Volume 4 Issue-1 Jan-Mar,15

Medical research must translate into improved treatments for patients with advancement in proteomics technology. This will allow us to measure thousands of molecules at a given point in time. These molecules in form of biomarkers give clues about underlying biological processes in health and disease as they are used to monitoring a disease or predict the outcome of a treatment The resulting insights will provide novel drug targets and protein-based markers contributing towards a futuristic basis for personalized medicine.

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Background:

Successful ICSI depends on ovarian response to stimulation and maturation of oocytes retrieved.

Objective:

To identify predictors of number of retrieved oocytes during intra cytoplasmic sperm injection(ICSI).

Methods:

A cross sectional study carried out at Islamabad Clinic Serving Infertile Couples @ Saudi Pak Tower from January 2011 till December 2012. Female subjects (n= 282) aged 20 -40 years had base line estimation of follicle stimulating hormone, estradiol, antral follicle count and ovarian volume on the second day of cycle. Down regulation of ovaries was followed by controlled ovarian stimulation for 12 ± 2days. On the day of ovulation induction by intramuscular injection of human chorionic gonadotropin, preovulatory follicle count (PFC) was measured by trans vaginal scan and serum estradiol, progesterone and interleukin I-β were estimated. Data was expressed as mean ± standard deviation and median with interquartile range. Correlation coefficient was measured to study degree of association of demographic and clinical factors with NRO. Univariate regression of NRO as dependent variable with predictors was confirmed by multivariate regression.

Results:

Retrieved oocytes had strongest correlation with PFC (r = 0.98). Multivariable analysis stipulated that in the presence of other variables PFC had similar strongest effect on oocytes. AFC showed significant but negative effect on NRO by multiple regressions. Progesterone, E2, IL-I β, FSH and injections used for stimulation had insignificant effect in the presence of other variables.

Conclusion:

PFC measured at the time of ovulation induction is strongest predictor of oocytes which are obtained during oocyte pick up procedure of ICSI.

Key Words:

Intracytoplasmic Sperm Injection, Pre-ovulatory Follicle Count, Ovarian Reserve, Antral Follicle Count, Controlled Ovarian Stimulation.

Background:

Craniopharyngiomas are benign slow growing tumours that are located within the sellar and para sellar region of the central nervous system. It is a rare but significant health problem in Pakistan. The point prevalence of this tumour is approximately 2/100,000.

Objective:

To determine the outcome of complete resection in patients with craniopharyngioma and to determine the relationship of different factors with outcome at 3 months of follow up.

Methods:

A case series study conducted in thirty five patients, who were diagnosed as cases of craniopharyngioma on the basis of history, clinical examination, CT and MRI appearances and histopathological examination. All patients underwent complete resection of craniopharyngioma. The study was conducted at the Department of Neurosurgery, Dow University of Health Sciences/ Civil Hospital, Karachi from 27thth December, 2006 and 27th December, 2007.

Results:

Good outcome was seen in thirty four (97%) patients, one (3%) had poor outcome in term of mortality. Age, Preoperative presence of neurological deficit, localization of the lesion and preoperative hydrocephalus just before placement of VP shunt and radical excision were the most important predictor of good outcome. The rest of factors studied such as Glassgow coma, duration of illness, and signs of meningeal irritation postoperative hydrocephalus had no effect on outcome.

Conclusion:

A complete excision of the tumour is recommended, if there is no hypothalamic invasion and in the presence of hypothalamic invasion, near total resection with post-operative radiotherapy. Endocrine disturbances need careful follow up and replacement.

Key Words:

Craniopharyngioma, Radiotherapy, Sellar And Para Sellar Region, Complete Resection, Outcome.

Background & Objective:

A unique study conducted in Karachi with actual facts and figures based on autopsy findings of killings in Police encounters during last three years, also highlighting the number of killings which occurred during last three years along with age group, parts of body involved in such deaths along with areas of Karachi, so as to give an overall picture of these encounters. More over the root causes of these encounters, along with recommendations to improve the prevailing law and order situation in Karachi enabling people to per sue their daily routine without any fear or threat to life and property.

Methods:

The study is an autopsy based descriptive cross-sectional study conducted at Mortuaries at Civil hospital, Jinnah Postgraduate Medical Center and Abbasi-Shaheed Hospital of Karachi. The duration of study is based on three years, from 1st Jan 2011 to October 31st 2014. Records were gathered from the office of the Police Surgeon, Karachi and each post mortem report was scrutinized by the authors who are senior Forensic Experts themselves. All cases of police encounters that were brought for autopsy were included in the study while any case which was not autopsied was excluded. Aside from this custodial deaths have been excluded in the study.

Results:

Total number of encounter deaths autopsied during the period of study are 260, with 135(51.92%) autopsied at JPMC, 95(36.54%) at Abbasi Shaheed Hospital and 30(11.54%) at Civil Hospital Mortuary. Identity of deceased was known in 108 cases (41.54%) and 152(58.46%) remained unidentified. Majority of cases were between 25-30 years (n=135, 51.92%), next in order of frequency were 31-35 years (n=46, 17.69%) and least in 36 and above years (n=37, 14.23%). On autopsy the pattern of frequency of body parts involved is ; bullet injuries in chest and abdomen in 110 cases (42.31%), only chest in 74 cases (28.46%), head in 17 cases (6.54%) and abdomen in 25 cases(9.62%).District wise Malir was venue of most of the encounter deaths 115(44.23%), followed by District South with 44 (16.92%) deaths, District East with 35(13.46). A comparison between 2013 and 2014, showed that the frequency of Police encounters has increased from 19.23% i.e. from 50 deaths in 2013 to 57.69% i.e.150 deaths in 2014, up to October 31st 2014.

Conclusion:

The word life has not been defined in the Constitution of Islamic Republic of Pakistan, but it does not mean nor can it be restricted only to vegetative or animal life or mere existence from conception to death. Life includes all such amenities and facilities which a person born in a free country is entitled to enjoy with dignity, legally and constitutionally. So it is the duty of the state to provide safety to public. Although it is a good attempt to clean the city from notorious elements in the city of Karachi, but the main thing is that law enforcing agencies carry it without political discrimination and in cases of police encounters the action should be justified to rule out extra judicial killings. Speedy trial of those apprehended in courts of law and protection to witnesses will be of great help.

Key Words:

Police, Encounters, Autopsy, Karachi.

Background:

Thyroid nodules comprise a diagnostic challenge mainly because of the need to exclude thyroid malignancy. Approximately, 4% is an estimated prevalence of thyroid nodule on palpation with 15% lifetime risk of developing a thyroid nodule.

Objective:

To provide importance of sonographic and doppler criteria for differentiation between benign and malignant solid thyroid nodules and their correlation with Fine-needle aspiration cytology (FNAC) or histopathology (HP).

Methods:

A prospective study of 103 patients (January 2012 to June 2013) selected from radiology department of Dr.Ziauddin Hospital Karachi who came for ultrasound (US) of thyroid with clinical diagnosis of thyroid nodule followed by FNAC. Presence of malignant features were taken as positive finding for malignancy. The results of US were compared with FNAC/HP and diagnostic accuracy was calculated.

Results:

Out of 103 cases, 80 were labeled as true positive because US and FNAC results were positive for malignancy while the 2 were false positive as US shows malignant features but FNAC results were negative. 8 patients were labeled as true negative because US and FNAC were negative for malignancy and 13 patients were false negative because US results were negative for malignancy but FNA results were positive. The overall sensitivity and specificity of US was 86.0% and 80.0% respectively. Similarly the positive predictive value (PPV) was 97.5%, negative predictive (NPV) was 38.0% and diagnostic accuracy was 85.43% when compared with FNAC/HP results.

Conclusion:

Although US is an important tool for prediction of thyroid nodule malignancy, it cannot substitute FNAC/HP for accurate detection for malignancy. However, it can reliably anticipate the suspicion lesions which need intervention on priority basis.

Key Words:

Fine-needle Aspiration Cytology, Nodule, Thyroid, Ultrasound.

A retrospective review of three patients with mycosis fungoides treated with total skin electron beam therapy , from the year 2007 to 2009 , at the Oncology department, Ziauddin University Hospital.

Key Words:

Mycosis Fungoides, Primary Cutaneous T-Cell Lymphoma, Total Skin Electron Beam Therapy.

Background:

A high prevalence rate of neonatal and adult tetanus in Pakistan reflects the failure of health care systems to provide adequate immunization. Health care workers (HCWs) of emergency departments (ED) are generally at the frontline to deal with patients of road traffic accidents, trauma and burns. However, it has been observed that these patients receive incomplete preventive measures to combat tetanus.

Objective:

To assess the knowledge of tetanus immunization among healthcare workers (HCW) of the emergency department (ED) at a tertiary care hospital.

Methods:

A cross sectional study was conducted on 104 HCWs of ED of Ziauddin University. A structured questionnaire was filled by HCWs during April and May 2014. Data were analyzed on SPSS 20.0. Categorical variables were presented as frequency and percentage, while continuous variables were presented as mean. P value of <0.05 was considered significant.

Results:

Total 104 HCWs from ED participated in the study. Only 11.8% (12) HCWs were aware of the correct dosing schedule in children under 12 years of age. 56.3% (58) and 68% (70) were aware of correct schedule in adult population and in pregnant females, respectively. Knowledge of tetanus immunization in different types of wounds according to previous immunization status of patients was also found inadequate.

Conclusion:

HCWs of ED have inadequate knowledge about tetanus prone injuries and its immunization, which needs to be addressed.

Key Words:

Tetanus, Immunization, Emergency Department, Healthcare Workers.

Background:

It is estimated that more than 6 million children die in the developing world at the hands of preventable conditions; primarily pneumonia and diarrhea. WHO in 1992 initiated the Integrated Management of Childhood Illness (IMCI) program as a strategy to provide an integrated approach for the management of major causes of childhood morbidity and mortality.

Objective:

To assess if IMNCI workshops that are held in hospitals that have post graduate training program in field of pediatrics are effective in enhancing knowledge; hence skills for improving health care delivery in limited resources.

Methods:

A KAP survey was conducted in 2013 among IMNCI trained doctors working in 5 tertiary care hospitals of Karachi. N=57 doctors were identified and administered a structured questionnaire based on recall questions and scenarios. Questionnaire was developed from a similar study conducted elsewhere. Data entry and analysis was done on SPSS version 20.

Results:

A total of n=57 doctors were included in the study, out of them resident medical officers (RMO) were n=10, postgraduate trainees (PG) n=38 and Medical Officers (MO) were n=9. Mean score of correct answers was 14 (3). No significant difference was observed when mean scores of PGs was compared with RMO and MO combined through application of Independent sample t test.

Conclusion:

The study revealed gaps in knowledge and practices of trained doctors regarding management according to IMNCI guidelines.

Key Words:

IMNCI, Vaccination, WHO, Training Programs.

Background:

Operative notes are an important element of documentation based quality management for clinical practice. Often narrated by surgeons, they are usually penned by hand and are crucial in case of medical and legal consequences.

Objective:

To assess the operative notes at a tertiary care hospital and compare them to the standards set by Royal College of Surgeons of England.

Methods:

An observational prospective study carried out in the department of general surgery over a time period of one month from June to July, 2014. Sixty operative notes including general surgery, urology, orthopedics and neurosurgery were included in this study and were assessed according to published guidelines of the Royal College of Surgeons of England.

Results:

A total of 60 operative notes were reviewed. All of them were handwritten, out of which 40 (66.7%) were written by the operating surgeon. None of the notes mentioned the time of the surgery and the type of surgery and had no diagrams to illustrate the operative findings. Almost all (96.7%) included the patients name and the procedure performed (95%) and only 66.7% mentioned the operative findings. Incomplete post-operative instructions were present in all the notes that were studied.

Conclusion:

Several areas were highlighted, that lacked essential information in the operative notes, including the time of the procedure, type of surgery, instructions for postoperative care, operative diagnosis, findings, and complications during the procedure indicating that the operative notes were incomplete and inadequate in many respects.

Key Words:

Operative Notes, Quality Management, Clinical Practice.

Obesity, attributable to the interaction of genetic makeup, lifestyle and environment Factors are a multifactorial disease. However, not all people with similar genetics or same environmental setup become obese. Currently, extensive research is being conducted regarding increases in the prevalence of obesity, apparent in many societies, studying their eating habits and physical activity. Although, people with obesity have the equal distribution of body fat, yet they do not suffer from the same medical ailments. The recent identification of obesity-risk FTO variants rs9939609 associated with body mass index (BMI) and risk of obesity in multiple populations has led to the major success in the field of obesity genetics, making FTO the first locus unequivocally associated with adiposity. The role of FTO gene as a risk factor of obesity has also been identified by the Genome wide association which is entirely a new approach. The function of FTO gene was unknown, but recent investigation showed that the FTO gene regulates ghrelin a key mediator of ingestive behavior, which might explain a predisposition to increased food intake leading to obesity. People with rs9939609 variant of the FTO gene are at increased risk of obesity they have higher circulating levels of the hunger hormone ghrelin, and feel hungry soon after eating a meal. This review focuses on the genetics of FTO gene and the association of each additionally minor allele of (FTO) rs9939609 single nucleotide polymorphism (SNPs) with the risk of obesity.

Autoimmune pancreatitis is a rare fibroinflamatory disorder of the pancreas with immunoglobulin G 4(IgG4) associated systemic disease which is steroid responsive. 1,2 It has a variable clinical presentation ranging from obstructive jaundice, abdominal pain, steatorrhea and diabetes mellitus. In general presentation of autoimmune pancreatitis as acute pancreatitis is considered to be uncommon. The article presents a case of a 30 years old female newly diagnosed as diabetes mellitus presented with obstructive jaundice with raised lipase and amylase treated as acute pancreatitis. Due to persistent elevation of amylase and lipase and deranged liver function test she was further evaluated her CT findings were typical of autoimmune pancreatitis with raised serum IgG4 levels diagnosed as autoimmune pancreatitis. She was treated with steroids and responded well and after few months presented with relapse.

Key Words:

Autoimmune Pancreatitis, Obstructive Jaundice, Immunoglobulin IgG4, Acute Pancreatitis.

Chronic myelogenous leukemia (CML) results from neoplastic transformation of a hematopoietic stem cell. It is cytogenetically characterized by the presence of Philadelphia chromosome which results from reciprocal translocation t(9;22) that juxtaposes the ABL gene on chromosome 9 with breakpoint cluster region (BCR) on chromosome 22 generating BCR-ABL oncogene. All BCR-ABL fusion proteins display activated tyrosine kinase activity. Their different types are associated with different clinical course and prognosis. We report a rare case of e1a3 BCR-ABL transcript. So far only 4 cases in patients with CML have been reported.

Key Words:

BCR-ABL, e1a3, CML.

Pfeiffer syndrome (PS) is a form of acrocephalosyndactyly, a group of rare genetic syndromes, and is characterized by variable degrees of bicoronal craniosynostosis, variable hand and foot malformations and various other associated manifestations. Type I Pfeiffer syndrome is compatible with life. It is characterized by normal intelligence and a classic phenotype of craniosynostosis, broad thumbs, and syndactyly. Types II and III are sporadic in occurrence, with more severe involvement of the central nervous system (CNS) than in type I. Type II is associated with the classic cloverleaf-shaped skull. Neurologic compromise is common in both types II and III.

Key Words:

Autoimmune Pfeiffer Syndrome (PS), Acrocephalosyndactyly, Craniosynostosis.

Introduction

With the passage of time the demands of health care delivery system are changing. The rate of scientific discovery and accumulation of knowledge is gathering speed. In order to prepare medical students as tomorrow’s leaders, an effort to improve the curriculum is unavoidable.