Journal of Islamabad Medical & Dental College

Voluntary Blood Donation and Social Media

admin jimdc — 2023-07-06

Genotyping of Platelet Alloantigens by DNA Sequencing in Pakistani Population

Inam Ullah — 2023-07-06

Introduction: Single-nucleotide polymorphism (SNP) in human platelet antigens (HPAs) glycoproteins leads to alloimmunizations and platelet disorders such as posttransfusion purpura, neonatal alloimmune thrombocytopenia, and refractoriness to platelet transfusion. To study the prevalence in a particular ethnic group, genomic DNA is used to genotype HPAs. Detection of these polymorphisms is imperative to identify the risk of alloimmunization and the provision of HPAs. Current study was planned to determine the frequency of HPAs in the Pakistani population of blood donors.

Methodology: Genomic DNA was extracted from blood samples of 300 randomly selected platelet donors from five major cities of Pakistan (Islamabad, Peshawar, Karachi, Quetta, and Mirpur). This study was approved by the ethical committee of Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan. Prior informed consent was taken from all the participants. Sequence-specific primers for platelets glycoprotein genes were designed using Primer 3 online software. The distinct targets were amplified through PCR. Amplified PCR products were eluted from the gel after electrophoresed, purified and sequenced. All the sequences and data obtained were analyzed through SPSS version 25.

Results: Genotyping of samples showed that among the subjected HPA systems, HPA-1, HPA-5, HPA-7w, HPA-19w, and HPA-21w systems were found to have both a and b alleles in the Pakistani population while only aa genotype was found in HPA-4, HPA-6w, HPA-8w, HPA-10w, HPA-11w, HPA-16w, and HPA-23w. The frequency of HPA-1a was 0.9333 and HPA-1b was 0.0666, HPA-5a was 0.8033 and HPA-5b was 0.1966, HPA-7wa was 0.98 and HPA-7wb was 0.02, HPA-19wa was 0.95 and HPA-19wb was 0.05 and HPA-21wa was 0.9866 and HPA-21wb was 0.0133. Among the analyzed HPAs, the mismatch probability was higher in HPA-5 while it was lower in HPA-21w.

Conclusion: HPA-4b, HPA-6b, HPA- 8b, HPA-10b, HPA-11b, HPA-16b and HPA-23b were absent. No homozygosity was found in the remaining genotyped HPAs. Our study suggests that it is necessary to establish HPA screening sites in blood banks to have HPA typed donor registry providing compatible therapeutic platelets to all unimmunized patients. Our data will be useful to understand and better treat the alloimmune-mediated platelet disorders.

Key words: Alloantigens, Genotyping, Sequencing, Platelets, Platelet alloantigens

The Stromal Expression of CD-10 in Breast Carcinoma and its Association with Estrogen, Progesterone receptors, Her2Neu and Tumor Grade

Nosheen Nabi — 2023-07-06

Introduction: In previous studies, role of stromal component in epithelial malignancies has been highlighted. CD10 is a member of metalloproteinase family that breaks down the protein components of extracellular matrix and epithelial tissue remodeling thus playing an important role in carcinogenesis and metastasis.

To evaluate CD 10 expression in breast carcinoma and assess its association with grade of the tumor, ER, PR and Her 2 Neu status.

Methodology: The study was carried in Federal Government Polyclinic Hospital (FGPH) and Pakistan Institute of Medical Sciences (PIMS), Islamabadԁ. Immunohistochemical panel of CD 10, ER, PR and Her 2 was applied to 171 cases of invasive breast carcinoma. The association of CD 10 anԁ ER/PR status was evaluated.

Results: Among 171 cases of breast carcinoma, 77.8% cases were CD-10 positive. A total of 65.5% of ER negative cases expressed strongly positive CD-10 in the stroma as compared to 37.2% of ER positive cases (P=0.001). In 64.4% of PR negative cases expressed strong positivity of CD-10 in the stroma compareԁ with 37.5% (42/112) PR positive cases (P=0.001). The association of CD-10 with HER-2-NEU was not significant (P=0.749). Association of high-grade tumor with CD 10 was not statistically significant (P=0.258).

Conclusion: It was observed that CD10 expression is associated with negative ER, PR status and with higher grades of the tumors, showing its prognostic significance.

Key Words: Breast cancer, CD 10, Estrogen receptors, HER2neu, Progesterone receptors

Peripheral Arteriovenous Malformations and their Response to Treatment Modalities: Experience at Tertiary Care Hospitals

Rashid Usman — 2023-07-06

Background: Arteriovenous malformations result in abnormal communication between veins and arteries. Treatment of AVMs can be surgical or non-surgical. This study aimed to assess the response of Peripheral Arteriovenous Malformations (AVMs) to various treatment modalities.

Methodology: This cross-sectional study was performed at Combined Military Hospital Lahore, Rawalpindi, and Midcity Hospital, Lahore Pakistan, from January 2016 to June 2020. Patients were divided into two groups based on gender. Their demographic data, clinical presentation, and treatments provided were assessed and comparison was done using Chi-Square Test.

Results: Of the 43 patients, 74.4% (n=32) were females with a male-to-female ratio of 1:3. Mean age was 27± 6 years (males) and 17± 4 years (females). Low-flow AVMs were more prevalent in females (81%, n=27). In males, 50% (n=5) AVMs were on the trunk whereas in females 93.9% (n=31) AVMs were on limbs. Doppler-guided foam sclerotherapy (DGFS) as the sole treatment was used in 95.3% (n=41) patients while 32.5% (n=14) patients underwent DGFS followed by surgical excision. In 4.6% (n=2) cases, angioembolization followed by surgical excision was done. One patient was treated with sirolimus. Recurrence was found in 20.9% (n=9) cases, of which 66.6% (n=6) had high-flow AVMs.

Conclusion: Male patients presented late and with mostly high-flow head and neck AVMs. Sclerotherapy alone or surgical excision with preoperative sclerotherapy or embolotherapy is an efficacious curative treatment for AVMs while sirolimus can be offered as a palliative option.

Key words: Arteriovenous Malformations, Enbucrilate, Sclerotherapy, Vascular Malformations

Challenge of Multidrug-resistant Strains of Enterobacteriaceae Isolated from Clinical Samples

Farhat Khurshid — 2023-07-06

Background: The rising level of antimicrobial resistance among bacterial pathogens is one of the most significant public health problems worldwide. Antibiotic resistance of clinically important bacteria, the types and levels of resistance and multidrug resistance (MDR) among pathogens is extremely important. With the rise of infections caused by ESBL-producing Enterobacteriaceae (ESBL-E) and with their co-resistance to many other antibiotic classes, carbapenems have been considered to be the last and life-saving agents against these life-threatening infections. The current study was carried out to determine the frequency, disease burden and therapeutic challenge of infections caused by multidrug resistant strains of Enterobacteriaceae with particular reference to Extended-Spectrum Beta-lactamase-producing Enterobacteriaceae (ESBL-E), Carbapenem-resistant Enterobacteriaceae (CRE) and the emerging infections caused by Extended-Spectrum Beta-lactamase-producing Carbapenem-resistant Enterobacteriaceae (ESBL-CRE)

Methodology: This cross-sectional study was carried out in the Microbiology Department of Islamabad Diagnostic Centre over a period of two years, from January 2018 to December 2020. Enterobacteriaceae isolated on culture from clinical samples were identified using appropriate characterization tests including the selective use of API 20E. Antimicrobial susceptibility testing (AST) and ESBL detection was performed on Vitek 2 compact system by Minimum Inhibitory Concentration (MIC) methodology. Isolates that were resistant to more than one carbapenem were identified as Carbapenem-Resistant Enterobacteriaceae ( CRE).

Results: Out of 7270 specimens that yielded the growth of Enterobacteriaceae, 2943 (40.5%) were ESBL positive (ESBL-E) and 487 (6.7%) were carbapenem resistant (CRE). Further analysis of CRE revealed 247/487 as non-ESBL-CRE and 240/487 as ESBL-producing CRE (ESBL-CRE). Maximum number of CRE isolates - both non-ESBL and ESBL CRE - were from urine specimens. Klebsiella species followed by Eschcerichia coli and Enterobacter were the dominant ESBL-CRE isolates. Admission to a health care facility was the major risk factor followed by advancing age.

Conclusion: Besides ESBL-E, Carbapenum-resistant Enterobacteriaceae (CRE), particularly those co-producing Extended-Spectrum Beta-lactamase (ESBL-CRE), (wherein resistance mechanisms to both carbapenems as well as to beta-lactam antibiotics are concomitantly expressed in the same organism), have emerged as the major pathogens of concern. The later appears to have introduced a new dimension in the resistance profile of infections caused by multidrug-resistant enterobacteriaceae.

Key words: Carbapenem Resistant Enterobacteriaceae, Extended-Spectrum Beta-Lactamase, ESBL-producing Carbapenem-resistant Enterobacteriaceae, Escherichia coli, Klebsiella, Multi-drug Resistant Enterobacteriaceae.

Pattern of Biopsy-Proven Renal Disease in Pakistan: A Single Center Experience

khawar sultan — 2023-07-06

Background: This study was conducted to determine pattern (spectrum) of renal diseases on basis of renal biopsy in a tertiary care hospital in Islamabad.

Methodology: This retrospective observational study was conducted at Nephrology department of Pakistan Institute of Medical Sciences Islamabad from February 2012 to April 2020. Results of all biopsies done during this period were analyzed to determine the prevalence of different renal diseases on basis of histopathology and immunofluorescence.

Results: There were 254 kidney biopsy samples studied during the course of study. Out of total 254 patients 133 (52.4%) were male and 121 (47.6%) were female. Mean age of participants was 34.47±7.67 years (Range:15-60 years). Primary glomerulonephritis and secondary glomerulonephritis was found in 169 (66.5%) and 48 (18.9%) respectively, while tubulo-interstitial disease was reported in 37 (14.6%) of the total biopsies. Among 169 biopsies that showed primary GN, IgA Nephropathy (IgAN) was the most common in 16% of the biopsies, followed by membranous GN in 15.4% while membranoproliferative GN (MPGN) was seen in 13.6%, and focal and segmental glomerulosclerosis (FSGS) was seen in 13% of primary GN. Among 48 biopsies with secondary GN, lupus nephritis (LN) was found to be most common in 83.3% followed by amyloidosis in 6.3%. Among 37 biopsies having tubulo-interstitial disease, acute tubular nephritis (ATN) and renal cortical necrosis was seen in 29.7% each followed by tubulo-interstitial nephritis in 18.9% and acute interstitial nephritis (AIN) was seen in 16.2%.

Conclusion: This study shows that primary GN is the most common finding on renal biopsy. Among them IgA Nephropathy is the commonest lesion followed by membranous nephropathy, MPGN and FSGS. Among secondary GN, Lupus Nephritis is the commonest lesion.

Key words: Glomerulonephritis, Renal Biopsy, Renal Disease, Renal histopathology

Comparison of Wound Infection after Reversal of Loop Ileostomy in Linear versus Purse-String Skin Closure of Stoma Site

Sohaib Haider — 2023-07-06

Introduction: Loop Ileostomy is a surgical procedure which is done to divert intestinal contents away from distal bowel to allow healing of the distal anastomosis and also for the relieve of obstruction in emergency situations. Reversal is done through local stoma site via linear closure technique as the standard procedure. Surgical site infection is the most commonly occurring & morbid complications of this technique and it can be reduced if closure is done by Purse string method. The aim of this study was to determine the more effective method of the two in terms of post-op surgical site infection.

Material & Methods: This Randomized Controlled Trial was conducted for six-month duration in Benazir Bhutto Hospital, Rawalpindi. Reversal patients presenting in outdoor-department were included and allocated randomly into either Purse-String closure group or linear skin closure group. Follow-up was done for thirty days and wound infection was identified by presence of purulent discharge from incision site. Organisms were isolated from fluid culture or tissue culture from the wound or abscess.

Results: We included a total of 90 patients in this study. 45 patients were randomly alloted to each group. The two groups were matched for various entry parameters. Wound infection was observed among 27(60%) in the linear closure group whereas 12(26.7%) in the purse-string group developed wound infection. This difference was statistically significant.

Conclusion: Given the low rate of associated wound infection, purse string closure of stoma reversal is recommended to be the preferred procedure for ileostomy reversal.

Key words: Loop Ileostomy, Linear closure, Purse string closure, Wound infection

Impact of Obesity on Lumbar Disc Herniation

Murtaza Ahmed Khan — 2023-07-06

Background: Prevalence of obesity is increasing worldwide and obese patients constitute a major portion of the spinal surgeon s practice. The patients with lumbar disc herniation present the most in the outpatient department of neurosurgery. Obesity not only leads to the disc herniation but also causes a surgeon a difficult ordeal while operating as it leads to more peri operative complications than normal weight patients. This cross-sectional study was planned to see the impact of obesity on lumbar disc herniation and its association with disease outcome.

Methodology This study was conducted in the department of neurosurgery at Sir Ganga Ram Hospital/ Fatima Jinnah Medical University (N=604; Males: n=368 Females: n=236) from December 15^th 2021 to July 31^st 2022. From the prospective registry, patients undergoing unilateral fenestration and discectomy, bilateral partial laminectomy and discectomy, and endoscopic discectomy were identified with complete BMI data.

Results: In total 604 patients, 368 were males and 236 were females, with age range 25-55 years with ± 4.9 SD. Among these 187 (30.9%) were managed surgically while 417 (69.1%) patients were managed conservatively, which were assessed on VAS (Visual Analogue Score) and Sciatica Bothersomeness Index (SBI). Among them 87 patients (20.8%) patients were of normal weight, 145 (34.77%) were overweight and 185 (44.36%) were obese. Among187 patients who underwent surgery; 74 (39.5%) underwent unilateral fenestration and discectomy, 113 (60.4%) underwent bilateral partial laminectomy and discectomy whereas 16 patients (8.5%) underwent endoscopic discectomy. Lumber Disc Herniation (LDH) was more frequent in obese and overweight individuals than in normal-weight patients.

Conclusion It was observed that in obese and overweight patients, the severity of pain was more as compared to normal patients. Higher the BMI more the excruciating pain and more neurological were seen with increasing trend of numbness and radiculopathy. Hence, obesity may have a robust impact on lumbar disc herniation apart from other pathologies involved.

Key words: Discectomy, Disc herniation, Laminectomy, Lumbar region, Obesity.

The Spectrum of Biochemical Changes in Thyroid Function Tests, Performed at Sahiwal Medical College, Sahiwal

Maryam Rafiq — 2023-07-06

Background: Thyroid disorders are among one the leading causes of endocrine problems worldwide. Hypothyroidism is very common and usually is more prevalent in females. Thyroid function tests (TFTs) play a vital role in the diagnosis and monitoring of thyroid diseases.

Methodology: This cross-sectional study was conducted at Sahiwal Medical College, Sahiwal after approval from the Institutional review board. The results of 2281 specimens tested for TFTs in the Pathology laboratory between August 2018 to December 2020 were included. Samples were analyzed by immunochemiluminescent assay method on an Access 2 analyzer by Beckman Coulter. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 25. A chi-square test was applied. P-value <0.05 was considered significant.

Results: A total of 2281 patient data was included in the study. The mean age of participants was 38.86±15.30 years and the majority were females. 64.1% of results were within the normal limit (euthyroid) while the remaining 35.9% had abnormal thyroid profiles. Hyperthyroidism was the most common abnormality (9.5%) followed by subclinical hypothyroidism (8.9%). Chi-square test revealed a statistically significant difference in age groups, with p-value of 0.004.

Conclusion: Thyroid diseases are quite common. Hyperthyroidism is slightly more prevalent than hypothyroidism in our community.

Key words: Hypothyroidism, Hyperthyroidism, Thyroid disorders, Subclinical thyroid disease.

The Assessment of Self Care Practices amongst Diabetic Patients of Rawalpindi, Pakistan

Rubab Zulfiqar — 2023-07-06

Background: Diabetes Mellitus is a chronic disease and with rapidly increasing prevalence, it requires continuous diabetic care beyond just glycemic control. It needs continuous self-management and multi factorial risk reduction strategies. This study aims to assess the self-care practices of diabetic patients living in Rawalpindi and to determine the relationship of sociodemographic characteristics with their self-care practices.

Methodology: This cross-sectional study was conducted in two private diabetic clinics of Rawalpindi from February to July 2022. A validated structured questionnaire using Summary of Diabetes Self-Care Activities (SDSCA) scale was administered to assess self-care practices of the study participants. A total of 230 participants through convenience sampling aged 25 to 86 years were recruited in the survey. SPSS version 22 was used to carry out the statistical analysis.

Results: The current study comprised of 107(46.5%) males and 123 (53.5%) females with mean age of 54.85 ±12.41 years. Among them, 65.2% had adequate self-care practices. It was found that marital status (p=0.004), educational status (p=0.002), monthly income (p=0.001) and duration of diabetes (p=0.006) were significantly associated with self-care practices of the participants.

Conclusion: More than half of the participants had adequate self-care practices. Sociodemographic variables like marital status, education, monthly household income and duration of diabetes were significantly associated with the self-care practices of diabetic patients.

Key words: Diabetes Mellitus, Pakistan, Self-Care, Self- Management, Survey

Relationship between Inflammatory Markers and Disease Outcome in COVID-19

sarah shah — 2023-07-06

Background: Coronavirus disease-2019 (COVID-19) has been labelled as a global pandemic and a cause of documented high mortality rates among severe or critical patients. This has been linked with hyperinflammation of the innate and adaptive immune systems and the resulting cytokine storm. Our study aims to evaluate the relationship between inflammatory markers and disease outcomes in COVID-19.

Methodology: This cross-sectional study was conducted at Federal Government Polyclinic (FGPC) Hospital, Islamabad for a period of 3 months. All the patients who had either RT-PCR for COVID-19 or HRCT findings suggestive of COVID were included in the study. The inflammatory markers like C-reactive protein (CRP), D-Dimers, and Lactate dehydrogenase (LDH) were done and a combined score DLC was calculated. The need for Oxygen (litres/min), Bilevel positive airway pressure (BIPAP), or Mechanical Invasive Ventilation was documented.

Results: The study was conducted on 213 patients which included 119(56%) male patients and 94(44%) female patients. COVID-19 PCR was positive in 193(90.6%) while 20 patients (9.4%) had a negative PCR but HRCT suggestive of COVID. HRCT was done in a total of 46 patients out of the 213 patients and 45 had features suggestive of COVID-19. The AUROC was 0.686(0.61-0.75) for D dimers, 0.688(0.61-0.75) for LDH, and 0.649(0.517-0.72) for CRP respectively, and Spearman rho values of (0.326, 0.328 and 0.266) respectively with a p-value (0.000).

Conclusion: D-dimer, LDH and CRP individually as well as a combined score of the inflammatory markers (DLC) and Oxygen requirement had a significant correlation with the mortality of the COVID-19 patients.

Key words: COVID-19, CRP, LDH, D dimers, DLC score.

A Descriptive Correlational Study of Vascular Foramina in Adult Human Femora in Cadavers in Pakistan

Dr. Arsalan Manzoor Mughal — 2023-07-06

Background: This study was conducted to study the variations in the number and location of nutrient and epiphyseal vascular foramina of the femur in the Pakistani population

Methodology: This descriptive cross-sectional study was conducted from April -June '2022 after getting ethical approval. Data collection tool: 24-gauge hypodermic needles & measuring tapes.

Data collection and Analysis: SPSS & Excel

Inclusion & exclusion criteria: Anatomically sound bones were included from the bone bank of RMU; pathological, deformed bones were excluded

Results: Out of 80 bones 66.6% had single nutrient foramina, whereas 31.3% had two on the shaft. 82.05% of foramina were type II, 16.67% were type I and 1.26% were type III. Only 2.5% had no foramina. Majorly the nutrient foramina were found on the medial surface, medial lips or between the lips of linea aspera. There was no significant difference bilaterally in the mean foraminal index, foraminal length, or several epiphyseal vascular foramina, which were 18.65 cm, 42.66 cm, and 16 cm respectively.

Conclusion: Most of the nutrient foramina in the femora were found in the middle third of the shaft, either on the medial lip of the Linea Aspera or on the shaft’s medial surface; however, variations in their location have been found. The mean epiphyseal vascular foramen ranged from 6 to 26.

The article finds its implications in orthopaedic surgery and osteogenesis.

Key words: Epiphyses, Diaphysis, Femur, long bones, Hip joint, Arteries, Pathology, Research, osteogenesis, Population

Actinomycosis, A Rare Cause of Perianal Fistula

Nosheen Nabi — 2023-07-06

Perianal fistula (fistula-in-ano) is one of the most common anorectal diseases. It is an abnormal connection between the anal canal and the perianal skin and is lined with granulation tissue. Although benign, the condition can cause significant distress and embarrassment to the patient. Major causes of an anal fistula are clogged anal glands forming anal abscesses. Other, much less common, conditions are infections, trauma and tumors. The treatment of an anal fistula depends on the etiology and location of the fistula. Most fistulas are treated surgically, through a variety of different procedures. Actinomycosis which is a gram positive bacteria can rarely cause perianal fistulas which is difficult to diagnose clinically so can result in mismanagement and recurrences leading to repeated surgeries.

Key words: Actinomycosis, Fistula in ano, Gram positive bacteria.

A Case Report on Abdominal Cocoon Syndrome

Sidra Rauf — 2023-07-06

Abdominal cocoon syndrome (ACS) is encapsulation of the abdominal organs by thick fibro-collagenous material forming cocoons. On the basis of the part of abdominal organ encapsulated, ACS is classified into three types. Patients with this condition usually present with intestinal obstruction. We present a case who presented to us with features of intestinal obstruction and was diagnosed as a rare case of abdominal cocoon syndrome on CT scan. He was managed operatively where adhenolysis was performed and patient had uneventful recovery. CT scan is found to be the investigation of choice. Laparotomy with excision of membrane overlying bowel loops is the treatment most commonly adopted by surgeons and it has satisfactory results.

Key words: Cocoon syndrome, Computed tomography, Intestinal obstruction.