPL
had a success rate of 100% while in the ESWL, 76.9%
were successfully treated with a 23% failure rate(table
13-14).
DISCUSSION
Ureteric stones have a high probability of spon-
taUreteric stones have a high probability of spontaneous
clearance. Spontaneous passage should be favored if
possible.9,10 According to a meta-analysis by the AUA
Guidelines Panel, newly diagnosed stones with a diam-
eter < 5 mm will pass in up to 98%, depending on the
degree of obstruction, urothelial edema and degree of
impaction.9 With close controls and in absence of risk
factors like impaired renal function, pain, urinary tract
Std. Deviation P value
35.1 7.8 0.665
36.1 9.2
Treatment Groups P VALUE
TPL ESWL
12 11 0.881
34.3% 31.4%
12 11
34.3% 31.4%
11 13
31.4% 37.1%
35 35
100.0% 100.0%
KJMS May - August, 2020, Vol. 13, No.2
 Table 2: Comparison of Gender Between Both Groups (n = 35 each)

Treatment Groups P VALUE

TPL ESWL
Gender of Patient Male 22 27
62.9% 77.1%
Female 13 8
0.192
37.1% 22.9%
Total 35 35
100.0% 100.0%

Table 3: Comparison of Size of Stone Between Both Groups (n = 35 each)

Treatment Groups P VALUE

TPL ESWL
Stone size Catego- 1-5mm 15 10
ries 42.9% 28.6%
> 5 to 10mm 20 25
0.212
57.1% 71.4%
Total 35 35
100.0% 100.0%

Table 4: Comparison of Duration of Illness Between Both Groups (n = 35 each)

Treatment Groups P VALUE

TPL ESWL
Duration Categories 2 to 5 months 22 22
62.9% 62.9%
> 5 to 8 months 13 13
1.0
37.1% 37.1%
Total 35 35
100.0% 100.0%

Table 5: Comparison of Effectivenss Between Both Groups (n = 35 each)

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 31 27
treatment 88.6% 77.1%
No 4 8
0.205
11.4% 22.9%
Total 35 35
100.0% 100.0%

KJMS May - August, 2020, Vol. 13, No.2 321

 Table 6: Age Groups 20 – 30 Years Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 10 11
treatment 83.3% 100.0%
No 2 0
0/156
16.7% 0.0%
Total 12 11
100.0% 100.0%

Table 7: Age Groups > 30 – 40 Years Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 10 4
treatment 83.3% 36.4%
No 2 7
0.021
16.7% 63.6%
Total 12 11
100.0% 100.0%

Table 8: Age Groups > 40 – 50 Years Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 11 12
treatment 100.0% 92.3%
No 0 1
0.347
0.0% 7.7%
Total 11 13
100.0% 100.0%

Table 9: Male Gender Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 20 24
treatment 90.9% 88.9%
No 2 3
0.205
9.1% 11.1%
Total 22 27
100.0% 100.0%

322 KJMS May - August, 2020, Vol. 13, No.2

 Table 10: Female Gender Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 11 3
treatment 84.6% 37.5%
No 2 5
0.026
15.4% 62.5%
Total 13 8
100.0% 100.0%

Table 11: Baseline Size of Stone 1-5mm Wise Stratification of Effectiveness

Treatment Groups P value

TPL ESWL
Effectiveness of Yes 15 7
treatment 100.0% 70.0%
No 0 3
0.024
0.0% 30.0%
Total 15 10
100.0% 100.0%

Table 12: Baseline Size of Stone > 5-10mm Wise Stratification of Effectiveness

Treatment Groups P value

TPL ESWL
Effectiveness of Yes 16 20
treatment 80.0% 80.0%
No 4 5
1.0
20.0% 20.0%
Total 20 25
100.0% 100.0%

Table 13: Duration of Illness 2-5 Months Wise Stratification of Effectiveness

Treatment Groups P VALUE

TPL ESWL
Effectiveness of Yes 18 17
treatment 81.8% 77.3%
No 4 5
109
18.2% 22.7%
Total 22 22
100.0% 100.0%

KJMS May - August, 2020, Vol. 13, No.2 323

 Table 14: Duration of Illness > 5-8 Months Wise Stratification of Effectiveness
Effectiveness of Yes
treatment
No
Total
infection or fever, these stones can be followed safely
until spontaneously cleared. However, most authors
recommend not exceeding 4-6 weeks, especially for
obstructive ureteric calculi.11,12 These data show that the
success rate is strongly influenced by the timing of ther-
apeutic intervention.13 The sooner therapy is initiated,
the more stones that might have passed spontaneously
will be treated and, thus, false results in favor of the
chosen procedure will be obtained. In particular small
stones have a high spontaneous passage rate and so
therapeutic intervention should be delayed to allow
clearance.13 In our study, patient aged 30 and above
had almost 80% success rate compared to ESWL with
a failure rate of 63.6% in the specific age group.Peschel
et al have reported on the differences that they have en-
countered in dealing with distal ureteral calculi with both
ESWL and TPL. TPL was significantly better in terms
of shorter operative time, fluoroscopy time and time to
achieve a stone free status. The authors recommend
TPL as first-line treatment for smaller stones (< 5 mm)
that do not pass spontaneously.
Compared with distal ureteral stones, TPL per-
formed for stones in the proximal ureter have been as-
sociated with lower success rates which are ascribed to
a more difficult access as well as the proximal migration
of stone fragments in TPL. In some studies it was found
that compared with the ESWL group treatment cost
was higher in the TPL group due to hospitalization and
inpatient costs.14 The best modality for the treatment of
ureteral stones is still debatable.14 Patients who stay far
from hospital more probably choose TPL over ESWL
to avoid frequent visits because of its high success
rate for single treatment.15 Patient’s economic status
also effects satisfaction level of the patients regarding
choice of TPL or ESWL for treating their ureteral stones
especially in a society like Pakistan where people with
middle, and low-income levels have difficulty in coping
with the costs incurred in private setups.15 In literature
there is a controversy regarding the financial burden
on patients.16
There are some important factors such as stone
location, size, composition, surgeon’s inclination and
patient’s choices that play a vital role in the decision
regarding the use of open, laparoscopic, ESWL or TPL
324
Treatment Groups P VALUE
TPL ESWL
13 10
100.0% 76.9%
0 3
0.066
0.0% 23.1%
13 13
100.0% 100.0%
for treating ureteral stones. In modern day practice,
SWL and TPL are considered as the first-line treatment
modalities for the treating ureteral stones.17
Shock wave lithotripsy is a noninvasive procedure
that can be performed as an outpatient procedure,
however it has its own disadvantages as long treatment
time, high retreatment rate and poor compliance by the
patient.15 AUA recommendations indicated that ESWL
be used as the first-line of management option for a
small stone (<1 cm) but indications had not been so
clear for using it for proximal ureteral stones of more
than 1 cm.18,19 The advancement in technology has led
to introduction of small caliber semi-rigid ureteroscope.
A combination of TPL and intracorporeal lithotripsy has
proven to be a viable alternative to ESWL.18 In our study,
we found that TPL had a shortened duration of illness
with treatment success in 80% of patients while ESWL
had a treatment effectiveness of 77.3% in a 2-3 months
follow-up but when compared a longer follow-up of 5-8
months, the treatment TPL was effective in 100% cases
while ESWL had a failure rate of 23.1%.
In a study done in Pakistan it was concluded that
ESWL was the preferred choice of treatment for proximal
ureteral stones, but ureterorenoscopic manipulation
with intracorporeal lithotripsy was also safe for a quicker
relief of symptoms in patients with proximal ureteral
stones.20 Laparoscopic approaches are reasonable
alternatives in cases, where ESWL and TPL have failed.
However, they did not mention the economic burden of
these procedures on the patients.
In our study, we found that based on stone size
1-5mm, TPL had a 100% success rate while ESWL had
30% failure rate and then in the stone size of 5-10mm,
TPL and ESWL both had comparable 80% success rate
respectively. The success rate (stone free rate) of TPL
has been around 80% in the proximal ureter. It is seen in
literature that TPL has a higher stone-free rate for stones
smaller than or equal to 10 mm in the distal ureter and
stones bigger larger than 10 mm in the proximal ureter.21
It is pertinent here that besides the influence of stone
size and position, the efficiency of the TPL procedure
depends on the experience and skill of the operating
urologist as well.22
KJMS May - August, 2020, Vol. 13, No.2
 Besides thinking about all the factors while de-
ciding a specific treatment modality, priority should be
always given to patient’s preference. Some patients
might have concerns regarding the anesthesia require-
ment and the invasive nature of TPL. But there may
be other set of patients who might prefer to have their
stone removed and the pain alleviated at the earliest
possible time, thus avoiding multiple treatment sessions
that might be required in case of SWL as treatment
modality.23
It was mentioned in a study that compared
with ESWL, ureteroscopic removal of ureteral stones
achieved a greater stone-free status, but with a higher
complication rate and longer hospital stay.24 However
during the course of our study, we have had more com-
plications associated with TPL subgroup with nominal
hospital stay of 1 day post procedure. Lee et al. reported
lack of any significant differences regarding patients’
satisfaction for either intervention (TPL or ESWL).25 In
a study conducted in Egypt, it was reported that the
mean costs for ESWL and TPL were EGP 5700 (EG-
P=Egyptian Pound) and EGP 6500 respectively.24 Lee
et al. reported costs of USD 1637 for ESWL and USD
2154 for TPL.25 In another study it was reported that
ESWL was more costly (USD 1255 for hospital costs,
and USD 1792 charged to the patient) compared with
TPL. However, different ESWL devices were used in
these studies and no recommendations can be made.
In one cost-effective study, the cost of ESWL was almost
GBP (GBP=Great Britain Pound) 1500 and GBP 2200
for TPL in patients with ureteral stones, however TPL of
stones larger than 10 mm diameter in the lower ureter
cost GBP 500 less than SWL.26
Stone size is a significant factor affecting the
stone-free state following any intervention for the treat-
ment of ureteral stones.27 One another factor in the
context of ESWL for ureteral stones treatment is the skin
to stone distance, which has also a role in determining
stone-free rates.27 Significantly in the age group 20-
30 years, the success rate of ESWL was 100% in our
study which hints at the significance of skin to stone
distance in the context of ESWL procedure due to the
observed fact that younger people have more lean phy-
siques(nominal BMI). Recent studies have reported that
CT scan Houndsfield units is a better predictor of stone
composition and potential fragmentation during ESWL
treatment.28,29 This area needs to be further explored
in future studies. Massoud et al. stated that in patients
who have stones of 500 to1000 HU, factors such as
body mass index of more than 30 kg/m2 and a lower
calyceal location make them less suitable for ESWL(29).
So the studies done previously have not accounted for
these confounding factors while comparing the TPL and
ESWL modality for the proximal ureter stones.
Alameddine et al. reported the complications of
TPL including perforation in 5/103 (4.8%) patients which
were treated with double-J stents except one patient
KJMS May - August, 2020, Vol. 13, No.2
who required nephrostomy tube placement and a lap-
arotomy for intraperitoneal drainage of collection.30 Two
patients (1.94%) developed sepsis. Their initial stone-
free rate for proximal TPL Group was 89%. Their mean
stone size was 10 mm±5.5 mm which was smaller. In
another study stone- free rate after TPL was 86.7%.31
In a study by Al-Marhoon et al, in ESWL of ureteral
stones, the majority of the complications were minor
with the most common being the loin pain in 21% of
the patients.32 In a study by Salem et al. complications
in the TPL group included 4 cases (4%) having mild
extravasation which were managed by DJ stenting.24
Aboutaleb et al. reported complications including stein-
strasse in 34.8% (ESWL group) and 3.7% (TPL group)
of the patients, and ureter perforation in 0% (ESWL)
and 7.4% (TPL) of the patients.24 While we had ureteral
perforation in 2 cases (1%).
There is marked heterogeneity of evidence in dif-
ferent papers. The burden of stones on the patient, skin
to stone distance, BMI, the urologist’s experience and
the availability of resources and appropriate technolo-
gies remain the principal criteria to inform the patients
about the treatment choice for the management of
proximal ureteral stones. This study was the first of its
kind however, we did not take into account the different
factors that may affect stone free rates in ESWL or TPL
groups while comparing the stone clearance rates for
TPL or ESWL for ureteral stones. Our results need to
be investigated more in larger groups and multicenter
prospective studies.
CONCLUSION
TPL is comparable to the ESWL in terms of its
effectiveness for ureteric calculi of size less than or equal
to 10mm. TPL can be recommended for quick relief of
symptoms but the procedure should be performed in
the center of excellence by the competent hands. In
Pakistan, ESWL is the cost effective treatment of choice
and can be ideal for people with nominal BMIs.
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KJMS May - August, 2020, Vol. 13, No.2
 INCIDENCE OF LOW BIRTH WEIGHT IN PREGNANT WOMEN
WITH ISOLATED OLIGOHYDRAMNIOS
Shabana Yasmeen1, Oreekha Amin2 , Ayesha Naz1

ABSTRACT
Introduction: Oligohydramnios affect 3% to 5% of pregnancies and is associated with increased pregnancy com-
plications, congenital anomalies and perinatal mortality. Therefore, adequate amniotic fluid volume is critical for the
normal fetal growth and development. Large scale national data showing the incidence of oligohydramnios in Pakistan
is lacking. Therefore, we conducted the study to determine the frequency of low birth weight in pregnant women with
isolated oligohydramnios.
Material and Methods: This descriptive cross-sectional study was carried out in the department of obstetrics and
gynecology Hayatabad Medical Complex, Peshawar from April 2015 to Oct 2015. This study included a total of 124
patients using non probability consecutive sampling technique for sample collection. Women with singleton pregnan-
cies at term 37 to 40 wks with non anomalous fetuses and with intact membranes and cephalic presentation and with
isolated oligohydramnios were included in study.
Results: Our study shows that among 124 women, 67 (54%) women were primi gravida while 57(46%) women were
multi gravida. Mean age was 26 years (SD ± 4.37) and mean parity was 3 (SD ± 2.02). Mean gestational age of pa-
tients was 38 weeks with SD ± 1.22. Low Birth weight among 124 patients was analyzed as 19(15%) neonates had
birth weight ≤ 2.5 Kg, 105(85%) neonates had birth weight > 2.5 Kg, Mean birth weight was 3.5 Kg with SD ± 4.62.
Conclusion: Our study concludes that the incidence of low birth weight was found to be 15% in pregnant women with
isolated oligohydramnios.
Key Words: Low Birth weight, pregnant women, oligohydramnios.

INTRODUCTION sign of potential fetal compromise and associated with

Oligohydramnios is a decreased amount of
amniotic fluid, affecting 3% to 5% of pregnancies.1
An accurate and reproducible method of determining
abnormality in amniotic fluid volume is sonographic
assessment of amniotic fluid index (AFI).2 AFI less
than or equal to 5cm is termed as oligohydromnios.3
The common etiological factors associated with oli-
gohydramnios are ruptured membranes, congenital
abnormalities and placental insufficiency.4 Among these
uteroplacental insufficiency is the most common cause
of prerenal oligohydramnios and the decrease amniotic
fluid is a direct result of decreased fetal renal perfusion.5
However, isolated oligohydramnios refers to absence
of maternal and fetal risk factors and failure to identify
a recognizable underlying etiology.6
Oligohydramnios has been implemented as a
1Department of Obstetrics & Gynecology, Hyatabad
Medical Complex, Peshawar.
2Department of MCH, Pakistan Institute of Medical
Sciences,Islamabad.
.........................................................................................
Address for correspondence:
????
??????
Cell No. ???
Email: ?????
increased incidence of adverse perinatal morbidity and
mortality2. Isolated oligohydramnios at term is one of
the major indicators for antenatal surveillance. However,
conflicting data exists concerning the implication of
isolated oligohydramnios on pregnancy outcome at
term. Various studies have reported that antepartum
olighydramnios is associated with increased perinatal
morbidity3,7-9. However, a study reported that isolated
oligohydramnios in the absence of any other maternal
or fetal complicating factor is not found to adversely
affect the fetal outcome. Though the fetal weight may
be slightly lower in babies born to mothers with oligo-
hydramnios.(p value < 0.05)10.Similarly another study
showed oligohydramnios in the absence of maternal
or fetal risk factors is not associated with an adverse
perinatal outcome when compared to pregnancies
managed expectantly.11,12 Moreover, a woman who is
at term with isolated oligohydramnios with reassuring
fetal surveillance and the absence of maternal morbidity
and evidence of fetal growth retardation is not associ-
ated with adverse perinatal outcome.13 A metaanalysis
published14 also reported that in term or post-term preg-
nancies, isolated ologohydramnios is associated with
increased risk of obstetric interventions but outcomes
are similar to those of pregnancies with normal amni-
otic fluid. Due to this conflicting data, still the available
literature is insufficient to make firm recommendations
supporting intervention for isolated oligohydramnios.
Here, in this study we aimed to evaluate the effect of iso-

KJMS May - August, 2020, Vol. 13, No.2 327

lated oligohydramnios at term on birth weight of babies. deviation. Qualitative data i.e low birth weight was
As there is no local study available on this topic so this presented in the form of frequency and percentages.
study may prove helpful for further research purpose. Birth weight was stratified among age, gravida, parity.
Post stratification chi square test was applied keeping
MATERIAL AND METHODS P value ≤0.05 as significant value. All the results were
presented in the form of tables and charts.
This descriptive cross-sectional study was con-
ducted in department of obstetrics and gynecology
RESULTS
Hayatabad Medical Complex, Peshawar from April 2015
to Oct 2015. Age distribution among 124 patients was an-
alyzed as 56(45%) women were in age 20-25 years,
The sample size was 124 using 20% of birth
50(40%) women were in age 26-30 years, 18(15%)
weight, 95% confidence level and 8%
women were in age 31-35 years. Mean age was 26
Sampling technique used was non probability years with SD ± 4.37. (table no 1)
consecutive sampling
Parity distribution among 124 patients was ana-
lyzed as 97(78%) women had parity ≤ 3 while 27(22%)
Inclusion criteria
women had parity > 3. Mean parity was 3 with SD ±
Age 20-35 years. 2.02. (table no 2)
Women with singleton pregnancies at term 37 Gravida distribution among 124 patients was
to 40 wks with non anomalous fetuses and with intact analyzed as 67(54%) women were primi gravida while
membranes and cephalic presentation and with isolated 57(46%) women were multi gravid. (table no 3)
oligohydramnios.
Period of gestation among 124 patients was ana-
Exclusion criteria lyzed as 63(51%) women had POG range 37-38 weeks,
40(32%) women had POG range 38-39 weeks, 21(17%)
• Women with unsure gestational age women had POG range 39-40 weeks. Mean POG was
38 weeks with SD ± 1.22. (table no 4)
• Women with multiple pregnancy
Low Birth weight among 124 patients was ana-
• Women with history of preterm rupture of mem-
lyzed as 19(15%) neonates had birth weight ≤ 2.5 Kg,
branes
105(85%) neonates had birth weight > 2.5 Kg, Mean
• Post term pregnancies, previous cesarean section, birth weight was 3.5 Kg with SD ± 4.62. (table no 5)
evidence of intrauterine gtowth retardation.
• Medical disorders like diabetes, hypertension, Table 1: Age distribution (n=124)
cardiac diseases and preeclampsia.
Age Frequency Percentage
This study was conducted after approval from
20-25 years 56 45%
hospital ethical and research committee. All pregnant
women attending antenatal clinic or labour room, who 26-30 years 50 40%
fulfill the operational definition, inclusion and exclusion 31-35 years 18 15%
criteria were included in the study after obtaining in-
Total 124 100%
formed written consent.
Mean age was 26 years with SD ± 4.37
All women attending OPD and labour room
undergo a sonographic assessment of amniotic fluid Table 2: Parity Distribution (n=124)
volume as an integral part of fetal assessment. A thor-
ough maternal history in order to establish adequate Parity Frequency Percentage
dating of pregnancy and targeted physical examination ≤3 97 78%
was performed to look for maternal condition that may >3 27 22%
be associated with oligohydramnios. In addition, ex-
amination also include per abdomen examination and Total 124 100%
bishop score. Eventually these mothers was induced Mean parity was 3 with SD ± 2.02
for this indication of oligohydramnios and outcome was Table 3: Gravida distribution (n=124)
analysed i.e weight of the newborns was measured in
kilograms by same weight machine provided in labour Gravida Frequency Percentage
room. All data was recorded in a predesigned performa.
Primi Gravida 67 54%
Data was entered & analysed using SPSS version
Multi Gravida 57 46%
21. Quantitative data like age, parity, period of gesta-
tion was presented in the form of mean and standard Total 124 100%

328 KJMS May - August, 2020, Vol. 13, No.2

 Table 4: Period Of Gestation (n=124) Table 5: Low Birth Weight (n=124)

Pog Frequency Percentage Low birth weight Frequency Percentage

37-38 weeks 63 51% ≤ 2.5 Kg 19 15%
38-39 weeks 40 32% >2.5 Kg 105 85%
39-40 weeks 21 17% Total 124 100%
Total 124 100% Mean age was 3.5 Kg with SD ± 4.62
Mean POG was 38 weeks with SD ± 1.22

Table 6: Stratification Of Low Birth Weight W.R.T Age Distribution (n=124)

LBW 20-25 years 26-30 years 31-35 years Total

≤ 2.5 Kg 8 8 3 19
>2.5 Kg 48 42 15 105
Total 56 50 18 124
Chi Square test was applied in which P value was 0.9564

Table 7: Stratification Of Low Birth Weight W.R.T Parity Distribution (n=124)

LBW ≤3 >3 Total

≤ 2.5 Kg 15 4 19
>2.5 Kg 82 23 105
Total 97 (78.3%) 27 (21.7%) 124
Chi Square test was applied in which P value was 0.9339

Table 8: Stratification Of Low Birth Weight W.R.T Gravida Distribution (n=124)

LBW Primi gravid Multi gravida Total

≤ 2.5 Kg 10 9 19
>2.5 Kg 57 48 105
Total 67 57 124
Chi Square test was applied in which P value was 0.8940

Stratification of low birth weight with age, parity dictor of adverse perinatal outcome in non-complicated
gravid is given in table no 6,7,8. pregnancies at term.

DISCUSSION Our study shows that among 124 women, 19

Oligohydramnios has been defined as amniotic
fluid index (AFI) ≤5 cm and borderline oligohydramnios
as AFI between 5 and 8 cm between 36–42 weeks of
gestation. In pregnancies of more than 40 weeks of
gestation, the incidence is more than 12 % as the am-
niotic fluid volume declines progressively.15 Moreover,
generally it is stated that oligohydramnios is associated
with poor perinatal outcomes.16 Women with oligohy-
dramnios are more likely to have non-reactive fetal heart
rate tracings, increased incidence of fetal distress, and
thus an increased incidence of caesarean sections.17
However, some studies show that AFI is a poor predictor
of adverse perinatal outcome and isolated oligohydram-
nios should not be the only parameter for predicting
perinatal outcome. The present study was carried out
to find whether oligohydramnios can be used as a pre-
(15%) neonates had birth weight ≤ 2.5 Kg, 105(85%)
neonates had birth weight > 2.5 Kg, Mean birth weight
was 3.5 Kg with SD ± 4.62.Similar results were found
in another study conducted by Reddy V et al18 in which
out of 3,567 patients 32 (0.9%) and 5 (0.15%) were
diagnosed as isolated oligohydramnios and polyhy-
dramnios, respectively. Among 32 (0.9%) newborns
of isolated oligohydramnios, 5 (15.62%) were very low
birth weight (< 1,500gms), 14 (43.75%) were Low Birth
Weight (1,500 – 2,500gms) and 13 (41%) were with
normal birth weight (2,500 - 3,800gms). None of the
cases were with large for gestational Age babies (>
3800gms). Further, preterm and term gestations were
17 (53.12%) and 15(46.8%) respectively in this group.
In another study conducted by Singhal SR et al19 a total
of 100 patients were observed in which 19 neonates
had birth weight ≤ 2.5 Kg while 81 neonates had birth

KJMS May - August, 2020, Vol. 13, No.2 329

weight > 2.5 Kg, Mean birth weight was 4 Kg with SD
± 2.98.Further, in another study conducted by Sowmya
K et al20 total number of cases studied were 100, out
of which 50 were in the study group and had an AFI 5
and 50 were in the control group and had an AFI>5. 24
babies (48%) in the study group had birth weight <2.5
kg, whereas 11 babies (22%) in the control group had
birth weight <2.5 kg (p value <0.05). This difference
was statistically significant. 7 babies in the study group
(14%) were admitted to the neonatal intensive care unit
(NICU), whereas 2 babies (4%) in the control group
had NICU admission (p value >0.05). Further, Morris
RK et al21., documented that isolated oligohydramnios
is associated with increased likelihood of iatrogenic
preterm delivery and comparatively lower birth weights.
Therefore, isolated oligohydramnios during second
trimester does not increase adverse perinatal outcome
significantly (but increases the caesarean section rate)
and therefore, should not be an indication for termina-
tion of pregnancy22.
CONCLUSION
Our study concludes that the incidence of LBW
was found to be 15% in pregnant women with isolated
oligohydramnios.
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in the maternal pulmonary circulation. Am J Obstet
Gynecol. 1986 Jan; 154(1):104-6.
2. Benson MD, Kobayashi H, Silver RK. Immunologic
studies in presumed amniotic fluid embolism. Obstet
Gynecol.2001 Apr; 97(4):510-4.
3. Farrar SC, Gherman RB. Serum tryptase analysis in a
woman with amniotic fluid embolism. A case report.
J Reprod Med. 2001 Oct; 46(10):926-8.
4. Kramer MS, Rouleau J, Baskett TF, Joseph KS, Ma-
ternal Health Study Group of the Canadian Perinatal
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ulation-based cohort study. Lancet. 2006 Oct 21;
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5. Knight M, Tuffnell D, Brocklehurst P, Spark P,
Kurinczuk JJ. Incidence and risk factors for amni-
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115(5):910-7.
6. Marcus BJ, Collins KA, Harley RA. Ancillary studies
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nios. In James DK, Steer PJ, Weiner CP, Gonik B, ed-
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WB Saunder publications. 2006; 278-285.
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9. Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos
R, Twickler DM, Remus RM. “ pregnancy outcomes
after ante partum diagnosis of oligohydramnios at or
beyond 34wks of gestation”. Am J Obstet Gynecol.
2000; 182: 909-920.
10. K S, Varghese SB, Borkar U. Effect of isolat-
ed oligohydramnios in otherwise normal term
pregnancy. IJBR [Internet]. 28Feb.2014 [cited
19Apr.2019];5(2):98-01.
11. Everett F, Magan, Dorota A, Doherty, Karan Field Et
al. “Biophysical profile with amniotic fluid volume
assessments. Am J Obstet Gynecol. 2004; 104: 5-10.
12. Umber A, Chohan MA. To determine the effect of
acute IV maternal hydration on AFV in patient with
3rd trimester oligohydramnios. Am J Obstet Gynecol
1995 Oct;173(4):1186-91.
13. Magann EF, Chauhan SP, Doherty DA, Magann MI,
Morrison JC. The evidence for abandoning the amni-
otic fluid index in favor of the single deepest pocket.
Am J Perinatol. 2007; 24(9):549-555.
14. Fong A, Chau CT, Pan D. Amniotic fluid embolism:
antepartum, intrapartum and demographic factors.
J Matern Fetal Neonatal Med. 2014 Jun; 30: 1-6.
15. Abida Ahmed. Amino acid infusion in oligohydram-
nios.JK practioner 2006 ;13(3): 140-141.
16. Ogundipe OA, Spong CY, Ross MG. “Prophylactic
amnioinfusion for oligohydramnios: a re evaluation.”
Obstet Gynecol. 1994; 4:544-548.
17. Hung Nu Chu, Mei Juan Shen Treating oligohydram-
nious with extract of salvia miltiorrhiza: A randomised
control trial. J Ther Clin Risk Management 2008;
4(1): 287-290
18. Reddy V, Kumar SS, Reddy N S. Birth weight and
term of the gestation in pregnancies complicated
by isolated oligo and isolated polyhydramnios. Int J
Reprod Contracept Obstet Gynecol. 2013;2(4):577-
580.
19. Singhal SR, Gupta R, Sen J. Low Amniotic Fluid
Index as a Predictor of Adverse Perinatal Outcome –
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20. Sowmya K, Betty Varghese and Umashankar Borkar
Y. Effect of isolated oligohydramnios in otherwise
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21. Morris RK, Meller CH, Tamblyn J, Malin GM, Riley
RD, Kilby MD, et al. Association and prediction of
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KJMS May - August, 2020, Vol. 13, No.2
 PREGNANCY RATE AFTER DIAGNOSTIC
HYSTEROSALPINGOGRAPHY IN INFERTILE WOMEN
Anjum Ara, Taskeen Rehana, Naheed, Tashfeen Irtaza Khan

ABSTRACT
Background: hysterosalpingography is a diagnostic procedure and can be used as therapeutic procedure also.
Objective: to determine the pregnancy rate after diagnostic hysterosalpingography in infertile women.
Methodology: this study was conducted in Naseer Teaching Hospital. A total of 80 patients presented to gynae de-
partment for the complaint of infertility were included in the study. Water insoluble materials (Ethiodol) was used as a
contrast medium for the Hysterosalpingography. All the Hysterosalpingography was done in the follicular phase of the
menstrual cycle of women. Patient were followed up for six months after the procedure and the conception, if present,
was confirmed by cessation of menstrual cycle and positive urine pregnancy test.
Result: Mean age was 28.5±5.05 years. On Hysterosalpingography 56 (70%) were having both tubes patent, 16
(20%) were having only one tube patent and 8 (10%) were having both tubes blocked. A total of 9 (11.25%) patients
conceived after 6 months. comparing the age groups, infertility type and tube patency with the Pregnancy rate no one
was associated significantly with the rate of Pregnancy rate (p value >0.05).
Conclusion: The study showed that there is one tenth chance of fertility after diagnostic hysterosalpingography in
woman with infertility. Further studies with larger sample size are recommended for confirmations of our results.
Key words: infertility, hysterosalpingography, oil soluble contrast medium

INTRODUCTION form of tubal flushing3, 4. A pregnancy rate of more than

Infertility is an important social problem as a
result of rapid urbanization and family nuclearization
associated with it. It produces many social, personal
and psychological impact on the life of a couple. the
prevalence of psychological distress have been noted
to be 37.3% in Pakistani infertile women1. Furthermore
many Pakistani women don’t have enough knowledge
about the infertality2.
Hysterosalpingography is a diagnostic procedure
for the evaluation of patency of uterus and fallopian
tube. It provides the radiographical evaluation of the
path taken by an ova which included uterine cavity and
fallopian tube. It makes us clear about the patency of
tube and uterus and evaluate any pathology in this tract.
It is done in the follicular phase of menstrual cycle. It a
diagnostic procedure but have proven to be therapeutic
also.
Clinical guidelines recommend the HSG in the
1????
.........................................................................................
Address for correspondence:
????
???
Cell No. ????
Email: ???
10% have been noted after HSG over six months5.
Many studies have explain the possible patho-
physiology behind this effect including mechanical
flushing of plugs or debris in fallopian, increasement in
ciliary motion or immunity related effect on endometri-
um6-12. The immunological phenomenon some people
say, as the oil soluble material may enhanced immunity.
However, the mechanism shown above may not
be the same over time or in different population. The
present study is aimed to determine the Pregnancy
rate after hysterosalpingogram in our local population
of infertility. This study result will be used as a evidence
on population catch by our hospital.
METHODOLOGY
A total of 80 patients presented to gynae depart-
ment for the complaint of infertility from 16 March 16,
2019 to 15 march 2020 were included in the study. All
those patients with not conceiving for more than 2 years
with unprotected sex in these 2 years were consider
infertile. All those with infertility, age of 18 to 45 years
old, willing for consent were included in the study. All
those with congenital anomalies of uterus, history of
any type of uterine or abdominal surgery, those with
serum creatinine of more than 1.5 mg/dl and those
patient with allergy to contrast medium were excluded
from the study. Consent was taken from all patients for
the hysterosalpingography as a diagnostic procedure
for the patency of uterus and fallopian tubes. Age was
noted and patient was evaluated for type of infertility

KJMS May - August, 2020, Vol. 13, No.2 331

(primary and secondary). Water insoluble materials
(Ethiodol) as a contrast medium for the Hysterosalpin-
gography. All the Hysterosalpingography was done in
the follicular phase of the menstrual cycle of women.
The instrument which gives least discomfort was used
for the delivery of contrast medium.
By interpreting the result of hysterosalpingog-
raphy patient were place and both patent tubes, one
patent tube and both blocked tubes.
Patient were followed up for six months after the
procedure and the conception, if present, was con-
firmed by cessation of menstrual cycle and positive
urine pregnancy test.
Data was analysis with the help of statistical soft-
ware SPSS version 23. Pregnancy rate after 6 months
was calculated and was compared with the age, fertility
type and tube patency.
RESULT
Mean age was 28.5±5.05 years. Most of the
patients (67.5%) were in age group 25 to 35 years and
most patient were having primary infertility (68.75%).
On Hysterosalpingography 56 (70%) were having both
tubes patent, 16 (20%) were having only one tube patent
and 8 (10%) were having both tubes blocked. (see table
1).
After the Hysterosalpingography total of 9
(11.25%) patients conceived. comparing the age
groups, infertility type and tube patency with the
Pregnancy rate no one was associated with the rate
of Pregnancy rate (p value >0.05). 5 patients of 9 who
conceive were in age range of 26-35 years old. Most
of the 9 patients, 7 were of primary infertility and in 8
out of 9 patients having both tube patent (table 2). All
these were not significantly associated.
Table 1: Baselines and pregnancy rate
Age Groups ≤25 years
26-35 years
>35 years
Infertility Primary infertility
Secondary infertility
Tube patency Both tubes patent
One tube patent
Both tubes blocked
Pregnancy rate Conceived
Not conceived
332
DISCUSSION
We evaluated the rate of pregnancy after 6months
of the hysterosalpingography, and we found the result
being 11.25%. this result was almost similar to the result
presented by Dreyer et al5.
We evaluated the only the oil soluble method
of hysterosalpingography for the Pregnancy rate. The
immunological theory showed the due to oil soluble
material the immunity in the endometrium may be en-
hance. Our result may show a bit positive toward this
hypothesis but study by shown that 25% of water-sol-
uble group and 30% of oil soluble group have positive
pregnancy rate with no significant difference13. However
study by Alan et all showed significant difference in
both these group (13% in water soluble and 29% in oil
soluble contrast medium, p value <0.001)14. Another
study showed that in long term Pregnancy rate both
have no extra benefits but author concluded that the
addition of water soluble to oil soluble material for hys-
terosalpingography shorten the time of conception15.
We did not find any association of age, fertility
type or finding of hysterosalpingography with the preg-
nancy rate. There was zero rate of pregnancy in patient
with both tubes blocked which is also physiological
valid point. There is less data available regarding these
variables. However Alper et al found that there is no
significant difference in the type of diagnosed infertility
on pregnancy rate13.
The limitation of our study included the small
sample size of 80 patients so the many test may have
insignificant value for production of statistically signif-
icant difference like only 1 patient conceived in those
with one tube patent. Also, the pregnancy rate after
hysterosalpingography as find in our study may be
natural occurrence and my have not association with
hysterosalpingography.
Count Percentage
21 26.25%
54 67.50%
5 6.25%
55 68.75%
25 31.25%
56 70.00%
16 20.00%
8 10.00%
9 11.25%
71 88.75%
KJMS May - August, 2020, Vol. 13, No.2
 Table 2: Comparison of age, type of infertility and tube patency with pregnancy rate

Pregnancy rate P value

Conceived Not Conceived
Count Percentage Count Percentage
Age Groups ≤25 years 3 3.75% 18 22.50% 0.673
26-35 years 5 6.25% 49 61.25%
>35 years 1 1.25% 4 5.00%
infertility Primary infertility 7 8.75% 48 60.00% 0.524
Secondary infertility 2 2.50% 23 28.75%
Tube patency Both tubes patent 8 10.00% 48 60.00% 0.239
One tube patent 1 1.25% 15 18.75%
Both tubes blocked 0 0.00% 8 10.00%

CONCLUSION dendritic cell and regulatory t cell profiles in the

peritoneal cavity: A possible mechanism by which
The study showed that there is one tenth chance oscm enhances fertility. The Journal of Immunology.
of fertility after diagnostic hysterosalpingography in 2017;198(11):4277-84.
woman with infertility. This chance does not depend
8. Johnson NP. Review of lipiodol treatment for infertili-
upon the age or type of infertility. Further studies with
ty–an innovative treatment for endometriosis‐related
larger sample size are recommended for confirmations infertility? Australian and New Zealand Journal of
of our results. Obstetrics and Gynaecology. 2014;54(1):9-12.

REFERENCES 9. Mikulska D, Kurzawa R, Rozewicka L. Morphology of

1. Qadir F, Khalid A, Medhin G. Social support, mari-
tal adjustment, and psychological distress among
women with primary infertility in pakistan. Women
& health. 2015;55(4):432-46.
2. Ali S, Sophie R, Imam AM, Khan FI, Ali SF, Shaikh A,
et al. Knowledge, perceptions and myths regarding
infertility among selected adult population in paki-
stan: A cross-sectional study. BMC Public Health.
2011;11(1):760.
3. Practice Committee of the American Society for
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4. Fields E, Chard J, James D, Treasure T. Fertil-
ity (update): Summary of nice guidance. Bmj.
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5. Dreyer K, Van Rijswijk J, Mijatovic V, Goddijn M,
Verhoeve HR, Van Rooij IAJ, et al. Oil-based or
water-based contrast for hysterosalpingography in
infertile women. New England Journal of Medicine.
2017;376(21):2043-52.
6. Gillespie HW. The therapeutic aspect of hystero-
salpingography. The British journal of radiology.
1965;38(448):301-2.
7. Izumi G, Koga K, Takamura M, Bo W, Nagai M,
Miyashita M, et al. Oil-soluble contrast medium
(oscm) for hysterosalpingography modulates
in vitro sperm phagocytosis by rat peritoneal macro-
phages under influence of oily contrast medium (lip-
iodol). Acta europaea fertilitatis. 1994;25(3):203-6.
10. Sawatari Y, Horii T, Hoshiai H. Oily contrast medium
as a therapeutic agent for infertility because of mild
endometriosis. Fertility and sterility. 1993;59(4):907-
11.
11. Soules MR, Mr S, Lr S. Oil versus aqueous media
for hysterosalpingosalpingography: A continuing
debate based on many opinions and few facts. 1982.
12. Yun AJ, Lee PY. Enhanced fertility after diagnostic
hysterosalpingography using oil-based contrast
agents may be attributable to immunomod-
ulation. American Journal of Roentgenology.
2004;183(6):1725-7.
13. Alper MM, Garner PR, Spence JE, Quarrington AM.
Pregnancy rates after hysterosalpingography with
oil-and water-soluble contrast media. Obstetrics and
gynecology. 1986;68(1):6-9.
14. Decherney AH, Kort H, Barney JB, Devore GR.
Increased pregnancy rate with oil-soluble hystero-
salpingography dye**presented in part at the society
for gynecologic investigators, march 1980, denver,
colo. Fertility and Sterility. 1980;33(4):407-10.
15. Steiner AZ, Meyer WR, Clark RL, Hartmann KE.
Oil-soluble contrast during hysterosalpingography
in women with proven tubal patency. Obstetrics &
Gynecology. 2003;101(1):109-13.

KJMS May - August, 2020, Vol. 13, No.2 333

ROLE OF PROGESTERONE IN PREVENTING PRETERM BIRTH
Shahdab, Shabana yasmeen, Ayesha Naz, Ghazala Shams

ABSTRACT
Background: Preterm birth is common world wide. In Pakistan about 11.4% births are preterm.
Objective: To determine in Role of Progesterone in preventing preterm birth in term of decreasing the preterm births
and prolonging the gestation age.
Methodology: this study was conducted in lady reading hospital Peshawar, from 1st June 2019 to 30 nov 2019 . Those
entire patients with at least one previous preterm birth were included in the study. After evauation for inclusion and
exclusion criteria the patient was prescribes 100mg progesterone suppository from the 28 weeks onward. The patient
was follow up until natural or preterm delivery.
Result: Out of total 53 patients with at least one previous preterm birth, 69.81% were having only one previous preterm
birth while 16% were having more than one previous preterm birth. The preterm birth before progesterone were distrib-
uted in gestational weeks as, Birth in 37-35 weeks was 32 (60.37%), Birth in <35 and >32 weeks are as 16 (30.19%)
and Birth in <32 weeks were 5 (9.43%). In the latest preterm birth before progesterone therapy the mean gestational
on preterm birth was 31.22±4.31 weeks. There was decrease in the preterm rate and also increased the gestational
age at birth after the progesterone suppository.
Conclusion: The preterm birth has been decreased with the vaginal usage of progesterone. This decrease was most
obvious in patients who’s previous preterm was in 35-37 weeks.
Key words: Preterm birth, preterm birth, gestational age, progesterone therapy.

INTRODUCTION and the uterine contractions have been decrease in pa-

Preterm birth is define as the birth occur before
37 weeks since last menstrual cycle1. About 13 million
births around the globe are effected by the preterm labor
in each year2. In all births about 5-11%3, 4 are preterm
with many studies shown further increase in frequency
in recent age5-7. In one in Pakistan The preterm birth
rate has been shown to be 11.4%8.
Babies born before 37 weeks are have increase
(about 40 times) mortality than those born at term9, 10
whereas the chance is higher in babies who are born
much early in pregnancy11. This augmented mortality
even occur in infant who are born from thirty two weeks
to thirty six week of pregnancy11. Also the weekly cost
on preterm baby have been estimated about $US10,000
per preterm baby in United States in 199012.
The progesterone administration is high risk
patient with preterm birth have shown benefits in some
studies13,14. In randomized control trial the preterm birth
1????
.........................................................................................
Address for correspondence:
Dr. Shabana yasmeen
?????????
Email: shabanayasmeen27@yahoo.com
Phone No: 03359868036
tient with risk of preterm as compared to placebo. The
preterm birth rate were 13.8% in progesterone group
vs 28.5% in placebo group13. Even a study showed the
injection of 17 alpha-OHP-CS has seems to prevent
prematurity in twin pregnancy. However the studies on
the length of pregnancy extension due to progesterone
vaginal suppository are scanty.
So to further find out the effect of progesterone on
the length of pregnancy and in decreasing the preterm
rate on Pakistani population, with such a high rate of
preterm birth8, is necessary. Result of my study can be
used for having local knowledge about this topic.
METHODOLOGY
This study was conducted in the Gynae depart-
ment of lady reading hospital with 6 month duration
from 1st june 2019 to 30th nov 2019. All the patients
with at least one previous preterm birth were included
in the study. Preterm birth was define as the birth of the
baby when occur before 37 weeks of gestation. Weeks
of gestation was calculated from the last menstrual
cycle of the patient. Married women, age of 19 to 40
years, single pregnancy, vaginal swab culture negative
for any organisms and presenting in before 28 weeks
of gestation were our inclusion criteria. All those with
multiple pregnancy, those with no previous history of
preterm birth, those with gestation age of more than 28,
those with congenital uterine or cervical anomalies and
those with known connective tissue diseases like anti
phospholipid antibody syndrome were excluded from

334 KJMS May - August, 2020, Vol. 13, No.2

the study.
All the patients were thoroughly examined be-
fore the start of the study and benefits and harms of
the study were explained. Baseline investigations and
culture of the vaginal swab were sent. The history of the
last preterm birth about the gestational week of loses
of pregnancy and the number of preterm birth was tak-
en. The patient were prescribes 100mg progesterone
vaginal suppository each day following 28 weeks of
gestation. The patient was advised to consult for any
onset of birth at any time. Preterm birth was define as
the onset of two or more uterine contractions confirmed
by external tocodynamometer with the cervical changes
including dilation of more than 2cm and progressive or
effacement of the cervix. The preterm birth was the birth
of the infant before 37 weeks of gestation.
The patient was followed up 2 weekly by tele-
phone for the compliance of the drug. The delivery date
was noted and the total gestational period, prematurity
was calculated.
Statistical analysis
This was done by the SPSS version 23. Patient
mean age, previous preterm births (one or more) and
the mean gestational ages were calculated. The fre-
quency of preterm birth in the progesterone therapy,
the mean gestational age during birth in progesterone
therapy was obtained. Then this mean was compared
with before progesterone therapy by Paired t test. Sig-
nificant level was set ≤0.05.
RESULTS
Out of total 53 patients with at least one previous
preterm birth, 69.81% were having only one previous
preterm birth while 16% were having more than one
previous preterm birth. The preterm birth before proges-
terone were distributed in gestational weeks as, Birth
Table 1 Data of previous preterm birth.
Previous preterm birth One previous Preterm birth
More than one Previous
Preterm Birth
Preterm birth Birth in 37-35 weeks
Birth <35 and >32 weeks
Birth in <32 weeks
Table 2 Means and standard deviations
Age of the patient
Gestational age at delivery in previous preterm birth
Gestation age at delivery during progesterone therapy
KJMS May - August, 2020, Vol. 13, No.2
in 37-35 weeks was 32 (60.37%), Birth in <35 and >32
weeks are as 16 (30.19%) and Birth in <32 weeks were
5 (9.43%) (table 1). In the latest preterm birth before
progesterone therapy the mean gestational on preterm
birth was 31.22±4.31 weeks (table 2).
After the progesterone therapy the mean ges-
tational age increase from 31.22±4.31 weeks to
35.43±3.41 weeks. The preterm delivery was reduced
from 53 patients (100%) to 32 (60.37%). The term de-
livery was noticed in 21 (39.62%) patients with p value
of <0.001. The Preterm birth decreased to 32 patients
on progesterone (p value <0.001) table 3.
DISCUSSION
In our study, out of total 53 patients with at least
one previous preterm birth, 69.81% were having only
one previous preterm birth while 16% were having
more than one previous preterm birth. Study done by
showed the 149/463 (32.18%) patients with more than
one preterm birth in both groups of progesterone and
placebo15.
The preterm birth in, our study, before progester-
one were distributed in gestational weeks as, Birth in
37-35 weeks was 32 (60.37%), Birth in <35 and >32
weeks are as 16 (30.19%) and Birth in <32 weeks were
5 (9.43%). The data from US showed that 75% of all
preterm babies are from 34-37 weeks of gestation , our
study result somewhat agree with that16. In the latest
preterm birth before progesterone therapy the mean
gestational at preterm birth was 31.22±4.31 weeks in
our study, study regarding this is very scanty, however
in America out of 11.6% preterm delivery rate, 1.93%
were less than 32 weeks of gestation17.
The preterm birth was reduced to 32 (60.37%)
in our study, this reduction was greater in patients with
preterm delivery in gestation age of 35-37 weeks. This
result was similar to the study done by in which the pro-
Number Percentage
37 69.81%
16 30.19%
32 60.37%
16 30.19%
9.43%
Mean SD
29.04 7.82
31.22 4.31
35.43 3.41
335
 Table 3 comparing the preterm characteristics in Previous Preterm and pregnancy treated with progesterone
In the last preterm
birth
Term Delivery 0 (0%)
Preterm Birth Birth in <37 and ≥35 32
weeks
Birth in 34-32 weeks 16
Birth in <32 weeks 5 4
Total 53
Gestational age 31.22±4.31
gesterone does decreased the preterm birth especially
in week 34-37 weeks18.
Limitation of this study include the non-random-
ization of the patients, patient may use other remedy
for preterm birth or this may be the natural process in
women with one previous preterm baby may deliver a
second baby at term naturally. Also the there was no
direct supervision on the patient to confirmed the daily
uses of progesterone
So further studies with full randomization and
also avoiding the above mention things to avoid bias
is recommended.
CONCLUSION
The preterm birth has been decreased with the
vaginal usage of progesterone. This decrease was most
obvious in patients who’s previous preterm was in 35-37
weeks.
REFERENCES
1. Organization WH. Recommended definitions, termi-
nology and format for statistical tables related to the
perinatal period and use of a new certificate for cause
of perinatal deaths. Modifications recommended by
FIGO as amended October 14, 1976. 1977.
2. Villar J, Abalos E, Carroli G, Giordano D, Wojdyla D,
Piaggio G, et al. Heterogeneity of perinatal outcomes
in the preterm delivery syndrome. Obstet Gynecol.
2004;104(1):78-87.
3. Steer P. The epidemiology of preterm labour. BJOG.
2005;112:1-3.
4. Wen SW, Smith G, Yang Q, Walker M, editors. Epi-
demiology of preterm birth and neonatal outcome.
Seminars in Fetal and Neonatal Medicine; 2004:
Elsevier.
5. Kuehn BM. Groups take aim at US preterm birth rate.
JAMA. 2006;296(24):2907-8.
6. Langhoff-Roos J, Kesmodel U, Jacobsson B, Ras-
mussen S, Vogel I. Spontaneous preterm delivery
in primiparous women at low risk in Denmark: pop-
ulation based study. BMJ. 2006;332(7547):937-9.
7. Tracy S, Tracy M, Dean J, Laws P, Sullivan E. Spon-
taneous preterm birth of liveborn infants in women
336
With progesterone P value
therapy
21 (39.62%) <0.001
18 <0.001
10
32
35.43±3.41 <0.001
at low risk in Australia over 10 years: a popula-
tion-based study. BJOG. 2007;114(6):731-5.
8. Shaikh K, Premji SS, Rose MS, Kazi A, Khowaja S,
Tough S. The association between parity, infant gen-
der, higher level of paternal education and preterm
birth in Pakistan: a cohort study. BMC Pregnancy
Childbirth. 2011;11(1):88.
9. Chan K, Ohlsson A, Synnes A, Lee DS, Chien L-Y,
Lee SK, et al. Survival, morbidity, and resource use
of infants of 25 weeks’ gestational age or less. Am
J Obstet Gynecol. 2001;185(1):220-6.
10. Low WGOTV, Infant B. European Community
collaborative study of outcome of pregnancy be-
tween 22 and 28 weeks’ gestation: Working Group
on the Very Low Birthweight Infant. The Lancet.
1990;336(8718):782-4.
11. Kramer MS, Demissie K, Yang H, Platt RW, Sauvé
R, Liston R, et al. The contribution of mild and
moderate preterm birth to infant mortality. JAMA.
2000;284(7):843-9.
12. Morrison JC. Preterm birth: a puzzle worth solving.
Obstet Gynecol. 1990;76(1 Suppl):5S-12S.
13. da Fonseca EB, Bittar RE, Carvalho MH, Zugaib
M. Prophylactic administration of progesterone
by vaginal suppository to reduce the incidence of
spontaneous preterm birth in women at increased
risk: a randomized placebo-controlled double-blind
study. Am J Obstet Gynecol. 2003;188(2):419-24.
14. Norwitz ER, Caughey AB. Progesterone supplemen-
tation and the prevention of preterm birth. Rev Obstet
Gynecol. 2011;4(2):60-72.
15. Meis PJ, Klebanoff M, Thom E, Dombrowski MP,
Sibai B, Moawad AH, et al. Prevention of recurrent
preterm delivery by 17 alpha-hydroxyprogesterone
caproate. N Engl J Med. 2003;348(24):2379-85.
16. Bastek JA, Adamczak JE, Hoffman S, Elovitz MA, Sri-
nivas SK. Trends in prematurity: what do changes at
an urban institution suggest about the public health
impact of 17-alpha hydroxyprogesterone caproate?
Maternal and child health journal. 2012;16(3):564-8.
17. MacDorman MF, Minino AM, Strobino DM, Guyer B.
Annual summary of vital statistics—2001. Pediatrics.
2002;110(6):1037-52.
18. Dodd JM, Crowther CA. The role of progesterone in
prevention of preterm birth. International journal of
women’s health. 2010;1:73-84.
KJMS May - August, 2020, Vol. 13, No.2
 FREQUENCIES OF DIFFERENT RISK FACTORS FOR
HEMORRHAGIC STROKE
Himayatullah, Raza Ullah, Sami ul Huq, Shahida Naz, Rab Nawaz

ABSTRACT
Background: Stroke is sudden onset of characteristic neurologic deficit pathologically due to infarcts (thrombotic or
embolic) and hemorrhages into brain1. 8-18% of strokes are hemorrhagic in nature but having high mortality and mor-
bidity2. This study was designed to know the common factors responsible for hemorrhagic stroke in our population.
Methods: This was a cross sectional study done at Department of Medicine, Khyber Teaching Hospital Peshawar
after approval from hospital ethical committee for a duration of 06 months. All patients of age more than 13 years with
hemorrhagic stroke were included in the study and were subjected to detailed history regarding the risk factors and
the confounders. Patients on anticoagulants, thrombolysis for any reason, or having traumatic brain hemorrhage were
excluded from the study. Total of 139 patients using WHO calculator were included with margin of error of 5% and
confidence interval of 95%.
Results: Among 139 patients studied, 79 were male and 60 were female. Among these, 25 patients were between
13-40 years, 69 patients between 41-60 years, and 45 patients between 61-70 years of age. Among these 139 patients
hypertension was found in 103 patients, diabetics in 40, smoking in 25, alcohol use in 4, previous history of transient
ischemic attack or stroke in 5, bleeding disorder in 3, while no identifiable risk factor in 4 patients.
Conclusion: Hemorrhagic stroke is a serious health problem with a very high mortality. Treating the responsible factors
vigorously and compliance to medications especially that of hypertension and diabetes mellitus and smoking cessation
can prevent hemorrhagic stroke significantly.
Key Words: Hemorrhage, stroke, hypertension, diabetes.

INTRODUCTION studies in adults with stroke) than in rural areas3. In Pa-

Hemorrhagic stroke or intracerebral bleed implies
to bleed into the brain parenchyma. It is much less
common than ischemic stroke which is a stroke due
to thromboembolism of CNS. According to worldwide
data only 8-18% of strokes are hemorrhagic including
some of which are due to subarachnoid hemorrhage2.
Though less in frequency, hemorrhagic stroke has much
higher mortality rate compared to ischemic one. One
of the review from a stroke center showed that out of
total 757 stroke patients 309 were having hemorrhagic
strokes which is 40.8%.  This means that hemorrhagic
stroke might be having greater frequency but due to
issues with the free availability of CT scan might have
overlooked these cases.
In urban areas of Asia hemorrhagic stroke is
two to three times more prevalent (up to 35% in some
1?????
.........................................................................................
Address for correspondence:
Dr. Raza Ullah
??????
Cell No. 03339298991
Email: dr.raza127@gmail.com
kistan, the frequency of hemorrhagic stroke in all stroke
patients range from 20% to 44% in different studies5.
Studies done in different hospitals of Pakistan showed
the frequency of hemorrhagic stroke to be 22-31% of
total stroke patients5 and this is rather higher in young
stroke patients (i.e. 32-43%)6.
Commonly recognized risk factors for hemor-
rhagic stroke are; Hypertension (up to 60% of cases),
Smoking (21%), Alcohol abuse (16%), Diabetes (22%),
Bleeding disorders, Previous history of stroke or TIA
(10%). There is slight difference between frequencies
of these risk factors among different parts of the world,
hypertension, smoking, and diabetes related hemor-
rhages are slightly higher in developing countries i.e.,
69%, up to 66% and 29.5% respectively, while alcohol
related hemorrhagic stroke has an edge in the devel-
oped countries.
This study will aid to our knowledge regarding
local burden of risk factors for hemorrhagic stroke as
there is significant difference in these frequencies while
comparing data from worldwide with Pakistan. The data
on this issue is very insufficient in Pakistan while its
impact on health is quite huge ranging from physical
to mental to economical disturbances.
MATERIALS AND METHODS
This cross-sectional study was conducted at

KJMS May - August, 2020, Vol. 13, No.2 337

Department of Medicine, Khyber Teaching Hospital
Peshawar after approval from hospital ethical committee
for a duration of 06 months. Sampling was done through
non probability consecutive sampling from 139 patients
using WHO calculator with margin of error of 5% and
confidence interval of 95%. All patients of age more than
13 years with hemorrhagic stroke were included in the
study and were subjected to detailed history regarding
the risk factors and the confounders. Patients on an-
ticoagulants, thrombolysed for any reason or having
traumatic brain hemorrhage were excluded from the
study. The diagnosis of hemorrhagic stroke was made
by doing computed tomography of the brain (CT Brain)
and clinical features. All the above information including
name, age, gender and address were recorded on the
study Performa. Strict exclusion criteria were followed
to control the confounders and bias in the study results.
DATA collected was entered to SPSS 16. Mean ± SD
was calculated for continuous variable like age, duration
and categorical variable like gender and risk factors
were expressed as frequencies and percentages. Sub
factor analysis was done according to the different
etiologies identified during the research. Risk factors
were stratified among age and gender to see the effect
modification. Results were presented as tables and
graphs.
RESULTS
Among 139 patients studied, 79 were male and
60 were female(table=1). These 139 patients were
divided into 3 age groups. 25 patients were between
13-40 years, 69 patients between 41-60 years, and 45
patients between 61-70 years of age(table=2).
Among these 139 patients hypertension was
found in 103 patients, diabetes in 40, smoking in 25,
alcohol use in 4, previous history of transient ischemic
attack or stroke in 5, bleeding disorder in 3, while no
identifiable risk factor in 4 patients. Highest number of
patients fell in combined risk factor of hypertension-di-
abetes followed by hypertension-smoking.
The gender distribution among different respon-
sible factors and age distribution are shown in (table
3) and (table 4) respectively.
DISCUSSION
In our study we studied different responsible
factors for hemorrhagic stroke. A study done by Brott
and colleagues showed that relative risk of hemorrhagic
stroke is twice compared to ischemic stroke is patients
with hypertension in African-Americans compared to
that in Caucasians and found to be 3.9. American blacks

Table 1: Gender Distribution Of Hemorrhagic Stroke Patients (n = 139)

Gender Number Percentage

Male 79 57%
Female 60 43%
Total 139 100%

Table 2: Age Distribution Of Hemorrhagic Stroke Patients (n = 139)

Age(years) Number Percentage

13 - 40 25 17.99%
41 - 60 69 49.64%
61 - 70 45 32.37%

Table 3: Gender Distribution of Different Responsible Factors For Hemorrhagic Stroke (n = 139)

Responsi- Male Female Total

ble Factor No; %age among %age among No; %age %age among No; %age
factors patients among fac- patients among
tors patients
62 60.19% 44.60% 41 39.81% 29.50% 103 74.10%
17 42.50% 12.23% 23 57.50% 16.55% 40 28.77%
22 88% 15.82% 3 12% 2.16% 25 17.98%
4 100% 2.87% 0 0% 0% 4 2.87%
3 60% 2.16% 2 40% 1.44% 5 3.60%
1 33.33% 0.72% 2 66.66% 1.44% 3 2.16%
3 75% 2.16% 1 25% 0.72% 4 2.87%

338 KJMS May - August, 2020, Vol. 13, No.2

 Table 4: Age/Gender Distribution Of Hemorrhagic Stroke Patients (n = 139)
Age Male
(years) No %age among %age in total No
age group patients
13 – 40 21 84% 15.11% 4 16%
41 – 60 40 57.97% 28.77% 29
61 – 70 18 36.73% 12.95% 27
TOTAL 79 56.83% 60
are at higher risk of subarachnoid hemorrhagic (RR
1.59), and intracerebral hemorrhage (RR 1.66) com-
pared to Caucasians. The frequency of hemorrhagic
stroke among stroke patients in Asia is 15 to 35% in
the urban adult populations; In rural areas it is two to
three times lower3. In Asian countries where industry
is evolving rapidly like china and India, prevalence
of stroke and its mortality is on the rise mostly due to
uncontrolled responsible factors like hypertension,
diabetes, dyslipidemia and smoking.
In Pakistan, the prevalence of hemorrhagic stroke
in all stroke patients range from 20% to 44% in different
studies4, 5, 6 . A cross sectional study was done in 2007
in Shaheena Jamil Hospital Abbotabad in order to know
the frequency of stroke in hypertensive patient. It was
found that out of 200 patients 13% has suffered from
stroke, out of which 4% was having hemorrhagic stroke6.
Vohra et al stated in their study that 34% of patients
with hemorrhagic stroke were below 50 years of age6.
A study published in lancet showed that hemorrhagic
stroke is much more common in stroke patients in
South East Asia and western Pacific region (30%) as
compared to that in Europe and North America (15%)7.
Commonly recognized risk factors for hemorrhagic
stroke are; Hypertension (up to 60% of cases), Smoking
(21%), Alcohol abuse (16%), Diabetes (22%), Bleeding
disorders, Previous history of stroke or TIA (10%).
In our study percentage of hypertensive patients
in hemorrhagic stroke patient was 74.1% (103 patients)
which is a bit higher than the international frequency
(60%). The main reason might be unawareness about
the complications of raised BP and non-compliance to
medications in socially, mentally and economically poor
region like Khyber Pakhtunkhwa.
The frequency of diabetes mellitus, the second
commonest responsible factor for hemorrhagic stroke
in our study was 28.78% (40 patients) which is also a bit
higher than international frequency (22%). The reason
might be the non-compliance with the medications, poor
dietary habits (since majority of our food is carbohydrate
rich), poor literacy rate, unavailability of medicines and
energy crisis that render insulin to be ineffective due to
storage in inappropriate temperature.
In our study the percentage of alcohol abuse
KJMS May - August, 2020, Vol. 13, No.2
Female Total
%age %age in total No %age in to-
among age patients tal patients
group
2.88% 25 17.99%
42.03% 20.86% 69 49.64%
60% 19.42% 45 32.37%
43.17% 139 100%
was 2.88% (4 patients) which is significantly lower than
the international data (16%). The reason might be the
religious restrictions and social values.
CONCLUSION
Hemorrhagic stroke is a serious health problem
with a very high mortality. Hypertension is the com-
monest responsible factor for hemorrhagic stroke
and should be properly managed and controlled to
prevent stroke since despite of intense research there
is no effective treatment of hemorrhagic stroke and the
only way to control is to prevent it by controlling the
responsible factors. Treating the responsible factors
vigorously and compliance to medications especially
that of hypertension and diabetes mellitus and smoking
cessation can prevent hemorrhagic stroke significantly.
REFERRENCES
1. Michael J. Aminoff, Vanja C. Douglas. Central Ner-
vous system disorders: current medical diagnosis
and treatment 2018; 1921-4.
2. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ,
Berry JD, Borden WB, et al. Heart disease and
stroke statistics--2012 update: a report from the
American Heart Association. Circulation. Jan 3
2012;125(1):e2-e220.
3. Jaya F, Win MN, Abdullah MR. Stroke patterns in
Northeast Malaysia: a hospital-based prospective
study. Neuroepidemiology 2002;21:28-35
4. Ahmad K, Jafary F, Jehan I, Hatcher J, Khan AQ,
Chaturvedi N, et al. Prevalence and predictors of
smoking in Pakistan: results of the National Health
Survey of Pakistan. Eur J CardiovascPrevRehabil.
2005;12:203-08.
5. Syed NA, Khealani BA, Ali S, Hasan A, Akhtar N,
Brohi H et al. Ischemic stroke subtypes in Pakistan:
the Aga Khan University Stroke Data Bank. J Pak
Med Assoc. 2003; 53: 584-88.
6. Vohra EA, Ahmed WU, Ali M. Aetiology and prog-
nostic factors of patients admitted for stroke. J Pak
Med Assoc. 2000; 50: 234-36.
7. Eastern Stroke and Coronary heart Disease Col-
laborative Group. Blood pressure,cholesterol, and
stroke in eastern Asia. Lancet 352, 1801-1807. 1998.
339
COMPARISON OF ANTIPYRETIC EFFICACY OF INTRAVENOUS
(IV) ACETAMINOPHEN VERSUS ORAL (PO) ACETAMINOPHEN
IN THE MANAGEMENT OF FEVER IN CHILDREN
Khalil Ahmad, Ansar Hussain, Habib ur Rahman, Khalid Khan, Irfan Khan, Hamayun Anwar

ABSTRACT
Background: Among all antipyretic agents or drugs the safest drug is acetaminophen. It has analgesic effect and widely
used among friable children.The acetaminophen was approved to use in short term management of fever and acute
pain. The primary objective of the study was to compare the antipyretic efficacy of IV acetaminophen against the oral
acetaminophen drug in the fever management among children.
Methods: An observational prospective cohort study was conducted on110 childrenwith high fever.All the children were
selected randomly. The cohort was followed up for a period of one-year starting from March 2017.
Results: A total of 110 children participate in this study. The baseline characteristics were almost similar in both the
groups. The mean age of the children for both of the groups was 5.9+3.1 years whereas the average weight for all the
children were 21.4+5.8. The weighted sum of temperature difference (WSTD) was observed at 180 minutes in group
II. This difference was statistically significant with a p value or 0.005. We also observed a rapid drop of temperature at
first 2 hours in group II where the remedy was IV acetaminophen.
Conclusion: Ivacetaminophen is safe and effective in fever reduction among children. Its administration is very useful
where the children refuse to take oral administration and the conditions where rapid reduction of temperature is required.
Keywords: Benign illness,antipyretic agent, food and drug administration (FDA),intravenous (IV)acetaminophen.

INTRODUCTION most 80 countries, the acetaminophen was approved to

In clinical medicine, fever is the commonest symp-
toms for all ages of patients.The fever may be defined
as a temperature above 98.90 F in morning or 99.90 F
in evening. [1-2]This can be occurred due to various
reasons that involved with various elements including
benign illness. The use of antipyretic agent as treatment
may not only lessen the fever but it will also improves
other related symptoms of fever like headache and
nausea etc. [2-4] Many extensive studies published in
literature that compares the efficacy of many antipyretic
agents including, ibuprofen, peracetamol etc.Among
these antipyretic agents or drugs the safest drug is
acetaminophen. It has analgesic effect and widely used
among friable children. In 1951 for the first time the oral
administration of acetaminophen was approved by food
and drug administration (FDA) in United States (US).
Though this drug was marketed in 1953 for the first time,
whereas in 2001 the first intravenous (IV) administration
of acetaminophen was approved in Europe. Among al-
1?????
.........................................................................................
Address for correspondence:
????
??????
Cell No. ???
Email: ?????
use in short term management of fever and acute pain.
[5-6] The most studied acetaminophen model endotoxin
induced febrile among intensive care (IC) patients. [7-9]
The primary objective of the study was to compare the
antipyretic efficacy of IV acetaminophen against the oral
acetaminophen drug in the fever management among
children.
MATERIAL AND METHODS
We had optedan observational prospectivecohort
design for the present study. A total 110childrenwith
high fever (Above 103o F)visiting the out patient depart-
ment (OPD) of the hospital wereregister.All the children
were selected randomly. The cohort was followed up
for a period of one-year starting from March 2017. The
exclusion criteria include all the childrenwith known
hypersensitivity to acetaminophen or other NSAIDs,
reduced liver function, active hepatic disease (HD),
the children with evidence of clinically significant liver
and renal disease were excluded from the study where
as all the children with high fever were included in this
study. All the children were divided into two groups
with respect to the treatment.The group I, containing
the children provided with Oral Acetaminophen and the
Group II with IV Acetaminophen as treatment. All the
demographic information along with diagnostic read-
ings and results were taken and recorded. The arterial
pressure was also measured through oscillometric
technique. Other diagnostic values were assessed,by
performing the standard operating procedure (SOPs).

340 KJMS May - August, 2020, Vol. 13, No.2

To assess the primary efficacy of outcomes as a result of
drug administration was monitored carefully. The child
parent or attendant signed an Informed consent form to
participate in this study; also the ethical approval was
taken from the hospital ethical committee.
Statistical analysis
All the information collected or noted from patients
were than enteredelectronically to MS EXCELL sheets
and stored in computer for further processes. Latterly
this data was prepared for SPSS and analyzed by using
its version 20. Descriptive statistics were applied by
calculating mean and standard deviation for women
characteristics and outcomes. Frequency distribution
and percentages were performed for all qualitative vari-
ables. All the P values less than 0.05 was considered
statistically significant in all inferential statistics.
RESULTS
A total of 110children participate in this study.
The group I contained 55 children and group II was
having the same number of children as of group I. The
group I children were given Oral Acetaminophen and
the children in Group II was given the IV Acetaminophen
as treatment. The baseline characteristics were almost
similar in both the groups. The mean age of the children
for both of the groups was 5.9+3.1 years whereas the
average weight for all the children were 21.4+5.8. Both
the groups were assessed for adverse outcome as a
result of their respective drug and dosage. More on the
details were given in table 1.
We have observed that the IV acetaminophen
rapidly reduce the fever as compared to oral acetamin-
ophen. The weighted sum of temperature difference
(WSTD) was observed at 180 minutes in group II. This
difference was statistically significant with a p value or
0.005. There were no significant difference in WSTD
was observed in both of the groups children at 4 hour
of treatment administration. We also observed a rapid
drop of temperature at first 2 hours in group II where
the remedy was IV acetaminophen. More on the fever
reduction with time and treatment is given in figure 1.
DISCUSSION
This study was planned to compare the antipyretic
efficacy of IV acetaminophen against the oral acetamin-
ophen drug in the fever management among children.
We have observed in our study, a rapid reduction in
temperature was seen with IV acetaminophen drug in
short time i.e. first two hours. It is well said in literature
that the fever is a physiological mechanism rather than
illness with beneficial effects against infection. It has not
been observed in any of the study that the temperature
itself causes any long-term neurological complications
in individuals. Usually most of the pediatricians initiate
an antipyretic remedy when the temperature increases
1010 F to improve the child comfort. [10] There are limit-
KJMS May - August, 2020, Vol. 13, No.2
Table 1: Detailed summary of the adverse effects or
outcomes
Adverse Group I n Group II n P Value
Outcome (%) (%)
Constipa- 0(0%) 2(3.6%) 0.004
tion
Rash or 0(0%) 2(3.6%) 0.007
Itching
Addition- 3(5.5%) 1(1.8%) 0.34
al dose
required
Dry mouth 0(0%) 2(3.6%) 0.004
* In Horizontal axis, each time point with a difference
of 30 minutes starting from 0 min
Figure 1: A detailed view of average temperature
reduction with time after dose in both groups
ed clinical evidences available that address the extents
of improved discomfort by antipyretics in fever or illness.
It has also been observed the daily routine activities has
been slowed down along with the discomfort in sleep,
behavior and the oral activity of the febrile child. [11]
Acetaminophen is an analgesic and antipyretic agent,
which is also synthetic. A safe risk against benefit ratio
is well established by the efficacy profile of acetamino-
phen. [12] In literature it is not known to be associated
with harmful drug-to-drug interactions. [13] We have
revealed in our study that the IV Acetaminophen in-
volved in reducing the temperature and discomfort in
children faster than the oral acetaminophen. We have
observed a significant difference of WSTD at 180 min-
utes by in-group II where the treatment remedy was IV
Acetaminophen. There was no difference observed after
4 hours of administration for both the groups along their
respective remedy. We have observed in our findings the
overall average temperature was less in group II. The
IV Acetaminophen provides faster reduction in overall
child temperature in first two hours of its administration.
This might be because of the pharmacokinetic superi-
ority of an intravenous administration. Conversely at 6
hour administration both the groups shows the same
reduction in temperature that shows the efficacy of IV
acetaminophen with faster relief than the oral adminis-
tration. Also the IV administration was advantageous in
children than the oral administration due to the pediatric
341
practical issues like refusing to take medicine etc. Even
the oral administration may also be used through rectal
route yielding erratic and slow absorption. [14-15] The
factors behind this may also be erratic placement of the
suppository, absorption variability with different suppos-
itories preparations and rectal pH at its administration.
The absorption usually tends to be highly gradual and
variable among children. [16-18] For an antipyretic
effect of acetaminophen, the usual active site is central
nervous system (CNS), therefore the cerebrospinal fluid
(CSF) concentration may be more pertinent in compar-
isons to plasma levels. We reported in our study, the
curves time to temperature reduction in both groups
with almost similar trends except for the time lag to
achieve CSF penetration. [19] In many other studies,
it was published that the IV route possesses the better
mean CSF concentration than the oral administration
of acetaminophen. [20] The IV administration, due to
its faster antipyretic activity or effect that lead to faster
fever corrections and corrections related symptoms.
These symptoms may include, nausea and vomiting.
CONCLUSIONS
We may conclude from our study that IV ac-
etaminophen is safe and effective in fever reduction
among children. Its administration is very useful where
the children refuse to take oral administration and the
conditions where rapid reduction of temperature is
required.
REFERENCES
1. Charles A, Dinarello PR. Fever and hyperthermia. In:
Longo DL, Fauci A, Kasper D, Hauser S, Jameson J,
Loscalzo J, editors. Harrison’s principles of internal
medicine. 18th ed. New York: McGraw-Hill; 2012.
p. 143-7. 
 AnesthAnalg. 2000;90:431–6.
2. Oborilová A, Mayer J, Pospísil Z, Korístek Z. Symp-
tomatic intra- venous antipyretic therapy: efficacy
of metamizol, diclofenac, and propacetamol. J Pain
Symptom Manag. 2002;24:608–15. 
 J Anaesth. 1995;42:982–6.
3. Kramer MS, Naimark LE, Roberts-Brauer R, McDou-
gall A, Leduc DG. Risks and benefits of paracetamol
antipyresis in young chil- dren with fever of pre-
sumed viral origin. Lancet. 1991;337:591–4. 
 ommendations. Anesthesiology. 1997;87: 244–52.
4. Thomas S, Vijaykumar C, Naik R, Antonisamy B.
Comparative effectiveness of tepid sponging and
antipyretic drug versus only antipyretic drug in the
management of fever among children: a randomized
controlled trial. Indian Pediatr. 2009;46:133–6. 
 Pediatrics. 2007;119:766–71.
5. Duggan ST, Scott LJ. Intravenous paracetamol (ac-
etaminophen). Drugs. 2009;69:101–13.
6. Prescott LF. Paracetamol: past, present, and future.
Am J Ther. 2000;7:143–7.
7. Peacock WF, Breitmeyer JB, Pan C, Smith WB, Royal
MA. A randomized study of the efficacy and safety of
intravenous acet- aminophen compared to oral ac-
342
etaminophen for the treatment of fever. AcadEmerg
Med. 2011;18:360–6.
8. Kett DH, Bretmeyer JB, Ang R, Royal MA. A random-
ized study of the efficacy and safety of intravenous
acetaminophen vs intrave- nous placebo for the
treatment of fever. ClinPharmacolTher. 2011;90:32–9.
9. Mullins ME, Empey M, Jaramillo D. A prospective
randomized study to evaluate the antipyretic effect
of the combination of acet- aminophen and ibupro-
fen in neurological ICU patients. Neurocrit Care.
2011;15:375–8.
10. May A, Bauchner H. Fever phobia: the pediatrician’s
contribution. Pediatrics. 1992;90:851–4.
11. Mistry RD, Stevens MW, Gorelick MH. Short term
outcomes of pediatric emergency department febrile
illnesses. PediatrEmerg Care. 2007;23:617–23.
12. Duggan ST, Scott LJ. Intravenous paracetamol (ac-
etaminophen). Drugs. 2009;69:101–13.
13. Pernerstorfer T, Schmid R, Bieglmayer C, Eichler
HG, Kapiotis S, Jilma B. Acetaminophen has greater
antipyretic efficacy than aspi- rin in endotoxemia: a
randomized, double blind placebo controlled trial.
ClinPharmacolTher. 1999;66:51–7.
14. Coulthard KP, Nielson HW, Schroder M, et al. Relative
bioavail- ability and plasma paracetamol profiles of
Panadol suppositories in children. J Paediatr Child
Health. 1998;34:425-31.
15. Gaudreault P, Guay J, Nicol O, Dupuis C. Pharma-
cokinetics and clinical efficacy of intrarectal solution
of acetaminophen. Can J Anaesth. 1998;35:149–52.
16. Beck DH, Schenk MR, Hagemann K, Doepfmer UR,
Kox WJ. The pharmacokinetics and analgesic effi-
cacy of larger dose rectal acet- aminophen (40 mg/
kg) in adults: a double-blinded, randomized study.
17. Montgomery CJ, McCormack JP, Reichert CC,
Marsland CP. Plasma concentrations after high-dose
(45 mg.Kg-1) rectal acet- aminophen in children. Can
18. Birmingham PK, Tobin MJ, Henthorn TK, et al.
Twenty-four- hour pharmacokinetics of rectal acet-
aminophen in children: an old drug with new rec-
19. Kumpulainen E, Kokki H, Halonen T, Heikkinen M,
Savolainen J, Laisalmi M. Paracetamol (acetamin-
ophen) penetrates readily into the cerebrospinal
fluid of children after intravenous administration.
20. Schutz RA, Fong L, Chang Y, Royal MA. Open label,
4-period, randomized crossover study to determine
the comparative pharma- cokinetics of oral and in-
travenous acetaminophen administration in healthy
male volunteers, poster presentation at the 32nd An-
nual Regional Anesthesia Meeting and Workshops
(American Society of Regional Anesthesia and Pain),
2007; April 19–22.
KJMS May - August, 2020, Vol. 13, No.2
 SULFASALAZINE INDUCED GRANULOMATOUS INTERSTITIAL
NEPHRITIS: AN UNUSUAL CASE OF CAUTION
Muhammad Hanif1, Abdul Wali Khan1, FNU Sunds2, Muhammad Ishaq3, Abat Khan3

ABSTRACT
Sulfasalazine is a non-biologic disease-modifying anti-rheumatic drug (DMARD) and anti-inflammatory agent that con-
tains 5-aminosalicylic acid (5-ASA) and sulfapyridine. It is used to treat bowel inflammation like crohn’s disease, and
chronic arthritis. Granulomatous interstitial nephritis (GIN) is a rare kind of acute kidney injury that mostly occurs with
antibiotics, non-steroidal anti-inflammatory drugs, infections, immune processes and foreign body reaction. Common
implicated antibiotics are ciprofloxacin, vancomycin, penicillin, cephalosporin and nitrofuruntoin. We are presenting a
49-year-old male who presented to emergency department with raised level of creatinine and was later diagnosed as
a case of granulomatous interstitial nephritis (GIN) secondary to sulfasalazine.
Key words: Sulfasalazine, granulomatous interstitial nephritis, 5-ASA, Sulfapyridine, Corticosteroids

INTRODUCTION A 49-year-old male with history of rheumatoid

Sulfasalazine is a non-biologic disease-modifying
anti-rheumatic drug (DMARD) and an anti-inflammatory
agent that contains 5-aminosalicylic acid (5-ASA) and
sulfapyridine and was originally proposed as a treat-
ment option for rheumatoid arthritis (RA) but later on it
has also been effectively used in inflammatory bowel
disease due to its anti-inflammatory properties. [1, 2]
Its efficacy in anti-inflammatory bowel disease (IBD)
depends on its effective release of 5-ASA from sulfas-
alazine in the distal gut where 5-ASA interacts with nu-
clear receptors [3] but its precise mechanism of action
in rheumatoid arthritis has not been fully elucidated
[4]. Sulfasalazine, unlike mesalazine is not commonly
associated with renal complications but still it has been
reported in granulomatous interstitial nephritis (GIN),
[5] acute interstitial nephritis (AIN) [1, 6] and nephrotic
syndrome [7]. In 20% of patients who present with id-
iopathic acute kidney injury, drug-induced AIN is one of
the most common underlying entity.[8] The presence of
granulomas with AIN is rare and mostly occur secondary
to antibiotics; cephalosporin, penicillin, vancomycin,
ciprofloxacin and nitrofuruntoin [9, 10]. Here, we are
presenting a case of granulomatous interstitial nephritis
(GIN) secondary to sulfasalazine in a patient who was
using this drug for rheumatoid arthritis for several years.
CASE REPORT
1Resident physician internal medicine, Hayatabad
Medical Complex, Peshawar, Pakistan.
2Khyber Medical College Peshawar, Pakistan
3Resident physician, Khyber teaching hospital, Pesha-
war, Pakistan
.........................................................................................
Address for correspondence:
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Cell No. ???
Email: ????
arthritis came to the emergency department with gen-
eralized body-aches, joints pain and subjective low
grade fever associated with chills and night sweats for
past 2 days. On examination he was afebrile, alert and
oriented. Baseline investigations were sent for analysis,
results of which were unremarkable except high levels of
creatinine (4.22mg/dl) and urea (47 mg/dL) with upper
normal level of potassium (5.1 mmol/L). Urinalysis re-
vealed bland urine with trace proteins and no red blood
cells, no cellular casts and no white blood cells. Urine
microscopy showed very few hyaline casts, granular
casts and few epithelial cells. Computed tomography
abdomen was done, the result of which was unremark-
able. He had no previous history of renal abnormalities.
He was advised to discontinue sulfasalazine which he
was taking for rheumatoid arthritis and follow up after
3 days. Repeat serum creatinine was found 5.23mg/dL
along with serum potassium level of 6mg/dL. He was
admitted for further evaluation and extensive work up
for anti-neutrophilic cytoplasmic antibodies (ANCA),
anti-glomerular basement membrane antibodies (an-
ti-GBM), cryoglobulins, hepatitis serology and com-
plements levels was done, the results of which were
unremarkable. He was planned for renal biopsy and it
showed discrete non-necrotizing granuloma along with
destruction of tubules with normal glomerular structure.
No definite involvement of vasculature was found on
renal biopsy (Figure 1a & 1b). Staining revealed no acid
fast bacilli and fungal organisms. He was discharged
with possible diagnosis of granulomatous tubulointer-
stitial nephritis secondary to sulfasalazine drug therapy
and was advised to follow up after a week. After a week
all his symptoms resolved except for a mild arthralgia
and his repeat serum creatinine was 2.2 mg/dL. He was
started on steroid for possible early recovery.
DISCUSSION
GIN is a rare and treatable histologically diag-
nosed disorder that mostly occurs due to infections,

KJMS May - August, 2020, Vol. 13, No.2 343


Figure 1a: Biopsy showing non-necrotizing granulo-
ma and tubulitis.
Figure 1b: Renal biopsy showing tubulitis.
medications, sarcoidosis and other rheumatological
diseases. [11]. Renal biopsy from human and exper-
imental animals have demonstrated that the release
of cytokine, chemokines, adhesion molecules and
growth factors from damaged tubular cells is the un-
derlying cause of AIN. This damage is cell mediated
in nature and has been attributed to activated type
1 helper T cells and delayed type 4 hypersensitivity
reactions as evident from numbers of lymphocytes
and macrophages seen under light microscopy [10].
GIN presentation can range from minimal proteinuria to
advanced acute renal failure and renal function mostly
improves on treating the underlying etiology and with
prednisolone [5]. Our case is typical but rare case of
sulfasalazine induced GIN, previously there have been
many cases of AIN and GIN reported with mesalazine
and antibiotics but to our knowledge this is the first case
of sulfasalazine induced GIN. We are reporting this case
to aware physician and healthcare workers of such rare
complication of sulfasalazine to make early diagnosis
and prevent further deterioration of kidney functions
as just withdrawal of the offending agent and possibly
a short course of corticosteroids is necessary to avoid
344
the overt renal failure.
CONCLUSION
Sulfasalazine induced GIN is a rare complication
of this drug. The physicians should be aware of such
rare complication, because early diagnosis and stop-
page of this drug can prevent the disaster outcome in
patients with GIN.
REFERENCES
1. Durando M, Tiu H, Kim JS. Sulfasalazine-Induced
Crystalluria Causing Severe Acute Kidney Injury. Am
J Kidney Dis. 2017;70(6):869-873. doi:10.1053/j.
ajkd.2017.05.013
2. Amos RS. The history of the use of sulphasalazine in
rheumatology. Br J Rheumatol. 1995;34 Suppl 2:2-6.
3. Desreumaux P, Ghosh S. Review article: mode of
action and delivery of 5-aminosalicylic acid - new
evidence. Aliment Pharmacol Ther. 2006;24 Suppl
1:2-9. doi:10.1111/j.1365-2036.2006.03069.x
4. Plosker GL, Croom KF. Sulfasalazine: a review
of its use in the management of rheumatoid ar-
thritis [published correction appears in Drugs.
2005;65(18):2591]. Drugs. 2005;65(13):1825-1849.
doi:10.2165/00003495-200565130-00008
5. Joss N, Morris S, Young B, Geddes C. Granuloma-
tous interstitial nephritis. Clin J Am Soc Nephrol.
2007;2(2):222-230. doi:10.2215/CJN.01790506
6. Augusto JF, Sayegh J, Simon A, et al. A case of sul-
phasalazine-induced DRESS syndrome with delayed
acute interstitial nephritis. Nephrol Dial Transplant.
2009;24(9):2940-2942. doi:10.1093/ndt/gfp277
7. Molnár T, Farkas K, Nagy F, Iványi B, Wittmann T.
Sulfasalazine-induced nephrotic syndrome in a
patient with ulcerative colitis.  Inflamm Bowel Dis.
2010;16(4):552-553. doi:10.1002/ibd.21049
8. Perazella MA, Markowitz GS. Drug-induced acute
interstitial nephritis. Nat Rev Nephrol. 2010;6(8):461-
470. doi:10.1038/nrneph.2010.71
9. Korzets Z, Elis A, Bernheim J, Bernheim J. Acute
granulomatous interstitial nephritis due to nitrofu-
rantoin. Nephrol Dial Transplant. 1994;9(6):713-715.
doi:10.1093/ndt/9.6.713
10. Rossert J. Drug-induced acute interstitial nephri-
tis. Kidney Int. 2001;60(2):804-817. doi:10.1046/
j.1523-1755.2001.060002804.x
11. Shah S, Carter-Monroe N, Atta MG. Granulomatous
interstitial nephritis. Clin Kidney J. 2015;8(5):516-
523. doi:10.1093/ckj/sfv053
KJMS May - August, 2020, Vol. 13, No.2
 INSTRUCTIONS FOR AUTHORS
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is the official journal of Khyber Girls Medical College
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 AUTHOR AGREEMENT
Journal_______________________________________________________________________________________________
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proper credit is given to the Khyber Journal of Medical Sciences. In case, the submitted article is not published; the
Editorial Board agrees to release its rights there in.
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A) None of the material in the manuscript has been published previously/currently under consideration for publication
elsewhere.
B) The article has not been accepted for publication elsewhere.
C) I have not signed any right or interest in the article to any third party.
D) I am able / willing to produce the data on which this article is based should the Editorial board of the journal of
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