Year 2021, Volume 37 - Issue 4

Open access Editorial | December 30, 2021
Are we picking up breast cancers early ?

Hina Jawaid, Maham Javed

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Population awareness is the hall mark of prevention and early diagnosis of breast cancer. Integrated primary and secondary health care services with a special focus on devising robust health education startegies would be the key players in decreasing the overall morbidity and mortality with this cancer in our country.

Open access Case Report | December 25, 2021
Pediatric craniopharyngioma with a rare presentation of tooth enamel like structures - a case report

Fizza Waqar, Mahvish Hussain, Shazia Riaz, Amber Goraya, Laeeq Ahmad, Samina Zaman

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Craniopharyngioma (CP) is a rare tumor accounting for <1% of all primary central nervous system (CNS) tumors. We herein report a case of a 2.5 years old male child  diagnosed with supra-sellar tumor on prenatal ultrasound. Histologically, the tumor had tooth enamel like structures, one of the rarest finding in the literature.  This case from Pakistan is hereby reported as a seventh such case world-wide. Our patient is a rare presentation of an antenatal diagnosis of CP with World Health Organization (WHO) grade I.

Open access Original Article | December 25, 2021
Role of Endometrial Receptivity Array for Implantation failure in In-Vitro Fertilization &amp; Intracytoplasmic Sperm Injection

Rabia Nafees, Haroon Latif Khan, Yousaf Latif Khan, Aisha Awais, Miss Anum Farooqi, Rameen Nisar

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Background & Objective:

Assisted reproductive technique is an evolving field with many recent advances. The success rate is low in developing countries where financial concerns prevail predominantly. This study was designed for the first time in any hospital in Pakistan to determine the role of Endometrial Receptivity Array (ERA) in patients with previous implantation failure to improve pregnancy outcome and to enhance the success rate of in-vitro fertilization & intracytoplasmic sperm injection (IVF/ICSI).


This study was carried out at the Lahore Institute of Fertility & Endocrinology, Lahore-Pakistan. A total of 16 patients were recruited after taking written informed consent. Only those patients were selected who had previous one or more implantation failures in IVF/ICSI cycles and had at least 2 or more good quality frozen embryos. RNA was obtained from the endometrial sample to check ERA through 238 genes expressed using RNA sequencing. Beta HcG level and scans were performed to confirm the clinical pregnancy.


All enrolled patients had an ERA test and their embryos transferred according to personalized window of implantation (WOI). A total of 5(31.3 %) patients were stimulated with a long protocol while 11 (68.7%) underwent a short protocol.  WOI was receptive in 12 (75%) patients, pre-receptive in 3 (18.2%) and post-receptive in 1 (6.2%), and most of patients showed receptivity at P5 (109-145 hours). Twelve patients (75%) had clinical pregnancy evident by positive beta HCG after embryo transfer. A significant association was found between WOI and receptivity (P<0.05).


The results of ERA in our study seem promising especially in our patients with previous one or more implantation failures. Although we have limited number of patients keeping in mind its financial constraints especially in developing countries, still ERA is considered a way of hope especially for those patients who have previous implantation failures.


Open access Original Article | December 25, 2021
Anatomical Parameters of Eye and Associated Histological Features are Potential Risk Factors for Development of Pterygium

Sadia Aman, Muhammad Muneeb Ather, Amanullah Qasim, Rabia Latif, Rakhshanda Jabeen, Uruj Zehra

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Background and Objectives: Pterygium occurs throughout the world but the exact pathogenesis is still not clear. The reports on the association between eye anatomical parameters and presence of pterygium is controversial, similarly how the histological features of the pterygium may differ due to these parameters is not known. Thus, the focus of this study was to explore this gap by assessing and comparing the anatomical parameters of eye in pterygium patients and in healthy controls. In addition, histological features of pterygium were assessed and correlated with the eye anatomical parameters of the patients.

Methods: Forty-one pterygium patients of age range 25-70 years undergoing surgery were included in the study after taking written informed consent. Forty-two age and sex matched healthy controls were also recruited for assessing anatomical eye parameters. Relevant history with demographic details of every subject was obtained. All participants underwent a thorough ophthalmic examination. Assessment of orbital protrusion and interpalpebral distance was measured by millimeter scale. Tear film breakup time (TFBUT) and Schirmer test was used for tear film assessment. Presence of any meibomian gland dysfunction (MGD) was examined by slit lamp. Post-surgical tissue samples from patients were assessed for histological features with H& E, PAS & Verhoeff stains. Data were processed and analyzed by using SPSS version 21.0.

Results: Eyeball protrusion and MGD was found higher in pterygium patients as compared to controls. Basement membrane fragmentation on histology significantly correlated with the eyeball protrusion (P<0.04) and TFBUT (P<0.020), inflammation significantly correlated with the MGD (P<0.05) while elastosis showed significant correlation with TFBUT (P<0.001).

Conclusion: It can be concluded that eye anatomical parameters might be the risk factors in the development of pterygium. The correlation between certain histological features & eye anatomical parameters indicate that anatomical eye parameters can be taken as risk factor for recurrence in these patients. 

Open access Original Article | December 25, 2021
Neuropathologic Damage Induced by Radiofrequency Ablation at Different Temperatures &ndash; An Experimental Study

Li Su, Yu Dong, Ying Chen, Baoguo Yao, Peng Song, Ruiting Xu, Rui Li, Ping Liu, Yu Zhang, Li Mu, Xin Tong, Linwei Ma, Jianjun Yu

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Background and Objective: Radiofrequency ablation (RFA) is a safe and less invasive technique that uses an electric current to damage nerve tissue to stop it from sending pain signals. This study was aimed to determine the molecular mechanism of neuropathologic damage induced by RFA at different temperatures.
Methods: A total of 36 Sprague Dawley rats were used as model with neuropathological injury. These rats were divided into six groups based on the temperature stimulation at 42°C, 47°C, 52°C, 57°C, 62°C, and 67°C. Conduction time, distance, and velocity were recorded after thermal injury. Hematoxylin and eosin staining was used to observe the histopathological changes of sciatic nerve. Neural ion channel proteins such as sodium voltage-gated channel alpha subunit 9 (SCN9A), sodium channel B3 subunit (SCN3B) and neurofascin (NFASC) expression in sciatic nerve tissue were detected detected by Western Blot.
Results: Nerve conduction velocity (NCV) gradually decreased with the increase in temperature and neuronal damage was seen at 67°C. H&E staining showed increased degeneration of neurons with an increase in temperature from 47°C to 67°C. SCN9A and SCN3B expression at 57°C, 62°C, and 67°C was much higher; however, NFASC expression was lower at same temperatures.
Conclusion: Neuropathological damage caused by RFA at different temperatures shows positive correlation with NCV. Heat transfer injury affects the expression of SCN9A, SCN3B, and NFASC in sciatic nerve tissue. 

Open access Original Article | December 25, 2021
Anti-Mullerian hormone and associated pregnancy outcomes in females with polycystic ovary syndrome undergoing In vitro fertilization-embryo transfer

Yuping Cao, Jiacheng Du

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Background and Objective: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women worldwide. Pregnancy in these women is highly affected by serum levels of Anti-Mullerian hormone (AMH). This study aimed to determine the association of serum AMH levels with pregnancy outcomes in females with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization-embryo transfer (IVF-ET)

Methods: A total of 200 PCOS patients undergoing IVF-ET in the Reproductive Medicine Center, Second People's Hospital of Jingmen, China were included. The patients were divided into two groups, A and B, based on their AMH levels. Serum sex hormones levels and pregnancy outcomes in terms of fertilization, cleavage, implantation, high quality embryo and biochemical  and clinical pregnancy rates were compared.

Results: Mean age of the patients was 28.74±2.07 years in group A and 29.74±2.23 years in group B. Participants in group A had lower serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) compared to group B. Also, better pregnancy outcomes and lower frequency of pregnancy complications were seen in the participants of group A (P<0.05). AMH serum levels showed high specificity and sensitivity in predicting IVF-ET clinical pregnancy in PCOS patients.

Conclusion: Serum AMH levels in females with PCOS  predict  improved sex hormone profile and clinical pregnancy outcomes after IVF-ET

Open access Original Article | December 25, 2021
Clinical outcomes of open surgical gastrostomy in patients with obstructive head and neck and esophageal carcinoma: a retrospective audit from Khyber Pukhtunkhwa

Sheikh Qais Falah, Iram Bashir, Asif Shams, Arshad Ali Marwat, Aftab Alam

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Background and Objectives: Gastrostomy is a well-established procedure for enteral feeding in patients with obstructive head and
neck carcinomas. The aim of the present study was to assess the mortality rate and other complications associated with open surgical
gastrostomy (OSG) in patients with obstructive head and neck and esophageal carcinomas in local population.
Methods: This retrospective audit was conducted at the surgical unit of a teaching hospital at Khyber Pukhtunkhwa from January 2013
to December 2019. A total of 30 head and neck cancer patients undergoing OSG for enteral feeding were included in this study. The
gastrostomy procedure was performed under local anesthesia. Patients were discharged on fourth to sixth postoperative day after enteral
feeding was fully established. The patients were followed up for any complications on 10th and 30th day postoperatively.
Results: The mean age of the patients was 42.3 ± 13.55 years (range 23 to 70 years). Females were affected more commonly than
males. One patient died during postoperative admission, while another patient passed away after getting discharged within first 30
days, postoperatively. Thus, the mortality rate was recorded as 6.66% (n = 2). No major complications were recorded while the minor
complications including tube blockage, tube dislodgment and peri-catheteral infection were noted.
Conclusion: Open surgical gastrostomy under local anesthesia is a safe and easy procedure for enteral feeding with low rate of complications
in patients with obstructive carcinomas of head and neck.


Open access Original Article | December 25, 2021
Knowledge and Perception Among Gynecologists Regarding Screening of Domestic Violence against Women

Rabia Nafees, Zahra Safdar, Faiqa Saleem Baig, Shazia Jang Sher

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Background and Objective: Domestic violence (DV) has been identified as a very serious problem that affects women and children at
all levels of society, regardless of race, financial status, religion, and level of education. DV in Pakistan is a very sensitive issue keeping in
mind the psychological, religious, and social aspects. The aim of the study was to assess the level of knowledge and perception about DV
amongst gynecologists working in the tertiary care teaching hospitals of Lahore city, Pakistan.
Methods: It was a cross-sectional survey study carried out among the doctors working in the Gynecology departments in different tertiary
care teaching hospitals of Lahore from July to August, 2021. A total of 154 doctors of the Gynecology departments participated in this study.
Results: Most of the participants (53.4%) had suboptimal knowledge regarding the screening tools for DV against the women reporting in
Gynecology clinics from July to August, 2021. A significant association was found between awareness regarding DV and an agreement for
introducing a formal training course (p < 0.05).
Conclusion: The knowledge and perception of health care providers to screen the cases of DV is the basic key to identify such victims.
However, a proper training of the staff handling such patients needs to be implemented at government level.

Open access Original Article | December 25, 2021
Serum PIVKA-II: Reference Interval of Healthy Population and Establishment of Its Cutoff Value for Hepatocellular Carcinoma Diagnosis in Pakistan

Faryal Husnain, M Dilawar Khan, Omar Rasheed Chughtai, Akhtar Sohail Chughtai, Shakeel Ashraf, Ahmed Yar

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Background and Objective:

PIVKA-II (Protein induced by vitamin K absence II) is an upcoming and promising new biological marker cited as having a definitive role in the early detection and diagnosis of hepatocellular carcinoma (HCC). Preliminary research shows PIVKA-II reference intervals (RIs) in serum to have substantial racial disparities globally.  Hence, this study aimed to determine the RIs and cut-off value of the serum PIVKA-II for the first time in healthy and patients with hepatocellular carcinoma in Pakistan.


Methods: This cross-sectional study comprised of 240 participants (120 diagnosed cases of HCC and 120 healthy individuals) registered at the Department of Chemical Pathology and Immunology, Chughtai Institute of Pathology, Lahore, Pakistan. The PIVKA-II serum level was analyzed using the Chemistry Analyzer through chemiluminescent micro-particle immunoassay (CMIA). The reference interval was subsequently established using the percentile method.


Results: In healthy Pakistani adults, the 95 percent reference interval for PIVKA-II was 15.55-43.03mAU/ml, and the cut-off was 148.81mAU/ml in HCC (hepatocellular carcinoma) cases. The male participants, exhibited higher PIVKA-II levels than the females (P < 0.002). There were no significant differences in the serum levels of  PIVKA-II with respect to age however variations were observed with respect to gender.


Determination of the reference interval for serum PIVKA-II in healthy adult Pakistani individuals and a cut-off for HCC diagnosis emphasizes the growing need to establish and verify reference intervals of analytes at a larger scale in our population. Ideally all clinical laboratories should establish their own reference intervals.

Open access Original Article | December 25, 2021
Assessment of dietary intake, anthropometric measurements and hormonal levels in child bearing age women with polycystic ovary syndrome

Shehla Javed Akram, Ejaz Mehmood Qureshi

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Background and Objective: Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women of reproductive age. The prevalence of PCOS is higher among Pakistani women as they may have poor dietary habits. The objective of the study was to determine the dietary intake pattern, anthropometric measurement and hormonal levels in patients with PCOS.
Methods: A cross-sectional study was conducted among 160 women presenting at the Gynecology and Obstetrics Department of Jinnah Hospital, Lahore, Pakistan. PCOS was assessed using Rotterdam criterion. For each woman, its demographical data, anthropometric measurements, hormonal as well as dietary intake were taken and comparison was made between the PCOS and healthy women.
Results: There was no significant difference between the mean of the age, weight, height and body mass index between the PCOS group and the healthy women. Hirsutism, acne, weight gain, and sleep disturbance over past one year were higher in PCOS group whereas change in bowel habits was significantly higher (p < 0.05) in healthy controls over a year as compared to PCOS. In hormonal analysis, luteinizing hormone and testosterone were significantly higher (p < 0.05) in PCOS group than the healthy women. In dietary analysis, fiber, ash, Zinc and Riboflavin were significantly found greater (p < 0.05) among healthy controls in comparison to woman suffering from PCOS.
Conclusion: PCOS characterized with increased body weight, hirsutism, acne, and sleep disturbance is common in our women. Furthermore, it significantly correlates to lower intake of Fe and fiber while higher intake of more caloric diet from carbohydrates and fats in their daily routine.

Open access Original Article | December 25, 2021
Efficacy of dexmedetomidine in combination with morphine for pain management in patients with cesarean section

Liang Zhang

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Background and Objective: Intraspinal morphine shows a high analgesic efficacy but may cause some adverse effects. Dexmedetomidine
(Dex) improves anesthetic actions and reduces anesthesia-related adverse reactions. This study was aimed to observe the efficacy and
safety of intravenous Dex combined with epidural morphine for pain management in patients after cesarean sections.
Methods: Eighty women undergoing cesarean sections were equally divided into two groups. Group A received Dex in combination with
morphine and group B received morphine only. Participants in both groups were given morphine after cesarean sections. After delivery,
women in the group A were given Dex, while participants in the group B were given physiological saline. Serum levels of cortisol, renin,
and potassium were measured before anesthesia, immediately and 24 hours after cesarean sections, and the visual analog scale (VAS)
and observer’s assessment of alertness/sedation scale (OAA/S) scores were assessed at 4, 8, 12, and 24 hours after cesarean sections. In
addition, post-operative adverse events and urine volume intraoperative and at 24-hour after cesarean section was measured.
Results: Lower serum levels of cortisol and renin were recorded in group A than group B immediately after cesarean sections (p < 0.05).
VAS score was low in group A than group B at 12 and 24 hours after cesarean sections (p < 0.05); however, no significant differences were
seen in the OAA/S score (p > 0.05). Lower frequency of shivering and nausea/vomiting was seen in group A than group B after cesarean
sections, and increased urine volume intraoperatively and after 24 hours of cesarean sections was observed in group A than group B (p <
Conclusion: Dex-morphine combination achieves a higher efficacy and lesser adverse events than morphine alone for post-cesarean