Outcome of neonates ventilated in NICU of a tertiary care hospital and factors associated with poor outcome

Objective: To ascertain the outcome of neonates who are ventilated for various reasons in our Neonatal Intensive Care Unit [NICU] and determine the risk factors associated with increased incidence of adverse outcome. Study Design: Retrospective study. Place and Duration of Study: Neonatal Intensive Care Unit of Combined Military Hospital Rawalpindi from Jul 2016 to Dec 2016

Material and Methods: All neonates who received mechanical ventilation during the study period were included in the study

Results: Total sixty seven [35.8% females and 64.15% males] neonates were ventilated during the study period for various reasons. Of these 67 neonates who were ventilated, 35 [52.23%] died and 32 [47.76%] survived to be discharged home. 10 babies were born less than 28+ 0weeks gestation and all [100%] expired. Of 7 babies born between 28+1-31+6 weeks gestation, only 01 [14.28%] survived. Of 50 newborns between 32+0-36+6 weeks, 20 [40%] died and 30 [60%] survived to be discharged home. In our cohort of ventilated babies, 7 weighed less than 1000 gm of which 6 [85.71%] died and only 01 [14.28%] survived. Of 18 babies born 1000-1499 gm, 14 [77.77%] died and 4 [22.22%] survived. Of 14 babies born between 1500-2499 gm, 6 [42.85%] died and 8 [57.14%] survived. Of all ventilated babies, 28 weighed more than 2500 gm, of which 10 [35.71%] died and 18 [64.28%] survived. Out of our cohort of 67 babies, 14 were diagnosed with hypoxic ischemic encephalopathy grade 3, of which 11 [78.57%] died and 3 [21.42%] were discharged. Twenty three had RDS, of which 11 [47.82%] died and 12 [52.17%] survived. Ten babies were ventilated due to sepsis, of which 6 [60%] died and 4 [40%] survived

Conclusion: We conclude that gestational age less than 32+0 weeks, birth weight less than 1500 gm, Hypoxic Ischemic Encephalopathy grade 3 and sepsis are associated with a poor outcome in babies who are mechanically ventilated

novel clinico-biochemical score for screening of inherited metabolic diseases in children

Objective: to evaluate a novel clinico-biochemical score for screening of inherited metabolic diseases [IMDs] in children in our setup

Study Design: descriptive analytical study

Place and Duration of Study: department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from August 2016 to August 2017

Methodology: clinical data, preliminary biochemical investigations, plasma amino acid [PAA] and organic acid profiles [where indicated] of 354 children, aged <1 year to 12 years, referred to the study place for evaluation of suspected inherited metabolic diseases, was collected and evaluated. A clinico-biochemical score card named Rawalpindi Inherited Metabolic Diseases Score [RISc] was devised, on a scale from 1 to 10, incorporating 5 clinical and 5 important biochemical findings, and each variable was assigned a score, based on its relative frequency/risk. Each case was then assigned the RISc score and evaluated for presence or absence of any inherited metabolic disease, based on the score. This score was validated keeping plasma amino acids and organic acid profiles [in selected cases] as reference standard

Results: patients were divided into three groups, based on RISc score as low RISc [0.5-2.5], medium RISc [3.0-5.5] and high RISc [6-10]. A total of 354 cases reported in 2016 and 2017 and 33 [9.3%] were diagnosed to be having IMDs. One [3.0%] patient from low RISc, four [12.1%] from medium RISc, and 28 [84.8%] from high RISc group were found to test positive for any one IMD. High RISc group had a statistically significant higher IMD rate than the other two groups [p<0.001]. Specificity, sensitivity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value and accuracy were 93%, 85%, 11.8, 0.16, 55%, 98% and 90%, respectively

Conclusion: the cost effective RISc, based on clinical data and preliminary biochemical investigations, is highly accurate in diagnosing IMDs in cost restrained setups. It is strongly suggested that the initial screening for suspected IMDs and decision for advanced laboratory testing be carried out, based on the RISc card presented in the study

Role of corticosteroids in reducing respiratory morbidity in neonates delivered by elective cesarean section before 39 weeks

Objective: to determine the effect of dexamethasone administration to women between 37 to 39 weeks of gestation on neonatal outcome in terms of respiratory morbidity and the need for NICU admission

Study Design: an experimental study

Place and Duration of Study: department of Obstetrics and Department of Neonatology, Military Hospital, Rawalpindi, Pakistan, from February to July 2017

Methodology: women with singleton pregnancies, undergoing elective cesarean section between 37-39 weeks. Neonates were evaluated for any respiratory morbidity and need for NICU admission as well as need of mechanical ventilation, length of hospital stay and final outcome

Results: out of 535 patients, 240 [44.8%] patients received steroid cover before their elective cesarean section [group 1]. Two hundred and ninety-five [55.2%] patients who did not receive steroid cover, were allocated group 2. Mean age of mother's in-group 1 was 29.20 +4.50 years and in-group 2, it was 29.34 +4.50 years. The mean gestational ages were 37.56 +0.66 weeks and 38.11 +0.79 weeks in groups 1 and 2, respectively. In-group 2, 14 [4.74%] newborns developed transient tachypnea of newborn [TTN], which was higher than the newborns in-group 1 [04 [1.66%], p = 0.049]. Also the number of neonates being admitted to NICU was greater in group 2 than in group 1 [23 [7.79%] vs. 06 [2.5%] respectively, p = 0.007].However, there was no statistically significant difference between the two groups with regard to final outcome, requirement for mechanical ventilation, length of hospital stay and APGAR scores at one and five minutes

Conclusion: steroid cover significantly reduced the risk of respiratory morbidity in babies delivered by elective cesarean section between 37-39 weeks

Efficacy of hypofractionated radiotherapy in loco-regional tumor control in breast

Objective: To evaluate the efficacy of hypofractionated radiotherapy [HFRT] in locoregional control [LRC] in breast cancer

Study Design: Descriptive case series

Place and Duration of Study: Oncology Department of CMH Rawalpindi, from Jan 2014 to Oct 2014

Material and Methods: Fifty three female patients with histopathologically confirmed breast cancer and Eastern Cooperative Oncology Group performance status [ECOG-PS]

Results: Fifty three female patients with histopathologically confirmed breast cancer and ECOG-PS

Conclusion: It is concluded that HFRT is a simple and effective protocol for LRC in breast cancer in our set up. Large scale randomized trials and longer follow up is needed to confirm the results

Frequency of increase in serum tumor marker carcinoembryonic antigen [CEA] levels in primary breast cancer [PBC] patients at the time of diagnosis

Objective: To determine the frequency of increase in serum tumor marker CEA levels in PBC patients at the time of diagnosis

Study Design: Cross sectional study

Place and Duration of Study: Oncology Department of Combined Military Hospital [CMH] Rawalpindi, from January 2014 to November 2014

Material and Methods: Sixty three female patients with histopathologically confirmed carcinoma of breast and age range from 20 to 70 years from Oncology outpatient department [OPD]/indoor patient department at CMH Rawalpindi, were selected. All patients were staged by clinical and radiological work-up that included physical examination, all base line investigations, serum biomarkers, chest radiograph, ultrasound abdomen and pelvis, bone scan, computed tomography [CT] scan/magnetic resonance imaging [MRI] of the chest [optional]. Patients serum carcino-embryonic antigen [CEA] levels were carried out only by blood sampling using chemiluminescent immunoassay with immulite 2000 CEA. Data analysis were done with the help of the Statistical Package for the Social Sciences [SPSS] version 19 software. Cut-off values of serum CEA levels >2.5 ng/ml were taken as elevated

Results: Sixty three female breast cancer patients with histopathologically confirmed carcinoma of breast revealed elevated serum CEA levels in three stages of the disease. The median age was 47 years [range, 20-70 years]. Fifteen [23.8%] patients had family history of the breast cancer. Invasive ductal carcinoma [IDCA] was the commonest histology with 60 [95.23%] patients. Most of the patients had advanced stage of the disease. Node positive cases were 53 [84.1%]. The frequency of abnormal CEA levels were varying from stage II to stage IV. Elevated serum CEA levels were noted in 4 [28.6%] of stage II, 19 [76%] of stage III and 17 [77.3%] patients of stage IV, respectively. Overall percentage increase in levels of serum CEA from stage I through IV were 0%, 6.34%, 30.2%, 26% respectively. The sensitivity of serum CEA in our primary breast cancer [PBC] patients was 63.5%

Conclusion: It is concluded that serum CEA had significant sensitivity in detecting breast cancer in our population. Elevated serum CEA levels were seen in various stages of our PBC patients

Ways to manage hepatitis C without cirrhosis: treatment by comparison of coded eastern medicine hepcinal with interferon alpha 2b and ribavirin

Hepatitis C virus [HCV] infection is a serious and significant global health problem in the Pakistan and elsewhere. In majority of cases HCV infection remains asymptomatic but in advance cases it may progress to fibrosis of liver, shrinkage of liver cells or failure of liver. The hepatitis C may progress to cause liver cirrhosis that mostly develop in 20% of the affected patients in 20 years with an increased risk in male, alcoholic drink, immune-compromised and who acquire HCV infection after the age of 40 years. This was an open-label prospective study conducted on 66 clinically and immunologically diagnosed cases of HCV infection. In Hepcinal treated group, there were significant improvement in HCV associated symptoms compared to control group [p<0.05]. While Interferon therapy resulted in significant improvement in serological response [55.88%] compared to Hepcinal treated patients [46.88%]. It was concluded that Hepcinal has shown better clinical response but no significant serological response [p=0.3244] and it might be an alternative therapy to treat hepatitis C infection and to prevent its progression into chronic ailment

Comparative clinical study on the efficacy of biocor plus compared with simvastatin for the management of hypercholesterolemia

Hypercholestriolemia is major risk factor that enhances the incidence of cardiovascular disease and coronary artery disease. The present study was conducted to normalize the lipid profile in the blood by using Biocor Plus for hypercholesterolemia compared with Simvastatin. It was prospective randomized case control study conducted on 70 diagnosed patients of hypercholesterolemia at Sohail Memorial Hospital, Karachi and Amir Habib Medical Center and Maternity Home, Karachi. Patients of both genders [30-70 years] with clinical diagnosis of Hypercholesterolemia. Sample sizes for this study included total of 70 subjects. There was statistically significant difference when comparing the effectiveness of test drug, Biocor Plus to control drug, Simvastatin for the treatment of primary hypercholesterolemia. This is clearly evident that the herbal coded test drug, Biocor Plus possesses a therapeutic value for the treatment of primary hypercholesterolemia. There were no untoward or significant side effects associated with the use of Biocor Plus that proved its good acceptability by the patients. Moreover there was subjective feeling of wellbeing regarding breathlessness and chest tightness or pressure in the patients taking Biocor Plus. This makes an interesting point to focus on this effective alternative drug for primary hypercholesterolemia

Clinical efficacy of polyherbal formulation Eezpain spray for muscular pain relief

The topical herbal formulation Eezpain spray consisting of natural ingredients that have been clinically proved for its analgesic and anti-inflammatory activity. The designed formulation on application knee and wrist joints, back of neck and shoulder, forearms and lower back exhibited significant efficacy. A total of 20 subjects both male and female applied Eezpain spray consisting of Gaultheria oil, Eucalyptus oil, Turpentine oil, Clove Oil, Menthol and Camphor. All the active materials are cited that these have analgesic activity in myalgia and neuralgia. The study design was prospective and opens as pilot study followed the inclusion and exclusion criteria. All the sign and symptoms were noted at baseline and at the end of 14 days treatment performance was evaluated. The statistical analysis was done by using Microsoft Excel2007 and SPSS version 18.0. It is concluded that Eezpain spray has shown efficacy in mild to moderate cases on applying locally to the affected parts to relieve pain from different ailments

A novel HPTLC method for quantitative estimation of biomarkers in polyherbal formulation

Objective: To explore the quantitative estimation of biomarkers gallic acid and berberine in polyherbal formulation Entoban syrup. Methods: High performance thin layer chromatography was performed to evaluate the presence of gallic acid and berberine employing toluene: ethyl acetate: formic acid: methanol 12:9:4:0.5 (v/v/v/v) and ethanol: water: formic acid 90:9:1 (v/v/v), as a mobile phase respectively. Results: The R

Quality of post graduate medical training in public and private tertiary care hospitals of Karachi

To assess the quality of postgraduate fellowship training and to determine the differences in the quality of postgraduate fellowship training in public and private teaching hospitals of Karachi. It was a cross sectional survey conducted in four public and private sector hospitals of Karachi from January to March 2012. A total of 246 postgraduate fellowship trainees were interviewed. A standardized questionnaire adopted from CPSP guidelines on postgraduate training standards was developed. Postgraduate fellowship trainees [PG's] were selected on the basis of convenient non-probability sampling technique. Fisher's exact test and chi-square test were used to find differences in quality of postgraduate training. The mean duty hours per week was highest in private sector hospitals i.e., 72.1 as compared to government sector hospital which was 58.3 [P-value <0.01]. Of the respondents, 66.0% of PG's in private hospitals agreed that they have a structured study program as compare to 46.5% in public hospitals [P-value <0.001]. Only 38.1% of PG's in public hospitals agreed that they spent appropriate amount of time with their family and friends as compare to 1.8% of PG's in private hospitals [P-value <0.001]. No significant difference was found in quality of supervision in both public sector and private sector hospitals. The attributes of different aspects of training were different in public and private sector hospitals. So significant room exists for improvement in the quality of postgraduate medical training as indicated by the less than desirable proportion of trainees being satisfied with different aspects of training

outcome comparison of the open Vs closed haemorrhoidectomy: a quasi-experimental study in tertiary care hospital

Objective: to compare open and closed haemorrhoidectomy for wound healing time, hospital stay and complications

Material and Methods: sixty patients fulfilling the inclusion criteria were selected for this study and divided into two groups. Group A was treated by open haemorrhoidectomy and group B by closed haemorrhoidectomy. Postoperatively patients were evaluated for wound healing time, hospital stay, early and late complications

Results: the mean wound healing time in closed haemorrhoidectomy group was 2.60+/-0.67 weeks. The mean wound healing time in op n haemorrhoidectomy group was 3.97+/-0.76 weeks. There were 2 [6.7%] patients of urinary retention in closed haemorrhoidectomy group and no patient in open haemorrhoidectomy group. There were 29 [96. 7%] patients of mild to moderate bleeding and 1 [3.3%] patient of severe bleeding in closed haemorrhoidectomy group. In open haemorrhoidectomy group, 1[3.3%] patient had no bleeding, 28 [93 .3%] patients had mild to moderate bleeding and 1 [3.3%] patient had severe bleeding. Among late complications at one month follow up, 1 [3.3%] patient developed anal stenosis in closed haemorrhoidectomy group. In open haemorrhoidectomy group there was 1 [3.3%] patient of anal stenosis and 1 [3.3%] patient of anal fissure

Conclusion: open haemorrhoidectomy has more reliable wound healing with lesser complications, though complete wound healing time is more as compared to the closed technique

Therapeutic effects of whole brain radiotherapy with carboplatin as radiation sensitizer in management of brain metastasis

To determine the efficacy of whole brain radiotherapy [WBRT] with carboplatin as radiation sensitizer in metastatic brain disease in our adult population. Quasi-experimental study. Department of Oncology, Combined Military Hospital [CMH], Rawalpindi, Pakistan from July 2011 to September 2012. Forty two patients with metastatic brain disease having ECOG performance status [PS] 3 or less with normal hematological and biochemical profile were treated with WBRT with 6MV Photon beam on linear accelerator using parallel opposed lateral beams to a dose of 30 Gys in 10 fractions. Carboplatin was administered in a dose of 150 mg/m2 on day 1 and 6 of WBRT. Improvement in PS and radiological response on CT scan/ MRI brain before and 30 days after the WBRT using response evaluation criteria in solid tumors [RECIST] was evaluated. Out of 42 patients, 38 [90%] showed improvement in PS, 4 [10%] showed either no improvement or worsening of PS [p< 0.001]. Seventeen [41%] patients had complete response, 19 [45%] had partial response, 3 [7%] showed stable disease and 3 [7%] had progressive disease. None of the patients showed grade 3/4 toxicity during treatment. WBRT with carboplatin as radiation sensitizer is effective in palliation of patients with metastatic brain disease

Frequency of infectious diseases among flood affected people at district Rajanpur, Pakistan

To identify the frequency of infectious diseases among flood victims during and after disaster at district Rajanpur, Punjab, Pakistan. A cross sectional study was conducted from 15[th] to 31[st] August 2010 at 17 flood affected places of District Rajanpur of Punjab Province, Pakistan. A total of 7814 affected people were interviewed consecutively by using semi-structured questionnaire visiting the relief camps during the study period. Information was obtained after taking informed consent regarding infectious diseases: Acute Respiratory Tract Infection, Eye Infection, Gastrointestinal Tract Infection, Ear Infection, Skin and Soft tissue Infection, and suspected Malaria. Data was entered and analyzed by using SPSS version 16.0. The results showed that the distribution of infectious disease cases presented to relief camps were Gastrointestinal cases [Acute Diarrhea]-30%, Skin and Soft Tissue Infection [33%], Eye [Conjunctivitis]-07%, Ear, Nose and Throat Infection [05%], Respiratory Tract Infection [21%], and Suspected Malaria [4%]. Their mean age was 23.15 +/- 17.53 years. Our study concluded that there was a high frequency of infectious diseases. The morbidity and mortality resulting from infectious diseases can be minimized if public health intervention efforts are implemented in a timely and coordinated fashion

In vitro efficacy of piperacillin/sulbactam, piperacillin/ tazobactam and cefoperazone/sulbactam against clinical isolates of pseudomonas aeruginosa - a comparative study

To determine the in vitro efficacy of Piperacillin/Sulbactam, Piperacillin/Tazobactam and Cefoperazone/Sulbactam against clinical isolates of Pseudomonas aeruginosa. Cross-sectional study Department of Microbiology, Armed Forces Institute of Pathology from January 2010 to September 2010. A total of 287 isolates of Pseudomonas aeruginosa recovered from various clinical specimens were taken under consideration. Routine microbiological methods were used to identify the organism. Susceptibility of the isolates was carried out by modified Kirby-Bauer disc diffusion method against piperacillin 100/sulbactam 30 [SPR130micro g], cefoperazone 75/sulbactam 30 [SCF105micro g] and piperacillin 100/tazobactam 10 [TZP110micro g], according to the guidelines provided by Clinical and Laboratory Standards Institute [CLSI]. The highest numbers of Pseudomonas aeruginosa isolates were found in pus swabs, followed by urine and endobronchial washings. Seventy five percent of clinical isolates of P. aeruginosa were susceptible to tazobactam/piperacillin, 71% to piperacillin/sulbactam and 70% to cefoperazone/sulbactam. The difference between the susceptibility of isolates to these three antimicrobials was statistically not significant [p>0.05]. We conclude that there was very little difference in the antimicrobial susceptibility of P. aeruginosa to the three beta-lactam/beta-lactamase inhibitor combination drugs studied. Periodic susceptibility testing should be carried out over a period of two to three years, to detect the current resistance trends. Moreover, a rational strategy on the limited and prudent use of anti-Pseudomonal agents is urgently required

Frequency of intraventricular hemorrhage in premature infants

To determine frequency of IVH in premature infants delivered at Military Hospital Rawalpindi. Descriptive study. The study was conducted in the Neonatal Intensive Care Unit at Military Hospital Rawalpindi. From September 2006 to February 2007. In this study 100 premature babies were included. High frequency ultrasound was used for evaluating IVH because of its non-invasive nature, easy availability and conveniences. A total of 100 babies were included in the study. Sixty-one babies were delivered by spontaneous vaginal delivery [SVD] while 39 babies by lower segment cesarean section [LSCS]. Mean gestational age was 32.3 +/- 2.12 weeks. Mean birth weight of the babies was 1637.7 +/- 349.25 grams. Total 11 cases of IVH were detected in study. Frequency of IVH was 11% in premature infants. We suggest that any premature infant born before 32 weeks gestation or weighing <1500g should be evaluated for IVH by cranial ultrasound

Accidental poisoning in children: frequency and outcome of the cases at a military hospital

To determine the frequency of accidental poisoning by various agents and their associated outcome in children. Descriptive Study. The study was carried out in emergency department at PNS Shifa hospital Karachi, from January 2007 to December 2008. A total of 200 patients reported with accidental poisoning during the study period. Detailed history and examination regarding the nature of poisoning was taken. Relevant investigations for purpose of diagnosis were carried out. Mortality and morbidity was noted on predesigned proforma. Total 200 patients were admitted with accidental poisoning during the study period. 155[77.5%] of patients belonged to less than 5 year age group. Most frequently ingested poison was kerosene oil [51%], followed by insecticides [17.5%], Oral route was involved in majority of cases 194[97%]. Complications were observed in 6% of cases, Pneumonia was the most frequently occurring complication in 8 [4%] cases of kerosene oil ingestion, followed by seizures in 2 [1%] cases of insecticide ingestion. No mortality was reported in this study. Acute childhood poisoning is a significant public health problem affecting mainly toddlers. Main substances responsible for acute poisoning are Kerosene oil, insecticides, bleach and drugs

Hallervorden spatz disease

Hallervorden-Spatz disease is an extremely rare cause of dystonia that carries a poor prognosis. A case occurring in an 11-yearold girl with progressive extra-pyramidal symptoms since infancy is described. The clinical picture and typical radiological findings are described

Diagnostic value of C-reactive protein and haematological parameters in neonatal sepsis

To analyse various parameters of sepsis screen singly and in combination to formulate a guideline for the diagnosis of neonatal sepsis. Design: A cross-sectional analytical study. Place and Duration of Study: The neonatal intensive care unit at the Paediatric Department, Military Hospital, Rawalpindi, over a period of seven months from 1st June to 31st December 2003. Subjects and One hundred neonates having clinical features of sepsis and 100 normal asymptomatic neonates were evaluated with a set of investigations. C-reactive protein [CRP], erythrocyte sedimentation rate, total leukocyte count, absolute neutrophil count [ANC], immature neutrophils to total neutrophil count ratio [I/T ratio], thrombocytopenia, degenerative changes in the neutrophils and gastric aspirate cytology [GAC] for polymorphs were used for diagnosis of neonatal sepsis. CRP was positive in 24/28 [85.7%] of group-A [proven sepsis] and 58/72 [80.5%] of group-B [probable sepsis] and had a specificity of 95%. ANC was the second most sensitive test having sensitivity of 71.4% for group- A and 63.9% for group-B and 88% specificity. For group-A, sensitivity of GAC for polymorphs and platelet count was 71.4% and 64.3% respectively. The sensitivity, specificity and predictive values [PV] of the individual tests and different tests combination was also calculated for group-A and B. A set of investigations including CRP, TLC, ANC, thrombocytopenia, cytoplasmic vacuolization in the neutrophils and GAC for polymorphs are highly sensitive in detection of culture negative cases of neonatal sepsis. Moreover, a combination of three tests enhances the sensitivity of these tests