Parenteral iron therapy in the treatment of iron deficiency anemia during pregnancy: a randomized controlled trial

To compare the efficacy and safety profile of total dose infusion of low molecular weight iron dextran with divided doses of intravenous iron sucrose for the treatment of iron deficiency anemia during pregnancy. Randomized controlled trial. Shifa International Hospital, Islamabad, over a period of two years from January 2008 to December 2009. Pregnant women at gestational age more than 12 weeks with the confirmed diagnosis of Iron Deficiency Anemia [IDA] were divided into two groups. In the group-A, intravenous iron sucrose was given in divided doses while in the group-B, total daily intake of Low Molecular Weight [LMW] of iron dextran was given. Post-infusion Hemoglobin [Hb] was checked at 4 weeks and at the time of delivery for both groups. Paired sample t-test is applied and comparison [in terms of rise in hemoglobin from pre to post] of both groups was not found to be significant. In the group-A [iron sucrose group], mean pre-infusion Hb levels was 9.09 +/- 0.83 gm/dl. Mean increase in Hemoglobin [Hb] was 10.75 +/- 1.097 gm/dl after 4 weeks of infusion and 11.06 +/- 0.866 gm/dl at delivery [p < 0.001]. In group-B [iron dextran group] pre-infusion haemoglobin was 8.735 +/- 0.956 gm/dl and the mean increase in hemoglobin was 10.613 +/- 1.22 gm/dl at 4-week while mean increase of 10.859 +/- 1.11 gm/dl at the time of delivery [p < 0.001]. Both LMW iron dextran, as well as iron sucrose are equally effective in treatment of IDA during pregnancy, however, LMW iron dextran has the advantage of single visit treatment

Are there predictors of post-operative outcome in patients undergoing mitral valve replacement for rheumatic valvular heart disease?

Rheumatic heart disease is the most common cause of valvular heart disease in developing countries. Frequently patients present quite late in their disease course. We sought to determine the predictors of post-operative outcome in patients undergoing mitral valve replacement for rheumatic heart disease. This retrospective study was conducted in Shifa International hospital, Islamabad from February 2003 to December 2006. 34 patients underwent mitral valve replacement due to rheumatic mitral valve disease. All patients had their demographic characteristics, operative details and comprehensive preoperative and post-operative echocardiographic parameters recorded. Data was analyzed using SPSS V.13 statistical software. Mean age of the study population was 35.09 +/- 10.52 years with female predominance [n =23, 67.6%]. After a mean follow-up of 187.22 +/- 17.51 days, the ability of preoperative and postoperative clinical and echocardiographic data to predict outcome and the impact of valve replacement on survival was assessed retrospectively. 30 patients [88.2%] underwent mitral valve Replacement due to underlying isolated rheumatic mitral valve while 4 patients [11.8%] had both mitral and aortic valve replacement. 12 patients [35.3%] had tricuspid valve annuloplasty done during the same operation. There were no perioperative deaths. There were 2 [5.9%] deaths after a mean period of 162 +/- 12 days as a result of prosthetic valve thrombosis. Comparison of pre-operative and post-operative echocardiographic data revealed statistically significant reduction in pulmonary artery systolic pressure in 28 patients [p-value 0.001], reduction in left atrial size in 31 patients [p-value 0.001] and reduction in right ventricular dimensions in 25 patients [p-value 0.001]. Actual probability of freedom from valve related death, including in-hospital mortality, at cumulative follow up duration of 25.76 +/- 17.62 months was 94.1% irrespective of preoperative echocardiographic parameters, mono or bivalvular replacement and post procedural congestive cardiac failure or thromboembolic events. Despite the fact that most patients in this study presented in advanced stages of rheumatic heart disease, we could not identify any independent intraoperative or preoperative echocardiographic characteristics which would predict worse postoperative outcome. Valve replacement should be potentially offered to all patients presenting with severe rheumatic valvular disease irrespective of the stage of the disease

Evidence for the best modality of delivering undergraduate medical curriculum

Shifa College of Medicine, Islamabad, Pakistan in its quest for excellence in medical education has adopted an integrated medical curriculum approach where basic and clinical science subjects have been integrated horizontally as well as vertically across the five years of undergraduate medical curriculum. The mode of curricular delivery is an area where we are experimenting with Interactive large group discussions, Structured Interactive Sessions, Problem based learning and Case based Instruction formats. There is always a divide in the faculty to accept as to which modality of curricular delivery is the best for the students and ultimately for the patients who are at the receiving end of this exercise

Validity of pipelle endometrial sampling in patients with abnormal uterine bleeding

We compared endometrial sampling by pipelle endometrial curette with Conventional dilatation and curettage [D and C] in patients with abnormal uterine bleeding. Endometrial sampling with pipelle curette was performed on 100 patients followed by formal D and C. Samples were labeled as A and B, respectively, and sent to a histopathologist who was blinded as to the method of sampling. The histopathology reports of both samples were compared, taking D and C as the gold standard. An adequate sample was obtained in 98% of cases by pipelle and in 100% of cases by D and C. Pipelle had a sensitivity, specificity, positive predictive value and negative predictive value of 100% for diagnosing endometrial carcinoma, hyperplasia and secretory endometrium. Pipelle also had high diagnostic sensitivity, specificity and negative predictive value [100%, 98% and 100%, respectively] for hyperplasia with atypia, and low sensitivity [57%] and positive predictive value [57%], but high specificity [97%] and negative predictive value [97%] for endometritis. Similarly, for proliferative endometrium, the pipelle technique had values of 94% and 93% for sensitivity and specificity, respectively. Both samples labeled as inadequate for histology by pipelle were polyps on the D and C report. Difficult endotracheal intubation was encountered in two cases of D and C. No other complications of the procedure were observed. The pipelle is a safe device for getting an adequate endometrial sample for histology, with a high sensitivity and specificity for detection of hyperplasia and malignancy

Risk factors in patients presenting with acute coronary syndrome to a tertiary care facility

Care facility our study evaluates the most commonly implicated risk factors associated with Acute Coronary Syndrome [ACS] in Pakistani patients presenting to a tertiary care facility. All patients presenting with Syndrome ACS to Shifa International Hospital over the six month period extending from May 2004 to December 2004 were included in this descriptive study. Patients were questioned for the presence or absence of conventional risk factors for coronary artery disease [CAD]. Body Mass Index [MBI] and lipid profiles were also documented. Data was entered into SPSS version 10.0 to obtain descriptive statistics. Over six months, 110 patients conforming to the inclusion / exclusion criteria were included in this study. 72.8% of the patients were from the Rawalpindi/Islamabad area. The male to female ratio was roughly 3:1. 22.7% of the patients were below the age of 50 years, and smoking was substantially more implicated in this population subset as compared to the rest of the study patients. Considering the term "Dyslipidemia" to encompass any one or more individual lipoprotein abnormalities and not merely elevation in total serum cholesterol, 96.5% of the patients were found to be dyslipidemic, most commonly on account of HDL less than 40 mg/dl [74.4%] or LDL more than 100mg/dI [72.1%] and elevated triglycerides [64.9%]. BMI>25kg/m2 was present in 41% of the patients, and 22. 1% were obese with BMI> 30kg/m2. Males were more likely to be smokers and females were more likely to be diabetic and hypertensive. Three simultaneous risk factors [hypertension, diabetes mellitus and dyslipidemia] were present in 4 1% of the cases. Traditional and validated risk factors were present in all patients. Hypertension, dyslipidemia and elevated BMI were seen more frequently in this patient population. In addition, more than a third of the patients had more than three risk factors for CAD, an observation which has significant preventive management implications

Training in reference management software: a part of new medical informatics workshops in Pakistan

Researchers in Pakistan can increase writing productivity, reduce errors in manuscripts and improve quality of their papers by hands-on workshops on bibliographic reference software. A workshop was conducted in an interactive tutorial format using an overhead projector to show screenshots of software at each step. Our Workshop included:1 starting the Endnote program [www.endnote.com];[2] manually entering a reference of a journal article[3] searching and importing references from PubMed[3] inserting a reference in Microsoft Word document in a journal-specific format;[4] essentials of journal article formatting; and[5] the ethics of respecting other peoples of intellectual effort by proper citations and avoiding plagiarism. A post-workshop test was administered to assess whether instructional objectives were attained. All the participants passed the post-workshop multiple choice questions and 85% rated the workshop as good, very good or excellent. A workshop on reference formatting in research writing is useful to promote high quality research work. We recommend holding workshops twice a year on research article formatting and reference software at medical colleges in Pakistan and other developing countries

Novel ways to increase medical informatics use by clinicians

Medical informatics is a multi disciplinary field, which combines different disciplines of medicine with information technology. Some of the major components of Medical Informatics are Hospital Information System, Computer based patient record, Medical imaging, Telemedicine, Bio informatics and Expert system or Artificial Intelligence, Neural networks and Robotics. In a medical college setting there are data analysis tools like S.P.S.S, presentation tools, e learning and web portals for students

Prevalence of antenatal care use of food supplements during pregnancy and lactation and factors responsible for not taking them in Tarlai urban slum of Islamabad

The objective of this study was to ascertain the prevalence of antenatal care, use of food supplements during pregnancy and lactation and factors responsible for not taking them in Tarlai, an urban slum of Islamabad. A Cross-sectional survey of 100 married women in the age range 15-45 years women utilizing and not utilizing antenatal care facilities during their previous pregnancy was carried out in April 2004. Data was collected through a structured questionnaire and processed and analyzed by using SPPS 10.0. Use of supplements was found high in women attending antenatal care. Realization of the importance of taking a healthy diet during pregnancy was significantly higher among women utilizing antenatal care. In most of the women's the diet remain unchanged. 56% women attended the antenatal care clinics. Those not taking food supplements, 39% were non affording, 21%had no concept of their benefits, 36% did not like to take and 4% felt nausea and vomiting. Just over 50% women received antenatal care. Utilization of antenatal care showed a positive impact on awareness of taking food supplements during pregnancy and lactation

Temperature regulation and standardization practices of clinical laboratories in Karachi

To examine the temperature regulation and standardization practices of clinical laboratories in Karachi. Forty five clinical laboratories in Karachi were examined for observing the standard protocols for running a lab with particular reference to temperature regulation. A questionnaire to the effect was filled. Among the 45 labs included, the mean complete blood count performed per day was 52 +/- 47. Only 5 [11%] labs had a temperature reader. Thirty [66.7%] labs had an air-conditioner installed, of which only 24 were found in working condition. Maintenance of instruments was carried out every 67.5 +/- .30.6 days. The mean number of haemolyzed samples was 2.3 +/- 1.7. Control was available in 24[53.3%] labs, which was used daily in only 10 labs. Quantity of blood was the same in all the tubes in only 33[73.3%] labs. Commercial laboratories should be properly registered and their quality standardized

Knowledge of type 2 diabetic patients about their illness: pilot project

To evaluate the baseline level of knowledge and awareness of diabetic patients about their disease and it's complications. It was a Cross Sectional Survey conducted at Foundation Clinic, Shifa College of Medicine, Islamabad, in April 2004. A structured questionnaire was used. Forty diabetic patients were interviewed to know their knowledge attitude and practices about diabetes. All data was entered into SPSS version 10.0. The data was re-validated and analyzed. Mean age of study participants was 45.35 +/- 13.05 years, 11[27.5%] were male and 29 [72.5%] were female. The mean BMI of the study participants was 27.06 +/- 6.29 kg/m2. Majority of the patients 27 [67.5%] had type 2 diabetes. The mean fasting blood sugar was 159 +/- 73.89 mg/dl and random blood sugar was 200 +/- 91.2 mg/dl, 50% of the patients were using antidiabetic drugs regularly and only 15% of the patients were regularly monitoring their blood glucose at home using a glucometer. Awareness level of the study participants was low. The awareness about the disease in majority of diabetic patients was not adequate in this study. Routine individual teaching and counseling represents an effective educational model [JPMA 55:221;2005]

Treatment of chronic hepatitis B with lamivudine

To study the efficacy of antiviral drug lamivudine for treatment of chronic hepatitis B in Pakistani population. Experimental study. A tertiary Care Center, from January 2000 to January 2004. Patients who had positive hepatitis B surface antigen [HBsAg] and elevated ALT were recruited. Both hepatitis Be antigen [HBeAg] positive and HBeAg negative patients were included. Treatment was given with lamivudine 100mg once a day for 12 months and they were followed every 2-3 months with ALT, HBeAg, and in certain cases with, HBV DNA [PCR]. Those patients who were HBeAg positive were considered to have achieved end of treatment response [ETR] when ALT was normal and HBeAg was negative and this was documented at two consecutive occasions, at least one month apart. Those patients who were HBeAg negative were considered to have achieved ETR when their ALT was normal and HBV DNA was undetectable. Patients were followed for further 6 months to evaluate for any relapse. A total of 105 patients were included. Eighty-two [78.1%] were males and 23 [21.9%] were females. Mean ALT of all patients was 87.15 +/- 46.01 u/dl. Seventy-two HBeAg positive and 15 HBeAg negative patients completed treatment with 23.6% and 80.0% response rate respectively [p <0.001]. The response of lamivudine in chronic hepatitis B in Pakistani population is encouraging in HBeAg negative patients but is rather low in those who are HBeAg positive

Risk factors for hepatitis C virus infection in patients on long-trem hemodialysis

To estimate the frequency of hepatitis C virus [HCV] infection in patients on hemodialysis at Shifa International Hospital and determine the association of various risk factors in the acquisition of hepatitis C infection. A cross-sectional analytical study. Shifa International Hospital from January 2002 to June 2003. All patients on long-term hemodialysis in Nephrology Unit of Shifa International Hospital were studied. Their medical records were reviewed for the presence of anti-HCV in all patients. Any risk factors were noted from the patient's records and from the history of those patients who were regularly attending the dialysis unit. A total of 97 patients on hemodialysis were included. Out of these, 23 [23.7%] were found to be anti-HCV positive. The mean age of HCV positive patients was 55.2 +/- 15.5 years while for the anti-HCV negative patients it was 54.9 +/- 15.1 years. There were 18 [78.3%] males in the HCV positive group while 46 [62.2%] males in the HCV negative group. The mean duration of dialysis among HCV positive patients was 2.9 +/- 2.7 years while the mean duration of dialysis in HCV negative patients was 1.51 +/- 0.86 years [p-value 0.000]. Anti-HCV positive group had significantly greater proportion of patients with a history of dialysis more than 2 years [43.5% vs 9.5%], adjusted odds ratio being 0.45 [95% CI 0.27-0.75]. No significant difference in other risk factors between the two groups was found. When years of dialysis were treated as categorical variable, significant difference between the anti-HCV positive and negative groups was found. The risk of getting HCV was found to be significantly associated with increasing years of dialysis, [adjusted p-value 0.002]. Patients on hemodialysis in our unit had 23.7% positivity of anti-HCV and history of dialysis over more than 2 years was noted to be a significant risk factor for acquisition of infection in these patients

Identification of seronegative pregnant women eligible for immunization against rubella

To estimate the frequency of Rubella seropositivity among pregnant women and thereby getting an estimate of seronegative women who should eventually be immunized against Rubella. A blood sample of 100 consecutive pregnant women coming for their first antenatal check-up at Shifa International Hospital, Islamabad, was collected in the year 2002. Enzyme-Linked immunosorbent assay [ELISA] technique was used to detect IgG antibodies against Rubella. Out of 100 pregnant women 61[61%] were positive for rubella [IgG antibodies] in the first trimester of pregnancy. Mean age of the study participants was 27 ' 3.27 years. Twenty-five [25%] women were primigravida, while 75 [75%] were multigravida. Majority of the women were housewives belonging to middle and lower middle socioeconomic class. We found 61% women had positive Rubella antibodies during first antenatal visit. Nearly 40% who were negative should be immunized against rubella, preferably before conception

Comparative study of knowledge, attitude and practices among antenatal care facitities utilizing and non - utilizing women

To compare the knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women, aged 15-49 years. A Cross-sectional survey was conducted between October 2003 and April 2004, including 200 married women in the age range 15-49 years. Knowledge, attitude and practices of women utilizing and not utilizing antenatal care facilities during their previous pregnancy were compared by calculating odds ratios and 95% confidence intervals. P values were obtained by doing chi-square test. Pallor was significantly lower among women utilizing antenatal care [57%] as compared to those who were not [77.6%]. [O.R 0.38 95% CI[0.18-0.81] p value 0.02]. Tetanus toxoid coverage was higher among women utilizing antenatal care [92%] compared to those who were not [59.2%] [O.R 10.8 95% CI[4.5-26.2]. Knowledge about danger signals in pregnancy and realization of the importance of eating a healthy diet during pregnancy was significantly higher among women utilizing antenatal care. Lesser prevalence of Anaemia and better tetanus toxoid coverage was seen among women attending antenatal care facilities.Identification of danger signals in pregnancy and recognition of nutritional demands of pregnancy are better understood by women utilizing antenatal care facilities