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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 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 PMDC & HEC, (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 Number (print & online) Availability of [www.pafmj.org] Online submission of articles on E-mail address: [[email protected]] Attraction of wider authorship and readership PAFMJ Standard on Serial Internet: 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. REFERENCES 1. 2. 3. 4. 5. 6. 7. Ahsan A, Jafarey SN. Unsafe abortion: Global picture and situation in Pakistan. J Pak Med Assoc 2008; 58(12): 660-1 Shaik Z, Abbasi RM ,Rizwan N, Abbasi S.Morbidity and mortality due to unsafe abortion in Pakistan.Int J Gynecol Obstet 2010; 110(1): 47-9. Tasnim N,Mahmud G,Fatima S,Sultana M. Manual vacuum aspiration:a safe and cost-effective substitute of Electric vacuum aspiration for the surgical mamagement of early pregnancy loss. J Pak Med Assoc 2011; 61(2): 149-53 Say L, Kulier R, Gulmezoglu M, Campana A, Medical versus surgical methods for first trimester termination of pregnancy. Cochrane Database Syst Rev 2005; 25(1): CD003037 Greenslade F, Benson J, Winkler J, Henderson V, Leonard A. Summary of clinical and programmatic experience with manual vacuum aspiration. Adv Abort Care 1993; 3: 1-4. Farooq F, Javed L, Mumtaz A, Naveed N. Comparison of manual vacuum aspiration, and dilatation and curettage in the treatment of early pregnancy failure. J Ayub Med Coll Abbottabad 2011; 23(3) World health organization. Safe motherhood: care of mother S177 13. 14. 15. 16. 17. 18. and baby at the health care centre. A practical guide. Maternal health and safe motherhood programme. Geneva : WHO Division of Family Health;1994. Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion: Evidence-based Green-top Guideline No.7. London: RCOG; 2011 Milingos DS, Mathur M, Smith NC, Ashok PW, Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG 2009; 116(9): 126871. Bluementhal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet 1994; 45: 261-7. Creinin MD, Edwards J. Early abortion: surgical and medical options. Curr Probl Obstet Gynaecol Fertil 1997; 20: 6-32. Macisaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol 2000; 183 (2 Suppl): S76-83 Mahomed K, Healy J, Tandon S. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion. Int J Obstet Gynecol 1994; 46: 27-32. Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med 1998; 7: 559-62. Hamoda H, Flett GM, Ashok PW, Templeton A. Surgical abortion using manual vacuum aspiration under local anesthesia: a pilot study of feasibility and women’s acceptability. J Fam Plann Reprod Health Care 2005; 31: 185-8. Wen J, Cai QY, Deng F, Li YP. Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review. BJOG 2008; 115:5-13. Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006; 108: 103-10. Abernathy M, Hord C, Nicholson LA, Benson J, Johnson BR. A guide to assessing resource use for the treatment of incomplete abortion. Carrboro,NC,USA: Ipas, 1993. 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. S178 Acute Appendicitis (USG) Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83 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 S179 Acute Appendicitis (USG) Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83 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. S180 Acute Appendicitis (USG) Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83 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 S181 Acute Appendicitis (USG) Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83 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. REFERENCES 1. Ferri F. Appendicitis. In: Ferri F. Ferri's Clinical Advisor, 12th ed. Philadelphia, Elsevier Mosby; 2012. p. 94. 2. Mohamed A, Bhat N. Acute Appendicitis Dilemma of Diagnosis and Management. The Internet Journal of Surgery. 2009 Volume 23 Number 2. 3. Zahid M, Jamal AU, Akhtar S, Shah TA. Critical review of acute appendicitis in females. Ann King Edward Med Coll 2004; 10:283–6. 4. Khan I, Rehman A: Application of Alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll, Abbottabad 2005, 17: 41–44. 5. SCOAP Collaborative, Cuschieri J, Florence M, Flum DR, Jurkovich GJ, Lin P, Steele SR, Symons RG, Thirlby R. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg.2008 Oct; 248(4):557-63. 6. Parks NA, Schroeppel TJ. Update on imaging for acute appendicitis. Surg Clin North Am. 2011 Feb; 91(1):141-54. [PMID: 21184905] S182 Acute Appendicitis (USG) Pak Armed Forces Med J 2016; 66 (Suppl-3): S-178-83 7. Wolfe J, Henneman P. Acute Appendicitis. In: Marx J, Hockberger R, Walls R, eds. Rosen's Emergency Medicine, 7th ed. Philadelphia, Elsevier Mosby; 2010. p. 1193-9. 8. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW; American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. 2010 Jan;55(1): 71-116. 9. O’Connel PR. The vermiform appendix. In: Russell RCG, Williams NS, Bulstrode CJK, editors. Bailey & Love’s short practice of surgery. 24th ed. London: Arnold, 2004: 1203-18. 10. Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol J, et al. Appendicitis: Evaluation of sensitivity, specificity and predictive values of ultrasonography, doppler ultrasonography and laboratory findings. Radiology. 2004; 230: 472-8. 11. Yu CW, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC. Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis. Br J Surg. 2013. Feb; 100(3): 322-9. 12. 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 Abbottabad. 2004 Jul-Sep;16(3):17-9. PMID: 15631364. 13. Gulzar S, Umar S, Dar GM, Rasheed R. Acute appendicitis- role of clinical examination in making a confident diagnosis. Pak J Med Sci 2005; 21(2): 125–32. 14. 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 Abbottabad. 2004 Jul-Sep; 16(3): 17-9. 15. Beasly SW. Can we improve diagnosis of acute appendicitis? BMJ. 2000 Oct 14; 321(7266): 907-8.PMID: 11030658 16. Malik KA, Khan A, Waheed I. Evaluation of Alvarado score in the diagnosis of acute appendicitis. J Coll Physicians Surg Pak. 2000; 10: 392-4. 17. Puig S, Hörmann M, Rebhandl W, Felder-Puig R, Prokop M, Paya K. US as a primary diagnostic tool in relation to negative appendectomy: six years experience. Radiology. 2003 Jan; 226(1): 101-4. PubMed PMID: 12511675 18. Mardan MAK, Mufti TS, Khattak I, Chilkunda N, Alshayeb AA, Mohammad AM, Rehman Z. Role of ultrasound in acute appendicitis. J Ayub Med Coll Abottabad Sep 2007; 19(3): 72-9 19. Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic appearance of the normal appendix in adults. J Ultrasound Med 2007;26(1):37–43 20. Sharma R, Kasliwal DK, Sharma RG. Evaluation of negative appendicectomy rate in cases of suspected acute appendicitis and to study the usefulness of ultrasonography in improving the diagnostic accuracy. Indian J Surg. 2007 Oct; 69(5): 194-7. 21. Yaqoob J, Idris M, Alam MS, Kashif N. Can outer-to-outer diameter be used alone in diagnosing appendicitis on 128-slice MDCT? World J Radiol. 2014 Dec 28; 6(12): 913-8 22. Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med. 2003 Jan 16; 348(3):236-42. 23. Gabrielle AE, Hasina RN, Ravelonarivo R, Ahmad A.Intestinal parasites simulating appendicitis on ultrasound: about two cases. Pan Afr Med J. 2015 Aug 31; 21: 322. 24. Singh S, Jha AK, Sharma N, Mishra TS.A case of right upper abdominal pain misdiagnosed on computerized tomography. Malays J Med Sci. 2014 Jul; 21(4): 66-8. 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. S184 Complications of Central Venous Catheters in Adults Pak Armed Forces Med J 2016; 66 (Suppl-3): S184-88 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 S185 Complications of Central Venous Catheters in Adults 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 S186 Complications of Central Venous Catheters in Adults Pak Armed Forces Med J 2016; 66 (Suppl-3): S184-88 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. REFERENCES 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 S187 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 S191 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 S192 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. REFERENCES 1. Ruth N. Communicating student evaluation of teaching results: rating interpretation guides (RIG\'s). Assess Eval High Educ. 2000; 25: 121-34. 2. Victroff KZ, Hogan S. Student's perception of effective learning experiences in dental school: a quantitative study using a critical incident technique. J Dent Edu.2006; 70: 124-32. 3. Sehgal R, Dhir BV, Sawhney A. Teaching technologies in Gross Anatomy. J Anatomic Soc India.1998; 48: 36. 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 behavior. Unpublished doctoral dissertation. Blacksburg, VA: Virginia Polytechnic Institute and State University; 1996. 16. 16.McGuffey C. Facilities. In: Walberg H, editor. Improving Educational Standards and Productivity. Berkeley: McCutchan Publishing Corporation; 1982. 17. 17.Brown, G. T. L., Hui, S. K. F., Yu, W. M., & Kennedy, K. J. (2011). Teachers’ conceptionsof assessment in Chinese contexts: A tripartite model of accountability, improvement and 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 S196 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 S197 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 S200 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 S201 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. REFERENCES 1. Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. JNeurolNeurosurgPsychiatr 2003; 74: 937-43. 2. Mckissock W, Richardson A, Walsh L. Anterior Communicating Aneurysms: A Trial of Conservative and Surgical Treatment. Lancet 1965; 1: 874-6. 3. Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, et al. Use of drains versus no drains after burrhole evacuation of chronic subdural haematoma: a randomized controlled trial. Lancet 2009; 374:1067-73. 4. Kinsella K, Velkoff VA. An aging world: 2001. US Census Bureau Series P95/01-1, 9. 2001. Washington, DC: US Government Printing Office, 2001. 5. Aoki N: Subdural tapping and irrigation for the treatment of chronic subdural hematoma in adults.Neurosurgery 14: 545-548, 1984. 6. Kuroki T, Katsume M, Harada N, Yamazaki T, Aoki K, Takasu N: Strict closed-system drainage for treating chronic subdural haematoma. ActaNeurochir (Wien) 143: 1041-1044, 2001. 7. Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y,Kirino T: The 19. 20. 21. 22. 23. S202 relationship of preoperative magnetic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma.JNeurosurg 87: 870-875, 1997. Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 2008; 22: 529-34. Lind CRP, Lind CJ, Mee EW. Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains.JNeurosurg 2003; 99: 44-6. Ramachandran R, Hegde T. Chronic subdural hematomas— causes of morbidity and mortality. SurgNeurol 2007; 67: 367-72. Gelabert-Gonzalez M, Iglesias-Pais M, Garcia-Allut A, MartinezRumbo R: Chronic subdural haematoma: surgical treatment and outcome in 1000 cases.ClinNeurolNeurosurg 107: 223-229, 2005. Markwalder TM, Seiler RW: Chronic subdural hematomas:to drain or not to drain? Neurosurgery16:185-188, 1985. Markwalder TM, Steinsiepe KF, RohanerM,Reichenbach W, Markwalder H: The course of chronic Subdural hematoma after burr-hole craniostomy and closed-system drainage. J Neurosurg 55: 390-396, 1981. Reinges MH, Hasselberg I, Rohde V, KukerW,Gilsbach JM: Prospective analysis of bedside percutaneous subdural tapping for the treatment of chronic subdural haematoma in adults. J NeurolNeurosurg Psychiatry 69: 40-47, 2000. Rocchi G, Caroli E, Salvati M, Delfini R: Membranectomy in organized chronic subdural hematomas: indications and technical notes. SurgNeurol 67: 374-380, 2007. Weigel R, Schmiedek P, Krauss JK: Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J NeurolNeurosurg Psychiatry 74: 937-943, 2003. Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, et al. Use of drains versus no drains after burrhole evacuation of chronic subdural haematoma: a randomized controlled trial. Lancet 2009; 374: 1067-73. Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y, Kirino T. The relationship of preoperative magnetic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma. J Neurosurg 1997; 87: 870-5. Wakai S, Hashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M. Efficacy of closed-system drainage in treating chronic subdural hematoma: a prospective comparative study. Neurosurgery 1990; 26: 771-3. Lind CR, Lind CJ, Mee EW. Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains. J Neurosurg 2003; 99: 44–46. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome,complications, and recurrence rate. Neurol Med Chir 2001; 41: 371–81. Gazzeri R, Galarza M, Neroni M, Conova A, Refice GM, Espostlo S. Continuous Subgaleal Suction Drainage for the treatment of Chronic subdural hematomas. ActaNeurochir 2007; 149 (5): 487-93. 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. S203 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 S204 Abruptio Placentae and Intrauterine Growth 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. S205 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 S206 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. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Vadhera RB, Pacheco LD, Hankins GD. Acute antihypertensive therapy in pregnancy-induced hypertension: is nicardipine the answer? Am J Perinatol 2009;26:495-9. Begum S, Aziz-un Nisa, Begum I. Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors. J Ayub Med Coll Abbottabad 2003; 15: 4952. Miller DA. Hypertension in pregnancy. In: Decherney AH, Nathan L, Goodwin TM, Laufer N (edi).Current diagnosis and treatment Obstetrics and Gynaecology.10th ed. New York: McGraw-Hill Companies 2007; 318-27. Duley L. Pre-eclampsia and the hypertensive disorders of pregnancy. Br Med Bull 2003; 67: 161-76. Sibai BM. Diagnosis, controversies and management of HELLP Syndrome. Obstet Gynecol 2004; 103: 981-91. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet 2005;365:785-99. Abassi RM, Rizwan N, Mumtaz F, Farooq S. Fetomaternal outcome among abruptio placentae cases at a University Hospital of Sindh. JLUMHS 2008; 7: 106-9. Sarwar I, Abbasi A, Islam A. Abruptio placentae and its complications. J Ayub Med Coll Abbotabad 2006; 18: 27-31. Hjartardottir S, Leifsson BG, Geirsson RT, Steinthorsdottir V. Recurrence of hypertensive disorder in second pregnancy. Am J Obstet Gynecol 2006; 194: 916–20. 10. Jelks A, Cifuentes R, Ross MG. Clinician bias in fundal height measurement. Obstet Gynecol 2007; 110: 892-9. 11. Wide-Swensson D, Strevens H & Willner J. Antepartum percutaneous renal biopsy. Int J Gynaecol Obstet. 2007; 98(2):88-92 12. Huppertz B. Placental origins of preeclampsia: challenging the current hypothesis. Hypertension 2008;51:970-5 13. Baker PN, (Ed). Obstetrics by Ten Teachers. 18th Edition, London, Arnold, 2006. p. 42-46, 158-70. 14. Rasmussen S, Irgens LM. History of fetal growth restriction is more strongly associated with sever e rather than milder pregnancy-induced hypertension. Hypertension 2008;51:1231-8 15. Roberts JM, Gammill HS. Preeclampsia–recent insights. Hypertension 2005;46:1243–9. 16. Tasleem H, Tasleem S, Adil MM, Siddique M, and Waheed K. 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 outcome among abruptio placentae cases at a University 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 intrauterine growth restriction, related or independent conditions? Am J Obstet Gynecol 2006; 194: 921-31. 19. Kramer MS, Usher RH, Pollack R, Boyd M, Usher S. Etiologic determinants of abruption placentae. Obstet Gynecol 1997;89:221-6. 20. World Health Organization. Risking death to give life. WHO Geneva: World Health Organization; 2005. 21. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. World Health Organization Analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066–74 22. Seed PT, Chappell LC, Black MA, Poppe KK, Hwang YC, Kasabov N et al. Prediction of Preeclampsia and Delivery of Small for Gestational Age Babies Based on a Combination of Clinical Risk Factors in High-Risk Women. Hypertens Pregnancy 2010; 2011; 30(1): 58-73. 23. Morgan-Ortiz F, Calderón-Lara SA, Martínez-Félix JI, González-Beltrán A, Quevedo-Castro E Risk factors associated with preeclampsia: case-control study Ginecol Obstet Mex. 2010; 78(3): 153-9. 24. Tuuli MG, Odibo AO.First- and second-trimester screening for preeclampsia and intrauterine growth restriction. Ab Mclin Led. 2010; 30(3): 727-46. 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. S208 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 S209 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 S210 Lignocaine with And Without Metoclopramide 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, S211 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. S212 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) S213 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). S214 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. 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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". S217 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 S218 Dietary Patterns in DM 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%), S219 Dietary Patterns in DM 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 S220 Dietary Patterns in DM 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, S221 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. REFERENCES 1. Iliyas-Shah-Ansari. Public Health and Community Medicine, 7th ed, 744, Medical Division, Urdu Bazar, Hashmi Trust Building, Karachi, Pakistan: Time Publishers; 2005,p. 607-8. 2. Kumar and Clark’s Clinical Medicine, 4th ed, 1326, Edinburgh, London, Philadelphia, Toronto, Sydney, Tokyo: W.B. Saunders publishers;1998, p. 959 3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes care. 2013 (1); 36 (Supplement 1):S6774. 4. WHO Report, Preventing Chronic diseases; a vital investment. (Cited on Sept. 2013) Available from http://www. who. int/ chp/chronic_disease_report/en/. 5. Ahmed MU, Seriwala HM, Danish SH, Khan AM, Hussain M, Husain M, et al.. Knowledge, Attitude, and Self Care Practices Amongst Patients With Type 2 Diabetes in Pakistan. Glob J Health Sci. 2015 (3); 8(7): 1. http://dx. doi.org /10.5539 /gjhs.v8n7p1. 6. Nazir SU, Hassali MA, Saleem F, Bashir S, Aljadhey H. 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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 S224 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: S225 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. 1992; 16:534–545. 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. 16. 17. 18. 19. 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. S229 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 S230 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. REFERENCES 1. Khalid M, Aslam N, Siyar M, Ahmad R. distribution of abo and rh (d) blood groups among blood donors in district mardan, pakistan. journal of saidu medical college. 2013; 3(2). 2. Umer Khan M, Waqas Bashir M, Rehman R, Ahmed Kiani R. Frequency of ABO and Rh (D) blood groups among blood donors in Lahore, Pakistan. International journal of Advanced Biological and Biomedical Research. 2014 1; 2(3): 597-600. 3. Schwarz HP, Dorner F. Karl Landsteiner and his major contributions to haematology. British Journal of Haematology. 2003 1; 121(4): 556-65. 4. Daniels G, Castilho L, Flegel WA, Fletcher A, Garratty G, Levene C, et al. International Society of Blood Transfusion Committee on terminology for red blood cell surface antigens: Macao report. Vox sanguinis. 2009 1; 96(2): 153-6. 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 of the brain and learning and memory. Guyton AC, Hall JE. Text book of medical physiology 11th ed. Philadelphia: Elsevier Saunders. 2006: 714-27. 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 alleles in different populations of southern Punjab, Pakistan. Anthropologischer Anzeiger. 1999 1: 33-9. S231 Blood Type and Rh Factor Among Blood Donors Pak Armed Forces Med J 2016; 66 (Suppl-3): S228-32 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) blood groups in Faisalabad, Pakistan. Pak J Biol Sci. 2002; 5(6): 722-4. 19. Chishti HM, Waheed U, Ansari MA, Wazir I, Hussain Z. ABO and Rhesus (D) blood group phenotypes in Mirpur, Azad Jammu Kashmir, Pakistan, 2008-12. J. Pub. Health. Bio. Sci. 2012; 1(2): 43-6. 20. Khan MS, Farooq N, Qamar N, Tahir F, Subhan F, Kazi BM, et al. Trend of blood groups and Rh factor in the twin cities of Rawalpindi and Islamabad. journal-pakistan medical association. 2006; 56(7): 299. 21. Khattak ID, Khan TM, Khan P, Shah SM, Khattak ST, Ali A. Frequency of ABO and Rhesus blood groups in District Swat, Pakistan. J Ayub Med Coll Abbottabad. 2008; 20(4): 127-9. 22. Khan MS, Subhan F, Tahir F, Kazi BM, Dil AS, Sultan S, et al. Prevalence of blood groups and Rh factor in Bannu region NWFP (Pakistan). Pak J Med Res. 2004; 43(1): 8-10. 23. Frances TF. Blood groups (ABO groups). Common Laboratory and Diagnostic Tests. 3rd Edition, Philadelphia: Lippincott. 2002: 19-5. 24. Bashwari LA, Al-Mulhim AA, Ahmad MS, Ahmed MA. Frequency of ABO blood groups in the Eastern region of Saudi Arabia. Saudi medical journal. 2001; 22(11): 1008-12. 25. Giri PA, Yadav S, Parhar GS, Phalke DB. Frequency of ABO and Rhesus blood groups: A study from a rural tertiary care teaching hospital in India. Int J Biol Med Res. 2011; 2(4): 988-0. 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. REFERENCES 1. Chohan A. Abnormal Uterine Bleeding. In: Chohan A. Fundamentals of gyaecology. 1st ed. Lahore: MAR Publications; 2000: 31-42. 2. Comeron IT. Menstrual disorders. In: Edmonds DK Dewhursts. Text book of abstetrics and gynaecology for Postgraduates. 6th ed. London: Blackwell Science, 1999: 410 – 19. 3. Levonorgestrel intra-uterine system for menorrhagia. [online] [cited 2001 Nov]. Available from: URL: http: //wwwoncbi. nlm.nih.gov /enterz /query. fcgi? cmd= Retrieve & db =pubmed & dopt = Abstract. 4. Lumsden MN, McGaviganJ.Menstruation and menstrual disorder. In: Shaw RW, Soutter WP, Stanton SL. Gynwecolody 3rd ed. London: Elsevier Science, 2003: 459 -76. 5. Panny N, Studd J. Non-contraceptive uses of the hormone releasing intra uterine system. In: Studd J Progress in obetetrics and gynaecology. Vol. 13th Edinburgh: Churchill Livingstone, 1998: 379-95. 6. Mirena Nonsurgical treatment for heavy menstrual bleeding [online] [cited 2003] Avaiable from URL: http: //www. indianinfoline. com/bize/mirc/html. 7. Jensen JT. Noncontraceptive applications of the levonogestrel intrauterine system [online] [cited 2002 Dec 2] Available from URL: http: // wwwoncbi. nlm. nih. gov/enterz /query. fcgi? cmd= Retrieve & db = pubmed & dopt =Abstract. 8. Luukkainen T. The levonorgestrel intrauterine system: therapeutic aspects. [onlie] [cited 2000 Oct-Nov] Available from URL: http: //wwwoncbi .nlm. nih. gov/enterz /query. fcgi? cmd=Retrieve & db=pubmed & dopt=Abstract. 9. Tucker D E. Mirena intrauterine system (IUS) [online] [cited 2001 July] Available from URL: http://www. women- health. com. uk/mirena.html. S236 10. Steinmann R. An intrauterine device: the Mirena, Women’s Life [online][cited 2001] Available from URL: http: //www. womenslife. com.za /Default. asp? Action = article and content. ID = /175. 11. Mitchel J. New Approval – Contraceptive IUD, Newsletter from Target Health Inc. [online] [citied 2003 Dec. 10] Available from URL: http://www. targethealth.com/publicmenu.html. 12. Hurskainen R, Teperi J, Ressanen P, Aattl AM. Grenam S, KivelaA et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trail 5-year follow-up. [online] [citied Mar 24] Available from URL: http: //www. ncbi. nim. nih. Gov /enterz /query. fcgi? cmd= Retrieve & db= pubmed & dopt=Abstract. 13. Monteiro I, Bahamondes L, Diaz J, Perrotti M, Petta C. Therapeutic use of levonorgestrel-releasing intrauterine system in women with menorrhagia: a pilot study(1). [online] [Cited 2002 May] Available from URL: http: //www. ncbi. nlm. nih. gov/ enterz/query. fcgi PMID: 12057782 [PubMed - Indexed for MEDLINE]. 14. Nagrani R, Bowen-Simkins P, Barrington JW Can the levonorgestrel intrauterine system replace surgical treatment for the management of menorrhagia? [Online] [Citied: 2002 Mar] Available from URL: http: //www. ncbi. nlm. nih. gov/ enterz/ query. fcgi PMID: 11950191 [PubMed - indexed for MEDLINE]. 15. Xiao B, Wu SC, chong J, Zeng T, Han LH, Luukkainen T Therapeutic effects of the levonorgestrel-releasing intrauterine system in the treatment of idiopathic menorrhagia [online] [cited] 2003 April] Available from URL: http: //www. ncbi. nlm. nih. gov/enterz/query.fcgiPMID: 12749438 [PubMed - Indexed for MEDLINE] 16. Stewart A, Cummins C, Gold L, Jordan R, Phillips W The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review. [online] [cited 2001 Jan] Available from URl: http: //www. ncbi. nlm. nih. gov/ enterz/ query. fcgi PMID: 11213008 [PubMed - Indexed for MEDLINE]. 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 S239 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. S241 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. 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Zheng RQ, Hui Wang Q, De Lu M, Bin Xie S, Ren J,. Liver fibrosis in chronic viral hepatitis:An ultrasonography study. World J Gastroenterol 2003; 9: 2484-9. 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). S245 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. REFERENCES 1. Heller R, Nollert U, Entholzner E. Anesthesia in ambulatory patients Anaesthesist. 2009; 58: 421-31. 2. Popping DM, Elia N, Marret E, Wenk M, Tramr MR. Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: a meta-analysis of randomized trials. Pain 2012; 153(4): 784-793. 3. Arzola, C. P.M. Wieczorek, Efficacy of low-dose bupivacaine in spinal anaesthesia for Caesarean delivery: Systematic review and meta-analysis. Br J Anaesth, 2011. 107(3): 308-318. 4. Breen TW, Shapiro T, Glass B, Foster-Payne D, Oriol NE. Epidural anesthesia for labor in an ambulatory patient. Anesth Analg 1993; 77: 919-24. 5. Li S, Coloma M, White PF, Watcha MF, Chiu JW, Li H, Huber PJ. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000; 93: 1225-30. 6. Gudaityte J, Marchertiene I, Pavalkis D, Saladzinskas Z, Tamelis A, Tokeris I. Minimal effective dose of spinal hyperbaric bupivacaine for adult anorectal surgery. Medicina 2005; 41: 675-84. 7. Maroof M, Khan RM, Siddique M, Tariq M. Hypobaric spinal anaesthesia with bupivacaine (0.1%) gives selective sensory block for ano-rectal surgery .Can J Anesth 1995; 42: 691-4. 8. Jukka V, Korhonen AM, Jokela RM, Ravaska P, Korttila K. Selective spinal anesthesia, a comparison of hyperbaric bupivacaine 4 mg versus 6 mg for outpatient knee arthroscopy.Anesth Analg 2001; 93: 1377-9. 9. Casati A, Fanelli G. Restricting spinal block to the operative side:why not? Reg Anesth Pain Med.2004; 29: 4–6. 10. Wassef MR, Michaels EI, Rangel JM, Tsyrlin AT. Spinal perianal block: a prospective, randomized, double-blind comparison with spinal saddle block. Anesth Analg 2007; 104: 1594–6. 11. Kazak Z, Ekmekci P, Kazbek K.Hyperbaric levobupivacaine in anal surgery : Spinal perianal and spinal saddle blocks.Anaesthesist. 2010; 59: 709-13. 12. Carron M, Freo U, Veronese S, Innocente F, Ori C. Spinal block with 1.5 mg hyperbaric bupivacaine: not successful for everyone. Anesth Analg 2007; 105: 1515–6. 13. Gurbet A, Turker G, Girgin NK, Aksu H, Bahtiyar NH. Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in out-patient anorectal surgery. J Int Med Res. 2008; 36: 964-70. 14. Gurbet A, Turker G, Girgin NK, Aksu H, Bahtiyar NH. Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in out-patient anorectal surgery. J Int Med Res. 2008; 36: 964-70. S247 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 S248 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%) S249 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 S250 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. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. CONCLUSION 17. 18. Intraperitoneal instillation of 0.5% bupivacaine S251 Farzaneh E, Zavvareh HT, Gharadaghi J, Sheikhvatan M. Prevalence and characteristics of gallstone disease in an Iranian population: a study on cadavers. Hepatobiliary Pancreat Dis Int 2007; 6: 509-12. Qureshi HU, Jan QA, Muqim R, Alam M, Khalil AR. Laparoscopic cholecystectomy — local experience. J Med Sci 2010; 18: 15-8. Golubović S, Golubović V, Cindrić-Stancin M, Tokmadzić VS. Intraperitoneal analgesia for laparoscopic cholecystectomy: bupivacaine versus bupivacaine with tramadol. Coll Antropol 2009; 33: 299-302. Feroci F, Kröning KC, Scatizzi M. Effectiveness for pain after laparoscopic cholecystectomy of 0.5% bupivacaine-soaked Tabotamp placed in the gallbladder bed: a prospective, randomized, clinical trial. SurgEndosc 2009; 23: 2214-20. Verma GR, Lyngdoh TS, Kaman L, Bala I. Placement of 0.5% bupivacaine-soaked Surgicel in the gallbladder bed is effective for pain after laparoscopic cholecystectomy. Surg Endosc 2006; 20: 1560-4. Alkhamesi NA, Peck DH, Lomax D, Darzi AW.Intraperitoneal aerosolization of bupivacaine reduces postoperative pain in laparoscopic surgery: a randomized prospective controlled doubleblinded clinical trial. Surg Endosc 2007; 21: 602-6. Maharjan SK, Shrestha S. Intraperitoneal and periportal injection of bupivacaine for pain after laparoscopic cholecystectomy. Kathmandu Univ Med J 2009; 7: 50-3. Garcia JB, Alencar Júnior AM, Santos CE. Intraperitoneal administration of 50% enantiomeric excess (S75-R25) bupivacaine in postoperative analgesia of laparoscopic cholecystectomy. Rev Bras Anestesiol 2007; 57: 344-55. Sarwar J, Zahir J, Dian A. Laparoscopic cholecystectomy. Professional Med J 2009; 16: 321-6. Narchi P, Benhamaou D, Bouaziz H. Serum concentrations of local anaesthetics following intraperitoneal administration during laparoscopy. Eur J ClinPharmacol 1992; 42: 223-5. Bupivacaine. [Online] [Cited 2011 August 3]; Available from: http://www.drugbank.ca/drugs/ DB00297. Iwase K, Takenada H, Ishizaka T. Serial changes in renal function during laparoscopic cholecystectomy. EurSurg Res 1993; 25: 203-12. Rosenblum M, Weller RS, Conard PL. Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. AnesthAnalg 1991; 73: 255-9. Liu J, Ding Y, White PF. Laparoscopic cholecystectomy: effect of ketorolac on postoperative pain and ventilatory function. AnesthAnalg 1993; 76: 1061–6. Mjåland O, Ræder J, Aasboe V. Outpatient laparoscopic cholecystectomy. Br J Surg 1997; 84: 958–61. Kehlet H, Rung GW, Callesen T. Postoperative opioid analgesia: time for reconsideration? J ClinAnesth 1996; 8:441–5. Alexander JJ. Pain after laparoscopy. Br J Anaesth 1997; 79: 369–78. Deans GT, Richardson T, Wilson MS, Brough WA. Absorption of bupivacaine from the pre-peritoneal space in laparoscopic hernia repair. Minim Invasive Ther 1995; 4: 175–7. 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 S252 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 S253 Accuracy of USG in Acute Appendicitis 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. S254 Accuracy of USG in Acute Appendicitis 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 S255 Accuracy of USG in Acute Appendicitis 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 S258 Laparoscopic Cholecystectomy 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). S259 Laparoscopic Cholecystectomy 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 S260 Laparoscopic Cholecystectomy 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 S261 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): 944- 8. 24. Suh SW, Park JM, Lee SE, Choi YS. Accidental gallbladder perforation during laparoscopic cholecystectomy: does it have an effect on the clinical outcomes? J Laparoendosc AdvSurg Tech A 2012; 22: 40-5. 25. Giger UF, Michel JM, Optiz I, ThInderbitzin D, Kocher T, KrahenbuhlL.Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery database. J Am Coll 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 S264 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 S265 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- S267 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 S268 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 S270 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, S271 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 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 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 S273 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. S274 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. S275 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 S276 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). S277 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 S278 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 S279 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. S280 POLICY OF THE JOURNAL It is policy of the Pakistan Armed Forces Medical Journal (PAFMJ) to publish articles pertaining to different fields of medical sciences providing sufficient contribution to medical knowledge. The journal is presently being published bimonthly. The articles may include new experimental methods of medical importance; new results obtained experimentally; new interpretation of existing results or data pertaining to clinical problems; or epidemiological work giving substantial scientific information pertaining to medical sciences. All such articles should aim for development of medical concepts rather than mere recording of facts. Incomplete studies will be discouraged. AIMS AND OBJECTIVES a. To publish original, well documented, peer reviewed clinical and basic sciences articles. b. To inculcate the habit of medical writing. c. To enable physicians to remain informed in multiple areas of medicine, including developments in fields other than their own. d. To share the experience and knowledge for benefit of patients. e. To document medical problems pertinent to military medicine like high altitude medicine, heat stroke, disaster management etc. f. To achieve the highest level of ethical medical journalism and to produce a publication that is timely, credible, and enjoyable to read. EDITORIAL FREEDOM Chief Editor has full authority over the editorial content of the journal. There is no interference in the evaluation; selection or editing of individual articles either directly or by creating an environment that strongly influences decisions. AUTHORSHIP AND CONTRIBUTORSHIP An “author” is generally considered to be someone who has made substantive intellectual contributions to a study. 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. 3. Final approval of the version to be published. Authors should meet conditions 1, 2, and 3. It is important to note that: a. Acquisition of funding, collection of data, or general supervision of the research group, alone, does not justify authorship. b. All persons designated as authors should qualify for authorship, and all those who qualify should be listed. c. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. d. Once authorship certificate is submitted no further change will be allowed. MANUSCRIPT PROCESSING Upon the initial submission of the manuscript, the author is acknowledged and allocated a reference member for future correspondence. This process takes place within 2 days. The manuscript is categorized according to the type of article into Original, Review, Case Report and so forth. Each type of article has a special format and should comply with the updated PAFMJ Instruction to Authors, which are published in all issues. Normally an article is reviewed by at least two subject experts and the other member of the editorial committee. If the reviewer has not sent review within stipulated period, a first and second reminder letters are sent within 2-3 weeks. If after the 2nd reminder the reviewer fails to reply, the matter is referred to editor who assigns it for an urgent review by one of the members of Editorial Advisory Board. The usual delay is in the reviewing process owing to the reviewer's professional and academic commitments. The reviewer's comments are communicated to the author. The revised version of the article is sent back to the reviewers. A period of 2-4 months is set to finalize the process. Accepted manuscript is then handed to statistician and bibliographer for data analysis and verification of reference respectively. The editor, then critically goes through each of the article, get their order, pagination and is sent to press for printing. PEER REVIEW POLICY Unbiased, independent, critical assessment is an intrinsic part of all scholarly work, including the scientific process. Peer review is the critical assessment of manuscripts submitted to journals by experts who are not part of the editorial staff. Peer review can therefore be viewed as an important extension of the scientific process. It is the policy of PAFMJ that every article received for publication is peer reviewed by at least two senior specialists of the concerned specialty. The “double blind” process is strictly followed. In certain controversial cases, the opinion of a 3rd reviewer is also obtained. In case of conflict of opinion between the two reviewers, the matter is referred to the Chief-editor. CONFLICT OF INTEREST 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. 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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