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PAKISTAN ARMED FORCES MEDICAL JOURNAL
Vol-66 (Suppl-3) 2016
Recognized by PMDC & HEC (Category X)
CONTENTS
ORIGINAL ARTICLES
Editorial Advisory Board
Chairman
Prof Syed Muhammad Imran Majeed
Members
Dr Asif Mumtaz Sukhera
Prof Iftikhar Hussain
Prof Sohail Hafeez
Dr Najm Us Saqib Khan
Dr Zahid Hamid
Dr Muhammad Ishtiaq Bashir
Editorial Committ ee
Chief Editor
Prof Jawad Khaliq Ansari
Editor
Prof Shahid Jamal
Joint Editors
Prof Tehmina Munir
Dr Naila Azam
Assistant Editors
Prof Khadija Qamar
Prof Muhammad Alamgir Khan
Dr Palvasha Waheed
Dr Syed Fawad Mashhadi
Dr Kulsoom Farhat
Dr Aliya Hisam
Bibliographer
Mr Muhammad Saeed
Statistician
Miss Sajida Javed
Editorial B oard Members
International
Dr. Desley Neil (Birmingham, UK)
Prof Mohammad Bagher Rokni (Tehran, Iran)
Prof Waheed-uz-Zaman Tariq (Al Ain, UAE)
Prof Ali-I-Musani (USA)
Dr. Ahmed Badar, (University of Dammam, KSA)
Dr Xu Jinlian (China)
Dr Syed Naveed Aziez (Australia)
Dr Imtiaz Ahmad Cheema (UK)
Dr Naeem Nabi (Canada)
National (Extra-Organizational)
Prof Shahid Pervez (Karachi)
Prof Muhammad Tayyab (Lahore)
Prof Zafar Nazir (Karachi)
Prof Shoaib Shafi (Rawalpindi)
Prof Assad Hafeez (Islamabad)
National (Organizational)
Prof Muhammad Ayyub
Prof Amjed I qbal
Prof Muhammad Ashfaq
Prof Maqbool Ahmad
Prof Mazhar Ishaq
Prof Salim Jehangir
Prof Zafar Iqbal Shaikh
Prof Shamrez Khan
Prof Naeem Naqi
Prof Tahir Mukhtar Sayed
Prof Arshad Mahmood
Prof Sohail Aziz
Prof Waseem Ahmed
Prof Shehla M Baqai
Dr Shahzad Mehmood
Dr Safdar Hussain
Ma na gement of Earl y Pregnanc y Loss: Manual Vacuum Aspi ration Vers us Dil atation
and Curettage
Saima Qamar, Saima Masood, Uzma Asif
S173
Acute Appendici tis ; Ul tr asonography as Pre-o perati ve Screeni ng Tool
Amer Hayat Haider, Mohammad Nazir Qureshi, Rizwan Bilal, Ijaz Ahmad
S178
Fr equency of Mecha ni cal Compl icat ions As socia ted Wit h Inserti on of Central Venous
Catheters i n Adult Pati ents at A Ter tiary Car e Fa cil ity
Muhammad Fahd Bin Haider, Kamran Aziz, Shahid Ahmed
S184
Percepti ons And Feedback of Medical St udents Towar ds Conduct of Examinat ion
Khadija Qamar, Gulshan Trali, Humaira Arshad
S189
Hist opathol ogical Spect rum of Endometri al Biopsies – A St udy of 378 Cases at Af ip
Paki stan
Syed Salman Ali, Iqbal Muhammad, Javeria Shaukat, Saeed Afzal, Shoaib Nayyar Hashmi, Syed
Naeem Raza Hamdani, Rabia Ahmed
S194
Si ngl e Burr -Hole Evacuati on of Chronic Subdural Ha emat oma - Use of Dra ins Ver sus
No Drai ns
Khurshid Ali Bangash, Aslan Javed Munir, Habib Ullah Khan
S199
Fr equency of Abrupti o Placentae And Int rauterine Gr owt h Rest ric tion in Wome n Wi th
Pre-Eclampsia And Pr egnancy Induced Hyper tensi on ( PI H)
Shaista Ambreen, Rubina Mushtaq, Khalida Perveen
S203
Fr equency of Pain Due To I nject ion of Pr opofol Wi th I V Admini str ati on of Lignoca ine
Wi th And Wi thout Met oclopra mide
Syed Ali Raza Ali Shah, Syeda Sarah Naqvi, Muhammad Ali Abbas
S208
Compar ison of Ear ly Neonata l Outcomes for Asymmetrical IUGR Wi th Normal And
Abnorma l Umbili cal Art ery Wavefor ms
Lubna Noor, Humaira Arshad, Humaira Tariq, Afeera Afsheen
S213
SELF-Car e And Diet ary Patt erns Among Di abetes Mel li tus Pati ents in Rawal pindi
Aliya Hisam, Naseer Alam Tariq
S217
Fr equency of Cerv ical Ribs Among Adult Mal es Seeki ng Employment in Pakistan
Army
Muhammad Arshad, Jawaid Hameed, Amer Zamir Sahi
S224
Dist ri but ion of Bl ood Type and Rh Factor Amo ng Blood Donor s of Lahor e
Muhammad Saeed, Shahida Hussain, Minza Arif
S228
Use of Mir ena – Levonor gestr el I ntra – Ut eri ne System (LNG IUS) I N Dy sfuct ion
Uter ine Bleeding in The Repro duc tive Age Gro up
Afroze Ashraf, Nilofar Mustafa, Nomia Saqib
S233
Vali dity of Gr ay Sca le Ul tra sonography in Dia gno sis of Chr onic Liver Diseas e of Viral
Et iology
Shaista Riaz, Riaz Ahmed Khokhar, Ashraf Farooq
S238
A Comparis on of Eff icac y Among Var ious Do ses of I ntra thecal Hyperbar ic Bupivacai ne
0.75% for Adult Anorectal Surger y
Mudassar Iqbal, Naveed Masood, Khurram Sarfraz, Khalid Zaeem Aslam, Mushtaq Hussain Raja
S244
Effectiveness of Intra-Peritonea l Admi nistration of 0.5% Bupi vacai ne i n Posto pe rati ve
Analges ia Af ter Lapar oscopic Cholec ystec tomy
Babar Shamim, Awais Ali Khan, Muhammad Rehan Saleem, Irfan Shukr, Afshan Aziz, Maria
Shahzadi
S248
Diagnos tic Accura cy of Ult rasonography i n The Di agnosis of Acute Appendici tis
Mansoor Hasan, Sajida Perveen, Muhammad Amer Mian
S252
Compar ison Be tween Harmoni c ACE Ver sus Conventional Monopolar Diat hermy in
Lapar oscopic Cholec ystec tomy i n Terms of Gal lbladder Perforation
Yasir Javed, Muhammad Tariq, Syed Mukarram Hussain, Anwar Ahmed, Shafqat Rehman,
Muhammad Asif Rasheed
S258
FIELD MEDICINE
Pat tern of I njuri es i n Counterterr oris m Operations : An Experience at A Terti ary Ca re
Hospit al
Muhammad Qasim Butt, Sohail Saqib Chatha, Adeel Qamar Ghumman, Mahwish Farooq
S263
CASE REPORTS
Extraskel etal Ost eosarc oma of Ant erior Abdomi nal Wal l: A Case Report And Revie w of
Li terature
Syed Salman Ali, Muhammad Zeeshan, Iqbal Muhammad, Saeed Afzal, Shoaib Nayyar Hashmi,
Syed Naeem Raza Hamdani
S267
Pol yostot ic Fibr ous Dyspla sia
Adil Qayyum, Ruqqayia Adil, Faisal Basheer, Jawad Jalil
S270
Lei omyoma Of The Anter ior Abdominal Wal l in A 26 Year Old Pregnant Woma n: A
Case Report
Saima Qamar, Nilofar Mustafa, Adeeba Akhter Khalil, Muhammad Jamil
S273
Anest he tic Ma na gement Of Huge Mul tinodul ar Goi ter Wi th Compromi sed Ai rway
Saleem Ahmed, Khalid Zaeem, Sanum Kashif, Syed Samee Uddin
S275
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Heredit ary Congenita l Facial Palsy
Muhammad Tariq
S277
Imaging of Abdominal Hydati dosis: A Rare Presentati on of a Common Conditi on
Javed Anwar, Saima Omar, Sanaullah, Koukab Javed
S279
Original Article
Management of Early Pregnancy Loss
Pak Armed Forces Med J 2016; 66 (Suppl-3): S173-77
ORIGINAL ARTICLES
MANAGEMENT OF EARLY PREGNANCY LOSS: MANUAL VACUUM ASPIRATION
VERSUS DILATATION AND CURETTAGE
Saima Qamar, Saima Masood, Uzma Asif*
Combined Military Hospital Lahore, Pakistan, *Islam Medical College Sialkot, Pakistan
ABSTRACT
Objective: To compare the safety and cost effectiveness of manual vacuum aspiration (MVA) with dilatation and
curettage (D&C) in first trimester pregnancy losses.
Study Design: Randomized control trial.
Place and Duration of Study: Conducted in Obstetrics and Gynaecology department of Combined Military
Hospital Lahore from July 2014 to June 2015.
Material and Methods: The study involved 120 women divided into two groups of 60 each through consecutive
sampling with one undergoing MVA and the other D&C. All women with gestational age <12 weeks with a
diagnosis of anembryonic pregnancy, failed medical induction, incomplete or missed miscarriage were included
in the study.
Results: The general characteristics of the groups were the same. In the MVA group the mean duration of
procedure was 13.4 (± 2.7) min with mean hospital stay being 14.2 (± 2.4) hours. The D&C group had a mean
duration of procedure of 24.6(± 5.3) min with mean hospital stay being 28.9 (± 4.8) hours. The mean cost of MVA
was Rs 4820 ± 270.76 versus Rs 14,280 ± 927.38 for D&C. In MVA and D&C groups incomplete evacuation
occurred in 3(5%) patients and 1(1.7%) patient respectively. The incidence of infection was 5% in MVA group and
3.3% in D&C patients. The rest of the complications occurred only in the D&C group, with 1(1.7%) patient having
uterine perforation, 1 (1.7%) having haemorrhage and 1(1.7%) having anaesthesia complications.
Conclusion: MVA is as safe and effective as D&C for the management of miscarriage. Moreover MVA is cost
effective as both hospital stay and procedure times are shorter.
Keywords: D&C, Miscarriage, MVA, Pregnancy termination.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Early pregnancy loss occurs in 15-20% of
recognised pregnancies. In spite of the fact that
there has been progress in the field of medical
technology, complications arising due to unsafe
abortion still lead to 10-13% of maternal deaths in
developing countries1,2. Hence we continue our
pursuit of a safe and cost effective method of
uterine evacuation.
Uterine evacuation is the removal of
products of conception. There are many ways of
performing this in the first trimester such as
Correspondence: Dr Saima Qamar, Asst Prof of Obs & Gynae
Department, Combined Military Hospital Lahore, Pakistan
Email: [email protected]
Received: 18 Jan 2016; revised received: 18 May 2016; accepted: 20 May
2016
vacuum aspiration, surgical methods and
pharmacological
methods.
Within
these
categories there are several different methods
that can be employed. These depend upon the
experience and training of the staff available and
the equipment and materials provided at the
time. A patient’s individual clinical status,
uterine size, pregnancy length and patient’s
choice are important considerations in deciding
which method is best suited.
MVA is a safe and effective method of
uterine evacuation with a success rate of 95 to 100
per cent3-5. It is quite practical when carried out
on an outpatient basis, requiring fewer resources
such as personnel, general anaesthesia, beds and
operating theatres. MVA requires low level of
pain management, with local anaesthesia, oral
S173
analgesics or light sedation, allowing the woman
to remain awake and aware of what is happening
during the procedure.
Indicators
for
considering
surgical
evacuation
include
continuous
excessive
bleeding, haemodynamic unstable patient and,
signs of infected retained products of conception.
weeks, any medical disorder such as anti HCV
positive or coagulopathy or haemodynamic
instability were not included. Similarly patients
with allergy to misoprostol and/or contraindication to use of misoprostol were not
included. Patients who had an allergic reaction to
local anaesthetic agents were also excluded.
Possible side effects of uterine evacuation
methods are abdominal cramping, menstrual like
bleeding, nausea and vomiting. Although less
common, complications include incomplete
evacuation, cervical tears, uterine perforation,
pelvic infection, haemorrhage and anaesthesia
complication.
A total of 120 women were included, 60 in
each group through non probability consecutive
sampling. The patients recruited were allowed to
proceed with the procedure on alternate basis i.e.
the first patient underwent manual vacuum
aspiration and the next one underwent dilatation
and curettage.
Sharp curettage is still the most widely
practiced method of dealing with incomplete
abortion in many developing countries. It usually
entails the use of general anaesthesia in an
operating theatre and often involves an overnight
stay in the hospital6.
The concept of MVA is basically identical to
routine surgical management of miscarriage
except in the fact that it accompanies the
recruitment of a handheld suction syringe.
Although the technique of MVA has been
used widely in USA, African, Asian and
European countries, its use in Pakistan, despite
being a low resource country, is low. Very little
data is available to prove its feasibility, safety and
efficacy over D&C in our setup. Hence we
conducted this study with the aim of comparing
the safety and efficacy of MVA over D&C in first
trimester pregnancy losses.
MATERIAL AND METHODS
This was a randomized control trial
conducted in Obstetrics and Gynaecology
department of Combined Military Hospital
Lahore from July 2014 to June 2015. All women
with gestational age <12 weeks with a diagnosis
of anembryonic pregnancy, incomplete or missed
miscarriage were included in the study after
informed consent.
Patients with clinical signs of infection
(fever, offensive discharge or generalised lower
abdominal pain) were not included. Patients that
were unwilling to participate in the study or
women
with
molar
pregnancy,
septic
miscarriage, uterine anomalies, leiomyomas >12
Vitals including pulse, temperature and
blood pressure were noted upon admission.
Diagnosis of miscarriage was made by history,
physical examination and ultrasonographic
scanning (USG). The date of the last menstrual
period and USG were used to determine the
gestational age.
All the women were given 400µg
misoprostol sublingual, 03 hours before
procedure for cervical priming. The time taken
for the misoprostol to dissolve was 10-15 min.
The patients were instructed not to sallow the
tablets during this period. For pain relief, 400-800
mg ibuprofen was administered orally one hour
before the procedure.
The women were requested to empty the
bladder right before the operation. The patient
underwent a vaginal examination in the
lithotomy position after proper cleaning with
antiseptic solution and draping.
Bimanual examination was done. The
anterior lip of the cervix was held with vulsellum
and para cervical block was given.
Ipas MVA Plus was used for evacuation. It
is a latex-free double-valve syringe with a
volume of 60 ml and has the ability to make a
S174
vacuum of 610 mm Hg to 660 mm Hg. Cannulas
were 24 cm long and were colour coded
correspondingly to their diameter, which ranged
from 4-12 mm. The suction cannula used was of
the same diameter (in mm) as the gestational age
Scores between 0-3 were considered to be mild,
4-6 as moderate and 7-10 as severe pain. All
patients with severe pain were given injectable
analgesics.
Table-1: Comparison of procedure indications and complications in both groups.
Indication for procedure
MVA(n=60)
D&C(n=60)
Incomplete miscarriage
9 (15.0%)
12 (20.0%)
Missed miscarriage
24 (40.0%)
20 (33.3%)
Anembryonic pregnancy
25 (41.7%)
27 (45.0%)
Failed medical treatment
2 (3.3%)
1 (1.7%)
Complications
Incomplete evacuation
3 (5%)
1 (1.7%)
Uterine perforation
0
1 (1.7%)
Infection
3 (5%)
2 (3.3%)
Blood loss >100 ml
0
1 (1.7%)
Anesthesia
0
1 (1.7%)
Table-2: Comparison of visual analogue score among both groups.
Level of pain
MVA (n=60)
D&C(n=60)
Mild(0-3)
53 (88.3%)
60 (100.0%)
Moderate(4-6)
5 (8.3%)
0 (0.0%)
Severe(7-10)
2 (3.3%)
0 (0.0%)
Table-3: Comparison of procedure cost and duration among both groups.
Time
MVA
D&C
Duration of procedure and post op
13.4 (±2.7)
24.6 (±5.3)
time (minutes)
Total time in hospital (hours)
14.2 (±2.4)
28.9 (±4.8)
Cost (Rupees)
4000-6000
60
0
13000-15000
0
59
>15000
0
1
Mean ± SD
4820 ± 270.76
14280 ± 927.38
p-value
0.752
0.37
p-value
0.024
p-value
<0.001
<0.001
<0.001
<0.001
p-value<0.05 taken as significant.
in weeks. The tube was flexible and tips were
rounded to help reduce the chances of uterine
perforation. The intrauterine contents were
aspirated through the cannula and when the
syringe was four-fifths full, it was removed from
the cannula and emptied. The syringe was then
prepared again.
After completion of procedure, products of
conception were sent for histopathology. Pain
scoring was done using visual analogue score.
Recordings were made on a 0-10 numerical scale.
Dilatation and curettage was performed
under general anaesthesia in the operation room.
Metallic dilators were used for dilatation and
sharp curettage was done until the procedure
was completed.
To decrease the bias both these procedures
were performed by senior registrar or assistant
professor and the data was collected on Performa.
Data entry and analysis was done by SPSS
version 20. The main outcomes include hospital
stay, hospital cost, complication and duration of
S175
procedure. Chi square and t-test were used for
categorical and continuous variables respectively.
A p-value of <0.01 indicated significance in all of
the analyses.
RESULTS
A total of 120 women participated in this
study. The mean age of the MVA group, in years,
was 26.1 ± 4.30 while the mean age in the DNC
group, also in years, was 27.3 ± 5.04 (p-value
being 0.16, not significant). The Gestational age
(wks) in the MVA group was 9.9 ± 1.20 and in the
D&C group it was 10.2 ± 1.40 (p-value being 0.21,
not significant).
In the MVA group 19 (31.7%) women were
primigravida, 36(60%) were multigravida and 5
(8.3%) were grand multigravida. The D&C group
had 18 (30%) women who were primigravida, 40
(66.7%) who were multigravida and 2 (3.3%) who
were grand multigravida.
The complete evacuation rate (success rate)
was similar in both groups (95% in MVA and
98.3% in D&C). The remaining cases were given
medical treatment to complete evacuation. With
regards to complication there is no difference
between the two. There was no excessive blood
loss requiring transfusion except in one case
which required laparotomy for perforation
during the procedures.
DISCUSSION
MVA is particularly appealing because it is
convenient and extremely safe. It is not associated
with an increased risk of pain, bleeding, uterine
perforation or infection. Furthermore it is cost
effective.
Employing MVA allows women to undergo
treatment in a timely way. With the removal of
the requirement of general anaesthesia, any
delays that are associated with availability of
operating room space can be avoided. The
woman can be discharged soon after the
procedure. MVA is a suitable technology for a
developing country like Pakistan where electrical
supply is not constant.
There has been an increase in the use of this
method in the developing world7. It is also
recommended as an effective and acceptable
surgical method in Royal College of Obstetrics
and Gynaecologists (RCOG) evidence based
guideline, the care of women requesting induced
abortion8. Many other studies have shown MVA
to be a practical alternative to EVA with high
success rates9-16. These studies have proved that
management of incomplete abortion with manual
vacuum aspiration is cost effective with short
hospital stay.
A systematic review of ten randomised trials
which involved 1660 women compared MVA
against EVA for first trimester miscarriage. There
was found to be no difference in the number of
complete evacuations and patient satisfaction16.
Another study conducted at Michigan
University compared 115 women undergoing
MVA with 50 women undergoing D&C in
theatre. The procedure itself took 80% more time
and costs were at least two-fold higher in D&C
than in the office setting17.
In an analysis of cost studies carried out in
Kenya, Mexico and the United States, MVA was
shown to be cheaper than D&C18.
The patient needs to be fully counselled on
what she should expect in each procedure and
ample time to reach a decision. Counselling
regarding contraception should also be given.
There appears to be no statistical difference in the
patient’s acceptability of MVA versus D&C16.
The complication rate is low in both groups
because the procedure was done by senior
personnel and not by trainees. There was only
one perforation in D&C group and none in MVA
group because MVA is done by soft flexible
cannula.
There are, however, limitations of the study.
The patients were not randomised to the
procedure. In addition, the sample size could not
be increased due to the unavailability of senior
registrar/ assistant professor.
S176
CONCLUSION
Our study shows that MVA is a better
option than D&C for surgical management of
miscarriage due to its cost effectiveness,
usefulness in the absence of electricity and its
reduction in total hospital stay time, while being
able to maintain the same level of complications
in selected patients.
8.
9.
10.
CONFLICT OF INTEREST
11.
This study has no conflict of interest to
declare by any author.
12.
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Original Article
Acute Appendicitis (USG)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83
ACUTE APPENDICITIS; ULTRASONOGRAPHY AS PRE-OPERATIVE
SCREENING TOOL
Amer Hayat Haider, Mohammad Nazir Qureshi*, Rizwan Bila, Ijaz Ahmad
Combined Military Hospital Hyderabad, Pakistan, * Military Hospital Rawalpindi, Pakistan, Combined Military Hospital,
Rawalpindi, Pakistan
ABSTRACT
Objective: To determine the accuracy of ultrasonography in confirming acute appendicitis in adult patients
presenting with relevant clinical features taking histopathology of removed appendix as the gold standard.
Study Design: Cross-sectional (Validation) study.
Place and Duration of Study: Radiology Department Combined Military Hospital (CMH) Rawalpindi from
August 2008 to February 2009.
Material and Methods: A total of 80 cases of clinically suspected acute appendicitis selected on non probability
convenience sampling technique were included in the study. They all underwent ultrasound evaluation.
Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of Ultrasound and
Ultrasound (USG) findings were calculated keeping surgical findings and histopathology of the removed
appendix as a gold standard, whenever appendectomy was carried out. SPSS version 16.0 was used to carry out
necessary statistical calculations.
Results: Out of 80 patients whose ultrasound examination of right lower quadrant (RLQ) was performed, 36
patients were correctly diagnosed as having acute appendicitis on USG out of 42 finally diagnosed cases based on
histopathology. Similarly we picked 18 normal appendices out of 38 non-appendicitis patients in which 6 proved
to be false negative. This showed that US scan has sensitivity of 86%, specificity 80%, PPV 92%, NPV 67% and
overall accuracy of 84%. The most accurate appendiceal finding for appendicitis was a diameter of 6 mm or larger
followed by non-compressibility of appendix.
Conclusion: Ultrasound has high diagnostic accuracy in diagnosis of acute appendicitis and helps to reduce
negative appendectomy rates. A greater than 6-mm diameter of the appendix under compression is the most
accurate US finding.
Keywords: Acute Appendicitis, Appendix, Appendectomy, Ultrasonography, Ultrasound.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Appendicitis is a common etiology of
abdominal pain, caused by acute inflammation of
the appendix and occurs in approximately 8-10%
of the population (over a lifetime)1,2. Acute
appendicitis is the most common surgical
abdominal emergency worldwide with life time
prevalence of one in seven3,4. The diagnosis of
acute appendicitis is mainly clinical but because
Correspondence: Dr Amer Hayat Haider, Combined Military
Hospital Hyderabad, Pakistan
Email:[email protected]
Received: 30 Jan 2012; revised received: 28 Dec 2015; accepted: 27 Apr
2016
of myriad presentation clinical assessment is
correct only in 80% of the total patients
presenting in the ER5. To prevent the dire
complications of the acute appendicitis, the
doubtful cases are preferably operated which
resulted in negative appendicectomy rate of
10-15% or even more in few cases, considered as
acceptable but ultimately carries both the risks of
mortality and morbidity6. The accurate diagnosis
of acute appendicitis is also important due to
many other abdominal conditions which may
simulate its clinical scenario especially in women
of reproductive age group, patients with mass
right iliac fossa (RIF) and in the extremes of
ages7,8.
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Routinely, diagnosis of acute appendicitis is
made upon the basis of clinical history, physical
examination and certain laboratory investigations
like total leukacyte count (TLC)9-10. In order to
improve the diagnostic accuracy different aids
have been introduced like different scoring
systems, gastrointestinal (GI) contrast studies,
ultra sonography (USG), computed tomography
(CT) scan, magnetic resonance imaging (MRI),
nuclear scan and laparoscopy8,11.
TLC is a commonly performed laboratory
investigation due to its availability and cost
effectiveness but due to its limited sensitivity and
specificity general surgeons require simple, cost
effective and readily available supportive
investigation
to
avoid
the
negative
appendicectomies12.
Many studies have claimed that the NPV of
CT scan is around 98%9, so certain people
especially in the west advocate its importance
due to the fact that it is not operator dependent
and chances of variations in results in various
setup are very less. The limitations of the CT scan
abdomen in our setups are its limited availability,
high cost and other general disadvantages like
extensive radiation dose and chances of contrast
reactions that make it a difficult diagnostic tool.
So there is utmost need to look for a diagnostic
tool that not only carries high sensitivity and
specificity but also cost effective, fast and readily
available.
USG of the abdomen is yet another practiced
investigation; its principle advantage is not its
highest accuracy but its non-invasive nature. The
diagnostic sign of acute appendicitis is
visualization of appendix on USG. However it
failed to gain popularity as a pillar of diagnosis in
the disease, because it is very much operator
dependent and results vary from person to
person depending upon the expertise of the
sonologist as well as certain patient factors like
obesity, gas filled gut loops in front of the
appendix, amount of inflammatory fluid around
the appendix and position of the appendix may
also add in its disadvantages13.
The significance of this study is that
ultrasound will definitely increase the confidence
of general surgeons in diagnosis of acute
appendicitis resultantly reducing the negative
appendicectomy rate, which will help the patient
by reducing the patient’s exposure to the
mortality, morbidity and certain post operative
complications like intestinal obstruction due to
adhesions and fertility problems in females7,14. It
will definitely reduce the burden on health care
system and overall society as undue surgeries
have socioeconomic impacts in the form of loss of
working days and declined productivity.
The rationale of this study was to add
further information and help in better
understanding of the role of USG in patients of
acute appendicitis. This also highlighted the
importance of ultrasound as a useful, readily
available, non-invasive and radiation free
investigation in these patients. The study was
based on the presumption that a thorough
appendicitis-specific USG examination yields
more accurate diagnosis helping to reduce high
negative appendectomy rates and thereby
benefiting the affected patients.
MATERIAL AND METHODS
This descriptive (validation) study was
conducted at the Radiology Department,
Combined Military Hospital Rawalpindi from
August 2008 to February 2009.
Patients of both genders more than 18 years
of age with presence of relevant clinical features
were included in the study.
Patients with mass right iliac fossa, known
history of appendicectomy, pregnancy, adnexal
mass, right ovarian torsion, or pelvic
inflammatory disease (PID) were excluded.
Data Collection Procedure
A total of 80 cases of clinically suspected
acute appendicitis selected on non probability
convenience sampling technique were included
in the study. They all underwent USG evaluation.
Sensitivity, Specificity, Positive Predictive Value
(PPV) and Negative Predictive Value (NPV) of
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Ultrasound and US findings were calculated
keeping surgical findings and histopathology of
the removed appendix as gold standard
whenever appendectomy was carried out. SPSS
version 16.0 was used to carry out necessary
statistical calculations.
RESULTS
There were 55 (69%) males and 25 (31%)
females out of a total sample of 80 patients. The
age of the patients ranged from 18 years to 70
years with a mean age of 21 years and SD ± 4. All
the patients were subjected to US abdomen
within
2-4 hours of presentation in the ER.
Findings of USG were matched against the
histopathological findings of appendix after
surgery.
US diagnosis of acute appendicitis was made
in 39 patients who underwent surgery.
Histopathology of the resected appendices
showed signs of acute appendicitis in 36, whereas
patients, among these 18 US negative patients,
persisted to have clinical signs and symptoms of
acute appendicitis. Surgical intervention was
carried out within 24 hours of US examination
and they turned out to be having inflamed
appendices on surgery and histopathology (thus
giving the non-visualization of the appendix at
Ultrasound a NPV of 67%). These were the FN
results of US as shown in table-1 and fig-1. Two
out of these six patients had perforated
appendicitis and the other four had retrocoecal
appendices.
In 38 non appendicitis patients, diagnosis
was confirmed on US in 15 patients, on surgery in
3 patients (3 US false positive cases), on
endoscopy in 2 patients and at clinical follow up
in 18 patients. Final diagnosis of all the patients is
shown in table-2.
Appendix was seen on US in 57 patients out
of 80 (71%) including 39 inflamed, 18 normal
Table-1: Breakdown of cases with appendicitis.
Ultrasound Positive
Ultrasound Negative
Histopathology Positive
True Positive
36
True Negative
12
39
18
Histopathology Negative
False Positive
3
False Negative
6
Table-2: Final diagnosis of the patients.
Valid acute appendicitis
Pain with no definitive cause
Mesenteric lymphadenitis
Cystitis
GE
PID
Peptic ulcer
Misc
Frequency
Percent
Valid percent
42
13
8
3
6
2
4
2
52.5
16.3
10.0
3.8
7.5
2.5
5.02
2.5
52.5
16.3
10.0
3.8
7.5
2.5
5.02
2.5
3 appendices turned out to be normal, thus
making 3 false positive (FP) US results.
In 41 US negative patients a normal
appendix was identified in 18 patients (47% of
USG negative patients) and in the remaining 23
(53%) appendix was not identified on US. Six
Cumulative
Percent
52.5
68.8
78.8
82.5
90.0
92.5
97.5
100
appendices and appendix was not seen in 23
patients. In these patients, a diameter of 6 mm or
larger was the most accurate finding for
appendicitis followed by lack of compressibility.
Appendicolith was found in only 20% of
appendicitis patients.
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DISCUSSION
It is agreed upon at various levels that acute
appendicitis is the most common surgical
emergency worldwide, warranting early surgical
intervention to prevent the complications1-3. Even
with the advent of modern clinical assessment
methods, acute appendicitis always puts the
surgeon’s clinical judgment into a real test in
majority of the cases, especially in the women of
reproductive age group and extremes of ages
resulting into a challenge for general surgeons
not only to prevent complications but also to
prevent unnecessary interventions7, 8.
The overall accuracy of clinical diagnosis of
acute appendicitis is approximately 80% with
mean negative appendicectomy rate of 20%,
mainly due to the difficulties faced in
differentiation of acute appendicitis from other
5 female patients with various gynecological
disorders,8 with mesenteric adenitis. Probable
diagnosis of peptic ulcer was given in one patient
and gut perforation in another patient due to
peptic ulcer disease, which all turned out the
same
on
follow
up.
This
beautifully
demonstrated the benefit of US for the provision
of an alternate diagnosis to explain the patient's
symptoms providing the opportunity to examine
rest of the abdomen and pelvis in a very short
acquisition time17,18.
The inability to visualize the normal
appendix is classically considered a major
weakness of US in the assessment of patients
suspected of having appendicitis because it
represents a serious limitation to confidently
excluding the diagnosis of appendicitis19.
US evaluation of the appendix ideally
Figure-1: Correlation between US & histopathological findings.
abdominal conditions5,6. To lower the rate of
unnecessary surgeries and to improve the
diagnostic accuracy, laboratory investigations
and imaging have been increasingly used,
particularly in equivocal cases15,16.
In patients who were US negative for acute
appendicitis (n=38), definite alternative diagnosis
were made on US in 15 patients, which included
includes the evaluation of the appendiceal wall
and appendiceal content. We decided to measure
the outer appendiceal diameter rather than
appendiceal wall thickness for two reasons.
Inflammation of the appendiceal wall may be
difficult to distinguish from hypoechoic
intraluminal pus, thus making measurement of
the appendiceal wall inaccurate and second the
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mucosal surface may be difficult to identify
within the appendix20. We found that
identification of an appendix measuring less than
6 mm in diameter was an accurate indication to
exclude appendicitis, with a NPV of 67%. Which
is slightly out of line with the studies by
Rettenbacher et al obtained a NPV of 100% with
this sign, whereas Rioux reported a NPV of 98%
with it20,21. The diameter of 6 mm or above for the
diagnosis of an inflamed appendix, which is the
most commonly reported threshold, had high
PPV (95%) in our study. The high PPV is out of
line with the data obtained by Rettenbacher et al
who reported an appendiceal diameter of 6 mm
or larger in 32% of symptomatic patients without
appendicitis in whom the appendix was
identified21. We found that hyperemia in the
appendiceal wall shown on the color doppler
images was a specific finding for appendicitis
that was encountered in only three of the patients
without appendicitis. The same high specificity
was already reported in previously published
studies in which flow was never identified in the
normal appendiceal wall22. This finding,
however, showed a sensitivity of only 45%.
Our evaluation of the content of the
appendiceal lumen focused on the presence of
intraluminal fluid as a sign of appendicitis,
whereas Rettenbacher and his fellows considered
the absence of gas in the appendiceal lumen as a
criterion for appendicitis. The same mechanism
might explain both the presence of fluid and the
absence of gas in an appendix. Obstruction,
which is the most common cause of appendicitis,
could lead to retention of pus or appendiceal
secretion with resorption of intraluminal gas. We
did not evaluate the presence or absence of gas in
the appendix because we considered that the US
appearance of a tiny appendicolith or a small
amount of feces could resemble gas and in
addition, its evaluation is easier at CT than at US
23,24. By contrast, appendiceal fluid, which is a
finding that has never been evaluated to our
knowledge, is easier to identify and its presence
could be a useful ancillary sign.
To summarize, our study suggests a quick
protocol to diagnose acute appendicitis especially
in equivocal cases with cost effectiveness,
avoiding radiation exposure and intravenous
contrast administration.
CONCLUSION
Ultrasound is a noninvasive highly
diagnostic investigation with the overall accuracy
of 84%. It has improved our ability to detect
appendicitis and its complications with improved
results and reduced rate of unnecessary surgeries
resulting
into
decreased
negative
appendicectomy rate. In addition various
diseases simulating acute appendicitis can also be
diagnosed especially in pregnant ladies and
extremes of ages. Tissue harmonic ultrasound
therefore is an imaging modality of preference in
cases of acute appendicitis.
Diameter of inflamed appendix more than 6
mm is the most sensitive US finding for
appendicitis with high PPV and NPV followed by
non-compressibility of the inflamed appendix.
These two US findings together provide the most
accurate diagnosis in suspected cases of acute
appendicitis.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
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S183
Original Article
Complications of Central Venous Catheters in Adults
Pak Armed Forces Med J 2016; 66 (Suppl-3): S184-88
FREQUENCY OF MECHANICAL COMPLICATIONS ASSOCIATED WITH INSERTION
OF CENTRAL VENOUS CATHETERS IN ADULT PATIENTS AT A TERTIARY CARE
FACILITY
Muhammad Fahd Bin Haider, Kamran Aziz*, Shahid Ahmed**
Combined Military Hospital Rahim Yar Khan, Pakistan, *Combined Military Hospital Lahore, Pakistan, **Military Hospital
Rawalpindi, Pakistan
ABSTRACT
Objective: To determine the frequency of overall mechanical complications associated with insertion of central
venous catheters in adult patients reporting to hospital.
Study Design: Observational study.
Place and Duration of Study: Department of Medicine Combined Military Hospital, Lahore & Army Cardiac
Center, Lahore (Pakistan) from June 2011 to December 2011.
Patients and Methods: Eighty seven adults fulfilling the inclusion criteria were included in the study through
non-probability consecutive sampling. Central venous catheters (CVCs) were inserted using standardised kits
and adopting Sledinger technique. The patients were observed for any immediate mechanical complications.
Standard treatment was offered to those developing complications except for catheter malposition which was not
corrected. All entries were made on the patients’ proformas.
Results: A total of 61(70%) catheters had complications with highest frequency associated with malpositioned
40(46%) catheters.
Conclusion: Catheter malposition was the most frequent complication encountered.
Keywords: CVCs (Central Venous Catheters), Complications, Mechanical.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Central venous catheters are used in
critically ill patients throughout the world to
allow hemodynamic monitoring and easy access
for administration of fluids and medication1.
There use is associated with various
complications. Published rates of complications
vary based upon anatomic site and operator
experience. An observational cohort study of 385
consecutive CVC (Central Venous Catheter)
attempts over a six month period found that
mechanical complications occurred in 33 percent
of attempts2. Other studies show variable rates
from 30% to 56%3,4. The present study was
designed to quantify the iatrogenic risk
Correspondence: Dr Muhammad Fahd Bin Haider Combined
Military Hospital Rahim Yar Khan, Pakistan
Email: [email protected]
Received 16 Feb 2016; revised received: 2 May 2016; accepted: 10 May
2016
associated with insertion of Central venous
Catheters at our center.
PATIENTS AND METHODS
This
Observational
study
recorded
mechanical complications associated with
insertion of 87 consecutive Central venous
Catheter catheters at Combined Military Hospital
(CMH) Lahore and Army Cardiac Center (ACC)
Lahore over a period of 6 months and 15 days
from 1st June 2011 to 15th December 2011 using
non-probability consecutive sampling. The
sample size was calculated using sample size
calculator keeping confidence level of 95%,
anticipated population proportion 0.33 and
absolute precision of 0.10. All adults aging more
than 18 years requiring a CVC on any grounds
(emergent, non-urgent, for hemodialysis or for
fluid status monitoring) were included. The
standard Seldinger technique was employed.
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This method gains access to the central vein via
an introducer needle through which a matching
guidewire is threaded to maintain venous access
after needle withdrawal. The catheter is advanced
into position over the intravascular guidewire
which is subsequently removed from the
catheter. The operators were from different
departments and at different strata of their
clinical experience Catheters inserted by any
technique other than the standard Sledinger
technique were excluded. CVCs selected were
one of these manufacturers- Arrow, Health Line
International Corporation and B Braun. Before
attempting operators wore sterilised gloves and
ensured sterile equipment. Verbal consent was
sought from the patients prior to the procedure in
all non-urgent cases. Choice regarding site of
insertion was left at the discretion of the operator
whose minimal qualification was MBBS. CVCs
were inserted by the operators independently
without ultrasound guidance and if they
remained unable to do so expert help was sought
or the procedure was abandoned. Failure of
insertion at one site was recorded and when
another site was chosen for insertion it was
considered a fresh attempt and was accordingly
entered into the data despite that it was the same
patient but was regarded a new one with
reference to the attempt made. Complications if
any were identified and recorded. Patients with
Jugular and subclavian vein catheters had their
chest radiographs taken for identification of
Pneumothorax and positioning of the catheters.
Supine patients had their CXR (AP) views. These
radiographs were personally seen by the author
himself and if required, expert help was sought
from the specialists in Radiology at the
Department of Radiology, CMH Lahore.
Catheters with ambiguous positioning had to be
excluded from the study wherever it was
practical and possible. Entries were made on
special patients’ proformas. Statistical analysis of
all the data was entered in the Statistical Package
for Social Sciences version 19.0 for analysis. Chi
square calculator was used to calculate p values
in cases where comparison was done. Mean and
standard deviation were calculated for age.
Frequency was calculated for qualitative
variables including: If the operator remained
unable to pass the catheter at the initially selected
site. The decision to change the site of insertion
after attempted insertion failure was also
considered a failure of placement at that
particular site; Assessed by return of blood and
free flow of fluid in all ports or any catheter
needing repositioning after review of the
radiograph or if the distal catheter tip was not in
the second right intercostal space5 on a postroanterior chest radiograph; Pulsatile flow into the
syringe and the bright-red colour of the blood;
Air in pleural space detectable clinically or on
chest radiograph. Other variables included No
Complication, Gender and Arrest.
RESULTS
A total of 87 patients were included in the
study out of which 59 (67.8%) were males and 28
(32.2%) were females. The age of patients varied
from 20 to 85 years with mean and SD
58.44 ± 13.80. 12 (13.8%) cases had history of prior
catheterisation almost all being Double Lumen
catheters. Distribution in three selected sites is
shown table-1. The frequency of two main types
of CVCs used was CVPs 53 (61%), Double
Lumens 34 (39%). The Frequency of outcome
variables is mentioned table-2. Some catheters
were associated with more than one
complication. Hemothorax and Arrest were not
encountered whereas one patient (0.011%)
developed SVT- a complication which had not
been selected as an outcome variable but merited
mention because frequency of arrhythmias in this
setting is very low in the published literature and
we encountered this rare complication. Overall
frequency of complications was 60 (69%) table-3.
Group comparison revealed: 23 (82%) females
and 37 (62%) males had complications (p=0.06)
table-4. 22 (64.7%) Double Lumens and 38 (71.6%)
CVP Lines were associated with complications
(p=0.49). Based upon site of insertion frequency
of complications was: Jugular 45 (75%),
Subcalvian 13 (21.6%), Femoral 2 (3.3%). 6 (50%)
CVCs inserted in pateients having history of prior
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S184-88
catheterisation were complicated in contrast to 54
(72%) CVCs associated with complications in
patients without prior history of catheterisation
(p=0.12).
DISCUSSION
In the present study a total of 87 catheters
were attempted over a period of about 6.5
months. Published rates of complications vary
from as low as 15% to as high as 56%6,7. An
observational cohort study of 385 consecutive
CVC attempts over a six month period found that
percutaneous punctures2. Based upon this it is
recommended that the number of percutaneous
attempts to be limited to three attempts at a time.
The tip of the catheter should ideally be
outside the right atrium and inside the desired
vein otherwise it can cause atrial perforation8,9.
Several studies mention cavoatrial junction as the
preferred site10. We defined right second
intercostal space as the correct site for cathter tip
position5. Recommended insertion distances are
16 cm for right-sided and 20 cm for left-sided
Table-1: Site distribution of the central venous catheterization.
Jugular
Subclavian
Femoral
Total
58 (66.7%)
21 (24.1%)
8 (9.2%)
87
Table-2: Frequency of outcome variables associated with the insertion of central venous catheterization.
Variable
Frequency
Malposition
38 (43.6%)
Failure to place
11 (12.6%)
Arterial puncture
4 (4.6%)
Pneumothorax
1 (0.011%)
Malposition +Pneumothorax
1(0.011%)
Malposition + Arterial puncture
1(0.011%)
Failure to place + Arterial puncture
4 (4.6%)
Hemothorax
0
No complication
27 (31%)
Total
87
Table-3: Overall frequency of complications.
Complication
No complication
Total
60 (68.9%)
27 (31%)
87
Table-4: Gender differences in frequency of complications.
Gender
Complications
Total
Female
Male
Total
Yes
No
23 (82%)
37 (62%)
60
5
22
27
mechanical complications occurred in 33 percent
of attempts. Complications included failure to
place the catheter (22 percent), arterial puncture
(5 percent), catheter malposition (4 percent),
pneumothorax
(1
percent),
subcutaneous
hematoma (1 percent), hemothorax (less than 1
percent), and asystolic cardiac arrest (less than 1
percent)2. Follows an account of salient features
of mechanical complications.
Studies have shown that failure to place
CVCs is proportional to the number of
28
59
87
internal jugular and subclavian vein catheters11.
Newer techniques like use of Ultrasound and
Right Atrial ECG prior to the placement of CVCs
can also help12,13 . The use of a chest radiograph
for confirmation of CVC position is now
mandatory14, though its sensitivity and specificity
are not that high15.
Once an arterial stick is suspected either by
bright red or pulsatile blood, the needle is
immediately withdrawn and direct but
nonocclusive pressure applied to the site
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continuously for 15 minutes to prevent
hematoma formation. Unrecognized arterial
cannulation with subsequent dilation and
catheter placement is associated with lifethreatening
hemorrhage
and
neurologic
complications16.
Overall subclavian catheters are associated
with higher rates of pneumothorax. Adherence to
the recommended insertion techniques helps in
reducing this complication.
Analysis of our data revealed that
predominantly the patients were males. The
patients were a mix of those on hemodialysis,
some required urgent CVC insertion based on
clinical grounds while others had undergone
CABG. The mean age was 58 years. Jugular vein
remained the favourite site of insertion (66.7%), it
is not known whether operators found it more
convenient or they relied on some studies which
show less complication rate with jugular as
compared to the subclavian approach17.
Regarding the frequency of types of CVCs, more
CVP lines were attempted than DLs. The overall
frequency of complications was 68.9% with
malposition being the chief complication (46%).
In some studies which have kept middle to lower
parts of Superior Vena Cava as positions of
choice for catheter tip along with cavoatrial
junction, complication rates as high as 56% have
been reported6,7. In another study18 which
compared the results of catheter position inserted
with and without the use of atrial ECG (in our
study we used a blind technique similar to the
group without atrial ECG) 48% of catheters were
malpositioned when carina and 4cm above it
were kept as reference area. Another fact to note
is that bedside chest x ray does not reliably
predict catheter tip position as the sensitivity and
specificity of chest x ray for proper catheter tip
position were 74.3% and 58.3% respectively15.
Nonetheless the complication rate can be reduced
by familiarization with guidelines that specify the
desired length of the catheter to be inserted20.
Jugular cannulation had the highest frequency of
complications (77.5%). Published literature shows
variable rates with both approaches2. Consistent
with international studies20, jugular cannulation
in our study was associated with higher rates of
arterial puncture as compared to subclavian
cannulation (12% vs 4.8%), the latter was
associated with higher rates of Pneumothorax
instead as compared to the internal jugular
cannulation (9.5% vs 0%). More females (82%)
than males developed complications at our
center. International data show varied results.
Another interesting result was higher frequency
of complications (72%) in patients who had not
been previously catheterised. Though it has been
seen that veins which have been previously
cannulated have difficult re-cannulation because
of thrombosis and possible alteration of anatomy
but the paradox in our study may possibly be
explained by recognition of this fact by the
operators and therefore leading to a selection bias
for the site. The patients who had experienced
Pneumothorax were chest intubated. Another
patient who developed SVT during catheter
insertion was administered injection Adenosine
12 mg I/V stat followed by catheter
repositioning. Sinus rhythm was restored after
some time. To decrease complications further
operators should be continuously kept informed
of the latest guidelines on the subject. Obtaining
radiographs was probably the most difficult part
of the study. It is suggested that medical
complexes should be built such that the clinical
and the diagnostic services are under one roof.
CONCLUSION
The frequency of complications associated
with CVC insertion at our center demands that
we should set a standard for correct placement of
catheter tips and then disseminate it to all of our
hospitals. In our study, typically a female without
history of
previous catheterisation and
undergoing jugular venous cannulation with a
CVP line best depicts a patient whose is most
likely to have a complication in our center with
the chief complication being catheter malposition.
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1. Akmal AH, Hasan M, Mariam A. The incidence of complications
of central venous catheters at an intensive care unit. Ann Thorac
Med. 2007; 2(2):61-3
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Complications of Central Venous Catheters in Adults
Pak Armed Forces Med J 2016; 66 (Suppl-3): S184-88
2. Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ,
Schneider RF. Mechanical complications of central venous
catheters. J Intensive Care Med. 2006; 21(1):40-6.
3. Akbar SA, Ali J, Ahmad N, Qasim M. Central Venous Pressure
Line. Professional Med J. 2009; 16(1):44-7.
4. Johnson.A.J, Holder A, Bishop SM, See TC, Streater CT.
Evaluation of the Sherlock 3CG Tip Confirmation System on
peripherally inserted central catheter malposition rates.
Anaesthesia. 2014; (69):1322-30.
5. A Yilmazlar, H Bilgin, G Korfali, A Eren, U Ozkan.
Complications of 1303 central venous cannulations. J R Soc Med.
1997; (90):319-321
6. Johnson.A.J, Holder A, Bishop SM, See TC, Streater CT.
Evaluation of the Sherlock 3CG Tip Confirmation System on
peripherally inserted central catheter malposition rates.
Anaesthesia. 2014; (69):1322-30.
7. McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V,
Mallory DL. Accurate placement of central venous catheters : a
prospective, randomizd, multicenter trial. Crit Care Med. 1993;
21(8):1118-23.
8. William T. McGee DC. Central Venous Catheterization: Better
and Worse. J Intensive Care Med 2006; 21; 51
9. Collier PE, Blocker SH, Graff DM, Doyle P. Cardiac tamponade
from central venous catheters. Am J Surg.1998;176:212-214]
10. Baskin KM, Jimenez RM, cahill AM, Jawad AF, Towbin RB.
Cavoatrial Junction and Central venous Anatomy: implications
for Central Venous access tip position. J Vasc Interv Radiol.
2008; 19(3):359-65.
11. Polderman KH, Girbes AJ. Central venous catheter use. Part 1:
mechanical complications. Intensive Care Med. 2002; 28(1):1
12. Gebhard RE; Szmuk P; Pivalizza EG; Melnikov V; Vogt C;
Warters RD. The accuracy of electrocardiogram-controlled
central line placement. Anesth Analg. 2007; 104(1):65-70.
13. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S,
Beverley C, Thomas S . Ultrasonic locating devices for central
venous cannulation: meta-analysis. BMJ. 2003; 327(7411):361
14. Abood GJ; Davis KA; Esposito TJ; Luchette FA; Gamelli RL.
Comparison of routine chest radiograph versus clinician
judgment to determine adequate central line placement in
critically ill patients. J Trauma. 2007; 63(1):50-6
15. Salimi F, Hekmatnia A, Shahabi J, Keshavarzian A. Evaluation
of routine postoperative chest roentgenogram for determination
of the correct position of permanent central venous catheter tip. J
Res Med Sci. 2015; 20(1):89-92.
16. Jobes DR, Schwartz AJ, Greenhow DE, et al. Safer jugular vein
cannulation: recognition of arterial puncture and preferential
use of the external jugular route. Anesthesiology 1983; 59:353.
17. McGeD C, Gould M K. Preventing Complications of Central
Venous Catheterization. NEJM. 2003; 348(12):1123-33
18. Sharma D, Singh VP, Malhotra MK and Gupta K. Optimum
depth of central venous catheter- comparison by Pere’s,
landmark and endocavitory (atrial) ECG technique: A
prospective study. Anes Essays Res. 2013; 7(2):216-20.
19. Peres PW. Positioning central venous catheters--a prospective
survey. Anaesth Intensive Care. 1990; 18(4):536.].
20. Robert W, Taylor, Ashok V, Palagiri. Centarl venous
Cathterization: Concise Definitive Review. Crit Care Med. 2007;
35(5):1390-96.
S188
Original Article
Medical Students View of Conduct of Examination
Pak Armed Forces Med J 2016; 66 (Suppl-3): S189-93
PERCEPTIONS AND FEEDBACK OF MEDICAL STUDENTS TOWARDS CONDUCT OF
EXAMINATION
Khadija Qamar, Gulshan Trali, Humaira Arshad
Army Medical College, National University of Medical Sciences (NUMS) Rawalpindi, Pakistan
ABSTRACT
Objective: The aim of this study is to evaluate the practicability of the environment during the practical session of
an exam.
Place and Duration of Study: August 07 to August 13, 2015 in the Department of Anatomy at Army Medical
College.
Study Design: Cross sectional survey.
Material and Methods: Two hundred second year MBBS students were selected using non-probability
convenience sampling, during a running practical session of the Second Professional Examination at the Army
Medical College. Feedback was collected from these students after they had undertaken their theory section of the
university exam. The student feedback was collected via an open and closed ended questionnaire which focused
on pre-examination arrangements, examination conduct and general impressions of examination environment.
Results: Of the 200 questionnaires distributed, 198 (99%) were returned duly filled. Overall, 78.7% were satisfied
with the waiting areas which were provided with basic amenities. Seventy six percent students were satisfied
with the punctuality of the session and 92.4%students agreed that instructions were clearly conveyed prior to
start of examination. About 68.5% of the students were satisfied with the helpful behavior of the conducting staff,
90.9% of the students agreed that instructions on stations were clear and concise and 78.2% of the students agreed
that adequate time was provided in performing tasks. Approximate 63.5%of the students were satisfied with the
general atmosphere of the laboratory and Dissection Hall.
Conclusion: Overall, the students were satisfied with the general environment and conduct of the exam.
Keywords: Assessment, Medical Education, Practicability of Assessment Procedures.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
The Army Medical College has an ambition
to provide thebest and most promising
environment and learning experience1 to
encourage students to perform to their full
capacity. There is a clear indication from students
that feedback on examinations is important to
them. Students play a critical part in the
evaluation, development and augmentation of
the quality of this learning experience2. Feedback
from students allows the college to evaluate how
its service establishment is viewed by its most
important group of stakeholders- the students.
Correspondence: Dr Khadija Qamar, Prof of Anatomy Dept, AM
College Rawalpindi, Pakistan (Email:[email protected])
Received: 08 Sep 2015; revised received: 29 Sep 2015; accepted: 30 Sep
2015
Students act as collaborators not just the passive
receivers of the teaching and learning process,
playing a crucial role. Feedback on any of the
learning processes whether it’s learning or
assessment provides
students
with
the
opportunity to remark on their experience3.
A feedback mechanism helps to highlight
the quality of students' learning and evaluation
experiences, as required in preparation for and as
part of review practices. This also provides a
vision of academic delivery in relation to the
expectations of students in order to improve that
component4. Feedback from students allows the
teachers to modify their methods to meet the
needs of the students. Many international experts
consider feedback to be an important element of
assessment for learning, naming it among the
S189
Medical Students View of Conduct of Examination
Pak Armed Forces Med J 2016; 66 (Suppl-3): S189-93
most critical influences on the students'
learning.The atmosphere of the examination
environment exemplifies an affective tone5.
Assessment is not just a test butis reflective of the
learning process. The physical environment
influences overall student satisfaction6 One way
in which the physical environment can impact
perceptions of service quality is by evoking
emotional responses that influence behaviors.
Plenty of research has been conducted regarding
how environmental factors such as ambience,
social interaction (attitude of the instructor), and
design cues (seating and layout) create affective
emotional responses from students and influence
overall satisfaction. A primary goal of creating
effective environments is to enhance the
assessment experience. Future researchers should
measure actual learning by directing specific and
varied measures in the exam place. These tools
can improve the teaching and assessment process
and subsequently enable educational institutions
to improve examination systems. A gap was
identified in the examination process through
direct evidence during this study. The rationale
of the present study was to obtain student
feedback on the examination environment at the
Army Medical College.
MATERIAL AND METHODS
The descriptive cross-sectional survey of 200
second year MBBS students at Army Medical
College using non-probability convenience
sampling was conducted from August 07 to
August 13, 2015, during the running session of
the Second Professional Examination. Feedback
was collected after students had undertaken their
theory part of the university exam, during their
practical session in the Department of Anatomy
.OSPE was organized by the individual
department for the practical component of the
subject. The student feedback was collected via
questionnaire focused on the pre examination
arrangements, the examination conduct, general
impression and any suggestions.
Students who completed the questionnaire
were not asked at any stage for their names.
There was no penalty for abstaining from
submission of feedback, since this drill was to
evaluate the deficiencies and conduct of
examination.
The Feedback questionnaire contained 21
questions out of which 19 questions were
prepared on Likert’s scale and two questions
were open ended. Responses from students in the
form of the feedback questionnaire were
statistically
analyzed
through
descriptive
analysis. Student response data was grouped
together for the entire class for the purpose of
data analysis. The faculty received a report which
summarized all the information organized as
percentage values.
RESULTS
Of the 200 questionnaires distributed, 198
(99%) were returned duly filled. Overall, 78.7%
were satisfied with the waiting areas which were
provided with basic amenities, 75.6% students
were satisfied with the punctuality of the timing
92.4% students agreed that instructions were
clearly conveyed prior to start of examination.
About 68.5% of the students were satisfied with
the helpful behavior and of the conducting staff,
90.9% of the students agreed that instructions on
stations were clear and concise and 78.2% of the
students agreed that adequate time was provided
in performing the tasks. Sixty four percent of the
students were satisfied with the general
atmosphere of the laboratory and Dissection Hall.
(table-1). The open ended questions were
analyzed for the qualitative data.Generally the
students were satisfied with the overall conduct
of examination but complained about the staff’s
attitude. Most of the students reported that the
examiners were very helpful and available when
needed. However the students found The Stair
hall waiting area, inappropriate due to nonavailability of food and water. Some of the
students thought that the time for the observed
and non-observed stations was not sufficient. The
general impression was that the system was
functional, but there was room for improvement.
In response to the suggestions for improving
S190
Medical Students View of Conduct of Examination
examination systems at AM College, ninety
percent students proposed for the waiting area to
be equipped with more seating arrangements,
fans and drinking water. They also suggested
that the Exam should be more organized and
systematic and a system should be devised to
spread the burden of simultaneous assessment of
5 subjects. Finally, it was deemed that the time
span for the viva was too long and tiring along
Pak Armed Forces Med J 2016; 66 (Suppl-3): S189-93
and examination process through feedback will
provide improvements in the system. Interest in
practical exercises by students appears average
from our results, and the reasons were mainly
inadequate equipment/manpower support.
Data Analysis
The questionnaires were administered on
paper and the data values were presented as
Table: Feedback regarding the general atmosphere of the laboratory and dissection hall.
Variables
Frequency
Percentages
Waiting area (comfortable, provided
Comfortable
155
78.7
with basic amenities etc
Un comfortable
36
18.3
Total
191
97.0
Timing observed punctually?
Yes
149
75.6
No
45
22.8
Total
194
98.5
Instructions clearly conveyed prior
Yes
182
92.4
to start of examination?
No
11
5.6
Total
193
98.0
Conducting
staff
helpful
/
Very helpful /
41
20.8
Cooperative?
cooperative
Helpful/cooperative
135
68.5
Not helpful
13
6.6
Not helpful at all
2
1.0
Total
191
97.0
Instructions on stations were
Yes
179
90.9
clear/concies?
No
10
5.1
Total
189
95.9
Time provide in tasks?
Excessive
18
9.1
Adequate
154
78.2
In-adequate
22
11.2
Total
194
98.5
General atmosphere of lab and DH?
Noisy
15
7.6
Quiet
125
63.5
Conductive to smooth
53
26.9
conduct
Disruptive
2
1.0
Total
195
99.0
with the short time limit for each station at gross
percentages and frequencies in order to
spotting. Student’s recommendations for better
calculatedescriptive data.
learning were as follows: examination space
DISCUSSION
should be a more interactive environment with
Learning
environments
are
typically
improved electricity supply. Smaller groups in
constructivist in nature, engaging learners in
practical sessions and improved supervision by
reasoning through broad resource sets7. A
teachers were also suggested by many students.
healthy and compassionate working environment
Involvement of students in program appraisals
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Medical Students View of Conduct of Examination
Pak Armed Forces Med J 2016; 66 (Suppl-3): S189-93
aids in the achievement of milestones, desired
results,
intended
standards,
professional
competence, sound knowledge and other
domestic oriented goals for people and
institutions. An unhealthy learning environment
becomes an obstacle that impedes the
development of outstanding performance in
individuals thus culminating in failure.
To preserve the sacredness of best
performance in
individuals,
a working
environment must be calm, clear, structured,
accountable,
well
regulated,
monitored,
communicative,
dedicated,
accommodative,
helpful and able to foster the considerations and
needs of the people along with divulging them
knowledge.
Assessment is an important part of
education. A medical curriculum should
constantly develop in response to the need of
students, institutions and communities8. Student
feedback about educational practices is a useful
basis for modifying and improving learning
environments. The ultimate aim of such feedback
is to identify areas of strength and weakness in
the examination environment. All of the staff that
interacts with the learners, needs to behave
professionally. Students should know who they
can contact if they feel they are being asked to do
anything that makes them feel uncomfortable.
Positive assertions displayed in the classroom
and referred to regularly with the sharing of
objectives and revising learning, actively foster
positive approaches and performances among
students, especially during examinations9.
Traditional exam exercises present students
with a tightly scripted practice that they are
expected to follow, making them physically
engaged
but
not
mentally.
Students'
understanding of the overall concepts in practical
sessions is thus poor, and their primary concern
is obtaining the expected results and writing
prescribed
reports10. Students
should
be
encouraged to work together, allowing for better
interactions and efficient supervision.
The physical environment has been thought
to interact with the learning process11. From one
perspective, the physical environment has been
thought to increase or decrease the likelihood
that learning and teaching will be effective. The
physical environment includes any characteristic
of the setting such as examination center style,
furnishings layout and comfort12, as it was the
case in our study. The seating organization might
influence both the existence and the nature of
social interaction13. A study of working
conditions have reported direct positive and
negative effects on learners' morale, sense of
personal safety and feelings of effectiveness
during the exam14.
Building renovations provide a renewed
sense of hope and a belief that the administration
cared for the learners' learning environment. The
ability to control the temperature of a learning
and assessment environment is crucial to the
effective performance of students.Uncomfortable
conditions not only make it difficult for students
to concentrate on their lessons, but inevitably
limit the amount of time spent on innovative
teaching methods such as cooperative learning
and group work.
Hines' study of large, urban high schools in
Virginia also found a relationship between
building condition and student achievement15.
McGuffey (1982) reported that heating and air
conditioning systems appeared to be very
important, along with special instructional
facilities (practical laboratories and tools)
contributory to student accomplishment. Proper
building maintenance was also found to be
related to better insistence and less castigating
problems in one cited study16.
Poor environmental settings such as flaking
paint, nonfunctioning toilets, poor lighting,
inadequate ventilation, and defective heating and
cooling systems can disturb learning as well as
the health and the self-esteem of students17.An
important finding in our research suggested that
the social element of the environment had a
major impact on student satisfaction. Educators
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Medical Students View of Conduct of Examination
Pak Armed Forces Med J 2016; 66 (Suppl-3): S189-93
should consider physical environment and how it
influences overall student satisfaction.
CONCLUSION
Overall, students were satisfied with the
general environment and conduct of the exam at
the Army Medical College.
ACKNOWLEDGEMENT
We thank all the students who participated
in the study.
CONFLICT OF INTEREST
The authors declare that they have no
conflict of interest.
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incident technique. J Dent Edu.2006; 70: 124-32.
3. Sehgal R, Dhir BV, Sawhney A. Teaching technologies in Gross
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4. Manzar B, Manzar N. To determine the level of satisfaction
among medical students of a public sector medical university
regarding their academic activities.BMC Res Notes.2011; 4: 380.
5. Black, P, Wiliam, D. Developing the theory of formative
assessment.EAEA2009;21(1), 5-31
6. Driscoll, C., Wicks, D. The customer-driven approach in
businesseducation: A possible danger?JEduc Bus 1998; 7:58–61
7. Oyebola DD, Adewoye OE, Iyaniwura JO, Alada AR,
Fasanmade AA, Raji Y. A comparative study of student's
performance in preclinical physiology assessed by multiple
choice and SEQ's.Af J Med Sci. 2000; 29: 201-5.
8. Barrows HS, Williams RG, Mary RH. A comparative
performance based assessment of 4th year students' clinical
skills. J Med Educ. 2001; 62: 805–7
9. Gauci SA, DantasAM, Williams DA, Kemm RE. Promoting
student-centered active learning in lectures with a personal
response.AdvPhysiol Educ. 2009;33: 60–71
10. Hudson JN, Buckley P. An evaluation of case-based teaching, an
evaluation of continuing benefit and realization of
aims.AdvPhysiol Educ. 2004;28: 15–22
11. 11.Nwobodo ED, Anyaehie UB, Nwobodo N, Awiwa C,
Ofoegbu E, Okonkwo C, et al. Students performance and
perception of neurophysiology: feedback for innovative
curricular reform in a Nigerian Medical school. Niger J
PhysiolSci 2009;24: 63–6
12. Stewat BY. The surprise element of a student-designed
laboratory experiment. J CollSci Teach. 1998; 17: 269–79
13. Tufts MA, Higgins-Opitz SB. What makes the learning of
physiology in a PBL medical curriculum challenging? Student
perceptions.AdvPhysiol Educ. 2009;33: 187–95
14. 14.Corcoran TB, Walker LJ, White JL. Working in urban schools.
Washington, DC: Institute for Educational Leadership; 1988.
15. 15.Hines E. Building condition and student achievement and
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16. 16.McGuffey C. Facilities. In: Walberg H, editor. Improving
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17. 17.Brown, G. T. L., Hui, S. K. F., Yu, W. M., & Kennedy, K. J.
(2011). Teachers’ conceptionsof assessment in Chinese contexts:
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irrelevance.IJSER 50(5-6), 307-320
S193
Original Article
A Study of Endometrial Biopsies
Pak Armed Forces Med J 2016; 66 (Suppl-3): S194-98
HISTOPATHOLOGICAL SPECTRUM OF ENDOMETRIAL BIOPSIES – A STUDY OF 378
CASES AT AFIP PAKISTAN
Syed Salman Ali, Iqbal Muhammad, Javeria Shaukat*, Saeed Afzal, Shoaib Nayyar Hashmi, Syed Naeem Raza Hamdani,
Rabia Ahmed
Armed Forces Institute of Pathology Rawalpindi, Pakistan, *Military Hospital Rawalpindi, Pakistan
ABSTRACT
Objective: To analyze the histopathological spectrum of endometrial biopsies.
Study Design: Descriptive case series.
Place and Duration of Study: Armed Forces Institute of Pathology (AFIP), Rawalpindi from December 2013 to
August 2015.
Material and Methods: All cases of endometrial biopsies were retrieved from AFIP data base. Age and
histopathological diagnosis was noted, irrespective of the clinical presentation of the patients. The data was
analysed by using computer software program SPSS version 19. Descriptive statistics like mean ± SD, percentages
and frequencies were calculated for age and histopathological diagnosis. The data collected for study was
statistically analysed using chi-square test.
Results: A total of 378 cases of endometrial biopsies were included in the study. The age at presentation ranged
from 13 to 75 years with median age of 40.73 ± 9 years. A total of 73.5% of the cases (n=278) were from 4th to 5th
decade of life. The most common histopathological diagnosis was secretory endometrium; present in 117 cases
(31%) followed by proliferative endometrium; 78 cases (20.6%). Disordered proliferative endometrium, chronic
endometritis and endometrium with hormone induced changes were observed in 62 (16.4%), 41 (10.8%) and 36
(9.5%) cases respectively. Atrophic endometrium was diagnosed in 8 cases (2.1%) and there were 3 cases (0.8%) of
endometrial polyp. Among endometrial hyperplasia, 23 cases (6.1%) were of simple cystic hyperplasia, 5 cases
(1.3%) were complex hyperplasia without atypia and 4 cases (1.1%) were complex hyperplasia with atypia.
Adenocarcinoma in situ (ACIS) was reported in only one case (0.3%). Comparison with other studies revealed the
results matching with some and differing with others. Association of age with histopathological pattern was
statistically significant with p value <0.05.
Conclusion: Endometrial biopsies revealed a wide variety of age specific histopathological diagnoses. Secretory
endometrium is the commonest diagnosis in women of reproductive age group whereas hyperplasia and
malignancy are common in premenopausal and postmenopausal age groups. Detailed analysis of endometrial
biopsies is therefore necessary for accurate diagnosis, appropriate treatment and favorable outcome.
Keywords: Endometrial biopsy, Histopathological spectrum.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Endometrium forms the innermost linning of
the uterine wall, it is glandular in structure and
dynamic in function as it passes through a series
of changes including proliferation, secretion and
menstruation during the menstrual cycle of a
woman. These cyclic phases are under the
influence of two female sex hormones, estrogen
Correspondence: Dr Syed Salman Ali, Histopathology Dept
AFIP Rawalpindi Pakistan (Email:[email protected])
Received: 26 Feb 2016; revised received: 14 Mar 2016; accepted: 31 Mar
2016
and
progesterone.
Estrogen
affects
the
proliferative phase whereas progesterone is
responsible for the secretory phase of menstrual
cycle. An intricate process regulates the
equilibrium between endometrial proliferation
and apoptosis, influenced by a number of factors
like age, environment, hormonal balance,
molecular mechanisms, and so forth; likewise
endometrium is subjected to a wide variety of
disturbances leading to several abnormalities.
Microsatellite instability, phosphatase and tensin
S194
A Study of Endometrial Biopsies
Pak Armed Forces Med J 2016; 66 (Suppl-3): S194-98
(PTEN) mutations, K-ras mutation, beta-catenin
mutation and PIK3CA mutation are the most
common genetic alterations in endometrial
defects1.
intrauterine conditions8. Endometrial biopsy
should be performed in all women over 35 years
of age with menorrhagia to rule out malignant or
premalignant lesions of the endometrium. It
Endometrial biopsy is a preferred procedure should also be considered in women between 18
for accurate diagnosis of endometrial pathology. to 35 years of age with abnormal uterine bleeding
9
This procedure is now considered as the first line who have risk factors for endometrial cancer .
diagnostic tool owing to its safety, accuracy,
This study was conducted to analyse the
2
histpathological spectrum of endometrial biopsies,
rapidity, convenience and cost-effectiveness .
Patients with premalignant or malignant their relative frequencies and to compare the
endometrial lesions may have the common results with other similar studies.
presenting complaint of abnormal uterine
bleeding2. Abnormal uterine bleeding accounts
for more than 70% of all gynaecological visits in
the peri- and postmenopausal years3. Main causes
of abnormal uterine bleeding include fibroids,
polyps, hyperplasia, malignancy and atrophy4.
MATERIAL AND METHODS
This retrospective descriptive case series was
carried out at Armed Forces Institute of Pathology,
Rawalpindi from December 2013 to August 2015.
All cases of endometrial biopsies were retrieved
from AFIP data base and included in the study
Table-1: Distribution of 378 cases of endometrial biopsies according to age groups.
Age Groups
Diagnosis
11-20
21-30
31-40
41-50
1-60
61-70
Secretory Endometrium
1
19
50
43
4
0
Proliferative
2
15
29
31
1
0
Endometrium
Disordered Proliferative
0
5
12
36
8
1
Endometrium
Chronic Endometritis
0
10
15
14
2
0
Hormone
Induced
0
4
7
12
3
0
Changes
Atrophic Endometrium
0
0
0
4
4
0
Endometrial Polyp
0
0
0
3
0
0
Simple
Cystic
0
2
5
13
3
0
Hyperplasia
Complex
Hyperplasia
0
0
1
2
1
1
without Atypia
Complex
Hyperplasia
0
0
1
0
1
2
with Atypia
Adenocarcinoma in situ
0
0
0
0
0
0
(ACIS)
Total
3
65
120
158
27
4
Endometrial biopsy is the most effective
diagnostic approach towards abnormal uterine
bleeding5. It not only detects the local lesions6 but
also prevents the women from undergoing
unwanted hysterectomy procedure7.
Total
71-80
0
117 (31%)
0
78 (20.6%)
0
62 (16.4%)
0
41 (10.8%)
0
36 (9.5%)
0
0
8 (2.1%)
3 (0.8%)
0
2 3(6.1%)
0
5 (1.3%)
0
4 (1.1%)
1
1 (0.3%)
1
378
irrespective of the age and clinical presentation of
the patient by non probability, consecutive
sampling technique. Cases with inadequate biopsy
were excluded from the study. Age and
histopathologic diagnosis was noted. A total of
The main aim of this minimally invasive 378 cases were included in the study. The data
procedure is to exclude serious pathological was analyzed by using computer software
S195
A Study of Endometrial Biopsies
Pak Armed Forces Med J 2016; 66 (Suppl-3): S194-98
program SPSS version 19. Descriptive statistics
like mean ± SD for age. Percentages and
frequencies were calculated for age and
histopathological diagnosis. A statistical analysis
between age and histopathological diagnosis was
done using chi-square test. A p-value <0.05
considered as a significant value.
patient as to whether the patient is
premenopausal,
perimenopausal
or
postmenopausal. Abnormal uterine bleeding is
defined as a bleeding pattern that differs in
frequency, duration, and amount from a pattern
observed during a normal menstrual cycle or after
menopause3.
RESULTS
The routine out-patient investigations for
abnormal uterine bleeding include blood complete
picture, platelet count, prothrombin time (PT),
activated partial thromboplastin time (APTT) and
liver function tests for ruling out any bleeding
disorder or coagulation defect. Serum and urine
human chorionic gonadotrophin (HCG) levels are
assessed to rule out pregnancy in women of
reproductive age group. Endocrine causes will be
ruled out by evaluating thyroid function tests,
follicle stimulating hormone (FSH), lutenizing
hormone (LH) and prolactin levels. Imaging
studies are then carried out, such as pelvic and
transvaginal ultrasound (USG) followed by
endometrial sampling, which can be a diagnostic
as well as therapeutic procedure. The reported
sensitivity of endometrial biopsy for the detection
of endometrial pathology is as high as 96%5.
Histopathological evaluation of endometrial
biopsies is necessary for exact diagnosis of
endometrial pathologies in patients of abnormal
uterine bleeding10.
The record from 1st December 2013 to 31st
August 2015 showed that a total of 378
endometrial biopsies were evaluated at AFIP,
Rawalpindi during this period. A total of 378 cases
of endometrial biopsies were included in the
study. The age at presentation ranged from 13 to
75 years with median age of 40.73 ± 9 years. 73.5%
of the cases (n=278) were from 4th to 5th decade
of life. The most common histopathological
diagnosis was secretory endometrium; present in
117 cases (31%) followed by proliferative
endometrium; 78 cases (20.6%). Disordered
proliferative endometrium, chronic endometritis
and endometrium showing hormone induced
changes were observed in 62 (16.4%), 41 (10.8%)
and 36 (9.5%) cases respectively. Atrophic
endometrium was diagnosed in 8 cases (2.1%) and
there were 3 cases (0.8%) of endometrial polyp.
Among 32 cases (8.5%) of endometrial
hyperplasia, 23 cases (6.1%) were of simple cystic
hyperplasia and 9 cases (2.4%) were diagnosed as
complex hyperplasia, out of which 5 cases (1.3%)
were complex hyperplasia without atypia and 4
cases (1.1%) were complex hyperplasia with
atypia. Adenocarcinoma in situ (ACIS) was
reported in only one case (0.3%). The distribution
of cases according to different age groups are
summarized in Table.1 and shown graphically in
fig-1. A significant statistical association was seen
between age and histopathological diagnosis with
p value < 0.001.
Our study has clearly revealed that the
occurrence of endometrial lesions increases with
advancing age. Age group of 41-50 years is the
commonest age group that showed the maximum
number of cases with proliferative lesions like
disordered
proliferative
pattern,
benign
endometrial polyp and hyperplasia. These
findings are in accordance with the findings
reported by Saraswathi et al5.
Our study shows that the mean age at the
Comparison with other studies revealed the time of diagnosis in our population is 40.73 ± 9
results matching with some and differing with years. The mean age reported by Jetley et al3 44.8
others.
years and Saadia et al2 42.5 years, is in
concordance with the mean age of the current
DISCUSSION
study.
Endometrial lesions responsible for abnormal
uterine bleeding are related to the age of the
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A Study of Endometrial Biopsies
Pak Armed Forces Med J 2016; 66 (Suppl-3): S194-98
The age range in our study is from 13 to 75 10.8% and 9.5% respectively in our study while
years which is in accordance with Vaidya et al10 Jetley et al3 showed it to be 9.1% and 2.7%
respectively. Chronic endometritis was of
(18-70 years) and Saraswathi et al5 (17-79 years).
In our study, predominant number of cases nonspecific type without any evidence of
showed normal physiologic phases such as granulomas. Hormone induced changes were seen
proliferative and secretory menstrual pattern. The in the endometrium of patients of atypical uterine
most common histopathological diagnosis was bleeding being managed by exogenous hormone
secretory endometrium (31%) followed by therapy.
proliferative endometrium (20.6%) comparable to
According to our study, frequency of
the results of Jetley et al3, 32.4% and 30.6% endometrial polyp in endometrial biopsies is 0.8%
which is lower as compared to Jetley et al3, 2.7%. It
respectively.
Figure-1: Relative frequency of histopathological diagnosis in Endometrial Biopsies.
A significant number of cases showed
disordered proliferative endometrium in the 41-50
years age group. Disordered proliferative pattern
occupies a position at one end of the spectrum of
proliferative lesions of the endometrium, and
carcinoma lies at the other end, with stages of
hyperplasia in-between4. Disordered proliferative
pattern was observed in 16.4% of our cases, which
is higher as compared to studies conducted by
Vaidya et al10 (13.40%) and Soleymani et al11
(15.4%). Increased health awareness leading to an
earlier stage of presentation could explain the high
incidence of disordered proliferative pattern in
our study.
is difficult to recognize polyps in curettage
specimens. These are identified by the presence of
epithelium on three sides of a polypoidal
fragment. Other identifying feature is fibrous
stroma and thick walled blood vessels in contrast
to the other endometrial fragments, thus
suggesting a polyp.
Our study showed 8.5% cases of endometrial
hyperplasia, among these 6.1% were of simple
cystic hyperplasia and 2.4% were diagnosed as
complex hyperplasia, out of which 1.3% were
complex hyperplasia without atypia and 1.1%
were complex hyperplasia with atypia. However,
according to the studies conducted by Jetley et al3
Chronic endometritis and endometrium with and Vaidya et al10, incidence of endometrial
hormone induced changes showed a frequency of hyperplasia is 10.8% and 10.92% respectively. The
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A Study of Endometrial Biopsies
Pak Armed Forces Med J 2016; 66 (Suppl-3): S194-98
possible explanation for the lower incidence of
endometrial hyperplasia in our study could be
that most of our patients belong to lower
socioeconomic class and the occurrence of risk
factors (obesity, diabetes, increased intake of
animal fat and sedentary life style) is low.
therefore necessary to rule out any preneoplastic
or neoplastic condition and hence a way to
compelling treatment and ideal result.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
The incidence of atrophic endometrium in
REFERENCES
our study is 2.1% which is slightly lower when
V, Kim JJ, Benbrook DM, Dwivedi A, Rai R. Therapeutic
compared to the results of Saraswathi et al5 which 1. Chandra
options for management of endometrial hyperplasia. J Gynecol
showed it to be 2.4%.
Oncol. 2016; 27(1): 08.
Malignant pathology (ACIS) was diagnosed
in 0.3% of our cases whereas in Soleymani et al11, it
is 0.7%. The lower incidence of malignancy in our
patients is most likely attributed to the practice of
early
childbearing
and
multiparity.
Adenocarcinoma of endometrium is the most
common genital cancer in women over 45 years of
age and its incidence is increasing with advancing
age9. Various studies have shown a probable role
of human papillomavirus (HPV) in the
pathogenesis of endometrial carcinoma, however
it has been revealed that HPV does not play any
significant role in the pathogenesis of endometrial
carcinoma, since endometrium does not appear to
be a suitable host for HPV replication12.
CONCLUSION
Histopathological
examination
of
endometrial biopsies revealed a wide spectrum of
age
specific
diagnoses
ranging
from
normal endometrium to malignancy. Secretory
endometrium is the commonest diagnosis in
women of reproductive age group whereas
hyperplasia and malignancy are common in
perimenopausal and postmenopausal age groups.
Careful
endometrial evaluation with an
understanding of the underlying causes is
2. Saadia A, Mubarik A, Zubair A, Jamal S, Zafar A. Diagnostic
accuracy of endometrial curettage in endometrial pathology. J
Ayub Med Coll Abbottabad. 2011; 23(1): 129-131.
3. Jetley S, Rana S, Jairapuri ZS. Morphological spectrum of
endometrial pathology in middle-aged women with atypical
uterine bleeding: A study of 219 cases. J Midlife Health. 2013; 4(4):
216-220.
4. Pyari JS, Rekha S, PK S, Goel M, Pandey M. A comparative
diagnostic
evaluation
of
hysteroscopy,
transvaginal
ultrasonography and histopathological examination in cases of
abnormal uterine bleeding. J Obstet Gynecol India. 2006; 56: 2403.
5. Saraswathi D, Thanka J, Shalinee R, Aarthi R, Jaya V, Kumar PV.
Study of endometrial pathology in abnormal uterine bleeding. J
Obstet Gynecol India. 2011; 61(4): 426-430.
6. Moghal N. Diagnostic value of endometrial curettage in abnormal
uterine bleeding - A histopathological study. JPMA. 1997;47:295–
9.
7. Sarwar A, Haque A. Types and frequencies of pathologies in
endometrial curettings of abnormal uterine bleeding. IJP. 2005;
3(2):65-70.
8. Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy
of hysteroscopy in the diagnosis of endometrial cancer and
hyperplasia. JAMA. 2002; 288: 1610-1621.
9. Riaz S, Ibrar F, Dawood NS, Jabeen A. Endometrial pathology by
endometrial curettage in menorrhagia in premenopausal age
group. J Ayub Med Coll Abbottabad. 2010; 22(3): 161-4.
10. Vaidya S, Lakhey M, Vaidya S, Sharma PK, Hirachand S, Lama S,
et al. Histopathological pattern of abnormal uterine bleeding in
endometrial biopsies. Nepal Med Coll J. 2013; 15(1): 74–7.
11. Soleymani E, Ziari K, Rahmani O, Dadpay M, Taheri-Dolatabadi
M, Alizadeh K, et al. Histopathological findings of endometrial
specimens in abnormal uterine bleeding. Arch Gynecol Obstet.
2014; 289(4): 845-9.
12. Karadayi N, Gecer M, Kayahan S, Yamuc E, Onak NK, Korkmaz
T, et al. Association between human papillomavirus and
endometrial adenocarcinoma. Med Oncol. 2013; 30(3): 597.
S198
Original Article
Burr-Hole Evacuation (Drains Vs No Drains)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S199-202
SINGLE BURR-HOLE EVACUATION OF CHRONIC SUBDURAL HAEMATOMA - USE
OF DRAINS VERSUS NO DRAINS
Khurshid Ali Bangash, Aslan Javed Munir, Habib Ullah Khan
Combined Military Hospital Rawalpindi, Pakistan
ABSTRACT
Objective: To compare the use of drain insertion into the subdural space with no drains after burr-hole drainage
of chronic subdural haematoma (CSDH) in terms of recurrence and neurological outcomes and complications.
Study Design: Randomised controlled trial.
Place and Duration of Study: The study was of 2 years duration conducted at neurosurgical unit Combined
Military Hospital (CMH) Rawalpindi from Nov 2009 to Sep 2011.
Material and Methods: A total of 72 patients were randomly assigned to two treatment groups, group 1 (n=36)
were subjected to burr hole craniotomy with use of drains and group 2 (n=36) were subjected to no drains. The
results were assessed at 3 months intervals in terms of recurrence and neurological outcomes and complications.
Results: In this study recurrence was 8.3% with the use of a drains and 28% with no drains (p< 0.00) after burrhole drainage of chronic subdural hematoma. The results of the study showed that a drain significantly reduced
the probability of recurrence. No other factor had a significant association with recurrence. There was not much
difference in complications associated with surgical procedure.
Conclusion: The recurrence is significantly less with the use of a drains after burr-hole drainage of chronic
subdural haematoma.
Keywords: Burr-hole drainage, Chronic subdural haematoma, Recurrence, Subdural drain.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Chronic subdural hematoma (CSDH) is
common in elderly people and is associated with
substantial morbidity and mortality1,2. Incidence
is about 5 per 100000 per year in the general
population3. Because the proportion of people
aged 65 years and older is expected to double
worldwide between 2000 and 20304, a large rise in
incidence is expected. Diagnosis can readily be
facilitated by brain computed tomography (CT)
and magnetic resonance imaging (MRI).
Excluding minimal subdural hematoma, therapy
is commonly surgical and a dramatic rapid
improvement in symptoms is frequently
observed. Postoperative recurrence rate of CSDH
with the use of burr-hole approach has been
Correspondence: Dr Khurshid Ali Bangash, Combined Military
Hospital (CMH) Rawalpindi, Pakistan
Email: [email protected]
Received; 14 July 2014: revised received: 14 Jul 2014; accepted: 14 July
2014
reported to vary from 3% to 35% is the focus of
research5-7. Area of concern is whether subdural
drains should be used with burr-hole craniotomy
as emerging evidence suggests that such drainage
of the subdural space lowers recurrence rates8-10.
However, further studies are required for this
dilemma. This study was carried out with the aim
to evaluate the results of treatment for chronic
subdural hematoma, especially in terms of
recurrence, following burr-hole drainage with
and without use of subdural drain.
Our hypotheses are:
1. Proportion of the patients with recurrence is
different between two groups.
2. Neurological outcome and Complication rate
is different between two groups.
MATERIAL AND METHODS
This study, a randomized controlled trial
was carried out in neurosurgical unit Combined
S199
Burr-Hole Evacuation (Drains Vs No Drains)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S199-202
Military Hospital Rawalpindi from Nov 2009 to
Sep 2011 in which use of drain insertion into the
subdural space was compared with no drains
after burr-hole drainage of CSDH. A total of 72
patients were inducted in the study and divided
in two groups. Group 1 (n=36) was subjected to
CT/ MRI study of brain were include in the
study. While patients who were operated once or
more (i.e. recurrence) for CSDH, and patients in
whom CSF diversion procedure was done and
who subsequently developed CSDH, and patients
of CSDH in whom surgery other than burr-hole
Table 1: Clinical presentation of patients with chronic subdural hematoma
Clinical presentation
Group-1
Headache
21(58%)
Gait disturbances and fall
20(55%)
Limb weakness
19(53%)
Memory disturbances
11(30%)
Altered sensorium
13(36%)
Speech impairment
9(27%)
Vomiting
7(18%)
Seizure
4(11%)
Cranial nerve palsy
3(8%)
Visual disturbances
5(14%)
Incontinence
3(8%)
Table-2: Complications of surgical procedures.
Post Op. Parameter
Group-1
Cranial nerve palsy New onset
0
Limb weakness Improved Deficit
14(70%)
Same
4(20%)
Deteriorated
1(6%)
Seizure New onset
01 (2%)
Acute SDH—
0
Wound infection/dehiscence
1 (2%)
Post operative fever
1 (2%)
Meningitis
0 1 (2%)
Empyema
0 1 (2%)
Table-3: Outcome in both groups at discharge and 3 months.
Group-1
Recurrence
3 (8%)
Mortality(At 3 months)
3 (8%)
Gross focal neurological deficit
At discharge
17 (47%)
At 03 months
9 (25%)
GCS -15 (2nd day)
29 (80%)
.
Group-2
22(61%)
24(67%)
18(50%)
8(22%)
15(42%)
6(17%)
7(18%)
5 (14%)
3(8%)
4 (11%)
3(8%)
Group-2
1 (2%)
9 (52%
5(29%)
3 (17%)
0
0 1 (2%)
2 (4%)
1 (2%)
0
0
p-value
0.321
Group-2
10 (28%)
6 (16%)
p-value
0.003
0.292
23 (64%)
11 (30%)
24 (66%)
0.159
0.605
0.186
0.321
0.321
0.562
1.00
0.321
0.321
GCS, Glasgow Coma Scale;
use of drains and group 2 (n=36) was subjected to
no drains. Informed written consent was taken.
Non-probability convenience sampling was
used as sampling technique.
Patients of either gender between 18 to 70
years and chronic subdural haematoma based on
evacuation was done, were not enrolled.
Patients were evaluated at the time of
admission
based
on
history,
physical
examination, blood investigation and imaging
studies. Coagulation parameters - platelet count,
prothrombin time (PT), activated partial
thromboplastin time (APTT)- were checked. On
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Burr-Hole Evacuation (Drains Vs No Drains)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S199-202
imaging, CSDH was analyzed as hypodense,
isodense, hyperdense, or mixed, on the basis of
the density of haematoma relative to brain tissue.
Before surgery, written informed consent was
obtained from the patient or was obtained from
the next-of-kin of comatose patients or those
otherwise unable to give consent. Out of 72
patients 64 (89%) were male and 8 (11%) female.
Male to female ratio was 8:1; with age ranging
from 17-70 years. Presenting complaints in both
groups are shown in (table-1). History of minor
head injury in the recent past was present in 76 %
of the patients. Level of consciousness was
assessed using Glasgow coma score (GCS); 93%
of patients had GCS of 9-15, and 7% had GCS of 8
or less. Hospital stay ranged from 2 days to 24
days with mean stay of 3 ± 4 days. Patients with a
gross neurological deficit at discharge had
usually deficit at admission. Therefore, the
variable for neurological deficit at admission was
a very strong and important predictor of deficit at
discharge.
Patients were reviewed at 3 months intervals
and effectiveness of the entire treatment was
measured by:
1. Recurrence
2. Neurological outcome and complications
Data was analyzed by using SPSS on
computer.
Relevant
descriptive
statistics;
frequency, rate and percentage was computed for
presentation of qualitative outcomes like
recurrence and complications. Quantitative
variables like age time etc. was presented as
mean ± standard deviation. Hypothesis 1 and 2
were tested by applying chi-square test at p<0.05
level of significance.
RESULTS
Complications associated with both surgical
procedures are shown in table-2 whereas
recurrence, mortality and gross neurological
deficits are shown in table-3 in both groups. The
results of the study showed that a drain
significantly reduced the probability of
recurrence (table-3). No other factor had a
significant association with recurrence. There was
not much difference in complications associated
with surgical procedure.
DISCUSSION
In the previous years, various surgical
treatments of CSDH have been reported12-15.
However, the extent of surgical therapy is still
controversial, and a standard therapy does not
exist. The most commonly used techniques are
burr-hole
craniotomy
with
or
without
11,16
drainage .
We have seen that patients with chronic
subdural haematoma treated with burr-hole
evacuation and placement of a subdural drain
had a much less recurrence rate, a better
functional outcome than that of those without
drainage. Moreover there was no difference in
postoperative complication in both groups.
Installation of a drainage system helps brain
expansion and accordingly decreases the chance
of recurrence13. According to Santarius et al
CSDH
with
burr-hole
evacuation
and
postoperative drainage had a recurrence rate
much less than of those without drainage. He
reported recurrence rate of 9% and 24% for
patients treated with drain and no drains
respectively17. Our findings accord with results
from two prospective studies.18,19 Wakai and coworkers19 reported recurrence rates of 5% for
drain and 33% for no drains. Tsutsumi and coworkers18 reported rates of 3.1% and 17%,
respectively. We report recurrence rates very
similar to those in the retrospective study by Lind
and co-workers20 who identified recurrence rates
of 10% for drain and 19% for no drain, and that of
Mori and Maeda21 who showed a recurrence rate
of 9.8% for use of drains. Ramachandranet al22 in
his cohort study found a recurrence rate of 4%
and 30% with and without drains respectively.
Gazzeri et al23 and Yu et al24 in their cohort
studies reported a recurrence rate of 7.6% and
6.6% respectively for all patient of CSDH treated
with drains after surgery. However another
school of thought is against the use of subdural
drains and it is a matter of debate. Major
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Burr-Hole Evacuation (Drains Vs No Drains)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S199-202
argument against the use of drains include
increased risk of damage to the brain with
placement of subdural drain and increased risk of
infection in leaving a drain in place. These
concerns are however more or less anecdotal
since recent evidence based studies have
demonstrated the efficacy of leaving a subdural
drain in place. Similar to other published
accounts18-20 we could not identify any difference
in frequency of medical or surgical complications
between drain and no drain groups. Taking all
these studies into consideration and the results of
our study we conclude that drain should be
placed in subdural space after evacuation of
CSDH and it should be kept for 48 hours.
Placement of subgaleal drain may be a safer
method but may not be equally as effective as
subdural drain.
CONCLUSION
8.
9.
10.
11.
12.
13.
14.
15.
The recurrence is significantly lesser with
use of a drain after burr-hole drainage of chronic
subdural haematoma.
CONFLICT OF INTEREST
16.
17.
This study has no conflict of interest to
declare by any author.
18.
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Yu GJ, Han CZ, Zhang M, Zhuang HT, Jtang YG. Prolonged
drainage reduces the recurrence of Chronic subdural hematoma.
Br J Neurosurg 2009; 23 (6): 606-11.
Original Article
Abruptio Placentae and Intrauterine Growth
Pak Armed Forces Med J 2016; 66 (Suppl-3): S203-07
FREQUENCY OF ABRUPTIO PLACENTAE AND INTRAUTERINE GROWTH
RESTRICTION IN WOMEN WITH PRE-ECLAMPSIA AND PREGNANCY INDUCED
HYPERTENSION (PIH)
Shaista Ambreen, Rubina Mushtaq, Khalida Perveen
Combined Military Hospital Rawalpindi, Pakistan
ABSTRACT
Objective: To determine frequency of Abruptio placentae and intrauterine growth restriction in pre-eclampsia
and pregnancy induced hypertension (PIH).
Study Design: It was a cross sectional study.
Place and Duration of Study: The study was carried out over a period of 9 months from 19-3-2009 to 18-12-2009 in
the Department of Obstetrics and Gynecology Military Hospital Rawalpindi, Pakistan.
Material and Methods: A total of 97 patients of PIH and pre-eclampsia out of 1525 patients with 20 weeks and
onward gestation presented in the OPD of military hospital Rawalpindi (gynae/obs department) in 9 months
from 19th March to 18th December 2009 who were included in the study. Patients were selected at 20 weeks
onwards and outcome was recorded at delivery. Feto-maternal morbidity was seen in PIH and pre-eclampsia.
The study outcome was noted as having intrauterine growth restriction (IUGR) or placental abruption.
Results: The majority of patients 73 (75.3%) were between 21-30 years and 23 (23.7%) patients were between 31-40
years whereas 1 (1.03%) patient was below 20 years of age. The mean age of patients was 28.9 ± 4.3 years. Out of
total 97 patients, 81 (83.5%) had pregnancy induced hypertension while remaining 16 (16.5%) patients had preeclampsia. Out of 81 patients of pregnancy induced hypertension, 12 patients (14.8%) had IUGR and 3 patients
(3.7%) had placental abruption. Out of 16 patients of pre-eclampsia, 2 (12.5%) each had IUGR and placental
abruption.
Conclusion: In the current study 17.5% patients had IUGR and abruption placentae in women having PIH and
pre-ecalmpsia. By controlling blood pressure (BP) patients can be prevented from having IUGR and abruption
and its resultant consequences to some extent.
Keywords: Abruptio Placentae, Fetal Growth Restriction, PIH, Pre-Eclampsia.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Hypertensive disorders are one of the
common
medical
complications
during
pregnancy and are associated with high maternal
and fetal morbidity and mortality in both under
developed and developed world1.
Pre-eclampsia
and
pregnancy
induced
Correspondence: Dr Shaista Ambreen, Combined Military
Hospital Rawalpindi, Pakistan
Email: [email protected]
Received: 11 Apr 2016; revised received: 12 May 2016; accepted: 13 May
2016
hypertension (PIH) are responsible for substantial
morbidity and mortality, perinatal deaths,
preterm births and intrauterine growth restriction
(IUGR)2. The International Society for the study
of hypertension in pregnancy (ISSHP) defines
PIH as blood pressure of at least 140/90 mmHg
on two occasions >4 hours apart after 20 weeks
(wks) gestation in a previously normotensive
gravida and pre-eclampsia as onset of
hypertension after 20 wks gestation with
proteinuria >0.3gm/24 hours urine collections2.
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Abruptio Placentae and Intrauterine Growth
Pak Armed Forces Med J 2016; 66 (Suppl-3): S203-07
Pre-eclampsia
complicates
5-7%
of
3
pregnancies . Fetomaternal morbidity depends
on gestational age at the time of disease onset,
severity of disease, quality of management,
presence or absence of pre-existing medical
disorders4,5. The consequences of these disorders
occur as maternal deaths which is rare, abruptio
placentae in (1-4%), IUGR (10-25%), perinatal
deaths (1-2%)6. Abruption is responsible for 8.3%
maternal deaths and 41.6% stillbirths7. The
prevalence of abruption in Pakistan is 4.4%8.
Military Hospital, Rawalpindi. A total of 97
women with PIH and preeclampsia from 20 wks
onwards gestation were enrolled in a period of 9
months from 19-03-2009 to 18-12-2009. All
participants belonged to same socioeconomic
status and age. After explaining the objectives of
study, written informed consent was taken from
each woman. All patients with pre-eclampsia
and PIH between 18 and 40 years of age,
presenting with signs of abruption placentae
were included in the study.
As the risk of IUGR increases with the
severity of PIH9, early diagnosis, close medical
supervision, and timely delivery are the cardinal
requirements of the management. By controlling
BP one can overcome the abruption and its
consequences to some extent9. Fetal management
(depending on gestational age) is done with
prophylactic steroids below 34 weeks gestation
with monitoring by fetal kick count chart,
ultrasound for fetal growth, cardiotocography,
twice-weekly Doppler ultrasound and timely
delivery10.
Patients having history of polyhydramnios,
external cephalic version, cigarette smokers,
alcohol, blunt trauma, large sized fibroid,
preterm premature rupture of membranes,
anemia, molar pregnancy, long standing heart
disease,
placenta
previa,
vasa
previa,
malnourished mothers were all excluded.
The major maternal hazards are the
consequences could be severe hypertension,
grand mal seizures and damage to other end
organs. However, with modern management,
preeclampsia can be ameliorated and eclampsia
largely prevented11.
In recent years there have been few
advances but pre-eclampsia and PIH are still
causing fetomaternal morbidity and mortality in
our health set-ups. It was perceived that this
study would help in early detection and timely
referral of these women for proper management,
provision of skilled and timely antenatal and
intrapartum health care and management of
complications so that resultant morbidity and
mortality may be averted.
MATERIAL AND METHODS
The study outcome was measured in terms
of frequency of IUGR and abruptio placentae.
IUGR was taken on the basis of symphisiofundal
height less than 3cm than expected for gestational
age. Selection bias and confounding parameters
were addressed by making sure that data
collection all study procedures were carried out
by the study investigator herself so that data
quality and continuity are maintained. careful
history, clinical examination and relevant
laboratory investigations [hemoglobin (HB%),
platelets, prothrombin time (PT) & obstetrical
Table: Distribution of cases by age (n=97).
Age (years)
No of patients
%age
< 20
01
1.0%
21-30
73
75.3%
31-40
23
23.7%
Mean ± SD
28.9 ± 4.3
ultrasound] were done.
For data analysis SPSS software was used.
Descriptive statistics was applied to calculate
mean and standard deviation from continuous
variables like age. Patients were selected
This was a cross sectional study, conducted
in the Department of Obstetrics and Gynaecology
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S203-07
Frequency and percentages were calculated from
categorical variables i.e. proteinuria, obstetrical
ultrasound, IUGR and placental abruption.
results in high maternal and perinatal morbidity
and mortality, preterm births and IUGR
worldwide12.
RESULTS
Early identification of high-risk pregnant
women and subsequent monitoring, are surely
pivotal steps in prevention. With its lifethreatening implications for both mothers and
babies, pre-eclampsia continues to be one of the
medical community’s greatest challenges due to
its complex presentation13.
The mean age of patients was 28.9 ± 4.3
years. Most of the study patients 73 (75.3%) were
between 21-30 years and 23 (23.7%) patients were
between 31-40 years of age whereas 1(1.03%)
patient was below 20 years of age. (table-1).
Out of 97 patients, 81 (83.5%) had pregnancy
induced hypertension while remaining 16 (16.5%)
patients had pre-eclampsia (fig-1).
Our study showed that a significant number
Of the patients with pregnancy induced
hypertension, 12 (14.8%) had IUGR while 3 (3.7%)
had placental abruption. Similarly, out of patients
with preeclampsia, 2 (12.5%)patients each had
IUGR and placental abruption (fig-2).
DISCUSSION
Global mortality for mothers during child
birth is about 500,000 with majority occurring in
developing world. In Pakistan with a total
population of more than one hundred and eighty
million, only 43% women have access to
antenatal facilities and a meager 23% deliveries
are being carried out by skilled personnel
Figure-1: Distribution of cases by PIH and preeclampsia (n=97).
of pre-eclamptic pregnancies also occur for the
first time in parous women. A similar report by
Rasmussen and Irgens14 witnessed that women
Figure-2: Frequency of IUGR and placental abruption in PIH and preeclampsia.
(doctors, nurses and midwifes). Pregnancy
induced hypertension and preeclampsia is a
serious pregnancy-specific complication that
with small for gestational age (SGA) births in the
first pregnancy have an increased risk of
preeclampsia in the next15.
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Abruptio Placentae and Intrauterine Growth
In the current study we found out that
abruptio placentae was present in 8.6% women
with PIH. In a comparable study by Tasleem et al
a significant clinical correlation was found
between PIH and abruptio placentaein 8% cases
who did not received treatment16,11. Another local
study at the Department of Obstetrics and
Gynecology (unit-II) of Liaquat University
Hospital, Hyderabad showed that there is a
significant clinical correlation between PIH and
abruptio placentae17. Our study findings are
consistent with these studies.
Preeclampsia and gestational hypertension
shared many risk factors, although there are
differences that need further evaluation. Both
conditions significantly increased morbidity and
mortality. In the current study, IUGR in
pregnancy induced hypertension (PIH) and preeclampsia was present in 14.8% and 12.5%,
respectively. Conversely, preeclampsia and
intrauterine growth restriction, often assumed to
be related to placental insufficiency18. Moreover,
there is independent associations placental
abruption with severe fetal growth restriction,
prolonged
rupture
of
membranes,
chorioamnionitis, PIH/ preeclampsia, and
advanced
maternal
age19.
Preeclampsia,
gestational hypertension, and unexplained
intrauterine growth restriction may have similar
determinants and consequences.
Overall we noted that 17.5% study cases had
IUGR and abruption placentae in pregnancies
with PIH and preeclampsia. WHO estimates that,
worldwide, over 100,000 women die from
preeclampsia each year, and the condition
continues to be responsible for maternal deaths
(in developed countries)20, perinatal mortality
and
morbidity,
including
IUGR
and
prematurity21.
Pak Armed Forces Med J 2016; 66 (Suppl-3): S203-07
et al showed multiple clinical risk factors increase
the risk of preeclampsia and SGA22. Study by
Morgan-Ortiz et
al23
showed
significant
association between low socioeconomic level and
past history of preeclampsia. Study by Tuuli and
Odibo24 showed that preeclampsia and IUGR
are major contributors to perinatal mortality and
morbidity.
Accurate prediction is important for
identifying those women who require more
intensive
monitoring,
permitting
earlier
recognition and intervention, and allowing
targeting of potential preventive measures to
those at risk.
Many studies have proven the relation of
early screening perinatal outcome, however,
there is a further need of large prospective
studies to not only evaluate the choice of
parameters and strategies of combination to
achieve the best predictive models24 but also to
rationalize the management options. In this way
the rates of maternal mortality and pregnancy
related complications in fetus can be averted.
Identifying patients at risk for preeclampsia
would allow an increase in perinatal surveillance
and possibly decrease the inherent maternal and
fetal morbidity and mortality associated with
severe preeclampsia and eclampsia.
CONCLUSION
Based on our study findings it can be
concluded that PIH and pre-eclampsia remains a
common complication of pregnancy that leads to
unacceptable increases in fetomaternal morbidity
and mortality.We found a significant proportion
of pregnancy outcome as IUGR and abruption
placentae in women having PIH and
preeclampsia.
Patients with suspicion of pregnancy
induced hypertension and pre-eclampsia should
Many other investigators have also
be monitored closely so that fetomaternal
witnessed similar consequences of PIH and
outcome may be improved and risk of IUGR and
preeclampsia as shown by our findings. Seed PT
Abruptio placentae is avoided.There is a need to
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Abruptio Placentae and Intrauterine Growth
Pak Armed Forces Med J 2016; 66 (Suppl-3): S203-07
find out preventive measures, proper antenatal
care and BP control can overcome PIH and preecalmpsia and can improve fetomaternal
outcome by reducing IUGR and abruption. We
suggest that further large scale studies for
validation of early screening of PIH and
preeclampsia
are
required,
moreover,
interventional studies are needed to assess
modalities that may prevent women from
developing these conditions.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
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Co-relation of Pregnancy induced Hypertension with Placental
Abruption and effect of antihypertensive therapy. Rawal Med
J 2005;30:59-61.
17. Abassi RM,Rizwan N,Mumtaz F,Farooq S.Fetomaternal
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Hospital of Sindh. JLUMHS 2008; 7: 106-9
18. Villar J, Carroli G, Wojdyla D, Abalos E, Giordano D, Ba'aqeel
H, et al. Preeclampsia, gestational hypertension and
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S207
Original Article
Lignocaine with And Without Metoclopramide
Pak Armed Forces Med J 2016; 66 (Suppl-3): S208-12
FREQUENCY OF PAIN DUE TO INJECTION OF PROPOFOL WITH IV
ADMINISTRATION OF LIGNOCAINE WITH AND WITHOUT METOCLOPRAMIDE
Syed Ali Raza Ali Shah, Syeda Sarah Naqvi, Muhammad Ali Abbas*
Combined Military Hospital Rawalakot, Pakistan, *Combined Military Hospital Rawalpindi, Pakistan
ABSTRACT
Objective: To determine the frequency of Propofol associated pain in patients undergoing general anaesthesia
using lignocaine alone and metoclopramide given prior to lignocaine.
Study Design: Double blind Randomized controlled trial.
Place and Duration of Study: It was conducted in Anaesthesia department, Combined Military Hospital,
Rawalpindi; over a period of Six Months from 20-02-2011 to 19-08-2011
Material and Methods: One hundred and twenty Patients were included in the study, and were randomly
divided into two groups of 60 each. 20 ml (1% aqueous) Propofol solution was mixed with 2 ml of 2% lignocaine.
Propofol dose was calculated as 2 mg/kg. Group A were given intravenous 10mg metoclopramide. One fourth
dose of propofol (1% aqueous solution) was then given in the most prominent vein of the hand through cannula
at a rate of 1 mL/s. Group B were given intravenous normal saline instead of metoclopramide, and then received
25% the total dose of propofol mixed with lignocaine in the same manner.
Results: Mean age was 31 ± 5.07 and 32.9 ± 6.42 in group- A and B respectively. In group-A, 70%patients and in
group-B, 65%patients were male. Pain was present in 4(6.7%) patients in group-A, and in 13 (21.7%) patients in
group-B. Significant difference between two groups was found (p=0.018).
Conclusion: It is concluded from this study, that intravenous metoclopramide given prior to mixture of lidocaine
and propofol is superior to administration of lidocaine mixed with propofol alone to prevent propofol induced
pain.
Keywords: Lidocaine, Metoclopramide, Pain on Propofol.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Propofol is one of the widely used
intravenous agents. It is not a water soluble drug
but the intravenous solution available in market
is 1% aqueous solution (20 mg/20 ml). It is oil-inwater emulsion which contains soybean oil,
glycerol and egg lecithin. This formulation is
known to cause pain on injection. Its incidence
varies from 28% to 90%1. Pain is severe, sharp,
itching or burning in nature that can cause
discomfort and distress to the patient.
A number of studies have been performed to
find out strategies to reduce the incidence of
Propofol associated pain including mixing of
Correspondence: Dr Syed Ali Raza Ali Shah, Main Operator
Theatre CMH Rawalkot Pakistan (Email:[email protected])
Received: 10 Mar 2014; revised receive: 11 Jun 2014; accepted: 12 Jun
2014
lignocaine or selecting a larger vein or combining
these two strategies, combination of intravenous
lignocaine and dexamethasone, pretreatment
with
fentanyl,
pretreatment
with
flurbiprofenaxetil and prior injection of certain
drugs like ondansetron, ketamine, opioids,
magnesium sulfate, ketorolac or tramadol.
Though lignocaine has been found to be
effective in reducing the incidence of pain,
however, Propofol associated pain may still be
there.
Metoclopramide increases gastric emptying,
intestinal transit and lower esophageal sphincter
pressure. This makes it one of the commonest
antiemetic used for prevention of preoperative
and postoperative aspiration, and postoperative
nausea and vomiting2. Importantly, it has local
anesthetic properties like lignocaine.
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Lignocaine with And Without Metoclopramide
Pak Armed Forces Med J 2016; 66 (Suppl-3): S208-12
Statistical data shows that the incidence of
Propofol associated pain is 5% when lignocaine
(40mg) and metoclopramide (10 mg) are given
together as compared to 20% when only
lignocaine is given3.
The rationale of the study is to find out
strategy to reduce the frequency of pain which
occurs on injecting Propofol so that it may be
used in other hospital as well. It will benefit
patients in terms of recovery and good anesthetic
experience.
MATERIAL AND METHODS
This was a Double blind Randomized
clinical trial. It was conducted in Main operation
theatre, Anaesthesia Department, Combined
Military Hospital Rawalpindi. This study was
carried out over a period of Six months from
20-02-2011 to 19-08-2011. Patients were included
in the study through Non-Probability consecutive
sampling. All ASA I and II patients of both
gender and 20 to 50 years of age coming for
elective surgeries,
who require general
anaesthesia. Patients who have history of
Allergy/ hypersensitivity to Lignocaine and
propofol.
 Disoriented patients.
Patients were randomly divided into two groups
using random numbers table-1% aqueous
solution of Propofol was mixed with 2 ml of 2%
lidocaine. Group-A was given 10mg of
metoclopramide intravenously. Then dose of
propofol was calculated at dose of 2mg/kg, and
25% of this dose was injected into most
prominent vein of the hand through cannula at a
rate of 1 mL/s. Group-B was injected with
normal
saline
intravenously
instead
of
metoclopramide, then they received 25% the total
dose of propofol mixed with lignocaine in the
same manner. Pain was assessed as per patient
response by the anaesthetist and was recorded.
Statistical analysis
All the data collected through the proforma
were entered into the statistical package for social
sciences (SPSS) version. Mean and standard
deviation (SD) were calculated for quantitative
data age, weightwhile frequency and percentage
were calculated for qualitative data as gender
andpain. Chi Square was used to compare gender
and pain responsebetween two treatments.
Independent samples t-test was used to compare
age. p-value of less than 0.05 was taken as
significant.
RESULTS
 Patient with carotid artery disease.
 Patient with coronary artery disease.
The study was conducted after approval of
the Hospital ethical committee and all the data
were recorded after explaining the risk and
benefits to the patients and getting informed
consent.
The patient and the anesthetist making
observations
were blind to the drug
administered. An intravenous access was secured
by 18G intravenous cannula in most prominent
vein of right hand of each patient before start of
surgery. Randomization was done by computer
generated table of random numbers. Patients
were monitored in the operating room using noninvasive blood pressure monitoring and pulse
oximetry. Rubber tourniquet was used to occlude
vein for 1 mintue before administration of drugs.
One hundred and twenty patients were
included in study, and they were randomly
divided in two groups of 60 each. Regarding age
distribution, majority of the patients in both
groups were between 20-30 Years of age. Mean
age was 31 ± 5.07 and 32.9 ± 6.42 in group-A and
B respectively (table-1); [p= 0.007]. In group-A, 42
patients (70%) and in group-B, 39 patients (65%)
were male, while 18 patients (30%) of group-A
and 21 patients (35%) of group-B were female
(table-2); (p= 0.559). Pain was present in 4
patients (6.7%) in group-A and 13 patients
(21.7%) in group-B. Frequency of pain was
significantly higher in group-B (p=0.018) (table-3).
DISCUSSION
The popularity and usage of propofol has
increased markedly around globe due to its rapid
onset and short duration of action. But, pain
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Lignocaine with And Without Metoclopramide
Pak Armed Forces Med J 2016; 66 (Suppl-3): S208-12
encountered upon its injection, is a major
drawback to its use. Different methods have been
tested, which had different level of success4.
pain may have delayed onset, but may be
immediate if it involves direct action on nerve
endings.
Site of injection and size of vessel are
directly related to incidence and severity of pain
caused by propofol4. For example, pain is less if
propofol is injected into antecubital fossa4.
Clinical factors such as younger age group and
female gender seem to increase pain on injection
of propofol5.
Many studies have been conducted on
efficacy of lignocaine, and they showed its
effective role9. It may be due to its local anesthetic
action or by inhibition of kinin release4. Different
Concentrations were tested. P. Lee et al compared
dose of 40 mg in two concentrations of 1% and
2%; and found good results. Sharon et al on the
other hand, used same volume but different
concentrations. He took 1 ml of 0.5%, 1% and 2%,
thereby using 5 mg, 10 mg, and 20 mg; and
So using larger vein, warming the site of
injection or cooling it, mixing lignocaine or
Table-1: Distribution on the basis of age among groups.
Group-A (Metoclopramide+lignocaine) (n=60)
Group-B (Lignocaine alone) (n = 60)
Age (Year)
No.
%
No.
%
20-30
39
65.0
38
63.3
31-40
13
21.7
16
26.7
41-50
08
13.3
06
10.0
Mean ± SD
31 ± 5.07
32.9 ± 6.42
p-value
0.007
Table-2: Gender distribution of two groups.
Group-A (Metoclopramide+ lignocaine)
Group-B (Lignocaine alone) (n = 60)
(n = 60)
Sex
No.
%
No.
%
Male
42
70.0
39
65.0
Female
18
30.0
21
35.0
p-value
0.559
Table-3: Distribution of cases by pain responses.
Group-A (Metoclopramide+ lignocaine)
Group-B (Lignocaine alone) (n = 60)
(n = 60)
Pain
No.
%
No.
%
Yes
04
06.7
13
21.7
No
56
93.3
47
78.3
p-value
0.018
pretreatment
with
different
drugs
like
metoclopramide, ondansetron, ketamine; can
reduce this pain6. Most common of these is
lignocaine but it may not be effective with pain
occurring in 13% and 32% patients4,7.
Propofol is an irritant to the skin and even
venous intema11. It is speculated that the pain is
due to formation of kinins, including bradykinin.
Bradykinin is a vasodilatoor and increases
permeability. So it increases contact of propofol
with free nerve endings, resulting in pain8. This
combined it with propofol (19 ml of 1% aqueous
solution). They recommended 20 mg for
prevention of propofol induced pain4.
In present study administration of
intravenous metoclopramide prior to injection of
2 ml of 2% lignocaine plus propofol, reduced
propofol-induced pain on injection significantly
as compared lignocaine alone for the sake of
prevention.
The use of lignocaine pretreatment to reduce
pain on propofol injection has become a standard
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S208-12
practice. In a systematic review, Picard and
Tramer found that lignocaine had the best effect
for minimizing pain. They also concluded that
retention of lignocaine with tourniquet similar to
Bier’s block was most useful method rather than
mixing lignocaine with propofol or giving IV
lignocaine before propofol injection10.
On the other hand, met oclopramide has
been shown to be effective for reducing the
incidence of pain on injection of propofol,
probably because of its local anesthetic action11.
Liaw and coworkers have compared different
techniques
that
included
intravenous
metoclopromide after venous occlusion by using
tourniquet. They concluded that this was the
most useful method for reducing propofol
induced pain on injection12. In the first report by
Ganta et al13, intravenous injection of
metoclopromide 5mg before the induction of
anesthesia with propofol, reduced the incidence
of pain on injection. Similarly, a mixture of
propofol to which metoclopromide 20mg is
added was effective for reducing the incidence of
injection pain. Maroof et al14 have demonstrated
the analgesic efficacy of metoclopramide 10mg
administered intravenously, using a venous
tourniquet for one minute before propofol
injection for reducing propofol-induced pain on
injection14. A comparative study has been
reported
that
intravenous
retention
of
metoclopramide with a tourniquet is the most
useful method for reducing the incidence of pain
on injection of propofol12. In a study Fujii and
coworkers have shown that intravenous
metoclopramide reduces pain effectively if 5 or 10
mg is given, and vein is occluded for 01 minute11.
Also, Fujii et al tried different doses of
intravenous lignocaine and metoclopramide.
They used lignocaine 40 mg, but dose of
metoclopramide was different. They tested 5 mg,
10 mg, and 2.5 mg. They concluded that using 5
or 10 mg of metoclopramide decreases the
incidence of pain; but mean intensity scores are
not reduced in comparison to 2.5 mg of
metoclopramide or placebo (normal saline)15.
Various studies were undertaken to find out
other drugs which could be as effective as
lignocaine in decreasing pain on injection.
Alfentanil was tested against lignocaine, and
combination of both was tested as well. And it
was found that combination is better than either
of these used alone, however, prevention was
better by alfentanil than lignocaine when used
alone (30% and 38.5%)16. Fentanyl has also been
counted in those opioids which can prevent
propofol induced pain17. Another study reported
that pretreatment with 100 micro gram fentanyl
provided reduction in propofol induced pain
which was not statistically different than that
with lignocaine18. Other opioids like remifentanil
are as good as lignocaine in relieving propofol
induced pain19.
One report suggests that combination of
prilocaine with propofol reduces pain to same
extent as with lignocaine20. Saadawy et al tried
various drugs like ketamine, thiopentone,
meperidine
and
lignocaine.
And
they
recommended that ketamine pretreatment at
dose of 0.4 mg/kg, with occlusion of vein for 1
minute21.
Yoshikawa examined the analgesic effect of
clonidine and found that pain on injection of
propofol was lower in group receiving
clonidine22.
Another report suggested that pretreatment
with magnesium sulfate 2.48 mmol can be used
as an alternative for reduction of pain on
propofol injection as it is a calcium channel
blocker and antagonist of NMDA receptor ion
channel23. However they noticed minimal pain on
injection of magnesium. Two recent studies with
IV paracetamolpre treatment showed that it is
effective in reducing pain but not as good as
40mg lignocaine20.
Ondansetron is a widely used anti emetic
drug. Ye et al24 tested ondansetron (OND) in rats,
and found it more potent local anesthetic than
lidocaine24. It was found that numbness is caused
when OND is injected subcutaneously. OND has
multiple actions like it is µ opioid agonist,
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Lignocaine with And Without Metoclopramide
Pak Armed Forces Med J 2016; 66 (Suppl-3): S208-12
sodium channel blocker, apart from being 5HT3
receptor antagonist. So it may be used to prevent
propofol induced pain. In a double blinded study
conducted, ondansetron 0.1 mg kg- 1was proved
to alleviate pain on injection of propofol upto
50%. Of course its anti-emetic effect is bonus too
in general anesthesia11. Recently Zahedi et al25
recommended its use for prophylaxis of propofol
induced pain.
CONCLUSION
It is concluded from this study, injecting
metoclopramide prior to administration of
lignocaine mixed in propofol is superior to
administration of lignocaine mixed with propofol
alone, for the sake of reducing propofol induced
pain. Administration of intravenous metoclopramide then 25% of the total calculated dose of
propofol (2 mg/kg) mixed with 2 ml of 2%
lignocaine provided the optimal dose and timing
to reduces propofol-induced pain on injection
significantly as compared to 25% the total dose of
propofol mixed with lignocaine in the same
manner, without metoclopramide before injecting
Propofol and lignocaine.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Chohedri AH, Seyedi M, Masjedi M. Propofol induced pain;
comparison between effects of Lidocaine Propofol mixture and
Metoclopramide premedication. Professional Med J 2008; 15:
205- 10.
2. Sandhu T, Tanvatcharaphan P, Cheunjongkolkul V.
Ondansetron versus metoclopramide in prophylaxis of nausea
and vomiting for laparoscopic cholecystectomy: a prospective
double-blind randomized study. Asian J Surg 2008;31:50-4.
3. Fujii Y, Nakayama M. Prevention of pain due to injection of
propofol with IV administration of lidocaine 40 mg +
metoclopramide 2.5, 5, or 10 mg or saline: a randomized,
double-blind study in Japanese adult surgical patients.
ClinTher 2007; 29:856-61.
4. Auerswald K, Pfeiffer F, Behrends K, Burkhardt U, Olthoff
D.Pain on injection with propofol. Anasthesiol Intensivmed
Notfallmed Schmerzther. 2005 May; 40(5): 259-66.
5. Hye-Joo Kang, Mi-Young Kwon. Clinical factors affecting the
pain on injection of propofol Clinical Research Article, Korean J
Anesthesiol 2010; 58: 239-43.
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6. Ohnhaus EE, Adler R. Methodological problem in the
measurement of pain: a comparison between the verbal rating
scale and the visual analogue scale. Pain; 1:379.
7. MonuYadav, PadmajaDurga, R
Gopinath.
Role
of
hydrocortisone in prevention of pain on propofol injection. J
AnaesthesiolClinPharmacol. 2011; 27(4): 470–474.
8. Coderre TJ, Katz J, Vaccarino AL, melcack R. Contribution of
central neuroplasticity to pathological pain: review of clinical
and experimental evidence. Pain 1993; 52:259-85.
9. Gehan G, Karoubi P, Quinet F. Optimal dose of lignocaine for
preventing pain on injection of propofol. Br J Anaesth 1991; 66:
324- 6.
10. Picard P, Tramer MR. Prevention of pain on injection with
propofol: a quantitative systematic review. AnesthAnalg 2000;
90:963-9.
11. Fujii Y, Uemura A. Effect of metoclopramide on pain on
injection of propofol. AnesthInt Care 2004; 32:635-56.
12. Liaw WJ, Pang WW, Chang DP, Hwang MH. Pain on injection
of propofol: the mitigating influence of metoclopramide using
different techniques. ActaAnaesthesiolScand .1999; 43:24-7.
13. Ganta R, Fee JPH. Pain on injection of propofol: comparison of
lignocaine with metoclopramide. Br J Anaesth 1992;69:316-7.
14. Maroof M, Khan RM, Khalid A, Siddique MSK, Rahman Z.
Pain associated with propofol injection is abolished by
pretreatment with metoclopramide. Br J Anaesth 1995; 74:84.
15. Fujii Y, Nakayama M. Prevention of pain due to injection of
propofol with IV administration of lidocaine 40 mg +
metoclopramide 2.5, 5, or 10 mg or saline: a randomized,
double-blind study in Japanese adult surgical patients.
ClinTher 2007; 29:856-61.
16. Kwak HJ, Min SK, Kim JS, Kim JY.Prevention of propofolinduced pain in
children:
combination of alfentanil and
lidocainevsalfentanil or lidocaine alone. Br J Anaesth. 2009 ;
103(3):410-2.
17. Ahmad
N, Zanariah
Y, Balan
S.Fentanyl pre-treatment
alleviates pain during injection of propofol-lipuro premixed
with lignocaine.Med J Malaysia. 2008; 63(5):431-3.
18. Fujii
Y, Itakura
M.A
comparison
of
pretreatment
with fentanyl and lidocaine preceded by venous occlusion for
reducing pain on injection of propofol: a prospective,
randomized, double-blind, placebo-controlled study in adult
Japanese surgical patients. ClinTher. 2009; 31(10):2107-12.
19. RoehmKD,Piper SN, Malick WH. Prevention of propofol pain
by remifentanil. AnaesthAnalg 2001;93;382-4.
20. Canbay O, Celebi N. Efficacy of intravenous acetaminophen
and lidocaine on propofol injection pain Br J Anaesth
2008;100:95-8.
21. Saadawy I, Ertok E, Boker A. Painless injection of propofol:
pretreatment with ketamine vs thiopental, meperidine, and
lidocaine. Middle East J Anesthesiol. 2007; 19(3):631-44.
22. Yoshikawa T, Wajima Z Ogura A. Orally administered
clonidine significantly reduces pain on propofol injection. Br J
Anaesth 2001; 86;874-6.
23. Memis D, Turan A, Karamanloglu B. The use of magnesium
sulfate to prevent pain on injection of propofol. AnesthAnalg
2002; 95:606-8.
24. Ye JH, Mui WC, Ren J. Ondansetron exhibits the properties of a
local anesthetic. AnesthAnalg 1997; 85:1116-21.
25. Zahedi H, Maleki A, Rostami G. Ondansetron pretreatment
reduces pain on injection of propofol.Acta Med Iran. 2012;
50(4): 239-43.
Original Article
Early Neonatal Outcomes & Umbilical Artery Waveforms
Pak Armed Forces Med J 2016; 66 (Suppl-3): S213-16
COMPARISON OF EARLY NEONATAL OUTCOMES FOR ASYMMETRICAL IUGR
WITH NORMAL AND ABNORMAL UMBILICAL ARTERY WAVEFORMS
Lubna Noor, Humaira Arshad*, Humaira Tariq, Afeera Afsheen
Combined Military Hospital Peshawar, Pakistan, *Combined Military Hospital Quetta, Pakistan
ABSTRACT
Objective: To compare early neonatal outcome of asymmetrical IUGR fetuses with normal and abnormal
umbilical artery Doppler waveforms.
Study Design: Cohort study.
Place and Duration of Study: Department of Obstetrics and Gynecology, Military Hospital, Rawalpindi from Jul
2010 to Dec 2010.
Material and Methods: Total of 66 patients with normal and abnormal Doppler umbilical artery waveforms with
asymmetrical IUGR were included in the study. The study group consisted of 33 patients having asymmetrical
IUGR with normal umbilical artery Doppler RI < 0.65 (Group 1) and 33 with abnormal umbilical artery Doppler
RI> 0.65 (Group 2) These underwent serial Doppler umbilical artery study. Neonatal outcomes measured in terms
of APGAR score, Birth weight, admission to NICU and number of still births.
Result: The mean gestational age at delivery of group 1 was 36 ± 2.0 weeks and mean gestational age of group 2
was 33 ± 2.9 weeks (p-value=0.002) The Birth weight in group 1 was 2078 ± 408 grams and group 2 was 1642 ±
426 grams (p-value=0.000). The APGAR score of neonate at 5 minutes in group 1 ranged 7.6 ± 2.2 and that in
group 2 with abnormal Doppler waveforms ranged 5 ± 2.3. These differences are statistically significant. Neonates
with APGAR of less than 7 were admitted to NICU.
In group 1, 24 neonates were having APGAR score of 7 or more and were not admitted to NICU while in
group 2, 24 were admitted to NICU as the APGAR score were less than 7. Chi-square test was used and the
difference was found significant. Still births in both the groups were compared. In group 1 there was only one
still birth whereas there were 4 still births in group 2 p-value=0.355. There is no significance differences (p>0.05).
Conclusion: Abnormal umbilical artery Doppler is a better predictor of neonatal outcome in terms of APGAR
score, Birth weight, NICU admission and probability of still births than normal Doppler study.
Keywords: Abnormal Doppler study, APGAR score, Birth weight, NICU admission.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Intrauterine growth restriction is a common
clinical sign of chronic fetal hypoxemia1. It is
difficult to differentiate between suboptimal fetal
growth due to intrauterine starvation and
adequate growth of constitutionally small
infants2.
Assessment of fetal growth and well being is
one of the major purposes of antenatal care. Fetal
growth is dependent on genetic, placental,
Correspondence: Dr Lubna Noor, Graded Gynecologist, CMH
Peshawar, Pakistan (Email:[email protected])
Received: 26 Aug 2014; revised received: 28 Jul 2015; accepted: 12 Feb
2016
maternal and environmental factors. Small for
gestational age fetus is either constitutionally
small or has failed to meet its growth potential so
is growth restricted. Constitutionally small
fetuses are otherwise normal. Intrauterine growth
restriction may be symmetrical or asymmetrical
and has high risk of perinatal mortality and
morbidity followed only by prematurity.
Placental insufficiency is the leading cause of fetal
growth restriction and is due to poor
uteroplacental blood flow and placental infarcts3.
There are various methods of diagnosis and
surveillance of IUGR i.e clinical assessment,
ultrasound biometry (abdominal circumference)
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Early Neonatal Outcomes & Umbilical Artery Waveforms
Pak Armed Forces Med J 2016; 66 (Suppl-3): S213-16
estimated fetal weight and Doppler velocitmetry.
No single measurement helps secure the
diagnosis; thus a complex strategy for diagnosis
and assessment is necessary. Doppler ultrasound
of umbilical artery is helpful than any other test
of fetal wellbeing in distinguishing between
normal small fetus and growth restricted fetuses
and is a good predictor in these growth restricted
fetuses at risk of antenatal compromise.
variables i.e. birth weight and APGAR score,
while frequency and percentages were presented
for categorical variables i.e. still births and NICU
admission; using SPSS 16. Chi-square test is used
to compare birth weights and admission
comparing to NICU. Independent t-test is used
for birth weights and APGAR score in both
groups. p-value of less than 0.05 is considered
significant.
MATERIAL AND METHODS
RESULTS
Study was conducted after permission from
ethical committee. An informed consent was
The mean age of patients on group-1 was
28 ± 4.5 years and in group-2 was 28 ± 5.0 years.
Table-1: Frequency distribution for admission to NICU in both groups.
N % (Percent) Apgar < 7
Group
1(normal umbilical artery Doppler waveforms)
2(abnormal umbilical artery Doppler waveforms)
27%
73%
taken from all patients that were included in the
study. Sixty six pregnant women with
asymmetrical IUGR in antenatal clinic of Military
Hospital Rawalpindi from July 2010 to December
2010 were included in study.
Patient information including age, parity,
gestational age at delivery and neonatal outcome
were endorsed in a specifically designed
proforma. Neonatal APGAR, birth weight and
admission to NICU.
Pregnant women were recruited in study
after 24 weeks if fundal height was 3cm less than
dates, from antenatal clinic in Military Hospital
Rawalpindi. All these patients underwent serial
growth scans and patients found to have
discrepancy of three or more weeks between
ultrasound measurements and menstrual dates
underwent Doppler umbilical artery study.
Women were allocated to group-1 with normal
umbilical artery waveform (RI<0.65) and group-2
with abnormal umbilical artery waveform
(RI>0.65).
Birth weights were recorded in grams.
Neonates with APGAR score less than 7 at 5
minutes were admitted to neonatal intensive care
unit. Mean and standard deviation for numerical
Seven women in group 1 and twelve in group-2
were primigravid.
The gestational age at delivery were 36 ± 2.0
weeks in group-1 and 33 ± 2.9 weeks in group-2.
Perinatal outcome
Birth weight in group-1 was 2078 ± 408
grams and in group-2 was 1643 ± 426 grams.
Independent sample t-test was applied and this
difference was found statistically significant
(p-value=0.000)
The APGAR score of neonates at 5 minutes
Figure-1: Distribution of still births in two
groups.
in group 1 ranged 7.6 ± 2.2 and that in group 2,
5 ± 2.3. This difference is statistically significant
(p-value=0.000).
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Early Neonatal Outcomes & Umbilical Artery Waveforms
DISCUSSION
Use of umbilical artery Doppler in modern
obstetrics has guided the obstetricians in
managing cases of IUGR. However there is
controversy as to which vessel provides the best
guide. Ductus venosus waveforms are time
consuming and require a skilled sonographer
whereas using middle cerebral artery waveforms
diagnose only an advanced fetal hypoxic stage1.
For these reasons umbilical artery is preferred in
clinical setting.
Follow up of patients with IUGR using
umbilical artery Doppler waveforms will help
guide further management. Different surveillance
patterns are adapted but the aim is to have good
outcome.
Many studies found correlation between
abnormal umbilical artery waveforms and poor
fetal outcome. Present study also demonstrate
this association. Compromised fetuses delivered
at early gestation as compared to those with
normal Doppler and required NICU care due to
prematurity. IUGR is associated with significant
morbidity in the form of meconium aspiration
syndrome
(MAS),
hypoglycemia,
hyaline
membrane disease (HMD), early onset sepsis
(EOS), intrapartum asphyxia, delayed milestones
and stillbirths. Use of Doppler ultrasound has
helped in better management of these patients 1.
In this study more NICU admissions and still
births seen in group-2 where Doppler umbilical
artery is raised in compromised fetuses.
Malhotra N and colleagues conducted a
study to evaluate role of umbilical artery Doppler
in growth restricted fetuses. Delivery in
pregnancies with abnormal Doppler was at early
gestation 27 ± 3.5 weeks as compared to those
with normal Doppler 37 ± 3.3 weeks. Birth weight
in abnormal Doppler was 742 ± 126 grams and
in normal Doppler was 1680 ± 259 grams1. This
study supports our result.
Pak Armed Forces Med J 2016; 66 (Suppl-3): S213-16
gestational age infants. This multivariate logistic
regression analysis revealed umbilical artery
Doppler study as a significant independent factor
for prediction of poor perinatal outcome4.
A prospective study by Spinillo and
colleagues on prognostic value of umbilical artery
Doppler studies in unselected preterm deliveries
in 2008 showed that absent or reverse enddiastolic flow in the umbilical artery is an
independent predictor of either neonatal death or
cerebral palsy in preterm growth-restricted
fetuses5. Hence strengthening our result.
CONCLUSION
A multidisciplinary approach is required for
managing pregnancies including obstetrician,
radiologist and neonatologist. Early detection,
evaluation and combined care can result in better
maternal and fetal outcome.
Doppler umbilical artery ultrasound is more
helpful than any other test of fetal well being in
distinguishing between normal fetus and growth
restricted fetus. Absent and reverse diastolic flow
velocities of umbilical artery are associated with
poor perinatal outcomes. The current therapeutic
goals are to optimize the timing of delivery to
minimize hypoxemia and maximize gestational
age.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Malhotra N, Chanana C, Kumar S, Roy K, Sharma JB.
Comparison of perinatal outcomes of growth restricted fetuses
with normal and abnormal umbilical artery Doppler waveforms.
Ind J Med Sci 2006; 60: 311-7.
2. Breeze ACG, Lees CC. Prediction and perinatal outcomes of fetal
growth restriction. Sem Fet Neonat 2007; 12: 383-97.
3. Smith GCS, Lees CC. Disorders of fetal growth and assessment of
fetal well being. In;Edmonds DK(edi)7th edi. Blackwell 2007; 15965.
4. Young Ji Byun, Haeng-Soo Kim, Jeong In Yang, Joon Hyung Yeon
Kim and SUk Joon Chang. Umbilical artery Doppler study as a
predictive marker of perinatal outcome in preterm small for
gestational age infants.Yonsei Med J 2009 28; 50: 39-44.
5. Spinillo A, Montanari L, Bergante C, Gaia G, Chiara A, Fazzi E.
Prognostic value of umbilical artery Doppler studies in
unselected preterm deliveries. Obstet Gynecol 2005; 105: 613-620.
6. Baschat AA, Galan HL, Bhide A, Berg C, Kush ML, Oepkes D, et
al. doppler and biophysical assessment in growth restricted
Study conducted by Young Ji Byun and
colleagues in 2009 to evaluate the merits of
umbilical artery Doppler study as a predictive
marker of perinatal outcome in preterm small for
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S213-16
fetuses: distribution of test results. Ultrasound Obstet Gynecol
2006; 27: 41-47.
Figeras F, Eixarch E, Meler E, Iraola A, Figueras J, Puerto B,et
al.Small-for-gestational age fetuses with normal umbilical artery
Doppler have suboptimal perinatal and neurodevelopmental
outcome. Eur J Obstet Gynecol Reprod Biol 2008;136:34-38.
Ott WJ. Intrauterine growth restriction and Dopller
ultrasonography. CMAJ 2008;178: 701-11.
Gerber S, Hohlfeld P, Viquerat F, Tolsa JF, Vial Y. Intrauterine
growth restriction and absent or reverse end-diastolic blood flow
in umbilical artery. A retrospective study of short and long term
fetal morbidity and mortality.Eur J Obstet Gynecol Reprod Biol
2006; 126: 20-6.
Cosmi E, Ambrosini G, D Antona D, Saccardi C, Mari G. Doppler,
cardiotocography and biophysical profile changes in growth
restricted fetuses. Ostet Gynecol 2005; 106: 1240-5.
Chauhan SP, Reynolds D, Cole J, Scardo JA, Magann EF, Wax J, et
al Absent or reversed end-diastolic flow in the umbilical artery. J
Miss Stae Med Assoc 2005;46:163-8.
Karsdorp VH, van Vugt JM, van Geijn HP, Kostense PJ, Arduini
D, Montenegro N. Clinical significance of absent or reversed end
diastolic velocity waveforms in umbilical artery. Lancet 1994; 344:
1664-8.
Salafia CM, Pezzullo JC, Minior VK, Divon MY. Placental
pathology of absent and reversed end-diastolic flow in growthrestricted fetuses. Obstet Gynecol 1997; 90: 830-6.
Sezik M, Tuncay G, Yapar EG. Prediction of adverse neonatal
outcomes in preeclampsia by absent or reversed end-diastolic
flow velocity in the umbilical artery. Gynecol Obstet Invest 2004;
57: 109-13.
Schwarze A, Gembruch U, Krapp M, Katalinic A, Germer U, AxtFliedner R. Qualitative venous Doppler flow waveform analysis
in preterm intrauterine growth-restricted fetuses with ARED flow
in the umbilical artery-Correlation with short-term outcome.
Ultrasound Obstet Gynecol 2005; 25: 573-9.
Gudmundsson S, Tulzer G, Huhta JC, Marsal K. Venous Doppler
in the fetus with absent end-diastolic flow in the umbilical artery.
Ultrasound Obstet Gynecol 1996; 7: 262-7.
Battaglia C, Artini PG, Galli PA, D'Ambrogio G, Droghini F,
Genazzani AR. Absent or reversed end-diastolic flow in umbilical
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association. Acta Obstet Gynecol Scand 1993; 72: 167-71.
Steiner H, Staudach A, Spitzer D, Schaffer KH, Gregg A, Weiner
CP. Growth deficient fetuses with absent or reversed umbilical
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Tyrrell SN, Lilford RJ, Macdonald HN, Nelson EJ, Porter J, Gupta
JK. Randomized comparison of routine vs highly selective use of
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Karsdorp VH, Dirks BK, van der linden JC, van Vugt JM, Baak JP,
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S216
Original Article
Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
Dietary Patterns in DM
SELF-CARE AND DIETARY PATTERNS AMONG DIABETES MELLITUS PATIENTS IN
RAWALPINDI
Aliya Hisam, Naseer Alam Tariq, Muhammad Hammad*, Umair Hassan**, Sania Iram***, Ifra Tariq****, Sajid Ali*****
Army Medical College, National University of Medical Sciences (NUMS), Rawalpindi Pakistan, *Combined Military Hospital Quetta,
Pakistan, **Combined Military Hospital Jhelum, Pakistan, ***Military Hospital Rawalpindi, Pakistan, ****Combined Military Hospital
Rawalpindi, Pakistan, *****Combined Military Hospital Lahore.
ABSTRACT
Objective: To find out the knowledge, attitude and practice among diabetic patients regarding their dietary
patterns.
Study Design: Descriptive cross-sectional study.
Place and Duration of Study: In a tertiary care hospital of Rawalpindi of six month’s duration from August, 2013
till January, 2014.
Patients and Methods: A sample size of 131 was calculated using the WHO sample size calculator. Convenience
sampling technique was used. Clinically diagnosed diabetes mellitus by a consultant and those who were able to
show the diabetes medication were included in the study. Any patient unwilling or failing to show the diabetes
medicine was excluded from the study. Data was collected by the researcher using pre-tested mixed
questionnaire. Data was entered into and analyzed using SPSS version 20.
Results: A total of 135 patients were enrolled in the study, with a mean age of 55.16 ± 10.47 years. There were 92
(68 %) males and 43 (32%) females. Good knowledge regarding diabetes mellitus was observed in 82 (60.7%) of
the participants while 53 (39.3%) were having poor knowledge. Positive attitude was observed in 51 (37.8%)
participants while negative attitude in 84 (62.2%). Good practice was observed in only 28 (20.7%) while poor
practice was seen in 107 (79.3%) of the participants.
Conclusion: Knowledge regarding self-care was sound among the diabetic patients but there existed a wide gap
between knowledge and practice. Attitude was positive in the educated class but deficient in the illiterates.
Healthy Dietary patterns were satisfactory among the study participants.
Keywords: Attitude, Diabetes mellitus, Dietary patterns, Knowledge, Practice.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
The term Diabetes mellitus is derived from
the Greek words ‘diabetes’ meaning “to go” and
‘mellitus’ meaning “honey’’1. It is a syndrome
characterized by chronic hyperglycemia that is
either due to the relative insulin deficiency or due
to resistance or sometimes both.
It affects 30 million people worldwide.
Diabetes is usually irreversible, and although the
Correspondence: Dr Aliya Hisam, Community Medicine Dept,
Army Medical College, Rawalpindi Pakistan
Email: [email protected]
Received; 04 May 2016: revised received: 23 May 2016; accepted: 24 May
2016
patients can live a normal life, its late
complications result in reduced life expectancy
and considerable uptake of health sources.
Macrovascular disease leads to an increased
incidence of IHD, peripheral vascular disease and
stroke. Microvascular disease causes diabetic
retinopathy, neuropathy and nephropathy2.
Diabetes has distinct clinical types, namely:Type 1 DM results from the body's failure to
produce insulin, and currently requires the
person to inject insulin or wear an insulin pump.
This form was previously referred to as "insulindependent diabetes mellitus" (IDDM) or "juvenile
diabetes".
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Dietary Patterns in DM
Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
Type 2 DM results from insulin resistance, a
condition in which cells fail to use insulin
properly, sometimes combined with an absolute
insulin deficiency. This form was previously
referred to as non insulin-dependent diabetes
mellitus (NIDDM) or "adult-onset diabetes".
The third main form, gestational diabetes
occurs when pregnant women without a previous
diagnosis of diabetes develop a high blood
glucose level. It may precede development of
type 2 DM.
Many processes injure pancreas and can
result in diabetes for example pancreatitis,
trauma,
infection,
pancreatectomy,
and
pancreatic carcinoma. Drugs also impair insulin
secretion and impairs insulin release. Several
genetic syndromes are associated with an
increased occurrence of diabetes3.
There is no disease which provokes greater
thought on diet than diabetes. Diet management
alone may suffice to prevent or treat diabetes in
10-15% of patients4. Even in others, effective diet
control helps in reducing the requirement of
drug/insulin and delays the onset of
complications such as blindness, renal failure,
stroke and heart disease.
Pakistan is currently on 7th number in the
world with regard to the number of diabetics and
according to the current studies, it will be ranking
4th by 2030. The estimated prevalence of diabetes
in Pakistan in 2011 was over 350 million and it is
expected to be more than 550 million by year
20305,6,9. Type 2 diabetes mellitus is more
dominant as compared to other types in
developing countries if compared to developed
countries. The medication of diabetes has a
successful effect on glycemic control in recent
years but lack of knowledge, poor attitude and
practice especially behavior change modifications
are tacloes leading to high burden of noncommunicable diseases7. This alarming situation
can have serious repercussions and presents as a
challenge for health care providers and health
care policy makers in the country.
According to a survey conducted in Karachi,
Pakistan, the prevalence of uncontrolled diabetes
mellitus was about 39% among persons with type
2 diabetes visiting a specialized care unit for
diabetes. Based on reports of studies5-8 conducted
in Pakistan, an upcoming epidemic of diabetes
mellitus complications is feared8. The scarcity of
health-care services and poor infrastructure for
health care in Pakistan is an important factor in
making it difficult to control the emerging
epidemic of DM in the country9.
To achieve and maintain glycemic control it
is very important to adopt and sustain multiple
self-care behaviors like blood glucose monitoring,
regular exercise, balance eating regime etc
Consumption of food is one of the major
component of daily living that effect
development and further progression of diabetes
mellitus10. People behavior is appropriately
predicted by the cultures, beliefs, attitudes that
they have regarding self-care as what individual
do with their knowledge and skills is what
determines their capabilities. Self-efficacy was
found to be an important predictor of self-care
behaviors in type 2 diabetes patients11.
According to WHO, NCD’s account for 46%
of all deaths in Pakistan, amongst which about
1% are caused by complications of diabetes.
WHO projects that over the next 10 years in
Pakistan:a. Over 6 million people will die from a chronic
disease.
b. Deaths from infectious diseases, maternal and
perinatal
conditions
and
nutritional
deficiencies combined will decrease by 12%.
c. Deaths from chronic disease will increase by
27%- most markedly by diabetes, which will
increase by 51%.
d. Pakistan is projected to lose 31 billion US
dollers over the next 10 years due to the deaths
from diabetes, stroke and heart disease12.
Level of awareness and availability of
professional dietetic services has shown potential
for better management of diabetes or its
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
complications. Diabetic patients have a lot of
misconceptions and myths about diet control and
this poses a need to dispel their myths and save
the nation a lot of budget which can be utilized in
other deficient sectors. The mounting number of
diabetic individuals especially in the younger
population owing to the increasingly sedentary
lifestyle and junk food eating habits has posed an
immense need that the problem must be dealt
with iron hands now.
METHODOLOGY
It was a descriptive cross sectional study
carried out in tertiary care hospitals of
Rawalpindi from August, 2013 till January, 2014.
Using WHO sample size calculator, the sample
size was calculated to be approximately 131 (with
Confidence Level (CL) of 95%, Anticipated
population proportion (p) of 0.68 and Absolute
precision (d) of 0.08). Convenience sampling
technique was used. Clinically diagnosed
diabetes mellitus patients by a consultant and
those who were able to show the diabetes
medication were included in the study. Any
patient unwilling or failing to show the diabetes
medicine was excluded from the study. Data was
collected by the researcher using pre-tested
mixed questionnaire. Participants were asked
about 12 questions regarding knowledge, attitude
and practice. Participants giving 8 or more correct
responses related to diabetes mellitus were
considered having sufficient knowledge, positive
attitude and good practice. Ethical Committee
approval was taken and from every patient
informed verbal consent was taken.
Data was entered and analyzed using
Statistical package for Social Sciences (SPSS)
version 20. Qualitative variables like knowledge,
attitude, practice etc are presented in the form of
frequencies
and
percentages.
Descriptive
statistics was used to calculate mean and
standard deviation for quantitative variables like
age. Chi square test of significance was applied to
find association between the demographic
variables and practice of self-care.
RESULTS
A total of 135 patients were enrolled in the
study, with a mean age of 55.16 ± 10.47 years.
There were 92 (68.1 %) males and 43 (31.9%)
females. Regarding education levels, about 18
(13.3%) were illiterate, 26 (19.3%) were under
matriculate, 34 (25.2%) had matriculation
completed, 38 (28.1%) were graduates and
19 (14.1%) were postgraduates.
When income in rupees per month was
inquired, 12 (8.9%) were having 3000 Rs, 4 (3.0%)
participants having 3000-5000 Rs, 15 (11.1%)
having 5000-10000 Rs , 28 (20.7%) having 1000020000 Rs, 34 (25.2%) having 20000-30000 Rs and
42 (31.1%) were having more than 30000 Rs.
Forty four (32.6%) participants were
diagnosed with diabetes from 1-3 years, 62
(45.9%) were diagnosed since last 4- 10 years and
29 (21.5%) having it for more than 10 years.
(Table).
They were asked if they know that they
should regularly check their blood sugar levels
checked, 133 (98.5%) replied yes and only 2
(1.5%) said no they don’t think so. When asked
that do they know that healthy diet prevent
diabetes, 104 (77%) said yes they know while 30
(22.2 %) said they don’t know. Participants were
asked if they think that weight control prevents
diabetes incidence, 78 (57.8%) said yes but 57
(42.2%) said no they don’t think it prevents
diabetes mellitus. When asked about regular
exercise that does this reduces chances of
diabetes, 69 (51.1%) said yes it does while 66
(48.9%) said no it does not. Knowledge regarding
smoking association with diabetes was asked and
only 13 (9.6%) replied that yes smoking is
associated with diabetes but a very large
percentage, 122 (90.4%) said that smoking is not
associated with occurrence of diabetes mellitus.
Participants were asked regarding treatment
options and multiple responses were observed.
Fifty six (41.5%) were in opinion of drugs being
treatment of diabetes, 100 (74.1%) knew insulin as
a treatment option, regular exercise also was
known as a treatment option by 42 (31.1%),
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
heathy diet, controlling weight, quitting smoking
was considered as treatment options by 37
(27.4%), 43 (31.9%) and 10 (7.4%) of the
participants. Good knowledge regarding diabetes
mellitus was observed in 82 (60.7%) of the
participants while 53 (39.3%) were having poor
knowledge.
Participant’s attitude was assessed regarding
dietary patterns and multiple responses were
three diets in 15 (11.1 %), 135 (100%) and 90
(66.7%) respectively. They were asked about the
effect of healthy diet on diabetes; 17 (12.6%)
participants said it cures diabetes mellitus, 105
(77.8%) said it controls, 7(5.2%) said it has no
effect and 6 (4.4%) said they don’t know. About
avoiding sugar alone can control diabetes was
perceived by 44 (32.6%) of the participants. Thirty
five (25.9%) participants also believed that once
Table: Association of demographic variables with practice of self-care among diabetes mellitus (n=135).
Variables
Frequencies (%)
p-value
Age (Mean ± SD)
55.16 ± 10.47
0.764
Gender
Male
92 (68.1)
0.063
Female
43 (31.9)
Education Status
Illiterate
18 (13.3)
Under matric
26 (19.3)
Matriculation
34 (25.2)
0.892
Graduation
38 (28.1)
Post-Graduation
19 (14.1)
Income (rupees per month)
< 3000
12 (8.9)
3000-5000
4 (3)
5000-10,000
15 (11.1)
10,000-20,000
28 (20.7)
0.202
20,000-30,000
34 (25.2)
> 30,000
42 (31.1)
Diagnosed with diabetes mellitus since how
many years
1-3
44 (32.6)
0.723
4-10
62 (45.9)
>10
29 (21.5)
Knowledge
Good
82 (60.7)
0.642
Poor
53(39.3)
Attitude
Positive
51 (37.8)
0.289
Negative
84 (62.2)
Practice
Good
20.7)
Poor
107 (79.3)
0.661
observed. They were asked if diabetic patient
should have protein rich, sugar free or fat free
diet and participants were in agreement for above
diabetes mellitus is controlled by insulin, dietary
restrictions are no longer required. Positive
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
attitude was observed in 51 (37.8 %) participants
while negative attitude in 84 (62.2%).
Patients were asked regarding their habit of
skipping a meal or snack deliberately to cut short
calorie or fat intake, 120 (4.8%) said that they
always practice skipping meal, 70 (51.9%) skip
meal off and on and 45 (33.3%) had never done
this. Participants were asked regarding their
dietary intake and multiple responses were
observed. Patients using low caloric diet were
only 39 (28.9%), 45.2% use reduced fat or fat free
products, 55 (40.7%) always used sugar free
products and 19 (14.1%) always used a written
diet plan to manage their daily dietary intake.
When asked about how often do they check their
blood sugar levels; 45 (33.3%) said occasionally,
48 (35.6%) 3-5 times per months, 20 (14.8%) 1-2
times a week, 6 (4.4%) 3-6 times a week, 11 (8.1%)
once a day, 2 (1.5%) twice daily. About 3 (2.3%)
said they have not been told by anyone to check
their blood sugar. Good practice was observed in
only 28 (20.7%) while poor practice was seen in
107 (79.3%) of the participants.
DISCUSSION
Diabetes is an important cause of morbidity
and mortality all over the world. Because of lack
of awareness about diabetes, most patients with
diabetes suffer from its complications13. Many
patients don’t know about diabetes to an extent
which is needed to improve their daily practices
regarding the disease. Nearly all of the patients
enrolled in the study knew that they should keep
their glucose level in check which was surely a
positive finding, attributed to the good health
education of the patients by the diabetic clinic
being run by Maj Gen Hamid Shafeeq in the
Military Hospital, Rawalpindi. Surprisingly
many of the patients knew about the prevention
of the disease and said that healthy diet, weight
control and regular exercise, all afford protection
against the disease. Most of them knew that
lifelong prevention was the key to control the
disease, however, a number of them said that diet
restrictions weren’t needed once the sugar is
controlled. A study showed that a planned
educational intervention in type-1 diabetics, who
even received monthly supplies of insulin free of
charge, did not improve the key aspects of the
practice component, even though the knowledge
and attitude improved14.
A comparative study of knowledge, attitude
and practices of diabetic patients cared for at a
teaching hospital free of charges and those cared
for at private clinics and charged for it showed
that although knowledge was quite good but
there existed a wide gap between knowledge and
practice15. According to a study conducted in
Egypt, it is the 9th country with prevalence of
diabetes. Diabetes management depends very
much on the persons owns ability to control it
and knowledge regarding its prevention and
management is one of the key components of
diabetes control16. In our study the knowledge
was more than fifty percent but when compared
with practice, it was not sufficient to control the
emerging and prevalent threat.
The attitude of the patients towards a sugar
free diet was positive in nearly everyone but not
for fat free diet which poses the diabetic
individuals to having hyperlipidemias and
consequently cardiovascular disease in the long
run. A study was conducted regarding self-care
role in diabetes management in India. It
concluded that to control diabetes associated
morbidity and mortality, we need to increase
self-care behaviors in many domains that is
healthy eating, food selection, physical exercise,
appropriate
medications,
blood
glucose
monitoring. Although many socio demographic,
economic, heath care services factors affect selfcare behaviors and attitudes
but
role of
clinicians is very critical in promoting self-care
and has to be highlighted. In this study, we only
focused on diabetic patient so further studies
regarding assessment and impact of clinician’s
role is required to be assessed17.
It was important to find out that more than
half of the patients knew that they should have a
sweet thing as soon as possible if they ever had
hypoglycemia. It was surprising to know that,
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Dietary Patterns in DM
Pak Armed Forces Med J 2016; 66 (Suppl-3): S217-23
though a small number, some patients said that
they would have insulin or the prescribed drugs
if they ever had hypoglycemia, which can be
disastrous for the patient. There is usually a lack
of compliance with the guidelines on the part of
the diabetic subject, which also indicates the
deficiencies in the physician’s knowledge,
implementation
techniques
and
attitude
18
problems . As far as treatment of the disease is
concerned, generally speaking, a gap exists in the
knowledge of the patients that insulin is the only
method of treatment of the disease while other
modalities are not. Similar findings were
suggested by a study about Qatari diabetic
patients with type II diabetes mellitus that there
were significant differences of knowledge and
attitude between educational levels. However
failure to foresee the long term complications of
the disease such as polyneuropathy, retinopathy
and nephropathy, leads to a poor practice
amongst the patients regarding their meals,
taking medication and modifying doses when
necessary19.
Diabetes is a life-long disorder and hard to
treat because, firstly doctors lack time and
secondly people with diabetes are deficient in
resources for comprehensive care. In our setup,
patients with symptoms demand a quick relief. If
they are asymptomatic, they avoid visiting the
doctor. The role of the health care provider, in the
case of chronic illness is different than that of
seasonal, episodic and temporary ailments20.
CONCLUSION
Knowledge regarding self-care was sound
among the diabetic patients but there existed a
wide gap between knowledge and practice.
Attitude was positive in the educated class but
deficient in the illiterates. Healthy Dietary
patterns were satisfactory among the study
participants.
RECOMMENDATIONS
A diabetic clinic focusing especially on selfcare can be planned in every hospital and also at
primary health care centre. Diet plans can be
issued to the patients in local language. Patients
must be counselled well about the hypoglycaemic
and hyperglycaemic episodes, nature of their
disease and its long term complications. Family
members and close relatives can be educated and
involved in the process to increasing self-care and
healthy diet.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
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S223
Original Article
Frequency of Cervical Ribs
Pak Armed Forces Med J 2016; 66 (Suppl-3): S224-27
FREQUENCY OF CERVICAL RIBS AMONG ADULT MALES SEEKING EMPLOYMENT
IN PAKISTAN ARMY
Muhammad Arshad, Jawaid Hameed*, Amer Zamir Sahi**
Combined Military Hospital Hyderabad, Pakistan, *Liaquat University of Medical & Health Sciences Hyderabad, **Pakistan
Army Selection & Recruitment Centre Hyderabad, Pakistan
ABSTRACT
Objective: To determine the frequency of cervical ribs among adult male population seeking employment in
Pakistan army.
Study Design: Cross sectional study.
Place and Duration of Study: Department of Diagnostic Radiology, Combined Military Hospital, Hyderabad
cantt from 1st October 2012 to 31st March 2014.
Material and Methods: The study was conducted on chest radiographs of 4337 adult males who reported for
recruitment in Pakistan Army irrespective of ethnicity.
Results: The prevalence of cervical ribs among adult males of Pakistan was 6.11% with 4.29% bilateral, 1.13%
right sided and 0.69% on left side.
Conclusion: Pakistani adult male population was observed to have 6.11% prevalence of cervical ribs, thus
justifying initial screening chest radiographs of all candidates for military recruitment that can pick up all cases of
cervical ribs in addition to exclusion of cardiopulmonary pathologies.
Keywords: Cervical rib, Chest radiograph, Elongated C7 transverse processes, Prevalence.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
initially associated with a “cervical rib
syndrome”. Later on, many fibrous, bony, and
muscular abnormalities were described as
causes of neuromuscular compression at the
thoracic outlet4,5. This has led to the term
“thoracic outlet syndrome”6, still used in current
publications. 10% of patients having thoracic
outlet syndrome were found to have cervical
rib7.
Cervical rib is a supernumerary rib which
arises from the seventh cervical vertebra. It is
congenital abnormality located above the
normal first rib. This condition is present in
approximately 1-2% of the population1,2. It is
usually attached to the first rib, close to the
insertion of scalenus anterior muscle (Figure-1).
It may consist of a complete rib, but often the
bone is present only for a variable distance, the
anterior part being made of a fibrous band.
Unlike a cervical rib, an elongated C7 transverse
process is fused with the C7 vertebra3.
It was felt to study a section of Pakistani
population to assess the usefulness of chest
radiographs to detect the cervical ribs before
induction in Pakistan army.
Cervical rib is usually asymptomatic and is
detected as an incidental finding when a chest or
neck x-ray is taken for some other purposes. The
neurovascular symptoms in the upper limb were
The purpose of this study is to know the
prevalence of cervical ribs in Pakistani adult
male population and to detect this pathology on
the basis of chest radiographs.
MATERIAL AND METHODS
Correspondence: Dr Muhammad Arshad, Dept of Diagnostic
Radiology CMH Hyderabad, Pakistan
Email:[email protected]
Received: 07 May 2014; revised received: 20 Aug 2014; accepted: 20
Aug 2014
This cross-sectional study was conducted
from 1st October 2012 to 31st March 2014 in the
Diagnostic Radiology department of Combined
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Frequency of Cervical Ribs
Pak Armed Forces Med J 2016; 66 (Suppl-3): S224-27
Military Hospital, Hyderabad cantonment,
Pakistan. 4337 chest radiographs of adult males,
ranging from 17 years to 23 years age, were
taken for induction in Pakistan army. Sample
size for the study was calculated by WHO
1. The rib must abut the seventh cervical
vertebral transverse process, which is seen to
project horizontally or caudally from the spine
(figure-2).
2. It must have no connection with the
Table-1: The number of cervical ribs in the study population.
Total cases studied
Number of cervical rib cases
Bilateral cervical rib
Right side
Left side
sample size formula for proportion studies8.
Two experienced radiologists reviewed these
radiographs. All radiographs were exposed on
X-ray system 660 mA, Villa Systemi, Italy and x-
4337
265 (6.11%)
186 cases (4.29%
49 cases (1.13%)
30 cases (0.69%)
manubrium sterni, thus distinguishing a cervical
rib from rudimentary first rib.
3. The cervical rib must be separate from, but
articulate with, the transverse process of C7. If
Figure- 1: Costo-scalene triangle, showing the anatomical structure.
ray films were processed on Fuji Automatic Film
Processor, FPM-4200 Japan. All technically
inadequate images were repeated to identify the
presence or absence of cervical ribs. In 265
individuals with suspicion of cervical ribs,
Anteroposterior projection of the cervical spine
was performed to confirm the presence of
cervical ribs.
fused with the vertebra, it was classed as an
elongated transverse process. Elongated C7
transverse processes were also noted which
were classified as any C7 transverse process
longer than the T1 transverse process.
RESULTS
In our study, 4337 cases were examined for
cervical rib. Median age was 19 years with age
range of 17 years to 23 years. 265 cases were
positive with an overall prevalence of 6.11%. Of
the 265 individuals with cervical ribs, 30 were on
the left, 49 on the right and 186 were bilateral
The following criteria to identify the
presence of a cervical rib on chest radiographs
were used:
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Frequency of Cervical Ribs
Pak Armed Forces Med J 2016; 66 (Suppl-3): S224-27
(table-1). A total of 451 cervical ribs were found
in our 265 cases. Of the fifty-two individuals
with long transverse processes giving an overall
prevalence of 1.20%, thirty-five were bilateral,
ten on right side and seven on left side. A total
of 87 elongated C7 transverse processes were
found in our 52 cases.
cases. Study by Guelkon et al used cervical spine
radiographs with additional oblique projections;
even then their prevalence rate was less than our
study17.
The use of CT imaging did not appear to
increase the prevalence of cervical ribs, which
was 1.4% in male population18. Cervical ribs
were identified on 1.2% of MRI examinations,
lower than CT, but MRI may equivalent
anatomic explanation for patients’ symptoms19.
MRI and CT scans can identify cervical root
injury from degenerative spurs, disc herniation,
or other causes. MRI can identify distortion or
displacement of the plexus in the thoracic outlet
or supraclavicular space, usually from fibrous
bands but also from clavicular abnormality.
Doppler ultrasound and angiography are only
useful in the presence of vascular clinical signs20.
DISCUSSION
We found overall prevalence rate of
cervical rib to be 6.11% which is too high as
compared to 0.42% in the London study
conducted on 1352 males9, 0.49% with bilateral
predominance in the Indian study conducted on
7,272 males10, and 1.36% in central India on 2500
males11.
Erken et al reported a prevalence of 6.2%
for cervical rib in a population sample from
Turkey12. Rakan F Bokhari et al in 2012 claimed a
higher prevalence of cervical rib and elongated
C7 transverse processes as 3.4% and 23%
respectively, in a population in Jeddah, Saudi
Arabia13. Two recent studies in Nigeria, first
using anteroposterior cervical spine radiographs
and second using posteroanterior chest
radiographs, found 0.4% prevalence of cervical
ribs in 245 males and 0.6% prevalence of cervical
ribs in 617 males respectively14,15.
a
“Radiographic evaluation of cervical spine”
at Wah, Pakistan in year 2010 demonstrated
3.9% prevalence of cervical ribs in 1000 cases of
mixed ages and both sexes16. The prevalence rate
of enlarged C7 transverse processes was 1.20%,
less than 2.21% noted for London population
and 23% in a population in Jeddah, Saudi
Arabia.
b
Figure-2: (a) Chest radiograph reveals bilateral
cervical ribs. (b) X-ray chest demonstrates right
cervical rib with pseudoarthrosis between
proximal and distal segments.
Difference of prevalence of cervical ribs
between different ethnic populations may
suggest true differences in the rate of cervical
ribs between populations. This suggests that
genetic or environmental factors may contribute
to the formation of cervical ribs. Our data
includes the Hyderabad division of Sindh
province which can be considered as
cosmopolitan region representing Pakistani
population; as it contains mixture of local
Sindhis, and migrants from India and other
parts of Pakistan with 5% Christians and 2%
Hindu communities.
The reason for higher prevalence rate of
cervical ribs in our study can be related to use of
chest as well as cervical spine radiographs.
There was no chance of missing rudimentary
cervical ribs or misinterpreting elongated C7
transverse processes as rudimentary cervical
ribs; as all cases with suspicious cervical ribs and
enlarged C7 transverse processes were subjected
to AP projection of cervical spine which
confirmed the presence of both entities in 100%
S226
Frequency of Cervical Ribs
Pak Armed Forces Med J 2016; 66 (Suppl-3): S224-27
CONCLUSION
[Online] cited on 15 Aug 2014. Available at: http: //www.
who.int/ chp/steps /resources/sampling/en/.
Brewin J., Hill M., Ellis H. Department of Anatomy, Guy's King's
and St. Thomas School of Biomedical Sciences London, United
Kingdom. Prevalence of cervical ribs in a London population.
Clinical Anatomy. April 2009; 22 (3): 331–6.
Anima G, Gupta D.P., Saxena D.K, Gupta R.P. Cervical Rib: It’s
Prevalence in Indian Population around Lucknow (UP). J of
Anatomical Society of India. 2012; 61(2): 189–191.
DK Sharma, Vishnudutt, Vandana Sharma, Mrithunjay Rathore.
Prevalence of 'Cervical Rib' and its association with gender,
body side, handedness and other thoracic bony anomalies in a
population of Central India. Indian Journal of Basic and Applied
Medical Research. March 2014; 3 (2): 593–597.
Erken E, Ozer HT, Gulek B, Durgun B. The association between
cervical rib and sacralization. Spine (Phila Pa 1976). 2002; 27:
1659–1664.
Rakan F Bokhari, Mohammad J Al-Sayyad, Saleh S Baeesa.
Prevalence of cervical ribs and elongated transverse processes in
Saudi Arabia, Saudi medical journal. 2012; 33(1):66–9.
Ebeye O Abimbola, Apare A Willido. Prevalence of Cervical
Ribs in a Nigeria population. IOSR Journal of Dental and
Medical Sciences. Feb. 2014; 13 (2):05–07.
Ani CC, Adegbe EO, Ameadaji M, Gabkwet A. Cervical Rib
Variant in a Nigerian Population. Jos Journal of Medicine. 2012;
6 (1): 60–62.
Salam A, Ahmed MU, Kohistani TA. Radiographic evaluation of
cervical spine. RMJ. 2010; 35(2): 152–155.
Gulekon IN, Barut C, Turgut HB. The prevalence of cervical rib
in Anatolian population. Gazi Med J. 1999; 10:149–152.
Viertel VG, Intrapiromkul J, Maluf F, Patel NV, Zheng W,
Alluwaimi F et al. Cervical Ribs: A Common Variant
Overlooked in CT Imaging. AJNR Am J Neuroradiol. Dec 2012;
33(11): 2191–4.
Walden MJ, Adin ME, Visagan R, Viertel VG, Intrapiromkul
J, Maluf F et al. Cervical ribs: identification on MRI and clinical
relevance. Clin Imaging. 2013; 37(5):938–41.
Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y,
Descatha A. Thoracic outlet syndrome: definition, etiological
factors, diagnosis, management and occupational impact. 2011;
21(3):366–73.
Our study found high prevalence rate of
6.11% of cervical ribs in Pakistani population but
low prevalence rate of elongated C7 transverse
processes of 1.20%.
9.
10.
ACKNOWLEDGEMENT
The authors express gratitude to Brigadier
Aamir Ijaz (Head of Academics, AFIP
Rawalpindi) for assistance in improvement of
manuscript.
11.
12.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
13.
REFERENCES
14.
1. Moore K.L. Clinically Oriented Anatomy 6th Ed. Lippincott
Williams & Wilkins. 2010; 460.
2. Galis F. "Why do almost all mammals have seven cervical
vertebrae? Developmental constraints, Hox genes, and cancer". J.
Exp. Zool.1999; 285 (1): 19–26.
3. Ebite L.E, Igbigbi P.S, Chisi J.E. Prevalence of true cervical rib in
adult Malawian population. J. Anat Sci. 2007; 1(1) 7–9.
4. Roos DB. Congenital anomalies associated with thoracic outlet
syndrome. Anatomy, symptoms, diagnosis, and treatment. Am J
Surg. 1976; 132:771–778.
5. Makhoul RG, Machleder HI. Developmental anomalies at the
thoracic outlet: An analysis of 200 consecutive cases. J Vasc Surg.
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6. Roos DB, Annest SJ, Brantigan CO. Historical and anatomic
perspectives on thoracic outlet syndrome. Chest Surg Clin N
Am. 1999; 9:713–723.
7. Leffert RD. Thoracic outlet syndromes. Hand Clin. May 1992;
8(2):285–97.
8. STEPS Sample Size Calculator and Sampling Spreadsheet
15.
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18.
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20.
S227
Original Article
Blood Type and Rh Factor Among Blood Donors
Pak Armed Forces Med J 2016; 66 (Suppl-3): S228-32
DISTRIBUTION OF BLOOD TYPE AND Rh FACTOR AMONG BLOOD DONORS
OF LAHORE
Muhammad Saeed, Shahida Hussain, Minza Arif*
Allama Iqbal Medical College Lahore Pakistan, *Postgraduate Medical Institute Lahore Pakistan
ABSTRACT
Objective: Present study was designed to provide baseline data about distribution frequency of blood type and
Rh factor among blood donors of Lahore.
Study Design: Cross sectional study.
Place and Duration of Study: Department of Transfusion Medicine Jinnah Hospital Lahore from January 2012 to
December 2014.
Patients and Methods: A retrospective data of ABO/Rh typing done by manual hema-agglutination techniques
of total 17994 blood samples were collected by non probability consecutive sampling technique and analyzed for
ABO/Rh typing. Demographic characteristics age and gender were noted and cross tabulation for gender and
ABO/Rh typing was done. Chi-square test was used to assess any statistical association.
Results: Out of total 17994 donors, 90.83% (16344) were Rh positive and 9.16% (1650) were Rh negative. Blood
group “B” was found to be most prevalent, with the frequency of 6127 (34.05%), followed by “O” 5980 (33.2%),
and “A” 4210 (23.39%) respectively. “AB” group was least common with a frequency of 1677 (9.31 %). 23.9% of
male donors were of blood group type “A”, 34.5% were type “B”, 33.3% were type “O” and 8.3% had “AB”. 6.2%
of female donor were of blood group type “A”, 18.6% were of type “B”, 32.0% were having type “O” and 43.2%
had “AB”. (p=.000).
Conclusion: We conclude that the over all frequency distribution of ABO blood groups in study population of
Lahore is “B”> “O”> “A”> “AB”. Blood group “B” was most prevalent and AB the least prevalent. Rh positive
phenotype is predominant (90.8%) with distribution of “B”+ve >, “o”+ve> “A”+ve > “AB”+ve. In group of Rh
negative phenotype (9.2%) “o”-ve > “B”-ve > “A”-ve> “AB”-ve.
Keywords: ABO, Gender, Lahore, Rh.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
In human beings blood is considered as lifeline
for the existence. The deficiency of this precious body
fluid in different situations of emergency and
accidents leads to irreplaceable loss of human life. Till
the 19th century the blood transfusion procedure was
unsafe, but the mystery of blood transfusion was
solved in 29th century with the discovery of ABO and
Rh blood group antigens1. Karl Landsteiner, who was
an Austrian, he was awarded by Nobel Prize for the
incredible discovery of ABO blood group system2.
This discovery brought a great breakthrough in the
field of transfusion medicine; later on in 1941,
Correspondence: Dr Muhammad Saeed, Pathology Dept, Allama
Iqbal Medical College, Lahore, Pakistan
Email: [email protected]
Received; 26 Jan 2016: revised received: 23 May 2016; accepted: 31 May
2016
Landsteiner and Wiener defined the Rhesus (Rh)
blood group system3.
Since 1901, around 700 red blood cells (RBCs)
antigens have been discovered, organized into 30
different blood group systems by International Society
of Blood Transfusion (ISBT)4. The ABO blood group
antigens due to their immunogenic nature took the
primary importance in transfusion system. The ABO
incompatibility is reported as the most common
reason of death during blood transfusion. Therefore
success of blood transfusion requires compatibility of
two main blood group antigen systems, ABO and Rh.
ABO blood group system is comprised of two
RBC antigens (A & B) and 6 different genotypes i.e.
OO, OA, OB, AA, BB, AB, and four phenotypes “A”,
“B”, “AB” and “O”, which are expressed by three
different alleles “A”, “B” and “O” located on
S228
Blood Type and Rh Factor Among Blood Donors
Pak Armed Forces Med J 2016; 66 (Suppl-3): S228-32
chromosome no 9 and two antibodies Anti-A and
Anti-B5. Blood group “A” contains A antigen and
Anti-B antibodies while individuals having blood
group “O” possess both antibodies (A & B) without
any antigen6. Antibodies are not present at the time of
birth but they are produced later on after exposure to
environmental antigens.
The presence or absence of Rh antigens in blood
is determined by a set of two alleles at another locus
on chromosome no 1 of RBCs7. Six different types of
Rh antigen are present in the form of 3 groups “Cc”,
“Dd” and “Ee”, every person acquires one from each
group. Antigen “D” is the strongest among these
groups and a person with “D” antigen will be Rh
positive and Rh negative in the absence of “D” antigen
respectively. There might be possibility of cross
transfusion reaction between antibodies and “D”
antigen in humans.
There is no spontaneous
production of antibodies against Rh antigens like in
ABO blood groups and they need repeated exposure
for the formation of significant amount of antibodies
so that, transfusion reaction would occur8.
guidelines of standard venipuncture by National
Committee for Clinical Laboratory Standards
(NCCLS) and transferred to tube containing ethylene
diamine tetra acetic acid (EDTA) anti-coagulant.
Antigen, antibody agglutination test using anti-sera of
Bio-laboratory USA was performed by classical slide
method for the determination of ABO blood grouping
and Rh-D factor. The ABO blood grouping
monoclonal
reagents
contained
hybridized
immunoglobulin’s secreting mouse cell-line. Rh-D
factor is determined by using IgM and IgG
monoclonal reagents.
Blood donors those positive for hepatitis B, C and
HIV were excluded from the study. Mean and
standard deviation was calculated for nominal
variable e.g. age, frequency tabulation was done for
categorical variable like gender, ABO and Rh
grouping. Cross tabulation was done for gender and
ABO and Rh grouping. Chi-square test was used to
assess any statistical significance among gender and
ABO and Rh grouping with p<0.05 as statistical
significance.
The distribution of ABO and Rh blood groups
are highly influenced by the type of race, regional
area, both populations both and the category of sub
population. In Pakistan studies reported the variation
among blood donors in different regions and
populations because of racial differences9.
The
collection of data related to frequency of blood groups
and incidence rate are multipurpose and useful in the
field of genetic research, evolution, blood transfusion
and organ transplantation10.
RESULTS
Therefore, this study was designed to provide
baseline data about distribution of ABO and Rh blood
groups in blood donors attending Jinnah hospital
Lahore, and provided to planners, hospital
administration and healthcare centers to make the
transfusion services efficient and safe.
Table-1 shows the gender and age distribution of
study group. Blood donation practices are found
higher at the younger age group of less than 40 years.
MATERIAL AND METHODS
This cross sectional study was conducted at the
Transfusion medicine department Allama Iqbal
Medical College & Jinnah Hospital Lahore (AIMC &
JHL) from January 2012 to December 2014. A
retrospective data of ABO/Rh typing done by manual
Heam-agglutination techniques of total 17994 blood
samples were collected by non-probability consecutive
sampling technique and analyzed for ABO/Rh typing.
Donor included in this study were those from whom
1.5 ml of blood samples was drawn following the
Total 17,994 blood samples were screened for the
determination of ABO and Rh-D groups. Out of total
17,994 blood donors 97.03% (17,460) were males and
only 2.96% (534) were females. This finding showed
that blood donation practices are very less among
female gender (table-1).
Numbers of blood donation practices at different
ages, in the given population were studied. (Table-1).
Out of total male donors 23.9% of male donors
were of blood group type “A”, 34.5% were of type
“B”, 33.3% were having type “O” and 8.3% had “AB”.
6.2% of female donors were of blood group type “A”,
18.6% were of type “B”, 32.0% were having type “O”
and 43.2% had “AB”. (p=.000). (Table-2).
Table-3 Shows the results of Rh negative and
positive with respect to gender of donors. According
to results Rh negative group is more prevalent (13.8%)
in females as compared to males (9.0%) (Table-3).
Table-3 Out of total 17994 donors, 90.8% (16344)
was Rh positive and 9.2% (1650) were Rh negative.
90.9% of males were Rh +ve and 9.1% were Rh –ve.
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Blood Type and Rh Factor Among Blood Donors
Pak Armed Forces Med J 2016; 66 (Suppl-3): S228-32
86.1% of females were Rh +ve and 13.9% were Rh –ve.
(p=.000)
The distribution of ABO phenotypes in the Rh
positive donors showed that, 4021 (24.6%) were “A”,
5504 (33.6%) were “B”, 1499 (9.1%) “AB”, and 5320
(32.5%) were “O”. In case of Rh negative donors, 189
(11.4%) were group “A” 623 (37.7%) were “B”, 178
(10.7%) were “AB” and 660 (40.0%) were “O”.
DISCUSSION
The frequency of ABO and Rh-D blood group is
different from one population to another all over the
In present study frequencies of the blood donors
from population of Lahore, admitted presenting in a
tertiary care hospital were studied and according to
results, among ABO blood groups, blood group “ B”
was most prevalent 6127 (34.05%), followed by “O”
5980 (33.20%), “A” 4210 (23.39%) respectively. “AB”
group was least common with a frequency of 1677
(9.31 %). In the Rh positive donors, 4021 (24.6%) were
“A”, 5504 (33.6%) were “B” 1499 (9.1%) were “AB”
and 5320 (32.5%) were “O’. In Rh negative donors, 189
(11.4%) were “A” 623(37.7%) were “B”, 178 (10.7%)
were “AB” and 660 (40.0%) were “O”.
Table-1: Demographic characteristic of blood donors.
Factors
Distribution in study population (n=17,994)
Number of donors
Percentages
Gender
Male
Female
Age groups
< 40 years
> 41 years
17,460
534
97.03%
2.96%
16014
1980
Mean age = 37.5 SD = 7.54 year
88.99%
11.00%
Table-2: Frequency of ABO blood groups among blood donors in Lahore (n=17,994).
S No.
1
Blood Groups
A
2
B
3
O
4
AB
Total
Male Donors
4177
23.9%
6028
34.5%
5809
33.3%
1446
8.3%
17460
100.0%
Female Donors
33
6.2%
99
18.6%
171
32.0%
231
43.2%
534
100.0%
Total Donors
4210
23.4%
6127
34.1%
5980
33.2%
1677
9.3%
17994
100.0%
X2 , p-value
X2= 789.007
p=0.000
Total
17460
100.0%
534
100.0%
17994
100.0%
X2 , p-value
X2= 14.521
p=0.000
Table-3: Comparison of Rh+ve and Rh-ve in donors gender group.
Gender
Male
Female
Total
Rh+ve Donors
15884
90.9%
460
86.1 %
16344
90.8%
Rh-ve Donors
1576
9.1%
74
13.9%
1650
9.2%
world. Blood group frequency and prevalence studies
are multipurpose and play a role in genetic research,
evolution,
blood
transfusion
and
organ
transplantation. It is also important in determining the
migration of races and in hereditary diseases9. Some
diseases like ischemic heart disease, gastric cancer, are
more common to develop in certain blood groups;
hence relationship of different blood groups with
diseases is important11.
Multiple studies have been reported from
different geographical areas of Pakistan about the
distribution of ABO and Rh-D blood groups in
Pakistani population12,13. According to these studies
there is great diversity in the distribution of blood
groups different areas of Pakistan.
A study from Sindh region of reported that blood
group “O” (36%) is most prevalent group followed by
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Blood Type and Rh Factor Among Blood Donors
Pak Armed Forces Med J 2016; 66 (Suppl-3): S228-32
group “B” (30%), group “A” (25%) and blood group
“AB” (9%) is least frequent respectively14.
Another study from “Baluchistan” reported the
frequency of different blood groups in following order
“O” (37.07%) > “B” (34.32%)> and “AB” (7.57%)
respectively15. Similar results were also reported form
Mandibahud din, WahCantt and Gujarat which
showed that blood group “O” is very common in
those areas of Punjab16. The studies from the province
other than Punjab (Sindh and Baluchistan) also
reported blood group “O” as a most dominant blood
group which is contrary to the results of our
study14,15,17.
In Hameed et al and Chisti et al, they reported
“B” group as most common and “AB” as least
common in Faisalabad and Azad Kashmir
respectively18,19. In another study from Rawalpindi by
Khan et al showed the percentages of various groups
among female subjects, “B” (32.87%), “O” (31.91%),
“A” (24.02%) and “AB” (11.20%) respectively were
shown. Distribution of Rh positive was 92.45% and Rh
negative was 7.55% in the considered population20.
A study from Swat reported by Khattak et al
showed that blood group “B” female subjects were
found to be dominant (28.06%) followed by “O”
(25.5%), “A” (24.50%) and group “AB” (9.43%) being
least common respectively21.
Another study from Bannu by Khan et al showed
that the distribution of ABO groups is in the order of
36.23% “B”, 31.03% “A”, 25.07% “O” and 7.67% “AB”.
The Rh-D positive was 89.23% and Rh-D negative
10.77% 22.
As in our study we found that in the population
of Lahore the “B” blood group is found in high
frequency as compared to other groups among donor.
The results of Rahim Yar Khan, Mardan, Islamabad,
Rawalpindi and Khyber Pakhtunkhwa (KPK)
Province were also similar to our study.
In our study 92.8% were Rh-D positive. Out of
total 17994 donors 90.9% (males) and 86.1% (females)
were Rh-D positive. These results were quite similar
to the results of Saudia Arabia (Rh+ve 93%), USA
(Rh+ve 85%) and British (Rh+ve 95%)23-25. According
to our study in community of Lahore Rh-D positive
is predominant and its frequency is quite near to other
regions of Pakistan.
CONCLUSION
We conclude that the over all frequency
distribution of ABO blood groups in study population
of Lahore is “B”> “O”> “A”> “AB”. Blood group “B”
was most prevalent and AB the least prevalent. Rh
positive phenotype is predominant (90.8%) with
distribution of “B”+ve >, “O”+ve> “A”+ve >
“AB”+ve. in Rh negative phenotype (9.2%) “O”-ve >
“B”-ve > “A”-ve> “AB”-ve.
CONFLICT OF INTEREST
All authors declare no conflict of interest and
financial support from any company or organization
Ethical Study protocol was approved by ethical
review board AIMC.
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donors in Lahore, Pakistan. International journal of Advanced
Biological and Biomedical Research. 2014 1; 2(3): 597-600.
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4. Daniels G, Castilho L, Flegel WA, Fletcher A, Garratty G,
Levene C, et al. International Society of Blood Transfusion
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5. Ghasemi N, Davar R, Soleimanian S. ABO Bloods group
incompatibility in recurrent abortion. Iranian journal of
Pediatric Hematology Oncology. 2011 15; 1(2): 62-6.
6. Hosoi E. Biological and clinical aspects of ABO blood group
system. The journal of medical investigation. 2008; 55(3, 4): 17482.
7. National Center for Biotechnology Information (NCBI).Bethesda
MD, U.S. National Library of Medicine; 2013. RHD Rh blood
group, D antigen Gene ID: 6007, updated on 3 2013 .
8. Guyton AC, Hall JE. The cerebral cortex; Intellectual functions
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9. Alam M. ABO and Rhesus blood groups in potential blood
donors at Skardu (Northern Areas). Pakistan Journal of
Pathology. 2005; 16: 94-7.
10. Anees M, Jawad A. Distribution of ABO and Rh Blood Group
Alleles in Sahiwal district of the Punjab, Pakistan. Proceedings
of the Pakistan Academy of Sciences. 2011; 48(1): 39-43.
11. Majeed T, Hayee A. Prevalence of ABO blood group and sub
groups in Lahore, Punjab (Pakistan). Biomedica. 2002; 18: 11-5.
12. Zafar NJ, Hasan K, Bukhari K. Prevalence of ABO and Rh blood
group amongst voluntary blood donors. J Rawal Med Coll. 1997;
1(2): 78-80.
13. Mian A, Farooq A. Distribution of AB0 and RH blood group
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14. Khaskheli DK, Qureshi AH, Akhund AA. Distribution of ABO
and Rh groups in the residents of Sindh. Pak J health. 1994; 31:
45-50.
15. Hussain A, Sheikh SA, Haider M, Rasheed T, Malik MR.
Frequency of ABO and Rh blood groups in population of
Balouchistan (Pakistan). Pakistan Armed Forces medical journal.
2001; 51(1): 22-6.
16. Iqbal M, Niazi A, Tahir M. Frequency of ABO and Rh blood
groups in Healthy Donors. J. Rawal. Med. Coll. 2009; 13: 92-4.
17. Bhatti R, Shiekh DM. Variations of ABO blood groups. Gene
frequencies in the population of Sindh (Pakistan). Annals of
King Edward Medical College. 1999; 5(3/4): 328-1.
18. Hammed A, Hussain W, Ahmed J, Rabbi F, Qureshi JA.
Prevalence of phenotypes and Genes of ABO and Rhesus (Rh)
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20. Khan MS, Farooq N, Qamar N, Tahir F, Subhan F, Kazi BM, et
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S232
Original Article
Use of Levonorgestrel Intra – Uterine System (LNG IUS)
Pak Armed Forces Med J 2016; 66 (Suppl-3): S233--37
USE OF MIRENA – LEVONORGESTREL INTRA – UTERINE SYSTEM (LNG IUS) IN
DYSFUCTION UTERINE BLEEDING IN THE REPRODUCTIVE AGE GROUP
Afroze Ashraf, Nilofar Mustafa*, Nomia Saqib**
Pakistan Air Forces Hospital Lahore Pakistan, *Combined Military Hospita Lahore Pakistan, **Lady Willingdon Hospital Lahore Pakistan
ABSTRACT
Objective: To assess the efficacy of Mirena in patients with dysfunctional uterine bleeding of reproductive age
group.
Study Design: Quasi-experimental study.
Place and Duration of Study: the Department of Obstetrics and Gynecology Lady Lady Willingdon Hospital
Lahore, from Jan 2012 to July 2012.
Material and Methods: Patients with dysfunctional uterine bleeding diagnosed on histopathology, not requiring
conception, Unfit / unwilling for surgery were included in the study after ruling out all other causes of abnormal
uterine bleeding. In thirty three patients of dysfunctional uterine bleeding, mirena was inserted. Sampling
strategy was non-probability purposive sampling.
Results: Among thirty three subjects inserted with Mirena LNG system follow up at 3 months, 36.4% had no
bleeding, 15.2% had spotting and 48.5% had heavy menstrual bleeding. At 6 month follow-up 90.9% had no
bleeding and 9.1% had heavy menstrual bleeding (p=.000). Efficacy at three month follow up was in 36.4% of the
subjects and at 6 months follow-up was in 75.8% of the patient (p=.000).
Conclusion: Mirena is an effective non-surgical treatment for dysfunctional uterine bleeding, in women of
reproductive age group with fewer incidences of side effects.
Keywords: Dysfunctional uterine bleeding, Mirena, Levonorgestrel-releasing intrauterine system.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Abnormal uterine bleeding in the absence of
an identifiable organic cause is called
dysfunctional uterine bleeding1. Mirena is the,
non-invasive, nonsurgical, option for many cases
of ‘Abnormal uterine bleeding’ i-e Fibroid,
Adenomyosis, Endometrial hyperplasia, and
Dysfunctional uterine bleeding2.
menorrhagia
requiring
reversible
contraception”3. Mirena consists of a plastic
T-shaped frame with a steroid reserviour around
the vertical stem of polymethylisilicone. The stem
contains 52mg of Levonorgestrel, the levo-isomer
of norgestrel, derived from the 19 nortestosterone progestogens, released at a rate of
20μg per day4.
In 1996, it was concluded that the
levonorgestrel
intra-uterine
system
(levonorgestrel IUS; Mirena–Schering Health
Care) was an effective contraceptive. The product
is now also licensed as a treatment for “idiopathic
menorrhagia”, with the claim that it “ may be
particularly useful in woman with idiopathic
The effect of all progestogens on the
endometrium is mediated via a decrease in
oestrogen receptors and an increase in the 17α
oxoreductase activity that converts oestradiol to
oestrone5. The normal treatment options for
menorrhagia are oral medications, injections,
diagnostic curettage (D & C), Endometrial
ablation and hysterectomy etc.
Correspondence: Dr Afroze Ashraf, Graded Gynaeclogist, PAF
Hospital Munir Road Lahore, Pakistan
Email:[email protected]
Received: 18 Feb 2013; revised received: 15 May 2014; accepted: 21 May
2014
Hysterectomy leads to a lot of personal
trauma to both the patient and her family. The
pre-post-operative medications along with loss of
working days and disturbance from the normal
S233
routine add to the cost of therapy. Surgery is
irreversible leading to loss of fertility and loss of
organ. It is difficult to perform in cardiac, diabetic
and obese patients.
Mirena offers an ideal option to every
woman who could like to conserve her organ,
avoid surgery and anemia, save time and money
with least interference with her day-to-day life6.
The LNG-IUS reduces menstrual bleeding
and dysmenorrhea, and is an effective
nonsurgical treatment for idiopathic menorrhagia
in premenopausal women. Women using the
device experience significant reductions in
menstrual flow and increases in haemoglobin7.
The LNG-IUS has been used in the prevention
and treatment of iron deficiency anemia. Correct
insertion is essential, and complications and side
effects are rare; fertility is preserved8.
Mirena is inserted during the menses or
within seven days from the beginning of
Menstrual cycle. It is checked after four to six
weeks. Yearly checks are advised after this
appointment. Mirena lasts for 5 years, if required;
a new one can be inserted at the same time the
old is removed9. The most common problem
associated with Mirena is that it takes about 3
months for the endometrium to atrophy. During
the time bleeding can be heavy and erratic but
almost always settles after 3-6 months usage10.
Temporary side effects may include headache,
nausea, mood changes, breast and acne11. By
providing improvement in Health-related quality
of life (HRQL) at relatively low cost, the LNG-IUS
may offer a wider availability of choices for the
patients and may decrease costs due to
interventions involving surgery12.
The rationale of this study was to assess the
efficacy of mirena for safety, effectiveness, non
invasiveness, cost effectiveness and the patient
morbidity and mortality associated with surgery.
MATERIAL AND METHODS
A Quasi-experimental Study was carried
out at department of Obstetrics and Gynecology,
Unit-III, Lady Willingdon Hospital, Lahore,
during a period of one year and 7 months. A total
of thirty three patients of dysfunctional uterine
bleeding not requiring contraception and unfit or
unwell for surgery were included in the study
through non probability purposive sampling
after ruling out all other causes of abnormal
uterine bleeding among these patients. After an
informed consent age, parity, obstetrical history,
gynecological history, past medical and surgical
drug and menstrual history and changes in the
bleeding pattern were evaluated. Detailed
systemic
examination
was
carried
out.
Laboratory investigations specified for the study
were mandatory for all patients and included
following tests: Ultrasonography, hepatitis
screening,
histopathology
of
endometrial
curetting and high vaginal swab. The efficacy of
Mirena and the side effects experienced were
evaluated 3 months and up to 6 months followup. Efficacy was measured by amount of blood
loss assessed by pictorial blood loss assessment
chart (PBAC) at 3 & 6 months follow up, by
patient’s subjective assessment of amount of
blood loss in terms of number of sanitary napkins
soaked and passage of clots and was categorized
as spotting, heavy menstrual bleeding and no
bleeding.
Data had been analyzed in SPSS version
17.0. Frequency and percentage were calculated
for menstrual pattern, complications of Mirena
and effectiveness at 3 and 6 month follow up.
Marginal homogentiy test was used to assess the
statistical significance for pattern of menstrual
bleeding, effectiveness and complications at 3
month and 6 month follow up with p<0.05 as
statistical significant.
RESULTS
Thirty three subjects those fulfilling the
inclusion criteria were included in the study.
Pattern
of
cycle
showed
81.8%
had
polymenorrhagia while 18.2% had menorrhagia.
(Graph no-1). At 3 months follow up 36.4 % had
no bleeding, 15.2 % had spotting and 48.5 % had
heavy menstrual bleeding. At 6 month follow-up
90.9 % had no bleeding and 9.1 % had heavy
S234
menstrual bleeding. (p<.000) (table-1). Regarding
side effects at 3 months, 18.2% of subjects had
pain, 21.2% had pain and infection, 45.5%
experience no side effect. At 6 months follow up
18.2% had pain, 6.1% had pain and infection
while 60.6 % had no side effect. Mirena was
expelled or misplaced in 15.2 % of patients
(p<.002). At three month follow up Mirena was
effective in 36.4 % of subjects, 63.3% it was
ineffective. After 6 months follow-up Mirena was
effective in 75.8% of the patient and was
ineffective in 24.2% of the patients. (p<.000)
(table-2).
DISCUSSION
A sample of thirty three patients was
collected from Gynecology and Obstetrics unit-
patients were diagnosed and labeled as cases of
dysfunctional uterine bleeding after excluding
other organic causes of abnormal uterine
bleeding
by
detailed history,
thorough
examination and relevant investigations. At 3
months of follow up 48.5% had heavy menstrual
bleeding 36.4% had no bleeding and 15.2% had
spotting but at 6 month follow-up 90.9% had no
bleeding and only 9.1% had heavy menstrual
bleeding. Mirena was effective in 75.8% of the
patient at end of six month follow up. A similar
study was conducted by Monterio I et al. The
objective of this study was to evaluate the efficacy
and performance, of Mirena up to 1 year, in the
treatment of women with menorrhagia. The most
common bleeding pattern at 3 months after
insertion was spotting, and after 6, 9 and 12
Table–1: Menstrual pattern after 3 & 6 months follow up (n=33).
Follow-up
At 3 month Follow- At 6 month Followup
up
No bleeding
Menstrual pattern
Spotting
Heavy menstrual bleeding
Total
Table-2: Effectiveness of LNG-IUS at 3 & 6 months (n=33).
12
30
(36.4%)
(90.9%)
5
0
(15.2%)
(0.0%)
16
3
(48.5%)
(9.1%)
33
33
Follow-up
At 3 month Follow- At 6 month Followup
up
Yes
Effectiveness
No
Total
Count
12
28*
% within Follow-up
36.4%
75.8%
Count
21
5
% within Follow-up
63.6%
9.1%
Count
33
33
% within Follow-up
III, lady Willington Hospital Lahore. These
months the majority women presented with
S235
amenorrhea or oligomenorrhea. Three women
requested removal of the LNG-IUS because of
spotting,
and six
women
expelled it
spontaneously. At 12 months 79.5% of
participants continued the use of LNG-IUS13.
Nagrani R et al conducted a similar study. The
four to five year long term follow up study
showed 50% of women continued to use the
device and 67.4% avoided surgery14. Xiao B at al
conducted a similar study. The objectives of the
study was to investigate the effect of the
levonorgestrel-releasing
intrauterine
system
(LNG-IUS) in the treatment of idiopathic
menorrhagia. In my study At 3 months follow up
36.4% had no bleeding, 15.2% had spotting and
48.5% had heavy menstrual bleeding but at 6
month follow-up 90.9% had no bleeding and 9.1%
had heavy menstrual bleeding and after 6 months
follow-up of Mirena was effective in 75.8% of the
patients.
In another study Thirty-four patients were
selected with menstrual blood loss over 80ml.
Mirena was inserted on cycle days 5-7 and follow
up was done at 3 months interval for 3 years. A
significant reduction of menstrual blood loss to
2.7ml (97.7% decrease), and 13.7ml (85.0%
decrease), at 6, 12, 24, and 36 months respectively.
After 6 months one-third of the patents
experienced
amenorrhea,
and
one-fourth
15
spotting .
In our study complications at 3 months,
18.2% of subjects had pain, 21.21% had pain and
infection while at 6 months follow up 18.2% had
pain, 6.1% had pain and infection. Mirena was
expelled or misplaced in 15.2% of patients.
Stewart A et al conducted a study to
determine whether the levonorgestrel-releasing
device (LNG-IUS) licensed at present for
contraceptive use, may reduce menstrual blood
loss with few side effects. If effective, surgery
could be avoided with consequent resources
savings. Five controlled trials and five case series
were found which measured menstrual blood
loss. Nine studies recorded statistically
significant average menstrual blood loss
reductions with LGN-IUS (range 74%-97%).
Another showed reduction in menstrual
disturbance score. The LGN-IUS was more
effective than tranexamic acid, but slightly less
effective than endometrial resection at reducing
menstrual blood loss. In one study, 64% of
women cancelled surgery at six months,
compared with 14% of control group women. In
another 82% were taken off surgical waiting lists
at one year16.
CONCLUSION
Mirena reduces menstrual bleeding and is
an
effective
non-surgical
treatment
for
dysfunctional
uterine
bleeding,
in
premenopausal women with less complications
among patients.
CONFLICT OF INTEREST
Authors have no competing financial,
professional or personal interests that might have
influenced the performance or presentation of
this work described in this manuscript.
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KivelaA et al. Clinical outcomes and costs with the
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pubmed & dopt=Abstract.
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Therapeutic use of levonorgestrel-releasing intrauterine system
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14. Nagrani R, Bowen-Simkins P, Barrington JW Can the
levonorgestrel intrauterine system replace surgical treatment for
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S237
Original Article
Gray Scale USG of Chronic Liver Disease
Pak Armed Forces Med J 2016; 66 (Suppl-3): S238-243
VALIDITY OF GRAY SCALE ULTRASONOGRAPHY IN DIAGNOSIS OF CHRONIC
LIVER DISEASE OF VIRAL ETIOLOGY
Shaista Riaz, Riaz Ahmed Khokhar*, Ashraf Farooq**
Shifa International Hospital Islamabad, Pakistan, ** Islamic International Medical and Dental College Islamabad, Pakistan, *WAPDA
Hospital Rawalpindi, Pakistan
ABSTRACT
Objective: To determine validity of gray scale ultrasonography in diagnosis of chronic liver disease of viral
etiology.
Study Design: Validation study.
Place and Duration of Study: Medical departments of Rawalpindi Medical College and Allied Hospitals,
Rawalpindi in collaboration with Radiology and Pathology departments from 16th June 2008 to 16th Dec 2008.
Material and Methods: A sample of 75 patients with polymerase chain reaction (PCR) positive for hepatitis B and
C comprising of 33 male and 42 female in the age groups of 19 to 58 years was taken for the study. The patients
fulfilling the inclusion criterion were subjected to abdominal ultrasound. Later on findings were confirmed by
histopathological findings. The patients were subjected to greyscale ultrasonography in the three parameters of;
Edge in terms of sharp, slightly blunted edge, moderately blunted edge and grossly blunted edge; Surface on
terms of smooth, slightly irregular, moderately irregular and markedly irregular; Parenchymal texture in terms of
fine, slightly coarse, moderately coarse and markedly coarse. For histological examination percutaneous liver
biopsy specimens were obtained from the anterior segment of the right lobe in each patient under the guidance of
ultrasound. Histopathological grading was distributed over 5 category scales, i.e. “No fibrosis; Fibrosis portal
expansion; Bridging fibrosis; Bridging fibrosis with lobular degeneration and Cirrhosis”.
Results: Statistical analysis of the current study revealed that; overall diagnostic accuracy of ultrasound as 86.67%
as comparable with gold standard biopsy. Sensitivity was found to be 92.98 %, and Specificity 66.67 %. Positive
predictive value was 89.83% and negative predictive value was 75.0% in comparison with gold standard of liver
biopsy.
Conclusion: The study concludes that ultrasound is equally reliable and dependable technique for the diagnosis
of chronic liver disease of viral etiology as compared to histopathological grading.
Keywords: Cirrhosis, Fibrosis stage, Histopathological Grading, Ultrasonography, Viral Hepatitis.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Viral hepatitis is a major public health
problem globally. Nearly 1% to 3% of the people
in developed world are chronically infected with
hepatitis C-virus while carriage rate in other
countries is reaching up to 35%1. The burden of
hepatitis C virus (HCV) related chronic liver
disease in Pakistan has increased over the years.
Recent data shows nearly 60 to 70% patients with
chronic liver disease tend to be positive for antiCorrespondence: Dr Shaista Riaz, 98-Khokhar House, Tipu
Road, Rawalpindi, Pakistan (Email: [email protected])
Received: 17 Jun 2013; revised received: 13 Aug 2014; accepted: 22 Aug
2014
HCV. It has been demonstrated that nearly 50%
patients with hepato- cellular carcinoma in
Pakistan are HCV positive2. Hepatitis B causes an
estimated 1 to 2 million deaths per year and there
are three hundred million carriers of hapatitis B
virus (HBV) in the world. Accurate estimation of
the disease severity is helpful for the evaluation
of the therapeutic effect and the prognosis of the
disease. At present there are various modalities
for this purpose, these including histology,
serology, and imaging3. Liver biopsy remains the
only accepted test for staging and grading of
chronic liver disease of viral etiology. However
this procedure is associated with significant
S238
Gray Scale USG of Chronic Liver Disease
Pak Armed Forces Med J 2016; 66 (Suppl-3): S238-243
patient morbity and a small but definite risk of
death1. On the contrary sonography is still the
most established, risk free method for diagnosis
and follow up of chronic viral hepatitis4-5
primarily because of its low cost, easy
performance and high acceptability for the
patient3. An ultrasound evaluation of the liver
fibrosis stage of chronic liver disease has been
performed by assessing various ultrasound
factors such as liver size, the bluntness of the
liver edge, the coarseness of the liver
parenchyma, nodularity of the liver surface, the
size of the lymph nodes around the hepatic artery
,the irregularity and narrowness of inferior vena
cava, portal vein velocity or spleen size5-6.
Therefore this study has been conducted to
evaluate the accuracy of liver fibrosis stage by
ultrasonography
and
compared
with
histopathological findings. The primary aim of
this work was to evaluate the validity of grey
scale ultrasonography in assessing diagnosis and
progression of chronic viral hepatitis in patients
College and Allied Hospitals Rawalpindi in
collaboration with Radiology and Pathology
departments from 16th June 2008 to 16th Dec 2008.
History of chronic liver disease based on the
detection of persistently raised levels of alanine
transferase (ALT) and positive PCR were the
inclusion criteria. Exclusion criteria were patients
with extreme of ages, patients who had a
previous histopathology diagnosis and patients
who were on interferon therapy. A sample of 75
patients with PCR positive for hepatitis B & C
were included in the study. The patients were
subjected to greyscale ultrasonography in the
three parameters of; Edge in terms of sharp,
slightly blunted edge, moderately blunted edge
and grossly blunted edge; Surface on terms of
smooth, slightly irregular, moderately irregular
and markedly irregular; Parenchymal texture in
terms of fine, slightly coarse, moderately coarse
and markedly coarse. All scans were carried out
using ALOKA Pro-sound 4000 SSD machine. The
procedure was carried out using a 3.5MHz
Table-1: Cross tabulation of ultrasonography and histopathology (n=75).
Ultrasonography
Cirrhosis
Fibrosis
No fibrosis
True positive
False Positive
Histopathology
53
06
No cirrhosis
False negative
True negative
04
12
Table-2: Diagnostic accuracy of gray scale ultrasonography.
Diagnostic accuracy
Percentage
Sensitivity
92.98 %
Specificity
66.67 %
Positive predictive value
89.83 %
Negative predictive value
75.0 %
Diagnostic accuracy
86.67 %
with chronic liver disease. Ultrasonography is a
non-invasive and comparatively less expensive
procedure with high patient acceptance. If it has
an established acceptable diagnostic validity, it
can be used in place of liver biopsies or
polymerase chain reaction (PCR).
MATERIAL AND METHODS
It was the validation study conducted in the
Medical departments of Rawalpindi Medical
convex curvilinear transducer and observation
were made according to the ultrasound score
system.
For
histological
examination
percutaneous liver biopsy specimens were
obtained from the anterior segment of the right
lobe in each patient under the guidance of
ultrasound. Histopathological grading was
distributed over 5 category scales, i.e. “No
fibrosis; Fibrosis portal expansion; Bridging
fibrosis;
Bridging
fibrosis
with
lobular
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Gray Scale USG of Chronic Liver Disease
Pak Armed Forces Med J 2016; 66 (Suppl-3): S238-243
degeneration and Cirrhosis”. An experienced
histopathologist without any knowledge of the
clinical details and the ultrasound findings
reviewed all the slides. The results were
compared with histopathology grading for ‘no
fibrosis to cirrhosis’ over a period of six months.
Data were stored and analyzed by SPSS
version 13.0. Sensitivity specificity, Positive
predictive value (PPV) and Negative predictive
value (NPV) of ultrasound were calculated taking
histopathological findings as gold standard.
Frequencies and percentages were calculated for
various ultrasound findings. A 2x2 table-1 was
used to associate the results of grayscale
ultrasonography with histopathology.
RESULTS
A total number of 75 patients were included
in this study. Of the total 75 patients, 42 (56%)
were female and 33 (44%) were male between the
age group of 19 to 58 years with the mean age of
34 years. No patient was lost or dropped from
the study. All these patients assessed in the three
standard parameters of grayscale ultrasound.
Results for the ultrasound edge, ultrasound
The results were compared and revealed
that for a sample size of 75, 53 patients having
fibrosis fall closely to the 52 patients reported to
have proven cirrhosis. The study therefore
established a close association between the results
of
ultrasound
indices
and
that
of
histopathological grading. Thus the validity of
gray scale ultrasonography in diagnosis of
chronic liver disease is established.
Statistical analysis of the current study
revealed that; overall diagnostic accuracy of
ultrasound as 86.67% as comparable with gold
standard biopsy. Sensitivity was found to be
92.98%, and specificity 66.67%. Positive
predictive value was 89.83% and negative
predictive value was 75.0%.
DISCUSSION
The aim of this work was to determine
diagnostic validity of grayscale ultrasonography
in chronic liver disease of viral etiology keeping
gold
standard
as
histopathology.
Ultrasonography is a non-invasive and
comparatively less expensive procedure. An
attempt was made through this study to find out
Figure-1: Ultrasound Images.
Image: Scores for the ultrasound features of the liver parenchymal texture; (a) Fine parenchymal texture, (b)
A mildly coarse parenchymal texture, (c) A coarse parenchymal texture probe, (d) a highly coarse
parenchymal texture
surface and ultrasound parenchymal indicating
that 50.6% of patients with blunted edge, and
52.1% having markedly irregular surface and
49.3%
patients
with
markedly
coarse
parenchyma.
an acceptable diagnostic accuracy, so that the
grey scale ultrasonography could be used in
place of liver biopsies or PCR
have
S240
Various gray scale ultrasound parameters
been evaluated and compared with
Gray Scale USG of Chronic Liver Disease
Pak Armed Forces Med J 2016; 66 (Suppl-3): S238-243
histopathology as a single ultrasound parameter
is limited in sensitivity and specificity for
diagnosis of early cirrhosis, as stated by Shen et
al15. Of the total 75 patients, 42(56%) were female
and 33(44%) were male between the age group of
19 to 58 years with the mean age of study
population as 34 years as a comparable sample.
A study conducted by Nishiura et al14 determined
fibrosis stage in chronic liver disease in 103
patients (60 male and 43 female patients) with a
percentage of 58% and 42% respectively, which is
closer to the current study.
The study conducted by Nishiura et al14
reported mean age of the patients as 51 years
implying a comparatively an older age sampled
population against 34 years as mean age being
reported by the current study. These results
reflect hepatitis B and C affects people in
developing countries like Pakistan comparatively
at a younger age than elsewhere as also
supported by Hameed S et al21.
Chronic liver diseases with viral infection
manifest varying degrees of hepatic fibrosis
ranging from no fibrosis to cirrhosis. Yoshida et
al revealed that the annual incidence of
hepatocellular carcinoma increased from 0.5%
among patients with the stage F0 or F1 fibrosis to
7.9% among the patients with stage 4 fibrosis16. It
has thus become increasingly apparent that the
fibrosis stage is a key factor in defining the
prognosis and management of chronic liver
diseases with a viral infection.
The gold standard in hepatology for the
diagnosis of the fibrosis stage has been a
histological liver evaluation based on specimens
taken either by a needle biopsy or at operation.
Recently, non-invasive and reliable assessments
for monitoring chronic liver disease using the
platelet counts13,14 aspartate aminotransferase
(AST)/alanine aminotransferase (ALT) ratio13
and serum hyaluronan and type III procollagen
amino-terminal peptide9 have been developed.
However, none of the currently available tests or
modalities can completely replace a histological
analysis. Previous studies have assessed several
methods for evaluating the fibrosis stage of
chronic liver disease using various ultrasound
parameters.
However, there have so far been few studies
concerning the accuracy in detecting the signs of
compensated cirrhosis by US. Gaiani et al10 and
Hung et al22 proposed a complex ultrasound
scoring system using indices of the liver surface,
parenchymal echogenecity, the vessel pattern,
spleen size etc to determine the fibrosis stage. In
addition,
recent
advances in
ultrasound
technology have now made it possible to
obtain more precise information about the liver
surface,
edge
and
parenchymal texture.
Therefore, this study has been conducted to
clarify whether the ultrasound scoring system
with a newly developed ultrasound equipment
based on the conventional parameters of the liver
edge, surface and parenchymal texture might
obtain sufficiently accurate results in comparison
with the histological findings for fibrosis
obtained by a liver biopsy.
With conventional ultrasound, the liver
surface has been most commonly utilized as a
sole indicator for the diagnosis of cirrhosis 6,13,
However, numerous papers have reported
that the sole factor of the liver surface can not
sufficiently distinguish cirrhosis from chronic
hepatitis. Gaiani et al confirmed that the stage of
Figure-2: Photomicrograph showing cirrhosis of
liverImage.
cirrhosis may be underestimated when based on
a single specimen and clarified that only two
ultrasound variables, namely liver surface
nodularity and the portal vein mean flow
velocity, independently contributed to the
diagnosis of cirrhosis10.
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Gray Scale USG of Chronic Liver Disease
Pak Armed Forces Med J 2016; 66 (Suppl-3): S238-243
Previous studies have assessed several
methods for evaluating the fibrosis stage of
chronic liver disease using various ultrasound
parameters. However, there have so far been few
studies concerning the accuracy in detecting the
signs of compensated cirrhosis by ultrasound11,12.
Gaiani et al10 and Hung et al22 proposed a
complex ultrasound scoring system using indices
of the liver surface, parenchymal echogenecity,
the vessel pattern, spleen size etc. to determine
the fibrosis stage. In addition, recent advances in
ultrasound technology have now made it possible
to obtain more precise information about the liver
surface, edge and parenchymal texture13. The
current study therefore validated the ultrasound
scoring system with newly developed US
equipment based on the conventional parameters
of the liver edge, surface and parenchymal
texture and thus obtained sufficiently accurate
results in comparison with the histological
findings for fibrosis obtained a liver biopsy, as
presented in table-1.
Although this study was limited on account
of the relatively small number of patients due to
the strict inclusion criteria, 53 patients were
found to have a fibrosis score of 4. Therefore, the
scoring system for predicting cirrhosis was found
to be 92.98% sensitive. A major drawback with
ultrasound in comparison with the liver histology
has been considered to be its failure to detect
mild fibrosis or none at all. This is however
considered a valid limitation with ultrasound
application,
which
might
otherwise
be
supplemented with histopathological technique
in rare cases.
Evaluating the ultrasound pattern using
either one or two parameters becomes much
more complex at the stage of chronic liver
disease than that of complete cirrhosis. The
current study having scoring system based
on three parameters such as the liver edge,
surface and parenchymal texture was able to
accurately predict the fibrosis stage. When an
exclusion of liver cirrhosis is requested, then
ultrasound alone is therefore considered to
provide sufficient information based on this
scoring system as validated in the current study.
Furthermore, if a histological analysis cannot
determine the fibrosis stage correctly due to
fragmentation or architectural distortion, then
this
ultrasound
diagnostic
modality
of
fibrosis could replace a histological diagnosis, per
se.
On the basis of results obtained from this
research, the current study concludes that
ultrasound is equally a very reliable, comparable
and dependable technique for the validation of
grayscale ultrasonography in diagnosis of chronic
liver disease of viral etiology as compared to
histopathological grading.
CONCLUSION
The study concludes that ultrasound is
equally a reliable, comparable and dependable
technique for the validation of grey scale
ultrasonography in diagnosis of chronic liver
disease of viral etiology as histopathological
grading.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
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Original Article
Bupivacaine (0.75%) for Adult Anorectal Surgery
Pak Armed Forces Med J 2016; 66 (Suppl-3): S244-47
A COMPARISON OF EFFICACY AMONG VARIOUS DOSES OF INTRATHECAL
HYPERBARIC BUPIVACAINE 0.75% FOR ADULT ANORECTAL SURGERY
Mudassar Iqbal, Naveed Masood*, Khurram Sarfraz**, Khalid Zaeem Aslam, Mushtaq Hussain Raja
Combined Military Hospital Quetta, Pakistan, *Combined Military Hospital Malir, Pakistan, **UN Mission Darfur, Sudan
ABSTRACT
Objective: To compare the efficacy of various doses of intrathecal hyperbaric bupivacaine 0.75% for adult
anorectal surgery.
Study Design: Randomized control trial.
Place and Duration of Study: The study was conducted at the department of Anaesthesia, Intensive Care and
Pain medicine, Combined Military Hospital (CMH) Quetta from November 2008 to October 2009.
Material and Methods: 120 adult patients undergoing anorectal surgery were randomly assigned to three groups.
Groups A (n=40) was given the lowest dose of 4.5mg intrathecal hyperbaric bupivacaine 0.75%, while group B
(n=40) and group C (n=40) were given 6.0mg and 7.5 mg,respectively. Dural puncture at L4/L5 level for drug
administration was done in the sitting position and patient was made to lie down after five minutes and block
level assessed.Variables to be assessed were level of sensory block indicated by number of dermatomes with
pinprick method and extent of motor block by Modified Bromage Score.
Results: Level of sensory block in groups A,B and C was 5.88 ± 0.94, 8.15± 0.83, 10.10 ± 0.78 dermatomes,
respectively (F (2, 117) = 245.976; p<0.0001 ANOVA; p<0.0001 group A vs B, group A vs. C and group B vs. C).
Extent of motor block was 4.83 according to the Modified Bromage Scale in group A, compared to 2.25 in group B
and 1.48 in group C (H (2) = 92.007; p<0.0001; p<0.0001 group A vs. B, group A vs. C and group B vs. C ).
Conclusion: Efficacy of three doses of intrathecal hyperbaric bupivacaine 0.75% was found to be statistically
different although all three doses produced adequate anaesthesia for anorectal surgery. The 4.5 mg dose of spinal
hyperbaric bupivacaine is recommended since the doses of 6 mg and 7.5 mg result in extensive motor block.
Keywords: Anorectal surgery, Hyperbaric bupivacaine, Spinal anaesthesia.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Anorectal diseases like hemorrhoids, anal
fistula and anal fissure are fairly common in our
adult population and treated surgically. Day care
surgery is being popularized worldwide due to
reduced health costs and remarkable safety
profile1. Anorectal surgery requires deep
anesthesia because the manipulated zone gets
multiple nerve supply and is reflexogenic2.
Spinal (intrathecal) anesthesia provides
reliable and intense surgical anesthesia and the
goals of early ambulation and discharge from
hospital can be achieved with spinal anaesthesia
Correspondence: Dr Mudassar Iqbal, Dept of Anaesthesia, CMH
Quetta, Pakistan (Email:[email protected])
Received: 14 Feb 2014; revised received: 17 June 2014; accepted: 20 Jun
2014
provided unnecessary extensive sensory and
motor block is avoided by adopting minimal
effective dose of a safe and short acting local
anesthetic2,3.
This study aims to determine the optimal
dose of hyperbaric bupivacaine 0.75% that would
be adequately effective to provide regional
anesthesia with added benefit of reduced motor
block, so that early post-operative ambulation
and discharge from hospital may be possible.
MATERIALS AND METHODS
These randomized control trials were
conducted at Department of Anaesthesia,
Intensive Care and Pain medicine, Combined
Military Hospital (CMH) Quetta, over a period of
one year from November 2008 to October 2009
after approval from the hospital ethical
S244
Bupivacaine (0.75%) for Adult Anorectal Surgery
Pak Armed Forces Med J 2016; 66 (Suppl-3): S244-47
committee. A total of 120 patients of both the
genders were included in the study after getting
informed written consent. Patients between ages
of 20 to 70 years, of American Society of
Anesthesiologists (ASA) class I and II were
selected while those having spine deformity,
body mass index (BMI) more then 40,
neuropathies,
local
sepsis,
coagulopathy,
severehypovolemia, severe aortic stenosis, severe
mitral stenosis, hypersensitivity to amide type
local anaesthetics and mental retardation were
excluded from study. The selected patients were
randomly divided in three groups i.e. group A
(patients receiving 4.5 mg of hyperbaric
bupivacaine0.75%), group B (patients receiving
6.0mg of hyperbaric bupivacaine 0.75%) and
group C (patients receiving 7.5mg of hyperbaric
bupivacaine0.75%). The hyperbaric bupivacaine
0.75% used was Abocaine Spinal Abbot
Laboratories Pakistan®. Dural puncture was
performed by 25-G Quincke needle (B.D®
Quincke spinal needle) at the level of L4-L5 inter
space with patients in sitting position. The dose
was injected intrathecally over one minutes with
the bevel directed caudally. Patient was kept in
sitting position for five minutes after
administration
of
intrathecal
hyperbaric
bupivacaine 0.75% before putting the patient to
lithotomy position for surgery.
Bias of data recording was curtailed by
using double blind method, neither patient nor
the anaesthetist or the trained assistant who were
evaluating the sensory and motor level after
spinal anaesthesia were knowing the dose
administered intrathecally ,and the anaesthetist
who performed spinal anaesthesia was not
included in recording the effect of block. The
level of block was measured after five minutes of
supine positioning i.e. 10 minutes after
administration of spinal anaesthesia.
The sensory block was measured by pinprick method.Sensory block measurements was
scaled according to number of dermatomes
anesthetized where 1=S5 ,5=S1,8=L3,10=L1 and
so on. The motor block was evaluated by
Modified Bromage Score which is a 6-point scale
where 1 indicates a complete block while 6
indicates full motor power of lower limbs ,as
given in Table-1.Any need of rescue
analgesia/anaesthesia
using
intravenous
ketamine (0.25mg/kg) was also recorded.
Computer software Statistical Package for
Social Sciences (SPSS) version 16.0 was used to
manage and analyze the data. Descriptive
statistics were used to describe the results i.e.
mean
and
standard
deviation(SD)
for
quantitative variables while frequency and
percentages for qualitative variables. Chi square
test was applied for the comparison of qualitative
variables. Quantitative variables were compared
through one way analysis of variance(ANOVA)
followed by Post-hoc Bonferroni test /KruskalWallis H test followed by Mann-Whitney U test
where appropriate. A p-value<0.05 was
considered as significant.
RESULTS
Total 120 patients were included in the
study. Male to female ratios in Group A ,B and C
were 35:5,33:7,34:6,respectively (p>0.05). Group
comparison revealed that the average age of
group A, B and C was 44.05 ± 11.00, 36.00 ± 3.95,
41.6 ± 6.17, respectively p<0.0001, group A vs B
(p<0.0001), group A vs C (p>0.05) and group B vs
C (p<0.01). Group comparison demonstrated that
the average weight of group A, B and C was
66.32 ± 8.31, 61.43 ± 9.48, 62.90 ± 10.12,
respectively (p>0.05).
The sensory block as measured by pinprick
method is shown in Table-2. The difference was
found to be significant (p<0.0001). All three
groups were significantly different from each
other (group A vs. group B, p<0.0001; group A vs.
group C, p <0.0001; group B vs. group C,
p<0.0001). Motor block score as measured by
Modified Bromage Scale is shown in Table-3. The
difference among the three groups was found to
be significant ( p<0.0001). All three groups were
significantly different from each other (group A
vs. group B, p<0.0001; group A vs. group C,
p<0.0001; group B vs. group C, p< 0.0001).
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Bupivacaine (0.75%) for Adult Anorectal Surgery
Pak Armed Forces Med J 2016; 66 (Suppl-3): S244-47
There were two cases(5%) in low dose group
A that required intraoperative rescue analgesia
with intravenous ketamine for minor abdominal
discomfort while one case each from group-B
(2.5%)and group C (2.5%) also required the same
(p-value>0.05).
DISCUSSION
Spinal anaesthesia for anorectal surgery has
been under continuous research with an aim to
determine a local anaesthetic dose that is
sufficient to provide selective sensory anaesthesia
without extensive motor block having added
benefit of safety in terms of neurological and
dose group and a difference of two dermatomes
between middle and high dose. Sensory block
level achieved with low dose group is S1, it was
sufficient to cover the nerve supply of the target
anorectal area and surgery was performed
without any pain suffered by the patient. Higher
dose is related to extra blockage of spinal nerves
and a higher level of sympathetic and motor
block and hence more hemodynamic instability
and motor paralysis leading to a poor quality of
anesthesia6,7.
Study conducted by Gudaitytė et al6 used
7.5, 5.0 and 4.5 mg doses of 0.5% hyperbaric
Bupivacaine for anorectal surgery and upper
Table-1 : Modified bromage score.
Score
Criteria
1
Complete block (unable to move feet or knees)
2
Almost complete block (able to move feet only)
3
Partial block (just able to move knees)
4
Detectable weakness of hip flexion while supine (full flexion of knees)
5
No detectable weakness of hip flexion while supine
6
Able to perform partial knee bend
Table-2: Sensory block across three groups.
Group_A (4.5mg)
Group_B (6.0mg)
Group_C (7.5mg)
n=40
n=40
n=40
p-value
Mean no of dermatomes
5.88
8.15
10.10
blocked
< 0.0001
Standard Deviation
0 .94
0 .83
0. 78
Table-3: Motor block across three groups.
Group_A (4.5mg)
Group_B (6.0mg)
Group_C (7.5mg)
p -value
n=40
n=40
n=40
Mean score (Modified
4.83
2.25
1.48
Bromage Scale)
< 0.0001
Standard Deviation
0.38
0.81
0.51
cardiovascular side-effects5,6. By reducing the
dose of local anaesthetic there is concern about
spinal
anaesthesia
failure.
This
study
demonstrated that 4.5 mg dose is sufficient to
provide surgical anaesthesia for minor anorectal
surgery. The cases that required rescue analgesia
with intravenous ketamine for minor abdominal
discomfort were equally distributed to three
groups.
Level of sensory block achieved in current
study with these three doses shows a difference
of three dermatomes between low and middle
sensory block levels achieved were 10.4 ± 1.7
(10=L1), 7.0 ± 2.2 (7=L4) and 6.7 ± 1.9 (6=L5)
respectively. The sensory level achieved was
similar to current study. Maroof et al7 in their
study, conducted in Saudi Arabia, used
hypobaric bupivacaine 0.1% in a of dose of 5mg
on prone jack knife position for anorectal surgery
and found this dose to be sufficient for minor
anorectal surgery. Selectively targeting local
anesthetic at nerve roots supplying the surgical
field was shown to be successful, and the use of
low dose bupivacaine produced favorable results
S246
Bupivacaine (0.75%) for Adult Anorectal Surgery
Pak Armed Forces Med J 2016; 66 (Suppl-3): S244-47
in unilateral spinal anaesthesia for short
procedure of lower limb as in knee arthoscopy8,9.
In current study the extent of motor block
was 4-5 points according to the Modified
Bromage Scale in low dose group cases,
compared to 2-3 score in 82.5% of middle group,
and 1-2 scores in 100% of group C cases. As the
dose increases motor block gets extensive. Patient
with low dose group A were able to move and
position themselves unaided before start of
surgery and similarly at the end of surgery
patients were able to move on to shifting trolley
with minimal aid of nursing staff but most of the
patient of middle dose group B and all of the high
dose group C patients were unable to do so as
they were having extensive motor block. This
applies also to early ambulation of low dose
group as very weak motor block resolve earlier
than the relatively profound block of middle and
high dose groups. These findings are similar to
that of Gudaitytė et al6 having a very weak motor
block with 4 and 5 mg dose and relatively
profound block with 7.5 mg dose and it is also in
agreement with findings of Wassef 10 where there
was almost no motor block with ultra low dose of
bupivacaine i.e.1.5 mg.Though studies with
1.5mg of bupivaciane for perianal block were
faced with mix of success10,11 and failures12. There
were studies that gave favourable result with
ultra low dose of local anesthetic with
combination of opioids13,14.
Further studies should be conducted using
serial recording of sensory and motor block
before, during and after surgery till regression of
block to S4, which will give a good indication for
time to home-readiness, that is the goal in
ambulatory anaesthesia. Tetanic stimulation
using peripheral nerve stimulators or transcutaneous electrical nerve stimulation, both of
which correlate well with pain of surgical
incision, will allow more objective assessment of
sensory block.
CONCLUSION
Efficacy of three doses of intrathecal
hyperbaric bupivacaine 0.75% for anorectal
surgery was found to be statistically different but
all of them provided satisfactory analgesia and
motor paralysis. Based on the result of this study
the dose of spinal hyperbaric bupivacaine
0.75%recommended for anorectal surgery is 4.5
mg. Doses of 6 mg and 7.5 mg are excessive due
to high sensory and motor blocks which are not
required for anorectal surgery.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
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anaesthesia with bupivacaine (0.1%) gives selective sensory block
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8. Jukka V, Korhonen AM, Jokela RM, Ravaska P, Korttila K.
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side:why not? Reg Anesth Pain Med.2004; 29: 4–6.
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block: a prospective, randomized, double-blind comparison with
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surgery : Spinal perianal and spinal saddle blocks.Anaesthesist.
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Combination of ultra-low dose bupivacaine and fentanyl for spinal
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Original Article
Pak Armed Forces Med J 2016; 66 (Suppl-3): S248-51
Bupivacaine (0.5%) in Laparoscopic Cholecystectomy
EFFECTIVENESS OF INTRA-PERITONEAL ADMINISTRATION OF 0.5%
BUPIVACAINE IN POSTOPERATIVE ANALGESIA AFTER LAPAROSCOPIC
CHOLECYSTECTOMY
Babar Shamim, Awais Ali Khan*, Muhammad Rehan Saleem*, Irfan Shukr*, Afshan Aziz**, Maria Shahzadi*
137 Medical Batallian Peshawar Pakistan, *Combined Military Hospital Rawalpindi, Pakistan, **Pakistan Air Forces Hospital
Chaklala Rawalpindi, Pakistan
ABSTRACT
Objective: To compare the effectiveness of 0.5% bupivacaine spray versus no spray in the gall bladder bed after
laparoscopic cholecystectomy in terms of postoperative pain in first 24 hours.
Study Design: Randomized control trial.
Place and Duration of Study: Surgical ward, Combined Military Hospital, Rawalpindi from Jan 2011 to Jun 2011.
Material and Methods: A total of 62 patients were included in this study and they were randomly divided into
two equal groups. At the end of laparoscopic cholecystectomy, 0.5% bupivacaine was sprayed in gall bladder bed
in a dose of 2 mg/ kg body weight in group-A whereas group B did not receive any intraperitoneal local
anesthetic agent. Results were compared and p-value calculated.
Results: Mean age of the patients was 42.3 ± 3.9 and 43.1 ± 2.9 years in group-A and B, respectively. In Group-A,
11 patients (35.5%) and in group-B, 13 patients (41.9%) were male while 20 patients (64.5%) in group-A and 18
patients (58.1%) in group-B were female. Comparison of pain at 8 hours, postoperatively showed that in group-A,
pain was reported in 8 patients (25.8%) and in group-B, in 24 patients (77.4%). Results were statistically significant
with p<0.001. Similarly comparison of pain at 24 hours revealed that in group-A, pain was reported in 9 patients
(29.0%) and in group-B, in 21 patients (67.7%). Results were statistically significant with p-value 0.002.
Conclusion: Intraperitoneal spray of 0.5% bupivacaine solution is effective in producing effective post-operative
analgesia after laparoscopic cholecystectomy.
Keywords: Bupivacaine, Laparoscopic cholecystectomy, Postoperative pain.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
analgesia3.
Gallstones
disease
has
worldwide
prevalence and the incidence is 1-3 % per year1.
Cholecystectomy is the treatment of choice for
symptomatic gallstones because it removes the
organ that contributes to both the formation of
gallstones and the complications ensuing from
them. Laparoscopic cholecystectomy has become
gold standard in recent times. Where
laparoscopic
cholecystectomy
has
greatly
reduced hospital stay, morbidity, cost and
convalescence time2 post-operative pain still
remains a problem requiring parenteral
After cholecystectomy, the postoperative
pain can be of two types; parietal and visceral.
After conventional open cholecystectomy, the
pain is mainly of parietal nature owing to the big
abdominal incision, whereas postoperative pain
after laparoscopic cholecystectomy is mainly of
visceral nature3,4. It often affects the right subdiaphragmatic region and is also referred to the
right shoulder in approximately 12 to 60% of the
patients4. Relief of this pain is of utmost
significance to achieve the true benefits of
laparoscopic cholecystectomy.
Correspondence: Dr Babar Shamim, 137 Medical Batallian
Peshawar Pakistan (Email: [email protected])
Received: 06 Jan 2014; revised received: 07 May 2014; accepted: 19 Aug
2014
The intra-peritoneal administration of local
anesthetic agents has been vastly studied but still
remains a controversial issue4. A lot of methods
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Bupivacaine (0.5%) in Laparoscopic Cholecystectomy
Pak Armed Forces Med J 2016; 66 (Suppl-3): S248-51
have been used for intra-peritoneal analgesia
such as packing the raw area with local anesthetic
soaked tabotamp4, local anesthetic soaked
surgical5
intraperitoneal
aerosolization6,
intraperitoneal
plus
periportal
injection7,
intraperitoneal administration alone and even
continuous delivery though Q-pump system8,9.
Some studies show significant pain relief3-7.
(26.67% with bupivacaine vs 66.67% in controls)4
whereas others profess little or no use of such
agents8,9 (mean visual analog score 2.4 with
bupivacaine vs 2.5 without bupivacaine).
The objective of this study was to find out an
optimal method for postoperative pain relief after
laparoscopic cholecystectomy in our setup. Since
our setup serves as tertiary care center for the
military
population
and
civilians
from
Rawalpindi, Islamabad, Northern areas and AJK,
this study may help us in making protocols for
postoperative pain relief and save precious
resources spent in pain management.
MATERIAL AND METHODS
Both male and female patients between 20 to
60 yrs of age and having symptomatic gallstones
were included in the study. Patients having
complicated gallstones (acute cholecystitis,
choledocholethiasis,
pancreatitis),
diabetes
mellitus, chronic renal failure, bleeding disorders,
immuno-compromised, previous abdominal
surgeries, pregnancy and bile leak during surgery
were not included in the study. Permission from
hospital ethical committee was obtained
(approval attached). A written informed consent
was taken from each patient included in the
study. Sixty two patients fulfilling the inclusion
criteria were selected and randomly divided into
two equal groups, A and B. Hospital registration
number, name, age, gender, address and phone
number (optional) were noted. General
anesthesia was given by same anesthetist in all
cases. Induction was done with fentanyl, Propofol
and atracurium with dosage according to the
weight of patient. Maintenance anesthesia was
with mixture of air, oxygen and sevoflurane.
Pneumoperitonem was achieved with Veress
needle through periumbilical incision and
maintained at a pressure of 12mm of mercury
during whole procedure. All of the operations
were performed by the same surgeon using
standard four port laparoscopic cholecystectomy
technique. At the end of laparoscopic
cholecystectomy, 0.5% bupivacaine solution was
sprayed in gall bladder bed in a dose of 2mg/kg
body weight in group-A whereas group-B did not
receive any intraperitoneal local anesthetic agent.
Parenteral postoperative analgesia was given
with intravenous ketorolac 30mg at 8 hours only,
in both groups. Patients in both groups were kept
in hospital for at least 24 hours.
Postoperative pain was assessed and scored
in both the groups using visual analogue score
from 0-10 at 8 and 24 hours, VAS above 4 will be
significant. Any patient requiring analgesic
onwards from 8 hours postoperative fell in the
category of pain and was recorded in the
proforma. All the information was recorded on a
specially designed proforma. Follow up was
ensured by recording contact numbers of
patients. Control of bias and confounding factors
was done by strictly following the exclusion
criteria. All the data had been analysed using
Statistical Package for Social Sciences (SPSS)
version 14.0. Descriptive statistics were applied to
summarize the data. Mean and standard
deviation (±SD) were calculated for all the
quantitative variables i.e. age. Frequency and
percentages were calculated for qualitative
variable i.e. pain and gender. Comparison of pain
was done using Chi-square test and the level of
significance was kept below 0.05.
RESULTS
A total of 62 patients (31 patients in each
group)were included in the study. Patients age
ranged from 31 to 60 years with mean age of
42.3(±3.9) and 43.1(±2.9) years in group-A and
group-B respectively (table-1). In Group-A, 11
patients (35.5%) were male whereas 20 patients
(64.5%) were female and in group-B, 13 patients
(41.9%) were male and 18 patients (58.1%) were
female (table-2).In group-A, 8 patients (25.8%)
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Bupivacaine (0.5%) in Laparoscopic Cholecystectomy
Pak Armed Forces Med J 2016; 66 (Suppl-3): S248-51
developedpain after 8 hours whereas 24 patients
(77.4%) had pain in group-B, with p-value<0.001
(table-3). Similarly comparison of pain at 24
hours revealed that 9 patients (29.0%) had pain in
group-A, whereas in group-B 21 patients (67.7%)
developed pain, with p-value 0.002 (table-4).
and hospital stay which contributes to
unanticipated admission after ambulatory
surgery. Pain also contributes to postoperative
nausea and vomiting. Thus, the establishment of
laparoscopic cholecystectomy as an outpatient
procedure
has
accentuated
the
clinical
Table-1: Distribution of cases by age among two study groups.
Age (Year)
Group-A 0.5% bupivacaine
Group-B without intraperitoneal local
anesthesia
No.
%
07
22.6
11
35.5
10
32.1
03
09.3
31
100.0
43.1 ± 2.9
No.
%
20-30
09
29.0
31-40
10
32.2
41-50
09
29.2
51-60
03
09.6
Total
31
100.0
Mean ± SD
42.3 ± 3.9
Group-A = Given 0.5% bupivacaine
Group-B = No intraperi-toneal
Table-2: Distribution of cases by gender among groups.
Group-A N=31
Gender
n (%)
Male
11 (35.5)
Female
20 (64.5)
Table-3: Comparison of pain among groups.
Group-A (N=31)
Group-B (N=31)
n (%)
n (%)
Yes
08 (25.8)
24 (77.4)
No
23 (74.2)
07 (22.6)
Pain at 24 hours
Yes
09 (29.0)
21 (67.7)
No
22 (71.0)
10 (32.3)
DISCUSSION
The development of minimal invasive
surgery has revolutionized surgical procedures
and in this process has influenced the practice of
anesthesiology as well10,11. The advantages of
laparoscopic surgery include reduced overall
adverse events, shorter hospital stay and rapid
return to normal activities. The success in healthy
adult patients has led to the introduction of more
extensive laparoscopic procedures in older and
sicker patients, as well as in pregnant
and pediatric patients12. Laparoscopic cholecystectomy is commonly performed in our
practice. Postoperative pain is the most common
complication of laparoscopic surgery, including
cholecystectomy13,14. Pain, prolonged recovery
Group-B N=31
n (%)
13 (41.9)
18 (58.1)
p-value
0.001
0.002
importance of reducing early postoperative pain
and nausea15. Improved postoperative pain
management using opioid-sparing regimens may
facilitate a high success rate of outpatient
laparoscopic cholecystectomy16. This study was
designed to compare the effectiveness of 0.5%
bupivacaine solution spray in the gall bladder
bed at the end of surgery versus no spray in
terms of post-operative pain relief in first 24
hours.
Early
pain
after
laparoscopic
cholecystectomy is multifactorial and complex. It
includes different pain components due to
different pain mechanisms. Abdominal wall
penetration by trocars produces somatic pain;
rapid distension of the peritoneum by CO2
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Bupivacaine (0.5%) in Laparoscopic Cholecystectomy
Pak Armed Forces Med J 2016; 66 (Suppl-3): S248-51
insufflation results in tearing of blood vessels,
traction of nerves, and release of inflammatory
mediators producing visceral pain; inflammation
or local irritation around the gallbladder bed,
liver, diaphragm or peritoneum, or both,
secondary to gallbladder removal and abdominal
muscle distension add to tissue injury and
produce visceral pain. Shoulder pain results from
peritoneal insufflation especially when an
exaggerated Trendelenburg position is used17.
solution produces effective post-operative
analgesia after laparoscopic cho-lecystectomy.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
Because postoperative pain following
laparoscopic cholecystectomy is multifactorial,
multimodal therapy may be necessary to
optimize pain relief. The present study shows
that the best therapy that significantly decreases
pain over the first 24 hours postoperatively, as
compared with the control group, is a 0.5%
bupivacaine solution sprays. Bupivacaine
solution spray (0.5%) has proven effective in
decreasing the number of patients who needed
rescue analgesics as compared with that in the
control group.
Bupivacaine is an amide-type local
anesthetic that is capable of producing prolonged
analgesia. The recommended dose for infiltration
is a maximum of 2 mg/kg. Narchi et al showed
that intraperitoneal instillation of 100 mg of
bupivacaine did not result in toxic plasma
concentrations10. The absence of toxicity was
confirmed by Deans et al who determined plasma
concentrations after instillation of 1.5 mg/kg
bupivacaine in the preperitoneal space during
hernia repair18. Results of present study are
comparable with above mentioned studies. In our
study, intraperitoneal bupivacaine reduced
postoperative pain significantly at 8 and 24 hours.
Similarly, there is no adverse effect of
bupivacaine encountered in our study.
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Golubović S, Golubović V, Cindrić-Stancin M, Tokmadzić VS.
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Original Article
Accuracy of USG in Acute Appendicitis
Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
DIAGNOSTIC ACCURACY OF ULTRASONOGRAPHY IN THE DIAGNOSIS OF ACUTE
APPENDICITIS
Mansoor Hasan, Sajida Perveen*, Muhammad Amer Mian*
Combined Military Hospital Zohb, Pakistan, *Combined Military Hospital Lahore, Pakistan
ABSTRACT
Objective: To determine accuracy of ultrasonography in the diagnosis of Acute Appendicitis using
histopathologic examination of resected appendix tissue as gold standard.
Study Design: Cross sectional validation Study
Place and Duration of Study: General Surgery Department Combined Military Hospital Lahore from 16th
December 2011 to 15th June 2012.
Material and Methods: The estimated sample size on 5% chance of error via WHO sensitivity and specificity
calculator was 230. Consecutive (non-probability) sampling technique was used.
Pre-operatively apart from other routine diagnostic work up, ultrasonography was performed by radiologist. The
decision to do appendicectomy was made independent of the findings of ultrasonography. After
appendicectomy, resected appendix was sent for histopathology.
Two by two tables was used to determine the sensitivity, specificity, true positive and negative values, false
positive and negative values and their predictive values. Data was entered in SPSS version 16 to calculate mean
and standard deviation for age. Male to female ratio for positive and negative appendicectomies was calculated.
Results: We found Sensitivity of USG 93.1%, Specificity 88.23 %, Positive Predictive value 93.1%, Negative
Predictive value 88.23 % and Diagnostic Efficacy 91.3 %. Mean and standard deviation for age was 30.27 and 13.76
respectively. Percentages for positive and negative appendicectomies in males were 77 and 23, while in females
45 and 55 respectively.
Conclusion: Ultrasonography is highly sensitive test with fair degree of specificity in diagnosing Acute
Appendicitis and its routine usage will improve diagnostic accuracy.
Keywords: Appendicitis, Histopathology, Ultrasonography.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Acute appendicitis is one of the commonest
causes of pain abdomen which requires
emergency surgery. Most of the time it is a
clinical diagnosis but all patients do not present
with the typical symptoms and signs of acute
appendicitis1. The lifetime incidence of this
disease is 12 percent in men and 25 percent in
women with approximately 7% of all people.
Diagnostic difficulty is encountered especially in
those patients who present with atypical
Correspondence: Dr Mansoor Hasan, General Surgeon,
Combined Military Hospital Zohb, Pakistan
Email: [email protected]
Received: 21 Jan 2016; revised received: 12 May 2016; accepted: 17 Mar
2016
findings, with poorly localized abdominal pain
and tenderness without either pain migration,
nausea or vomiting, fever or leukocytosis2. This
results in negative laparotomy rate ranging from
15-40%.
Diagnostic accuracy achieved by history and
examination only is about 70-80 percent in adults.
There are many investigations that have been
recommended to improve the diagnosis like
leukocyte count, C-reactive protein, laparoscopy,
peritoneal aspiration and lavage, C.T. Scan and
radioactive scanning. Some scoring systems like
Alvarado, Ripasa, Ohmann and Eskelinen score
have been formulated to achieve better accuracy
in diagnosis. Unfortunately, these are either
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Accuracy of USG in Acute Appendicitis
Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
unreliable or invasive or extremely expensive or
not practicable in routine in our country. TLC is a
very cheap and readily available investigation,
but carries a sensitivity and specificity of 83 %
and 62.1 % respectively3.
Prevalence of appendicitis in adults is 7 % so
anticipated population proportion (p) is 0.07,
confidence level is 95 % and absolute precision
(d) required is 0.07. By using sensitivity and
specificity calculator, the sample size is 229.
Ultrasonography is one of the new
diagnostic techniques that have improved the
diagnostic accuracy and outcome in acute
appendicitis4. It is non-invasive, inexpensive,
easy to perform and available in most parts of
our country. Ultrasonographic findings of
appendicitis
usually
comprise
of
noncompressible, tubular, non-peristaltic, blindending structure, 6mm or greater in diameter, or
the presence of an appendicolith with a normalsized appendix1. Studies have revealed very high
sensitivity and specificity up to 98 % and 82 %,
respectively5. Because ultrasound is highly userdependent, operator skill may be an important
factor in the diagnostic accuracy of appendicitis.
Although CT abdomen is a better option but its
hazards like exposure of iatrogenic ionizing
radiation,
the
expensive
scanners
and
unavailability in all medical institutions
particularly in developing countries make it less
useful.
Only those cases which fulfilled the
inclusion criteria were included in the study; and
patients falling into exclusion criteria were
excluded. A total of 230 cases were studied
during this period and were included in the
study. All these 230 patients satisfied the
inclusion and exclusion criteria. Consecutive
(Non Probability) sampling was used for sample
selection.
The rationale of the study on this topic is
that other investigations as mentioned above are
either unreliable or invasive or not practicable so
these investigations can’t be used routinely for
the diagnosis of acute appendicitis. Ultrasound is
cheap and widely available investigation which if
found accurate in this study can be employed for
the diagnosis of acute appendicitis. In clinical
suspicion of appendicitis, ultrasound can confirm
or exclude appendicitis, can also identify its
complications and alternative diagnosis can also
be offered.
MATERIAL AND METHODS
It is a cross sectional validation study which
was conducted at General Surgery Department,
Combined Military Hospital Lahore from 16th
December 2011 to 15th June 2012.
All the patients above the age of 17
regardless of gender, with clinical diagnosis of
Acute Appendicitis were considered for inclusion
into the study. To exclude any other systemic
infection patients were evaluated on three
parameters, i.e. history, examination and
investigations. Blood complete picture was a
routine investigation. Patients with chest
infection were investigated with chest x-ray;
while patients with urinary tract infection were
investigated with urine routine examination.
Ultrasonography was performed using
5MHz probe frequency by consultant radiologist.
The decision to do appendicectomy was made
independent of the findings of ultrasonography.
After appendicectomies performed by classified
surgeon, resected appendix was sent for
histopathological examination by consultant
pathologist at Combined Military Hospital
Lahore Pathology laboratory (who was unaware
of the ultrasound findings). Based on
histopathological findings patients were divided
into 2 groups:
1.
Inflamed Appendix
2.
Normal Appendix
Pre-operative ultrasonography findings and
histopathology report of resected appendix were
endorsed on patient’s proforma.
Data analysis and statistical methods
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
All the data collected through the Proforma
was entered into the statistical package for social
sciences (SPSS) version 16 and analyzed through
its statistical package. Mean and standard
deviation was used for quantitative data like age
while frequency and percentage was calculated
for qualitative data like gender and findings on
histopathology and ultrasound. Two by two
tables was used to determine the sensitivity,
specificity, true positive and negative values,
false positive and negative values and their
predictive values as follows:
Sensitivity
Sensitivity = a / a +c x 100
Specificity
The statistical analysis of the study was done
using a 2 x 2 table for comparison of USG with
histopathological diagnosis of Appendix (table.1).
These figures are based on the data of 230
patients. Sensitivity of USG was 93.1 %,
Specificity 88.23 %, Positive predictive value
93.1%, Negative predictive value 88.23 % and the
Diagnostic efficacy 91.3 % (table-2).
The percentage of positive and negative
appendicectomy in males was 77% and 23%,
while in females it was 45% and 55% respectively
(table.3). The frequency of diagnosis of acute
appendicitis and normal appendix based on USG,
and Histopathology was 145 & 85, and 145 & 85
respectively.
DISCUSSION
Specificity = d / b + d x 100
Positive Predictive Value (PPV)
Positive Predictive value = a / a + b x 100
Negative Predictive Value (NPV)
Negative Predictive value = d / c + d x 100
Diagnostic efficacy
Diagnostic efficacy = a + d/ a + b + c + d x 100
RESULTS
A total of 230 cases were included in the
study after observing inclusion and exclusion
criteria. The results were therefore based upon
230 cases. The results of this study have been
summarized in tables-1- 3.
The mean age and standard deviation for
histopathology proven appendicitis was 30.39
and 13.79 and for positive USG findings was
30.39 and 13.96 respectively.
It is without any doubt that acute
appendicitis puts a lot of burden when to talk
about present day emergency abdominal surgery.
It always tests the clinical judgment and
professional capabilities of a surgeon if not all but
in majority of cases; especially in women,
children and old patients. It is very important for
a general surgeon to make an early accurate
diagnosis of acute appendicitis, not only to
prevent perforation and peritonitis but also to
prevent
unnecessary
operation.
Different
diagnostic modalities are available for diagnosis
of Acute Appendicitis at an early stage. TLC,
Urine RE, CRP and CT scan abdomen are the
most effective methods, however none of them is
perfect and all have advantages and
disadvantages. Though the combination of
various diagnostic modalities will give the best
results, yet a search for the single best and
reliable technique will continue.
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
At present, the role of abdominal imaging is
indicated in most of the cases of clinical
USG alone in the diagnosis of acute
appendicitis carries a high sensitivity and
Histopathology of appendix
Inflammed Appendix
Normal Appendix
Signs of acute appendicitis
Yes
True Positive [a]
False Positive [b]
on ultrasonography
No
False Negative [c]
True Negative [d]
Table-1: 2 x 2 Table: Accuracy of USG in diagnosis of Acute Appendicitis.
Histopathology of Appendix
Inflamed appendix
Normal appendix
True Positive (a)
False Positive (b)
a+b
Yes
Signs of acute
145
135
10
appendicitis on
False Negative (c)
True Negative (d)
c+d
ultrasonography
No
85
10
75
a+c
b+d
a+b+c+d
145
85
230
Table-2: Diagnostic Accuracy of USG.
Diagnostic Accuracy
Calculation based upon 2 x 2 table
Percentage
Sensitivity
a / a +c x 100
93.1
Specificity
d / b + d x 100
88.23
Positive Predictive Value
a / a + b x 100
93.1
Negative Predictive Value
d / c + d x 100
88.23
Diagnostic Efficacy
a + d/ a + b + c + d x 100
91.3
Table-3: Percentage for Positive and Negative Appendectomy in Males and Females (n=230).
Histopathology of
Gender
Total number of cases
Percentage
Appendix
Acute Appendicitis
100
77
Male
Normal Appendix
30
23
Acute Appendicitis
45
45
Female
Normal Appendix
55
55
appendicitis6. However, the choice of which
study to use, either US or CT remains a point of
contention. Whenever role of a diagnostic test is
justified, the most important factor in
consideration is its sensitivity, specificity, positive
and negative predictive values, invasiveness,
availability, cost and its hazards. CT abdomen
clearly has its advantages, with sensitivity
approaching 100% and its ability not to be
operator dependent, and in patients in which
ultrasound is difficult to perform, such as those
who are obese. However, the risks of contrast
administration, exposure to ionizing radiation,
cost and non-availability are all limiting factors.
specificity. Authors have claimed sensitivity in
the range of 98% and specificity of 82%. Others
have proved sensitivity of 92% and specificity of
88%7. Its cost effectiveness, availability and noninvasiveness have made it more appealing and
useful diagnostic tool in acute appendicitis.
Diagnostic accuracy, reported to range from 71 to
97 percent, is dependent on operator skill. Major
advantages
of
ultrasonography
include
noninvasiveness, short time, no radiation
exposure, and potential for discovering other
causes of abdominal pain.
Nicolas Kessler et al7 evaluated Sensitivity,
Specificity of USG, TLC and CRP in diagnosis of
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
acute appendicitis. They concluded that US-aided
identification of a normal appendix was a
significantly more common finding for the
exclusion of appendicitis than was the normality
of both WBC and CRP levels (72% vs. 47%) and
had a significantly higher NPV (98% vs. 84%).
TLC and CRP in diagnosis of Acute Appendicitis
were also of interest for Khan MN et al3 They
showed that TLC and CRP both they not very
specific. The sensitivity and specificity of WCC in
this study was 83 % and 62.1 % and that for CRP
was 75.6 % and 83.7 %.
A retrospective study of patients who
underwent US for right iliac fossa pain
suggesting acute appendicitis assessed the
accuracy of ultrasonic diagnosis5. When the
appendix was detected, the sensitivity, specificity
and accuracy of ultrasound for making a
diagnosis of appendicitis were 97.6 %, 82.0 %,
91.5 %, respectively.
Randen A Van et al8 performed a study in
which appendicitis was assigned to 284 of 942
evaluated patients (30%). Of 147 patients with a
thickened appendix, local probe tenderness and
peri-appendiceal fat infiltration on US, 139 (95%)
had appendicitis. On CT, 119 patients in whom
the appendix was completely visualised,
thickened with peri-appendiceal fat infiltration,
114 had a final diagnosis of appendicitis (96%).
When at least two of essential features were
present on US or CT, sensitivity was 92% (95% CI
89–96%) and 96% (95% CI 93–98%), respectively.
In another study 802 patients were included.
Use of CT was kept to a minimum (17.9%), with a
US:CT ratio of approximately 6:1. Positive and
negative predictive values for the clinical
diagnosis of appendicitis were 63 and 98%,
respectively; for US 94 and 97%, respectively; and
for CT 100 and 100%, respectively9 Despite the
established superiority that CT has over
ultrasound for the diagnosis of appendicitis,
recent studies have advocated for a first-line
ultrasound approach with adult patients
presenting with possible appendicitis10,11.
Diagnostic efficacy of USG in our study was
found to be 91.3%. The highest values of
Diagnostic efficacy found in the literature are
93.70%2. Generally speaking positive USG
findings in a patient with suspicion of Acute
Appendicitis has a high diagnostic accuracy. Its
use as a routine but in conjunction with other
diagnostic tools like clinical judgment, TLC and
CRP levels will definitely bring the surgeon to the
brink of a much accurate diagnosis.
Acute Appendicitis is a common abdominal
emergency that urge for early surgery to prevent
complications. Such condition demands early
diagnosis with confidence to avoid unnecessary
operation. Many diagnostic tools have been
advocated to improve diagnostic accuracy, not a
single proved to be the best one. Usefulness of US
in the diagnosis of acute appendicitis is now
established. Our results are comparable to any of
the internationally and locally conducted studies.
CONCLUSION
Based on this study we make following
conclusions:
In conclusion ultrasound is a useful adjuvant to
the clinical armamentarium of the present day
surgeon.
It
can
reduce
the
negative
appendicectomy rate without adversely affecting
the perforation rate particularly in equivocal
cases.
An important additional advantage of
ultrasound is the diagnosis of alternative
conditions in abdomen mimicking acute
appendicitis.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Chiang DT, Tan EI, Birks D. ‘To have or not to have’. Should
computed tomography and ultrasonography be implemented as
a routine work-up for patients with suspected acute appendicitis
in a regional hospital? Ann R Coll Surg Engl. 2008; 90: 17–21.
2. Al-Khayal KA, Al-Omran MA. Computed tomography and
ultrasonography in the diagnosis of equivocal acute
appendicitis. Saudi Med J. 2007 Feb: 28(2):173–80. Review.
S256
Accuracy of USG in Acute Appendicitis
Pak Armed Forces Med J 2016; 66 (Suppl-3): S252-57
3. Khan MN, Davie E, Irshad K. The role of white cell count and Creactive protein in the diagnosis of acute appendicitis. J Ayub
Med Coll. 2004; 16: 17–9.
4. Mardan MKA, Mufti TS, Khattak IU, Chilkunda N, Alshayeb
AA, Mohammad AM, et al. Role of ultrasound in acute
appendicitis. J Ayub Med Coll Abbottabad 2007; 19: 72–79.
5. Himeno S, Yasuda S, Oida Y, Mukoyama S, Nishi T, Mukai M, et
al. Ultrasonography for the diagnosis of acute appendicitis.
Tokai J Exp Clin Med. 2003 Apr; 28(1): 39–44.
6. Howell JM, Eddy OL, Lukens TW, Thiessen MEW, Weingart SD,
Decker WW. Clinical policy: critical issues in the evaluation and
management of emergency department patients with suspected
appendicitis. Ann Emerg Med. 2010; 55:71–116.
7. Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol J, et
al. Appendicitis: evaluation of sensitivity, specificity, and
predictive values of US, Doppler US, and laboratory findings.
Radiology 2004; 230: 472–478.
8. Randen A, Lameris W, Es H. A comparison of the accuracy of
ultrasound and computed tomography in common diagnoses
causing acute abdominal pain. Eur Radiol. 2011 July; 21(7):
1535–1545.
9. Boudewijn R. Toorenvliet B, Wiersma F. Routine ultrasound and
limited computed tomography for the diagnosis of acute
appendicitis. World J Surg. 2010 October; 34(10): 2278–2285.
10. Keyzer C, Zalcman M, De Maertelaer V, Coppens E, Bali MA,
Gevenois PA, et al. Comparison of US and unenhanced multidetector row CT in patients suspected of having acute
appendicitis. Radiology. 2005; 236: 527–34.
11. Gaitini D, Beck-Razi N, Mor-Yosef D, Fischer D, Ben Itzhak O,
Krausz MM, Engel A. Diagnosing acute appendicitis in adults:
accuracy of color Doppler sonography and MDCT compared
with surgery and clinical follow-up. AJR Am J Roentgenol. 2008;
190: 1300–6.
S257
Original Article
Pak Armed Forces Med J 2016; 66 (Suppl-3): S258-62
Laparoscopic Cholecystectomy
COMPARISON BETWEEN HARMONIC ACE VERSUS CONVENTIONAL MONOPOLAR
DIATHERMY IN LAPAROSCOPIC CHOLECYSTECTOMY IN TERMS OF
GALLBLADDER PERFORATION
Yasir Javed, Muhammad Tariq*, Syed Mukarram Hussain**, Anwar Ahmed***, Shafqat Rehman****, Muhammad Asif
Rasheed*****
Combined Military Hospital Rawalakot Pakistan, *Combined Military Hospital Multan Pakistan, **Combined Military Hospital Quetta
Pakistan, ***Combined Military Hospital Kohat Pakistan, ****Combined Military Hospital Bhawalnagar Pakistan,
*****Combined Military Hospital Gujranwala Pakistan
ABSTRACT
Objective: To compare Harmonic scalpel with conventional Monopolar Electrocautery hook in terms of
gallbladder perforation rate in Laparoscopic Cholecystectomy.
Study design: Randomized controlled trial.
Place and Duration of Study: Department of Surgery Combined Military Hospital (CMH) Rawalpindi, Pakistan,
from Feb 2013 to Oct 2013.
Methodology: Consecutive 280 patients of cholelithiasis, fulfilling inclusion criteria, were included in this study
after taking written informed consent and approval from hospital ethical committee. They were divided into two
equal groups of 140 patients i.e. “Group A” who underwent LC by Harmonic scalpel and “Group B” in which
conventional Monopolar electrocautery was used for dissection of gallbladder.
Results: An increased incidence of 21.42% gallbladder perforation (GBP) in laparoscopic cholecystectomy (LC),
was observed in “Group B” using Monopolar electrocautery for dissection as compared to 8.57% in “Group A”
using Harmonic scalpel (p=0.002). Male gender was significantly associated with increased GBP i.e. 33.33% as
compared to females 12.29% irrespective of the instrument used.
Conclusion: Harmonic scalpel is better alternative to traditional Monopolar Electrocautery in LC due to decrease
incidence of GBP.
Keywords: Bile duct injuries, Conventional monopolar electrocautery, Gallstones, Harmonic scalpel,
Laparoscopic cholecystectomy.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
management of gallstones by each passing day4-6.
Gallstones having a prevalence of 4% in
Asian population1 is the most common biliary
disease being encountered in surgical practice.
Surgery should be undertaken in patients with
symptomatic gallstones2,3 with the aim to remove
gallbladder that is responsible for both formation
and complications associated with them. With the
advent of laparoscopic cholecystectomy (LC) and
continuous improvement in its technique there is
evidence of low threshold for operative
Two methods of dissection being used in LC
include Conventional Monopolar Electrocautery
and Harmonic scalpel. Harmonic scalpel uses
ultrasound energy for dissection, cutting and
coagulation at the same time, which results in
low temperature, decreased smoke/ lateral tissue
damage7-11 and enables it to replace four
instruments that were used in traditional LC12,
leading to less complications by avoiding
frequent
instrumentation
and
iatrogenic
gallbladder
perforations
(GBP)
during
13-15
dissection . Rationale of this study was
comparison
of
Harmonic
scalpel
with
Correspondence: Dr Yasir Javed, Surgical Specialist CMH
Rawalakot Pakistan (Email: [email protected])
Received: 25 Mar 2016; revised received: 12 May 2016; accepted: 16 May
2016
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S258-62
Electrocautery in LC, to determine the preferred
method of dissection in terms of iatrogenic GBP.
MATERIAL AND METHODS
This randomized controlled trial was
conducted after approval of hospital ethical
committee, at the Department of General
Surgery, Combined Military Hospital Rawalpindi
Pakistan, from Feb 2013 to Oct 2013. 280
consecutive patients including both male and
female ranging from 18-80 years with
symptomatic gallstones i.e. presenting with
biliary colic, dyspepsia, post-prandial distress,
bloating, fat intolerance along with ultrasound
findings of cholelithiasis were included in the
study
using
non-probability
consecutive
sampling. Exclusion criteria included patients
with USG findings of acute cholecystitis,
empyema gallbladder, cholangitis, gallstone
pancreatitis, choledocholithiasis, patients having
coexisting gall bladder malignancy, patients
having previous history of upper midline
laparotomy and patients with positive Hepatitis
B and C serology. WHO calculator was used to
calculate sample size with level of significance
5%, power of test 80% and anticipated population
proportion percentages 18.6% vs 7.1%1. Patients
were randomized into two groups “A” and “B”
using lottery method which constituted 140
patients in each group (n=140). No subjects were
dropped out or lost at any point in the study.
All those patients who met the inclusion
criteria were planned for elective laparoscopic
cholecystectomy after complete history, physical
examination abdominal ultrasonography and
baseline investigations (Blood complete picture,
Liver function tests, Renal functions tests,
Hepatitis B, C screening by ELISA, Chest
radiograph and Electrocardiogram). Patients
were admitted one day before the surgery when
their written informed consent was taken. All the
patients received a preoperative prophylactic
cefuroxime intravenous injection, which was
continued till 18 hours post-surgery. All surgeries
were performed under general anesthesia by the
same surgical team, which included consultant
laparoscopic surgeon who had performed more
than 200 laparoscopic cholecystectomies. Patients
were discharged from hospital depending upon
the individual recovery.
Data was entered and analyzed using SPSS
version 20.0. Qualitative variables like Gender
and Gallbladder perforations were analyzed by
using Frequencies and Percentages whereas,
quantitative variables like Age, Mean and
Standard Deviations were calculated by using
descriptive statistics. “Chi-Square” test was used
to compare both instruments in terms of
gallbladder perforation rate and a “p-value” of <
0.05 was considered significant.
RESULTS
The study population comprised of two
hundred and eighty patients fulfilling the
inclusion criteria were divided into two groups
“A” and “B” that underwent LC by using
harmonic scalpel and electro cautery respectively.
In Group A mean age was 43.72 years (SD 13.47)
while in Group B mean age was 46.56 years (SD
12.62).
In group A, 16.4% patients (n=23) were male
while 83.6% (n=117) were female with male to
female ratio of 1:5.08.
In group B, 9.3% patients (n=13) were male
while 90.7% (n=127) were female with male to
female ratio of 1:9.7.
In group A, number of gall bladder
perforations were 8.57% (n=12) as compared to
21.42% (n=30 ) in group B. The overall result in
terms of gallbladder perforation rates between
two groups i.e. Harmonic versus Monopolar
diathermy using Chi square test was highly
significant with a p-value of 0.002 (less than 0.05).
(Table-1).
It was also observed that male gender was
associated with increased risk of GBP ie 33.33% in
males (12 GBP out of 36 patients) versus 12.29%
in females (30 GBP out of 244 patients). The
difference was statistically significant with pvalue of 0.002. (Table-2).
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S258-62
DISCUSSION
Total number of iatrogenic gallbladder
perforations (GBP) noted in our study was 15%,
which is comparable to the study conducted by
Kandil, but it is much smaller then other studies
in which GBP ranges from 21.6%15 to even 36%16.
GBP by Monopolar Electrocautery dissection
constitutes 21.42% (30 patients) out of total 15%
GBP in our study which is quite less than 49.5%
reported in study conducted by Janssen et al17.
The reason for this gross difference in GBP is
probably because of the patient selection criteria.
Our study included elective cases of symptomatic
gallstones in which there are less chances of
complicating factors whereas the study
patients sustained GBP with Harmonic Ace while
21.42% patients sustained GBP when Monopolar
Electrocautery was used. These results are
comparable to the studies performed by Bessa15
(10% vs 30%, respectively) and Kandil1 (7.1% vs
18.6%, respectively). Results of our study are
comparable to meta-analysis of five studies
published by Sasi18, in which 30 patients
sustained GBP out of 256 in Harmonic group
making ultrasound dissection 89% safe, where as
out of 263 in Monopolar electrocautery group 86
cases of GBP, with a safety of 68% was reported.
Confounding factors present in these studies like
active inflammation of gallbladder, complicated
cases including empyema gallbladder/ Mirrizi’s
Table-1: Group wise distribution of gallbladder perforation according to the Gender.
p-value
Groups
Perforations
Male
Female
Total
Group A
Yes
6
6
12
0.001
No
10
118
128
Total
16
124
140
Group B
Yes
6
24
30
0.231
No
14
96
110
Total
20
120
140
Over all in both
Yes
12
30
42
0.002
groups
No
24
214
238
Total
36
244
280
Table-2: Complications among the two study groups.
Groups
Complications
Frequency
Percentage
Monopolar Diathermy
Cystic artery Bleeding
2
0.8
Biloma (one due to slippage of clip from
2
0.8
cystic duct and one from liver bed)
Gut injury
1
0.4
Harmonic scalpel
Common hepatic duct injury
1
0.4
Bleeding from cystic artery (which was
1
0.4
controlled laparoscopically).
Port site Hernia
1
0.4
mentioned included complicated cases. Secondly
in our study all the LC were performed by senior
consultant surgeon only whereas in the study
mentioned LC was performed by both consultant
and trainee surgeons making gallbladder more
susceptible to perforation during dissection.
Comparison of the two instruments used for
dissection in our study showed that 8.57%
syndrome, perioperative abnormal anatomy/
dense fibrotic adhesions and variable expertise of
the surgical team were all excluded in our study.
In comparison to few local studies, study
conducted by Nadim19 included a total of 128
patients out of which overall, harmonic and
electrocautery GBP rates were found to be 20.3%,
10.9% and 29.7% respectively that is comparable
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Pak Armed Forces Med J 2016; 66 (Suppl-3): S258-62
to our results i.e. 15%, 8.57% and 21.42%
respectively. Another study comprising of 110
patients revealed similar results in comparison of
iatrogenic GBP by Harmonic and Electrocautery.
Total of 17 patients (20%) underwent GBP during
laparoscopic cholecystectomy out of which 5
(9.1%) were Harmonic induced while 17 cases
(30.9%) were attributable to Electrocautery20.
Sample size of both above-mentioned studies was
less then our study, but shared common sample
selection criteria and exclusion of similar
confounding factors.
Efficacy of harmonic dissection has been
described in another local study carried out in
military settings, including 110 patients21. GBP
occurred only in 3 patients (2.72%), which is
amazingly low as compared to our study and
most of the national and international studies.
This may be attributable to the careful selection of
study group; better operating facilities or
expertise of surgical team but the results cannot
be generalized because no comparison was made
between harmonic and electrocautery dissection.
However, there is one international study
carried out by Redwan22 in which no statistically
significant difference in GBP between the
harmonic versus electrocautery was observed
(p=0.46), although the incidence of GBP was
lesser with harmonic dissection in comparison to
electrocautery group.
Besides primary result of this study, risk
analysis of gender on GBP was also calculated.
Out of 36 males in total, 12(33.33%) sustained
iatrogenic GBP in our study, no matter which
method of dissection was used, which is much
more as compared to 12.29% (30 out of 244 cases)
in female patients (p=0.002). This statistically
significant effect of gender on GBP has been
described in many international studies23-25.
Results of these studies show similar effect of
gender on iatrogenic GBP as evident in our study,
however sample size used in these studies are
comparatively much larger. Reason behind the
phenomenon of higher GBP in males is perhaps
the increased tolerability, leading to delayed
presentation responsible for comparatively
increased adhesions and fibrosis in Calot’s
triangle as well as between gallbladder and liver
bed predisposing iatrogenic GBP during
dissection.
Results of our study cannot be generalized
to whole population as our study group
contained either entitled patients having military
backgrounds or non-entitled patients who
belongs to the high and middle socioeconomic
class.
Selection of study group was narrowed
down to include elective cases of symptomatic
cholelithiasis only, in which anatomy and
dissection of calots triangle is relatively easier
with less chances of per operative complications
as compared to the complicated cases.
In comparison of both instruments, only one
aspect of complication was assessed i.e.
gallbladder perforation, which does not, makes
an instrument completely safe or superior over
the other nor determines its overall efficacy.
It was not possible to blind surgeons and
eliminate bias completely as operating team was
in picture of instrument being used on the
patient.
CONCLUSION
Ultrasonic dissection of gallbladder with
Harmonic scalpel reduces the risks of gallbladder
perforation and bile spillage, thereby not only
keeps the operative field clean but also helps the
less experienced surgeon in identification of
correct dissection plane and less frequent change
of instruments.
RECOMMENDATIONS
Harmonic scalpel is a better alternative to
electrocautery with less gallbladder perforations
and should be routinely used in laparoscopic
cholecystectomy.
Main drawback of presently available
ultrasonic devices is their cost, which may
outweigh the potential benefits and free
availability of this technology especially in third
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Laparoscopic Cholecystectomy
Pak Armed Forces Med J 2016; 66 (Suppl-3): S258-62
world countries; further studies are required to
determine their cost-benefit analysis.
Existing classification of biliary injuries is
inadequate and does not include the associated
vascular injuries, an explicit and comprehensive
classification of biliary injuries need to
formulated in order to educate the upcoming
surgeons regarding different possibilities of risks
involved in Laparoscopic cholecystectomy.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Kandil T, El Nakeeb A, El Hefnawy E. Comparative Study
between Clipless Laparoscopic Cholecystectomy by Harmonic
Scalpel Versus Conventional Method: A Prospective
Randomized Study. J Gastrointest Surg. 2010; 14(2): 323-8.
2. Sandler RS, Maule WF, Baltus ME. Factors associated with
postoperative complications in diabetes after biliary tract
surgery. Gastroenterology 1986; 91: 157-162.
3. Ransohoff DF, Miller GL, Forsythe SB, Hermann RE. Outcome of
acute cholecystitis in patients with diabetes mellitus. Ann Intern
Med 1987; 106: 829-832.
4. Legoretta AP, SilberJH, Constantino GN, Kobylinski RW, Zata
SL. Increased cholecystectomy rate after the introduction of
laparoscopic cholecystectomy. JAMA 1993; 270: 1429-32.
5. C M Lam, F E Murray, A Cuschieri. Increased cholecystectomy
rate after the introduction of laparoscopic cholecystectomy in
Scotland. Gut. 1996; 38(2): 282-284.
6. Schwesinger WH, Diehl AK. Changing indications for
laparoscopic cholecystectomy. Stones without symptoms and
symptoms without stones. SurgClin North Am. 1996; 76(3): 493504.
7. Sietses C, Eijsbouts QAJ, von Blomberg BME, Cuesta MA:
Ultrasonic energy vsmonopolarelectrosurgery in laparoscopic
Cholecystectomy: influence on the postoperative systemic
immune response. SurgEndosc 2001; 15: 69-71.
8. Antonutti R, Fontes-Dislaire I, Rumeau JL. Experimental study
of monopolar electrical and ultrasonic dissection. Ann Chir 2001;
126: 330.
9. Carlander J, Johansson K, Lindstrom S .Comparison of
experimental nerve injury caused by ultrasonically activated
scalpel and electrosurgery. Br J Surg 2005; 92: 772.
10. Barrett WL, Garber SM.Surgical smoke a review of the literature.
SurgEndosc 2003; 17: 979.
11. McDonald R, Biswas P. A methodology to establish the
morphology of ambient aerosols. J Air Waste Mgmt 2004; 54:
1069.
12. Tebala GD. Three port laparoscopic cholecystectomy by
harmonic dissection without cystic duct and artery clipping. Am
J Surg 2006; 191: 718–20.
13. MinutoloV, GaglianoG, RinzivilloC, LiDestriG, CarnazzaM,
Minutolo O, et al: Usefullness of the ultrasonically activated
scalpel in laparoscopic cholecystectomy: our experience and
review of literature. 2008; 29(5): 242-5.
14. Altaf K, Huang W, Javed MA, Mukherjee R, Mai G, Hu W, et al,
A meta-analysis of randomized clinical trials that compared
ultrasonic energy and monopolar electrosurgical energy in
laparoscopic cholecystectomy. J Laparoendosc AdvSurg Tech
A 2012;22(8): 768-77.
15. Bessa SS, Al-Fayoumi TA, Katri KM, Awad AT. Clipless
laparoscopic cholecystectomy by ultrasonic dissection. J
Laparoendosc AdvSurg Tech A 2008; 18: 593-8.
16. Ioannis T; Nikolaos N; Nikolaos S; Maria C;IoannaK;Thomas C.
Complications of Laparoscopic Cholecystectomy: Our
Experience in a District General HospitalSurgical Laparoscopy,
Endosc& Percutaneous Tech: 2009; 19: 449-458.
17. Janssen I. M. C, Swank D. J, Boonstra O, Knipscheer B. C,
Klinkenbijl J. H. G, van Goor H. Randomized clinical trial of
ultrasonic versus electrocautery dissection of the gallbladder in
laparoscopic cholecystectomy. B J S2003; 90(7): 799 – 803.
18. Sasi W. Dissection by ultrasonic energy versus monopolar
electrosurgical energy in laparoscopic cholecystectomy. JSLS.
2010; 14: 23–34.
19. Khan N, Ahmad M, Ahmad Z, Khan A, Sadiq M. Safety of
ultrasonic dissection versus conventional electrocautery
dissection during laproscopic cholecystectomy in terms of gall
bladder perforation. J Postgrad Med Inst 2013; 27(2): 157-63.
20. Ahmed N, Mian MA, Zaidi SH, Inam S, Rehmani JA.
Association of iatrogenic gall bladder perforation in
laparoscopic cholecystectomy with harmonic scalpel and
electrocautery. Pak Armed Forces Med J. 2013; 63-1.
21. Zaidi AH, Haleem A, Rana S. Use of harmonic scalpel in
laparoscopic cholecystectomy. Pak Armed Forces Med J 2011;
61: 20-4.
22. Redwan AA. Single-working instrument, double trocar,
clipless
cholecystectomy using harmonic scalpel: a feasible,
safe, and less invasive technique. J Laparoendosc AdvSurg Tech
A 2010; 20(7): 59- 603.
23. Hui TT, Giurgiu DI, Margulies DR, Takagi S, Iida A, Phillips
EH.Iatrogenic gallbladder perforation during laparoscopic
cholecystectomy: etiology and sequelae. Am Surg. 1999; 65(10):
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24. Suh SW, Park JM, Lee SE, Choi YS. Accidental gallbladder
perforation during laparoscopic cholecystectomy: does it have
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Tech A 2012; 22: 40-5.
25. Giger UF, Michel JM, Optiz I, ThInderbitzin D, Kocher T,
KrahenbuhlL.Risk factors for perioperative complications in
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Surg.2006; 203(5): 723-8.
S262
Field Medicine
Injuries in Counterterrorism Operations
Pak Armed Forces Med J 2016; 66 (Suppl-3): S263-66
FIELD MEDICINE
PATTERN OF INJURIES IN COUNTER TERRORISM OPERATIONS: AN EXPERIENCE
AT A TERTIARY CARE HOSPITAL
Muhammad Qasim Butt, Sohail Saqib Chatha, Adeel Qamar Ghumman*, Mahwish Farooq**
Combined Military Hospital Kohat, Pakistan, *Military Hospital Rawalpindi, Pakistan, **Jinnah Hospital Lahore, Pakistan
ABSTRACT
Objective: To determine the pattern of injuries sustained by military persons in counterterrorism operations.
Study Design: Descriptive study with retrospective data collection.
Place and Duration of Study: The study was carried out at Combined Military Hospital (CMH) Kohat over a
period of four years from December 2008 to December 2012.
Material and Methods: Data of patients was collected by noting the injuries suffered by soldiers and officers
evacuated from operational area and their outcome after treatment in tertiary care hospital from hospital papers.
Results: Total of 1226 patients were received from operational area over a period of 4 years from December 2008
to December 2012. One hundred and fifty seven (12.8%) were brought in dead while 1069 (87.2%) were received
alive. Twelve (0.98%) patients died during hospital treatment. All patients were male. A total of 593 (48.4%)
suffered limb injuries, 50 (4.1%) suffered neck injuries, 61(5%) had chest injuries, 30 (2.4%) suffered head injuries,
62 (5%) presented with abdominal injuries, 52 (4.3%) suffered eye and face injuries, 3 (0.2%) suffered acoustic
trauma, 9 (0.7%) had vascular injuries while 366 (29.8%) suffered multiple injuries. In 480 (39.2%) patients
mechanism of injury was fire arm injuries, 34 (2.8%) suffered road traffic accidents while in 712 (58.1%) injury
was caused by Improvised Explosive Device.
Conclusion: There is a shift in the pattern of injuries in modern warfare therefore necessary training of medical
staff is required along with speedy evacuation of patients to tertiary care hospitals.
Keywords: Counterterrorism, Improvised Explosive Device, Military.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
War has affected humans since the dawn of
time and lust for control of power ,resources,
land has led to military conflicts amongst various
nations during the course of history. However
with
improvement
in
weaponary
and
introduction of various deadly weapons and
their possession by many nations has led to
change in pattern of injuries suffered during
modern war era.
The pattern of war by terrorists is different
from the conventional warfare and with no
apparent enemy the injuries suffered by the
military as well as civilian populations are
Correspondence: Dr Sohail Saqib Chatha, Dept. of Surgery
CMH Kohat, Pakistan (Email:[email protected])
Received: 22 May 2013; revised received: 14 Mar 2014; accepted: 17
Mar 2014
different than those inflicted by conventional
warfare. Moreover injury patterns also depend
upon type of terrain where operations are being
carried out, weapons used by the terrorists,
weather affecting the area and training of military
personnel to fight such unconventional war. The
changes in wound patterns can mostly be
attributed to the enemy’s unconventional tactics
in this irregular war (e.g. widespread use of
Improvised Explosive Devices (IEDS), as well as
the wide spread use of individual body armour,
Kevlar helmets ,and heavily armoured vehicles.
Individual body armour and Kevlar helmets
provide vital protection for the head, chest, and
abdomen, mitigating the effect of what would
otherwise be life-threatening injuries1. The
reduction in thoracic injuries was first observed
in Operation Desert Storm, when individual
S263
Injuries in Counterterrorism Operations
Pak Armed Forces Med J 2016; 66 (Suppl-3): S263-66
body armour was employed on a large scale for
the first time. This operation saw a decline in
thoracic injuries to 5% compared to 13% seen
during the Vietnam War2. A continued reduction
in thoracic injuries has also been demonstrated in
several studies conducted during Operation Iraqi
Freedom/Operation Enduring Freedom3.
Due to its specific geopolitical location and
being a major alloy of United States of America
(USA) in war against terror, Pakistan is also one
of the major countries affected by terrorism and
its military and paramilitary forces are facing the
gigantic task of fighting against terrorist
activities. There is paucity of literature to identify
were also included in this study. Injuries
occurring to the civilian population were
excluded because of lack of availability of
considerable data and difficulty in their
follow-ups.
Initial treatment was provided by buddy or
nursing staff present at the scene and further
treatment provided by nearby field hospital.
Triage was carried out and patients were
transferred to tertiary care hospital by road as
well as aerial route. All patients were received in
the emergency by surgeon on duty, emergency
doctor, ward nurse and other paramedical staff.
On arrival of the patient primary survey was
Figure-1: Pattern of injuries in counterterrorism operations.
the pattern of injuries suffered by military
persons involved in counterterrorism operations
and a need to know the pattern of injuries is
strongly felt. This study was done to find out the
pattern of injuries in counterterrorism operations,
mortality rates and adequacy of treatment after
reaching tertiary care hospital.
MATERIAL AND METHODS
The descriptive study was carried out at
Combined Military Hospital Kohat and included
the army personnel of all ages brought from
operational area to the tertiary care hospital over
a period of four years between December 2008 to
December 2012. Injuries occurring as a result of
Road Traffic Accidents (RTA) related to militancy
carried out as per Advanced Trauma Life
Support (ATLS) protocol. Initial resuscitation was
carried out and patients were grouped as per the
part of body injured including limbs, thorax,
head and neck, abdomen, face, vascular and
multiple injuries. Multiple injuries included more
than one organ injured. The mode of injury was
also noted. Those requiring emergency or
immediate surgery were shifted to operation
theatre and necessary surgery was performed
while those not requiring surgery were shifted to
the respective wards. Clinical data of all patients
was documented on specific format particularly
mentioning the details of their injuries and
essentials of treatment. Data had been analysed
using the statistical package for social sciences
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Injuries in Counterterrorism Operations
Pak Armed Forces Med J 2016; 66 (Suppl-3): S263-66
(SPSS) version 13.0. Decriptive Statistics were
used to described the results.
RESULTS
Total of 1226 patients were received from
operational area over a period of four years. All
were male. A total of 157 cases (12.8%) were
received dead while 1069 (87.2%) were received
alive. Twelve patients (0.98%) died during stay at
hospital. Most common organs injured were
limbs 593 (48.4%) followed by neck injuries 50
cases, (4.1%), chest injuries 61cases (5%), head
terrorism, insurgency, and guerrilla warfare.
There is no uniformed enemy, no defined front
lines or order of battle, and allegiances can be
fluid4. As a result, most combat casualties occur
due to ambush, or increasingly from the use of
IEDs5 whereas most of the combat casualties in
conventional
war
are
due
to
fragments/splinters6. Peleg et al has reported
95% injuries as a result of small arms and
explosive devices in hospitalized terrorist
victims, when not taking Road Traffic Accidents
into account7, whereas in our study (58.1%)
Figure-2: Cause of injuries in counterterrorism operations.
injuries 30 cases (2.4%), abdominal injuries 62
cases (5%), eye and face injuries 52 cases (4.2%),
acoustic trauma 3 cases (0.2%), and vascular
injuries 9 cases (0.7%) (fig-1). Amongst the
injured 366 patients (29.8%) suffered injury to
more than one organ and were grouped in
category of multiple injuries.
Most common cause of injury was IED in
712 patients (58.1%) followed by 480 (39.2%)
getting injured by firearms while in 34 (2.8%) the
cause of injury was road traffic accidents (fig-2).
Head injury was the cause of death in 3 cases
while 9 deaths occurred due to multiple injuries.
DISCUSSION
In counterinsurgency operations the
patterns of injuries inflicted is different from
conventional warfare because of an irregular war,
in which enemy tactics are primarily based on
patients suffered injuries due to IEDs. Zouris et al
has reported 75% injuries to small arms and
explosives in US marines in Iraqi war8.
Appenzeller has reported two-third injuries
attributable to blunt trauma and only one-third to
combat-type injuries; 74% of blunt injuries due to
motor vehicle accidents, accounting for 47% of
overall trauma9.
Extremity
wounds
and
fractures
traditionally comprise the majority of traumatic
injuries in armed conflicts10. Half (48.4%) of our
patients suffered limb injuries. Appenzeller, in
Kosovo war, also reported extremity injuries to
be the most common injuries occurring in 54% of
all patients. Zouris, in Iraqi war, reported 70% of
all injuries to upper and lower extremities, a
percentage consistent for battlefield injuries since
World War II8. Multiple injuries were the second
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Injuries in Counterterrorism Operations
Pak Armed Forces Med J 2016; 66 (Suppl-3): S263-66
largest group of injuries (29.8%), followed by
abdominal (5%) and chest (5%) injuries. Body
armour has been shown to protect military
personnel from most ballistic projectiles to the
torso, thus increasing survival.
Early recognition, prompt management and
adequate training of healthcare workers
employed in these areas contribute a lot to better
outcome of the injured personnel. Prehospital
treatment of the injured should focus on
resucitation of the patient, control of
haemorrhage and speedy evacuation to the
nearby health facility. Management according to
ATLS guidelines with specific emphasis on ABC
greatly affects the outcome of injured patients
and reduce mortality rate. Immobilization of
cervical spine and maintenance of oxygen
delivery are the primary and most important
intervention11. Advanced life support (ALS)
procedures can be performed by paramedics on
major trauma patients without prolonging onscene time. The speedy evacuation to better
healthcare facilities is also a major determinant
to the outcome of patients. Two different
methods of transfer of trauma victims have been
suggested; one, ‘Scoop and scoot’ other ‘Stay and
stabilize’. First one is ideal for urban settings,
with short distances and good transportation
facilities whereas second one is more helpful in
difficult terrains and long distances. Another
concept, ‘In-transit stabilization, constitutes
resuscitation during transfer to nearby hospitals.
The option primarily depends on facilities
available for transfer, distance to trauma centre
and severity of trauma.
As in our study and many other studies
conducted in case of counterterrorism injuries
bulk of injuries occurred as a result of IEDs, so
an armoured vehicle named “COUGAR” was
developed as part of the U.S military’s "Mine
Resistant Ambush Protected" vehicle program
and they observed that no soldiers had died in
more than 300 IED attacks on Cougars12.
Moreover identifying and disrupting the network
that create and initiate IEDS ,preparing and
training soldiers for an IED environment can help
in reducing the casualities.
CONCLUSION
Since there is a shift in pattern of injuries
suffered during modern warfare, so necessary
changes are required to be inculcated amongst
the training of medical staff dealing with such
injuries.We stress on improved training of the
healthcare workers and the soldiers employed in
counterterrorism operations alongwith speedy
and timely evacuation to tertiary care hospitals.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Mazurek, M. T., Ficke, J. R. The scope of wounds encountered
incasualties from the global war on terrorism: from the
battlefieldto the tertiary treatment facility. J. Am. Acad. Orthop.
Surg.14: S18– 23, 2006.
2. Belmont, P. J., Goodman, G. P., Zacchilli, M.. Incidenceand
epidemiology of combat injuries sustained during “The
Surge”portion of Operation Iraqi Freedom by a US Army
Brigade CombatTeam. J. Trauma 2010
3. Owens, B. D., Kragh, J. F., Jr., Macaitis, J. Characterization of
extremity wounds in Operation Iraqi Freedom and Operation
Enduring Freedom. J. Orthop. Trauma 21: 254– 257, 2007.
4. Covey, D. C. From the frontlines to the home front: the crucial
role of military orthopaedic surgeons. J. Bone Joint Surg. 91-A:
998– 1006, 2009.
5. Bird, S. M., Fairweather, C. B. Military fatality rates (by cause) in
Afghanistan and Iraq: a measure of hostilities. Int. J. Epidemiol.
36: 841– 846, 2007.
6. Rai KM, Kale R, Mohanty SK. Treatment of casualties in a
forward hospital of Indian Army. Medical Journal Armed Forces
India 2004; 60: 20-24.
7. Peleg K. Patterns of injury in hospitalized terrorist victims. The
American Journal of Emergency Medicine. 2003;21:258–262.
[PubMed]
8. Zouris JM. Wounding patterns for U.S. Marines and sailors
during Operation Iraqi Freedom, major combat phase. Mil
Med. 2006;171: 246–252. [PubMed]
9. Appenzeller GN. Injury Patterns in Peacekeeping Missions: The
Kosovo
Experience. Military
Medicine. 2004;169:187–191.
[PubMed]
10. Kragh J, Macaitis J, Svoboda S, Wenke J. Characterization of
Extremity W ounds in Operation Iraqi Freedom and Operation
Enduring Freedom. Symposium Journal of Orthopaedic
Trauma. 2007; 21: 254–257.
11. Kill C. Prehospital treatment of severe trauma. Anasthesiol
Intensivmed
Notfallmed
Schmerzther. 2007;42:708–
714. [PubMed].
12. Cougar-Protection
Against IEDs http: // usmilitary.
About.com/od /armyweapons/a/cougar.
S266
Case Report
Extraskeletal Osteosarcoma
Pak Armed Forces Med J 2016; 66 (Suppl-3): S267-69
CASE REPORTS
EXTRASKELETAL OSTEOSARCOMA OF ANTERIOR ABDOMINAL WALL: A CASE
REPORT AND REVIEW OF LITERATURE
Syed Salman Ali, Muhammad Zeeshan, Iqbal Muhammad, Saeed Afzal, Shoaib Naiyar Hashmi,
Syed Naeem Raza Hamdani
Armed Forces Institute of Pathology Rawalpindi, Pakistan
ABSTRACT
We report a case of an extremely rare soft tissue tumour, extraskeletal osteosarcoma in a 62 year old Pakistani
male, who presented with a slowly growing painless mass of anterior abdominal wall and died within one year of
diagnosis. The clinical, radiological and pathological features of this neoplasm will be discussed, along with a
review of the literature.
Keywords: Extraskeletal osteosarcoma.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Extraskeletal osteosarcoma (ESOS) is a rare
malignant mesenchymal tumour which does not
involve the skeletal system directly1. It accounts for 12% of all soft tissue sarcomas and 4-5% of all
osteosarcomas2. To date, fewer than 300 cases of ESOS
have been reported3.
abdominal wall revealed, an irregular swelling in the
left iliac fossa, measuring 10 x 6 cm, firm in
consistency, attached to the overlying skin but not to
CASE REPORT
A 62 year old male, known case of hypertension
and a chain smoker for the last 20 years, presented to
our institute in April 2015 with complaints of
gradually increasing painless swelling in the left lower
abdominal wall for the last 5 years and mild oozing of
blood from the swelling for the last 4 months.
History goes back to 5 years, when the swelling
appeared as a mild painless nodule in the left iliac
fossa, which over the 5 years gradually increased in
size and became a small cauliflower like growth, but
the patient still ignored it, as it was not associated with
any symptoms. He became worried, when blood
started to ooze from the swelling. Then he reported to
one of the local hospitals, where his biopsy was done
and sent to our institute for review and application of
immunohistochemistry (IHC). Biopsy review at our
institute, reported the lesion as high grade
pleomorphic sarcoma more in favour of extra skeletal
osteosarcoma. Local examination of the anterior
Correspondence: Dr Syed Salman Ali, Histopathology AFIP
Rawalpindi Pakistan (Email:[email protected])
Received: 08 Feb 2016; revised received: 04 Feb 2016; accepted: 02 Mar
2016
Figure-1: Gross and cut section morphology of the
specimen.
the underlying structures with mild oozing of blood.
Contrast enhanced CT scan of abdomen was
done, which reported the lesion as either sarcoma or
desmoid, along with the advice for biopsy. As bone
scan already ruled out the possibility of any primary
skeletal involvement, excisional biopsy was done in
May 2015 and resected specimen was sent to our
institute for histopathology. The cut surface of the
specimen, showed a solid grey brown tumour with
areas of haemorrhage and necrosis (fig-1).
The microscopy revealed multiple foci of
neoplastic osteoid surrounded by atypical spindle cells
having hyperchromatic nuclei with high NC ratio and
a mitotic rate of about 7/10 HPF. A total of 60% of the
tumor showed necrosis (fig-2). An extended panel of
IHC was applied which showed positivity for
osteonectin, vimentin and a Ki 67 index of about 40-
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Extraskeletal Osteosarcoma
Pak Armed Forces Med J 2016; 66 (Suppl-3): S267-69
50% (fig-3) and negativity for CD 99, SMA, Desmin,
ER, PR and Congo red, thus giving a definitive
diagnosis of ESOS. So, the patient was advised follow
up chemotherapy with cisplatin, doxorubicin and
methotrexate regimen, which he tolerated well
initially but unfortunately he died after 2nd cycle of
chemotherapy in October 2015.
mineralization and lack of skeletal involvement.
Histopathologically, it shows reverse zonal pattern in
which malignant spindle cells with marked nuclear
atypia surrounds varying amounts of neoplastic
osteoid and/or cartilage2.
Immunohistochemically, the expression of
antigens in ESOS varies in the reported cases.
DISCUSSION
ESOS was first described by Dr. Harwell Wilson
in 19411. It is a rare malignant mesenchymal tumor,
which occurs outside the bone tissue and is formed of
neoplastic cells that produce osteoid and/or cartilage4.
It is more prevalent in males in the 6th decade of life
and accounts for 1-2% of all soft tissue sarcomas and 45% of all osteosarcomas2.
Most common primary site of involvement of
ESOS is lower extremity (48%) followed by upper
extremity (23%), retroperitoneum (17%) and trunk
(11%) whereas the most common metastatic site is
lungs (80%) followed by bone (8%), liver (8%),
peritoneum and adrenals (<5%) 5.
There are two theories reported with regard to
the mechanism behind evolution of ESOS. The tissue
residue theory suggests that the mesoblastic
component forms during embryonic development and
Figure-2: Photomicrograph of ESOS (HaematoxylinEosin original magnification 40x).
However, it shows positivity for osteonectin and
vimentin whereas negativity for epithelial markers3.
Today, molecular analysis may resolve the diagnostic
dilemma in ambiguous cases. Fluorescence in situ
hybridization (FISH) analysis has revealed the
amplification and/or overexpression of 2 oncogenes
b
a
c
Figure-3: Photomicrograph of ESOS. (a) Osteonectin original magnification 40x. (b) Vimentin original magnification
20x. (c) Ki 67 original magnification 20x.
then the formation of bone and osteosarcoma occurs.
The metaplasia theory suggests that muscle interstitial
fibroblasts are subjected to external or internal
stimulation, including trauma, inflammation and
metaplasia of the osteoblasts or chondrocytes, which
evolves into osteosarcoma6.
The diagnosis of ESOS must be made using a
combination of the clinical manifestations, radiological
and pathological findings. Clinically, it usually
presents as a slowly growing painless mass. Radiology
will reveal a soft tissue mass with variable amounts of
namely MDM2 and CDK4 in ESOS7.
Histologically, ESOS is divided into 6 subtypes
depending upon the predominance of the type of
matrix as osteoblastic, chondroblastic, fibroblastic,
malignant fibrous histiocytoma-like, talengiectatic and
well differentiated6. Differential diagnosis to be
considered includes myositis ossificans, parosteal
osteosarcoma, ossifying fibromyxoid tumour, synovial
sarcoma and malignant melanoma7.
Wide resection is the treatment of choice for
extraskeletal osteosarcoma. Adjuvant chemotherapy
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Extraskeletal Osteosarcoma
Pak Armed Forces Med J 2016; 66 (Suppl-3): S267-69
and/or preoperative radiation therapy may be useful,
although extraskeletal osteosarcoma seems relatively
chemoresistant compared to osseous osteosarcomas8.
Prognosis of ESOS is usually poor. The 5-year
survival rate is 37% or less. Although partial
spontaneous regression of extraskeletal osteosarcoma
has been reported in a few cases. Approximately 50%
of the tumors recur locally and lung metastases
develop within 3 years after diagnosis. Tumor size is
an important prognostic factor. Patients with tumors
>5 cm usually have an unfavorable clinical course. The
histological subtypes of ESOS have also been related
to prognosis. The fibroblastic and chondroblastic
subtypes may have a slightly better prognosis
compared to the other subtypes9.
CONCLUSION
The diagnosis of ESOS must be made using a
combination of the clinical manifestations, radiological
and pathological findings. Clinically indolent lesions
sometimes turn out to be malignant on
histopathology, which is a gold standard for
diagnosis. Role of immunohistochemistry has become
vital and reviews in difficult cases are not uncommon,
which are meant for quality assurance and as a
learning tool.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Wilson H. Extraskeletal ossifying tumors. Ann Surg.
1941;113:95-112.
2. Hoch M, Ali S, Agrawal S, Wang C, Khurana JS. Extraskeletal
osteosarcoma: A case report and review of the literature.
Radiology Case. 2013; 7(7): 15-23.
3. Tao SX, Tian GQ, Ge MH, Fan CL. Primary extraskeletal
osteosarcoma of omentum majus. World Journal of Surgical
Oncology. 2011; 9: 25.
4. Gulia A, Puri A, Jain S, Rekhi B, Juvekar S. Extraskeletal
osteosarcoma with synchronous regional lymph node and soft
tissue metastasis: a rare presentation of an uncommon tumor. Eur
J Orthop Surg Traumatol. 2013; 23: 317-21.
5. Puranik AD, Purandare NC, Bal MM, Shah S, Agrawal A,
Rangaraian V. Extraskeletal osteosarcoma: An uncommon variant
with rare metastatic sites detected with FDG PET/CT. Indian J
Med Paediatr Oncol. 2014; 35(1): 96-8.
6. Wu Z, Chu X, Meng X, Xu C. An abdominal extraskeletal
osteosarcoma: A case report. Oncology Letters. 2013; 6: 990-2.
7. Sabatier. Low-grade extraskeletal osteosarcoma of the chest wall:
case report and review of literature. BMC Cancer. 2010; 10: 645.
8. Strippoli. Chemotherapy dilemma in extraskeletal osteosarcoma.
Oncology Letters. 2015; 9: 2567-2571.
9. Mavrogenis AF, Papadogeorgou E, Papagelopoulos PJ.
Extraskeletal osteosarcoma: A case report. Acta Orthop
Traumatol Turc. 2012; 46(3): 215-19.
S269
Case Report
Polyostotic Fibrous Dysplasia
Pak Armed Forces Med J 2016; 66 (Suppl-3): S270-72
POLYOSTOTIC FIBROUS DYSPLASIA
Adil Qayyum, Ruqqayia Adil, Faisal Basheer, Jawad Jalil*
Combined Military Hospital Abbottabad, Pakistan, *Combined Military Hospital Multan, Pakistan
ABSTRACT
Fibrous dysplasia is a non inherited skeletal disorder in which bone-forming cells fail to mature and produce too
much fibrous or connective tissue. We report a case of 3 years old female with limping gait and limb length
discrepancy. X-ray lower limb showed lucent expansile lesions in metaphyseal regions of right femur & tibia.
Skeletal survey showed unilateral monomelic similar like lesions involving right lower limb and right iliac bone,
right humerus and radius. On the basis of X-ray and biopsy findings, diagnosis of polyostotic fibrous dysplasia of
right upper and lower limb was made. She was referred to Rehabilitation department for management of her
limb length shortening and bone deformities.
Keywords: Fibrous dysplasia, Limb length shortening, Polyostotic.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Fibrous
dysplasia
also
known
as
Lichtenstein – Jaffe disease, is a non inherited
skeletal disorder in which bone-forming cells fail
to mature and produce too much fibrous or
connective
tissue.
There
is
abnormal
differentiation of osteoblasts, which leads to
replacement of normal marrow and cancellous
bone by immature woven bone with fibrous
stroma1. Areas of healthy bone are replaced with
this fibrous tissue.
The importance of early diagnosis is that if
not detected earlier, the disease may progress
causing deformities of limbs, skull & face. Early
detection can prevent loss of vision from orbital
involvement or malignant transformation of the
lesion.
The defect occurs at some point after
conception, most likely early in fetal
development. Monostotic fibrous dysplasia,
characterized by involvement of only one bone, is
considerably more prevalent than the polyostotic
form. Males and females are thought to be
affected evenly, although recent research has
Correspondence: Dr Adil Qayyum, MCPS, FCPS, Classified
Radiologist, Radiology Department CMH Abbottabad, Pakistan.
Email:[email protected]
Received: 11 August; revised received: 17 Sep 2014; accepted: 30 Sep
2014
shown a slight female preponderance. Any bone
may be affected, the long bone, skull, and ribs
most often2. In monostotic fibrous dysplasia, ribs
and proximal femoral site accounts up to 28%
and 23% respectively.
CASE REPORT
My patient 3 years old female reported in
children OPD at CMH Abbottabad, with vague
complaints of limping gait for last 3 to 4 months.
No other clinical complaints were present. On
examination, the child’s right lower limb was 2
cm shorter than the left side. X-ray lower limb
was advised which showed multiple, lucent,
expansile lesions in metaphyseal regions of right
femur & tibia with surrounding sclerosis and
internal ground glass haze. Provisional Diagnosis
of Fibrous dysplasia was made and skeletal
survey was done. Unilateral monomelic lesions
are noted, involving right lower limb and right
iliac bone along with similar like lesions in right
humerus and radius (fig-1). No other bone was
involved.
Her serum alkaline phosphatase was also
raised. Bone biopsy was done for further
confirmation of diagnosis, which showed small
nonmineralized trabeculae of woven bone in
bland cellular and collagenous matrix in the
lesions. More radiolucent lesions were composed
of predominantly fibrous elements, whereas
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Polyostotic Fibrous Dysplasia
Pak Armed Forces Med J 2016; 66 (Suppl-3): S270-72
more radiopaque lesions contained greater
proportion of woven bone. On the basis of X-ray
and biopsy findings, diagnosis of polyostotic
fibrous dysplasia of right upper and lower limb
was made. Detailed history was taken to rule out
any history of acne, precocious puberty,
pigmented cutaneous lesions and endocrine
abnormalities to rule out McCune Albright
syndrome. She was referred to Rehabilitation
department for further management of her limb
length shortening, to improve joint mobility and
to correct bone deformities.
vision from orbital involvement or benign /
malignant transformation of the lesion. Followup is important in fibrous dysplasia to prevent
deformities as a result of the disease and check
for recurrence. In 50 percent of cases, fibrous
dysplasia will re-occur.
In our case, patient presented with limping
gait and fibrous dysplasia was incidentally
discovered. International studies also showed the
condition is often an incidental finding and is
usually painless. Children usually present with
leg pain, limp and pathological fracture.
DISCUSSION
Fibrous dysplasia in itself is not a rare
disorder; it is reported to represent 5% to 7% of
benign bone tumors. It is primarily a
developmental abnormality of the bone-forming
mesenchyme in which fibrous tissue gradually
expands and replaces the bone. It is believed to
be
a
non-neoplastic
hamartomatous
developmental lesion of bone, of unknown
origin. Fibrous dysplasia is a sporadic condition
that results from a postzygotic mutation in the
GNAS1 (guanine nucleotide binding protein, α –
stimulating activity polypeptide1) gene. In most
cases, the radiographic characteristics of
polyostotic Fibrous Dysplasia and the clinical
information are sufficient to allow the
practitioner to make a diagnosis without a
biopsy.
Males and females are thought to be affected
evenly, although recent research has shown a
slight female preponderance. Our patient was
also a female patient. There is wide range of
presentation between 10 and 70 years of age, with
75% of patients presenting before the age of 30
years. Mean age of polyostotic fibrous dysplasia
is 8 years. Our patient was 3 years old.
It is important to have an earlier diagnosis of
fibrous dysplasia to prevent the further
complications and identify patients who will
benefit from non surgical or surgical treatment.
The disease can be diagnosed & managed earlier
before progressing towards deformities of limbs,
skull & face. Early detection can prevent loss of
Figure-1. Unilateral
fibrous dysplasia.
monomelic
polyostotic
Alternatively it may present due to bony
expansion or remodeling3. Morbidity may arise
from compression and displacement of adjacent
structures. This is particularly true in craniofacial
fibrous dysplasia, where the content of the orbit
or cranial nerves may be compressed. The
distribution of bones in polyostotic fibrous
dysplasia is often unilateral and monomelic.
Femur, which is the commonest being 91 %
involved. The other common sites are tibia 81%,
pelvis 78%, skull & facial bones 50%, foot, ribs,
upper extremities, lumbar spine, clavicle and
cervical spine4.
The radiographic features on various
modalities are quite diagnostic. The lesion has
typical ground-glass opacities which may be
completely lucent (cystic) or sclerotic with well
circumscribed lesions on plain radiographs.
Extremities like femur is a common site with
classical radiographic features5. Our patient also
presented with similar lesions in upper & lower
limbs. It may also lead to bowing deformities,
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Polyostotic Fibrous Dysplasia
Pak Armed Forces Med J 2016; 66 (Suppl-3): S270-72
shepherd's crook deformity of femoral neck,
discrepant limb length, looser zones and
premature fusion of growth plates leading to
short limb/stature. CT scan also confirms
ground-glass opacities with well-defined borders,
expansion of bone, with intact overlying bone
and endosteal scalloping. MRI is not particularly
useful in differentiating fibrous dysplasia from
other entities as there is marked variability in the
appearance of the bone lesions, and they can
often resemble tumour or more aggressive
lesions. T1W sequence show heterogeneous
signal, usually intermediate. T2W with
heterogeneous signal, usually low, but may have
regions of higher signal and T1W post contrast
images may have heterogeneous contrast
enhancement6. Nuclear scan demonstrates
increased tracer uptake on Tc99 bone scans
(lesions remain metabolically active into
adulthood).
Fibrous dysplasia might be monostotic or
polyostotic or involve large area of the skull. The
lesions of fibrous dysplasia appears in three
distinctive clinical patterns. The most severe form
of FD is McCune-Albright syndrome, which is
more commonly found in females and is
associated with short stature due to premature
closure of the epiphyses and with endocrine
abnormalities and pigmented cutaneous lesions.
Another severe form is Mazabraud syndrome. It
is characterized by the association of polyostotic
fibrous dysplasia of the bones with solitary
tumours of large muscle groups, occurring
predominantly in the lower limbs, and
myxomas7.
Pathological fractures are the most common
complication of this entity as bone affected by
fibrous dysplasia is weaker than normal and thus
susceptible to fractures. Sarcomatous dedifferentiation
(osteosarcoma,
fibrosarcoma,
malignant fibrous histiocytoma or rarely
chondrosarcoma) is occasionally seen (less than
1%) and is more common in the polyostotic
form8.
The differential diagnosis of fibrous
dysplasia includes lesions like Paget's disease,
Non ossifying fibroma, Simple bone cyst,
Enchondroma, Adamantinoma, Aneurysmal
bone cyst, Osteofibrous dysplasia, Diffuse
sclerosing osteomyelitis and Giant cell tumour.
The main factor that guide the approach are the
patients age, location of the lesion, symptoms
along with classical radiographic appearance.
Treatment may include reduction in risk of
complication such as rickets or fractures and
medications to strengthen bones. Medication
known as bisphosphonates have been shown to
reduce pain associated with the disease.
Physiotherapy is done to improve joint mobility
and surgery to correct bone deformities.
Radiotherapy is contra-indicated not only
because the tumor is radioresistant but also
because of the probable increase of the capacity
for the dysplasia sarcomatous transformation.
Usually the prognosis is good although
complications occur more frequently among
young patients or those with polyostotic forms of
the disorder.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Bhattacharyyal, Islam N, Cohen D. Diagnostic discussion. Fibrous
dysplasia of bone. Todays FDA 2014; 26(1):47-50
2. MacDonald-Jankowski D. Fibrous dysplasia: a systematic review.
Dentomaxillofac Radiol 2009: 38(4):196-215
3. V Nitvasri, PS Haris, T Bose, A Balan. Fibrous dysplasia- a 13-year
retrospective radiographic analysis in a south Indian population.
Dentomaxillofac Radiol 2011; 40(5):282-9
4. Thomsen MD, Rejnmark L. Clinical and radiological observations in a
case series of 26 patients with fibrous dysplasia. Calcif Tissue Int 2014;
94(4):384-95
5. Mrabet D, Rekik S, Sahli H, Ben AM, Meddeb N, Sellami S. An
extensive hemimelic polyostotic fibrous dysplasia: a case report.
Rheumatol Int 2012; 32(4):1075-8
6. Park SK, Lee IS, Choi JY, Cho KH, Suh KJ, Lee WJ, at al. CT and MRI
of fibrous dysplasia of the spine. Br J Radiol. 2012; 85(1015):996-1001
7. Faivre L, Nivelon-Chevalier A, Kottler ML, Robinet C, Khau van Kien
P, Lorcerie B, et al. Mazabraud syndrome in two patients: clinical
overlap
with McCune-Albright syndrome.
Am
J
Med
Genet 2001; 99:132-6
8. Garg MK, Bhardwaj R, Gupta S, Mann N, Kharb S, Pandit A.
Sarcomatous transformation (Leiomyosarcoma) in polyostotic fibrous
dysplasia. Indian J Endocrinol Metab 2013;17(6):1120-3
S272
Case Report
Extra Uterine Leiomyoma
Pak Armed Forces Med J 2016; 66 (Suppl-3): S273-74
LEIOMYOMA OF THE ANTERIOR ABDOMINAL WALL IN A 26 YEAR OLD
PREGNANT WOMAN: A CASE REPORT
Saima Qamar, Nilofar Mustafa, Adeeba Akhter Khalil, Muhammad Jamil
Combined Military Hospital Lahore Pakistan
ABSTRACT
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permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
A uterine fibroid, also known as uterine
leiomyoma is a benign smooth muscle tumor of
the uterus. Although intramural fibroids located
within the wall of the uterus are the most
common type of uterine leiomyomas, fibroids can
also be found in supporting structures such as the
broad ligament1. The incidence among women is
generally 20-25 %2.
unremarkable. On general physical examination
she was of average built, well oriented in time,
place and person. Her vitals were normal. There
were no positive fin dings in the general
physical, respiratory, cardiovascular or central
nervous system examinations. The abdomen was
protruding due to pregnancy and there was a
Abdominal wall fibroids, however, are an
uncommon finding and are thought to be due to
seeding following surgical resection of uterine
fibroids3.
CASE REPORT
A patient xyz, 26 years of age, non-booked,
with a degree in faculty of art, presented in
gynecology outpatient department at 36 weeks of
gestation. She had been married for one year and
was currently primigravida. Her pregnancy was
uneventful during the first trimester, but during
the second trimester she noticed a swelling the
size of a large lemon in her right iliac fossa. She
reported to a doctor in private sector, where all
her investigations and ultrasound was done and
she was diagnosed as having a solid mass in the
anterior abdominal wall. As she was pregnant
and the mass did not seem to be causing any
trouble, so no further intervention was done. The
mass was not painful but kept gradually
increasing in size. She had no other urinary or
bowel complaint, normal appetite and no history
of weight loss. The baby was growing well. Her
past medical, surgical and family history was
Correspondence: Dr Saima Qamar, Asst Prof, Obs/Gynae Dept
CMH Lahore Pakistan (Email: [email protected])
Received: 03 May 2016; revised received: 06 Jun 2016; accepted: 15 Jun
2016
Figure: specimen of uterine leiomyoma.
mass in the right iliac fossa approximately 10cm x
6cm. On palpation it was firm in consistency, not
mobile, non-tender and had regular margins. Her
baseline investigations were within normal limits.
An ultra sound was advised from the radiology
department for the diagnosis of the mass.
On ultrasound report the mass was 11cm x
6.7cm, homogenously solid with a central area of
necrosis measuring about 1-2cm located in the
anterior abdominal wall. Surgical consultation
was done and as she was near term so
intervention was planned at the time of delivery.
A cesarean section was planned at 38 weeks of
gestation. Abdomen was opened through
pfannenstiel incision and uterus through
transverse lower segment incision baby was
delivered along with placenta, uterus stitched in
double layer. Baby was normal and healthy with
Apgar score 10/10 at 5 minutes. The surgeon was
involved for further intervention. The mass was
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Extra Uterine Leiomyoma
Pak Armed Forces Med J 2016; 66 (Suppl-3): S273-74
easily removed from the anterior abdominal wall
through pfannenstiel incision. There were no
adhesions with the surrounding structures.
Hemostasis was secured and specimen was sent
for histopathology, on histopathology report it
was confirmed that the masswas a leiomyoma.
Histopathology report showed spindle-shaped
smooth muscle cells in interlacing bundles and
whorls. The patient’s recovery was uneventful.
DISCUSSION
Fragments of uterine leiomyomas can
unintentionally be implanted and grow in
abdominal-wall incisions
after
laparoscopic
myomectomy4. In women with no evidence of
uterine leiomyomas, there is still a possibility that
cesarean section may cause the abdominal wall
leiomyoma5.
Cases
of
primary
abdominal
wall
leiomyoma are rare and because of this there is
very little literature available on them7.
CONCLUSION
Benign primary leiomyoma of the
abdominal wall can occur and this rare entity
should be considered in the diagnosis of the
anterior abdominal wall tumors in any patient
without any concomitant tumors elsewhere in the
abdomen or any antecedent history of abdominal
or pelvic surgery.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
Primary abdominal wall leiomyoma are very
rare if there has been no previous surgical
procedure performed. However, the exact cause
of the origin of primary leiomyoma from the
anterior abdominal wall is unclear. It has been
postulated that the transformation of the cells of
the vessel wall in the anterior abdominal layer
due to somatic mutations and interplay of
hormonal and growth factors6.
This patient had undergone no previous
surgical
procedures,
caesarean
section,
laparotomy or laparoscopy and had no history of
uterine leiomyomas. The tumor grows in
pregnancy due to maternal hormonal effect and
this typically occurred in this patient.
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1. Muffly T, Vadlamani I, Weed JC. Massive leiomyma of the broad
ligament. Obstet Gynecol.2007; 109 (2 pt 2): 563–5
2. Hoffman BL. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson
LM, Bradshaw KD, Cunningham F. editors. Williams
GYNECOLOGY. 2nd ed. New York: McGraw Hill; 2012. p. 22462480.
3. Lalor PF, Uribe A, Daun GS. Denovo growth of a large
preperitoneal lipoleiomyoma of the anterior abdominal
wall. Gynecol Oncol. 2005; 97(2): 719–21. doi: 10.1016 /j. ygyno.
2005. 01. 050.
4. Moon HS, Koo JS, Park SH, Park GS, Choi jg, Kim SG. Parasitic
leiomyoma in the abdominal wall after laparoscopic
myomectomy. Fertil Steril. 2008; 90(4): 1201.e1–e2
5. Igberase GO, Mabiaku TO, Ebeigbe PN, Abedi HO. Solitary
anterior abdominal wall leiomyoma in a 31-year-old multipara
woman: a case report. Cases Journal. 2009; 2: 113. doi: 10. 1186
/1757- 1626-2- 113.
6. Al-Wadaani HA. Anterior abdominal wall leiomyoma arising de
novo in a perimenopausal woman.Oman Med J. 2012; 27(4): 323–
25
7. Sreelatha S, Kumar A, Nayak V, Punneshetty S, Hanji N. A rare
case of primary parasitic leiomyoma. Int J Reprod Contracept
Obstet Gynecol. 2013; 2(3): 422–24.
Case Report
Pak Armed Forces Med J 2016; 66 (Suppl-3): S275-76
Goiter with Compromised Airway
ANESTHETIC MANAGEMENT OF HUGE MULTINODULAR GOITER WITH
COMPROMISED AIRWAY
Saleem Ahmed, Khalid Zaeem, Sanum Kashif, Syed Samee Uddin
Military Hospital Rawalpindi Pakistan
ABSTRACT
A 52 years old woman with MNG, came for thyroidectomy. Goiter was huge, causing tracheal compression,
narrowing and deviation to the left. For induction of general anesthesia (GA), awake intubation with 6.5mm ID
(Internal diameter), armoured endotracheal tube (ETT) was performed with the help of flexible fiber-optic
bronchoscope (FOB).
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Globally, endemic goiter is prevalent in
different regions of the world and is caused by
iodine deficiency. For the effective release of
airway compressive symptoms, thyroidectomy is
usually indicated3. Airway and respiratory
embarrassment can be avoided by proper airway
management before surgery4. In suspected
difficult airway circumstances, awake ETI should
be done5.
CASE REPORT
The patient was a 52 years old woman
diagnosed as MNG, initially she had anterior
neck swelling which increased in size
Physical examination revealed a middle age
woman averagely built. She could talk and
breathe without difficulty in the standing and
sitting positions but developed mild dyspnea in
supine position. Her BP was 143/69mmHg, with
a heart rate of 52 beats per minute. Systemic
examination was unremarkable except prominent
anterior neck swelling of 11cm x 9cm in size and
multinodular in nature as shown in fig-1. Mouth
opening was adequate, with Mallampati grade 4
but neck extension was very limited and
thyromental distance couldn’t be measured.
Routine laboratory investigations and
thyroid function test were within normal limits
except Chest x-ray and CT-scan showed severe
Figure-1: Patient before and after Thyroidectomy.
Figure-2: CT-Scan Neck showing
tracheal narrowing
progressively over the years and she developed
dyspnea in supine position. She had been on
tablets propranolol and carbimazole for
hyperthyroidism.
Correspondence: Dr Sanum Kashif, Classified Anesthesiologist
MH Rawalpindi Pakistan (Email: sanumdr@gmail,com
Received: 29 Apr 2016; revised received: 13 Jun 2016; accepted: 15 Jun
2016
tracheal narrowing and left-sided deviation of
trachea, as shown in fig-2.
The diagnosis of MNG with compromised
airway was made and total thyroidectomy was
planned. To secure airway for ventilation, options
were discussed with the patient and surgeon and
consensus was made for awake fiberoptic ETI.
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Goiter with Compromised Airway
Pak Armed Forces Med J 2016; 66 (Suppl-3): S275-76
ENT team was on board for an emergency
tracheostomy. The patient was in sitting position,
intravenous inj. Glycopyrolate 0.2mg, Xylocaine
nasal spray, 4% lidocaine local spray used for
gargles and 2% lidocaine 3ml injected intratracheal, using 25G spinal needle with ultrasound
guidance as no tracheal ring was palpable. The
ETT of 6.5mm ID was threaded over FOB and
after successful intubation with the help of FOB,
the ETT was connected to the anaesthesia
machine via breathing circuit and was ventilated
successfully throughout the procedure.
Thyroidectomy went uneventful and by the
end of the procedure she was successfully
extubated so transferred to the surgical ICU and
was kept there for 24 hours, then shifted to ward
and later on discharged to home on 3rd day of
surgery.
DISCUSSION
Thyroidectomy for huge MNG with
compromised airway is usually associated with
difficult airway management at the time of
induction of anesthesia, during and after
surgery6,7. Management of difficult airway is of
prime importance to the anesthetist as well as to
the surgeon8. Failed endotracheal intubation
incidence is high with Mallampati ¾ and neck
mobility less than 90 degree9. Due to the extent of
air way distortion in our patient, strategy was
discussed with the patient and informed consent
taken for awake ETI with the help of flexible FOB.
Awake ETI using flexible FOB is the gold
standard in difficult airway management10. In the
mentioned case, neither intraoperative nor postoperative complications occur.
compromised airway should be considered for
awake endotracheal intubation with the help of
flexible FOB.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Saikat SQ, Carter JE, Mehra A, Smith B, Stewart A. Goiter and
environmental iodine deficiency in the UK-Derbyshire: a review.
Environ Geochem Health 2004; 26: 395-401.
2. Ogbera AO, Fasanmade O, Adediran O. Pattern of thyroid
disorders in the south western region of Nigeria. Ethn Dis. 2007;
17: 327-30.
3. Vanderpas J. Nutritional epidemiology and thyroid hormone
metabolism: Annu. Rev. Nutr. 2006; 26: 293–322.
4. Agarwal A, Agarwal S, Tewari P, Gupta S, Chand G, Mishra A,
et al. Clinicopathological profile, airway management, and
outcome in huge multinodular goiters: an institutional
experience from an endemic goiter region. World J Surg. 2012;
36: 755-60.
5. Kovacs G, Law J. A, Petrie D. Awake fiberoptic intubation using
an optical stylet in an anticipated difficult airway. Ann Emerg
Med. 2007; 49: 81-3.
6. American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Practice guidelines for
management of the difficult airway: an updated report by the
American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology. 2003; 98:
1269–1277.
7. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult
intubation in apparently normal patients: a meta-analysis of
bedside screening test performance. Anesthesiology. 2005; 103:
429–437.
8. Naguib M, Scamman FL, O'Sullivan C, Aker J, Ross AF,
Kosmach S, et al. Predictive performance of 3 multivariate
difficult tracheal intubation models: a double-blind, casecontrolled study. Anesth Analg. 2006; 102: 818–824.
9. Merah NA, Wong DT, Foulkes-Crabbe DJ, Kushimo OT, Bode
CO. Modified Mallampati test, thyromental distance and interincisor gap are the best predictors of difficult laryngoscopy in
west Africans. Ind J Anaesth. 2005; 52: 291-6.
10. Soo Hwan Kim, Su Jin Woo, Jong Hoon Kim. A comparison of
Bonfils intubation fiberscopy and fiberoptic bronchoscopy in
difficult airways assisted with direct laryngoscopy. Korean J
Anesthesiol. 2010; 58: 249-55.
CONCLUSION
Airway management of large MNG with
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Case Report
Pak Armed Forces Med J 2016; 66 (Suppl-3): S277-78
Hereditary Congenital Facial Palsy
HEREDITARY CONGENITAL FACIAL PALSY
Muhammad Tariq
Combined Military Hospital Lahore, Pakistan
ABSTRACT
Hereditary congenital facial palsy (HCFP) is a rare disorder. We report the case of 20 year old woman who
presented with right sided facial weakness since her infancy. Among five generations of her family, 12 other
members had facial palsy. Her detailed clinical assessment revealed no abnormality other than right sided facial
paresis. A diagnosis of autosomal dominant hereditary congenital facial palsy was made.
Keywords: Autosomal dominant, Facial palsy, Five generations.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Hereditary congenital facial paresis (HCFP)
is an isolated dysfunction of facial nerve. It
belongs to a group of congenital diseases known
as congenital cranial dysinnervation disorders
(CCDDs), characterized by abnormal eye and
facial movements1.
Industries Taxila (HIT) in Dec 2012. She produced
a hand written list of their family members (made
by her father, an employ of HIT) among 5
generations, suffering from congenital facial
weakness (fig-1). According to this list 12 other
The disorders belonging to CCDDs include
Duane syndrome, Möbius syndrome, horizontal
gaze palsy, congenital ptosis and congenital facial
palsy. Although Möbius syndrome and HCFP
share some clinical features, they are different
entities.
Möbius syndrome is a developmental
disorder of lower brainstem associated with facial
palsy and impairment of ocular abduction.
Hereditary congenital facial weakness results
from maldevelopment of facial nucleus and its’
nerve. There may be complete or partial absence
of facial nerve on one side or both sides2.
Figure-1: List of the family members having
facial weakness.
CASE REPORT
A 20 year old female patient with congenital
right sided facial weakness was referred to
Neurology Clinic of Military Hospital (MH)
Rawalpindi by Medical Officer of Heavy
Correspondence: Dr Muhammad Tariq, Classified Medical
Specialist & Neurophysician CMH Lahore Pakistan
Email: [email protected]
Received: 09 Nov 2015; revised received: 19 Oct 2015; accepted: 27 Jun
2016
members of her family suffered from congenital
facial weakness:
1. Maternal grandfather of her father (Left) (1st
Generation).
2. Mother of her father (Left) (2nd Generation).
3. One maternal Uncle of her father (Right) (2nd
Generation).
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Hereditary Congenital Facial Palsy
Pak Armed Forces Med J 2016; 66 (Suppl-3): S277-78
4. One Maternal aunt of her father (Right) (2nd
Generation).
60%. In addition to facial weakness congenital
deafness may also be present3.
5. Her Father ( Right (3rd Generation).
Michielse et al describe a third large
autosomal dominant HCFP family originating
from Pakistan. Linkage analysis identified the
locus at 3q21–22, like the Dutch HCFP1 family4.
6. Her paternal uncle (Right) (3rd Generation).
7. Her paternal aunt (Right) (3rd Generation).
8. Her brother (Right) (4th Generation).
9. Daughter of maternal cousin of her father
(Right) (4th Generation).
10. Elder niece of her father (left) (4th Generation).
11. Daughter of niece of her father (left) (5th
Generation).
12. Son of niece
Generation).
of
her
father
(Left)
(5th
Neurological
examination
revealed
unilateral lower motor neuron paresis of right
facial nerve. Detailed clinical assessment revealed
no other abnormality. A diagnosis of autosomal
dominant hereditary congenital facial palsy was
made. She was explained the prognosis of the
disease. Since then she was lost for follow up.
DISCUSSION
HCFP is a rare autosomal dominant
inherited disorder affecting some families. Two
large HCFP families i.e. HCFP1 and HCFP2 were
first described in two Dutch families. Linkage
analysis in these two families identified two
different loci, 3q21–22 in HCFP1 and 10q21–22 in
HCFP2, indicating genetic heterogeneity for this
disorder.
The phenotype for HCFP1 family is an
asymmetric, mostly bilateral, weakness of facial
muscles with a penetrance of 95%. The
phenotype of HCFP2 family is often
characterized by an asymmetrical, unilateral or
bilateral facial weakness with a penetrance of
In a large Dutch family in which 46 persons
in 6 generations had congenital facial paralysis
Kremer et al examined 31 family members,
including 20 affected persons. The proband had
asymmetric facial weakness. He was born with
facial weakness similar to his grandmother and
many of his siblings. His obligate carrier mother
had no evidence of facial muscle weakness5.
In HCFP an appropriate history and
physical examination is sufficient to make a
diagnosis. An extended physical examination is
needed
to
exclude
other
congenital
malformations. Imaging and neuromuscular
testing may be necessary for treatment planning.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Gutowski NJ, Bosley TM, Engle EC. 110th ENMC International
Workshop: the congenital cranial dysinnervation disorders
(CCDDs). Neuromuscul Disord 2003; 13: 573–8.
2. Verzijl HTFM, van der Zwaag B, Lammens M, Donkelaar H J,
Padberg GW. The neuropathology of hereditary congenital facial
palsy vs Moebius syndrome. Neurology 2005; 64: 649-53.
3. Verzijl HT, van den Helm B, Veldman B, Hamel BC, Kuyt LP,
Padberg GW, et al. A second gene for autosomal dominant
Mobius syndrome is localized to chromosome 10q, in a Dutch
family Am J Hum Genet 1999; 65: 752-56.
4. Michielse CB, Bhat M, Brady A, Jafrid H, van den Hurk JAJM,
Raashid Y, et al. Refinement of the locus for hereditary congenital
facial palsy on chromosome 3q21 in two unrelated families and
screening of positional candidate genes. Europ J Hum Genet 2006;
14: 1306-12.
5. Kremer H, Kuyt LP, van den Helm B, van Reen M, Leunissen
JAM, Hamel BCJ, et al. Localization of a gene for Moebius
syndrome to chromosome 3q by linkage analysis in a Dutch
family. Hum Molec Genet 1996; 5: 1367-71
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Case Report
Imaging of Abdominal Hydatidosis
Pak Armed Forces Med J 2016; 66 (Suppl-3): S279-80
IMAGING OF ABDOMINAL HYDATIDOSIS: A RARE PRESENTATION OF A
COMMON CONDITION
Javed Anwar, Saima Omar, Sanaullah, Koukab Javed
Combined Military Hospital Multan, Pakistan
ABSTRACT
A 76 year old male patient with history of progressive abdominal distension was referred for ultrasound (US)
examination to look for the cause of distension. US examination followed by the CT scan abdomen and pelvis
revealed multiple unilocular and multilocular cysts along with daughter cysts and cystic ascites. On the bases of
imaging the case was diagnosed as abdominal hydatidosis. Imaging plays a pivotal role in the diagnosis of
hydatidosis.
Keywords: Hydatid, Hydatidosis, Imaging.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Hydatid disease is caused by cestode tape
worm Echinococcus granulosus and rarely by
Echinococcus multilocularis. In humans it
commonly involves the liver (75%) and lungs
(15%). Rest of the (10-15%) cases are seen to
involve other organs. Abdominal and peritoneal
hydatidosis is only seen in 2% cases1-3. Here we
present a case of a 76 year old man who was
referred for US examination to look for the cause
of abdominal distension; later on he was
diagnosed as extensive abdominal hydatidosis on
the bases of imaging findings.
the liver causing scalloping of hepatic borders.
Cystic masses were also seen in the pelvis and
CASE REPORT
A 76 year old male patient presented with
progressive abdominal distension over last five
years. There was no significant past medical and
surgical history or history of trauma.
Examination of abdomen revealed positive fluid
thrill test suggesting abdominal ascites. He was
referred
for
US
(ultrasound)
abdomen
examination. His US examination demonstrated
the presence of overwhelmingly echogenic free
fluid. Multiple unilocular and honeycomb like
cluster of multilocular cystic masses were noted
within the peritoneal cavity, particularly around
Correspondence: Dr Sanaullah, Radiology Department CMH
Multan Pakistan (Email: [email protected])
Received: 29 Jan 2016; revised received: 23 Jun 2016; accepted: 27 Jun
2016
Figure–1: (a) Multiple well defined round cysts of
variable sizes are noted clustered together on USG
images, few of them demonstrating internal
undulating membranes, (b) Multiple round cysts with
calcified walls in hypochondrial regions on
scanogram, (c) CT demonstrates the largest cyst in the
left hypochondrium with coarsely calcified walls and
a small air fluid level exerting mass effect on adjacent
structures, (d) Gross ascites of increased attenuation
(34 HU) containing honey comb like clusters of cysts
and free floating peritoneal cysts.
few cysts were also demonstrated in the liver.
Most of the multi cystic masses showed coarse
calcification in their wall. CT (Computed
Tomography) study reaffirmed the US findings
and demonstrated the daughter cysts with cystic
spoke wheel pattern, densely calcified wall and
an air fluid level in the largest cyst in the left
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Imaging of Abdominal Hydatidosis
Pak Armed Forces Med J 2016; 66 (Suppl-3): S279-80
hypochondrium (fig-1). On the base of
characteristic US and CT findings the case was
diagnosed as extensive abdominal hydatidosis.
DISCUSSION
Hydatid disease is a worldwide problem
particularly in cattle grazing areas. It is difficult
to diagnose extra hepatic hydatid disease as it is
not usually suspected. Its diagnosis prior to the
surgery is very important so that the surgeon
must be aware of the exact diagnosis as to avoid
the spillage during surgery2,4.
Imaging plays on essential role in the
diagnosis and evaluation of this disease. US, CT
scan and MRI examination can diagnose hydatid
disease. Choice of imaging method depends on
the involved organ, and radiologic findings range
from purely cystic lesion to completely solid
appearance. US is the imaging method of choice
but CT has a high sensitivity of 94%. MRI is the
best choice to demonstrate cystic component. It
also helps to determine vascular or biliary tree
involvement2,5. The purpose of presenting these
case is to share a rare presentation of hydatid
disease which otherwise commonly involves liver
and lungs.
CONFLICT OF INTEREST
This study has no conflict of interest to
declare by any author.
REFERENCES
1. Almalik A, Alsharidi A, Al-Sheef M, Enani M. Disseminated
abdominal hydatidosis: a rare presentation of common
infectious disease. Case reports in infectious diseases. 2014; 2014.
2. Marrone G, Crino F, Caruso S, Mamone G, Carollo V, Milazzo
M, et al. Multidisciplinary imaging of liver hydatidosis. World J
Gastroenterol. 2012; 18(13): 1438-47.
3. Gandhiraman K, Balakrishnan R, Rathna Ramamoorthy RR.
Primary Peritoneal Hydatid Cyst Presenting as Ovarian Cyst
Torsion: A Rare Case Report. Journal of clinical and diagnostic
research: JCDR. 2015; 9(8): QD07.
4. Wani RA, Malik AA, Chowdri NA, Wani KA, Naqash SH.
Primary extrahepatic abdominal hydatidosis. International
Journal of Surgery. 2005; 3(2): 125-7.
5. Acharya AN, Gupta S. Peritoneal hydatidosis: a review of seven
cases. Tropical Gastroenterology. 2010; 30(1): 32-4.
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POLICY OF THE JOURNAL
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Conflict of interest exists when as author (or the author’s institution), reviewer, or editor has
financial or personal relationships that inappropriately influence (bias) his or her actions (such
relationship are also known as dual commitments, competing interests, or competing loyalties).
However, conflicts can occur for other reasons, such as personal relationships, academic
competition, and intellectual passion. Increasingly, individual studies receive funding from
commercial firms, private foundations, and government. The conditions of this funding have the
potential to bias and otherwise discredit the research.
When authors submit a manuscript, whether an article or a letter, they are responsible for
disclosing all financial and personal relationships that might bias their work. To prevent ambiguity,
authors must state explicitly whether potential conflicts do or do not exist.
It is the discretion of editorial committee of PAFMJ to resolve any conflict of interest between
the author(s) and reviewers. Editors may choose not to consider an article for publication if they
feel that the research is biased by the sponsors funding the research project.
PLAGIARISM
Plagiarism is the unauthorized use or close imitation of the language and thoughts of another
author and representing them as one’s own original work. Within the academia, researcher is
considered academic dishonesty or academic fraud and offenders are subject to academic censure.
Plagiarism can be unintentional or intentional reproducing academic material without appropriate
citation. Similarly self plagiarism is the re-use of significant, identical or near identical portions of
one’s own work without citing the original work. This is also known as “Recycling fraud”. Worst
form of plagiarism is to steal the whole article from some journal and publish it under own name in
another journal. Lately the use of internet has made it easier to plagiarize, by copying the electronic
tests and using them as original work.
It is the policy of editorial committee of PAFMJ to blacklist any author found to be guilty of
plagiarism. The name of author(s) committing plagiarism will also be disseminated to editors of
other medical journals, PM&DC and HEC.
BIOMEDICAL ETHICAL COMMITTEE
When reporting experiments on human subjects, authors should indicate whether the
procedures followed were in accordance with the ethical standards of the responsible committee on
human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as
revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki
Declaration, the authors must explain the rationale for their approach, and demonstrate that the
institutional review body explicitly approved the doubtful aspects of the study. When reporting
experiments on animals, authors should be asked to indicate whether the institutional and national
guide for the care and use of laboratory animals was followed.
In case of any study involving clinical trial, taking of informed consent of patients is mandatory.
Whenever editorial committee of PAFMJ feels necessary, the research paper will be referred to
the ethical committee of the center for Research in Experimental and Applied Medicine (CREAM)
based at Army Medical College, for its evaluation and approval.
EDITORIAL OFFICE
The editorial office has been established at Army Medical College, Rawalpindi, Pakistan.
EDITORIAL ADVISORY BOARD
The editorial advisory board will be as per following appointments.
Surgeon General/DGMS (IS), Pak Army
Chairman
Chief Editor PAFMJ/Principal, Army Medical College
Member
Director General Medicine
Member
Director General Surgery
Member
Commandant AFPGMI, Rwp
Member
Deputy Surgeon General/DGMS (IS)
Member
DGMS (Navy)
Member
DGMS (Air)
Member
A meeting of editorial advisory board is held as often as required to give approval/decision on
matters forwarded by editor pertaining to any change in the existing policy, appointment/deletion
of any member of the editorial board and any other point.
THE EDITORIAL BOARD
The members of the editorial board are appointed keeping in view their professional
competence (advisers) in different fields of medical sciences. The aim is to have members having
wide experience in different fields of medical sciences. In addition to senior specialists from Armed
Forces, senior professionals from civil sector as well as from foreign countries will be co-opted with
approval of the editorial advisory board.
EDITORIAL COMMITTEE
An editorial committee consisting of chief editor, editor(s), joint editor, assistant editor(s) and
the editorial secretaries meet at least once a month to expedite the business of the journal.
The editorial committee follows the guidelines provided by International Committee of medical
Journal editors in” Uniform Requirements for Manuscripts Submitted to Biomedical Journals:
Writing and Editing for Biomedical Publication” which can be downloaded from
http://www.icmje.org/
PUBLICATION TIMELINES
Timelines for print and online publications are as under:Issue
Month
Date
1
Jan, Feb
28th Feb
2
Mar, April
30th April
3
May, June
30th June
4
July, Aug
31st Aug
5
Sep, Oct
31st Oct
6
Nov, Dec
31st Dec
GUIDELINES FOR AUTHORS
Articles and all editorial correspondence should be sent to Editor, PAFMJ C/O Army Medical
College, Abid Majeed Road, Rawalpindi.
EDITORIAL
Each editorial is written by one member of the editorial board as solicited by the editor. The
editorial is scientific review on one or two of the current topics pertaining to medical sciences
(preference is given to subjects pertaining to Army health problems).
SUBMISSION OF ARTICLE
Original Paper
Manuscript must be accompanied by a certificate signed by author and all coauthors that they have
seen and approved the final version of the manuscript and they have not submitted the manuscript
to any other journal. All manuscript should be typed in double spacing on A-4 paper (8.25” x 11.70”
= 21.0 cms x 29.70 cms) white bond paper with one inch (2.5 cms) margin on both sides. The article
submitted should not exceed 2500 words (excluding references and abstract) with maximum 18-25
references and 3–5 figures or tables. If prepared on a word processor/computer, a properly
protected, CD should be sent with the manuscript. Each manuscript should include:
1. Title page:
Complete title of the article
Name of author(s)
Department(s)
Institution(s) at which work was performed
Official phone/fax no, cell no, personal e-mail address (to whom correspondence is to be
addressed) in case of posting please provide new address
Short running title for header
2. Structured Abstract:
Objective
Study Design
Place and duration of study
Patients and Methods
Results
Conclusion
Keywords 3 – 10 (Medical Subject Headings – MeSH) in alphabetical order
3. Text:
Introduction: This should summarize the purpose and the rationale for the study. It should neither
review the subject extensively nor should it have data or conclusions of the study.
Patients and Methods: This should include exact method or observation or experiment. If an
apparatus is used, its manufacturer’s name and address should be given in parenthesis. If the
method is established, give reference but if the method is new, give enough information so that
another author is able to perform it. If a drug is used, its generic name, dose and route of
administration must be given. Methodology section should contain (Without headings) study
design, place and duration of study, sample size, sampling technique, inclusion and exclusion
criteria, data collections procedure and data analysis procedure. Statistical method must be
mentioned and specify any general computer programme used. The Info system used should be
clearly mentioned.
Results: It must be presented in the form of text, tables and illustrations. The contents of the tables
should not be all repeated in the text. Instead, a reference to the table number may be given. Long
articles may need sub-headings within some sections (especially the Results and Discussion parts)
to clarify their contents. Extra or supplementary materials and technical details can be placed in an
appendix where it will be accessible. It may be omitted from the printed version but may be
published in the electronic version of the journal.
Discussion: This should emphasize present findings & the variations or similarities with other
work done in the field by other workers. Detailed data should not be repeated in the discussion
again. Emphasize the new and important aspects of the study and the conclusions that follow from
them. It must be mentioned whether the hypothesis mentioned in the article is true, false or no
conclusions can be derived.
Conclusion: Should be in line with the objectives and results.
Conflict of Interest: When authors submit a manuscript they must disclose all financial and
personnel relationship that might bias their work. Authors must state explicitly whether potential
conflicts do or do not exist. They should do so in the manuscript on the title page. Additional
details can be provided if necessary in a covering letter which accompanies the
manuscript. Authors of study funded by an agency with proprietary or financial interest in the
outcome must sign a statement that they had full excess to all the data in the study and take
complete responsibility for the integrity of the data and the accuracy of the data analysis. This
statement should be submitted along with the manuscript.
Acknowledgements (if any): All contributors who do not meet the criteria for authorship should be
covered in the acknowledgement section. It should include persons who provided technical help,
writing assistance and departmental head that only provided general support. Financial and
material support should also be acknowledged. Persons who have contributed materially but do
not justify authorship can be listed as “clinical investigators” or “participating investigators” or
“scientific advisors” or “critically reviewed the study proposal or collected data. Disclosure
(Presentation of the article in any conference, seminar, symposium before submission to PAFMJ)
Authors contributions: Authorship credit should be based on 1) substantial contributions to
conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the
article or revising it critically for important intellectual content; and 3) final approval of the version
to be published. 4) Agreement to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work are appropriately investigated
and resolved. Authors should meet conditions 1, 2, 3 and 4. (For details of Authorship Criteria
kindly consult ICMJE guidelines)
Acquisition of funding, collection of data, or general supervision of the research group, alone does
not justify authorship. All persons designated as authors should qualify for authorship & all those
who qualify should be listed.
· All persons designated as authors should qualify for authorship and all those who qualify should
be listed.
· Each author should have participated sufficiently in the work to take public responsibility for
appropriate portions of the content.
· In case of more than one authors in a manuscript, the contributions of each person listed as
author in the study should be mentioned.
When a large, multi-center group has conducted the work, the group should identify the
individuals who accept direct responsibility for the manuscript. These individuals should fully
meet the criteria for authorship defined above and editors will ask these individuals to complete
journal-specific author and conflict of interest disclosure forms. When submitting a group author
manuscript, the corresponding author should clearly indicate the preferred citation and should
clearly identify all individual authors as well as the group name. Other members of the group
should be listed in the acknowledgements. Addition and deletion of authors may not be permitted
after submission with authorship proforma signed by authors.
References: (Fifty Percent References should be of last five years and all references listed
consecutively as numerical in parentheses. The final bibliography should be in the order in which
they are quoted in the text and written in Vancouver Style). References appearing in a table or
figure should be numbered sequentially with those in text. DOI number of those references where it
is available. PAFMJ follows Index Medicus style for references and and abbreviated journal names
according to the list of Journals indexed in Index Medicus
Journals: Standard journal article. (List all authors when six or less; when seven or more, list only
first six and add et al)
You CH. Lee KY, Chey WY, Manguy R. Electrogastrographic study of patients with unexplained
nausea, bloating and vomiting. Gastroenterology 1980; 79: 311-4.
Chapter in a book: Weinstein L, Swartz MN. Pathogenic properties of invading micro organisms.
In: Sodeman WA Jr, Sodeman WA, eds. Pathologic physiology: mechanisms of disease. WB
Saunders, Philadelphia 1974; 457-72.
4. Tables and Figures: 3 – 5 figures and or tables are allowed (each table, complete with legends
and footnotes, should be merged in the manuscript).
5. Proof Reading: Final version of manuscript is sent to corresponding author for proof reading
before publication to avoid any mistakes. Corrections should be conveyed clearly & Editor
informed by e-mail.
Reviews: The purpose of a review is to provide clinicians, scientists and those in training with a
clear and up to date concept of a subject of current interest. It should be very informative
thoroughly referenced and easily readable with fluency of language. The text should not exceed 3-7
journal pages. For information’s regarding the typing and reference style, please follow the
instructions above. It should contain an unstructured abstract with 3-10 keywords (MeSH) followed
by Introduction/Background and Discussion portions of the main article. Maximum word count
should be from 2500 – 3000 words (excluding references and abstract) with 25 – 30 references
Field Medicine: It has been decided by the Editorial Board to include articles relating various
aspects of military medicine in the journal. These articles reflect various medical problems faced by
the troops deployed in the field or hard areas and the preventive measures to overcome them.
Rapid Communication: Rapid/Special/Short communication should be complete work, not merely
a preliminary report and should not exceed 1500 words with one figure and/or one table. An
editorial decision will be provided rapidly without reports. For writing and references style, please
refer to the instruction above.
Case Report: Short report of cases, clinical experience, drug trails or adverse effects may be
submitted. They should not exceed 700 words, 10 bibliographic references and either two concise
table or one figure. The report must contain genuinely new information.
Letters: Opinions on topics and articles recently published in the journal will be considered for
publication if they are constructive in nature and provide academic/clinical interest. These letters
will be forwarded to author of the cited article for possible response. The editor reserves the right to
shorten these letters, delete objectionable comments, make other changes, or take any other suitable
decision to comply with the style of the journal.
Note: All articles submitted to PAFMJ must only be submitted to this journal and may not have
been published elsewhere in part or total. The authors will be requested to sign an agreement to
give the copyright to the publishers. The authors will be required to assist the editors for reviewing
proof before publication.
LETTER FROM INSTITUTIONAL REVIEW BOARD / BIOMEDICAL ETHICAL COMMITTEE/
ETHICAL REVIEW COMMITTEE
Authors are required to send letter from Institutional Review Board / Biomedical Ethical
Committee / Ethical Review Committee must be sent along with Original articles, Rapid
communications and Case reports.
PROCESSING /PUBLICATION FEE
Reference to GHQ letter no. 3543/242/DMS-5(b)-R3O1S dated 09 Oct 2014, the processing fee of Rs.
1000/- is to be paid at the time of submission of the article through pay order/Demand draft/
Crossed cheque payable in the favour of PAFMJ-AMC OR PAFMJ account. In case of out station
cheque please include Rs. 348/- (Rupees three hundred forty eight) as bank charges. It is further
intimated that AMC/ADC officers will have to pay Rs. 2500/- and the Civil authors` will have to
pay Rs. 5,000/- as publication charges/fee, if the article is accepted for publication. The charges for
case report and short communication will be half of the above charges. (Payable before issuance of
acceptance letter).
FAST TRACK PUBLICATION
If the article process is complete and acceptance letter is issued to author. In such case if the
authors want to publish the article on urgent/self finance basis then the charges are as
follows:Submission charges
Rs 1000.00
Publication charges
Rs 15000.00 (all categories)
The article will be published in the next coming issue.
GUIDELINES FOR REVIEWERS
1. An unpublished manuscript is a privileged document. Please protect it from any form of
exploitation. Don’t cite a manuscript or refer to the work it describes before it has been
published and don’t use the information that it contains for the advancement of your own
research or in discussions with colleagues.
2. Adopt a positive, impartial attitude toward the manuscript under review, with the aim of
promoting effective and accurate scientific communication. If you believe that you cannot judge
a given article impartially, please return it immediately to the editor.
3. Reviews must be completed by the date stipulated on the review form. If you know that you
cannot finish the review within that time, immediately return the manuscript to the editor. If
possible, provide the names and addresses of two reviewers who are competent to handle the
subject matter.
4. In your review, consider the following aspects of the manuscript:a. Significance of research question or subject studied.
b. Originality of work.
c. Appropriateness of approach or experimental design.
d. Adequacy of experimental techniques.
e. Soundness of conclusions and interpretation.
f. Relevance of discussion
g. Soundness of organization.
h. Adherence to style as set forth in instructions to authors.
j. Adequacy of title and abstract.
k. Appropriateness of figures and tables.
l. Length of article.
m. Adherence to correct nomenclature (genetic, enzyme, drug, biochemical etc).
n. Appropriate literature citations.
5. Any help you can give in clarifying meaning will be appreciated. If you wish to mark the text of
the manuscript, use a pencil or make a photocopy, mark it, and return it together with the
original.
6. You can be particularly helpful in pointing out unnecessary illustrations and data that are
presented in both tabular (and graphic) form and in detail in the text. Such redundancies are a
waste of space and readers time.
7. A significant number of authors have not learnt how to organize data and will benefit from
your guidance.
8. Do not discuss the paper with its authors.
9. In your comments intended for transmission to the author, don’t make any specific statement
about the acceptability of a paper. Suggested revision should be stated as such and not
expressed as conditions of acceptance. Present criticism dispassionately and avoid offensive
remarks.
10. Organize your review so that an introductory paragraph summarizes the major findings of the
article, gives your overall impression of the paper and highlights the major shortcomings. This
paragraph should be followed by specific numbered comments which if appropriate may be
subdivided into major and minor points.
11. Confidential remarks directed to the editor should be typed (or handwritten) on a separate
sheet, not on the review form. You might want to distinguish between revisions considered
essential and those judged merely desirable.
12. Your criticisms, arguments and suggestions concerning the paper will be most useful to the
editor and to the author if they are carefully documented. Do not make dogmatic, dismissive
statements, particularly about the novelty of work. Substantiate your statements.
13. Reviewer’s recommendations are gratefully received by the editor. However, since editorial
decisions are usually based on evaluations derived from several sources, reviewers should not
expect the editor to honor every recommendation.
14. Categories of recommendation: accept, reject, modify, or convert to some other form. Very few
papers qualify for “accept” upon original submission for publication except for minor style
changes.
15. Keep a copy of the review in your files. The manuscript may be returned to you for a second
review. You might require this copy to evaluate the author’s responses to your criticisms.
PAFMJ Advertising Tariff
Price is Per Issue
Placement
One Issue (Pak Rs)
Inside Page (Ordinary)
Full Page A4 size
Inside Page (Ordinary)
Half Page A4 size
Bottom Size Strips
20,000 (Four Colors)
15,000 (Black & White)
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Insertions per issue
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First page after front cover
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Overseas advertisements will be charged equal amount in dollars plus 100 dollars.
The
Pakistan
Armed
Forces
Medical
Journal
(PAFMJ)
is
an
official
journal of Army Medical Corps and is being published since 1956. The journal’s
credibility is evidenced by:
Recognized by Pakistan Medical & Dental Council and Higher Education Commission
Islamabad (Category X)

Inclusion of PAFMJ Indexed in WHO Index Medicus (IMEMR), EBSCO Host

Indexation of PAFMJ in Cumulative Index Medicus of Eastern Mediterranean Region
Journals

Allocation of International Standard Serial Number

Availability of PAFMJ on Internet: [www.pafmj.org]

Online submission of articles on E-mail address: [[email protected]]

Attraction of wider authorship and readership
ADDRESS FOR CORRESPONDENCE:
The Editor,
Pakistan Armed Forces Medical Journal
C/O Army Medical College
Abid Majid Road, Rawalpindi – (Pakistan)
Tel: 0092 51 561 31152, 31457-9 Ext-329
E-mail: [email protected]
The editorial committee acknowledges the assistance of Steno Typist Muhammad Saeed,
LDC Amjad Zaman and LDC Mudassar Mustafa for manuscript typing, composing and graphic
analysis of this journal.
PAKISTAN ARMED FORCES MEDICAL JOURNAL
Vol-66 (Suppl-3) 2016
Recognized by PMDC & HEC (Category X)
CONTENTS
ORIGINAL ARTICLES
Management of Early Pregnancy Loss: Manual Vacuum Aspiration Ver sus Dilatation and Cu rettage
Saima Qamar, Saima Masood, Uzma Asif
S173
Acute Appendicitis; Ultrasonograph y as Pre-operative Screening Tool
Amer Hayat Haider, Mohammad Nazir Qureshi, Rizwan Bilal, Ijaz Ahmad
S178
Frequency of Mechanical Complications Assoc iated With Insertion of Central Venous Catheters in Adu lt Patients at A
Tertiary Care Facility
Muhammad Fahd Bin Haider, Kamran Aziz, Shahid Ahmed
S184
Perceptions And Feedback of Medical Students Towards Conduct of Ex amination
Khadija Qamar, Gulshan Trali, Humaira Arshad
Histopath ological Spectrum of End ometrial Biopsies – A Study of 378 Cases at Afip Pakistan
Syed Salman Ali, Iqbal Muhammad, Javeria Shaukat, Saeed Afzal, Shoaib Nayyar Hashmi, Syed Naeem Raza Hamdani, Rabia Ahmed
Single Burr-H ole Evacuation of Ch ronic Subd ural Haematoma - Use of Drains Versus No Drains
Khurshid Ali Bangash, Aslan Javed Munir, Habib Ullah Khan
S189
S194
S199
Frequency of Abrup tio Placentae And Intrau terine Growth Restric tion in Women W ith Pre-Eclampsia And Pregnanc y
Induced Hypertension (PIH )
Shaista Ambreen, Rubina Mushtaq, Khalida Perveen
S203
Frequency of Pain Due To Injection of Prop ofol With I V Administration of Lignocaine
Metoclop ramide
Syed Ali Raza Ali Shah, Syeda Sarah Naqvi, Muhammad Ali Abbas
S208
With And W ithou t
Comparison of Early Neonatal Ou tcomes for Asymmetrical I UGR With Normal And Abnormal Umbilical Arter y
Waveforms
Lubna Noor, Humaira Arshad, Humaira Tariq, Afeera Afsheen
S213
SELF-Care And Dietary Patterns Amon g Diabetes Mellitus Patients in Rawalpindi
Aliya Hisam, Naseer Alam Tariq
S217
Frequency of Cervical Ribs Among Adu lt Males Seeking Employment in Pakistan Army
Muhammad Arshad, Jawaid Hameed, Amer Zamir Sahi
Distribu tion of Blood Type and Rh Factor Am ong Blood Don ors of Lah ore
Muhammad Saeed, Shahida Hussain, Minza Arif
Use of Mirena – Levonorgestrel Intra – Uterine System (LNG IUS) IN Dysfuction Uterine Bleeding in The Reproductive
Age Group
Afroze Ashraf, Nilofar Mustafa, Nomia Saqib
Validity of Gray Scale Ultrasonography in Diagnosis of Chron ic Liver Disease of Viral Etiology
Shaista Riaz, Riaz Ahmed Khokhar, Ashraf Farooq
A Comparison of Eff icacy Among Various Doses of Intrathecal Hyperbaric Bupivacaine 0.75% for Adult Anorectal
Surgery
Mudassar Iqbal, Naveed Masood, Khurram Sarfraz, Khalid Zaeem Aslam, Mushtaq Hussain Raja
Effectiveness of In tra-Peritoneal Adm inistration of 0.5% Bupivacaine in Pos toperative Analgesia Af ter Laparoscopic
Cholecys tectomy
Babar Shamim, Awais Ali Khan, Muhammad Rehan Saleem, Irfan Shukr, Afshan Aziz, Maria Shahzadi
Diagnostic Accuracy of Ultrasonography in The Diagnos is of Acute Ap pendicitis
Mansoor Hasan, Sajida Perveen, Muhammad Amer Mian
Comparison Between Harmonic ACE Versus Conventional M onop ola r Diathermy in Laparoscopic Ch olecystectomy in
Terms of Gallbladder Perforation
Yasir Javed, Muhammad Tariq, Syed Mukarram Hussain, Anwar Ahmed, Shafqat Rehman, Muhammad Asif Rasheed
FIELD MEDICINE
Pattern of Injur ies in Cou nterterrorism Operations: An Experience at A Tertiary Care Hospital
Muhammad Qasim Butt, Sohail Saqib Chatha, Adeel Qamar Ghumman, Mahwish Farooq
CASE REPORTS
Extraskeletal Osteosarcoma of Anterior Abd ominal Wall: A Case Repor t And Review of L iterature
Syed Salman Ali, Muhammad Zeeshan, Iqbal Muhammad, Saeed Afzal, Shoaib Nayyar Hashmi,
Syed Naeem Raza Hamdani
Polyostotic Fibrous Dysp lasia
Adil Qayyum, Ruqqayia Adil, Faisal Basheer, Jawad Jalil
Leiomyoma Of The Anterior Abd ominal Wall in A 26 Year Old Pregnant Woman: A Case Report
Saima Qamar, Nilofar Mustafa, Adeeba Akhter Khalil, Muhammad Jamil
Anesthetic Management Of Huge Multin odular Goiter With Compromised Airway
Saleem Ahmed, Khalid Zaeem, Sanum Kashif, Syed Samee Uddin
Hereditary Con genital Facial Pals y
Muhammad Tariq
Imaging of Abd ominal Hydatidos is: A Rare Presentation of a Common Cond ition
Javed Anwar, Saima Omar, Sanaullah, Koukab Javed
S224
S228
S233
S238
S244
S248
S252
S258
S263
S267
S270
S273
S275
S277
S279