Latest Articles

Open access Original Article | December 25, 2021
Efficacy and safety of intravenous dexmedetomidine pumping plus epidural morphine administration versus epidural morphine administration alone for post-caesarean analgesia

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Background & Objectives: Intraspinal morphine shows a high analgesic efficacy but high incidence of adverse events and dexmedetomidine (Dex) improves anesthesic actions and anesthesia-related adverse reactions. This study compares the efficacy and safety of intravenous Dex and epidural morphine administration versus morphine alone for post-caesarean analgesia.

Methods: Eighty women receiving caesarean sections were assigned to the Dex-morphine combination group and morphine group. Subjects in both groups were given morphine after caesarean sections. After delivery, women in the combination group were given Dex, while subjects in the morphine group were given physiological saline. Serum cortisol, renin and potassium was measured before anesthesia, immediately and 24 hours after caesarean sections, and the visual analog scale (VAS) and observer’s assessment of alertness/sedation scale (OAA/S) scores were assessed 4, 8, 12 and 24 hours after caesarean sections. In addition, post-operative adverse events were recorded, and intraoperative urine volume and urine 24-hour volume after caesarean sections were measured.

Results: Lower cortisol and renin was measured in the combination group than in the morphine group immediately after caesarean sections (P < 0.05), while no significant differences were found in serum potassium between two groups at each time point (P > 0.05). Lower VAS scores were measured in the combination group than in the morphine group 12 and 24 hours after caesarean sections (P < 0.05); however, no significant differences were seen in the OAA/S score (P > 0.05). Lower incidence of shivering and nausea/vomiting was seen in the combination group than in the morphine group after caesarean sections, and greater intraoperative urine volume and urine volume within 24 hours after caesarean sections were measured in the combination group than in the morphine group (P < 0.05).

Conclusion: Dex-morphine combinations achieve a higher efficacy and lower incidence of adverse events than morphine alone for post-caesarean analgesia.

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

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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) because ERA was started for the

Methods:

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.

Results:

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).

Conclusion:

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
Anti-Mullerian hormone and associated pregnancy outcomes in females with polycystic ovary syndrome undergoing In vitro fertilization-embryo transfer

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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 Review Article | December 25, 2021
Angiotensinogen - A Potential Diagnostic and Prognostic Candidate Gene  for Adenocarcinomas of Rectum and Stomach

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The Angiotensinogen (AGT) gene encodes for angiotensinogen protein that mainly regulates blood pressure and maintains the fluid and salt balance in the body. AGT expression variations have been documented earlier in only a few subtypes of human cancers, the multi-omics profiling of AGT as a shared biomarker in different other subtypes of human cancers remains to be uncovered. In the current study, AGT multi-omics analysis in 24 major subtypes of human cancer were performed using different authentic online databases and bioinformatics analysis including UALCAN, Kaplan Meier (KM) plotter, Human protein Atlas (HPA), GENT2, MEXPRESS, cBioportal, STRING, DAVID, TIMER., and CTD database. AGT is found commonly up-regulated in most human cancers. Overexpression of AGT is significantly correlated with the poor overall survival (OS) of only rectum adenocarcinoma (READ) and Stomach Adenocarcinoma (STAD). This implies that AGT plays a significant role in the development and progression of these cancers. We further noticed that AGT is also overexpressed in READ and STAD patients of different clinicopathological features. Pathways enrichment analysis revealed that AGT is involved in various diverse pathways. While, a few interesting correlations were also documented between AGT expression and its promoter methylation level, CD8+ T immune cells level, and CNVs. Moreover, we also predicted a few drugs through gene-drug interaction analysis that could be used in the treatment of READ and STAD by regulating the AGT expression. Our findings suggest that AGT alone might be helpful in predicting the diagnosis and prognosis of READ and STAD patients commonly.

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

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Background and Objective:

Domestic violence 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. Domestic violence 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 domestic violence 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. 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 domestic violence against the women reporting in Gyneacology clinics. A significant association was found between awareness regarding domestic violence 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 domestic violence 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
Neuropathologic damage induced by radiofrequency ablation at different temperatures – An Experimental Study

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Background and Objective: Radiofrequency ablation 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 radiofrequency ablation at different temperatures.

Methods: A total of 36 Sprague Dawley (SD) rats were used as model with neuropathological injury. These rats were divided into 6 groups based on temperature stimulation at 42℃, 47℃, 52℃, 57℃, 62℃ and 67℃. Conduction time, distance and velocity were recorded after thermal injury. Hematoxylin and eosin (H&E) 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 was  detected by Western Blot.

Results: Nerve conduction velocity gradually decreased with the increase in temperature and neuronal damage was seen at 67℃. H& E staining showed increased degeneration of neurons with an increase in temperature from 47℃ to 67℃. SCN9A and SCN3B expression at 57℃, 62℃, and 67℃ was much higher however, NFASC expression was lower at the same temperatures.

Conclusion: Neuropathological damage caused by RFA at different temperatures shows   positive correlation with nerve conduction velocity. Heat transfer injury affects the expression of SCN9A, SCN3B and NFASC in sciatic nerve tissue.

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

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Background and Objective: Gastrostomy feeding is a well-established procedure for enteral feeding of patients having obstructive malignancy of head and neck (includes oral cavity, pharynx and larynx) and esophagus. This study aimed to assess the mortality and other complications associated with open surgical gastrostomy (OSG) performed under local anesthesia.

Methods:  Patients having cancer of head and neck and esophagus who underwent open surgical gastrostomy for feeding purposes at surgical unit, Mufti Mehmood Memorial Teaching Hospital (MMMTH), Dera Ismail Khan, Khyber Pukhtunkhwa from January 2013 till December 2019 were included in this study. The patients with lower esophageal cancer involving stomach were excluded from the study. The gastrostomy procedure was performed under local anesthesia. Patients were discharged on 4th to 6th postoperative day after feeding per gastrostomy was fully established. The patients were checked for any complications in ward and during follow up visits on 10th and 30th day postoperatively.

Results: This study was conducted on 30 consecutive patients fulfilling selection criteria. One patient died in the ward while one patient died after getting discharged in first 30 days postoperatively. Thus, the mortality rate was 6.66 % (n = 2). Regarding minor complications, two patients (6.66 %) had tube blockage, three (10 %) developed peri-catheter infection while the tube got dislodged in one patient (3.33 %).

Conclusion: Open surgical gastrostomy under local anesthesia is a safe and easy procedure with low rate of complications.

                                                               

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

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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
Assessment of dietary intake, anthropometric measurements and hormonal levels in child bearing age women with polycystic ovary syndrome

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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 Case Report | January 03, 2022
Diagnosis and Treatment of Adult-Onset Still’s Disease in a Female Patient - A Case Report with Review of the Literature

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ABSTRACT Adult onset Still’s disease (AOSD), a rare autoinflammatory disorder, presents with many non-specific symptoms, such as rash leukocytosis, spiking fever and sore throat. Laboratory tests show high levels of C-reactive protein, ferritin and erythrocyte sedimentation rate reflecting the systemic inflammatory process. The patient was a middle-aged woman with high grade fever (39.8°C), sore throat, rash on limbs with pruritus, mainly at the joints (elbow, knee, and ankle), myalgias, poor appetite and arthralgia. Serum ferritin level was above 1500 (normal value: 14-233) ng/L. Anti-neutrophil and antinuclear antibodies and rheumatoid factors were negative. Combination of symptoms and ferritin levels led to the diagnosis of adult Still’s disease. She received a dose of methylprednisolone 40 mg twice a day, intravenously for one week with tapering to 40mg in the morning and 20mg in the evening in the second week and 40mg orally in the morning and 8mg in the evening for the next couple of weeks. After 15 days of initial treatment, fever and skin rashes subsided and other symptoms also gradually improved in further two weeks. This case highlights the importance of early diagnosis and timely treatment of adult Still’s disease to prevent potentially fatal complications. 

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

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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.

Conclusions:

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.